REF: CG 21 VERSION: 3.0

Transfer of Patient Policy (including Intra & Inter Hospital Transfers) SUMMARY & AIM The Policy sets out the requirements in order to ensure patients have the safest transfer between health care facilities. This includes transfer between departments/wards and hospital sites within NCUHT, and transfer from NCUHT to other health care providers. Whatever the reason for, and type of transfer, the key underlying principle is that patients should continue to receive care that fully meets their needs, throughout the transfer process.

TARGET AUDIENCE: All staff who are involved in the transfer of patients between wards/departments/other care providers and hospitals .

TRAINING: The training for this policy falls into two categories:

Awareness of the policy and procedure to be followed All Site Co-ordinators, Ward Managers & Accident and Emergency Sisters/Shift Leads must be aware of the requirements of this policy and procedure to be followed and sign to confirm they have read and understood the policy.

Clinical training for staff escorting patients (all levels) The Trust is committed to raising awareness of effective transfer planning by the provision of training for all staff within the Trust. Clinical Directors, Consultants, Clinical Leads, Matrons and Ward Sisters will ensure that all staff have access to training and education to maintain up to date knowledge of local and national policies relating to transfers, which will be reflected in their Training Needs Analysis profile. All staff must be made aware of this policy at local induction.

EVIDENCE OF IMPLEMENTATION: x Inter and Intra Hospital Transfer audit which is undertaken by the North East and Cumbria Critical Care Network x Audit of transfers between WCH and CIC. x Monitoring of incidents relating to patient transfer.

KEY REQUIREMENTS 1. All transfers should be based on clinical need. 2. All risks associated with transferring a patient should be minimised in order to ensure the transfer is safe for both patients and staff. 3. Individual guidelines for specific patient groups, and senior clinical judgement, must be used in conjunction with this policy to ensure that all patient needs are met. This specifically includes the Trust Guideline for the Transfer of Adult patients between WCH and CIC (Appendix E), the Trust Guideline for the transfer of paediatric patients between hospital sites (Appendix D) and the Critical Care Transfer Guidance (Appendix A). 4. Exemplary communication between all involved parties is crucial to ensure safe transfer, this includes clear documentation. 5. The following documentation must be completed for the following transfers: x Critical Care Transfers – see appendix B. x Adult Transfers from WCH to CIC – see appendix F&G. x Paediatric Transfers – See appendix D.

North Cumbria University Hospitals NHS Trust Transfer of Patient Policy to include Intra & Inter Hospital Transfers Publication Date: 19/03/2015

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DOCUMENT CONTROL Author/Contact

Dr Fiona Graham, Consultant Anaesthetist & Clinical Director, Clinical Audit Tel: 01946 523412 Email: [email protected]

Executive Director Lead

Medical Director

Equality Impact Assessment

23/03/2010 – no change required

Version

3.0

Status

Approved

Publication Date

19/03/2015

Review Date

30/09/2015

Approved by: Clinical Policy Group

Date: October 2014

Trust Policy Group

Date: 19/03/2015

Please note that the Intranet version of this document is the only version that is maintained. Any printed copies should therefore be viewed as “uncontrolled” and as such, may not necessarily contain the latest updates and amendments. Approved policies related to this policy Name Policy Transfer of Adult Patients between NCUHT Hospital Sites (WCH and CIC) Guideline Transfer of Paediatric Patients between NCUHT Hospital Sites Safe Identification of Patients using Identity Bands

Document Reference / Hyperlink See Appendix E

Health & Safety Policy

health-and-safety-policy.pdf

See Appendix D safe-identification-of-patients-with-identitybands.pdf

Safe Keeping of Patients Property, Money safe-keeping-of-patients-property-moneyand Valuable and-valuables-policy.pdf Moving and Handling Policy

moving-and-handling-people-and-inanimateloads.pdf

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Statement of changes made Version Date 2.0 20/07/2010 2.1 13/08/2014

Changes made from previous version Approved at Governance Committee Summary section and sections 1 and 2 re-written Section 3 – added further abbreviations Section 5 – Added Director of Nursing & Midwifery, BUDs and Deputy BUD duties and updated 5.6 and 5.8 responsibilities. Renumbered policy from section 6 onwards. Sections 6.4 to 6.7 have been re-written.

2.2

26/09/2014

Section 5.3 – CD/Matron for critical care added Section 11 – narrative taken out and added as appendix A Section and appendices numbering re-aligned Appendices F and G added Section 6.5 – risk categorisation table updated in line with guidelines.

2.3

7/3/2015

New section 6.8 added to include NCUHT guideline for transferring adults from WCH to CIC (Appendix E). Updated section 6.9 to reference NCUHT guideline for transfer of paediatric patients (Appendix D). Appendices updated. Section 5.3 –changed to include all CDs and matrons to ensure we cover all specialties. Section on volunteers as escorts removed. Section 6.15 strengthened regarding documentation. New Section 6.16 on privacy and dignity added. Director lead for policy changed to Medical Director.

List of Stakeholders who have reviewed the document Name Gail Naylor Dr Jeremy Rushmer Dr Denis Burke, Mr Nick Strong, Dr Jonathan Cardwell.

Job Title Director of Nursing & Midwifery Medical Director Business Unit Directors

Date 10/02/2015 10/02/2015 10/02/2015

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TABLE OF CONTENTS 1. 2. 3. 4. 5.

INTRODUCTION ......................................................................................................... 5 PURPOSE OF THE DOCUMENT ............................................................................... 5 ABBREVIATIONS / DEFINITION OF TERMS USED.................................................. 6 SCOPE ............................................................................................................... 6 DUTIES ............................................................................................................... 6 5.1 CEO / Board Responsibilities ........................................................................... 6 5.2 Medical Director Responsibilities ...................................................................... 6 5.3 Clinical Directors and Matrons .......................................................................... 7 5.4 Business Unit Director / Deputy Business Unit Director Responsibilities .......... 7 5.5 Line Managers Responsibility ........................................................................... 7 5.6 Staff Responsibility ........................................................................................... 7 5.7 Transferring Staff Responsibilities .................................................................... 7 5.8 Receiving Staff Responsibilities ........................................................................ 7 5.9 Escorting Medical And Nursing Staff Responsibilities ...................................... 8 6. POLICY ............................................................................................................... 8 6.1 Method of Transfer ........................................................................................... 8 6.2 On Departure from the Ward or Department .................................................... 9 6.3 On Arrival at the Destination ............................................................................. 9 6.4 Assessment and Pre Transfer Preparation of the Patient ................................ 9 6.5 Escorts – Role, Selection and Competencies ................................................. 10 6.6 Patient Monitoring During Transfer ................................................................. 12 6.7 Communication ............................................................................................... 12 6.8. Escorting Adult Patients from West Cumberland Hospital (WCH) to the Cumberland Infirmary (CIC) ............................................................................ 12 6.9 Escorting Critical Care Patients To Another Hospital ..................................... 12 6.10 Escorting Paediatric Patients .......................................................................... 13 6.11 Escorting Mental Health Patients .................................................................... 13 6.12 Escort By Pre-Registration Nursing Students ................................................. 13 6.13 Escort By Health Care Assistants And Assistant Practitioners ....................... 14 6.14 Escort By Therapists ....................................................................................... 14 6.15 Documentation ............................................................................................... 14 6.16 Privacy and Dignity ......................................................................................... 15 7. IMPLEMENTATION AND TRAINING REQUIREMENTS .......................................... 15 8. PROCESS FOR MONITORING COMPLIANCE WITH THIS POLICY ...................... 16 9. ASSOCIATED DOCUMENTATION .......................................................................... 16 10. REFERENCES .......................................................................................................... 17 APPENDIX A - ESCORTING CRITICAL CARE PATIENTS TO ANOTHER HOSPITAL ... 18 APPENDIX B - ITU INTER & INTRA HOSPITAL TRANSFER FORM ............................... 23 APPENDIX C - CORONARY CARE TRANSFER FORM .................................................. 25 APPENDIX D - NCUHT GUIDELINE FOR THE TRANSFER OF PAEDIATRIC PATIENTS BETWEEN HOSPITAL SITES ............................................... 27 APPENDIX D1 NORMAL PAEDIATRIC RANGES ........................................................... 41 APPENDIX E - NCUHT GUIDELINE FOR THE TRANSFER OF ADULT PATIENTS BETWEEN WCH AND CIC ...................................................................... 42 APPENDIX F - TRANSFER COMMUNICATION TOOL (SBAR) (THIS IS AN EXAMPLE COPY – PLEASE ORDER FOR USE) ..................................................... 56 APPENDIX G - TRANSFER ASSESSMENT CHECKLIST ............................................... 57 Page 4 of 57

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INTRODUCTION Patients may require transfer between health care facilities for a number of reasons including upgrade of care, repatriation and bed pressures. The trend for centralisation of services within the NHS continues to increase the number of patients who must be transferred. Transfer is a potentially hazardous process for the patient as they move from one safe environment to another via a relatively uncontrolled environment. Care must be taken to minimise the risk of transfer for all patients, especially those at risk of deterioration, by: Planning the transfer carefully: Unnecessary patient movements must be avoided, but where essential the patient must be fully assessed and stabilised prior to transfer. Communication between all involved parties must be clear and thorough. In particular, transfers late at night (after 10pm) should be avoided unless in the clinical best interests of the patient. Minimising discomfort during transfer: Ambulant patients should not be asked to exert themselves eg by walking long distances or climbing more than one flight of stairs. Appropriate conveyance must be provided for non-ambulant patients. The patient must also be supported emotionally during the move, with full explanation of all processes and reasons for the transfer being given. Providing safe intra transfer care: The patient must be escorted at all times by someone able to monitor and manage problems that may arise during transfer. Relevant equipment and medications must be readily available. Ensuring that information and records related to the patient are transferred securely and effectively: Handover should be face to face, utilising SBAR, wherever possible, but must be supported by appropriate written information. Medical and nursing notes, medication charts etc must be transported safely in accordance with the Trust’s Information Governance Policy. The Trust’s IT systems must be updated promptly when a patient is transferred.

2.

PURPOSE OF THE DOCUMENT This document is intended to promote safety and high quality patient experience by providing clear guidance to staff regarding the transfer of patients between clinical areas.

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3.

ABBREVIATIONS / DEFINITION OF TERMS USED ABBREVIATION / TERM USED ABCDE Approach AED BP COPD ECG GCS HCA LDRP NCUHT NIBP NIPPB NIV NWAS ODP PCA RMN SBAR SCBU SpO2

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DEFINITION A standard resuscitation procedure as per resuscitation training. Automated external defibrillator Blood Pressure Chronic Obstructive Pulmonary Disease Electrocardiogram Glasgow Coma Score Health Care Assistant Labour Delivery Recovery & Post natal North Cumbria University Hospital Trust Non invasive blood pressure Non invasive positive pressure breathing Non invasive ventilation North West Ambulance Service Operating Department Practitioner Patient Controlled Analgesia Registered Mental Health Nurse Situation Background Assessment Recommendations Special Care Baby Unit Oxygen saturations

SCOPE This policy and procedure applies to all Healthcare Practitioners involved in the assessment, transfer and escort needs of Adult, Mental Health and Paediatric Patients when being transferred internally between wards / departments on a single hospital site, and to other NCUHT sites and to tertiary centres. This policy applies at all times, within and outside normal working hours.

