discharge and transfer of children

8/20/2019 Discharge And Transfer Of Children

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Policy for the Discharge and Transfer of Children and Young People from Child Health


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Table of Contents

1. Introduction ......................................................................................................................... 3

2. Purpose of this Policy/Procedure...................................................................................... 3

3.

Scope ................................................................................................................................... 4

4. Definitions / Glossary ......................................................................................................... 4

5. Ownership and Responsibilities........................................................................................ 4

5.3. Role of the Con sultant Medical Staf f & Medical team .............................................. 4

5.6. Role of Nursing Staf f ................................................................................................... 5

5.7.

Role of Paediatr ic Disch arge Liaison ......................................................................... 6

6. Standards and Practice ...................................................................................................... 7

6.1. Discharge of Chi ldren/Youn g People witho ut cont in uing h ealthcare need ............ 7

6.3. Discharge of Chi ldren/Youn g people with Complex and Ongo ing Healthcare

Requirements ......................................................................................................................... 7

6.9. Discharge of Chi ldren and Youn g People in Specia l Circum stances ..................... 8

6.14. Discharge of Infants from the Neonatal Unit (NNU) .............................................. 9

6.15. Discharge of Chi ldren and Young people with Mental Health Issues ................. 9

6.16. Discharge from the Emergency Department ......................................................... 9

6.22. Transfer of Chi ldren and You ng People ............................................................... 10

6.23. Discharge invo lv ing Chi ldren and Yo ung People from The Isles of Sci l ly....... 10

7 Dissemination and Implementation 10


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1. Introduction1.1. This policy has been developed to support Trust Staff in the discharge and transfer ofchildren and young people. It is a requirement of the “NSF for Children Young People &Maternity Services” to have in place a policy that meets the specific needs of this group.This policy for discharge and transfer must be adhered to when discharging or transferringchildren and young people.

1.2. This policy states the responsibilities of the multidisciplinary team when dischargingor transferring children/young people from services. It conforms to guidelines for dischargefrom hospital laid down in the following documents:

DH: Working Together to Safeguard Children 2013 DH NSF For children young people and maternity services (2004) DH: Framework for Assessment of Children in Need and Their Families 2001 Children Act 2004 DH: Discharge from Hospital, Pathway, Process and Practice 2003

1.3. This version supersedes any previous versions of this document.

2. Purpose of this Policy/Procedure2.1. The purpose of this document is to outline the Trust policy for the Discharge andTransfer of children and young people and contains the responsibilities, procedures andthe documentation required to carry out the process. The policy becomes effective fromthe date of ratification

2 2 To ensure that consideration is given to appropriate and timely discharge or transfer


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3. Scope3.1. This policy applies to all staff members, and their Line Managers, who are involvedwith the discharge or transfer for children or young people.

4. Definitions / Glossary Clinical Review - This may be an assessment of how the patient is doing in regard to

the reason for admission and current clinical problems; it may be undertaken by aresponsible practitioner, e.g. Consultant or other experienced doctor or nurse. Thereview will enable progress to be assessed when planning for discharge.

Discharge - When the policy talks about” dischar ge” this should apply to any transferof a patient from the acute setting to home/place of residence.

Transfer – This refers to the transfer of children/young people from child health toanother hospital or other health or social care facility

Foundation Doctor (F1 & F2) - A doctor who is on a structured training programme,usually in the first 1-2 years of their qualification.

PAS – patient administration system – real time bed management system which allpatients are admitted onto.

5. Ownership and Responsibilities5.1. Staff involved with the discharge or transfer planning of children and young peopleare required to follow this policy and be clear with regard to their individual roles and

responsibilities within the process The Policy will be available on the Document Library


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Will ensure that a discharge summary is sent to the children/young people’s healthvisitor/ school nurse. This should be within 24 hours of discharge. Parents can begiven a copy, if available, prior to them leaving the ward.

Have a responsibility, in consultation with medical staff for co-ordinating whichmultidisciplinary team members and agencies need to be involved in the assessmentand discharge/transfer plan for the children/young people. If the child has nursingneeds, the Children’s Community Nurses should be notified as soon as possiblefollowing admission via a Paediatric Community Nursing referral form (Appendix 6 &7). All members of the multidisciplinary team involved in the child or young personscare must also be made aware of any transfer.

