DISCHARGE AND TRANSFER POLICY

Transcription

1 DISCHARGE AND TRANSFER POLICY Document Reference: Document Owner: Accountable Committee: Ratified by: Stephanie Jenkins Divisional General Manager Clinical & Research Governance Committee Document Ratification Committee Version: 1.0 Document Author: Date Approved: 27 July 2011 Date Ratified: Christopher Smith - Community Link Team Manager Pending Date issued: 27 th July 2011 Review date: July 2013 Target audience: Trust Staff Equality Impact Assessment: 22/7/11 Key points How to plan and manage patient discharge in order to reduce length of stay How to communicate effectively between all disciplines to facilitate continuity of care How to transfer patients internally and externally, safely and appropriately Additional requirements specific to patient groups What documentation is to accompany the patient on discharge and transfer Page 1 of 30

2 Contents Section Page 1.0 ASSOCIATED DOCUMENT INTRODUCTION Statement of intent Equality Impact Assessment Good Corporate Citizen Purpose Scope DUTIES DEFINITION OF TERMS USED WITHIN THIS DOCUMENT DISCHARGE Referral to the Community Link Team Patients with existing social support Referral to District Nurses Transport General Practitioner (GP) Community specialist equipment Discharge medication /48 prior to planned date of discharge Day of discharge Documentation to Accompany the Patient on Discharge Process to follow for Discharge "Out of Hours" Self-Discharge TRANSFER OF PATIENTS General principles for the transfer of patients between Wards Process for transferring patients between Wards Documentation to accompany the patient on internal transfer Process for transferring patients between Wards and Departments External Transfer (to another health care facility) Referral Process - District General Hospitals Referral Process Hospices 14 Page 2 of 30

3 6.8 External transfer process - both within working hours and Out of Hours Documentation to Accompany the Patient on External Transfer PATIENT GROUPS People with a learning disability People with Mental Health Issues Vulnerable adults People with language difficulties Patients Identified to be nearing the end of their life The Young Oncology Unit Treatment with Radioactive Iodine 131 or other Radionuclide Therapies The Critical Care Unit CONSULTATION, APPROVAL AND RATIFICATION PROCESS DISSEMINATION & IMPLEMENTATION Dissemination Implementation Training/Awareness PROCESS FOR MONITORING EFFECTIVE IMPLEMENTATION REFERENCES VERSION CONTROL SHEET 19 Appendices 1 Multi-Disciplinary Form 20 2 Patient Infectious Status and Control Notification Form 21 3 Patient External Transfer From 22 4 Patient Internal Ward Transfer Form 25 5 Rapid discharge checklist for ward based teams 26 6 Safe Transfer of Critically Ill patients from Critical Care Unit 27 Page 3 of 30

4 1.0 ASSOCIATED DOCUMENTS Bed management policy implementation and communication plan Patient Isolation policy Policy for Safeguarding Vulnerable Adults "SITREP Definitions Guidance Document" Community Care (Delayed Discharges) Act 2003 NHS Continuing Health Care Process The Medicines Practice Operational Policy Home Oxygen 2.0 INTRODUCTION The Community Care (Delayed Discharges) Act 2003 introduced a new approach with the aim of sustaining reductions in delayed discharges and/or transfers of care. This is the current definition for a discharge / transfer: A patient is ready for discharge home or external transfer to another healthcare provider when; A clinical decision has been made that the patient is ready for transfer or discharge and A multi-disciplinary team decision has been made that the patient is ready for discharge or external transfer and, The patient is safe to be discharged or externally transferred 2.1 Statement of intent The Discharge and Transfer Policy is the Trust approved document for the management of risk associated with the discharge or internal/external transfer of patients. The Trust and its partner health and social care organisations are committed to providing safe and appropriate transfer and discharge of patients in collaboration with health and social care professionals, patients, relatives and carers and with consideration of people with additional needs. 2.2 Equality Impact Assessment This policy endeavors to deliver care in such a way as to treat patients fairly and respectfully regardless of age, gender, race, ethnicity, religion/belief, sexual orientation and/or disability. The care and treatment provided will respect the individuality of each patient. In line with the Trust policy on equality and diversity this document has been screened using the approved e-tool. 2.3 Good Corporate Citizen As part of its development, this policy was reviewed in line with the Trust s Corporate Citizen ideals. As a result, the document is designed to be used electronically in order to reduce any associated printing costs. 2.4 Purpose This policy sets out the standards expected by The Christie NHS Foundation Trust in relation to the safe and appropriate transfer and discharge of patients: To ensure a safe, timely and effective discharge/transfer from the hospital or internal transfer for all patients Page 4 of 30

