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OPERATIONAL POLICY AND PROCEDURES
FOR THE DISCHARGE AND TRANSFER
OF PATIENTS
Policy Number
Ratifying
Committee
Date Ratified
Reviewed
Next Review Date
Accountable
Director
Policy Author
Policy Application
Related Policies
List of Staff for
Circulation
Equality impact
assessment (EIA)
completed
840992867
EHT/CN/045/2011
CPC
November 2004
July 2007, October 2009, January 2011
January 2013
Director of Clinical Operations
Written By: Angela May
Reviewed By: Jackie Walker, July 2007
Blake Edwards, January 2011
Trust-wide
Major Incident Policy; Emergency Pressures Escalation
Plan; Nurse Led Discharge; Duty / Site Management
Services Operational policy
Executive Directors
Assistant and Clinical Directors
Consultants, General Managers, Matrons, JSCC
Executive and Directorate PAs
November 2009
Page 1 of 107
In developing this policy the following legislation has been duly considered:
Data Protection Act 1998
Data Protection issues have been considered with regards to this policy. Adherence to this
policy will therefore ensure compliance with the Data Protection Act 1998 and internal
Data Protection Policies.
Diversity Policies
Equality issues have been considered with regards to this policy. Adherence to this policy
will therefore ensure compliance with Equal Opportunity legislation and internal Equal
Opportunity policies.
Freedom of Information Act 2000
Freedom of Information issues have been considered with regards to this policy.
Adherence to this policy will therefore ensure compliance with the Freedom of Information
Act 2000 legislation and internal Freedom of Information policies.
Health and Safety Act 1974
Health and Safety issues have been considered with regards to this policy. Adherence to
this policy will therefore ensure compliance with Health and Safety legislation and internal
Health and Safety policies.
Human Rights Act 1998
The Human Rights Act 1998 has been considered with regards to this policy.
Proportionally has been identified as the key to Human Rights compliance. This means
striking a fair balance between the rights of the individuals and those of the rest of the
community. There must be a reasonable relationship between the aim to be achieved and
the means used.
Race Relations Amendment Act 2000
The Race Relations Amendment Act 2000 has been considered with regards to this
policy. Adherence to this policy means that the Trust will eliminate discrimination on the
grounds of race and will promote race equality and good race relations.
The Mental Capacity Act 2005
The Mental Capacity Act 2005 has been considered when developing this policy/these
guidelines to ensure the guiding principles of the act are adhered to with reference to
testing and assessment of capacity, consulting others and protecting the best interests of
the patient. The Mental Capacity Act provides a statutory framework to empower and
protect vulnerable people who are not able to make their own decisions. It makes it clear
who can take decisions, in which situations, and how they should go about this. It enables
people to plan ahead for a time when they may lose capacity.
Policy date: November 2004
Next Review: January 2013
Page 2 of 107
Contents
Page
1.
1.1
1.2
1.3
Introduction
Discharge Planning
Objectives
DOH Guidelines
6
6
6
2.
2.1
2.2
Government Directives
Community Care Act 2003 (delayed discharges etc)
NHS & Community Care Act 1990
7
7
8
3.
3.0
Duties, Roles and Responsibilities
Internal transfers
Duty Manager
External transfers
consultant
medical/surgical team
Nurse in charge
Duty Manager
Discharge/ transfer liaison team
Discharge / transfer liaison nurse
Discharge / transfer Care Co-ordinator
Discharge Support Workers
9
9
12
4
5.
5.1
5.2
5.3
5.4
5.5
5.6
5.7
5.8
Co-ordinating a discharge / transfer – role of the
Discharge Liaison Team
Co-ordinating a discharge / transfer – role of the Nurse
Co-ordinating a discharge / transfer – role of the
medical staff
Patient Groups
Multi-disciplinary Team Meetings
Purpose
Principles
Frequency
Attendance
Facilitation
Format
Documentation
Roles and Responsibilities
6.
Flow charts
6.1
Social, multiple, complex and older persons care needs
flow chart
Ealing Hospital Trust Reimbursement Process flowchart
Ealing Social Services & Ealing Hospital Choice Policy
flow chart
16
Documentation to accompany patients on
23
3.01
3.1
3.2
3.3
6.2
6.3
7.
Policy date: November 2004
Next Review: January 2013
Page 3 of 107
12
13
14
14
18
20
discharge & information to be given to the
patient
8.
Discharging and Transferring Patients Out of
Hours
23
9.
9.1
9.2
Discharge Planning Training
Nurse Discharge Training
Doctors Discharge Planning
24
24
24
10.
10.1
10.2
10.3
10.4
10.5
Discharge Lounge
Aims and Objectives
Opening Hours
Admission to the Lounge
Evaluation
Flow chart for Patient Identification
24
25
25
24
25
26
11.
11.1
11.2
11.3
Pharmacy Discharge Policy
Discharge Procedures
Discharge Procedures for Lamas Ward
Dossette Boxes
27
27
27
27
12.
12.1
12.2
Transport
Booking Criteria
Out of Hours Booking
28
28
28
13.
13.1
13.2
13.3
13.4
Transfer of Patients & Transfer Documentation
Internal Transfers
Transfer of patients to and from other hospitals
Infection Control and Transfer / Placement of Patients
Single sex accommodation
28
28
28
29
30
14.
Reporting Failed Discharges, Transfer and Discharge
Incidents
30
15.
Monitoring effectiveness of the policy
31
Discharge/ Transfer requirements
Specialist care / departments involved in the
discharge / transfer of patients and related documents:
APPENDIX
APPENDIX
APPENDIX
APPENDIX
APPENDIX
1
2
3
4
5
APPENDIX 6
APPENDIX 7
APPENDIX 8
Accident & Emergency
Critical Care Admission and Transfer policy
Discharge protocol for paediatric patients
Maternity Services–Transfer and Discharge
Improving Discharge management and
reducing length of stay
Repatriation of Patients
Alcohol and Drug Abuse Pre-discharge Advice Sheet
Breast Care Patients
Policy date: November 2004
Next Review: January 2013
Page 4 of 107
APPENDIX
APPENDIX
APPENDIX
APPENDIX
APPENDIX
APPENDIX
APPENDIX
APPENDIX
APPENDIX
APPENDIX
APPENDIX
APPENDIX
APPENDIX
APPENDIX
APPENDIX
APPENDIX
APPENDIX
APPENDIX
APPENDIX
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
Cardiac Patients
Dermatology Department
Diabetes Nurse Specialists
Haematology & HIV Patients
Homeless Patients
Infection Control
Nutrition & Dietetics
Palliative Care Patients
Respiratory Care
Speech & Language Therapy
Tissue Viability
Vulnerable Adults
Ealing Rehabilitation Services
Active Rehabilitation and Integrated Services of Ealing
Clayponds Hospital
Continuing Care Assessments
Community Nursing
Bibliography for Discharge Planning Management
Government Publication References
Policy date: November 2004
Next Review: January 2013
Page 5 of 107
1. Introduction
1.1 Transfer and Discharge planning
Transfer and Discharge planning is an integral part of a patient-centred quality approach to care.
Ealing Hospital NHS Trust is committed to ensuring an effective system is in place to support the
safe return of patients to the community. It ensures the community is responsive to the needs of
the patient and carers whilst making efficient use of resources within the Trust and Community.
For the purpose of this policy the term ‘discharge’ denotes a patient who is deemed medically fit to
leave hospital and is safe to transfer into community care. The term ‘transfer’ denotes a patient
who is moved to another health care organisation / rehabilitation facility.
The successful discharge of patients from hospital requires close collaboration and co-operation
between the professions in the day-to-day management of the patient. It is a process that is
commenced on admission of the patient and carried through into the community after discharge.
This policy will outline the needs of patients, carers and staff in order for effective and efficient
discharges to take place in the Trust.
Maternity and Paediatric discharge protocols are attached as appendices to the policy.
1.2 Objectives of the policy
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To ensure the patient and his/her carers are given the opportunity to participate in the
discharge planning process, as recommended by the DOH guidelines.
To prepare the patient and his/her carers both physically and psychologically for
transfer home/back to the community.
To provide continuity of care between the hospital, community and GP by facilitating
effective communication within the multi-professional team.
To provide a safe and organised transfer home by ensuring that all necessary health
care/ social care facilities are in order to receive the patient.
To promote discharge of patients who are medically fit therefore improving the patients’
journey and supporting the emergency capacity pressures within the trust.
To ensure a multidisciplinary team approach to discharge which commences on
admission of the patient.
To reduce the number of delayed discharges.
1.3 DOH Guidelines
Key principles
The key principles for effective discharge and transfer of care are that:
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Unnecessary admissions are avoided and effective discharge is facilitated by a ‘whole
system approach’ to assessment processes and the commissioning and
delivery of
services.
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The engagement and active participation of individuals and their carer(s) as equal partners
is central to the delivery of care and in the planning of a successful discharge.
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Discharge is a process and not an isolated event. It has to be planned for at the time of
admission across the primary, hospital and social care services, ensuring that individuals and
their carer(s) understand and are involved in the care planning decisions as appropriate.
Policy date: November 2004
Next Review: January 2013
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
The process of discharge planning is co-ordinated by a named person who has responsibility
for co-ordinating all stages of the ‘patient journey’. This involves liaison with the preadmission case co-ordinator in the community at the earliest opportunity and the transfer of
those responsibilities on discharge.
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Staff should work within a framework of integrated multidisciplinary and multi-agency team
working to manage all aspects of the discharge process.
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Effective use is made of transitional and intermediate care services, so that existing acute
hospital capacity is used appropriately and individuals achieve their optimal outcome.
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The assessment for, and delivery of, continuing health and social care is organised so that
individuals understand the continuum of health and social care services, their rights and
receive advice and information to enable them to make informed decisions about their future
care.
2. Government Directives
2.1 Community Care (Delayed Discharges etc.) Act 2003
The Government announced its intention to introduce a system of reimbursement in Delivering the
NHS Plan in April 2002. It is based on a system used in Scandinavia that has had a major impact
on reducing delayed discharges. The Community Care (Delayed Discharges etc.) bill was
introduced into the House of Commons on 14 November 2002 and the Bill received Royal Assent
on 8 April 2003.
The Act places duties upon the NHS and councils with social services responsibilities in England
relating to communication between health and social care systems around the discharge of
patients and communication with patients and carers. The NHS is required to notify councils of any
patient’s likely need for community care services, and of their proposed discharge date. These new
duties came into force in October 2003 when the NHS and councils are expected to begin
operating the system in shadow form.
The Act also introduces a system of reimbursement for delayed hospital discharges. This will apply
initially to adult patients receiving acute medical care. If a patient remains in hospital because the
council has not put in place the services the patient or their carer need for discharge to be safe, the
council will pay the NHS body a charge per day of delay. This charge has been set to be higher
than the costs of providing alternative and more suitable social care and is currently £120 in
London and parts of the South East and £100 elsewhere in England.
The new duty for councils to pay the NHS for delays came into force on 5 January 2004, providing
a financial incentive for councils to promptly assess and transfer people from an acute ward (where
they are at risk of losing their independence) to a more appropriate community setting as soon as
they are ready for discharge, and provide an appropriate range of support to facilitate avoiding
unnecessary admissions. The Act thus promotes the independence of older people and means
that more people will be cared for in the most appropriate setting for their needs.
As health commissioners, PCTs have a key role to play in working with NHS bodies and councils in
identifying the main causes of delay in their local systems, and in channelling investment to tackle
these to reduce delays and thus the need for reimbursement.
Strategic Health Authorities have a specific duty under the Act to establish dispute resolution
panels, and appoint members to them. These panels are similar in form to continuing care
adjudication panels. Their composition and duties are set out in the Regulations.
Policy date: November 2004
Next Review: January 2013
Page 7 of 107
This document provides detailed guidance on how to put these new responsibilities into practice.
Further help, including frequently asked questions, sample protocols for partners to adapt locally,
and links to the legislation, is available at
www.doh.gov.uk/reimbursement
The Act places certain duties on NHS organisations and councils:

NHS bodies have a new statutory duty to notify social services of a patient’s ‘likely need for
community care services’ (referred to as an ‘assessment notification’) and their proposed
discharge date (referred to as a ‘discharge notification’). These measures help to clarify
responsibilities and promote good partnership working.
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There is then a defined timescale for social services to complete the individual’s
assessment and provide appropriate social care services.
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A reimbursement charge of £100/£120 per day is paid by Social Services to the acute trust
if Social Services have not met their obligations – that is, to assess the patient (and carer if
appropriate) and provide social care services within the set time – and that that is the sole
reason for the delay in discharge from hospital. If any element of the delay is related to
NHS areas of responsibility then reimbursement does not apply. Delays should be
calculated on a daily basis, although it is a matter for NHS bodies to decide in consultation
with councils how and when invoices for delays will be issued.
Part 1 of the Community Care (Delayed Discharges etc.) Act 2003 aims to:
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Strengthen joint working and encourage clear and timely communication with new statutory
duties on the NHS and councils;
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Improve assessment and provision of community care services for people in hospital by
introducing financial incentives; and encourage development of new service capacity, which
can facilitate patient transfer to community settings which promote independence or
prevent unnecessary admission.
Ealing Health and Social Care have reinvested the money from reimbursement back into the
system to implement new roles across health and social care.
2.2 The NHS and Community Care Act 1990
The Act has brought in some of the biggest changes in the welfare state since the Second World
War. The community care changes were originally described in a 1989 government document
called Caring for People. The NHS and Community Care Act 1990 which followed translated these
ideas into legislation.
Community care is not a new concept; it has been around for many years. But the community care
changes are new. Community Care generally means helping people who need care and support to
live with dignity and independence in the community. This is very important to many people e.g.
with MS. It may mean being cared for in the home but as well as, for some people, special needs
housing or residential or nursing homes.
The Government's aims are to:
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Make the best use of public money
Encourage local authorities to set priorities
Ensure that local authorities check on the quality of care which is being provided
Encourage local authorities to use other organisations to provide services
Policy date: November 2004
Next Review: January 2013
Page 8 of 107
What Are The Main Changes?
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Summary of the key points of the Community Care Act
Local Authority Social Services Departments have overall responsibility for Community
Care
Local Authorities must produce and publish Community Care Plans
Local Authorities must assess people who they think may be in need of Community Care
Services
Local Authorities must arrange for the provision of care
Local Authorities must encourage and promote the development of private and voluntary
agencies by purchasing care and/or services from them
Local Authorities must establish a Complaints procedure.
3. Roles and Responsibilities for the discharge and transfer of patients
3.0. Internal Transfers
For any internal transfer moving patients from one ward/clinical area to another within the hospital
the Duty Manager is responsible for ensuring no internal transfers place after 2200hrs, unless the
Duty Manager feels that the transfer is absolutely essential with regard to patient dependency
(need for critical care) / most appropriate care to be given. The exception to the above will be the
transfer of patients from the A&E department to a suitable ward bed. When transfers are
necessary to safeguard emergency beds or to ensure specialist care they are coordinated by the
Duty Manager in liaison with the nurse in charge of the ward and the medical teams.
It is the responsibility of the Duty Manager to facilitate the transfer of medically fit patients out of
Intensive Care / High Dependency Unit to acute as soon as possible. Prior to transfer, the Duty
Manager will obtain an adequate report of the patients’ needs and requirements for a safe and
appropriate placement to ensure that the receiving ward has adequate staffing to support the
patients needs.
3.01 External Transfers to and from other hospitals
Referral of patients to other hospitals for specialist treatment and those patients requiring transfer
to Ealing Hospital NHS Trust from another acute NHS Trust needs to be on a consultant-toconsultant basis prior to any transfer taking place.
For any external transfer the appropriate medical/surgical team need to liaise with the nurse in
charge to inform them of the medical referral on the day that this occurs.
The nurse in charge will then liaise with the bed manager/clinical site manager at the
accepting/referring hospital to ensure transfer to or repatriation takes place at the earliest
opportunity.
The Duty Manager will collect information on patients for transfer and those for repatriation
according to the duty management local protocol and an exchange of patients will be organised,
where this is possible, if bed availability is limited.
Transfer of patients in and out of the hospital must be facilitated by the Discharge Liaison Team
who will confirm that the patients have been referred and/or accepted by medical staff.
3.1 Co-ordinating a discharge/ transfer – role of the Discharge Liaison Team
The Discharge Liaison Team is made up of several team members in individual
posts who work in conjunction with one another, creating a team that aims to
improve, streamline and problem solve in all matters pertaining to discharge and
transfer
Policy date: November 2004
Next Review: January 2013
Page 9 of 107
The roles and responsibilities and structure of the Discharge Liaison Team are as
follows:
Discharge / transfer Liaison Nurse: ext 5400
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To enhance the discharge / transfer process by improving communication between the
acute hospital, community health and social services, and ensuring patients are
discharged at the appropriate time with the appropriate services in place.
Review Continuing Care Assessment (CCA) forms completed by wards to ensure
accuracy and completeness prior to them being sent to social services and the PCT.
Where appropriate complete CCA forms for complex discharges across clinical areas.
Identify problem areas around discharge / transfer and support with positive solutions.
To be instrumental in initiating, negotiating and implementing changes to the existing
discharge liaison and community liaison functions, with the aim of providing an
integrated admission/discharge/transfer co-ordination service.
Provide expert guidance and knowledge on all matters relating to discharge / transfer to
professional and lay service users.
Identify the need and co-ordinate case conferences or discharges.
Initiate nurse assessments making nursing recommendations for long term placements
and packages of care.
Advise, organise and assist with nursing equipment to affect safe discharge, in
conjunction with the community nursing services.
Liaise closely with the ward & medical staff, therapists and hospital social workers in
facilitating the discharge / transfer of patients from hospital.
Monitor patients known to social services and advise on options available to them when
planning discharge.
Make nursing recommendations for long-term placements and packages of care.
To liaise closely with members of the intermediate care team on admission avoidance
and discharge support care packages.
Support and advise patients and carers who require intervention to enable effective
discharge / transfer
To attend MDT meetings as appropriate and to support and advise the team when
planning complex discharges.
To increase awareness of the role of colleagues within the community, statutory,
voluntary services and encourage appropriate referral.
The Discharge Liaison must facilitate the transfer of patients in and out of the hospital. The
Discharge Liaison Team will confirm that the patients have been referred and/or accepted
by medical staff.
Discharge / transfer Care Co-ordinator: ext 5266
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Support and advise patients and carers who require intervention to enable effective
discharge.
To increase awareness of the role of colleagues within the community, statutory,
voluntary services and encourage appropriate referral.
In conjunction with the discharging nurse, provide constructive feedback to senior nurses
and matrons on their staffs performance and competence in executing discharge-/
transfer planning procedures
Provide expert guidance and knowledge on all matters relating to discharge/transfer to
professional and lay service users.
Establish and maintain good communication links and liaison with ward staff, therapists,
community staff, statutory and voluntary agencies as appropriate for ward/ consultant
based teams.
Identify the need and co-ordinate case conferences.
Policy date: November 2004
Next Review: January 2013
Page 10 of 107
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Advise, organise and assist with nursing equipment to affect safe discharges / transfers
in conjunction with the community nursing services.
To advise on options available to patients when planning discharge.
To liaise closely with members of the intermediate care team on admission avoidance/
discharge support care packages.
To attend and lead MDT meetings as appropriate, and to support and advise the team
when planning complex discharges / transfers
To collate data in order to aid the reimbursement process.
To advise staff on equipment needs for patients post discharge.
To be proactive in developing a trust wide system for tracking planned discharges and
triggers to identify when blocks to discharge are occurring.
To identify delayed discharges and target solutions where possible to expedite
discharge.
Discharge Administrator: ext 5292
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To deal with all telephone enquiries on behalf of the Discharge Liaison Team.
Ensure all emailed and faxed social work referrals are entered onto the reimbursement
database, and appropriately forwarded to the respective social service departments.
Ensure the inpatient database is kept fully up to date and reflects the current delays for
individual patients in the trust.
To liaise with all members of the MDT and individual departments within the hospital, on
patient matters to ensure all referrals to social services are given a daily up to date
predicted discharge date, in order to expedite discharges and track patients’ journeys.
To liaise with the Hospital Care Management Team and external social services
departments in order for them to undertake assessment of patients within the required
time scales, and update ward staff and social services on patient progress.
Discharge Support Workers
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To work as a member of the ward team, participating in patient care and discharge
planning under the supervision and direction of qualified nurses.
Communicate with external agencies, i.e. Social Services, Nursing Homes, ICS and
EMI, in order to facilitate a speedy and effective discharge process.
Following consultation with senior staff, and under their direction, facilitate inter
department movement in order to speed up treatment and intervention.
To collect and deliver specimens, x-ray forms, medication requests etc for the ward.
To attend ward based MDT meetings and update discharge plans as necessary.
To make appointments and enter patients details on the PAS System, retrieve patient
medical records, photocopy documents, organise non emergency transport etc, in the
absence of the ward clerk.
To ensure that TTA forms are completed by medical staff to ensure efficient and
effective patient discharge.
Prepare documentation by completing patient personal details on nursing, pathology
forms etc, as directed by nursing staff.
To ensure safe/complete discharge/transfer of patients.
To ensure attention is paid to patients’ individual needs.
Obtain specimens e.g. urgent bloods for discharge pending patients.
To inform qualified staff of variations in planned patient progress, via ward rounds with
medical staff.
To contribute to patient progress documentation regarding discharge facilitate
Occupational Therapists referrals, Intermediate Care Service referrals and Clayponds
referral forms.
Policy date: November 2004
Next Review: January 2013
Page 11 of 107
3.2 Co-ordinating a discharge – role of the nurse
The role of the nursing staff in discharge planning is commenced on the patients’
admission and completed when the patient is discharged from hospital into the most
appropriate community setting depending on their individual needs. The role of the
nurse in ensuring this process takes place is as follows:
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Assess health and social needs using the Discharge Risk Assessment documentation
within the nursing admission document on admission.
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With assistance of the Discharge Liaison Nurse complete the CCA checklist and send
this for review to the discharge team.
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Complete a Section 2 notification form where applicable and forward to the In-patient
Management Team and email the completed form or fax on 0208 967 5551.
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Ensure existing community based services are advised of the admission within 24hrs.
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Commence an individual care plan on admission, including documentation of the
patients needs with regard to discharge.
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Ensure appropriate referrals to the multi-disciplinary team are made at the correct point
in the patients stay.
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Refer to the Hospital Care Management Team for assessment, where indicated, at the
earliest opportunity.
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Refer to District Nursing service where appropriate, with enough time for the service to
be implemented and sufficient dressings/appliances to cover the first 7 days (and Bank
Holidays) in the community.
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Provide relevant discharge documentation to the patient and community nursing staff.
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To ensure patients understand the treatment given to them whilst in hospital, with
particular emphasis on change in lifestyle, diet, exercise etc.
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To ensure frail / older patients have a relative / carer / warden available to arrange for
the home to be heated and food to be available when they return home.
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To maintain patient flow by ensuring beds are vacated as early as is safely possible.
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To complete the discharge checklist with patient / carer / advocate prior to discharge.
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To ensure the return of all property to the patient, including valuables, prior to discharge.
Valuables should be reclaimed from the hospital safe on a Friday, prior to a weekend
discharge.
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To ensure that in the case of discharge plans being altered or if a patient signs his/her own
discharge, that those affected are informed and that any necessary changes are made to
facilitate appropriate care in the community.
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To ensure the patient is discharged appropriately attired and that the time of discharge is
appropriate.
Policy date: November 2004
Next Review: January 2013
Page 12 of 107
3.3 Co-ordinating a discharge/transfer – role of the medical staff
The role of the Medical Staff in discharge planning commences on admission through
to discharge of the patient from hospital. The roles and responsibilities of the Medical
Staff in coordinating discharge are as follows:
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To discuss with the patient and/or carer (prior to admission if possible) the likely
outcome, possible length of stay and level of support that may be required on discharge.
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To participate in multi-professional assessments.
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To monitor the patients progress and discus with the multi-professional team.
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To refer to Clayponds for rehabilitation where indicated and appropriate.
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To refer to Psychiatric assessment where indicated.
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To set an estimated discharge date with the multi-professional team when a patient is
first admitted to a ward area. This is to be updated on the completion of each MDT
meeting.
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To confirm the date of discharge with the patient and/or carer at least 24 hours prior to
discharge.
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To complete EPRO to ensure that the prescribed TTA’s can be dispensed at the earliest
opportunity, but at least 24 hours prior to the confirmed date of discharge.
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To explain medications to the patient (and/or carer/responsible person) along with
written instructions.
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To ensure education in self medication administration has taken place where indicated.
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To ensure all patients receive the same standards of care regardless of whether they are
treated on medical or surgical departments, especially with regards to discharge
planning.
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To notify GP’s of any special arrangements including home assessments, at least 24
hours prior to the patients’ discharge.
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To ensure GP letters are fully completed within the EPRO system prior to the patients
discharge. In cases where patients are being discharged to the care of a new GP e.g.
nursing or residential home, a full discharge summary must be given.
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Referral of patients to other hospitals for specialist treatment and those patients
requiring transfer to Ealing Hospital NHS Trust from another acute NHS Trust needs to
be on a consultant-to-consultant basis prior to any transfer taking place.
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For any external transfer the appropriate medical/surgical team need to liaise with the
nurse in charge to inform them of the medical referral on the day that this occurs
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For Tertiary referrals / transfers or where a patient is referred to any third party, to advise
the GP in writing of any recommendation for treatment and where possible in advance of
any treatment being carried out.
Policy date: November 2004
Next Review: January 2013
Page 13 of 107

