Policy for the Discharge and transfer of children and young people ...

• Must inform the GP at the earliest opportunity of any child/young person whose carertakes his or her discharge against medical advice.5.4. The Consultant along with other relevant team members will be notified if a parenttakes home a child/young person against medical advice and will advise as to whether thechild/young person would be classed as ‘at risk of significant harm’.5.5. When necessary Social Services and the Police can be contacted to enable thechild/young person to be returned to hospital. Please refer to Appendix 5 for the Self-Discharge Pathway.• Must ensure, that, whenever possible, discharge prescriptions are completed inadvance, to allow adequate time for the dispensing of medicines and the provision ofinformation to the child/young person and carer.• Must liaise with relevant other providers when a transfer is required to ensureacceptance of the transfer and to agree any necessary arrangements.• When a decision has been made to transfer, the consultant or senior doctor willensure that the receiving service has a full written account of care delivered withinRCHT stating clearly the reasons for transfer. This must be discussed fully with theparents/carers and whenever possible with the child or young person.5.6. Role of Nursing StaffNursing Staff involved in the discharge/transfer of children or young people:• Should collect and clearly document accurate information relating to the child/youngperson’s individual social circumstances as soon as possible followingadmission/service contact. This information will form the basis of their dischargeplanning arrangements and will be included in any transfer documentation.• Should discuss all babies under a year of age with the health visitor /midwife withreference to the vulnerability criteria (Appendix 4) as applicable, and ensure thisdiscussion is documented. The Paediatric Discharge/Liaison Co-Ordinator can becontacted for further advice and support.• Should assess children/young people against the vulnerability criteria (Appendix 4),and where a child/young person is identified as ‘vulnerable’ discuss them with theHealth Visitor/School Nurse and ensure this discussion is documented. ThePaediatric Discharge/Liaison Co-Ordinator can be contacted for further advice andsupport.• Identify any specialist medical equipment or support required along with the multidisciplinary team and inform Community Nurse, Midwife, Health Visitor or SchoolNurse to allow for equipment to be in place at time of discharge.• Will provide written information concerning discharge in the form of the PaediatricDischarge Leaflet – Going Home – Preparing for your Child’s Discharge fromHospital.Policy for the discharge and transfer of children and young people from child healthPage 5 of 38

• Will ensure that a discharge summary is sent to the children/young people’s healthvisitor/ school nurse. This should be within 24 hours of discharge. Parents can begiven a copy, if available, prior to them leaving the ward.• Have a responsibility, in consultation with medical staff for co-ordinating whichmultidisciplinary team members and agencies need to be involved in the assessmentand discharge/transfer plan for the children/young people. If the child has nursingneeds, the Children’s Community Nurses should be notified as soon as possiblefollowing admission via a Paediatric Community Nursing referral form (Appendix 6 &7). All members of the multidisciplinary team involved in the child or young personscare must also be made aware of any transfer.• Have a responsibility for ensuring that the relevant community nurse/healthvisitor/school nurse is invited to attend any multidisciplinary meetings regardingdischarge or transfer. Adequate notice of such meeting must be given wheneverpossible. The Paediatric Discharge/Liaison Co-Ordinator can be contacted for furtheradvice and support.• Will ensure that transfers of children/young people to other provider units from acutepaediatric services use the same standards as discharges, and that the transferdocumentation (appendix 8) is completed, transport is arranged and personalproperty and the relevant medical records are transferred with the child/youngperson.• Will co-ordinate transport arrangements at the earliest opportunity to ensure that thetiming takes account of the care arrangements made for the day of discharge. Whentransport is required for transfer this will also be arranged by the nursing staff whomust at all times liaise with Patient Transport Services (PTS) ensuring a riskassessment is carried out when considering mode of transport• Should ensure that the children/young people’s carers are involved in assessmentsand discharge or transfer plans. Their views should be sought, recorded andcommunicated with other members of the multidisciplinary team.• Will ensure that, if necessary, the community nursing services have full written detailsof nursing requirements, equipment and disposable supplies required for dischargeand continuing care at home by helping them to complete their nursing assessmentdocumentation. This may be part of the agreed discharge plan or a copy of thedischarge summary.• Should ensure that children/young people and carers are given relevant information,verbally and in writing, regarding medication, follow up services, health educationand where to get help if needed. The guidance for Open Access to the PaediatricWards (Child Health Website -May 2009) should be followed for those who mayrequire this facility.• Should ensure child/young person is discharged from PAS5.7. Role of Paediatric Discharge Liaison5.8. Whilst responsibility for managing discharge remains with the ward, the PaediatricDischarge/Liaison Co-Ordinator will provide assistance/support, where appropriate, inPolicy for the discharge and transfer of children and young people from child healthPage 6 of 38

