Accountability Handover Policy For Registered Health Care Professionals · Accountability Handover...

Accountability Handover Policy for Registered Health Care Professionals

of 21 Date Issued: 5th October 2018

Review Date: October 2020

Accountability Handover Policy For Registered Health Care

Professionals

(Including Intra-Area Patient Handover / Transfer, and Handover at a Change of Shift)

Issue Date: v2.0, 13

th November 2017

v2.1, 5th

October 2018

Disclaimer

Overarching policy statements must be adhered to in practice.

Clinical guidelines are for guidance only. The interpretation and application of them remains the responsibility of the individual clinician. If in doubt contact a senior colleague or expert.

The Author of this clinical document has ultimate responsibility for the information within it.

This clinical document is not controlled once printed. Please refer to the most up-to-date version on the intranet.

Caution is advised when using clinical documents once the review date has passed. Clinical Document Template v4.0 12-05-2014




CONTENTS

SECTION DESCRIPTION PAGE

1 INTRODUCTION 2

2 SCOPE OF DOCUMENT 4

3 DEFINITIONS AND/ OR ABBREVIATIONS 6

4 ROLES AND RESPONSIBILITIES 7

5 NARRATIVE 8-9

5.1 Assessment of need 8

5.2 Considerations following accountability handover for intra-ward transfer

9

5.3 Accountability Handover Sheets and Stickers 9

6 EVIDENCE BASE / REFERENCES 10

7 EDUCATION AND TRAINING 10

8 MONITORING COMPLIANCE 11

9 CONSULTATION 12

10 EQUALITY IMPACT ASSESSMENT (EIA) 12

11 KEYWORDS 12

12

APPENDICES (list)

Appendix A – Supporting Guidance: ED / UCC Handover and Transfer Pathway Appendix B – Supporting Guidance: Ward Shift to Shift Accountability Handover Pathway Appendix C – Supporting Guidance: Ward Transfer Pathway Appendix D –Yellow Internal Transfer Handover Sticker (Representational copy) (FKIN030343) Appendix E – Accountability Handover Record Sheet (FKIN030344) (Representational copy) Appendix F – ED / UCC Internal Transfer Handover Document (Representational copy) Appendix G – Equality Impact Assessment Form

12

13 14

15 16

17

18

19-20

DOCUMENT CONTROL (Last page) 21

1. INTRODUCTION

1.1 Sherwood Forest Hospitals NHS Foundation Trust (The Trust) is dedicated to outstanding care, its shared values and behaviours, to the delivery of high quality safe care. It recognises that the handover of patients forms a key component of high quality hospital care.

1.2 The accountability handover process has at its core a set of practices fundamental in

helping to achieve the highest standard of patient centred care. 1.3 It is a tangible recognition or acceptance that nurses adhere to the principle of taking

professional ‘responsibility for the care they provide and answer for their own judgments and actions in a way that is agreed with their patients, and the families and carers of their patients, and in a way that meets the requirements of their professional bodies and the law’ (Manley et al 2011).




1.4 The necessity ‘for a formal, structured handover of care between the transferring and receiving teams’ to exist has been part of NICE guidelines since 2007 (guidance.nice.org.uk/cg50).

1.5 The process of nurse to nurse handover will help ensure that all information regarding a

patient’s current and anticipated care needs are communicated seamlessly between staff, maximising patient safety. When the process is followed patient safety is maximised as:

any outstanding items of care are highlighted,

a summary of care is handed over,

and clarification of items of care, including omissions, occurs. 1.6 Accountability handover can be self- sustaining and a gatekeeper of practice only

when:

The process is led within each area,

It is accompanied by visual confirmation of documentation entries

It is followed within every area without exception

The environment exists to accept challenge from colleagues and peers as actions of ‘critical friends’ to improve practice

Consequences exist for not following the process 1.7 When handing over the care of a patient it is essential that the accountability handover

process takes place first time – every time. 1.8 This policy aims to ensure that all information regarding patients current and anticipated

care needs are communicated seamlessly between staff, maximising patient safety. 1.9 The purpose of this policy is to inform staff working at the Trust of the correct

procedures in relation to the handover of patient care from one clinical area to another, and from one nurse to another.