5 To ensure the patient is always treated as an individual with due regard shown to their personal choice, cultural characteristics and dignity. To ensure patients and carers are involved throughout the discharge/transfer planning process. To promote discharge planning in the pre-admission phase or as early as possible following admission. 2.5 Scope This policy applies to all adult inpatients 3.0 DUTIES The Chief Executive The Chief Executive has overall responsibility for ensuring that the organisation adheres to the standards set out in this policy. This duty may be delegated to an executive/senior manager but accountability to the Board remains with the Chief Executive. Medical Staff Medical Staff are responsible for: Deciding and communicating when a patient is medically fit for discharge. Discussing this date of discharge with the Ward Manager / Co-ordinator prior to discussion with the patient Discussing with the patient and carers, the potential length of stay and the level of care and support likely to be required on discharge as soon as possible. Attending any multi-disciplinary meetings or Case Conferences when requested to do so by a member of the multi-disciplinary team who is co-ordinating the discharge / transfer arrangements Multi-disciplinary team The Multi-disciplinary team (MDT) comprises of key individuals involved in the care of the patient. The MDT is responsible for preparing the patient for discharge and for arranging community services. NB: If a patient was previously receiving support in the community their care worker should be contacted and included in all arrangements made by the multi-disciplinary team Divisional Managers/Clinical Directors, Lead Nurses, Departmental Managers and Ward Managers It is the responsibility of Divisional Managers/Clinical Directors, Lead Nurses, Departmental Managers and Ward Managers to: Implement the discharge and transfer policy, to monitor compliance and ensure any deficiencies are rectified. Report any Discharge and Transfer related clinical incidents via the Trust incident reporting system and take remedial action where appropriate. Ensure all staff, for which they have responsibility, attend any training appropriate to their role The seamless transfer between ward to ward, community services and inpatient settings and vice versa The assessment of any risk prior to and during the transfer/discharge period Ensuring that transfers and discharges within their area of responsibility are managed appropriately Page 5 of 30

6 The ward manager has ultimate responsibility for ensuring that the following procedures take place and for co-ordinating plans in consultation with the medical staff and the multi-disciplinary team. The Community Link Team The community link team is responsible for: Supporting nursing and medical staff in the preparation of discharge/transfer plans. Advising the ward multi-disciplinary team on nursing and support services available in the community and on the process of making referrals. Advising nursing and medical staff where the patient s needs requires consideration of an in-patient placement e.g. hospice or other hospital unit. Assessing inpatients in regards to their eligibility to enter into the NHS Continuing Healthcare process in line with government directives and legislation. Completing the Home Oxygen Therapy Service. process Individual Staff It is the responsibility of each individual member of staff involved in the discharge and transfer of patients to: Complete trust approved training relevant to their role Adhere to the discharge and transfer policy Report any discharge and transfer related clinical incidents via the trust incident reporting system. Clinical and Research Governance Committee The Clinical and Research Governance Committee retains overall responsibility for compliance against this policy. 4.0 DEFINITIONS Term Audit Assessment Care package Care pathway Care planning Carer Meaning Means the formal examination of the organisations records, financial situation or compliance with a set of standards Means a process whereby the needs of an individual are identified and the impact on their daily living and quality of life evaluated. Means a combination of services designed to meet a person s care needs. Means an agreed and explicit route an individual takes through health and social services. Means a process based on an assessment of an individual s needs that involves determining the level and type of support to meet those needs, the objectives and potential outcomes that can be achieved. Means a person who provides care for a patient. This can be a relative or friend who provides care on a voluntary basis or a professional Page 6 of 30

