Specialty Nursing, Changi General Hospital, Singapore
Specialty Nursing, Changi General Hospital, Singapore.
BMJ Open Qual. 2024 Jul 15;13(3):e002666. doi: 10.1136/bmjoq-2023-002666.
Compassionate discharges (ComD), commonly known as rapid discharges, are urgent one-way discharges for critically ill hospitalised patients with death expected within hours or less than 7 days, to die at their place of choice-usually in their own home. Challenges abound in this time-sensitive setting when multiple parties must work together to prepare medically unstable patients for discharge, yet healthcare staff are largely unaware of the process, resulting in delays.
Process mapping, an Ishikawa diagram and a Pareto chart were used to identify barriers, which included timely acquisition of home equipment and medication and poor communication among stakeholders. In May 2020, the Quality Improvement (QI) team embarked on a pilot project to reduce family caregiver anxiety and delays in the ComD process while maintaining a success rate above 90% over a 12-month period.
Three Plan-Do-Study-Act (PDSA) cycles were used to refine a ComD resource package that was developed; this consisted of a checklist, a kit and caregiver resources. This was to support nurses, doctors and families during this difficult and emotional transition. Items in the ComD resource package were revised iteratively based on user feedback, with further data collected to measure its usefulness.
The 12-month ComD success rate over 3 PDSA cycles were 88.9%, 94.2% and 96.7%, respectively, after each cycle. There was a consistent reduction in the level of family anxiety before and after caregiver training and resources. Reasons for failed ComD included acute clinical deterioration or delays in obtaining home oxygen support.
The ComD resource package allowed collaborative work across different disciplines, strengthening the safety and utility of ComD and allowing patients to die in their place of choice. These are ubiquitous across settings; this QI problem is thus relevant beyond our local institution.
同情性 discharge（ComD），通常称为快速 discharge，是为预计在数小时内或不到 7 天内死亡的重症住院患者进行的紧急单向 discharge，以便在其选择的地点——通常是自己的家中——死亡。在这个时间敏感的环境中，当多个方面必须共同努力为不稳定的患者做好 discharge 准备时，存在着诸多挑战，但医疗保健人员对此过程知之甚少，导致出现延误。
流程映射、石川图和帕累托图用于确定障碍，包括及时获得家庭设备和药物以及利益相关者之间沟通不畅等。2020 年 5 月，质量改进（QI）团队开展了一个试点项目，以减少家庭护理人员的焦虑和 ComD 流程中的延误，同时在 12 个月内保持 90%以上的成功率。
使用三个计划-执行-研究-行动（PDSA）循环来完善 ComD 资源包，该资源包包括检查表、套件和护理人员资源。这是为了在这个困难和情绪化的过渡时期为护士、医生和家庭提供支持。ComD 资源包中的项目根据用户反馈进行了迭代修订，并进一步收集数据以衡量其有用性。
在 3 个 PDSA 循环中，12 个月的 ComD 成功率分别为 88.9%、94.2%和 96.7%。在 caregiver 培训和资源之后，家庭焦虑水平持续降低。ComD 失败的原因包括急性临床恶化或在家中获得氧气支持的延迟。
ComD 资源包允许不同学科之间的协作工作，增强了 ComD 的安全性和实用性，使患者能够在选择的地点死亡。这些在不同环境中普遍存在；因此，这个 QI 问题不仅与我们当地机构有关。