1.10 Guidance has been developed to support and guide clinical staff in ensuring that

practice meets the required standard, see

Appendix A – Supporting Guidance: ED / UCC Handover and Transfer Pathway

Appendix B – Supporting Guidance: Ward Shift to Shift Accountability Handover Pathway

Appendix C – Supporting Guidance: Ward Transfer Pathway 1.11 Within The Trust on any given day of the week and at any hour, patient handovers are

being conducted between departments and ward areas and within ward areas at designated times, primarily shift change. There are recognised risks associated with a failure to handover effectively; primarily, an increase in the incidence of patient harm, in addition to an increase in patient morbidity and mortality (World Health Organisation 2007 & Intensive Care Society 2009, the National Patient Safety Agency (NPSA).

1.12 Inadequate handover of care can have a negative effect on the quality of care a patient receives. This is evident in DATIX patient related incidences: medications errors resulting from poor communication leading to missed and omitted medication, and inconsistent communication of a patient’s condition or management plan which has resulted in harm.

1.13 Such instances of patients being transferred to areas without adequate handover of

care have the potential to affect patient’s emotional well-being, the quality of care they




receive, and increased and unnecessary duplication of questions and therefore negatively affecting their perception of care the Trust provides.

1.14 This policy will also provide guidance to monitor and evaluate if a safe, consistent and

appropriate practice standard for handover is being achieved. 1.15 Patient information relating to the care received in clinical areas and if specific key items

of care are handed over will be observed. 1.16 Accountability both legally and professionally is required of all registered professionals

who are responsible and answerable for their actions and may be asked to justify them.

2. SCOPE OF DOCUMENT This clinical document applies to: Staff group(s)

Registered Nurses and Midwives (NMC) including bank and agency staff.

HCA’s – health care assistants.

Operating Department Practitioners (HCPC registered)

AHP’s who are involved in the prescription of treatment and interventions for patients that is required to be handed over.

Clinical area(s) All in-patient areas at all hospital sites are required to use the accountability handover process when handing over patient care.

In-patient areas: (adult and paediatrics, Operating theatres and recovery rooms, Day Surgery Unit, Endoscopy, Cardiac Catheterisation Lab, ICCU, Assessment areas - adults and paediatrics including ED (Emergency Department, Kings Mill), UCC (Urgent Care Centre, Newark) and wards.

(Kings Mill Hospital, Mansfield Community Hospital and Newark Hospital). Documentation Use of the yellow Internal Transfer handover Sticker (Appendix D) is required for all patients who require transfer of care from one clinical area to another ensuring there is a standardised approach to handing over the fundamental components of information required to enable a safe and succinct handover.

With respect to ED, the yellow internal transfer document will be incorporated into the ED specific documentation.

Shift to Shift Handover Accountability Record Sheet (appendix E) must be completed following a decision to admit. It must be completed in entirety prior to a patient transferred to a ward, or within 6 hours of the decision to admit being made. This document must also be completed at bedside shift to shift handover of care. The completed documents will form part of the patient’s integrated record of care and should remain insitu as part of this record.

As this document / sheet follows the patient during their in-patient stay it provides a template for ensuring there is a standardised approach to handing over the fundamental components of information required to enable a safe handover.




ED / UCC Shift handover and transfer process is detailed in appendix A

Ward shift to shift Accountability Handover process is detailed in appendix B

Ward to ward internal transfer process is detailed in appendix C

Patient group(s)

Patients who are being transferred:

from ED to assessment areas; EAU, TAU, SAU, AECU, from ED to ward areas, and between ward areas (including to the Discharge Lounge, MCH and Newark) are required to be transferred with an internal accountability handover record and yellow internal transfer handover sticker.

to and from theatre, ICCU, Endoscopy, Cath. Lab. occurs using the local accountability handover document incorporated in the specific pathway for each area.

from KMH, other NHS organisations and community settings to MCH and Newark a verbal handover is given and recorded on their SBAR profoma.

Exclusions:

The following patient groups are all exempt: o those attending the Trust’s out-patient’s departments for consultations, o and those who are due to be discharged home.

