DOC

Transfer Policy - Portsmouth Hospitals NHS Trust

By Thomas Hill,2014-03-21 02:01
8 views 0
Transfer Policy - Portsmouth Hospitals NHS TrustNHS,Trust,nhs,trust

    Transfer Policy

    Version2

    Name of responsible (ratifying) committeePatient Safety Working GroupDate ratified16 February 2012

    Document Manager (job title)Operations Centre Manager

    Date issued29 February 2012

    Review dateDecember 2014 (unless requirements change)

    Electronic locationManagement Policies

    Related Procedural DocumentsDischarge Policy, Patient Identification Policy

    Transfer; safe; timely comfortable transfer of patients;

    external; internal; inter-hospital; Care; Medical Key Words (to aid with searching)treatment; Health and safety; Occupational health and

    safety; Clinical guidelines; Clinical procedures;

    Administration

    In the case of hard copies of this policy the content can only be assured to be accurate on the date of issue marked on the

    document.

    For assurance that the most up to date policy is being used, staff should refer to the version held on the intranet

    Transfer Policy. Issue 2. 29 February 2012

    (Review date: December 2014 (unless requirements change)

    Page 1 of 12

CONTENTS

     Appendices............................................................................................................................... ......... 2

     Appendix A: Transfer Checklist ........................................................................................................... 2

     QUICK REFERENCE GUIDE............................................................................................................. 3

     1. INTRODUCTION ............................................................................................................................. 4

     2. PURPOSE............................................................................................................................... ........ 4

     3. SCOPE ............................................................................................................................................ 4

     4. DEFINITIONS............................................................................................................................... ... 4

     5. DUTIES AND RESPONSIBILITIES.................................................................................................. 5

     6. PROCESS............................................................................................................................... ........ 6

     7 TRAINING REQUIREMENTS ........................................................................................................ 10

     8 REFERENCES AND ASSOCIATED DOCUMENTATION............................................................... 10

     9 EQUALITY IMPACT STATEMENT ................................................................................................. 10

     10 MONITORING COMPLIANCE ..................................................................................................... 11

     As a minimum the following will be monitored to ensure compliance ................................................ 11

     Appendices

    Appendix A: Transfer Checklist

    Transfer Policy. Issue 2. 29 February 2012(Review date: December 2014 (unless requirements change)

    Page 2 of 12

    QUICK REFERENCE GUIDE

    For quick reference the guide below is a summary of actions required. This does not negate the need those involved in the process to be aware of and follow the detail of this policy.

    1.Transfers should normally occur between 08:00 and 22:00

    2.A transfer checklist must be completed by the transferring and receiving nurse

    3.All other relevant documentation must accompany the patient

    4.The need for an escort must be assessed

    a.Level 1, 2, 3 patients and patients whose respiratory or cardiovascular systems are

    unstable must be accompanied by a registered healthcare professional

    5.The need for any equipment to accompany the patient must be assessed e.g. oxygen,

    intravenous infusions, pressure relieving aids

    6.All medicines and personal property must accompany the patient

    7.The receiving ward must be made aware of any infection risk

    8.Patients must be handed over to, and welcomed onto, the receiving ward

    9.There must be adequate, appropriate and timely communication between transferring and

    receiving staff and with the patient, relative or carer

    10.Out of hours transfers (22:00 – 08:00) must be avoided unless the patient’s condition or

    operational demands of the organisation dictate.

    Transfer Policy. Issue 2. 29 February 2012

    (Review date: December 2014 (unless requirements change)

    Page 3 of 12

    1.INTRODUCTION

    Portsmouth Hospitals NHS Trust (the Trust) recognises that there is frequently a requirement to transfer patients internally and externally to other healthcare providers: for the purposes of the provision of clinical care, undertaking investigations and to facilitate patient flow. This policy aims to facilitate the safe, timely and comfortable transfer of patients, by stipulating the types of transfers and the escort required.

    An internal transfer takes place when a patient remains under the care of Trust Health Professionals and who is not removed from the Patient Administration System (PAS).Patients who may require transfer within the Trust include:

    Transfers to departments for investigations.

    Transfers from the Emergency Department

    Transfers between wards

    Transfers between sites.

    The principal responsibility of all staff is to maintain patient wellbeing, provide optimal care during the period away from the principal care area/ward, report and document outcomes and action taken.

    2.PURPOSE

    The purpose of this policy is to provide direction, guidance and the underlying principles for staff to support safe and appropriate transfer of patients.

    The key to safety is through risk assessment and communication. All patients undergoing transfer must be risk assessed for clinical need during transfer by a registered nurse/midwife who must take responsibility for providing the verbal handover of the patient to the receiving area.

    3.SCOPE

    This policy applies to all groups of patients requiring transfer and to all staff who are involved in those transfers.

