Standard Operating Procedure Discharge/Transfer of Patients from St John s Hospice In-Patient Unit

Transcription

1 Standard Operating Procedure Discharge/Transfer of Patients from St John s Hospice In-Patient Unit DOCUMENT CONTROL: Version: 1.1 Ratified by: Quality Assurance Sub Committee Date ratified: 2 February 2018 Name of originator/author: Macmillan Palliative Care Nurse Consultant Name of responsible Clinical Policy Review Group committee/individual: Date issued: 14 March 2018 Review date: July 2018 Target Audience All Medical, Allied Healthcare Professionals and Nursing Practitioners working with St John s Hospice who are involved in referring, admitting and discharging patients

2 1. Aim This Standard Operating Procedure (SOP) is to provide additional guidance to the Trusts Policy for the Discharge/Transfer of patients from In Patient Services whose aim is to provide core guidance which is applicable to all services. This SOP represents best practice in relation to the safe and appropriate transfer and discharge of patients from St John s Hospice In-Patient Unit:- To ensure a safe, timely and effective discharge/transfer from the hospital or internal transfer for all patients To ensure the patient is always treated as an individual with due regard shown to their personal choice, cultural characteristics and dignity To take into consideration any Advance Plan, Preferred Place of Care wish (see Policy for Advance Directives and Advance Decisions) 2. Scope It is the responsibility of each individual member of staff involved in the discharge and transfer of a patient to: Complete Trust approved training relevant to their role Adhere to the Policy for the Discharge/Transfer of Patients from In-Patient Services Report any discharge and transfer related clinical incidents via the Trust incident reporting system 3. Link to overarching policy and/or procedure This SOP is to be used in conjunction with the Policy for the Discharge/Transfer of Patients from In-Patient Services. 4. Procedure Preparation to enable safe and effective discharge which will support continuity of care and wellbeing. 4.1 Multi-disciplinary team are responsible for:- Deciding and communicating when a patient is medically fit for discharge and documenting the decision clearly within the medical notes and on the TPP system. Deciding the appropriateness of transferring patients to other areas as either being part of the patients pathway or within their best interests Discussing this date of discharge/transfer with the ward co-ordinator prior to discussing with the patient Take into consideration of any Advance Plan, Preferred Place of Care (see Policy for Advance Directives and Advance Decision) Page 2 of 6

3 4.2 Medical Staff are responsible for:- Assess and prescribe any medication the patient requires for discharge/transfer (see Policy for Safe and Secure Handling of Medicines, SOP for Controlled Drugs, SOP for Administration of a Controlled Drug in a Community Setting, SOP for Safe and Secure Handling of medicines in a Community Setting) Pre-emptive prescribing for discharge providing a seven day supply Provide the patient with the date for any required follow up appointment for attendance to Consultant s Out Patient Clinics within St John s Hospice prior to leaving the ward Document all the above in the patients electronic record on SystmOne Produce a medicines administration letter which will include explicit advice to the patients GP/receiving medical team about appropriate prescribing of medication and a copy being faxed to the patient s GP, Community Intervention Crisis Team, Out Of Hours GP service, District Nursing Team, and any other significant care provider A more detailed discharge letter to be input onto TPP to allow access to the wider community teams. A copy should be sent to the GP within ten working days of the patient s discharge or transfer. Where a patient is being discharged/transferred to any other service as well as the GP letter, a transfer letter should also be completed by the medical team During an episode of in-patient care the need may arise to transfer a patient to another care setting either within or outside the Trust. There is a need for good communication between the Trust and the receiving hospital/unit, with photocopies of the relevant records being provided and a formal documented handover of care between the Trust and receiving service A detailed record is to be made in the patients transfer letter of:- All information provided to the receiving service The date on which is was provided Who provided it Any additional information requested prior to the transfer Discussion with the patient and carers about the planned transfer Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) information Rational for transfer 4.3 Ward Co-ordinators/Named Nurses are responsible for:- On admission the admitting nurse must assess and identify any special requirements that may need to be considered to facilitate the patients discharge. Discharge documentation must be commenced on or as soon as possible after admission and all communication and action taken concerning discharge clearly documented. Work Page 3 of 6