5.

DUTIES 5.1 CEO / Board Responsibilities The Chief Executive and Trust Board jointly have overall responsibility for the strategic and operational management of the Trust, including ensuring that Trust policies comply with all legal, statutory and good practice requirements. 5.2 Medical Director Responsibilities The Medical Director has the delegated responsibilities on behalf of the Chief Executive and Trust Board to implement this policy and support clinical specialities and disciplines of staff across the Trust.

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5.3 Clinical Directors and Matrons All Clinical Directors and Matrons (including Chief Matrons) are responsible for monitoring that staff adhere to the policy within their respective clinical specialties. 5.4 Business Unit Director / Deputy Business Unit Director Responsibilities Business Unit Directors / Deputy Business Unit Directors are responsible for the effective implementation of this policy within their business units, ensuring that employees are familiar with the requirements of the policy. 5.5 Line Managers Responsibility Line manager’s responsibility is to ensure that staff are aware of this policy and that patients are transferred safely. 5.6 Staff Responsibility All Staff Trust –wide must read and adhere to this policy and have a working knowledge of this policy and other policies related to patient transfer. 5.7 Transferring Staff Responsibilities Staff on the transferring ward/department must be aware of their own responsibilities and accountability, re: patient transfer as set out within this document. When a decision to transfer has been made, the nurse in charge of the transferring ward/department must ensure that the patient and their relatives (where relevant) are aware of the reason for and details of the transfer. Staff on the transferring ward/department have an obligation to provide a thorough handover to the receiving team, and to ensure that information regarding the transfer is clearly documented within the nursing and/or medical notes. Staff on the transferring ward/department must assess the patient and select the appropriate mode of transport. They are responsible for making logistical arrangements to provide safe transfer of the patient, their clinical information and property. 5.8 Receiving Staff Responsibilities The ward/department/hospital must ensure they have received a comprehensive Handover prior to accepting the patient and documented clearly within the patients nursing and/or doctors notes.

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5.9 Escorting Medical And Nursing Staff Responsibilities Escorting staff have a responsibility to ensure their own safety during the transfer by: x x x x x x

Wearing appropriate Personal Protective Equipment Wearing appropriate warm, high visibility clothing and sensible footwear. Disposing of clinical waste safely. Utilising appropriate moving and handling techniques and ensuring that they receive training and updates in these techniques as per their individual training matrix (see Moving and Handling Policy). Remaining seated and wearing seatbelts at all times in a moving ambulance. Following safety instructions from ambulance staff at all times

Escorting staff have a responsibility to ensure patient safety during the transfer by: x x x x x x x

6.

Ensuring that a thorough assessment of the patient’s condition and needs is made before departure, and that regular re-evaluations are made during transfer. Ensuring that they receive a thorough handover from the team caring for the patient prior to transfer. Ensuring that the patient is fully prepared, secured and as comfortable as possible as the transfer environment can be hostile, with risks including hypothermia and the effects of inertial forces. NCUHT escorting the patient must advise the ambulance crew regarding the patient’s condition and the urgency of transfer, so that an appropriate speed of transfer can be determined. Ensuring that they, and the ambulance crew, are aware of the precise location and access route to the intended destination. Ensuring that all necessary equipment and medication is readily available. Acting at all times in the patient’s best interests. In the case of serious deterioration it may be appropriate to return to base or continue to the destination. Advice should be sought from senior colleagues if in doubt.

POLICY 6.1 Method of Transfer The mode of transfer chosen will depend on a variety of factors including, the distance to be travelled, the patient’s clinical condition and the urgency of the transfer. Intra hospital transfers may be on foot, in a wheelchair, on a trolley or a bed. If a patient is to walk, they must agree to this, and must be escorted to their destination. The shortest practical route should be chosen and unnecessary use of stairs avoided. If the patient is unable to walk, the nurse caring for him or her must ensure that an appropriate choice of conveyance is a made and that this is used safely eg correct use of footrests on wheelchair, trolley sides used correctly. The key principle is to select a mode of transport which is safe, and avoids any unnecessary patient discomfort. The Trust’s policy on moving and handling must be adhered to, and the assistance of portering and other staff obtained when needed. Page 8 of 57

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Checks must be made to ensure that any pieces of equipment accompanying the patient, eg drip stands and infusion pumps, are secure before departure. Intra hospital transfers are generally by land ambulance. Senior staff from the transferring unit must liaise with NWAS with regard to the patient’s needs and urgency of transfer. 6.2 On Departure from the Ward or Department Staff from the transferring ward/department must telephone the receiving unit immediately prior to the patient’s departure, to provide the receiving unit with an estimated time of arrival, and confirm arrangements. 6.3 On Arrival at the Destination On arrival at the destination, the accepting ward/department will direct the patient into an appropriate bed / trolley space and receive a comprehensive hand over of the patient’s medical/nursing notes, drugs and patients property. 6.4 Assessment and Pre Transfer Preparation of the Patient The first assessment must be “does the patient need to be transferred? ” followed by “ is it safe to transfer the patient. Need will depend on factors such as individual department protocol, bed availability, and of course the patient’s clinical condition. Safety again depends on the patient’s condition along with the presence of suitable staff, equipment and medications. Steps should be taken to ensure that the patient is as stable as possible prior to transfer, acknowledging that it is sometimes impossible to fully stabilise patients before departure, particularly those being moved in order to receive specialist care and interventions. Input from a senior clinician should be sought when any doubt exists. All patients must be assessed using a standard ABCDE approach. Where airways compromise is suspected, a critical care assessment is mandatory. Other significant problems identified should be managed according to relevant clinical guidelines, and input from a senior clinician must be sought, especially if patients do not respond rapidly to treatment. All patients must have their NEWS score assessed at least once prior to transfer, and scoring must be repeated regularly throughout the peri-transfer period. NEWS score, the patient’s acute pathology and the patient’s chronic health status should be combined to make an assessment of both the urgency and risk of the transfer. This assessment can then be used to inform decisions regarding both the time frame for the transfer and the escort which is required. This policy, and the clinical guidelines for specific patient groups should be used for guidance, but it is impossible to predict every possible situation. Senior clinical advice must be sought if any doubt exists. Page 9 of 57

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6.5 Escorts – Role, Selection and Competencies All patients being transferred between health care facilities must be accompanied by an individual with the skills necessary to meet their needs. Escorts may be members of NCUHT staff or ambulance crew, depending on circumstances. The role of an escort is to provide on-going monitoring and clinical care of the patient, to communicate with and provide emotional support for the patient, and to communicate with and handover effectively to other health care professionals in the chain of care. The choice of escort for individual patients should reflect this. The role of therapists, unqualified staff and volunteers is considered elsewhere in this policy. Transfers between hospital departments may potentially be carried out by student nurses or by porters without ward staff if the patient is a low risk level 0 patient. (See below for levels of care.) However, some level 0 patients will benefit from escort from a member of ward nursing staff or a HCA because of additional care needs eg elderly, confused or distressed patients. The nurse in charge of the transferring department will make this assessment. All level 1,2 or 3 patients must be accompanied by a registered nurse (or ODP). Level 3 and some level 2 patients will also require a medical escort. Level 0

Criteria Patient whose needs can be met through normal ward care

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 Patients requiring more detailed observation or intervention including support from a sing failing organ system or postoperative care and those ‘stepping down’ from higher levels of care. Patients requiring advanced respiratory support alone or basic respiratory together with support of at least two organ systems. This level includes all complex patients requiring support for multi-organ failure.

2

3

When transfer is between 2 hospitals, slightly different considerations apply. The following table, taken from the Trust Clinical Guideline on Inter Hospital Transfer of Adult Patients provides guidance on selection of escorts in that patient group:

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Risk Category LOW

MEDIUM

HIGH

SPECIAL

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Clinical Features

Care Requirements

Escort Requirements

NEWS 0-4 GCS 15 Stable or improving NEWS 5-6 or any single score >3 GCS 12-15 Recent opioid analgesia UNSTABLE

Minimal monitoring. No infusions in situ.

No NCUHT staff generally required.

Regular non invasive monitoring. Likely to have iv infusion in progress.

Where a patient is stable and a blue light response is not required a UCS or VAS response have the necessary skills to complete the transfer

Existing Critical Care patients. NEWS > 7 Rapidly deteriorating. *AAA repairs to be treated as HIGH risk for ambulance response time but SPECIAL regarding escort requirements. Patients with high NEWS scores but in whom further interventions en route have been deemed inappropriate.

Often multiple infusions. Continuous monitoring, often invasive. May be sedated and ventilated.

Patients being transferred for palliative care with existing DNAR status. Or Leaking AAA patients requiring immediate transfer to theatre.*

RGN with appropriate competencies likely to be needed to assist with deteriorating patient, manage infusions etc. EMT2 or paramedic. Anaesthetist and ODP/ RGN with critical care transfer competencies for all ventilated patients. Practitioner with critical care transfer competencies may be appropriate for some nonventilated transfers.

Escort by appropriately skilled NCUHT nursing staff or NWAS staff according to patient condition and staff availability. NCUHT medical escort not generally required

*AAA repairs to be treated as HIGH risk for ambulance response time but SPECIAL regarding escort requirements.

Some medium and all high risk patients will require an NCUHT staff escort. Need for a nurse escort for medium risk patients will depend on the use of NCUHT medical devices as well as the clinical condition of the patient. If a paramedic crew is available, it may not be necessary for a nurse to travel with all medium risk patients, but this cannot be assumed. If difficulties arise in locating an escort with suitable competencies from within the transferring department, advice from the relevant Matron/Site Co-ordinator must be sought. They will liaise with relevant managers and NWAS where appropriate, in order to facilitate a safe transfer, whilst maintaining adequate cover elsewhere. Guidance regarding transfer of children, critical care patients and mental health patients is provided later in this policy. Specific clinical guidelines should also be consulted in these cases.

