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Transfer Policy (adults) 4.0 Final Policy detailing the procedures and protocols for the transfer of patients EQUALITY IMPACT The Trust strives to ensure equality of opportunity for all both as a major employer and as a provider of health care. This policy has therefore been equality impact assessed by the Clinical Governance Committee to ensure fairness and consistency for all those covered by it regardless of their individual differences, and the results are shown in Appendix 11. Version: Authorised by: Date authorised: Next review date: Document author: 4.0 Final Critical Care Steering Group September 2014 September 2016 Trust Transfer Lead Tameside Hospital NHS Foundation Trust Transfer Policy (Adults) VERSION CONTROL SCHEDULE Transfer Policy (adults) Version : 4.0 - Final Version Number 1.0 final 2.0 draft Issue Date April 2007 Jun 2009 2.0 final August 2009 3.0 Draft 4.0 August 2011 September 2014 Revisions from previous issue Original Updating of format, change of Trust name and inclusion of monitoring section Amendments incorporated following CG committee review Amendments following audit Version 4 (September 2014) Page 2 of 35 Please check intranet for latest version Tameside Hospital NHS Foundation Trust Transfer Policy (Adults) TABLE OF CONTENTS EQUALITY IMPACT ................................................................................................... 1 1.0 INTRODUCTION ................................................................................................. 4 3.0 SCOPE ............................................................................................................. 4 4.0 DEFINITIONS ................................................................................................... 5 5.0 DUTIES ............................................................................................................... 5 6.0 POLICY STATEMENT ...................................................................................... 7 7.0 THE TRANSFER PROCEDURE (INTRA-HOSPITAL) ......................................... 7 Level 0 and 1 patients. ............................................................................................ 7 8.0 transfer of level 2 and level 3 patients within the trust (intra-hospital)...... 10 9.0 Transfer out of the hospital (inter-hospital) ......................................................... 11 10.0 MONITORING .................................................................................................. 13 11.0 IMPLEMENTION AND STAFF TRAINING ................................................. 13 12.0 MONITORING ................................................................................................. 13 APPENDIX 1 : Levels of transfer and minimum requirements. ............................. 15 APPENDIX 2:TRANSFER EQUIPMENT AND PERSONNEL ........................... 16 APPENDIX 3: GUIDELINES FOR NON-CLINICAL TRANSFERS ........................ 18 APPENDIX 4: TRANSFER LETTER .................................................................... 19 APPENDIX 5: INTERNAL HOSPITAL TRANSFER ............................................ 21 APPENDIX 6: SBAR VERBAL HANDOVER SHEET FOR INTERNAL TRANSFER .............................................................................................................................. 22 APPENDIX 6: EXTERNAL HOSPITAL TRANSFER ........................................... 23 APPENDIX 7: ........................................................................................................ 24 APPENDIX 8: NON CLINICAL CRITICAL CARE TRANSFERS (Outside Transfer Group) ................................................................................................................... 25 APPENDIX 9: PROCEDURE TO BE FOLLOWED FOR ITU/CRITICAL CARE TRANSFER-OUT OF THE LOCAL TRANSFER GROUP (REFERENCE HSC 2000-17)................................................................................................................ 26 APPENDIX 10: ...................................................................................................... 27 APPENDIX 11: transfer of level 2 and 3 patients in event of no critical care beds. 29 Appendix 11: EQUALITY IMPACT ASSESSMENT TOOL .................................... 30 Appendix 12: Transfer audit proforma ................................................................... 31 Appendix 13:A/E Transfer Checklist Form ............................................................ 35 Version 4 (September 2014) Page 3 of 35 Please check intranet for latest version Tameside Hospital NHS Foundation Trust Transfer Policy (Adults) 1.0 INTRODUCTION The Trust recognises that patient transfer must be undertaken with the correct safety checks by the correct personnel. The NPSA Seven Steps to Patient Safety includes requirements for patient transfer in Step 3 Integration your risk management activity actions 17 and 18. The NHS Litigation Authority (NHSLA) Risk Management Standards accreditation scheme at level 3 requires the Trust to have in place a policy to reduce risks associated with Patient Transfer and to monitor the effectiveness of the policy. This procedure is to be adhered to for any adult patient who requires transfer either within or outside of the hospital with the exception of Maternity patients. Special considerations for the transfer of maternity patients are specified in the following Trust documents ‘Guideline for the in-utero transfer of Mothers’ ‘Transfer/Escort of Maternity Patients Policy’ ‘Guideline for transfer to main unit of a woman in labour booked for home birth.’ Special consideration for paediatric patient transfer is specified in the Trusts ‘Paediatric transfers policy’ ‘Guideline for the transfer of an infant out of or into the NICU.’ These are available on the Trusts intranet. Levels of care of adult patients This procedure refers to “levels of care” of adult patients which are defined as follows:0. 1. 2. 3. Patients whose care can be delivered at ward level Patients who are at risk of deteriorating/stepping down from a higher level of care High dependency patients Intensive care patients Utilising these levels of care in the description of the patient will help with decision making about escort personnel. Appendix 1 specifies the required personnel related to the patient’s degree of illness, whilst appendix 2 provides a flow chart identifying the pathway for organising internal and external transfers. 