7 Page 7 of 30 Clinical and Research Governance Committee Commissioning carer employed to provide care Means a Trust committee authorised by and accountable to the Risk committee Means the process of specifying, securing and monitoring services to meet identified needs. Consent Means agreement, approval or permission as to some act or purpose, given voluntarily by a competent person, legally effective. DGH District General Hospital Discharge Discharge from the Trust to a community setting i.e. patient's home or nursing home. Drug Authorisation Letter Equality Impact Assessment External transfer Internal Transfer This is a document that is signed by a Doctor which gives the district nurse authorisation to give specified medication, by which route, when it is to commence and how long it is to be given for. An equality impact assessment is an assessment to determine whether a proposed document or activity is likely to have a negative or adverse impact on sections of the community. Inpatient transfer from The Christie into another health care setting i.e. District General Hospital, Hospice Means the transfer of an inpatient from a department to a ward, or another department. Mental Capacity Means the mental ability to understand the nature and effects of one s acts. mibg Room (Isolation Room on the YOU) Meta IodoBenzyl Guanidine (adrenaline analog, treatment for neuroendocrine tumours Multidisciplinary Means when professionals from different disciplines, such as social work, nursing and therapy, work together. NHS Continuing Healthcare Patient A package of care set up and paid for by the National Health Service Means a person who is receiving medical treatment Out Of Hours Outside of normal working hours Monday to Friday 9:00 to 17:00. Rehabilitation Means a programme of therapy and rehabilitation designed to restore independence and reduce disability TTO Means To Take Out - abbreviation used to describe Discharge/Transfer Medication that is provided by the Trust. For further details see

8 Trust YOU Medicines Practice Operational Policy. Means The Christie NHS Foundation Trust Young Oncology Unit NB: Patients with additional needs beyond their immediate physical health needs may require specialist input and additional considerations in the planning of external transfer or discharge. For additional requirements specific to patient groups see section 7. Where required specialist advice should also be sought from the CLT as early as possible 5.0 DISCHARGE On admission the admitting nurse must assess and identify any special requirements that may need to be considered to facilitate the patients discharge. This should include any learning or physical disabilities that the patient might have and any written instructions that will assist staff in the management and provision of care (i.e. Traffic Light Passport/Learning Difficulties) This must be accurately and comprehensively recorded in the electronic/paper nursing documentation. Discharge documentation must be commenced on or as soon as possible after admission and all communication and action taken concerning discharge clearly documented. An estimated date of discharge should be identified by the admitting nurse on admission and documented within the nursing documentation Referrals to members of the multi-disciplinary team must be made via the Multidisciplinary Referral Form (Appendix 1) as soon as potential discharge needs are identified 5.1 Referral to the Community Link Team Patients with complex care needs should be referred to the community link team as soon as possible after admission. The team will assess the patients care needs, identify if they need to be involved with their case and will lead on their discharge planning as appropriate. Community Link Team will annotate directly into patient's Health Records. Factors to consider when an agreed date of discharge is identified: 5.2 Patients with existing social support Where the patient already has service provision from community Social Services and there is NO CHANGE in the patient or carer s needs, the ward nurse must liaise directly with the patient s local social services to arrange for the re-starting of existing services on discharge. If the previous care package was cancelled on admission (dependant on the respective social service authority's policy) the ward nurse must send a new Multidisciplinary Referral Form to the trust Social Work Team to action 5.3 Referral to District Nurses Referrals to community nursing services must be made by the ward nurse, where possible, a minimum of 48 hours prior to discharge or as soon as a discharge date has been identified i.e. if a patient is a booked admission for one night only or can be discharged on the day they are declared medically fit for discharge. The referral should be made using the Trust's district nurse referral forms which are available in all inpatient areas. If the patient has an identified infectious status (alert on electronic Page 8 of 30