4 alongside the Policy for the discharge/transfer of patients from in-patient services section as standard requirements for all patients being discharged Once a discharge date has been set to co-ordinate the discharge process, taking into account patient needs and wishes which may be included in Advance Plan or Preferred Place of Care (see Policy for Advance Directives and Advance Decisions) Record and manage appropriately any delays in discharge/transfers of care as per appendix 1. Allow opportunities for the different staff groups to discuss and agree the discharge care plan via various arenas such as case conferences, best interest meeting and internal and external multi-disciplinary team meeting agendas Obtain clarity from patient/family and/or medical team on mode of discharge transport and document clearly in patient s notes Make appropriate arrangements for the provision of any support services required in the community checking with the patient/family carer that they know how to access these services in the event of an emergency If the patient has a NOMAD ensure that an FP10 form is completed 48 hours prior to discharge and given to the family. Cross reference prescribed discharge medication against medication delivered and produce Take Home Medication chart. Liaise with pharmacy/prescribing medic for discrepancies. Complete IR1 if deemed appropriate. Order take home medications 24 hours prior to discharge. Provide the patient/family/carer with a Take Home Medication both verbally and written information and advice to support compliance with the guidelines on how to take the medication, on the medication itself and any side effects in order to support informed decision making. Obtained signed discharge medication consent form for patient records Produce a discharge communication sheet for all appropriate services required to be involved in patient care when discharged also completion of the Trust healthcare Associated Infections Risk Assessment form. Document all of the above clearly in the patient records on SystmOne On transfer of patients to another care setting either within or outside the Trust, coordinate transfer: Organise transport Ensure that written and verbal handover is given to the receiving organisation. Ensure that the relevant paperwork is collated and prepared for the transfer. Page 4 of 6

5 DNACPR information Ensure that the patient and family/carers are aware of the transfer and the rationale. 5. DNACPR DNACPR Status it is the responsibility of the discharging clinician to ensure that the patients GP is informed of a DNACPR order via the discharge letter, and that all agencies involved in the patients care in the community are informed of the order. The DNACPR order must be reviewed before discharge. It may not be possible to review the DNACPR for out of hours transfers, at this point the review will be done by the accepting service. The original DNACPR order should be given to the patient/carer. Staff should ensure that the patient/carer is aware of and fully understands the order. 6. Training implications All staff who in the course of their work undertake duties in relation to the discharge/transfer of patients and in relation to this SOP, all staff to attend the following training:- Medication management Controlled Drugs (CD) reconciliation training Record Keeping 7. Links to Any Associated Documents Policy for Safe and Secure Handling of Medicines SOP for Controlled Drugs SOP for Administration of a Controlled Drug in a Community Setting SOP for Safe and Secure Handling of Medicines in a Community Setting Lifecycle of Clinical and Corporate Records Policy Clinical Risk Assessment and Management Policy Risk Management Strategy Policy for Copying Letters to Service Users Incident Reporting Policy Policy for Advance Directives and Advance Decisions Adults Do Not Attempt Cardio Pulmonary Resuscitation (DNACPR) policy Page 5 of 6

6 Appendix 1 Delayed Discharges Patient is determined Fit for Discharge Document in Ward Diary, patient notes and on TPP. Communicate to nursing team and patient s family / care Responsibility: Multi professional team Delayed Discharge Complete DTOC form accordingly including the reason for delay. Responsibility: Nurse in charge Complete IR1 form & Inform Modern Matron Record details of delayed discharge. Responsibility: Multi professional Team Review Patients Fit for Discharge status to be reviewed at each subsequent ward round / MDT meeting, identified delays and any changes to status to be completed accordingly. Responsibility: Multi professional team Weekly DTOC Form Delayed discharge information to be transferred onto weekly monitoring form. This should be completed at the end of each week to reflect activity during the week ending. Completed forms should be sent electronically to Performance and Information Officer by each Tuesday. Responsibility: Ward Sister Information Reviewed and validated in conjunction with Ward Manager / Modern Matron. Responsibility: Performance & Information Officer DTOC activity shared with commissioners via weekly communication. Page 6 of 6 Responsibility: Performance and Information Officer