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Competencies required will depend on the level of care required by the patient and their specific needs. These competencies should be demonstrated through existing Trust assessments, for example, health care professionals escorting patients with intravenous fluids which will require intervention during the transfer, must have completed the intravenous drug administration competency assessment and scope of practice. Specific Training For Transfer courses must be completed by staff involved in transfer of critical care patients. For clinical skills where formal Trust assessments do not exist, the nurse / midwife in charge must ensure that the escort is competent to care for the patient. All staff have a responsibility to work within the bounds of their own competencies. Anaesthetists will generally only accompany intubated and ventilated patients. It is not appropriate to ask an anaesthetist to accompany a patient in case of airway interventions being required en route. If there is a realistic expectation that intubation will be required during the transfer it is safer to manage the situation pre-emptively and intubate prior to departure. 6.6 Patient Monitoring During Transfer The appropriate monitoring, recording of observations and documentation must continue during patient transfer in accordance with the patient’s condition and plan of care. If the patient’s condition deteriorates during transfer then the medical team responsible for the patient should be contacted. 6.7 Communication Exemplary communication between all parties is the key to successful transfer. This includes communication between the transferring unit and receiving unit, staff and patient/relatives and, where relevant NCUHT staff and NWAS. More detailed guidance is given in the Trust Guideline for Inter Hospital Transfer of Adult Patients. An SBAR based communication tool [Appendix F] and pre transfer checklist [Appendix G] is also available within that guideline, to help facilitate good communication. 6.8. Escorting Adult Patients from West Cumberland Hospital (WCH) to the Cumberland Infirmary (CIC) For the transfer of adult patients between WCH and CIC, the Trust has a specific guideline in place which should be followed for all patients (see appendix E). 6.9 Escorting Critical Care Patients To Another Hospital When escorting critical care patients to another hospital, follow procedure as outlined in Appendix A and the ITU Inter and Intra Hospital Transfer form (Appendix B).

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6.10 Escorting Paediatric Patients For the transfer of paediatrics, the Trust has a specific guideline in place which should be followed for all transfers of paediatric patients between hospital sites (see appendix D). When utilising the assessment tool (Appendix D1), if the child scores 1 or above, the relevant Health Care Professional must also escort them. In addition, if the child is being escorted outside of the originating department building, the escort must be a registered Nurse / Midwife. All Trust employees who independently escort a child must have Disclosure and Barring Service (DBS). Appendix D1 outlines the normal paediatric ranges for vital signs. Any deviation from these would indicate the need for medical review prior to transfer. When neo-nates are being transferred to the Special Care Baby Unit (SCBU) from LDRP they must be transferred on a resuscitaire and not carried in the arms of a midwife or Consultant Paediatrician. 6.11 Escorting Mental Health Patients Patients sectioned under the Mental Health Act (1983) must be escorted by a Registered Mental Health Nurse. In addition if, based on clinical assessment the patient also requires an escort, an additional appropriately trained health care professional must accompany the patient. Dual trained RMN’s can independently escort patients who require a registered general Nurse. Prior to transfer of patients sectioned under the Mental Health Act (1983) to another Trust, the Site Manager must be informed and must complete the form 24 (section 19 of the Mental Health Act). This, along with the original section papers must then accompany the patient. Patient sectioned under the Mental Health Act (1983) leaving a hospital site must be transferred using NWAS for security and safety reasons. Sectioned patients who have been granted Section 17 leave by their RMO (Responsible Medical Officer) may or may not require an escort off the ward. Leave may be granted for therapeutic purposes or to attend off-site appointments. Conditions of leave, including duration and escort requirements, should be clearly indicated on the leave form. Risk assessment should be undertaken before each period of leave is reviewed. 6.12 Escort By Pre-Registration Nursing Students Students should not independently escort patients other than low risk level 0 patients. The allocated registered nurse / midwife or nurse / midwife in charge should use their clinical judgement and identify an appropriate escort prior to transfer. Students should not independently escort patients outside the hospital grounds. Staff should refer to the Practice Placement Guidelines for Pre-Registration Students for further information. Page 13 of 57

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6.13 Escort By Health Care Assistants And Assistant Practitioners Health Care Assistants and Assistant Practitioners may independently escort patients with a score of 0.5 or below when assessed utilising the Levels of Care assessment tool. 6.14 Escort By Therapists Occupational Therapists may be the required patient escort on home visit assessments. Occupational Therapists and Therapy Assistants may escort patients with a score of 0.5 or below when assessed utilising the Levels of Care assessment tool. There will always be two members of staff, one of which will be a registered Occupational Therapist, present at the home assessment. The registered Occupational Therapist will be responsible for ensuring that they fully aware of the patients medical history, including any medical or functional changes in the last 24 hours, and have discussed these with the registered nurse responsible for the patients care on the ward. Occupational Therapy staff will adhere to the guidance in the NCAHT Occupational Therapy Guidance for Working in the Community. 6.15 Documentation When the assessment tool is used to help assess escort requirements the score and the plan for transfer should be written into the Nursing / Midwifery notes. For all patients: The patient’s records folder should accompany the patient when he/she is transferred from one department to another in the trust with a clear documented handover such as outlined at appendix F. During transfer, it is the responsibility of any staff involved in the transfer to ensure that confidentiality of the patient’s records is maintained; any communication with the patient must respect their confidentiality and ensure information is handed over to the next healthcare professional receiving the patient. For adult patients being transferred from West Cumberland Hospital to the Cumberland Infirmary: The patient’s records folder should accompany the patient when he/she is transferred from one department to another in the trust with a completed Situation Background Assessment and Recommend (SBAR) Transfer tool (see appendix F). The transfer checklist (see appendix G) should be completed by the lead clinician (nurse or doctor) organising the transfer. For all children: The paediatric SBAR transfer document should be completed (see appendix D).

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For patients under a Mental Health Act: Section refer to section 6.10 for details of documentation that must accompany them. 6.16 Privacy and Dignity It is essential that the privacy and dignity of a patient being transferred is maintained. Patients should have clothing and blankets in order that they are appropriately covered. Efforts must be made, before transfer, to ensure that the patient is as comfortable as possible i.e. free from pain and nausea and vomiting, and do not need to go to the toilet.

7.

IMPLEMENTATION AND TRAINING REQUIREMENTS

The training for this policy falls into two categories: Awareness of the policy and procedure to be followed All Site Co-ordinators, Ward Managers & Accident and Emergency Sisters/Shift Leads must be aware of the requirements of this policy and procedure to be followed and sign to confirm they have read and understood the policy. Clinical training for staff escorting patients (all levels) The Trust is committed to raising awareness of effective transfer planning by the provision of training for all staff within the Trust. Clinical Directors, Consultants, Clinical Leads, Matrons and Ward Sisters will ensure that all staff have access to training and education to maintain up to date knowledge of local and national policies relating to transfers, which will be reflected in their Training Needs Analysis profile. All staff must be made aware of this policy at local induction.

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PROCESS FOR MONITORING COMPLIANCE WITH THIS POLICY

The process for monitoring compliance with the effectiveness of this policy is as follows: Monitoring/audit Methodology arrangements Business Unit Safety & Review of incidents Quality reports including those in relation to transfers will be part of the quarterly Safety and Quality report. Audit Report on the results of the audit findings from the ITU Inter and Intra Hospital Transfer audit which is undertaken by the North East and Cumbria Critical Care Network Audit A sample of transfers from WCH to CIC will be reviewed to assess compliance with this policy and supporting guideline.

Lead Deputy Business Unit Director

Reporting Committee Safety & Quality

Frequency Quarterly

CD / Matron for Critical Care

Business Unit Governance Board

Annual

Chief Matrons (medicine and surgery)

Business Unit Governance Boards

Annual

Wherever the above monitoring has identified deficiencies, the following must be in place: x Action plan x Progress of action plan monitored by the appropriate committee (minutes) x Risks will be considered for inclusion in the appropriate risk registers 9.

ASSOCIATED DOCUMENTATION x Critical Care Guidance on Critical Care Transfers (Appendix A). x NCUHT Clinical Guideline for Transfer of Adult Patients Between Hospitals 2014 (Appendix E). x NCUHT Clinical Guideline for Paediatric Transfers between hospital sites (Appendix D).

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10. REFERENCES BMJ [2002]. Safe Transfer and Retrieval the Practical Approach. Edited by Driscoll, P, Macartney, I., Mackway-Jones, K., Oakley, P. BMJ Publishing Group. London. Department of Health (1999). Comprehensive Critical Care A Review of Adult Critical Care Services. Department of Health. London. Department of Health (1983) Mental Health Act Clarke, F.L., Batchelor A.M., Lawler P.G., Whyte, S., Garcia, E., Cosgrove, J. Gascoigne, D., Kilner, A., Kane. P., Stoddart, J.C., Bonner, S., Mahoney, P. [1998]. Transport of the Critically Ill. Training for Transfer. Cosgrove, J.F., Snowden, C.P., Roy, A. I., Nesbitt, I., Green, J.D. [2001] RecordKeeping during transfer of critically ill patients – room for improvement? Care of the Critically Ill; 17, [3]: 88-93. Cosgrove, J.F, Kilner, A.J. [2003]. Transfer of the critically ill adult patient – a view from the north. Care of the Critically Ill Patient; 19, [2]: 58-63 Intensive Care Society (2009). Levels of critical care for adult patients. Intensive Care Society Standards and Guidelines. London. Intensive Care Society (2002) Guidelines for the transport of the critically ill adult. London Huband,T. Trigg,E (2004) Practice in Children’s Nursing-Guidelines for hospital and community. Churchill Livingston. London. Lawler, P.G. [2000]. Transfer of critically ill patients: Part 1 – Physiological concepts. Care of the Critically Ill Patients; 16, [2]: 61-65. Lawler, P.G. [2000]. Transfer of the critically ill patients: Part 2 – Preparation for transfer. Care of the Critically Ill; 16, [3]: 94-97. NHS Executive [1996] Guidelines on admission to and discharge from Intensive Care and High Dependency Units. Department of Health London. NHS Management Executive [1992] Ambulance and other patient transport services. Department of Health. London. Nursing & Midwifery Council (2009) Record Keeping: Guidance for Nurses and Midwives. London Pope, B (2003) Provide safe passage for patients. Nursing Management. 34 (9) p41-46 Resuscitation Council UK (2004) Standards for clinical practice and training Watson D. (2006). Planning to ensure the safe transfer of hospital patients. Nursing Times: Vol 102, No 9: 21-22. Page 17 of 57

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APPENDIX A - ESCORTING CRITICAL CARE PATIENTS TO ANOTHER HOSPITAL 1.

ASSESSMENT

This stage aims to stabilise the patient ready for transfer. 1. Identify: 2. Action: x x x x x

A – Airway B – Breathing C – Circulation D – Disability E – Exposure

3. Effect:

evaluate what effect the management of treatment is having on the patient

4. Evaluate:

Determine what management / treatment is required now for the patient

2.

CONTROL FOLLOWING INITIAL ASSESSMENT x x x

x x 3.

the patient’s problem assess what is being done for the patient

Identify which Clinician is taking control of the transfer of the patient Identify the team leader: - the transfer team leader will be in overall control of the transfer They must be experienced in transferring critically ill patients, as they will have the responsibility for organising resources, contacting ambulance services, ensure communication is optimal, evaluate the need for transfer of this patient, over-see preparation of the patient and equipment, discharge the patient Allocate key roles to members of staff Close liaison with the clinical team leader is essential. COMMUNICATION

Successful transfer of a critically ill patient from one clinical area / department to another requires organisation, co-operation and co-ordination of many individuals from a number of specialities. Therefore effective communication is essential if this is to be achieved. The clinician responsible for the decision to transfer the patient has the ultimate responsibility for any communication that occurs within the dispatching unit. The accepting clinician has ultimate responsibility for communication at the receiving unit. The clinicians are able to delegate some of these calls; however calls relating to those requesting the transfer to another hospital and accepting of the patient should be at Registrar / ST 3 and above level. In all cases the preferred option is a ‘face to face’ handover and must occur for vel of care 1,2,3 (7.2 / Levels of Care Assessment Tool ) ensuring there is a written account of the information in the patients nursing and/or medical notes.