In addition Maternity Unit patients are exempt as this aspect of their care is covered in the following procedural document: o Maternity Unit Guideline for Handover of Care on Site.

It is required that medical staff adhere their specific processes and policy regarding patients that require review or assessment by another speciality or when the care of patients are handed over from shift to shift.

Related Trust policies and guidelines and/ or other Trust documents:

Clinical Record Keeping Standards Policy

Medicines Policy

Nutrition and Hydration Policy

Medical Equipment User Training Policy

Medical Device Management Policy

Observations and Escalation Policy for Adult Inpatients

Escort and Transfer Policy for Adult Patients

Handover of maternity Care on Site Guideline




3. DEFINITIONS AND/OR ABBREVIATIONS

Acco

un

tab

ilit

y

Han

do

ver

A process that facilitates the continuity of information provision for the purposes of planning patient care between staff who are changing shifts, or when a patient is being transferred from one area to another for continued assessment, treatment or care handover. The practice of handing over a patient’s care can be:

Verbal – by phone and in conjunction with a completed accountability handover sticker or

Face to face - the nurse handing over a patient’s care directly to the receiving nurse.

Verb

al

Han

do

ver

The provision of telephone handover using the SBAR tool.

From RN to an RN in another area to ensure optimisation of safe and effective care provision for a patient

Where face to face handover is not required.

Following confirmation by a RN assessment that the patient’s condition does not warrant an RN transfer based on the guidance contained within the Escort and Transfer Policy for Adult Patients.

This occurs between: o ED and receiving areas o EAU to Ward areas, and, o between ward areas (including the Discharge Lounge, MCH and Newark) on internal transfer where patients care is transferred from one area to another where a face to face, 1:1 handover, RN:RN is not required.

Fa

ce t

o f

ace

or

1:1

ha

nd

ov

er

The process of handing over the care of a patent face to face from one registered staff member to another using an SBAR process to ensure optimisation of safe and effective care provision for a patient. This type of handover takes place where the patient’s condition is such that it requires the accompaniment of a registered staff member – theatre recovery to the Ward area, transfer from ED, from an assessment area to a ward area where their condition dictates the presence if a Registered Nurse as per the Escort and Transfer Policy for Adult Patients, and on ward areas in relation to shift to shift handover.

Reg

iste

red

Sta

ff

A registered member of the staff either directly employed by the Trust or individuals employed by a third party to work within SFH e.g. agency staff. This relates primarily to Nursing staff but can relate to other professional groups e.g. Doctors, Midwives and Acute Care Practitioners (ACP) or Operating Department Practitioners (ODP).

Healt

hc

are

Su

pp

ort

Wo

rkers

Non-registered staff employed as band 2 or 3 either directly employed by the Trust or individuals employed by a third party person to work within SFH.




SBAR Situation; Background; Assessment; Recommendation

ED Emergency Department

EAU Emergency Assessment Unit

TAU Trauma Assessment Unit

SAU Surgical Assessment Unit

AECU Ambulatory Emergency Care Unit

ICCU Intensive Critical Care Unit

UCC Urgent Care Centre – Newark

4. ROLES AND RESPONSIBILITIES

4.1 The Chief Nurse is responsible for the content and implementation of this policy. 4.2 Divisional Heads of Nursing are responsible for ensuring that necessary measures

are in place to support the safe implementation and monitoring of the use of the policy in practice. They will need to take measures where practice has been deemed potentially unsafe.

4.3 Matrons are responsible for ensuring that all staff accountable to them are aware of this

policy and adhere to its standards. It is the manager’s responsibility to investigate and rectify any discrepancies identified.

4.4 Ward Sister/ Charge Nurses/Departmental Leader will act as role models and are

responsible and accountable for the policy implementation among staff in practice, and the monitoring of standards and best practice associated with it. They will ensure that all staff in the sphere of their responsibility have access to training to develop the skills and competence, this includes the completion of the associated work books and study sessions in a timely manner. The ward leaders will be expected to complete the monthly nursing metrics without exception to provide assurance of compliance in relation to Accountability Handover. For areas that generate non-compliance ward leaders with the assistance from matrons will be required to formulate an action plan, implement learning and provide feedback where necessary.

