Quality and Safety Programme Inter-hospital transfers - adults

Transcription

1 Quality and Safety Programme Inter-hospital transfers - adults London quality standards October 2014

2 Introduction A lack of robust inter-hospital transfer and acceptance standards is a current issue for some cohorts of patients in London with delays experienced in initial transfers and repatriation. The need for transfers between hospitals is likely to increase as a result of service changes underway in London and it is therefore essential to ensure that the quality of care and experience received by patients is improved and that transfer protocols are consistent across London s hospital sites. The standards have been developed by the clinical expert and patient panels of the quality and safety programme and the London Ambulance Service. The standards do not override any existing agreed formal network arrangements. Any future network arrangements should consider the standards. The standards do not override the minimum expectations defined by London Ambulance Service. The standards override locally agreed transfer protocols and Trust/Hospital transfer policies The standards cover transfers between acute hospitals sites, and between acute Trusts. The standards apply to all transfers regardless of day or time. The standards apply to all categories of patients unless specified otherwise. The standards apply to transfers from midwifery led units to obstetric units. The standards apply to transfers from hospitals to hospices. The standards apply to initial patient transfers and the repatriation of patients, unless stated otherwise. The standards apply to the transfer and acceptance of adults only. All acute hospitals are to form networks where an acute service is provided on some but not all hospital sites. All transfers will be the responsibility of the defined network, including the clinical governance arrangements. 2

3 Types of IHT transfers: Types of Transfer Critical transfers Immediate transfers Clinical transfers Non-urgent transfers Definition* Critical transfers are undertaken where a patient requires immediate life-saving intervention at a specialist centre. Examples include: neurosurgery, vascular surgery (including dissecting and leaking aneurysms), rescue or primary angioplasty, rescue angioplasty for hyperacute stroke patients, immediate cardiovascular surgery, major trauma treatment or management, stroke patients suitable for thrombolysis, haemorrhage requiring embolisation. Immediate transfers are undertaken where patients require transfer for life or limb saving treatment (ambulance dispatched within the hour) or management and the patient s clinical condition must necessitate the use of a fully equipped Accident and Emergency vehicle. Examples include: patients with complications of bariatric surgery, sudden loss of vision, immediately limb threatening injury, new onset ischaemic limb, cauda equina / spinal cord compression, ENT emergency, transfer between CCU/ITU/ICU, admission to an ITU (may not be ventilated), in-utero emergencies (where labour imminent), patient with monitors/infusions/sedation which cannot be switched off for the journey, acutely sick person in non emergency departments hospital (eg. mental health hospital), emergency renal dialysis (not routine dialysis session). Clinical transfers are undertaken where a patient is not critical or immediate but the patient s clinical conditions necessitate the use of a full equipped Accident and Emergency vehicle. They are those in-patients with limited mobility or who are currently monitored, who require transportation for assessments, appointments and/or medical investigations. Examples include: tracheostomy patients, repatriation of tertiary patients, cardiac patients going for investigations, mental health patients, maternity patients not in labour being moved for bed / cot capacity reasons, transfers for specialist investigations eg. MRI, interventional radiology etc, urgent humanitarian end of life care transfers. If a patient does not fall into either the critical, immediate or clinical transfer categories, it is the responsibility of the hospital s PTS provider to undertake the journey. Where a patient is clinically stable, the default position is that the hospitals PTS provider is responsible for any transfer. The acute Hospital Trust has responsibility to ensure that their PTS provider is able to undertake the types of transfers that are required (i.e walking patients, wheelchair patients, patients on oxygen therapy, stretcher patients, bariatric patients and mental health patients) and hospice transfers. Service provider London Ambulance Service (LAS) London Ambulance Service (LAS) London Ambulance Service (LAS) Proposed but not currently commissioned Patient transport service (PTS) *Definitions provided by London Ambulance Service. The examples included under the definition of each category are not an exhaustive list. 3

4 Standard 1 Trust boards to be accountable for having and monitoring robust and cohesive policies for inter-hospital transfers (IHTs) - including repatriations that encompass the agreed pan-london standards. All hospitals to be linked into networks for clinically indicated IHTs. Intensive Care Medicine (2011) Improved patient safety during critical care transfers resulting from a sustained Network approach The Trust s IHT policy is to be ratified by the Board and reviewed annually. Patient experience standards: Standard 2 A patient s privacy and dignity is to be maintained as far as possible throughout the transfer. NICE (2012) Patient experience standards Doncaster and Basetlaw Hospitals (2010) Policy for the transfer of Patients and their records Inform (conscious) patient where and why they are being transferred, discussion of transfer should be documented in the patient s notes Keep the patient covered and warm All transfer notes in a single opaque folder Transfer all patient s possessions in a single closed bag 4