elation to communication between hospital and community services. The PaediatricDischarge/Liaison Co-Ordinator pathways are detailed in Appendix 9.6. Standards and Practice6.1. Discharge of Children/Young People without continuing healthcareneed6.2. When the hospital admission has been straightforward, discharge planningneed not be elaborate, but must include:• Written information to the GP and Health Visitor/Midwife (under 5’s) and School• Nurse (over 5’s). All parents and carers must be informed of this sharing ofinformation and they must be given the opportunity to let us know if they do not wishthis to happen. This information must be copied to the parents and/or young person• Enter record of admission in parent held record including height and weight.• Appropriate information, in writing, where available for the parents/young personabout any likely after effects and follow on treatment• Provision of written information to parents/carers about medication, including safestorage and side effects. The instructions/advice on the discharge summary isacceptable, as are patient information leaflets.• What to do should their child/young person’s condition deteriorate.• Written point of contact in case of difficulty.• Written arrangements for follow up.• Written and verbal health promotion/illness prevention advice.• Whenever there is information sharing or verbal consent, details should bedocumented in the health record• Discharge Plan and Checklist (Appendix 3) is completed and filed in the child’snotes.• Discharge from PAS6.3. Discharge of Children/Young people with Complex and On-goingHealthcare Requirements6.4. Where there is a more complex hospital episode and/or the child has ongoinghealthcare needs (e.g. long term illness, disability or life limiting conditions) discharge ortransfer planning must include all of the above and, appropriate consideration must begiven to:• Medical information being sought from the previous NHS Trust(s) before dischargewhere a child is admitted to hospital with an ongoing medical problem. (To includeinformation about any social or child protection concerns).• Social Services contact and follow up arrangements.• Primary Care contact and follow up arrangements.• Community Children’s Nursing / Allied Health Professional contact and follow uparrangements - the ward needs to be aware of the roles of these groups, their referralprocesses and the information they will require, prior to discharge, to support childrenwho are discharged with additional needs.• Community Paediatric contact details and follow up• On-going hospital contact and follow up arrangements• Equipment needs.• Parent/Carer’s proficiency in managing their child’s condition and associated needsPolicy for the discharge and transfer of children and young people from child healthPage 7 of 38

6.5. A discharge planning meeting should be provisionally booked within 24-48 hours ofadmission for those children with complex needs whose discharge may not bestraightforward.6.6. It is the responsibility of the hospital nursing staff in consultation with the medicalstaff to coordinate which multi-agency teams need to be involved in the assessment anddischarge or transfer of children and young people. Due to the complexity of some of thesedischarge or transfer arrangements there must be a named person, known to the child andfamily, who will co-ordinate ongoing care. This person will act as the single point of contactshould the family experience difficulty with ongoing care arrangements. This person canbe identified via the common assessment framework process.6.7. The Paediatric Discharge/Liaison Co-Ordinator can be contacted for further adviceand support with this process.6.8. Ward staff should ensure that parent’s/carer’s are adequately trained in the care oftheir child before discharge. This applies to the administration of medicine, in addition tothe management of any equipment.6.9. Discharge of Children and Young People in Special CircumstancesChild Protection Concerns• Where there are concerns about possible child protection issues, there mustbe a multi-agency action plan agreed and recorded before the child leaves hospital.• Any legal orders arising from the admission should be recorded (with copies filed ifavailable)• The child must be registered with a GP before discharge• No child can be discharged or transferred from hospital, where there are childprotection concerns without the permission of the responsible ConsultantPaediatrician. This can only be given once a clear, agreed action plan is in place andconfirmation that the child is being discharged/transferred to a place of safety.• So far as possible, all investigations should be completed before discharge/transfer,even if the child is deemed medically fit, with clearly documented plans in place forany remaining/follow up investigations.• Medical information should be sought from the previous NHS Trust(s) beforedischarge where a child admitted to hospital with an ongoing medical problem, or isrecognized as at risk of harm, has already been treated at another hospital.• All follow-up plans, for all agencies, must be clearly documented and confirmed.• If the child is discharged to an address other than their home address and/or into thecare of someone other than their parent, this must be clearly recorded in the healthrecord, taking care with regard to confidentiality• Whenever possible the child, parents/carers should be informed of all arrangementsmade, whilst taking care with regard to confidentiality.• The Named Nurse for child protection, can be contacted for further advice via RCHTswitchboard in working hours.• The Multi Agency Referral Unit (MARU) can be contacted in office hours on 030012311166.10. If there are urgent concerns out of office hours, either contact the duty doctor for childprotection (via RCHT switchboard) or the on call social worker (via 01208 251300)6.11. Transition to Adult ServicesPolicy for the discharge and transfer of children and young people from child healthPage 8 of 38

When a young person has ongoing care needs, and is reaching the age where adultservices will be assuming responsibility for this, the transition of care should be recorded inthe notes. A named person known to the young person and their family should beidentified where possible for contact in case of difficulty.6.12. Children who have remained in hospital for 3 months or longerThese children will be subject to Section 85 of the Children Act 2004. The Trust has aresponsibility to notify social services in these circumstances and when the child isdischarged or transferred to another health provider. Please refer to multi agency guidancere children who are in hospital for more than three months as directed by namedprofessionals for child protection.6.13. Palliative care needsChildren who have palliative care needs must have an identified key-worker to co-ordinatean appropriate support network within the home setting. They require a written plan oftreatment and intervention, details of which have been agreed with the family and sharedwith the community teams prior to discharge.6.14. Discharge of Infants from the Neonatal Unit (NNU)The previous standards all apply to infants being discharged from NNU who may alsohave a co-ordinated programme of follow up, with special arrangements for vision,hearing, developmental progress and ongoing support. All of this should be recorded in thechild’s notes. The principles of children with continuing healthcare need outlined above islikely to apply to this group of patients.6.15. Discharge of Children and Young people with Mental HealthIssuesWhere a child has an identified mental health need, arrangements must be made in thedischarge or transfer plan for follow up from the Child and Adolescent Mental HealthService (CAMHS). Where this is not thought to be necessary the reason(s) for thisdecision need to be agreed with the child/young person’s consultant and documented inthe health record.6.16. Discharge from the Emergency Department6.17. Many children will be seen and assessed in the Emergency Department and deemedmedically fit for discharge during the working day, evenings, weekends or bank holidays.For most children this can occur safely and without concern for the social circumstances.6.18. The clinical staff discharging the patient must ensure that, in addition to a full medicalassessment, they make & document an assessment of the social circumstances andconsider if the child and their accompanying carers can safely return home. If there is anyconcern that the child may not be able to return home safely and in a timely way,consideration should be made of provision of hospital transport or admission to childhealth until such time that public transport is easily accessible.6.19. Where a child and their parent/carer have arrived by ambulance and are deemedmedically fit for discharge, it is the parent/carers responsibility to arrange transport home.If the discharge is to occur during unsocial hours parents/carers should still try and arrangetransport home. In exceptional circumstances where this may not be possible andparents/carers have exhausted all avenues, further advice can be sought from ChildPolicy for the discharge and transfer of children and young people from child healthPage 9 of 38