9 health records) the additional Patient Infectious Status and Control Notification Form (Appendix 2) must also be completed and given to the DN team. 5.4 Transport Transport for discharge needs to be coordinated/booked by the nursing staff in advance of the discharge date. Where appropriate patients and their carers are encouraged to provide their own transport If their own transport is available this should be used in the first instance Where own transport is not available or appropriate a transport request must be made to the transport department, using the electronic proforma and sent by to the Transport Dept, or a completed paper copy can be taken to the transport department The transport request should provide details of o Patient s name and hospital number o address patient being transported from (i.e. ward) o address patient is being transported too o date and time transport required o special requirements (i.e. oxygen) o mode of transport (i.e. stretcher, chair) o special instructions (i.e. carry patient into house) The transport department will then book transport with North West Ambulance Service, taxi or a trust approved private firm. Where the need for discharge is urgent transport should be arranged as above, however if the transport cannot be arranged for an "on the day" discharge the Community Link Team or nursing staff should contact the Transport department to arrange private transport if possible 5.5 General Practitioner (GP) The GP should be contacted by telephone prior to the patient s discharge when: o continuous medical treatment and/or monitoring is required, or o when medical follow-up will be required by the GP within a week of discharge The GP should also be informed of the patient's infection status 5.6 Community specialist equipment Where the need for specialist equipment has been identified by the nursing staff/mdt member a request for the equipment must be made directly to the community nurses by completing the district nurse referral form or via the Occupational Therapy Team For advice or where there are difficulties in the provision of equipment staff should contact the Community Link Team or the respective MDT member 5.7 Discharge medication Prior to discharge patients must be prescribed one weeks supply of medication and where required up to one weeks supply of dietary feeds. Short-course treatments such as antibiotics, cytotoxic chemotherapy and associated drugs should be supplied in full. Discharge medication must be prescribed on the discharge prescription sheet available on all wards If a repeat prescription is necessary the GP must receive full details on the discharge summary. Where Parentral Nutrition at home is required the medical team must refer the patient to the Intestinal Failure Unit at Hope Hospital by completing a referral form that is available on the Dieticians Intranet Site. Page 9 of 30

10 5.8 24/48 prior to planned date of discharge Prior to the day of planned discharge, the medical team in consultation with the ward nurse, the patient and carer must check that: o the patient is suitable for discharge o all relevant arrangements are in place o the date is confirmed with the patient and carer Arrangements for patient follow-up must be discussed with the medical staff. An outpatient appointment, where appropriate, must be made prior to discharge or sent on to the patient as soon as this has been arranged 5.9 Day of discharge The medical team responsible for the patient s care must review the patient and record in the health record the patient s medical fitness for discharge If there are changes in the patient s condition and/or treatment that affect the discharge plan, relevant members of the multi-disciplinary team must be consulted and all community services notified All key actions and communications regarding discharge arrangements should be recorded in the patient s Health Records. A copy of the discharge medication sheet, containing initial admission details should be given to the patient/their carer to be delivered to their GP on discharge Any valuables that are being held securely on the ward must be returned to the patient before discharge and their receipt documented Documentation to Accompany the Patient on Discharge It is essential that patients are discharged with sufficient information about their treatment to ensure continuity of future care. This must include: A copy of discharge drug prescription to be given to the GP, which includes an immediate admission summary. A copy of the district nurse referral form to be given to the district nurse by the patient, if required Drug Authorisation Letter (if required) Appointment card for next outpatient visit or admission if arranged prior to discharge Relevant advice sheets from multidisciplinary team member if appropriate 5.11 Process to follow for Discharge "Out of Hours" Patient discharge should not routinely take place out of hours, evening, weekend or Bank Holiday However, if an unplanned patient discharge occurs out of hours and the patient does not require any community support then they should be discharged as detailed within discharge section of this policy 5.12 Self-Discharge If a patient wishes to take their own discharge from hospital against medical advice the medical team responsible for the care of that patient at that time must be contacted. The risks of self discharge should be discussed with the patient and they should be encouraged to stay to complete their treatment. Where the patient still wishes to self discharge this must be clearly recorded in the patient s Health records by the Medical team. The patient should be asked to sign a self-discharge form located on each ward. If the patient refuses to sign the form a contemporaneous record should be made in the patient's Health records. Page 10 of 30

