Bisidimo General Hospital

ADMISSION AND DISCHARGE

PROTOCOL

Second Edition
2015 EFY

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Introduction

This admission and discharge protocol is developed to ensure proper

implementations of patient flows in Bisidimo Hospital.

General Objectives
The purpose of this protocol document is to provide health
professionals with best practices, processes, and guidelines to deliver
both effective and efficient admission and discharge processes

Specific Objectives

1) To show standardized processes for admission and discharges that

should be adhered to by all staff.
2) To provide technical guidance that can be used for training and
development of relevant staff particularly the liaison officers.
3) To provide guidance for Coordinators and Team leaders on monitoring
and evaluation of the admission and discharge process.
4) To ensure elective admissions are prioritized and effected on the
strict basis of clinical need.
5) To support the improvement of bed management

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Application
These Procedures are to be followed by all clinical staff at Bisidimo Hospital

Clinician reviews patient and decides on admission

and level of urgency based on finding

Physician completes record/admission form

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 Liaison officers receive admission
form and update waiting list

Liaison officers review waiting list and gives

admission date based on the clinical urgency

Patient escorted by staff to IP with medical records

Ward clerk/ nurse receives patient,

register and put MR on IP folder

Orient patient to the

ward and Assessment
D by ward case team

In Patient Care
- Progressive care and feedback
Discharge to patient and family
- Diagnostic services
- Pharmacy services

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Roles and Responsibilities
Hospital SMT
o Ensure that there is hospital- wide communication and
awareness of the A&D protocols;
o Ensure training is given to relevant staff.
o Avail necessary inputs for implementation.
o Carryout periodic monitoring and evaluation of the proper
application of the A&D Protocols.
o Ensure that Admission and discharges are carried out seven
days a week.
o Receive and review regular reports on bed occupancy
and bed management improvement processes.

Medical Director/Chief Clinical Officer

o Champion the implementation of the A&D Protocols.
o Discuss A&D protocols with doctors in the “morning
sessions”.
o Ensure that all Case Team Leaders and those admitting and
discharging patients are thoroughly familiar with the
protocols.
o Review and discuss monitoring and evaluation reports
with the Hospital liaison service and make
recommendations for improvement.

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 Liaison officers
o Update the elective admissions waiting list.
o Assign an admission date to patients based on the urgency
of the clinical need as date indicated by the physician in
the patient notes.
o Secure a bed for the patient.
o Maintain good communications with inpatient case teams and
the wards.
o Ensure that the patient receives proper directions to the ward.
o In collaboration with ward staff, play a leading role in co-
ordination of discharges.

o Ensure regular bed census is carried out, reported and used to

update and manage the bed resources.

Admitting Physicians
a) Adhere to hospital guidelines when deciding on admitting a
patient.

b) Indicate the level of urgency for admission based on the urgency

of clinical need.
c) Ensure that these protocols and existing national guidelines
relating to children, birthing mothers and major diseases are
followed during admission.
d) Ensure that an estimated length of stay, where possible, is
placed in the patients notes.

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Ward Nurses
a) Welcome and familiarize the patient with the ward surroundings.
b) Review notes and ensure all requirements are met/planned to be
met.
c) Assess the patient and prepare the nursing Care Plan, involving
the patient, and relevant others, and place in the patient medical
record within 8 hours of admission.
d) Follow the guidance set out for admissions and discharges.
e) Maintain good communication with the Liaison Office
particularly in relation to emergency admissions, pending and
actual discharges, and bed status reports.

Discharging Physicians
a) Adhere to the hospitals’ discharge protocols or these set out in this
document.
b) Wherever possible do ward rounds early in the day and discharge
early in the day.
c) Has responsibility for correctly completing all the relevant
documentation.
d) Discharging at weekends shall be made.