5 Standard 3 A patient s relative/carer is to be properly communicated with and informed where and when the patient is being transferred. When a patient is a critical or immediate transfer from an emergency department, the sending hospital is to provide direction and support to assist the relative/carer in getting to the receiving hospital. Developed by Patient Experience Panel A birthing partner is to be allowed in the ambulance when a woman in labour, in the immediate post-natal period, or for any obstetric complication, is transferred from a midwifery led unit to an obstetric unit unless clinically unsafe or their presence would compromise the care being given. A parent/carer is to be allowed in the ambulance when a vulnerable adult is transferred unless clinically unsafe or their presence would compromise the care being given. It is not appropriate for parents/carers to travel with any patient transferred from an intensive care unit to an intensive care unit in an ambulance. 5

6 Standard 4 All IHT agreements to be made between senior clinicians (at least ST4 or equivalent) at both the sending and receiving hospitals. For critically ill patients requiring intensive care, involvement is required from consultants at both the sending and receiving hospitals. LAS (2009) Acute NHS Trust guidance on London Ambulance Service interhospital transfers AAGBI (2009) Safety guideline: inter-hospital transfer ICS (3 rd edition 2011) Guidelines for the transport of the critically ill adult Doncaster and Basetlaw Hospitals (2010) Policy for the transfer of Patients and their records For critical transfers an ST4 is to assess the patient for safety of transfer and agree the requirements for medical or nursing staff to accompany the patients during transfer. Equivalent to ST4 is a career grade doctor (staff doctor, speciality doctor, associate specialist or other non-training grade doctor), with clinical competencies at least equivalent to a trainee at ST4 level. For non-urgent transfers a senior clinician can be a senior nurse. The named consultant or responsible consultant in the sending and receiving organisation must authorise the decision to transfer the patient. For consultant involvement for critically ill patients requiring intensive care it is not necessary for the consultant to be on-site. If the consultant is unavailable this is to be recorded in notes. Transfer must not be delayed awaiting consultant approval. Clinical involvement is to be recorded in notes and available for audit. When making an agreement on an IHT SBAR communication tool is to be used between clinicians at the sending hospital, and between clinicians at the sending and receiving hospital. 6

7 Standard 5 The receiving hospital is to inform the sending hospital whether it can accept a proposed IHT within the agreed timeframes. South London Cardiac and Stroke Network (2012) High level guidance for patients accessing stroke services in south London Critical transfer Instant decision Immediate transfer Decision within 30 minutes Clinical transfer Decision within 1 hour Non-urgent (PTS) Decision within 1 hour This standard applies to initial IHT and not repatriations. When requesting a transfer the sending hospital must agree to take the patient back once the specialist intervention has occurred and if it is clinically appropriate for the patient to be repatriated. Acceptance implies that a bed is available for the patient at the receiving hospital. For critical and immediate transfers once a decision has been made to transfer a patient and a patient has been accepted then the transfer should be booked immediately. For critical transfers, as soon as a patient is transfer ready the call to LAS should be placed; investigations not relevant to a clinical decision on whether to accept the patient should be carried out at the receiving hospital. In circumstances when the patient requires some stabilisation prior to transfer (e.g. intubating, HC03 infusion to get ph >7, haemofiltration if K >7) the local clinician is to ensure immediate stability. 7

8 Standard 6 When LAS or PTS agree to an IHT they are to dispatch or arrive at the hospital within the agreed times. LAS (2009) Acute NHS Trust guidance on London Ambulance Service interhospital transfers Critical transfer Next available ambulance: category A response arrival at the referring hospital in eight minutes in 75 per cent of cases. Immediate LAS will aim to dispatch to the referring hospital within 60 minutes of the transfer request being made. transfer Clinical transfer LAS will aim to dispatch to the referring hospital within two hours of the transfer request being made or within 45 minutes of a booked transfer time. Non-urgent (PTS) PTS will aim to arrive within two hours of the request being made or within 45 minutes of a booked transfer time. If a patient is being transferred for a pre-booked appointment the patient is to arrive on time for the appointment. Within 45 minutes of a booked transfer time would be if a transfer was booked for 15:00 hours then transport should arrive between 2.30pm and 3.15pm. Unless in the clinical interest of the patient transfers are not to take place between the hours of 10pm and 6am. 8