2.0 PURPOSE The rationale for this procedure is to ensure that all adult patients shall be transferred safely without compromising their condition (Intensive Care Society, 2011). 3.0 SCOPE This document applies to all adult patients requiring transfer with special consideration for those stated in section 1 of this policy. The policy should be adhered to by all staff, professional, administrative, bank, agency and locum who may be involved in the Version 4 (September 2014) Page 4 of 35 Please check intranet for latest version Tameside Hospital NHS Foundation Trust Transfer Policy (Adults) transfer of patients, internally or externally to the Trust. The scope of this policy is Trust wide. This policy should be applied in conjunction with the other specialist transfer policies in operation, the Trust Bed Management and escalation policy and Greater Manchester emergency admissions policy. 4.0 DEFINITIONS Critically ill- Levels of CareScoop and run – Time critical transfer- Patients who have severe physiological disturbance sufficient to require single or multiple organ support 2 or 3 care). Refers to the intensity of nursing care required by the patient. See section 1. Refers to the procedure for the transfer of patients with suspected ruptured abdominal aortic aneurysm. Patients in whom a life saving intervention is required at another centre, necessitating the transfer. E.g. ruptured AAA, expanding extra-dural haematoma. 5.0 DUTIES 5.1 Chief Executive The Chief Executive has overall accountability for ensuring that the Trust meets its statutory and non-statutory obligations in respect of maintaining appropriate standards of patient transfer. The Chief Executive devolves the responsibility for monitoring and compliance to the Medical and Executive Nursing Directors. 5.2 Directors Directors are responsible for ensuring that the requirements of the Trust’s Patient transfer policy are effectively managed within their Directorate and that staff are aware of, and implement, those requirements. 5.3 Director of Nursing/Medical Director The Director of Nursing and Medical Director are responsible for ensuring that Trust staff upholds the principles of correct patient transfer and that appropriate polices and procedures are developed, maintained, and communicated throughout the organisation in co-ordination with other relevant organisations and stakeholders. 5.4 Divisional Responsibilities Divisional leads are responsible for ensuring safe transfer methods are communicated and implemented within their areas of responsibility Any incident arising from the transfer of a patient should be investigated at a local (divisional) level and any actions taken to prevent reoccurrence and minimise risk, these actions should then be discussed at the critical care steering group meeting, and taken to Critical Care governance by the trust transfer lead for the Trust. Documentation should be copied to the Risk Management advisor to allow completion and closure of the incident. Any lessons to be learnt should be shared at the appropriate Outreach forum and the Critical Care Governance Meeting and distributed trust-wide. Any ongoing patient transfer risks should be registered on the Divisional Risk register. Version 4 (September 2014) Page 5 of 35 Please check intranet for latest version Tameside Hospital NHS Foundation Trust Transfer Policy (Adults) 5.5 Ward Manager/Departmental Manager /Matron Responsibilities It is the Ward Manager or Departmental Managers responsibility to ensure that the staff are made aware of the Trust processes for the safe transfer of patients and encourage all qualified staff to attend transfer training at the Critical Care Skills Institute. These procedures should be included in the induction of all staff that may be involved in the admission and ongoing care of the patient. Any incidents arising from patient transfer should be investigated and reported to the Matron or ward Manager via the risk management incident route. It is the responsibility of the ward manager team leader to determine the level of escort required for each individual patient. 5.6 Medical Staff Responsibilities All medical staff must follow the Trusts procedures for the transfer of patients. Senior medical staff responsible for the supervision and training of doctors should ensure that junior medical staff are aware of their role and competent to undertake when transferring. Any incidents arising from patient transfer should be reported by medical staff via the risk management incident reporting route. 5.7 All Staff It is the responsibility of every registered nurse, support worker or other member of staff to ensure that the transfer policy is adhered to when transferring a patient, and to identify training needs where required via a training needs analysis. All staff should report any patient incidents arising from transfers via the Risk Management route. The Ward Manager should be informed of the incident. 5.8 Risk Management The Risk Management Department will record all patient transfer incidents reported through the risk reporting route. This data will be included in the monthly reports to the Heads of Departments. Any specific incidents of concern identified will be discussed at the Risk Management Committee meeting. The Risk Management Committee reports to the trust board. 5.9 Trust Transfer Co-ordinator The Anaesthetic department designate a consultant in Anaesthesia and Critical care to act as Lead consultant for Transfers. This consultant will be involved in training and policy development with regards transferring patients, especially critically ill patients. They report to the Anaesthetic DMT and Critical Care transfer and quality of transfers, obtained from ICBIS (Intensive Care Bed Information Service) on monthly basis. 