Policy No: OP33 Version: 3.0 Name of Policy: Bed Management, Patient Transfer and Escalation Policy Effective From: 08/02/2010 Date Ratified 11/11/2009 Ratified SafeCare Council Review Date 01/09/2010 Sponsor Director of Nursing and Midwifery Expiry Date 10/11/2012 Withdrawn Date This policy supersedes all previous issues.
Version Control Version Release Author / Reviewer Ratified By / Authorised By Date 1.0 Jan 2006 TFP Jan 2006 Changes (Please identify page no.) 2.0 Sept 2008 Divisional Managers 3.0 08/02/2010 Divisional Managers SafeCare Council SafeCare Council Sept 2008 11/10/2009 2
CONTENTS PAGE 1. Policy Statement 5 2. Aim of Policy 5 3. Roles and Responsibilities 3.1 Board of Directors 5 3.2 Chief Executive 5 3.3 Divisional Managers/Divisional Directors 5 3.4 Assistant Divisional Managers 6 3.5 Medical Staff 6 3.6 Bed Managers 6 3.7 Clinical Liaison and Discharge Team 7 3.8 Night Site Manager 7 3.9 Matron 7 3.10 Ward Sister/Charge Nurse (delegated to Nurse in Charge) 8 3.11 Allied Health Professionals 9 3.12 Named Nurse/Midwife 9 3.13 Accident and Emergency Sister/Charge Nurse and Clinical Lead 10 3.14 Senior Nurse on Call 10 3.15 Organisational Chart 10 3.16 Reasonable Adjustment 11 3.17 Privacy and Dignity 12 4. Bed Management Process 13 4.1 Reporting Mechanisms 13 4.2 Bed State 14 4.3 Patient s Awaiting Admission 14 4.4 Trigger Levels & Escalation 15 5. Early Supported Discharge and Alternatives to Admission 15 6. Transferring or Boarding of Patients 15 6.1 Roles and Responsibilities when a Patient is Transferred 15 6.2 Transfer following Resuscitation 15 6.3 Transfer as a Result of Being Boarded 16 7. Reception of Patients Diverted From Other Trusts 17 8. Control of Infection 17 9. Monitoring the Effectiveness of the Policy 20 10. Equality and Diversity 23 11. References 23 12. Associated Documents 23 13. Appendices 24 3
Appendix 1 Bed Management Meetings Guidance 25 Appendix 2 Bed Management Meetings Proforma 26 Appendix 3 Division of Medical Services Action Cards 29 Appendix 4 Division of Surgical Services Action Cards 32 Appendix 5 Critical Care Action Cards 35 Appendix 6 Action Card for When All Specialties are Under Pressure 39 Appendix 7 Accident & Emergency Escalation Plan 41 Appendix 8 Guidance for Boarding Patients to Treatment Centre 43 Appendix 9 Procedures for Cancelling Elective Surgical Admissions 44 Appendix 10 On-Call for Vascular Patients 48 Appendix 11 Information to Support Management of Beds on Critical 49 Care and Escalation Appendix 12 Children s Services Escalation Plan 55 Appendix 13 Mental Health Services Information 57 Appendix 14 Maternity Services Escalation Plan 58 Appendix 15 Mortuary Services Escalation Plan 67 Appendix 16 Pharmacy Escalation Plan 68 Appendix 17 Useful Telephone Numbers and Contacts 70 Appendix 18 Infection Risk Assessment Tool 73 Appendix 19 Known Infection / Colonisation Record 74 Appendix 20 Proformas for Completion When Transferring Patients 75 4
1. POLICY STATEMENT Gateshead Health NHS Foundation Trust delivers care to the population of Gateshead. Establishing a logical flow of patients through the Trust is key to maximizing bed availability in order to effectively manage fluctuations in workload. As a key principle Gateshead Health NHS Foundation Trust will not close to emergency admissions. When hospital resources are stretched e.g. shortage of beds, exceptionally high attendances in the Accident and Emergency Department etc, hospital remains the safest place for seriously ill people and closure of the hospital will be on the instruction of the Chief Executive or nominated officer. 2. AIM OF THE POLICY The aim of this policy is to ensure that every emergency admission is allocated a bed within four hours and no elective admission is cancelled because of lack of bed availability. The policy will clarify roles and responsibilities. Effective communication and teamwork is crucial to the implementation of this policy requiring regular dialogue with nursing staff, medical staff, and the Infection Prevention and Control Team (IPCT). 3. ROLES, RESPONSIBILITIES AND DUTIES 3.1 Board of Directors The Board of Directors is responsible for ensuring that there is a robust system of Corporate Governance within the organisation. This includes having a systematic process for the development, authorisation and management of policies 3.2 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. 3.3 Divisional Managers/Divisional Directors are responsible for: Ensuring that systems are in place so that the Bed Management, Patient Transfer and Escalation Policy is implemented effectively within individual divisions Producing the annual corporate winter plan Making the decision to open extra beds or a ward if the trigger level of bed availability within the Trust is not achieved Communicating with Gateshead Primary Care Trust to ensure that systems are in place to engage the o Community Matrons o Urgent Care Team o Walk In Centre o GP Practices particularly in times of escalation. 5
3.4 Assistant Divisional Managers are responsible for: Ensuring systems are in place to manage patient access effectively within the Division. To ensure day-to-day capacity is available for the individual specialty and to identify any trends, which are causing a blockage to the patient journey. This will be reported at the weekly Achieving the Targets meeting (ATT). To ensure a forward thinking and planning approach for the provision of patient care services. 3.5 Medical Staff are responsible for: Determining the discharge date of each patient in consultation with the patient, carer, ward staff and other agencies if required. Documenting the estimated date of discharge and sharing this with the patient, carer, and those involved in the patients care. The anticipated length of stay and planned discharge date will be agreed within 24 hours for emergency admissions and prior to admission for elective admissions. Collaborating with the ward nursing team to identify patients who are appropriate to be boarded to other specialties if required Ensuring that when the decision to discharge / transfer a patient is made during a ward round, the appropriate medical documentation is completed prior to the medical team leaving the area. Ensuring that if the discharge / transfer is planned for a future date and the patient s drug requirements are known, the prescription is prepared in advance of the discharge date. Organising additional ward rounds during