724 - Admissions Policy Procedure and Guidelines PDF
724 - Admissions Policy Procedure and Guidelines PDF
724 - Admissions Policy Procedure and Guidelines PDF
PROCEDURES AND
GUIDELINES
Date
Page(s)
Compiled by:
Ratified by:
Comments
Approved by
Date:
June 2005
Review:
June 2007
Volume 8
Patient Care
First ratified
July 2005
Issue 1
Part I (Admissions)
CONTENTS
Section
Item
Admissions
Volume 8
Patient Care
Index
Capacity Management
Policies by Location
Intensive Care
Admission of Prisoners
10
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Issue 1
Part I (Admissions)
GLOSSARY OF TERMS
A&E
ASPH
CCU
CF
COE
DTA
Decision to Admit
EBS
ECMS
ED
Emergency Department
EPS
EPU
ICD
IgA
Immuno-globulin A
ITU
MAU
MRSA
NICE
ODPS
OPD
PAS
SITREP
SpR
SWCCN
Volume 8
Patient Care
Cystic Fibrosis
Situation Report
Registrar
Surrey Wide Critical Care Network
TCI
To Come In
TTO
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Part I (Admissions)
ADMISSIONS
INDEX
Section 1
Capacity Management
1.1
1.2
1.2.1
1.3
1.3.1
1.3.2
1.4
1.4.1
1.4.2
1.5
1.6
1.7
Aims
Principles of Capacity Management
Single Sex Accommodation
Bed Management Processes
Bed crisis (inc Capacity Management Policy)
Doctors responsibility regarding Capacity Management
Transfer of patients
Treat & Transfer
Escorts for patient Transfers to Other Hospitals
Patient Repatriation
Emergency Capacity Management Scheme (ECMS)
Admissions Office Case Note Retrieval
Section 2
Admission Policies: By Location
2.1
2.2
2.3
2.4
2.5
2.6
2.7
2.8
2.9
2.10
Emergency Admissions
Medical Admissions
Transfer from A&E/ED
Acute Admissions from OPD
Planned Medical Admissions
MAU
Coronary Care Unit
Chaucer Ward
Angiography
Physiotherapy
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Section 3
Admission Policies for the Surgical Orthopaedic and Trauma Directorate
3.1
3.2
3.3
3.4
3.5
3.6
3.7
3.8
3.9
3.10
3.10.1
3.11
Admission Categories
Patients Who Do Not Arrive
Late Cancellations
Management of Weekend Booked Admissions
Guidelines to follow in the Event of a Threatened Cancellation
Private Patients Referred to the NHS
Pre-admission Clinic
Day of Admission
Guidance for Admission of Medical Patients to Orthopaedic Wards
Gynaecological Patients
Referral and Admission of Patients Attending the Early Pregnancy Unit (EPU)
Admission to Day Surgery Unit
Section 4
Intensive Care
4.1
4.2
4.3
4.4
4.5
4.6
4.7
4.8
4.9.
4.10
4.11
4.12
Section 5
Admission Policy for Paediatrics
Section 6
Admission Policy for Infected Patients
Section 7
Policy for Patients Admitted with Special Needs
7a
Section 8
Patients Under Section
Section 9
Admission of Prisoners
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Patient Care
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Issue 1
Part I (Admissions)
Section 10
Admission of Older People
10.1
10.2
Section 11
Appendices
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Part I (Admissions)
ADMISSIONS
Section 1
1. CAPACITY MANAGEMENT
1.1
AIMS
To ensure that: Patients are admitted to Ashford & St Peters Hospitals for appropriate clinical reasons. Patients should not be
admitted due to lack of social support.
There is minimum disruption to planned elective admissions whilst responding positively to emergency admission
requirements.
Patients are provided with the bed placement that is most appropriate to their medical need and which takes into
account any additional special needs throughout their inpatient stay.
If a patients medical needs change, the decision to alter the patients bed location will take account of: the time that the patient would spend in an alternative speciality
the ability of an alternative speciality to respond to the patients care needs, (if it is only a temporary
placement)
the overall on-costs to patients and carers of any move.
If a move occurs, continuity of care needs to be maintained and effective communication of treatment/care protocols are
a priority.
When patients specific conditions have been assessed/stabilised/treated and there remains no medical need for the
patient to remain in hospital the patient should be moved to a more appropriate environment without delay.
All staff utilise the Capacity Management system.
A Real Time Capacity Management system is operating.
1.2
The Capacity Managers and in their absence, Site Co-ordinators are responsible for:
i
ii
Ensuring appropriate communication between the medical staff, the wards and the Accident and Emergency
(A&E) / Emergency Department (ED).
iii
Liaison with the relevant managers/clinicians in respect of prioritising admissions and to initiate contingency
plans, if necessary.
iv
Patients and/or families will be provided with comprehensive information and reassurance about their treatment
and care following admission.
Children, pregnant women and post-natal mothers and babies will always be admitted to the appropriate clinical
unit for their age and condition.
vi
vii
Discharge planning will commence prior to admission for planned admissions and on admission, or as soon after
admission as possible, for emergency admissions.
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A patient (presenting at Ashford hospital) warranting admission for specific speciality intervention (Gynaecological,
Surgical and Orthopaedic) should be Treated and Transferred (See Appendix 1 & 1a for Guidelines on Emergency
Assessment and Transfer of Patients) to St Peters. Depending on the condition of the patient, (i.e., if the patient has
IV drugs insitu) the patient will be transferred in an ambulance and accompanied by
viii a paramedic,
ix
a nurse and paramedic or
x
a doctor, nurse and paramedic.
xi
On admission it is essential that patients with mental health needs/learning difficulties have their community
psychiatric nurse/key worker notified of their admission.
xii
If a patient does not warrant admission on clinical grounds, but it may be unsafe to discharge them because of
their social situation from the A&E, ED or Medical Admissions Unit (MAU), then an Occupational Therapist
Care Manager or the Intermediate Care Team should be informed in an attempt to facilitate immediate discharge.
xiii
Where a patient is living alone with no immediate support, during office hours the Intermediate Care Sister or
Duty Case Manager (dependent on whether the concern is nursing or social) should be contacted in the usual way.
Contact telephone numbers and bleep numbers are kept in A&E / ED.
xiv
Out of office hours, when a need for services is identified, the Emergency Duty Intermediate Care Sister or Duty
Care Manager, should be informed at the earliest opportunity (on-call contact numbers can be obtained via
switchboard).
1.3
a)
i.
There will be a minimum of four bed states (AH & SPH) obtained daily. Bed states will be assessed routinely at:
06.30 by the Site Co-ordinator
08.30 by the Admissions Office
10.30 &15.00hrs (at CAT meeting)
19.30 by the Site/Co-ordinator
NB. At all other times the Capacity Manager/Site Co-ordinator should ensure they are appraised of the current sitespecific bed-state.
ii. All wards must ensure the Capacity Managers/Site Co-ordinators are kept up to date regarding the current bed status.
iii.
All ward rounds should be planned AM in order to expedite progression of patients through the hospital system.
iv. It is the responsibility of the nurse in charge to ensure that trained nurses are aware of the current bed-state and the
forecast for the next 12 hours, including all outliers on the ward.
v.
When confirming a bed state, empty beds must be declared even when they are identified for expected patients. The
nurse confirming the bed-state should inform the Capacity Manager or Site Co-ordinator that they are expecting a
patient for a particular bed (this includes patients expected from other hospitals).
It is the responsibility of the admitting Consultant, or their deputy (SHO/REG), warrants admission.
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ii.
The responsibility of locating vacant beds for emergency patients lies with the Capacity Manager/Site Co-ordinator.
The Capacity Manager/Site Co-ordinator will liaise with the Nurse in charge when a suitable bed has been
identified.
iii. The trolley wait definition is in accordance with National guidelines and has been agreed by DOH Sitrep/ROCR
(2003). The waiting time in relation to trolley waits begins when there is a decision to admit, not from the arrival
time in A&E. Total time in A&E must not exceed 4 hrs. It is the responsibility of the A&E shift leader to
measure waits. Patients are moved out according to how long they are in the department following a decision to
admit and according to clinical priority.
iv. Please see Appendix 2 for Admission of Medical Patients to the MAU. (Appendix 2a; 2b; 2cfor Capacity
Management Flow SPH & AH Medical Patients and A&E/Ward Communication Guidelines)
v.
For all specialities there is a need to maintain speciality Consultant based wards. However if there is a need to
outlie patients, please refer to guidelines displayed in each ward and the Site Co-ordinators file for transferring
patients as outliers Buddy Link System. (See Appendix 2)
vi. When the St Peters and Ashfords ED A&E Department has reached maximum capacity, the Observation Bay
(SPH) & Theatre Area (AH) may be used to accommodate patients either awaiting transfer to a ward area, or
patients who require 24 hour observation (and /or pending results of tests etc. may be discharged). See Appendix 8.
vii. Any patient awaiting Emergency Theatre or Endoscopy may be transferred to the Day Unit or Endoscopy Unit as
priority prior to transfer to ward bed.
c) Review of numbers of patients waiting planned admission
i.
The day before admission, the CAT meetings will assess projected discharges across the hospitals and the number
of pre-cancelled elective patients for admission, to assess whether planned admissions can still be accommodated.
(See Appendix 4; 4a & 4b)
ii.
The admissions list should indicate whether the planned admission is urgent/routine or a long waiter, and whether
a patient has been cancelled on a previous occasion, in order to avoid second cancellation.
On the day of admission if there are sufficient beds, admissions office will confirm bed availability with the patient.
Fielding at Ashford Hospital confirm directly.
ii.
If there are insufficient beds to accommodate all planned admissions the admission office staff will, inform the
patient, the Consultants secretary. The Capacity Managers will inform theatres.
PRIORITY TWO
Long Waiters
PRIORITY THREE
iii. Priority should usually be given to those patients awaiting a bed in the A&E / ED. Examples of when planned
admissions supersede emergency admissions include patients with clinically urgent conditions i.e. cancer or a long
waiter (11 months +).
iv. In the event of dispute the Capacity Manager will refer to the Head of Admissions and/or the Director of
Operations, whose decision is final
iii. The Admissions Office and the Capacity Manager/Site Co-ordinator must record all cancelled/deferred admissions.
All patients who are cancelled on the day of admission should be offered a re-admission date within 28 days. No
patient under the 28 day rule will be cancelled.
v.
All cancellations should be made in advance of the to come in (TCI) date, rather than on the day, wherever
possible. (See Appendix 4 & 4a for Pre-cancellation Protocol and Explanation of Pre-cancellation &
Cancellation (on the day).
vi. Patients not fitting the Day Surgery criteria are admitted to an inpatient ward but may be discharged the same day, if
fully recovered.
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As and when serious bed shortages are anticipated, actions should be taken according to the Capacity
Management Policy (See Appendix 3)
Pre-cancellation Guidelines (See Appendix 4)
Admission Criteria for Day Surgery please see Appendix 5
For guidelines on the use of Private Capacity, please see (Appendix 6, Guidelines for NHS Admissions to
Private Hospitals. & 6a, Guidelines for Transfer of NHS Patients to Private Hospitals (Runnymede &
Shakespeare Suite).
1.3.2
i.
Ensure that the Capacity Manager/Site Co-ordinator is informed of ALL patients requiring admission or transfer
from any area within or external to the hospital
ii. Plan the case mix of elective admissions in accordance with anticipated availability of beds and theatre time
iii. Identify the priority of patients for admission (using clinical and social criteria as appropriate) during the out-patient
consultation. Ensure patients are informed of anticipated length of stay.
iv. Visit outlying patients daily
v. Ensure that the medical contribution to each patients discharge is directed at achieving a problem free discharge
and that discharges are planned a minimum of 24hrs in advance.
vi. Ensure that all patients for discharge are reviewed as a priority every morning, except when urgent clinical need
dictates otherwise
vii. Ensure all post-take ward rounds take place am and that a discharge date, including plan of action is clearly
documented.
viii. Identify patients suitable for transfer to MAU or AH/SPH according to clinical priority in response to capacity
speciality deficits.
