I started working as a discharge registrar back in 2020. I noticed that my previous trust put these shifts out on the locum app I was a member of.
I took a few and really started enjoying it. The locum salary is on a NHS PAYE payslip with tax deducted at source ( like our main salaries). I do not need to fill any timesheets and it is all done via my phone app ( Patchwork - Healthcare Workforce Solution )
This is what I do:
1.Meet the discharge liason officer(DLO)/ discharge coordinator at 0800 AM who has a list of patients on various medical wards who are fit for discharge and have been flagged up by the nurses. The DLO comes at 0730 AM so she has a good 30 min to talk to nurses in charge of wards and make a list to get me going.
2. The DLO also goes through the electronic white boards which are have updates from Friday on patients who can potentially go home. They give me a list.
3.I start seeing those patients - it is like a mini ward round.
4. I start off with their OBS and bloods - as this helps me make a decision early.
5.I then examine them
6.I then document everything in a SBAR format
7. If they are frail, I ask our rapid access therapy team to see them - which includes a team of OT/PT who are available for ward reviews of patients who are fit for discharge.
8. I do their discharge summaries - medications and type in a narrative
9. The pharmacy team has my number so if there are any queries , they can contact me directly.
10. By 12 PM , I have been to all the medical wards and then go to the AMU - where I discharge at least 5 more patients. The reason I go to AMU later on is that the nurses there are very good at maintaining patient flow hence do not need a DLO ( who can now focus on the discharges from 0800 to 12 PM, arrange transport, etc) . They have already prepared a list of patients for me to see and I again, assess them, do the discharge summaries and then update the nurse in charge.
However, in your trust you might feel going to AMU first would help as patients who have already been post taked just need a quick senior review and can go home thereby creating capacity waiting in ED for medical beds.
11. By 1400, I have completed around 20 to 25 discharge summaries. All medications have been validated by pharmacy as well.
12. I then go to the bed managers office and have a meeting with the DLO, Bed manager and manager on call and we identify medically fit patients from my list who can go to rehabilitation beds, etc whilst awaiting discharge planning.
13. After this, I go help in ED - there are a few patients who have been post taked but are awaiting beds on the medical wards. I see if I could discharge any of these safely.
14. I go to ambulatory care unit to see if they need any help.
On a good day, I discharge at least 25 patients. On a bad day, it is around 10.
These are the patients that actually physically leave the hospital , thus freeing up beds and maintaining patient flow.
HOW I REIEW PATIENTS
It is like doing a ward round. I do a SBAR like
S (SITUATION): 65M, admitted 5 days ago with SOB
B ( BACKGROUND): COPD, IHD, T2DM
A ( ASSESSMENT): Events since admission:
ABG: pH: 7.40, pco2: 6.5 PO2: 10 , HCO3: 30
CRP: 5, Hb 130, WCC: 8, PLT: 300 , Urea: 4, Cr: 60, K: 4.0 , Na: 135
CXR: hyper-expanded
Flu, COVID -
Wheeze on admission
Rx for IE of COPD
Seen by RSN ( Respiratory specialist nurses) - for O/P F/U, good inhaler technique
PRN nebs - last taken 24 hours ago
O/E: GCS 15/15
Chest clear,
Feels well, mobilizing independently, keen to go home
R ( RECOMMENDATION/PLAN):
Home today
discharge summary done
RSN F/U as O/P
I will complete the medications for discharge , do a quick discharge summary and tick it off.
NURSE LED DISCHARGE:
If let's say they are on oxygen ( and are not on LTOT at home):
A patient on 1 L of O2, SO2: 92% , known COPD with T2RF, admitted with IE of COPD, on oral ABx and PRN nebs. Not required any nebs since 24 hours. In this case, I will ask the nurse to remove the oxygen and I will quickly examine them - if they are fine, speaking full sentences and if they maintain their target SO2 a few hours later after removing their oxygen, can mobilize and still maintain their target SO2, they can go home.
This can be a nurse led discharge
So I will do their medications and discharge summary and update the electronic board:
' If mobilizing, SO2 between 88-92% at 1300, home '
Hence the nurses can discharge the patient
I will clearly document this in the notes, inform the nurse in charge of the patient and the ward in charge nurse along with the DLO.
