transfer policy.doc

Transfer Policy

Version 2

Name of responsible (ratifying) committee Patient Safety Working Group

Date ratified 16 February 2012

Document Manager (job title) Operations Centre Manager

Date issued 29 February 2012

Review date December 2014 (unless requirements change)

Electronic location Management Policies

Related Procedural Documents Discharge Policy, Patient Identification Policy

Key Words (to aid with searching)

Transfer; safe; timely comfortable transfer of patients; external; internal; inter-hospital; Care; Medical treatment; Health and safety; Occupational health and safety; Clinical guidelines; Clinical procedures; Administration

In the case of hard copies of this policy the content can only be assured to be accurate on the date of issue marked on the document.

For assurance that the most up to date policy is being used, staff should refer to the version held on the intranet

Transfer Policy. Issue 2. 29 February 2012(Review date: December 2014 (unless requirements change)

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CONTENTS

QUICK REFERENCE GUIDE................................................................................................................3

1. INTRODUCTION.............................................................................................................................3

2. PURPOSE.......................................................................................................................................3

3. SCOPE............................................................................................................................................3

4. DEFINITIONS.................................................................................................................................3

5. DUTIES AND RESPONSIBILITIES................................................................................................3

6. PROCESS.......................................................................................................................................3

7. TRAINING REQUIREMENTS.........................................................................................................3

8. REFERENCES AND ASSOCIATED DOCUMENTATION.............................................................3

9. EQUALITY IMPACT STATEMENT................................................................................................3

10. MONITORING COMPLIANCE........................................................................................................3

Appendices

Appendix A: Transfer Checklist


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QUICK REFERENCE GUIDE

For quick reference the guide below is a summary of actions required. This does not negate the need those involved in the process to be aware of and follow the detail of this policy.

1. Transfers should normally occur between 08:00 and 22:00

2. A transfer checklist must be completed by the transferring and receiving nurse

3. All other relevant documentation must accompany the patient

4. The need for an escort must be assesseda. Level 1, 2, 3 patients and patients whose respiratory or cardiovascular systems are

unstable must be accompanied by a registered healthcare professional

5. The need for any equipment to accompany the patient must be assessed e.g. oxygen, intravenous infusions, pressure relieving aids

6. All medicines and personal property must accompany the patient

7. The receiving ward must be made aware of any infection risk

8. Patients must be handed over to, and welcomed onto, the receiving ward

9. There must be adequate, appropriate and timely communication between transferring and receiving staff and with the patient, relative or carer

10. Out of hours transfers (22:00 – 08:00) must be avoided unless the patient’s condition or operational demands of the organisation dictate.


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1. INTRODUCTIONPortsmouth Hospitals NHS Trust (the Trust) recognises that there is frequently a requirement to transfer patients internally and externally to other healthcare providers: for the purposes of the provision of clinical care, undertaking investigations and to facilitate patient flow. This policy aims to facilitate the safe, timely and comfortable transfer of patients, by stipulating the types of transfers and the escort required.

An internal transfer takes place when a patient remains under the care of Trust Health Professionals and who is not removed from the Patient Administration System (PAS).

Patients who may require transfer within the Trust include:

Transfers to departments for investigations. Transfers from the Emergency Department Transfers between wards Transfers between sites.

The principal responsibility of all staff is to maintain patient wellbeing, provide optimal care during the period away from the principal care area/ward, report and document outcomes and action taken.

2. PURPOSEThe purpose of this policy is to provide direction, guidance and the underlying principles for staff to support safe and appropriate transfer of patients.

The key to safety is through risk assessment and communication. All patients undergoing transfer must be risk assessed for clinical need during transfer by a registered nurse/midwife who must take responsibility for providing the verbal handover of the patient to the receiving area.

3. SCOPEThis policy applies to all groups of patients requiring transfer and to all staff who are involved in those transfers.

‘In the event of an infection outbreak, flu pandemic or major incident, the Trust recognises that it may not be possible to adhere to all aspects of this document. In such circumstances, staff should take advice from their manager and all possible action must be taken to maintain ongoing patient and staff safety’

4. DEFINITIONSDiagnostic/Treatment Transfer: the movement of a patient from one service to another within the Trust for an assessment/diagnostic procedure or treatment

Escort: any member of staff who is involved with escorting patients and who has the relevant knowledge and skills to provide a high standard of care during the transfer; to ensure patient safety is not compromised. An escort can be:

Registered professionals, doctors, registered nurses and midwives, operating department practitioners

Non registered professional, healthcare assistants and other clinical support workers

External transfer: the temporary movement of a patient to an acute care environment service external to the Trust, e.g. for investigations or interventions that, for whatever reason, cannot be provided by Portsmouth Hospitals NHS Trust. This should not be confused with a discharge,


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as the intention is that, once the investigation or intervention has been completed, the patient will return to our care.