1.4
TRANSFER OF PATIENTS
Patients may be transferred for treatment to or from other hospitals. Reasons for transferring patients include:
Bed shortages
Patient to receive private treatment
Tertiary referrals
1.4.1
Treat and transfer of emergency patients from the A&E, ED, MAU or Ward to a cover site is part of the Capacity
Management Plan and used in the event of bed shortage. (See Appendix 1a)
1. The current bed -state should be ascertained. This is to include the following information:
i.
Update regarding patients awaiting a bed in A&E, ED or MAU
ii.
Availability of additional bed cover at either Ashford or St Peters
iii.
If bed cover is required and is available, the extent of the cover is to be agreed and
appropriate doctors on both sites, by the Capacity Manager / Site
Co-ordinator/Discharge Co-ordinator following the post-take ward round.
communicated to all
2.
Doctors must ensure that a full hand over is given to the receiving site providing the cover. Registrar to Registrar
hand-over, (including plan of care, urgent tests pending, special needs e.g. disability, hearing problems etc).
3.
Patients transferred should be transported direct to the cover hospital ward and not A&E/ED
4.
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5.
Transport can be arranged via the Ambulance Service. Ensure they are informed of the treat and transfer
arrangement and transfer the patients to the appropriate receiving area/ward. No patients should be transferred after
10pm.
NOTE: All patients for transfer must be considered clinically stable
6.
It is essential that a record is kept (including accepting Doctors name) of all patients transferred to outlying areas,
including the private hospitals
7.
The Capacity Manager or Site Co-ordinator out of hours will ensure that doctors know the location of their patients
8.
If patients are transferred at weekends, a record should be forwarded to the Capacity Manager
9.
All patients transferred must have a property checklist completed prior to transfer and checked on the receiving
ward.
10. If NHS patients are transferred to a private hospital who are for discharge the next day, all medications including
TTOs should accompany the patient. The family should be informed and where possible, discharge transport
arranged in advance of the transfer.
11. The Shakespeare Suite and Runnymede Hospital occasionally experience difficulty when trying to contact doctors
to review patients. If patients need to be reviewed between 17.00 hours and 09.00 hours, the appropriate on call
team must be notified of the transfer.
12. The Capacity Manager and Discharge Co-ordinators will monitor all patients transferred
1.4.2
ODPs are expected to act as escort in support of anaesthetist if the patient has a compromised airway. ODPs should
not be asked to substitute for nurses in escort situations.
1.5
Patients admitted for treatment to another hospital should be repatriated to a hospital of their own residence, avoiding
unnecessary delays.
All inter-hospital sites are programmed to occur during the working day so that patients transferred from a ward in an
other hospital to a ward within the Ashford & St Peters Hospitals should arrive at a time that allows for the ward based
team to make a formal assessment of the patient and programme a planned course of action required to cover specific
needs.
All teams receiving patients from inter-hospital transfer should insist on a full documentation of patients clinical state
prior to transfer and should be aware if patients are being transferred in a clinically critical condition.
If patients are deemed to be potentially unstable or require immediate assessment for the possibility of subsequent
speciality involvement or if the patients arrive outside working hours that the initial point of delivery of the patient
should be to Accident & Emergency or the Emergency Department.
This would provide a safe supervised site for the initial processing of the patient. The on-call speciality team should
then be informed if a patient is likely to arrive after 5pm.
1.5.1
i.
ii.
1.5.2
i.
Patients admitted to another hospital under a treat and transfer arrangement, who have continuing clinical
needs
ii.
Local residents admitted to another hospital, who are actively under the host hospital for a related condition
and who have continuing clinical needs
The receiving hospital has a clear responsibility for these patients and is obliged to respond promptly. The patients
should be repatriated within 48 hours of the request.
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1.5.3
i.
ii.
1.5.4
i.
ii.
iii.
1.5.5
Consideration must be given to pressures within the A&E, ED, MAU and to elective activity.
Patients should be placed according to previous consultant episode. In all cases, the relevant clinician must first
authorise the repatriation
i.
Patients who live within the Ashford & St Peters Hospitals catchment area, who are admitted as an emergency
into out of area hospitals, require Registrar to Registrar referral.
ii.
Liaison thereafter should be between the respective Capacity Managers or out of hours the Site Co-ordinator
iii.
With repatriation following an ICU transfer, the aim should be to transfer directly from the ICU of the host
hospital to the receiving hospitals general ward, HDU or ICU.
iv.
Orthopaedic wards require the patient to have one MRSA screening clearance or 3 if contact has been involved.
v.
In all cases, it is the responsibility of the hospital seeking the repatriation to make contact with the appropriate
Capacity Manager at the receiving hospital and to provide all relevant clinical and social information
vi.
Hospital MRSA screening policies should not prevent them from meeting their obligations under this protocol
vii.
The time limits should be observed at the weekends as well as during the week. Although it is recognised that
local Capacity Management arrangements and the availability of the accepting clinical team at the weekends
may have an influence
1.6
The ECMS is responsible for controlling all GP and 999 generated emergency admissions. Patients who live in areas
that are equidistant from more than one hospital are transported to the one under the least pressure at the time of the call.
The scheme is to help ensure that patient workload is shared more equally whilst protecting the interests of patients and
their relatives. (Please see Appendix 11 for details of ECMS)
1.7
Section 2
ADMISSION POLICIES BY LOCATION
2.1
EMERGENCY ADMISSIONS
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i.
ii.
iii.
iv.
MEDICAL ADMISSIONS
2.2
i.
All Emergency admissions will be admitted via the A&E/ED, (ASPH). Gynaecology patients maybe admitted
via the Early Pregnancy Unit (EPU). The Capacity Manager/Site Co-ordinator must be informed of all
admissions.
Emergency Surgical admissions will be seen and assessed initially by a House Officer (at St. Peters) followed
by a Registrar. For Orthopaedics a Senior House Officer will be required to assess patients prior to a decision
to admit.
Patients admitted as Emergencies will be admitted under the care of the admitting team and should be
transferred to the care of the Consultant specialising in the patients particular condition via a formal referral
process.
Where possible all Surgical/Orthopaedic patients will be admitted to their speciality ward area.
(Please see Appendix 8 for Guidelines on the use of the Observation Bay AH & SPH)
ii.
All medical admissions will be seen by a medical Senior House Officer (SHO) or Registrar to assess their medical
condition.
All acutely ill patients will be initially assessed by the on-take team. Following a DTA, patients must be
transferred to a bed according to their speciality need.
Patients may be admitted from A&E/ED for further observation and assessment. These patients should be
transferred MAU. Plans for investigation and early referral for relevant investigation should be initiated within the
first 24 hours of admission.
All attempts should be made to avoid admission of patients who are medically stable but do not have sufficient
support to return to the home environment. Such patients should be referred to the Intermediate Care Team to see
if direct discharge can be facilitated. If these patients are admitted, early involvement of social services and/or the
elderly care teams is essential. For further information, please refer to the Discharge Policy.
iii.
iv.
v.
Following a decision to admit, all patients will be transferred as soon as possible from the A&E/ED dept to a
ward appropriate for their ongoing, specialist needs. Hand-over will take place on the ward. (See Appendix 2c
A&E/Ward Communication Guidelines).
2.4
i.
ii.
iii.
Acute admissions from the Outpatient Department must be sanctioned by a Registrar or a Consultant
These acute admissions will remain under the care of the admitting team, unless a formal referral to another
team/speciality is made.
All admissions from the OPD must be admitted direct to an appropriate ward area via the Capacity Manager.
In the event there is no immediate ward bed, patients should wait in the DSU (up to 7.30pm) or clinic area (up
to 5pm). Patients can remain in OPD providing the following criteria are met:
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2.5
2.6
i.
ii
Iii
Iv
2.7
CORONARY CARE UNIT (CRITICAL CARE UNIT AH, CORONARY CARE UNIT
SPH)
A copy of flow-charts 1 4, relating to: Coronary Care Unit admissions can be found in Appendix 12.
a) Eligibility Criteria
There is no age limit for admission of patients to the Coronary Care Unit.
Any patient with Angina, Myocardial Infarction (Fast Track MI STREP/TPA), Heart Failure, Arrhythmias i.e.,
Ventricular Tachycardias, new Supraventricular Tachycardias for Cardioversion/Angioplasties/Electro-physiological
Studies or patients with chest pain, can be admitted to the Coronary Care Unit.
Because of the nature of the Unit, patients of both sexes can be accommodated in the same area.
b) Admission
i.
Only the SHO and above may admit patients to the Coronary Care Unit.
ii.
Only Senior Nurses (Sister), in the Coronary Care Unit may accept patients for admission. (The CCU must
ensure the Capacity Manager is informed as soon as a request for a bed has been made).
iii.
If possible an empty bed should be made readily available to receive emergency admissions from
A&E/ED/MAU or other departments within the Hospital.
iv.
If CCU is full and there are no patients suitable for transfer out of the Unit, emergency patients can be
admitted to ITU, after consultation with the Consultant/Registrar Anaesthetist. It is the responsibility of the
SHO/Registrar, to make the necessary arrangements and to keep the Capacity Manager informed. As soon as
possible, a bed needs to be created in Coronary Care Unit and the patient from ITU repatriated.
NB: The day bed will be reserved for patients requiring EPS studies. This bed will also be used as over-spill for
emergency admissions (Angio Suite to be informed).
2.8
Flow charts relating to the Chaucer Ward admissions can be found in Appendix. 13
Chaucer ward is a 16-bedded unit for the use of patients with a diagnosis of stroke or head injury, who require
rehabilitation.
a) Criteria for admission
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i.
The following criteria should be met for a patient to be admitted to the Stroke Unit:
Adults aged 17 years and above.
Clinical diagnosis of stroke or head injury.
Potential impact of intensive rehabilitation must be deemed as positive.
NB: Patients are not to be unconscious (unless there is no alternative placement).
ii.
If there is a bed shortage, a medical patient with elderly care needs may be admitted
iii.
No unstable cardiac or high dependant patients should be admitted unless there is appropriate specialised
nursing supervision
iv.
Where possible stroke/head injury patients outlying in other areas should be repatriated.
b) Access to beds
i.
Referral to the stroke unit must be made by either the admitting medical team or via SPH Care of the Elderly
Consultants/ or the on-call Medical Registrar.
ii.
Each referral will be discussed by the Doctor with the appropriate Consultant and Sister or nominated deputy
at the earliest opportunity.
iii.
The final decision will be based upon admission criteria and overall availability of beds.
iv.
v.
vi.
Responsibility for the care of the patient will remain under the lead Consultant for the unit.
The Registrar or SHO, will clerk the patient using the standard Stroke Unit proforma.
Under normal circumstances, further investigations, treatment and general management will follow the Stroke
Unit Integrated Care Pathway (ICP). Significant variances from the ICP (e.g. development of complications,
requirements for medical intervention i.e. invasive procedures) may warrant transfer of patient to alternative
speciality area.
NB: Stroke Lead Consultant will identify patients for transfer in/out of unit.
2.9 ANGIOGRAPHY
Angiography procedures are carried out in the Angiography Suite at St Peters Hospital. Information regarding the
need for Inpatient Coronary Angiography can be found in Appendix 14... A flow chart outlying the procedure to
follow for patient transfer for Day Case Angiography (from Ashford Hospital St Peters Hospital) is found in
Appendix 15.
Section 3
ADMISSIONS POLICY FOR THE SURGICAL, ORTHOPAEDIC & TRAUMA
DIRECTORATES (See Appendix 17)
3.1 ADMISSION CATEGORIES
Patients are admitted to the Surgical Directorate as:
Acute admissions, via the Accident and Emergency Department
Acute admissions, via the Out Patient Department
Elective admissions from the waiting list.
