Consulted With: Post/Committee/Group: Date:

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1 AMBULANCE HANDOVER PROTOCOL WHEN OFF LOAD TIME IS LIKELY TO EXCEED 30 MINUTES Policy Register No: Status: Public Developed in response to: NHSE Directives CQC Fundamental Standards: Safe and Responsive Consulted With: Post/Committee/Group: Date: Paula Woods Matron ED 21/02/2018 Suzanne Hoare Matron ED 21/02/2018 Rebecca Summerskill Matron Emergency Care 21/02/2018 Helen Ali Senior Site Manager 21/02/2018 Edward Hockaday Service manager, Emergency Care 21/02/2018 Tim Lightfoot Divisional Director, Medicine /Emergency 21/02/2018 Stephen Hughes Consultant Emergency Medicine 21/02/2018 Alexander Hieatt Consultant Emergency Medicine 21/02/2018 Brian Kennedy Consultant Emergency Medicine 21/02/2018 Ajay Thomas Consultant Emergency Medicine 21/02/2018 Pallav Bhatnagar Consultant Emergency Medicine 21/02/2018 Pawan Gupta Consultant Emergency Medicine 21/02/2018 Neil Campbell Consultant Acute Medicine 21/02/2018 Lyn Hinton Director of Nursing 21/02/2018 Ellie Makings Site Medical Director 21/02/2018 Jo Myers ADoN Surgery 21/02/2018 Ali Cutherbetson Head of Women and Children Services 21/02/2018 Hillary Bowring ADoN Medicine 21/02/2018 Professionally Approved By: Peter Fry Chief Operating Officer 25/02/2018 Version Number 1.0 Issuing Directorate Medicine and Emergency Care Ratified by: DRAG Chairman s Action Ratified on: 27 th June 2018 Trust Executive Board Date July 2018 Implementation Date 27 th June 2018 Next Review Date subject to Employment Law May 2021 Author/Contact for Information Ahmad Aziz, Clinical Director Emergency Care Angela Wade ADoN Emergency Care Policy to be followed by (target staff) Physicians, Nursing, Operational Staff, Emergency Department Staff, all other MEHT staff as appropriate. Distribution Method Internet & Website Related Trust Policies (to be read in conjunction with) Full capacity policy and Trust Escelatin EEAST Delayed Handover Policy Document Review History: Review No: Reviewed by: Issue Date: 1.0 Ahmad Aziz & Angela Wade 27 th June 2018 Page 1 of 8

2 Index 1. Purpose 2. Scope 3. Aims 4. Staffing and Training 5. Estates, Facilities and Equipment 6. Operational Procedure 7. Work-streams 8. Evaluations and Monitoring 9. Documentation 10. Communications and Implementation 11. Appendices Appendix A - Equality Impact Assessment (EIA) Appendix B - Risk Management Page 2 of 8

3 1.0 Purpose 1.1 The purpose of this document is to produce a standard operating procedure for safe management of patients who attend by ambulance and require offload to the ED, when ambulance handover exceeds 30 minutes 1.2 To identify the appropriate location and staffing for extra capacity when required. 1.3 To ensure efficient and effective ambulance handover process 2.0 Scope 2.1 This SOP applies to the process whereby patients care is taken over from the EEAST services to MEHT and enabling the release of the crew as per NHSE directives 3.0 Aims 3.1 To perform an initial assessment of all ambulance arrivals to ED and the Acute Medical Unit (AMU) within 15 minutes this does not constitute a full patient triage. 3.2 To stream to the appropriate areas of the Emergency Village. 3.3 To release the ambulance crews within 30 minutes 3.4 To identify an area (s) that ensures safety and privacy 3.5 To initiate an urgent trust wide response to regain Emergency Village flow 4.0 Staffing and Training 4.1 Any additionally created capacity will require staffing above the current establishment. This would be in the form of; One registered Nurse 24/7 Two Healthcare Assistants (HCA) 24/7 and 08:00 20:00 ED trained receptionist (08:00-20:00) ED Trained Receptionist (08:00 midnight) ANP (08:00-20:00) 4.2 If AMU waiting room is required for offload, staff will be sourced from the discharge lounge 4.3 Staffing will be expressed in terms of Whole Time Equivalents (WTE s) and where the staff members have be recruited from e.g. Permanent, Bank or Agency 4.4 Extra staffing will be required during the first week of implementation to support the new process and ensure patient care and safety is maintained Page 3 of 8

4 5.0 Estates, Facilities and Equipment 5.1 The following areas have been identified for offloading patients in the following priorities; All available capacity in the Major area of the department including; Ambulance bay ( up to 4 patients on trolleys) ESAT ( up to 6 patients) Resus ( up to 3 patients) ACU (up to 6 trolleys) between the hours 20:00 07:00 Plaster room ( 1 Trolley) Minors Cubicles (up to four trolleys) up to maximum 60 minutes. The second ACU waiting room can be utilized to offload GP heralded patients 5.2 To enable offloading patients to the Minors area the GP in ED service needs to be relocated to the purpose build area (primary care GP unit A102) 5.3 The following equipment may be required for each patient; Monitor if required Oxygen cylinder Suction Trolley Handheld call bell 6.0 Operational Procedure 6.1 ED team will log arrival time to the department when the patient arrives in the ambulance bay with ambulance CAD number 6.2 The team will take a handover from the ambulance crew and document the handover time as well as the ambulance observations on the ED clinical notes. 6.3 The ambulance crew will liaise with the identified ambulance receptionist who will then book the patient into Lorenzo from the ambulance handover sheet. 6.4 The patient is transferred from an ambulance stretcher onto a hospital trolley and PIN number given to clear 6.5 Patients will be streamed to the above identified areas depending on the initial assessment and clinical priority. 6.6 Patients will be streamed to the identified areas in the priority described in Patient streamed to the Minors area should be priority three or four ( NEWS 4) Page 4 of 8

