Principle 4: Embed multidisciplinary team reviews

Organisations should ensure they have adequate discharge services, seven days a week.

All patients’ physical and mental health status, medication needs, nutrition and hydration status, and limited functional assessments should take place in the acute setting.  This information is shared with the multidisciplinary team who will describe the support the patient requires once they are discharged or transferred. The following steps will ensure the best outcomes:

  • Carry out multidisciplinary reviews of all patients twice a day
  • Make sure all patients have a board round every day
  • Hold reviews as often as necessary, ensuring outstanding actions for the day are completed and results of requested investigations are actioned

You should be aiming to:

  • Review the patient’s functional and physiological status
  • Identify a plan for the patient including a discussion around all possible discharge options
  • Establish what the patient is waiting for
  • Work out how any constraints or barriers can be removed.

The outcomes of the multidisciplinary meeting should be shared with patients and their families or carers.

There should be an effective escalation process to ensure constraints causing unnecessary patient waiting are removed. Following confirmation of a medical decision to discharge, transfers from the ward or unit to the designated discharge area should happen promptly. This should be within one hour of that decision for patients on Pathway 0, and the same day for people on all other pathways. Discharge from the discharge area should happen as soon as it is possible and safe – often within two hours, or on the same day (preferably before 5pm).

The systematic use of weekly long-stay patient reviews can reduce the number of in-patients with a LOS exceeding 20 days by up to 50%.

These reviews introduce supportive challenge and help ward multidisciplinary teams consider criteria led discharge for patients who no longer meet the criteria to reside. Any member of the multidisciplinary team (e.g. junior doctor, nurse or allied health professional), can enact without the need of a consultant but arrangements should be in place to contact them if needed.

The review should be carried out on the ward, led by a senior member of staff. Any assessment of short and long-term needs should happen in the community via the ‘Discharge to Assess’ model. There should be a case manager assigned to each system to facilitate timely discharge.

Reviews should capture both qualitative and quantitative information on the reasons for the wait, with a report compiled from all the material gathered. They should aim to identify:

  • Why patients are in hospital for seven days or more
  • Recurring themes (and where possible, patient characteristics) so patient groups can be identified earlier in the future, and the chance of an extended stay is reduced
  • Areas of good practice
  • Areas with the opportunity for improvement

The outcomes from the report should be used to ensure that lessons learnt or questions still to be answered can be built into internal actions and local system action plans.

We need to identify the reasons behind stays of seven days or more and the actions which can be taken to avoid delays. By doing so, we can help significantly reduce deconditioning and second and third phase illnesses.

Links to further resources