Introduction

Going home from hospital is a welcome event for the majority of patients, where they can be assured of support from their families and a range of services. For others, it is a more worrying event, especially if they live alone and may have less access to services they might require. For the majority of patients, regardless of their level of support, there will be concerns about how they are going to manage after surgery. This concern will, of course, be dependent on the kind of surgery and, most importantly, what kind of diagnosis may have been the outcome (e.g. if a patient has undergone surgery for removal of a cancerous tumour, worry over whether it has all been removed or not). Psychological care and effective communication are two very important areas where the nurse has to develop skills, and as a student nurse you will be assessed in these areas as part of your ‘fitness for practice’ Nursing and Midwifery Council (NMC) (2010) standards (see Box 10.1 for examples of relevant competencies to be achieved).

Preparation for discharge from hospital

Preparation for a patient's discharge from hospital is a multidisciplinary team effort which is coordinated in most situations by the nurse. This person is referred to as the ward-based care coordinator in the Department of Health (DH) (2003) guidance. As can be seen in the DH (2003) principles, it is implicit in any policy to ensure that discharge planning should be co-ordinated by one person.

The DH (2003:46) sees this as part of ‘co-ordinating the patient journey’ and identifies the following key principles underpinning this aspect of effective discharge and transfer of care policy:

The nurse's role in discharging patients home from hospital

If we use the idea of the nurse as the ward-based care coordinator, the DH (2003) document states that ‘this is an important, highly skilled role and requires an experienced practitioner who has a good understanding of discharge planning’. Key tasks considered to be important to this role are given in Box 10.2. The report suggested that this role could be enhanced to include nurse-led discharge.

You may come across patients who decide that they no longer want to stay in hospital and choose this against medical advice. It is important to consider whether the patient ‘understands the risks they are taking in discharging themselves’ or whether in fact they are ‘not competent to understand the risks associated with discharge due to his or her medical condition’ or the same but ‘due to mental health problems’ DH (2003).

The DH (2010) has published a good practice toolkit for organisations to ensure best practice in discharge planning. You can access this for general information at: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_113950 (accessed July 2011).

Oakley (2010) also sets out the criteria for discharge of a patient following day surgery which can be used as an aide-memoire for checking what needs to happen prior to the patient going home. These criteria are given in Box 10.3.

Practice placement learning pathways (hub and spoke placements) and discharge planning and implementation

As a student, it is important to be able to gain experience in this process in any context. As discussed in earlier chapters, given the importance also of understanding the patient's journey during admission for surgery and ongoing care during the perioperative period, it is an excellent opportunity to gain experience with members of the multidisciplinary health and social care services and learn about their part in the discharge of patients from hospital. Examples of members of the multidisciplinary team who may be involved in discharge planning and implementation are:

The nurse's role in the aftercare of the patient following discharge home from hospital (the first 2 weeks)

Once patients hasve been discharged following surgery, they are in the care of the health centre and their GP, together with the community nursing team. A written discharge summary will have been sent to the GP together with some kind of care transfer plan which will enable the essential continuity of care to be carried out. A follow-up appointment to check on the patient's progress will have been made with the patient's consultant surgeon and his/her team. If there is a discharge co-ordinator in charge of the patient's discharge, they will act as the main liaison with the relevant agencies involved in the community. Social services may be involved if the patient requires additional support: for example, if they live alone, a ‘meals at home’ service may have to be organised.

Given that patients' stay in hospital, even for major surgery, is now much shorter than in the past, patients can still require care that they would normally have had in hospital. In addition, some postoperative complications may still occur, and the community team will be vigilant in their observations with regards to these, working together with either the family or carer and, in some situations, care home staff.

Potential complications or problems could be:

One of the tasks that nurses in the community now undertake is removal of sutures at the agreed postoperative period, and for many of you, developing skills in removing a variety of wound closure materials such as clips and sutures will be gained in your community placements rather than in a surgical one. It is imperative, however, that you become familiar with all kinds of techniques in this area in order to be able to answer patients' questions with regards to wound care following their discharge from hospital. This applies to both day care patients and those who have had major surgery.

Supporting the patient and their family following discharge home

If a patient has had major surgery, they will require emotional support as well as practical, especially if the diagnosis linked to the surgery was not favourable (e.g. cancer diagnosis). Often surgery may be a palliative short-term outcome to ensure an enhanced quality of life for the patient. This would have been discussed with them following surgery. They may need further surgery and/or chemotherapy and radiotherapy. Again, it is essential that you are aware of the possible outcomes of surgery, and your mentor can support your learning by enabling you to observe him/her discussing with patients some of the questions they may have in relation to such outcomes. Gaining permission of the patient is important in situations where confidentiality or sensitive issues are going to be discussed.

Patients discharged from hospital have access to the whole community multidisciplinary team. If you are undertaking a community placement, one of your opportunities for learning about caring for a patient undergoing surgery will be the reverse of someone on a surgical ward placement. Your mentors may already have a system in place where there is a ‘swapping over’ of students in order to ensure that you gain an overall experience of the patient journey.

Summary

Management of a patient's discharge home from hospital begins on their admission to hospital. NHS trusts and surgical wards have policies and procedures in place to ensure effective and continuous care of the patient, which includes liaising with family and carers who will be the main support for the patient when they arrive home.

Understanding the evidence base for effective discharge planning and management of the postoperative period following discharge is key to your successful learning of total patient care.