Critical and Urgent Care Advice &Transfer Protocol at Louth Hospital

Transcription

1 Critical and Urgent Care Advice &Transfer Protocol at Louth Hospital Reference No: G_CS_39 Version 1.3 Ratified by: LCHS Trust Board Date ratified: 29 th July 2014 Dr Yvonne Owen, Commissioning Lead Name of originator / author: Lynne Young, Programme Consultant, LCHS Name of responsible committee / Individual Quality Scrutiny Group Date issued: September 2017 Review date: December 2017 Target audience: All Staff Distributed via Website 1

2 Critical and Urgent Care Advice &Transfer Protocol at Louth Hospital Version Control Sheet Version Section / Para / Appendix Version / Description of Amendments Date Author / Amended by New Policy July 2014 K Kerman & Benson Extended Extended Extended August 2016 Corporate Assurance Team January 2017 Corporate Assurance Team September 2017 Corporate Assurance Team Copyright 2017 Lincolnshire Community Health Services NHS Trust, All Rights Reserved. Not to be reproduced in whole or in part without the permission of the copyright owner. 2

3 Critical and Urgent Care Advice &Transfer Protocol at Louth Hospital Contents Version control sheet Policy statement Section Page 1. Introduction 5 2. Aims and Outcomes of the Critical and Urgent Care Advice and Transfer Protocol 5 3. Background 6 4. Service Outline 6 5. Service Provision 6 6. Performance Requirements 7 7. Management and Governance 7 Appendix 1 Admission Protocol for Louth Hospital 8 Appendix 2 Admission & Decision to Transfer Algorithm 10 Appendix 3 Chest Pain Protocol for Louth Hospital 11 Appendix 4 Acute Medical/A&E Competencies for Louth Doctors 12 NHSLA Monitoring Template 16 Equality Analysis 17 3

4 Critical and Urgent Care Advice &Transfer Protocol at Louth Hospital Procedural Document Statement Background East Midlands Ambulance Service operates a protocol which excludes adult patients with serious illness, specialist needs or significant trauma being taken to Louth Hospital (appendix 1). Clinicians working within Louth Hospital will follow agreed protocols regarding the care of patients who become seriously or critically unwell or who present with chest pain of cardiac origin (appendix 2 and 3). All doctors who will be working within the Urgent Care Centre at Louth Hospital will be required to achieve a minimum competency level within the scope of acutely ill or injured patients (appendix 4). Competency will be maintained by ongoing personal development and annual appraisal and re-validation. Statement The purpose of this protocol is to establish safe and consistent pathways of care for patients with deteriorating health which cannot be accommodated within Louth County Hospital. The objective of this protocol is to set clinical standards to improve the admission and transfer of appropriate patients should their condition deteriorate. Responsibilities Chief Executive, all Directors, General Managers, Clinical Governance Managers, Service Managers, Staff Training All new members of staff will be introduced to the Organisation s procedures, during the Organisation Induction programme. Dissemination Website Via Identified in the Organisation s staff newsletter 4

5 1. INTRODUCTION This Critical and Urgent Care Advice & Transfer Protocol is designed to ensure that Lincolnshire East CCG, purchase a service that will deliver the outcomes set out within: Shaping Health at Louth Hospital East Lindsey Practice Based Commissioning Service Specification for a Consultant Led Hospital at Louth It is also intended to support the delivery of the outcomes set out within: Our Health, Our Care, Our Say Commissioning for Health and Wellbeing Framework Shaping Health for Lincolnshire 2007 Lincolnshire Sustainability Review AIMS AND OUTCOMES OF THE CRITICAL AND URGENT CARE ADVICE AND TRANSFER PROTOCOL The overall aims of the service Protocol are to: Provide a 24/7 telephone service to a medical consultant or senior registrar to advise on initial management of seriously ill adult patients who attend the Urgent Care Centre or are in-patients at Louth Hospital Provide a 24/7 direct line to a medical consultant or senior registrar for advice on assessment, immediate management and transfer if necessary for patients presenting with or developing an acute cardiac problem while attending or admitted to Louth Hospital Provide a 24/7 fax or telemetry ECG interpretation service Provide educational and clinical support for the safe administration of thrombolysis to patients with acute STEMI at Louth Hospital Provide advice on fluid balance in post-operative patients and patient who require parenteral fluid therapy Advise on the transfer needs (priority and escort competencies) for patients who require specialist and/or critical care at an alternative hospital site Provide advice on the management of post-operative patients who have undergone surgery at Louth Hospital and who develop complications or become acutely unwell following surgery Provide clinical and educational support to doctors and practitioners working within the Urgent Care Centre and on the medical wards at Louth Hospital The provision of a critical and urgent care advice service will result in the following outcomes: Direct access for Louth Hospital clinicians to critical and urgent care advice for seriously ill and injured adult patients (via Senior A&E Consultant or RMO) Direct access for Louth Hospital clinicians to senior cardiology advice for patients attending the Urgent Care Centre or admitted to the medical wards (via RMO) 5