9 Standard 7 If a specialist centre is unable to accept an IHT on clinical grounds clear reasons for the decision and targeted advice on further care must be provided to the sending hospital. The name of the specialist giving advice should be recorded in the patient s medical notes at the sending hospital. Networks are to undertake as minimum an annual audit of all cases where transfers were refused. Where not accepting for clinical reasons is noted, this should always be discussed with a consultant at both hospitals, advice given and recorded. Standard 8 Where a specialist centre within a network lacks capacity to take an IHT within appropriate timescale, the specialist centre is responsible for finding an alternative destination for the patient. Celia Ingham Clark (2011) Draft guidelines for a networked approach to surgical services London. Appropriate timescales are detailed in standard 5. A conversation is to take place outlining the alternatives and issue escalated if a resolution cannot be found. Existing local policies for acceptance apply to patients aged 15 to 18 years who are being transferred to an adult ITU. 9

10 Standard 9 A request to LAS and PTS for an IHT is not to be made until agreement to transfer has been reached between hospitals with appropriate clinical involvement. LAS (2009) Acute NHS Trust guidance on London Ambulance Service interhospital transfers Doncaster and Basetlaw Hospitals (2010) Policy for the transfer of Patients and their records The patient must be ready for transfer at the point the request to transfer is placed with LAS and PTS. When requesting an IHT from LAS and PTS the sending hospital is to ask for any specialist equipment or special requirements for the transfer. Standard 10 The sending hospital retains clinical responsibility for the patient until handover at the receiving hospital has taken place. Handover should take place within 15 minutes of arrival. LAS (2009) Acute NHS Trust guidance on London Ambulance Service interhospital transfers Doncaster and Basetlaw Hospitals (2010) Policy for the transfer of Patients and their records The receiving hospital is responsible for providing advice on patient management if required. This standard applies to both initial transfers and repatriations ie. the hospital the patient is being moved from retains responsibility. 10

11 Standard 11 The sending hospital is to ensure the patient is accompanied by an appropriate clinical escort(s) during the transfer, who is ready for transfer when LAS or PTS arrive. Prior to the IHT of any patient a risk assessment must be undertaken by a suitably competent member of clinical staff to determine the level of anticipated risk during transfer and identify the patient s minimum clinical escort requirements. ICS (3 rd edition 2011) Guidelines for the transport of the critically ill adult AAGBI (2009) Safety guideline: inter-hospital transfer LAS (2009) Acute NHS Trust guidance on London Ambulance Service interhospital transfers BAPM (2008) Management of acute in-utero transfers: a framework for practice London Ambulance Service is unable to guarantee a paramedic crew for critical, immediate and clinical transfers. A clinical escort may be required to travel with a patient transferred via Patient Transport Service (PTS). All hospitals must use a risk assessment too to determine escort requirements. The assessment must be documented in the notes and available for audit. Appendix 1 is given as an example risk assessment tool. Appropriate clinical escorts are to be able to undertake any treatment that may be needed during the journey. The expectation is that critically ill patients are to be accompanied by a minimum of two suitably trained, experienced and competent attendants during transfer in addition to London Ambulance Service staff. The background of the staff and the competencies required will depend on the nature of the underlying illness, co-morbidity, level of dependency and risk of deterioration during transfer but a clinician must have the competency to manage a patient in an out-of-hospital environment and work autonomously (ST4 or equivalent). All transfers of women in labour and in the immediate post natal period, or for any obstetric complication should be accompanied by a midwife. It is not essential for a risk assessment to be carried out if the transfer is time critical. This decision should be recorded in notes and available for audit. Where the transfer is delayed more than 15 minutes the London Ambulance Service crew will be stood down and the transfer will need to be rebooked. 11