Booked Admissions Project (BAP) See Booked Admissions Policy
Pathway for Adult Trauma Patient (See Appendix 17a)
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ii.
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The aim is to have all Elective Surgical, Orthopaedic, Inpatients and Day cases attend Pre-admission clinics 3 6 weeks
prior to their planned date of admission.
For Orthopaedics, once the patient has been deemed as fit for surgery their admission date is confirmed at preassessment this will soon be the case in other specialities.
All patients who require inpatient planned surgery are pre-assessed to:
Assess if surgery is necessary, and whether the patient is fit to undergo the planned surgery.
Provide information about the planned surgery and length of hospital stay, and minimize any anxiety
regarding their admission and recovery.
Involve other health professionals as appropriate as to the patients needs, at the earliest opportunity to ensure
smooth provision of care and prevent delayed discharge.
Involve the patient and carer where appropriate and with the patients consent, in the assessment process to
help their understanding, and involve them in the care and support of the patient.
NB Where possible there should be a pool of patients who have been pre-assessed and are ready to come
into hospital in an attempt to reduce the did not arrive rates of cancelled surgery. (NICE Pre-assessment
Guidelines 2003)
Patients for major surgery should be brought in to hospital the afternoon before a morning. Procedure and in
the morning of the operation, for an afternoon procedure (unless specific preparation is required).
Patients are asked to telephone the Admissions Office prior to admission to confirm that a bed is available.
Medical patients in the initial acute stage of Methicillin Resistant Staphylococcus Aureus
Medical patients in the initial acute stage of a chest infection with a productive cough
Medical or surgical patients who are colonised/infected with Methicillin-Resistant Staphylococcus Aureus
N.B. Patients with chronic wounds such as pressure sores and leg ulcers should only be transferred following
advice from a member of the Infection Control Team.
3.10
GYNAECOLOGICAL PATIENTS
Gynaecological patients (Ashford Hospital) should be transferred to St Peters Hospital A&E Department
out of hours for review by the Gynaecological team prior to a decision to admit being made. (See Appendix
17).
3.10.1 Referral and Admission of Patients Attending the Early Pregnancy Unit (EPU)
i.
See patients with problems in early pregnancy, i.e. bleeding/pain from conception, until booked with the
Midwife at around 14 weeks.
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ii.
iii.
Referrals are received from GPs, A&E/ED, the Ultrasound Scan Department, Midwives and self-referrals.
It is not always necessary to see patients on the day of referral and may be more appropriate to see them the
following day when there is access to an Ultrasound scan.
NB: Out of hour referrals are seen in A&E, dependent upon the source of referral.
If there are requirements for bed for a patient the Capacity Manager/Site Co-ordinator should be contacted
immediately. Patients with Hyper-emesis should be transferred, where possible, to Joan Booker ward. Patients
who may require urgent surgery should either be started off in the Day Surgery Unit or where possible sent to a
bed on Kingfisher Ward.
For gynaecological patients requiring admission whom are seen at Ashford Hospital, (See Appendix 17) the on-call
Registrar should be contacted to accept the patient. The Registrar must contact the Capacity Manager/Site Coordinator at St Peters to ascertain bed availability and agree appropriate time for transfer. All documentation must
accompany the patient.(where possible such patients should be admitted to a ward area)
The decision to admit patients, as inpatients or day cases shall in the first instance be made by the Consultant
during the OPD consultation.
ii.
All patients deemed appropriate to be treated as day cases, must be pre-assessed at the earliest possible point. If
patients do not meet the criteria for Day Surgery, they should be referred immediately back to the Consultants
secretary, who will ensure the patient is given a TCI (To come in) date as an inpatient.
iii. There may be occasions when it is not safe to discharge a patient home following day surgery, due to an unforeseen
outcome following their procedure. In these circumstances an overnight bed will be secured
iv. Guidelines for Anaesthetic Suitability for Day Surgery (See Appendix 19)
v.
vi. British Association of Day Surgery proposed a trolley of procedures, which are suitable for day surgery in some
cases. Annex A & Annex B (Appendix 20)
NB: There may be occasional circumstances, where it may be necessary to start an inpatient procedure in the DSU, to
avoid a cancellation. The DSU should be notified of this as early as possible, in order that they may assess the bed
availability within the unit.
Section 4
INTENSIVE CARE UNIT (ICU) ADMISSIONS POLICY
INTRODUCTION
i.
The ICU should be available to all patients who are deemed recoverable and might reasonably benefit from the
facility. The Unit at St Peters Hospital admits patients from the age of 16 and upwards; there is no upper age limit.
ii.
It is recognised that the indication for admission is to provide specialist medical or nursing care.
iii. At Ashford Hospital there is the capacity to accommodate a maximum of three patients (1 x ventilated and 2 x
HDU). At St Peters Hospital a maximum of eight ventilated patients can be cared for at any one time.
iv. Admission/Transfer Procedures. (See Appendix 21 for Criteria for & Admission to Critical Care and 21a. for
Guidelines for the Transfer of Patients to Critical Care)
i.
Before any patient can be admitted to the ICU, the Anaesthetic Registrar on call must be contacted. The
Registrar of the admitting team should contact the Anaesthetic Registrar for ICU, who will liaise with ICU staff. If
there is sufficient capacity and the patient meets the ICU admission criteria, then the referral will be accepted. The
consultants in charge of the Unit have the absolute right to decide on all admissions and discharges to and from the
Unit. Proposed major elective procedures, which will require postoperative intensive care, should be notified to the
unit as soon as the surgery date is booked. Bed availability must be checked 24 hrs prior to the date of surgery and
additional staff booked if required.
ii.
All patients admitted to the ICU are the joint responsibility of the Anaesthetic team and the Consultant team
under whom they were originally admitted to the hospital. The admitting team should provide medical care, unless
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the patient is formally handed-over to another firm or to the anaesthetists. Anaesthetic staff will advise on
respiratory therapy and aspects of intensive care. All patients must be visited at least once a day by the admitting
team, or in the absence of the admitting team the on-call team must have a comprehensive hand-over and visit daily.
iii.
A senior doctor (Registrar) should only institute any change to the treatment of a patient after consultation with
the firms involved.
iv.
A decision to transfer a patient out of ICU to the ward area will be made by the ICU team, in collaboration with
the admitting team. (See Appendix 22)
The nurse in charge at Ashford CCU will contact the nurse in charge at St. Peters ITU, to check
for bed availability.
Only the nurse in charge of ITU can refuse a patient admission on the grounds of bed
availability or staffing. The Anaesthetic Registrar needs to be made aware of this decision. If
there is a problem regarding admission, the Head of Nursing or General Manager is to be
consulted.
If a bed is available then:
The referring doctor at Ashford Hospital needs to speak to the Anaesthetic Registrar at St. Peters
Hospital to give details regarding the patients condition. The patient needs to be referred to a speciality
team at St Peters Hospital by the admitting team at Ashford Hospital.
Staff at Ashford Hospital will arrange transport and members of the transfer team (Anaesthetist, nurse,
ODP) should be made aware.
All notes and X-rays are to accompany the patient.
If a bed is not available:
If there is no bed at St Peters Hospital ITU, the ECMS/NICBR should be contacted.
(For ITU Transfer flow from AH to SPH please see Appendix 25)
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The Surrey Wide Critical Care Network (SWCCN) is committed to the safe transfer of all critical care patients
who require transfer to a different critical care facility.
ii.
Critical care transfers are necessary for clinical/specialist treatment. The SWCCN is committed to reducing, and
hopefully negating, the need for non-clinical transfers
iii.
iv.
All potential options will be explored within the individual Trusts critical care service prior to a decision being
made to transfer a patient.
v.
The following options should be explored by the nurse in charge of the critical care unit:
Utilising an un-staffed bed in the critical care unit by the temporary use of:
Moving appropriate nursing staff to critical care unit from Recovery or elsewhere in the Trust
Nurse in charge caring for a patient
Exploring Bank/Agency /Overtime options
1 nurse caring for 2 patients (1 nurse:2 patients ratio)
Moving a nurse from another critical care unit in the SWCCN if possible and appropriate
N.B Any decision made is dependant upon skill mix and feasibility
ii.
Holding the patient in Recovery or an alternative safe place
iii.
Creating a bed in the critical care unit by discharging a patient to a step down area with Outreach
support if appropriate
iv.
Re-evaluating patient/nursing dependency within the critical care unit
i.
vi.
Patient to be assessed by a Critical Care Consultant as to requirement for transfer and to explore other potential
treatment options with the patients team.
Once the decision has been made that a non-clinical transfer is unavoidable, the final decision for which patient
should be transferred lies with the critical care consultant in charge
ii.
All units must follow the SWCCN joint transfer protocols with Surrey and Sussex Ambulance Service NHS
Trusts.
iii.
The decision regarding which patient could take into account the following:
Patient safety/stability for transfer
The existing patients on the critical care unit and their care requirements
The number of previous transfers an individual patient may have had
Ventilatory weaning programmes of particular patients
iv.
Wherever possible, all patients will receive their required surgical procedures prior to transfer i.e. following
treat and transfer principle.
All transfers will take place using the SWCCN joint transfer protocol with Surrey and Sussex Ambulance
Service NHS Trusts.
ii.
The SWCCN Transfer Audit Form (SWCCN 1) will be used for all critical care transfers and is the legal
record of transfer.
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iii.
Adherence to the principles of the management during transport section of Intensive Care Society
Guidelines for the transport of the critically ill adult patient (2002)
The SWCCN 1 form must be completed and a copy returned to the Network Coordinator.
ii.
All transfer forms will be reviewed by the Network Medical Lead and Network Coordinator.
iii.
Any clinical incidents arising from transfer will be investigated by the Network Medical Lead in conjunction
with the lead consultant for critical care of the referring trust.
iv.
A database of critical care transfers will be established and be utilised for data analysis, information and audit
purposes.
v.
An annual audit of Network critical care transfers will be undertaken and a relevant action plan produced
vi.
Trust critical care transfers must be reviewed at each Trust Critical Care Delivery Group meeting
All transfers out of transfer group must be reported on the Network Adverse Transfer Form (Appendix 24)
ii.
A copy of this form must be sent to the Trust Critical Care Manager or Senior Nurse for action within the Trust
according to individual Trust policy
iii.
A copy of this form must also be sent to the Network Co-ordinator for information and investigation
iv.
All adverse transfers must be reported on the Trust SITREP reports to the Strategic Health Authority and
relevant PCT
All adverse critical care transfers must be investigated and a short report produced on the Network proforma
(Appendix 23)
ii.
Investigation of all adverse transfers will be initiated by the relevant Critical Care Manager or Senior Nurse
and the Network Coordinator
iii.
Feedback from these investigations will be provided to the Trust Critical Care Delivery Group
4.11
It is the responsibility of each individual critical care unit to monitor their outliers within each hospital they
were transferred to on a regular basis or as decreed by local operational policy
It is the principle ethos and responsibility of each individual critical care unit to facilitate repatriation of
transferred patients as a priority if appropriate
The Department of Health requires Trusts to have identified specific groups of hospitals/ Trusts to contain transfers for
non-clinical reasons, and therefore reduce the numbers of long distance transfers.
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The agreed transfer groups for the Surrey Wide Critical Care Network are:
Trust/ Hospital
TRANSFER TO ITU ST. PETERS HOSPITAL FROM OTHER AREAS OF THE TRUST
4.12
i.
ii.
If a bed is available:
The ward or department must liaise with ITU for transfer of the patient
Where possible a member of the ITU nursing team should go and assess the patient.
A doctor and nurse from the relevant area must accompany the patient to ITU to give a formal hand-over.
If a bed is not available
The person in charge of ITU should contact ECMS/EBS in an attempt to transfer the patient to an alternative site.
Members of the transfer team are to be notified by the nurse in charge of ITU.
ICU is to be contacted with the patient details for their Refused Admission data.
