They also defined an earliest expected day of discharge (EEDD) (Table 2), which was distributed to all members of the team. This information helped ward nurses and therapists were better able to plan to mobilize patients appropriately postoperatively and ensure consistency in communication of expected length of stay to patients.
Perioperative Laxatives
Laxatives were prescribed initially for one patient and we checked to see if the patient and nursing staff were happy with the change. In the next test cycle all patients on one consultant’s list were prescribed laxatives. To track laxative use, a data collection sheet was attached to the patient's medical records on admission. With improved data collection, laxatives were then prescribed on admission for all elective spinal patients. The process has now become routine, occurring even when key change agents are absent.
Preoperative Carbohydrate Drinks
Preoperative high-calorie drinks were initially prescribed for one surgeon’s patients who were predicted to be staying 2 or more nights in the hospital. The preoperative assessment clinic (POAC) staff were asked to give these patients preoperative carbohydrate drinks at their pre-assessment clinic, and patients would self-administer their carbohydrate drinks preoperatively. However, POAC staff found it too difficult to give drinks to some patients and not to others, so it was decided that all patients should receive a drink. The clinical nurse practitioners note that the drink is given on the data collection sheet. However, it was observed that when team champions did not remind staff to administer the preoperative carbohydrate drinks, they were not given. We then asked the surgical admissions lounge staff if they would give preoperative carbohydrate drinks to patients and they agreed. This worked better than using POAC staff.
Patient Daily Aims
Members of the team felt that setting daily aims with patients would help optimize and prepare them for discharge. A laminated sheet with handwritten aims was trialed with 1 patient. He found it very useful, particularly the aims on diet and mobilization. When tested on all patients for a week, not only did they find it useful but nursing staff felt it improved communication between shifts. With greater staff buy-in and a move into a new purpose-built ward, we used white boards that were affixed to the door to the ensuite bathroom in each single patient room. Aims were discussed on ward rounds with patients by consultants or clinical nurse practitioners, and the goals agreed upon with patients before being written on the white boards. They included goals such as removal of urinary catheters, mobilization independently or with staff, and requirements such as radiographs to check position of instrumentation. Spot-checks on the ward showed good compliance with setting daily aims and high rates of satisfaction from patients.
Hospital at Home
The Hospital at Home team consists of experienced community-based nurses who provide wound care and analgesia advice for selected patients postdischarge to prevent readmission. This team supported early discharge for patients undergoing hip and knee replacements, and when approached they felt they could offer wound care and analgesia advice in the community for spinal surgery patients. This was tested with one patient with a wound who had daily care at home for 8 days following discharge from hospital. A further 2 patients were later cared for by the Hospital at Home team, with a total of 7 bed days saved. It has now become routine for the team to accept spinal patients when they have the capacity.