Discharge plan:

Discharge planning should start early in the patient’s admission - either at the pre-assessment stage or the clerk-in. It should NOT start when the patient is medically ready for discharge.

Both medical and nursing staff  should specifically ask the patient and relatives about the home circumstances. They should advise the family on the expected performance status of the patient postop and what is a reasonable expectation of ability to perform basic household tasks after major surgery. Most patients after thoracotomy will need full live-in support for a number of weeks after surgery. Therefore going home alone to an empty house is usually inappropriate. If the family cannot provide full care, convalescent care will need to be arranged.

If difficulties are expected, please contact the social workers early in the admission.

Change of discharge plan:

It is not unusual for the family or the patient to change their perception of their circumstances after they see how debilitating major surgery actually is. When they see their relative in pain, with drains, masks, tubes etc they often will realise that they cannot supply the required care in the post discharge period.

It is important to re-assess the post-discharge plan with the patient and relatives after their surgery and make appropriate social work arrangements.

Review

Review arrangements must be made before discharge and written on the discharge note - it is NOT to be left blank. NOT all patients require a thoracic review e.g. palliative patients, terminal care patients, most stents, most talc pleurodesis and Pleur-X catheter patients do not need a review as the MacMillan nurses will be keeping a close eye on them. However, it is important to state this on the discharge note.

For those who are being reviewed: on discharge all thoracotomy, thoracoscopy, pneumothorax, pleural effusion and chest trauma patients (and others where indicated) are to be given an Xray form and instructed to go to the Xray department half an hour before their designated outpatient appointment. This includes patients being referred back to Daisy Hill, Craigavon and Altnagelvin clinics (just use a RVH form). This saves time for the patient at the OPD clinic.

Most patients can be reviewed at about 6 weeks. One exception to this are those with whom pathology has not been discussed. Arrangements should be made for the pathology to be discussed face-to face. Usually this means the next thoracic outpatient clinic, preferably with the MacMillan nurse in attendance, but in some cases it may be more appropriate to contact the GP or referring physician to fulfill this role.

Patients with a drain in situ or with a wound issue should be seen at next week’s clinic.

Discharge Summary

The discharge summary should be addressed to the GP but copied to the referring physician and where appropriate, to the oncologist.

Oncology referrals

These should be dictated and given to the secretaries to type. That way there will be an official copy, both hard copy and electronic, with a copy filed in the notes.