Unless this copy has been taken directly from the Trust intranet site (Pandora) there is no assurance that this is the most up to date version

Policy No: OP84 Version: 2.0 Name of Policy: Internal Patient Transfer and Escort Policy Effective From: 07/09/2015 Date Ratified 12/08/2015 Ratified SafeCare Council Review Date 01/08/2017 Sponsor Director of Nursing, Midwifery and Quality Expiry Date 11/08/2018 Withdrawn Date Unless this copy has been taken directly from the Trust intranet site (Pandora) there is no assurance that this is the most up to date version This policy supersedes all previous issues Patient Transfer and Escort Policy v2

Version Control Version Release Author/Reviewer Ratified by/authorised by 1.0 19/09/2014 Faye Butler SafeCare Council Date 10/09/2014 Changes (Please identify page no.) 2.0 07/09/2015 Julie Jones / Caroline Lane SafeCare Council 12/08/2015 Adding in reference to SBAR transfer form Patient Transfer and Escort Policy v2 2

Contents Section Page 1 Introduction... 4 2. Policy scope... 4 3. Aim of policy... 4 4 Duties (roles and responsibilities)... 4 5 Definitions of terms... 5 6 Process for transfer... 6 7 Providing an escort for transfer... 7 8. Training... 8 9. Equality and diversity... 8 10. Monitoring compliance with the policy... 8 11. Consultation and review... 9 12 Implementation of policy... 9 13 References... 9 Appendices Appendix 1 (In-patient SBAR Transfer form)... 10 Appendis 2 (Critical Care transfer form)... 11-12 Appendix 3 (Antenatal& Postnatal Handover of Care)... 13-15 Appendix 4 (Patient Escort QE Site Quick Reference Guide)... 16 Patient Transfer and Escort Policy v2 3

Patient Escort Policy 1 Introduction Gateshead Health NHS Foundation Trust is committed to the provision of high quality health care in all aspects of its services to patients and staff. There are many occasions when a patient needs to be transferred in the hospital to other wards or departments and which may require escort. This policy is therefore intended to offer safeguards and guidance to ensure staff and patient safety throughout the transfer process. 2 Policy scope This Policy applies to all health care professionals working within Gateshead Health NHS Foundation Trust involved in the assessment of patients to determine the need for escort during transfer within the hospital. It provides clear guidance and instruction to all staff with regard to the transfer and escort of adult and paediatric patients within and across the Queen Elizabeth Hospital site. All staff using this policy should ensure that the basic principles of respect, explanation, privacy and dignity apply to all patients in the transfer setting. They must use this policy in conjunction with a range of existing good practice guidance from professional bodies and existing Trust policy with particular reference to: Bed management, patient transfer and escalation plan (OP33) Safeguarding patient privacy and dignity (OP29) Manual handling policy (RM06) Control of infection policy (IC01) Personal protective equipment (IC02) Hand hygiene policy (IC04) Safeguarding adults policy (OP75d) Safeguarding children policy (OP75a) Resuscitation policy (RM27a) Outside of this policy is the transfer of children as there is a Regional Policy for this. When transferring paediatric patients to longer term care, usually at either Newcastle Upon Tyne Hospitals or City Hospitals Sunderland, this policy should be followed. The escort section of the policy should be followed for all patients within QE Gateshead, including paediatric, maternity services and mental health. 3 Aim of policy The key aims of this policy are to ensure the safe transfer of patients between wards and departments. In addition it will support the safety of those patients who will be spending time in other departments away from their ward base with or without an escorting healthcare professional or assistant. It will also provide clear guidance for staff that will ensure staff and patient safety. It applies to all transfers, both in and out of normal working hours. 4 Duties - roles and responsibilities The Trust Board: The Trust has ultimate responsibility for providing effective healthcare services to patients. They are responsible for ensuring there is support available to ensure the safety and wellbeing of patients in our care. Patient Transfer and Escort Policy v2 4