5.10 Outreach Team The Outreach team are responsible for updating and revision of the policy in collaboration with the Trust Transfer Co-ordinator. The team are also responsible for design and performance of audits into transfers and where feasible will provide assistance for stabilisation prior to transfer of critically ill patients. Version 4 (September 2014) Page 6 of 35 Please check intranet for latest version Tameside Hospital NHS Foundation Trust 6.0 Transfer Policy (Adults) POLICY STATEMENT The purpose of this policy is to provide a standard Trust wide procedure which will ensure that adult patients are transferred safely. To provide staff with a clear course of action for transferring patients internally and out of the Trust. This policy includes the procedure to be followed for ITU/Critical Care Transfers-out of the Local Transfer and guidelines for the care of patients who require emergency surgery for ruptured aortic aneurysm. 7.0 THE TRANSFER PROCEDURE (INTRA-HOSPITAL) The nurse caring for the patient will arrange the necessary personnel for transfer using the triage table that accompanies the policy. Transfers from A/E will be documented using the Transfer form in Appendix 8. Decision to transfer patient (i) Intra-hospital transfers a. Patients often require transfer both from area of entry (e.g. the Emergency Department (ED) / Medical Assessment Unit (MAAU) to wards as well as from ward to ward or escalation of care. The transfer of patients between wards is a decision made jointly by bed managers and staff within the clinical area, including doctors and nurses. b. Level 0 patients-decision made by senior nurse/shift leader or NNP (Night Nurse Practitioner) c. Level 0 (unwell) – decision made by senior nurse/shift leader or NNP d. Level 1 – decision made by senior nursing staff but may need to be discussed with medical staff prior to transfer. e. Level 2-3 – trigger scoring on NEWS, decision made by medical staff that are to be responsible for patient in area transferred into (physicians for MHDU (Medical HDU, ITU/anaesthetics for ITU) (ii) Inter-hospital transfers a. All patients moving out of hospital are either discharges to another facility or transfers of care. The medical staff should be involved in approving every transfer. The be managers should also be informed. b. Level 2 needs to be base speciality decision +/- ITU/anaesthetics if they are to be involved. c. Level 3 needs to be ITU/anaesthetics decision and base speciality also. Level 0 and 1 patients. (i) Prior to Transfer This procedure is applicable to all external transfers, regional or out of region. Prior to transfer, the nurse will: Version 4 (September 2014) Page 7 of 35 Please check intranet for latest version Tameside Hospital NHS Foundation Trust Transfer Policy (Adults) 1. Ensure that the patient is aware of the reason for transfer. 2. Evaluate (using tools in Appendices) The grade and nature of staff required to safely transfer patient. The monitoring required to safely transfer the patient Other equipment required e.g. oxygen, infusion devices, defibrillator/monitor suction, Arrange ambulance or porters depending on the destination and ensure that all other necessary preparations are made prior to arranging for the ambulance and porters. When an Auxiliary/CSW/Nurse undertakes a patient transfer it must be ensured that they receive a handover from a Registered Nurse before leaving the Ward or Department. Ensuring that the Auxiliary / CSW is competent to undertake the transfer. 3. Ensure that all the necessary transportation equipment is present, in full working order, batteries fully charged, and that there is enough oxygen to last during transfer. (See Oxygen calculation chart – appendix 4). Minimum equipment for transfers is detailed in Appendix 5. 4. Collect and check all the patients medications properly required for transfer. Ensure that patient’s notes, and blood results go with the patient to their destination. If the transfer is external, they will follow the Trust's Health Records Policy in transfer of notes and x-rays which have to be booked out for tracking purposes. 5. If the patient is required to be transferred with blood transfusion ongoing or with blood products, the nurse will ensure that arrangements are made in line with the Trusts Blood Transfusion policy. Contact Transfusion Department. 6. Discard any prepared drugs that are not required on transfer and document this in patient’s notes. 7. Ensure appropriate monitoring attached (see appendix 5). If a syringe driver is attached, the nurse will ensure that the syringe is left in the driver, not on or in the patient’s bed. 8. Check that the transfer checklist has been completed and that all nursing and medical documents to go with the patient are assembled, along with the patient property if required. Medications specific for that patient must also accompany them, stored appropriately as per hospital policy. Remember, C.L.E.A.R.D Case notes and charts Lab results – current / latest Equipment / spare if required Audit forms / checklists Version 4 (September 2014) Page 8 of 35 Please check intranet for latest version Tameside Hospital NHS Foundation Trust Radiographs / reports External transfer Drugs – checked and secured Transfer Policy (Adults) (ii) During the transfer journey 1. All level 1 patients must have their ECG monitored throughout as well as consideration for Blood Pressure & Oxygen Saturation 2. The escort personnel must ensure meticulous attention is given to ensure that all equipment, intravenous lines, tubes and drains remain adequately secured throughout the journey to prevent them from being dislodged or disconnected, and ensure that all observational parameters are stable prior to transfer – document NEWS score pre transfer. 3. The escort personnel will ensure that drainage collection systems (such as colostomies and urine bags) have been emptied and recorded on the fluid balance chart. 4. The escort team will ensure that bed rails (or equivalent) are up and locked in position. If the patient is in a chair, the team will ensure that the patient’s feet are on the stand. The appropriate manual handling techniques will be used for patient transfer. All monitors and infusion devices should be secured appropriately and not rested on the trolley or patient. The team will ensure that infusion devices are stored at or below heart level. 5. Full guidelines for the transfer of critically ill patients may be found on the Tameside intra-net in ICU guidelines section 10: Transferring critically ill patients. 6. NB – specific arrangements apply to patients with suspected ruptured aortic aneurysm, where “scoop and run” principles normally apply. Please see appendix 8. 