Internal transfer: the movement of a patient from one clinical area to another within the Trust. For example:

For investigations From the Emergency Department Between wards Between sites

Patient groups:AdultsLevel 0 Patients whose care can be met through normal ward care in hospital

Level 1 Patients at risk of their condition deteriorating, or those recently relocated from higher levels of care, whose needs can be met on an acute ward with additional advice and support from the critical care team

Level 2 Patients requiring more detailed observation or intervention including support from a single failing organ system or post–operative care and those “stepping down” from higher levels of care

Level 3 Patients requiring advanced respiratory support alone or basic respiratory support together with support of at least two organ systems. The level includes all complex patients requiring support for a multi – organ failure

Out of Hours: a transfer that occurs between 2200 and 0800

5. DUTIES AND RESPONSIBILITIES

The Operations Centre Manager is responsible for resolving any operational issues relating to the transfer of patients, as escalated by the clinical team

The Matron is responsible for:

The day to day operational management of the Transfer Team and the development of transfer processes to ensure they remain responsive to the changing needs of the Trust.

Escalating any unresolvable matters associated with patient transfer to the Director of Nursing (or nominated deputy); in particular those matters relating to patient care, patient safety and other quality issues

Escalating any operational issues related to transfer to the Operations Centre Manager In association with members of the Transfer Team, carrying out education amongst

Trust staff to ensure they have the appropriate skills and knowledge to implement safe patient transfer

Receiving information on all adverse incidents and near misses relating to patient transfer

In association with members of the Transfer Team, undertaking an annual review of this policy, to ensure it continues to meet the operational needs of the Trust and its patients.

Developing and implementing an action plan with defined timescales to address any changes to the transfer process, as highlighted by review of the policy and/or trends identified through adverse incidents and near misses.

Escalating any problems with the implementation of the action plan to the Emergency Pathway Manager


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Duty Hospital Manager: out of hours and in the absence of the Operations Centre Manager or Matron/Hospital at Night service, the Duty Hospital Manager has responsibility for managing any issues relating to patient transfer and for providing support and guidance

Transfer Team report directly to the Matron and are:

Employed to undertake the majority of internal transfers, with the support of clinical teams and the Portering Services. The exceptions to these transfers are those required by child health, obstetric and critical care service patients

In association with the Matron, responsible for carrying out education amongst Trust staff to ensure they have the appropriate skills and knowledge to implement safe patient transfer

In association with the Matron, responsible for reviewing and continually developing this policy, to ensure it continues to meet the requirements of the Trust and its patients

The registered nurse on the Transfer Team will, in conjunction with the registered nurse caring for the patient in the clinical area, undertake a risk assessment to ascertain by whom the transfer should be undertaken.

Nurse Escort regardless of status, is responsible for:

Positively identifying the patient to be transferred Ensuring all relevant documentation is completed and transferred with the patient Confirming the correct destination for the transfer Monitoring the status of the patient during the transfer, using the appropriate monitoring

devices Taking all appropriate action, should the patient’s condition change

Ward Managers are responsible for:

Ensuring their teams are aware of the requirements of this policy Ensuring there are operational systems in place within their teams to fulfill the

requirements of this policy at local level Reporting any transfer issues to the relevant Modern Matron, for support to ensure the

ongoing safety of their patients

Ward ClerkWard Clerks are responsible for copying the patient’s health record, the booking of transport and any other required administrative duties to support safe patient transfer

6. PROCESSInternal TransfersInternal transfers normally take place between 08:00 and 22:00

6.1 Staffing

6.1.1 The Transfer Team will carry out the majority of transfers, within hours

6.1.2 Porters will support the transfer process with requests submitted via the Helpdesk (ext 6321). Urgent transfers must be requested as such, as a response time of 5 minutes from portering services is required

6.1.3 All staff involved in the transfer process are required to follow infection control practice guidance related to protective equipment and hand hygiene


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6.1.4 Ward staff are responsible for ensuring patients are suitably dressed and blankets provided if necessary, to ensure comfort and maintain privacy and dignity

6.1.5 The receiving ward/department must ensure that a member of staff is available to receive the patient and take handover from escort if necessary.

