Approved by: Transfer or Discharge of Patients Addiction & Mental Health Program - Senior Operating Officer, Mental Health & Seniors Care Edmonton Corporate Policy & Procedures Manual Number: VII-B-230 Date Approved December 1, 2016 Date Effective December 9, 2016 Next Review (3 years from Effective Date) December 2019 Purpose To facilitate the safe transfer or discharge of patients from an acute inpatient mental health unit. Policy Statement Covenant Health staff and physicians shall adhere to the requirements and responsibilities identified in this policy and procedure to facilitate a coordinated approach for the transfer or discharge of patients from an acute inpatient mental health unit. Applicability This policy and procedure applies to all Covenant Health acute inpatient mental health programs, and the staff and physicians working within those programs. Responsibility Identified within procedure. Procedure 1. Transfer of a patient to a receiving unit/facility 1.1 Prior to any transfer of a patient, staff at the referring facility will first determine whether the patient is a Formal or Informal Patient. 1.2 In accordance with Section 23 of the Mental Health Act, formal patients may be transferred between unit/facility for the purpose of providing hospital treatment not available at the referring unit/facility and returned to the referring unit/facility upon conclusion of the treatment. 1.3 In accordance with Section 22(1) of the Mental Health Act, formal patients being transferred from a referring unit/facility to a receiving unit/facility shall be transferred under a Form 6. 1.4 Staff will ensure that any transfer is planned and coordinated and takes in to consideration the following, but not limited to: a) degree of urgency/immediacy of transfer; b) appropriateness and readiness of site/facility patient is being transferred to (i.e. type and acuity of receiving unit); c) patient s observation level; d) requirement/availability of appropriate escort; e) patient s condition including mental status;
VII-B-230 Page 2 of 6 f) patient s assessed risk at time of transfer and current level of risk to self and others; g) patient s treatment plan; and h) patient s schedule of medication and use of unscheduled (i.e, as-needed medications). A written physician s order of necessary and unscheduled prescription medication is required. 1.5 Where transport is necessary, prior to Emergency Medical Services (EMS) or support services being booked for the patient transfer to an alternate unit/facility, there must be a physician s order on the patient care record authorizing the transfer. 1.6 In circumstances where patients are being transferred to an alternate unit/facility, the referring or sending unit will be responsible for making arrangements for the transfer, confirming the name of the accepting physician and designated unit/facility with all parties but not limited to, the receiving unit, the receiving physician and Protective Services (where applicable). 1.7 In emergency situations, when a patient is unable to agree to transfer, the patient s agent/guardian/nearest relative or family member will be advised as soon as possible (subject to the immediacy of the situation). 2. Documentation and reporting of a patient s condition prior to transfer to a receiving unit/facility 2.1 The patient s health care professional from the referring unit shall provide: a) a verbal report of the patient s condition to the receiving unit; and b) a detailed report of the patient s condition to the Emergency Medical Service staff involved in transferring the patient.. 2.2 The report about the patient s condition (per Sec. 2.1) shall include, but not be limited to the patient s: a) level of risk to harm self and others; b) observation level; c) status under the Mental Health Act. d) mental state; e) physical condition, including any infection prevention information as appropriate; f) treatment plan;
VII-B-230 Page 3 of 6 g) medications and allergies; and h) any additional information that may be pertinent to the safe transfer of the patient (e.g., patient access to personal property).harm self and others; 2.3 The agreement and plan of the patient transfer will be documented in the patient s health record. Copies of all appropriate patient care record documentation will accompany the patient on transfer. 2.4 Confidentiality of all patient care records and information transferred between units/facilities must be maintained by staff involved in transferring patients. 3. Accompanying a patient to an appointment within a facility 3.1 Patients being accompanied to appointments within a facility will be assessed by staff prior to being transported/accompanied/escorted and staff will consider the following: a) patient s observation level; b) patient s condition and mental state; c) patient s assessed risk at time of transfer to an appointment including the patient s level of risk to self and others; d) patient s treatment plan; e) patient s schedule of medication and use of prn (a written physician s order of prn, and; f) requirement/availability of an appropriately trained escort. 3.2 An appropriate level of staff member (and/or support services) will be identified to accompany patients to appointments within facilities where the assessment in section 3.1 deems attendance at the appointment at that time necessary and is in the patient s best interests. 3.3 Where required, ongoing care/treatment will be provided by appropriate staff during any accompaniment of patients between departments within a facility. 3.4 The referring unit remains responsible for the care of the patient throughout the off-unit appointment including those circumstances where a patient is not accompanied to an appointment.