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Where a telephone handover has been assessed and deemed as appropriate by a qualified nurse for patient’s with a Level of care 0 & 0.5 (7.2 / Levels of Care Assessment Tool )the following actions must occur: x x x

Nursing documentation must include all aspects of the plan of care required for that patient. The nurse receiving the handover must document the plan of care required for the patient. The plan of care is clarified when the patient is accepted on the ward by a qualified nurse.

A comprehensive handover must be provided either face to face or by telephone to the receiving ward / department / hospital; What needs to be communicated to the listener? x x x x x x

Who you are [state your status and who you are calling on behalf of] What is needed [state clearly and succinctly what is needed from the listener in terms of both personnel and services]? What are the relevant patient details [patients full name, date of birth, current location] What is the patient’s problem [presentation of clinical details, any other pertinent information] What treatment/management has been instigated to address the problem Ask the receiving unit to re-iterate the information, so that no misunderstanding occurs. Written Records

Written records must be accurate are essential from both clinical and legal perspectives. Data required is:x x x x x x x

Patient details Timings Clinical baseline history and examination Clinical interventions and effects of those interventions Investigations carried out and their results Conditions during transfer Names of responsible clinicians at each stage of the transfer

This can be partially achieved by completing the structured transfer form, which is used throughout the North East and Cumbria. “INTER HOSPITAL TRANSFER FORM” [Appendix B] Coronary Care Transfer Documentation [Appendix C]

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4. EVALUATION Evaluation is essential and this process commences from the first contact with the patient. It is necessary to identify whether the transfer is necessary or appropriate, if so does the patient take priority in comparison with others in the hospital. When requesting an ambulance follow the guidelines [Appendix E]. 5. TRANSFER CATEGORY x Emergency: (Emergency ambulance for immediate transfer. Response time approx. 8 minutes) x Urgent: (Urgent transfer is defined as a transfer that needs to be collected and transferred within a specific period of time, determined by the clinician [DoH 1992, 2.3. State time frame that the ambulance is required) The clinician in charge of the patient will make this “transfer category” decision. Evaluate the need for medical & nursing personnel, equipment, and transport. 6. PREPARATION OF THE PATIENT AND TRANSFERRING PERSONNEL When transferring a patient the same level of care should be maintained throughout. Therefore prior to transfer the patient needs: x Stabilise the patient to reduce physiological complications x All necessary equipment must be checked prior to transfer x Personnel undertaking the transfer must be fully prepared and aware of their role in its activity. 6.1 Equipment Transfer equipment to be checked daily and after each transfer, this should beconfirmed with a signature:x x x x x x

Transfer ventilator Transfer bag Transfer monitor Transformer Infusion pumps Transfer documentation

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6.2 Reminder When organising the medical and nursing staff follow the reminder to ensure that nothing is forgotten: x x x x x x x x

P hone [access to a phone is essential] E nquiry number [contact numbers from both the recipient and receiving hospital] R evenue [money for any emergencies] S afe Clothing [health and safety, high visibility jackets must be worn] O rganised route [know exactly where the recipient hospital is] N utrition [food and drinks if it is a long journey] A to Z [Street map of town you are going to] L ift home [Once the patient is handed over to the recipient hospital ensure you have a lift back to base]

7. TRANSPORTATION Transportation of a patient is achieved in three distinct phases. The aim is to provide seamless appropriate care throughout. x The patient is moved from the transferring unit to the transferring vehicle x The vehicle, team, and the patient move from the referring to the receiving Unit x The patient is moved from the transferring vehicle to the receiving unit trolley or bed 7.1 Prior to departure check Prior to departure, during transfer, arrival at destination: x x x x x

A – Airway B – Breathing C – Circulation D – Disability E – Exposure

7.2 Drugs x Ensure sufficient drugs available for the journey x Ensure reliable infusion site/s for delivery x Ensure battery lives of infusion pumps are adequate for the journey 7.3 Oxygen Calculate amount required for the journey x x x x x

Patient’s minute volume Journey time Ventilator driving gas pressure Expected journey time x2 Amount of gas required

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7.4 Monitoring x x x x x x x x

Electro cardio graph Central venous pressure Invasive arterial pressure Capnography / End –tidal CO2 Respiratory rate Neurological / Glasgow coma score Renal / urine output Temperature

7.5 Handover at receiving hospital x x x x

Case notes Laboratory reports / x-rays / CT scans Evaluation of nursing care from admission to discharge Audit [ITU “INTERHOSPITAL TRANSFER FORM, retain green copy for audit]

Return equipment to your own department Unstable patients should only be transferred when emergency investigation, procedure or treatment is required in order to stabilise the patient’s condition. These patients must be assessed by the medical team in charge of care prior to transfer, with referral to Critical Care Outreach and / or anaesthetics as appropriate. NOTE: TRANSFERRING CRITICALLY ILL PATIENTS VIA AMBULANCE SERVICE Guidelines: - Request by North West Ambulance Service. When you are aware that there is a potential emergency/urgent transfer [DoH 1992, 2.2] to another hospital, the following guidelines are to improve communication and efficiency. x x

Inform ambulance control that you have a potential emergency transfer. Provide as much information as possible. When the patient is stabilised and ready to be transferred, phone ambulance control and request:Emergency ambulance for immediate transfer. [Response time approx. 8 minutes, 14–19 mins “The Patients Charter”.]

When an ambulance is required for an urgent transfer to another hospital, inform ambulance control and provide as much information as possible. Urgent transfer is defined as a transfer that needs to be collected and transferred within a specific period of time, determined by the clinician [DoH 1992, 2.3] State time frame that the ambulance is required. NHS Management Executive [1992], “Ambulance and other patient transport services”, Department of Health.

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APPENDIX B - ITU INTER & INTRA HOSPITAL TRANSFER FORM Hard copies of these forms are available on ITU and CCU wards.

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APPENDIX C - CORONARY CARE TRANSFER FORM Hard copies of these forms are available on ITU and CCU wards. PATIENT DETAILS NAME………………………………………………… ADDRESS……………………………………………. ………………POSTCODE…………………………... AGE/DOB…………………………………………….. MALE/FEMALE……………………………………… N.O.K…………………………………………………. CONTACT NUMBER……………………………….……………. NAMED NURSE……………………………………... CONSULTANT………………………………………. DRUG ALLERGIES………………………………….

TRANSFER DETAILS DATE OF ADMISSION/TIME………………. REASON FOR ADMISSION……………………….. ……………………………………………………….. DIAGNOSIS………………………….……………… REASON FOR TRANSFER………………………… ……………………………………………………….. HOSPITAL…………………………………………… WARD………………………………………………… DATE/TIME…………………………………………..……… …………………………………………………

PREPARATION FOR TRANSFER YES PATIENT INFORMED/PATIENT INFORMATIOM PACKAGE TRANSPORT STATE LEVEL REQUIRED EMERGENCY/URGENT DOCTORS LETTER NURSING DOCUMENTATION NOTES/XRAYS ETC [PHOTOCOPIED] DISCHARGE SCRIPT/DRUG CHART MEDICATION TRANSFERRED FAMILY INFORMED CONTACT RECIPIENT HOSPITAL ON DEPARTURE WITH E.T.A. CANNULA INSITU

NO

ESCORT NAME OF DOCTOR……………………………………………………………………………………………….. NAME OF NURSE………………………………………………………………………………………………….

EQUIPMENT/TRANSFER x x x x x x

YES

NO

PORTABLE MONITOR OXYGEN TRANSFER BAG EMERGENCY DRUG BOX PUMPS/EQUIPMENT – TRANSFORMER PACING BOX

AMBULANCE CHECK LIST x CHECK OXYGEN SUPPLY x PATIENT/STAFF SAFETY x MONITOR EQUIPMENT –SAFE SET-UP x IS INTUBATION EQUIPMENT AVAILABLE x DEFIB & GEL PADS x OPIATE ANALGESIA

YES

NO

HANDOVER TO RECEIVING AREA DATE………………………………………………………………………………………………………………… TIME…………………………………………………………………………………………………………………. HANDOVER GIVEN TO…………………………………………………………………………………………… DOCTOR/NURSE SIGNATURE…………………………………………………………………………………… COMMENTS FROM RECIPIENT HOSPITAL…………………………………..

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TIME DRUGS………………………………………. ………………………………………………... ………………………………………………... …………………………………………………

MONITORING

Sa02 CVP (mmHg) RESPS TEMP

VITAL SIGNS BLOOD PRESSURE (mmHg) HEART RATE 260 240 220 200 180 160 140 120 100 80 60 40

DRUGS ADMINISTERED DURING TRANSFER

TIME

SIGN

COMMENTS

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APPENDIX D – NCUHT Guideline for the Transfer of Paediatric Patients between hospital sites

TRANSFER OF PAEDIATRIC PATIENTS BETWEEN HOSPITAL SITES

Document control and approval process Document Type: Clinical Guideline Clinical Lead: Dr Glyn Jones Author/s: Dr Glyn Jones Directorate: Paediatrics Approved by Division/Sub Committee: Child Health Clinical Governance Meeting

Date approved by Child Health Governance Board: November 2014 Date of Issue: November 2014 Review Date: November 2015 Version: 1.0

Document Summary Relevant to: Paediatric Wards and Departments, Emergency Care, Anaesthetics Brief Description: Guidance for staff involved in the transfer of paediatric patients between the West Cumberland Hospital and Cumberland Infirmary Carlisle and transfer of patients to specialist care in Newcastle. Covers assessment of the patient, communication strategies and logistics of transfer.

Specialities: Paediatrics, Emergency Care, Anaesthetics.

Criteria for use: Paediatric Patients requiring transfer between WCH and CIC, or WCH and CIC to Great North Children’s Hospital (GNCH) Important notes: This guideline provides guidance on the logistics of arranging a transfer as well as clinical assessment and communication strategies. It incorporates a clinician to clinician communication tool and a pre transfer checklist. Exclusions: Neonates

Keywords: Paediatric; Transfer; Deterioration; SBAR; PICU Sign Off Clinical Lead Signature……………………….. Print Name Dr Glyn Jones Author Signature…………………………….... Print Name Dr Glyn Jones Trust Approver Signature……………………. Print Name Dr Jeremy Rushmer

Date 4.11.14 Date 4.11.14 Date 13.03.14

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TRANSFER OF PAEDIATRIC PATIENTS BETWEEN HOSPITAL SITES 1.