6 Reduction in the number of unnecessary transfers of patients with cardiac problems to a secondary care site Facilitation of the timely and safe transfer of critically ill and injured patients from Louth Hospital to other sites for definitive and critical care Positive support for clinicians working at Louth Hospital 3. BACKGROUND East Midlands Ambulance Service operates a protocol which excludes adult patients with serious illness, specialist needs or significant trauma being taken to Louth Hospital (appendix 1). Clinicians working within Louth Hospital will follow agreed protocols regarding the care of patients who become seriously or critically unwell or who present with chest pain of cardiac origin (appendix 2 and 3). All doctors who will be working within the Urgent Care Centre at Louth Hospital will be required to achieve a minimum competency level within the scope of acutely ill or injured patients (appendix 4). Competency will be maintained by ongoing personal development and annual appraisal and revalidation. 4. SERVICE OUTLINE The service has been implemented following the transfer of the Urgent Care Centre to LCHS on 1 st April The Decision to Transfer Algorithm is shown in Appendix 2. A direct line of communication must be established to enable the Clinician at Louth to speak with and be advised by a Specialist Registrar or Consultant on the initial management and transfer of patients from the Louth site. This communication will take place following discussion between the Louth Clinician and the Louth Medical Consultant on duty. The aims and outcomes outlined above must be delivered by the service and will be monitored and audited by the Clinical Management Team for Louth Hospital. 5. SERVICE PROVISION The 24/7 direct access telephone advice and support will be provided by clinicians with appropriate competencies that are agreed by the commissioner and provider. Regular audit of the service will be undertaken by the Clinical Management Team and will be shared with the provider. Any necessary changes to services that arise from the results of audit will be communicated to the provider and an agreement reached according to contractual arrangements. All sites that involve patient contact will adhere to infection control and decontamination guidelines and will comply with building regulations and Health & Safety legislation. 6

7 6. PERFORMANCE REQUIREMENTS Performance and outcomes will be measured by auditing: Referrals to the critical and urgent care advice service Patient experience and outcomes for sick and injured adults attending Louth Urgent Care Centre who are referred to the provider for specialist advice, support and management Outcomes for patients attending Louth Urgent Care Centre with primary or secondary cardiac problems Outcomes for patients admitted to Louth Hospital with primary or secondary cardiac problems Usage, access and outcomes for the 24/7 cardiology advice and ECG interpretation service Patient experience The level of support perceived by Clinicians at Louth Appropriateness of referrals to the service 7. MANAGEMENT AND GOVERNANCE Adult medical, trauma and post-operative services at Louth Hospital will be managed by the Clinical Management Team with contribution from the providers of Specialist Support Services. Any untoward incidents that occur will be reported by the provider or by clinicians at Louth Hospital to the Clinical Management Team. A full root cause analysis will be undertaken and the findings and actions communicated to all involved parties and stakeholders. Any serious untoward incidents that involve patient harm will be immediately brought to the Clinical Management Team for referral to and advice from the Clinical Risk Management service for NHS Lincolnshire. Clinical Governance arrangements for acute medical services will comply with the Governance policy for the provider of services at Louth Hospital. 7