    In the event of an infection outbreak, flu pandemic or major incident, the Trust recognises that it may not be possible to adhere to all aspects of this document. In such circumstances, staff should take advice from their manager and all possible action must be taken to maintain ongoing patient and staff safety’

    4.DEFINITIONS

    Diagnostic/Treatment Transfer: the movement of a patient from one service to another within the Trust for an assessment/diagnostic procedure or treatment

    Escort: any member of staff who is involved with escorting patients and who has the relevant knowledge and skills to provide a high standard of care during the transfer; to ensure patient safety is not compromised. An escort can be:

    Registered professionals, doctors, registered nurses and midwives, operating

    department practitioners

    Non registered professional, healthcare assistants and other clinical support workers

    Transfer Policy. Issue 2. 29 February 2012

    (Review date: December 2014 (unless requirements change)

    Page 4 of 12

    External transfer: the temporary movement of a patient to an acute care environment service external to the Trust, e.g. for investigations or interventions that, for whatever reason, cannot be provided by Portsmouth Hospitals NHS Trust. This should not be confused with a discharge, as the intention is that, once the investigation or intervention has been completed, the patient will return to our care.

    Internal transfer: the movement of a patient from one clinical area to another within the Trust. For example:

    For investigations

    From the Emergency Department

    Between wards

    Between sites

    Patient groups:

    Adults

    Level 0 Patients whose care can be met through normal ward care in hospital

    Level 1 Patients at risk of their condition deteriorating, or those recently relocated from higher levels of care, whose needs can be met on an acute ward with additional advice and support from the critical care team

    Level 2 Patients requiring more detailed observation or intervention including support from a single failing organ system or post–operative care and those “stepping down” from higher levels of care

    Level 3 Patients requiring advanced respiratory support alone or basic respiratory support together with support of at least two organ systems. The level includes all complex patients requiring support for a multi – organ failure

    Out of Hours: a transfer that occurs between 2200 and 0800

    5.DUTIES AND RESPONSIBILITIES

    The Operations Centre Manager is responsible for resolving any operational issues relating to the transfer of patients, as escalated by the clinical team

    The Matron is responsible for:

    The day to day operational management of the Transfer Team and the development of

    transfer processes to ensure they remain responsive to the changing needs of the

    Trust.

    Escalating any unresolvable matters associated with patient transfer to the Director of

    Nursing (or nominated deputy); in particular those matters relating to patient care,

    patient safety and other quality issues

    Escalating any operational issues related to transfer to the Operations Centre Manager

    In association with members of the Transfer Team, carrying out education amongst

    Trust staff to ensure they have the appropriate skills and knowledge to implement safe

    patient transfer

    Receiving information on all adverse incidents and near misses relating to patient

    transfer

    In association with members of the Transfer Team, undertaking an annual review of this

    policy, to ensure it continues to meet the operational needs of the Trust and its patients.

    Transfer Policy. Issue 2. 29 February 2012

    (Review date: December 2014 (unless requirements change)

    Page 5 of 12

    Developing and implementing an action plan with defined timescales to address any

    changes to the transfer process, as highlighted by review of the policy and/or trends

    identified through adverse incidents and near misses.

    Escalating any problems with the implementation of the action plan to the Emergency

    Pathway Manager

    Duty Hospital Manager: out of hours and in the absence of the Operations Centre Manager or Matron/Hospital at Night service, the Duty Hospital Manager has responsibility for managing any issues relating to patient transfer and for providing support and guidance Transfer Team report directly to the Matron and are:

    Employed to undertake the majority of internal transfers, with the support of clinical

    teams and the Portering Services. The exceptions to these transfers are those required

    by child health, obstetric and critical care service patients

    In association with the Matron, responsible for carrying out education amongst Trust

    staff to ensure they have the appropriate skills and knowledge to implement safe patient

    transfer

    In association with the Matron, responsible for reviewing and continually developing this

    policy, to ensure it continues to meet the requirements of the Trust and its patients

    The registered nurse on the Transfer Team will, in conjunction with the registered nurse

    caring for the patient in the clinical area, undertake a risk assessment to ascertain by

    whom the transfer should be undertaken.

Nurse Escort regardless of status, is responsible for:

    Positively identifying the patient to be transferred

    Ensuring all relevant documentation is completed and transferred with the patient

    Confirming the correct destination for the transfer

    Monitoring the status of the patient during the transfer, using the appropriate monitoring

    devices

    Taking all appropriate action, should the patient’s condition change

    Ward Managers are responsible for:

    Ensuring their teams are aware of the requirements of this policy

    Ensuring there are operational systems in place within their teams to fulfill the

    requirements of this policy at local level

    Reporting any transfer issues to the relevant Modern Matron, for support to ensure the

    ongoing safety of their patients

    Ward Clerk

    Ward Clerks are responsible for copying the patient’s health record, the booking of transport and any other required administrative duties to support safe patient transfer