7. The team will regularly recheck that patient is stable and that all equipment and monitoring devised are functioning. The team will ensure that the patient is adequately and appropriately clothed or wrapped for the journey to prevent heat loss and to maintain the patients’ dignity in line with Trust procedures for the promotion and management of patient dignity. 8. Transfer should commence in slow, steady manner. For level 1 patients ensure the receiving Department are made aware when the patient sets off. 9. Treat and document any care provided during the transfer. (iii) On arrival at the transfer destination. 1. The escort team will ensure that the patient is formally handed over to receiving caring team. The escort team will assist staff to settle the patient and to ensure all equipment is transferred, and the correct flow rate of infusions is checked. 2. If patient has attended an OPD clinic or investigation and is returning, ensure all relevant points in section 7.2 above are continued. The escort team will follow appropriate Trust procedures for requesting transport for return journey, or bleep porters if internal. Version 4 (September 2014) Page 9 of 35 Please check intranet for latest version Tameside Hospital NHS Foundation Trust Transfer Policy (Adults) (iv) On completion of transfer, the escort team will: 1. Ensure transportation equipment is returned to place of origin, cleaned stored away, and all electrical items put on charge. If any problems with equipment occurred during transfer, these should be reported to the appropriate department before leaving. Any drugs and disposable equipment used should be replaced. 2. Document and report any event or problems encountered whilst escorting the patient. Report this via Incident Reporting Policy. (iv) Out of Hours This policy applies to transfers out of hours, with the consideration that in the absence of the bed manager, the Night Nurse practitioner will co-ordinate the transfer of patients internally and externally and will liaise with appropriate authorities. (V) Theatre discharges Most patients who are returned to the ward following surgery are suitable for escort by Theatre orderly, Anaesthetic Nurse or Ward Nurse. Occasionally a patient may require a medical escort as a level 1 patient. This will be discussed on an individual patient basis. 8.0 TRANSFER OF LEVEL 2 AND LEVEL 3 PATIENTS WITHIN THE TRUST (INTRA-HOSPITAL) If a patient is identified as a level 2 or 3 transfer then all the above basic principles (in section 7 (I – iv) apply. There are a number of additional factors to consider: (i) Escorting Personnel. All level 2 transfers require a qualified nurse to accompany them. This may be a trained ward nurse, an ED/anaesthetic nurse or an Outreach nurse. All level 2 transfers require a doctor to transfer them. Depending on the nature of the patient’s problems this may be either a doctor from the patient’s speciality (e.g. medicine, surgery, gynaecology, etc) or anaesthetics / ITU. The decision should be made by the consultants involved in the care of the patient. All level 3 transfers (that are ventilated or likely to be imminently ventilated) require anaesthetic / ITU doctors to accompany them. Nursing escort must be a qualified nurse who has been trained in transfer of level 3 patients or deals with such patients as part of their routine work (e.g. anaesthetic or ITU nurse). (ii) Equipment and monitoring All level 2 patients require ECG, NIBP, Sp02. Most require invasive pressure monitoring. Level 2/3 patients should be transferred with 02, cylinders, defibrillator, Version 4 (September 2014) Page 10 of 35 Please check intranet for latest version Tameside Hospital NHS Foundation Trust Transfer Policy (Adults) emergency transfer bag. Level 3 patients will require, in addition, a portable ventilator and ample 02 supply (see appendix for details of cylinder 02 content). (iii) During transfer (iv) Ring to warn receiving area (usually MHDU or ITU) that you are settling off, All level 2-3 patients should be continually monitored throughout the transfer and be aware of the nearest telephone point or ward should you encounter problems en route. On arrival at destination A thorough hand-over to appropriate grade of staff is vital Hand-over should follow the principles of ACCEPT (see ITU guidelines section 10 at (http://tis/documents/section10transfertransport.pdf) (v) Theatre transfer It is a standard that level 2 patients moving from theatre recovery to ITU/HDU/MHDU require an anaesthetist to accompany them. Rarely will it be the case that the patient does not require and escort. This should be at the discretion of the senior anaesthetist involved in the case and agreed with the anaesthetic nursing staff prior to discharge and transfer from recovery. All level 3 must have an anaesthetist accompanying them from recovery to ITU as well as a suitably qualified nurse. 9.0 Transfer out of the hospital (inter-hospital) Level 0 and 1 patients. The process for transfer is the same in principle as intra-hospial transfers for level 0 and 1 patient. Additional considerations are: o For Level 1 patients consider the potential for deterioration. The authorising doctor must assess the potential need for a medical escort in liaison with the ward team leader or NNP /bed manager. The accompanying doctor will be one from the transferring speciality. o Extra-care needs to be taken to check equipment and monitor power and that there is adequate drugs and oxygen available for the transfer duration. o Ensure documentation is up to date prior to transfer i.e. Nursing notes Observation charts Medical notes Relevant lab results Version 4 (September 2014) Page 11 of 35 Please check intranet for latest version Tameside Hospital NHS Foundation Trust Transfer Policy (Adults) o Consider that external transfers may result in exposure to lower temperatures and ensure ample blankets etc. o Inform receiving unit of departure. Level 2 and 3 Patients Full guidance on transfer of critical ill patients between hospitals can be found at (http://tis/documents/section10transfertransport.pdf) Salient issues are: (i) (ii) (iii) (iv) (v) Need for transfer: decision must be made at consultant level Suitability for transfer: this is a consultant level decision, made on discussion with relevant staff (e.g. senior nursing staff, manager-on-call). For level 2 patients the decision should be made by base