8 Appendix 1 Admission Protocol for Louth Hospital Louth Hospital UCC and In-patient Beds Review Date: March 2015 PATIENTS WITH THE FOLLOWING CONDITIONS SHOULD NOT BE BROUGHT BY AMBULANCE TO LOUTH UCC DEPARTMENT OR BE ADMITTED BY GPs OR OTHER AGENCIES (Unless there is a need for immediate resuscitation/stabilisation of the patient (OR NEED FOR ANALGESIA) that cannot be effectively provided by the ambulance crew) TRAUMA Any trauma patient with a NEWS score of 5 or more Glasgow Coma Score (GCS) <13 Head injured patients on warfarin All stabbings/gunshot wounds that involve penetration of the chest or abdomen Long bone fractures (incl. suspected neck of femur) Compound fractures Obvious large joint dislocations (knees/ankles) Suspected abdominal, pelvic or significant chest injury Suspected spinal injuries Serious scalds and burns (>10%TBSA and/or airway burns and burns involving hands) GYNAECOLOGICAL, OBSTETRIC Pregnant women who have vaginal bleeding and/or significant abdominal pain MEDICAL/SURGICAL PATIENTS Any patient with a NEWS score of 5 (unless end of life or patient choice) Patients with chest pain of suspected cardiac origin with ST segment ECG changes (incl. LBBB) Patients with suspected acute stroke (FAST positive) Gastro-intestinal haemorrhage (upper and lower) presenting with fresh bleeding Patients with acute, severe abdominal pain Patients who are actively bleeding and have a known haematological disorder (e.g. haemophilia) PAEDIATRICS (Up to 16 years) Injured or ill children who have one or more of the following: Abnormal appearance (colour; tone; interaction) Increased work of breathing (RR; accessory muscles; recession; noise) Circulatory compromise (colour; CRT; conscious level) Children with >5% TBSA or airway/hand burns All other patients may be brought to Louth Urgent Care Centre and will be assessed We will continue to support patient choice in the provision of palliative care and end of life Advice can be obtained on the following telephone numbers: ext Bleep Duty Doctor or Consultant Doctor 8

9 PHYSIOLOGICA L PARAMETERS Respiration Rate The NEWS scoring System In some settings, patients will have an impaired level of consciousness as a consequence of sedation, eg following surgical procedures. Thus, the assessment of consciousness level and the necessity to escalate care should be considered in the time-limited context of the appropriateness of the consciousness level in relation to recent sedation. For patients with known hypercapnoeic respiratory failure due to chronic obstructive pulmonary disease (COPD), recommended British Thoracic Society target saturations of 88-92% should be used. These patients will still score if their oxygen saturations are below 92 unless the score is reset by a competent clinical decision-maker and patientspecific target oxygen saturations are prescribed and documented on chart and in the clinical notes. All supplemental oxygen when administered must be prescribed. Glossary of Terms < >25 Oxygen Saturations < >96 Any Supplemental Oxygen Yes No Temperature < >39.1 Systolic BP < >220 Heart Rate < >131 Level of Consciousness A V, P or U TBSA total body surface area LBBB left bundle branch block RR respiratory rate CRT- capillary refill time 9

10 Appendix 2 Admission & Decision to Transfer algorithm 1. Assess patient and measure NEWS score 2. Consider need for specialist care NEWS score of 5 or more Patient needs specialist care* Contact Critical & Urgent Care Advice Service & arrange urgent transfer -? 999 -? escort NEWS score of 2-4 and Patient meets criteria for admission to Louth** Admit patient to Louth via duty doctor Commence care pathway with hourly observations and review of NEWS Patient meets criteria for admission to Louth** and has NEWS score of 0-1 Admit patient to Louth via duty doctor Commence care pathway with 6 hourly observations and review of NEWS * Patients with the following conditions should NOT be admitted to Louth (but may be transferred back following acute care): Acute Myocardial Infarction; Acute Stroke; Shock; Septicaemia; Ketoacidosis; Acute Renal Failure; Acute surgical needs ** Patients with the following conditions may be admitted to Louth (providing their NEWS score is <3): Stable CVA (if re-vascularisation not appropriate); Acute on chronic heart failure; Lower respiratory tract infection; exacerbation of asthma and COPD; GI upset requiring parenteral fluids; Urinary tract infection; Dizziness/loss of balance; stable medical condition requiring parenteral analgesia (e.g. biliary colic); back pain (for social/pain relief); Palliative care/symptom control 10