Appendix 21: Criteria for & Admission to Critical Care; 21a: Guidelines for the Transfer of Patients to Critical
Care.
Appendix 22 contains information relating to Transfers from Critical Care at Ashford, to ICU and Discharge
from ITU
Appendix 23: Surrey Wide Critical Care Network (Report Proforma)
Appendix 24: Adverse Incident Form
Appendix 25: ITU Transfer from AH (CCU) to St Peters ITU
NB: The Capacity Manager is to be kept informed of all patient movements.
Section 5
ADMISSION POLICY FOR PAEDIATRICS
Information on admission to the paediatric areas is given in the table below.
Age Range
(years)
Bed Capacity
Access
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Oak/Ash
0 16th birthday if in full time education
Oak
12 day beds
1 cubicle for medical/surgical admissions.
Opening hours 7.15 7.45 Monday Friday
Ash
29 of which:5 dedicated to 13-15 years
11 cubicles
1)
Planned admission
2)
Day care (Medical & Surgical)
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3)
Emergency (via Unit Bleep-holder, 8119)
Transfer of patients requiring overnight stay
from Merlin to Oak/Ash Please see
Appendix 26
Guidelines For The Use Of Cubicles On Ash Ward
Children with febrile neutropenia
Children who
Children with severe immune deficiency
require a cubicle Babies up to 6 weeks
for their own
protection
Note:
On some occasions it may be appropriate to put twin infants in one cubicle.
Children with IgA deficiency do not require a cubicle.
Transfer
Children who
are a risk to
others
Children who
require a cubicle
for privacy for
themselves or
their family
NB:
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Patient Care
Chickenpox
Gastroenteritis e.g. salmonella, rotavirus
Bronchiolitics
MRSA
Note:
Care must be taken to avoid admission of highly infectious children, such as those with
chicken pox, wherever possible and arrangements should be made to expedite their safe
discharge home.
Children with infection such as meningitis may leave the cubicle after 48 hrs of treatment
providing this has been discussed with the medical staff. (Provided that nasal carriage has been
treated with either Ceftiaxone or Rifampicin).
In certain circumstances consideration should be made for targeted isolation: example
the avoidance of having a child with whooping cough in contact with un-immunised infants.
Patients with CF may require a cubicle.
There are several situations where a cubicle may be appropriate.
This would include the dying child.
If a cubicle is utilised for a child who does not absolutely require one, please make it clear to
the parents on admission, that the child may have to be moved out of the cubicle during their
stay.
It is the responsibility of the person in charge of each shift, to re-assess the situation and act
accordingly, in order to avoid moving families unnecessarily during the night.
Pregnant adolescents (of whatever age) under the care of the Obstetricians will not be admitted
to Oak ward.
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Neonates requiring phototherapy or with a weight loss greater than 10% may be admitted to the
Transitional Care area, based on Joan Booker Ward, Abbey Wing. The precondition is that the
mother lives in.
Neonates
Adolescents
i.
ii.
iii.
iv.
NB:
Guidelines for
admission of
patients from
Paediatric A&E
Children under 16 years Please also see Policy and Procedure Manual. Vol. 8, Patient Care, No 4
Guidelines for Admission of children aged 15 years and under.
The paediatric bleep (119) should be kept with the Nurse in Charge on Ash ward, or her
deputy, at all times. Check that the bleep is working if not, the battery can be changed by the
staff on switchboard.
If A&E have a patient that requires admission, the beepholder must be contacted to assess the
bed/cubicle state. Overnight, the main A&E department must liaise with the bleep holder about
admissions and bedstate.
If the doctor admitting would like to inform the ward directly about the patient, this should be done
through the bleepholder.
The bleepholder should inform the appropriate nurse/s of details of the admission. The childs
name should be added to the board so that all nurses are aware of expected patients.
When A&E are ready to admit the patient, the bleepholder must be contacted to confirm that
the ward is ready for the admission. A&E can be informed of the allocated bed space for easier
admission to the ward.
If more than one patient is ready for admission, liaison between A&E and the bleepholder can
determine if they can be escorted to the ward at the same time.
Occasionally, A&E only have one nurse, so assistance may be required from the ward in
escorting patients for admission. A&E should inform the ward when they have only one nurse
available.
If the ward is full and no discharges are expected, A&E must be informed to transfer of
patients can be arranged, if required, after assessment by the on-call paediatricians.
A&E should contact the bleepholder around 1700 hours to assess the bed availability for the
evening. If there are any further admissions to the ward after this time, i.e. from Merlin/ Ashford
A&E/OPD, then paediatric A&E should be informed of a reduction in bed availability.
Section 6
ADMISSION POLICY FOR INFECTED PATIENTS
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Please see the Infection Control Policy and Procedure Manual for information regarding different infection
types.
Guidelines for Admitting Patients with Methicillin Resistant
Staphylococcus Aureus (MRSA)
Ashford Hospital
1.
2.
3.
4.
5.
6.
7.
NB.
Please refer to the Infection Control Policy and Procedure manual for further details. The Microbiologists, Dr.
Grundy and Dr. Kirk, may be contacted out of hours via Switchboard if the above cannot be dealt with by the
Site Co-ordinator.
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Section 7
POLICY FOR PATIENTS ADMITTED WITH SPECIAL NEEDS
This section of the policy outlines the special additional needs of disabled people being admitted to the acute hospital. It
specifically applies to people with sensory, physical, speech difficulties as well as clients with mental health problems or
learning difficulties. (For Protocol for Admission of Patients with Learning Disabilities, please see Appendix 28)
7.1
to be treated in the same way as any other person, without pre-judgement about disability or the quality of life of
disabled people
to make use of hospital services and facilities
to relevant and accessible information, especially about the hospitals provision for disabled people
7.2
to be asked about their personal need in advance of a pre-arranged appointment or admission, or at the first
encounter on an emergency visit or admission
to be consulted directly about their treatment and all arrangements made on their behalf
7.3
that hospital staff recognise and respond to the needs of disabled people
that all aspects of the hospitals provision for disabled people are regularly reviewed
7.4
That the disabilities they experience are not increased by inflexible regulations or routines.
NB
It is essential that patients with mental health needs/learning difficulties have their community psychiatric
nurse/key worker notified (within 24hrs) of their admission.
All patients with special needs should have their care workers/ carers involved in their treatment to provide support and
specialist advice if they wish.
All ward/clinic areas have a special needs directory of information to help them assist you with useful contacts etc.
(For Special Needs Directory, please See Policy Guidance on the Trust Intranet. Search in: - Documents;
Policies & Procedures; Special Needs Patients)
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Section 9
ADMISSION OF PRISONERS
This policy relates to prisoners of Police, Prison Service and the Customs and Immigration Service.
Prisoners present a series of challenges to hospital staff who must balance three overriding principles:
The rights and needs of the individual to be properly cared for;
The security of the Trust;
The right of the patient to confidentiality
The balance must be reached in collaboration with the custody staff on duty.
All Times
The security officer must be informed of the arrival of any prisoner to a hospital department. This is for information
only.
Confidentiality
Hospital staff must give careful consideration to the patients rights to confidentiality when asking for or giving
information in the presence of custody officers. Whenever possible, sensitive information should be managed in a way
which maintains the rights of confidentiality and dignity of the prisoner.
Prisoners as inpatients
When a patient is admitted via A&E or ED, the nurse in charge should notify the Security Office, the Capacity
Manager in normal office hours, or the Site Co-ordinator at all other times.
Prisoners should be treated preferably in a side room if accompanied by a prison officer.
All Necessary clinical observations and procedures will be carried out while seeking to maintain the dignity of the
patient whenever possible.
Removal of restraints
See Appendix 31 for flow chart, detailing the proposed procedure for custody officers in relation to the removal of
restraints from patients.
Section 10
ADMISSION OF OLDER PEOPLE
10.1
URGENT CARE FOR OLDER PEOPLE (See Appendix 32 for flow chart)
10.2
PERSONAL INFORMATION FORM (See Appendix 33 for; Hospital Admission Personal Information
Sheet)
Section 11
ADMISSIONS APPENDICES
References
Mental Health Act 1983, Secretary of State for Health in exercise of power conferred on him by Section 16
(1) of the National Health Act of 1977.
Your Guide to the National Health Service, Department of Health, Jan 2001
NICE (Pre-assessment Guidelines 2003)
Intensive Care Society Guidelines (management during transport) section.
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ADMISSIONS APPENDICES
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Section 11
Admissions Appendices
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
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Appendix 1
Patients may be transferred for treatment to or from other hospitals. Reasons for transferring patients
include:
Bed shortages
Patient wishes to receive private treatment
Tertiary referrals
All requests for transfers should be directed through the Capacity Manager, or Site Co-ordinator out of
hours.
Criteria for Patient Transfer (see flow diagram)
The following criteria are to be used when there is a need to transfer patients as outliers within the main site of
Ashford or St. Peters hospitals, or transfer NHS patients to the Shakespeare Suite/Runnymede Hospital.
PATIENT
Medically stable
Minimal assistance with
self-care
For imminent/
uncomplicated discharge
Confused
Aggressive
Medically unstable
Heavy
Requires intense rehab
YES
NO
NOT SUITABLE
FOR TRANSFER
NB
YES
TRANSFER OF PATIENT
Inform Doctor of transfer
Inform Capacity Manager
Notify on-call team if after 5pm
and before 9am
Notify Capacity Manager for a
Weekend transfer via CSNPs
Office
Ensure all property is with the
patient on transfer
Full hand-over must take place
NOT SUITABLE
FOR TRANSFER
For patients transferred within the main hospital site of SPH, please refer to guidelines on Buddy System
NO
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Appendix 1a
Patient needs
Acute Ortho/Surgical
Admission
Transfer - SPH
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Transfer
AH
Appendix 2
MEDICAL ASSESSEMENT UNIT (SPH)
A&E Admission
GP Admission
Ward Clerk obtains patients notes and xrays(Out of hours via A&E reception)
MAU Dr. assesses patient
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Appendix 2a
SPH
Capacity Management Flow for Medical Patients
(Including Buddy Wards)
MAU
A&E
(28 beds)
(26 beds)
Maple
Birch
Cardiology
(29 beds)
(30 beds)
(25 beds)
Holly
Cedar
May
Respiratory
Gastroentology
C of E
Falcon
Juniper
Kestrel
Surgery
(Ortho)
(Surgery)
Chaucer Ward - AH
Appendix 2b
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Ashford
ED
(Medicine)
(30 beds)
(16 beds)
(30 beds)
(28 beds)
(30 beds)
Arnold Ward
Chaucer
Wordsworth
Keats
Bronte
Stroke Unit
COE
Endocrine Rheumatology
Respiratory
Surgery
(28 beds)
Eliot Ward
Surgical
Orthopaedic
(30 beds)
Dickens
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Appendix 2c
In an attempt to avoid delays in the transfer of patients from the A&E and Emergency Department to a Ward area
the following guidelines should be adhered to.
All requests for beds must be made (as soon as decision to admit known or as soon as it is recognised patient will need a
bed) to the Capacity Manager/Site Co-ordinator who will allocate accordingly. The Capacity Manager/Site Co-ordinator
will then inform the receiving ward of the allocation.
1.
Following agreed allocation, the Capacity Manager/Site co-ordinator will agree with the ward shift leader a definite
transfer time. This time must ensure that all patients reach the ward/MAU within the 4 hour target
2.
The Capacity Manager/Site Co-ordinator will contact A&E/ED and inform them of the agreed time for transfer.
A&E/ED should transfer the patient at the agreed time unless otherwise contacted by the receiving ward (i.e. in the
event of a crisis situation)
3.
A&E/ED will then transfer the patient at the agreed time. (A&E/ED staff to give a full hand-over on arrival to ward
area). (If an A&E/ED staff member cannot accompany the patient, a full hand-over should take place via the
telephone).
4.