Have a responsibility for ensuring that the relevant community nurse/healthvisitor/school nurse is invited to attend any multidisciplinary meetings regardingdischarge or transfer. Adequate notice of such meeting must be given wheneverpossible. The Paediatric Discharge/Liaison Co-Ordinator can be contacted for furtheradvice and support.

Will ensure that transfers of children/young people to other provider units from acute

paediatric services use the same standards as discharges, and that the transferdocumentation (appendix 8) is completed, transport is arranged and personalproperty and the relevant medical records are transferred with the child/youngperson.

Will co-ordinate transport arrangements at the earliest opportunity to ensure that thetiming takes account of the care arrangements made for the day of discharge. Whentransport is required for transfer this will also be arranged by the nursing staff who

t t ll ti li i ith P ti t T t S i (PTS) i i k


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relation to communication between hospital and community services. The PaediatricDischarge/Liaison Co-Ordinator pathways are detailed in Appendix 9.

6. Standards and Practice

6.1. Discharge of Children/Young People withou t cont in uing healthcare

need

6.2. When the hospital admission has been straightforward, discharge planningneed not be elaborate, but must include:

Written information to the GP and Health Visitor/Midwife (under 5’s) and School

Nurse (over 5’s). All parents and carers must be informed of this sharing ofinformation and they must be given the opportunity to let us know if they do not wishthis to happen. This information must be copied to the parents and/or young person

Enter record of admission in parent held record including height and weight. Appropriate information, in writing, where available for the parents/young person

about any likely after effects and follow on treatment Provision of written information to parents/carers about medication, including safe

storage and side effects. The instructions/advice on the discharge summary isacceptable, as are patient information leaflets.

What to do should their child/young person’s condition deteriorate. Written point of contact in case of difficulty. Written arrangements for follow up. Written and verbal health promotion/illness prevention advice. Whenever there is information sharing or verbal consent, details should be

documented in the health record

Di h Pl d Ch kli t (A di 3) i l t d d fil d i th hild’


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6.5. A discharge planning meeting should be provisionally booked within 24-48 hours ofadmission for those children with complex needs whose discharge may not bestraightforward.

6.6. It is the responsibility of the hospital nursing staff in consultation with the medicalstaff to coordinate which multi-agency teams need to be involved in the assessment anddischarge or transfer of children and young people. Due to the complexity of some of thesedischarge or transfer arrangements there must be a named person, known to the child andfamily, who will co-ordinate ongoing care. This person will act as the single point of contactshould the family experience difficulty with ongoing care arrangements. This person canbe identified via the common assessment framework process.

6.7. The Paediatric Discharge/Liaison Co-Ordinator can be contacted for further adviceand support with this process.

6.8. Ward staff should ensure that parent’s/carer’s are adequately trained in the care oftheir child before discharge. This applies to the administration of medicine, in addition tothe management of any equipment.

6.9. Discharge of Children and You ng People in Special CircumstancesChild Protection Concerns

Where there are concerns about possible child protection issues, there mustbe a multi-agency action plan agreed and recorded before the child leaves hospital.

Any legal orders arising from the admission should be recorded (with copies filed ifavailable)

The child must be registered with a GP before dischargef f


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When a young person has ongoing care needs, and is reaching the age where adultservices will be assuming responsibility for this, the transition of care should be recorded inthe notes. A named person known to the young person and their family should beidentified where possible for contact in case of difficulty.

6.12. Children who have remained in hospital for 3 months or longerThese children will be subject to Section 85 of the Children Act 2004. The Trust has aresponsibility to notify social services in these circumstances and when the child isdischarged or transferred to another health provider. Please refer to multi agency guidancere children who are in hospital for more than three months as directed by namedprofessionals for child protection.

6.13. Palliative care needsChildren who have palliative care needs must have an identified key-worker to co-ordinatean appropriate support network within the home setting. They require a written plan oftreatment and intervention, details of which have been agreed with the family and sharedwith the community teams prior to discharge.

6.14. Discharge of Infants from the Neonatal Unit (NNU)

The previous standards all apply to infants being discharged from NNU who may alsohave a co-ordinated programme of follow up, with special arrangements for vision,hearing, developmental progress and ongoing support. All of this should be recorded in thechild’s notes. The principles of children with continuing healthcare need outlined above islikely to apply to this group of patients.

6.15. Discharge of Children and Young people with Mental Health

I


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Health, specifically in relation to the availability of the Macdonald Suite Familyaccommodation.