OTHER EXAMPLES OF NURSE LED DISCHARGES:
1. Bloods
If Potassium less than ****, can go home
If CRP<100, can go home
2. If TWOC ( trial without catheter) successful , can go home. If unsuccessful, and in retention, re-catheterize and for TWOC clinic in 2 weeks
3. If opened bowels, can go home
In all these cases, I always come back to ensure that this plan is enacted upon. As it can get busy onthe ward, especially with minimal staffing. The bed managers also facilitate this when I meet them at 1400 as they can call the ward and find out.
UNWELL PATIENTS
But if they are a CAP, on 4 L of O2, no background of any lung pathology, bloods from last night show a CRP of 450 - it is unlikely they will be fit to go home. So I would request bloods for them for the next day and update the board ' if CRP<100, off O2 and able to mobilize'
Now they are not going home today. Hence there is no point of me doing the discharge summary. They will need a proper review the following day.
Hence in such cases, I document:
ATSP (asked to see patient) re discharge
On O2 ( new), CRP 450 yesterday at 2000
Rx for CAP - IV Abx
NOT MFFD ( medically fit for discharge)
Plan:
Bloods tomorrow
Senior review if CRP<100, off O2 and able to mobilize with Target SO2>94%
WHY I PREFER DOING MY OWN DISCHARGE SUMMARIES
When I was a 'baby' SHO, I absolutely hated it when the registrar would see the patient, leave it to the SHO to do the discharge summary and there were loads of questions from us - like whether to start certain suspended drugs, etc.
So I promised myself that I would do my own discharges when I become a reg - I started my ST3 tarining in 2019 and since then, I have always done my own discharge summaries for the following reasons:
I already know the patient and have assessed them. it will take me a minute to type in the narrative.
I would review the medications anyway - so while I am doing that, I would transfer them to the discharge medications list ( it is very easy in the trust I work in) which takes maximum 1 minute - This way, I would address any medication omissions
Since I have deemed the patient fit for discharge , I would know everything about the medications. Hence the pharmacists can call me directly and ask me any questions.
It takes me less than 2 minutes to do the discharge summaries. I have been doing these for 4 years now ( I started my ST3 training in 2019)
FINANCIAL BENEFIT
It costs around 400 GBP per patient per night in a NHS bed ( figures taken from various managers and websites, depends a lot on what care the patients need- can be as low as 200 and as high as 500)
So if I discharge 15 patients ( my average on a single day over a weekend ), I save the trust around 7,000 GBP per night for a discharge reg shift I do on a single day. If I work 2 days, it is 14,000 GBP.
Unfortunately, I am not paid according to the number of discharges I do. But it helps the trust as they do not need to pay a consultant to do this.
I however, find these shifts very rewarding as I get to send people home and the smile they give to me when I inform them they can go home ( of course - I would not say this if they are awaiting OT/PT as they may not be discharged the same day) makes it all worth it.
As I do my own discharge summaries, I do not need a FY1/SHO to scribe/type on my behalf.
MY FINANCIAL BENEFIT
I am paid locum salary for this - the reg rates can vary from 70 to 90 GBP an hour or even go upto 100/hr. So even if the trust pays me 1300 GBP for a whole shift , they still save money.
MY TRAINING
I am an acute internal medical registrar in my ST6 year ( at the time if writing this). This is part of my training - ie to identify patients who can go home and facilitate discharges.
I work closely with DLOs, bed managers and managers on call and I really enjoy this role of improving patient flow.
MY IDEA OF IMPROVING PATIENT FLOW IN ALL NHS TRUSTS
Hire more discharge registrars - put these shifts out as locum and if the rate is good ( I feel us registrars deserve at least 70 GBP an hour, escalated to 100/hr for last minute shifts ), people will take these shifts.
WHEN I DELAY DISCHARGES
Gut feeling - sometimes, I have a bad feeling about a patient. An example - A patient admitted with pericardial effusion, drained, ? home today as drain removed 36 hours ago and bedside ECHO 24 hours ago showed no residual fluid. However they have gone into AF with fast ventricular response just 2 hours ago, now controlled by beta blocker.
They later developed a HAP with high CRP, WCC and were requiring O2.