periods of red alert Fast tracking assessments in Accident and Emergency as appropriate Ensuring all admissions, including those from clinic, additions to the list and transfers from other hospitals are directed via the bed managers to ensure that the hospital bed state remains correct and up to date. Non urgent admissions/transfers may be delayed during a period of amber or red alert, and it may be appropriate to explore alternatives to admission (e.g. rapid access to the next available clinic) Work with the nursing teams to ensure that on every ward there is a minimum of 2 planned morning discharges 3.6 Bed Managers are responsible for: Liaising with Critical care to ensure that transfers in/out are completed by 2200 hours Operational responsibility for the daily management of admissions and ensuring that an up to date bed state and record of patients waiting for admission is maintained Monitoring the quality of bed state reports provided by individual wards and reporting recurrent problems to the appropriate Matron for action Keeping up to date on current best practice in bed management and liaising on a regular basis with neighbouring hospitals to ensure patients who require repatriation are accommodated in a timely manner Ensuring terminal cleans are co-ordinated in accordance with the Trust s Infection Prevention and Control policies 6
Co-ordination of information for presentation at bed meetings 3.7 Clinical Liaison and Discharge Team (CLAD) The purpose of this team is to play a pivotal role in optimising patient access and discharge for elective and emergency inpatient care activity. This involves working closely with Divisional Matrons and Waiting List Co-ordinators and Ward sisters to ensure a forward thinking and planning approach to the provision of patient care services. Predicting discharges on a daily basis Provide a discharge planning service 7 days per week Facilitating palliative care discharges for those patients wishing to go home to die Raising awareness regarding resources available to facilitate safe effective and timely discharges Actively working to achieve no delays in patient discharge. Attending case conferences as required. Investigating complaints re complex discharges. Coordinating discharge audits. Monitoring and maintaining an up to date database on delays in discharge. Offering advice and working with internal and external stakeholders to resolve issues. Communicating with the patient and relatives, using support mechanisms i.e. interpreting service or key workers to ensure the patient is able to understand what is being said to them Delivering effective discharge training for clinical staff and recording training. Ensuring all groups of staff adhere to Gateshead Health NHS Foundation Trust discharge policy. Empowering, supporting and educating colleagues within the ward/dept areas with regard to complex discharge issues. 3.8 Night Site Manager There are two strands to this role: As Bed Manager to participate in a 24/7 rota to provide timely and appropriate allocation of beds for all emergency and planned admissions to the Trust, ensuring waiting time directives are adhered to. As a Night Site Manager to be responsible for the overnight site management of the hospital and delivery of services. 3.9 Matrons are responsible for: The Division Matron s role is to proactively action issues identified within their area of responsibility. They are also available to provide support and advice to the ward team and to support the team in the management of effective discharge. 7
The Matron will provide support and advice to ward staff when they experience difficulty in identifying patients suitable for boarding. Work with the Clinical Leads to ensure that patient pathways are streamlined to prevent delays. Support nursing staff to ensure safe and timely discharge. Ensuring all admissions are allocated an appropriate bed in area of responsibility within agreed access time and thus preventing cancellations due to bed availability. Facilitation of bed meetings. 3.10 Ward Sister/Charge Nurse (delegated to Nurse in Charge) The Ward Sister/Charge Nurse is responsible for empowering ward staff and other members of the multidisciplinary team (MDT) to achieve effective and timely discharge. Ensure that the person in charge is identified on each shift to provide regular updates on: o Current bed availability o Transfers to/from Critical Care o Expected discharges over the next 24 hours When delegated e.g. to the ward clerk, the Nurse in Charge will be held accountable for the information being correct and timely Ensure that systems are in place on the ward so that the patient is reviewed on a daily basis by a healthcare professional to confirm that the patient is on target with their discharge plan Vacated beds are confirmed immediately to the bed manager as soon as they occur and terminal cleans are carried out promptly Highlight to the relevant clinical team/bed manager any instances when they assess that a patient should be transferred to Intermediate Care and Critical Care Identify any potential delayed discharges to the Clinical Liaison and Discharge Team to try and avoid delays Make certain that individual nurses on the ward plan the discharge of their patients from admission Arranging for discharges to be completed on the morning of the day of discharge (prior to 10am) and for ensuring relevant support services (Pharmacy, Transport) are given timely notice of discharge Ensure staff understand the bed management and escalation policy and the discharge policy and are updated of any changes Ensure staff understand that at times wards will be expected to: o Take boarders o Boarders will be placed in an appropriate part of their ward following an infection control risk assessment o Move staff to another area to support the delivery of clinical care The ultimate responsibility for providing accurate bed state updates rests with the Ward Sister/Charge Nurse (or nominated deputy). He/She must keep the appropriate Matron aware of any concerns about staffing and/or the implementation of this policy 8
