Booking Elective Trauma Surgery for Inpatients

Transcription

1 ADT31 Version 3.1 Trauma Team Operational Areas Included Trauma Co-ordinator Roles Responsible for Carrying out this Process All other areas Operational Areas Excluded GEN01 Logging into Lorenzo GEN02 Searching for a Patient GEN33 Registering a Patient Associated Procedures ADM02 Adding a Patient to the Inpatient or Day Case Waiting list (Non Partial booking process) ADM04 Scheduling an Inpatient or Day Case for surgery NON PARTIAL ADM11 Rescheduling an Inpatient or Day Case appointment

2 Contents... 1 description Scheduling an Elective Trauma Patient Appendix 1: Deleting a Procedure Added in Error Appendix 2: Rescheduling a TCI Date Page 2 of

3 Process Flow Patient requires elective trauma surgery Patient placed on access plan Inpatient bed booked Patient arrives on ward Patient does not arrive on ward Bed booking cancelled Page 3 of

4 description. If a patient has been seen in A&E or fracture clinic, there may be occasions when they require trauma surgery to improve their condition. This standard operating procedure describes the process for booking that surgery and ensuring that the patient is placed on the elective trauma list. This process is only for patients that go home following the decision by the clinician that they need surgery. Any patient that is an emergency trauma admission and need surgery is not an elective patient and will not follow this process. If a clinician in the Emergency department or Fracture clinic decides that trauma surgery is required for one of their patients, they should inform a receptionist who will contact the trauma coordinator by bleep. The following details should be provided: Patient name Date of birth Hospital number (if known) Condition Type of surgery required Clinician preferences Provisional date of surgery Once the trauma coordinator has been informed, if the patient is to go home and return at a later date, they will place the patient on the trauma list and book a date for the patient to come in. Page 4 of

5 Adding a Patient to the Elective Trauma List 1. Log into Lorenzo using your smart card. See GEN01 Logging in to Lorenzo if you require further guidance. Once opened, Lorenzo defaults to the My work application tab. 2. From the My work menu on the left hand side select Access planning. 3. The Access Planning task pane is displayed 4. Select Create access plan from the Access Planning menu on the left hand side. Page 5 of

6 5. Patient search screen is displayed, the Search criteria defaults to the Advanced search tab. 6. In the Search criteria search for the patient using the Trust search protocol Search 1 Enter NHS Number in the Identifier field, continue to step 7. Search 2 Enter Hospital Number in the Identifier field continue to step 7. Search 3 Against the correct fields enter Surname, Gender and Date of birth from (dd/mm/yyyy) continue to step 7. Search 4 Search using Surname, Forename, Gender, Date of Birth From field and ensure the best match option is selected by clicking on the drop down arrow against External soundex search field. Page 6 of

7 Continue to step 7. For further guidance on how to search for a patient refer to GEN02 Searching for a Patient. 7. Click on Find. 8. If Patient Found If a patient is found then the patient will appear in the Search results pane. Verify and confirm patient s demographic details using the scroll bar and if details are correct proceed to step 12. If the correct patient is not identified, click on the Search criteria. Click Clear and go to step 6. If multiple patients are found a message will appear stating match the search criteria. It is advisable to refine your criteria. Please note if the user chooses to view the search results, this action will be audited. Click No to view the matches and proceed to step If the patient is not found Depending on the method of searching one of these Page 7 of

8 screens will appear. 1. Click OK go to next step Click on the Search criteria tab go to next step Click Clear Return to step 6 to perform a new search and enter the next Search criteria NOTE: If all 4 searches are complete, the patient must be registered; refer to GEN33 Registering a Patient. 11. Multiple matches Verify and confirm patient s demographic details by using the scroll bar. If the correct patient is identified click the select box against the patient, a symbol will appear, continue to step 12. Page 8 of

9 If the correct patient is not identified, click on the Search criteria Click Clear and go to step Click on Next 13. The Referrals screen is displayed Click on the Search For Select (SFS) button against the Referral type field to choose a referral for the patient s access plan. 14. By default, the search window returns all open referrals. NOTE: Patient may have more than one referral To confirm referral details use the scroll bar to look at the Referred to Name column. For elective trauma patients sent straight from A&E with no fracture clinic appointment, select the Accident and Emergency referral with the appropriate date. For elective trauma patients referred via Fracture Clinic, select the Fracture Team referral with the appropriate date. Page 9 of