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ADMISSIONS POLICY AND PROCEDURES
1. Objectives
The key objectives underpinning an effective and coherent admissions and
discharge policy for emergency and elective patients are:
• The provision of an integrated personal health and social services
as per the hospital guideline/ practice/ implemented through
social worker.
• The utilization of resources to maximize clinical and
organizational effectiveness and outcomes.
• The establishment of fully integrated networks (within or
between the facilities) of emergency care which are accessible
to each person.
• The provision of levels of local access to emergency care
while simultaneously ensuring high quality clinical care.
• The acquisition of clinical admissions data to assist service
planning and monitoring.

2. Eligibility for Free Services

2.1 The eligibility for free health care is based on Regional Health
Care Financing Reform Proclamations. These Proclamations must
be adhered to.
2.2 Eligibility is not an automatic right. Each adult has to
demonstrate eligibility in their own right. This is normally
demonstrated by the possession of a Fee Waiver letter.
2.3 In addition, according to Oromia law, there is a minimum list of
exempt services which all are entitled to receive, free of cost.
2.4 Only persons who meet the eligibility criteria, as defined by the
Government can receive publicly-funded (i.e. free or subsidized)
health and disability services.

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3. Principles
3.1 Emergency Department (ED) admissions
The principles of emergency department admissions are discussed
in the coming sections.
3.2 Elective admissions
The principles of elective admissions are discussed in the coming
sections.

4. Process
4.1 Introduction
4.1.1 All admissions should be arranged through the Liaison
Service following the process described below.

4.1.2 Upon arrival on the ward, the nurse should receive the
patient to initiate admission process and give orientation
and instruction about facilities (such as toilet and showers)
to the patient and care-givers etc.

4.1.3 The patient should be assessed by a medical doctor upon

arrival on the ward and a History and Physical Examination
Assessment should be completed. This should include the
immediate management plan for the patient.

4.1.4 Additionally, a Nursing Assessment should be completed

within 8 hours of admission and a Nursing Care Plan
developed.

4.1.5 All emergency patients who require admission to

Hospital (as assessed by an appropriate health
professional) will be admitted under the care of an
appropriate senior physician /Midwife/an appropriate
health professional. The decision as to whether to admit
the patient is to be made on clinical grounds.

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 4.1.6 Patients who require hospital admission but where the
hospital does not have adequate services to meet their needs
are to be transferred to a more appropriate hospital (as per
the requirements of the Inter-Facilities Transfer of Patients
Procedure).

4.2 Admission to Hospital Pediatric Unit

4.2.1 All children admitted to a hospital are to be admitted to a

Pediatric Unit, and are to remain there for the duration of
their hospital stay, unless there are specific exceptional
circumstances which warrant a shift to another ward.

4.2.2 Children requiring intensive monitoring are to be admitted

to the Intensive Care Unit (ICU) at the hospital.

4.2.3 A sick mother with a ‘boarder infant’ may be admitted to a

Pediatric Unit, provided that:
o the mother’s illness is of short duration;
o the mother is not an isolation patient, and;

o In the absence of the mother, nursing staff should

ensure that all of the baby’s needs including
nutrition, are fully met.

4.2.4 Sick adults are not to be admitted to the Pediatric Unit,

unless there are specific exceptional circumstances which
warrant such an admission.

4.2.5 Conditions of existing patients are to be taken into account

when well children are accompanying a sick mother into
the Pediatric Unit.

4.2.6 The nurse in charge of Pediatric Unit, in consultation with the

ward doctor, is responsible for making the decision regarding

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 the admitting of a sick mother and a well child into the
Pediatric Unit.

4.3 Precautions and Considerations

4.3.1 All emergency patients who require admission to hospital
(as assessed by a Doctor) will be admitted under the care
of an appropriate health professional.

4.3.2 Elective admissions are undertaken on the basis of a referral

from health facilities to a hospital.

4.3.3 All children admitted to Hospital are to be admitted to Pediatric

Ward.