Ensure that all patients have an up to date discharge plan and an estimated discharge date Escalate delays or problems that may affect the patients pathway e.g. delays with tests, specialist input Ensuring that at least 2 patients are identified per day for morning discharges Proactively working with the medical staff to identify patients who are appropriate for boarding Ensuring that appropriate infection control risk assessments are carried out before a patient is transferred to another area Identifying, booking and facilitating ward staff attendance at discharge and infection control training as per the ward and Trust s training needs analysis. 3.11 Allied Health Professionals Are responsible for working with the MDT to ensure that the patient is progressing in a timely way to achieving their discharge goal Highlighting to the Nurse in Charge any barriers to effective and timely discharge 3.12 Named Nurse/Midwife are responsible for Co-ordination and pro-active management of patient care from admission to discharge / transfer, reinforcing the estimated date of discharge with all team members involved in the patient s care and that the patient is discharged as soon as they are clinically stable and fit for discharge by ensuring: A full assessment of social circumstances is undertaken on admission. A full assessment of the patient s status re transmissible disease / infection. The relevant documentation is completed on admission and is updated throughout the patient s stay. The patient s physical norm is identified on admission and when it is achieved so that discharge is not delayed due to non-recognition of their maximum capabilities. Timely investigations and follow up of results. Early communication with relatives, carers and/or professionals in the primary care setting occurs. Referrals to the relevant multi-disciplinary team members are made in a timely fashion and the team is kept updated regarding the patient s progress. Documentation reflects involvement of the Multi Disciplinary Team. Patients who do not require acute care are identified to the Nurse in Charge/ Discharge Liaison Team so that appropriate arrangements for alternative care until hospital discharge can be made. Patients and relatives are informed when patients are to be boarded to another ward. Available beds are used in a timely manner. Completion of discharge/transfer communication proforma is completed 9
Individual discharge training needs are identified with their Ward Manager and actioned 3.13 A&E Senior Sister and Clinical Lead are responsible for: Ensuring that the person in charge is identified on each shift to provide regular updates on current occupancy, and expected admissions and discharges over the next 2 to 4 hours Encourage A&E staff to identify potential patients for discharge and take appropriate action, including referrals to Primary Care, Social Services and Community Care Ensuring A&E staff understand this guidance in relation to all access targets Keeping the appropriate Matron/Assistant Divisional Manager updated about any concerns re staffing, infection control issues and/or the implementation of this guidance Specifically in A&E, the Nurse in charge of each shift is responsible for reporting and documenting as appropriate any concerns about stays over 3 hours so that appropriate action can be taken to prevent a 4-hour breach to the appropriate Matron/Assistant Divisional Manager. 3.14 Senior Nurse on Call: The Senior Nurse on Call from 5pm each evening and at any time over weekends/bank holidays will work with the Bed Manager / Night Coordinator and Matrons to ensure effective use of beds is maintained and the Accident and Emergency Department targets are met in conjunction with the Clinical Teams. 3.15 Organisation Chart Divisional Managers/Divisional Directors Assistant Divisional Managers/Clinical Leads Matrons Junior Medical Staff Infection Prevention & Control Team AHP CLAD Ward Sisters/ Charge Nurse Medical Teams Bed Manager 10
3.16 Reasonable Adjustment: The Disability Discrimination Act (2005) places a duty on all public authorities when carrying out their functions, to have due regard to the need to promote equality of opportunity for people with disabilities. The Act states that the duty requires public authorities to have due regard to the need to take steps to take account of the disabled persons disabilities, even where that involves treating disabled persons more favourably than other persons. Staff are expected to use their judgement to act appropriately in order to meet the needs of patients with disabilities. An example of a reasonable adjustment may be to situate a disabled patient who is prone to falling closer to a nurses station. If a patient with a learning disability finds the noisy or busier areas of a ward distressing, it may be more appropriate to move them to a quieter bay or room following discussions with the patient and their carer. 3.17 Privacy and Dignity: Every patient has the right to receive high quality care that is safe, effective, and respects their privacy and dignity. This is one of the guiding principles of the NHS constitution and at the core of local NHS visions. Gateshead Health NHS Foundation Trust is committed to providing every patient with same-sex accommodation, helping to safeguard their privacy and dignity when they are often at their most vulnerable. This means providing a same sex sleeping area, bathroom and toilet facilities. When planning where a patient is to be accommodated every effort must be made to comply with the Trust s Safeguarding Privacy and Dignity policy (OP29). It is recognised that there are some exceptional circumstances where providing fast effective care for the patient may take priority over ensuring same-sex accommodation. Where mixing does occur, it must be in the interest of all the patients affected. It is also a judgement that needs to be revisited and reviewed regularly throughout the patient journey. It is not acceptable for people to share sleeping accommodation unless it can be clinically justified for each patient. Some of the circumstances in which this might apply are as follows: Patient needs very high tech care, with one-to-one nursing (eg ICU, HDU) Patient needs very specialised care, where one nurse might be caring for a small number of patients and cannot safely leave the room other than for very short periods (eg immediately following major surgery) Patient needs very urgent care (eg rapid admission following a heart attack) Assessing the Accommodation: 11