Health, specifically in relation to the availability of the Macdonald Suite Familyaccommodation.6.20. A discharge summary should be sent to the GP.6.21. The Health Visitor/Midwife (under 5’s) and School nurse (over 5’s) should be notifiedof the attendance.6.22. Transfer of Children and Young People• When children/young people are being transferred within the hospital details of thetransfer should be documented in the health record.• When children/young people are transferred to another provider the transferdocument (appendix 8) should be completed and the Patients Transport Service(PTS) at RCHT should be consulted to book appropriate transport.• Out of hours transfers should be minimal and based on risk assessment of theclinical situation as outlined in RCHT Guideline for Critical Care Transfers.Arrangements for this type of transfer will be made with SWAST directly and theRCHT site co-ordinator notified.• The personnel who accompany the child /young person will be decided by seniorclinical staff based on clinical need and staff availability – this will be documented inthe health record or on the transfer document. Clinical assessment should be done inline with RCHT Policy for Observation and Monitoring in Child Health and recordedon the patient records for intra hospital transfers and on the transfer document ifbeing transferred to another provider.6.23. Discharge involving Children and Young People from The Isles ofScilly (IoS)• When planning a discharge/transfer to the IoS due regard must be given to theadditional time needed to reach the Islands because of the limited transport servicesavailable, particularly at weekends. In addition consideration should also be given totransfer times involved if onward transport by boat from St. Mary’s is required whenthe child/young person lives on an off-island.• It will need to be confirmed that the child/young person is medically fit to travel to theairport, and onward by air.• If the family have a return ticket nursing staff will provide assistance/advice, ifnecessary, about how to book a flight.• If the family do not have a return ticket it will be necessary for them to contact thePatient Transport Service Office (PTS) on 01872 252211 to request a travel warrantto return to the Isles of Scilly and to arrange a flight.• Nursing staff will provide families with information regarding transport to the airport.• Where a child and their parent/carer have arrived by ambulance and are deemedmedically fit for discharge, it is the parent/carers responsibility to arrange transporthome. If the discharge is to occur during unsocial hours further advice can be soughtfrom Child Health, specifically in relation to the availability of the Macdonald SuiteFamily accommodation.7. Dissemination and Implementation7.1. Ward and Department Managers are responsible for ensuring adequatedissemination and implementation of the policy within their own areas.Policy for the discharge and transfer of children and young people from child healthPage 10 of 38

7.2. All managers will be aware of the contents of this policy and will ensure that theirstaff have read and understood the procedures and processes relating to the dischargeand transfer of patients. New versions of the policy will be circulated to all managers fordissemination to their staff with a summary of all amendments made to the updatedversion.8. Monitoring compliance and effectivenessElement to bemonitoredLeadToolFrequencyReportingarrangementsActing onrecommendationsand Lead(s)Change inpractice andlessons to besharedCompletion of a discharge planDocumentation of liaison with other professionals and agenciesTimeliness of documentation to other professionalsCompletion of a transfer documentDocumentation of details of transfer in patient notesSenior Matron Child HealthAn agreed audit tool developed by the Directorate and registeredwith clinical effectiveness as part of the annual records audit, toinclude the elements to be monitored described aboveMonthly quality audits will monitor the completion of discharge plansAnnually for the whole policy through audit of recordsMonthly for ward quality audits on discharge plansAudits will be reported via the Divisional Audit and Guidelinesmeeting in the Directorate. Action plans, incidents and complaintsrelated to discharge and transfer will be brought back to theDirectorate via Clinical Governance meetings.Reports should be discussed at the appropriate Operational BoardReports should be discussed at the appropriate Operational Board andany high risk areas highlighted and action plans developed to addressany gaps identified.Lessons will be shared with all the relevant stakeholders bypresentation at Child Health audit and guidelines meetings and via theChild Health risk management newsletter. Following liaison withrelevant stakeholders, any required changes to practice will bediscussed at Directorate Clinical Governance meetings, prior to beingreflected in this policy and implemented clinically.9. Updating and ReviewThe policy author is responsible for ensuring the policy is kept up to date, with reviews beingcarried out at least once every 3 years, reflecting changes in legislation where necessary.The author must also ensure the policy has been screened to establish if it requires a fullImpact Assessment against the Race Relations Amendment Act to ensure no minority groupis discriminated against within the document.10. Equality and Diversity10.1. This document complies with the Royal Cornwall Hospitals NHS Trust serviceEquality and Diversity statement.10.2. Equality Impact AssessmentThe Initial Equality Impact Assessment Screening Form is at Appendix 2.Policy for the discharge and transfer of children and young people from child healthPage 11 of 38