5 7.0 Escalation 7.1 NIC and EPIC will continuously monitor departmental capacity and acuity to identify patients who can be re- allocated to the appropriate area of the department to maintain flow through the department and available capacity for incoming ambulances. 7.2 ESDAR will support the department to facilitate early assessment and discharge at the front door 7.2 The trust full capacity protocol will be triggered (via the COM) when there are two patients in the ambulance bay who can t be streamed to Majors area of the department. This is to prevent the utilization of the Minors offload area and initiate a trust wide response. Specific requirement is for all DTAs in Majors and five patients from AMU transferred to the inpatient areas. This process should be completed in 45 minutes to regain flow within the Emergency Village to achieve 15 minutes handover and release of the ambulance crews in less than 30 minutes. 7.3 Patients can only be offloaded to the Minor cubicle if the trust full capacity protocol has been triggered. Offloaded to the Minor area will trigger the initiation of trust full capacity policy. 7.4 The following members of staff must be contacted when the trust full capacity protocol is initiated; ED Matron ADoN, Emergency Care Clinical Director, Emergency Care Service Manager, Emergency Care ADO, Emergency Care COO in hours (exc. on call out of hours) 8.0 Evaluations and Monitoring 8.1 This process will be monitored using the following processes: All handover episodes are to be completed within 15 minutes. Achievement of the 30 minutes ambulance clear through Lorenzo and EOE pin number The Emergency Department Clinical Quality Indicators (CQI s); When this process is triggered an incident should logged on the DATIX system Monthly RAF review 9.0 Communications and Implementation 9.1 This policy will be implemented following receiving communication form NHSE confirming implementation date 9.1 Following ratification, the policy will be published on the intranet and via broadcast staff where appropriate. 9.3 It is the responsibility of the author to ensure that all staff that are directly affected by it are made aware via direct s or face-to-face meetings. Page 5 of 8

6 11.0 References Effective Approaches in Urgent and Emergency Care paper 2 Rapid Assessment and Treatment Models in Emergency Departments, Emergency Care Intensive Support Team, June 2012 Leeds EM EM in Yorkshire: Rapid Assessment and Treatment process RAT in the ED ; December Page 6 of 8

7 Appendix (a) Equality Impact Assessment (EIA) Title of document being impact-assessed: Equality or human rights concern. (see guidance notes below) Gender Race and ethnicity Disability Religion, faith and belief Sexual orientation Age Transgender people Social class Carers. Does this item have any differential impact on the equality groups listed? Brief description of impact. No, we apply the SOP equitably to all gender groups of patients working in a patient centered way to meet their needs. This SOP is patient specific and provides a framework for individual working recognising race and ethnicity in the approach. The SOP aims to work positively and proactively with people who have a disability. People s faith, beliefs and religion are taken into account as part of the process of Assessment process in the ED. There is no impact on sexual orientation as part of discharge planning as any relevant requirements or needs are taken into account. We work with all patients irrespective of age to support Assessment and Treatment of Patients in the most appropriate setting. There is no barrier to transgender individuals by the use of this policy. Issues such as travel, communications etc are taken into account through the patient centered approach we use in the Assessment and Treatment of patients. Carers views are taken into account through this process and will follow/refer to the Carers Policy as appropriate. How is this impact being addressed? Date of assessment: February 2018 Names of Assessor(s): Ahmad Aziz Page 7 of 8

8 8 Appendix (b) Risk Management The following issues should be considered and appropriate escalation processes followed: Environment Inadequate Staffing Numbers and Skills Mix Demand Exceeds Capacity Lack of Cubicle Spaces Minors Cubicles ACU area overnight Details Each team should not work more than four hours ESAT shift The process can only take pace when the staffing requirements (as described in section 4) are available Too many ambulances arriving at the same time. There is a possibility that due to high demand etc, cubicle space is not available to allow ESAT process. There is a possibility speciality teams will not be able to respond to a request from ED due to clinical priorities within their clinical areas. Actions Staff should be rotated to ensure that they do not exceed a four hour ESAT Shift. There should be a discussion between the consultant and the nurse in charge regarding re-assigning staff to explore the feasibility of starting the process. Any ambulance awaiting 15 minutes or more should be fasttracked to a cubicle in Majors and assessed by either the ESAT team at a later stage or by a clinician assigned to the Major area. The shift co-ordinator should be aware of the ambulances waiting and direct patients to free cubicles when the wait to offload is in excess of 15 minutes. This should be escalated to the charge nurse or co-ordinator to assist with the flow of patients out of the ESAT rooms. As a last resort the patient can be transferred back to the ambulance bay and monitored by the staff assigned to that area. This should be addressed through the Trust escalation policy underpinned by the agreed Internal Professional Standards. ACU waiting room