To send full discharge summaries to the GP’s within 14 days of the patients’ discharge,
except for stays of short duration  48 hours.
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To notify GP’s within 1 working day in the case of death.
4. Patient Groups
This policy applies to the following patient groups, all inpatients, Paediatrics and Maternity
inpatients. Condition specific patient groups are detailed in the appendices.
5. MDT (Multidisciplinary Team) Meetings
5.1 Purpose
To gain a multidisciplinary team view and clarify the current status of the patient, whilst setting
rehabilitation goals aiming and planning for discharge.
5.2 Principles
 Regular MDT meetings are essential for good communication, delivery of high quality
nursing care and effective discharge planning.

Discharge planning commences on admission to hospital with the accurate
documentation of patient pre morbid information, relevant biographical and social details.

Discharge date is provisionally set within 24 hours of admission on the post take ward
round. It is finalised when the patient is deemed medically fit for discharge and safe for
transfer.

All patients are discussed at the MDT meeting, to ensure opportunities for discharge
planning are maximised and that no patient is accidentally left out.
5.3 Frequency of MDT meetings
Weekly MDT meetings will be held on a pre-agreed day which is suitable for the whole of the
MDT. Mini MDT meetings will be held Monday to Friday during the early morning so that
clinical staff can reassess if there are any delays in the patient pathway that need addressing
and who should deal with this.
5.4 Attendance at MDT meetings
It is expected that all MDT members listed below will attend the majority of the weekly
meetings:







Discharge Liaison Nurse
Consultant – if unable to attend they will ensure that a Registrar is available
The Ward Sister or designated deputy
Discharge Support Worker if one allocated to the ward
Therapists – if unable to attend will contact the ward staff or discharge care coordinator
to provide necessary information about patients
Team Social Worker if available – if unable to attend will contact the ward staff or
discharge care coordinator to provide necessary information about the patients
It may be appropriate for other outside agencies to attend. In addition other junior
medical and nursing staff should be encouraged to attend.
Policy date: November 2004
Next Review: January 2013
Page 14 of 107
5.5 Facilitation of MDT meetings
A senior member of the team should be identified as the facilitator, preferably the Ward
Sister, as they will be aware of all the issues surrounding the patients. In addition to
facilitating the meeting, they should ensure that a list of all patients to be discussed is
available for the meeting.
5.6 Format of the Meeting
 All patients within the firm are considered.
 Introduction of patient by facilitator.
 Group decision about whether the patients’ progress or discharge planning needs to be
discussed further at this stage.
 For relevant patients a brief focused summary of medical issues is given.
 Review of goals set at the last meeting, led by the facilitator, with contribution by all team
members beginning with the discipline that has had the most input.
 New goals will be agreed and documented by the facilitator.
 Set discharge date.
 Summary by facilitator of agreed actions.
 Where patients are to be discussed from various wards, a timetable should be arranged
in order that staff can attend as needed.
5.7 Documentation at MDT’s
 A list of all patients including:
Patients name.
Borough of residence
Date of birth
Date of admission
Diagnosis

A record should be kept of any decisions made about patients. It is the responsibility of
the senior nurse present to ensure that these are documented in the patients nursing
notes / communication sheet.

A member of the medical team should be identified as responsible for making entries to
the medical notes as necessary.
5.8 Roles and Responsibilities
It is the responsibility of the facilitator to keep the meeting running to time and to ensure that
everyone has a fair hearing. The Consultant is responsible for medical care and the decision
that a patient is medically fit for discharge, in conjunction with multidisciplinary ‘fit for
discharge’ criteria. The Ward Sister may lead the decision making on discharge for patients
who are medically fit for discharge. For each goal set key people will be identified to take
action, and this will be documented. They will then take responsibility for dealing with this and
feeding back at the next meeting. The medical teams should produce the list of patients.
Good Conduct of Meetings
Meetings will start on time with any necessary information repeated at the end of the meeting
for latecomers. Bleeps will not be answered during the meeting unless completely
unavoidable. Any opportunities for MDT teaching and team-building should be taken as
appropriate.
Policy date: November 2004
Next Review: January 2013
Page 15 of 107
6.1 Social, multiple, complex and older person care needs flow chart
Risk assessment
paperwork completed
on admission
(Ward staff)
Decision made to admit
patient as Elective /
Emergency
Section 2 notification
faxed to DLT if applicable
(Ward staff)
MDT decision re
patients discharge
If patient medically fit
& no ongoing therapy
needed - discharged
If further
problems
Patients’ choice /
capacity with regards
to placement
If case conference
needed – refer to
DLT - has to be
MDT decision
MDT discussion
? Requires
continuing care
? Likely to
require social
care
? Resident of
Ealing borough
Section 2
notification to
HCMT by 12md
DLT
Social services to
review pt within 3
days of FFD date
5 days prior to estimated
discharge date, informal
notification provided to SS (DLT)
Policy date: November 2004
Next Review: January 2013
Patients details incl. proposed
date of discharge entered
onto PAS
(Ward staff / clerks)
Page 16 of 107
No fixed abode but
LBE’s responsibility
No fixed abode
unclear & unclear
who responsible
Continue to manage
as if LBE responsible
Find out which authority
is responsible
Medically fit 24hrs prior
to EDD
Awaiting social
services input
only
No
Informal notification to social
services with the details of
what the patient is waiting
for
(DLT)
EHT issue discharge
notification before 12 noon
(Section 5) (DLT)
Is Social Services provided
within 24 hours of
notification?
No
Initiate claim for
reimbursement
(DLT)
Ward to follow up why there is
delay with SS. Inform DLT of
delay and if patient becomes
medically unwell whilst awaiting
SS.
Policy date: November 2004
Next Review: January 2013
Page 17 of 107
Yes
Patient discharged.
6.2 EHT Reimbursement Process
Reimbursement Flow Chart
The following flow chart outlines the process whereby the reimbursement scheme is implemented
in the Trust. Patients admitted to Ealing Hospital and likely to require social care will follow one of
the flow chart routes depending on their requirements.
Decision made to admit patient as
Elective/emergency
Risk assessment
paperwork completed on
admission
(Ward Staff)
Patient details including
proposed discharge date
entered onto PAS (LBS)
Section 2 notification faxed to
DLT (Ward staff)
YES
Patient requires
continuing care?
(Ward staff/clerks)
Ward nurse assessment
completed and forwarded
to PCT for decision
Patient is likely to
require social care
YES
Resident of Ealing Borough /
or no fixed abode but LBE’s
responsibility
No fixed abode unclear
& unclear who
responsible
No fines
paid by
LBE
Fines paid
by LBE
Continue to manage as
if LBE responsible
Find out if another
authority is responsible
YES
Section 2 notification
to HCMT/SS by 12 noon
(DLT)
SS confirm receipt
By 2pm (SS)
SS to ‘review’ patient within
3 days of FFD date
LBE claim
reimbursement
from other
authority
(SS)
Policy date: November 2004
Next Review: January 2013
If proposed FFD more than 7
days away
5 days prior to estimated
discharge date, informal
notification provided to SS (DLT)
Page 18 of 107
Medically fit 24 hours prior to
estimated discharge date
EHT notify SSD that no longer FFD,
reason for this and new proposed FFD
date (DLT)
No
YES
Informal notification to SS
with detail of what patient is
waiting for
(DLT)
Awaiting SS input
NO
YES
EHT issue discharge
notification before 12 noon
(Section 5)
(DLT)
SS confirm via return
receipt whether service is
available or not by 2pm
(SS)
SS provided within
24 hours of
notification
YES
Initiate claim for
reimbursement
(DLT)
Patient discharged
Policy date: November 2004
Next Review: January 2013
NO
Page 19 of 107
6.3 FLOW CHART
Ealing Social Services and Ealing Hospital Joint Procedure for Ealing hospital
Re: Choice Policy and discharge to a care home
STAGE 1
Patient
admitted
Patient given leaflet EHT 01
at admission
Referral made for
assessment
Section 2 Notification
MDT Com. Care
assessment begins
HCMT Care manager gives patient
leaflets EHT02 and EHT03 (plus
additional leaflets/booklets)
Patient assessed for capacity by medical
team – screening assessment
Medical Team
can assess for
capacity
Medical Team
can’t assess for
capacity
Medical team refer
patient to psychiatrist
Med team record
capacity on
medical notes and
inform care
manager in writing
A
Policy date: November 2004
Next Review: January 2013
Psychiatrist fills in
EHT04, copies to
medical file/care
manager. Informs NOK
using EHT05
B
Page 20 of 107
Assessment and
care plan
completed
Funding applied
for and agreed by
IC Manager
Care Manager begins
discussing options for
future placement/care
package with patient/NOK
A
B
10 days after assessment
that patient is fit for
discharge
SITREP status:
‘SSD Care Home’
Patient has
capacity
Patient does not
have capacity
HCMT Team
Manager offers 2
placements using
letter EHT06
HCMT Team Manager
offers 2 placements to
NOK using letter EHT07
Patient/NOK accepts
offer and is
discharged
Patient/NOK refuses
offer
SITREP status:
‘SSD Patient/family
choice’
HCMT Team Manager informs IC
Service Manager and EHT Gen.
Manager Medicine
HCMT Service Manager and EHT
Gen. Manager Medicine agree to
invoke Stage 2A or 2B
STAGE 2A
Patient has
capacity
Policy date: November 2004
Next Review: January 2013
STAGE 2B
Patient does not
have capacity
Page 21 of 107
2A
2B
Patient asked to
sign formal refusal
using form EHT08
Patient
refuses to
sign
EHT08 recorded
in files
Patient
signs
EHT08 –
copied to
files
Best interests meeting called
by HCMT Service Manager
and EHT Gen. Manager
Medicine
“Best interests” mtg.
agrees future placement
and make arrangements
for discharge as
appropriate
Outcome of “Best
interests” Mmtg. sent to
NOK
HCMT Team Manger
informs HCMT Service
Manager and EHT Gen.
Manager Medicine
Patient discharged
from hospital and
transferred to new
placement
HCMT Service Manager
and EHT Gen. Manager
Medicine invoke
STAGE 3 – SSD
No delayed discharge
charge to SSD from this
date
SITREP status:
‘NHS patient/family
choice
STAGE 3
Referred to EHT legal.
Policy date: November 2004
Next Review: January 2013
Page 22 of 107
7. Discharge Documentation & information to be given to the patient

On a patient’s admission to the hospital a discharge risk assessment must be carried out as
part of the nursing admission documentation – the risk assessment tool is contained within
the nursing admission booklet. For elective patients this risk assessment should be carried
out at pre-assessment so that discharge issues can be identified at the earliest stage.

Once the discharge risk assessment is completed, the ward nurse must decide whether a
Section 2 notification to social services is required with regard to being able to meet the
patient’s social and health care needs on discharge. When medically fit for discharge a
section 5 must completed via the discharge team.

On planning for a patient’s discharge the risk assessment should be referred to alongside
multidisciplinary assessments and discussions that have taken place with the patient, their
carers and family members.

Prior to the patient’s discharge a discharge checklist must be completed (contained within
the nursing admission booklet) to ensure all plans have been put in place to maintain the
patient’s safety on discharge.

Each patient must be discharged home with a copy of their TTA’s and a copy of their
discharge summary which has been completed on EPRO by the medical team which they
are under. This will list the medications that they have been prescribed and what follow-up
arrangements/appointments are required. Their General Practitioner will receive a typed
discharge summary within 48 hours.

The ward nurse must go through the discharge summary with the patient on their discharge
so that the patient fully understands the information provided and the medications that they
have been prescribed. Any concerns about the patient’s understanding of their medications
must be escalated at the earliest opportunity during the patient’s admission, so that
appropriate arrangements have been made to ensure the patient’s safety with regard to
medication administration on the patient’s discharge.

If a patient is discharged to a care home / to another hospital transfer letters must
accompany the patient detailing their physical and psycho-social needs and what care has
been delivered. All nursing documentation for the admission, discharge and transfer of
patients must be available at ward level.

A community services referral form must be completed for those patients who require
further care in the community, such as district nursing services. The need for this care must
be communicated to the appropriate community service prior to discharge – please see
relevant appendices.
8. Discharging and transferring patients out of hours
Special consideration must be taken for those patients discharged or transferred outside of normal
office hours so that the patient’s safety is maintained at all times, particularly for those patients who
live alone and are discharged to their own homes. The usual discharge / transfer procedures as
outlined within this policy should be followed, however special arrangements may need to be
communicated to the patient, their carers and family members. Consideration should be taken for
transport needs and whether transport services can be provided as part of the out of hours service
(see section 9).
Policy date: November 2004
Next Review: January 2013
Page 23 of 107
The duty manager should be informed of any special arrangements that have been made for
patients’ discharge / transfer outside of normal office hours, so that if there are any difficulties the
duty manager can support in resolving these. The duty manager will support nurse led discharge at
weekends and will assist in discharge rounds should this be required out of normal office hours.
Careful consideration should be taken when discharging elderly frail patients and both nursing staff
and the duty manager must ensure that appropriate support services are in place prior to the
patients discharge home if this is required.
Good communication is essential with carers should transport services delay a patient’s discharge
home. Documentation for discharge / transfer of patients outside of normal working hours remains
the same as within normal office hours.
9. Discharge Planning Training
9.1 Nursing Staff Discharge Training
Discharge training is incorporated into the Trust induction for all new employees. The introduction
to discharge planning is delivered by the Discharge Liaison Team. Attendance and feedback are
monitored by the Training Department.
Incorporated in the session are:






Introduction to discharge including re-imbursement & DOH guidelines
The discharge process (an overview) including social flow charts
Roles and responsibilities (incl Discharge Liaison, Nursing Staff & Medical Staff.)
Multidisciplinary Team Meetings, Continuing Care Assessments & District nursing
training
Discharge Lounge, Transport & discharge documentation training
Evaluation and Feedback
Discharge training will be delivered by the Discharge Liaison Team to ward staff on an ongoing
basis via one-to-one and group teaching. This training will include nurse led discharge protocols
and competency assessment of this practice will be assessed at ward level by clinical staff.
Developments within discharge planning and management will be shared at the Ward Sisters
Forum and the Corporate Nursing Meetings and senior nursing staff will be expected to take any
required changes forward within their clinical areas and advise their staff accordingly.
9.2 Doctors discharge planning training
New intakes of medical staff receive training on discharge planning and management at their
induction to the Trust. They are given the opportunity to meet the Discharge Liaison Team and
have a basic introduction to the discharge process within Ealing. They are given written
information about best practice in discharge management and they have the opportunity to ask
questions.
10. The Discharge Lounge
The discharge lounge has been developed to assist with the capacity pressures within the Trust,
and streamline arrangements for patients at the point of discharge.
All patients occupying an acute bed, who fit the criteria, are transferred to the lounge on the day
of their discharge. There the final stages of their in-patient stay are facilitated to ensure timely
and effective discharge. The lounge is also used for patients discharged from the A&E
department awaiting transport home or TTA’s.
Policy date: November 2004
Next Review: January 2013
Page 24 of 107
The lounge provides a quality waiting area with nursing supervision and assistance in a safe and
comfortable environment for patients discharged from ward based care. Patients on the lounge
are provided all meals and medication until safely discharged home.
10..1 Aims and Objectives
 Increase the effective utilisation of acute beds in the Trust.
 Improve and streamline the patient journey through co-ordinated discharge management.
 Assist in achieving emergency access targets.
 Support the emergency capacity pressures within the Trust.
10.2 Opening Hours
 The lounge is open Monday – Friday 0900 – 2000 hrs
 Patient occupancy is between the hours of 0900 – 2000 hrs
 Weekends and public holidays the lounge is closed-although this currently under review
10.3 Admission to the Lounge
 Patients are accepted into the lounge according to the admission criteria (please refer to
the Discharge Lounge Operational Policy). If the lounge reaches full capacity, a
prioritisation order for admission will be implemented. Priority will be given to in-patients
that can transfer early in the day, thus using maximum utilisation of the area.
 It is the responsibility of the ward and A&E staff to identify suitable patients and refer them
to the lounge using the appropriate documentation.
 It is the responsibility of the discharge lounge charge nurse to keep updated with daily
discharges and ensure all appropriate patients are transferred to the lounge.
10.4 Evaluation
Evaluation of the discharge lounge is an ongoing process and includes the following:



Numbers of patients through the lounge – figures collected monthly by Discharge Lounge
staff.
Time of day patients sent to the lounge from the wards – figures collected weekly by
Discharge Lounge staff.
From which areas patients are sent to the lounge - figures collected weekly by Discharge
Lounge staff.
Policy date: November 2004
Next Review: January 2013
Page 25 of 107
10.5 Process for identification of patients for the Discharge Lounge
Patients for
discharge
monitoring forms
completed
previous day by
ward staff
Lists collected by
night 218, DL staff
collect at 08.00 hrs
following day
Identified
patients
transferred
from 0900 hrs
onwards
DL Charge Nurse
rings wards at
08.15 to verify
discharges
DL Staff
Nurse Attend
Bed
Meeting
10h30
Suitable Patients
discharged on post
take ward rounds
and following mini
MDTs
Transferred to
DL ASAP
Definite &
potential
discharges for
the day
identified
Transferred
10h30 onwards
Discharge
Lounge
OPEN
0900 – 2000 hrs
Policy date: November 2004
Next Review: January 2013
Page 26 of 107
Regular
communication
between DL, 218,
A&E and the wards
0900-2000 hrs
Telephone
updates on
discharged
patients
& transfers
organised
Transferred
Between
0900 – 2000 hrs
11. Pharmacy Discharge Policy
The pharmacy department offers a fully comprehensive service to a number of Trusts. These
include:
Ealing Hospital NHS Trust (approx 296 beds)
Meadow House and Clayponds community services (part of Ealing PCT)
TTA (Tablets to Take Away) Policy
TTAs’ must be written at least 24 hours in advance of a patient being discharged. All TTA’s must
be completed on the EPRO system, See EPRO policy/procedure.
11.1 PHARMACY DISCHARGE PROCEDURE
This must be read in conjunction with the EDS Operation Procedure available on the Trust
intranet site.
Dispensing for discharge (D for D) operates on most wards throughout the Trust.
D for D is defined as a system of medication supply which amalgamates both in-patient and
discharge supplies. All medicines are stored in individual patient bedside lockers.
The ward is visited by a pharmacist and technician team daily to assess the suitability for reuse of
patients own drugs (POD’s), and supply medication ready for discharge.