10 15. Once the correct referral is identified select it by placing a tick in the box to the left of the row. Once selected an arrow icon is displayed Click Select. 16. On return to the Referrals window, the correct referral details have been pulled through. Click Next. 17. The Type/Source Selection screen is displayed Page 10 of

11 18. Against Access Plan Type select Elective Admission. 19. The Health Organisation field defaults to Tameside Hospital NHS Foundation Trust 20. Click on the search button next to Profile Code 21. Search for the Access plan profile by entering the Profile Name e.g. Trauma and Orthopaedic White Board. You can enter the first few letters followed by the wildcard character % e.g. Trauma% Click on Find Now Page 11 of

12 22. Select the relevant Profile Code by placing a tick in the box to the left of the correct row. Once selected an arrow icon is displayed Click Select. 23. The Profile Code details are pulled through. Click Next. 24. Access Plan Details screen is displayed. Page 12 of

13 25. The radio button defaults to Team. All the team details for the elective trauma list will be populated into the team fields. If the team has multiple specialties, select the correct one from the drop down menu. 26. Select the Priority as Urgent for elective trauma cases. 27. Enter the relevant Administrative Category NOTE: Select Private patient only for patients where it has been agreed that they will be treated privately. 28. Select the Elective Admission Type from the drop down box This should be Elective Booked for trauma surgery patients. 29. From Intended Management select: Day Case (No overnight Stay) for Day Case patients that won t be staying overnight in hospital. Ordinary Admission (at least one night) for patient that are planned to stay in hospital at least one night. Page 13 of

14 30. Access Plan Start Date is populated automatically. 31. Enter any further information in the Comments box e.g. Type of anaesthetic, procedure details, specialist equipment needed. Click Next at the bottom of the screen. 32. The General Resource Requirements screen is displayed where you can enter information about any requirements needed for the patient s surgery. Page 14 of

15 33. On the Clinical Requirements tab, tick the box against Interpreter Required if an interpreter is needed and from Preferred language select the relevant language. NOTE: This does not book the interpreter; it just indicates on the waiting list that one will be needed. 34. Click on the Procedure Requirements faux tab. 35. If the patient requires anaesthetic change radio button to Yes. Using the scroll bar search for the relevant option and select by placing a tick in the tick box i.e. General, Local 36. Click on the Inpatient Scheduling faux tab. Page 15 of

16 37. Do not change any values against Patient confirmation required. 38. Scroll down to the middle of the window. Against Preferred Ward select the ward you want patient to come in. If the ward you would like the patient to go to is not listed, go to the next step, otherwise skip to step Click Remove to untick the selected ward. 40. Against Preferred Ward click on the ellipsis button. Page 16 of

17 . Against Name enter the ward name. Click Find NOTE: To bring back all the wards use the wild card symbol %, e.g. ward% and click Find. 42. Select the ward by placing a tick in the box to the left of the correct row. Click OK to return to the General Resource Requirements tab. 43. Click Next. Page 17 of

18 44. The Resource Monitoring screen appears. Put a tick against the Have all resources been identified? box as this will allow scheduling to be done immediately after the access plan has been created. Click Next. 45. The Coding and Grouping screen appears. 46. Enter a Procedure code if known. If you wish to enter the procedure name instead, proceed to the next step. 47. To enter a procedure name, click on the next to Code Click on the Description radio button. Under Recent 25 you can also find the last 25 procedures that you searched for. Page 18 of

19 48. Type the procedure name and click NOTE: If you are not sure of the procedure s full description and you want to bring back all results, for example hip, use the wild card symbol %. Type hip% and click 49. Any matching search results are returned. Select the correct procedure name. 50. The procedure is now recorded. If you want to add another procedure (i.e. if the consultant needs to do two procedures at the same time), repeat the action from Steps If you want to delete a procedure added in error refer to Appendix 1: Deleting a procedure or diagnosis added in error 51. Click on Finish to launch the Create Offer window and book a bed for the patient. Go to step 52. Page 19 of

