Download transfer policy (adults)

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