Appendix 1. Governance InformationDocument TitleDate Issued/Approved: January 2014Date Valid From: January 2014Date Valid To: January 2017Directorate / Department responsible(author/owner):Contact details: 01872 252636Brief summary of contentsSuggested Keywords:Target AudienceExecutive Director responsible forPolicy:Policy for the Discharge and Transfer of Childrenand Young People from Child HealthMary Baulch, Matron Child HealthCaroline Amukasana Paediatric discharge liaisonnurseThis policy states the responsibilities of themultidisciplinary team when discharging ortransferring children/young people from child health.Paediatrics, Children, Young People, Neonates,Discharge, Transfer.RCHT PCH CFT KCCGMedical DirectorDate revised: January 2014This document replaces (exact title ofprevious version):Approval route (names ofcommittees)/consultation:Divisional Manager confirmingapproval processesPolicy for the Discharge and Transfer of Childrenand Young People from Child Health version 3.0Child Health Senior Nurses, ConsultantPaediatricians Child Health, RCHT SitemanagementSheena Wallace, Divisional General ManagerWomen & Children’sName and Post Title of additionalsignatoriesSignature of Executive Director givingapprovalPublication Location (refer to Policyon Policies – Approvals andRatification):Document Library Folder/Sub FolderLinks to key external standardsRelated Documents:none{Original Copy Signed}Internet & Intranet Intranet OnlyPaediatricsCare Quality Commission Outcomes1,2,4,6,7,9,14, and 21NHSLA Risk Management Standards 4.9 and 4.10Multi Agency Safeguarding Children PoliciesRCHT Adult Discharge PolicyRCHT Policy on Clinical Record KeepingPolicy for the discharge and transfer of children and young people from child healthPage 12 of 38

Training Need Identified?Guideline for Open Access to the PaediatricWards (Child Health website)Policy for Children who are in Hospital formore than three monthsRCHT Policy for patient observation andmonitoring in Child HealthClinical policy for safe transfer of patientsbetween care areas or between hospitalsDH: Working Together to Safeguard Children2013DH NSF For children young people andmaternity services (2004)DH: Framework for Assessment of Children inNeed and Their Families 2001Children Act 2004DH: Discharge from Hospital, Pathway,Process and Practice 2003Reder P. et al (1993) Beyond Blame RoutledgeLONDONReder P. & Duncan S. (1999) Lost InnocenceRoutledge LONDONBrowne K. (1995) in The Child ProtectionHandbook edited by Wilson & James BalliereTindall LONDONCEMACH (2004) Why Mothers Die(2000-2002) Report on confidential enquiries intomaternal deaths in the United Kingdom,RCOG Press LONDONAppendix 7- original document from CornwallFoundation trustAppendix 8- Original document from regionalcritical care group.NoPolicy for the discharge and transfer of children and young people from child healthPage 13 of 38

Version Control TableDateVersionNoMay 09 V1.0Summary of ChangesFinal amendments approved;EIA Completed; documentpublishedChanges Made by(Name and Job Title)Mary BaulchSenior Matron Child HealthMay 11 V2.0 Full review & consultationMary BaulchSenior Matron Child HealthDec 11 V3.0Rewording of transfer element toclarify processMary BaulchMatron Child HealthJan 14 V4.0 Full review & consultationCaroline AmukusanaPaediatric Liaison/DischargeCo-OrdinatorTabitha Fergus Deputy wardmanger- re formatAll or part of this document can be released under the Freedom of Information Act2000This document is to be retained for 10 years from the date of expiry.This document is only valid on the day of printingControlled DocumentThis document has been created following the Royal Cornwall Hospitals NHS TrustPolicy on Document Production. It should not be altered in any way without the expresspermission of the author or their Line Manager.Policy for the discharge and transfer of children and young people from child healthPage 14 of 38

Appendix 2. Initial Equality Impact Assessment FormName of the strategy / policy /proposal / service function to be assessed (hereafter referred toas policy) (Provide brief description): Policy for the Discharge and Transfer of Children andYoung People from Child HealthDirectorate and service area:Is this a new or existing Policy?Child HealthExistingName of individual completingTelephone: 01872 252636assessment:1. Policy Aim*Who is the strategy /policy / proposal /service functionaimed at?Mary BaulchThis policy has been developed to support Trust Staff in thedischarge and transfer of children and young people. It is arequirement of the “NSF for Children, Young people and MaternityServices” to have in place a policy that meets the specific needs ofthis group.2. Policy Objectives* To ensure safe and effective discharge and transfer of children andyoung people from the Child Health Directorate3. Policy – intendedOutcomes*4. *How will youmeasure theoutcome?5. Who is intended tobenefit from thepolicy?6a) Is consultationrequired with theworkforce, equalitygroups, local interestgroups etc. aroundthis policy?b) If yes, have these*groups beenconsulted?Safe and timely discharge and transfer of patientsAnnual audit of discharge documentationRCHT Staff and PatientsNoN/AC). Please list anygroups who havebeen consulted aboutthis procedure.7. The ImpactPlease complete the following table.Are there concerns that the policy could have differential impact on:Equality Strands: Yes No Rationale for Assessment / Existing EvidenceAgePolicy for the discharge and transfer of children and young people from child healthPage 15 of 38

Sex (male, female, transgender/ genderreassignment)Race / Ethniccommunities /groupsDisability -learningdisability, physicaldisability, sensoryimpairment andmental healthproblemsReligion /other beliefsMarriage and civilpartnershipPregnancy and maternitySexual Orientation,Bisexual, Gay, heterosexual,LesbianYou will need to continue to a full Equality Impact Assessment if the following have beenhighlighted:You have ticked “Yes” in any column above andNo consultation or evidence of there being consultation- this excludes any policieswhich have been identified as not requiring consultation. orMajor service redesign or development8. Please indicate if a full equality analysis is recommended. Yes No 9. If you are not recommending a Full Impact assessment please explain why. No areasrelevantSignature of policy developer / lead manager / directorM.Baulch. C.AmukasanaDate of completion and submission28/11/13Names and signatures ofmembers carrying out theScreening Assessment1.2.Keep one copy and send a copy to the Human Rights, Equality and Inclusion Lead,c/o Royal Cornwall Hospitals NHS Trust, Human Resources Department, Knowledge Spa,Truro, Cornwall, TR1 3HDA summary of the results will be published on the Trust’s web site.Signed _____M.Baulch, C.Amukasana__________Date _____15/01/14___________Policy for the discharge and transfer of children and young people from child healthPage 16 of 38