INTRODUCTION

This guideline has been designed to facilitate the smooth transfer of paediatric and neonatal patients between the two general hospitals within North Cumbria University Hospitals Trust and from either of these hospitals to specialist care at the Great North Children’s Hospital (GNCH) in Newcastle. Predominantly it will apply to children and young people who need to be transferred from WCH to CIC or from either of those hospital sites to GNCH for ongoing care as their condition does not meet the criteria for admission to WCH. It is recommended that the principals, process and checks set out in this guideline should be followed for all paediatric transfers. The guideline covers patient assessment and the decision to transfer, criteria for escorts, and the process for communication and organisation of a transfer. Appendices cover particular arrangements for specific patient groups 2. PROCESS DECISION MAKING AND ASSESSMENT

Two key questions need to be answered: 1) Does the patient need to be transferred? 2) Is it safe to transfer the patient? Need for transfer Will be related to the child or young person’s specific condition e.g. requires an intervention, level of care or length of stay not provided on the current site, or may be a resource issue e.g. no beds available at present site. Each site will have specific criteria regarding patient groups cared for on each site. Whatever the circumstances, if the patient cannot be cared for optimally in their current location, transfer should be considered. Safety It is impossible to completely eliminate all risks of transfer. An assessment of the risks v benefits of transfer must be made for all patients, and steps taken to minimise the risk of transfer. Risks can be minimised by optimising the patient’s therapy prior to transfer, appropriate selection of equipment and staff to accompany the patient, and exemplary communication between all personnel involved in the transfer. Senior medical and nursing staff must be involved in the decision to transfer.

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Assessment of benefit involves: 1) Understanding what components of the patient’s care plan cannot be delivered in their current location. 2) Understanding the value of that care to the patient. 3) Consideration of the potential outcomes of not transferring the patient, including any treatment limitations or delays which would occur. Assessment of risk combines: 1) Full assessment of the patient’s overall physiological status by means of PEWS scoring. At least two sequential physiological assessments should be carried out to determine the trend. 2) Assessment of any specific risks that may be encountered during transfer, related to the patient’s clinical condition. By considering these factors it should be possible to determine an approximate timescale required, and the patient’s risk grading. This information can then be used to decide upon the appropriate mode of transport and the competencies required by any escorting staff.

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RISK CATEGORISATION

Patients can be broadly categorised into one of 5 risk categories as described in the following table. In all cases consider parents/carers needs and any safeguarding issues. Risk Category LOW

Clinical Features

MEDIUM/ STABLE

PEWS 5-6 or any single score >3 GCS 12-15 (or A on AVPU) Recent opioid analgesia Stable or improving Risk of deterioration low or very low

MEDIUM UNSTABLE

PEWS 0-4 GCS 15 (or A on AVPU) Stable or improving

PEWS 5-6 or any single score >3 GCS 12-15 Recent opioid analgesia UNSTABLE

Care Requirements Minimal or no monitoring requirements during transit. No infusions in situ. Non invasive monitoring. May have iv infusion in

Frequent non invasive monitoring. Likely to have iv infusion in progress.

Head Injury and those patients that need urgent neurosurgical input who are transferred for ongoing care at tertiary unit

Existing Critical Care patients. PEWS > 7 Rapidly deteriorating.

No NCUHT staff generally required. EMT ambulance with parent escort OR Parents may be able to transport child

EMT 2 or paramedic. RN(C) with relevant competencies to manage care requirements in transit.

progress. **

Or

HIGH

Escort Requirements*

Often multiple infusions. Continuous monitoring, often invasive. May be sedated and ventilated.

The level of escort required will need to be a consultant decision but at least: x EMT2 or paramedic, with a specialty doctor or PNP (with competencies with of at least ST4 including APLS provider status.) Some escorts may need a consultant paediatrician. If a consultant paediatrician is required to do escort duties then another consultant will be ned to be called in to cover the clinical areas. This currently works well but is done on a “good will basis” In all unstable patients consider need for anaesthesia assessment prior to arranging transfer and if airway unstable or respiratory support likely to be required, escalate to HIGH RISK – see category below Note - Parents may not be able to travel with the child. Call PICU at GNCH. Who will arrange for the retrieval team to come and collect child and advise on interim management.*** Maintain critical care on site until PICU team arrives – see initiation of intensive care flow chart

Notes: *NCUH staff working in an ambulance are working off NCUH property. We need to make sure the appropriate governance/personal and professional liability/accident at work cover is in place. ** Medium stable patients: Wherever possible children should be adequately hydrated so that intravenous fluids are not necessary during the journey. If this is not possible and the child needs fluids on route and escort will need to be provided. *** High risk patients: Where the need is for PICU the retrieval arrangements are clear, well-rehearsed and effective. Where the need is for HDU level care in a tertiary centre there is limited or no provision for retrieval. In these situations there needs to be a case by case consultant led decision as to the level of escort required.

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INITIATION OF PAEDIATRIC INTENSIVE CARE (Not neonates)

Notes: Patient specific additional risk factors may alter the overall risk and affect the need for an escort. For example patients with a tracheostomy in situ particularly those requiring frequent suctioning always require an escort with relevant competencies even if their condition is stable. Also see guideline for the management of severe bronchiolitis All “high risk” paediatric patients where there is the potential for deterioration should be referred for an anaesthetic/critical care opinion prior to transfer. Anaesthetic/Critical care assessment is also mandatory for all patients where the airway is compromised. Consideration should be given to early pre-emptive intervention, particularly if there are airway concerns. Steps should be taken to avoid the need for interventions en route wherever possible. Clinical staff should never be expected to intubate a paediatric patient during transfer. If there is a realistic likelihood of a patient requiring intubation en route do this is in a controlled manner, before the transfer.

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5. STABILISATION AND ONGOING MANAGEMENT OF THE PATIENT Steps needed to optimise the outcome for the patient should be taken in an “ABC” fashion. Once the decision to transfer has been made, arrangements for the transfer should be made concurrently with ongoing investigation and treatment of the patient. Whilst non urgent interventions which may delay or impede transfer should not be carried out at the transferring unit, it is imperative that close observation and response to changes in the patient’s condition continue once the decision to transfer has been made. A paediatric consultant must be involved in the care and decision making for all paediatric patients who need to be transferred and are unwell and at risk of deterioration or not improving. Analgesia – It is important that patients’ pain should be managed effectively prior to transfer, and steps taken to minimise discomfort in transit. Consideration should be given to physical measures such as splinting of injured limbs as well as analgesic drugs. Multimodal analgesia utilising paracetamol, local anaesthetic techniques where appropriate, and possibly NSAIDS is preferred. NSAIDS should not be given to patients with known or suspected bleeding, those who are dehydrated or shocked or those with any other recognised contraindication. If opiates are required, small titrated intravenous doses should be given to minimise side effects. Anti emetic therapy should be considered, especially for those patients who have received opioid analgesia and those who have a history of motion sickness. (Please see paediatric pain management guideline for further information.) 6. COMMUNICATION Exemplary communication between all personnel involved in the transfer is crucial. As well as facilitating safe transfer, good communication improves patient experience. There are 3 key areas of communication: 1) Between the transferring and receiving units. 2) Between the transferring unit and NWAS. 3) Between staff and the patient/patient’s family. 6.1 Communication between staff at transferring and receiving units: An SBAR based Communication Tool – see appendix 3 has been devised for this purpose. Whilst it is a useful communication tool, there will be occasions where experienced clinicians may need to make rapid judgements about when and how to transfer individual patients. It is good practice to provide a written handover of care, however if rapid transfer is required there may not be time for completing the form, in this situation a verbal handover must be given. The transferring doctor (ie the person who is arranging the transfer) should complete the form prior to telephoning the receiving doctor and use this information to inform the conversation. Following the telephone call the form should be scanned and emailed to the receiving unit. Page 32 of 57

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This is to ensure that the receiving team have key information about the patient before s/he arrives on the ward and can be better prepared to take over care. The transferring unit should also telephone the receiving unit as the patient leaves, so that the receiving team are aware of the likely time of arrival. 6.2 Communication with NWAS. A senior member of the transferring team should telephone ambulance control when transfer is arranged. NWAS crews are unable to wait in the hospital for long periods whilst patients are prepared for transfer, so an ambulance should not be called when there are still multiple outstanding tasks. The staff member making the call should be able to provide clinical information about the patient and the desired time frame for the transfer. Reference to the information on the SBAR form already prepared may be beneficial. The NWAS Call Handler will complete an NWAS screening tool and in the event of difficulty will arrange for a clinician to clinician call back to negotiate arrangements. It must be understood that NWAS deal with a high volume of calls and are required to prioritise scarce resources. We need to provide objective and sufficiently detailed information to allow Ambulance Control to despatch the most appropriate vehicle to each patient. The best way to deal with problems is by negotiations to be undertaken by senior staff able to discuss the patient’s needs and the reasons for the requested time frame. 6.3 Communication with patient/family. Good communication about the transfer can help to ease anxiety for patients and their parents or carers. Prior to transfer the patient, and their parents or carers, should be informed regarding: 1) The reason for transfer. 2) The intended destination. 3) The expected time frame for transfer. 4) Parents and carers should be given contact details for the receiving unit and, if necessary, directions. 5) If any delays or changes in plan occur the parents or cares and the child or young person should be kept updated of the reasons. 6) Information given to the parents/carers and patient should be recorded in the patient records 7.

MONITORING AND TREATMENT DURING TRANSFER

Precise requirements will vary from patient to patient. In deciding the needs of the individual patient it should be remembered that monitoring during transfer should be at least of the same standard and frequency which the patient would receive in the transferring unit.

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As a minimum, a full set of observations and PEWS score should be made and recorded before the patient leaves the transferring unit, and on arrival in the receiving unit. Unstable/higher risk patients will require observations to be recorded in transit. The relevant paediatric observation chart should be used whenever observations need to be recorded during transfer. Emergency ambulances carry standard monitoring and emergency equipment as listed in Appendix 1, which may be used in an emergency. Escorting staff should review the list and ensure that any other drugs or equipment that are likely to be required by their patient in transit are obtained from the base hospital prior to transfer. Drugs to be “routinely” administered on route (e.g. infusions which may run out) should be provided by NCUHT. However, steps should be taken to minimise risk in transit by ensuring, as far as is possible, that any infusions in progress have adequate volume left to last for the predicted transfer time plus handover time at the receiving hospital. 8.

STAFF SAFETY DURING TRANSFER

Whilst travelling by ambulance, escorting staff should remain seated at all times, and seatbelts must be worn. In the event that a patient intervention is needed, the ambulance crew should be informed, and they will stop the vehicle when it is safe to do so. NCUHT staff must follow safety advice given by NWAS staff at all times during the transfer. 9.