    6.PROCESS

    Internal Transfers

    Internal transfers normally take place between 08:00 and 22:00

    6.1 Staffing

    Transfer Policy. Issue 2. 29 February 2012

    (Review date: December 2014 (unless requirements change)

    Page 6 of 12

    6.1.1 The Transfer Team will carry out the majority of transfers, within hours6.1.2Porters will support the transfer process with requests submitted via the Helpdesk

    (ext 6321). Urgent transfers must be requested as such, as a response time of 5

    minutes from portering services is required

    6.1.3All staff involved in the transfer process are required to follow infection control

    practice guidance related to protective equipment and hand hygiene6.1.4Ward staff are responsible for ensuring patients are suitably dressed and blankets

    provided if necessary, to ensure comfort and maintain privacy and dignity6.1.5The receiving ward/department must ensure that a member of staff is available to

    receive the patient and take handover from escort if necessary.

    6.2 Escorts

    6.2.1The nurse-in-charge of the patient’s care will assess (Appendix A) if an escort is

    required and record any such requirement in the patient’s health record. The

    nurse-in-charge will remain accountable for the patient’s care at all times 6.2.2The staff member acting as an escort must be competent to use any equipment

    that is being transferred with the patient and ensure it has sufficient battery life for

    the period of the transfer

    6.2.3All patients categorised as level 1, 2 and 3 require a registered professional escort 6.2.4Escorts are required to ensure that the patient’s wellbeing is considered at all

    times and must actively engage with the patient during the whole transfer process.

    6.3 Communication

    6.3.1There must be adequate and effective communication between the transferring

    and receiving ward/department

    6.3.2Ward to ward transfers between specialties will be facilitated by the nurse-in-

    charge of the ward/department, the Duty Hospital Manager and Transfer Team6.3.3The nurse-in-charge of the patient’s care on the transferring ward must provide a

    verbal telephone handover to the receiving nurse if not accompanying the patient.

    Alternatively the nurse-in-charge of the transferring ward will hand over to the

    Transfer Team who will then hand over to the nurse on the receiving ward 6.3.4The escort and the ward/department where the patient is being transferred to,

    whether permanently or temporarily for investigations/intervention, must be aware

    of any current infection risk prior to transfer.

    6.3.5Patients will be informed at the earliest opportunity of the need for a transfer and

    provided with an explanation of why the transfer is necessary.

    6.3.6With the consent of the patient, relatives, carers or others will be advised of

    transfers to another ward. Note: it is not necessary to notify relatives, carers or

    others when a patient is temporarily absent from the ward e.g. for diagnostic

    investigations or interventions.

    6.4 Documentation

    6.4.1The nurse-in-charge is responsible for ensuring that all appropriate health records

    accompany the patient

    Transfer Policy. Issue 2. 29 February 2012

    (Review date: December 2014 (unless requirements change)

    Page 7 of 12

    6.4.2The transfer checklist (Appendix A), which forms part of the nursing

    documentation, must be completed by the nurse responsible for the patient’s care

    at the time of the transfer

    6.4.3Patients must have an accurate patient identification band and on arrival in the

    receiving ward the band must be removed and replaced with amended details: in

    accordance with the Patient Identification Policy

    6.5 Other

    In general, when transferred, other than internally for investigations or interventions6.5.1All dispensed medications must accompany the patient.

    6.5.2All property must accompany the patient together with a completed property form. 6.5.3The registered nurse is responsible for deciding if existing pressure relieving

    equipment should move with the patient

    Note: it may be that even for temporary internal transfers for investigations or

    interventions that the nurse on the transferring ward may consider it necessary for

    some medications and/or pressure relieving aids to accompany the patient.

    6.6 Intravenous Infusions

    6.6.1All infusions containing drugs, including Potassium or TPN must be on an infusion

    pump with appropriate battery life for the transfer and the registered professional

    must have been trained and competent to use the equipment.

    6.6.2If the patient requires a continuous infusion or the infusion can not be stopped

    during the transfer (advice sought from a doctor) the registered nurse responsible

    for the assessment must clearly state, on the Transfer Checklist, the action

    required for any ongoing intravenous infusion.

    6.6.3If close observation of the patient is required, or if drug administration is required,

    a registered professional must always act as the escort for the patient. It is

    acceptable for a non – registered member of staff to escort a patient connected to

    an IVAC infusion pump but ONLY when 0.9% saline or 5% Glucose/Dextrose

    Saline or Hartmans is being administered. Non-registered staff are not allowed to

    transfer patients receiving intravenous drug therapies and they are not allowed to

    touch or use any infusion device. If a patient has been assessed as competent to

    self administer medication by a registered professional and is using an ambulatory

    infusion device then it is acceptable for a non–professional to act as an escort.

