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Implementation of Discharge Planning Patients‘ Chronic Kidney Disease in Ward of a Private Hospital in West Indonesia

Received 13 February 2021 Accepted 4 August 2021 Published 5 September 2021 Background: The quality of hospital services is measured through the provision of nursing care, especially by providing discharge planning to patients. Nurse’s role as an educator can be applied through providing discharge planning. Based on data obtained at a Private Hospital in Western Indonesia, CKD is ranked fifth as the biggest killer diseases, and it was found that 8 out of 10 discharge planning forms of CKD patients were not filled in completely. Objective: This study aims to describe the implementation of discharge planning in CKD patients in ward of a Private Hospital in West Indonesia. Methods: This research is quantitative descriptive method, with the documentation studies. Data collection used observation checklist and total sampling technique. The source of data in this research is 286 medical record of CKD patients in March–August 2019. The data analyzed using by univariate analysis. Result: discharge planning was not implemented (66.1%), while implemented (33.9%). Based on result, that discharge planning to CKD patients has not been done properly. Recommendation: Further research can focus on factors that influence the implementation of discharge planning. The results can be a reference for making standard and discharge planning forms specifically for CKD patients. Keyword:

The results of the systematic and meta-analyzes show the global prevalence chronic kidney disease (CKD) of 13.4%. According to the Global Burden of Disease result in 2010, CKD was 27th leading cause of death in the world in the 1990s and increase to 18th in 2010 (Kemenkes, 2017). In Indonesia, according to Riset Kesehatan Dasar (Riskesda) on 2018, the prevalence of CKD increased to 0.38% (Pranita, 2020).
In Private Hospital of West Indonesia, CKD is one of the diseases that are often served and the top ten disease (Medical Record Private Hospital in West Indonesia, 2019). According to Social Security Organizing Agency (BPJS), in terms of treatment financing, CKD is the second largest in Indonesia (Kemenkes, 2017 The care of patients with CKD is complex and requires assessment, intervention, education over several days or decades (Neyhart et al., 2010). Role's nurse as educator is important to increase quality service in hospital because nurses have responsibility to reduce patient morbidity rate. The quality of hospital service is measured through provision nursing care, one of which is apllied by providing discharge planning to patients. Discharge planning is an information to assists patients and families in carrying out ongoing care at home, so that patients do not have complication experience and can recovery quickly, and reducing hospital readmission (Li et al., 2014).
Ideally, discharge planning begins at admission, which requires patient and family cooperation to identify recovery goals and discharge needs. Then, nurses and other teams of health professionals plan with the patient for discharged to the appropriate level of care. Discharge documentation includes medications, diet, community resources, follow-up care, and emergency contact persons. All this information is included in a printed discharge summary document that is given to the patient on discharge (Potter et al., 2020).
The research in Islam Jemursari hospital on 2014, of the 59 respondent who were given discharge planning during treatment, 35 of them were able to understand well and 24 other respondents did not really understand the provision of discharge planning education (Maslakha & Santy, 2015).According to observation result in ward of Private Hospital in West Indonesia that of 20 patients' CKD who was given discharge planning, 9 (48%) of them was understood and 11 (52%) was not understood about nursing care plan.
The number of patient visits to the hemodialysis unit tended to increase with an average of 1786 visits per month, in contrast to the number of visits by control patients to clinic which tended to fluctuate. According to observation while researcher were in ward of Private Hospital in West Indonesia found that 7 of 10 nurses had not provided complete education, and only provides an explanation of medication therapy, does not explain what foods are good for consumption and what foods should be avoided, as well as what activities should be limited, how to treat CDL or cimino to avoid infection, if this can be done by the nurse, it is expected that the patient recurrence rate can be pressed and explain it when the patient will home care.
With the implementation of discharge planning, it is hoped that the patient will have a good understanding of the therapy program being undertaken, self-care at home, food ingredients that must be limited, so that discharge planning is very influential on patient compliance in undergoing treatment (Maslakha & Santy, 2015). According to medical record from 10 records patients' CKD on August 2019, 8 of them that fulfilling discharge planning was not implemented well and 2 others that fulfilling discharge planning was implemented by nurses.
Based on previous research, it is known that there are hospitals that have not been maximal in carrying out the discharge planning.Several factors have caused the discharge planning to be not maximal is human resources who do not understand the importance of discharge planning, the unavailability of standard operating procedures and guidelines of discharge planning, and the existence of obstacles from personnel factors, like providers and customers (Hardivianty, 2017).
The aims of research is to determine the implementation of discharge planning patients' CKD in ward of Private Hospital in West Indonesia.