Following assessment by a qualified staff member in the A&E/ED Department those patients deemed to be
medically stable may be transferred to the ward area either by a qualified nurse or HCA/student if assessed to be
appropriate. However, the ward must be informed beforehand and a full telephone handover given from registered
nurse to registered nurse
5.
If there is a delay in the transfer of patients from the A&E/ED Department to the ward, (due to a lack of
nurse/porter availability) A&E/ED will inform the Site Co-ordinator, who should organise to help to escort the
patient to the appropriate area. Ensuring that the transfer of patients is carried out at intervals to avoid patients
arriving at the same time.
6.
If there is a delay in transfer by the ward (for any reason other than clinical) the Head of Nursing (HON) designated
to the area will be contacted by A&E/ED
7.
A&E must ensure patients are notified in advance of transfer to a mixed gender area. In the event a patient refuses
to go they should, where possible be placed in the Observation Bay A&E/ED
8.
Where patients are transferred from A&E/ED to Ashford to a ward area it should be explained we are one
organisation on 2 sites and the bed allocation has been decided upon in order to manage their care needs
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Appendix 3
March 2005
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Contents
Item
Page
Contents
Glossary
App.
Nos
Volume 8
Appendix
Page
Additional information
10
11
12
13
Treat and Transfer Flow for Medical Patients St. Peters to Ashford
Avoiding 12 hour Trolley Wait
14
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Glossary
A&E
CC
CCU
CM
Capacity Manager
CSNP
DC
Discharge Co-ordinators
DL
Discharge Lists
DM
Duty Manager
DPM
DTA
Decision to Admit
ECC
ECMS
ED
GM
General Manager
HAD
HON
Head of Nursing
ICT
MAU
PP
Private Patient
SC
Site Co-ordinator
SpR
Specialist Registrar`
SSM
TCI
To Come In
OCC
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Capacity Manager
To establish:
DTAs in A&E/ED including breech
times.
Elective TCIs
Outlyers
Repatriations via other hospitals
Update bed score (minimum twice
daily
Action Plan
Escalation
? If necessary
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Ward Pressures
Ward Short-falls/Staffing Issues
Other Site Influencing Factors
Escalate?
(See Appendix 2)
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10.30 & 3 pm AH
10.30 & 3 pm - SPH
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At 3pm; if projected demand is greater than bed availability, consider opening additional capacity
SPH
AH
Maple 1
Shakespeare 4 +
CCU 1
Holly 1
Cedar 1
Surgery
Falcon Physio Bay 5
NB: (See Appendix 4) for additional information regarding appropriate staffing for these areas.
Trolley Waits:
In the event of potential 12 hour Trolley Waits (from decision to admit timed and dated by clinician) to leaving the
department, the Duty Manager/Director on-call should be informed at hour 10. (See Appendix 7)
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A&E/ED
Actual and projected demand including breech times. Divert status. On-call Teams response times
and awareness of current wait times; according to 4 hr escalation plan
CC
Bed state (cross-site), number of wardable patients, demand from own and other hospitals
CM
A&E actual DTAs, elective admissions, patients from other hospitals (inc priority rating) (status at
other site). At the weekend, chair the daily planning meetings at 10.30 and 15.00 hours
DC
Produce next day discharge list for each speciality (ASPH) and communicate to all via hard copy
to all ward areas and Site Co-ordinator.
DU
Confirm Discharge Unit Nurse cover and number of patients expected in unit
DM
Attend Weekend Planning Meeting (10.30 and 15.00 hours) and escalate accordingly, working
with the Site Co-ordinator and Capacity Manager
HAD or
Deputy
HON/Rep
ICT
MAU
SC
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Chair week day meetings at ASPH. Projected demand for each Speciality, Communicate to ECMS
Ward short-falls/pressures
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Escalation Responsibilities
(in and out of hours)
Capacity Manager
Transfer staff between sites dependent upon area of greatest pressure, (Liaise with Matron/HON if available)
Support the transfer of patients out of A&E/ED as required.
Put out for additional staffing to support opening of additional capacity (Liaise with Matron/HON if available)
Support wards where pressure is greatest.
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Discharge Co-ordinator
Inform Pharmacy, Transport and other Diagnostic areas of escalation, to escalate patient throughput.
Transfer staff between sites dependent upon area of greatest pressure, (Liaise with Matron/HON if available)
Support the transfer of patients out of A&E/ED as required.
Put out for additional staffing to support opening of additional capacity, (Liaise with Matron/HON if available)
Support wards where pressure is greatest.
Communicate with the Duty Manager/Senior Support Manager, issues relating to avoiding long waits in
A&E/ED
Intermediate Care:
NB: In the event additional capacity required in hours page 8359out of hours via 01932 722929. If there are unused
Community beds these should be declared to A&E/ED.
ECMS Divert
During times of increased pressure A&E/ED Manager/HAD/CSNP/Site Coordinator, will review/change divert status
dependent upon the site with greatest demand.
Telephone supervisor on 01737363885 and request change of divert of next 2 hour, follow up conversation with
Fax 01737360393.
Site Co-ordinator/ CSNP Duty Manager (10-18.00 Sat /Sun)
Escalate to Senior Support Manager in the event of Critical Delays in Assessment, Treatment and Transfer
within 4hr Escalation Plan.
On-site to attend capacity meeting at 10.30am & 3pm. Support CM/site co-ordinator in the escalation process
when necessary
Communicate with the Senior Support Manager, issues relating to avoiding long waits in A&E/ED
Support ED/A&E in the event there are delays in assessment of major/minor patients.
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AH
10.30 am
3.30 pm
10.30 am
3 pm
AH
Staffing pressures
Divert position
Action plan
Yes / No
NB: Dependency for both departments must be updated by the A&E/ED shift-leader every 2 hrs. If additional areas are
open these must be included in the dependency scores per site.
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Additional Information
During normal working hours 8.00 am to 8.00 pm the Heads of Nursing for Medicine, Surgery and Orthopaedics and
Discharge Co-ordinators will be responsible for managing the discharge process (with Capacity Managers) across their
wards and bringing the relevant activity information to the Daily Planning Meetings.
Out of hours 8.00 pm to 8.00 am (including bank holidays) the capacity management process will be led by the
CSNP/Site Co-ordinator supported by the A&E/ED shift leader, unless the Capacity Manager is on duty and then they
will work together with the site/CSNP and A&E/ED shift leader
Bank holidays and weekends the Site Co-ordinator /CSNP, Capacity Manager, Duty Manager will manage the Capacity
Management process. The site Co-ordinator/CSNP or Duty Manager will liaise with the Senior Support Manager as
necessary
In relation to additional staffing to support the Escalation Plan detailed below is the ratio of additional staff to manage
additional beds.
Site:
No. of Additional Beds
SPH:
Carpet beds
4
Falcon
5
Day Surgery
5/10
NB: Birch (Only to be used to
2 (Bay 1 & 2)
Additional Staffing
0
1xRN
(1/2x E/D Grade & 1 x HCA)
0
AH:
Shakespeare Suite
DSU
4
5/10
NB: Fielding as overspill needs to be approved at Director Level. Please note requires lead-in/preparation time as no
phones, call bells, drugs, reduced equipment etc. In the event additional capacity is required in DSU plus 1 Trained will
be necessary and Director to agree.
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NB: Where there is high probability that the patients operation cannot be carried out on the date originally agreed it is
acceptable to cancel the patient in advance. This is not warning the patient of a likely cancellation but an actual
cancellation.
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1st hour
If > 3 patients waiting to be seen by A+E Dr. escalate to A+E Duty Consultant/Registrar
A+E Duty Consultant/Registrar attends all priority
calls in hours.
A+E Dr. to complete history, examination, investigation x-rays + blood taken. Refer to speciality team within 1
hour 15 mins.
Investigations
undertaken
1hr 15mins
2nd Hour
Results of all
investigations
to be available
- x-ray, bloods
4th hour
3rd hour
Volume 8
Specialist
investigations
- CT/USS
2hrs 30mins
Contact
Site
Co-ordinator
Bleep 8897
Bleep 8429
Bleep 8803
Bleep 8895
Bleep 8872
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Site Co-ordinator
Continues to
monitor situation.
If predicted 10 hr
breech from DTA
contact senior
support managers
(SSM)
Site Co-ordinator
Contact
Senior Support
Manager
Contact Numbers/Bleeps
Patient Care
If specialist Reg/
Consultant not
responding within 15
mins escalate to A/E
manager -Jean Haire
OUT OF
HOURS
Escalation Managers
Bleep 8346
Ext: 3026
Bleep 8449
Bleep 8394
Bleep 5227
Bleep 5299
Bleep 5597
Critical Care (These patients will usually fall into the exception category)
Coronary Care
Gastroentrology Cedar
Ascertain patients suitable for outlying (see next day discharge lists)
NB: If patient requires specialist intervention and it is deemed inappropriate to outlie to a non speciality bed direct from
A&E i.e. Medical patient to Surgery/Ortho or Visa Versa. Transfer existing inpatient from ward to outlying area.
Patient should be transferred according to discharge/outlying list.
DoK wing can accommodate patients requiring telemetry satellite cardiac monitoring i.e. Juniper; Elm; Holly;
May; Cedar
SPH
Holly Juniper/Elm
Cedar Surgery (Kestrel)
Birch (GM) - Falcon
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Patient Care
Buddy Wards:
AH
Any patient can be outlyed to either Dickens (non-infected
patients) or Eliot Wards
NB: See appendix 8 for appropriate criteria for patients
suitable for transfer
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PATIENT
Confused
Aggressive
Medically unstable
Heavy
Requires intense rehab
YES
NO
NOT SUITABLE
FOR TRANSFER
NB
Medically stable
Minimal assistance with self-care
For imminent/uncomplicated discharge
EDD within 48hrs
YES
Transfer
NO
NOT SUITABLE
FOR TRANSFER
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Patient needs
Acute,
Ortho/Surgical
Admission -
Transfer SPH
Note: *In the absence of Capacity Manager Site Co-ordinator/CSNPs liaise re: beds
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Patient needs
Acute
Medical
Admission &
is appropriate
for T&T
Transfer to
AH
Further delay
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Appendix 4
Pre-cancellation Guidelines
Capacity: If there are to be provisional cancellations, they must occur before the TCI date usually the day before.
Liaise with the appropriate medical team (SpR or above) and or the Consultant secretary, to confirm which
patients must not be cancelled under any circumstances e.g. life-threatening illnesses and agree order
of priorities.
Liaise with the appropriate wards. Discuss possible discharges, early bed vacation.
Daily meeting at 3pm with designated discharge co-ordinator and Head of Nursing, A&E/ED to forward
plan depending on situation in A&E/ED on both sites, and predicted number of discharges over next 24
hours.
Finalise and agree number of patients to be provisionally cancelled before TCI date with Head of
Admissions, or in her absence, General Manager for Surgery, Assistant Manager for Orthopaedics & Trust
Waiting List Manager (Carol Hearn).
Contact all those patients according to priority rating and inform them of the actual/potential need to
cancel their operation
Cancel all of these patients on the P.A.S. system or record actions on PRL sheet for admissions.
On the TCI day review bed availability for all these patients and those in A&E/ED requiring admission
after early morning bed state has been confirmed.
Once numbers of available beds have been confirmed and you are satisfied it is correct and up-to-date, a
decision can be made on how many of the provisionally cancelled patients can be admitted.
For any patient that has to be definitely cancelled, follow usual hospital procedure.
N.B. Telephone or email out of hours Consultant secretary and Theatres. In hours the Consultant must be
informed. (See Appendix 20 for advice on fasting)
Footnotes
Important to be at least 24 -48 hours projected overview of the number of patients TCI on each day and their priority
rating.
Sunday admissions should be prioritised on Fridays at the 3pm meeting and the Capacity Manager on duty Friday,
Saturday should telephone patients to advise them of potential/actual cancellation.