speciality, with or without discussion with ITU/Anaesthetic staff. For level 3 patients the decision for suitability rests with ITU/Anaesthetic consultant and receiving unit ITU consultant. Staff to accompany level 2 inter-hospital tranfers are: Qualified nursing staff (trained in transfer) If unavailable then it is responsibility of on-call manager or senior nurse to identify suitable nurse escort. Medical escort i. Most level 2 patients may be safely accompanied by doctor from referring speciality (see appendix) ii. Rarely a level 2 transfer requires and ITU/Anaesthetic escort. If one is required then the patient probably needs to be escalated to a level 3 patient and intubated. iii. The decision to send an anaesthetist / Intensivist. Ruptured AAA patients are an exception to the medical escort rule, unless intuabed and level 3 already (see Appendix). Full transfer equipment and monitoring-consider use of transfer trolley (stored on ITU) Ensure ample 02 for journey to and from ambulance Monitor batteries checked. Monitor ECG, NIBP, Sp02, Invasive Pressures, EtCO2 Defibrillator Ample syringe pumps and batteries Transfer Bag Ventilator (Oxylog 3000 or LTV) Ample supply of infusion drugs to cover transfer time potential delays (e.g. traffic) Personal equipment e.g. phone, money, appropriate attire Patients property If transferring a patient who is ventilated, the patient will be attached to the portable ventilator at least 20 minutes prior to Version 4 (September 2014) Page 12 of 35 Please check intranet for latest version Tameside Hospital NHS Foundation Trust Transfer Policy (Adults) transfer, and arterial blood gases will be taken after that to ensure that the parameters set are satisfactory for the patient. Further details of transferring ventilated patients can be found in ICU guidelines section 10. (vi) (vii) Phone receiving unit immediately prior to departure As well as notes, investigations etc ensure a Critical Care transfer form is completed. (viii) The escort team will ensure that the patient is formally handed over to receiving caring team. The escort team will assist staff to settle the patient and to ensure all equipment is transferred, and the correct flow rate is infusions are checked. (ix) Ensure transportation equipment is returned to place of origin stored away, and all electrical items put on charge. If any problems with equipment occurred during transfer, these should be reported to the appropriate department before leaving. Any drugs and disposable equipment used should be replaced. (x) Document and report any event or problems encountered whilst escorting the patient on ICBIS form. Out of Hours This policy applies to transfers out of hours, with the consideration that in the absence of the bed manager, the Night Nurse Practitioner will co-ordinate the transfer of patients internally and externally and will liaise with appropriate authorities. 10.0 MONITORING This policy was developed by Outreach in conjunction with the medical transfer lead then distributed through the Clinical Governance Committee. After incorporating comments as appropriate from members the policy was ratified by the Critical Care Steering Group and disseminated to the leads in the Trust for implementation within their area. The policy was made available to staff on the Trusts intranet. 11.0 IMPLEMENTION AND STAFF TRAINING Training is provided for all staff members undertaking level 2 – 3 transfers. This training is accessed via Critical Care Skills Institute. The policy will be launched through Trust e-mail. 12.0 MONITORING The policy will be monitored by the Transfer Lead by periodic audit and analysis. They will produce an annual monitoring report for the Risk Management Committee which will include monitoring information of Version 4 (September 2014) Page 13 of 35 Please check intranet for latest version Tameside Hospital NHS Foundation Trust Transfer Policy (Adults) a. Duties b. Transfer requirements which are specific to each patient group c. Documentation to accompany the patient when being transferred d. Process for transfer out of hours Where the annual monitoring report identifies gaps and omissions in the policy progress will be action planned and the outcome assessed progress will be reported through the Risk Management Committee until completion. 13.0 REVIEW This policy will be formally reviewed in 2016 – two years after first approval/implementation, or earlier depending on the results of monitoring, changes in legislation, external reports or recommendations or changes in practice. 14.0 REFERENCES 1. Modernising Critical Care Service HSC 2000/017 2. Standards and Guidelines for levels of Critical Care for adults – Intestive Care Society, 2005 3. htt://tis/documents/section10transfertransport.pdf 4. Guidelines for the transport of the Critical ill adult (3rd Edition 2011) Intensive Care Society. Version 4 (September 2014) Page 14 of 35 Please check intranet for latest version Tameside Hospital NHS Foundation Trust Transfer Policy (Adults) APPENDIX 1 : Levels of transfer and minimum requirements. Degree of illness VEHICLE Extra equipment Ambulance Nursing Driver-porter or technician Trained nurse – critical care experience from sending or receiving unit Intensive Critical Single cot accident & emergency ambulance with Stretcher Siren Speed Suction Oxygen Basic Life Support kit Defibrillator ICU trained doctor of at least specialist registrar level Occasional according to perceived risk Occasionally intensive care technician or operating department practitioner If necessary for safety or to prevent distress, primary c a r e r f r o m o wn home, nursing home or institution A d va n c e d Life Support kit Ventilator Monitor Syringe pump Extra drugs 20 minutes but ~10 if immediate intervention required in receiving area 10 minutes A d va n c e d Life Support kit Monitor Syringe pump Ill-stable 30 minutes 60 minutes Basic Life Support practitioner (technician or trained nurse) with driver-porter. Nurse from sending unit if no other nurse in team Often monitor Occasional syringe pump Unwell 120 minutes Patient transport (PTS) vehicle Well Urgency Other Carer Advanced Life Support practitioner (paramedic or enhanced nurse) with driver-porter or technician. Nurse from sending unit if no other nurse in team I l l - unstable Medical PTS vehicle or taxi or car First-Aider