11 Appendix 3 Chest Pain Protocol for Louth Hospital CHEST PAIN OF SUSPECTED CARDIAC ORIGIN Chest Pain of suspected cardiac origin with ST elevation or ST-T wave changes, or LBBB ( new or doubtful old LBBB) Chest pain of suspected cardiac origin with normal ECG or confirmed old LBBB Aspirin 300mg unless contraindicated Oxygen should be given only if saturations are <94% and patient is not at risk of hypercapnic respiratory failure. (Type 2 respiratory failure COPD patients should have sats of 88-92%) Discuss thrombolysis at Castle Hill or Lincoln TICAGRELOR 180 MG PO unless contraindicated after confirming the plan with Castle hill or Lincoln Arrange 999 transfer GTN spray 1-2 puffs unless contraindicated Aspirin 300mg unless contraindicated Clopidogrel 300mg unless contraindicated Fondaparinux 2.5mg unless contraindicated or likely to have coronary angiography within 24 hours, or if creatinine is>265um/l Oxygen should be given only if saturations are <94% and patient is not at risk of hypercapnic respiratory failure. (Type 2 respiratory failure COPD patients should have sats of 88-92%) Admit to Manby Ward for Cardiac monitoring Troponin I & CK Measurement at 12 Hours POSITIVE TROPONIN Refer to cardiology routinely as inpatient. If any of the following occur then discuss with DPOW / Lincoln regarding transfer: 1. ECG changes develop 2. Uncontrolled chest pain occurs 3. Haematological evidence of multi organ failure NEGATIVE TROPONIN Reconsider diagnosis and further investigations into differential diagnoses. Negative troponins do not exclude cardiac ischemia as a cause of chest pain. Clinical judgement should be used and patients referred to cardiology as appropriate Evidence from NICE guidelines CG 95 Chest pain of recent origin and CG 94 Unstable angina & NSTEMI 11

12 Acute Medical / A&E Competencies for Louth Doctors Appendix 4 Indicators A&E Assessment and Management of level 3 A&E patients Assessment and management of non-elective patients with serious illness or injury Arrange timely transfer of patients requiring specialist or critical care using appropriate pathways Referral of patients for diagnostics and Specialist management in line with the ELPBC Strategy Provision of clinical supervision and mentorship to nursing staff and ECPs Required Knowledge and Skills All Medical Staff Be able to assess and manage patients with: Head and neck injury/pain Facial and eye injuries ENT infection and injury Chest pain and respiratory problems Abdominal pain Uro-genital problems Limb and joint injury/pain Back injury/pain Burns Wounds Allergies Arrange and interpret appropriate investigations including: X-Rays Blood and urine testing Arrange appropriate referral for specialist out-patient management using Choose and Book Arrange appropriate referral for diagnostics and follow-up Acute Medical Emergencies Management of acute medical conditions, according to national Guidelines, pathways and protocols Provision of immediately necessary treatment to acute medical patients Management of drug treatment for patients with an urgent or emergency condition Arrange appropriate admission to Louth Hospital or alternative site Acute post-operative care for elective surgical patients 12 Be able to assess and manage patients with acute medical conditions All Medical Staff Assess and manage patients with: Chest Pain Breathing difficulty Collapse/altered conscious level Asthma COPD Stroke/TIA Epilepsy and seizures Diabetic problems Vomiting and other GI symptoms Headache Infection Other acute medical problems Interpret ECGs and cardiac rhythms Manage fluid and acid/base balance Monitor and adjust drug treatments Provide routes and dosages for emergency drugs in adults and children Explain the treatment implications of