4.5 All Registered Healthcare Professionals have, as part of their professional standards

both a duty of care to their patients and accountability for their practice standards. This is a requirement of their Regulatory Body in order to practice (in the case of Nursing, the NMC, AHP’s, the HCPC, or medical colleagues the GMC). In addition all registered healthcare professionals are personally responsible and professionally accountable in ensuring that they receive and handover all aspects of patient information that is relevant for the continued optimisation of patient care. It is the responsibility of the registered healthcare professional to ensure the safe transfer of patients from clinical areas to the receiving area either ward area or assessment area. It is also the responsibility of the registered health care professional to ensure that an appropriate handover of a patient’s care to the receiving clinical area occurs prior to the patient leaving the area. It is therefore required of the Registered Member accountable for that patient care’s to delegate and instruct the transfer of patients taking into account the clinical needs of the patient and the competency of those undertaking this activity. Responsibility and accountability for delegation of actions to healthcare support workers remains at all times with the Registered Nurse undertaking the delegation

It is the responsibility of the ward based registered healthcare professional to ensure all relevant transfer documentation is fully completed prior to leaving the clinical area. It is




the responsibility of the receiving nurse to ensure they have signed the yellow internal transfer accountability handover sticker on receipt of handover. It is the responsibility of the registered nurse to ensure they have fully completed and signed the Accountability Handover Record Sheet at the point of bedside handover. The receiving nurse will ensure they have assessed agreed and highlighted actions from the given handover and sign in receipt of shift handover of care.

4.6 All Healthcare Support Workers in common with their registered nursing colleagues

have a duty of care to their patients and are therefore required to undertake all activities as per the relevant policy. They must ensure that they undertake any activities / actions in accordance with the relevant Trust policy. Those who are directly involved in the transfer of patients under direction of a Registered Nurse must sign the appropriate section of the accountability handover document relevant to that area.

5. NARRATIVE 5.1 Assessment of need 5.1.1 The ‘minimum safe standard’ (Intra-ward Transfer SOP, Accountability SOP) regarding

the transfer of patient care and accountability handover between areas / individual practitioners is that a verbal handover of patient information occurs remotely from one registered practitioner to another. For additional guidance see:

Appendix A – Supporting Guidance: ED / UCC Handover and Transfer

Appendix B – Supporting Guidance: Ward shift to shift Accountability Handover Pathway

Appendix C – Supporting Guidance: Ward Transfer Pathway

5.1.2 It is acknowledged that in certain circumstances and clinical areas this is the only feasible method of handover of patient care (eg ED to EAU). This however must occur prior to a patient leaving an area.

5.1.3 This verbal handover will enable staff in the assessment area or receiving ward to forward plan for receipt of the patient and ensure equipment, the environment and appropriate staff are optimised to maximise care standards.

5.1.4 It is the responsibility of the receiving nurse on receipt of the patient and following verbal handover to check and confirm that all of the items that have been handed over are factually accurate ensuring that the verbal account of the patients care is accurate.

5.1.5 In all other instances the transfer of patient accountability between staff, and at handover time, must take place face to face with the nurse handing over care using SBAR principles. The nurse receiving care accepts responsibility and accountability for that patients care at that time.

5.1.6 All staff involved in patient handover are required to ensure that the appropriate handover process is followed and where a patient is transferred to another clinical area / department the appropriate mode of transport, escorting personnel and equipment required for that patient’s needs are utilised and adheres to the processes and guidance described in the Trust’s Escort and Transfer Policy for Adult Patients

5.1.7 In instances where a non-registered staff member undertakes handover face to face in the absence of a registered colleague, a verbal handover between registered staff in the




transferring area and the receiving area must occur prior to transfer. It is the responsibility of the RN allocated to that patient’s care to ensure that this occurs.

5.1.8 Staff will make every effort where possible to ensure that the patient is transferred at an appropriate time of the day and that this does not occur prior to protected mealtimes, or in the case of transfers from EAU to ward areas it does not take place after 11 pm / 23:00 hours.