Nurses - if a nurse looking after a patient does not think a patient can go home, do not try to discharge them. The nurses know the patient the best. An example - a patient had a fall overnight. X ray- no fracture but have a prosthesis. Still in pain but controlled with strong analgesia. CT confirmed peri-prosthetic fracture.
Patient choice - a known COPD, who comes in every month knows herself the best. If she says that she feels breathless and is needing more of her PRN inhalor and does not feel ready to go home , it is reasonable to keep her for another night - most times, these patients with chronic conditions know themselves.
DELAYS IN DISCHARGE NOT IN MY CONTROL
You might do 40 discharge summaries but find only 20 patients have actually left the building.
Other delays include:
Care home cannot take the patient over the weekend - the on call manager can help when I meet them at 1400
The patient is COVID +, but asymptomatic so care home cannot accept - in some cases, they have side rooms and some have this facility which on call managers can help with
The family is unable to look after the patient - hence they may need rehab/respite/etc - this can take days!
These can be frustrating but I try not to bypass these delays and can only escalate to the on call manager. They do help as much as they can.
HOW IMPORTANT THIS IS
I feel every trust should have discharge registrars over the weekend. They should be paid locum so that registrars are motivated to do these shifts.
It makes a massive improvement for patient flow and the trust also benefits financially.
I took a few and really started enjoying it. The locum salary is on a NHS PAYE payslip with tax deducted at source ( like our main salaries). I do not need to fill any timesheets and it is all done via my phone app ( Patchwork - Healthcare Workforce Solution )
This is what I do:
1.Meet the discharge liason officer(DLO)/ discharge coordinator at 0800 AM who has a list of patients on various medical wards who are fit for discharge and have been flagged up by the nurses. The DLO comes at 0730 AM so she has a good 30 min to talk to nurses in charge of wards and make a list to get me going.
2. The DLO also goes through the electronic white boards which are have updates from Friday on patients who can potentially go home. They give me a list.
3.I start seeing those patients - it is like a mini ward round.
4. I start off with their OBS and bloods - as this helps me make a decision early.
5.I then examine them
6.I then document everything in a SBAR format
7. If they are frail, I ask our rapid access therapy team to see them - which includes a team of OT/PT who are available for ward reviews of patients who are fit for discharge.
8. I do their discharge summaries - medications and type in a narrative
9. The pharmacy team has my number so if there are any queries , they can contact me directly.
10. By 12 PM , I have been to all the medical wards and then go to the AMU - where I discharge at least 5 more patients. The reason I go to AMU later on is that the nurses there are very good at maintaining patient flow hence do not need a DLO ( who can now focus on the discharges from 0800 to 12 PM, arrange transport, etc) . They have already prepared a list of patients for me to see and I again, assess them, do the discharge summaries and then update the nurse in charge.
However, in your trust you might feel going to AMU first would help as patients who have already been post taked just need a quick senior review and can go home thereby creating capacity waiting in ED for medical beds.
11. By 1400, I have completed around 20 to 25 discharge summaries. All medications have been validated by pharmacy as well.
12. I then go to the bed managers office and have a meeting with the DLO, Bed manager and manager on call and we identify medically fit patients from my list who can go to rehabilitation beds, etc whilst awaiting discharge planning.
13. After this, I go help in ED - there are a few patients who have been post taked but are awaiting beds on the medical wards. I see if I could discharge any of these safely.
14. I go to ambulatory care unit to see if they need any help.
On a good day, I discharge at least 25 patients. On a bad day, it is around 10.
These are the patients that actually physically leave the hospital , thus freeing up beds and maintaining patient flow.
HOW I REIEW PATIENTS
It is like doing a ward round. I do a SBAR like
S (SITUATION): 65M, admitted 5 days ago with SOB
B ( BACKGROUND): COPD, IHD, T2DM
A ( ASSESSMENT): Events since admission:
ABG: pH: 7.40, pco2: 6.5 PO2: 10 , HCO3: 30
CRP: 5, Hb 130, WCC: 8, PLT: 300 , Urea: 4, Cr: 60, K: 4.0 , Na: 135
CXR: hyper-expanded
Flu, COVID -
Wheeze on admission
Rx for IE of COPD
Seen by RSN ( Respiratory specialist nurses) - for O/P F/U, good inhaler technique
PRN nebs - last taken 24 hours ago
O/E: GCS 15/15
Chest clear,
Feels well, mobilizing independently, keen to go home
R ( RECOMMENDATION/PLAN):
Home today
discharge summary done
RSN F/U as O/P
I will complete the medications for discharge , do a quick discharge summary and tick it off.