13 drug treatments to patients and/or carers Interpret and manage haematological and biochemical investigations Interpret Chest Xrays and other respiratory investigations and take appropriate action Provide appropriate level information and support for patients to help them understand their condition and it s implications Acute Mental Health Care Be practiced in the diagnosis and management of patients presenting with an urgent mental health condition Be practised in the immediate management of patients who have harmed themselves or who present with acute mental health difficulties To work within the law in relation to mental health issues To communicate effectively with patients To confidently manage acute disturbance In-Patient Care Liaison with GPs, nurse or other practitioners and A&E staff who wish to admit a patient to Louth Hospital Admission of patients to Louth Hospital according to agreed admission criteria Clerking in of in-patients using standardised records and implementation of investigation/management plans Involvement in discharge planning In-patient care including clinical supervision, practical skills and supportive care Documentation of care, intervention and variance Communication with all others involved in patient care Provide appropriate level information and support for patients to help them understand their condition and it s implications Consider the differential diagnoses relevant to urgent care and manage appropriately: -delirium - drug and alcohol problems - self-harm - acute psychosis or other disturbance Assess mental state Assess for suicide risk Prioritise management Safely and confidently work within the Mental Health and Capacity legislation Be aware of de-escalation techniques and the use of rapid tranquilisation when necessary Admission criteria for Louth Hospital The Modified Early Warning Score system for physiological assessment Protocols and pathways for transfer of patients that do not fit the admission or MEWS scoring criteria for Louth Hospital Management protocols for the conditions that are appropriate for admission to Louth Hospital The bed management process for Louth Hospital The standardised patient documentation pack The requirements for timely and effective discharge Practical skills: Phlebotomy Intravenous cannulation 13

14 Life Support a. Airway (with C-Spine control for trauma patients) Provide basic airway support using manual techniques and simple aids Provide more advanced airway care using LMA or endotracheal intubation Provide needle or tube cricothyroidotomy for obstructed airway Provide Manual in-line stabilisation of C-spine when appropriate Correct sizing and use of cervical collar b. Breathing and oxygen therapy Provide assessment and support for patients with breathing difficulty Deliver appropriate Oxygen therapy Arrange appropriate transfer for patients for patients who do not fit the criteria for admission to Louth Hospital Fluid therapy Urinary Catheterisation ECG/CXR/Blood result interpretation Be able to: Assess the patency of a patient s airway Identify any potential threat to the airway Recognise the patient with a time critical airway problem Perform a range of manual manoeuvres to open and maintain a clear airway Choking protocols for adults and children Head tilt/chin lift Jaw thrust Correctly size and insert an OP airway Correctly size and insert a NP airway Assess the need for more advanced airway care and ensure competence of staff to undertake this Correctly size and insert a LMA Assess the potential for cervical spine injury Apply a correctly sized cervical collar and fully immobilise the patient Arrange appropriate radiological imaging of the cervical spine Be able to: Undertake clinical assessment of the patient with breathing difficulty Arrange appropriate investigations incl. SpO2, CXR, ABGs, peak flow, ECG Provide appropriate oxygen therapy according to BTS Guidelines Provide ventilatory support if necessary Provide needle thoracocentesis for tension pneumothorax c. Circulation with haemorrhage control and circulatory support Provide Advanced Life Support for cardiac arrest (ERC 2005 guidelines) Provide appropriate management for Be able to: Assess patients for cardiac arrest and physiological shock Provide CPR for patients in cardiac 14

15 patients with physiological shock Provide circulatory support using fluid and drug therapy Assess the cause of physiological shock and provide appropriate immediate treatment Control external haemorrhage Recognise internal haemorrhage Recognise the need for early transfer of shocked patients arrest Provide intravenous or intraosseous access Administer appropriate cardiac drugs including adrenaline, atropine, amiodarone, calcium chloride and bicarbonate Provide appropriate circulatory support using drugs and fluids Arrange appropriate investigations to establish the cause of cardiac arrest of shock Provide treatment for acute anaphylaxis according to the RCUK protocol 2008 Control external haemorrhage by direct and indirect techniques Assess the potential for internal haemorrhage and arrange early transfer to definitive care 15

16 NHSLA Monitoring Template Minimum requirement to be monitored Process for monitoring e.g. audit Responsible individuals/ group/ committee Frequency of monitoring/audit Responsible individuals/ group/ committee (multidisciplinary) for review of results Responsible individuals/ group/ committee for development of action plan Responsible individuals/ group/ committee for monitoring of action plan RCA to be undertaken following breaches RCA Louth Urgent Care Group Throughout the year Louth Urgent Care Group Louth Urgent Care Group Louth Urgent Care Group 16

