Consider how the communication needs of the child and mother in the scenario could have been met more effectively.

• List three things that mum and child found positive about the discharge

Answer:

1. The family were taken into a private room to discuss the discharge
2. The nurse was kind, she reassured the child and was very sensitive towards him
3. They were given written contact details for support when they left hospital

• Could anything have been done differently to ensure the discharge was more effective?

Answer:

1. The discharge should have been planned from the pre-op stage
2. Mum should have been prepared for length of surgery and the expected recovery time and process
3. Mum should have been supported through process while child was in surgery – the nurse could have spoken honestly with mum at this stage regarding any pain her child may experience post surgery
4. Structured support could have been put in place as parents are often anxious regarding the surgical procedure and taking their child home post surgery
5. Continuity of care: having the same nurse from admission to discharge helps the child and family to build a therapeutic relationship with the nurse
6. Provision of detailed specific information on the different pain medication and its administration post surgery to provide optimum pain relief. Information on other techniques which could be used to relieve pain
7. The nurse could have provided time to speak to mum without Ross being present before discharge to enable mum to raise worries and concerns that she may not have felt comfortable raising in the presence of her child
8. Written discharge information should have been available both adult and child friendly.

Brenner et al. (2015) interviewed parents who had to become the primary care giver when their child was discharged home. They expressed frustration at the time it took to get everything ready for discharge, they were fearful of the levels of competence in community services and worried how they were going to cope in the future. While all of the parents interviewed spoke of the value of the staged process to going home, they collectively identified themselves as overwhelmed when they were eventually dis­charged from hospital. Parents stated that they were often ‘petrified’ or ‘terrified’ in their initial days at home despite their perceived clinical readiness and sense of empowerment while in the hospital.

Parents also spoke about ‘stepping stones’, whereby they had a phased discharge home, with the parent taking increased responsibility of care as the process rolled out.

• Why might the parents have valued a stepping stones approach?

Answer:

1. Stepping stones to home included phased responsibility for care. Parents valued the experience of being able to take their child home for a few hours or overnight
2. This is because they became aware of the level of organisation and management of care delivery that would be required for their child on eventual discharge
3. Parents found this stepping stone approach enabled them to identify knowledge or skill gaps and then focus on developing their capability ready for the next visit home

‘I can’t wait to get home. This is a recurrent theme in my head from the moment we are en route to hospital, never mind the weeks that my daughter is an inpatient.

She’s doing great so we are stepping down from PICU to a ward. She’s doing great, but we can’t get a transfer back to our local hospital because she is still on oxygen. She will require a drizzle of oxygen for about a month after this infection. It’s how she rolls. The healthcare staff would have known that if they had spoken to me. We have oxygen at home and portable oxygen for car journeys. There appears to be a disconnect between the opinions of the staff on the ward and the consultant, whom I have never met.

Then I get the news I’m waiting for: if she does well tonight we get home tomorrow. She does well. In the morning we wait, and wait, for rounds. After lunch, we get to speak to a doctor. It now transpires that we can’t go home because she’s still on oxygen. After a long discussion we get to go back to our local district general hospital. We stay overnight and they have a much smoother final discharge for us. Yes, we are going home on a drizzle of oxygen. Yes, we have supplies of medicines which we require for home. Yes, I’m confident that we are making the correct and safe choice for my daughter.’

How could discharge have been smoother? Mum’s view:

• Anticipate discharge: you know that you will need supplies of regular medication for discharge so order them up at least 24 hours in advance so that they are ready for discharge
• Manage my expectations: give me a clear and concise plan of what is going to happen and when
• Ask me questions: if you had spoken to me at all about how we manage my daughter at home you would have known that she is on oxygen at night, but that she habitually requires a ‘drizzle’ of oxygen (low flow oxygen) in the daytime for weeks after a bad respiratory virus
• I know my daughter: please listen to what I have to say about her day to day care
• Continuity is important: make sure each health professional has the same opinion before speaking with parents/child
• A multidisciplinary (MDT) meeting is important: it would have been easier to assess my daughter’s health progress if she wasn’t admitted as an unknown entity; don’t discharge her like one either
• It is important to be honest and open with parent/ child: after a long period of having my daughter as an inpatient I am getting less sleep, feeling more exhausted, more worried and less tolerant. Do me the courtesy of paying attention to the little things
• Update relevant professionals of changes to care needs: one recurrent problem that we have is that my daughter’s medicines change by weight or by condition. If you are discharging a patient with complex care needs, it would help to give the patient/parent an updated medicine/dosage list detailing changes to hand in to their GP on discharge. Often when we order new supplies from our GP the latest dosage has not been communicated. I can medicate as per the updated dosage at home. I know it is not 1.8ml but 2ml, as instructed by the doctor during the admission. The problem comes when we have home nursing, or when we have a hospice stay or are admitted again.

• After reading this mother’s account, what should/could the staff have done to better facilitate her daughter’s discharge?

