Transfer of Care Policy and Procedures

Transcription

1 Transfer of Care Policy and Procedures 1

2 Version: Status Lead Director/Manager responsible Name originator/author: Ratified by: of V4 Final version David Shakespeare/ Chris Kelly Chris Kelly Integrated Governance Sub group Date ratified: 24 th February 2010 Date Policy is Effective From 24 th February 2010 Review date: February 2011 Expiry date: February 2013 Date of Equality and Diversity Impact Assessment Date of Health Inequalities Impact Assessment Target audience: NHS Walsall/ WCH linked documents Distribution of the document See appendix 5 and 6 All WCH staff involved with transfer of adult patients. Consent Policy Mental Capacity Act Guidance Infection Control Policies Available on NHS Walsall Internet site. Implementation of the document Document Control and Archiving Cascaded through Information Governance and Professional Forum. Accessed via local internet site. Obsolete or superseded documents will be removed from the intranet and where relevant replaced with an updated version. Previous versions will be archived in the safeguard system in accordance with the Records Management NHS Code of Practice; disposal and retention schedule. As stated in section 8.0 Monitoring Compliance and Effectiveness References Relate to National guidance and Best Practice. 2

3 CONTRIBUTION LIST Key individuals involved in developing the document Name Designation Pauline Hurst Clinical lead for District Nursing Sharon Cooper Team Lead Learning Disabilities Emma Fisher Practice Education Facilitator for District Nursing David Shakespeare Head of Professional Practice Liz Brown Clinical Team Leader Specialist Rehabilitation Services Hazel Wilkes Commissioning Manager Complex Care Sweera Sandhu Infection Control Nurse Lead Amanda Beaumont Head of Infection Prevention and Control Circulated to the following for consultation Name/Committee/Group/ Designation Jan Peters Discharge Liaison Team Manager Debbie Shaw Operational Manager Neurological Rehabilitation Services Margaret Williams Head of Intermediate Care and Rehabilitation Ann Coyle Interim Assistant Director of Provider Services Elaine Beeson Interim Head of Physiotherapy and Podiatry Caroline Townsend Healthcare Governance Facilitator Leon Talbot Interim Manager Intermediate Care Donna Chaloner Head of Adult Prevention Services Louise McMahon Head of Community Nursing Services Sue Crabtree Head of Palliative & End of Life Care Liz Staples Head of Learning Disability Nursing/Clinical Service Manager Lois Wilson Clinical Lead Learning Disability Service 3

4 Version Control Summary Significant or Substantive Changes from Previous Version A new version number will be allocated for every review even if the review brought about no changes. This will ensure that the process of reviewing the document has been tracked. The comments on changes should summarise the main areas/reasons for change. When a document is reviewed the changes should using the tracking tool in order to clearly show areas of change for the consultation process. Version Date Comments on Changes Author 1 27/1/10 Chris Kelly 2 29/1/10 Following first consultation Chris Kelly process 3 4/2/10 Following second consultation Chris Kelly meeting 4 9/2/10 Following final consultation Chris Kelly 4

5 Contents Pg 1.0 Introduction Purpose Definitions Duties Transfer of Care Process Assessment Authority to Proceed Consent Training/Skills Avoidance of Inappropriate Admission to Hospital Process for Unplanned Referral To Secondary Care Intermediate Care Continuing Health Care Receiving a Service User From Secondary to Primary 15 Care 5.1 Infection Control: The Transfer of Patients with a 15 0 known/suspected infection 5.1 Transfer of Care to and From the Learning Disability 16 1 Service 6.0 Dissemination And Implementation Document Control And Archiving Monitoring Compliance And Effectiveness References And Associated Documentation Appendix