11 The ward nurse must ensure that as far as possible the patient s discharge plan is implemented. 6.0 TRANSFER OF PATIENTS Internal Transfer 6.1 General principles for the transfer of patients between Wards The general principle is to avoid moving patients between wards unless this is essential. Reasons for inter-ward transfers include: Where an acutely ill patient requires more intensive/different treatment and this cannot be delivered by the ward on which the patient is currently resident. Where there is an urgent need to facilitate an admission to a ward and this can only be achieved by transferring the patient to create a vacant bed on that ward. Where there is a clearly identified clinical or risk management need to transfer a patient to an alternative ward i.e. communicable infection Ward staff must not transfer patients in/out of side rooms without first discussing with the bed manager / duty manager as this can impact on the availability of beds for planned/sos admissions. 6.2 Process for transferring patients between Wards An assessment must be carried out by nursing staff instigating the transfer as to the patient s suitability to be transferred at that time. This must include the patient's medical status and the mode of transport that is required The reason for the transfer must be clearly documented in the Health Records (paper and electronic) Transfers must be agreed by the respective ward shift co-ordinator The need for the transfer must be fully explained to the patient by the ward nursing staff. If clinically indicated and the transfer is for infection control requirements this must be explained, maintaining confidentiality, to the patient and the receiving ward The next of kin should be informed by the ward nurse (if not already done so by the patient). The nursing staff on the ward the patients is transferring from must co-ordinate the patient's transfer, by: o Providing a full nursing handover to the receiving ward staff either in person or via the telephone. o The handover must include the patients details, diagnosis, specific ongoing treatment or care needs, medication and infusions that are in progress, equipment that is required to assist in the patient's care, details of any incidents or injury that has occurred during the current inpatient episode social situation and discharge plans. o Clearly and accurately completing the Internal Transfer Form o Ensuring that the patients medication is cleared from the POD locker and/or other storage areas ready for transfer. o Ensuring all belongings are collected ready for transfer o Ensuring that all the clinical records are collected and filled in the paper Health Record o Ensuring that the transfer of the patient's paper Health Record from one Page 11 of 30

12 ward to another is entered into the patient's electronic Health Record in line with health records policy o Deciding on and arranging, via the portering department, the appropriate mode of transfer i.e. chair/trolley o Escorting the patient, where deemed appropriate by the registered nurse, to the receiving ward with the porter. Where the patient is not in agreement with the transfer intervention from the senior nurse, modern matron or consultant must be sought. 6.3 Documentation to accompany the patient on internal transfer All patient information must accompany the patient at the time of transfer. This includes: o Patient Internal transfer form for inter ward transfers (appendix 3) o Health Record (papers) o Observation charts o Nursing documentation o Current inpatient medication prescription and administration record o Supplementary charts in use *this list is not exhaustive 6.4 Process for transferring patients between Wards and Departments Ward to Department An initial assessment must be carried out by the nursing staff instigating the transfer as to the patient s suitability to be transferred. The nursing staff on the ward the patients is transferring from must co-ordinate the patient s transfer by: o Liaising with the department prior to the transfer to ensure the department staff are aware of the patients clinical requirements i.e. clinical condition, infection control status o Deciding on and arranging, via the portering department, the appropriate mode of transfer i.e. chair/trolley o Escorting and remaining with the patient where clinically indicated i.e. if the patient s medical condition is unstable o Ensuring any medical attachments i.e. catheters, drains, infusions are made secure and identified to the receiving departmental staff o Ensuring that any relevant patient documentation, i.e. paper Health Record; test results accompany the patient if requested by the department. Health Records will be required where the patents stay at the department is for extended periods or the investigation/treatment involves an invasive procedure. Where there is any doubt the nurse transferring the patient must check with the receiving department Department to Ward An initial assessment must be carried out by department staff as to the patient s suitability to be transferred back to the ward. The staff in the department must co-ordinate the transfer by: o Informing the ward staff that the patient is ready for transfer, where required o Deciding on and arranging, via the portering department, the appropriate mode of transfer i.e. chair/trolley o Ensuring a member of the ward team or departmental team escort the patient if clinically indicated Page 12 of 30

