JINKA GENERAL HOSPITAL

DISCHARGE PLANning
PROTOCOL

BY CG &QIU
SEPTEMBER 2015/2022
JINKA SNNP, ETHIOPIA
 JGH INPATIENT DISCHARGE PLAN PROTOCOL

Contents
ACRONOMYS................................................................................................................................1
INTRODUCTION.........................................................................................................................2
KEY ELEMENTS OF IDEAL DISCHARGE PLANNING..........................................................2
STANDARDS TO BE MET...........................................................................................................4
1. Responsibilities........................................................................................................................4
2. Medical Discharge Summary...................................................................................................4
3. Discharge Planning..................................................................................................................5
4. Before Discharge......................................................................................................................6
5. On Discharge............................................................................................................................6
6. Repeat Admission....................................................................................................................6
7. Documentation.........................................................................................................................6
STANDARDS TO BE MET (refer also to Appendix 1).................................................................7
REFERANCES................................................................................................................................9

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ACRONOMYS
GP-=General Practitioner
JGH=Jinka General Hospital
LMC= Lead Maternity Career
MDT= Multi-Disciplinary Team
RN-=Registered Nurse
SMO-=Senior Medical Officer

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INTRODUCTION
Discharge Planning will begin prior to admission when admitted electively, or will be
commenced within 24 hours of current admission, Ideal discharge planning processes facilitate
the transition from hospital to home and prevent subsequent re-presentations to hospital& post
discharge complication. Common post-discharge complications include adverse drug events,
hospital-acquired infections, and procedural complications.
Many of these complications can be attributed to discharge planning problems, such as:
 Changes or discrepancies in medications before and after discharge
 Inadequate preparation for patient and family related to medications, danger signs, or
lifestyle changes
 Disconnect between clinician information-giving and patient understanding
 Discontinuity between inpatient and outpatient providers
Involving the patient and family in discharge planning can:-
 Improve patient outcomes,
 Reduce unplanned readmissions, and
 Increase patient satisfaction.
 Improve hospital quality and safety.

KEY ELEMENTS OF IDEAL DISCHARGE PLANNING

I= INCLUDE the patient and family as full partners in the discharge planning process.
 Always include the patient and family in team meetings about discharge.
 Remember that discharge is not a one-time event but a process that takes place
throughout the hospital stay.
 Identify which family or friends will provide care at home and include them in
conversations.
D=DISCUSS with the patient and family five key areas to prevent problems at home:
1. Describe what life at home will be like e.g. Include the home environment, support needed,
what the patient can or cannot eat, and activities to do or avoid.

2. Review medications
Use a reconciled medication list to discuss the purpose of each medicine, how much to take, how
to take it, and potential side effects

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3. Highlight warning signs and problems.

Identify warning signs or potential problems. Write down the name and contact information of
someone to call if there is a problem
4. Explain test results
Explain test results to the patient and family. If test results are not available at discharge, let the
patient and family know when they should get the results and identify who they should call if
they have not gotten results by that date.
5. Make follow-up appointments
Offer to make follow-up appointments for the patient. Make sure that the patient and family
know what follow-up is needed.
E=EDUCATE the patient and family in local language about the patient’s condition, the
discharge process, and next steps at every opportunity throughout the hospital stay.
Discharge planning should be an ongoing process throughout the stay, not a one-time event. You
can:
 Elicit patient and family goals at admission and note progress toward those goals
each day
 Involve the patient and family in bedside shift report or bedside rounds
 Share a written list of medicines every morning
 Go over medicines at each administration: What it is for, how much to take, how
to take it, and side effects
 Encourage the patient and family to take part in care practices to support their
competence and confidence in caregiving at home
A=ASSESS how well doctors and nurses explain the diagnosis, condition, and next steps in the
patient’s care to the patient and family and use teach back.
 Provide information to the patient and family, repeat key pieces of information
throughout the hospital stay
 Ask the patient and family to repeat what you said back to you in their own words to be
sure that you explained things well
L=LISTEN to and honor the patient’s and family’s goals, preferences, observations, and
concerns.
 Invite the patient and family to write questions or concerns
 Ask open-ended questions to elicit questions and concerns.