20 Scheduling an Elective Trauma Patient 52. Click Yes to the question that appears about creating an offer for the patient. This will launch the TCI screen and allow you to book a bed for the patient. This message and window will not launch if step 44 has not been completed. 53. The Search to come in Offer window opens. 54. Start search from select the date you would like the patient to come in using the drop down calendar. Page 20 of

21 55. End search enter the latest date you wish the patient to come in by. 56. Search for field will default to All, do not change. 57. If you know approximately how long the patient will be staying post-surgery, update the Expected length of stay field to the correct amount of days. Page 21 of

22 58. Click on Check Availability 59. Search results are now displayed showing all available bookings for the ward. To view all available beds for the selected day expand the view by clicking on the node button. 60. Select the bed by clicking in the box to the left of the row. Note: Booking a bed will ensure better bed planning, although it does not hold the patient to that particular ward or bed if the details change on admission. Patients can be overbooked onto the ward (although not over admitted). 61. Click Next Page 22 of

23 62. Create to come in Offer window opens, defaulting to Written. 63. Against Patient response field select Accept from the drop down menu. 64. Against Booked date/time enter time you want the patient to come into the ward Page 23 of

24 65. Enter any further comments in the Comments box. NOTE: Any comments that have been added while creating the Access Plan will be visible now in the comments box. You can verify them at this stage. 66. Click Update. 67. The Offer status will now be shown in an Accepted status and the patient will be ready to be selected by the ward clerk on admission. 68. Click Finish Page 24 of

25 69. The Select document templates window appears displaying all available TCI letters for the patient. If you wish to print a letter to send to the patient, select the correct letter by placing a tick in the box to the left of the correct row and clicking OK. If you don t want to print a letter, click Cancel and proceed to step The Select Printer window appears. Choose Local Print if you wish to print an offer letter for the patient. 71. Surgery date is now booked for patient. Page 25 of

26 Appendix 1: Deleting a Procedure Added in Error 1. In the Coding and Grouping screen, use the scroll bar to identify the procedure that has been added in error. 2. Select the procedure added in error by placing a tick in the box to the left of the row. 3. Scroll across to the Update Reason column and enter a reason as to why you are deleting the procedure. 4. Click Page 26 of

27 4. The incorrect procedure has now been removed. Page 27 of

28 Appendix 2: Rescheduling a TCI Date 1. Log into Lorenzo using your smart card. See GEN01 Logging in to Lorenzo if you require further guidance. Once opened, Lorenzo defaults to the My work application tab. 2. From the My work menu on the left hand side select Access planning. 3. The Access Planning task pane is displayed 4. From Access plan type drop down box select Elective admission 5. Click on the search for select button next to Patient ID Page 28 of

29 6. Patient search screen is displayed, the Search criteria defaults to Advanced search faux tab. 7. In the Search criteria search for the patient using the Trust search protocol Search 1 Enter NHS Number in the Identifier field, continue to step 8. Search 2 Enter Hospital Number in the Identifier field continue to step 8. Search 3 Against the correct fields enter Surname, Gender and Date of birth from (dd/mm/yyyy) continue to step 8. Search 4 Search using Surname, Forename, Gender, and Date of Birth From field and ensure the best match option is selected by clicking on the drop down arrow against External soundex search field. Continue to step 8. Page 29 of

30 For further guidance on how to search for a patient refer to GEN02 Searching for a Patient. 8. Click on Find. 9. If Patient Found If a patient is found then the patient will appear in the Search results pane. Verify and confirm patient s demographic details using the scroll bar and if details are correct proceed to step 13. If the correct patient is not identified, click on the Search criteria. Click Clear and go to step 7. If multiple patients are found a message will appear stating match the search criteria. It is advisable to refine your criteria. Please note if the user chooses to view the search results, this action will be audited. Click No to view the matches and proceed to step If the patient is not found Depending on the method of searching one of these screens will appear Click OK go to Page 30 of