5.2 Considerations for accountability handover for intra-ward transfer The following must be considered when undertaking a transfer of a patient following accountability handover: 5.2.1 Is the most appropriate method of handover being used – verbal, or face to face?

5.2.2 Following assessment of a patient’s condition is the staff member being used to conduct

this escort appropriately – do they have the necessary skills / knowledge / ability?

5.2.3 Do the staff involved know the required infection control and safety issues associated with this patient?

5.2.4 Has a verbal handover been provided to the receiving ward area using SBAR?

5.2.5 Does the patient’s condition, indicated by their NEWS score, necessitate a registered staff member to accompany the patient?

5.2.6 If intra-venous fluids are in progress does it necessitate a registered staff member to accompany the patient?

5.2.7 Does the patient have an intravenous drug infusion in progress, which precludes a HCA / Porter from transporting the patient to the clinical area unaccompanied?

5.3 Accountability Handover Sheets & Stickers A yellow Internal Transfer Handover Sticker has been developed to record the necessary information required for a safe and effective handover from one practitioner to another. This relates to when a patient is transferred from one clinical area to another. (See Appendix D). The Accountability Handover Record Sheet has been developed for when care is transferred from one practitioner to another at a change of shift within the same clinical area. (See Appendix E). The transferring nurse and the accepting / receiving nurses are both required to sign the sheet to confirm their responsibility and accountability for the patient’s care.




6. EVIDENCE BASE / REFERENCES

NMC (2015) The Code: professional standards of practice and behaviour for nurses and midwives

NMC (2013) Accountability and delegation: What you need to know.

NMC (2015) Accountability and Delegation A Guide for the Nursing Team.

NMC (2010) Standards for Competence for Registered Nurses.

Intensive Care Society (2009) Levels of Critical Care for Adult Patients

Manley (et al 2011) Principles of Nursing Practice: Development & Implementation Nursing Standard 25 (27).

http://www.npsa/nhs.uk/ - National Patient Safety Agency

7. EDUCATION, MANDATORY TRAINING AND REGULATION Accountability handover as a Trust priority is a process that is discussed with new employees during nurse / HCA on induction sessions. In addition it is embedded through other training that is attended by nursing staff: nurse focus days. It is an area where audit is conducted monthly, results are fed back to ward leaders and Matrons with support and educational input provided where necessary.

Trust Registered Nursing Staff All registered nursing staff are required to familiarise themselves with this policy, the process involved in accountability handovers and must read and sign the induction pack that is available on every clinical area. If there are any items of that require clarification / explanation it is the responsibility the registered nursing staff member to discuss it with the Ward Sister / Charge Nurse or his or her deputy. Non-compliance with the process will result possible disciplinary action by means of the Trust disciplinary process. All registered staff hold the responsibility for assessing patients for transfer and identifying the appropriate escort and method of transport which should be recorded on the yellow internal Accountability Handover sticker. Agency Nursing Staff All registered nurses are accountable for their practice and should adhere to the Code of Professional Conduct governing fitness to practice. They are required to adhere to the practices involved in handing over of patients to registered colleagues and ensuring that the information, actions and omissions are correct and does not compromise patient care or confidentiality. “Lack of knowledge, skill or judgement which means a nurse or midwife is unfit to practise” and “Lack of competence is a lack of knowledge, skill or judgement of such a nature that the nurse or midwife is unfit to practise safely.”

http://www.npsa/nhs.uk/




Nurses or midwives who are competent and fit to practise should: have the skills, experience and qualifications relevant to the part of the register they have joined. Demonstrate a commitment to keeping those skills up to date, and deliver a service that is capable, safe, knowledgeable, understanding and completely focused on the needs of the people in their care” (NMC 2010) Student Nurses A student nurse is as part of his/her training programme / progression towards registration required to achieve set objectives as laid down by their academic institution / university. It is encouraged that as part of this process, student nurses actively involve themselves in the process of undertaking accountability handover for patients. Accountability for the process even though it is undertaken by the student nurse remains with the responsible Registered Nurse.