TTA is completed by the doctor on Epro before medication can be dispensed.

Before 11am
Bleep technician/pharmacist to inform of a discharge
The technician will empty bedside locker and assemble TTA
Pharmacist will check the TTA and counsel patient at bedside
If items are required from the dispensary the urgency of the
established and TTAs will be completed in the pharmacy

TTAs will be
After 11am
Empty the patient’s bedside locker
Return unlabelled ward stock items to stock cupboard
Send remaining items together with drug chart
to pharmacy for dispensing
11.2 PHARMACY DISCHARGE PROCEDURE FOR LAMMAS WARD
 If the TTAs consist of items stated on the approved list (located on medicine cupboard
door) then leave the TTA on the ward for the pharmacist to dispense.
 However, if there are items on the TTAs that are not stated on the approved list then send
the TTA to pharmacy.
 If the patient is to be discharged prior to the pharmacist visit then send the TTA to
pharmacy.
11.3 DOSETTE BOXES
 Patients discharged with district nurse referral
Nursing staff to liaise with district nurse to ensure arrangements have been made with G.P
and community pharmacist to provide weekly prescriptions and dispensing service. The
referral must be accepted before dispensing of medication or discharge of patient. Any
problems refer to pharmacist or Discharge Liaison Team.

Patient discharged without District nurse referral
Refer to pharmacist or Discharge Liaison Team.
Policy date: November 2004
Next Review: January 2013
Page 27 of 107
IN ALL CASES WHERE PHARMACY IS TO FILL A DOSETTE BOX ON DISCHARGE AT
LEAST 24 HOURS NOTICE MUST BE GIVEN
12. Transport
12.1 Booking Criteria
Transport for ward & A&E patients is organised as follows.
 Transport for patients is booked according to suitability criteria.
 This criteria is divided up into patients that are suitable, patients who are not suitable for
medical or risk reasons and patients who are independent and able to make their own
arrangements.
 Posters and suitability criteria booklets are available on the wards for staff to refer to should
they be unsure of the criteria or booking procedure.
 Those patients not fitting the criteria are expected to make their own arrangements for
getting home. This is at the discretion of the nursing staff however.
 Staff can arrange taxi’s for patients who are unable to use public transport or who have no
one to collect them. Alternately patients can use the free phone situated in the main
reception area. Patients are expected to pay for the taxi’s themselves.
 For those patients fitting the criteria, a transport booking form is completed and forwarded
to the transport department.
 Patients requiring specialised crew are booked through LAS. Authorisation must be
obtained from the budget holder prior to this being booked.
 Patients waiting hospital transport will be transferred to the discharge lounge on the day of
their discharge, where they will be collected by the transport team.
 Transport booking forms from A&E, AAU, Minors and Trolleys must have a shift leaders
signature and name printed.
12.2 Out of Hours Booking




The transport department is a 24 hour service.
Office hours are between 8am – 7 pm, Monday – Friday. The transport office can be
contacted between these times on Ext 5405 / 5185.
Out of hours times are between 7 pm – 8am, Monday to Friday and Weekends. The on-call
team can be contacted during these hours on 02075104210
The on-call manager can be contacted in the case of extreme emergencies on
07736592647. Please note that staff should only contact the on-call manager if they cannot
resolve an issue with the on-call driver.
13. Transfer of Patients & Documentation
Ealing Hospital NHS Trust provides a service for the residents of the London Borough of Ealing.
It’s local commissioner of acute services is the Ealing Primary Care Trust. Patients may need to be
transferred to and from the hospital based on their usual place of residency and this may include
repatriation from or to countries outside of the United Kingdom. Transfer letters will accompany all
transfers out of Ealing Hospital detailing the patient’s personal data; next of kin data and specific
information re-medical treatment received and current health and social care needs.
13.1 Internal Transfers
This is defined as moving patients from one ward/clinical area to another within the hospital. No
internal transfers should be taken place after 2200hrs, unless the Duty Manager feels that the
transfer is absolutely essential with regard to patient dependency (need for critical care) / most
appropriate care to be given. The exception to the above will be the transfer of patients from the
A&E department to a suitable ward bed. When transfers are necessary to safeguard emergency
Policy date: November 2004
Next Review: January 2013
Page 28 of 107
beds or to ensure specialist care they are coordinated by the Duty Manager in liaison with the
nurse in charge of the ward and the medical teams.
Every effort will be made to minimise the need for internal transfer in the interest of the patients’
management, comfort and infection control.
Patients who are medically fit for transfer out of Intensive Care / High Dependency Unit to acute
wards will be facilitated by the Duty Manager as soon as possible. Prior to transfer, the Duty
Manager will obtain an adequate report of the patients’ needs and requirements for a safe and
appropriate placement to ensure that the receiving ward has adequate staffing to support the
patients needs.
Tracheostomy patients transferred from the Intensive Care Unit may only be transferred to 6 North
(Respiratory Care), 4 South (Cardiac Care) or 7 North (General Surgery). Patients requiring noninvasive ventilation should be transferred to 6 North ward and / or CCU in the first instance.
13.2 Transfers to and from other hospitals

Referral of patients to other hospitals for specialist treatment and those patients requiring
transfer to Ealing Hospital NHS Trust from another acute NHS Trust needs to be on a
consultant-to-consultant basis prior to any transfer taking place.

The appropriate medical/surgical team need to liaise with the nurse in charge to inform
them of the medical referral on the day that this occurs. The nurse in charge will then liaise
with the bed manager/clinical site manager at the accepting/referring hospital to ensure
transfer to or repatriation takes place at the earliest opportunity.

The Duty Manager will collect information on patients for transfer and those for repatriation
according to the duty management local protocol and an exchange of patients will be
organised, where this is possible, if bed availability is limited.

Transfer of patients in and out of the hospital must be facilitated by the Discharge Liaison
Team who will confirm that the patients have been referred and/or accepted by medical
staff.

A repatriation form must be completed for those patients transferring to Ealing Hospital
NHS Trust from another acute Trust. This will provide information on patient condition,
infection status and care needs. This information must be obtained prior to patient transfer
so that appropriate placement, equipment and staffing are ensured. The Discharge Liaison
Team will fax the form to the referring Trust and will request that once completed it is faxed
back to the nurse in charge.

If patients are being repatriated from a hospital in another country the Consultant must
ensure that the nurse in charge has the details of the repatriation company in order to
coordinate the transfer.

Every effort is made to ensure an appropriate bed is available as soon as possible for
patient repatriation.
(Please refer to Appendix 6 for repatriation procedure for Duty Manager use)
13.3 Infection Control and Transfer / Placement of Patients
It is essential to utilise beds in a way that minimise the risk of spread of infection between patients
as per Infection Control Policy. Close liaison with the Bed Manager, Ward staff and the Infection
Policy date: November 2004
Next Review: January 2013
Page 29 of 107
Control Team to ensure effective risk assessment, prioritisation of all isolation rooms and
containment of infection or outbreak is essential.

Infection control precautions should be adhered to at all times when identifying suitable
beds for patients to be admitted to.

All patients with suspected infection that is deemed to be contagious in line with the
infection control policy should be isolated accordingly.

If a side room is required for an emergency admission/ patient requiring barrier nursing and
one is not available, the Infection Control Team (ICT) should be contacted to identify which
patients across the Trust may be transferred out of side rooms (update at 10.30 a.m. bed
management meeting that ICT attend).

The side room database should be updated each night by the Night Nurse Practitioner so
that the list of patients is accurate for the bed management meeting the following day.

The infection control policy should be adhered to at all times, a copy of which is kept in the
Bed Managers office.

Please also refer to the Cohort Nursing of Infected Patients guidelines with regard to when
there is a shortage of side-rooms.

The outbreak of infection guidelines should be adhered to when an outbreak of diarrhoea
and vomiting and/or an identified infection has been reported.
13.4 Single Sex accommodation
All patients transferred to/within the hospital must be allocated to a single sex bay if their medical
condition allows. Wherever possible a side room will be allocated to ensure single sex bays are
maintained, even within high dependency areas if capacity of side rooms allows for this.
Ward Managers/Matrons must escalate to the Bed Manager/Head of Nursing if there are any
issues around bed management in their areas specific to gender. The bed manager/Head of
Nursing will ensure that patients are re-allocated to another ward should there be issues around
capacity and patient flow to the wards due to gender issues.
This is a government target and there are set rules and guidelines which can not be breached
regarding single sex accommodation. All enquiries should be addressed to the Head Nurse or
Director of Nursing. Please see policy related to this area.
14. Reporting Failed Discharges and Discharge and Transfer Incidents






Any failure to discharge/transfer a patient effectively/safely must be reported via the
Trusts Incident Reporting System.
Any near misses where patient discharge/transfer is concerned must be reported via
the Trusts Incident Reporting System.
Investigation of patient discharge incidents will be the responsibility of the
departmental manager, as per Trust policy.
As well as forwarding the incident form to the clinical risk department (within 3 days),
the Trusts Discharge Manager will be informed by the department manager of all
discharge incidents/near misses to allow for a thorough multiprofessional investigation
into the cause of the incident/near miss.
Patient discharge/transfer incidents will be reviewed by each clinical Division every 3
months to establish areas of risk and plan for improvement of patient services.
After hours failed discharges must be reported to the Duty Manager.
Policy date: November 2004
Next Review: January 2013
Page 30 of 107
15.
Monitoring effectiveness of the policy
o
Completion of discharge risk assessment paperwork – 6-monthly audit to be completed by
Discharge Liaison Team.
o
Evaluation of discharge training – numbers of attendees and feedback – information
collected by Training Department.
o
Questionnaire to staff re-content of discharge policy – annual audit to be completed by
Discharge Liaison Team.
o
TTAs prescriptions – when these are received – day/time – to be monitored by Discharge
Lounge staff and Pharmacy.
o
Case management referrals – numbers to be collected by the Discharge Liaison Team and
by OPRAC staff.
o
Documentation at MDT meetings to be monitored by the Discharge Liaison Team.
o
MDT meeting schedule and attendees to be monitored by the Discharge Liaison Team
o
Readmission audit to be undertaken by the Discharge Liaison Team.
o
Review of incident reporting forms for transfers and discharges as in point 11 above.
Policy date: November 2004
Next Review: January 2013
Page 31 of 107
Appendix 1
Operational Discharge / transfer Policy for A&E
(Majors, Minors, Resuscitation Room, CDU, “Recovery”, CPEU)
Purpose: To ensure safe and complete discharge of patient to appropriate environment.
Process:

Patient medically cleared for discharge by doctor and cleared for discharge by ARISE
Team if necessary.

Mobility discussed with shift leader; assess whether patient requires wheelchair/stretcher.

Relatives/nursing home informed if necessary.

“Out of hours”: “Caring for you” transport to be arranged in accordance to “CFY” policy.

Patient appropriately dressed.

TTA’s arranged and appropriate advice card(s) given if necessary; OPA arranged and
patient informed if necessary (i.e. Fracture Clinic, District Nurse Referral…)

Patient’s property checked: i.e. clothes, shoes, keys, own medication – all property to
remain with patient at all times.

Remove Venflon + apply dressing on site

Wristband to be removed at time of actual discharge.

Wristband to remain on patient if transferring to discharge lounge.

Appropriate timing of discharge from A&E for vulnerable patients.

Complete all discharge information of PAS and Symphony.
1.1 Discharge / transfer checklist for asthma in A&E
All patients with severe or life threatening asthma will be referred to the medical team on call.
For patients with mild asthma
The General Practitioner will;
 Receive a discharge letter stating severity of attack, treatment given and changes
made to regular therapy.
The patient will
 Receive instruction on the medication regime prescribed for them including what the
action of the different inhalers is and when they should take them.
 Have an adequate supply of medication when they leave the hospital
The A&E dept.
 Will check the patient’s inhaler technique and take appropriate action as necessary.
 Will advise the patient on appropriate follow up.
Policy date: November 2004
Next Review: January 2013
Page 32 of 107
For patients with moderate asthma
The General Practitioner will
 Receive a discharge letter stating severity of attack, treatment given and changes
made to regular therapy.
The patient will
 Receive instruction on the medication regime prescribed for them including what the
actions of the different inhalers are and when they should take them.
 Have an adequate supply of medication when they leave the department
The A&E dept will
 Prescribe 40mg Prednisolone for 7 days
 Increase baseline inhaled treatment by adding a long acting beta 2 agonist or by
doubling the dose of inhaled steroid
 Will check the patient’s inhaler technique and take appropriate action as necessary.
 Will advise the patient on appropriate follow up
Policy date: November 2004
Next Review: January 2013
Page 33 of 107
North West London
Network Admissions Policy for
Adult Critical Care Services
Drafted: G Suntharalingam, NW London Hospitals NHS Trust
Version: 1.09, *Final* Feb 2005. For annual review.
1
Definitions
1.1
Levels of care
(National Framework Document “Comprehensive Critical Care: A review of Adult
Critical Care Services”)
Level 0: Normal acute ward care.
Level 1: Acute ward care with additional advice and support from critical care team.
Level 2: More detailed observation or for support of a single failing organ system only,
other than advanced respiratory support
Level 3: Support of at least two organ systems, or advanced respiratory support
2
Common principles
2.1
Philosophy of adult ITU admission
(Reworked from Dept of Health document EL-96-20, “Guidelines on admission to and
discharge from Intensive Care and High Dependency Units”, March 1996)
i. Patients are admitted to critical care areas for advanced life support and
monitoring, during active treatment of an underlying clinical condition. The
clinical condition which has resulted in the patient needing critical care should be
identifiable, acute and potentially reversible
ii. Admission for critical care is only appropriate if the patient can be reasonably
expected to survive and receive sustained benefit in quality of life.. An increasing
requirement for organ support is not in itself a reason to admit a patient who is
suffering their final illness, and who has no apparent avenue of recovery.
iii. Even when there is an acute reversible component, the patient’s chronic health
status (impairment of organ systems or physiological reserve) may significantly
affect the patient’s ability to survive and benefit from an intensive care episode.
This requires careful assessment, but should not be prejudiced by age or ethnicity.
iv. A patient’s stated or written preference for or against intensive care must be taken
into account. The role of relatives in the case of an incapacitated patient is to
represent their understanding of what the patient would wish.
Policy date: November 2004
Next Review: January 2013
Page 34 of 107
3
Referral procedure
3.1
Referral
i. Any consultant or appropriately experienced member of their team may refer
patients to critical care services.
ii. In addition, nursing or allied health professional staff, or members of the outreach
team where one exists, may need to alert critical care medical staff directly in
circumstances of unusual urgency. In these cases the referring team must always
be alerted in parallel and are expected to attend.
iii. The referring team shall maintain responsibility for the patient up to admission to
intensive care, and shall remain responsible for ongoing management if admission
is refused or deferred.
iv. No Unit in the Network shall accept a patient for transfer from any department
(wards/theatres/A&E) of another hospital unless he or she has been referred to the
critical care team of the referring hospital and assessed as suitable.
3.2
Response to referral
The critical care team shall review the patient according to clinical urgency. Critical
care review does not imply that care of the patient has been taken over, or absolve the
referring team of responsibility. Review may result in one of several outcomes:
i. Decision to admit
Criteria
 Patient has a reversible acute condition and is appropriate for advanced
intervention as discussed in section 2.1.
 Patient needs level 2 or level 3 care, or is likely to need such care in the near
future, and would be at risk if he or she remains in a general ward area.
 The severity and time course of the patient’s condition is such that further
management of the acute illness, or simple fluid and oxygen resuscitation
measures on the general ward, are unlikely to improve the patient’s condition
or to reduce the need for admission.
Policy date: November 2004
Next Review: January 2013
Page 35 of 107
Action
 Transfer to appropriate critical care area as soon as available. This may mean
transfer within the hospital, within the Transfer Group, or outside the Transfer
Group. See section 4 – admission procedure.
ii. Decision for active level 1 (ward) management and review
Criteria
 Patient has a reversible acute condition and is appropriate for advanced
intervention as discussed in section 2.1.
 Patient does not clinically need level 2 or level 3 facilities at present but may do
later. Patient can be safely monitored on an acute general ward at present.
 Patient would benefit from simple resuscitation and basic organ support in an
acute ward setting with advice from critical care team (level 1).
 Patient would benefit from further investigation and management of underlying
acute condition in an acute ward setting.
Action
 These measures may render level 2 or level 3 care unnecessary if carried out
promptly. It is not in any patient’s best interests to undergo an avoidable
intensive care admission.
 The referring team has full responsibility for ensuring that such measures are
adequately executed. Critical care team input shall be advisory and may
include bedside training or interventional support at their discretion.
 Critical care team shall maintain active review at agreed intervals, either direct
review by Unit clinicians or via outreach team. Patient shall be urgently
reviewed with a view to admission if condition deteriorates.
iii. Substantive decision not to admit
Criteria
 Patient is suffering his or her final illness – the clinical deterioration and organ
failure for which he or she has been referred is not amenable to treatment of
an underlying acute problem; or any such acute problem has already
progressed beyond reasonable hope of recovery.
 Patient’s co-morbidity and poor physiological reserve make the prospect of
Policy date: November 2004
Next Review: January 2013
Page 36 of 107
significant and sustained recovery minimal
 Patient refuses admission, either by previous stated wish or on discussion with
critical care and referring team.
Action
 Decision shall be discussed between referring team, critical care team, and
relatives. The role of the relatives is to represent the anticipated wishes of the
patient, rather than to make an active end of life decision.
 Where there is dissent, discussion should be referred to consultant level. Initial
discussion may take place at junior or senior trainee level according to local
policy but in principle, trainee critical care team members should not refuse
admission without senior discussion.
 The intensive care consultant is the final gatekeeper for critical care admission.
No referring staff may order or force an admission which has been refused by
the critical care team after discussion at consultant level. In cases of extreme
dissent the Unit lead clinician, respective clinical directors and risk
management team should be consulted.
 Critical care staff shall render assistance and advice on palliative or other
supportive care of refused patients. However, final responsibility for ongoing
management shall rest with the referring team.
 The patient’s resuscitation status should be reviewed under the Trust’s “Do Not
Resuscitate” policy as a logical and integrated part of critical care discussion.
4
Admission procedure
4.1
ITU Bed State

The nurse-in-charge and the intensive care consultant shall agree upon one of
three operating states for level 3 (ITU) areas:

“Green”: Open to all admissions. The unit is able to accept referrals from
within the Trust, elsewhere in the Network, or outside the Network on the basis
of clinical need.

“Amber”: Closed to external transfers. In-house emergencies can be
managed (by flexible use of HDU beds, by short-term ventilation in Recovery or
Theatre areas, or by other means) but transfers cannot be accomodated, whether
from within or outside the Network. A Unit with one remaining full ITU bed may
declare itself to be in either the Green or the Amber state: this will depend on
local policy, availability of other in-house resources, and individual judgement.

“Red”: Closed to A&E and all other external referrals. New in-house
Policy date: November 2004
Next Review: January 2013
Page 37 of 107
patients cannot be accomodated without transferring either the new patient or a
more stable patient (see below).
4.2
Course of action when Unit closed to referrals (State Red)

If a new in-house referral is judged to be suitable for ITU admission but there
are no beds, then either the newly referred patient or a more stable patient
currently in the intensive care unit shall be transferred to another hospital.

The decision of which patient to transfer has significant ethical and medicolegal
implications. Each Trust has a duty of care to all its patients inside and outside
ITU, and must triage resources accordingly. However, transferring an existing
stable ITU patient means removing them from a place of safety against that
patient’s own best interests.

Therefore, in line with prevailing opinion and practice throughout the vast
majority of hospitals in the Network, it is anticipated that a patient already on
ITU should be transferred out only under exceptional circumstances.

Conversely, the Network clinicians as a body accept that it may, on occasion, be
unavoidably necessary to transfer a current intensive care patient. The balance of
likely clinical outcomes for both patients must be carefully weighed, especially
if putting a stable patient at risk for the sake of another who is unlikely to
survive. Units with available beds must support any decision, once taken.

The decision shall be discussed between Units and with referring medical or
surgical teams and relatives of each patient involved, but the final decision of
which patient to transfer rests with the the intensive care consultant of the
referring Unit, who is responsible for both patients; no critical care team should
place another Unit under unreasonable pressure to substitute referred patients.