Men and women should not normally have to share sleeping accommodation or toilet facilities Single-sex accommodation can be provided in: Single-sex wards (i.e. the whole ward is occupied by men or women but not both) Single rooms with adjacent single-sex toilet and washing facilities (preferably en-suite) Single-sex accommodation within mixed wards (i.e. bays or rooms which accommodate either men or women, not both; with designated single-sex toilet and washing facilities preferably within or adjacent to the bay or room). In addition patients should not need to pass through opposite sex accommodation or toilet and washing facilities to access their own. What happens when mixing is unavoidable? When mixing men and women is unavoidable, every reasonable effort should be made to rectify the situation as soon as possible. Until that time, staff may need to take extra care to safeguard privacy, particularly in sleeping and sanitary areas. In all instances where mixing of men and women is unavoidable, the patient, their relatives and carers, should be informed of why the situation has occurred, what is being done to address it, who is dealing with it and some information as to when it may be resolved. If mixing does occur this will be documented by the Bed Managers and discussed by the Matrons at the regular bed meetings. If it is felt that the patients care has been compromised a datix will be completed and an action plan developed. Any episodes will be reported by the PALS lead to the Privacy and Dignity Steering Group. 4. BED MANAGEMENT PROCESS The Bed Manager liaises with the Matron and Clinical Liaison and Discharge Team on a daily basis identifying those patients whose discharge is delayed and who are suitable to be cared for in another area. The Ward Manager/Nurse in Charge will have ensured that the following information is clearly documented on ward allocation boards. This information will be agreed by the ward team during handover at the beginning of the morning, afternoon and evening shifts and will be updated by the Shift Co-ordinator as the situation changes throughout the 24-hour period. (B) (H) To denote patients suitable for boarding To denote patients planned to be discharged and the time this is 12
(?H) expected to take place To denote patients who could potentially be discharged The Bed Manager and Clinical Liaison and Discharge Team (DLT) will visit each area on a daily basis and review all current in-patients with the Ward Manager / Named Nurse / Deputy with a view to determining suitability for discharge / transfer from the acute ward area. The Clinical Liaison and Discharge Team will pick up any discharge issues, which cannot be resolved at ward level. The appropriate Specialty Matron will be kept informed of the blockages and the DLT will support the Named Nurse / Deputy, Ward Manager and Matron in further investigation into ward processes where discharge issues are identified. These patients will be identified to the Clinical Liaison and Discharge Team to take advice and utilise her expertise. If appropriate the Clinical Liaison and Discharge Team will work with the Named Nurse and Ward Manager to resolve any issues. The Clinical Liaison and Discharge Team will identify all patients whose discharge into Nursing Home / Residential Care is delayed and will assist the ward staff to progress any issues identified, liaising with Social Worker Teams and Complex Discharge Co-ordinator as required. The Speciality Matron will be informed of any blockages in this process. In the event of Trigger levels not being reached, it will be necessary to alert and advise the Matrons as described below. 4.1 Reporting Mechanisms On Monday to Friday there is an emailed handover from the Night Site Managers to the Divisional Managers, Bed Managers, Waiting List Coordinators, Assistant Divisional Managers and Matrons. Meetings are then held at 11am; 3pm with the appropriate staff if the Trust is on green. Frequency of meetings may change when the Trust is on amber and red at the discretion of the matrons, Bed Managers and Senior Nurse On Call. Appendix 1 outlines the recommended format of the bed meeting. 4.2 Bed State Throughout the day the bed state will be updated using the bed monitoring proforma including: (See Appendix 2) Number of empty beds by ward, specialty, male/female and side wards. Number of patients expected to be discharged that day. Number of patients boarded out or awaiting transfer to other hospital sites. Number of beds blocked by patients awaiting arrangements for discharge and the reasons for these delays. Number of patients waiting for isolation facilities. Potential patients who will be ready to come out of Critical Care the next day. Number of electives due to come in the next day. 13
It is the responsibility of ward staff to provide accurate and timely information. The Divisional Matron will review the position with ward staff, particularly at times of pressure. 4.3 Patients Awaiting Admission The Bed Manager will be informed of patient admissions and demand for beds by nurse co-ordinator in A&E, Waiting List Managers and Matrons. The following information will be recorded on the Waiting for Admission proforma: Time of admission to A&E Department. Time notified of bed requirement. Patient details including clinical condition and infection status. Awaiting specialty. Source of admission. Contact number of patient (for elective admissions). Time and area of bed allocation. Admissions will be prioritised by the Matron in times of bed shortages depending on clinical need. However, all listed patients will be admitted within the shortest time scale possible, meeting the 4-hour target. For some patients with unstable conditions and clinical uncertainty, the G.P may wish (or insist) that the patient is to be admitted to the Accident & Emergency department, (if an acute bed is not immediately available) for potential resuscitation. 4.4 Trigger Levels and Escalation Trigger levels denote the number of available beds on the Queen Elizabeth Hospital site at which point concern may be raised regarding the ability to effectively manage admissions promptly and within routine procedures. Appendices 3-5 are action cards for each speciality to follow in the event of pressures in their particular speciality using a traffic light system. When all areas are under pressure and in amber / red alert additional action is outlined in Appendix 6. Appendices 7-17 provide additional information that may be required to support the bed management and escalation processes. 5. EARLY SUPPORTED DISCHARGE & ALTERNATIVES TO ADMISSION Several services have been developed to provide an alternative to hospital admission and support early discharge: CROP Team The Urgent Care Team 14