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 Schedule at least one meeting specific to discharge planning with the patient and family
caregivers

STANDARDS TO BE MET
1. Responsibilities
a) All relevant health professionals will be involved with discharge planning and will
maintain the required discharge documentation.
b) The decision to medically discharge a patient is to be made initially by the responsible
SMO/Consultant or Lead Maternity Career (LMC) or their delegated authority. The
health professionals will document in the health record the patient / client’s readiness for
discharge.
c) Parameters for discharge in the form of Criteria Lead Discharge must be written in the
patient health record by the Consultant, LMC or their delegated authority.
d) There must be evidence that discharge information has been discussed with patient /
client / family by the relevant health professionals.
e) The Registered Nurse (RN) who is responsible for the patient / client at the time of
discharge, must ensure the discharge process is completed.
2. Medical Discharge Summary
a) The ultimate responsibility for the discharge documentation rests with the responsible
Senior Medical Officer who is responsible for the patient's management and includes the
monitoring of the discharge process.
b) In complex cases and those needing follow up this discharge summary must be discussed
with the Responsible Senior Medical Officer (SMO). In some cases it may be necessary
to forward a copy to the Responsible SMO for approval.
c) The Senior Medical Officer or delegate is responsible for any tests ordered on an
inpatient, including results that come in after the patient has been discharged. They must
follow up on all results and are responsible for further communication with the Senior
Medical Officer/GP if required.
d) Where the Senior Medical Officer/ GP status is unknown or where uncertainty exists,
contact must be made with the assigned care provider e.g. LMC to ensure that the above
process is adhered to and that the patient’s discharge details are communicated to the
person responsible for their care.
3. Discharge Planning
3.1 Discharge Planning will begin prior to admission when admitted electively, or will be
commenced within 24 hours of current admission.
3.2 There will be a Discharge Plan formulated in partnership with the patient / client and /or
family
3.3 The Discharge Plan will include evidence of the following:

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a) Assessment of patient / client’s needs, post discharge.

b) Identification of family support and other agencies / services already involved.
c) Documentation of expected plan / strategies to meet patient / client’s discharge needs.
d) An indication of anticipated length of stay.
e) Medical discharge summary, includes:
i. Principal diagnosis – condition found to be primarily responsible for patient’s admission to
hospital
ii. Any secondary conditions that existed at the time of admission for which treatment was given
or that arose during the patient’s stay, or affected length of stay or treatment / care
iii. Principal procedure performed for definitive treatment that required the greatest level of
hospital resources or which was performed for treatment of the principal diagnosis
iv. Other significant procedures undertaken that were either surgical in nature or carried
procedural risk and / or required special equipment only available in the acute care setting
v. Specific follow up requirements to support continuity of care once the patient is discharged
from hospital
f) Discharge summaries must include all changes to a patient’s medication – discontinued drugs,
new additional drugs and changes in doses. Expected duration of treatment should be indicated
where this is time limited.
g) Specify information to be given to the patient.
3.4 Referrals will be actioned within 24 hours to the appropriate health professional or other
service provider as identified in the initial and subsequent patient assessments.
3.5 All complex discharges are actively planned within the multi-disciplinary team (MDT).
3.6 Referral needs will be assessed on an ongoing basis.
3.7 Staff education in discharge planning processes to be included in ward / service / unit
orientation and clearly documented.
4. Before Discharge
a) Each member of a MDT (when appropriate) must clear the patient for discharge.
b) All referrals and any discharge equipment will be organized if required and liaison with
community providers confirmed.
c) Patient education shall be appropriate for the level of understanding of patient / client and
/ or family. Evidence of patient education to be documented in the patient’s health record.

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d) Transfer letter if required and the discharge information is explained and given to the
patient and / or family before they leave hospital.
e) Enhanced communication with GPs must be given when there are new additional
treatments with risk attached to them that require specific GP follow up eg warfarin,
statin prescriptions.
5. On Discharge
a) Final discharge tasks completed as detailed in the Admission to Discharge Planner
b) Completed Medication reconciliation, if required.
c) All referrals to community providers are confirmed and explained to patient.
d) Information required for the patient to manage at home and the planned follow-up
arrangements explained and given to patient.
e) Patients who are assessed as vulnerable, e.g. elderly, the very young, and / or without an
accompanying support person, should be discharged at a time when there is appropriate
access to support services, provisions, family, community support.
f) In the event of patient re-admission, SMO/consultant, GP, or specialist nursing follow up
on discharge is mandatory
6. Repeat Admission
a) Repeat admission may signal that the discharge plan was insufficient for the patient’s
needs resulting in failed transition to the next setting of care.
b) The repeat admission of patient within 28 days record to flag that must be followed as an
outcome measure that the patient has a high risk of further re-admission.
7. Documentation
a) All Health professionals involved with discharge planning will document in the health
record the patient / client’s readiness for discharge from Hospital or Inpatient Health
Care.
b) SMO / GP / Consultant completes discharge documentation as per standard.
c) Nursing staff are responsible for ensuring that the discharge summary section of the
Admission to Discharge Planner or patient pathway is complete prior to patient
discharge.
d) Administration staff will undertake to forward information in the necessary timeframes.