6.2 Escorts

6.2.1 The nurse-in-charge of the patient’s care will assess (Appendix A) if an escort is required and record any such requirement in the patient’s health record. The nurse-in-charge will remain accountable for the patient’s care at all times

6.2.2 The staff member acting as an escort must be competent to use any equipment that is being transferred with the patient and ensure it has sufficient battery life for the period of the transfer

6.2.3 All patients categorised as level 1, 2 and 3 require a registered professional escort

6.2.4 Escorts are required to ensure that the patient’s wellbeing is considered at all times and must actively engage with the patient during the whole transfer process.

6.3 Communication

6.3.1 There must be adequate and effective communication between the transferring and receiving ward/department

6.3.2 Ward to ward transfers between specialties will be facilitated by the nurse-in-charge of the ward/department, the Duty Hospital Manager and Transfer Team

6.3.3 The nurse-in-charge of the patient’s care on the transferring ward must provide a verbal telephone handover to the receiving nurse if not accompanying the patient. Alternatively the nurse-in-charge of the transferring ward will hand over to the Transfer Team who will then hand over to the nurse on the receiving ward

6.3.4 The escort and the ward/department where the patient is being transferred to, whether permanently or temporarily for investigations/intervention, must be aware of any current infection risk prior to transfer.

6.3.5 Patients will be informed at the earliest opportunity of the need for a transfer and provided with an explanation of why the transfer is necessary.

6.3.6 With the consent of the patient, relatives, carers or others will be advised of transfers to another ward. Note: it is not necessary to notify relatives, carers or others when a patient is temporarily absent from the ward e.g. for diagnostic investigations or interventions.

6.4 Documentation

6.4.1 The nurse-in-charge is responsible for ensuring that all appropriate health records accompany the patient

6.4.2 The transfer checklist (Appendix A), which forms part of the nursing documentation, must be completed by the nurse responsible for the patient’s care at the time of the transfer

6.4.3 Patients must have an accurate patient identification band and on arrival in the receiving ward the band must be removed and replaced with amended details: in accordance with the Patient Identification Policy


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http://www.porthosp.nhs.uk/Clinical-Policies/Patient%20Identification%20Policy.doc

6.5 Other

In general, when transferred, other than internally for investigations or interventions

6.5.1 All dispensed medications must accompany the patient.

6.5.2 All property must accompany the patient together with a completed property form.

6.5.3 The registered nurse is responsible for deciding if existing pressure relieving equipment should move with the patient

Note: it may be that even for temporary internal transfers for investigations or interventions that the nurse on the transferring ward may consider it necessary for some medications and/or pressure relieving aids to accompany the patient.

6.6 Intravenous Infusions

6.6.1 All infusions containing drugs, including Potassium or TPN must be on an infusion pump with appropriate battery life for the transfer and the registered professional must have been trained and competent to use the equipment.

6.6.2 If the patient requires a continuous infusion or the infusion can not be stopped during the transfer (advice sought from a doctor) the registered nurse responsible for the assessment must clearly state, on the Transfer Checklist, the action required for any ongoing intravenous infusion.

6.6.3 If close observation of the patient is required, or if drug administration is required, a registered professional must always act as the escort for the patient. It is acceptable for a non – registered member of staff to escort a patient connected to an IVAC infusion pump but ONLY when 0.9% saline or 5% Glucose/Dextrose Saline or Hartmans is being administered. Non-registered staff are not allowed to transfer patients receiving intravenous drug therapies and they are not allowed to touch or use any infusion device. If a patient has been assessed as competent to self administer medication by a registered professional and is using an ambulatory infusion device then it is acceptable for a non–professional to act as an escort. However, the device must have been checked by a registered professional prior to commencement of the transfer, to ensure there is sufficient battery life and medication for the duration of the escort.

6.7 Oxygen Therapy

6.7.1 If the patient’s respiratory or cardiovascular status is unstable a registered nurse must always act as the escort for the patient.

6.7.2 The registered nurse making the assessment is responsible for ensuring that all required information is given to the patient’s escort.

6.7.3 Prior to commencement of the transfer, the registered nurse must check and

ensure there is sufficient oxygen in the cylinder required for the full duration of the transfer.

6.8 Tissue Viability6.8.1 All patients must have a documented, up to date, Waterlow Assessment prior to

transfer


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6.8.2 The registered nurse is responsible for deciding if the patient requires pressure-relieving equipment during transfer

6.9 External Transfers All conditions and arrangements relating to internal transfers apply, plus

6.9.3 Only a copy of the health record must accompany the patient: the original must be retained by the Trust

6.9.4 If an escort is to accompany the patient, confirmation of the return journey arrangements for the escort must be made by the nurse-in-charge of the transferring ward

6.10 Maternity Transfers All maternity transfers are considered as emergencies and the maternity service works in partnership with South Central Ambulance Trust to achieve rapid and seamless transfer processes.

