Standard Operating Procedure Safe To Wait in Urgent Care Services

Transcription

1 Standard Operating Procedure Safe To Wait in Urgent Care Services Reference No: G_CS_91 Version 2 Ratified by: LCHS Trust Board Date ratified: 5 th April 2018 Name of originator / author: Teresa McNally Name of responsible committee / Individual Effective Practice Assurance Group Date issued: Review date: Target audience: All Staff Distributed via Website Chair: Elaine Baylis, QPM Chief Executive: Andrew Morgan

2 Standard Operating Procedure Safe To Wait in Urgent Care Services Version Control Sheet Version Section / Para / Appendix Version / Description of Amendments Date Author / Amended by 1 New Policy 31/08/2017 Laura Dilley 2 Title / SOP Revision 5/4/18 Teresa McNally 3 Approved at May 2018 EPAG Copyright 2018 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. Chair: Elaine Baylis, QPM Chief Executive: Andrew Morgan

3 Standard Operating Procedure Safe To Wait Urgent Care Services Contents Version Control Sheet Page 2 Introduction Page 4 Safe To Wait Page 5 Triage Page 8 Triage Categories and Definitions Page 9 Documentation Page 9 Training Page 10 Audit Page 10 Key aims Page 10 Flowchart Page 12 References Page 13 Appendix One General Discriminators Page 14 Appendix Two Patient Advice Poster Page 15 3

4 Introduction Face to face Urgent Care is provided by Lincolnshire Community Health Services as follows: Spalding MIU Gainsboroug MIU Peterborough MIIU Louth UCC Skegnes UCC Boston OOHs and Streaming Lincoln OOHs and Streaming Grantham OOHs Stamford OOHs These services see a mixture of walk in patients, and patients who have booked appointments via 111 / CAS The scope of Urgent Care Services, is broadly to see patients with minor illness and injury. Patients who have accessed the service via 111, have already been through a level of assessment intended to identify emergency patients, and to direct these patients to the most appropriate service. However, their condition may be more severe than assessed, or have deteriorated in the interim. Patients who self present may not realise the seriousness of their condition, or the most appropriate service to access, and there is concern among staff in Urgent Care around patient expectation of the level of service that is available. Consequently, patients with a range of acuity will attend Urgent Care services and it is important that any potentially time-critical, acutely unwell patients are rapidly identifed, treated promptly, and transferred to emergency care services if needed. Each of the services will operate a consistent process to ensure that acutely unwell patients are identified at the earliest possible point on arrival at the service: Safe to wait begins at reception All walk in patients are assessed within 15 minutes There is a consistent triage process where this is appropriate 4

5 This SOP should be implemented in conjunction with : P_CS_16 Physiological Observations G_CS_76 Guideline for Paediatric Observation Priority Score P_CS_49 Sepsis Screening Policy 1. Safe to Wait Spalding MIU Gainsboroug MIU Boston OOHs and Streaming Lincoln OOHs and Streaming Grantham OOHs Stamford OOHs How do we know that patients are safe while waiting in these services?: 1. Reception staff use Safe to Wait Guidance 2. Patients who are unwell are rapidly flagged to a Health Care Professional (HCP) for assessment 3. Waiting times are generally short 4. Patients with booked appointments have had a level of assessment prior to being booked in to the service 5. Patients are given advice on what to do should they feel more unwell while waiting 6. HCSWs in Streaming and OOHs are trained to undertake base line observations NEWS and POPS The Safe To Wait Guidance will ensure that reception staff are aware of Red Flag Signs and symptoms that indicate that someone presenting at the unit may require immediate or urgent attention. When documenting in the record, reception staff should document SAFE TO WAIT NEEDED adjacent to the usual information about the complaint. For example Head Injury SAFE TO WAIT NEEDED. The HCP will then easily be able to identify these patients and prioritise them. If the patient is presenting with a condition that needs assessing immediately, then the Receptionist should inform a HCP by directly speaking to them 5