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STANDARDS TO BE MET (refer also to Appendix 1)

Process Tasks / Standards Responsibility
First contact  Patient referred to hospital – refer to policy
with hospital Admission, Handover of Responsibility & Patient
Care Management
Health professionals
 Discharge planning to begin prior to admission when
admitted electively or within 24 hours of current
admission
 Nursing assessment to be completed within 8 hours
 Focal nurse(Ward head) providing information and
notified patient about admission
Discharge Plan
 Need to referral to Allied Health professional
commenced –
Admission & Pre-admission

identified and referral(s) sent within 24 hours – Head Nurse (RN)

Admission to
reviewed on daily basis
Discharge
 Discharge plan commenced
Planner
 Expected length of stay discussed with patient /
client, family

Patient education is given and documented by

Patient health professionals Health professionals and
Education Education is targeted to the level of understanding Health Literacy Unit
of the patient
 All patients must be medically discharged
Set parameters  Consultants may set written parameters in health Specialist Consultant /
for medical record in the form of Criteria Led Discharge from GP / LMC delegated
discharge which their delegated authority or senior Head Nurse authority
may discharge patient
Make discharge  Prior to discharge the following needs to occur: RN or delegated
arrangements  Transport arrangements confirmed authority

 Follow up appointments made on Referral Clinic

Discharge

 Written discharge information discussed with patient

/
client, family, given to patient / caregiver and

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documented in health record

 Return of patient’s own medication documented
 Return all patient’s property (Client Personal
Property)

Patient / caregiver / family informed

All documentation given to patient on discharge
Confirm e.g. Prescription, medical certificate Discharge Nurse
Ensure all issued equipment goes with patient on
discharge Consumers
Outpatient appointments
Medical on discharge where possible
Discharge The discharge summary must be completed no later GP/SMO
Summary than 24 hours following discharge
Nursing
Discharge  Nurse should be signed on discharge summary Discharging Nurse
Summary
Arrange follow  Follow up outpatient appointments made and
Nursing staff
up appointments confirmed prior to
 Any issues / problems relating to patient / client Case Managers /
discharge to be identified and reported Nurse Educators /
Post discharge

Monitoring and
 All unplanned re-admissions to be assessed using Allied Health
Evaluation
outcome measure so that cases of re-admission is professionals / District
understood and appropriate actions taken Nurse

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REFERANCES
1, Moretto, N.; Comans, T.A.; Chang, A.T.; O’Leary, S.P.; Osborne, S.; Carter, H.E.; Smith, D.;
Cavanagh, T.; Blond, D.; Raymer, M. Implementation of simulation modelling to improve service
planning in specialist orthopaedic and neurosurgical outpatient services. Implement. Sci. 2019, 14, 78.
[CrossRef]

2,Schjødt, K.; Erlang, A.S.; Starup-Linde, J.; Jensen, A.L. Older hospitalised patients’ experience of
involvement in discharge planning. Scand. J. Caring. Sci. 2021. [CrossRef]

3, Shepperd S, McClaran J, Phillips CO, et al. Discharge planning from hospital to home. Cochrane
Database Syst Rev. 2010;20;(1):CD000313.

4, Bauer M, Fitzgerald L, Haesler E, et al. Hospital discharge planning for frail older people and their
family. Are we delivering best practice? A review of the evidence. J Clin Nurs 2009; 18(18):2539–46

5, Scott, I.A. Preventing the rebound: Improving care transition in hospital discharge processes. Aust.
Health Rev. 2010, 34, 445–451. [CrossRef]

6, Department of Health &Human Resources USA Agency of health Care Research & quality
*www.ahrq.gov.t Advancing the Practice of Patient- and Family-Centered Care

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