Discharge and transfer policy - Torbay Care Trust

Discharge and Transfer Policy
NHS Unclassified
Discharge and Transfer of Patients from
Community Hospitals Policy
Date: October 2012
Date: October 2012
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Discharge and Transfer Policy
NHS Unclassified
Partners in Care
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Document Information
Date of Issue: October 2012 Next Review Date: October 2013
Version: 1 Last Review Date: October 2012
Author:
Birgit Morrison/Tracey McKenzie
Directorate: Community Hospital Operational
Approval Route
Approved By: Care and Clinical Policies Group Date Approved:
Care and Clinical Policies Group 24/10/12
Links or overlaps with other strategies/policies:
Care Quality Commission Outcomes
Community Care (Delayed Discharges) Act 2003
Consent Policy
Clinical Handover of Care Policy 2012
Infection Control Policies and Procedures
Medicines Management Policy
Mental Capacity Act 2005 Policy and associated Deprivation of Liberty Safeguards Policy and
Codes of Practice
National Carers Strategy
National Framework for NHS Continuing Healthcare and NHS funded Nursing Care
Transfer Policy - 2011 (Torbay Care Trust)
Discharge documentation: Discharge Checklist, Discharge medicines chart (on icare)
Amendment History
Issue Status Date Reason for Change Authorised
1 Final July 2012 Review and change of existing TCT
Transfer policy for new
organisation.
24/10/12
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Discharge and Transfer Policy
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Contents
no
Pages
1 Introduction 3
2 Statement/Objective 3
3 Roles and Responsibilities 4-7
4 Infection Control 7
5 Mental Capacity 7
6 Learning Disabilities 7
7 Mental Health 8
8 Non English speaking/Sensory Deficits 8
9 Delayed Discharge/Transfer of care 8
10 Reporting 9
11 Patient preparation for Discharge/Transfer process. 9
12 Monitoring and Evaluation 10
13 Training 10
14 References 10
15 Patient Discharge information booklet 11
1. Introduction
1.1 The rationale for this policy is to ensure that patients shall be safely transferred or
discharged from all Torbay and Southern Devon Community hospitals to an appropriate
environment utilising a person centred approach.
1.2 Hospital discharge and/or inter hospital transfer planning should be provided whilst
taking into account the complexity and/or acute medical needs of the patient.
1.3 The scope of the policy applies to all adult patients requiring transfer and discharge to
locations in and out of Torbay and Southern Devon Community Hospitals.
1.4 This policy applies from the point of admission to community hospitals when the
discharge process commences.
2. Statement/Objective
2.1 To maximise patient safety and minimise risk.
2.2 To assess patients prior to transfer and/or discharge thereby ensuring the patients’
individual needs will continue to be met in the new environment.
2.3 To ensure patients and carers are partners in the transfer or discharge process and will
be fully involved when making explicit decisions about future care settings where
possible.
2.4 To maintain ongoing communication between primary care, secondary care and other
partners in the patient’s transfer where appropriate.
This should be: Timely, contemporaneous, appropriate, accurate and auditable whilst
avoiding abbreviations and including all ongoing care requirements.
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2.5 To ensure the transfer and discharge process involves appropriate; personnel,
equipment provision, documentation, referrals and medication.
2.6 To ensure where a mental capacity assessment is required this will have been
completed during the admission process. In the event of an urgent transfer the
professional will, if possible, complete the best interest assessment.
2.7 To reduce and prevent delayed discharges by utilising appropriate policies and
procedures and discuss with clinical and social care managers as soon as any delay is
identified.
3. Roles & Responsibilities
3.1 Assistant director of community hospitals is responsible for ensuring the discharge
systems and processes are effective, efficient and adhered to.
3.2 Community hospital matrons are responsible for ensuring discharge processes meet the
required standards set by the organisation and are embedded in clinical practice.
3.3 Ward managers or the nurse in charge are responsible for ensuring the discharge
processes are operationalised and embedded in daily work.
3.4 Community hospital clinical staff are responsible for adhering to the Discharge policy.
Transport:
3.5 The Ambulance/Patient Transport services will require information in order to determine
transport requirements with regards to the patient’s individual needs, including
infections, oxygen etc.
3.6 A paramedic (9)999 ambulance crew must be called to transfer any clinically unstable
patient requiring immediate emergency treatment and transfer to the acute care trust.
