Ashby ward at Lincoln County Hospital is a rehabilitation unit for people with acquired brain injury. Staff are highly skilled and trained to help people adjust and adapt to their life they had prior to this.
Although patients have always been complex, over the last couple of years the hands on care and complexity has heightened greatly and the discharges were taking up a great deal of the staff nurses time.
Deputy sister Teresa Hurdley and at the time staff nurse Carolyn Skelton agreed their was definitely a gap in the service we was providing. With this in mind we created a unique job description to stream line our service from admission to discharge. Specialist Outreach Discharge Liaison Nurse, once I was in post the job description grew and grew!
Firstly, I took control of the referral process to continuing Health Care for patients requiring further rehabilitation, the paper work was was originally created by Teresa Hurdley. I now help and advise other wards and hospitals on this process.
Rehabilitation prescriptions is another achievement created by myself and Dr Viola Asimba, the patients journey is detailed in this along with admission and discharge data which shows how well the patient as progressed.
The paper work was adapted from the Major trauma centre at Queen’s Medical Centre who we liaise closely with and regularly take patients from them once they are medically stable to be transferred to us.
Myself and another colleague recreated key worker paper work, these meetings are daily and an essential part of the patients journey as the team help the patient achieve their goals. I regularly scribe and lead these meetings. Adaptation of the weekly MDT format was another area where myself and Teresa have stream lined to make more efficient, we both now lead and scribe this and reduced the time we spend by half.
The waiting list is another area I have taken control of, ensuring the referrals are all discussed at our MDT, then liaise closely with our team, and assess the patients on other wards. Emotional support for the patient and families, this can be a daily recurrence, time and reassurance is needed and cannot be rushed, Therapy dependency scores for UKROC data for NHS England, care plans, Social work referrals, Healthcare check lists, decision support tool meeting, referrals to HART and Allied reablement, out of area referrals for placements, Safe guarding champion, audits, presentations, liaise and visit other rehab units, headway and carers first referrals, order of equipment, trained on PAS system for admissions and discharges, live board information, interviews, and generally help out when the ward and deputy sister are in annual leave.
Carolyn Skelton, Specialist Outreach Discharge Liaison Nurse
Teresa Hurdley, Deputy Ward Sister
Olubuymi Ogunyemi, Ward Manager
The can view the full rehab prescription document here
and the out of area discharge proforma here