8. MONITORING COMPLIANCE

Minimum Requirement

to be Monitored

(WHAT – element of compliance or effectiveness within the

document will be monitored)

Responsible Individual

(WHO – is going to monitor this element)

Process for Monitoring

e.g. Audit

(HOW – will this element be

monitored (method used))

Frequency of

Monitoring

(WHEN – will this element be monitored

(frequency/ how often))

Responsible Individual or Committee/

Group for Review of Results

(WHERE – Which individual/

committee or group will this be reported to, in what format (eg

verbal, formal report etc) and by who)

Incident themes and trends involving accountability handover/ handover reported will be categorized according to level of risk.

Divisional Governance Teams

Incident reporting: Datix

As required

Divisional Governance Forums

Compliance with handover documentation standards

Ward leaders/ Matron

Nursing Metrics

Monthly

Ward assurance Forum




9. CONSULTATION The following individuals, groups of staff and Trust group(s)/ committee(s) have been consulted in the development/ update of this document:

Contributors:

Communication Channel: e.g. Email

1:1 meeting/ phone

Group/ committee meeting

Date:

Victoria Bagshaw: Deputy Chief Nurse Email – Policy 1:1 Meeting

03/04/17

Claire Madon: Lead Nurse For Professional Practice

Email- Policy 1:1 Meeting

31/03/17

Nursing, Midwifery and Allied Health Professional Business Meeting

Meeting 30/10/17

10. EQUALITY IMPACT ASSESSMENT (EIA) The Trust is committed to ensuring that none of its policies, procedures and guidelines discriminates against individuals directly or indirectly on the basis of gender, colour, race, nationality, ethnic or national origins, age, sexual orientation, marital status, disability, religion, beliefs, political affiliation, trade union membership, and social and employment status. An EIA of this policy/guideline has been conducted by the author using the EIA tool developed by the Diversity and Inclusivity Committee. See Appendix G for completed EIA Form.

11. KEYWORDS Nursing Handover Sheet, Accountability Handover

12. APPENDICES Appendix A – Supporting Guidance: ED / UCC Handover and Transfer Pathway Appendix B – Supporting Guidance: Ward Shift to Shift Accountability Handover Pathway Appendix C – Supporting Guidance: Ward Transfer Pathway Appendix D –Yellow Internal Transfer Handover Sticker (Representational copy) (FKIN030343) Appendix E – Accountability Handover Record Sheet (FKIN030344) (Representational copy) Appendix F – ED / UCC Internal Transfer Handover Document (Representational copy) Appendix G – Equality Impact Assessment Form




Supporting Guidance: ED/UCC Handover and Transfer Pathway

Appendix A

All patients who present to ED:

Accountability for patient care rests with the nurse allocated to care for that patient whilst they are

in ED or UCC. Completion of the accountability handover section incorporated onto the front sheet

of the ED paperwork must be completed.

Shift to shift Handover:

When patient care is handed from one nurse to another nurse (minors to majors, majors to the

resuscitation area or shift to shift) the accountability handover section incorporated on the front

sheet of the ED paper work must be completed.

For all ED patients that are discharged :

The discharge section found in the back page of the ED paperwork must be completed.

For all patients admitted:

Transferring and receiving areas will liaise with each other to confirm ability to accept patient.

The nurse in charge of the patients care is responsible for ensuring the yellow accountability transfer section (found on the back page of the ED documentation) is fully completed in preparation for the transfer (appendix F).

The RN in charge of the patients care will undertake an assessment of the patient to determine which type of escort is required for transfer in line with the Escort and Transfer Policy for Adult Patients. This will then be documented upon the yellow accountability transfer document found on the back page of the ED paperwork.

Telephone Handover from RN to RN if Patient Does not Require Nurse Escort:

It is the responsibility of the RN in charge of the patients care to provide a verbal handover using the SBAR format.

Handover to Receiving Ward:

Handover will be given by the transferring escort using the yellow accountability transfer document.

The receiving area MUST sign the yellow transfer document following handover of care (appendix F).




Following the verbal handover the RN handing over the patients care and the RN accepting the patients care must sign the Accountability Handover Record Sheet (Appendix E) in order to complete the handover process.