and other attendant including Driver o o o Driver First aid kit Oxygen Pocket mask As available Version 4 (September 2014) Page 15 of 35 Please check intranet for latest version Tameside Hospital NHS Foundation Trust Transfer Policy (Adults) APPENDIX 2:TRANSFER EQUIPMENT AND PERSONNEL DEGREE OF ILLNESS Level 3 patient EXAMPLE Ventilated patient stabilised in ED/MAAU/ward/MHDU then transferred to ITU. Ventilated patient from ITU transferred to other area (e.g. CT, theatre, cardiology, endoscopy) Level 2 patient Post-operative high risk surgery or with invasive monitoring Critical ill patient suitable for single organ support. Post cardiac arrest not for ITU Level 1 patient- unwell Post-surgical Post/peri-MI Patient for urgent CT scan e.g. CVA Patient transferring from higher level of care (e.g.ITU/HDU) PARS > Ward patient who requires 02 or IV fluids or If on 02 ten monitor SpO2 other infusion Level 0 patient-unwell Level 0 patient Ward patient with no 02, fluid or infusion EQUIPMENT Ventilator & Cylinder Transfer trolley Monitoring (including invasive leads and EtC02) Syringe pumps Transfer bag Portable suction Defibrillator (if needed) Transfer trolley Monitoring (including invasive if appropriate) Syringe pumps Transfer bag Portable suction Defibrillator Monitoring (NIBP, ECG, Sp02) Emergency equipment 02 Cylinder and face mask None required Version 4 (September 2014) PERSONNEL Anaesthetist Qualified nurse (transfer trained or from appropriate speciality area e.g. anaesthetics, MHDU, ITU, ED, NNP) Doctor (see guidance) - Anaesthetist/ITU - Speciality doctor - Qualified nurse - NNP Qualified nurse (at discretion and responsibility of nursing shift leader) Escort personnel at discretion of nursing shift leader/ward manager. Non-Qualified staff / porter. Page 16 of 35 Please check intranet for latest version Tameside Hospital NHS Foundation Trust Transfer Policy (Adults) 7.6 Aatix incident form should be completed by any staff member who feels that the transfer was in anyway unsafe or inappropriate. 7.1 internal hospital transfers Please refer to Appendix 3 7.2 External hospital transfer Please refer to Appendix 5 8.2 Monitoring and Review Please refer to Appendix 7 – compliance monitoring tool. Version 4 (September 2014) Page 17 of 35 Please check intranet for latest version Tameside Hospital NHS Foundation Trust Transfer Policy (Adults) APPENDIX 3: GUIDELINES FOR NON-CLINICAL TRANSFERS This form should be jointly completed by the Bed Manager/Night Co-oridinator and the Nurse in Charge of the medical ward and then filled in the patients medical notes. Date: Patient name: Ward from: Consultant responsible for care: Patient Number: Ward to: Exclusion criteria (these patients should NOT be considered for transfer): Patients with dementia or demonstrating sign of confusion Patients triggering on the NEWS – unless documented in the management plan that the patient is not for escalation in treatment Patients with complex social needs likely to remain in hospital longer than 48 hours Patients deemed at end of life Patients who have had a fall since admission Patients with clostridium difficile or any other infection that may contribute to an outbreak i.e. Norovirus. NB: An incident form should be completed in the event that a patient transferred has had more, than one non-clinically justified move. Please complete the following checklist and action prior to transfer Yes No Comments Is there a clear treatment plan in the notes? Have the next of kin been notified of the move? If the patient has MRSA-have screens been completed? Has a property list been completed? Has a member of the medical team been informed Has an MNP been informed? Has an incident form been completed (where appropriate) Form completed by: Bed manager/night co-ordinator Signature: Nurse in charge Printed name: Signature: Printed name: Version 4 (September 2014) Page 18 of 35 Please check intranet for latest version Tameside Hospital NHS Foundation Trust Transfer Policy (Adults) APPENDIX 4: TRANSFER LETTER Name: Address: Next of Kin: Address: Post code: DOB: G.P: Post code: Telephone: Informed of transfer: Age: VISIT INFORMATION Admission date / time: Ward transferring from: Transfer date / time: Provisional diagnosis: Current complications: Medical history: Social history: PATIENT CARE NEEDS Mental health: Mobility: PROBLEMS / NEEDS Eating / Drinking (special diet): Communication: Breathing: Version 4 (September 2014) Page 19 of 35 Please check intranet for latest version Tameside Hospital NHS Foundation Trust Transfer Policy (Adults) Elimination: Washing / dressing: Knowledge needs: Sleeping / resting: Skin integrity: Waterlow Score Additional comments: CHECKLIST Allergies: Yes / No Drugs (TTO’s / Non-stock items / patient’s Patients notes / Care file: Patient’s blood forms: Property disclaimer Cannula removed: Sutures: Safety rails night: Safety rails day; Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No FUTURE HEALTHCARE Plan: Patient understanding: Relatives understanding: Name: Date Version 4 (September 2014) Page 20 of 35 Please check intranet for latest version Tameside Hospital NHS Foundation Trust Transfer Policy (Adults) APPENDIX 5: INTERNAL HOSPITAL TRANSFER This pathway assumes patient and carer involvement and consent to transfer. Clinical transfer to specialist ward requested by medical team Patient and carer Informed with Rationale. Named Nurse informed Bed Manager Clinical transfer to specialist ward requested by medical team Named Nurse and bed manager to complete ‘guidelines for non-clinical forms’ and file in patient’s case notes. Bed manager liaises with receiving ward to confirm bed availability. If there is no bed available it may be necessary for the bed manager to liaise with the medical team to consider the options. Named Nurse gives a verbal handover to a staff nurse on the receiving ward and completes the SBAR documentation. (Appendix 4) Prior to transfer the named nurse must: Ensure the patient is wearing the accurate identity bracelet Pack up patient’s medication Ensure all nursing documentation is updated Provide all of the patient’s own property and update property checklist Arrange for an appropriately qualified escort to accompany the patient if required At transfer the names nurse must send the following with the patient: Medication All relevant documentation, i.e. nursing