12 Standard 12 The specialist centre receiving a patient is to inform the sending hospital with the estimated date of discharge/repatriation as soon as possible, and no later than 48 hours from admission. London Trauma System (2012) Transfer of care / repatriation policy NWL cardiac and stoke network (2009) Patient movement protocols for NW London stoke services Adult Emergency Services Standards (2011) The specialist centre is to update the sending hospital if the estimated date of discharge/repatriation changes. The Bed Management Team and clinical team should be informed at the sending hospital. The sending hospital is the hospital where the patient was transferred from. If a patient is repatriated to a local hospital closer to their home rather than the sending hospital, the estimated date of discharge/repatriation is to be sent to the hospital the patient is expected to move to. The sending hospital has a responsibility to send all paperwork and scans in timely manner to support this. 12

13 Standard 13 Once a patient is clinically fit for transfer back, a repatriation notification is to be sent to the Bed Management Team and clinical team at the sending hospital. The repatriation is to occur within 24 hours of the notification. London Trauma System (2012) Transfer of care / repatriation policy NWL cardiac and stoke network (2009) Patient movement protocols for NW London stoke services South London Cardiac and Stroke Network (2012) High level guidelines for patients accessing stroke services in south London Appropriate clinical teams at both hospitals to agree that the patient is clinically fit for repatriation and a named consultant and speciality are confirmed. A repatriation notification is to detail the time and date the patient is fit for transfer The repatriation notification should not be sent earlier than 24 hours prior to patient being fit for transfer. The sending hospital is to confirm bed allocation, time and date bed available for patient. The repatriation is not to take place between the hours of 10pm and 8am. The escalation process is to be activated if repatriation has not occurred with 24 hours of notification. Hospitals should audit the use of repatriation procedures. The sending hospital is the hospital where the patient was transferred from. 13

14 Standard 14 All IHT to be carried out with appropriate clinical documentation. On arrival at the receiving hospital, an adequate structured handover is required to the receiving team. North west London critical care network (2008) Adult critical care record of transfer ICS (3 rd edition 2011) Guidelines for the transport of the critically ill adult Photocopies of relevant notes should travel with the patient or the documentation should be sent electronically via a secure connection. Nonavailability should be documented. All relevant investigation results must be transferred to the receiving hospital via IEP (Image Exchange Portal) or within transfer documentation. The transfer form should be signed by a clinician in the receiving hospital and a photocopy inserted into the patient s original notes in the transferring organisation. All patient records and information transferred between organisations must be treated confidentially. During the handover all relevant clinical information should be communicated. 14

15 Standard 15 All hospitals to have an escalation process in place which is instigated where timescales are not met for all IHTs. Adaption from source: North west London (2009) Cardiac and Stroke Network: patient movement protocols for NW London stroke services London Trauma System (2012) Transfer of care / repatriation policy If a request to transfer has been refused or transfer of care has not occurred with appropriate timescales communication should be initiated between the named accountable or responsible consultant for the patient at sending and receiving hospital. The escalation policy is to follow the bronze (bed manager), silver (general manager level), gold (executive team level) chain. The escalation policy applies to all transfer categories. Patients should continue to be cared for in the appropriate facility by the appropriate team while waiting for the transfer to take place. Standard 16 Unless otherwise directed by the receiving hospital at the point the transfer is agreed, all patients are to be received via the emergency department to be booked in and receive resuscitation if appropriate. This standard excludes a woman in labour, ward to ward transfers including critical care unit to critical care unit, and a patient being repatriated. Other exceptions include direct transfers to heart attack centres and arrhythmia units. A woman in labour should be received in a maternity unit entry to the maternity unit should be arranged at the point of transfer agreement between hospitals in order to mitigate obstacles entering the unit. Patients being transferred directly from one ward to another, ie. to a critical care unit, should be received directly in the receiving ward - entry to the ward should be arranged at the point of transfer agreement between hospitals, in order to mitigate delays entering the ward. Patients being repatriated should be received directly in the receiving ward - entry to the ward should be arranged at the point of transfer agreement between hospitals, in order to mitigate obstacles entering the ward. If a patient is to be received outside of the emergency department, the discussion between hospitals and the receiving location is to be formally documented on the transfer form and London Ambulance Service/Patient Transport Service is to be informed at the point of request. 15

