Neurosurgical Transitional Care Programme

Discharge Program Process Abbreviations: AA: administrative assistant; MRN: medical record number; OT: occupational therapy; PT: physical therapy; and TCT = Transitional Care Team.

CLINIC (pre-enrolment)

• Patient has clinic visit with surgeon and is identified for surgery
• Surgeon identifies that the patient is eligible to participate in the program and consents the patient for enrolment.
• Patients will be given a written information sheet on the program, and will have the opportunity to receive the information via email as well.
• Their consent will be obtained in clinic; the use of interpreters will be used for individuals with special communication needs.

AFTER CLINIC

• Once individuals consent to be randomised into the study, their MRN will be given to the TCP nurse, who will randomise the patient into the control or intervention group using a random number generator.
• Patients randomised to the TCP will be given a pre-determined discharge date when they are called to schedule their operation. The anticipated discharge date will be determined by each surgeon's expected length of stay per procedure.
• AA provides brief intro to patient about the discharge pilot, including need for family member to be present to take patient home after appointment is complete. The surgery and discharge appointments are then booked.
• AA sends surgical letter (with anticipated length of stay and discharge appointment date/time) and discharge pilot postcard to patient via email or mail
• AA enters case and discharge information into NSU Discharge Calendar
• Transitional Care Team (TCT) checks NSU Discharge Calendar daily for scheduled cases and discharge appointments

ADMISSION (TCT)

• TCT monitors operating theatre regularly for post-op pilot patients and visits daily
• TCT updates Safety Round white boards with all discharge appointment information
• TCT sends daily dept. email, including PT/OT, with following day's discharge appointment details

ADMISSION (INPATIENT/OUTPATIENT TEAMS)

• Patient is deemed appropriate for impending discharge by neurosurgery team
• TCT updates Safety Rounds white board and discusses discharge checklist with care team.
• Inpatient team completes discharge summary
• Inpatient team completes take-away medication list by 4pm one day prior to discharge appointment
• Inpatient team rationalises the need for further blood tests (as part of standard medical treatment, not for study purposes).
• Inpatient team confirms PT/OT is complete
• Inpatient team completes discharge checklist and puts in letter tray in TCP Nurse office for collection

POST-DISCHARGE APPOINTMENT

• Staff nurse or ward sister discharges patient
• TCT pulls discharge medications from pharmacy for appointments
• Healthcare assistant or staff nurse transports patient to discharge appointment
• Discharge appointment checklist completed by TCT for appointment
• Volunteer transports patient to hospital exit or Discharge Lounge

AFTER POST-DISCHARGE APPOINTMENT

• TCT/volunteer scans signed discharge appointment checklist into medical record
• TCT/volunteer records data in the spreadsheet
• TCT/volunteer shreds checklists
• TCT communicates any outstanding issues to primary teams
• Patient is asked to complete a patient satisfaction survey which will be sent via post and email. A second request will be sent at one week and two weeks post discharge.

FOLLOW-UP PHONE CALLS

• After completion of post-discharge appointments, TCT makes follow-up phone calls
• Call template is completed
• Call template is scanned into medical record
• All outstanding issues will be signed out to the primary teams by the TCT

Outcome measures will be collected through:

Intake forms Longitudinal data collection from hospital medical records and patient satisfaction surveys.

Data collected will be 30-day unplanned hospital re-admissions (to the same institution as the index operation) and length of hospital stay, the latter of which will be evaluated continuously by the number of hours of the initial hospitalisation. Time of discharge (with an early discharge defined as before 12:00 PM) will also be recorded.