6.20. A discharge summary should be sent to the GP.

6.21. The Health Visitor/Midwife (under 5’s) and School nurse (over 5’s) should be notifiedof the attendance.

6.22. Transfer of Children and Young People

When children/young people are being transferred within the hospital details of the

transfer should be documented in the health record. When children/young people are transferred to another provider the transferdocument (appendix 8) should be completed and the Patients Transport Service(PTS) at RCHT should be consulted to book appropriate transport.

Out of hours transfers should be minimal and based on risk assessment of theclinical situation as outlined in RCHT Guideline for Critical Care Transfers. Arrangements for this type of transfer will be made with SWAST directly and theRCHT site co-ordinator notified.

The personnel who accompany the child /young person will be decided by seniorclinical staff based on clinical need and staff availability – this will be documented inthe health record or on the transfer document. Clinical assessment should be done inline with RCHT Policy for Observation and Monitoring in Child Health and recordedon the patient records for intra hospital transfers and on the transfer document ifbeing transferred to another provider.

6.23. Discharge involving Childr en and Young People from The Isles of


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7.2. All managers will be aware of the contents of this policy and will ensure that theirstaff have read and understood the procedures and processes relating to the dischargeand transfer of patients. New versions of the policy will be circulated to all managers for

dissemination to their staff with a summary of all amendments made to the updatedversion.

8. Monitoring compliance and effectiveness

Element to bemonitored

Completion of a discharge planDocumentation of liaison with other professionals and agencies

Timeliness of documentation to other professionalsCompletion of a transfer documentDocumentation of details of transfer in patient notes

Lead Senior Matron Child Health

Tool An agreed audit tool developed by the Directorate and registeredwith clinical effectiveness as part of the annual records audit, toinclude the elements to be monitored described above

Monthly quality audits will monitor the completion of discharge plans

Frequency Annually for the whole policy through audit of records Monthly for ward quality audits on discharge plans

Reportingarrangements

Audits will be reported via the Divisional Audit and Guidelinesmeeting in the Directorate. Action plans, incidents and complaintsrelated to discharge and transfer will be brought back to theDirectorate via Clinical Governance meetings.

Reports should be discussed at the appropriate Operational Board

A ti R t h ld b di d t th i t O ti l B d d


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Appendix 1. Governance Information

Document TitlePolicy for the Discharge and Transfer of Children

and Young People from Child Health

Date Issued/Approved: January 2014

Date Valid From: January 2014

Date Valid To: January 2017

Directorate / Department responsible(author/owner):

Mary Baulch, Matron Child HealthCaroline Amukasana Paediatric discharge liaisonnurse

Contact details: 01872 252636

Brief summary of contentsThis policy states the responsibilities of themultidisciplinary team when discharging or

transferring children/young people from child health.

Suggested Keywords:Paediatrics, Children, Young People, Neonates,Discharge, Transfer .

Target AudienceRCHT PCH CFT KCCG

Executive Director responsible forPolicy:

Medical Director

D t i d J 2014


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Guideline for Open Access to the PaediatricWards (Child Health website)Policy for Children who are in Hospital formore than three months

RCHT Policy for patient observation andmonitoring in Child HealthClinical policy for safe transfer of patientsbetween care areas or between hospitalsDH: Working Together to Safeguard Children2013DH NSF For children young people andmaternity services (2004)DH: Framework for Assessment of Children inNeed and Their Families 2001Children Act 2004DH: Discharge from Hospital, Pathway,Process and Practice 2003Reder P. et al (1993) Beyond Blame RoutledgeLONDON

Reder P. & Duncan S. (1999) Lost InnocenceRoutledge LONDONBrowne K. (1995) in The Child ProtectionHandbook edited by Wilson & James BalliereTindall LONDONCEMACH (2004) Why Mothers Die(2000-2002) Report on confidential enquiries intomaternal deaths in the United Kingdom,

RCOG P LONDON


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Version Control Table

DateVersion

NoSummary of Changes

Changes Made by

(Name and Job Title)

May 09 V1.0

Final amendments approved;EIA Completed; documentpublished

Mary BaulchSenior Matron Child Health

May 11 V2.0 Full review & consultationMary BaulchSenior Matron Child Health

Dec 11 V3.0Rewording of transfer element toclarify process

Mary BaulchMatron Child Health

Jan 14 V4.0 Full review & consultation

Caroline AmukusanaPaediatric Liaison/DischargeCo-OrdinatorTabitha Fergus Deputy ward

manger- re format

All or part of this document can be released under the Freedom of Information Act2000

This document is to be retained for 10 years from the date of expiry.