3.7 A paramedic 2-4 hour ambulance crew must be called to transfer any patient requiring
an urgent/unplanned specialist review, intervention or admission to the acute care trust
as deemed necessary by a GP/ doctor in charge of the patient’s care.
3.8 Transport to outpatient department appointments should be arranged as soon as the
appointment is confirmed.
3.9 Staff arranging patient transport should, ideally, call before 1pm for same day transport.
3.10 Staff should arrange transport home or to the ongoing care provider at the earliest
opportunity after the patient is deemed fit for discharge.
3.11 Where appropriate, relatives or friends should be approached to collect the patient from
the hospital setting.
3.12 All staff involved in arranging patient transfers/discharges should be aware of the
procedures and ensure that all relevant staff, patients and carers are informed of the
transfer/discharge date and time.
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3.13 Staff escorting patients should be aware of the procedures to be followed and be
competent to undertake the transfer.
3.14 Staff receiving patients into their department should be able to accept the patient on
arrival and ensure that all patients needs can be met following transfer.
3.15 Out of hours transfers (after 5pm) should be undertaken only when absolutely
necessary. The procedure, however, will remain the same.
3.16 Exclusions to this process include patients attending a department in another hospital
for investigation.
Medical Staff:
3.17 Where appropriate medical staff should inform the patient, carers or relatives of the
decision to transfer a patient to another care provider.
3.18 Medical staff should ensure that when a patient is deemed medically fit for discharge
this is documented clearly in the notes and is timed, dated and signed.
3.19 Following a multidisciplinary team (MDT) agreement to discharge a patient, the doctor
is required to complete the discharge medication documentation, prescribing a 28 day
supply of relevant medication.
3.20 It is the responsibility of the discharging/transferring doctor to provide a written record of
the initial reason for the patients admission, diagnosis, medication prescribed at the time
of discharge, including medication discontinued and additions made during the
admission including the rationale. Care provided during the admission and requirements
for immediate and on -going needs post discharge e.g. INR monitoring , planned follow
up ,infections where applicable and contact details of the responsible medical
practitioner for any post discharge queries. The correspondence must include the
details of the need to transfer (if applicable), the confirmed date of discharge/transfer,
any outstanding referrals/appointments tests and investigations and clear guidance on
follow up requirements and frequency e.g. Reducing dose of medication commenced
such as amiodorone after initially loading doses.
3.21 It is the responsibility of the attending doctor to complete the full discharge summary
within 24 hours of discharge.
Nursing Staff:
3.22 The admitting nurse should initiate a discharge checklist within 24 hrs of the patient’s
admission to a community hospital. (icare -Community Hospital Documentation).
3.23 The decision to transfer a patient to another hospital should normally be made by the
GP/ doctor in charge of the patient’s care, however in an emergency situation the nurse
in charge may make this decision.
3.24 The communication for urgent transfers to an acute unit must be made utilizing all
relevant patient documentation and following the Clinical Handover of Care Policy
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3.25 The nurse responsible for the patients discharge/transfer will ensure that all
assessments are up to date and appropriate to this episode of care prior to patient
transfer/discharge.
3.26 Where the patient is expected to be discharged to a nursing/residential/intermediate
care setting or has a need for a package of care in their home, the Multi-Disciplinary
Team (MDT) is responsible for completion of a Health Needs Assessment, Continuing
Healthcare Checklist and/or full Continuing Healthcare Assessment (when appropriate).
3.27 The registered nurse responsible for the patient when a transfer for tests or
investigations is required, must ensure that medical notes (enclosed in a notes transfer
bag) and any medications required for the period of time that the patient will be away
from the community hospital ward, should accompany a patient, or when transferred to
another NHS Healthcare provider.
3.28 Patients being transferred to nursing or residential homes should have their multidisciplinary
assessment /transfer forms reassessed on the day of discharge to ensure
that the patient remains fit for transfer.
3.29 The registered nurse responsible for the patient should assess to determine that there
has been no significant change in the patient’s risk category immediately prior to
transfer/discharge.
3.30 When arranging End of Life care in a patients’ home environment nurses should, where
appropriate, undertake a “fast track” referral to the Continuing Healthcare service, as
well as maintaining open communication with all services required on discharge.
