ALL BOXES MUST BE COMPLETED THEN EMAIL TO: rbh-tr.s_vreferral@nhs.net Referral Proforma: Long term respiratory care SLEEP AND VENTILATION TEAM RBHT (for Non-invasive review, Invasive ventilation support/weaning/ Tracheostomy support, Sleep Studies, Cough augmentation) Date of Referral Patient Name: DOB: NHS Number Sex (delete appropriately) Male / Female Weight: Home address Contact number GP details (name and address) Name of Referring Hospital / Home / GP Name of Responsible Consultant Ward Contact Number Diagnosis Primary PMH Resuscitation status / Ceiling of Care Current Condition:
Reason for Referral (please tick) Assessment for domiciliary non-invasive ventilation & set up Advice and support for Weaning from prolonged invasive ventilation Set up onto long term invasive ventilation, support discharge and community management Home outpatient assessment Long term tracheostomy management Sleep Study Cough augmentation assessment Current PCF = RIG insertion AIRVO Current Ventilation Requirements Please state if requiring O2 and how much Last ABG: Date & Time Please state if on Invasive or Non-invasive ventilation and /or O2 Latest Spirometry Tracheostomy tube Date put in: Invasive Ventilation Current Settings: MODE PS PEEP Avg RR Avg VT ph pco2 po2 BE HCO3 Sats DATE: Non-invasive Ventilation Current Settings: MODE IPAP EPAP Ti RR FEV1 FVC FEV1/FVC Type / Model: Size: Cuffed: Uncuffed: Fenestrated: Non-fenestrated:
Please Tick /Circle as Appropriate: Bed Dependency Level 1 Level 2 Level 3 Side Room Required YES NO PEG/RIG/NGT PEG RIG NGT INFECTION STATUS: Please ensure all swabs are taken and results emailed with this Proforma. If this is not done the patient CANNOT BE CONSIDERED FOR TRANSFER Please tick and list if patient is colonised with any of the organisms listed DATE TAKEN: MRSA C.DIFF VRE CRE OTHER Pseudomonas NURSING NEEDS AND MOBILITY: Please enter Y or N in all boxes that are relevant to the patient. If the patient is accepted for transfer a more in depth assessment will be required. Is the patient self caring Can the patient press a call bell Does the patient need hoisting Is the patient incontinent Does the patient have a urinary catheter Can the patient verbally communicate Does the patient have long term carers at home Is the patient a wheelchair user Does the patient have any pressure sores Does the patient have PEG/RIG Does the patient have NGT Prior to this admission was the patient living at home Any other comments:
DISCHARGE PLANS / FOLLOW UP: PLEASE TICK ALL RELEVANT BOXES Patient to be returned to referring hospital following treatment at the Royal Brompton Hospital Patient to be discharged back to normal place of residence following treatment at the Royal Brompton Hospital Outpatient follow up by Sleep and Ventilation Team at Royal Brompton Hospital Sleep and Ventilation Community Outreach follow up at home Shared follow up with referring / local hospital
OFFICIAL USE ONLY: Date Referral Received Triaged By: Date of MDT Discussion MDT members present (Please tick all those present) Professor Simonds Professor Polkey Dr A Hare Debbie Field Sarah Price Adam Rochester Elaine Pneu Ward Physio Ward Nurse SLT OT Dr M Hind Dr M Chatwin Dietician Discharge coordinator Psychologist Decision Made DECISION YES NO Patient for transfer Patient decline Patient for outreach Action Agreed (please state) Physiologist(s) Follow up plans