METHOD
This study uses descriptive quantitative design with study documentation. The sample of this study is 286 medical record patients' Chronic Kidney Disease (CKD) that was hospitalized since March -August 2019 in ward of a Private Hospital in West Indonesia. Technique sampling this study uses total sampling. This research is secondary data, and uses observation checklist instrument consist of characteristic patient(include age, gender, and classification CKD), and the discharge planning implementation form was carried out on CKD patients was made by researcher. The Faculty of Nursing Universitas Pelita Harapan ethical committee has approved this study (001/RCTC-EC/R/RSUS/I/2020). This study uses univariate analysis.

RESULT AND DISCUSSION
The highest respondentcharacteristic based on age were in range 46 -55 years old as many as 84 people (29.4%), male gender as many as 148 people (51.7%), and classification of diagnose hemodialysis is CKD on hemodialysis as many as 171 people (59.8%) ( Table 1).

Characteristic Respondent
Based on the results of the study, it was found that the age of CKD patients was more at 46-55 years old. The research is in line with research at RSUP Dr. M. DJamil Padang that CKD patient was more at 40-60 years old, because there is a decrease in kidney function according to age, which shows a progressive decrease in Glomerular Filtration Rate (GFR) and Renal Blood Flow (RBF), which decreases around 8 ml/min/1.73 m2 per decade since the patient is 40 years old (Aisara et al., 2018). In Distinct to the systematic review research conducted in Australia that there is an increase in CKD at 70 years and over (Hill et al., 2016).
The result of this study was found that CKD patients was more male gender at 51.7%. This research is in line with the result of previous study at RSUP Dr. M. Djamil Padang, showed that more patients' CKD were male as many as 59 patients (56.7%). This is related to the causes of CKS such as kidney stones which also occur in many men (Aisara et al., 2018). However, it is different with the result of systematic review at Australia Hospital that two-third of the study, the prevalence of CKD was higher in women. This is becaused that women have less muscle mass than men, where muscle mass is as the main determinant of serum creatinin concentration (Hill et al., 2016).
Based on the result of this study,it was found that the patients hospitalized were CKD on hemodyalisis (59.8%). The previous research in the hemodialysis room at Dr. Pirngadi Hospital Medan in 35 patients, where 31 CKD patients did not adhere to the dietary rules, so it can be concluded that CKD patients will more often be hospitalized for hemodialysis. Therefore, the cause of hospitalization for CKD patients is not adhering to diet rules (Tarigan et al., 2016). This study is also supported by previous research, it was found that patients with CKD on HD often experienced repeated hospitalizations, where the average number of CKD on HD patients who treated reapeatedly (> 2 times per year) was 46.3%. This is due to the non adherence of CKD patients and also influenced by the low level of patient education (Hidayati, 2018).
Implementation of Discharge Planning According to the result of the study, it was found that in the medical record status of CKD patients in March -August 2019 in a Private Hospital of West Indonesia, more discharge planning was not implemented as many as 189 documents (66.1%). This is in line with research conducted at the Jamaica Hospital which stated that of the 131 patients statuses were audited from medical record consisting of 6 wards, it was found that 14.3% of nurses provided and wrote the teaching to patients or families 72 hours after admission, and 18.3% of nurses wrote the teaching to the patients by the time the patient is discharged. Then, 15.3% of nurses wrote discharge planning at 72 hours after admission, and 6.9 % wrote discharge planning at 24 hours after admission. Where in the audited documentation, there were 84.7% no patient teaching entries made within 72 hours of patient admission (Abdul-Kareem et al., 2019).