The Chief Executive: The Chief Executive is ultimately responsible for ensuring effective corporate governance within the organisation and therefore supports the Trust-wide implementation of this policy. Trust Managers: Managers are responsible for ensuring all members of staff understand how the In-patient Transfer Policy applies to them and their patients. Managers are also responsible for ensuring that where necessary, local procedures are developed, to support the implementation of this policy. Managers should review the effectiveness of the implementation of this policy, and take appropriate remedial action when they become aware of any acts or omissions that contravene it. Healthcare professionals: Once the decision to transfer a patient is agreed, it is the responsibility of the clinician in charge of the patient to assess the needs of the patient and make an informed decision regarding their escort needs during transfer prior to authorising their departure from the clinical area. The healthcare professional is responsible for undertaking a pre transfer assessment before a patient leaves a clinical area, this is to determine if a nurse escort is required, and to take appropriate steps to obtain one, All healthcare professionals must therefore demonstrate an appropriate understanding of the escort requirements and the procedure for reporting concerns. All Nursing /Medical staff transferring /escorting patients: Familiarise themselves with this policy, its contents and appendices Ensure that prior to transferring or escorting a patient transfer they have been given adequate information regarding the patient to be able to care sufficiently for them during the process. Provide effective care for the patient during transfer by being aware of the patients condition and current needs. Maintain the patient s dignity and respect throughout. Registered Nurses/Midwives are personally accountable for their own safe practice, actions and omissions as outlined in the NMC Code. Medical staff are personally responsible for their own safe practice, actions and omissions as outlined in GMC duties of a Doctor/ good medical practice. Nursing Assistants and Pre-registered nurses should only undertake patient transfer if basic life support training is complete and up to date and when it has been deemed appropriate to their duties by their Ward/unit manager. This can be delegated to the nurse in charge on a day to day basis. All non clinical staff (e.g. porters) escorting patients: Familiarise themselves with this policy, its contents and appendices Ensure that prior to escorting a patient transfer they have been given any necessary information regarding the patient to be able to safely transfer.(e.g. any infection control risks, mode of transfer, escort requirements) Maintain the patient s dignity and respect throughout. Familiarise themselves with emergency telephone numbers and location of receiving area. 5 Definitions of Terms Clinician any qualified member of staff with the knowledge, skill and competency to assess the patients requirement for escort. Within this policy, clinician refers to all clinical staff including doctors, nurses and midwives. Where it is stated the clinician in charge or the clinician Patient Transfer and Escort Policy v2 5

coordinating this refers to the person who is caring for the patient and responsible for making the arrangements for transfer, in most cases this will be the registered nurse or midwife. Transfer of care when it is deemed appropriate to move the care of a patient from one area to another based upon the needs of the patient receiving the right care in the right place. Escort defined as to accompany a person for protection with regards to safety and psychological wellbeing during transfer from one area to another. (Oxford Illustrated Dictionary.) The escorting member of staff has a responsibility to ensure that the patient is safe throughout the transfer and that their immediate physical and psychological needs are met. Any person involved in the transfer of a patient should have the necessary knowledge, skills and experience to be able to achieve a safe transfer. Health care professionals any staff group responsible in the assessment process regarding the decision to escort. Levels of Care for Adult and Paediatric patients this refers to the intensity of nursing care required by the patient. The following levels of care have been taken from the Intensive Care Society Standards (ICS) published in 2002 and Paediatric Intensive Care Standards (2001): Level 0 Patients whose needs can be met through normal ward care in an acute hospital. Level 1 Patients at risk of their condition deteriorating, or those recently relocated from higher levels of care whose needs can be met on an acute ward with additional advice and support from the critical care team. Level 2 Patients who require more detailed observation or intervention. This may include support for a single failing organ system or postoperative care, and those stepping down from higher levels of care. Level 3 Patients who require advanced respiratory support alone, or basic respiratory support together with support of at least two organ systems. This level includes all complex patients requiring support for multi organ failure. 6 Process for transfer 6.1 Patients should only be transferred between 09.00 hrs. 22.00 hrs. with the exception of those patients being transferred based on clinical need or from assessment units such as Coronary Care, Critical Care or Accident and Emergency to a base ward. It is only in exceptional circumstances that the transfer of patients will occur outside of these times including protected meal times. 6.2 When a patient is being transferred from one clinical area to another within the organisation, it is vital that the patient is placed according to clinical need, paying particular attention to the issues related to infection control and privacy and dignity. Prior to a patient being transferred the transfer must be discussed and explained to the patient, relatives and carers as appropriate. When a patient is transferred from one ward to another a short verbal handover, conducted by a registered nurse, from the sending ward using the SBAR format, will be completed. The handover will be received by a registered nurse completing In Patients Transfer Form based upon a SBAR handover (Appendix 1). This must take place prior to transfer and include a recent NEWS Score / observations taken. Patient Transfer and Escort Policy v2 6