4.3.4 Bisidimo Hospital operate a policy where no patient is refused

admission, but the admission may be delayed and managed
according to our hospital waiting list guidelines and
requirements.

5. Medical Determination for Admission

 To support the medical necessity of an inpatient admission, the
doctor/Admitting health professional must adequately document (in
the patient’s medical record) that a provider with applicable
expertise expressly determined that the patient required services
involving a greater intensity of care that could be provided safely
and effectively in an outpatient setting.

 Such a determination may take into account: the amount of time the
patient is expected to require inpatient services, but must not be
based solely on this factor. The decision to admit is a medical
determination that is based on factors, including but not limited to
the:
 patient’s medical history; patient’s current medical
needs; severity of the signs and symptoms exhibited by
the patient;
 medical predictability of an adverse clinical event
occurring with the patient;
 results of outpatient diagnostic studies;

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  types of facilities available to inpatients and outpatients;

6. Contra Indications for Admission

6.1 The patient’s condition has been improving substantially and is

approaching either normal clinical parameters or the patient’s
baseline.
6.2 The admission is for monitoring, observation or other
interventions that have to date been successfully delivered outside
of a hospital setting.
6.3 The admission is primarily to observe for the possible
progression of labor when examination and monitoring does not
indicate definite progression of active labor leading to delivery.
6.4 The admission is primarily for education, teaching, minor
medication changes and/or monitoring, or adjustment of
therapies associated with a medically stable condition(s).

6.5 The admission is primarily due to the: amount of time a patient

has spent as an outpatient in a hospital or other outpatient
setting; need for diagnostic testing or obtaining consultations
services; age of the patient, and; convenience of the physician,
hospital, patient, family, or other medical provider.

6.6 Clinical conditions accepted for admission into the ICU may
include: Acute Chest Pain; Acute Myocardial Infarction;
Arrhythmias; Insertion of Temporary Pacemaker; Pulmonary
Embolism (requiring high level support); Inotropic Treatment;
Intensive Airway Management; Ventilator Care; Trauma;
Overdose; Ketoacidosis; Eclampsia; and Unconscious/semi-
conscious

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7. Documentation
 The Liaison Officer (during working hours) or after-hours
will process the admission and send all paper-work and
patient medical records to the Ward on completion. The
exception to this is where during working hours where the
Ward Clerk has chosen to do the emergency admissions and
arranged admissions.

 When a patient arrives directly at a ward, as a transfer from

another Hospital or on referral from a GP, the ward is to
inform the Liaison Officer that the patient has arrived, and
then send down a completed Manual Data Sheet for
admissions so it can then be processed.

 There should also be a process for documentation of

admissions in the ER and the ICU.

8. Refusal for Admission

 Bisidimo Hospital have a policy whereby the decision to admit a

patient is made on clinical grounds,

 But this admission may be delayed and/or managed according to our

Hospital Waiting List guidelines and requirements.

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Emergency Admissions
A typical emergency pathway is shown in figure below.

Emergency

Assessment and intervention/ treatment

Functional assessment and diagnosis

• Clinical
Timely
• Functional
discharge
• Social
LOS discussed with patient

Decision to admit and initial clinical

management plan

Expected date of discharge based on anticipated

length of stay

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Principles of Emergency Admissions
Emergency Department (ED) admissions
 Only emergency patients should be admitted to the hospital through
the Emergency Department. This may require a subtle shift of
emphasis from ‘semi elective’ admission to more rigorous
assessments to ensure the appropriateness of hospital admissions and
maximize the number of available beds for elective admissions.

Emergency Patient Admission Process

Emergency Resuscitation and Rehabilitation Unit in ER;

 Short Stay observation wards or Resuscitation and Rehabilitation

Units (RRUs) are advocated in emergency patient care. Such units
should be directly adjacent to the Emergency Department and should
be supervised by specialists in Emergency Medicine.

 The length of stay should not be greater than 24 hours.