13 o Providing written instructions to accompany the patient if there are any specific required observations, restrictions (i.e. strict bed rest, nil by mouth etc) or instructions (i.e. potential radioactivity of body fluids require specific disposal, patient has to remain lying flat for a specified number of hours) that need to take place once the patient returns to the ward. 6.5 External Transfer (to another health care facility) Where it is identified by the medical and MDT members that a safe discharge home is currently not achievable and the patient requires ongoing 24 hour care, a referral back to their District General hospital or hospice may be the most appropriate action to take. Where long-term care is anticipated for either psychosocial support unrelated to active disease or chronic severe disability but the condition of the patient is likely to remain stable for some time consideration can be made to the use of other organisations for example nursing home care or continuing care at home. Such complex cases should be discussed with the appropriate healthcare worker/organisation; The senior nurse/doctor at the Hospice or organisation The local social work authority The Palliative Care Support Team The Community Link Team In all cases the patient and their carers should be involved in all the discussions in regards to their proposed external transfer to ensure their opinions are taken into account. 6.6 Referral Process - District General Hospitals The Medical Team with responsibility for the patient s treatment must make the direct referral (by telephone) to the appropriate medical team and the receiving hospital.. As a minimum they must inform the receiving medical team of the patient's: o Name o Date of Birth o Diagnosis/prognosis o Ongoing care requirements o Infection status When the patient is accepted for transfer a request should be made that the receiving Medical team at the accepting hospital give the patients details to their bed manager. The person making the referral must document in the patient s health records the name and grade of the person receiving the referral and the name of the accepting Consultant. The treating medical team must complete a medical transfer letter to accompany the patient Once referral has been made and the patient accepted by the receiving medical team the nursing staff/medical team must contact the Bed Manager in the Admission Team by telephone/verbally informing them of the patients: o Name o Date of Birth o Hospital number o Diagnosis/prognosis o Ongoing care requirements o Infection status o Receiving medical team and hospital The Admissions Team will then commence regular daily liaison with the bed Page 13 of 30

14 managers at the receiving hospital to arrange the patient s transfer. 6.7 Referral Process Hospices Prior to referral to a hospice the patient and/or carer must be consulted about the reason for the referral i.e. for symptom control/end of life care. Verbal consent must be obtained before a referral is formally made. The Hospice specific referral form must be obtained by the nursing staff from the Community Link Team and completed by the treating doctor. Once completed the ward clerk/nursing team must fax the form directly to the relevant hospice. The person making the referral must document in the patient s health records the name of the hospice and the date of the referral The nursing staff should contact the respective hospice the next working day to check that referral has been received, reviewed and if the patient has been accepted onto the hospice active waiting list The hospice will contact the ward when a bed becomes available for the transfer to take place 6.8 External transfer process - both within working hours and Out of Hours The receiving organisation will confirm bed availability, location and proposed date of transfer via telephone to the Bed Management Team in working hours. Out of hours the receiving organisation will confirm the bed availability with the ward directly. Patient (and next of kin where required) must be informed of this information by the ward nursing team Transport for external transfer must be coordinated/booked by the nursing staff in advance of the discharge date/time. In working hours transport request must be made to the transport department, using the electronic proforma and sent by to the Transport Dept address or a completed paper proforma can be taken to the transport department The transport request should provide details of o patients name o address patient being transported from o address patient is being transported too o date and time transport required o special requirements (i.e. oxygen) o mode of transport (stretcher, chair) o Special instructions (i.e. carry into house) The transport department will then book transport with North West Ambulance Service, If the external transfer is to take place "out of hours" the ward nurse must contact the North West Ambulance Service directly via switchboard, to arrange the required transport. On the day of transfer the medical team responsible for the patient s care must review the patient and record in the health record the patient's medical fitness for external transfer On the day of transfer the ward nursing staff must contact, by telephone, the receiving organisation to confirm transfer arrangements. Nursing staff must complete the external transfer form to accompany the patient 6.9 Documentation to Accompany the Patient on External Transfer Patient external transfer form which includes the Infectious Status and Control Discharge Form completed by the nursing staff (Appendix 2) A hand written (on hospital headed paper) medical transfer letter, completed by Page 14 of 30