6 1.0 Introduction This policy details the roles and responsibilities of Walsall Community Health staff and the procedures for the safe Transfer of Care (including discharge) of adult service users from and within Walsall Community Health, from hereon identified as the organisation. Procedures within this policy are generic to all staff involved in the transfer of care/discharge process for adult service users and have been developed through a multiprofessional approach. This policy aims to provide guidance and principles for all Health Care Practitioners, service users and carers to ensure appropriate and safe transfer in the event of referral to and/or the admission to onward statutory, voluntary, primary, intermediate or secondary care services. The aim is to provide an integrated approach across all disciplines involved in the care of the service user. Underpinning this policy is the Single Assessment Process (SAP) ensuring service user and carer involvement and effective co-ordination of services. High standards of communication between practitioner, service user and carer and other members of the multi-disciplinary team (MDT) are essential to this process. This policy is intended to be used as a reference tool to ensure good practice by all personnel involved in transfer of care and so achieve a positive service user and carer experience. The policy is to be used by all staff within the organisation engaged in the transfer of service users between care settings and the following guidance should therefore be considered in conjunction with any local service area guidelines. 2.0 Purpose The concept of safe to discharge is embedded in the Community Care (Delayed Discharges etc) Act (1) In order to ensure safe assessment, older people, in particular, need prompt and effective assessment by appropriate professionals. The role of the multi-disciplinary team, including the consultant, in this assessment is central. (2) 2.1 To ensure that the well being of the service user is maintained and optimal care is provided during any transfer period. 2.2 To ensure that the duties and responsibilities of staff who are engaged in the transfer of the adult service user is explicit and understood. 6

7 2.3 To ensure that adult service users are discharged or transferred from service areas in a safe, timely and appropriate manner 2.4 To ensure that when implementing transfer arrangements for service users, these arrangements are considered in line with other existing policies such as the Consent, Infection Control and the Mental Capacity Act Guidance. 2.5 To ensure that a service user discharge or transfer to any other department or service provider or to a patient's new or usual place of residence from the organisation will always be carried out in a safe and appropriate manner, with consideration to the service users individual needs. 2.6 To provide standards of care to ensure that decisions to transfer/discharge a service user are made appropriately in line with their care pathway. 2.7 To minimise the risk to service users in the deterioration of their clinical condition 2.8 To provide adequate information to support safe transfer of service users and minimise the risk of misidentification. 2.9 To provide adequate clinical supervision of the service user while being transferred where appropriate To ensure service users are always treated as individuals and are provided with a seamless transfer from one care / support setting to another with effective plans in place to ensure safe transfer To ensure the hospital and community facilities are utilised appropriately for the benefit of all service users To ensure that service users and carers have a clear understanding of the transfer of care process and take responsibility for their part in it. 7

8 3.0 Definitions Single Assessment Process (SAP) Multi-professional person centred assessment process. Multi-Disciplinary Team (MDT) All professionals involved in the coordination of care Patient transfer: - The process whereby a patient is moved from one clinical area to another within the organisation or to another organisation. Day care treatment: - Day care patients are admitted for care or treatment which can be completed in a few hours and does not require a hospital bed or overnight stay. Urgent transfer: - Refers to transfer to an Acute Hospital when the medical condition of the patient has deteriorated to the level of requiring specialist treatment that cannot be given, or there is a sudden medical event compromising the life of the patient. Non urgent transfer: - Refers to transfer planned and arranged in advance. 4.0 Duties 4.1 Managing Director Walsall Community Health It is the responsibility of the Managing Director to ensure that the organisation discharges its duties under respective legislation and NHS guidance. 4.2 Heads of Service It is the responsibility of Heads of Service to: Ensure that all staff attend mandatory training relating to Mental Capacity Assessment and that courses are recorded on ESR. Are aware of the process and responsibilities identified within this policy. 4.3 Clinical Team Leaders It is the responsibility of clinical team leaders to: 8

9 Ensure staff are aware of the process and responsibilities of transfer/discharge relating to this policy. Ensure that only appropriately qualified and skilled practitioners are identified to perform care co-ordination. 4.4 The Health Professional is responsible for: The co-ordination of safe discharge arrangements for service users in their care. Contribution to the assessment of discharge/transfer needs of service users in their care. Ensuring that discharge procedures outlined in this policy are adhered to for service users in their care. Co-ordinating the functions of all other staff involved in discharge arrangements. All members of the MDT must complete relevant sections of the appropriate local documentation or SAP documentation including nurses, Allied Health Professionals (AHPs) and social workers in line with local SAP or local guidelines. All members of the wider MDT must take a proactive approach to appropriate and safe patient transfer, including equipment needs by planning with service users and their carers/families. Any service areas that are not using the SAP documentation must use local service area documentation and include any current or relevant past healthcare acquired infections such as MRSA, Clostridium difficile or ESBL. The attached Transfer Form may be used to identify this information (Appendix 1). 4.5 Clinical Services are responsible for: Acting upon referrals made within the timescales outlined in this policy and local referral guidance. Ensuring that confirmation of the acceptance of the referral has been assured and communicated/reordered appropriately. Contributing to the assessment of discharge/transfer needs of referred service users. Completing discharge/transfer arrangements to ensure safe and timely discharge/transfer for referred service users. 9