Transfer to ward for proper admission

A. If the patient is to be admitted as an emergency, a clinical

member of the relevant Case Team should contact the Liaison
Service providing, as a minimum, the following information:
• Patient name and medical record number;
• Summary of clinical history and reason for admission;
• Case team to which patient should be admitted (for example
surgical case team, internal medicine case team etc), and;
• Urgency of admission.

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 B. When a request for admission is made, the Liaison Officer
should follow the steps below:
1. Is a bed immediately available in the relevant inpatient

case team/ward? If yes  admit patient.

The Liaison Officer should inform the attending clinician of the

admission, the patient should be transferred to the ward, and any
necessary administrative tasks carried out with the assistance of a
runner.
If no  the Liaison Service should consider finding a bed in another
facility.
2. Is there any patient in the relevant case team/ward due to
be discharged that day?
If yes  confirm that patient will be discharged. Identify and address
any factors that are delaying discharge. Consider moving patient to
Transit Lounge (if available) or another waiting area. In this way the
bed can be freed and the new patient can be admitted.
If no  the Liaison Service should consider finding a bed in another
facility.
3. Is a bed available within another case team/ward?
If yes  discuss with Director of Inpatient Services, and if
appropriate, admit patient to that bed and inform the Leader of the
Inpatient Case Team that is responsible for the patient where the
patient is located. Ensure that the patient is transferred to ‘correct’
case team bed/ward as soon as a bed there becomes available.
If no  the Liaison Service should consider finding a bed in another
facility.

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 4. Is there an elective admission that could be cancelled to make a bed
available for the patient?
If no  the Liaison Service should consider finding a bed in another
facility.
As far as possible, planned admissions should not be cancelled.
However depending on the priority it may be necessary to do so.
Factors to be considered are: The clinical urgency of both the
planned admission and the emergency patient requiring admission
should be performed within 5 minutes; The time on waiting list,
distance travelled and other pertinent social circumstances of the
elective case, and; The availability of a bed in another facility for
the emergency patient requiring admission, and the distance to
reach that facility.

C. What are the important factors influencing patient admission

from the Emergency Department (ED) to inpatient services?
1. Extended access to rapid assessment clinics and outpatient imaging,
pharmacy, and basic laboratory services.
2. Rapid assessment and extended access to diagnostics (unnecessary
delays in admitting and/or discharging patients from hospital may
arise from avoidable delays in patient assessment by specialists,
duplication of tests or the absence of high or low dependency beds).
3. Early Senior Medical decision making available at the point of
admission.
4. Close multi-disciplinary team work.
5. Nationally agreed standardized triage processes to ensure clinical
prioritization of patients on their arrival in the Emergency
Department and to ensure timely and appropriate care is
delivered.
6. Prioritization should be based on the clinical background and
should be decided by the treating physician.

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 7. There should be regular and influential audit of clinical activity.

8. The critical role of Support Staff should be acknowledged with

appropriate support for professional development and influence in
decision making at all levels.
Emergency obstetrics
o Birthing mother only to be admitted if in active labor.
o Birthing Mothers should be transferred immediately to the
delivery ward.
o A rapid assessment for any complications or abnormal risks
should be made and plan and actions addressing these put in
place.

Maternity Admissions
o An assessment of the risk of delivery must be carried out
before admission during antenatal care.
o Mothers should be directed, or escorted when necessary, to the
delivery ward.
o High risk and complicated cases must be clearly identified and
arrangements put in place to reduce the risk and facilitate safe
delivery in complex cases.
o In caesarian cases and in other low risk non-complex cases
an expected length of stay should be given to the mother and
placed on the patient notes.
o On admission, care should be provided according to existing
national standards and guidelines.
o After normal delivery, the mother should be kept under
observation for six hours by the ward doctor or other
appropriate health professional. This must be planned for on
admission.
o Complex and high risk cases must be transferred to the
maternity ward and care provided according to existing
national standards and guidelines.

