Improvement of Hospital Discharge in Orthopaedics-Trauma Management and 60-day Rehabilitation

As those overseeing hospital discharges, we identified significant obstacles in orthopedic trauma rehabilitation, often essential for patients to regain autonomy. High demand, limited resources, and extensive waiting lists delay discharge and increase post-surgical complications. Public rehabilitation options for safe in-home recovery are scarce, which further delays optimal patient outcomes.Using Lean and Lean Health methodologies, our project sought to enhance discharge and recovery. We meticulously traced patient journeys from admission to discharge, identifying delays, assessing solutions, and gathering insights from 100+ patient surveys. By focusing on patient experience, we pinpointed high-value care aspects and highlighted improvement areas to boost safety and satisfaction.Our phased improvement plan began with internal standardization, establishing clinical and non-clinical manuals, checklists, and post-discharge guidance. We developed cross-departmental protocols for better integration, then initiated partnerships with health and social entities like Santa Casa da Misericórdia, local municipalities, and SPMS (Serviços Partilhados do Ministério da Saúde) to streamline external referrals. Automated alerts were set up to notify primary care centers of patients needing post-hospitalization home or outpatient care. Additionally, we explored telemonitoring solutions to support in-home recovery for eligible patients.Keywords: Discharge Planning, Integrated Care, Out-of-hospital Rehabilitation, Autonomy, Safety and Trust, Continuity of Care, Interdisciplinary Collaboration, Telemonitoring, Caregiver Support, Patient and Staff Satisfaction.Conclusion This project, which is now in its implementation phase, has already achieved some successes, such as raising awareness among boards of directors and establishing partnerships with several organisations. Santa Casa da Misericórdia de Lisboa has already shown interest in collaborating. A 'Carers' Exchange' will be set up and the SCML school in Alcoitão will be available for internships as part of the project, with recent graduated Physioterapists. However, there are still no measurable results in relation to the ultimate goal of the project: to provide community solutions and home care after discharge with a guarantee of rehabilitation. Indicators to be achieved include early discharge planning, reduction in length of stay, readmissions, complications and nosocomial infections, and increased patient satisfaction. The pilot project focuses on trauma patients, but can be replicated in other departments/hospitals. The focus on these patients is due to the social impact of lost working days and family support, ensuring timely recovery and avoiding complications. The wellbeing and satisfaction of these patients has a positive effect on access to new patients, a reduction in waiting lists and a more effective network.