and case-notes Property Version 4 (September 2014) Page 21 of 35 Please check intranet for latest version Tameside Hospital NHS Foundation Trust Transfer Policy (Adults) APPENDIX 6: SBAR VERBAL HANDOVER SHEET FOR INTERNAL TRANSFER One handover sheet per patient transfer To be completed by nurse receiving verbal handover File in patients nursing notes on arrival to ward / department SITUATION Date: Time: Patients Name: Age / DOB: NHS Number: Hospital Number: Coming from: Going to: Next of Kin aware Yes/No Property listed Yes/No Receiving Nurse: How many times transferred? BACKGROUND Diagnosis and treatment inc PMH and care needs ASSESSMENT Track and Trigger Score……………….. Nurse giving handover: Paine score……………………………… Infection Risk? Yes / No If yes state why…………………………. MRS Screen Yes / No Invasive devices: Yes / No IV cannula Yes / No Urinary Catheter Yes / No Other please state: …………………………………………. VTE Yes / No Waterlow Score………………………….. Skin intergrity (if has pressure ulcer location and grade) ……………………………………………………………….. ……………………………………………………………….. Specialist Mattress Yes / No MUST score……………………………… Oral Status……………………………….. Fall Risk? Yes / No Mobility issues? ………………………… ……………………………………………. Allergies…………………………………. Version 4 (September 2014) Page 22 of 35 Please check intranet for latest version Tameside Hospital NHS Foundation Trust Transfer Policy (Adults) APPENDIX 6: EXTERNAL HOSPITAL TRANSFER This pathway assumes patient and carer involvement and consent to transfer. Consultant decision that clinical transfer is required to another acute care setting If critical Care transfer, ring ICBIS for regional bed availability once bed/hospital sought Patient and carer informed with rationale Bed manager keeps named nurse informed. Medical tem liaises with on call/specialist team and the other organisation. This may be done by telephone and/or support by fax. Nursing / Medical team informs bed manager that the patient has been accepted by the other organisation. Bed manager liaises with bed manager at other organisation re: estimated date and time of transfer Confirmation of date and time of transfer Document in patient’s notes if Critical Care transfer obtain ICBIS form Bed manager contacts bed manager at other organisation date re: progress Discussed at daily bed meeting at escalated to other organisation site manager if delay is >48hrs. Prior to transfer the named nurse must: Ensure the patient is wearing the accurate identity bracelet Pack up the patients medication Ensure all nursing documentation is updated Provide all of the patient’s own property and update property checklist Arrange for an appropriately qualified escort to accompany the patient if required Book transport if required. Complete patient transfer form (Appendix 2) At transfer the named nurse must send the following with the patient Medication All relevant documentation, i.e.patient transfer letter, nursing documentation and copies of case notes relevant to the admission/case notes as appropriate Property Version 4 (September 2014) Page 23 of 35 Please check intranet for latest version Tameside Hospital NHS Foundation Trust Transfer Policy (Adults) APPENDIX 7: APPROXIMATE DURATION OF USAGE FOR TYPICAL WARD SIZE CYLINDERS FROM FULL (137 bar) AT VARIABLE FLOW RATES OXYGEN CYLINDER SIZE C PD D 170 300 340 FLOW RATE E F G 680 1360 3400 APPROXIMATE LIFE OF CYLINDERS IN HOUR 2 4 6 8 10 12 1 1/2 ~ 1/2 ~ 1/8 1/8 2 1/2 1 1/4 ~ 1/2 1/2 1/4 1~ 1 1/4 1 ~ 1/2 1/4 5 1/2 2~ 1~ 1 1/2 1 ~ 11 1/2 5 1/2 3~ 3 2 1/4 1~ 1 1/4 14 1/4 9~ 7 5 1/2 4~ 14 1/8 1/4 1/4 1/2 1 1/2 4 AIR CYLINDER SIZE FLOW RATE 2 4 6 8 10 12 14 E F 640 1280 G 3200 APPROXIMATE LIFE OF CYLINDERS IN HOUR 5 1/4 2 1/2 1~ 1 1/4 1 1 1/2 10 1/2 5 1/4 3 1/2 2 1/2 2 1~ 1 1/2 Version 4 (September 2014) 26 1/2 13 1/4 8~ 6 1/2 5 1/2 4 1/2 3~ Page 24 of 35 Please check intranet for latest version Tameside Hospital NHS Foundation Trust Transfer Policy (Adults) APPENDIX 8: NON CLINICAL CRITICAL CARE TRANSFERS (Outside Transfer Group) ADDITIONAL INFORMATION / EXCEPTION REPORT Strategic Health Authority: Trust: Transfer Details: Patient ID Greater Manchester Tameside Hospital Foundation Trust (RMP) Date of Transfer: From: To: Contact for Further Information / Follow Up: Contact at Trust: Name: Contact at St HA: Name: Comments / Follow Up Action: Reason for Transfer: Telephone: Telephone: Version 4 (September 2014) Page 25 of 35 Please check intranet for latest version Tameside Hospital NHS Foundation Trust Transfer Policy (Adults) APPENDIX 9: PROCEDURE TO BE FOLLOWED FOR ITU/CRITICAL CARE TRANSFER-OUT OF THE LOCAL TRANSFER GROUP (REFERENCE HSC 2000-17) This procedure should be followed for all non-clinical ITU/Critical Care transfersout of the local transfer group. The local transfer group for Tameside is Manchester Royal Infirmary, Wythenshawe, North Manchester, Bury, Rochdale, Stockport, Oldham, Trafford, Hope, Wigan and Bolton. Transfers within the local transfer group do not form part of this procedure and reporting mechanism. Transfers-out for expert management e.g., cardiac, neurology, burns or to renal centres are outside this procedure and reporting mechanism. Procedures If a bed in not available in the local transfer group, a bed should be found as close to Tameside as possible. Intensive care bed availability is accessed through ICBIS. When a bed is located the responsible consultant for each trust must agree the transfer. This is as per Admission and Discharge policy for ITU at http://tis/documents/admissionanddischargepolicyforituV02.pdf. This is reproduced in Appendix 9 In hours the transfer should then be approved by the Executive Director of Clinical Services or another Director in the following order on behalf of the Chief Executive. o Director of Nursing o Director of Planning and Performance Out of hours the team arranging the transfer should inform the first on call manager who will notify the second on call manager. The ITU sister/charge nurse in charge of the shift should be informed of all transfers. The Transfer Form should be completed and returned to the Trust information department. Before 9:45am each working day the bed manager should inform the information department that the transfer has taken place (for SITREP data). In office hours the Executive Director nominated deputy will inform the PCT of the transfer out of the