If a patient on ITU is transferred or discharged for the benefit of another
individual or individuals, it is recommended that the reasons for transfer,
together with anonymised clinical details of the other patient(s) involved, should
be fully documented and archived by means of a Trust clinical incident report.
4.3
Successful admission (State Green or Amber): information flow
Upon agreement by the critical care team that the patient is suitable for admission:

The nurse-in-charge shall be consulted before the patient is accepted, to ensure
that nursing staffing levels are adequate to care for the new admission.

If patient is transferred directly from A&E or accepted from another hospital, the
relevant specialty or on-take general team shall be contacted and asked to
assume responsibility for management after discharge from ITU.
Policy date: November 2004
Next Review: January 2013
Page 38 of 107

Relatives shall be informed of admission by ITU staff.

The patient’s GP shall be informed of admission by telephone, letter or email.
Policy date: November 2004
Next Review: January 2013
Page 39 of 107
5
ITU admissions from outside the hospital
5.1
Ward to ITU (i): Patients needing current or anticipated ITU care and
local specialist care (e.g. oncology, vascular surgery), referred from
another hospital to a medical or surgical team outside ITU
Referral to critical care will be made by the local (receiving) consultant or their team.
Referral centres may operate a priority system between referring hospitals to manage
demand. It is the responsibility of the receiving specialty team to contact the ITU
medical staff and to verify bed availability before accepting the patient into the
hospital.
5.2
Tertiary referral centres with existing links outside the Network may choose to
prioritise their admissions so as to provide a service both within the Network and to
other hospitals relying on them for support.
Ward to ITU (ii): Patients needing current or anticipated ITU care and local specialist
care (as above), referred from another hospital direct to the receiving ITU team
5.3
Availability of beds will be confirmed but the referring hospital will then be asked
to contact the appropriate specialist on-call team who, if they wish to accept the
patient, will in turn make a referral to the critical care team.
ITU to ITU: Patients primarily requiring ITU care and critical care expertise, referred
5.4
directly from Unit to Unit. Includes clinical transfers to specialist Units, and nonclinical transfers due to lack of beds.
5.5
Referrals will be considered and accepted by the intensive care team. If there is an
ongoing problem relating to the original cause of admission (e.g. related to
surgery), the appropriate specialist team on-call should be asked to review the
patient on arrival. The on-take team in the relevant speciality at time of arrival
Policy date: November 2004
Next Review: January 2013
Page 40 of 107
shall be responsible for care of the patient after discharge from ITU, and will be
notified as such.
ITU to ward: Repatriation of ITU patients
A repatriation policy is under separate discussion.
Private sector to NHS: Emergency requests for critical care assistance
The Network and its constituent Trusts have a duty of care to all patients in the area,
and will render all necessary assistance when clinically indicated. However, standard
critical care admissions guidelines and equity of access shall be considered to apply to
both NHS and private sectors. The critical care expectations and consent of private
patients and their relatives shall be assessed and managed in line with those in the
NHS: there can be no discrimination, either for or against private patients.
Policy date: November 2004
Next Review: January 2013
Page 41 of 107
Appendix 3
Discharge Protocol for Paediatric Patients
Procedure
Check list
Patients are reviewed throughout the daythere is a formal ward round in the morning
but there may also be a further ward round
in the afternoon/evening depending on the
dependency and unit activity.ric medical
team and named nurse for the patient.
Once a decision is made to discharge a
patient home the following principles apply.
The patient is discharged without any
follow up but is given the copy of the epro
discharge letter
The patient is discharged with an out
patients appointment
Appendix 1
The patient is discharged home with a
follow up review on the day ward
The patient is on home leave and returning
for daily/nightly treatment
This appointment is made by the named
nurse phoning through to the day ward to
book a time and date for review
The patient is discharged home with a
paediatric community nurse referral
Appendix 2
OPD
appointment
Day Care
follow up
Paediatric
community
follow up
All patients discharged from the ward will
have a completed epro and a copy of that
letter given to the parent/carer
Discharge
letter
Patients who are discharged and require
medicines to take home-once the
medicines have been dispensed, the nurse
who completed the discharge will ensure
that she has explained when and how to
give the medication
Advice on
how to
administer
medication to
parent/carer
Policy date: November 2004
Next Review: January 2013
Page 42 of 107
Date
Signature of
discharge
nurse
Appendix 4
GUIDELINE FOR THE CARE AND MANAGEMENT OF MATERNITY ADMISSION TO THE
EMERGENCY DEPARTMENT
1.
INTRODUCTION
Maternity patients refer to all pregnant women and women in the 6 weeks postpartum period.
Fifty two of the 295 women (18%) who died from direct and indirect maternal deaths in 2003 –
2005 died in Emergency Department (ED). The main diagnoses in relation to these cases were
pulmonary embolism, ectopic pregnancy, intracerebral bleed and sepsis. While not all of these
deaths were avoidable, a significant few resulted from poor understanding of basic clinical signs in
sick pregnant women.
Babies delivered in ED were also associated with poorer outcome particularly in the absence of
appropriate staffing and equipment.
All clinicians in ED must have regular training in the identification and management of the sick
maternity patient and ectopic pregnancy, including the need to be aware of its atypical clinical
presentations such as those mimicking gastrointestinal disease. Nevertheless, management of
maternity patients often warrants a multi-disciplinary approach.
Following assessment by ED or GPs, patients <20 weeks gestation (without obstetric interventions
e.g. amniocentesis, cervical cerlage) should be followed up in Early Pregnancy Unit (EPU).
Patients >20 weeks gestation will be managed (providing the reason for admission is obstetric
related) in Labour Ward (LW), Antenatal Clinic (ANC) or Day Assessment Unit (DAU).
Pregnant women arriving in ED >20 weeks gestation who have a non-obstetric related
complication/condition should be managed by the ED. Obstetric opinion can be sought by
contacting the Labour Ward Coordinator or Obstetric Registrar.
Patients from EPU will have their clinical e-records in Viewpoint. Booked maternity patients should
carry their hand held Maternity Records. These should be updated to reflect any consultation
made.
Contacts for the Obstetrics and Gynaecology Teams are: Obstetric Registrar bleep 310, SHO
bleep 069.
2.
GENERAL MANAGEMENT OF PREGNANT WOMEN ATTENDING EMERGENCY
DEPARTMENT

Pregnancy testing should be routine for all women of child-bearing age if the pregnancy
status is unknown.
The management of pregnant women seen in ED must involve an experienced doctor
familiar with women’s health and local protocols.
Pregnant women >20 weeks gestation assessment unless the patient is unstable.
Pregnant women with the following, otherwise unexplained signs, must be seen by the
Registrar or Consultant from the Obstetric Gynaecology Team:



a) Abdominal pain/vaginal bleeding
Policy date: November 2004
Next Review: January 2013
b) Severe headache
Page 43 of 107
c) Hypertension
e) Breathlessness
g) Chest pain



2.1

2.1.1
Concurrent pathologies may exist and should be considered.
Pregnant women should be examined in an appropriately equipped room or cubicle.
The care of pregnant women with medical conditions requiring treatment should be
discussed and planned in conjunction with the Obstetric Gynaecology Team.
DOCUMENTATION:
A record of the presentation, diagnosis and management must be made in the appropriate
Viewpoint or hand held Maternity Record.
Admission:




2.1.2
All maternity admissions should be discussed with the Registrar or Consultant from the
Obstetric Gynaecology Team.
The Obstetric Gynaecology Consultant in charge should be made aware of all maternity
admissions either directly or via the on-call Obstetric Gynaecology Registrar.
Pregnant women should be admitted to Lammas Ward or appropriate general ward with
appropriately trained Midwives or Nurses.
In the event of being admitted into a medical ward or ITU for managing a predominantly
medical condition, the patient should be reviewed by an Obstetrician/Gynaecologist or a
Midwife regularly. The patient’s name should be recorded on the Labour Ward board or
gynaecology hand over sheet. These wards should alert clinicians of patients t hat
have not been reviewed.
Discharge:

3.
d) Proteinuria
f) Pyrexia
h) Known ectopic pregnancy or PUL
A discharge summary should be sent to the GP and Obstetrician/ Midwife in charge.
GENERAL MANAGEMENT OF POST PARTUM WOMEN ATTENDING THE
EMERGENCY DEPARTMENT
Post partum women are seen in the ED by the Obstetric SHO/Registrar and if necessary admitted
to the appropriate ward. A discharge summary should be sent to the GP.
4.
GENERAL MANAGEMENT OF PREGNANT WOMEN COLLAPSED, MISCARRYING OR
DELIVERYING IN ED
Local resuscitation and delivery protocols and guidelines should be observed in conjunction with
the following recommendations:

5.
The Obstetric, Gynaecology and/or Midwifery Team should be fast bleeped or contacted via
switchboard to attend the resuscitation, miscarriage and/or delivery.
DELIVERING OR MISCARRYING IN ED
Where it is known that such a pregnant woman is being brought in to ED by ambulance, the
Obstetric Gynaecology on call Registrar and/or Delivery Suite Coordinator is informed in advance.
Policy date: November 2004
Next Review: January 2013
Page 44 of 107
Delivery, generally >20 weeks gestation is best conducted in Labour Ward whenever feasible.
However, resuscitation, if required, should not be delayed by the process of transferring the
patient.
If the pregnancy is known or suspected to be viable, the Paediatric Team should also be fast
bleeped or contacted via switchboard to attend the delivery. The team will include a Paediatric
Nurse with the necessary neonatal resuscitation equipment and/or incubator.
6.
PREGNANT WOMAN COLLAPSED IN ED
The appropriate resuscitation team(s) should be fast bleeped or contacted via switchboard to
attend the resuscitation.
The team will include a Caesarean Section Scrub Nurse with the necessary caesarean section
pack(s).
The Perimortem caesarean section is part of the resuscitation procedure in any women who
arrests in the second half of pregnancy. It should be undertaken to facilitate maternal resuscitation
within 5 minutes of the arrest if there is no initial response to advanced life support in the tilted
position.
Consideration for a hysterectomy may be necessary to facilitate resuscitation.
In non-viable foetuses, discussion about post mortem investigation, cremation, or burial should be
made with the couple before any sensitive disposal.
Administration of anti-D in non-immunised Rhesus negative women should be given prior to
discharge.
If the patient is not admitted, a gynaecology consultation should be arranged in 2-6 weeks.
MATERNAL TRANSFER GUIDELINES (OFF SITE)
1.0
INTRODUCTION
It is important both from Risk Management and CNST points of view that every Maternity Unit has
in place an approved and effective system in place for the transfer of women between various
areas of care provision.
Transfer details to and from the Maternity Service are recorded in the maternal notes by the
Midwife.
ITU has a locally agreed admission/discharge/transfer document.
These guidelines aim to outline the procedure and responsibilities of staff for the safe and efficient
transferring of women to, from and within the Ealing Hospital NHS Trust (EHT).
Policy date: November 2004
Next Review: January 2013
Page 45 of 107
1.1




AREAS COVERED BY GUIDELINES:
IUT to and from Ealing Hospital
Postnatal transfer to and from Ealing Hospital
Transfer of homebirth to Ealing Hospital
Transfer between CDS and other specialist areas e.g. ITU/HDU
1.2





SCOPE OF GUIDELINES:
Midwives
Obstetricians
Anaesthetists
Neonatal Staff
ITU/HDU Staff
2.0
2.1



2.2
IN UTERO TRANSFER OUT OF EHT
CRITERIA:
Between 23 and 28 weeks of gestation where delivery is likely but not imminent.
>28/40 if SCBU has no facility to look after baby (no cots or staff).
Both woman and fetus(es) are stable and delivery not imminent.
INDICATION:
Labour or delivery for either maternal and/or fetal conditions <28/40 or if SCBU has no available
cots.
Examples of maternal and fetal conditions:
Maternal:
- Severe PET
- Medical conditions necessitating early delivery
Fetal Conditions:
- Preterm labour <28/40
- IUGR
- Congenital abnormalities
- Any condition requiring complex or prolonged intensive care
2.3




2.4






CONTRAINDICATIONS TO TRANSFER:
Cervix >4 cm dilated
Non-reassuring FHR trace
Women who are cardiovascularly or haemodynamically unstable e.g. ongoing APH,
fulminating PET
Any condition that warrants immediate delivery in the interest of woman or baby(ies)
PROCEDURE:
Need for IUT is recognised and discussed with the Obstetric Consultant.
Obstetric SpR/SHO to contact EBS for details of the nearest available cot(s).
Obstetric SpR to liaise with SCBU of receiving hospital to confirm cot availability.
Once confirmed, Obstetric SpR to liaise with Labour Ward Coordinator/SpR/ Consultant of
receiving Unit to confirm Labour Ward availability to accept woman and write a covering
referral letter to receiving Unit.
Explanation and details of receiving unit given to the woman and her family by SPR or
Midwife.
All discussions and information provided should be documented in the maternal notes.
Policy date: November 2004
Next Review: January 2013
Page 46 of 107





Midwife or Ward Clerk to photocopy maternity notes for receiving Unit.
Midwife to check equipment necessary for transfer e.g. tocolytic drugs, delivery and
resuscitation kits available.
Labour Ward Coordinator to liaise with LAS for ambulance transport.
A Midwife of reasonable experience to escort woman to receiving Unit after ensuring woman
and/or fetus is still stable for transfer by performing CTG if appropriate and maternal
observations TPR BP Oxygen saturations if necessary. These observations to be
documented in the maternal notes prior to transfer.
On arrival at receiving Unit, a comprehensive handover of care between EHT Midwife and
Midwife of receiving Unit to take place before returning to EHT. All transfer documentation
including times destination and name of receiving midwife to be entered into maternal notes.
3.0
IN UTERO TRANSFER INTO EHT
3.1
INDICATION:
Labour or delivery for maternal and/or fetal condition(s) after 28 weeks of gestation and accepted
by SCBU.
3.2


CRITERIA:
>28 weeks and SCBU has adequate facilities.
Stable maternal and fetal conditions prior to transfer.
3.3

PROCEDURE:
Referring Unit to liaise with SCBU/Labour Ward Coordinator/Obstetric SpR/Consultant and
arrange transfer.
On arrival, comprehensive handover between referring Unit Midwife and Labour Ward
Midwife. Details to be documented in maternal notes.
Obstetric SpR to review woman within 30 minutes of arrival and document findings and
management plan in maternal notes. Consultant to be informed of admission by SPR.
SCBU informed of arrival. Information documented on whiteboard.
If delivery imminent, Obstetric SpR to liaise with Neonatologist/ Anaesthetist/Theatre Team
as appropriate.
If delivery not imminent for neonatology, review when available.
Plan of Management to be documented in notes.






4.0
POSTNATAL TRANSFER
4.1
INDICATIONS FOR TRANSFERRING OUT OF EHT:
Maternal and/or neonatal requirements for other specialist services not provided at EHT.
4.2
PROCEDURE:
Women whose babies need to be transferred out who are otherwise well and have had an
uncomplicated birth and immediate postnatal period:

Discharge from Postnatal Ward.

Inform GP/Community Midwife/Health Visitor.

Arrange:
o Rooming in with Postnatal Ward of receiving Unit.
o Local Community Midwife follow up.
o Transport to Unit- private or ambulance.

Maintain postnatal records.
Women who are not well enough to be discharged (post LSCS/complicated birth):
Policy date: November 2004
Next Review: January 2013
Page 47 of 107




Labour Ward Coordinator or Obstetric Team to liaise with Postnatal Ward of receiving Unit
and arrange transfer.
Document Plan of Management and photocopy notes.
Inform GP/Community Midwife/Health Visitor regarding transfer.
Arrange transport - ambulance with Midwife escort.
5.0
WOMEN TRANSFERRING TO A SPECIALIST UNIT
5.1
INDICATIONS:
Unwell women who require specialist input not available at EHT e.g. Neurosurgery, Cardiothoracic
Unit.
5.1






6.0
PROCEDURE:
Need for transfer discussed with patient/relatives/midwifery/obstetric/ anaesthetic/critical care
teams - decision to transfer should be jointly made by Consultants and Senior
Midwives/Nursing Staff.
Discuss need for transfer with Specialist Unit.
Inform Supervisor of Midwives (SOM) on call.
Once transfer agreed:
o Fax referral letter to Unit.
o Photocopy notes.
o Arrange transport with Midwife/Obstetric/Anaesthetic escort as appropriate.
o Complete discharge from EHT paperwork.
Arrange for appropriate discharge for baby:
o Home if well
o SCBU/Transitional Care of receiving Unit if requiring further input.
Inform Community Midwife/GP/Health Visitor.
TRANSFER FROM COMMUNITY TO HOSPITAL
6.1




INDICATION – INTRAPARTUM:
Obstetric emergency.
Neonatal emergency.
Maternal request.
Procedure required that cannot be carried out at home e.g. repair of 3rd degree tear.
6.2

PROCEDURE IN LIFE-THREATENING EMERGENCIES:
Community Midwife:
o -Contact Labour Ward Coordinator/Obstetric SpR and discuss need for transfer.
o Explain need for transfer and discuss with woman (if maternal condition allows) and her
family. Document this in the birth notes.
o Arrange Paramedic ‘blue light’ ambulance by calling 999. Give details to operator.
Explain need for emergency transfer. The local arrangement with LAS is that the 999
number is used by the Midwife to summon a ‘blue light’ ambulance for all home birth
transfers.
o Escort woman to hospital and handover care to Labour Ward Team.
o Liaise with Labour Ward the following day regarding further Plan of Management.
o Ensure discharge paperwork is completed to inform GP/Community Midwifery Team.
Paramedics will complete LAS paperwork (CAS sheet) and provide Midwife with a carbon copy
which should be placed in the maternal notes.
Document all transfer information including reason for transfer, times of calls made, time of
ambulance arrival, time of arrival in Labour Ward, name of receiving Midwife.
Policy date: November 2004
Next Review: January 2013
Page 48 of 107
6.3

PROCEDURE IN NON-LIFE THREATENING CASES:
Community Midwife:
o Contact Labour Ward Coordinator/Obstetric SpR for advice who will decide the best place
for women to be reviewed e.g. Labour Ward/Day Assessment Unit (DAU)/Antenatal Clinic
(ANC)/Postnatal Ward.
o Arrange appropriate transport. This will depend on the maternal condition.
o Liaise with appropriate area within 1 hour to ascertain woman has arrived and for Plan of
Management.
o Inform GP/Community Midwifery Team of Plan of Management.
Document all details of transfer including time of transfer and destination in the maternity postnatal
notes.
MATERNAL TRANSFER GUIDELINES (ON SITE)
1.
INTRODUCTION
The transferring of women between areas is a recurrent theme within Maternity Departments.
Prior to any woman being transferred between the maternity wards, the Midwife Co-ordinator of an
area, should agree to receive the woman at a mutually beneficial time. A direct handover of care is
advocated for all transfers. However, there are times of high clinical activity when appropriate
planning and face to face handover is not always possible. In these circumstances, the Midwife
must ensure the client’s safety and transfer as is deemed the most appropriate and handover to
the receiving staff via telephone.
2.
TRANSFERRING CLIENTS FROM ANC TO DELIVERY SUITE
Give the woman all the information she needs to facilitate her understanding; what is happening
and the reason for her admission to Labour Ward or the Antenatal Ward. Give the client support
and answer any questions she may have.
The client can walk to the Delivery Suite/Antenatal Ward and the Midwife can handover verbally on
arrival. Reason for transfer and time of transfer should be documented in the Green handheld
notes.
3.
TRANSFER FROM ANTENATAL WARD TO DELIVERY SUITE
A Midwife, to facilitate an appropriate handover of care, should accompany any client being
transferred. However, if the Midwife is unable to accompany the client, then a Healthcare
Assistant can attend whilst the Midwife ensures a telephone handover has taken place.
Complicated or high risk cases (including labourers) must have a Midwife escort.
4.
TRANSFER OF WOMEN AND THEIR BABIES FROM DELIVERY SUITE TO THE
POSTNATAL WARD
All uncomplicated vaginal deliveries can be transferred to the wards on a wheelchair with the
mother carrying the baby.
LSCS’s or women with heavy epidural can be transferred on a hospital bed, with the help of a
Porter accompanied by a Midwife.
The Midwife must ensure her notes are complete and accompany the mother to the ward. The
Midwife will handover verbally to the receiving staff.
Policy date: November 2004
Next Review: January 2013
Page 49 of 107
Transfer to the postnatal ward is documented on page 20 of the birth notes. The receiving staff
member should ensure that the mother has a call bell and that the first postnatal assessment and
orientation to the ward section in the maternal postnatal notes is documented/completed. The
baby should have 2 ID bands and a cot card and security tag device and this should be
documented in the notes with an explanation given to the mother re: Tagging Security System.
If a midwife cannot accompany the client, a Healthcare Assistant will accompany her; whilst the
Midwife ensures an appropriate handover of care via the telephone.
5.
TRANSFERRING AN ANTENATAL WOMAN TO THE WARD
Clients are encouraged to be mobile and walk to the ward; this is dependent upon complaint and
reason for admission.
There must be an appropriate verbal handover of care to the receiving Midwife on the ward.
At all times, ensure the woman understands what is happening and any reasons for transfer.
Details of transfer including time of transfer and location should be documented in the notes by the
transferring Midwife.
6.
TRANSFER HOME POSTNATALLY
Both the mother and baby will be transferred home postnatally after the Midwife has completed a
postnatal check and the baby is reviewed by a Midwife (qualified in exam of the newborn) or the
Neonatal Team. These checks are documented in the maternal and baby postnatal notes. She/he
should ensure that the appropriate obstetric reviews have been carried out if necessary prior to
discharge.
The Midwife will ensure all the relevant documentation is completed and the data entered into the
computers.
The woman will receive her maternal and baby postnatal notes, information on how to contact the
Community Midwife, the emergency telephone number for Labour Ward and the Postnatal Ward
telephone number.
She will also receive an Ealing Postnatal information booklet, information on reducing the risk of
cot death and a child health record book.
The Midwife must ensure the following:

The correct transfer address.