4. Discharge against medical advice VII-B-230 Page 4 of 6 4.1 If a voluntary inpatient from an acute mental health unit wishes to selfdischarge (i.e., leave against medical advice) nursing staff should ascertain the reasons why the patient wishes to leave and where possible, staff should encourage the patient to stay, until assessment by a psychiatrist, or designate, can be completed. If appropriate to the situation, staff could offer a quiet place to reconsider their decision, and/or engage them in a meaningful conversation. 4.2 Where possible, the attending psychiatrist/on-call physician will be called to see a voluntary patient wishing to self-discharge themselves, prior to their leaving the unit to assess the patient. 4.3 At the discretion of the nursing staff, if immediate action is necessary to prevent imminent harm to the patient or others, a patient may be detained until a psychiatrist can assess the patient. The attending psychiatrist/on-call physician will be made fully aware of the immediacy of the situation. 4.4 The most responsible health care professional shall document the selfdischarge (discharge against medical advice) on the patient s health record. Details of the discussion he/she had with the patient, including an explanation of the risks/consequences of the self-discharge, should be noted on the patient s health record. 5. Follow up of patients after discharge 5.1 For ALL patients, the health care professional shall ensure there are appropriate arrangements for follow up. Reasonable attempts will be made to ensure: a) An appointment for follow-up care is to occur within a maximum of seven calendar days with an appropriate health care provider (e.g., General Physician, outpatient mental health provider, other support provider). Staff will provide the patient with telephone numbers as appropriate and document this in the patient health record; or b) Arrangements are in place for a follow up telephone call within seven days of discharge. 5.2 If the follow up plan includes a telephone call, the patient is to be informed of the purpose of the call prior to discharge. Any requests of the patient regarding this call should be taken into account as much as possible (e.g., leaving messages on voicemail, time of day of the call, etc.) This call is to be made by a health care professional authorized to perform a restricted activity. 5.3 Upon contacting the patient by telephone, the health care provider shall find out how the patient is managing since being discharged.
VII-B-230 Page 5 of 6 a) If the patient reports they are managing well, then the health care professional shall simply offer continued support, answer any questions the patient may have, and document the call for retention in the health record. b) If the patient reports they are not managing well, then the health care professional shall perform a risk screen and/or assessment. If risk is high/imminent, the heath care professional shall activate, as appropriate, the local process for urgent or emergent care, document the information, and submit the completed documents per local processes for retention in the health record. If risk is low/moderate, the health care professional shall ensure that the patient has a safety plan in place and contact information for crisis assistance services, and then document the information and submit the completed documents per local processes for retention in the health record. 5.4 If the health care professional is unable to contact the patient or the patient s emergency contact, the health care professional shall: a) notify the follow-up health care provider; and b) document the attempts to contact the patient. Note: Professional judgement shall determine if there is a concern for the safety of the patient. In such a case, consent is not required prior to contacting the emergency contact. 5.5 For patients who have been identified as being at elevated risk for suicide during their admission, the health care professional shall ensure that the patient has a copy of his/her personal safety plan. With appropriate patient consent, the receiving health care provider shall be provided with a copy of the patient s personal safety plan. 5.6 In accordance with Section 32 of the Mental Health Act, staff will provide communication regarding the patient s discharge to the patient s agent guardian, nearest relative or family member (with consent); and Community Treatment Team and/or patient s family physician (if known), including the recommendations for treatment. Follow-up appointments for patients to attend out-patient mental health programs will be provided where appropriate. Definitions Health care professional means and individual who is a member of a regulated discipline, as defined by the Health Disciplines Act or the Health Professions Act, and who practices within scope or role.
VII-B-230 Page 6 of 6 Related Documents Covenant Health, Consent to Treatment/Procedures, P/P #VII-B-50 Covenant Health, Consent to Treatment/ Procedure(s) - Formal Patients and Persons Subject to Community Treatment Orders under the Mental Health Act, P/P #VII-B-65 Revisions December 6, 2013 October 15, 2012