X3.7 Discharge planning

Involving the patient’s general practitioner in a case conference and developing a care plan may facilitate early discharge

Discharge planning involves the patient, external lay and professional carers, the multidisciplinary hospital and com­munity team and the patient’s regular GP. It should com­mence on admission and be documented within 24–48 hours (see Box 11). Appropriate patient education and attention to pre­ventive management are likely to reduce the frequency of further acute exacerbations. Assessment of social supports and domestic arrangements are critical in discharge plan­ning. Medicare items support aspects of discharge planning. See http://www.health.gov.au/internet/main/publishing.nsf/Content/mbsprimarycare-factsheet-chronicdisease.htm

A discharge pack, which includes general information about COPD, advice on medication use and written instruc­tions on use of inhalation and oxygen devices, if appropriate, as well as a plan for management of worsening symptoms, should be provided. The GP (and respiratory outreach program, if available) should be notified during the patient’s admission. A case conference involving the multidisciplinary team and GP may assist successful transition to the commu­nity. Medicare Benefits Schedule Enhanced Primary Care item numbers may be claimed for “participation in a case conference” and “contribution to a care plan” (see section D).

Before discharge, referral to a comprehensive pulmonary rehabilitation program should be considered.

Box 11: Criteria for discharge

Suggested criteria for a patient’s readiness for discharge include:

  • The patient should be in a clinically stable condition and have had no parenteral therapy for 24 hours
  • Inhaled bronchodilators are required less than four-hourly
  • Oxygen delivery has ceased for 24 hours (unless home oxygen is indicated)
  • If previously able, the patient is ambulating safely and independently, and performing activities of daily living
  • The patient is able to eat and sleep without significant episodes of dyspnoea
  • The patient or caregiver understands and is able to administer medications
  • Follow-up and home care arrangements (eg, home oxygen, home-care, Meals on Wheels, community nurse, allied health, GP, specialist) have been completed.