This document is only valid on the day of printing


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Appendix 2. Initial Equality Impact Assessment Form

Name of the strategy / policy /proposal / service function to be assessed (hereafter referred to

as policy ) (Provide brief description): Policy for the Discharge and Transfer of Children andYoung People from Child Health

Directorate and service area:Child Health

Is this a new or existing Policy?Existing

Name of individual completingassessment: Mary Baulch

Telephone: 01872 252636

1. Policy Aim*

Who is the strategy /policy / proposal /service functionaimed at?

This policy has been developed to support Trust Staff in the

discharge and transfer of children and young people. It is arequirement of the “NSF for Children, Young people and MaternityServices” to have in place a policy that meets the specific needs ofthis group.

2. Policy Objectives* To ensure safe and effective discharge and transfer of children andyoung people from the Child Health Directorate

3. Policy – intendedOutcomes*

Safe and timely discharge and transfer of patients

4. *How will youmeasure theoutcome?

Annual audit of discharge documentation

5. Who is intended tobenefit from the

RCHT Staff and Patients


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Sex (male, female, trans-gender / genderreassignment)

Race / Ethniccommunities /groups

Disability -learningdisability, physicaldisability, sensoryimpairment andmental healthproblems

Religion /other beliefs

Marriage and civilpartnership

Pregnancy and maternity

Sexual Orientation,Bisexual, Gay, heterosexual,Lesbian

You will need to continue to a full Equality Impact Assessment if the following have beenhighlighted:

You have ticked “Yes” in any column above and

No consultation or evidence of there being consultation- this excludes any policieswhich have been identified as not requiring consultation. or

M j i d i d l t


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Appendix 3. – Discharge Plan and Checklist- Sample only CHA2690 V4


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Sample only CHA2690 V4


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Appendix 3a. Discharge Checklist and Parent Skills-Neonatal Unit. Sample Only CHA3060


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Appendix 4. Vulnerability Criteria

1. Poor parenting affecting child’s health or development.

2. One or both parents under 21 years.3. Step-parent/co-habitee member of household

4. Violence within the family (includes animals and domestic abuse)

5. History of cruelty- includes child protection categories 1,2,3,4.

6. Parents abused/neglected

7. Drug/alcohol abuse of main carers

8. Frequent incidents/injuries9. Behavioural/ emotional vulnerability of child

10. Unreal expectations of child

11. Failure to thrive

12. Mental illness of main carers

13. Mother suffering with post natal depression

14. Any other factor which makes professionals instinctively uneasy

15. Family closing down to outsiders

16. Parents with learning disabilities

17. History of criminality

18. Family isolated within the community

19. Homelessness

20. Late ante natal booking

21 L k f t ith i


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Appendix 5. Self Discharge Pathway

If a parent chooses to take the discharge of their child against medical advice, staff shoulddiscuss this with the parents, establishing their reasons and explaining the risks this could have

on their child’s health.

All discussion should be clearly documented in the child’s health record.

If the parent still requests discharge, the appropriate doctor must be contacted immediately in

order to review the child and further inform and explain any associated risks to the parent. If these interventions fail to deter the parent, the impact on the child ’s welfare must be assessed

by nursing and medical staff, and safeguarding procedures should be followed if leaving thehospital would place the child at significant risk of harm.

Safeguarding procedures should also be followed if the child is subject to a protection plan or isa child in Care.

If the child is removed against medical advice, and there are significant safeguarding concerns,the Trust security department should be contacted to assist, and an immediate referral to

Children’s Social Care must be made.Staff should not place themselves at risk in trying to prevent the parent leaving with the child.

If there are no safeguarding concerns, and the child will not be at significant risk of harm

following discharge, the parent should be asked to sign a ‘Discharge Against Medical Advice’ form.


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Appendix 6 - Referral Pathway for Children’s Community Nurses(CCN) or Diana Nurses (October 2013)

The referral should be completed electronically on the correct referral form, identifyingthe specific input required from the CCN/Diana Nursing Service.