    However, the device must have been checked by a registered professional prior to

    commencement of the transfer, to ensure there is sufficient battery life and

    medication for the duration of the escort.

    6.7 Oxygen Therapy

    6.7.1If the patient’s respiratory or cardiovascular status is unstable a registered nurse

    must always act as the escort for the patient.

    6.7.2The registered nurse making the assessment is responsible for ensuring that all

    required information is given to the patient’s escort.

    Transfer Policy. Issue 2. 29 February 2012

    (Review date: December 2014 (unless requirements change)

    Page 8 of 12

    6.7.3Prior to commencement of the transfer, the registered nurse must check and

    ensure there is sufficient oxygen in the cylinder required for the full duration of the

    transfer.

    6.8 Tissue Viability

    6.8.1All patients must have a documented, up to date, Waterlow Assessment prior to

    transfer

    6.8.2The registered nurse is responsible for deciding if the patient requires pressure-

    relieving equipment during transfer

    6.9 External Transfers

    All conditions and arrangements relating to internal transfers apply, plus

    6.9.3Only a copy of the health record must accompany the patient: the original must be

    retained by the Trust

    6.9.4If an escort is to accompany the patient, confirmation of the return journey

    arrangements for the escort must be made by the nurse-in-charge of the

    transferring ward

    6.10Maternity Transfers

    All maternity transfers are considered as emergencies and the maternity service works in

    partnership with South Central Ambulance Trust to achieve rapid and seamless transfer

    processes.

    The guidelines on transfer can found on the Maternity Services Departmental webpage.

    The guideline covers the transfer of mothers, babies and neonates, including process,

    responsibilities, communication pathways and documentation.

    6.11Transferring the Critically Ill Patient

    The transfer of critically patients is governed by the policy and procedures produced by

    the Wessex Critical Care Network.

     Inter-hospital transfer guidance is available on the Critical Care Departmental webpage6.12 Out of Hours Transfers

    Out of hours’ transfers are those that occur between 22:00 and 08:00 hours. The

    arrangements as described above apply to transfers ‘out of hours’. However, it is

    recognised that such transfers are far from ideal and will be avoided unless the:

    6.12.1The patient’s condition deteriorates, necessitating a transfer out of hours

    6.12.2The operational demands of the organisation make such a transfer unavoidable.

    If an out of hours transfers is necessary

    6.12.3The nurse-in-charge of the transferring ward must risk assess all patients, to

    determine which patient is in the most favourable clinical condition for transfer.

    The assessment must include, but is not necessarily limited to:

    Dependency of patient

    Instability of condition

    Behavioural risks and concerns

    Transfer Policy. Issue 2. 29 February 2012

    (Review date: December 2014 (unless requirements change)

    Page 9 of 12

    6.12.4 The on-call registrar/consultant may be called to identify or review patients for

    suitability to transfer if the nursing teams need confirmation of suitability or are

    unable to identify safe, suitable patients from a clinical perspective.

    6.12.5The nurse-in-charge must inform the Duty Hospital Manager who will support the

    transfer

    6.12.6Any decision to transfer out of hours must be clearly documented in the patient’s

    health record

    6.12.7The relatives will be informed as soon as possible in hours, unless the patient

    requests otherwise or there is an overriding clinical reason for informing them out

    of hours. Any decision to notify relatives, carers or others out of hours is the

    responsibility of the patient’s clinician

    7TRAINING REQUIREMENTS

    7.1Members of the Transfer Team, in conjunction with the Lead Nurse – Clinical Practice,

    are responsible for educating staff, temporary or substantive, to ensure they have the

    required knowledge and skills to allow the safe and timely transfer of all patients across

    ‘general’ clinical areas

    7.2Staff from the Department of Clinical Care are responsible for educating staff in the care

    and transfer of patients in and out of the Department

    7.3Carillion Management Team are responsible for training and supervising porters involved

    in the transfer of patients

    8REFERENCES AND ASSOCIATED DOCUMENTATION

    External

    Medical Stability and ‘Safe to Transfer’: Department of Health (2003) www.dh.gov.uk

    The transfer of frail older NHS patients to other long stay settings: Department of

    Health (1998) www.dh.gov.uk

    Ensuring the Effective Discharge of Older Patients from NHS Acute Hospitals. The

    Stationery Office. www.nao.org.uk

    Internal

     Patient Identification Policy

     Discharge Policy

    9EQUALITY IMPACT STATEMENT

    Portsmouth Hospitals NHS Trust is committed to ensuring that, as far as is reasonably practicable, the way we provide services to the public and the way we treat our staff reflects their individual needs and does not discriminate against individuals or groups on any grounds.This policy has been assessed accordingly

    Transfer Policy. Issue 2. 29 February 2012

    (Review date: December 2014 (unless requirements change)

    Page 10 of 12

Report this document

For any questions or suggestions please email
cust-service@docsford.com