15 the medical team (for hospital transfer only) Photocopy of the current inpatient stay episode of the medical health records (for hospital transfer only) Photocopy of patient's current inpatient medication prescription and administration record If there are any external Health records and X-rays belonging to the hospital the patient is transferring to they should accompany the patient. If the patient is being transferred to a hospice or nursing/residential home one week's supply of their current medication should be provided 7.0 PATIENT GROUPS The following groups of patients may require additional support with external transfer and discharge arrangements: 7.1 People with a learning disability Specific Requirements Where an individual has a health action plan with a patient passport or other personal information that will assist staff in developing plans for transfer or discharge this must be utilised to support the patient both as an inpatient and at transfer/discharge Where Social Services or other specialist services such as learning disability support are involved in the patients ongoing management they must be contacted by the nursing team as soon as possible following admission to ensure a collaborative approach to transfer/discharge Family and carers must also be also be included in transfer/ discharge arrangements where appropriate 7.2 People with Mental Health Issues Specific requirements Where a patient has a community care plan in place this should be taken into account when planning transfer/discharge If the patient has an allocated community healthcare worker they too should be involved, as early as possible following admission, to ensure a collaborative approach to transfer/discharge Referral to the Psycho-Oncology team may also be beneficial to help ensure continuity of care takes place 7.3 Vulnerable adults Specific requirements Where a patient is vulnerable staff should refer to the Policy for Safeguarding Vulnerable Adults Support is available from the Social Work department who will undertake an assessment of the patients needs and liaise with community social service teams. For capacity issues See Mental Capacity Act Policy 7.4 People with language difficulties Specific requirements For patients whose first language is not English staff must ensure an interpreter is present when discharge or transfer plans are being discussed so the patient is actively involved in any plans/discussions that are made. An interpreter can be arranged through any member of staff, by following directions on the Interpreter Request Form. 7.5 Patients Identified to be nearing the end of their life Specific requirements Page 15 of 30

16 When patients for whom no more active treatment is planned and have been given a short prognosis it may be the patient's wish to return home to receive their end of life care in the community. The nursing staff should contact the Community Link team by the Multidisciplinary Referral Form to discuss the specific needs of the patient. If appropriate The Community Link Team will take over the patient's case and will facilitate the discharge. If the Community Link Team cannot take on the patient s case then staff must use the rapid discharge checklist (Appendix 5) as an aid, when facilitating discharge in such instances. 7.6 The Young Oncology Unit Specific requirements The Young Oncology Unit does not routinely accept patients under the age of sixteen. The two exceptions to this are: o Patients requiring Total Body Irradiation TBI (5 day admission transfer back to the Children s Hospital). o patients requiring radioactive iodine 131 (discharged when radioactivity levels are considered safe by the department of nuclear medicine) The unit has its own dedicated discharge nursing team to ensure a safe and timely discharged of all YOU patients. 7.7 Treatment with Radioactive Iodine 131 or other Radionuclide Therapies Specific requirements People receiving these therapies will only be treated on the Iodine Suite on Ward One or in the MIBG room in the YOU, as the treatment requires isolation or other radiation protection precautions to be applied. A strictly controlled regime of treatment is implemented once the radionuclide has been administered and the patient becomes radioactive. In preparation for a safe discharge the patient s radioactivity level is monitored by the nuclear medicine staff. Monitoring is conducted in one of either two trust approved methods: o Initially at point of treatment and again on the day of discharge o Initially at point of treatment and then extrapolated out to set a discharge date in advance. Frequency of monitoring will be determined by the nuclear medicine staff and will depend on the individual and the radionuclide being used. When an acceptable level is reached/ determined by the nuclear medicine staff, the patient will be allowed to safely leave the hospital rooms/unit. Each patient is assessed by nuclear medicine staff on an individual basis, taking into consideration: o Home circumstances o Contact with family and young children Some patients may be discharged with certain restrictions on their activity. Discharge will take into account the duty of care for the patient s family and other people with whom the patient may come into contact. On discharge, if it is necessary for the patient to follow restrictions on their behaviour for a short period, to reduce the radiation doses to others to an acceptable level, those restrictions will be discussed with the patient by nuclear medicine staff. An advice card will be issued to the patient by nuclear medicine staff summarising the restrictions and the range of dates over which they should be applied. Page 16 of 30

