Gwent Healthcare Trust
The Stroke Rehabilitation Ward at Nevill Hall Hospital is held in high regard within the Trust for its culture of promoting independence and ensuring patients are given every chance of transferring to the next stage of their care in a timely and appropriate manner.
Communication within the ward's multi-disciplinary team and between staff and patients/family/carers is seen as critical to the patient's progress through the system. Staff start communicating with relevant parties as soon as a patient arrives on the ward. All the necessary referrals are made swiftly and staff realise the need to talk to family members and carers to pick up quickly any issues that might act as a barrier to discharge. Carers and family members are also surveyed every month about various aspects of care, including questions about personal circumstances that could delay discharge.
Multi-disciplinary team meetings are held weekly where discussions involve the patient's remaining care needs, medication needs, need for further investigations and discharge arrangements. Staff told us this forum is particularly effective because all disciplines are present and problems are solved quickly. Having all disciplines present also means the meeting can receive all relevant information about the patient and that the collective knowledge about intermediate care services is broad.
The ward also uses multi-disciplinary note writing. All disciplines write in the patient's notes to detail exactly what actions they have taken. This is seen as effective in improving communication between disciplines and ensuring all actions that should have been taken are being taken.
Further documentation used on the ward includes a multi-disciplinary discharge plan which details all arrangements that must be made before a patient can be safely discharged. Copies of this form are retained by the patient and the ward and a copy is placed in the patient's notes. A separate discharge planning document is used that contains a discharge/transfer checklist that nurses must sign when certain actions have been completed. Actions include informing the patient of discharge, arranging transportation and having a care plan in place.