Overstay roles and responsibilities

Overstay Reduction Initiative Unit Roles and Responsibilities

Admitting Nurse

1. Complete the Nursing Discharge Screening Tool within 24 hours of the patient being admitted
2. Generate consults when required
3. Identify any possible additional barriers to patient discharge to the Transition Coordinator as they arise
4. Continue to participate in discharge planning with the Care team

Unit Manager and Charge Nurse

1. Ensure Discharge Screening Tool is complete within first 24 hours
2. Ensure all new staff are trained in using the Discharge Screening Tool

Unit Clerk

1. Remove old stickers
2. Add copies of the Nurse Discharge Screening Tool to all new charts
3. Keep the Transition Coordinator binder available at the desk
4. Order new coloured stickers when required (instruction in binder)

Data Collectors

1. Review Discharge Screening Tool between 24 hours post admission and 3 business days
2. Enter all key data (see wiki references ) into the database and generate a colour
3. Document the colour on the Discharge Screening Tool
4. Put a copy of the Discharge Screening Tool into the Transition Coordinator binder
5. Write the name of all “Red” high risk patient on the Assignment Sheet in the binder
6. take forms out of binder about monthly and send to Linda Hathout

Transition Coordinator

1. Check the assignment sheet
2. When a new patient has been assigned, sign and date the assignment sheet
3. Add your name to the Cardex
4. Discuss cases with RN
5. Keep copies of blank cases notes in the Transition Coordinator binder
6. Document on the Case Notes Sheet:
   1. Action requirements per specialty
   2. Anticipated date of service completion
   3. Actual discharge date per specialty
   4. Notes on any barriers to discharge
7. Monitor patient status on an ongoing basis to ensure preparations are in place for discharge
8. Ensure appropriate allied health services are engaged at the appropriate time
9. Review allied health plans to understand expected timeframes for preparations
10. Facilitate if services have been stalled or delayed to get the plan back on track
11. Be aware of the patient’s home dynamics and if there are any possible barriers to discharge
12. Ensure early communication with caregivers
13. Attend discharge rounds
14. Update chart if new barriers to discharge are identified
15. Update the discharge date on the Assignment Sheet
16. Leave Case Notes in the Transition Coordinator binger
17. Coordinate coverage with colleagues if you are intending on being away for more than 3 business days