31 next step Click on the Search criteria tab go to next step Click Clear Return to step 7 to perform a new search and enter the next Search criteria. 12. Multiple matches Verify and confirm patient s demographic details by using the scroll bar. If the correct patient is identified click the select box against the patient, a symbol will appear, continue to step 13. If the correct patient is not identified, click on the Search criteria. Click Clear and go to step 7. Page 31 of

32 13. Click on Next 14. On return to the access plan search window, the patient s ID and name have been entered into the appropriate fields. Click Find to search for all access plans that patient has. 15. A list of all open access plans that the patient has will be listed. Find the elective trauma list entry and select it by clicking in the box to the left of the correct row. 16. Click the Slider bar at the bottom of the window to open up further details about the access plan. Page 32 of

33 17. Access Plan Entry Details are now displayed. 18. Click on the Offer Details tab. 19. The existing TCI date that has been offered to the patient is now visible. Scroll across to confirm the details NOTE: Under Offer details you will be able to see any previous cancellations and recorded offers for patient. The most recent offer will always be on the top of the list with an arrow next to it Page 33 of

34 20. Manage cancellation within Access Planning task pane is now active Click on Manage cancellation 21. The Cancel Offer screen is displayed. The Cancellation date/time is populated automatically with today s date/time, but change this using the drop down calendar if required. 22. Against the Cancelled by field select the correct reason Select Hospital/Trust Prior to day of Admission if the hospital is cancelling the surgery. Select Patient/Carer if it was patient s decision to cancel the surgery date. Page 34 of

35 23. Against the Cancellation Reason field enter the reason why you are cancelling the TCI date using the drop down box. NOTE: The cancellation reason list will be different depending if the surgery date is rescheduled by hospital or it is patient decision 24. From Offer Outcome drop down box select Remain on Access Plan only NOTE: Only select Remove Access Plan Entry if you want to completely remove the patient from the trauma list. 25. Enter any further information in the Comments field. Click on Finish. 26. A question box appears Do you wish to create an offer? Select Yes Page 35 of

36 27. The Search to come in Offer window opens allowing you to give the patient a new date. 28. Start search from select the date you would like the patient to come in using the drop down calendar. 29. End search enter the same date as the Start search from date. Page 36 of

37 30. Search for field will default to No preferences; do not change. 31. Expected length of stay defaults to 1 day. If you know approximately how long the patient will be staying post-surgery, update this field to the correct amount of days. 32. Click on Check Availability Page 37 of

38 33. Search results are now displayed showing all available bookings for the ward. To view all available beds for the selected day expand the view by clicking on the node button. 34. You can see all beds for the selected ward on that particular day Select the bed by clicking in the box to the left of the row. Note that although you are booking a bed for the patient, this can be changed on admission, so does not mean that the patient will have to stay in that bed. It is more important for planning purposes. 35. Click Next 36. Create to come in Offer window opens, defaulting to Written. Page 38 of

39 37. Against Patient response field select Accept from the drop down menu. 38. Against Booked date/time enter time you want the patient to come into the ward 39. Enter any further comments in the Comments box. NOTE: Any comments that have been added while creating the Access Plan will be visible now in the comments box. You can verify them at this stage. Page 39 of

40 40. Click Update.. The Offer status will now be shown in an Accepted status and the patient will be ready to be selected by the ward clerk on admission. 42. Click Finish 43. The Select Printer window appears. Choose Local Print if you wish to print an offer letter for the patient. If you do not wish to print a letter, click Cancel. 44. The TCI date has now been rescheduled. The patient will also need to be rescheduled on ORMIS. Page 40 of

41 Document Control Version Number Date Document Status Author / Modifier / Reviewer Details Approved Signatory /04/2013 Draft Monika Vorberg SOP Creation /04/2013 Draft Phil Taylor Ready for testing /04/2013 Draft Monika Vorberg Minor revision /05/2013 Draft Monika Vorberg Patient search added /05/2013 Draft Monika Vorberg Updated following BPV /07/2013 Final Mike Maitre Updated to Final /09/2013 Final Monika Vorberg Access plan name confirmed and steps cross referenced