Gateshead Intermediate Care Team Walk In Centre at Bensham Hospital 6. TRANSFERRING OR BOARDING OF PATIENTS. 6.1 Roles & Responsibilities When a Patient is Transferred. When a patient is transferred within Gateshead Health NHS Foundation Trust or to another hospital or organization, the medical staff are responsible for providing documentation / communication regarding the patient s medical condition and treatment / management plan. The Named Nurse / Deputy is responsible for coordinating the transfer process, communicating verbally with the receiving ward to give an overview of the patient s previous care and must complete the appropriate communication proforma as a minimum requirement as per Gateshead Health NHS Foundation Trust Hospital Discharge Policy (OP13). Patient transfers should take place between the hours of 0900 2200 hours with the exception of those patients being transferred for a clinical need or from assessment units such as CCU, Critical Care Department and A&E to a base ward. 6.2 Transfer following resuscitation. Gateshead Health NHS Foundation Trust Resuscitation Policy (RM27a) includes guidance regarding post-resuscitation care and subsequent transfer as it interfaces with this policy staff must ensure it is read in conjunction with this document. 6.3 Transfer as a result of being boarded In the context of this policy, a boarder is defined as: A patient residing on a ward outside their admitting specialty. Patients who are suitable to board are those who are: Medically stable Ready for discharge Not confused or suffering from dementia It is acknowledged that, at times, there will be no patients that fit this criteria. Under these circumstances the clinical teams will be expected to make decisions based on their professional judgement, to identify patients to move. In the event of patients being boarded the Named Nurse / Deputy or nurse in charge will explain this to the patients and relatives, if possible, in a manner appropriate to the patient s individual needs accessing the support of the interpretation services or support worker if required. 15
If the relatives are not present it is the responsibility of the Named Nurse / Deputy transferring the patient to notify the next of kin / person to notify of the patient s transfer, when possible, and ensure that this is documented on the transfer communication proforma. The boarding 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 a supply of appropriate beds. The decision to board patients will be co-ordinated by the Bed Manager. While there are no protected beds within the hospital all beds that are planned for elective admissions later that day or the following day should be last in line to board to. The Bed Manager will liaise with the Matron from the Division to which patients are boarded at the regular bed meetings. The Bed Manager should inform the appropriate wards of the arrangements to transfer or board a patient. As stated above Ward Staff on the transferring ward will remain responsible for providing necessary clinical detail to facilitate arrangements. When it is necessary to board from one specialty to another it is best practice to allocate a single bay to accommodate the patients from the boarding specialty whenever possible. Advice must be sought from the Infection Prevention and Control Team for any patient/s with a known or suspected infection. The boarding of patients should take place between the hours of 09:00 and 22:00 each day. Only in exceptional circumstances will the moving of patients occur outside these hours or during protected mealtimes. No patient should, during their stay, be boarded out more than once. This does not include transfers from any subsequent transfer to the care of another Consultant or Specialty for a clinical need. The dignity and quality of care given to the patient will be maintained throughout the transfer or boarding process (OP 29). Staff must use their professional judgment when attempting to move patients who would be clearly distressed by the move e.g. patients with learning difficulties or there is knowledge that the family have raised strong concerns. When patients are boarded out from the specialty, which would normally receive the admission, it becomes the responsibility of the receiving ward and patient s consultant team to ensure they receive the same standard of care. If needed, advice can be sought from the specialty Matron. Action on boarding out should be implemented as far as possible between the above hours in order to avoid patient transfer at unsociable times. Patients should, in normal circumstances, be boarded onto the most suitable ward with regard to the clinical care required for the individual patient. Circumstances such as skill mix, infection status on the receiving ward should be taken into consideration. 16
Information on patients boarded into different specialties will be reported on a daily basis through the SITREP report in line with DH guidance. This report / information will be shared with the Divisional Managers and Assistant Divisional Managers at the weekly Achieving the Targets meeting. When transferring (either within Gateshead Health NHS Foundation Trust or to another hospital / organization) boarding or receiving a patient all nursing documentation must be updated It is the responsibility of the Named Nurse / Deputy to make an assessment of the patient s needs to determine if an escort (qualified or unqualified) is required to accompany / stay with the patient when they are being transferred to another ward, department or site within Gateshead Health NHS Foundation Trust. This decision will depend upon the patient s clinical & nursing needs and may require further discussion with the relevant receiving department or Medical staff to confirm. The Named Nurse / Deputy on the base ward must ensure the appropriate documentation (see below) accompanies the patient to the receiving ward / dept / theatre. Appropriate transfer communication proforma & infection control assessment screening tool Documentation including patient assessment, care plan, risk assessments and evaluation Medical notes (Records Management Policy OP10) Consent form / relevant pre-op / pre investigation checklist (if appropriate) Investigation results e.g. X-Rays etc Observation/ monitoring charts Discharge checklist Up to date property list Prescription sheet Specialist medications (if oxygen ensure adequate supply with patient) Hand held patient notes. Specialist equipment (e.g. cardiac monitor, infusion device - ensuring in good working order with battery backup if necessary) (see individual appendices for specific transfer requirements to/from specialist areas within Gateshead Health NHS Foundation Trust) If it is deemed that a patient is to be transferred for a clinical reason or boarded out of hours the process described above will still apply. If the patient is to be transferred to a healthcare organisation outside of Gateshead Health NHS Foundation Trust then the process described in the medical records policy (Records Management Policy OP 10), section 4.1, must be followed, for any queries relating to the transfer 17