If the referral form is not completed correctly it will not be accepted and will be returnedto the referrer. (The CCN/Diana team can be contacted prior to referral to discuss)

Referrals are made to the Children’s Community Nurses (CCN) or DianaNurses via the CCN/Diana referral form

Referral should be emailed [email protected]

The CCN/Diana Team may contact referrer to discuss referral and to confirmdetails (action time - non-urgent → 10 working days Urgent→ 3 working

days)

Referral will be discussed by the team and a nurse will be allocated if thereferral is accepted

f f f f

mailto:[email protected]:[email protected]


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Additional Information for initial visit –

Information that could be given and obtained during the initial visit if appropriate;

What is the family expectation of the Diana Team, what information have they beengiven?

The Diana Team do not provide long term direct/ hands on care

Supporting and empowering family to provide care for their child

Identify training needs

Discuss supplies; set up PLUSS, Vygon as necessary.

Explain to parents that we will help them to manage their supplies but it is not our

responsibility to know when they are running out and/or to deliver more at short notice.Help families to understand the services they are accessing and sign post families toother services as necessary

Multi – disciplinary liaison;

In the first instance the Diana nurse will speak to other professionals, there after it will beup to the parents to contact professionals as necessary. This will be different during Endof Life!

Discuss psychology involvement – if appropriate Amanda could act as the second personComplete nursing assessment and care plans, wishes document if appropriate-

Discuss care packages if necessary

Equipment; what have they got, where did it come from, what do they need, assetnumbers, servicing

Obtain consent – consider age and mental capacity

Provide service leaflets


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Appendix 7 – Children’s Community Nurses/Diana Nurses referralform. Sample only. Forms available from paediatric HDU

Community Children’s Nursing Team and Diana Nursing Team

Referral FormPaediatric Community Services

C/O Children’s Services Care Management CentreTruro Health Park

Infirmary HillTruro

TR1 2JA

Tel:Tel: 01872 221400

Fax: 01872 246938

Name of Child:

NHS No:

ICS No:

Hosp No:Known as:

D.O.B.:Gender:

Out of County Patient? Y / N?

Financial agreement from referring trust? Y / N?


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Reason for visit:

Diagnosis:

G.P. name / address / telephone number:


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Date first visit requested:

Consultant:

Date Visiting County (if applicable):

Other Professionals involved with Family:


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Referrals must be emailed to the Care Management Centre:

[email protected]

Normally the team will need forty eight hours for an acute referral and five working days forother referrals. We will always be pleased to discuss the possibility of short notice referrals andwill respond if we can.

Supplies/equipment requested for CCN’s to provide:

Supplies to be provided by referrer:

mailto:[email protected]:[email protected]


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Appendix 8-TRANSFER DOCUMENTSample only. Forms available from paediatric HDU

Patient's Weight ………………………………………………

Date: ………………………………………… Time: …………………………………….

Mode of Transport: Ambulance Hospital Transport

Para-Medic Ambulance Own Transport

Other ……………………………………………………………

Destination: ………………………………………………………………………………….…

Receiving Doctor: ………………………………… Tel. No: ………………………………...

Receiving Nurse: ………………………………….. Tel. No: ………………………………...

PLEASE AFFIXPATIENT'S ADDRESSOGRAPH

1. Discussion with receiving unit / Name of Staff Member…………………………..………

2. Handover provided


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OBSERVATIONSTIME

T

E

M

P

C

B

P

200

mm

Hg


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NEURO

OBS:

Glasgow Coma

Scale (4-15 yrs)

Children’s Coma

Scale (< 4 yrs)TIME

C

O

M

A

SC

A

L

E

Eyes

Open

Spontaneously 4 Spontaneously 4

Eyes closed byswelling

= C

To Speech 3 To Speech 3

To Pain 2 To Pain 2

No Response 1 No Response 1

Best

MotorResponse

Obeys verbal commands 6 Obeys verbal commands 6

Usually the best armresponse

Localises pain 5 Localises pain 5

Flexion to pain 4 Withdraws in response 4

Abnormal flexion 3 Abnormal flexion 3

Extension to pain 2 Abnormal extension 2

No Response 1 No Response 1

BestVerbal

Response

Orientated & converses 5 Smiles, orientated to sounds,follows objects, interacts

5

Endotrachealtube ortracheostomy

=T

Disorientated & converse 4 Crying InteractsConsolable Inappropriate

4

Inappropriate words 3 Inconsistently MoaningConsolable

3

Incomprehensible sounds 2 Inconsolable Irritable 2

No Response 1 No Response No Response 1

P U P I L S

Right Size Size + reacts- no reactionc eyes closed

Reaction Reaction

LeftSize Size

Reaction Reaction

FLUIDS

TIME


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TRANSFER CHECK LIST

SELF-INFLATING AMBU BAG - INF / PAED / ADULT SYRINGES

50ML

OXYGEN / AIR CYLINDERS 10ML / 5ML LEURLOCKX 2 / X 3 E SIZE ( X 1 WITH VENT VALVE )

