Targeted discharge planning for stroke patients became regular practice after study showing it reduced number of days in hospital.
“We needed a solution to better target length of stay,” says Cindy Chan, occupational therapist and principal investigator for the targeted discharge planning study. “Targets should be specific and reflect functional needs of each patient.”It used to be that the Fraser Health Rehabilitation Program would estimate a stroke patient’s length of stay in hospital by using generic ranges such as two to four weeks or four to six weeks. This was difficult for health care workers who were trying to plan and prioritize next steps in care and for patients and families who needed to plan next steps for when the patient was ready to return to the community. These kinds of generic averages also provided leaders and staff with vague targets for program planning and evaluation.
Rehab Program leadership routinely look for solutions to this challenge as well as ideas to reduce the number of days a stroke patient needs to stay in one of two High Intensity Rehab units at Surrey Memorial and Eagle Ridge hospitals. A shorter stay in one of the 46 beds means a patient is ready sooner to return to the community and begin any community-based rehab they may require. It also means savings for the health system of at least $1000 per day per bed, which can then go toward treating new stroke patients.
A key step toward progress took place a few years ago when Rehabilitation Program Medical Director, Dr. Andrew Dawson, went to the Canadian Stroke Congress and brought back the idea of targeted discharge planning presented by St. Joseph’s Hospital of London, Ontario. “Dr. Dawson thought it was a great idea and looked into how we could make it happen,” says Cindy.
Because Rehab Program leadership had already been looking for solutions, they approved funding for a year-long study. The study of over 200 stroke patients was conducted by Cindy and a team of nurses, occupational therapists, physiotherapists and doctors from spring 2014 through spring 2015 at both Surrey Memorial and Eagle Ridge hospitals. A multi-disciplinary team was involved in the study so multiple perspectives in post-stroke care would be included.
Study results showed that using targeted discharge planning, including identifying a targeted discharge date within the first week of stay, reduced the length of stay by an average of 4.5 days and up to 9 days. This was compared to a similar study group the year prior who were given generic estimates of their length of stay.
The targeted discharge planning process involves a mix of patient-specific health data, clinician change champions, and patient and family education. Timelines for targeted discharge dates take into account historical data of similar patients as well as measures of the patient’s functional independence when they first arrive in hospital. Staff report results to the Canadian Institute for Health Information’s National Rehabilitation Reporting system that helps inform subsequent targeted discharge dates.
The new process also allows for flexibility so a targeted discharge date can be adjusted throughout a patient’s stay depending on their progress and the judgement of the clinicians who are caring for the patient. “Evidence-informed in this case isn’t only based on research and data, but also includes the patient’s needs and clinician judgement,” says Cindy.
Based on the study results, it was an easy decision for the Rehab Program senior leadership to approve the continuation of targeted discharge planning as standard practice in the High Intensity Rehab units. “The process flowed from study to practice,” says Cindy. “Because we’re a regional program, the study was conducted at both hospitals, so leaders and staff for both units were already on board and familiar with the process.”
As part of the ongoing implementation of targeted discharge planning, regular evaluations take place to address any problems. For example, these check-ins have helped identify ways staff can work to determine a targeted discharge date within days of a patient’s arrival in hospital. They’ve also helped identify that excellent communication is key to everyone understanding the process and having a more positive experience.
With a successful implementation in place for stroke patients, Cindy notes there’s an eye on expansion: “The wish is to be able to do this for all inpatient Rehab units – covering more than 120 additional beds – once a similar infrastructure can be put into place.”
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