out of hours, then the Senior Nurse on call must be contacted for advice. 7. RECEPTION OF PATIENTS DIVERTED FROM OTHER TRUSTS On occasions Gateshead Health NHS Foundation Trust may be asked to accept admissions from other hospitals who are experiencing bed shortages. Under normal circumstances such admissions will be accepted. However, if this situation arises during periods of Gateshead Health NHS Foundation Trust bed shortages we will accept such admissions only when we have more than the trigger level of beds in the specialty required, taking into account an overview of the bed state across the Trust. The decision to accept/refuse admissions from neighbouring hospitals will be made by the Senior Nurse on Call in close collaboration with the Director on Call and after taking advice from the Divisional teams. In accepting admissions from neighbouring (host) hospitals it must be made clear to the requester that GPs should continue to refer to the host hospitals admitting medical team. This will ensure that beds at the normal host hospital are used as they become available and the number of extraordinary admissions to Gateshead Health NHS Foundation Trust can be monitored. 8. CONTROL OF INFECTION The term Health Care Associated Infection (HCAI) encompasses any infectious agent acquired as a consequence of a person s treatment by the NHS or which is acquired by a health care worker in the course of their NHS duties. The prevention and control of HCAIs is a high priority for all parts of the NHS. Effective prevention and control of HCAIs has to be embedded into everyday practice and applied consistently by everyone (The Health Act 2006: Code of Practice for the Prevention and Control of Health Care Associated Infections). All Infection Prevention and Control policies are available on all wards. The Trust Infection Prevention and Control Policy (IP1 26) outlines roles and responsibilities for all Trust personnel. The MRSA/Multi Drug Resistant Policy must be read in conjunction with this policy. On admission and transfer of every patient referral must be made to the Infection Control Risk Assessment tool (appendices 2). The tool must be completed on admission and transfer of the patient to any ward/department within the Trust. The known infection/colonisation record (KIC) (Appendix 19) must also be completed and updated as necessary in the front of the patient s medical record. Screening of patients is specific to planned treatment or current circumstances and advice is always available from a member of the IPCT. Effective communication i.e. teamwork is essential between the Infection Prevention and Control Team (IPCT) and Bed Managers. They will work in 18
close collaboration for admission, transfer, discharge and movement of patients between departments and other health care facilities. Other relevant external agencies will be involved/informed as necessary. Reducing the risk of transmission of infection within the hospital is an essential component of the bed management strategy (DoH 2003 Winning Ways Working Together to Reduce Associated Health Care Infection in England). Patients admitted to hospital with a suspected or known infection should not be admitted to wards in which severely immunosuppressed patients are nursed or patients having undergone recent joint replacement/implant surgery e.g. patients with a suspected Group A Haemolytic Streptococcus throat infection (quinsy) should not be admitted to an orthopaedic surgical ward. All patients with a diagnosis of cellulitis must be nursed in a side-room or placed in a bay with similar or low risk patients following discussion with the IPCT. In the event of a higher than normal incidence of an alert organism / condition e.g. Clostridium difficile associated diarrhoea or an outbreak of an infections disease e.g. Norwalk Virus, M.R.S.A, Rotavirus, patients must not be transferred to other wards or hospitals without discussion with the Infection Prevention and Control Team. Any patient considered to be an infection risk to other patients must be risk assessed in order to decide on the most suitable placement of the patient e.g. single room. The following factors must always be considered a) Reduce the risk of transmission of infection by minimising the movement of potentially infected patients. b) Inform the receiving ward in advance of the transfer of all clinical and infection information. c) Constant assessments need to be made before transferring patient s intra and inter wards. However the infectious status of a patient should not prevent a patient moving for a clinical need. Ward staff to contact IPCT and Bed Manager. Named Nurse to fully document and verbally hand over the patient ensuring that the known infection colonisation (KIC record) (Appendix 19) is up to date and any check, screening swabs or specimens have been collected or planned for.(please refer to appendix 20). If a member of staff is in any doubt regarding the placement of patients with a known or suspected infection they should refer to the Infection, Prevention and Control policies or contact the IPCT for advice. During office hours the IPCT can be contacted via bleep 2057 (nurse) or out of hours, the Microbiologist via the Queen Elizabeth switchboard. Risk Assessment A risk assessment must always be made by the nurse/doctor admitting or caring for the patient in conjunction with the Bed Management and Infection Prevention and Control Team. 19