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Appendix 4a
Contact has to be made with the patient by the Capacity Manager the day before TCI
date. Priority to ensure appropriate (in the event required) cancellation is essential.
Clinically urgent must not be cancelled i.e. CAS; long waiters; 2hrs time
cancellation.
28 Day guarantee:
Patient is cancelled on the day for a hospital reason, e.g., no beds, overrun in
theatres, surgeon sick, etc and should have a TCI date negotiated in less than 28
days.
CEA:
This method of recording PAS only occurs when the patient is physically on hospital
grounds and is cancelled for either a patient (e.g., patient is unwell) or hospital
reason and they still need to have the surgery.
PRC on PAS
Hospital
Surgery cancelled
no longer required
Patient
WLC on PAS
Cancellation
on the day but still needs
admission
Hospital
28 day guarantee
precise details
of cancellation
entered on
Widget
Patient
Please remember all PAS entries must include a history of events to facilitate exception reporting, e.g., CEA Patient
cancellation patients blood pressure high return to OP clinic.
All dates must be agreed with the patient and recorded with the correct booking type code (BAP and BK).
NB:- If the Capacity Manager cannot pre-cancel the patient prior to admission and the patient is subsequently cancelled
on the day. This will be a 28 day cancellation. IT department to be informed.
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Appendix 4b
Every Friday, a PAS printed copy of all Sunday booked admissions to come in (TCI) should be left for the attention
of the Site Co-ordinator by the Capacity Manager.
The Capacity Manager will pre-cancel all appropriate patients (in the event of no beds being available) and outlie
those patients who must not be cancelled. These patients will be highlighted on the TCI list, following consultation
with the appropriate speciality team.
N.B. Where possible, major/clinically urgent/long wait cases should be a priority not to be cancelled.
If patients are cancelled, a record should be kept and given to the Capacity Manager on the Monday morning.
Those patients who are not to be cancelled, should be deferred, contacted at home and given advice regarding
Nil By Mouth (NBM) status from midnight (unless the patient is a diabetic, in which case, a light breakfast should
be advised, no later than 7.00 a.m. on the day of the operation).
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Appendix 4c
3) Additional Comments.
A decision to suspend the patient may be appropriate following cancellation of an admission offer.
suspension procedure is not described here.
The
When recording cancellations or postponements, it is the reason in each case that is required (not who made
the decision.) Thus if any Hospital-Related reason is given on the day of admission, a new admission date
must be agreed within 28 days. This is not the case for Patient-related Reasons.
From the above summary it is clear that it is most important that the accurate primary and secondary reasons
for admission cancellation are determined and then passed to admission staff, to ensure the PAS record is
correct, enabling the appropriate subsequent waiting-list and admission management decisions to be made.
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4) Definitions.
TCI
PAS
PRC
CEA
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Appendix 5
Orthopaedic/Surgical inpatients who are due for surgery the following day
UNSUITABLE CRITERIA
Patients with infections or diarrhoea of unknown cause are EXCLUDED from Admission Criteria
Patients who are MRSA Positive or are known to have had MRSA without a negative clearance are
EXCLUDED from Admission Criteria
Insulin dependent patients diabetic patients on diabetic clamp treatment regime are EXCLUDED from
admissions criteria.
1.
Head of Admissions/Capacity Manager will contact the Day Surgery Head of Nursing/Shift Leader (Day
Surgery) to agree the use of Day Surgery as additional capacity.
In exceptional circumstances, where appropriate elective/next day discharge cannot be identified A&E Dr.
(with the Day Surgery shift leader) will agree suitable patients for transfer i.e., next day drainage of an abscess
etc.
3.
All patients will be accompanied by a nurse escort and a detailed hand-over given to the Day Surgery staff.
4.
All relevant documentation must be transferred with the patient including observations, blood glucose
monitoring records, drug charts, fluid chart, admission details, patient medical notes and x-rays.
5.
A&E staff must transfer patients to Day Surgery Unit via the PAS system.
6.
All patients admitted to the Day Surgery Unit will be nursed on a bed to reduce any risk to pressure areas.
7.
8.
For planned admissions, Capacity Manager/Admissions to inform ward to transfer Notes & x-rays
9.
Patients admitted over the weekend will be discharged before 8am on Monday mornings.
NB:
Patients admitted over the weekend will be discharged before 8am on Monday mornings to free up sufficient
capacity for the patients undergoing eye surgery. In the event it is anticipated that Day Case activity maybe
affected. Patients must be pre-cancelled and Consultants/Secretaries informed.
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Appendix 6
Patient Transfer
Responsibility for arranging transfer from other wards and departments, arranging porters, informing patients,
relatives and clinicians rests with the Capacity Manager/ Site Co-ordinator.
Where possible, porters will be responsible for transfer with nurse to nurse hand-over
If the Runnymede Hospital is quiet and can help, Runnymede staff can collect patients or take patients back
If the patient is being transferred from NHS to private the Runnymede will collect as appropriate.
Property
The nurse in charge will ask relatives to take all unnecessary property and leave only the essentials
They will also ask relatives to list the property and will include the list in the patients notes.
X-rays
The Runnymede Hospital will perform any necessary X-rays at agreed prices.
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Appendix 6a
Ensure Consultant has sanctioned transfer of patient and a Consultant has accepted care of patient in private
hospital.
Contact Reservations on ext. 3001 Runnymede and ext. 4111 Shakespeare Suite, or bleep holder.
Nurse and Porter with bed, trolley or wheelchair to collect patient from St Peters Hospital. If transfer of NHS
patient to help capacity as a result of severe NHS bed shortage, St Peters nurse will be expected to escort patient to
Runneymede bed and to/from theatre
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Appendix 7
1.
Admissions to collect case notes for elective and emergency inpatients (admitted via the A&E/ED or as a
booked admission/pre-admission
2.
Notes retrieved directly from health records/relevant departments/other hospitals and sent to wards
3.
Utilise tracking system via PAS to ascertain whereabouts of notes and re-track when found
4.
Daily elective printout produced to identify case notes required for both SPH and AH inpatients and day cases
allowing for last minute add-ons.
5.
Daily faxes/pinkies/phone calls received from ASPH/peripheral hospitals requesting case notes for
admissions/clinics/emergencies
6.
Throughout each day case notes retrieved for MAU, A&E/ED & all wards
7.
In the event elective patients (on day of admission) have a ward change, the admissions office must ensure case
notes are redirected in a timely manner.
8.
SPH only - (Sundays) paperwork collected from A&E for all emergency admissions between Friday pm and
early am Sunday. Urgent Ashford faxes received Sundays to be processed.
9.
For all inter-ward/site (including community hospitals) transfers, notes should accompany patients and be
tracked as appropriate
A&E/ED to ensure all Cas cards are filed in the notes of patients admitted as an emergency
COB May 04
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Appendix 8
Patients may be admitted to the Observation Bay if the A&E/ED Consultant or Senior Nurse considers it appropriate.
Such patients would include:
The Observation Bay is not for patients waiting for an inpatient bed. However, if the main A&E/ED Department is
under strain due to the amount of patients waiting for beds, it is acceptable to use the Observation Bay. Certain patients
should not be admitted to this area - these would include:
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Appendix 9
GPs who use Surrey Ambulance Service as their transport provider, who require admission for a patient to an acute
Trust, MUST telephone the ECC prior to contacting the on call teams. The destination site will be decided
dependent upon activity at the Trusts and the location of the patient. Transport is arranged if required.
The ECC then informs the agreed Trust of the patients details by computer link.
The GP MUST then contact the on call team at the receiving site to exchange clinical details, and they MUST send
a full referral letter with the patient. If any of the three component parts of the referral process are omitted, please
inform the ECC via A&E/ED links.
Any patient with an EC Ref number is considered to have been accepted on behalf of the relevant on call team, and
therefore should be treated as such these patients should not be treated as walk in cases for the Casualty Officers.
The Trust will inform the ECC of their A&E/ED activity status regularly throughout the day. This information is
used to inform the GPs as to which Trust is most appropriate.
The scheme only affects patients who are served by Surrey Ambulance Service NHS Trust, requiring emergency
admission to Acute Trusts in Surrey.
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Appendix 10
A&E
CCU
Capacity Manager
Medical
assessment (inc.
ECG)
Thrombolysis
(See Thrombolysis
procedure)
MI?
Yes
No
No
Admit
Patient delayed
in A&E
End
Yes
No
Medical
Bed
Available
No
Alert Capacity
Manager
Yes
Porter + CCU/ A&E
Nurse transfer patient
to CCU.
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Ward
CCU
Capacity Manager
Transfer stable
patient out of CCU
to make bed
Porter + CCU Nurse if available. Otherwise A&E/ED Nurse transfer patient to CCU.
No
CCU
bed
available
Medical
bed
available
Yes
Yes
Porter + CCU/A&E
Nurse transfer patient to
CCU.
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OPD
CCU
Capacity Manager
Porter + CCU Nurse if available. Otherwise A&E/ED Nurse, transfer patient to CCU.
Patient stable
Patient delayed
in OP
Consultant phones
CCU
re. bed
No
CCU
bed
available
No
Medical
bed
available
Alert Capacity
Manager
Yes
Yes
`
Porter + CCU/A&E Nurse
transfer patient to CCU
Transfer stable CCU
patient to a medical
bed
Inform Capacity
Manager
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CCU/Theatre
Yes
DAY OF ADMISSION
Patient phones in to check bed
availability
Rebooked to closest
available date
Bed available?
No
Yes
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Appendix 11
Site Co-ordinator/
Capacity Manager
Patient requires
admission
Patient
meets
admission
criteria
Bed
available
Yes
NO
Admitted to medical
ward. (patient logged in
Chaucer diary)
Yes
Patient admitted
Admit to medical
ward
No
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Appendix 12
The patient will attend and be admitted to the Day/Birch Ward/MAU and be processed as any other day case
patient, including the recovery period following the Coronary Angiogram. Ashford patients will be scheduled for
the morning to facilitate before 4pm return to Ashford.
EPS/ICD patients who have their procedure in the afternoon. Bed should be booked on CCU, (daybed) for
overnight care. Patient to be discharged home either same evening (EPS) or next day (ICD).
Note: If in extreme circumstances due to pressures in A&E, the Capacity Manager, knowing the requirement
for a bed and taking all options into consideration, decides it is not possible to guarantee a bed, then the
Angiography Suite /Day Ward will be notified by the Capacity Manager.
In this event, the Capacity Manager will notify the Day Ward as early as possible on the day, preferably before
9am, prior to the procedure commencing. The Angiography Suite receptionist will then rebook the patient for
a Coronary Angiogram at a later date.
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Appendix 13
YES
YES
Bed available
NO
YES
Patient transferred
Routine Angiogram
NO
Proceed to Angioplasty?
YES
Capacity Manager to
transfer patient direct
to CCU for post
procedure care
NO
Transfer patient
(following plasty) to
CCU
Patient returns to
AH following
appropriate recovery
period
Ideally same day
Patient returns to
Frimley Park from
Day ward
NO
YES
Patient Care
YES
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Appendix 14
PHYSIOTHERAPY DEPARTMENT
(Criteria for Referral)
EMERGENCY ON CALL
The physiotherapy Service provides 24-hour cover for emergency duties on an on call basis. There is a
Physiotherapist covering the service who is on-call from 4.30 p.m. to 8.00 a.m. A list of on-call Physiotherapists is
available at switchboard. There is a named person on-call each evening.
The Physiotherapist reserves the right, on judgement, whether it is a necessary call-out or not after speaking to
the referrer.
EMERGENCY CALLS MUST MEET THE FOLLOWING CRITERIA:
a) The patients medical condition would significantly deteriorate without Physiotherapy intervention.
b) The call-out has been initiated by a registrar or above, or in ITU by Senior nursing staff that have a genuine and
knowledgeable concern about the patients condition. OR
Where a patients condition deteriorates, or in the event of a new admission who needs treatment before 8.30am the
next working day, an emergency call may be made by a registrar/ITU nurse of Consultant. (Please note calls will
be not accepted from nursing staff or house officers).
c) Patients already receiving physiotherapy for respiratory conditions are assessed by the ward physiotherapist
during the day, and, if necessary, evening physiotherapy treatment will be arranged.