If the woman lives out of area, phone/fax the discharge to relevant hospital and document.
The same has been completed in the notes.

Send printouts to GP/Health Visitor/Midwife.

Collect any TTA’s if required.
7.
7.1

TRANSFER OF WOMEN BETWEEN CDS AND ITU
INDICATION FOR TRANSFER TO ITU:
Maternal condition requiring intensive or critical care input e.g.:
o Following massive obstetric haemorrhage
o Severe pre-eclampsia/eclampsia
o Cardio-respiratory complications
o Diabetic complications
This list is not exhaustive.
Policy date: November 2004
Next Review: January 2013
Page 50 of 107
7.2
SHIFT CHANGE:
7.2.1
CDS:
Whenever care is transferred from one member of staff to another, a verbal handover is provided.
This transfer of care is documented in the notes, together with the name and designation of the
new staff member.
A record of the patient’s details and staff member(s) caring for the patient is documented in the
Communication Book.
7.2.2
Postnatal Ward:
Whenever care is transferred, a verbal handover is provided.
The staff on duty and the patients allocated to each staff member are recorded in the work book.
7.2.3
Medical Staff:
A verbal handover is given to the on coming staff. A patient handover sheet is used to document
patient details and treatment required.
7.3
ROLES AND RESPONSIBILITIES:
7.3.1
Obstetricians/Anaesthetists:
The decision to transfer to ITU will be made by the Obstetric and Anaesthetic Team and should be
at Consultant level. The Anaesthetist will accompany the woman to ITU and provide handover.
The Medical Team should provide a full and clear explanation to the woman (if possible depending
on maternal well being) and her family on the reason for transfer.
The plan of management should be clearly documented e.g. timing of removal of drains,
thromboprophylaxis, etc.
The reason for transfer should be documented in the maternity notes.
7.3.2
Midwife:
The Midwife is responsible for accompanying the woman to ITU. She/he should provide a detailed
verbal handover to the receiving Nurse and document the handover and transfer details including
time of transfer in the maternal notes.
The Midwife or Labour Ward Coordinator should document the woman’s details on Labour Ward
board to ensure daily review of woman for antenatal/postnatal checks.
Ensure baby is cared for in the appropriate place i.e. SCBU or with relatives.
On admission to ITU, a Critical Care Admission document is completed by the receiving Nurse.
8.




TRANSFER OF WOMEN BACK TO CDS FROM ITU
The handover of care takes place between nursing and midwifery staff/medical and obstetric
staff.
Transfer from ITU is agreed by ITU Medics and the Obstetric Team.
Labour Ward is informed by ITU staff by phone of the transfer.
The critical care discharge/transfer checklist is completed by the ITU staff prior to discharge.
This is filed in the woman’s ITU notes.
Policy date: November 2004
Next Review: January 2013
Page 51 of 107



9.




10.
On admission to Labour Ward, a verbal handover is taken by the receiving Midwife and the
transfer details; including times of transfer, name of receiving Midwife, are recorded in the
maternal notes.
Plan of management should be documented clearly.
Woman to be reviewed by the Obstetric Team within an hour of returning to Labour Ward or
on the next ward round.
TRANSFERRING A BABY TO Neonatal Unit (NNU)
Ensure that the baby is appropriately labelled. Two ID bands and a cot card.
Document if Vitamin K has been given.
Complete the baby’s notes ASAP and compute the data ASAP. This is to ensure the baby
has a hospital number so further tests and investigations can be undertaken.
Baby should be transferred in a cot or on a resuscitaire depending on condition of the baby.
POST DELIVERY TRANSFER OF BABY FOR SURGERY
See Perinatal Network Guideline.
Policy date: November 2004
Next Review: January 2013
Page 52 of 107
Appendix 5
IMPROVING DISCHARGE MANAGEMENT AND REDUCING
LENGTH OF STAY
Nurse in Charge responsibilities





NIC (Nurse in charge) is responsible for discharge planning/arrangements on each shift
and is the key contact for communication
NIC to brief DSW on tasks required each day re-patient care needs in progressing
discharge and the nursing team must be very clear about the DSW role
Social worker/MDT must liaise with the NIC in the first instance re-information on patients
Ensure provisional discharge date is communicated to patient, family and MDT
Ensure senior nursing representation at mini MDT and weekly MDT
Doctors’ responsibilities







SHO/Registrar to attend the mini MDT meeting every morning (Mon-Fri) and ensure
provisional discharge date given
Consultant/Registrar to attend weekly MDT (see MDT guidelines)
The medical team to review potential discharges first thing in the morning
TTAs to be completed on EPRO as early as possible in a patient’s admission and not left to
the day of discharge
Blood forms to be written up the day before if discharge depends on blood film review and
bloods to be taken evening before discharge by nursing team if possible – results to be
checked first thing in the morning, day of discharge.
Escalate to Consultant if there is a delay with diagnostics/specialist review
Always explore discharge to patient’s own home as the first option with family members,
before suggesting care home placement
Weekly MDT meetings





Agree who will be the Lead (chair) for MDTs (will vary for different clinical areas)
The Consultant/Matron/Ward Manager jointly agree the Lead and together they take
responsibility in ensuring MDTs are effective
Ward Manager/Matron to attend the MDT on weekly basis
Guidelines for MDT meetings to be circulated by the MDT Lead to all members of the MDT
so that the group agree standards
MDT minutes sheet to be used at all MDTs (see guidelines)
Mini daily MDTs




Ensure these happen and they are effective – see discharge focus toolkit
Discharges must be anticipated 24 hrs earlier (or sooner) in line with proposed discharge
date
Issues such as dossette box need/family availability/preparation of services must be
considered daily
Anticipate potential for weekend discharges and ensure these happen – nurse in
charge/nursing team to support this culture (discuss at Thurs/Fri ward round/mini MDT and
use potential discharge monitoring sheet, copying to the duty manager)
Long Stayers’ meeting

Daily meeting for all inpatient areas to discuss top 5 delayed discharges
Policy date: November 2004
Next Review: January 2013
Page 53 of 107


Long stay patients are discussed on a Wednesday and Friday. Present at the meeting are
HoN/Matrons/Social Services/Discharge Liasion tea,/rehabilitation servcies
Meeting to look at support required in expediting discharge arrangements and common
themes impeding discharge planning and progression
Bed meetings





Nurse in charge, Matron/Ward Manager and DSW to attend 10.30 bed meeting on AMU
Bring patient names to 10.30 bed meeting – those patients for potential/definite discharge.
Patients suitable for ARISE services/Clayponds/medically fit and waiting for POC to be
identified to the chair of the meeting
Patients identified as medically fit and waiting must have TTAs (including dossette box if
appropriate) done
Matron/Ward Manager to attend 230pm bed meeting and to escalate difficulties being
encountered re-discharge arrangements and review bed status.
Policy date: November 2004
Next Review: January 2013
Page 54 of 107
Appendix 6
Repatriation of patients from other hospitals to EHT
Repatriation of patients from other NHS Trusts to EHT must be given a high priority and should
occur in a timely, safe & effective manner. The Senior Nurse Practitioner/Bleep 218 holder
must be contacted / informed by the accepting EHT clinical team that a specific patient is for
repatriation back to EHT. A repatriation form must be completed by the referring hospital.
Process
a) A repatriation form must be completed by the transferring hospital. The Senior Nurse
Manager/ Duty Manager will email/fax a copy of said form to the Bed Manager at the
transferring hospital for completion prior to it being faxed back.
b) This form must be completed for EACH patient being repatriated back to EHT from other
NHS Trusts.
c) Should the request be made by the Bed Manager at the transferring hospital:
whenever possible they should be advised that doctor-to-doctor ‘hand-over’ should occur,
and the patient be accepted by an EHT clinical Consultant/Team. The EHT clinical
consultant/ team should then inform the Senior Nurse Practitioner/Duty Manager that the
patient has been formally accepted. If this is not possible a copy of the patient’s notes
should be faxed to the Senior Nurse Practitioner/Duty Manager at EHT along with a
completed ‘Repatriation of Patients’ form. The Senior Nurse Practitioner/Duty Manager will
then liaise with the appropriate ‘on-call’ team to decide whether or not the patient can be
repatriated on the day of request.
d) Bed allocation & Transfer arrangements must NOT be made until the Senior Nurse
Practitioner/Duty Manager has received a completed form.
e) On receipt of the repatriation form, the Senior Nurse Practitioner/Duty Manager must
allocate a bed on the appropriate ward/area within EHT at the earliest
opportunity(preferably within 24/48 hours-bed availability dependant)
f) Brief details regarding the request for repatriation back to EHT must be recorded on the
‘Transfer In’ form held in the Senior Nurse Practitioner/Duty Manager file.
g) When it is not possible to repatriate the patient back to EHT on the date of request the
Senior Nurse Practitioner/Duty Manager must contact the Bed Manager of the transferring
hospital on a daily basis confirming that the patient’s condition/ requirements have not
changed and to keep the bed manager there informed regarding reasons for any delay in
transfer and (where possible) give an estimate of when the transfer may occur.
h) On EHT bed-allocation, the Senior Nurse Practitioner/Duty Manager should make every
effort to have the patient’s EHT medical notes delivered to the receiving ward. A copy of the
repatriation form is to be made available to the receiving ward for entry into the patient's
medical notes.
i)
Returning patients must arrive no later than 16.00 hrs.
j)
If patient is unable to return before 16.00 hrs the accepting team must be made aware in
order to make arrangements with the on-call team.
k) If the transfer does occur out-of-hours or at a weekend, the patient must be assessed and
clerked by the EHT on-call team and handed back to the accepting team at the earliest
Policy date: November 2004
Next Review: January 2013
Page 55 of 107
opportunity.
l)
Repatriated patients transferred back to EHT must go directly to a pre-allocated bed and
should NOT be brought to the Accident and Emergency department unless requiring
stabilisation/ resuscitation following sudden deterioration in their condition during the
transfer.
REPATRIATION FORM FOR EALING HOSPITAL NHS TRUST
Patient details:
Hospital No.
DoB:
Age:
M/F
Address:
Tel No:
Next of Kin:
Relationship:
Address:
Informed: Y/N
Transferring Hospital/Ward:
Tel. No.
Contact No.
Transferring Consultant:
EHT Accepting Consultant/Team:
EHT Ward/Unit:
Diagnosis:
EHT Hospital No:
Investigations:
Clinical Condition (please tick)
Ventilated □ Tracheostomy □ BIPAP □
CPAP □ NIVV □
Please give details:
Lines Inserted:
Central Venous Catheter: Y/N
Arterial Lane: Y/N
Date:
Urinary Catheter: Y/N
NGT: Y/N
Date:
Size:
Size:
NG Tube □
Date:
Date:
Surgical Drain □
UWSD □
PEG □
Please give details:
Airway:
ETT: Y/N
Size:
Tracheostomy: Y/N
Date:
Size:
Double/Single lumen.
Date:
Cardiovascular System:
Date:
Time:
Policy date: November 2004
Next Review: January 2013
HR:
BP:
Page 56 of 107
CVP:
Inotropes: Y/N
Details:
Policy date: November 2004
Next Review: January 2013
Page 57 of 107
Appendix 7
Alcohol and Drug Abuse Pre-discharge Advice Sheet
First point of contact is the Alcohol and Drugs Nurse Specialists attached to the Trust as some
discharges do not need referral to The Gatehouse Alcohol Team, Community aftercare services
are available to patients post detoxification programmes

Referral to Gatehouse Clinic
 Once the patient and referring team have discussed the possibility of further enhanced
alcohol interventions, the Gatehouse Clinic will accept a faxed referral.
 Referrals should be faxed to 0208 354 8470.
 Patients are sent an appointment for assessment if they are considered to be eligible
candidates for rehabilitation. Currently the appointment wait is approximately 4 weeks for
routine cases. Priority assessment can be seen within 2 weeks .
 There is no immediate bed availability. However has directed access to in patient beds at the
Max Glatt Unit for appropriate patients.
 Pending the outcome of the assessments, patients are considered for potential enhanced
alcohol intervention or referral to residential rehabilitation.
There are 4 other options, which may be considered according to the individual patient
needs and requirements. These are as follows;





Option 1
EACH is a voluntary organisation that helps people with both drug and alcohol problems..
Open to anyone that is abstinent to alcohol, ideal to anyone that is discharged post
detoxification programmes.
Has access to 1-two-1 counselling, structured day groups, open group sessions and Cognitive
Behavioural Therapy.
Written referral only, usually appointment made for assessment made within 2 working days
and can commence talking therapies within the week.
Offers structured day programme for 12 weeks for the most stable .
Option 2
 Ealing DAIS (Drugs, Alcohol. Interventions Support.) is run CRI is a national charity
providing in excess of 160 services in towns and cities across England and Wales
(020 8843 5900)
 Community-based services offer flexible support ranging from advice and information to
structured treatment programmes. Services seek to reduce harm and promote abstinence,
and to help people recover from the damaging effects of substance misuse
 Monday, Wednesday & Friday from 9:00am – 5:00pm Tuesday & Thursday from 9:00am 8:00pm:
 Self referrals, offers drop ins. No Appointment needed





Option 3
The TASHA Foundation is a services for people affected by mental health difficulties and/or
substance misuse. Information, counselling and holistic health care. Skills training.
Family/carers support group
Phone, and written referrals accepted.(done no offer drop in)
TASHA Foundation provides counselling services, family therapy, aftercare programmes,
training projects, self-help opportunities and out-of-hours support to individuals affected by
substance misuse and/or mental health difficulties
Mobile: 07943 030313 Fax: 020 8571 9983
Option 4
Policy date: November 2004
Next Review: January 2013
Page 58 of 107





For telephone help and advice there is a free national alcohol helpline ‘Drinkline’ available on
free phone number 0800 917 8282.
Lines are open from 09h00 – 23h00.
This line is open to those who have a recognised drink problem, and to those who have a
concern regarding a relative or friend.
Alcoholics Anonymous will advise on meetings and information. They will arrange an
accompaniment for the candidate to attend the first of their meetings.
They are available on free phone number 0845 769 7555
Patients on opiate substitution medication
Policy date: November 2004
Next Review: January 2013
Page 59 of 107
If patient are already known to the Gatehouse and are prescribed opiate substitution whilst in
hospital Liaison with the care manager at the Gatehouse so that a community prescription
can be set up and also the dispensing pharmacist notified.(020 8354 8962)
If a patient is known to the Ealing DIP (Drug Intervention Programme) Please contact
substance misuse practitioner(arrest referral worker) with so prescribing as dispensing can be
organised.(020 7899 2162)
Please give 24 hour notice prior to discharge so that prescribed treatment can re-commence
in the community.
Patients not known to any substance misuse service but being prescribed opiate substitution
medication whilst in hospital.
Liaise with the Alcohol and Drugs Nurse Specialists as early as possible. It may be possible
to continue prescribing in the community with support from the Gatehouse. If not the patient
with have to be discharged without any substitute medication due to risk of overdose.
Policy date: November 2004
Next Review: January 2013
Page 60 of 107
Appendix 8
Breast Care Patients / Macmillan Breast Nurse Specialists
There are two Macmillan Breast Nurse Specialists. They are based in the Macmillan team
office on level 9 and work:
Mon – Fri 8am until 4pm.
Ext 5693 and they carry bleeps 018 or 282.
Referral to the Macmillan Breast Nurse Specialist can be made directly from any member of
staff or from the patient by phone or bleep.
All women seen in the Breast Clinic and diagnosed with breast cancer are seen by the Breast
Nurse Specialist, who is then responsible for carrying out assessment and monitoring of
psychosocial issues in response to diagnosis and treatment. Information about treatment for
breast cancer is provided and written material supplied.
Women who are admitted with other conditions and have a history of breast cancer may wish
to see a Breast Nurse Specialist during their stay, this should be offered where possible.
What may initially seem an unrelated illness may in fact be attributed to their previous breast
cancer or treatment.
The Breast Nurse Specialist also carries out fitting of breast prosthesis, provides advice and
support on altered body image issues, breast reconstruction and assessment of lymph
oedema.
Policy date: November 2004
Next Review: January 2013
Page 61 of 107
Appendix 9
Department of Cardiology / Heart Function Clinic
1. Introduction and background
Despite substantial recent advances in the field of cardiovascular medicine, chronic heart failure
remains an illness of appalling mortality, with a 30% 12 month mortality for moderate failure,
increasing to 50% in severe heart failure. Heart failure accounts for 5% of all adult medical
hospitalisations annually, incurring huge costs for the NHS, estimated at just over £625 million
per year. The disease leads to prolonged inpatient stays with 30-40% readmitted within 12
months. With the increasing age of the general population and improved survival following
myocardial infarction, the incidence of heart failure is set to continue to increase. There are
between 1-5 new cases/1000 population identified annually in the UK.
2. The Ealing Multidisciplinary Heart Function Team
CONSISTS OF:
Consultant Cardiologist
One part time Clinical Nurse Specialists in Heart Function
PA to Consultant
Cardiac Physiologist
SpR Cardiology
Further groups who will have involvement with the Heart Function Group are the: Cardiac
rehabilitation nurses
Meadow House Palliative Care Team
Pharmacists
Dieticians
Physiotherapists
Social Services
Clinical psychology
Community team – heart failure nurse, GP’s and matrons
1. Aims and objectives

To optimise the medical management of patients with heart failure whilst retaining particular
attention to the individual needs of the patient

To provide comprehensive education for patients with heart failure and their carers about
the management of heart failure and provide psychological support from diagnosis to end of
life issues

To ensure a holistic approach to the care and management of patients with heart failure
thus promoting empowerment, self care and well-being
Policy date: November 2004
Next Review: January 2013
Page 62 of 107

To improve patients quality of life and satisfaction with the service

To reduce the incidence of hospitalisations for heart failure both first acute admissions and
readmissions

To improve service provision of and accessibility to heart failure services within Ealing
Hospital Trust, in primary care and other health care providers, such as tertiary centres for
more complex medical, interventional (device) therapies and heart failure surgery

To encourage and develop research into clinical practice thus ensuring a flawless, evidence
based heart failure service
2. Objectives of the Heart Function Service









