Rapid improvement guide to improving weekend discharges

Despite increased focus on seven-day working and hospital discharge, weekend discharges from hospital are about 40% lower than weekday discharges. This contributes to the ‘Monday challenge’ of more demand but less inpatient bed capacity.

This simple, structured approach can help increase the weekend discharge rate:

Thursday – Think

• What did we learn? From the Monday audit and weekend plan about what we may need to do differently? What actions have been taken to make discharges easier this weekend?
• Effective use of expected date of discharge (EDD) Every patient's progress towards their EDD should be assessed and recorded every day at a board round, and reassessed during the ward round led by a senior clinical decision-maker with multidisciplinary team input.
• Criteria led discharge With clear plans (which include physiological, functional, and social criteria for discharge) documented in patient’s notes, experienced nurses and allied health professionals should be able to discharge appropriate patients. This brief guide can help teams develop criteria led discharge.
• Consider using the Inpatient Discharge Decision Support Tool You may find it useful to trigger a question about a patient's need to continue to stay in hospital and consideration of alternative ways of providing ongoing care for the patient after discharge.
• Forecast and communicate your demand through the emergency department is highly predictable. The rolling forecast available from bed meetings can be used to anticipate peaks and help you develop a workforce plan. This plan should be communicated to all clinical leaders and used to ensure senior decision-making capacity can meet the anticipated demand.

Friday – Finalise

• Develop weekend ‘potential discharge’ lists Ward-based teams should identify those patients who no longer meet criteria to reside (CtR) or who are waiting for a specific element of care; the inpatient discharge decision support tool can help with this. Targeted lists can focus the attention of teams working before and over the weekend to support these discharges.
• Take out drugs (TTAs/TTOs) and discharge letter Most TTAs/TTOs should be written up before or finalised during the board/ward round. Delays in writing TTAs/TTOs and discharge letters at weekends or batching these jobs (setting specific writing, collecting, portering or delivery times for all TTAs/TTOs) create a peak in demand that inevitably leads to delays. Involve pharmacy teams early to resolve the constraints delaying TTOs/TTAs in your hospital – the issues will be well-known to frontline clinical teams.
• Transport There is often a drop in the provision of transport at weekends. This can compound the weekend effect and contribute to an extended length of stay. Booking transport (if required) in advance can help. Site teams need to be made aware of any transport issues at the earliest opportunity.

Weekend – Work

• Discharge work needs to be urgent, not routine To make beds available over the weekend, hospital teams need to prioritise what will enable discharge, whether that is a scan, blood test or something else. Hospital managers should ensure arrangements and agreements are in place to prevent a patient’s slot for ‘inpatient investigations and tests’ does not change into an ‘outpatient slots’ when they are discharged. Therapy and equipment teams need to be able to provide discharge enabling interventions and equipment over the weekend.
• Seven-day working Often this is perceived as providing a level of ‘cover’ over seven days. However, maintaining care and flow over seven days requires a whole system approach to seven-day working. Issues such as limited access to blister packs, controlled drugs, shorter pharmacy opening times or reduced access to porters to take medications from the dispensary to the ward contribute to delayed discharges at weekends. Therapies need to be able to cover all discharge enabling interventions over the weekend. Similarly, reducing the same day emergency care (SDEC) capacity on a weekend could result in admitting more people who could have been supported at home.
• Safety netting Clinical teams should develop a safety netting mechanism to support discharge. This may take the form of a simple call back post-discharge to check a patient is recovering as expected or needs support from a community or third partner.

Monday – Monitor

• Monday audit What happened to the planned discharges? Why did they not happen? Track patient level issues and challenges and use simple techniques, such as the 5 Whys to gain greater understanding of the root-cause that needs attention. If the issues appear to be ‘system’ related community partners must be part of the problem-solving process.

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