16 Standard 17 It is inappropriate for patients to remain in the emergency department of the receiving hospital unless the emergency department offers the only appropriate facilities and expertise suited to the patient s current condition. The receiving hospital must arrange immediate transfer to the most clinically appropriate department. Once received in an emergency department, patients who require critical transfer for emergency operation should be transferred directly to the operating theatre complex or imaging suite of the receiving hospital. Once received in an emergency department, patients who require immediate transfer for emergency operation should be transferred directly to a surgical assessment unit or critical care unit of the receiving hospital. Once received in an emergency department, patients who require emergency medical specialist care (for example, renal or liver failure) should be transferred directly to a specialist unit within the hospital. Once received in an emergency department, patients who require interventional radiology to be transferred to the interventional radiology suite of the receiving hospital. Once received in an emergency department, patients who require primary coronary angioplasty to be transferred to a cardiac catheter suite. Standard 18 For all IHTs on arrival at the receiving hospital a patient must be seen by the receiving specialist team within the agreed timeframe. Critical transfer Immediately Immediate transfer Clinical transfer Non-urgent (PTS) Within 30 minutes Within 1 hour Within 1 hour The receiving medical team who accepted the patient takes responsibility for the patient once handover is complete in the receiving hospital, even if the patient was handed over in the emergency department. For repatriation the receiving team can be considered to be a multidisciplinary team if appropriate. 16

17 Audit: Standard 19 All IHTs should be subject to continuous prospective audit involving all hospitals in the network, with at least annual review. Celia Ingham Clark (2011) Draft guidelines for a networked approach to surgical services AAGBI (2009) Safety guideline: inter-hospital transfer ICS (3 rd edition 2011) Guidelines for the transport of the critically ill adult As a minimum the audit must include: - Standard 4 (level of clinical involvement in decision to transfer) - Standard 5 (timeframe for decision to accept transfer) - Standard 6 (the time the transfer took place) - Standard 11 (risk assessment documented in notes) - Standard 13 (timeframe for repatriation) - Standard 14 (inclusion of information in transfer documentation) - Standard 18 (timeframe to see specialist team) The audit is to include both those patients successfully transferred and those patients where a transfer was deemed inappropriate or found not to be possible. The audit is to feed into the organisation quality and risk management structures. 17

18 Appendix 1: Example of a Risk Assessment Tool for minimum escort requirements [Source: Chelsea and Westminster Hospital NHS Foundation Trust: Policy for the escort and transfer of patients between care settings, April 2010] Adult Patient Escort Risk Assessment Tool - used as an aide memoir The Escort Risk Assessment tool should be used as a guide to support decision making. Please refer to the main policy for guidance of when to use this tool Risk Assessment Factors All Adult patients requiring Level 1, Level 2 (HDU) or Level 3 (ITU) care 3 Aggressive or sectioned under the Mental Health act or on the recommendation of the Lead Nurse for Mental Health or Psychiatric Liaison Nurse 3 Women who are 20 weeks pregnant and in active Labour 3 Acute difficulty in breathing-wheeze, stridor, distressed, tracheotomy or artificial airway 3 Any patient requiring an invasive diagnostic or interventional procedure (patients referred for invasive ambulatory care, or those who are likely to be given sedation during investigations) Medical device insitu such as, a drainage system e.g.(not urinary catheter), intravenous infusion or TENs machine 2 IV opiates/sedation in past 1 hr or via infusion 2 Patients pre and post operative or invasive procedure (More than one patient can be escorted to theatre by one member of staff 2 Any patient who is having a blood transfusion, chemotherapy or on continuous IV therapy that is of an opiate nature or other drug likely to alter patient s physical state (this includes patients with an arterial line in situ). Infusions can only be stopped in exceptional circumstances and in consultation with medical staff. 2 Adults with an acute altered degree of conscious level or acute confused state (GCS < 15) 2 Cardiac monitoring & / or Chest pain within previous 4 hours 2 Adult patients with a CEWSS Score 1 2 Out of hours CT scan, MRI scan or angiogram 2 Patients with dementia and at risk of wandering if relative/carer not present 1 IV Fluids therapy only 1 Oxygen <40 % therapy only 1 Patients with Mental Health needs on Standard or Intermittent observations 1 Results Guide to minimum patient escort requirements Score 2 Score of 3 or above Registered Nurse / Midwife/Registered Mental Nurse (RMN) escort consider expert advice Score of 2 Score of 1 or below Registered Nurse / Midwife/Registered Mental Nurse (RMN)/ODP escort Health Care Assistant/Student Nurse/ Student Midwife/Transport Staff /Volunteer (when available This is not a total scoring system; application of this tool is intended as a guide only it should not replace clinical judgment. 18