6 (NOT via the instant messaging system as there is no way to know that they have seen the message). It is the clinician s responsibility to make a clinical assessment of the patient and decide on the appropriate action / urgency. It must be remembered that reception staff are not usually clinicians, and therefore it is safer to ask for a patient to be prioritised and deemed to be safe to wait, rather than remain unassessed in the waiting room and become very unwell. Safe to Wait Guidance IN ANY OF THE CASES BELOW OR IF IN ANY DOUBT: INFORM THE CLINICIAN IN PERSON (INTERUPT CONSULTATION IF NECESSARY) DOCUMENT SAFE TO WAIT NEEDED IN RECORD Patient s Condition Identifiable Signs Acute/Major Burns Deep or large burns/scalds Any burns to special areas (Face, Neck, Groin/Genitals) Difficulty breathing or swallowing Anaphylaxis (allergic Sense of impending doom reaction) Swelling of throat, mouth or face Difficulty in swallowing or speaking Reported fast heart rate Severe asthma Abdominal pain, nausea and vomiting Sudden feeling of weakness Collapse and unconsciousness Major Limb Injury Any apparent limb deformity Severe Pain Major bleeding Any apparent amputation Altered Consciousness Any level of altered consciousness Asthma/Breathing Unable to talk in full sentences Difficulties Chest pain or palpitations Agitation 6

7 Confusion Noisy breathing Cyanosis (blue lips or fingers, etc) Chest Pain Looks unwell Shortness of breath Pale/clammy Nausea/vomiting Facial Wounds Gross facial swelling Bleeding from the ear/nose/mouth Visible deformity Patient struggling to talk due to injuries Generally Unwell Adult or Pale/Clammy Child Feeling of impending doom Feeling faint Severe pain Persitent vomiting Unable to pass urine (urine retention) Distressed/inconsolable child Major Bleeding/Wounds Deep or large wounds Major bleeding Loss of function or sensation to limb/hand/foot Large foreign body in wound (nail, large piece of glass, etc) Major Head Injury Any level of altered consciousness Persistent vomiting Confusion Unable to walk (new onset) Overdose/Poisoning Any overdose or poisoning Pregnancy Problems Severe pain Heavy bleeding Sick/Distressed Child Cyanosis (blue lips or extremities) Not responding normally to parents/carers Parents/carers report child is very hot Any breathing difficulty or noisy breathing Report of non-blanching rash 7

8 Neck stiffness Distressed/inconsolable child Severe pain If there is any doubt or concern about a patient, even if not covered in the above table, always consult a HCP. NB: ALL patients presenting should be booked in to the service and assessed by a HCP. Under no circumstances should a patient be directed elsewhere, without booking in, assessment, and documentation of the advice given. Patients waiting to be seen in OOHs / Streaming services where there is a HCSW should have a full set of observations and NEWS or POPS score recorded while waiting to see the HCP. Any abnormal scores should be referred to the HCP There is signage and information should be given to patients arriving at these services, advising what to do should they feel they are becoming more unwell whilst waiting. See Appendix Two 2. Triage Peterborough MIIU Louth UCC Skegnes UCC How do we know the patients are safe while waiting in these services?: 1. Reception staff use Safe to Wait Guidance 2. All patients have a full assessment / recording of observations (if appropriate) within 15 minutes 3. Patients are assigned a triage catergory using the Manchester Triage guidance Observations should be recorded, in line with the Physiological obs policy, and a NEWS or POPS recorded for ALL patients presenting with an illness. 8

9 Observations for patients with minor injury is at the descretion of the HCP Observations may be undertaken and recorded by HCSWs who have had appropriate training Triage decisions should only be made by HCPs who have been trained in Manchester Triage and the decision making process Triage Categories and Definitions Number Name Colour Maximum time to full assessment by Practitioner or Doctor (mins) 1 Immediate Red 0 2 Very Urgent Orange 10 3 Urgent Yellow 30 4 Standard Green Non-urgent Blue 240 The Urgent category s maximum time to assessment has been adapted from 60 minutes (as suggested in Emergency triage) to 30 minutes, as in an Urgent Care setting these patients should be assessed and referred if needed within a short time frame. Patients assessed as Immediate or Very Urgent will generally need a 999 emergency ambulance requesting immediately and should not wait to have the full assessment carried out, as they will need rapid transfer to secondary care. Documentation To document the triage category in SystmOne, right click on the patient attendance, go to triage and assign triage category. A box will then appear to document the triage category, the time it was carried out (it defaults to the current time but can be amended), and who they were triaged by. Confirm by clicking ok. This will then document the triage colour/category on the main attendance screen. 9