PORTABLE CYLINDER FROM BEDSPACE NORMAL SYRINGES

10ML / 5ML / 2ML / 1ML

PORTABLE SUCTION

APPROPRIATE SUCTION CATHETERS INSULIN SYRINGES

ECG MONITOR GLUCOSE MONITOR

POWER PACK AND LEAD

ETCO2 MONITOR APPROPRIATE CABLES IV EXTENSION LINES

THERMOMETER 3 WAY TAPS / T-PIECE

FACE MASKS SPACE BLANKET

NEO / INFANT / CHILD / SML & LGE ADULT

DRUG LABELS

GREEN TUBING

SCISSORS / FORCEPS

NEBULISER SET + TUBING

NG TUBE & LITMUS PAPER

STETHOSCOPE

GLOVES 6.0 - 8.5

YANKERS X 2

GAUZE X 2

GUEDAL AIRWAYS SIZES (x1 of each):

4 / 3 / 2 / 1 / 0 / 00 / 000 SURGISILK 3/0 / SURGICAL BLADES /

SUTCHER CUTTER

ELASTOPLAST / ASSORTED TAPE /

PLASTERS GAMGEE / BUBBLE WRAP

SYRINGE PUMPS BATTERIES (Appropriate for equipment)


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NURSING REFERRAL FORM - TRANSFER OF PATIENTS

Home

From Ward

Ward Tel. No.

Hospital

To:

Hosp. No:

Surname:

Forenames:

Age: Religion:

D.O.B.

Home Address:Discharge Address:


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Nursing Requirements (Including special diets, feeding and dressings)

Drugs and Medicines

Family Information

Follow-up treatments and appointments


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Appendix 9 – Paediatric Discharge Liaison Co-Ordinator PathwayPATHWAY FOR CHILDREN’S WARDS (HDU, POLKERRIS, HARLYN, FISTRAL)

Attend wards to gather information regarding any new admissions and on-going cases

Consider riorit /com lexit of resentin cases

COMPLEX PRESENTATIONe.g – long term illness, disability, life limiting conditions, or children

who will re uire additional su ort after dischar e

ROUTINE PRESENTATIONe.g – non-complex planned admissions,

minor infections/injuries, children who will not needadditional support after discharge

Work with the wards to ensure any relevant community professionalshave been informed and this has been documented in ward notes (and

by Discharge/Liaison Co-Ordinator on Electronic Records when availableand where appropriate, * for community notes ensure that any call is

followed up with email to add to patient community notes.)

* Responsibility for contacting relevant professionals remains withthe ward, and community professionals maintain responsibility forcommunication with the ward, unless there are specific, significantcomplications that would benefit from intervention by the Paediatric

Dischar e/Liaison Co-Ordinator

Re-assess on regular visits to wardand review in the event of any

change

It remains the responsibility of community professionals to attend relevantmeetings – in the event of significant difficulties attending meetings the

Paediatric Discharge/Liaison Co-Ordinator can attend and provide feedbackto the community

After involvement in Discharge Planning Meeting, where appropriate,discharge may be followed with a call to the family to ensure that the

discharge plan is being followed and to ensure that the family have therelevant contact details for the community teams/professionals.

A follow up meeting in the community may also take place if appropriate.