ARRIVAL AT RECEIVING UNIT

Precise handover details will depend on the escorting personnel and the receiving venue. The escorting personnel should give a verbal handover to the receiving personnel and hand over the hospital notes, with the SBAR form on the front. If the receiving member of staff is non-medical, the doctor on duty for the ward must be informed as soon as possible. Every patient who is transferred in from another site must be reviewed by a doctor as soon as possible. It is not necessary to perform a complete readmission process, but the patient and documentation, including drug chart should be reviewed by the receiving medical team. This review, and any changes to the patient’s condition or therapy, must be recorded in the medical notes. Individual teams should set criteria for the acceptable time frame within which a transferred patient must be reviewed, and what grade of doctor should perform the first review. Ward nursing staff must be made aware of these criteria. Ward staff must ensure that IT systems are updated with the patient’s new location and consultant. Patients must be informed of the name of their new consultant and named nurse.

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Please note that NWAS cannot guarantee to return NCUHT staff and equipment to the base hospital. In the event that this is not possible, hospital transport should be arranged by calling the matron or OSM for the relevant area (duty matron or manager out of hours) for authorisation. Switchboard can then arrange a hospital taxi. 10.

TRANSFER OF INFANTS FROM THE NEONATAL UNITS

The majority of infants who need transfer from either of the NCUH sites are usually being transferred to a tertiary unit and these infants are managed under the network agreements for neonatal transfer. There may be occasions where an infant will need to be transferred between the SCBU’s within NCUH or there is a request from the tertiary unit for us to transfer one of our babies back. The principals within this policy apply equally to these infants. In addition see neonatal transfer guidelines: http://nww.staffweb.cumbria.nhs.uk/clinical/clinical-guidelines/neonatalguidelines/neonatal-guidelines-2013-15-with-links.pdf

11.

MONITORING / AUDIT DETAILS

Adherence to this guideline will be monitored through the annual child health audit programme as part of the discharge and transfer audit. In addition there are regular peer review meeting of transfer of children between NCUH and NuHFT.

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APPENDIX 1 Equipment and Drugs Available on NWAS Emergency Vehicles

Monitoring Lifepak 12/15 monitor incorporating ECG, NIBP, pulse oximeter and capnograph. Blood glucose monitor. Airway Equipment ET tubes – range of sizes LMAs – range of sizes Oral airways – range of sizes Face masks Suction pump and catheters Breathing Equipment Self inflating bag Para pac ventilator Circulation equipment Iv cannulae – range of sizes Giving sets Defibrillator Drugs Allergy management Adrenaline 1:1000 Chlorphenamine 10mg Hydrocortisone 100mg Analgesics Codeine 15mg/5ml Ibuprofen suspension 100mg/5ml Ibuprofen 200mg tablets Paracetamol suspension 120mg/5ml Paracetamol 500mg tablets Antibiotic Benzylpenecillin 600mg Anti emetic Metoclopromide 10mg

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Cardiovascular Adrenaline 1:10 000 Amiodarone 300mg Aspirin 300mg Atropine 1mg Enoxaparin 60mg GTN 2mg buccal Heparin 500 units/ml Lignocaine 100mg/5ml Tenecteplase 10 000 units Tranexamic acid 500mg/5ml Hypoglycaemia management Dextrose gel 40% Dextrose 10% 500ml bags Glucagon 1mg IV Fluids 0.9% saline 500ml 10% dextrose 500ml Neurological Diazepam 5mg rectal tube Diazemuls 10mg/5ml Obstetric Syntometrine 500mcg Respiratory Hydrocortisone 100mg Ipatropium bromide 250mcg Naloxone 400mcg/1ml Salbutamol 2.5mg Salbutamol 5mg Nerve agent antidote kit (NAAK)

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APPENDIX 2

Specific guidance for orthopaedic and surgical patients Some orthopaedic and surgical cases are more time critical than others, and will require more rapid transfer so that surgery can be carried out as soon as possible. Delay in surgical treatment in these cases can adversely affect outcome significantly. Conditions of this type include: Torsion of testes/ovaries Abdominal obstruction Open fractures Septic arthritis Suspected compartment syndrome Dislocated joints Not all patients with this type of urgent surgical presentation or injury will have a high PEWS score, The ambulance service use physiological status as an important part of the decision making process to judge urgency of transfer. It is therefore very important that when communicating with NWAS about this type of patient we stress that the condition requires urgent surgical intervention, to ensure that they are given appropriate priority. Remember that the person taking the initial call at NWAS may not have the experience or authority to deal with every request, but senior clinical staff are always available to discuss specific problems. A call back from the senior clinician on duty at NWAS can be requested if problems are encountered.

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Appendix 3. Paediatric SBAR Transfer Document Name

Weight

NHS Number

DOB

Age

T Number /A&E Number

Referring Consultant

Referred to (Hospital)

Consultant

Name of Dr Accepting Referral……………………..Name of Dr making referral………………………..Referral Accepted Y/N Presenting Condition………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………………. Reason for Referral……………………………………………………...……………………..................................................

SBAR report

NOTES

Situation

S B A R

I am calling about . The patient's condition is……………………. I have just assessed the patient: I am concerned about ……………………………………

Background The History is….. patient's status is: A,V,P,U; PEWS Score is: If PEWS ABOVE 4 COMPLETE THE REVERSE SIDE OF THIS FORM

Assessment (use current status) This is what I think the problem is: The problem seems to be cardiac infection neurological respiratory or I am not sure what the problem is but the patient is deteriorating Recommendation I suggest or request that you……….. .

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Current Status A Intubated Y/N Pressures…./…..

Oral /Nasal Tube Size…….

Length…….

Effort

Noise

Hand Bagging Y/N

Ventilator

B Resp Rate………

Mild Moderate Severe

Stridor Wheeze

Oxygen N/C/Mask/Headbox L/min………… %...................

C Heart Rate………

Blood Pressure ………

Cap Refill………sec

Urine Output………ML/KG/Hr

D GCS…………../15

Pupils Size L=…………R=………… React L=Y/N R=Y/N

A V P U

E Urinary catheter Y/N Size…… Temperature …….. Rash? ....................... NGT Size………..

Y/N

Access IV x …. … IO

Arterial line Y/N CVL

Type………. PH……….. PO2…………

Time……… PCO2……….. BEx…………..

U’s E’s Time………. K………… Cr………….

Na……….. Ur…………… Gluc………….

Gas

FBC

Time……… Plt……….. PT………. Fib……

CXR = Y/N

Hb……….. WCC……….. APPT……..

Fluids given…………………………… …………………………………… …………………………………… …………………………………… …………………………………… …………………….. Drugs Given…………………………… …………………………………… …………………………………… …………………………………… …………………………………… ……….

Y/N

Y/N

PEWS Score……… PEWS Trigger Pain Score………. Other……………………… ……………………………… ……………………………… ……………………………… ……………………………… Parents…………………… ……………………............... ........................................... .........

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APPENDIX D1 - NORMAL PAEDIATRIC RANGES The following table show the normal vital sign ranges for paediatric patients. Any deviation from this normal indicates the requirement for medical review prior to transfer. Heart Rate Age 12

Heart Rate (Beats per min) 110-160 100-160 95-140 80-120 60-100

Respiratory Rate Age 12

Respiratory Rate (breaths per min) 30-40 25-35 25-30 20-25 15-20

Blood Pressure Age 12

Systolic Blood Pressure (mmHg) 70-90 80-95 80-100 90-110 100-120

Temperature Age 12

Core Temperature (degrees centigrade) 36.5 – 37.5 ≤ 37.1 ≤ 37.1 ≤ 37.1 ≤ 37.1

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APPENDIX E – NCUHT guideline for the transfer of adult patients between WCH and CIC

TRANSFER OF ADULT PATIENTS BETWEEN NCUHT HOSPITAL SITES Document control and approval process Document Type: Clinical Guideline Clinical Lead: Dr Denis Burke, BUD Medicine & Emergency Care Author/s: Dr F Graham Directorate: Medicine and Emergency Care. Approved by Division/Sub Committee: Clinical Policy Group Date approved by Division/Sub Committee: October 2014

Date of Issue: Issued for immediate use from 5 September 2014 Review Date: September 2015 Version: 5

Document Summary Relevant to: Trust Wide Brief Description: Guidance for staff involved in the transfer of patients between the West Cumberland Hospital and Cumberland Infirmary Carlisle. Covers assessment of the patient, communication strategies and logistics of transfer.

Specialities: Emergency care, Surgery, Orthopaedics, Medicine.

Criteria for use: Adult patients requiring transfer between wards or departments in WCH and CIC.

Important notes: This guideline provides guidance on the logistics of arranging a transfer as well as clinical assessment and communication strategies. It incorporates a clinician to clinician communication tool and a pre transfer checklist.

Exclusions: Excludes paediatric transfers and transfers to sites outside our own Trust, although many of the same basic principles will apply to other transfers. The Trust Policy for Transfers should be referred to for all other transfer related issues. For paediatric transfers out of hospital staff should follow the specific guideline for paediatrics which can be found at Appendix D of the Trust Transfer Policy.

Keywords: Transfer, Ambulance, West Cumberland Hospital, Paramedic, Guidance, Emergency, 999 Sign Off Clinical Lead Signature……………………….. Print Name Dr Denis Burke Author Signature…………………………….... Print Name Dr F Graham Trust Approver Signature…………………….. Print Name Dr Jeremy Rushmer

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TRANSFER OF ADULT PATIENTS BETWEEN NCUHT HOSPITAL SITES

1. INTRODUCTION This guideline has been designed to facilitate the smooth transfer of patients between the two general hospitals within North Cumbria University Hospitals Trust. Predominantly it will apply to adult emergency admissions to be transferred from WCH to CIC as a result of recent service reconfiguration, though the same process and checks should be followed for all transfers, including those patients being returned from CIC to WCH. The guideline covers patient assessment and the decision to transfer, criteria for escorts, and the process for communication and organisation of a transfer. Appendices cover particular arrangements for specific patient groups

2. PROCESS DECISION MAKING AND ASSESSMENT Two key questions need to be answered: 1) Does the patient need to be transferred? 2) Is it safe to transfer the patient? Need - may be related to the patient’s specific pathology eg requires an intervention not available on the current site, or may be a resource issue eg no beds available at present site. Each specialty will have specific criteria regarding patient groups cared for on each site. Whatever the circumstances, if the patient cannot be cared for optimally in their current location, transfer should be considered. Safety - It is impossible to completely eliminate all risks of transfer. An assessment of the risks v benefits of transfer must be made for all patients, and steps taken to minimise the risk of transfer. Risks can be minimised by optimising the patient’s therapy prior to transfer, appropriate selection of equipment and staff to accompany the patient, and exemplary communication between all personnel involved in the transfer. Senior medical and nursing staff must be involved in the decision to transfer. Assessment of benefit involves x Understanding what components of the patient’s care plan cannot be delivered in their current location. x Understanding the value of that care to the patient. x Consideration of the potential outcomes of not transferring the patient, including any treatment limitations or delays which would occur. Assessment of risk combines x Assessment of the patient’s overall physiological status by means of NEWS scoring. In the majority of patients, time should be available for at least two sequential physiological assessments to be carried out to determine the trend. x Assessment of any specific risks that may be encountered during transfer, related to the patient’s clinical condition. By considering these factors it should be possible to determine an approximate timescale required, and the patient’s risk grading. This information can then be used to decide upon the appropriate mode of transport and the competencies required by any escorting staff.