QUESTIONS ASKED BY ON CALL PHYSIOTHERAPIST
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Consolidation of lung
Patient not for active treatment
Pleural effusion
Pneumothorax
Recent Pulmonary Embolism
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Part I (Admissions)
Appendix 15
PATIENT
Elective
Admission
Emergency Admission
Yes
Via
A&E
No
No
Yes
Via
OPD
URGENT
SOON
ROUTINE
Assessed by Ortho
SHO or higher
Sanctioned by Ortho
Reg or higher
Yes
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No
Refer to appropriate
consultant for review
Part I (Admissions)
Appendix 15a
SURGERY
NO
SURGERY
MR ELLIOTT (DSE)
MR ROUSHDI (HR)
MR SINNERTON (RSI)
FOLLOW
UP
FOLLOW
UP
DSE # CLINIC
(MON)
RSI # CLINIC
(TUE)
MR NEWMAN (KJN)
MR SIMONIS (RBS)
IN THE AGREED
CONSULTANT # CLINIC
(SEE LIST)
MR SCHOFIELD (CBS)
KJN # CLINIC
(WED)
CBS # CLINIC
(THUR)
MR HASSAN
PREVIOUS
MR BLOOMFIELD (MDB)
SURGERY
AH # CLINIC
(FRI)
MR BUCHAN(MB)
REVERTS TO
OPERATING
CONSULTANT
(DISLOCATED HIPS ,
ETC)
MR KHALEEL (AKH)
FOLLOW
UP
AKH ORTHO
CLINIC (WED)
CONSULTANT ORTHO
CLINIC
PATIENTS ADMITTED FROM TRAUMA BOARD WILL BE UNDER THE CARE OF OPERATING CONSULTANT
PATIENTS ADMITTED FROM CLINIC WILL BE UNDER THE CARE OF THE CLINIC CONSULTANT EXCEPT WHEN CONSULTANT
ON LEAVE THEN IT WILL BE THE ON CALL CONSULTANT
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Appendix 16
EMERGENCY
via A&E
ASSESSMENT
by Doctor
ACUTE
via OPD
ELECTIVE
Waiting list
ASSESSMENT &
SANCTION
by Registrar/
Consultant
ASSESSMENT
at OPD clinic and
priority status given
Bed Required
PRE-ASSESSMENT
No
Yes
Discharge
TCI DATE &
ADMISSION
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DSU
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Appendix 17
Nurse arranges transport (via SAS) to SPH A&E and informs the shift leader at SPH
All case-notes, ultrasound reports and x-rays MUST be sent with the patient
Patient arrives at SPH A&E and the A&E Shift leader will inform the appropriate
team
Specialist Team review the patient
1
other speciality
EPU Outpatient
? discharge
If admission is necessary, the nurse will liaise with the Capacity Manager Or Site Co-ordinator
NB: Unstable
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astroenterology patients i.e. active GI bleed, should be transferred to SPH A&E department
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Appendix 18
DEFINITION
Fasting before surgery is necessary to avoid the risk of regurgitation and vomiting.
In order to avoid dehydration, electrolyte imbalance, malnutrition and general malaise it is important patients do not fast
for longer than is necessary and evidence shows that patients can benefit from water only up to 2 hours before surgery.
POLICY
The Association of Anaesthetists of Great Britain and Ireland recommends fasting periods based on the American
Society of Anaesthesiologists (ASA) Guidelines
the chewing of gum should be treated as an oral fluid and prohibited for 2 hours pre-operatively
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Appendix 19
AGE
There is no upper age limit for patients
GENERAL HEALTH
All patients should be classified according to the American Society of Anaesthesiologists (ASA) grading system:
Grade 1 Fit and healthy
Grade 2 Mild to moderate systemic disease with no limitation of activity
Grade 3 Severe systemic disease with some limitation of activity
Grade 4 Life-threatening disease with severe limitation of activity
Grade 5 Moribund patient with little chance of survival
Unless specifically excluded by any of the following criteria, all patients of ASA grade 1-3 should be acceptable for
day surgery.
Endocrine Disease
Diabetes Mellitus
Well controlled diabetes mellitus is acceptable for short procedures providing there will be no
Significant disruption to a patients appetite and food intake.
Please see a list of procedures suitable for diabetic patients, Appendix 2.
Neurological disease
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Epilepsy
Patients with epilepsy controlled on treatment should be suitable
4.5 Neuromuscular disorders
These will need to be discussed with the relevant anaesthetists
2
Renal disease
Patients on haemodialysis or chronic ambulatory peritoneal dialysis (CAPD) are not suitable for day surgery.
ANAESTHETIC HISTORY
Wherever possible, where there is a history of or a family history of problems with anaesthesia, the relevant
notes or details should be obtained and the appropriate anaesthetist contacted. A history of problems with
anaesthetics does not necessarily mean that the patient is unsuitable for day surgery
LENGTH OF PROCEDURE
Previously, an arbitrary limit of one to two hours was set as the limit for operations considered to be suitable
for day surgery. Absolute length of an operation is now considered less important than pain and postoperative
problems. Patients need not be admitted solely because their operation has been longer than anticipated.
HOME SUPPORT
The patient must have:
A responsible adult with tem for the first 24 hours after a procedure involving a general anaesthetic or
sedation.
Access to a telephone
No limitation of ordinary physical activity. Angina or Dyspnoea with strenuous or rapid prolonged exertion.
Slight limitation or normal activity. Angina or dyspnoea with rapid walking, climbing stairs, emotional stress.
Significant limitation of normal activity e.g. angina or dyspnoea climbing a flight of stairs. No angina at rest.
Incapacitation. Angina or other symptoms of cardiac insufficiency with mildest effort or at rest.
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Appendix 20
Annex A
The Audit Commission Basket of 25
1.
2.
3.
Inguinal Hernia Repair repair of outpouching of the abdominal sack of the groin
4.
5.
Anal Fissure Dilatation or Excision treatment for tear of the skin at the anal region
6.
7.
8.
Varicose Vein Stripping or Ligation removal of tortuous and incompetent veins in the leg
9.
Transurethral Resection of Bladder Tumour removal of a tumour by an instrument inserted into the bladder
10. Excision of Dupuytrens Contracture removal of fibrous tissue under the skin of the palm that causes the
fingers to become bent
11. Carpal Tunnel Decompression incision in the wrist to relieve the pressure on the median nerve as it passes into
the hand
12. Excision of Ganglion removal of a lump usually around the wrist, hand or foot
13. Arthroscopy the use of an instrument to look inside a joint for diagnosis and/or treatment
14. Bunion Operations straightening of the big toe and removal of bony overgrowth causing it to bend
15. Removal of Metal ware removal of pins or plates used to stabilise a fracture
16. Extraction of Cataract with/without Implant removal of a cloudy eye lens and, if appropriate, replacement
with a synthetic one
17. Correction of Squint repositioning of the muscles of the eyeball
18. Myringotomy relief of glue ear by making a small hole in the ear drum to release pressure and inserting a tube to
avoid recurrence
19. Tonsillectomy removal of the tonsils
20. Sub Mucous Resection relief of nasal blockage caused by bent cartilage in the middle of the nose
21. Reduction of Nasal Fracture repositioning of the bone in the nose
22. Operation for Bat Ears removal of skin and cartilage at the back of the ears
23. Dilatation and Curettage/Hysteroscopy examination of the inside of the uterus and removal of tissue if
necessary
24. Laparoscopy use of an instrument introduced through the abdomen for diagnosis and treatment of internal organs
often by gynaecologists
25. Termination of Pregnancy evacuation of the contents of the pregnant womb
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Annex B
Maintaining the supermarket analogy, the British Association of Day Surgery proposed a trolley of procedures, which
are suitable for day surgery in some cases.
Some have been adopted by the Audit Commission into their revised basket (2001). The others are:
1.
2.
Thoracoscopic sympathectomy
Keyhole chest surgery to reduce excess sweating of the hands
3.
4.
Partial thyroidectomy
Removal of diseased thyroid gland in the front of the neck
5.
Superficial parotidectomy
Removal of the salivary gland in the cheek usually for non-cancerous tumours
6.
7.
Urethrotomy
Division of narrowing/stricture in the outflow from the bladder, often through a telescope
8.
9.
Laser prostatectomy
Shrinkage of some cases of prostate enlargement using laser
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Appendix 21
Dept/Policy No.
Gail Webster
Applies to:
Issue Date:
Review Dates:
Nursing
July 2003
July 2005
Reviewed By:
July 2007
Director of Nursing
July 2009
Cross Ref:
Aim
To ensure that patients are provided with the appropriate level of care according to their clinical needs in order to
facilitate the best possible outcomes from critical illness. This policy provides the criteria for three levels of care and
these will indicate whether this care can be provided at the Runnymede or whether the patient should be transferred to St
Peters HDU or ITU in line with our service level agreement.
Classification of critical care patients
Level
Care required
Where is this provided
Level 0
Patients whose needs can be met through normal ward care in an acute
hospital
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.
Runnymede
Level 2
St Peters HDU
Level 3
St Peters ITU
Level 1
Runnymede
Criteria
The table below is not a definitive list of criteria but rather a guide. Clinical judgement is vital. The Runnymede
Hospital can provide Level 1 care. Should the patients requirements extend to level 2 or 3, transfer to St Peters
Hospital must be arranged. See Critical Care Transfer Policy
Level 0
Examples
Oral medication
Bolus iv medication
PCA
Observations required less than 4 hourly
Level 1
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Part I (Admissions)
level of care
Patients in need of additional monitoring,
clinical input or advice
Patients requiring additional facilities for at
least one aspect of critical care delivered in
general ward environment
Level 2
Respiratory
organ
system
uncorrected
Cardiovascular
Unstable requiring continuous ECG and invasive pressure monitoring
Haemodynamically unstable requiring infusions of vasoactive drugs
Heart rate >120bpm
Hypotension systolic<80mmHg for>1 hour
Central nervous system
CNS depression sufficient to prejudice airway and protective reflexes
GCS<10
Level 3
Patients needing advanced
system monitoring and support
respiratory
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Patients who have been in ITU or HDU at St Peters may return to The Runnymede for Level 1 care once they no longer
fulfil the criteria for level 2 or 3 care. This decision will be made by the Consultant in liaison with the Ward Sister.
Consultant responsibility for Critical Care
The admitting Consultant will give a comprehensive handover of the patient to the Nurse-in-Charge and the RMO.
The Consultant will ensure that if they are not familiar with critical care that the patient is referred to an appropriate
anaesthetist or intensivist with admitting privileges for this aspect of care.
The patient receiving level 1 care at the Runnymede will be visited at least twice per day by an appropriate Consultant.
References
DoH (2000) Comprehensive Critical Care. A review of Adult Critical Care Services London : Department of Health
IHA (2002) Guidance on Comprehensive Critical Care for Adults in Independent Sector Acute Hospitals London:
Independent Healthcare Association
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Appendix 21a
Dept/Policy No.
Gail Webster
Applies to:
Issue Date:
Review Dates:
Nursing
July 2003
1) July 2005
______________
Cross Ref:
Reception
Reviewed By:
2) July 2007
_______________
Discharge policy
Director of Nursing
3) July 2009
_______________
Aim
Patients who require level 2 or 3 critical care will need to be transferred to HDU or ITU at St Peters Hospital with
whom we have a service level agreement for the provision of critical care. The aim is to transfer the patient with
continuing medical treatment while minimising the detrimental effects to the patient.
Responsibilities
The decision to transfer the patient must be made by the lead consultant after full assessment of the patient and
discussion between the appropriate consultants at the Runnymede and at St Peters.