The guidelines on transfer can found on the Maternity Services Departmental webpage. The guideline covers the transfer of mothers, babies and neonates, including process, responsibilities, communication pathways and documentation.

6.11 Transferring the Critically Ill PatientThe transfer of critically patients is governed by the policy and procedures produced by the Wessex Critical Care Network.

Inter-hospital transfer guidance is available on the Critical Care Departmental webpage

6.12 Out of Hours Transfers‘Out of hours’ transfers are those that occur between 22:00 and 08:00 hours. The arrangements as described above apply to transfers ‘out of hours’. However, it is recognised that such transfers are far from ideal and will be avoided unless the:

6.12.1 The patient’s condition deteriorates, necessitating a transfer out of hours

6.12.2 The operational demands of the organisation make such a transfer unavoidable.

If an out of hours transfers is necessary

6.12.3 The nurse-in-charge of the transferring ward must risk assess all patients, to determine which patient is in the most favourable clinical condition for transfer. The assessment must include, but is not necessarily limited to:

Dependency of patient Instability of condition Behavioural risks and concerns

6.12.4 The on-call registrar/consultant may be called to identify or review patients for suitability to transfer if the nursing teams need confirmation of suitability or are unable to identify safe, suitable patients from a clinical perspective.

6.12.5 The nurse-in-charge must inform the Duty Hospital Manager who will support the transfer

6.12.6 Any decision to transfer out of hours must be clearly documented in the patient’s health record


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http://pht/Departments/CriticalCare/Guidelines/Forms/AllItems.aspx?RootFolder=%2FDepartments%2FCriticalCare%2FGuidelines%2FTransferring%20critically%20ill%20patients&FolderCTID=&View=%7B2588418C-7DDB-45C9-AF6F-822932D0ADC1%7D

http://pht/Departments/CriticalCare/Guidelines/Forms/AllItems.aspx?RootFolder=%2FDepartments%2FCriticalCare%2FGuidelines%2FTransferring%20critically%20ill%20patients&FolderCTID=&View=%7B2588418C-7DDB-45C9-AF6F-822932D0ADC1%7D

http://pht/Departments/Maternity/Maternity%20Services%20Guidelines/Forms/AllItems.aspx

6.12.7 The relatives will be informed as soon as possible in hours, unless the patient requests otherwise or there is an overriding clinical reason for informing them out of hours. Any decision to notify relatives, carers or others out of hours is the responsibility of the patient’s clinician

7 TRAINING REQUIREMENTS 7.1 Members of the Transfer Team, in conjunction with the Lead Nurse – Clinical Practice,

are responsible for educating staff, temporary or substantive, to ensure they have the required knowledge and skills to allow the safe and timely transfer of all patients across ‘general’ clinical areas

7.2 Staff from the Department of Clinical Care are responsible for educating staff in the care and transfer of patients in and out of the Department

7.3 Carillion Management Team are responsible for training and supervising porters involved in the transfer of patients

8 REFERENCES AND ASSOCIATED DOCUMENTATIONExternal

Medical Stability and ‘Safe to Transfer’: Department of Health (2003) www.dh.gov.uk The transfer of frail older NHS patients to other long stay settings: Department of

Health (1998) www.dh.gov.uk Ensuring the Effective Discharge of Older Patients from NHS Acute Hospitals. The

Stationery Office. www.nao.org.uk

Internal Patient Identification Policy Discharge Policy

9 EQUALITY IMPACT STATEMENT

Portsmouth Hospitals NHS 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 assessed accordingly


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http://www.porthosp.nhs.uk/Management-Policies/Discharge%20Planning%20Policy.doc

http://www.porthosp.nhs.uk/Clinical-Policies/Patient%20Identification%20Policy.doc

http://www.nao.org.uk/

http://www.dh.gov.uk/

http://www.dh.gov.uk/

10 MONITORING COMPLIANCE

As a minimum the following will be monitored to ensure compliance


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Minimum requirement to be monitored

Lead Tool Frequency of Report of

Compliance

Reporting arrangements Lead(s) for acting on Recommendations

100% of transfers meet the requirements specific to each patient group

Operations Centre Manager

Random audit of 50 sets of medical

records

Annually Policy audit report to:

Nursing and Midwifery Committee

Operations Centre Manager / CSC Heads of Nursing

100% of documentation that accompanies a patient when being transferred is accurately completed


Random audit of 50 sets of medical notes




100% of out of hours transfers comply with the requirements of this policy


Random audit of 30 sets of medical notes

for patients transferred out of hours




Appendix ATRANSFER CHECKLIST


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