3.31 The discharging nurse should ensure the appropriate documents are enclosed in an
envelope to be given to the patient/carer on discharge/transfer from a community
hospital.
3.32 The discharging nurse is responsible for ensuring that the patient has all appropriate
Medication on transfer/ discharge. This must be fully discussed and
Understood with the patient/carer/family as appropriate and the patient understands
what the medication is being taken for and the medication concordance
sheet is created. All concordance issues identified
3.33 If wound dressings are required, the nurse discharging the patient should ensure that
the appropriate referral has been made ,i.e. community nursing team, with a supply of
dressings (28 day supply) and an updated wound care plan being sent with the patient.
3.34 If a patient is discharged with other specialist needs e.g. catheter in situ, the
discharging nurse will ensure that appropriate referrals have been made and equipment
available on discharge.
3.35 Patients should be transferred /discharged with their current Treatment Escalation plan
(TEP). A photocopy of this should be kept in the patient notes for future reference.
The Multidisciplinary team:
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3.35 The Multidisciplinary team will meet on a weekly basis to ensure a unified approach to
patient transfers and discharges. These teams should include, where possible, Hospital
Matrons, GP’s, Hospital nurses, Physiotherapists, Occupational therapists, Community
Matrons, ACS colleagues, MHOP nurses, Community nurses and Discharge
coordinators. Community hospital pharmacist support must also be sought where
appropriate. All team members will provide up to date and appropriate patient
information to enable appropriate ongoing care settings to be identified.
Patient escorts:
3.36 The skill level of the patient escort should be decided by the nurse in
charge of the ward. All patients being escorted remain the responsibility of Torbay and
Southern Devon Health and Care Trust.
3.37 All members of staff undertaking escort duties should be competent to do so and be
aware of any actions needed in the event of any change in the patient’s condition.
3.38 In the event of accompanying patients for radioactive procedures, it should be ensured
by the nurse in charge that the escort is not pregnant.
3.39 Pre-registration students are not professionally accountable and therefore cannot
be called to account for their actions and omissions by the NMC and must
work under direct supervision. This deems it inappropriate to utilise student nurses for
escort duties.
3.40 In the event that the ward does not have sufficient staffing levels to cover patient escort
duties, the nurse in charge should, whenever possible, obtain additional staff from
another area or from the nurse bank.
4. Infection Control
4.1 It is the responsibility of all staff to ensure that infection control procedures are carried
. out as stated in Torbay and Southern Devon Health and Care Trust Infection Control
Policies and Procedures.
4.2 For advice on the transport of patients with infectious conditions, the Infection Control
Team should be contacted on 01803 547199 or 547198.
4.3 The receiving department/transport department or community setting must be informed
of any infectious conditions prior to transfer/discharge of the patient. This is in line with
the Trust’s Infection Control Policies and Procedures.
5. Mental Capacity
5.1 If there are any concerns over the patients’ ability to make a decision relating to any
aspect of treatment or transfer/discharge process then you must follow the Mental
Capacity guidelines.
Five Key Principles of the Mental Capacity Act 2005 (laid out in section one of act)
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1. Assumption of capacity: ‘A person must be assumed to have capacity unless it is
established that he/she lacks capacity’.
2. Assisted decision making: ‘A person is not to be treated as unable to make a
decision unless all practicable steps to help him/her to do so have been taken
without success’.
3. Unwise decision: ‘A person is not to be treated as unable to make a decision merely
because he/she makes an unwise decision’.
4. Best Interests: ‘ An act done or decision made under this Act for or on behalf of a
person who lacks capacity must be done, or made, in his/her best interests’.
5. Least restrictive alternative: ‘Before the act is done, or the decision is made, regard
must be had as to whether the purpose for which it is needed can be effectively
achieved in a way that is less restrictive of the persons’ rights and freedom of
action’.
5.2 All decisions taken with regard to an individual’s mental capacity must be clearly
recorded in the relevant case notes.
6. Learning Disabilities
6.1 If a patient has learning disabilities, consideration should be given as to whether the
information provided is in the best format for the patient to understand.
6.2 It should be ensured that consent is obtained to enable discussions with relevant next of
kin or Carers.