Streamline the service to provide a systematic approach to identification and treatment of
patients with heart failure in primary and secondary care
Provision of a high quality service
Development and continuing expansion of service to meet local needs
Construction of a flexible service to provide rapid accessibility across primary and
secondary care.
Effective communication between the heart function service / patients / carers / primary and
secondary care physicians
Provision of education and support for patients with heart failure and their carers and
involvement in their management and end of life decisions
Provision of advice, support and training for GP’s, junior doctors, nurses in primary and
secondary care and health care professionals caring for patients with heart failure
Maintenance of database of patients with heart failure to provide up to date access to
patients past history and current management
Audit and review of service to ensure objectives are met and up to date research and
evidence based practice is reflected in the service
5. Mode of referral
There are several possible sources of patients to be referred to the Heart Function clinic, including
in-patients under the care of medical and surgical firms at Ealing Hospital and out-patient referrals
usually from local GPs. However, all patients referred to the Heart Function clinic must have the
appropriate form completed (see Appendix 2) and preliminary investigations performed to confirm
the diagnosis of heart failure (see NICE guidelines appendix 1). Dr. Rosen or SpR cardiology will
approve all referrals to the clinic.
Completed forms must be returned to:
Clinical Nurse Specialist Heart Function,
Dept. of Cardiology,
Ealing Hospital NHS Trust,
Uxbridge Road,
Southall,
Middlesex UB1 3HW
Fax Number 020 8967 5007
Patients will be sent an appointment according to the earliest possible availability, on a partial
booking basis.
Policy date: November 2004
Next Review: January 2013
Page 63 of 107
6. Criteria
Inclusion Criteria
 Inpatients with clinically defined heart failure, confirmed by either echocardiography or a
raised BNP.
 Patients with New York Heart Association (NYHA) Class II/IV, moderate to severe LV
dysfunction (e.g. ejection fraction <40%).
 Outpatients with a working diagnosis of heart failure on the NICE algorithm included in
Appendix 1.
Exclusion Criteria
 Patients with major physical co-morbidity, in whom non-cardiological problems require to be
resolved in the first instance
 Patients in whom it is felt that psychological factors might inhibit any potential benefits from
the Heart Function Group
 Patients <18 years
Policy date: November 2004
Next Review: January 2013
Page 64 of 107
Appendix 10
Dermatology Department
What Dermatology offers;
The dermatology Unit is committed to clinical governance and providing high quality care as well
as meeting the challenge of implementing new services, as dictated by patients and local
communities changing needs.
Clinic Opening Hours:
Monday – Wednesday 9am – 5pm
Thursday
No Doctor’s clinic
Friday
9am – 4pm
Change of Appointments
Direct line; 0208 967 5429
Between the hours of 8:30am – 4:30pm, Monday to Friday
Treatment Area
Monday – Friday: 07:30am – 3pm
Public Holidays
Closed
Nurse led Clinic
Tuesday: 08:30am to 12:00pm
Wednesday: 09:00am to 12:00pm
Friday: 09:00 to 12:00
Services within the Department
Main Outpatients Clinic;
Daily treatment, patch testing, minor surgery, specialised microscopically guided skin surgery
(MOHs’), Review of Post op Wound and removal of sutures, Change of Dressing, DCP
Treatment for Viral Warts,Iontophoresis treatment for Hyperhydrosis, infliximab for I.V infusion,
phototherapy and chemo-phototherapy, and nurse-led clinic for monitoring of systemic
medication and biologic medication.
The unit also accepts referrals from GP’s and Specialists within Ealing Hospital as well as from
other hospitals. (Hammersmith, Hillingdon, Charring Cross, West Middlesex, Northwick Park).
Dermatology utilises in-patient general medical beds as required. Dermatology SPR are on call
out of hours.
In-patients
A small number of patients require in-patient admission, due to the severity of their symptom.
Departmental nurses work with the ward nursing staff with regards to patients’ treatments and
education of junior medical and nursing staff.
Policy date: November 2004
Next Review: January 2013
Page 65 of 107
Concerns
If the patients have any concerns regarding their treatment they are advised to speak to the
nurse looking after them or the Sister in charge. The Matron of the unit will also discuss any
issues that the patients have and those which have not been resolved for them.
The patients may wish to contact the Patient Advice and Liaison Service (PALS) who provide
advice and support. Pals will also be able to deal with any concerns and guide the patient
through the different services available within the NHS, including the formal complaints
procedure.
PALS can be contacted using the free phone number: 0800 064 1120.
Policy date: November 2004
Next Review: January 2013
Page 66 of 107
Appendix 11
Diabetes Nurse Specialists
Base:
Diabetes offices,
Level 6,
Ealing Hospital
Direct line/ answer phone 020 8967 5519
Fax 020 8967 5305
The DNS team is not an emergency service; the team works 9am to 5pm Monday to Friday.
When in the hospital the nurses are contactable by phone on their direct line or on bleep 096
when out of the office. Non urgent messages can be left on the answer phone. Referrals are
usually seen within 24hr.
Role:
To provide a high standard of educational and clinical support on the management of diabetes
for patients and health care staff. The team see patients in both Ealing Hospital, Ealing PCT
(Clayponds Hospital, diabetic mini-clinics in GP surgeries, patients homes, nursing and
residential homes) and St Bernard’s Hospital.
Referrals:
Newly diagnosed diabetic patients for education
Patients new to insulin that need to be taught to self-administer
Patients that need update on managing their diabetes
Patients that would like to learn how to monitor their blood glucose
Diabetic’s that are pregnant admitted to general wards
FOR ADVICE ON STARTING OR ADJUSTING DIABETIC MEDICATION PLEASE CONTACT
DIABETES REGISTRAR, BLEEP 002 OR 287
How to refer:
On the Diabetes Nurse Specialist referral form.
Staff can also be contacted by phone to discuss the referral but must be followed up
with a referral form.
Discharge / planning:
When discharging patients on insulin, ward staff must identify early if there is any problem i.e.
 Does the patient need training or educational input?
 Is a district nurse required?
 Who is giving the insulin and do they need training?
 If the patient is already know to district nurse service, liaise prior to discharge so visit can
be restarted.
Ensure that patient/ is discharged with:


Clear written instruction on name, dose and time of insulin.
Written Sharps disposal information and sharps bin.
Enough Syringes, pen needles etc until patient able to get prescription from GP.
Policy date: November 2004
Next Review: January 2013
Page 67 of 107


Clear prescription information for GP re syringe or pen needle etc.
It the district nurse is giving the insulin they need a letter signed by doctor stating name of
insulin and dose and time.
Follow up:All diabetic patients need regular reviews either at their GP practice or if there have more
complex problems they will be seen in the hospital diabetes clinics i.e. type 1 patient and those
type 2 on insulin.



Check where they have had previous diabetes care and make sure that it is
re-established.
If no previous diabetes care, either refer back to GP or if more complex refer to Ealing
Hospital diabetic clinic.
If the diabetes nurse specialists have seen the patient on ward and taught them to give
insulin they will follow them up in the community or in the diabetes clinic
Policy date: November 2004
Next Review: January 2013
Page 68 of 107
Appendix 12
Haematology & HIV Patients
When patients are well enough to go home, we will make the necessary arrangements for you to
receive your medications and transport will be arranged if necessary. Otherwise, patients are
expected to make their own way home.
Prior to leaving the hospital, patients are given lists of contact numbers for either the
Haematology or HIV list depending upon diagnosis.
Haematology Patients advice on discharge are as follows:
Patients who have recently had a course of chemotherapy may experience side effects.
Chemotherapy often produces a fall in your normal blood count; therefore patients are prone to
infections and to bleeding.
Therefore, they are advised to contact one of the Haematology Team if they become unwell or
experience any of the following symptoms:
Rise in temperature
Bleeding from nose/gums
Blood in the urine
Breathlessness
Nausea and Vomiting
Pain / Swelling at the site of infusion
During normal working hours (9 am – 5 pm):
Haematology Nurse Practitioner: 020 8967 5562 / 020 8967 5000 Bleep 431
Haematology Registrar:
020 8967 5000 Bleep 083
Haematology SHO: 020 8967 5000 Bleep 084
After 5 pm, weekends and Bank Holidays:
Contact the On Call SHO via main switchboard:
Contact Wilmot ward:
020 89675000
020 89675667
1. HIV Patients advice on discharge is as follows:
During normal working hours (9am – 5pm):
The HIV patients are advised to contact the Robert Dann Unit if they have any worries about their
health or queries regarding their medications. The nursing staff in the unit will advise them if they
need to come to clinic to be reviewed by a doctor or if they can wait until their next clinic
appointment.
Robert Dann Unit
020 89675554
After 5 pm, weekends and Bank Holidays:
Patients are advised to contact Wilmot Ward and speak to the senior nurse who will triage patient
over phone and advise them on the necessary steps to take i.e. going to their GP, going to the
nearest A&E or Ealing A&E. The HIV patients are no longer advised to come straight to the
ward. If they do so, they will be sent to A&E, and the HIV SHO on call will be informed.
Policy date: November 2004
Next Review: January 2013
Page 69 of 107
Wilmot Ward:
020 89675667
2. Haematology Day Unit
The Haematology day unit looks after patients with a wide variety of blood disorders including
Leukaemia, Sickle cell anaemia and Hodgkin’s disease and can provide written information on
these disorders to patients and carers.
Various treatments and investigations are carried out in this unit e.g. chemotherapy, blood
transfusion, blood tests and bone marrow aspirations.
A patient support group has been established which is very active in raising funds to develop the
unit and its facilities for the patients. The group has regular meetings to discuss relevant issues
and at times various speakers are invited to attend the meetings to raise awareness.
Integral to the smooth running of the unit is the multidisciplinary team of Haematology Nurse
Specialist, Consultants, junior medical staff, nurses, pharmacist, laboratory staff and
administration staff.
Contact details:
0208 967 5562
Policy date: November 2004
Next Review: January 2013
Page 70 of 107
Appendix 13
Homeless Persons Advice Sheet
1. Discharge to the homeless Persons Unit / Housing Resettlement Officer
during normal working hours





Patients (In-patients not A&E patients) with identified housing issues(not adequate or
appropriate housing to return to) are to be referred to the Discharge Liaison Team within 24
hours of admission, who in turn will refer to Health Care Management Team 1.
The discharging team should issue the patient with a brief discharge letter, giving any
details of any special circumstances, which may help with housing/temporary
accommodation.
It is important to have TTA’s and a discharge letter ready the day before discharge, in
order for the discharge to be facilitated by 09.30am the following morning.
For patients who have a planned discharge and have special housing needs, i.e. where
there is a disability, there is an appointment system available. The discharging team
should, whenever possible, contact the number listed below to arrange a suitable time prior
to the patients planned discharge date and not on the day of discharge.
The numbers listed below are for the ‘Reception Advisors’ who will advise on the
appointments system.
Discharge to:
Ealing Town Hall Annexe
New Broadway
W5 2BY
Tel: 0208 825 5000 (Main switchboard & ask for the
persons unit.)
Homeless
2. ‘OUT OF HOURS’ DISCHARGE FOR THE HOMELESS



If the patient is claiming benefits ‘Shelter Nightline’ will assist with hostel and bed
availability. They also have social workers, advisors and very often a visiting GP, attached
to them to assist the client with personal matters and advice.
The service will take self-referral clients.
The line is a free phone number and is available as a 24-hour service, but is often busy for
long periods of time. Persistent dialling gets the caller through.

Telephone 0808 800 4444

Please see the London Borough of Ealing ‘Night Shelters’ list for additional local hostels
and refuges.
Policy date: November 2004
Next Review: January 2013
Page 71 of 107
Appendix 14
Infection Control
Standard Infection Control Practice, which consists of standard precautions and transmission
precautions, should be followed when caring for any patient in any healthcare setting.
Standard Infection Control Precautions are a single set of precautions to be used routinely by all
healthcare practitioners in the care of all patients all the time.
Transmission precautions are additional precautions that are only required for a smaller group of
patients’, usually in hospital only who are known, or suspected to be colonised or infected with
high risk organisms spread through airborne-droplet and / or contact routes. These are used in
addition to standard precautions following a risk assessment.
When planning the discharge of any patient who has or has had a communicable disease or is
carrying a multi-resistant organism a risk assessment should be carried out to identify any
infection risk outside hospital.
The patient must be made aware if they have or are carrying a communicable disease or a multiresistant organism and any health care professional that is to care for the patient in the
community must be informed to enable them to complete a risk assessment for the patients
ongoing care.
The Infection Control Nurses may be consulted for assistance with, or advice on the discharge
infection risk assessment; if necessary a referral will be made by them to the Community
Infection Control Advisor or the Health Protection Unit Communicable Disease Control nurse.
The Infection Control Nurses may be contacted on the following numbers:
Infection Control Office
ext. 5246
Senior Nurse Infection Control
bleep 085
Infection Control Nurse
bleep 051
Policy date: November 2004
Next Review: January 2013
Page 72 of 107
Appendix 15
1.
NUTRITION AND DIETETICS
INPATIENTS ON THERAPEUTIC DIETS.
Please notify us 2/3 days prior to discharge for patients to be assessed and individualised dietary
advice given on discharge:







Newly diagnosed Type 1 and Type 2 patients with Diabetes (Adult and Paediatrics).
Patients with swallowing problems and nutritional inadequacy requiring texture modification.
Renal/liver patients with related nutritional complications.
Liver patients with related nutritional complications.
Patients with sever inflammatory bowel disease requiring nutrition support.
Cystic fibrosis patients (Paediatrics), food allergies and intolerance (Adult and Paediatrics).
Patients who are immuno suppressed. Newly diagnosed HIV/AIDS and neutropenic
patients.
2.
PATIENTS DISCHARGE ON NUTRITION SUPPORT
A)
Discharged with supplements
Nurses/Dr refer to Dietitian if NRS > 6 and patients on high protein/high calorie diets will usually
be assessed regarding nutritional intake prior to discharge.
Doctors are ONLY expected to write TTA’s on EPRO for supplements if Dietitian has written “to
continue on discharge” in the drug chart. The supply amount prescribed should be for ONE week
only. However in the rare case that the patient had not been referred to the Dietitian in hospital,
the Doctor can advise the GP to refer that patient to the Community Nutrition Support Dietitian for
in-depth review and follow up.
The hospital Dietitian will organise follow up in the community on discharge, by liaising with the
feed company for continue delivery of the supplement to the patient’s home and will organise for
community colleagues to monitor patients either in their home/in community clinics.
B)
Discharged on tube feeds
Dietitians are closely involved in the discharge of patients on nutrition support (enteral feeding) into
the community. Please inform the department 5 days prior to discharge for patient going on a tube
feed for the first time so package of care can be organised and arrangements are in place for
continued monitoring and prescriptions.
 Nursing staff to refer to checklist for discharge.
 A named nurse or company representative discussed the following with patient or
carers:
- setting up feed
- pump operation
- checking position of the tube
- safety/hygiene aspects
- feed storage
- flushing of the tube with water
- recognition of potential problems of diarrhoea, vomiting, pulmonary aspiration.
The Dietitian:



Provides a feeding regime for the home.
Provides an enteral pump and stand for discharge.
Provides a weeks supply of giving sets.
Policy date: November 2004
Next Review: January 2013
Page 73 of 107




Provides manufacturers information on looking after PEG site if applicable.
Organise for prescription and delivery of feed to home with feed company.
Send a report to the GP with discharge feeding information.
Refer the patient to a Community Dietitian for continued review and monitoring.
The Doctor:

Update EPRO with Dietitians recommendation for tube feed.
Equipment:
The items below will be sent with the patient on discharge:





Fresenius pump/stand/7 days giving sets supplied by the Dietitian.
7 days supply of syringes/PH paper supplies by the ward.
7 days supply of sterile water if to nursing home by the ward.
7 days of enteral feed (on EPRO).
Home enteral feeding regime supplied by the Dietitian.
Nurses checklist for Enteral Tube Feeds used for the discharged patients.
ENTERAL TUBE FEEDS
Nurses Checklist for Discharge of Patients
Patient Name: _____________________
Discharging Ward:
Hospital Number: __________________
Date of proposed discharge:__________
Once patient’s discharge has been confirmed
Initials of
named nurse
Date
Initials of
named nurse
Date of
training
Inform Dietitian 5 days prior to discharge
Nursing staff to arrange pump training for patient/ family/ carers.
(Training can begin even if PEG has not yet been placed)
Phone Fresenius representative: Nick Matato 07776498790
Complete nursing discharge form for patients informing Nursing Home
that patient is being enterally fed.
If discharged home inform District Nurse 5 days prior to discharge
Training aspects to be covered prior to discharge (for
carer and/or patient)
Setting up of feed
Company Nurse
Pump operation (including emergency back-up in event of malfunction)
Company Nurse
Checking positioning of tube
Safety/hygiene aspects (to decrease risks of contamination)
Feed storage
Policy date: November 2004
Next Review: January 2013
Page 74 of 107
Flushing of tube with water (as instructed in tube feeding regime)
Recognition of potential problems of diarrhoea, vomiting, pulmonary
aspiration
Items to be sent with patient on discharge
Fresenius Feeding Pump, Stand and giving sets (via dietitian)
7 days supply of syringes (ward issue), PH paper if NGT in situ, and
Sterile Water if discharge to Nursing Home (ward issue)
Number of syringes required per day (if d/c home): ________
7 days supply of enteral feed (Ordered by Dietitian from Pharmacy
stores – will be delivered to ward)
Enteral Feeding Home Regimen (via dietitian)
Merck PEG guidelines (via endoscopy, found in patients
medical notes)
Contact numbers for emergencies
Policy date: November 2004
Next Review: January 2013
Page 75 of 107
Initials of
named nurse
Date
Appendix 16
Hospital Based Macmillan Team
Palliative Care Patients
The hospital based Macmillan service is broken into two teams,
Oncology and Palliative care.
Within palliative care there are two clinical nurse specialists:
 Ext 5270 bleep 490
 Ext 3089 bleep 491
Within the oncology nursing team there is:
 Lead Nurse for Cancer Services – Ext 3086 bleep 365
 2 generic Oncology Nurse Specialists – Ext 5773 bleep 379 and Ext 3298 bleep 527
 2 Breast Care Nurse Specialists – Ext 5693 bleep 018 and Ext 3093 bleep 282
The teams work Monday to Friday 8-4pm and are based in an office on ward 7N. For out of
hours advice please contact Meadow House on 89675597
Remit of Oncology Nursing team







Basic symptom control advice
Emotional and psychological support of patient and carer
Financial support and advice
Assistance with discharge planning
Referral to other services
Information about treatment
Education to other staff
Remit of Palliative Care Team





Complex symptom control advice
Complex emotional and psychological care
Assistance with discharge of dying patients
Assistance with care of dying patients
Assessment for hospice admission
1. Recommendations for Discharging Palliative Care Patients into the Community
Palliative care patients frequently have multiple and complex problems that make excellent
communication and explanation essential for providing good quality care.
Many patients want to be cared for in their own home, choosing ultimately, to die there and this
can be achieved in most cases. Because prognosis can be quite short, it is important, where it
is the patient's explicit wish to be at home, to try and discharge people as quickly as possible. In
some cases this may mean that not everything has been set up in advance of discharge. As long
as the patient and family are aware of the situation and all involved informed, it can still go
ahead. The patient/family should be made aware of any restrictions/limitations in the service
provided for discharge caused by discharging the patient early.
This does not aim to take the place of the discharge policy or the community information manual,
but to point out some strategies which will aid the good discharge of a palliative care patient.
The discharge liaison sisters can also be contacted to aid with complex discharges.
Policy date: November 2004
Next Review: January 2013
Page 76 of 107
2. Recommendations

Discharge planning should start as soon as possible after admission as is feasible. You do
not need a definitive discharge date to commence discharge planning. Assessments
required by occupational therapists and social services for community care should be
processed early and progress on this communicated regularly to the clinical team.

When the need for palliative care has been identified the hospital Macmillan Nurses can
apply for palliative care funding (PCF). They will complete a written assessment of clinical
needs and together with a summary of identified social care needs from the palliative care
social worker a decision will be made by the specialist health assessor at Meadow House
Hospice as to whether care will be jointly funded by health or social services or fully by
health.
All professional and voluntary agencies providing ongoing care in the community (whether
they are new or to be restarted), must be contacted in advance of discharge, preferably
with at least 48 hours notice. This will include the GP and District Nurses, Specialist
Palliative Care Services, Social Services, Voluntary Agencies. This information may be
written or spoken and is in addition to the medical discharge summary.


Where the patient has complex problems, such that the GP is likely to visit within a week of
discharge or be contacted early as an emergency, then the clinical team should phone / fax
updated information to the GP within 24 hours of discharge.

Nurse to nurse handovers on discharge are equally important and for complex discharges,
the District Nurse should be invited into the hospital prior to discharge
so arrangements can be made for an assessment of need on discharge on an individual
basis. A written discharge referral letter from the ward nurse to the District Nurse is
invaluable.

Appropriate patients should have an OT assessment including home visit, where possible
prior to discharge.

If the patient is not known to the hospital Macmillan Nurses and they are being considered
for referral to the Community Specialist Palliative Care Service on discharge, this should be
discussed and agreed with the GP in advance.