Appendix 3. – Discharge Plan and Checklist- Sample only CHA2690 V4Policy for the discharge and transfer of children and young people from child healthPage 17 of 38

Sample only CHA2690 V4Policy for the discharge and transfer of children and young people from child healthPage 18 of 38

Appendix 3a. Discharge Checklist and Parent Skills-Neonatal Unit. Sample Only CHA3060Policy for the discharge and transfer of children and young people from child healthPage 19 of 38

Policy for the discharge and transfer of children and young people from child healthPage 20 of 38

Appendix 4. Vulnerability Criteria1. Poor parenting affecting child’s health or development.2. One or both parents under 21 years.3. Step-parent/co-habitee member of household4. Violence within the family (includes animals and domestic abuse)5. History of cruelty- includes child protection categories 1,2,3,4.6. Parents abused/neglected7. Drug/alcohol abuse of main carers8. Frequent incidents/injuries9. Behavioural/ emotional vulnerability of child10. Unreal expectations of child11. Failure to thrive12. Mental illness of main carers13. Mother suffering with post natal depression14. Any other factor which makes professionals instinctively uneasy15. Family closing down to outsiders16. Parents with learning disabilities17. History of criminality18. Family isolated within the community19. Homelessness20. Late ante natal booking21. Lack of engagement with service22. Poor living conditions23. Poor attendance at appointments24. Chaotic lifestyle25. Frequent contact with the serviceNB. THE NUMBER OF TICKS NEED NOT INDICATE THE LEVEL OF CONCERN I.E. ONE TICK MAY BE ASSERIOUS AS FOUR.Policy for the discharge and transfer of children and young people from child healthPage 21 of 38

Appendix 5. Self Discharge PathwayIf a parent chooses to take the discharge of their child against medical advice, staff shoulddiscuss this with the parents, establishing their reasons and explaining the risks this could haveon their child’s health.All discussion should be clearly documented in the child’s health record.If the parent still requests discharge, the appropriate doctor must be contacted immediately inorder to review the child and further inform and explain any associated risks to the parent.If these interventions fail to deter the parent, the impact on the child’s welfare must be assessedby nursing and medical staff, and safeguarding procedures should be followed if leaving thehospital would place the child at significant risk of harm.Safeguarding procedures should also be followed if the child is subject to a protection plan or isa child in Care.If the child is removed against medical advice, and there are significant safeguarding concerns,the Trust security department should be contacted to assist, and an immediate referral toChildren’s Social Care must be made.Staff should not place themselves at risk in trying to prevent the parent leaving with the child.If there are no safeguarding concerns, and the child will not be at significant risk of harmfollowing discharge, the parent should be asked to sign a ‘Discharge Against Medical Advice’form.If the parent refuses to sign, this must be fully documented in the child’s health record.The parent should be advised to contact their G.P. practice for ongoing care.If possible normal discharge procedures should be followed with regard to giving advice,arranging for medication etc.Whenever clinically indicated, appropriate outpatient follow-up arrangements should still beoffered/made when a child/parent discharges against medical adviceA young person assessed as having capacity to understand the consequences of taking theirown discharge against medical advice may wish to take their own discharge. In this case staffshould try to dissuade the patient from doing so.If this is unsuccessful the young person’s parents must be notified and the patient should beasked to sign a ‘Discharge Against Medical Advice’ form. They should be advised that otherrelevant professionals (e.g. G.P., Social Worker, School Nurse) will be informed of theirdecision.Without exception, the child’s GP and Health Visitor/School Nurse and any other keyprofessionals involved in the child’s care must be informed at the earliest opportunity, preferablywithin 24 hours, that the child has left/been removed from the ward.If a parent expresses that they wish to discharge their child due to a complaint or concern aboutcare, every effort must be made to address and resolve the complaint/concern with reference tothe Trust Complaints’ Policy, to enable care to continuePolicy for the discharge and transfer of children and young people from child healthPage 22 of 38

Appendix 6 - Referral Pathway for Children’s Community Nurses(CCN) or Diana Nurses (October 2013)Referrals are made to the Children’s Community Nurses (CCN) or DianaNurses via the CCN/Diana referral formThe referral should be completed electronically on the correct referral form, identifyingthe specific input required from the CCN/Diana Nursing Service.If the referral form is not completed correctly it will not be accepted and will be returnedto the referrer. (The CCN/Diana team can be contacted prior to referral to discuss)Referral should be emailed toChildrens.services@cornwall.nhs.ukThe CCN/Diana Team may contact referrer to discuss referral and to confirmdetails (action time - non-urgent → 10 working days Urgent→ 3 workingdays)Referral will be discussed by the team and a nurse will be allocated if thereferral is acceptedReferrer will be notified if referral is not accepted, with reasons why it is notacceptedIf referral is accepted, CCN/Diana Team will contact the family to arrange tovisit – Action time - non-urgent – 10 working days Urgent – 3 working daysInitial visit will be a 2 person visit –To identify any potential risks for future visitsTo give 2 perspectives when formulating a plan of careTo ensure that the family are not reliant on a single person for futurevisits, advice, etcFollow up will be according to individual needDischarge Criteria – If there is no assessed nursing need, or the child oryoung person has had no contact or support for a period of six monthsPolicy for the discharge and transfer of children and young people from child healthPage 23 of 38