When a patient is being transferred from the Critical Care Department to a base ward then a Critical Care Transfer sheet must be completed by Critical Care staff (Appendix 2) It is the responsibility of the nurse in charge / deputy to establish if an escort is required based on the patients clinical and nursing needs. For maternity services the transfer of patients should be documented on their own documentation (Appendix 3a, 3b & 3c). The boarding or outlying of patients should be avoided as far as possible; however there are times when such activity becomes a necessary part of managing emergency admissions and maintaining patient flow. The decision to board will be coordinated by the Duty Matron and the Bed Management Team following discussion at the Bed Meetings held daily. For further information refer to policy OP 33. Patients should only be subjected to one additional move as a boarder or outlier during their hospital episode when this is not directly related to their clinical management plan. 7 Providing an escort for transfer 7.1 Prior to the transfer of patients within the QE site, an assessment of potential risk, using clinical judgement and policy guide must be undertaken to ensure the patient is escorted and transferred safely without harm. This policy and its supportive appendices aim to ensure safe and appropriate transfer and escort of a patient and reduce risks by: Providing guidance on patient assessment prior to transfer Provide guidance for making the correct decisions regarding appropriate escort and mode of transfer Allocation of appropriate escort to maintain patient safety during transfer 7.2 The registered nurse must use their clinical judgement to make an appropriate assessment of the patients clinical condition to determine if an escort is required and to ensure the escort is able to care for the patient during transfer. 7.3 Nurses should use the quick reference guide (Appendix 4) to assist with making this decision if required. 7.4 A registered Nurse Escort however MUST be provided if any of the following apply: The Patient is causing clinical concern The patient has had a recent NEWS/PEWS trigger The patient has a potential risk to airway E.g. post op / post procedure / post sedation / recent seizures or vomiting) The Patient has acute respiratory problems The Patient is dependent on continuous oxygen greater then 4L/min The Patient is receiving continuous high risk medication Infusions or treatments E.g. Blood / Opiates/ PCA / Epidural / Antibiotics / Insulin /Heparin / Potassium based infusions The patient requires continuous cardiac monitoring 7.5 Appropriate monitoring must be able to continue during patient transfer in accordance with the patient s condition and plan of care. 7.6 Health care assistants are responsible for patients during transfer if they have accepted the delegated task from a registered nurse. Patient Transfer and Escort Policy v2 7

7.7 A registered nurse should provide health care assistants undertaking transfer with a full handover of any relevant patient needs/ issues prior to the transfer 7.8 Following the assessment of the patient the patient movement should be booked onto portertrak for transfer. If the patient requires escort, escort should be entered on the system. No escort should be entered if the patient has been assessed as not requiring an escort. There is no need to stipulate qualified or unqualified on the system. 8 Training Members of staff who make the decision to escort should have undergone appropriate support in order to ensure that they develop the competencies required. The policy will be promoted at ward and department local induction, to ensure that all members of staff have an understanding of the role of the escort and how to access the policy. 9 Equality and diversity The Trust is committed to ensuring that, as far as is reasonably practicable, the way we treat members of staff and patients reflects their individual needs and does not discriminate against individuals or groups on the grounds of any protected characteristic.. This policy is therefore intended to offer safeguards to both patients and members of staff prior to transfer to another ward or department. In this way, the policy promotes equality of opportunity and values diversity. The policy adopts a human rights approach by considering a wide variety of situations, and encourages supportive, reasonable arrangements to promote fairness, respect, equality, dignity and autonomy. 10 Monitoring compliance with the policy Standard/process/issue Policy complies with OP27 Policy for the development, management and authorisation of policies and procedures Staff are aware of the policy and able to implement it effectively Informal feedback from patients and carers about patient escort issues Compliance into the completion of SBAR In Patient Transfer Forms Review of incidents occurring regarding the transfer of patients Monitoring and audit Method By Committee Frequency OP27 Checklist Upon Review Refer to Training and Local Induction. Discussed in the PALS / Complaints quarterly analysis PALS & Complaints Manager Annual review Quarterly reports Audit Matrons SafeCare Annual review Trend monitoring Matrons SafeCare Quarterly Patient Transfer and Escort Policy v2 8