17 Equality Analysis Name of Policy/Procedure/Function* Critical and Urgent Care Advice and Transfer Protocol at Louth Hospital Equality Analysis Carried out by: Vivienne Benson Date: Equality & Human rights Lead: Rachel Higgins Director\General Manager: Sue Cousland *In this template the term policy\service is used as shorthand for what needs to be analysed. Policy\Service needs to be understood broadly to embrace the full range of policies, practices, activities and decisions: essentially everything we do, whether it is formally written down or whether it is informal custom and practice. This includes existing policies and any new policies under development. 17

18 Section 1 to be completed for all policies A. Briefly give an outline of the key objectives of the policy; what it s intended outcome is and who the intended beneficiaries are expected to be B. Does the policy have an impact on patients, carers or staff, or the wider community that we have links with? Please give details C. Is there is any evidence that the policy\service relates to an area with known inequalities? Please give details D. Will/Does the implementation of the policy\service result in different impacts for protected characteristics? The objective of this protocol is to set clinical standards to improve the admission and transfer of appropriate patients should their condition deteriorate. This protocol will have an impact on patients, carers and staff as patients will be transferred to other more appropriate health care settings. No No Disability Sexual Orientation Sex Gender Reassignment Race Marriage/Civil Partnership Maternity/Pregnancy Age Religion or Belief Carers Yes If you have answered Yes to any of the questions then you are required to carry out a full Equality Analysis which should be approved by the Equality and Human Rights Lead please go to section 2 The above named policy has been considered and does not require a full equality analysis Equality Analysis Carried out by: Vivienne Benson Date: No x x x x x x x x x x 18

19 Section 2 Equality analysis Title: Critical and Urgent Care Advice and Transfer Protocol at Louth Hospital Relevant line in: What are the intended outcomes of this work? Clinicians working within Louth Hospital will follow agreed protocols regarding the care of patients who become seriously or critically unwell or who present with chest pain of cardiac origin Who will be affected? Patients, employees and others engaged in or affected by the activities and services of the Trust. Evidence The Government s commitment to transparency requires public bodies to be open about the information on which they base their decisions and the results. You must understand your responsibilities under the transparency agenda before completing this section of the assessment. What evidence have you considered? List the main sources of data, research and other sources of evidence (including full references) reviewed to determine impact on each equality group (protected characteristic). This can include national research, surveys, reports, research interviews, focus groups, pilot activity evaluations etc. If there are gaps in evidence, state what you will do to close them in the Action Plan on the last page of this template. Disability None Sex None Race None Age None Gender reassignment (including transgender) None Sexual orientation None Religion or belief None Pregnancy and maternity None 19

20 Carers None Other identified groups None Engagement and involvement Was this work subject to the requirements of the Equality Act and the NHS Act 2006 (Duty to involve)? No How have you engaged stakeholders in gathering evidence or testing the evidence available? No How have you engaged stakeholders in testing the policy or programme proposals? No For each engagement activity, please state who was involved, how and when they were engaged, and the key outputs: Summary of Analysis There is no evidence to demonstrate that discrimination may occur, as no particular group would be adversely affected as the policy is mainly in relation to the Health and Safety of all staff and service users. This would be monitored and recorded through incident reporting mechanisms. If the monitoring procedure identified an issue in terms of adverse impact appropriate action will be taken.. Eliminate discrimination, harassment and victimisation No Advance equality of opportunity No Promote good relations between groups No What is the overall impact? No Addressing the impact on equalities No Action planning for improvement There is no evidence to demonstrate that discrimination may occur, as no particular group would be adversely affected as the policy is mainly in relation to the Health and Safety of all staff and service users. This would be monitored and recorded through incident reporting mechanisms. If the monitoring procedure identified an issue in terms of adverse impact appropriate action will be taken. Please give an outline of your next steps based on the challenges and opportunities you have identified. Include 20

21 here any or all of the following, based on your assessment Arrangements for continued engagement of stakeholders. Arrangements for continued monitoring and evaluating the policy or service for impact. For the record Name of person who carried out this assessment: Vivienne Benson Date assessment completed: 7/8/14 Name of responsible Director/ General Manager: Sue Cousland Date assessment was signed: 21