10 All departments and services must adhere to their standard response times. 5.0 Transfer of Care Process The complete assessment of service users is essential to ensure that they are discharged or transferred safely to a setting most suitable for their individual needs and in accordance with local referral criteria and guidance. Therefore, transferring to external bodies or internal services requires appropriate assessment and communication of service users needs to the receiving service or department. 5.1 Assessment SAP It is essential that a standardised framework for assessment across health and social care and any other appropriate agencies is used. There is a commitment across the majority of adult services within the organisation to use the Single Assessment Process as introduced in the NHS Plan (2000) (3) and it is a requirement of the National Service Framework for Older People (2001) (4) to deliver person centred care. Key organisations within Walsall i.e. Walsall Manor Hospital Trust, Walsall Social Care Directorate are also committed to using SAP for all adult service users. All adult services currently not engaged with the Single Assessment Process must complete the appropriate local documentation to include any past or current relevant healthcare acquired infections. The Transfer Form (Appendix 1) within this document may be completed and sent to the receiving service which identifies elements of infection control information Risk Assessments undertaken may include the assessment of risk. Risk management requires that multidisciplinary team involvement ensuring all perspectives are considered and agreement is reached in relation to the service user abilities, strengths and weaknesses. Service user and carer involvement, contribution and agreement to the risk assessment are essential. The service user must be at the centre of the assessment, contributing fully to the gathering of information of the care plan (Changing Times 2003: Improving Services for Older People) (5) Planning Onward referral and/or admission to and accepting responsibility on discharge from hospital or other setting, should be viewed as a whole process. Therefore, planning needs to begin as early as practicable 10

11 between primary, secondary and health and social care organisations ensuring that the service user and their family understand and contribute to the decision making process. Multi-disciplinary pre-assessments, where appropriate, ensure that the service users and carers expectations are agreed in order to meet individual needs and facilitate effective transfer of care. This is a key time to explain what to expect in their transfer and allows key decisions about care needs and future plans. The engagement and active involvement of individuals and their carer(s) as equal partners is central to the delivery of care and in the planning of a successful discharge (DOH Hospitals Pathways, Processes & Practice 2003). (6) Care Co-ordination The Care co-ordination role within the Single Assessment Process aims to support a seamless approach to care delivery within the transfer of service users across services. This is an important and highly skilled role and requires an experienced practitioner who has a good understanding of the single assessment process and discharge planning. The role has traditionally been undertaken by nurses; however it may be appropriate in a transitional or rehabilitation service for a therapist or social worker to be the care co-ordinator/ case manager. The care co-ordinator has the lead responsibility for co-ordinating all aspects of the care of the service user including discharge/transfer planning. This role requires a proactive seven-day approach to ensure the plan is progressing smoothly and in a timely manner and to take immediate action to address problems in support of the multi-disciplinary team. 5.2 Authority to Proceed Patient consent should be obtained following National Guidelines for Best Practice, including competency to consent issues in respect of patients with a mental health condition or learning disability. (7) Service users rights under the Human Rights Act must be taken into account in decision making. The Mental Capacity Act 2005 (8) provides a statutory framework to empower and protect vulnerable people who are not able to make their own decisions. It makes it clear who can take decisions, in which situations, and how they should go about this. It enables people to plan ahead for a time when they may lose capacity. Guidance set out in the Act should be considered when implementing this policy This procedure should only be carried out by staff that are competent and have attended their mandatory update. 5.3 Consent 11