Answer:

1. To ensure a timely and effective discharge the planning for the child’s discharge should have started on admission to hospital
2. A through assessment of the child and family should have been undertaken to meet their individual needs
3. A discharge planning meeting with the multidisciplinary team and mum would have enabled the development of a robust discharge plan with clear and concise goals, and a timeframe for discharge.  This would have enabled mum to understand the discharge process and giving timeframes may have relieved some of mum’s anxieties and help build confidence in the team
4. Mum should have been given the opportunity to meet with the consultant to discuss the care of her child 
5. Communication is central to this process to ensure that mum is fully informed and has the opportunity to discuss any concerns with the team. Open communication between the child, family and healthcare professionals is a crucial component of safe effective discharge planning.  Effective communication helps to reassure parents, avoid confusion and reduces parental anxieties.  It also helps to empower the family to build their confidence and help them make informed decisions

• How can we ensure that the multidisciplinary teams work in partnership with the mother on the detail of the discharge plan?

Answer:

1. The child and family need to be actively engaged and fully involved in the discharge process; they should be partners in care and are crucial members of the multidisciplinary team
2. A parent needs to be supported and enabled to participate in multidisciplinary team meetings; if required, an advocate should be identified to aid in this process
3. The majority of parents of children with complex health needs are experts in their child’s needs. Respecting parents’ unique knowledge and experience is crucial in the discharge planning process. In this case a multidisciplinary meeting would also have enabled mum to share her expertise with the team
4. From the case presentation, it is clear that mum felt there was disconnection between the consultant and the ward staff which raised her anxieties and did not promote confidence in the decisions being made for her child. It is essential that the multidisciplinary work effectively as a team for families to have confidence in their decisions
5. When discharge is planned in partnership with the child and family, and commenced on admission, parents experience less stress and anxiety. This also helps foster continuity of care and builds a continuing collaborative relationship

• What aspects of the discharge process could have been anticipated and arranged prior to the day of discharge?

Answer:

1. The application of systematic processes and communication systems spanning the child, family and the professionals involved in the child care is essential to ensure safe and effective discharge
2. The use of discharge policies, procedures and pathways can help structure the process of discharge planning. They can assist in the implementation of timeframes, i.e. at what point or when crucial decisions should be reached and how these are communicated to the child/family/multidisciplinary/multiagency team.
3. Discharge checklist or summary can be used to collate key information record outstanding tasks
4. Using estimated dates of discharge can help to co-ordinate discharge plan and crucial discharge planning activities 
5. The use of a single shared record assists in communication and co-ordination
6. For children with complex care or social needs a key worker can ensure that the family are kept fully informed and are partners in any decisions and actions. The key worker will liaise with other professionals in the multidisciplinary team to ensure that the family are being fully supported. The key worker can act as an advocate for the child and family ensuring that the family’s concerns and anxieties are being addressed and the family’s voice is being heard 
7. Assign a discharge co-ordinator

Sarah was antenatally diagnosed with a complex heart condition: tetralogy of Fallot. Following delivery, she was admitted to the neonatal unit for observation. She was clinically well and, following a review by the cardiology team, it was decided that she could be cared for on the transitional care unit. This unit provides care for neonates who are essentially well but have additional care needs met by a team of nursery nurses and require ongoing monitoring by neonatal medical staff. Sarah required daily blood pressures and intermittent oxygen saturation monitoring due to her heart condition. She also needed to establish breast feeding. She was transferred to the unit by a neonatal nurse who gave a verbal handover. Written discharge letters were also given to these members of staff. The medical discharge letter did not contain a clear plan for the baby as it was assumed that the following day a member of the medical team would review Sarah. During the following shift, the nursery nurses caring for Sarah expressed concern about the appropriateness of her transfer. They were anxious about her heart condition and doubted their ability to manage her care in a safe manner. Sarah was readmitted to the neonatal unit for ongoing care.

• What assumptions were made about the transfer and how did they contribute to the nursery nurses’ anxiety?

Answer: Sarah had been antenatally diagnosed with a complex congenital heart defect but was essentially well. It is common that infants with this condition who are well can be cared for at home until they are older when they return to the hospital for corrective surgery. Transferring Sarah to the transitional care unit for observation would enable the medical team to gain reassurance that she will remain well enough for discharge home and give the family the opportunity to gain confidence in caring for her within a safe environment. Establishing breast feeding within this environment – where baby and mother can be together – has proven to be much more successful than when babies are on the neonatal unit. This has additional health benefits for Sarah.

• How could this have been avoided?

Answer: The assumption that nursery nursing staff would be comfortable with caring for a child with a ‘complex congenital heart condition’ was made. As Sarah was well it was assumed that everyone would have a good understanding and be reassured that her condition would not compromise her health. It was assumed that staff would be happy to await further instructions from the medical team as required.

In reality, staff were not comfortable with caring for Sarah as they did not have enough knowledge to understand her diagnosis and the potential implications for their practice.

Subsequent to this, comprehensive teaching about congenital heart defects and care of infants with such diagnoses has been provided for staff on the transitional care unit. In addition to this, the need for clear plans within discharge letters has also been emphasised.

• What impact do you think readmission to the neonatal unit had on the family?

Answer: The family may have been given the impression that care provided was inadequate. The majority of hospital complaints stem from poor communication and this incident is a clear example of this. At no time was Sarah put in an unsafe position and the care provided was appropriate. However, the staff anxiety would not have helped build confidence and trust between the family and healthcare professionals caring for Sarah