Supporting Guidance: Ward Shift to Shift Accountability Handover Pathway:

Appendix B

All patients that are admitted on to a ward area:

As part of the admission process the Accountability Handover Record Sheet (appendix E) must be completed. It must be completed in its entirety prior to a patient being transferred to a ward area or within 6 hours of the decision to admit being made.

The bedside Handover must occur immediately after the ward safety briefing

Shift to shift handover.

Verbal:

Introduce on-coming RN to patient at the bedside, informing them you are handing over care.

Liaise with patient and reassess pain score and analgesia control.

Handover any key events from previous shift using SBAR.

Agree clinical condition of patient by performing visual assessment and NEWS check.

Handover if any amendments are required to plan of care or frequency of care.

Handover any risk assessments that will require implementing/ammending. For example: falls, bedrails, Enhanced Observations, VIP score etc

Agree foreseeable key actions for receiving RN.

Documentation Check:

Electronic observations and escalation (agree escalation status).

Medication Chart (checking infusions, rate, prescription. Check for any omissions taking particular note of critical medications)

Ward Safety Briefing: Handover of all patients to all staff who are due to commence the next shift. Critical information

should be discussed – any key events from previous shifts, NEWS, Falls, Pressure Damage, deterioration or AND.




Supporting Guidance: Ward Transfer Pathway:

Appendix C

All Patients requiring transfer to another ward environment:

Positively identify the patient and inform them of the proposed transfer. Using the Escort and Transfer Policy for Adult Patients, the RN in charge of the patients care will

undertake an assessment to determine which escort is suitable to perform the transfer.

The receiving ward will be contacted to confirm the ability to accept patient from transferring area.

The nurse in charge or the nurse in charge of patients care will ensure all the relevant documentation is completed including the yellow Internal Transfer Handover Sticker (Appendix D) and the Accountability Handover Record Sheet (Appendix E)

Accountability Handover Process RN to RN:

A verbal handover from the transferring RN to receiving RN is conducted using the SBAR format along with the content of the Yellow Internal Transfer Handover Sticker (Appendix D).

The yellow Internal Transfer Handover Sticker (Appendix D) is required to be completed in full and stuck into the Accountability Handover Record Sheet (Appendix E)

It is the responsibility of the receiving nurse to ensure that all the items handed over are checked against the Accountability Handover Record Sheet (Appendix E) and that any discrepancies are identified, documented and addressed during the handover process.

The receiving nurse will be required to sign the yellow internal transfer sticker on receipt of handover.

Accountability Handover process from escort to RN:

A telephone handover will be given by the RN from the receiving ward to the transferring ward RN using the SBAR format. Details will be given regarding essential information regarding the patient’s delivery of care.

The escort will verbally handover the information contained upon the yellow Internal Transfer Handover Sticker (Appendix D).

The receiving ward will accept handover for the patient and sign the yellow Internal Transfer Handover Sticker (Appendix D)




Internal Transfer Handover Sticker (Ward) (Representational copy)

INTERNAL TRANSFER ACCOUNTABILITY HANDOVER STICKER

S Presenting Complaint / Diagnosis:

Relevant History / Treatment Plan:

B Allergies: Red allergy wrist band in situ? Y / N White wrist band : Y / N

Is the patient at risk of falls? Y / N Has the patient fallen within the last 72 hrs? Y / N

A Has an Enhanced Patient Observation Risk Assessment been performed? Y / N Level: Normal Close Constant

Has an Enhanced Patient Support Risk Assessment performed? Y / N / NA Level: Is the Patient fit to ‘OUT-LIE’ as Patient Outlier Policy & Decision Tool? Y / N

Pressure area Assessment:

Safeguarding Concerns and actions:

Sepsis Screening Tool Completed? Y / N

Mobility Status:

Does this patient have capacity? Y / N Infusion details :

Is this patient confused? Y / N Blood Glucose Level:

Catheter in s i t u Y / N Transfer NEWS score:

Isolation Required Y / N Resuscitation Status FULL / A.N.D.

Ward Specific Information:

R Recommendations, Omissions & Outstanding:

I have assessed this patient & confirm they may be transferred without the accompaniment of an RN.