17 7.8 The Critical Care Unit Specific requirements The Critical Care Unit has its own process to follow when transferring patients Patients are not discharged home directly from the Critical Care unit therefore discharge arrangements do not apply. These patients are transferred either to an inpatient ward or to a neighbouring hospital. Safe Transfer of Critically Ill Patients guidance document (Appendix 6) 8.0 CONSULTATION, APPROVAL AND RATIFICATION PROCESS Consultation This policy has been developed in consultation (via and face to face with department representatives) with the following key stakeholders: Matrons Ward Managers Clinical Service Managers Bed Managers Community Link Team Approval The Clinical & Research Governance committee has authority to approve this procedural document in accordance with Policy for the Development and Management of Procedural Documents Ratification Process The Management Board has authority to ratify this procedural document in accordance with Policy for the Development and Management of Procedural Documents 9.0 DISSEMINATION & IMPLEMENTATION 9.1 Dissemination To ensure that this procedural document comes to the attention of those people who need to adhere to and act upon the requirements contained within it the document will be posted on the intranet and where applicable the historical version archived, by ing the ratified document to the web team The Governance Team will be notified of board ratification of the document to enable update of the Procedural Document Register The Web Team will receive copies of any associated forms for posting in the Forms section of the intranet A completed Procedural Document Development Checklist will be submitted to the Governance team to facilitate an audit of compliance with this policy ensuring that review of each document occurs prior to the review date assigned to the document. Dissemination will be co-ordinated by the policy author 9.2 Implementation This procedural document will be implemented immediately following approvals. Implementation of this policy will be co-ordinated by divisional service managers. 9.3 Training/Awareness Divisional Management Teams are responsible for raising awareness of this procedural document amongst their staff 10.0 PROCESS FOR MONITORING EFFECTIVE IMPLEMENTATION The effectiveness of this policy will be monitored via an annual audit of no less than 10 patients discharged, no less than 10 patients externally transferred and Page 17 of 30

18 no less than 10 patients internally transferred over a two week period based on the NHSLA minimum requirements, undertaken by the Community Link Team. The results and subsequent action plan will be reported to the Clinical & Research Governance Committee and monitored by the same committee quarterly. In addition incidents and complaints relating to the discharge and transfer process, that have been identified via the trust reporting system IRF or via the trust complaints system, will be reported to the appropriate division and monitored by the Clinical and Research Governance Committee. The Clinical and Research committee shall ensure where incidents and complaints on discharge and transfer are received, the opportunity for learning and improvement is not lost and such reports include an action plan to address any identified deficiencies REFERENCES Department of Health (2003), SITREPS , Government Legislation (2006), Safeguarding Vulnerable Groups Act, Ministry of Justice (2008), Human Rights Guidance Documents, Department of Health (2009), The national framework for NHS continuing healthcare and NHS-funded nursing care NHS Primary Care Commissioning, Home Oxygen, Mental Heath Act (2007) Mental Capacity Act (2005 effective from 1 st October 2007) Page 18 of 30

19 12.0 VERSION CONTROL SHEET Version Date Author Status Comment /11 Neil Wrathall Draft Policy Generated /11 Chris Smith Final Amended to reflect new trust template and in line with NHSLA requirements Page 19 of 30

20 Multi-Disciplinary Referral Form All urgent referrals should also be phoned through to the relevant department Appendix 1 Referral will NOT be accepted if all the fields have not been fully completed Please affix sticker if available Hospital No:... Admission date:.. NHS No: Patient Name:... Patient Address: Tel:.. Mob.. Date of Birth:... Age:. Ethnicity:.. Language:. Interpreter required: Yes No Social circumstances: Does the patient live alone? Yes No ` Diagnosis/Treatment Details - current health/nursing needs Estimated discharge date: Treatment Completion date:. Ward:... Consultant:. GP Name/Address:.... Tel:... Has patient given consent to referral? Physio: Yes No Occ Therapy: Yes No Comm Link: Yes No Social Work: Yes No If NO, who has given consent. Has patient given consent to information being shared with other professionals/all MDT referrals? Yes No Is there a care package already in place? Yes No Patient aware? Yes No Accommodation: Tenure: Local authority / Private / Housing Assoc / Other Next of Kin:... Relationship to patient:.. Address: Postcode: Tel no:... Mob no: Patient referred to (this admission) Reason for referral Physiotherapy Tel Fax Occupational Therapy Tel Fax Community Link Team Tel Fax Social Work Tel Fax Assistance required Sitting Standing No assistance Minimal assistance Full assistance Is patient able to communicate basic needs? Does patient require chest physio? Yes No Yes No Walking Moving in bed Does patient require suction/oxygen? Yes No Transferring Washing/Dressing Is pain control a problem? Yes No Aids currently in use/required: Referred by: Date: Date Rec:. Page 20 of 30