6.3 Patient referral to the Learning disabilities team should be considered where appropriate
7. Mental health
7.1 Where the patient has a diagnosis of Dementia or other mental health illness a
capacity assessment should be undertaken. This will indicate the patient’s ability to
make a decision regarding their on-going care setting.
7.2 If possible a patient with mental health issues should be transferred/discharged in
daylight hours. Next of kin/carer informed so as to attend their discharge/transfer
destination if able.
7.3 Next of kin/carers should be involved in the transfer discharge process so that, where
possible, they are able to greet the patient within the new care setting.
8. Non English speaking/sensory deficits:
8.1 If the patient does not speak English, or has a sensory deficit, consider using translation
services or obtain assistance from the British Sign Language Society or providing
information in a different form e.g. written/pictorial.
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9. Delayed Discharge/Transfer of Care
9.1 The statements below are taken from the Community Care (Delayed Discharges) Act
2003 and are used to define a delayed transfer/discharge for patients in Torbay and
Southern Devon Health and Care Trust.
It should be recognised that only patients fulfilling this criteria should be reported as a
delayed transfer/discharge. Where any of the criteria below is not fulfilled and/or there
is no documented evidence the patient cannot be defined as being a delayed
discharge/transfer of care:
A delayed transfer occurs when a patient is ready for transfer from a hospital bed, but is
still occupying such a bed.
A patient is ready for transfer from hospital care when:
The consultant and clinical team agrees that the patient is ready for transfer and this is
recorded in the medical notes –‘Medically fit for Discharge’.
The multidisciplinary team agrees that the patient is ready for transfer/discharge.
The patient is safe for discharge/transfer.
10. Reporting
10.1 Monitoring of delayed transfers of care will take place via icare (delayed discharges
section)on a daily basis, but will be reported weekly to the Assistant Director for
Community Hospitals for onward Strategic reporting.
10.2 The information must be accurate and it is the responsibility of each ward to report all
delayed transfers of care on the SITREP/icare system.
10.3 The Matron, and in their absence, Deputy Matron/ Ward Sister/Charge Nurse is
responsible for ensuring that the data is collected in his/her hospital and discussed with
the relevant General Manager prior to an agreement of the delay and submission.
11. Patient Preparations for Discharge/Transfer - process
11.1 The nurse must ensure that the patient is aware of the reason for transfer or discharge
and has the mental capacity to agree to the transfer or discharge. If the patient’s mental
capacity is in question then a best interest assessment must be considered.
11.2 The address that the patient is being discharge to must be checked prior to discharge
as this is not necessarily the home address/ address on the hospital record.
11.3 The patient's next of kin should be notified of the transfer/discharge as soon as possible.
11.4 Where the patient is to be transferred to another health or social care setting the relevant
MDT member must ensure the receiving unit is notified of the expected transfer so that
appropriate equipment can be prepared for the patient if required.
11.5 A multi-disciplinary assessment/transfer form (where appropriate) should be fully
completed and attached to the patient’s notes in a sealed, labelled envelope for the
receiving area.
11.6 Ensure all necessary transportation equipment is present and in full working
Order i.e. Batteries fully charged and enough oxygen to last during transfer.
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11.7 It is essential that medical notes (enclosed in a notes transfer bag) should accompany a
patient, when they are being transferred to another NHS setting.
11.8 Ensure the patient’s medical notes are booked out for tracking purpose on the
appropriate computer system.
11.9 All patient medications should be checked prior to transfer/discharge. If medication or
intravenous infusions require disconnecting for transfer then this should be documented
on the patient transfer form as appropriate. All medications should be stored and
transferred as per Torbay and Southern Devon Health and Care Trust policy.
11.10 If the patient needs to be transferred/discharge using a wheelchair ensure that the
patient’s feet are on the foot rest. Use the appropriate manual handling techniques for
patient transfer/discharge.
11.10 Ensure analgesia and motion sickness medication is prescribed and available and
offered prior to transfer/ discharge if required.
11.11 Medicines should be checked and be current – obsolete medicines that belong to the
patient can only be disposed of with the consent of the patient (advice in SOP storage
and transport of medicines)
11.12 If transfer/discharge journey or outpatient investigation is expected to be lengthy
arrange a packed lunch/snack as appropriate.
11.13 Ensure that all of the patient’s property is packed securely in hospital property bags or
in patients own cases. All valuables must be documented using the
Trust’s property book and correctly signed for.