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Elective Admissions

Elective

Clinician reviews internal/external referrals and

decides on admission and level of urgency

Liaison officers with written note of level of urgency

Liaison officers update waiting list

Liaison officers review waiting list and gives

admission date based on clinical urgency

Pre admission assessment

• Clinical
• Functional
• Social
LOS discussed with patient
Bed management position reviewed

Referral to Specialist team for assessment

of complex needs if necessary

Patient admitted for elective surgical procedure

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 Principles Elective Admissions
o A patient’s episode of care should be planned before his/her
admission and should take account of the entire pathway up to and
after discharge from hospital. Patients and their caregivers should be
partners in this planning.

o The bed management service should operate on a permanent basis,

i.e. for 24 hours on every day of the year.

o There should be a network information service which proceeds

elective admission after an appointment for admission has been
made and the waiting list is checked.

Elective Admission Process

 Elective admissions may be booked by the liaison officer.

When a patient requires elective admission the patient is
sent to the Liaison Officer with adequate information
reflecting: Patient name and medical record number;
Summary of clinical history and reason for admission;
Case team to which patient should be admitted (for
example surgical case team, internal medicine case team
etc), and Urgency of admission (set criteria related to:
pathology of the disease, socio-economic status of the
patient, and distance of the patient’s residence).

 The Liaison and Referral Service should book the

admission date, the bed and give an appointment card to
the patient.

 On the day of admission, the Liaison Officer should submit

the medical records of the patient to the admitting clinician
on the day of the admission.

 On a daily basis, the Liaison Officer should inform each

Inpatient Case Team of any elective admissions for the
following day to ensure that the required service is
available and allow the Case Team to make all necessary
preparations for the admission.

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  The following key requirements have been identified to
facilitate effective elective admission practices:
1. All patients should have a treatment plan within 8 hours of
admission.
2. Centralized waiting list management.
3. Agreement on the parameters for scheduling operation theatre
lists with the OR team.

4. Pre-admission assessment as a standard requirement for all

elective admissions to ensure appropriate planning of the entire
patient journey. Diagnostics such as pathology and imaging
should be done in advance upon multidisciplinary team
decision.
5. The anticipated Length of Stay (LOS) for elective admissions
indicated as early as possible by the physician and
communicated to the Liaison Service to facilitate scheduling.
6. Increased day surgery can also be supported by pre-admission
assessment to ensure appropriate scheduling and to minimize
time transfer to inpatient beds.
7. Length of Stay (LOS) after admission should be monitored to
minimize hospital acquired infections, cost for the patients, and
appropriately manage bed occupancy.

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Summary of Patient Admission Procedures

 Effective and coherent admissions and discharge policy for emergency

and elective patients are very important for proper utilization of
hospital beds;

 Based on admitting physician’s recommendation liaison officer

should coordinate beds for admission .

Emergency admissions processes

 Emergency Admissions shall not be greater than 24 hours ER

Department;

 Then transfer to ward has to be facilitated for proper inpatient

admission if necessary.

 If the patient is to be admitted as an inpatient, a clinical member of

emergency case team should contact the liaison officers.

 As a minimum the following information has to be delivered: Patient

name and medical record number; Summary of the clinical history
and reason for emergency admission ; Case team to which patient
should be admitted like surgical case team, internal medicine case
team etc and Expected date of discharge

When request for admission is made the liaison officer should follow the
steps below:

 Is a bed immediately available in the relevant inpatient case

team/ward? If yes – admit patient;

 The liaison officer should inform the case team leader of the receiving
ward that the patient should be transferred to that ward and any
necessary administrative tasks carried out with the assistance of
runner;

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  Is there any patient in the relevant case team /ward due to be discharge
that day? If yes --- confirm that patient will be discharged. Identify
and address any factors that are delaying discharge. Consider moving
patient to transit lounge (if available) or another waiting area. In this
way the bed can be freed and the new patient can be admitted ;

 Is a bed available within another case team/ward? If yes --- discuss

with director of inpatient service and the responsible physician for the
patient where the patient is located, ensure the patient will be properly
followed and managed by appropriate case team, and ensure that the
patient is transferred to correct case team bed/ward as soon as a bed is
available.