12 Service user consent should be obtained. Every adult has the right to make his or her own decisions and must be assumed to have capacity to do so unless it is proved otherwise. Informed consent must be obtained before any procedure is undertaken as it is a general legal and ethical principle that valid consent must be achieved. (7) This policy should also be considered in line with Walsall Community Health Consent policy and guidelines. 5.4 Training/ Skills All staff undertaking transfers/discharges must feel competent and confident that their competence and confidence are maintained within the NMC Code (9) / HPC Code of Conduct (10) or Professional Body guidance All aspects of mandatory updates should be maintained relating to Mental Capacity assessment. 5.5 Avoidance of inappropriate admission to hospital Community services such as Intermediate Care, Community Matrons, Specialist Nurses and the District Nursing have been developed to assist in preventing inappropriate admissions to hospital. On occasions service users may be transferred across services within the organisation however, for some service users an admission to hospital may be entirely appropriate. On admission from one community provider service to another or onto an external provider it is expected that the following areas are addressed: The community service will refer to the appropriate accepting speciality / secondary care service. Copies of pertinent documentation e.g. SAP documentation including current medication should accompany the patient. Where SAP is not used local transfer documentation which includes past or current relevant healthcare acquired infections must be completed. The transfer form (appendix 1) within this document may be used. The process remains the same for all referrals including out of hour referrals. Where possible family and/or carers will be informed and involved in the transfer of care. 12

13 It will be the responsibility of the referring practitioner to inform all parties involved in the support of the service user in the community of the transfer of care. The referrer will continue to be contactable to aid the discharge planning or appropriate return transfer. 5.6 Process for unplanned referral to Secondary Care For the occasions where it has been decided that hospital referral is appropriate and necessary it is the responsibility of the co-ordinating professional to: Discuss and agree with the appropriate medical practitioner responsible for the service user within the community. Inform next of kin and involve carers within the process. Liaise with the receiving department to provide necessary information including any current or relevant past healthcare acquired infections. Complete local transfer documentation or SAP documentation where appropriate to accompany the patient to the receiving department. In the event that the necessary written documentation has not been completed at the point of transfer of the service user, for example in the event of an urgent or emergency transfer, then a comprehensive verbal assessment will be given by a member of the community team to the receiving service and copies of necessary documentation will be forwarded as soon as possible. Inform members of the MDT involved in the care of the service user. 5.7 Intermediate Care The NHS plan (DOH 2000) set out a new programme to promote independence for older people, by developing a range of services delivered in partnership between primary and secondary healthcare, local government services, in particular social care, and the independent sector (Discharge from hospital: pathway, process and practice DOH 2003) (6). Intermediate care is a range of integrated services that are intended to: promote faster recovery from illness; 13

14 prevent unnecessary admission to an acute hospital bed; support timely discharge; reduce avoidable use of long-term care; maximise independent living. It is designed to ensure that patients get the most appropriate type and quality of care at the right time and right place which contributes to the effective use of resources and capacity in the health and social care system at a local level. With support from the wider specialist service areas the Intermediate Care Team provide care to facilitate avoidable admissions or earlier discharge. The service also provides intermediate care beds within Walsall for ongoing rehabilitation, nursing support and assessment for future care needs. The community team will also provide ongoing rehabilitation within the service users own home if appropriate. Referral to the Intermediate Care Team should be made using the local Protocol for referral (11). 5.8 Continuing Health Care The assessment for, and delivery of, continuing health and social care is organised so that individuals understand the continuum of health and social care services, their rights, and receive advice and information to enable them to make informed decisions about their future care (3). Continuing care, frequently referred to as long-term care, is the provision of care over an extended period of time as the result of disability, accident or illness, to meet both physical and mental health needs. NHS Continuing health care is a package of care funded solely by the NHS. Continuing Care and Continuing Health Care can be provided in a range of settings, from an NHS Hospital, Care Home or Hospice, to a person s own home. (12). Eligibility Criteria for Continuing Health Care are specified by a National Framework (14) which incorporates the use of specific tools as part of the assessment process to determine whether the complexity and intensity of a person s needs demonstrates a primary health need. The specific tools used in the determination of eligibility are, in the first instance, a Checklist which indicates if a full assessment is required (Decision Support Tool). This assessment is by a multi disciplinary team and takes a personcentred, holistic approach using the principles of the Single Assessment Process ensuring that the views of the individual and their representatives are considered. The individual or their representative should be given a copy of the completed checklist together with the letter explaining the process. If a full assessment is completed (Decision Support Tool), the coordination of the referral is facilitated by the named practitioner who 14