Access to Marie Curie nursing services for short-term input in the home, is only available
via the District Nurses. Marie Curie can also provide twilight nurses.
3.Other Support At Home
Ealing Crossroads Care Scheme
Provides free care breaks for those caring for ill and disabled relatives, friends or children.
Address
Hillview Surgery
179c Bilton Road,
Perivale
Greenford
Middlesex
UB6 7HQ
Telephone
020 8728 7000/7002
Fax
020 8728 7001
Website
www.crossroads.org.uk
Area covered
Borough of Ealing
Policy date: November 2004
Next Review: January 2013
Page 77 of 107
Main service
 Trained care support workers provide day and evening respite between the hours
of 8am - midnight
Overnight service
 An extension of the main service for carers who are unable to get an undisturbed
nights sleep contact Telephone, fax or email Monday - Friday, 9am - 5pm, 24hour answerphone.
Marie Curie Cancer Care
A Cancer Charity providing care for patients in the community and in hospices.
Address
89 Albert Embankment, London SE1 7TP
Telephone
020 7599 7777
Fax
020 7599 7788
Email
[email protected]
Website
www.mariecurie.org.uk
Area covered
National
Services
 A national network of Marie Curie nurses provides free palliative nursing care in patients'
homes
 Ten Marie Curie Centres across the UK provide specialist palliative care to people on an
inpatient and outpatient basis and in people's homes
 Referrals are made through GPs or district nurses
Contact Telephone, fax or email Monday - Friday, 9am - 5pm.
4. Hospice Referrals
Hospices Are Not ‘alternative’ Nursing Homes!
Hospices provide specialist palliative care, and do not accept referrals for people who simply
require a long-term nursing home placement.
Hospices have an 'active' and very ‘specific’ admissions policy and criteria.
Referrals are made according to catchment geographical area.
Meadow House Hospice
Meadow House Hospice is a single storey building with 14 beds in the grounds of Ealing
Hospital, Uxbridge Road. The hospice opened in 1987 as one of the first NHS run hospice
facilities in London.
Referrals are received from GP's, District Nurses, members of the Community Palliative Care
Teams and hospital wards. Referrals can also come from patients and carers, however the
clinician's permission is always sought following these referrals.
Referrals must provide clear detailed medical information, to facilitate effective decision-making.
For referrals to be presented at the daily admissions meeting, they must be with the Referrals
Officer by 9.20am Monday - Friday Tel: 020 8967 5758 Fax: 020 8967 5756
Following the admissions meeting the referrer will be notified of the decision and outcome, such
as: acceptance and potential date of admission, or inappropriate referral.
Referrers who wish to challenge a decision may discuss this with the Consultant in Palliative
Medicine, Meadow House Hospice, Uxbridge Road, Southall. Middlesex UB1 3EU Tel: 020 8967
5758 Fax: 020 8967 5756
Policy date: November 2004
Next Review: January 2013
Page 78 of 107
5. Hospice Referral Criteria
Hospice referrals should be considered for patients requiring:

1-2 weeks Respite / Rehabilitation
Complex symptoms such as pain, nausea and vomiting or psychosocial issues
(It is preferred that home arrangements +/- social service support be already established)
Short Term Assessment and Symptom Control
Patients at any stage of their disease process may be admitted for symptom control
(Admission is usually offered for a period of 1-2 weeks with an expectation of discharge
afterwards once patient's condition is stabilised)

Terminal Care
Considerably marked deterioration in health with a prognosis of days to weeks, not
months
(It is not appropriate to transfer people who are unconscious and very close to death; exceptional
cases accepted. However, this should be discussed with the hospice prior to transfer)
6. How do we refer to the Hospice?
Meadow House Hospice requires all new referrals to be made in writing by fax, using the referral
form. All sections of the form must be completed including an estimated prognosis.
Meadow House Hospice - for people who live in Hounslow, Isleworth, Heston, Feltham and West
London.
6.
Specialist Palliative Care in the Community
Patients at home remain under the care of their GP and District Nurse. In this way, the Primary
Health Care Team retain responsibility for providing effective palliative care.
Referral to the Community Specialist Palliative Care Team is only one aspect of discharge
planning. District Nurse referral should also be made especially in those with advanced or
progressive disease.
8. Role of the District Nurse in Palliative Care
Patients with advanced disease should always be referred to their District Nursing Team
on discharge (see Discharge Policy). This is very important even if you do not feel they have
current physical nursing needs. The District Nurses can make contact with the patient, family /
carer, and carry out an initial assessment, and anticipate future problems and support before
difficulties arise.
The district nursing service is made up of teams of nurses led by a trained district nurse. They
assess, plan and provide for the nursing care needs of people living at home and their carers.
District nurses work closely with GPs, practice nurses, social services and voluntary
organisations. They can also provide equipment that may be needed specifically for nursing
someone at home. Each district nursing team works with a different group of GPs and they are
usually based at the health centres or GP surgeries.
9. Equipment provided by District Nurses
District nurses (DNs) assess the need for and provide any equipment required to nurse somone
at home or to prevent problems such as pressure sores. The equipment they can provide will
vary but generally it includes hoists, pressure relief cushions and mattresses, commodes and
bed. You can get the contact mumber for the appropriate district nurse from the patients GP
surgery.
Policy date: November 2004
Next Review: January 2013
Page 79 of 107
Our local Specialist Community Palliative Care Team at Meadow House Hospice works
alongside the District Nurses and GPs to provide specialist advice in complex symptom control
situations and to support patients and their carers with advanced progressive disease.
10. Role of Community Specialist Palliative Care Nurses
Community Palliative Care / Hospice Symptom Control Teams:



Work closely with District Nurse and GP teams
Give advice about specialist symptom control
Provide cancer information and emotional support for patients, families and carers
Monitor patients' condition and alert other services as needed
They do not:  Provide hands-on care or replace District Nurse in-put
 Provide hands-on care or replace Social Service in-put
 Usually visit patients every day
Some patients will already be known to their Community Specialist Palliative Care or Hospice
Team. Check with the patient. New referrals should only be made in writing by fax to the
appropriate team. Sample forms have been included. Please photocopy extras as required.
Policy date: November 2004
Next Review: January 2013
Page 80 of 107
Appendix 17
17.1. Role of the respiratory nurse specialists for adults with COPD and asthma at Ealing
Hospital Trust
Aims of the service
 To promote education and support to adult patients and carers in the management of
Asthma and COPD
 To facilitate holistic care through the interaction of the multidisciplinary team.
 To ensure optimal management by utilising evidence based guidelines and reflection from
clinical audit.
 To work towards clinical excellence in clinical areas by educational development of staff.
The respiratory nurses can access patients in three ways:
Inpatient management
There are two respiratory nurse specialists who manage an inpatient workload caring for patients
admitted with an exacerbation of asthma and COPD. Education and advice is provided on
treatment, lifestyle, managing their condition at home and what to do if their symptoms reemerge. Relevant literature and contact details for organisations that can provide further advice
and support on health promotion e.g. smoking cessation services.
Outpatient clinics
Patients are seen in respiratory nurse led clinics, wherever practicably possible, following their
discharge home. Oxygen will not routinely be provided for patients on discharge from hospital.
Decisions regarding assessment for long term oxygen therapy LTOT) will made in an outpatient
setting and during a period of clinical stability.
Pulmonary rehabilitation
In conjunction with the multidisciplinary team the respiratory nurses support and advise patients
on the pulmonary rehabilitation programme and assess and refer patients most likely to benefit
from the course.
Please note: There is no provision for the respiratory nurses at Ealing Hospital
in the community at present.
Referrals
The respiratory nurses would ideally like to see patients within 24-48 hours following admission.
Furthermore, early referral ensures that each patient is seen.
Referrals can be made directly from health care professionals to the respiratory nurses, in
several ways:
 Via the bleep system on either bleep 559 (Jacqui Reilly) or 371 (Jayne Manning).
 Direct telephone line to the respiratory nurses’ office on ext. 5755.
 Respiratory nurse attends the track meeting on AMU each day (except weekends and bank
holidays) to identify new admissions.
17.2. Discharge checklist for patients following admission for a community acquired
pneumonia
Discharge criteria
The medical team will review the patients on the day of discharge
Patients are suitable for discharge if no more than 1 adverse sign is present (unless this in know
to be normal for an individual patient.) Adverse signs are
 Temperature above 37.8c
 Heart rate above 100
 Respiratory rate above 24
 BP Less that 90 systolic
Policy date: November 2004
Next Review: January 2013
Page 81 of 107



Oxygen saturation on room air of less that 90%
Abnormal mental status
Unable to maintain oral intake.
The General practitioner will receive


A discharge letter stating the diagnosis, treatment that has been given and details of
the discharge medication
Details of follow up arrangements
The patient will receive



Instruction in the medication regime they may have to take
If the medication is to be administered by a carer then the carer will receive instruction
in the medication regime
Information regarding follow up
The medical team will

Ensure follow up is arranged with a repeat chest x-ray at 6 weeks post discharge. If that
x-ray does not show resolution of the pneumonia that the medical team will arrange
referral to chest clinic.
17.4. Discharge checklist for patients following admission for an exacerbation of COPD
Patients must be established on their inhaled medication for 24 hours prior to discharge
The general practitioner will by the Medical Team,

Receive a discharge letter stating the treatment that has been given and details of
the discharge medication.
The patient will from the pharmacist,





Receive instruction regarding the medication regime that has been prescribed for
them.
If the medication is to be administered by a carer the carer will receive instruction
regarding the medication regime prescribed.
Be able to use the inhaled device prescribed.
Have an adequate supply of medication on discharge from hospital.
Have received input from physiotherapy, occupational therapy and social work if
appropriate.
The medical team will:


Ensure a referral to the clinical nurse specialist for respiratory medicine is made at
the earliest opportunity.
Ensure that patients who have had an episode of respiratory failure have
satisfactory oximetry or arterial blood gas results before discharge.
The clinical nurse specialist in respiratory medicine will:

See the patient on the ward prior to discharge when ever possible.
Policy date: November 2004
Next Review: January 2013
Page 82 of 107


Arrange follow up for the patient to be seen in the nurse led clinic.
Ensure that the patient understands their medication and has an inhaler device that
they can use effectively.
17.5. Discharge checklist for patients following inpatient treatment of pulmonary
tuberculosis.
The General practitioner will by the Medical Team,



Be informed of the patient’s diagnosis
Be informed of the patient’s discharge medication
Be informed of the follow up arrangements
The patient will from the pharmacist,


Receive 1 month’s supply of anti tuberculosis medication
Receive explanation of their medication regime including specific advice on when to take
their medication as well as advice regarding side effects and drug interaction
The medical team will ensure



That a referral has been made to the clinical nurse specialists for TB
That the patient’s diagnosis has been notified
That appropriate follow up has been arranged
The ward staff will

Ensure that the patients contact details are clearly documented prior to discharge
The pharmacist will

Ensure that the patient has been counselled with regard to their drug regime including side
effects and drug interactions.
The clinical nurse specialist for TB will



Ensure that the patient is not lost to follow up.
Ensure that appropriate contact tracing occurs.
Ensure that the patient receives advice and support throughout the period of their
treatment.
17.6. Discharge checklist for patients following inpatient treatment of asthma
Discharge criteria
All patients must have changed for nebulised to inhaled medication for at least 24 hours prior to
discharge
Discharge is indicated when peak expiratory flow is over 75% of best-known or predicted peak
expiratory flow and diurnal variation is less that 25%
The general practitioner will from the Medical Team,
 Receive a discharge letter stating the severity of the attack, treatment given and
discharge medication
 Receive details of follow up arrangements
The patient will from the pharmacist,
Policy date: November 2004
Next Review: January 2013
Page 83 of 107

Receive instruction on the medication regime prescribed for them including what the
actions of the different inhalers are and when they should take them.
Have an adequate supply of medication when they leave the hospital

The medical team will
 Ensure a referral has been made to the clinical nurse specialist in respiratory medicine at
the earliest opportunity
 Ensure that the patients meet the discharge criteria
 Ensure that the patient has received 40mg of Prednisolone for a minimum of 7 -10 days.
The clinical nurse specialist in respiratory medicine will
 See the patient on the ward prior to discharge when ever possible.
 Ensure whenever possible that arrangements have been made for the GP to review the
patient within 48 hours of discharge.
 Arrange follow up for the patient to be seen in the nurse led clinic.
 Ensure that the patient understands their medication and has an inhaler device that they
can use effectively.
17.7. Discharge checklist for patients with a pneumothorax
The General practitioner will by the Medical Team,


Informed of the size of the pneumothorax and treatment given
Informed of follow up arrangements
The patient will by the Medical Team be,


Advised of signs of worsening condition and action to be taken
Advised not to fly for 6 weeks after resolution of the pneumothorax.
The medical team will take appropriate action determined by the size of the pneumothorax.




For patients requiring no intervention a follow up x-ray will be performed in 2 weeks
For patients with a first presentation of a pneumothorax requiring a simple aspiration
they will be observed to ensure clinical stability prior to discharge.
For patient with a recurrent pneumothorax that can be treated with simple aspiration
they will be admitted for 24 hours to ensure no recurrence. The patient should be
referred to chest clinic for follow up.
For patients requiring insertion of a chest drain a chest x-ray will be performed to
ensure the re inflation of the lung following the removal of the chest drain. The patient
should be referred to chest clinic for follow up.
Policy date: November 2004
Next Review: January 2013
Page 84 of 107
Appendix 18
Ealing Primary Care Trust Speech and Language Therapy Provision to Ealing Hospital NHS
Trust
1. Mission Statement
The Speech and Language Therapy department at Ealing Hospital aims to provide high quality
assessment, treatment and management packages of care to adult patients referred with oropharyngeal swallowing and/or communication disorders. Detailed transfer reports are completed
to ensure seamless care when the patient transfers to the community.
The department also provides a weekly videofluoroscopy clinic in partnership with the Radiology
department at Ealing Hospital Trust.
Speech and Language Therapy can be highly effective in helping patients overcome or
compensate for the consequences of a communication/swallowing disorder. These can arise as
a result of:
 Acquired neurological disorder (for example: stroke, head injury, dementia).
 Progressive neurological disorder (for example: Parkinson’s disease, Motor Neurone
Disease, and Multiple Sclerosis).
 Tracheostomy and ventilator-dependency (as a result for example of weaning difficulties
post-surgery).
 Disorders of the voice (whether of organic or psychogenic origin).
 Non-specific swallowing disorders (sometimes as a result of very discrete stroke or advanced
age).
2. Service Provision
The Speech and Language department provides a service to EHT on the wards for in patients.
The in-patient service is available 8.30 am – 4.30 pm Monday to Friday.
An initial assessment package of care is provided to determine patient needs. A treatment
package is then provided with multi disciplinary goal setting where appropriate.
We also provide an ENT Outpatients Service, which is managed by a Clinical Specialist Speech
& Language Therapist in ENT and Voice. Other Outpatients a re seen by the Speech &
Language Therapist team in the community who are based at Clayponds Hospital and Ealing
Day Treatment Centre.
The team of therapists at Ealing Hospital do not provide a service to SCBU or Level 10, the
paediatric wards. This is available from the paediatric team based at Carmelita House.
Contact Details for Speech Therapist at Ealing Hospital: 020 8967 5000 Ext 3835 Bleeps 271,
281 & 344.
Policy date: November 2004
Next Review: January 2013
Page 85 of 107
Appendix 19
The Role of the Tissue Viability Nurse
1. Provision of specialist advice:

Wound Assessment: There is a referral criterion, ensuring appropriate assessment and
advice on treatment strategies for those wounds, which meet the criteria or are posing
management difficulties.

Causes of various wounds: To identify the underlying aetiology of wounds and try to
prevent recurrence either through correcting the underlying cause or through lifestyle
promotion and education.

Dressing Selection: To advise on dressing selection in order to enhance the wound
environment, and the formation of a wound dressing formulary.

Treatment strategies: to give adjunctive advice on ways of promoting wound healing.

Patient education: To educate clients and carers about the causes of wounds and
assist them in developing strategies to avoid recurrence.

Vascular clinic: to support staff and provide treatment advice within the vascular and
leg-ulcer clinic.
2. Access to specialist therapies:


Topical Negative Pressure (V.A.C. therapy): Advise on the appropriate usage and to
monitor response to therapy as well as facilitating access to the required equipment.
Larvae therapy: Advice monitoring education and application.
3. Provision of equipment:



Monitor and advise on the Trust’s response to bed-frame and mattress provision in
paediatric maternity and adult settings.
Specialist ITU therapies such as rotational and proning equipment.
Monitoring of the Trust’s equipment management contract.
4. Community Liaison:







The community TVN participates within the vascular clinic by running a nurse-led
chronic ulcer clinic.
Formation of a joint wound formulary.
Liaison with Community TVN and District Nurses re-discharge of complex wounds.
Follow-up of clients discharged with wounds causing concern within the community.
Equipment recommendations for provision in the community.
Sharing of educational opportunities.
Both Community and Hospital Tissue Viability Nurses act as a second opinion in
complex cases.
Policy date: November 2004
Next Review: January 2013
Page 86 of 107
Appendix 20
Protection of Adults at Risk
Protection of adults at risk is undertaken in London by the main statutory agencies- local councils,
the police and NHS organisations. All work together to prevent harm and abuse and also to deal
with suspected or actual abuse
The term “ adult at risk” has been used to replace vulnerable adult. An adult at risk may therefore
be a person who:







Is elderly and frail due to ill health, physical disability or cognitive impairment
Has a learning disability
Has a physical disability and/or sensory impairment
Has mental health needs including dementia or a personality disorder
Has a long term illness/condition
Misuses substances or alcohol
Is a carer such as a family member/friend who provides personal assistance and care to
adults and is a subject to abuse
 Is unable to demonstrate the capacity to make a decision and is in need of care and
support
(This list is not exhaustive)
Discharge Planning
Discharge planning of an adult at risk needs to be undertaken by the multi-disciplinary team.
Consideration should be given to the following:
 Has the patient experienced any abuse prior to admission this may either be physical,
psychological, financial, discriminatory, sexual and neglect prior to admission.
If the answer is yes then an assessment of risk must be undertaken prior to discharge. The risk
assessment will seek to determine:
 What the actual risks are-the harm that has been caused, the level of severity of the harm
and the views and wishes of the adult at risk
 The persons ability to protect themselves
 Who or what is causing the harm
 Factors that contribute to the risk, for example, personal, environmental, relationships,
resulting in an increase or decrease to the risk
 The risk of future harm from the same source
The risk assessment should also take into account wider risk factors such as the risk of fire in the
person’s home.
If the patient has capacity it is important that they are involved and agree with the plan for
discharge.
If the patient is returning to their own home it is important that the patient’s GP is involved and
aware of the plan.
A copy of the plan should be sent separately to the GP or manager of a care facility. It will be the
responsibility of the ward sister to ensure that this information is enclosed with the discharge
summary at the time of discharge.
The monitoring of the discharge plan in relation to safeguarding is the responsibility of Social
Services
Policy date: November 2004
Next Review: January 2013
Page 87 of 107
Appendix 21
Ealing Rehabilitation Services
1. Occupational Therapy Department
MISSION STATEMENT
Occupational Therapists assist patients in setting and achieving goals giving them the
opportunity to achieve greater independence following illness or disability. This may involve
making suitable adaptations to their environment.
At the point of discharge from the Service, where appropriate, patients are referred to other
Occupational Therapy services for ongoing treatment or to review/re-assess need.
Where necessary, in conjunction with other members of the multi-disciplinary team, Occupational
Therapists refer to community support services to facilitate a safe discharge.
Discharge summaries outlining Occupational Therapy intervention are forwarded to the patient’s
GP. Where relevant, Occupational Therapy reports are forwarded to other health and social care
professionals.
2. Service provision / access to services
The Occupational Therapy Department provides a service to adult in-patients at Ealing Hospital
and an out-patient service for patients referred by Ealing Hospital consultants.
Inpatient Service – Monday – Friday 8.30 – 4.30
Outpatient Service – Monday – Thursday 9.00 – 4.30
Referrals are accepted for Occupational Therapy intervention and treatment from out-patient
clinics at Ealing Hospital. Referrals are also accepted from other members of the out-patient
team e.g. Physiotherapists, Psychologists. All referrals are made by completion of a Ealing
Hospital NHS Trust Rehabilitation Request Form signed by the referring doctor.
The majority of referrals come from Rheumatology and Orthopaedics but patients are also
referred from other out-patient clinics including Day Hospital for the Elderly and Neurology.
N.B. The team of therapists on-site at Ealing Hospital does not provide a service to
paediatric wards on Level 10.
the
3. Prioritisation
Patients given the highest priority are those patients requiring Occupational Therapy
intervention who are medically fit and ready for discharge.
If patients are not medically fit or become medically unwell following receipt of referral they will be
monitored (reviewed three times a week). If, following discussion with medical staff, the situation
seems likely to continue for more than two weeks then a patient will be discharged from
Occupational Therapy as intervention is not appropriate. A new referral will be accepted following
an improvement in the patient’s medical status.
4. DISCHARGE CRITERIA
A patient will be discharged from Occupational Therapy if any of the
following apply: a. Initial assessment has been completed and no further intervention is indicated.
b. Occupational Therapy needs have been identified and addressed and intervention is
complete.
Policy date: November 2004
Next Review: January 2013
Page 88 of 107
c. A patient is discharged from hospital prior to Occupational Therapy intervention being
completed.
d. Active Occupational Therapy intervention is currently inappropriate due to a patient
becoming medically unwell for a protracted period (see Standards of Prioritisation above).
5. Inpatients’ Physiotherapy
Objective
Ensure safe discharge of patients with a Multidisciplinary approach.
Principles



To ensure a Multidisciplinary approach
To ensure patients’ rights are central to decision-making on discharge
To help to ensure all staff understand and implement the discharge policy
Summary
Patients are discharged from physiotherapy services if patient is medically fit to go home and
 Achieved pre- admission rehab status or
 Independently mobile with or without aid (ensuring clearance from Occupational Therapist if
necessary) and
 Can manage stairs safely and independently (if they have to access stairs at home
regularly) or
 Do not have any rehab potential (determined after thorough assessments and or regular
input without any success) or
 Patient continually refusing physiotherapy input
If patient has rehab potential and an ongoing need for physiotherapy they are referred on to
various sites depending on
 Patients’ rehab needs
 Referral criteria at various sites
 Patients’ choice
Patient is given verbal information and leaflets (if available) prior to referring patient to the various
sites.
Patients’ consent is mandatory and is well documented.
All members of the MDT involved are aware of every stage of progress via patient notes and MDT
weekly meetings.
Sites
Ealing
 Clayponds
 ICS- PDRS (Garden Court Rehab Unit)
 Community Physiotherapy / Community Respiratory Physiotherapy
 Outpatients EHT
 ARISE
Hounslow- Single Point of Access
REFERRAL CRITERIA for various sites are attached
REVIEW
This policy will be reviewed annually or sooner should the need arise.
Policy date: November 2004
Next Review: January 2013
Page 89 of 107
FURTHER RESOUCES
Further information concerning the policy and discharge procedures can be obtained from the
contacts listed below.
Ealing Hospital:
Acute Team Lead
020 8967 5632
Musculoskeletal Coordinator
020 8967 5067
Neuro Clinical Specialist
020 8967 5000 bleep 112
Respiratory Team Lead
020 8967 5000 bleep 115
Senior Physiotherapist Admissions Unit
020 8967 5000 bleep 453
Senior Orthopaedic Physiotherapist
020 8967 5000 bleep 273
Clayponds
Therapy Coordinator
020 85604011
Lead Physiotherapist
020 85604011
Neuro Physiotherapist
020 85604011
ARISE
Therapy Coordinator
Lead Physiotherapist
Paediatrics
Paediatric Therapy Manager
Senior Paediatric Physiotherapist
Policy date: November 2004
Next Review: January 2013
020 8967 bleep 560
Page 90 of 107
Appendix 22
Ealing Rehabilitation Services
1. Inpatient Occupational Therapy Service
OBJECTIVE
Occupational Therapists assist patients in setting and achieving goals giving them the
opportunity to achieve greater independence following illness or disability. At the time of
discharge this may involve making suitable adaptations and/or provision of equipment to their
environment.
Service provision / access to services
The Occupational Therapy Department provides a service to adult in-patients at Ealing
Hospital.
Inpatient Service – Monday – Friday 8.30 – 4.30
N.B. The team of therapists on-site at Ealing Hospital does not provide a service to
paediatric wards on Level 10.
the
Prioritisation
Patients given the highest priority are those patients requiring Occupational Therapy
intervention who are medically fit and ready for discharge.
If patients are not medically fit or become medically unwell following receipt of referral they
will be monitored (reviewed three times a week). If, following discussion with medical staff,
the situation seems likely to continue for more than two weeks then a patient will be
discharged from Occupational Therapy as intervention is not appropriate. A new referral will
be accepted following an improvement in the patient’s medical status.
DISCHARGE CRITERIA
A patient will be discharged from Occupational Therapy if any of the
following apply: a. Initial assessment has been completed and no further intervention is indicated.
b. Occupational Therapy needs have been identified and addressed and intervention is
complete.
c. A patient is discharged from hospital prior to Occupational Therapy intervention being
completed.
d. Active Occupational Therapy intervention is currently inappropriate due to a patient
becoming medically unwell for a protracted period (see Standards of Prioritisation above).
2. Inpatients’ Physiotherapy
OBJECTIVE
Ensure safe discharge of patients with a Multidisciplinary approach.
Principles
Policy date: November 2004
Next Review: January 2013
Page 91 of 107