 Patients in critical condition or with emergency signs needing

immediate attention, should be received by a nurse who will evaluate
the nature and severity of the illness and inform the responsible
physician in 15 minutes.

 If there are emergency clinical signs to be addressed by physicians, the

informed physician must come and see the patient immediately.

 Being the most critical patients directed to the inpatient department,

these patients should have comprehensive evaluation, addressing all
components of health and diagnosis should not rely on OPD
evaluation notes as there may be a misdiagnosis or developments in
the condition of the patient.

Elective Admission Process

 Liaison officer has to book elective admission.

 When a patient requires elective admission a clinical member of the

relevant case team should send at minimum the following information:
Patient name, phone number and medical record number; Summary of
the clinical history and reason for admission; Case team to which
patient should be admitted like surgical case team, internal medicine
case team; and Urgency of admission (set criteria related to: pathology
of the disease, socio-economic status of the patient, and distance of the
patient’s residence);

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  The liaison officer should book the admission date and give an
appointment card to the Patient and patient number, and take contact
information of patient and/or care giver. The liaison officer should also
give his/her or office contact address to the patient so that the patient
can phone and get information about his/her admission schedule.

 On the day of admission, the patient should report to the liaison officer
and from there he/she will be assisted to make any necessary payment
or registration and will be directed to the relevant inpatient case
team/ward.

 On a daily basis, the liaison officer should inform each inpatient case
team of planned admissions for the following day to ensure that the
required service is available and allow the case team to make all
necessary preparation for the admission.

 In case admission schedule or treatment is changed the liaison officer

should inform the patient and family.

 The following key requirements have been identified to facilitate

effective elective admission practices:

1. All patients should have a treatment plan within 8 hours of

admission.

2. Centralized waiting list management shall be made by Liaison

unit;

3. Agreement on the parameters for scheduling operation theatre

lists with the OR team;

4. Effective management of the admission process requires

knowledge of: The total number of beds; The number of
occupied beds at the evening census (bed occupancy) ; The
number of beds that are to be evacuated that day ; Number of
beds with prolonged length of stay and its causes.

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 5. Admission and discharge service shall be 24 hours a day, 7
days a week, 365 days a year, including holidays and
weekends.

 Upon arrival on the ward, there should be a quick assessment of the

condition of the patient by the receiving nurse.

 For patients in a stable condition, the nurse will initiate the ward
admission process, including orienting patients and families to the
facilities such as toilets, showers, introducing relevant staff, giving
instructions for care-givers etc.

 The responsible duty physician should then complete the evaluation of

the patient in no less than 2 hours.

 Nursing process need to be completed in no later than 8 hours (before

the next shift) and all efforts have to be made to make patient centered
and improve the overall quality of the care beyond documentation.

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P
a
g
e

2
6

o
f

3
8
Discharge Protocols
The discharge pathway is shown below D

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Expected date of discharge based
on anticipated length of stay

Page 28 of 38
Nurse- initiated Specialist
Senior physician Simple Discharge Complex Discharge team led
Nurse
Supported facilitated
Clinical management plan including EDD Referral to Specialist team and social
based on LOS and /or ICP implementation care including any section notice
Patient/carer involved Clinical management plan including EDD
Discharge planned based on LOS and /or ICP implemented

Daily review EDD Patient/carer involved

Feedback loop
24 hours
Discharge Checklist Care package designed and agreed including
Before EDD
any section notice

By monitoring Patient meets clinician criteria for discharge Anticipated LOS/EDD reviewed by Specialist
on EDD Discharge lounge or home/place of residence team on regular bases