15 should ensure the appropriate document is formally signed, and sent to the appropriate responsible commissioner. A copy should be retained within the clinical/service area documentation. The referral will go to the Eligibility Panel for formal consideration for NHS Continuing Health Care approval. This will inform the appropriate care planning arrangements. 5.9 Receiving a Service User Transfer from Secondary Care into Primary Care Twenty-four hours notice should be expected for routine discharges; however in special circumstances this will require negotiation between the transferring and receiving parties including the service user and carers All appropriate sections of the patient s Single Assessment Process documentation must be completed legibly, dated and signed and faxed to the appropriate community services team For areas of complex care requirement it is advisable that verbal communication between the service area discharging and the service area receiving is made. This allows for clarification of needs and a smoother transition of care If appropriate, the community nurse should visit the ward prior to discharge to discuss or observe any special requirements Where appropriate the community nurse should attend case conferences relating to service users to be discharged/transferred into their care In complex cases and for service users with multiple needs, the Discharge Liaison Team will co-ordinate discharge/transfer between secondary and primary services As part of the transfer process from Secondary Care to Primary care, it is expected that a minimum of three days medication/dressings plus a clear signed medication directive and appropriate referral documentation accompanies the service user Infection Control: The transfer of patients with a known/suspected infection

16 Transfer forms need to communicate current or relevant past infections (such as MRSA / C.difficille / ESBL) (12) Prior to transfer, the medical/nursing team in charge of the patient has the responsibility to ensure that the relevant information, regarding any infection control precautions relating to a specific patient, including any post transfer results is passed onto: A senior member of staff of the receiving ward, / care home. Community nursing services. GP. Social services. Care agencies The ambulance service must be notified as far in advance as possible and notified of any precautions necessary Following death of a patient all relevant persons must be informed of precautions to be taken e.g. GP, funeral director Known MRSA positive status is not a contra indication for transfer to a care home from a Primary Care based bed Further information can be obtained via the Infection Control Team 5.11 Transfer of Care from and To the Learning Disability Service Changes in care arrangements and environments can be a frightening and distressing experience for some adults with a learning disability if the transfer is not undertaken in a person centred way. All service users will be central to, and involved in, the planning for their transfer Transfer of service users with a learning disability can include admission into or discharge from WCH residential, Step-down / Forensic and Treatment and Assessment Units or transfer to Acute Services as well as outpatient appointments or to undertake a defined procedure, diagnostic test, consultation, therapy or treatment. It may also be relevant to transfer due to deterioration with mental health that may require an alternative secure setting. 16

17 It is important that collaboration and partnership working prevail in order to ensure that all staff involved, in both organisations, are clear regarding their accountability for the care of the service user When a service user is admitted to an Acute Service or attending a primary care appointment the Learning Disability Service will retain responsibility for advising about how the specialist learning disability care needs can be met effectively during their period of care. However the acute or primary care service will hold the overall responsibility for providing the care required The learning disability service will provide comprehensive assessment of the service user s individual needs, the development of a risk management plan to address identified risks and a clear indication of the level and nature of observation required and advising on how this might be provided In the event that the necessary written documentation has not been completed at the point of transfer of the service user, for example in the event of an urgent or emergency transfer, then a comprehensive verbal assessment will be given by a member of the learning disability team to the receiving service and copies of necessary documentation will be forwarded as soon as possible. This information must include and relevant past or current health care acquired infections. The Transfer Form within this policy (appendix 1) may be used If a service user is transferred to an acute service their bed within the learning disability in patient service will remain open. If the transfer is to another provider service the period of leave will be agreed at the discharge meeting and the bed kept open until the agreed date A member of the learning disability team, with the appropriate skills and knowledge to undertake the role, will accompany the service user during the transfer, the staff member will be known to the service user and be familiar with their care and needs If the risk assessment indicates it, more than one staff member may be required to accompany the service user (The Safe and Supportive Observation of Service Users Policy should be used to guide this process). 17