Additional Information for initial visit –Information that could be given and obtained during the initial visit if appropriate;What is the family expectation of the Diana Team, what information have they beengiven?The Diana Team do not provide long term direct/ hands on careSupporting and empowering family to provide care for their childIdentify training needsDiscuss supplies; set up PLUSS, Vygon as necessary.Explain to parents that we will help them to manage their supplies but it is not ourresponsibility to know when they are running out and/or to deliver more at short notice.Help families to understand the services they are accessing and sign post families toother services as necessaryMulti – disciplinary liaison;In the first instance the Diana nurse will speak to other professionals, there after it will beup to the parents to contact professionals as necessary. This will be different during Endof Life!Discuss psychology involvement – if appropriate Amanda could act as the second personComplete nursing assessment and care plans, wishes document if appropriate-Discuss care packages if necessaryEquipment; what have they got, where did it come from, what do they need, assetnumbers, servicingObtain consent – consider age and mental capacityProvide service leafletsRemember some families will be able to absorb more information than others, a secondassessment visit may be necessary.Policy for the discharge and transfer of children and young people from child healthPage 24 of 38

Appendix 7 – Children’s Community Nurses/Diana Nurses referralform. Sample only. Forms available from paediatric HDUCommunity Children’s Nursing Team and Diana Nursing TeamReferral FormPaediatric Community ServicesC/O Children’s Services Care Management CentreTruro Health ParkInfirmary HillTruroTR1 2JAOut of County Patient? Y / N?Tel:Tel: 01872 221400Fax: 01872 246938Financial agreement from referring trust? Y / N?Name of Child:Known as:D.O.B.:NHS No:ICS No:Hosp No:Gender:Parent/Guardian:Address:Address for visit:Telephone numbers - Home:Mobile:Directions to visit address:Policy for the discharge and transfer of children and young people from child healthPage 25 of 38

G.P. name / address / telephone number:Diagnosis:Reason for visit:Current Medication:Policy for the discharge and transfer of children and young people from child healthPage 26 of 38

Date first visit requested:Date Visiting County (if applicable):Consultant:Other Professionals involved with Family:Additional information:Policy for the discharge and transfer of children and young people from child healthPage 27 of 38

Referrals must be emailed to the Care Management Centre:Childrens.services@cornwall.nhs.ukNormally the team will need forty eight hours for an acute referral and five working days forother referrals. We will always be pleased to discuss the possibility of short notice referrals andwill respond if we can.Supplies to be provided by referrer:Supplies/equipment requested for CCN’s to provide:Name of referrer:Date of Referral:Date referral sent:Contact Details:Policy for the discharge and transfer of children and young people from child healthPage 28 of 38

Appendix 8-TRANSFER DOCUMENTSample only. Forms available from paediatric HDUPLEASE AFFIXPATIENT'S ADDRESSOGRAPHPatient's Weight ………………………………………………Date: …………………………………………Time: …………………………………….1. Discussion with receiving unit / Name of Staff Member…………………………..………2. Handover provided…………………….……..…………………………………………….Mode of Transport: 3. Departure time Ambulance Hospital Transport……………….…….……………………………………………………….Para-Medic AmbulanceOwn TransportOther ……………………………………………………………Destination: ………………………………………………………………………………….…Receiving Doctor: ………………………………… Tel. No: ………………………………...Receiving Nurse: ………………………………….. Tel. No: ………………………………...Accompanying Staff / Family:Dr: ……………………………………………………..Nurse: ……………………………………………….…Parent / Carer / Other: …………………………………Contact Details of Parent / Carer / Other: …………………………………………………….Current Care Issues:1. ………………………………………………………………2. ………………………………………………………………3. ………………………………………………………………Principle reason for transfer:Policy for the discharge and transfer of children and young people from child healthPage 29 of 38

OBSERVATIONSTIMET 39EM 37PC 35333129B 200Pmm 180Hg160140120100R 80ES 60PS 40C 20VP 10mmHg0CRTSp0 2Blood SugarFi0 2/0 2ModeVentilatorRatePressures

PUPILSNEUROOBS:COMASCALEEyesOpenBestMotorResponseBestVerbalResponseRightLeftGlasgow ComaScale (4-15 yrs)Children’s ComaScale (< 4 yrs)Spontaneously 4 Spontaneously 4To Speech 3 To Speech 3To Pain 2 To Pain 2No Response 1 No Response 1Obeys verbal commands 6 Obeys verbal commands 6Localises pain 5 Localises pain 5Flexion to pain 4 Withdraws in response 4Abnormal flexion 3 Abnormal flexion 3Extension to pain 2 Abnormal extension 2No Response 1 No Response 1Orientated & converses 5 Smiles, orientated to sounds,follows objects, interactsDisorientated & converse 4 Crying InteractsConsolable InappropriateInappropriate words 3 Inconsistently Moaning 3ConsolableIncomprehensible sounds 2 Inconsolable Irritable 2No Response 1 No Response No Response 1SizeReactionSizeReactionSizeReactionSizeReaction54TIMEEyes closed byswellingUsually thebest armresponse= CEndotrachealtube ortracheostomy=T+ reacts- no reactionc eyes closedTIMEFLUIDSINTAKEOUTPUTTOTALUrineTOTALBALANCETRANSFER EVALUATION FORMAirway / C-SpineBreathingCirculationFamilyEnvironmentGlucoseDisabilityOther Comments………………………………………………………………………………………………………………………....……………………………………………………………………………………………………………………Policy for the Discharge and Transfer of Children and Young People from Child Health………………………Page 31 of 38Signed: ………………………………………………………………….. Date:……………………………………………….