Where there is no changeand the presentation remainsroutine, discharge should be

straightforward andcompleted without the

additional need for supportfrom the Paediatric

Discharge/Liaison Co-Ordinator

In the event ofchanges to

presentation, followpathway for Complex

Presentation

Children meeting the Criteriafor Outreach will be

supported by OutreachNurses – e.g. Respiratory,

Oncology, Diabetes, etc.These discharges are likely to

proceed without additionalneed for support

Health Visitors and School Nursesmay not be informed of routine, non-

complex admissions unless theyspecifically request to be informed

Community professionals includeHealth Visitors, School Nurses,

Community Therapies, Communitynurses and community

Paediatricians… and any other

Safeguardingconcerns identified

should be shared bythe wards with the

Named Nurse forSafeguarding, andrelevant policies andprocedures followed

If a child is identified as a Looked After Child it is the ward/departments responsibility to inform Child in Care Team of admission/discharge. Paediatric Discharge/Liaison Co-Ordinator can assist with this and will double check that information has been shared


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LIAISON WITH SERVICES OUT OF COUNTY – (in development)

**Children’s Community Nurses, for the purpose of this pathway, includes the Diana Nurses

If a child is identified as a Looked After Child it isthe ward/departments responsibility to inform

Child in Care Team ofadmission/discharge/transfer. Paediatric

Discharge/Liaison Co-Ordinator can assist withthis and will double check that information has

Any Safeguarding concerns identified should beshared with the Named Nurse for Safeguarding,and relevant policies and procedures followed

Out of county service to be provided with Paediatric Discharge/Liaison Co-Ordinator contact details.

Paediatric Discharge/Liaison Co-Ordinator to attend Children’s Community Nurse Team meetings on a regular basisand remain updated from the wards in order to ensure awareness of any children that are receiving treatment out of

In the first instance, it is the responsibility of the ward transferring/receiving the patient from out-of county to inform therelevant community service, and responsibility for maintaining communication with the ward remains with the

community staff involved.

Paediatric Discharge/Liaison Co-Ordinator role is to liaise with community services (and RCHT wards wherenecessary) regarding any discharge/transfer plans he/she has been informed of (ensuring community staff have beeninformed of any transfers out of and into Cornwall where appropriate), and to intervene as appropriate where specific,

significant complications arise in the discharge process.

Document in ward notes and on Electronic Records when available.* For community notes ensure that any call is followed up with email to add to patient community notes where

electronic recording is not available.


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NEONATAL

Attend ward regularly to gather information regarding any new and on-going cases. Attend weekly ‘Baby in the Family’ meetings

Infants meeting the Neonatal Outreach Criteriawill have discharges co-ordinated by the

Neonatal Unit Team.These discharges are likely to proceed without

the additional need for support from thePaediatric Discharge/Liaison Co-Ordinator.

Liaise with Outreach Nurses, community Nurses and the ward where infants are transferred fromNeonatal to Polkerris. Following transfer, refer to pathway for Children’s Wards

Infants who will not require complex support afterdischarge may not meet the criteria for the OutreachNurses – Paediatric Discharge/Liaison Co-Ordinator toprovide any appropriate additional support for these

infants as required by the ward – i.e. Additional Liaisonwith Health Visitors or any other relevant professional

If a child becomes identified as aLooked After Child it is the

ward/departments responsibility toinform Child in Care Team.

Paediatric Discharge/Liaison Co-Ordinator can assist with this and can

double check that information has

been shared

Safeguarding concernsidentified should be sharedwith the Named Nurse for

Safeguarding, and relevantpolicies and procedures

followed


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EMERGENCY DEPARTMENT (AND MINOR INJURY)

Paediatric Discharge/Liaison Co-Ordinator to attend Emergency Department (ED) on a regular basis toaddress any communication issues they may have. Also maintain a level of communication with the

Identify any issues that require follow up in the community - via communication folder in ED

Safeguardingconcerns will be

identified by ED and areferral made to

Named Nurse forSafeguarding

Straightforwardattendances that do

not require communityfollow up, should not

need additionalsupport from the

Paediatric

Discharge/Liaison Co-Ordinator

Facilitate referral to the relevantcommunity service for those childrenwho require follow up treatment in the

community but do not fall underSafeguarding – a communication folder

is in place in ED for this purpose.

Explore links with community services, inparticular the Children’s Community

Nurses, and encourage ED and MIU torefer to community services in order to

accurately highlight the level of need forcommunity follow up.

This is a Pathway underDevelopment and will be subject to

regular review.

Explore links with communitystaff – such as Health

Visitors, School Nurses, andChildren’s Community Nurses

to identify communicationconcerns

If a child is identified as aLooked After Child it is thedepartments responsibility

to inform Child in CareTeam of

admission/discharge.Paediatric

Discharge/Liaison Co-Ordinator can assist with

this if required

** Children’s Community Nurses, for the purpose of this pathway, includes the Diana Nurses

discharge and transfer of children

Documents