The transfer process is the joint responsibility of the referring consultant and transfer staff.
Actual transfer procedure
Once the decision has been made, a full assessment of the patients needs during transfer must be made by the
consultant. St Peters hospital will send a fully equipped retrieval team to fetch the patient.
The patient should be accompanied by the referring consultant and a ward nurse who can give a comprehensive
handover to the receiving medical and nursing team.
Patients who are being transferred straight from theatre will be transferred according to the theatre policy.
The patients next of kin must be informed of the transfer as soon as possible with a full discussion of the reasons etc.
when appropriate
Main Reception must be informed of the transfer to update Medax.
Charging
The Patient Liaison Officer must be informed of the transfer so that arrangements can be made for cover by the patients
private medical insurance or the person responsible for the patients bill.
The patients account will be charged with the daily critical care rate.
References
DoH (2000) Comprehensive Critical Care. A review of Adult Critical Care Services London : Department of Health
IHA (2002) Guidance on Comprehensive Critical Care for Adults in Independent Sector Acute Hospitals London:
Independent Healthcare Association
ICS (2002) Transport Standard London: Intensive Care Society
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Appendix 22
The shift leader or ward clerk (under the direction of the shift leader) should undertake discussion with the Capacity
Managers ONLY.
2.
As soon as possible in the morning inform the Capacity Manager of any potential discharge from the unit.
3.
4.
The Capacity Manager will keep the unit informed of the progress being made with regard to capacity
5.
The Capacity Manager will, wherever possible, give a time when a bed will be available when informing the unit of
the name of the ward.
6.
The Capacity Managers will ensure that at least one bed can be made available for ITU discharges so that a bed is
available for emergency/elective admissions. This should reduce delay in accessing an emergency critical care bed
and avoid urgent cancellations.
7.
If a bed is not required for a discharge that day the Capacity Managers should be informed as soon as possible so
that the bed may be used for another patient.
8.
Patients SHOULD NOT be discharged from the unit after 20.00 hours unless in an emergency.
9.
When receiving a patient, the units should inform the Capacity Manager of the admission, where the patient is
coming from and what consultant they are under. If an emergency from theatre, the Shift Leader should ascertain
what ward the patient had been on and inform the Capacity Manager.
10. Discharges from the unit should, wherever possible, be planned and under controlled conditions so that the patient
(and relatives) can be made ready and a proper handover given to the ward staff.
11. Discharge to the Surgical HDU should also involve the Capacity Manager so that they are aware that a bed must be
made available for a discharge from the HDU to accommodate the patient coming from ITU.
12. The senior staff on HDU should inform the Capacity Manager as soon as possible about admissions and agree
discharges from the unit so that a good flow of patients is achieved between ITU and HDU.
13. In order to ensure capacity for planned admissions, the Capacity Managers will be required to liaise with ITU/HDU
at least 24hrs in advance of electives TCIs
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Appendix 23
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Appendix 24
Adverse Incident Form
Transfer of Critically Ill Patients Out of Transfer Group
Non-clinical transfers of patients to or from units outside these agreed groups or the Network should be recorded as
adverse incidents, and the following documentation completed
1
Hospital No:
Name of Patient:
Transferred from:
Receiving Hospital:
On agreement of transfer, the General Manager responsible must be informed by the Consultant/most senior nurse on
duty as soon as possible during working hours:
2
Hospital No:
Name of Patient:
Transferred from:
Accepting Consultant:
On completion, please send this form to: Your Critical Care Manager or Senior Nurse for action
A copy should also be sent to the Network Co-ordinator
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The Surrey Wide Critical Care Network (SWCCN) is committed to the safe transfer of all critical care patients
who require transfer to a different critical care facility.
iii.
Critical care transfers are necessary for clinical/specialist treatment. The SWCCN is committed to reducing, and
hopefully negating, the need for non-clinical transfers
iv.
v.
All potential options will be explored within the individual Trusts critical care service prior to a decision being
made to transfer a patient.
The following options should be explored by the nurse in charge of the critical care unit:
ii
Utilising an un-staffed bed in the critical care unit by the temporary use of:
Moving appropriate nursing staff to critical care unit from Recovery or elsewhere in the Trust
Nurse in charge caring for a patient
Exploring Bank/Agency /Overtime options
1 nurse caring for 2 patients (1 nurse:2 patients ratio)
Moving a nurse from another critical care unit in the SWCCN if possible and appropriate
N.B Any decision made is dependant upon skill mix and feasibility
iii.
Holding the patient in Recovery or an alternative safe place
iv.
Creating a bed in the critical care unit by discharging a patient to a step down area with Outreach
support if appropriate
v.
Re-evaluating patient/nursing dependency within the critical care unit
vi.
vii.
Patient to be assessed by a Critical Care Consultant as to requirement for transfer and to explore other potential
treatment options with the patients team.
Transfer Decision
2.1 Once the decision has been made that a non-clinical transfer is unavoidable, the final decision for which patient
should be transferred lies with the critical care consultant in charge
2.2 All units must follow the SWCCN joint transfer protocols with Surrey and Sussex Ambulance Service NHS Trusts.
2.3 The decision regarding which patient could take into account the following:
Patient safety/stability for transfer
The existing patients on the critical care unit and their care requirements
The number of previous transfers an individual patient may have had
Ventilatory weaning programmes of particular patients
2.4 Wherever possible, all patients will receive their required surgical procedures prior to transfer i.e. following treat
and transfer principle.
During Transfer
3.1 All transfers will take place using the SWCCN joint transfer protocol with Surrey and Sussex Ambulance Service
NHS Trusts.
3.2 The SWCCN Transfer Audit Form (SWCCN 1) will be used for all critical care transfers and is the legal record of
transfer.
3.3 Adherence to the principles of the management during transport section of Intensive Care Society Guidelines for
the transport of the critically ill adult patient (2002)
Post Transfer
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4.1 The SWCCN 1 form must be completed and a copy returned to the Network Coordinator.
4.2 All transfer forms will be reviewed by the Network Medical Lead and Network Coordinator.
4.3 Any clinical incidents arising from transfer will be investigated by the Network Medical Lead in conjunction with
the lead consultant for critical care of the referring trust.
4.4 A database of critical care transfers will be established and be utilised for data analysis, information and audit
purposes.
4.5 An annual audit of Network critical care transfers will be undertaken and a relevant action plan produced
4.6 Trust critical care transfers must be reviewed at each Trust Critical Care Delivery Group meeting
Trust/ Hospital
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Appendix 25
Ashford
Ashford
CCU
Doctor
Nurse in charge
Bed
available?
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Yes
No
Transfers patient
Contact EBS
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Appendix 26
Overnight stay
(Merlin to Ash)
Merlin nurse
Bed
available?
Yes
No
Merlin nurse
Merlin nurse
Contact
Surgical team
Contact EBS
Inform
Site Co-ordinator AH
of transfer
Arrange transport
(including nurse escort)
Inform
Capacity Manager at SPH
5 227
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Appendix 27
1.
2.
> 16 years
IS FOLLOW-UP REQUIRED?
If IN full time education
ACU
Contributors:
Ratified by:
Date:
Review Date:
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Appendix 28
Flows From
Protocol for the Care of People With Learning Disabilities Using Acute Hospital Services
Core Principles
Admission to the
Acute Hospital
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Care delivered
according to care plan
and protocols
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Discharge Planning
Refer to Trust Discharge Planning Policy and
follow appropriate flow chart
Ensure involvement of
Patient
Carers
Issue 1
Part I (Admissions)
YES
NO
YES
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NO
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YES
MEDICATIONS
Specific attention should be given to the patient's
medication regime including preparation, times and
method of administration; these may have been tailored
to the individual patient's needs and should continue
while in hospital
DAY OF ADMISSION
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DISCHARGE PLANNING
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NO
2.
YES
No
Yes
IMPORTANT
PATIENTS WITH A LEARNING DISABILITY WILL REQUIRE COMPLEX
DISCHARGE PLANNING WHICH SHOULD COMMENCE AT THE TIME OF
ADMISSION
Adapted from Lothian University Hospitals Trust and Lothian Primary Care NHS Trust A COLLABORATIVE
APPROACH TO CARING FOR PATIENTS WITH A LEARNING DISABILITY IN THE ACUTE HOSPITAL
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Legal Position
The patient may be restrained by
staff using reasonable force under
the provisions of Common Law
Section 5(2)
Form 12
Leaflet 3
72 hours
Section 2 or 3
Form 24
(As C above)
Section 2 or 3
Form 24
(As C above)
(Reverse of C above)
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Duration
None
Part I (Admissions)
Further Action
Contact Security Staff to assist
with removal from site. Police
only to be involved if possible
injury to others or damage to
property has taken place
Appendix 30
The Crisis Response Team are part of the Abraham Cowley Unit, situated in the grounds of St Peters Hospital. The
purpose of the team is to provide Rapid Nursing clinical Assessment (usually within 60 minutes) and follow up response
to acute mental health and unexpected life altering events within the Bournewood Trust catchment area.
Hours
4pm - midnight
weekdays
9am - 8pm
weekends
In specific terms
1
They will assess and refer on to other agencies (often the local Community Mental Health team).
They offer an out of hours Casualty Liaison service to dove tail with the daytime service This usually means
Psychiatric follow up on self harm.
The team let the patient when possible; choose the location for consultation - home or hospital.
The team often will use the Internet to provide Psycho-educational resources to give to patients.
The team cannot work with people that are drunk and we will not enter situations where their personal safety
will be unreasonably compromised.
The team can offer weekend packages of support, as part of ongoing plans of care.
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Appendix 31
REMOVAL OF RESTRAINTS AT HOSPITAL
DURING TREATMENT, CONSULTATION OR BEDWATCH
Remove restraints
IMMEDIATELY
NO
YES
NO
Remove
restraints
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Appendix 32
Emergency Presentation
At Crisis
Assessment - appropriate referral
to speciality.
Admit? or Discharge?
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Appendix 33
(e.g.
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Weight
Eye colour
Title:_______________________
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REFERENCES/BIBLIOGRAPHY
Appendix 5:- DoH. Day Surgery: Operational Guide. Waiting, Booking and Choice. Department of Health, August
2002.
Appendix 20:- Practice Guidelines for Preoperative Fasting and the Use of Pharmacologic Agents to Reduce the Risk of
Pulmonary Aspiration: Application to Healthy Patients Undergoing Elective Procedures A Report by the American
Society of Anesthesiologists . Developed by the Task Force on Preoperative Fasting and the Use of Pharmacologic
Agents to Reduce the Risk of Pulmonary Aspiration
Appendix 21:- (Contemporary Management of Angina) Published by American Family Physician.(Dec 1999)
Appendix 21 (Page 64 & 65) DoH. Day Surgery: Operational Guide. Annex A: Audit Commission Basket of 25 page
20 and Annex B. Trolley of Procedures suggested by the British Association of Day Surgery; page 24.
Appendix 21:-Preoperative Assessment The Role of the Anaesthetist Nov 2001. Section 10, page 11.
Appendix 23:- DoH (2000) Comprehensive Critical Care. A review of Adult Critical Care Services London :
Department of Health
IHA (2002) Guidance on Comprehensive Critical Care for Adults in Independent Sector Acute Hospitals London:
Independent Healthcare Association
Appendix 23a:- DoH (2000) Comprehensive Critical Care. A review of Adult Critical Care Services London :
Department of Health
IHA (2002) Guidance on Comprehensive Critical Care for Adults in Independent Sector Acute Hospitals London:
Independent Healthcare Association
ICS (2002) Transport Standard London: Intensive Care Society
Appendix 30:- Adapted from Lothian University Hospitals Trust and Lothian Primary Care NHS Trust A
COLLABORATIVE APPROACH TO CARING FOR PATIENTS WITH A LEARNING DISABILITY IN THE
ACUTE HOSPITAL
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