10 Triage Clinicians must document which flowchart has been used, which discriminator defines the category, and which category has been selected Any allergies should also be documented. If any medication is given at triage, then this must be documented. Pain, then it should be assessed using pain scores (ideally from 0 10). The patient should be asked if they have already taken any analgesia before attending the department (over the counter or prescribed), the time of the last dose, how many doses in the past 24 hours, and its effect if any. Appropriate pain relief should be offered to the patient either prescribed or using PGD as per the LCHS Medicines Management Policy. Training All clinicians undertaking triage should have a clear understanding of the triage process, which clinical observations to perform, and when to escalate patients. Clinicians must have evidence of training / assessment of competency to conduct triage. Audit The most effective audit continuously assesses clinicians for accuracy and is linked by reflective practice and, if necessary, additional training to improve performance. The method outlined below is suggested by the Manchester Triage Group and is designed to audit the quality of decision making against the Manchester Triage System standard, along with standards of escalation and documentation. Key aims: All triage clinicians are identified All episodes of triage are identified 2% of episodes per practitioner (minimum of 10 episodes) are randomly selected Episodes are assessed by a senior clinician, experienced in triage Completeness of episodes is expressed as a simple proportion Accuracy of episodes is expressed as a simple proportion 10

11 Number of incomplete episodes is fed back to the clinician Overall accuracy is fed back to the clinician Any causes of inaccurate triage are fed back to the practitioner 10% of episodes assessed are performed independently by a second senior clinician and any differences moderated by discussion Monthly audits should be performed on the introduction of triage to an area, but this frequency can be reduced to 3-6 monthly once a consistent high standard is demonstrated. Criteria Yes No Comments Correct use of presentational flow chart Specific discriminators correctly selected (record as seen on triage record) Pain score recorded Correct triage category assigned (based on patient presentation and discriminators) Demonstrated ability to navigate the computerised triage system Triage record documented accurately and correctly Re-triaged where necessary Completeness: An episode is complete if all the steps necessary to reach the conclusion have been undertaken. The method requires that the clinician excludes all the discriminators in any higher priority. Thus if SpO 2 appears as a discriminator in the chart selected, then the episode would be incomplete if no result was recorded. The most common error is to fail to record a pain score. Accuracy: An episode is recorded as accurate if both the presentation and discriminator selected are appropriate. It is important to realise that there may be appropriate alternatives; thus audit should be carried out by a clinician with sufficient experience to make this judgement 11

12 Flowchart: Select 2% (min 10 records) A Total Presentation No B Inaccurate appropriate? Yes C Incomplete No Sufficient information? Yes Discriminator No appropriate? Yes D Accurate Check that A = B+C+D % incomplete = C/A x 100 % accuracy = D/A x 100 Targets: 0% episode incomplete 95% accuracy 95% agreement between assessors 12

13 If these targets are not met, then feedback must be given to the clinician, and the audit should be repeated monthly. References Emergency Triage: Manchester Triage Group (2013) NICE Cliniical Knowledge Summary Mild to Moderate Pain (2015) 13

14 (Appendix One) Table of General Discriminators Discriminator Category Maximum time to full assessment by Practitioner or Doctor (mins) Airway compromise Inadequate breathing Exsanguinating haemorrhage Shock Unresponsive child Currently fitting Uncontrollable major haemorrhage New abnormal pulse Altered conscious level Very hot Hot baby Cold Severe pain Uncontrollable minor haemorrhage History of unconsciousness Warm newborn Hot Moderate pain Warm Recent mild pain Recent problem Immediate 0 Very Urgent 10 Urgent 30 Standard 120 None of the above Non-urgent

15 Appendix Two Do you think your condition is worsening while you are waiting to be seen? What to do: Report back to the reception desk immediately 15