The following issues must be taken into account; a) The virulence of the organism that the patient is suspected or known to be isolating. b) The level/numbers of immunosupressed patients nursed within the ward. c) The type of surgical procedures undertaken and nursed within the ward area. d) Every effort must be undertaken to segregate elective and segregated admitted patients. Discharge home should not be delayed because of MRSA carriage. Contact the IPCT for advice giving information of estimated date of discharge. Clear written guidance regarding the patient care in the community should be completed on the discharge checklist. Any infectious investigation results received after discharge should be notified to the patients GP by the ward team. 20
Assessment for Emergency & Planned Admission for Patients Who Are Posing A Potential Colonisation/Infection Risk (in order to reduce the transmission of infection) Joint planning between IPCT and Bed Management for planned patient admission, transfer and discharges and movement between departments and other health care facilities. Patients considered to be isolating an alert organism/condition (please refer to separate flow chart for the routine assessment of patients presenting with possible viral gastroenteritis) It is essential that patients presenting with an infection or who acquire an infection during treatment are identified promptly and managed according to good clinical practice for the purposes of treatment and to reduce the risk of transmission. Refer to the Isolation Policy for guidance regarding the need for isolation nursing Reduce movement of patients If isolation nursing is required can the patient be admitted to an appropriate single room in the main hospital NO An appropriate single room is not available YES Admit patient to a single room and commence isolation nursing precautions Determine if an isolation room can be made available by performing a risk assessment relating to the: 1. Area of the hospital/specialty where the patient is to be nursed 2. Virulence of the infection/organism 3. Route of transmission 4. Infectious status of patients currently occupying the single rooms Exclusions: Patients with sputum carriage of MRSA and who have a productive cough or patients with a skin condition where excess shedding of the skin can be expected must not be moved out of a single room Patients in a high risk area e.g. Critical Care or Orthopaedics must not be moved out of a side room without discussion with IPCT or Night Site Manager NO Single room not available; contact the IPCT or out of hours the microbiologist on call. YES Single room made available. Admit patient and commence isolation nursing. 21
Flow Chart for Management of Patients with Suspected Viral Diarrhoea & Vomiting March 2008 Suspected Viral Case Able to admit to side room No side room available Yes Admit and fully document risk reduction actions and precautions taken in the patient s care plan. Obtain a stool specimen and clearly indicate on the request card that viral illness is suspected Admit to bay following discussion with the 2057 bleep holder or out of hours microbiologist on call No closed bay available Determine if an isolation room can be made available by performing a risk assessment relating to the: 1. Area of the hospital/specialty where the patient is to be nursed 2. Virulence of the infection/organism 3. Route of transmission 4. Infectious status of patients currently occupying the single rooms Exclusions: Patients with sputum carriage of MRSA and who have a productive cough or patients with a skin condition where excess shedding of the skin can be expected must not be moved out of a single room Patients in a high risk area e.g. Critical Care or Orthopaedics must not be moved out of a side room without discussion with IPCT or Night Site Manager Yes No further action No Side room not available following risk assessment Admit patient to non D&V bay in close bay. Notify as critical incident. 22
9. MONITORING EFFECTIVENESS OF THE POLICY To ensure the effectiveness of this policy the Divisional Managers or nominated deputies will liaise with the appropriate groups of staff to monitor: - Datix forms over the previous year that highlight: 1. exceptions with regard to Privacy and Dignity. 2. inability to isolate an infected patient Number of incidents raised in PALS report highlighting any privacy and dignity, boarding or bed management issues. Number of incidents raised in the Patient Tracker system with regards to privacy and dignity, boarding or bed management issues. Number of incidents raised in formal Complaints reports with regards to privacy and dignity, boarding or bed management issues. Number of elective patients cancelled due to lack of bed availability The above information will be shared with the SafeCare Council and then shared and cascaded to individual Divisions via the SafeCare Leads, Assistant Divisional Managers and Matrons 10. EQUALITY AND DIVERSITY. The Trust is committed to ensuring that, as far as is reasonably practicable, the way we provide services to the public and the way we treat our staff reflects their individual needs and does not discriminate against individuals or groups on any grounds. This policy has been appropriately assessed. 11. REFERENCES Department of Health (2004) Achieving timely simple discharge from hospital: A toolkit for the multi-disciplinary team. DOH, London Department of Health (2003) The Community Care (Delayed Discharges etc) Act 2003: Guidance for Implementation. The Stationary Office, London Department of Health, (2000) The NHS Plan: A Plan for Investment, A Plan for Reform. The Stationary Office, London The Health Act 2006: Code of Practice for the Prevention and Control of Healthcare associated infections Department of Health (2003) Winning Ways Working Together to Reduce Associated Health Care Infection in England. The Stationary Office, London City Hospitals Sunderland Bed Management and Patient Transfer policy 23
South Tyneside NHS Foundation Trust Effective Bed Management Guideline 12. ASSOCIATED DOCUMENTATION This policy must be read in conjunction with the following Gateshead Health NHS Foundation Trust Policies: See front page Infection Prevention and Control Policies (IC1 26) Safeguarding Patients Privacy & Dignity (OP29) Patients Access Policy (OP12) Discharge Policy (OP13) Resuscitation Policy (RM27a and RM27b) Records Management Policy (OP10) Vascular Rota and Patient Transfer Protocol (reviewed 2008) 24