11 Consultation and review The policy was developed using best practice guidelines, in consultation with key staff groups and following a pilot of the Quick Reference Guide (Appendix 1). 12 Implementation of policy This policy will be circulated by the Trust Secretary as detailed in OP27 Policy for the development, management and authorisation of policies. Individual healthcare professionals have a responsibility to ensure they understand the role of the nurse escort and take appropriate steps to implement this policy effectively, including reporting any concerns as appropriate. Managers are responsible for ensuring all members of staff understand how the Patient Escort Policy applies to them and their patients. Managers are also responsible for ensuring that where necessary, local procedures are developed, to support the implementation of this policy. Managers should review the effectiveness of the implementation of this policy, and take appropriate remedial action when they become aware of any acts or omissions that contravene it. 13 References Internal Patient Transfer and Escort Policy (March 2009) The Royal Free Hampstead NHS Trust Patient Escort Policy (January 2011) County Durham and Darlington NHS Foundation Trust Clinical Policy for the Safe Transfer and Escort of Patients Heart of England NHS Foundation Trust (April 2012) 14 Appendices Appendix 1: SBAR Inpatient Transfer Form Appendix 2: Critical Care transfer tool Appendix 3: Maternity Handover Forms (a Antenatal handover, b Delivery suite to SCBU, c Delivery suite to Postnatal) Appendix 4: Patient Escort (QE Site) Quick reference guide Patient Transfer and Escort Policy v2 9

Appendix 1 Patient Transfer and Escort Policy v2 10

Appendix 2 Patient Transfer and Escort Policy v2 11

Patient Transfer and Escort Policy v2 12

Antenatal Handover of Patient Care (SBAR) To be completed for all transfers between AN and LW (Except planned low risk IOL & early labour admissions) Appendix 3a Please tick appropriate boxes ( ) or circle correct answer SBAR report Situation Reason for transfer: Antenatal Handover Current antenatal issues (summary): Background Gravida: Para: Gestation: weeks Midwifery led Consultant led Significant medical history: Yes No please state: Significant Obstetric history: Yes No please state: Obstetric Risk Assessment: High Low Thromboembolism: High Low Assessment BP: Pulse: bpm Temp: C Resps: rpm Previous MEOWS trigger: Yes No Abdomen: Foetal heart: bpm CTG interpretation: Urinalysis: Uterine Activity: Vaginal Loss: discharge / amniotic fluid Colour: Bloods: taken and / or results: Recommendations Antenatal care plan: including observations and foetal monitoring Further tests / treatments required: Identified indications for medical review: Signature of person transferring patient: Signature of person receiving patient: Date and time of transfer: Patient Transfer and Escort Policy v2 13

Delivery Suite to Postnatal Handover of Baby s Care (SBAR) - Only to be completed if baby is transferred immediately to SCBU Please tick appropriate boxes ( ) or circle correct answer SBAR Report Postnatal Handover Situation Date of Delivery: Time of delivery: Delivery: Normal Ventouse Forceps Appendix 3b Elective LSCS Reason: Emergency LSCS Reason: Baby: Postnatal SCBU Paediatric Alert? Yes No details: Background Gestation: weeks Mother s blood group: Baby s blood group: Antibodies: Antibodies: Family issues identified: Yes No AN2: Yes No Assessment Bloods taken / results: Swabs taken / results: Initial Assessment: Colour: Skin: Eyes: Mouth: Cord: Passed meconium? Yes No Passed urine? Yes No Skin to skin Breast fed Length of feed: mins Artificially fed mls ID bracelet x 2 present and correct? Yes No Temperature on transfer: C Birth weight: kg Recommendations Routine postnatal care? Yes No Further tests / treatments required: Identified indications for medical review: Is there an Individual Management Plan in place? Please document plan on page 4. If baby requires regular observations (Meconium, GBS) ensure that observation chart is up to date PRIOR to transfer to PN ward. Signature of person transferring baby: Signature of person receiving baby: Date and time of transfer: Patient Transfer and Escort Policy v2 14