To ensure a Multidisciplinary team (MDT) approach
To ensure patients’ rights are central to decision-making on discharge
To help to ensure all staff understand and implement the discharge policy
Summary

Patients are discharged from physiotherapy services if patient is medically fit to go home
and
Achieved pre- admission rehab status or
Independently mobile with or without aid (ensuring clearance from Occupational
Therapist if necessary) and
Can manage stairs safely and independently (if they have to access stairs at home
regularly) or
Do not have any rehab potential (determined after thorough assessments and or
regular input without any success) or
Patient continually refusing physiotherapy input





If patient has rehab potential and an ongoing need for physiotherapy they are referred on to
various sites depending on

Patients’ rehab needs

Referral criteria at various sites

Patients’ choice
Patient is given verbal information and leaflets (if available) prior to referring patient to the
various sites.
Patients’ consent is mandatory and is well documented.
All members of the MDT involved are aware of every stage of progress via patient notes and
MDT weekly meetings.
Sites
Ealing




Rehab at Clayponds Hospital
Musculoskeletal (MSK) Rehab Outpatients at EHT
ARISE
Hounslow- Single Point of Access
REFERRAL CRITERIA for Occupational Therapy and Physiotherapy are attached
PHYSIOTHERAPY
C:\Documents and C:\Documents and C:\Documents and C:\Documents and C:\Documents and
Settings\SYam\Desktop\Physiotherapy
Settings\SYam\Desktop\physiotherapy
acute
Settings\SYam\Desktop\physiotherapy
neuro priorities.doc
adult
Settings\SYam\Desktop\physiotherapy
therapy team.doc
orthopaedics.doc
Settings\SYam\Desktop\physiotherapy
respiratory.doc
women's health.doc
OCCUPATIONAL THERAPY
C:\Documents and
C:\Documents and
Settings\SYam\Desktop\OT prioritisation
Settings\SYam\Desktop\OT
of patients.doc Referral.doc
REVIEW
Policy date: November 2004
Next Review: January 2013
Page 92 of 107
This policy will be reviewed annually or sooner should the need arise.
FURTHER RESOUCES
Further information concerning the Rehab provided at EHT or information in this regarding Rehab
and discharge procedures can be obtained from the contacts listed below.
Rehab Services at Ealing Hospital:
Lead for Acute Therapies
020 8967 5632
Lead Occupational Therapy Adults
020 8967 5131
Policy date: November 2004
Next Review: January 2013
Page 93 of 107
Appendix 23
Clayponds Hospital Referral Form
Criteria for Admission to Clayponds
1. The patient must be medically stable.
2. The form must be completed by all clinicians concerned with the patient. N/A (not applicable)
to be written if sections are not applicable.
3. Patient must demonstrate: a) Orientation

May be measured using three questions from the mini mental score, i.e.: i.
ii.
iii.

Where are you?
What year is it?
How old are you?
And can be judged by non-verbal communication and/or Speech Therapist’s report if
patient is dysphasic.
b) Motivation


The patient must have been co-operating with therapy to date.
The patient/carer must also want to be referred to Clayponds.
c) Evidence of rehabilitation potential

To be measured by whether the patient has changed significantly as a result of therapy.
(The above criteria will be confirmed on assessment by the Clayponds team).
4. Patients with pressure sores will be considered, as long as the pressure sore is healthy and
healing and does not inhibit rehabilitation potential.
5. Patients with Clostridium Difficile or MRSA may be considered. Up to date information on
infectious status will need to be available at the time of assessment.
If the patient is not accepted, a reason for this will be given. If the refusal is not absolute,
objectives may be set which, once met, will qualify the patient for review.
STANDARD CLAYPONDS REFERRAL FORM
Name & Address of Referring Hospital:
EALING HOSPITAL NHS TRUST
Uxbridge Road, Southall, Middlesex, UB1 3HW
Date of admission to hospital:
Patient consents to referral
Policy date: November 2004
Next Review: January 2013
Ward & Tel No:
NOK informed of referral
Page 94 of 107
PATIENT DETAILS
Patient’s Name:
Address:
DOB:
Hospital No:
Post Code:
GP:
NOK Name:
NOK Contact no:
SOCIAL HISTORY (including formal and informal support)
Current housing: (please circle)
Own/ Rented
Flat
Warden
controlled
House
Residential
home
Nursing home
1st language if not English:
How long has patient lived in Borough of Ealing:
MEDICAL
Active medical problems including dates:
Latest Blood Results:
 Medically stable
date:
_________
Results/Investigations/Appointments Outstanding:
Medical section completed by:
Sign:___________________Print Name:_________________Designation:___________________________
Date:_______________________
Contact number/Bleep____________
Name of Patient:
Page 2
NURSING
Please comment on patient’s general condition:
Policy date: November 2004
Next Review: January 2013
Page 95 of 107
 MRSA
If Yes, please name the site__________________
Yes/No
Is the site covered
 Clostridium Difficile within last 4 weeks:Yes/No
 Pressure Area Location:________ Grade:______
Nursing section completed by:
Sign:___________________Print Name:_________________Designation:___________________________
Date:_______________________
Contact number/Bleep____________
THERAPY
Therapy goals achieved during inpatient stay (add timeframes)
1.
2.
3.
This patient has the potential to achieve the following goals at CPH (add timeframes)
1.
2.
3.
Therapy section completed by:
Sign:___________________ Print name:__________________ Designation:_________________________
Date:_______________________
Contact number/Bleep_____________
Please continue on a separate sheet if necessary
Policy date: November 2004
Next Review: January 2013
Page 96 of 107
REFERRAL TO CLAYPONDS HOSPITAL FOR STROKE PATIENTS
Name & Address of Referring Hospital:
EALING HOSPITAL NHS TRUST
Uxbridge Road, Southall, Middlesex, UB1 3HW
Patient consents to referral
PATIENT DETAILS
Patient’s Name:
NOK informed of referral
DOB:
Hospital No:
Address:
Post Code:
GP:
NOK Name:
NOK Contact no:
Admission date to Acute Hospital:
Ward & Tel No.:
SOCIAL HISTORY including formal and informal support
Current housing: (please circle)
Own/ Rented
Flat
Warden
controlled
House
Residential
home
Nursing home
1st language if not English:
How long has patient lived in Borough of Ealing?
MEDICAL
Active medical problems:
 Recent CT Scan
date: __________
Results:__________________________________________________
 Stroke diagnosed
date:_________
 Medically stable
date: _________
Results/Investigations/Appointments Outstanding:
Medical section completed by:
Sign:___________________Print Name:_________________Designation:___________________________
Date:_______________________
Policy date: November 2004
Next Review: January 2013
Contact number/Bleep____________
Page 97 of 107
Name of Patient:
Page 2
NURSING
Please comment on patient’s general condition:
 MRSA
If Yes, please name the site__________________
Yes/No
Is the site covered
 Clostridium Difficile
Yes/No
 Pressure Area Location:________ Grade:______
Nursing section completed by:
Sign:___________________Print Name:_________________Designation:___________________________
Date:_______________________
Contact number/Bleep____________
THERAPY
Therapy goals achieved during inpatient stay (add timeframes)
1.
2.
3.
This patient has the potential to achieve the following goals at CPH (add timeframes)
1.
2.
3.
Therapy section completed by:
Sign:___________________ Print name:__________________ Designation:_________________________
Date:_______________________
Contact number/Bleep_____________
Please continue on a separate sheet if necessary
Policy date: November 2004
Next Review: January 2013
Page 98 of 107
WARD STAFF TO FAX REFERRAL (including Stroke referrals)
TO
JOYCE JAMES (Fax No. 5345)
SUPPORT SYSTEMS MANAGER, ARISE (based at EHT).
DO NOT FAX STROKE REFERRALS DIRECT TO CLAYPONDS
CPH
REFERRAL
MEDICALLY STABLE
Fax completed referral form.
(Must be fully completed by Doctor,
Therapist and Nurse)
MEDICALLY
UNSTABLE
Send front sheet only
INCOMPLETE REFERALS
Joyce James or ARISE colleagues, advises ward and referral is not
accepted until completed referral is received. If just the Therapy
section is incomplete then a Senior Therapist is contacted.
TRANSFERS TO CLAYPONDS
+Clayponds will contact the ward
when a bed is available.
+Clayponds will advise Joyce
James when a patient can transfer.
+Patients must transfer to
Clayponds before 3pm
If there are any
changes to patient's
progress, keep
ARISE updated.
'Phone 5116
+Please arrange for
TTAs as soon as the
referral is made.
+Advise ARISE
IMMEDIATELY a
patient becomes
medically unstable
(ext 5116).
Thank You
WARDS:
If you have any
problems, i.e.
transport, please
ask Jackie
Walker for
assistance.
TO CPH
Ext. 5763
Policy date: November 2004
Next Review: January 2013
WARDS
Page 99 of 107
Appendix 24
Continuing Care Assessments
In accordance with Department of Health guidance, the eight primary care trusts have worked
with local authority colleagues to develop common criteria for older people with physical or
mental frailty and younger adults with physical disabilities, learning disabilities or mental health
problems.
Aim:
The aim of continuing care is to provide the right long term support to clients, to promote
independence, prevent deterioration and maximise their health and quality of life. In order to
achieve this, the criteria for continuing care should meet the following principles:
Continuing Care – Core Values and Principles












Needs led (acknowledging layers of complexity)
Equitable (not age related)
Culturally sensitive
Client centred.
Single assessment process the key to assessing continuing care.
Assessment for continuing care should follow assessment for rehabilitation.
Regular review built into the process.
Easily understood (clear definition of terms)
Administratively simple.
Building on guidance and good practice.
Criteria should not relate to the anticipated location of care.
A change of funding agency should not necessarily mean a change of home.
North West London Criteria for NHS Funded Continuing Care
For younger adults (aged 16 and over) and older people with a physical disability, a learning
disability or a mental health problem, including a mental illness associated with old age.
 To be considered under these criteria, clients must be over 16 years old and registered with
a GP in one of the Primary Care Trusts within the North West London sector or
unregistered but at the point of initial assessment considered “usually resident” in one of
these boroughs.
 In all cases, a multi-disciplinary assessment must be carried out, convened by the Local
Authority, in order to determine the application of the criteria to any particular client.
 Clients who have an ongoing neurological dependency, characterised by any of the
following will automatically be eligible for NHS continuing care:
o Unconsciousness
o Need for mechanical ventilation via a tracheostomy.
o Persistent vegetative state following diagnosis by a consultant during the multi
disciplinary assessment.

Depending on the nature and the intensity of their needs, there will be an additional group
of clients who may be eligible
Policy date: November 2004
Next Review: January 2013
Page 100 of 107
Appendix 25
Community Nursing – Adult service
Criteria For Admission To The District Nursing Service
Clients must be
 Aged 16 or over,
 Have needs that require trained nursing intervention,
 Housebound, home visits are primarily for housebound patients. District nursing services will
work with the referrer to identify the most appropriate service for non-housebound patients.
Referrals
Regular liaison with members of the primary health care team should help agree admission to
the nursing caseload, how best to provide the necessary care and lend support to difficult
decisions that may be required if any patient cannot be admitted to the caseload.
Waiting Lists
A waiting list for patients being discharged from hospital and requiring admission to a District
Nursing caseload will only be implemented as a last resort.
Criteria for priority admission to the service across locality (where capacity allows)




IMMEDIATE ACCESS, Terminal illness (i.e. someone has expressed a wish to die at home
with a lifestyle expectancy of two weeks or less) or to prevent hospital admission.
PRIORITY A, Enabling Care, for life threatening illness requiring active and / or intensive
nursing care, e.g. diabetes (unable to be self-taught), COPD, cancer, or to prevent
admission.
PRIORITY B, Curative Care, e.g. acute / chronic wound management.
PRIORITY C, Maintenance Care, Diabetes (who are self-taught), post operative care,
incontinence, medication. (Referrals for medications from hospitals will only be
accepted if a prior pharmacy assessment says the patient is not capable of selfmedicating, and all alternative arrangements, e.g. carer / relative have been explored).
‘Single Tasks’
Current resources only allow that single tasks will be carried out only if the client is already
receiving a package of care, or is physically housebound, e.g. Venepuncture, Immunisation, Ear
Syringing, Suture / Clip removal.
Medical Equipment
With the exception of South Westminster locality (who have a joint funding agreement with Social
Services) patients requiring the provision of medial equipment will only be seen when there is
already District Nursing intervention. Disposable items such as urinals and bedpans will not
usually be issued and clients will be encouraged to purchase these and other items.
Hospital Discharges
Hospital discharge referrals should usually be made within 4 days notice. Where this is not
possible, e.g. people referred after a visit to A&E or short term emergency admissions, discharge
timing must be negotiated to ensure safe hand over to DN teams. Adequate dressings /
medication must be provided, and / or any specific instructions. It is highly recommended that a
Policy date: November 2004
Next Review: January 2013
Page 101 of 107
joint assessment with social services is made prior to discharge for clients who have complex
needs in the ‘Immediate Access’ or ‘Priority A’ categories.
The community services referral form should be utilised for referrals (SP007/02/07) and this
should be completed fully. This form should be available at ward level and can be ordered via the
printing unit at West London Mental Health Trust. Please ensure that this form is faxed through to
the appropriate district nursing service and that this is followed up with a telephone call so that
receipt of fax can be acknowledged.
Policy date: November 2004
Next Review: January 2013
Page 102 of 107
Practices participating in Post Discharge Procedures
Acton
Bhatt V
Cabot
Datta
Jones
Keen
McKeigue
Pambakian
Reddy
Robinska
Saujani
Central Ealing
Bayer
Carter
Dhillon
Evans
Lauder
Pietroni
Russell
Valentine
Hanwell
Cowen
Freeman
Lau
Leonard
Light
Naish
Sahota
Stewart
Policy date: November 2004
Next Review: January 2013
North NAG
Anderman
Balachandran
Bhatt R
Goraya
Moore
Parmar
Seimon
Shah
South NAG
Ali
Garg
Gill
Jenkins
Joshi
Lewis AD
Patel PM
Segall
North Southall
Botros
Korpal
Qadan
Rizki
Saluja
South Southall
Davis
Hayat
Lahon
Mangat
Maw
Singh
Page 103 of 107
Riverside Community (NHS) Trust
District Nursing Service / Night Nursing Service Communicating Guidelines
Service Provision
The Night Nursing Service in Riverside Community (NHS) Trust (Ealing) provides nursing care to
clients on the District Nurses’ caseload. It is based at Clayponds Hospital and provides a full
service from 19.30 hours until 00.30 hours. Two team members are available on bleep /
telephone from 16.30 hours to aid communication between day and night nursing services. From
00.30 hours to 08.30 hours a nurse form the NNS is available on call to respond to urgent calls
from clients, carers, GPs and other sources.
Referral


Referral to the NNS is at the discretion of the DN Sister in collaboration with the NNS
Faxed referrals made to Clayponds Hospital should include the following:
Name of patient
Address of patient
GP
Diagnosis
Copy of summary sheet and care plan
Name of DN referring
Social Situation (i.e. lives alone / residential home)
Access
Reason for request for nursing input
Date and time of visit requested
Patient registration form
Please note that if you need to contact the District Nurses after 5pm, telephone:
020-8560 4011 (Clayponds Hospital)
and leave a message
Policy date: November 2004
Next Review: January 2013
Page 104 of 107
Community Nursing Services within Riverside Community Health Care NHS Trust
Important Questions to Consider when Planning a Discharge
1. Is there going to be a need for continuing nursing care?
2. What ongoing nursing care is needed?
3. Can the need be more appropriately met by a Practice Nurse, District Nurse, Community Nurse,
Community Psychiatric Nurse, Minor Treatment Centre, Paediatric Home Care Nurse.
4. Please inform Community Nurse Services of discharge as early as possible, with a minimum of
four working days notice, which includes the day you refer and the day of discharge.
5. New assessments are not routinely undertaken at weekends.
6. Patients requiring wound care need a minimum of three days supply of dressing changes if the
dressing is to be done daily or more, or three dressing changes if the dressing is to be done
less frequently. These supplies are to include cleansing agent, bandages and tape.
NB: It takes 48 weekday hours to obtain a prescription.
7. Patients requiring eternal feeding / IV Therapy or continence supplies must be discharged wit
one week’s supply of appropriate equipment.
8. Patients needing supervision with medication need a legible drug chart/request letter signed
and dated by a doctor, without which medication cannot be given. A pharmaceutical
assessment in liaison with nursing staff must have taken place, and the medication must be
dispensed in an appropriate form. If a Dosette box is to be used, then the appropriate box
should be filled with one week’s supply of medication.
NB: Medication supervision is only undertaken by the District Nursing service when there is
no one else who can do this, e.g. family/carer.
For Other areas: Please refer to your Community Manual or contact the Community Liaison Sisters in the
Discharge Liaison Office within the Intermediate Care Services Department: Ext. 5400 or 5576
The Primary Care Access Centre closed in March 2010
Policy date: November 2004
Next Review: January 2013
Page 105 of 107
Appendix 26
Bibliography for Discharge Planning Management

British Thoracic Society guidelines for the management of community acquired pneumonia
in adults – 2004 update. Published on the BTS website 30.4.04

Management of Chronic Obstructive Pulmonary Disease in adults in primary and secondary
care. Clinical guideline 12. British Thoracic Society in collaboration with National Institute
for Clinical Excellence. February 2004.

British guideline on the management of asthma. Thorax. Feb 2003 Vol. 58 Supplement 1

British guideline on the management of asthma. Thorax. Feb 2003 Vol. 58 Supplement 1

British Thoracic society guidelines on the management of pulmonary embolism. Thorax
1997: 52 (supplement 4): S2

Control and prevention of tuberculosis in the United Kingdom: Code of practice 2000.
Thorax 2000: 55: 887-901

British Thoracic Society guidelines for the management of spontaneous pneumothorax.
Thorax 2003; 58. (supplement 2)

Discharge Planning the Code of good Practice, version 2 (June 2002).

Ealing Hospital NHS Trust, Infection Control Practice and Isolation Policy, June 2003.

Ealing Primary Care NHS Trust, Infection Control Policies, July 2003.

BHF Stats Database published 2002 figures from 2000.

NICE Guidelines for the management of Adult Chronic Heart Failure published by National
Institute for Clinical Excellence 2003.

Southall and West Ealing Primary Care Access Centre Leaflet.

British Red Cross, Caring for people in crisis, Home from Hospital Service Leaflet.

Ealing Intermediate Care Service, Housing and Social Services and Ealing NHS, Garden
Court Scheme Leaflet.

Turning Point, Turning Lives Around, Southall Alcohol Advisory Service Leaflet.

Turning Point, Ealing Drugs Advisory Service Leaflet.

Turning Point, Hartley House, Residential Alcohol Project Leaflet.

City Roads, positive action for drug users leaflet.

Dietetic standards for nutritional support – Produced by the British Dietetic Association
December 1996.

Ealing Hospital Enteral Feeding Policy and Procedures policy number CP01.
Policy date: November 2004
Next Review: January 2013
Page 106 of 107
Appendix 27
Government Publication References

NHS and Community Care Act (1990) London HMSO

Department of Health (2003) Discharge from hospital:
pathway, process and practice.

Department of Health: The Community Care (Delayed Discharges etc.) Act 2003

HOC, Committee of Public Accounts (2003) Ensuring the effective discharge of older
patients from the NHS acute hospitals.

Health and Social Care Act 2001

Department of Health: Supporting the implementation of patient advice and liaison services.
A resource pack. Jan 2002.

North West London Continuing Care; An Agreement and Assessment Tool for NHS Funded
Continuing Care for Younger Adults and Older People with Physical Disabilities, Learning
Disabilities or Mental Illness April 2003

National Service Framework (NSF) for CHD standard 6 – Heart Failure, published by the
DOH in 2000.

NHS, Health Promotion England, Health Education Authority 1998.

Protection of Vulnerable Adults, Policy and Procedures, Housing and Social Services,
version 3.1 – November 2003.
Policy date: November 2004
Next Review: January 2013
Page 107 of 107