TRANSFER CHECK LISTSELF-INFLATING AMBU BAG - INF / PAED / ADULTOXYGEN / AIR CYLINDERSX 2 / X 3 E SIZE ( X 1 WITH VENT VALVE )PORTABLE CYLINDER FROM BEDSPACEPORTABLE SUCTIONAPPROPRIATE SUCTION CATHETERSECG MONITORPOWER PACK AND LEADETCO2 MONITOR APPROPRIATE CABLESTHERMOMETERSYRINGES50ML10ML / 5ML LEURLOCKNORMAL SYRINGES10ML / 5ML / 2ML / 1MLINSULIN SYRINGESGLUCOSE MONITORIV EXTENSION LINES3 WAY TAPS / T-PIECEFACE MASKSNEO / INFANT / CHILD / SML & LGE ADULTSPACE BLANKETDRUG LABELSGREEN TUBINGSCISSORS / FORCEPSNEBULISER SET + TUBINGNG TUBE & LITMUS PAPERSTETHOSCOPEGLOVES 6.0 - 8.5YANKERS X 2GAUZE X 2GUEDAL AIRWAYS SIZES (x1 of each):4 / 3 / 2 / 1 / 0 / 00 / 000 SURGISILK 3/0 / SURGICAL BLADES /SUTCHER CUTTERELASTOPLAST / ASSORTED TAPE /PLASTERSGAMGEE / BUBBLE WRAPSYRINGE PUMPSVOLUMETRIC PUMPDRUG BAGINOTROPES / RESUS DRUGSSEDATIONMISCELLANEOUSINTRA-OSSEOUS NEEDLEIV CANNULAS (e.g. Neoflon, Medicut, etc.)ASSORTED IV BUNGS / STERETSBATTERIES (Appropriate for equipment)FAMILY - INFORMED / CONSENT / DIRECTIONSCOPIES OF NOTES / X-RAYS / REF. LETTERRESTRAINT IN TRANSPORTACCEPTING HOSPITAL AWARE OF DEPART.STAFF - FOOD & DRINK / MONEY / PHONEARRANGEMENT FOR RETURNING STAFFFOR INTUBATED CHILDRENVENTILATOR LARYNGOSCOPE HANDLES X 2ETT 2.5 - 8.5 UNCUFFED / CUFFEDFLEXIBLE CATHETER MOUNTSTYLET SIZESANGLE PIECE12 X 22.2 X 1 LARYNGOSCOPE BLADES:1 X SHORT STRAIGHTENDOTRACHEAL TAPE1 X LONG STRAIGHT1 X SHORT CURVEDLARYNGOSCOPE BULBS X 2 SPARE1 X LONG CURVEDAQUAGEL X 2MAGILLS:1 SMALL1 LARGEOTHER: …………………………………………………….OTHER: …………………………………………………….Policy for the Discharge and Transfer of Children and Young People from Child HealthPage 32 of 38

NURSING REFERRAL FORM - TRANSFER OF PATIENTSHomeTo:FromWardWard Tel. No.HospitalHosp. No:Surname:Age:Religion:Forenames:D.O.B.Home Address:Discharge Address:Tel. No:Consultant:Social Worker:General Practitioner:Address:Health Visitor (HV):HV Informed of Transfer: Yes / NoOther:Next of Kin:Address:Relationship:Tel. No:Date of Admission:Relatives notified of Transfer: Yes / NoDate of Transfer:Diagnosis and Brief Summary of Patient's conditionOther Comments (e.g. Allergies, Special Disabilities, Pre-existent Conditions, to include infectious status etc.)Policy for the Discharge and Transfer of Children and Young People from Child HealthPage 33 of 38

Nursing Requirements (Including special diets, feeding and dressings)Drugs and MedicinesFamily InformationFollow-up treatments and appointmentsDate 1. ……………………………………… Time …………………………… Place ………………………………………………Date 2. ……………………………………… Time …………………………… Place ………………………………………………What arrangements have been made for transport? …..………………………………………………………………....Please photocopy and keep1 copy in notesSignature …………………………………………………Designation ……………………………………………….Date ……………………………………………………….Policy for the Discharge and Transfer of Children and Young People from Child HealthPage 34 of 38