Delivery Suite to Postnatal Handover of Mother s Care (SBAR) To be signed by both the transferring midwife and the receiving midwife Please tick appropriate boxes ( ) or circle correct answer SBAR report Postnatal Handover Situation Date of delivery: Time of delivery: Delivery: Normal Ventouse Forceps Elective CS reason: Emergency CS reason: Spontaneous Induced Analgesia if appropriate: Perineum: intact 1 st 2 nd 3 rd 4 th Episiotomy Sutured Yes No Drains: Yes No IVT type and rate: Appendix 3c Estimated blood loss: mls Background Gravida: Para: Gestation: weeks Risk assessment prior to labour: High Low If high, please state reason: Blood group: Antibodies: Rubella Immune Yes No Personal Issues identified: Yes No AN2 Yes No Assessment BP / Pulse bpm Temp C Resps bpm Previous MEOWS trigger Abdomen: Passed Urine: Yes No If no please record time of last void: (SRC insitu) (document time and volume of 1 st void in P/N care section on p.8) Lochia: Heavy / normal / light Bloods: taken and / or results: Recommendations Risk assessment following delivery: High Low If high, please state reason: If high risk postnatally please document individualised management plan on page 6-7 Further tests / treatments required: Identified indications for medical review: Signature of person transferring patient: Signature of person receiving patient: Date & Time of transfer: Patient Transfer and Escort Policy v2 15

Appendix 4: Patient Escort (QE Site) - Quick Reference guide This aims to guide staff with appropriate escort requirements and does not replace the clinical judgement and ultimate decision of the Registered Nurse Assessment of Patient Risk Minimum Escort requirement Mode of transfer Minimum Skills required Maintaining own airway No Oxygen support required during transit Stable observations no NEWS triggers in last 4 hours No medical devices in progress during transfer Alert and orientated Low Adults - Porter Children - HCA or Preregistered student Nurse Walk Wheelchair Bed/Cot Trolley Familiar with trust transfer policy Understands Transfer process. Clinical staff BLS/PLS Maintaining own airway Stable on Continuous Oxygen less than 4L/Min Stable observations no NEWS triggers in last 4 hours No medical devices that may require intervention during transfer. Confused /disorientated High risk of falls / likely to wander Requires continuous cardiac monitoring Risk to airway (e.g. post op / post procedure / post sedation / recent seizures or vomiting) Acute respiratory problems Requires continuous oxygen greater then 4L/min Recent NEWS trigger within the last 4 hours Continuous Infusions or treatments in situ E.g. Blood /PCA/Epidural/Antibiotics/Insulin Patient causing clinical concern / increasing NEWS score Clinical challenging behaviour Med Adults - HCA, Pre-registered student Nurse or Therapist & Porter Children - Registered Paediatric Nurse Wheelchair Bed/Cot Trolley Awareness of patient s current clinical condition and needs. Familiar with trust transfer policy Understands Transfer process. BLS / PLS High Adults - Registered Nurse/ and Porter Children- Registered Paediatric Nurse and HCA / Pre-registered student +/- Medic if indicated For manifestations of aggression consider security escort Bed/Cot Trolley Aware of patient s current clinical condition and needs. Familiar with trust transfer policy Understands Transfer process BLS / PLS Requires Invasive / Non Invasive Ventilatary Support Acute respiratory problems Unstable Circulatory System Complex Patients requiring support for multi organ failure Critical Adults- Critical Care Clinician / Practitioner and Critical Care Nurse/ART Nurse +/- porter Children PICU Retrieval Team or Critical Care Clinician/Paediatric Clinician & Consultant/Middle Grade & Registered Nurse Bed/Cot Trolley Aware of patients current clinical condition and needs Appropriate Critical care skills Familiar with trust transfer policy Understands Transfer process ALS / PLS Patient Transfer and Escort Policy v2 16