Involves nursing actions to ensure coordination and continuity for patients transferring between care settings or levels.
Discharge Planning: Starts at admission when the care journey begins.
Person-Centred Care
Importance of understanding patients’ cultural beliefs and practices during admission, transfer, and discharge.
Admission assessments must identify relevant Social Determinants of Health (SDOH) and incorporate cultural beliefs.
Adapt communication strategies to meet cultural needs of patients for clarity and understanding.
Evidence-Informed Practice
Nurse to Nurse Hand-offs: Can create information gaps, omissions, and errors.
Effective Hand-offs: Improve communication of patient issues and risks.
Utilizing standardized hand-offs can reduce errors and enhance communication.
Medication Reconciliation: Essential for avoiding medication errors.
Review medications with the patient at admission to obtain the Best Possible Medication History (BPMH).
Safety Guidelines
Identification of Needs: Determine if patients have sensory or communication needs, and if they use assistive devices.
Discharge Needs Screen: Screen all patients on admission for potential discharge needs to ensure proper teaching.
Inclusion in Planning: Involve patients, families, and relevant healthcare professionals in the planning process to promote successful transitions.
Safety Guidelines Continued
Patient Background Consideration: Assess the patient’s background, health literacy, and capacity to understand instructions.
Care Coordination: Collaborate with healthcare providers to develop a discharge plan ensuring safe transitions home or to alternative facilities.
Resource Identification: Assist in identifying necessary resources as patients transition through the healthcare system.
Common Admission Procedures (Skill 2-1: Admitting Patients)
Placement: Determine appropriate receiving area for the patient.
Patient Rights Explanation: Provide information about patient rights and advance directives.
Orientation: Guide the patient on healthcare facility policies and procedures.
Needs Assessment: Assess healthcare problems and needs of the patient upon admission.
Preliminary Testing: Conduct necessary testing and screening specific to each facility and patient condition.
Individualized Plan of Care: Develop a personalized care plan post-assessment.
Insurance Verification: Determine the patient’s healthcare payment source.
Role of Admission Personnel
Professional Relationship: Initiate and maintain a courteous and professional relationship with patients.
Identification Band: Secure an identification band on the patient’s wrist containing full legal name, facility number, healthcare provider, and birth date.
Consent Form Instruction: Instruct the patient or guardian on reading the general consent form for treatment.
Canada’s Health Care System
Medicare: Refers to Canada’s publicly funded healthcare system.
Provincial/Territorial Plans: Canada has 13 plans managed by provincial and territorial governments responsible for healthcare service management, organization, and delivery.
Federal Government Responsibilities
National Standards: Set and administer through the Canada Health Act.
Funding Support: Provide financial support for provincial and territorial health care services.
Targeted Support: Support health service delivery for specific groups.
Health Functions: Oversee health-related functions like consumer product regulation, research, promotion, protection, disease monitoring, and prevention.
Canada Health Act
Legislation Overview: Outlines conditions provincial and territorial health insurance programs must meet for federal funding eligibility.
Five Pillars:
Public Administration: Health insurance plans must be publicly administered.
Comprehensiveness: Must cover all medically necessary services.
Universality: All residents must have access to the same medically necessary services.
Portability: Residents maintain coverage when moving between provinces.
Accessibility: The healthcare system must be accessible without financial or other barriers.
Patients’ Rights
Rights associated with health care:
Informed consent.
Recognition of a substitute decision maker.
Acknowledgment of advance care plans.
Right to a second opinion.
Confidentiality and privacy concerning personal health information.
Right to pain and symptom management.
Right to refuse treatment.
Request for assisted death.
Access to end-of-life care.
Provision for advance directives.
Involvement in organ procurement.
Advance Directives
Definition: A document outlining medical or non-medical treatment preferences for future care, or designating a decision-maker if capacity is lost.
Ensures the patient's medical care choices are respected when they cannot advocate for themselves.
A copy must be maintained in the patient's medical record.
Role of the Nurse (1 of 2)
Conduct a thorough nursing assessment upon admission.
Review any existing advance directives.
Ensure completion of necessary diagnostic testing.
Provide continuity of care throughout the transitional processes.
Role of the Nurse (2 of 2)
Same Day Admission:
Offer instructions regarding surgery/treatment purposes, preparatory steps, and post-care.
Patient Teaching: Utilize various educational methods like classes & calls home.
Emergency Department Admission:
Notify nursing division and report relevant admission information.
Collect information from ED nurses regarding the patient.
