Modernization of Discharge Planning in Princess Margaret Hospital (PMH)

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Abstract Summary
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Authors (including presenting author) :
Li KY(1), Chan WMM(1), Heung LW(1), Chan CS(2), Lai PY(2), Wong YF(1), Yip TH(1), Wong SP(1), Tsing WL(1), Chick YL(1), Suen D(1), Chung SC(1), Lee WY(1), Leung SS(1)
Affiliation :
(1)Community Nursing Service, Princess Margaret Hospital (2)Information Technology, Princess Margaret Hospital
Introduction :
Discharge planning is a process that begins with a patient’s admission and continues throughout the patient’s stay till discharge. Currently, there is no corporate-wide electronic system to support end-to-end workflow for discharge planning and service request on community care. To make discharge planning more robust and responsive to patient needs, PMH Community Nursing Service (CNS) initiated an electronic workflow interlacing the discharge planning process and care transitions into the Daily Patient Care Plan through Patient Clinical Hand-Over System (PCHOS).
Objectives :
1.To provide timely post-discharge support services; 2.To save administrative efforts and workload in daily patient care and liaison duties; 3.To promote better patient outcomes and discharge experience
Methodology :
Electronic referral system for post-discharge community care services, being jointly developed with PMH Information Technology department, was commenced in mid-August 2018. The initiation was to transform a series of discharge planning processes from paper-based to electronic ones. Based on the Out-Patient Appointment System, referral creation is automated once admission of active case under community care service is detected. The automation enables nurses using PCHOS to recognize the previous care needs of patient before admission, complement nursing assessment on admission and review possible change of care needs. In creating new referrals, nurses merely one-click-to-refer for CNS in PCHOS. Arrangement across teams is communicated by email notification and the system for new referral and actual discharge from hospital. In view of managerial use, the system generates reports that allow nurses to analyse the patient referral network and audit changes or discrepancies throughout the whole process.
Result & Outcome :
From mid of August to February 2019, total 6,390 referrals received, an average of 1,000 referrals was created every month via PCHOS for post-discharge support services. There was no loss of service request by cause of fax chaos and missing information. The workflow was streamlined to improve work efficiency and increase productivity. Patients’ service needs from hospital to community were stratified and conformable community care services were arranged. Full communication with patient and carers was achieved to reassure effective coordination of post-discharge support services and elimination of potential barriers to discharge.

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