24 hours
Discharge Checklist
Before EDD

Patient meets clinician criteria for discharge By monitoring

Discharge lounge or home/place of residence on EDD

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Principles of Discharge
The core principles for effective discharge planning provide that:
1. A patient’s use of a hospital bed and their discharge should be
planned before their admission, where possible.
2. The estimated date of discharge should be documented and
communicated to the patient and relevant personnel within 8
hours of admission.
3. Discharge should be “streamlined” e.g. prescriptions and letter
should be completed in a timely manner; transport booked and test
results made available promptly.
4. Patients who were seriously ill should be regularly discussed by
the MDT to facilitate timely discharge.

Discharge Process
 The decision for discharge should be made by a physician who
should complete a discharge summary for the patient.

 A copy of the discharge summary containing medical history

should be given to the patient and a second copy filed in the
Medical Record.

 If a patient was referred from another facility the discharging

physician should also complete the feedback section of the Referral
Form.

The processes required for effective discharge planning provide that:

1. Discharge coordinator/Liaison Officers shall be available to

ensure delays are minimized and extensive patient and family
involvement in decision making processes.
2. Referrals to physiotherapy, occupational therapy, and
psychosocial support shall be identified as early as possible to
access aids and appliances as appropriate.

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 3. Discharge documentation should be audited to ensure
compliance with A and D protocols.
4. Analysis of trends and data should be undertaken by the
discharge coordinator/ Liaison Officer and communicated to
SMT.
5. Multidisciplinary teamwork is the key to success with
discharge planning.

6. A patient’s discharge plan shall be coordinated by a

nominated member of the multidisciplinary case team.
7. Appropriate bodies within the attending case team should be
involved in the discharge planning process.
8. Patients and their caregivers should be partners in the discharge
planning process.

9. There should be early involvement of Pharmacy to increase

compliance with medication.

10. Patients (or parents, caregivers, surrogate, or guardians) should co-

sign the patient’s discharge letter ensuring that the discharge
instructions have been clearly explained to them.

11. An expected date of discharge should be set within 24 hours of

admission or in many cases before admission for elective patients
and communicated to the patient and all staff in contact with the
patient.

12. The expected date of discharge should be proactively managed

against the treatment plan by ward staff on a daily basis and
changes communicated to the patient.

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 13. Ward rounds should be scheduled in a way that it allows a review
at least daily of all patients by a senior clinical staff member.

14. Inpatient case teams can make significant improvements by:

• identifying anticipated length of stay and expected date of
discharge on admission;
• using a Discharge Predictor as a core tool for effective bed
management;
• providing an updated list of expected discharges on a shift basis;
• discharging patients in the morning on the day of discharge, and;
• discharging patients over the weekend and holidays.

Key Steps in Timely Discharge

• Expected date of discharge is identified early as part of patient’s
assessment within 8 hours of admission (or in pre-assessment for
elective patients). It is based on the anticipated time needed for
tests and interventions to be carried out and for the patient to be
clinically stable and fit for discharge.
• The patient and caregiver are involved and informed about
the clinical management plan and the expected date for
discharge.
• In parallel, all the necessary arrangements are put in place to
optimize the (simple) discharge including Discharge Summary,
outpatient appointment, hospital sick leave completed, any
medicines to be taken away, and patient transport arrangements
confirmed.

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 • Daily review of the patient’s condition and response to treatment
will determine if the expected date of discharge needs to be
revised.
• Review of planned/actual discharge date. Did it go according to
plan? Complete audit on a regular basis.

Medical Determination for Discharge

• Vital signs must be stable and consistent with age and the
clinical baseline correct orientation as to time, place and
person.
• Adequate pain maintenance and has supply of oral analgesia.
• Understands how to use oral supplied analgesia and has
been given written information about these.
• Ability to dress and walk where appropriate.
• Minimal nausea, vomiting or dizziness.
• Has at least taken oral fluids.
• Minimal bleeding or wound drainage.
• Has passed urine (if appropriate).
• Has a responsible adult to take them home.
• Written and verbal instructions given about postoperative
care.
• Knows when to come back for follow up (if appropriate).