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3.

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RISK CATEGORISATION Patients can be broadly categorised into one of 5 risk categories as described in the following table. Risk Category Clinical Features Care Requirements Escort Requirements NEWS 0-4 Minimal monitoring. No NCUHT staff LOW GCS 15 No infusions in situ. generally required. Stable or improving NEWS 5-6 or any single Regular Where a patient is MEDIUM score >3 non invasive stable and a blue monitoring. light response is not GCS 12-15 required a UCS or Recent opioid analgesia Likely to have iv VAS response have UNSTABLE infusion in progress. the necessary skills to complete the transfer

HIGH

Existing Critical Care patients. NEWS > 7 Rapidly deteriorating. *AAA repairs to be treated as HIGH risk for ambulance response time but SPECIAL regarding escort requirements.

SPECIAL

Patients with high NEWS scores but in whom further interventions en route have been deemed inappropriate. *AAA repairs to be treated as HIGH risk for ambulance response time but SPECIAL regarding escort requirements.

Often multiple infusions. Continuous monitoring, often invasive. May be sedated and ventilated.

Patients being transferred for palliative care with existing DNAR status. Or Leaking AAA patients requiring immediate transfer to theatre.*

RGN with appropriate competencies likely to be needed to assist with deteriorating patient, manage infusions etc. EMT2 or paramedic. Anaesthetist and ODP/ RGN with critical care transfer competencies for all ventilated patients. Practitioner with critical care transfer competencies may be appropriate for some nonventilated transfers. Escort by appropriately skilled NCUHT nursing staff or NWAS staff according to patient condition and staff availability. NCUHT medical escort not generally required

Notes: Patient specific additional risk factors may alter the overall risk and affect the need for an escort. For example, a patient with a chest drain in situ who was otherwise stable would require an escort with the skills to manage a chest drain, even if the patient has a low NEWS. Patients with a tracheostomy in situ, particularly those requiring frequent suctioning, generally require an escort with relevant competencies. Page 44 of 57

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An NCUHT escort is required whenever a medical device, such as an infusion device, belonging to the Trust is in situ. Depending on the situation, NWAS may be able to transfer a patient with iv fluids that do not require to go through a volumetric pump, but the risk/benefit of this situation should be considered on an individual basis. If any therapy can safely be discontinued for the duration of transfer this may be considered also. All “high risk” patients should be referred for a critical care opinion prior to transfer. Critical care assessment is also mandatory for all patients where the airway is compromised. Consideration should be given to pre-emptive intervention, particularly if there are airway concerns. Steps should be taken to avoid the need for significant interventions en route wherever possible. Anaesthetists will generally only accompany intubated patients. Neither anaesthetic nor ambulance personnel should be expected to intubate a patient during transfer. If there is a realistic likelihood of a patient requiring intubation, en route, the safest option is to do this is in a controlled manner, before the transfer. 4.

STABILISATION AND ONGOING MANAGEMENT OF THE PATIENT

Steps needed to optimise the patient should be taken in an “ABC” fashion. Completion of the Transfer Checklist will aid logical patient preparation and is mandatory before the patient leaves the transferring unit. Once the decision to transfer has been made, arrangements for the transfer should be made concurrently with ongoing investigation and treatment of the patient. Whilst non urgent interventions which may delay or impede transfer should not be carried out at the transferring unit, it is imperative that close observation and response to changes in the patient’s condition continue once the decision to transfer has been made. In some circumstances, eg the actively bleeding patient, it will not be possible to fully resuscitate the patient prior to transfer. In these cases delay in obtaining definitive treatment may be extremely detrimental. Senior medical staff must be closely involved in the care of such patients. Analgesia – It is important that patients’ pain should be managed effectively prior to transfer, and steps taken to minimise discomfort in transit. Consideration should be given to physical measures such as splinting of injured limbs as well as analgesic drugs. Multimodal analgesia utilising paracetamol, local anaesthetic techniques where appropriate, and possibly NSAIDS is preferred. NSAIDS should not be given to patients with known or suspected bleeding, those who are dehydrated or shocked or those with any other recognised contraindication, and should be used with great caution in the elderly. If opiates are required, small titrated intravenous doses should be given to minimise side effects. Anti emetic therapy should be considered, especially for those patients who have received opioid analgesia and those who have a history of motion sickness. (Please see Trust guideline “Analgesia – Emergency Care Guideline” for further information.) 5.

COMMUNICATION

Exemplary communication between all personnel involved in the transfer is crucial. As well as facilitating safe transfer, good communication improves patient experience. There are 3 key areas of communication: 4) 5) 6)

Between the transferring and receiving units. Between the transferring unit and NWAS. Between staff and the patient/patient’s family.

5.1 Communication between staff at transferring and receiving units: An SBAR based Communication Tool has been devised for this purpose. The transferring doctor (ie the person who is arranging the transfer) should complete the form prior to telephoning the receiving doctor and use this information to inform the conversation. Following the telephone call the form should be scanned and emailed to the receiving unit. This is to ensure that the receiving team have key information about the patient before s/he

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arrives on the ward and can be better prepared to take over care. The transferring unit should also telephone the receiving unit as the patient leaves, so that the receiving team are aware of the likely time of arrival. In cases where major deterioration in transit is a significant possibility, a plan of action should be made and documented prior to departure (eg whether to return to base or continue). The escorting team should be given contact details of a senior clinician from whom further advice can be sought in the event of difficulties in transit. 5.2 Communication with NWAS Please refer to flow chart Appendix 4 before contacting EOC. A senior member of the transferring team should telephone ambulance control with the outcome of the flow chart in Appendix 4. NWAS crews are unable to wait in the hospital for long periods whilst patients are prepared for transfer, so an ambulance should not be called when there are still multiple outstanding tasks. The staff member making the call should be able to provide clinical information about the patient and the desired time frame for the transfer. Reference to the information on the SBAR form already prepared may be beneficial. The NWAS Call Handler will complete an NWAS screening tool and in the event of difficulty will arrange for a clinician to clinician call back to negotiate arrangements. It must be understood that NWAS deal with a high volume of calls and are required to prioritise scarce resources. We need to provide objective and sufficiently detailed information to allow Ambulance Control to despatch the most appropriate vehicle to each patient. Please do not request a higher level crew than is really needed. The best way to deal with problems is by negotiations to be undertaken by senior staff able to discuss the patient’s needs and the reasons for the requested time frame. Dialling “999” to obtain a rapid response from the ambulance service is inappropriate in all but the most immediately life threatening situations and is strongly discouraged. 5.3 Communication with patient/family Interhospital transfer is a time of great stress for patients and their relatives but good communication can help to ease their anxiety. Prior to transfer the patient, and where appropriate, their family, should be informed regarding: 1) 2) 3) 4) 5) 6)

The reason for transfer. The intended destination. The expected time frame for transfer. Relatives should be given contact details for the receiving unit and, if necessary, directions. If any delays or changes in plan occur the patient and relatives should be kept updated of the reasons. Information given to the patient and relatives should be recorded in the patient records

6.

MONITORING AND TREATMENT DURING TRANSFER

Precise requirements will vary from patient to patient. In deciding the needs of the individual patient it should be remembered that monitoring during transfer should be at least of the same standard and frequency which the patient would receive in the transferring unit. As a minimum, a set of observations should be made and recorded before the patient leaves the transferring unit, and on arrival in the receiving unit. Unstable/higher risk patients will require observations to be recorded in transit. A specific form is used for critical care transfers, but the standard Trust observation chart should be used for other patients. Emergency ambulances carry standard monitoring and emergency equipment as listed in Appendix 1, which may be used in an emergency. Escorting staff should review the list and ensure that any other drugs or equipment that are likely to be required by their patient in transit are obtained from the base hospital prior to transfer. Page 46 of 57

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Drugs to be “routinely” administered en route (eg infusions which may run out) should be provided by NCUHT. However, steps should be taken to minimise risk in transit by ensuring, as far as is possible, that any infusions in progress have adequate volume left to last for the predicted transfer time plus handover time at the receiving hospital. 7.

STAFF SAFETY DURING TRANSFER

Whilst travelling by ambulance, escorting staff should remain seated at all times, and seatbelts must be worn. In the event that a patient intervention is needed, the ambulance crew should be informed, and they will stop the vehicle when it is safe to do so. NCUHT staff must follow safety advice given by NWAS staff at all times during the transfer. 8.

ARRIVAL AT RECEIVING UNIT

Precise handover details will depend on the escorting personnel and the receiving venue. (Eg transfers to a critical care area will almost certainly have a medical escort and handover will generally be to another doctor, whereas on general wards the handover will often be ambulance staff to nursing staff). The escorting personnel should give a verbal handover to the receiving personnel and hand over the hospital notes, with the SBAR form on the front. If the receiving member of staff is non medical, the doctor on duty for the ward must be informed as soon as possible. Every patient who is transferred in from another site must be reviewed by a doctor as soon as possible. It is not necessary to perform a complete readmission process, but the patient and documentation, including drug chart should be reviewed by the receiving medical team. This review, and any changes to the patient’s condition or therapy, must be recorded in the medical notes. Individual teams should set criteria for the acceptable time frame within which a transferred patient must be reviewed, and what grade of doctor should perform the first review. Ward nursing staff must be made aware of these criteria. Ward staff must ensure that IT systems are updated with the patient’s new location and consultant. Patients must be informed of the name of their new consultant and named nurse. Please note that NWAS cannot guarantee to return NCUHT staff and equipment to the base hospital. In the event that this is not possible, hospital transport should be arranged by calling the matron or OSM for the relevant area (duty matron or manager out of hours) for authorisation. Switchboard can then arrange a hospital taxi. 9.