18 The person escorting will ensure they communicate any necessary information required to the receiving person and take responsibility for handing over any medication and personal belongings etc If a service user is subject to the provisions of the Mental Health Act 1983 staff will follow the Code of Practice to the Mental Health Act 1983 (revised 1999) Admission of a service user into a learning disability unit will not take place until the nurse in charge has assessed and agreed the suitability of the admission When a service user is transferring from a Learning Disability Unit the Consultant Psychiatrist is responsible for ensuring the receiving service is prepared to accept the service user and the name of the doctor accepting the transfer will be documented in the health record The service user will take an up to date health action plan with them when attending any health appointment or admission to acute services and the Acute Liaison Nurse could be contacted to assist It may be appropriate for service users to participate in familiarisation visits prior to any transfer and the use of easy read literature or DVD etc may be useful to explain the process and purpose of the transfer. 6.0 Dissemination and Implementation The policy will be disseminated via the SAB s alert system operated within the organisation and will be accessible through the local Walsall Community Health internet site. 7.0 Document Control and Archiving The policy will be reviewed bi-annually by the Governance Department or as changes are identified which require immediate action and alteration to the document. 18

19 8.0 Monitoring Compliance and Effectiveness The organisation will annually audit its practices for compliance with this policy. The audit will identify areas of operation that are covered by associated organisational policies and identify which procedures and/or guidance should comply with the policy; Follow a mechanism for adapting the policy to cover missing areas if these are critical to the safe transfer of patients, and use a subsidiary development plan if there are major changes to be made; Set and maintain standards by implementing new procedures, including obtaining feedback where the procedures do not match the desired levels of performance; and Highlight where non-conformance to the procedures is occurring and suggest a tightening of controls and adjustment to related procedures. All incidents and near misses in relation to service user transfer/discharge should be reported using the organisational process for Investigating and Analysing Incidents. The results of audits will be reviewed by the Transfer of Care group and be reported to the Provider Board. 9.0 References and Associated Documentation 1. The Community Care (Delayed Discharges etc.) Act 2003 Guidance for implementation. 2. Health and Social Care Change Agent Team /Reimbursement Implementation Team Definitions -- Medical Stability and Safe To Transfer NHS PLAN (2000) DOH 4. NSF For Older People (2001) DOH 5. Changing times: Improving services for older people Report on the work of the health and social care change agent team 2003/04 (DOH 2004) 6. Discharge from hospital: pathway, process and practice DOH (2003) 7. Reference Guide to Consent for Examination or Treatment. (2001) Department of Health. London: Department 19

20 8. The Mental Capacity Act. (2005). D.O.H. 9. NMC (2008) The Code. NMC: London 10. Health Professions Council (2008) Standards of Conduct, Performance and Ethics. HPC: London. 11. Protocol for discharge/transfer of patients requiring ongoing rehabilitation from acute services to WCH Intermediate Care & Rehabilitation services February Department of Health (2001). Continuing care: NHS and local councils responsibilities.(hsc 2001/015: LAC (2001) 18). London: Department of Health 13. Department of Health (2009). Health and Social Care Act (2008): The Code of Practice for the NHS on the prevention and control of healthcare associated infections and related guidance. Department of Health. London. 14. Department of Health (2009 (revised)). The National Framework for NHS Continuing Healthcare and NHS- funded Nursing Care 20

21 10.0 Appendix 1 Inter-healthcare patient infection risk assessment form guidance This form is designed to assess the potential risk of patient/client infection. It should be completed by the transferring facility and supplied to the receiving healthcare establishment or the patient s/client s GP. In most cases, patients/clients will not present any infection control risks; however, it is essential to confirm this by completing the form in full A confirmed risk patient/client is one who has been confirmed as being colonised or infected with organisms such as MRSA, glycopeptide-resistant enterococci, pulmonary tuberculosis and enteric infections including Clostridium difficile. Patients/clients with suspected risks include those who are awaiting laboratory tests to identify infections/organisms or who have been in recent contact with infected patients/clients, e.g. in close proximity to an infected patient/client. For patients/clients with diarrhoeal illness, please use the Bristol stool chart to indicate the frequency and type of stools over the past week. Please indicate in the confirmed or suspected risk box if the diarrhoea is known or suspected to be infectious. Definition of diarrhoea: An increased number (two or more) of watery or liquefied stools (i.e. types 6 and 7 only) within a duration of 24 hours. Complete the form for every patient/client transfer to another healthcare facility. Complete the form prior to booking ambulance or other transport. Please use the Other information box to list protective equipment being used to assist in patient/ client care. This equipment may include gloves, aprons or masks. 21