Quick Quiz (1 of 2)
Required items during admission:
General consent form for treatment
Patient’s rights
Advance directives
Health insurance options
Quick Quiz Answers (2 of 2)
Correct options:
General consent form for treatment
Patient's rights
Advance directives
Role of the Nurse
Coordinate the admission process comprehensively for all patients.
Assess the patient’s fatigue and comfort levels.
Understand the patient’s fears or concerns.
Assist the patient and family in adjusting to the healthcare environment.
Skill 2-1: Delegation and Collaboration
Nursing assessment during admission remains non-delegable to unregulated care providers (UCPs).
Task delegation for UCPs includes:
Preparing the patient’s room with necessary equipment.
Securing personal care items.
Escorting the patient and family to the nursing unit.
Skill 2-1: Recording and Reporting
Record history and assessment findings in an electronic medical record or relevant forms.
Include a copy of the advance directive in the medical record, if available.
Notify healthcare providers regarding patient arrival and report unusual findings.
Secure admission orders if not yet provided.
Skill 2-1: Special Considerations for Teaching
Communicate to patients that different nurses will care for them on shifts.
Engagement in teaching occurs throughout the admission process.
Pediatric Considerations: Explain rooming-in and visiting policies and encourage parental involvement.
Gerontological Considerations: Support interventions aimed at maintaining functional status and focus on fall prevention.
Transferring Patients (Skill 2-2)
Goals:
Ensure continuity of care and enhance transitions.
Prevent interruptions or omissions affecting care.
Initiate collaboration with an interdisciplinary team early.
Improve communication and meet safety goals.
Elements of Effective Hand-offs
Face-to-Face Communication: Preferred between team members for clarity.
Structured Written Forms: Use standardized forms that include minimum essential data.
Intent-Capturing Content: Include information that communicates the intent of care.
Utilize formats such as SBAR (Situation, Background, Assessment, Recommendation) or IPASS the BATON to ensure effective hand-offs.
Person-Centred Approach in Transferring Patients
Responsibility Continuity: Nurses must ensure care responsibility continues until a proper transition occurs.
Incorporate interprofessional collaboration for shared decision-making involving patients and caregivers.
Assess patient capacity and decision-making ability carefully.
Maintain open and honest dialogue about transition-related risks.
Skill 2-2: Delegation and Collaboration
Assessment and decision-making tasks during transfers cannot be delegated to UCPs.
Tasks UCPs can assist with:
Help the patient with dressing.
Gather and secure personal belongings and necessary equipment.
Escort the patient to the nursing unit or transport area.
Skill 2-2: Recording and Reporting
Sending Nurse Documentation:
Patient status
Nursing plan of care
Date and time of transfer
Method of transport
Receiving Nurse Documentation:
Record date and time of patient arrival.
Indicate reason for transfer and method of transport.
Document patient condition and care provided upon arrival.
Skill 2-2: Special Considerations in Teaching
Ensure patients can restate critical information during transfer.
Pediatric Considerations: Ensure parents are well-informed about expectations.
Gerontological Considerations: Guarantee accessibility to significant support individuals.
Long-term Care: Involve social workers or discharge planners during transfer.
Discharging Patients (Skill 2-3)
Proper planning is crucial for transitioning patients to the most independent care level.
Goals include providing appropriate levels and quality of care throughout illness stages.
Short hospital stays complicate discharge planning.
Effective discharge planning is linked to decreased readmission rates and increased patient satisfaction.
Identify appropriate discharge destinations based on patient needs.
Begin addressing pre- and post-discharge requirements early to ensure smooth transitions.
Discharge Process Stages
Acute Stage: Initial care upon admission.
Transitional Stage: Process of moving towards recovery and eventual discharge.
Continuing Care Stage: Ongoing management after discharge.
Primary challenge lies in communication; patients and families must understand home care management and expectations prior to discharge.
Skill 2-3: Delegation and Collaboration
Assessment, care planning, and educational instruction tasks required for discharging patients are non-delegable to UCPs.
Tasks UCPs may assist with:
Gathering and securing patient personal items.
Transporting patients to the discharge transport vehicle.
Skill 2-3: Recording and Reporting
Document patient discharge thoroughly using a discharge summary form.
Provide the patient with a signed copy of the discharge summary.
Document unresolved issues in the nurse's notes, detailing arrangements for resolution.
Record and document patient vital signs and status of health issues at the discharge time.
Skill 2-3: Special Considerations
Teaching Considerations: Evaluate patient pain and fatigue prior to instructional sessions.
Pediatrics: Involve family members in the child's care transition.
Geriatrics: Acknowledge older adults and families often overestimate their post-discharge care management capabilities.
Care in Community: Assess the primary caregiver's availability and skills, along with additional care resources that may be necessary.