12. Monitoring and Evaluation
12.1 The effectiveness of this policy will be monitored through audit of transfers, and review of
complaints, or clinical incidents.
12.2 Patients discharged home are phoned within 48 hours of their discharge to ensure the
discharge process has been successful and identify any issues relating to the discharge
process. Action will be taken as required.
13. Training
13.1 In house training in relation to patient transfer and discharge will be provided during
Clinical Area Induction and MDT meetings.
13.2 Clinical leads are responsible to ensure that all staff are aware of this policy.
14. References
Community Care (Delayed Discharges) Act (2003)
South Devon Health Care Foundation Trust Discharge policy (2010)
15. Appendix 1 – Patient Discharge Information Booklet
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Appendix 1
PATIENT DISCHARGE INFORMATION BOOKLET
Please place a photocopy of this document in the patient’s notes and copy to the
relevant healthcare professionals on discharge.
Name:
Or insert label
Ward/Team:
NHS No:
Date of Birth:
Admission Date:
Discharge Date:
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CONTACT DETAILS
Named nurse:
Ward Telephone No.
Care Manager:
Telephone No.
Occupational Therapist:
Telephone No.
G.P
G.P Name & Practice
Address
G.P informed? Yes No Date informed:
Admitting Diagnosis
Confirmed Diagnosis
Physiotherapy
Occupational Therapy
Nursing
GP/ GPSI
Weight: Height: BMI: MUST score:
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Name:
Or insert label
NHS No:
Date of Birth:
PACKAGES OF CARE
Package of care starting:
Frequency of care:
Name of Care provider:
Telephone no. of Care
Provider:
DAY CARE
Is Day Care required? Yes No Start Date:
Location of Day Care:
Frequency:
MEALS ON WHEELS
Are Meals on Wheels required? Yes No
Provider:
Telephone No. of Provider:
Frequency:
PHYSIOTHERAPY
Is physiotherapy required? Yes No Start Date:
Contact Telephone No.
PODIATRY
Podiatry informed of foot ulceration? Yes No
Date of appointment with podiatry team:
PHARMACY
Has the Pharmacy been informed of the Yes No
discharge?
If Yes, please provide details of Pharmacy: Yes No
Has the Pharmacy been informed of new Yes No
medications?
Has the Pharmacy been informed of when Yes No
repeat medication is required?
Is a Dossette system required? Yes No
Is this a two week supply? Yes No
ADVICE SHEETS GIVEN TO PATIENT
Hip replacement: Yes No
Knee Replacement: Yes No
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Falls Prevention: Yes No
Keeping Warm: Yes No
Nutrition Advice: Yes No
How to Contact GP Out of Hours Service: Yes No
VTE Advice: Yes No
Other: ......................................................... Yes No
Name:
Or insert label
NHS No:
Date of Birth:
OUTPATIENT APPOINTMENTS
Appointment
with:
Specialty:
Date:
Location:
Transport Yes No
booked:
Details of
transport
arranged:
OUTPATIENT APPOINTMENTS
Appointment
with:
Specialty:
Date:
Location:
Transport Yes No
booked:
Details of
transport
arranged:
OUTPATIENT APPOINTMENTS
Appointment with:
Specialty:
Date:
Location:
Transport booked: Yes No
Details of transport
arranged:
Time:
Time:
Time:
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8 TELEPHONE NUMBERS
9
10 Torbay Care Trust Customer Service Centre
Telephone No.
11 01803
219700
Telephone No. for Evenings &
Weekends
12 www.torbaycaretrust.nhs.uk
13 01803 524519
Use this number if you are concerned e.g. if your carer has not arrived.
In an Out of Hours Emergency: When your surgery is closed
Devon Doctors: 14 0845 6710 270 15 www.devondoctors.co.uk
NHS Direct: 16 0845 46 47 17 www.nhsdirect.nhs.uk
Use this number if you feel unwell during hours outside of your surgery’s usual
opening hours.
Torbay care Trust Infection Prevention & Control Team
Telephone No. 18 01803 557163
The Infection Prevention & Control Team are available Monday- Friday, 9am- 5pm.
19
20 Volunteer Involvement
21 Name of Volunteer 22
Group
23 Telephone No. 24
25 Use this number if ................Each hospital to fill in as applicable............
26
27
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