22 Inter-healthcare patient infection risk assessment form Patient/client details: (insert label if available) Name: Address: NHS number: Date of birth: Consultant: GP: Current patient/client location: Receiving facility hospital, ward, care home, district nurse Contact no: Is the ICT/ambulance service aware of transfer? /No Transferring facility hospital, ward, care home, other: Contact no: Is the ICT aware of transfer? /No Is this patient/client an infection risk? Please tick most appropriate box and give confirmed or suspected organism Confirmed risk Organism: Confirmed risk Organism: Suspected risk Organism: No known risk Patient/client exposed to others with infection e.g. D&V /No If patient/client has diarrhoeal illness, please indicate bowel history for last week: (based on Bristol stool form scale) Is the diarrhoea thought to be of an infectious nature? /No Relevant specimen results (including admission screens MRSA, glycopeptide-resistant enterococcus SPP, C. difficile, multi-resistant Acinetobacter SPP) and treatment information, including antimicrobial therapy: Specimen: Date: Result: Treatment information: Other information: Is the patient/client aware of their diagnosis/risk of infection? /No Does the patient/client require isolation? /No Should the patient/client require isolation, please phone the receiving unit in advance. Name of Staff member completing form:. Print Name: Contact Number: For further advice, please contact your infection control team/adviser 22

23 Appendix 2 Checklist for the Review and Approval of Procedural Document To be completed and attached to any procedural document that requires ratification Title of document being reviewed: /No Comments 1. Title Transfer of Care policy Is the title clear and unambiguous? It should not start with the word policy. Is it clear whether the document is a guideline, policy, protocol or standard? 2. Rationale Are reasons for development of the document stated? This should be in the purpose section. 3. Development Process Is the method described in brief? This should be in the introduction or purpose. Are people involved in the development identified? Do you feel a reasonable attempt has been made to ensure relevant expertise has been used? Is there evidence of consultation with stakeholders and users? 4. Content Is the objective of the document clear? Is the target population clear and unambiguous? Are the intended outcomes described? Are the statements clear and unambiguous? 5. Evidence Base Is the type of evidence to support the document identified explicitly? Are key references cited? Are the references cited in full? Adult Service Users within WCH References/National Guidance Are supporting documents referenced? Appendix 1 23

24 Title of document being reviewed: /No Comments 6. Approval Does the document identify which committee/group will approve it? If appropriate have the joint Human Resources/staff side committee (or equivalent) approved the document? 7. Dissemination and Implementation Is there an outline/plan to identify how this will be done? Does the plan include the necessary training/support to ensure compliance? 8. Document Control Does the document identify where it will be held? Have archiving arrangements for superseded documents been addressed? N/A WCH Professional Forum Supporting Processes and Groups 9. Process to Monitor Compliance and Effectiveness Are there measurable standards or KPIs to support the monitoring of compliance with and effectiveness of the document? Is there a plan to review or audit compliance with the document? 10. Review Date Is the review date identified? Is the frequency of review identified? If so is it acceptable? As required 11. Overall Responsibility for the Document Is it clear who will be responsible for coordinating the dissemination, implementation and review of the documentation? Lead Director If you are assured that the correct procedure has been followed for the consultation of this policy, sign and date it and forward to the chair of the committee for ratification. Name Christine Kelly Date 9/2/10 Signature Chris Kelly Ratification Committee Professional Forum 24

25 Ratification Committee Approval If the committee is in agreement to ratify this document, can the Chair sign and date it and forward to the \Head of Assurance Name Date Signature 25

26 Flow Chart for Approval of Procedural Documents Appendix 3 Procedural Document Process Complete the Procedural Document Registration Form Send Registration Form to the Head of Assurance See Procedural Document Policy Consultation Process Approval See Procedural Document Policy Ratification Dissemination to Staff and PDF Version on Intranet Implementation Monitoring Review 26