Appendix 9 – Paediatric Discharge Liaison Co-Ordinator PathwayCommunity professionals includeHealth Visitors, School Nurses,Community Therapies, Communitynurses and communityPaediatricians… and any othercommunity services involved.PATHWAY FOR CHILDREN’S WARDS (HDU, POLKERRIS, HARLYN, FISTRAL)Attend wards to gather information regarding any new admissions and on-going casesConsider priority/complexity of presenting casesROUTINE PRESENTATIONe.g – non-complex planned admissions,minor infections/injuries, children who will not needadditional support after dischargeRe-assess on regular visits to wardand review in the event of anychangeWhere there is no changeand the presentation remainsroutine, discharge should bestraightforward andcompleted without theadditional need for supportfrom the PaediatricDischarge/Liaison Co-OrdinatorHealth Visitors and School Nursesmay not be informed of routine, noncomplexadmissions unless theyspecifically request to be informedIn the event ofchanges topresentation, followpathway for ComplexPresentationSafeguardingconcerns identifiedshould be shared bythe wards with theNamed Nurse forSafeguarding, andrelevant policies andprocedures followedChildren meeting the Criteriafor Outreach will besupported by OutreachNurses – e.g. Respiratory,Oncology, Diabetes, etc.These discharges are likely toproceed without additionalneed for supportCOMPLEX PRESENTATIONe.g – long term illness, disability, life limiting conditions, or childrenwho will require additional support after dischargeWork with the wards to ensure any relevant community professionalshave been informed and this has been documented in ward notes (andby Discharge/Liaison Co-Ordinator on Electronic Records when availableand where appropriate, * for community notes ensure that any call isfollowed up with email to add to patient community notes.)* Responsibility for contacting relevant professionals remains withthe ward, and community professionals maintain responsibility forcommunication with the ward, unless there are specific, significantcomplications that would benefit from intervention by the PaediatricDischarge/Liaison Co-OrdinatorIt remains the responsibility of community professionals to attend relevantmeetings – in the event of significant difficulties attending meetings thePaediatric Discharge/Liaison Co-Ordinator can attend and provide feedbackto the communityAfter involvement in Discharge Planning Meeting, where appropriate,discharge may be followed with a call to the family to ensure that thedischarge plan is being followed and to ensure that the family have therelevant contact details for the community teams/professionals.A follow up meeting in the community may also take place if appropriate.If a child is identified as a Looked After Child it is the ward/departments responsibility to inform Child in Care Team of admission/discharge. Paediatric Discharge/Liaison Co-Policy for the Discharge and Transfer of Children and Ordinator Young People can from assist Child with Health this and will double check that information has been sharedPage 35 of 38

LIAISON WITH SERVICES OUT OF COUNTY – (in development)Out of county service to be provided with Paediatric Discharge/Liaison Co-Ordinator contact details.Paediatric Discharge/Liaison Co-Ordinator to attend Children’s Community Nurse Team meetings on a regular basisand remain updated from the wards in order to ensure awareness of any children that are receiving treatment out ofcountyIn the first instance, it is the responsibility of the ward transferring/receiving the patient from out-of county to inform therelevant community service, and responsibility for maintaining communication with the ward remains with thecommunity staff involved.Paediatric Discharge/Liaison Co-Ordinator role is to liaise with community services (and RCHT wards wherenecessary) regarding any discharge/transfer plans he/she has been informed of (ensuring community staff have beeninformed of any transfers out of and into Cornwall where appropriate), and to intervene as appropriate where specific,significant complications arise in the discharge process.Document in ward notes and on Electronic Records when available.* For community notes ensure that any call is followed up with email to add to patient community notes whereelectronic recording is not available.If a child is identified as a Looked After Child it isthe ward/departments responsibility to informChild in Care Team ofadmission/discharge/transfer. PaediatricDischarge/Liaison Co-Ordinator can assist withthis and will double check that information hasbeen sharedAny Safeguarding concerns identified should beshared with the Named Nurse for Safeguarding,and relevant policies and procedures followed**Children’s Community Nurses, for the purpose of this pathway, includes the Diana NursesPolicy for the Discharge and Transfer of Children and Young People from Child HealthPage 36 of 38

NEONATALAttend ward regularly to gather information regarding any new and on-going cases.Attend weekly ‘Baby in the Family’ meetingsInfants meeting the Neonatal Outreach Criteriawill have discharges co-ordinated by theNeonatal Unit Team.These discharges are likely to proceed withoutthe additional need for support from thePaediatric Discharge/Liaison Co-Ordinator.Infants who will not require complex support afterdischarge may not meet the criteria for the OutreachNurses – Paediatric Discharge/Liaison Co-Ordinator toprovide any appropriate additional support for theseinfants as required by the ward – i.e. Additional Liaisonwith Health Visitors or any other relevant professionalLiaise with Outreach Nurses, community Nurses and the ward where infants are transferred fromNeonatal to Polkerris. Following transfer, refer to pathway for Children’s WardsIf a child becomes identified as aLooked After Child it is theward/departments responsibility toinform Child in Care Team.Paediatric Discharge/Liaison Co-Ordinator can assist with this and candouble check that information hasbeen sharedSafeguarding concernsidentified should be sharedwith the Named Nurse forSafeguarding, and relevantpolicies and proceduresfollowedPolicy for the Discharge and Transfer of Children and Young People from Child HealthPage 37 of 38

EMERGENCY DEPARTMENT (AND MINOR INJURY)Paediatric Discharge/Liaison Co-Ordinator to attend Emergency Department (ED) on a regular basis toaddress any communication issues they may have. Also maintain a level of communication with theTrust’s Minor Injury Units (MIU)Identify any issues that require follow up in the community - via communication folder in EDIf a child is identified as aLooked After Child it is thedepartments responsibilityto inform Child in CareTeam ofadmission/discharge.PaediatricDischarge/Liaison Co-Ordinator can assist withthis if requiredSafeguardingconcerns will beidentified by ED and areferral made toNamed Nurse forSafeguardingStraightforwardattendances that donot require communityfollow up, should notneed additionalsupport from thePaediatricDischarge/Liaison Co-OrdinatorFacilitate referral to the relevantcommunity service for those childrenwho require follow up treatment in thecommunity but do not fall underSafeguarding – a communication folderis in place in ED for this purpose.This is a Pathway underDevelopment and will be subject toregular review.Explore links with community services, inparticular the Children’s CommunityNurses, and encourage ED and MIU torefer to community services in order toaccurately highlight the level of need forcommunity follow up.Explore links with communitystaff – such as HealthVisitors, School Nurses, andChildren’s Community Nursesto identify communicationconcerns** Children’s Community Nurses, for the purpose of this pathway, includes the Diana NursesPolicy for the Discharge and Transfer of Children and Young People from Child HealthPage 38 of 38