Patient Death

 Patient Deaths and Care for deceased care shall be managed

according to Hospital Death protocol. See the Death protocol for
additional information.

Summary of Discharge process

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  Decision for discharge should be made by the treating physician,
who should complete a discharge summary.

 First copy of the discharge summary should be given to the patient,

while the second copy has to be documented in the Medical Record.

 If the patient was referred from another facility, the discharging

physician should also complete the feedback section of the referral
paper, and, that should, be given to the patient, to give to the
referring health institution.

 Patients ready for discharge should be counseled by the attending

physician, nurse in charge and clinical pharmacist before discharge.
Pre-discharge counselling encompasses the following: Share the
discharge plan while patient is on the ward, before starting the
process ; An explanation of the patient’s diagnosis, investigation
results and treatments given ; An explanation of any medications that
the patient should continue to take upon discharge; Arrangements for
follow up, if any and Any ‘caution or attention’ that the patient has
to be aware of;

 The discharging nurse has to make sure all the necessary registers are
filled and administrative duties, including financial issues are settled
before the patient is sent to the liaison office;

 The discharge process should be complete in no more than 2 hours

(including administrative issues);

 The patient with their medical record must to be sent to the liaison
office, with the help of a runner.

 The liaison officer has to check the completeness of all the necessary
documents and send the patient home after filling the necessary
registers (With appointment card and appointment register filled, if
appointment was asked for on the discharge summary sheet.

 The medical record of discharged patient should be returned to

medical record department within 24 hours of discharge.

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 Monitoring and Evaluation

1) Conduct periodic audits of the A&D protocols once quarterly

using the audit/ framework and checklist.
2) Review findings by the A&D protocols team and make
recommendations for improvement to the SMT.

3) SMT should get regular reports on bed management and monitor the
results.

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Sample Admission Checklist

Yes No N/A

1. Has the patient information been collected?

2. Has the clinician seen the patient and decided on admission?

3. If birthing mother, has risk and other antenatal assessment been

done? 4. Has the clinician filled out the admission form and notes?

5. Are the following shown?

• Clinical priority
• Estimated length of stay

6. Has the liaison officers received the admission form?

7. Has the waiting list been updated?

8. Has the clinical, functional and social pre

admission assessment been done?

9. Has the liaison officers discussed the admission

with the Patient and relatives where relevant?

10. Has the bed been allocated in a timely

manner? 11. Is the patient eligible for free service?

12. If no, has all financial issues been settled?

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Sample Discharge Decision Checklist

Yes No N/A

1. Has a date of discharge been estimated and documented?

2. Has the patient been involved or informed?

3. Is the patient clinically stable and fit for discharge?

4. Has medications been dispensed and purpose,

regime explained to patient?

5. Is the discharge summary and any other relevant

information included for the receiving facility?

6. Outpatient appointments made and given to patient?

7. Patient given information about self-care and who to

contact if symptoms return?

8. Has the patient been given a hospital sick certificate if

required? 9. Has the patient settled all financial issues?

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Sample Admission Urgency Notification Card

Date
----------------------------------------------
Name of the department issuing admission
----------------------------------------------------------

Name of the patient

----------------------------------------------------------
Card number
--------------------------------
Name and signature of the physician approving admission
----------------------------------------------------------------------------------------------------------------

Urgency of the admission

Emergency (immediate admission)

--------------------------------------------------------- Non

emergency but priority (admission within two weeks) -------------------------- Non

emergency (admission in two weeks or more) --------------------------------------

Name and signature of the Liaison officer accepted admission

----------------------------------------------------------------------------------------------------------------

Date of patient appointment for admission --------------------------------

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