MONITORING / AUDIT DETAILS

Processes to be monitored via Clinical Directors at CPG. All incidents relating to transfers, including delays, must be reported on the incident reporting system Ulysses. A copy or note of this reported incident should also be sent to the central inbox: [email protected]

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10. REFERENCES / EVIDENCE BASE 1. Interhospital transfer – The Association of Anaesthetists of Great Britain and Ireland (2009) 2. National Early Warning Scores, Report of Working Party – The Royal College of Physicians (July 2012) 3. Transport of the Critically Ill Adult – The Intensive Care Society (July 2011) 4. Best Practice Guidelines for the Management and Transfer of Patients with a diagnosis of Ruptured Abdominal Aortic Aneurysm to a specialist Vascular Centre – College of Emergency Medicine/The Vascular Society/Royal College of Radiologists 5. Clinical Policy for safe transfer of patients between care areas or between hospitals – Royal Cornwall Hospitals (March 2012) 6. Survey of surgical patients transferred between WCH and CIC – Patient Experience Team NCUHT (March 2014) (Personal Communication)

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APPENDIX 1 – Equipment and Drugs Available on NWAS Emergency Vehicles

Note the medications carried by NWAS are for pre-hospital emergency use only as outlined within the Service PGS’s. Monitoring Lifepak 12/15 monitor incorporating ECG, NIBP, pulse oximeter and capnograph. Blood glucose monitor. Airway Equipment ET tubes – range of sizes igels – range of sizes Oral airways – range of sizes Face masks Suction pump and catheters Breathing Equipment Self inflating bag Para pac ventilator Circulation equipment Iv cannulae – range of sizes Giving sets Defibrillator Drugs Allergy management Adrenaline 1:1000 Chlorphenamine 10mg Hydrocortisone 100mg Analgesics Codeine 15mg/5ml Ibuprofen suspension 100mg/5ml Ibuprofen 200mg tablets Paracetamol suspension 120mg/5ml Paracetamol 500mg tablets Antibiotic Benzylpenecillin 600mg Anti emetic Metoclopromide 10mg

Cardiovascular Adrenaline 1:10 000 Amiodarone 300mg Aspirin 300mg Atropine 1mg GTN 2mg buccal Tranexamic acid 500mg/5ml Hypoglycaemia management Dextrose gel 40% Dextrose 10% 500ml bags Glucagon 1mg

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IV Fluids 0.9% saline 500ml 10% dextrose 500ml Neurological Diazepam 5mg rectal tube Diazemuls 10mg/5ml Obstetric Misoprostol 200mcg tablets Respiratory Hydrocortisone 100mg Ipatropium bromide 250mcg Naloxone 400mcg/1ml Salbutamol 2.5mg Salbutamol 5mg Nerve agent antidote kit (NAAK)

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APPENDIX 2 – Specific Guidance for patients with leaking AAA. All patients requiring surgery for a leaking AAA from within the Solway Basin are now treated at CIC as this is the designated Vascular Centre. Patients arriving at WCH should be discussed with the on call vascular surgeon, contacted via switchboard as soon as possible. Resuscitation along standard “ABC” lines should be instituted, though overly aggressive fluid resuscitation preoperatively should be avoided. Attempts to normalise the patient’s blood pressure prior to surgery have been associated with increased bleeding and worse outcome, therefore a philosophy of “permissive hypotension” should be followed. The patient’s conscious level should be used as a guide to the adequacy of resuscitation, but a systolic blood pressure of 70-90mmHg is generally acceptable. Careful analgesia should be provided in accordance with Trust guidelines. Suitability for transfer should be decided in conjunction with the vascular surgeon on call and will depend upon the patient’s current physiological state and their pre-existing co-morbidities. If the patient is considered suitable for transfer this should be arranged as soon as possible. Delayed transfer has been shown to be associated with worse outcomes and transfers must not be delayed by prolonged attempts at resuscitation, or procedures such as urinary catheterisation, arterial or central line insertion etc. An NCUHT staff escort is not generally required for this group of patients. (Reference 4). The on call vascular surgeon will liase with theatres etc at CIC to make arrangements to receive the patient. If patients are deemed unsuitable for surgery, then palliative care should be arranged at WCH. Transfer of the dying patient should be avoided.

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APPENDIX 3 – Specific guidance for orthopaedic patients Some orthopaedic cases are more time critical than others, and will require more rapid transfer so that surgery can be carried out as soon as possible. Delay in surgical treatment in these cases can adversely affect outcome significantly and therefore all orthopaedic transfers should be a PES 20 minute response to standardise the decision making process for the response required. Conditions of this type include: x x x x

Open fractures Septic arthritis Suspected compartment syndrome Dislocated joints

Not all patients with this type of urgent injury will have a high NEWS score, particularly if they are young and fit prior to the injury. The ambulance service use physiological status as an important part of the decision making process to judge urgency of transfer. It is therefore very important that when communicating with NWAS about this type of patient we stress that the condition requires urgent surgical intervention, to ensure that they are given appropriate priority. Remember that the person taking the initial call at NWAS may not have the experience or authority to deal with every request, but senior clinical staff are always available to discuss specific problems. A call back from the senior clinician on duty at NWAS can be requested if problems are encountered.

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APPENDIX 4 Guidance For Ambulance Requests For Interhospital Transfers Ncuh

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Appendix 5 Transfer Communication Tool (this is an example copy – please order for use) Transferring Ward / Site: Receiving Ward / Site: Date:

AFFIX PATIENT LABEL HERE TIME :

hrs

TRANSFER COMMUNICATION TOOL

S Situation

Patient name………………………………………….. Age……………. Presenting Complaint…………………………………………………….. Working diagnosis…………………………………………………………

B

Current Problem

Drugs

Comorbidities

Allergies

Physiology

Investigations

Background

A Assessment Therapy Last oral intake

R

Transfer to:

Recommendation

Anticipated timescale

Ongoing Therapy/General Comments

Outstanding Investigations

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Appendix 6 Transfer Assessment Checklist (this is an example copy – please order for use) TRANSFER ASSESSMENT CHECKLIST Date:

Time:

Transferring Site:

Receiving Site:

Name of Clinician Completing Checklist: Ward/Dep:

Patient Name: Hospital Number

Date of Birth:

AIRWAY Are there any concerns about the airway? If there are concerns regarding airway patency, urgent critical care assessment is mandatory. BREATHING Have I assessed and recorded RR, SaO2 and breath sounds?

Please confirm

Is the patient receiving appropriate respiratory therapy? (eg O2, nebulisers, chest drain)

Yes Details :

No

Has a CXR been done if needed? YN NA

Yes

No

N/A

Is there anything more I need to do for the patient’s breathing before transfer? Do I need help? CIRCULATION Have I assessed and recorded pulse, BP, CRT and UOP?

Please confirm

Have I identified potential sources of fluid loss?

Yes

No

Details : Is appropriate iv fluid therapy on going?

Yes

No

N/A

Have relevant blood tests been taken and blood cross matched if necessary?

Yes

No

N/A

Has the patient got appropriate iv access?

Yes

No

N/A

Is catheterisation required?

Yes

No

N/A

Is there anything more I need to do for the patient’s circulation before transfer? Do I need help? DISABILITY Have I assessed and recorded the patient’s AVPU score? YN NA

Yes

No

N/A

Have I checked, recorded, and where appropriate treated the patient’s blood sugar? YN NA

Yes

No

N/A

Have I checked and recorded the patient’s pupillary size and reactivity.

Yes

No

N/A

Is there anything more I need to do for the patient’s conscious state before transfer? Do I need help? EVALUATION Have I checked the patient’s temperature and instigated warming or cooling measures if required?

Yes

No

Have I assessed, recorded and where necessary treated the patient’s pain? Is analgesia effective?

Yes

No

Are there any wounds or injuries of any type that need attention prior to transfer?

Yes

No

Does this patient require antibiotics, and if so have they been given?

Yes

No

Are there any electrolyte imbalances that require urgent treatment?

Yes

No

Have all urgent investigations been completed?

Yes

No

Has any non essential therapy been temporarily discontinued?

Yes

No

Has SBAR communication with the receiving clinician occurred? YN

Yes

No

Has an escort been identified if necessary?

Yes

No

Is the receiving unit expecting the patient?

Yes

No

Is all documentation prepared for transfer?

Yes

No

Has NWAS been contacted and time frame agreed?

Yes

No

Does the patient and his/her family understand where they are going, when and why?

Yes

No

Is there anything more I need to do for the patient before transfer? Do I need help? LOGISTICS AND COMMUNICATION

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APPENDIX F – TRANSFER COMMUNICATION TOOL (SBAR) (this is an example copy – please order for use) Transferring Ward / Site: Receiving Ward / Site: Date:

AFFIX PATIENT LABEL HERE TIME :

hrs

TRANSFER COMMUNICATION TOOL

S Situation

Patient name………………………………………….. Age……………. Presenting Complaint…………………………………………………….. Working diagnosis…………………………………………………………

B

Current Problem

Drugs

Comorbidities

Allergies

Physiology

Investigations

Background

A Assessment Therapy Last oral intake

R

Transfer to:

Recommendation

Anticipated timescale

Ongoing Therapy/General Comments

Outstanding Investigations

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APPENDIX G – TRANSFER ASSESSMENT CHECKLIST (this is an example copy – please order for use) TRANSFER ASSESSMENT CHECKLIST Date:

Time:

Transferring Site:

Receiving Site:

Name of Clinician Completing Checklist: Ward/Dep:

Patient Name: Hospital Number

Date of Birth:

AIRWAY Are there any concerns about the airway? If there are concerns regarding airway patency, urgent critical care assessment is mandatory. BREATHING Have I assessed and recorded RR, SaO2 and breath sounds?

Please confirm

Is the patient receiving appropriate respiratory therapy? (eg O2, nebulisers, chest drain)

Yes Details :

No

Has a CXR been done if needed? YN NA

Yes

No

N/A

Is there anything more I need to do for the patient’s breathing before transfer? Do I need help? CIRCULATION Have I assessed and recorded pulse, BP, CRT and UOP?

Please confirm

Have I identified potential sources of fluid loss?

Yes

No

Details : Is appropriate iv fluid therapy on going?

Yes

No

N/A

Have relevant blood tests been taken and blood cross matched if necessary?

Yes

No

N/A

Has the patient got appropriate iv access?

Yes

No

N/A

Is catheterisation required?

Yes

No

N/A

Is there anything more I need to do for the patient’s circulation before transfer? Do I need help? DISABILITY Have I assessed and recorded the patient’s AVPU score? YN NA

Yes

No

N/A

Have I checked, recorded, and where appropriate treated the patient’s blood sugar? YN NA

Yes

No

N/A

Have I checked and recorded the patient’s pupillary size and reactivity.

Yes

No

N/A

Is there anything more I need to do for the patient’s conscious state before transfer? Do I need help? EVALUATION Have I checked the patient’s temperature and instigated warming or cooling measures if required?

Yes

No

Have I assessed, recorded and where necessary treated the patient’s pain? Is analgesia effective?

Yes

No

Are there any wounds or injuries of any type that need attention prior to transfer?

Yes

No

Does this patient require antibiotics, and if so have they been given?

Yes

No

Are there any electrolyte imbalances that require urgent treatment?

Yes

No

Have all urgent investigations been completed?

Yes

No

Has any non essential therapy been temporarily discontinued?

Yes

No

Has SBAR communication with the receiving clinician occurred? YN

Yes

No

Has an escort been identified if necessary?

Yes

No

Is the receiving unit expecting the patient?

Yes

No

Is all documentation prepared for transfer?

Yes

No

Has NWAS been contacted and time frame agreed?

Yes

No

Does the patient and his/her family understand where they are going, when and why?

Yes

No

Is there anything more I need to do for the patient before transfer? Do I need help? LOGISTICS AND COMMUNICATION

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