At hospital Sydney, Australia, 23% of nurses reported adhering to the discharge process according to policy aspects. However, there are 10 obstacles in providing discharge planning and the nurses stated that the biggest barrier in providing discharge planning in the ward was too busy for a week. Another obstacle is that the patient cannoy communicate, fees pain when discussing their condition, and the patient's illness is beyond prediction. When the nurse is busy and has difficulty communicating, the most important thing is re-communicate the important information (Graham et al., 2013).
In facts, some patient are more in needs discharge planning, because of their health-related risks. The barriers to effective discharge planning, besides ineffective communication, lack of clarity of roles among members of the health care team (responsibility and follow up), dan lack of resources (e.g rehabilitation) (Potter et al., 2020). The majority of discharge planning occurs when the patient wants to go home, thereby limiting the ability of the patient and family to be optimally prepared and the resources needed for disharge (Graham et al., 2013).
Discharge planning can also not be implemented because of the workload and motivation of the nurses. The high of workload, where the nurses do various jobs at once, so that nurses only carry out discharge planning with a general part (Graham et al., 2013). Previous research also stated that nurses' motivation was related to nurses' performance in documenting discharge planning. Where motivation is high, documentation of discharge planning is complete well (Natasia et al., 2014). One of the focuses of discharge planning is to ensure the patient's transition to a place where the patient can properly fulfill their care needs (Potter et al., 2020). Then, Discharge planning is very useful for patient independence and readiness when doing home care (Shofiana & Kurniawati, 2014). Therefore, the role of nurses as educators to CKD patients is that patients are able to diet according to recommendation and can handle the side effects of dialysis independently at home.
While, the research at the Martha Friska Hospital in Medan shows that the implementation of discharge planning is sufficient for 41.1%. In the field, many nurses do not write down the schedule time to return to hospital for control, as well as things that need to be avoided at home (Frida & L, 2020). The same thing with research in ward of Hospital type C, it was found that the implementation of discharge planning with the highest frequency category in accordance with standard operational procedures (SPO) was obtained as many as 42 respondents (65.6%) and the lowest frequency was carry out according to standard operational procedures as many as 22 respondents (34.4%). It becaused that the professional nursing services is greatly affect for improvement quality for patients (Marliany et al., 2017).
Discharge planning must be done optimally by increasing the nurses'knowledge. Therefore, discharge planning is very important for chronic kidney disease patients. Through implementation of discharge planning is expected the patient has a good understanding about therapy programs, self-care, that was done after hospitalized (Maslakha & Santy, 2015;Potter et al., 2020), and as well food ingredients that should be limited/avoided, such as foods high in sodium and potassium. The hospital with higher discharge planning quality can be reducing the patient readmission rates (Henke et al., 2017). If the implementation of discharge planning was not implemented properly specifically for CKD patient will be affect the increase of patient hospitalized and dialysed, because patiens experience overload anemia, dysfunction, and infection.

LIMITATION OF THE STUDY
This study used documentation study, so there is an error level, due to the incomplete status.

CONCLUSION AND RECOMMENDATION
The discharge planning for CKD patients was not implemented properly where 189 documents (66.1%) were not implemented, and only 97 documents (33.9%) were carried out properly. So that this may be one of the factors causing the high number of CKD on HD patients and non HD CKD patients who are hospitalized again with cases of overload, anemia and infection. The recommendation for further research can focus on factors that influence the implementation of discharge planning, making discharge planning forms. The results can be a reference for making standard discharge planning specifically for CKD patients.