27 Appendix 4 Procedural Document Registration Form To be completed by Lead Director Document Title: Transfer of Care Policy Name Title Extension No. Lead Director or Manager David Shakespeare Head of Professional Practice Lead Author Chris Kelly Professional Development Unit Manger Committees/Groups /individuals for consultation Consultation list as page 3 of the policy plus Professional Forum members. Ratification committee/group WCH Professional Forum To be completed by lead author Does the document supersede another document? No Title and registration number of superseded document: Outline of the document: include the purpose/aim of the document This policy aims to provide guidance and principles for all Health Care Practitioners, service users and carers to ensure appropriate and safe transfer in the event of referral to and/or the admission to onward statutory, voluntary, primary, intermediate or secondary care services. The aim is to provide an integrated approach across all disciplines involved in the care of the service user. Evidence of best practice/standards (include National Guidelines, e.g. NICE or new legislation) Reference Title 1. The Community Care (Delayed Discharges etc.) Act 2003 Guidance for implementation. 2. Health and Social Care Change Agent Team /Reimbursement Implementation Team Definitions - Medical Stability and Safe To Transfer NHS PLAN (2000) DOH 4. NSF For Older People (2001) DOH 5. Changing times: Improving services for older people 27

28 Report on the work of the health and social care change agent team 2003/04 (DOH 2004) 6. Discharge from hospital: pathway, process and practice DOH (2003) 7. Reference Guide to Consent for Examination or Treatment. (2001) Department of Health. London: Department 8. The Mental Capacity Act. (2005). D.O.H. 9. NMC (2008) The Code. NMC: London 10. Health Professions Council (2008) Standards of Conduct, Performance and Ethics. HPC: London. 11. Protocol for discharge/transfer of patients requiring ongoing rehabilitation from acute services to WCH Intermediate Care & Rehabilitation services February Department of Health (2001). Continuing care: NHS and local councils responsibilities. (HSC 2001/015: LAC (2001) 18). London: Department of Health 13. Department of Health (2009). Health and Social Care Act (2008): The Code of Practice for the NHS on the prevention and control of healthcare associated infections and related guidance. Department of Health. London. 14. Department of Health (2009 (revised)). The National Framework for NHS Continuing Healthcare and NHSfunded Nursing Care Resource implications for implementation Please indicate the methods that will be used to implement the procedural document i.e. training, indicating that required resources have identified funding. SAB S Alerts and WCH Internet access. Procedural Document Review It is the responsibility of the ratification group to agree the review period. The lead Director and the lead author are responsible for ensuring that the procedural document is reviewed and updated in line with emerging research evidence and local requirements when necessary and at least every three years. Review period Ratification group has agreed: 2 years Lead Director Signature: Date: Lead Author Signature: Chris Kelly Date: 9/2/10 Head of Assurance Signature: Date: Procedural Document Number and section i.e. HR

29 Equality Impact Assessment Tool Appendix 5 To be completed and attached to any procedural document when submitted to the appropriate committee for consideration and approval. Title of the policy/guidance: 1 Does the policy/guidance affect one group less or more favourably than another on the basis of: /No Comments Race No Ethnic origins (including gypsies and No travellers) Nationality No Gender No Culture No Religion or belief No Sexual orientation including lesbian, No gay and bisexual people Age YES Application of Policy for Adult Service Users Only Disability - learning disabilities, No physical disability, sensory impairment and mental health problems 2 Is there any evidence that some No groups are affected differently? 3 If you have identified potential discrimination, are any exceptions valid, legal and/or justifiable? 4 Is the impact of the No policy/guidance likely to be negative? (If no, please go to question 5.) If so can the impact be avoided? What alternatives are there to achieving the policy/guidance without the impact? Can we reduce the impact by taking different action? 29

30 5 Health inequalities 6 Please consider the following questions relating to Human Rights Act: Will it affect a person s right to life? Will someone be deprived of their liberty or have their security threatened? Could this result in a person being treated in a degrading or inhuman manner? Is there a possibility that a person will be prevented from exercising their beliefs? Will anyone s private and family life be interfered with? No No No No No If you have identified a potential discriminatory impact of this procedural document, please complete Impact Assessment Action Plan identifying the action required to avoid/reduce this impact. For advice in respect of answering the above questions, please contact the Equality and Diversity Manager.. Is further detailed impact assessment required? /No If yes, please detail how this is to be processed and by whom Details (names and roles) of staff involved in this impact assessment Name Role Date completed Outcome Chris Kelly PDU Manager 9/2/10 Complete 30

31 Impact Assessment Action Plan Appendix 6 Issue Proposed Action Rationale Person Responsible By When 31

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