Authors: (including presenting author): :
Leung WM, Fung PS, Wong F, Kong SC, Karn KY, Lee KY
Affiliation: :
Community Nursing Service, United Christian Hospital
Keyword 1: :
Single Point Triage Team
Keyword 2: :
pre-discharge assessment
Introduction: :
Upon hospitalization, the ward staff and patients frequently encounter confusion regarding the roles of various liaison team from Community nursing service (CNS) and Integrated Care and Discharge Support for High-Risk Patients (ICDS). Each team has its own approach to pre-discharge assessments. As a result, these teams may implement different community services based on varying recruitment criteria, which can lead to overlapping efforts. As the CNS and ICDS have integrated their service at Sept 2024 in United Christian Hospital (UCH), the Single Point Triage Team (SPTT) was initiated to enhance operational efficiencies and to streamline the process of pre-discharge assessment for the patients in UCH.
Objectives: :
1) Re-engineer the service model on pre-discharge assessment in high-risk patients to ensure right time, right place, and right care
2) to create a seamless and timely discharge process
Methodology: :
The initiative commenced in Nov 2024 at UCH, led by the link Nurse of ICDS and Liaison Nurse of CNS. The “One Ward One SPTT Nurse” concept was introduced to optimize the communication process among the ward staff. To streamline the referral system, patient flow was systematically evaluated using the unique referral, current assessment protocols and established various checklists to boost efficiency. Consequently, the SPTT nurse was pivotal in coordinating community support upon patient discharge from the hospital to home, which included resources for community service (e.g. CNS, virtual ward, home care service, home exercise etc.)
Result & Outcome: :
One Stop Service successfully expedited the completion of pre-discharge interviews without requiring additional manpower. A review of the ICDS case management program revealed that 24% of patients have either temporary or life-long nursing treatment for conditions such as Foley care, intramuscular Injection, or wound care. The SPTT nurse will continue oversee ongoing assessment, resulting in a 50% reduction in time require by both ICDS link nurses and CNS liaisons to conduct duplicated and fragmented assessments prior to integration. In this connection, a notable improvement was observed a four-month period, with referrals for face-to-face assessments rising from 75% to 97% due to synergy effect. In October 2025, a staff satisfaction survey evaluated the SPTT’s impact on pre-discharge assessment, 87 responses from ward staff were collected over a one-week period, indicating improved efficiency and higher degree of satisfaction, with an average score of 4.45 out of 5.