NURSE LED DISCHARGE:
If let's say they are on oxygen ( and are not on LTOT at home):
A patient on 1 L of O2, SO2: 92% , known COPD with T2RF, admitted with IE of COPD, on oral ABx and PRN nebs. Not required any nebs since 24 hours. In this case, I will ask the nurse to remove the oxygen and I will quickly examine them - if they are fine, speaking full sentences and if they maintain their target SO2 a few hours later after removing their oxygen, can mobilize and still maintain their target SO2, they can go home.
This can be a nurse led discharge
So I will do their medications and discharge summary and update the electronic board:
' If mobilizing, SO2 between 88-92% at 1300, home '
Hence the nurses can discharge the patient
I will clearly document this in the notes, inform the nurse in charge of the patient and the ward in charge nurse along with the DLO.
OTHER EXAMPLES OF NURSE LED DISCHARGES:
1. Bloods
If Potassium less than ****, can go home
If CRP<100, can go home
2. If TWOC ( trial without catheter) successful , can go home. If unsuccessful, and in retention, re-catheterize and for TWOC clinic in 2 weeks
3. If opened bowels, can go home
In all these cases, I always come back to ensure that this plan is enacted upon. As it can get busy onthe ward, especially with minimal staffing. The bed managers also facilitate this when I meet them at 1400 as they can call the ward and find out.
UNWELL PATIENTS
But if they are a CAP, on 4 L of O2, no background of any lung pathology, bloods from last night show a CRP of 450 - it is unlikely they will be fit to go home. So I would request bloods for them for the next day and update the board ' if CRP<100, off O2 and able to mobilize'
Now they are not going home today. Hence there is no point of me doing the discharge summary. They will need a proper review the following day.
Hence in such cases, I document:
ATSP (asked to see patient) re discharge
On O2 ( new), CRP 450 yesterday at 2000
Rx for CAP - IV Abx
NOT MFFD ( medically fit for discharge)
Plan:
Bloods tomorrow
Senior review if CRP<100, off O2 and able to mobilize with Target SO2>94%
WHY I PREFER DOING MY OWN DISCHARGE SUMMARIES
When I was a 'baby' SHO, I absolutely hated it when the registrar would see the patient, leave it to the SHO to do the discharge summary and there were loads of questions from us - like whether to start certain suspended drugs, etc.
So I promised myself that I would do my own discharges when I become a reg - I started my ST3 tarining in 2019 and since then, I have always done my own discharge summaries for the following reasons:
I already know the patient and have assessed them. it will take me a minute to type in the narrative.
I would review the medications anyway - so while I am doing that, I would transfer them to the discharge medications list ( it is very easy in the trust I work in) which takes maximum 1 minute - This way, I would address any medication omissions
Since I have deemed the patient fit for discharge , I would know everything about the medications. Hence the pharmacists can call me directly and ask me any questions.
It takes me less than 2 minutes to do the discharge summaries. I have been doing these for 4 years now ( I started my ST3 training in 2019)
FINANCIAL BENEFIT
It costs around 400 GBP per patient per night in a NHS bed ( figures taken from various managers and websites, depends a lot on what care the patients need- can be as low as 200 and as high as 500)
So if I discharge 15 patients ( my average on a single day over a weekend ), I save the trust around 7,000 GBP per night for a discharge reg shift I do on a single day. If I work 2 days, it is 14,000 GBP.
Unfortunately, I am not paid according to the number of discharges I do. But it helps the trust as they do not need to pay a consultant to do this.
I however, find these shifts very rewarding as I get to send people home and the smile they give to me when I inform them they can go home ( of course - I would not say this if they are awaiting OT/PT as they may not be discharged the same day) makes it all worth it.
As I do my own discharge summaries, I do not need a FY1/SHO to scribe/type on my behalf.
MY FINANCIAL BENEFIT
I am paid locum salary for this - the reg rates can vary from 70 to 90 GBP an hour or even go upto 100/hr. So even if the trust pays me 1300 GBP for a whole shift , they still save money.