Appendix 1: Bed Management Meetings Guidance Gateshead Health NHS Foundation Trust Actions to take place at Bed Meetings To be held routinely at 11am and 3pm, 7 days a week, more often if bed pressures. The Senior Nurse within medicine with patient flow responsibilities will facilitate and lead bed meetings. This will be the Band 7 holding bleep 1200 out of hours / weekends in negotiation and collaboration with the other 2 lead bleep holders. The Senior Nurse within medicine with patient flow responsibilities to receive information from Discharge Liaison Nurses every morning. As above at weekends. Infection Control Nurses to report any concerns on a daily basis to the Senior Nurse within medicine with patient flow responsibilities and to attend bed meetings when appropriate. As above at weekends. Up to date bed state required for each speciality, including number of cubicles available. Review electives to come in for each speciality and plan how they will be accommodated. At 3pm note number of electives expected the following day. Review Accident and Emergency pressures, noting next breach time and review of breaches that have occurred that day. Make a plan to accommodate patients awaiting discharge from Critical Care Department. At 3pm meeting make a note of patients who will be potentially ready for discharge from Critical Care the following day and make a plan to facilitate proactively. Monitor patients awaiting transfer back to QEH and make a plan to facilitate this. Review staffing position across the Trust and make a plan to support pressure areas. On a Friday and any day when there are particular pressures representative from Nurse Bank to attend. Staffing over weekend to be considered and planned for. On a Friday electives for admission over weekend to be discussed and plans made for accommodating. Concerns to be discussed with Senior Nurse On Call and relevant specialities. 25
Appendix 2: Bed Management Meetings Proforma SITE MANAGEMENT, ESCALATION & ACTION PLAN Date: LEADER: Attendance: - Time: BED MANAGER: Apologies Medical Bed State Green (fine) Amber (alert) Red (crisis) Surgical Bed State Green (fine) Amber (alert) Red (crisis) A & E Green (fine) Amber (alert) Red (crisis) Critical Care Green (fine) Amber (alert) Red (crisis) Breaches from 00:00hrs: Electives TCI: Medical Surgery Gynae/Onc Ortho Number of Boarders: Predicted Discharges from boarders PATIENTS AWAITING TRANSFER BACK FROM NEWCASLE HOSPITALS OR OTHER & PLAN FOR THEIR RETURN PATIENTS AWAITING TRANSFER TO NEWCASTLE ACTION / COMMENT Are we on call for vascular (indicate with a tick) Yes No Paediatric status: LEAD PERSON Plan for potential Critical Care patients to come out (at 3pm meeting plan for next day) and number of elective admission anticipated Number of elective admissions for next day (at 3pm meeting) Med Surg Ortho Gynae Other 26
Speciality and Ext 1 Acute older person - 5901 2 Acute older person - 2002 3 Stroke 2003 4 Respiratory 2004 5 Cardiology 2005 6 Escalation 2006 11 Gastroenterolo gy 2011 Total No. Beds In Use (cubicles) 24 (6) MEDICINE Total No. of Male/Female Beds 24 (6) F 11, M - 13 23 (2) F 11, M 11 1 either/or Male Female Cub Stroke Beds Available 1F 1M 25 (2) F 14, M - 10 NIV Bed available? 24 (4) F 9, M 12 4 either/or 8 (4) F 4, 4 either/or State if 24 (4) F 9, M 11, 4 either/or open 12 PIU 2825 Additional beds (Resp/gastro/g en med) 2012 17 Rheu/Haem/Di ab 2017 CCU Cardiology SSOU 2018 Short Stay 3965 PIU = 10 BED Additional beds 18 (6) plus a further 2 if needed 24 (14) 8 (2) 22 (2) MAU 5916/5906 15 (5) Ass Area 3990 9 TOTALS F 5, M 5 F 6, M 6 6 either/or Total of patients to accommodate: MAU GP s A&E Leaves: 9 General Surgery 2009 10 General Surgery 2010 14 Orthopaedics 2014 14 Orthopaedics 2014 Crit 2 2008 Crit 3 2007 SURGERY 29 (5) All male 30 (6) All female 30 (5) F 10, M 10 6 either/or 22 (6) F 10, M 10 6 either/or Combined 16 JUBILEE 21 Orthopaedics - 2021 18 (6) F 8, M 4 6 either/or 22 Stroke Rehab - 2022 24 (6) F 13, M - 11 23 Dual Care - 2023 24 (6) 24 General Rehab + 24 (6) F 11, M - 13 CROP - 2024 25 General Rehab + Ortho - 2025 1 Elective Orthopaedics - 3004 24 (6) All Female TREATMENT CENTRE 30 All single rooms 27 Additional beds open? 2 Elective Surgery - 3005 30 All single rooms (20 beds Fri, Sat, Sun) DUNSTON HILL HOSPITAL
Mgt Dryburgh Ward - 6455 22 (3) St Bedes - 6526 8 (4) Springwell - 6466 10 (8) Male only Saltwell 6210 18 (6) Sunniside - 6202 20 (8) 28
Appendix 3: Division of Medical Services Action Cards Division of Medical Services Action Card for GREEN bed status The majority of the following will be present to indicate a green bed state within the Medical Division. Key indicators will be: Able to accommodate electives Able to accommodate patients awaiting transfer from Newcastle on a timely basis Able to accommodate Critical Care Department discharges A & E Department functioning safely Beds sufficient to meet emergency demand within 4 hour target Less than 10 outliers in other specialities Routine action required on a daily basis Monitoring of A & E times Proactive management of electives admissions with TCI list published the week before Twice daily multi-speciality bed meetings to be facilitated by person with Patient Flow Duties in conjunction with designated person from other specialities (see action card for format of bed meetings) Update from Discharge Liaison Team every morning Continue regular review of in patients with a proactive plan for discharge with the medical staff Review all outliers on a daily basis with proactive plan Review of potential discharges from Critical Care indicating to Bed Manager which ward patients should be discharged to Review of patients that maybe suitable for transfer to Jubilee Wing Identification of patients suitable for Ward 23 Publication of daily outliers list Early identification of appropriate patients for transfer to Dunston Hill Hospital Daily liaison with Community Matrons regarding patients who potentially need their input Weekly meetings with Social Services At Friday 3pm bed meeting review with Surgical/Orthopaedic/Gynae Divisions the admission list for following week so plan can be made for the weekend. By whom A & E co-ordinator and Bed Manager for Medicine PIU staff in conjunction with Bed Managers and secretaries Matron with patient flow responsibilities Discharge Liaison Team with member of Medical Division office staff Nursing and medical staff on the ward Medical Staff Relevant nurse practitioners Discharge Liaison Nurses Medical Staff Older Persons Team Nurses Mental Health Team Discharge Liaison Nurse / Team Older Persons Team Nurses Ward staff Discharge Liaison Nurse Discharge Liaison team Team at Bed meeting 29