network. The policy on loan of case notes should be adhered to by staff involved. Version 4 (September 2014) Please check intranet for latest version Tameside Hospital NHS Foundation Trust Transfer Policy (Adults) APPENDIX 10: EXTRACT FROM THE GUIDELINES FOR THE MANAGEMENT OF PATIENTS WITH SUSPECTED RUPTURED ABDOMINAL AORTIC ANEURYSM Contacts for this policy: Executive Director of Clinical Services. Nominated Deputy-Service Manager, Emergency & Critical Care Division. Full guidance may be found in Admission and Discharge policy for ITU at http://tis/documents/admissionand dischargepolicyforituV02.pdf Patients with a provisional diagnosis of Ruptured Abdominal Aortic Aneurysm (RAAA) may come from various sources: General Practitioners SMUHT A&E Department (or a ward) SMUHT “vascular supported” Hospitals: Stepping Hill Hospital, Stockport Trafford General Hospital Tameside General Hospital Macclesfield General Hospital Guidelines for staff in A&E Departments of Referring Hospital with respect to the Transfer of Patients with RAAA On a Tuesday or Thursday, or out of hours Manchester Royal Infirmary take day, you will be instructed to contact MRI. Once a firm diagnosis of RAAA has been made by a referring hospital, and the patient accepted by the SMUHT Vascular SpR, the patient should be transferred to SMUHT Acute Block Operating Theatre Recovery without Version 4 (September 2014) Please check intranet for latest version Tameside Hospital NHS Foundation Trust Transfer Policy (Adults) delay. There should be a “scoop and run”, in order to improve the chances of patient survival. The time delay from diagnosis to application of an infrarenal aortic cross clamp by a vascular surgeon should be minimal. The patient should be transferred with: A functioning IVI through a wide bore cannula A urinary catheter in situ Eight units of type specific blood in the ambulance, or following as soon possible by taxi Oxygen mask on Adequate analgesia “on board” There must not be delay to wait for full cross match of blood, or for anaesthetists to insert central venous catheters etc. It is not necessary for a doctor, either surgical or anaesthetic, to accompany the patient. All that is required is a paramedic ambulance. (in the event of a cardiac arrest during transfer, the patient is not going to survive, and so the presence of a doctor will not affect outcome.) If a patient requires medical intervention prior to transfer that alters the degree of support they are receiving e.g. intubation and ventilation, invasive monitoring, vasopressor support, then the category of transfer changes from time critical to intensive. In these circumstances the patient must be accompanied by an anaesthetist / intensivist as per normal policy. Version 4 (September 2014) Please check intranet for latest version Tameside Hospital NHS Foundation Trust Transfer Policy (Adults) APPENDIX 11: transfer of level 2 and 3 patients in event of no critical care beds. Taken from http://tis/documents/admissionanddischargepolicyforituV02.pdf Version 4 (September 2014) Please check intranet for latest version Tameside Hospital NHS Foundation Trust Transfer Policy (Adults) Appendix 11: EQUALITY IMPACT ASSESSMENT TOOL Yes/No 1. Does the policy/guidance affect one group less or more favourably than another on the basis of: Race No Ethnic origins (including gypsies and No travellers) Nationality No Gender No Culture No Religion or belief No Sexual orientation including lesbian, No gay and bisexual people Age No Disability - learning disabilities, physical disability, sensory impairment mental health problems No and 2. Is there any evidence that some groups are affected differently? No 3. If you have identified potential discrimination, are any exceptions valid, legal and/or justifiable? N/A 4. Is the impact of the policy/guidance likely to be negative? No 5. If so can the impact be avoided? N/A 6. What alternatives are there to achieving the policy/guidance without the impact? N/A 7. Can we reduce the impact by taking different action? N/A Version 4 (September 2014) Please check intranet for latest version Comments Tameside Hospital NHS Foundation Trust Appendix 12: Transfer audit proforma Version 4 (September 2014) Please check intranet for latest version Transfer Policy (Adults) Tameside Hospital NHS Foundation Trust Version 4 (September 2014) Please check intranet for latest version Transfer Policy (Adults) Tameside Hospital NHS Foundation Trust Version 4 (September 2014) Please check intranet for latest version Transfer Policy (Adults) Tameside Hospital NHS Foundation Trust Version 4 (September 2014) Please check intranet for latest version Transfer Policy (Adults) Tameside Hospital NHS Foundation Trust Transfer Policy (Adults) Appendix 13:A/E Transfer Checklist Form YES NO N/A PATIENT DETAILS YES NO N/A PRESCRIBED MEDICATION GIVEN IN A/E NAME BAND IN SITU Comments _________________________ PATIENT ALERT/ORIENTATED __________________________ PATIENT INFORMED OF TRANSFER NG TUBE NOK INFORMED CATHETER NOK PRESENT CHEST DRAIN NAME: _____________ GLASGOW COMA SCORE ____/15 RELATIONSHIP: _____________ PAIN SCORE ____/10 DISCLAIMER SIGNED PATIENT CHECKED FOR PRESSURE AREAS PATIENT PROPERTY IDENTIFIED WATERLOW SCORE Comments _____________________ TRANSFER ______________________________ RECEIVING WARD IDENTIFIED AIRWAY SECURE BED BUREAU INFORMED ARTERIAL LINE INSERTED ED NOTES/CHARTS PHOTOCOPIED BLOOD GAS TAKEN PATIENT CARE LEVEL IF EXTERNAL BLOOD RESULTS NOTED PATIENTS OWN MEDICATIONS SENT BLOODS TAKEN TROLLEY CHECKED FOR TRANSFER CENTRAL LINE INSERTED SUITABLE TRAINED ESCORT CHECK X-RAY PERFORMED MONITOR CHECKED AND SECURE C SPINE CLEARED ALARM PARAMETERS SET ECG PERFORMED EMERGENCY DRUGS IV ACCESS OBTAINED DEFIBRILATOR NEURO OBS RECORDED/STABLE PORTABLE VENTILATOR O2 THERAPY SPARE INFUSIONS/DRUGS FiO2_____ Ward _____________ PATIENT MEDICATION STARTED PATIENT ADEQUATELY WRAPPED PATIENT ON MEDICATION SUITABLE FOR TROLLEY WAIT PRESCRIBED INFUSIONS STARTED HANDOVER GIVEN TO RECEVING WARD NUMBER OF INFUSIONS NAMED NURSE _____________________________________ OTHER ESCORT --------------------------------------------------------------- VENTILATED SIGNED __________________________________________ VITAL SIGNS RECORDED/STABLE DATED ________________ TIME______________________ Version 4 (September 2014) Please check intranet for latest version