Discharge PlanningWho’s Role Is It Anyway?
Andrea Ferns
Children’s Long Term
Ventilation Co-ordinator
CARA Service
Children’s Assisted
Respiratory Advisory (CARA)
Service
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Andrea Ferns – Discharge
Co-ordinator
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Gillian Halley – Consultant Intensivist

Ruth Wakeman - Physiotherapist
PICU/HDU/NICU
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R.B.H.
G.O.S.H
Evelina
St Thomas’
Chelsea &
Westminster
St Mary’s
St George’s
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Whittington
Royal London
Kings
Cambridge
Brighton
PCT Boundaries
London
Bedfordshire
Hertfordshire
Essex
Kent
Surrey
Sussex
Aims and Learning
Outcomes

Identify the role of the Community
Children’s Nurse in relation to discharge
planning for children on long term
ventilation

Explain the different roles of ‘key workers’

Consider the responsibilities being placed
upon Community Children’s Nursing
Services
Guidelines

Hospital to Home – Guidance on
discharge management and community
support for children using LTV (2005)

National Service Framework (2001)
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Together from the Start (2003)
Key Worker - Definition

‘Federal
employees who
are generally
responsible for
distributing
campaign
materials’
Key Worker
 Takes
responsibility for
organizing the discharge
planning for children on long
term ventilation
Hospital Team
A
named nurse/team from
PICU/HDU/NICU is ‘responsible’
for co-ordinating discharge
planning from acute setting
Community Nursing Team
A
‘key worker’ will be allocated
and ‘responsible’ for coordinating discharge and
management of child in the
community
Starting the Process

Key worker from acute setting contacts
the Key worker from the community

Key worker (Community) contacts local
authority commissioners

Health Needs Assessment carried out/1st
MDT meeting

Funding needs to be agreed in principle
Health Needs Assessment

Who is
responsible for
carrying out a
health needs
assessment?
Housing Assessment
 Who
is
responsible?
Equipment List
 Who
is
responsible?
Funding Agreed – What
Happens Now?
Timescales
 Responsibilities
 Purchase of equipment
 Recruitment of carers/nurses
 2nd MDT meeting

Training of Home Carers

PCT is responsible for training their
own carers

Agency/Care Providers are
responsible for training their own
carers
Competency Training

Competency Guidelines

How often updates required?

Who is responsible for updating the
parents/carers?
Final Discharge Arrangements

Date and time for discharge are set
in agreement with family

Emergency services/utility services
informed

Medical passport
Discharged Home
Implications for Community
Children’s Nurses
Training
 Maintaining skills
 Resources
 24 hour support for carers/parents
 Time

Aims and Learning
Outcomes

Identify the role of the Community
Children’s Nurse in relation to discharge
planning for children on long term
ventilation

Explain the different roles of ‘key workers’

Consider the responsibilities being placed
upon Community Children’s Nursing
Services
QUESTIONS?
www.longtermventilation.nhs.uk