MY TRAINING
I am an acute internal medical registrar in my ST6 year ( at the time if writing this). This is part of my training - ie to identify patients who can go home and facilitate discharges.
I work closely with DLOs, bed managers and managers on call and I really enjoy this role of improving patient flow.
MY IDEA OF IMPROVING PATIENT FLOW IN ALL NHS TRUSTS
Hire more discharge registrars - put these shifts out as locum and if the rate is good ( I feel us registrars deserve at least 70 GBP an hour, escalated to 100/hr for last minute shifts ), people will take these shifts.
WHEN I DELAY DISCHARGES
Gut feeling - sometimes, I have a bad feeling about a patient. An example - A patient admitted with pericardial effusion, drained, ? home today as drain removed 36 hours ago and bedside ECHO 24 hours ago showed no residual fluid. However they have gone into AF with fast ventricular response just 2 hours ago, now controlled by beta blocker.
They later developed a HAP with high CRP, WCC and were requiring O2.
Nurses - if a nurse looking after a patient does not think a patient can go home, do not try to discharge them. The nurses know the patient the best. An example - a patient had a fall overnight. X ray- no fracture but have a prosthesis. Still in pain but controlled with strong analgesia. CT confirmed peri-prosthetic fracture.
Now I could have discharged this patient on high dose codeine but that is very risky. Luckily, I locum in trusts where I have a very good relationship with my nurse colleagues and I trust their judgement. As a registrar, I have learnt that they do know their patients better than anyone else.
Patient choice - a known COPD, who comes in every month knows herself the best. If she says that she feels breathless and is needing more of her PRN inhalor and does not feel ready to go home , it is reasonable to keep her for another night - most times, these patients with chronic conditions know themselves.
DELAYS IN DISCHARGE NOT IN MY CONTROL
You might do 40 discharge summaries but find only 20 patients have actually left the building.
Frail patients with social needs
The discharge process is a bit more complicated for frail patients.
For example a medically fit frail patient will
Be assessed by the PT/OT team
Then they will call the next of kin ( NOK) and see if they are okay
Ensure the patient can get into the house
For example a medically fit frail patient will
Be assessed by the PT/OT team
Then they will call the next of kin ( NOK) and see if they are okay
Ensure the patient can get into the house
Other delays include:
Care home cannot take the patient over the weekend - the on call manager can help when I meet them at 1400
The patient is COVID +, but asymptomatic so care home cannot accept - in some cases, they have side rooms and some have this facility which on call managers can help with
The family is unable to look after the patient - hence they may need rehab/respite/etc - this can take days!
These can be frustrating but I try not to bypass these delays and can only escalate to the on call manager. They do help as much as they can.
HOW IMPORTANT THIS IS
I feel every trust should have discharge registrars over the weekend. They should be paid locum so that registrars are motivated to do these shifts.
It makes a massive improvement for patient flow and the trust also benefits financially.
HOW TO ESTABLISH THIS IN YOUR TRUST
I have trialled it in the trust I am currently based at. I approached the directors about this and showed examples of how many discharges I had as a discharge registrar. They agreed to trial it and kept a log of patients discharged by me - So far, my average number of discharged patients has been around 20 per shift - hence I have saved the trust around 8,000 GBP per night. They are quite keen to continue this and are liaising with therapists to have a dedicated team with me to help improve patient flow further.
I will be publishing some official statistics soon as I feel this should be adopted nationally , unless your trust has something better ( feel free to comment below if you do have any suggestions).
SAFETY FIRST!
It is important to be a safe doctor at all times. No matter how busy it is, you should not make any unsafe decisions. There is always a medical consultant available in case you want a second opinion so do not take any risks which you might regret later on. As at the end of the day, you are the doctor who has signed off a patient to go home.
I will be publishing some official statistics soon as I feel this should be adopted nationally , unless your trust has something better ( feel free to comment below if you do have any suggestions).
SAFETY FIRST!
It is important to be a safe doctor at all times. No matter how busy it is, you should not make any unsafe decisions. There is always a medical consultant available in case you want a second opinion so do not take any risks which you might regret later on. As at the end of the day, you are the doctor who has signed off a patient to go home.
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