Date: Time: Signed: (RN) Print: (RN)

Patient must be electronically transferred to the receiving area ’s holding bay on Medway PAS prior to leaving the ward:

Y / N

I have provided a verbal handover for this patient’s care to the receiving ward and transfer responsibility & accountability for their care to the receiving RN.

Transferring Nurse Signature _____________RN initials____________Date___________Time__________Ward_____

Receiving Nurse Signature ______________RN initials___________ Date____________Time___________Ward______

Version 4, March 17. FKIN030343

Appendix D




Accountability Handover Record Sheet (Representational copy)

Appendix E




ED / UCC Internal Transfer Handover Document (Representational copy)

Presenting complaint

Diagnosis

Treatment Plan.

Drug chart commenced Y / N Allergies: ID band in situ Y/N

Capacity Status: Transfer NEWS Score: Blood glucose recorded: Resuscitation status: AMT Score: Has the patient been identified at harm of:- Pressure damage Y / N Action: Falls. Y / N Action: Vulnerable adult Y / N Action: Domestic violence. Y / N Action: Self Harm Y / N Action: Any safeguarding concerns? Action taken:

Recommendations/Omissions/ outstanding treatments:- I have assessed this patient and have deemed them suitable for transfer without the accompaniment of an RN: RN signature :_____________ Date:_________ Time:_______

I have provided a verbal handover providing a summary of care given to the patient. I have highlighted any outstanding items or omissions. I have provided a handover regarding any areas of risk noted within the assessment phase. Transferring RN or carer name:____________ Signature:________________ Band:_________________ Date:____________ Time:________ Destination:________________

I accept responsibility for this patient and agree to review all accompanying notes to complete a full and safe accountability handover. Accepting RN name:___________ RN signature:________________

Date:____________ Time:______________

Appendix F




Appendix G – Equality Impact Assessment (EqIA) Form (please complete all sections)

Name of service/policy/procedure being reviewed: Accountability Handover Policy for Registered Healthcare Professionals

New or existing service/policy/procedure: Existing

Date of Assessment: 21/11/2017

For the service/policy/procedure and its implementation answer the questions a – c below against each characteristic (if relevant consider breaking the policy or implementation down into areas)

Protected

Characteristic

a) Using data and supporting information, what issues, needs or barriers could the protected characteristic groups’ experience? For example, are there any known health inequality or access issues to consider?

b) What is already in place in the policy or its implementation to address any inequalities or barriers to access including under representation at clinics, screening?

c) Please state any barriers that still need to be addressed and any proposed actions to eliminate inequality

The area of policy or its implementation being assessed: Whole policy

Race and Ethnicity: Nil Not applicable None

Gender:

Nil

Not applicable None

Age:

Nil Not applicable None

Religion: Nil Not applicable None

Disability:


Sexuality:


Pregnancy and Maternity:


Gender Reassignment:

Nil

Not applicable None

Marriage and Civil Partnership:


Socio-Economic Factors (i.e. living

in a poorer neighbourhood /

social deprivation):


What consultation with protected characteristic groups including patient groups have you carried out?

None required

What data or information did you use in support of this EqIA?

Job descriptions for registered professionals who will be using the policy – focusing on communication




NMC requirement for language skills

As far as you are aware are there any Human Rights issues be taken into account such as arising from surveys, questionnaires, comments, concerns, complaints or compliments?

No

Level of impact From the information provided above and following EqIA guidance document (insert link), please indicate the perceived level of impact: Low Level of Impact For high or medium levels of impact, please forward a copy of this form to the HR Secretaries for inclusion at the next Diversity and Inclusivity meeting.

Name of Responsible Person undertaking this assessment: Alison Davidson

Signature: Alison Davidson

Date: 21/11/2017




Document control/ supporting information for this clinical document

Title:

Accountability Handover Policy For Registered Health Care Professionals

(Including Intra-Area Patient Handover / Transfer and Handover at a Change of Shift)

Document category: Clinical Policies and Guidelines

Reference:

CPG-TW-AHP

Version number:

2.1

Approval: v. Approved by:

Approval Date:

2.0 Nursing & Midwifery Business Meeting

30-10-2017

2.1 Virtual approval via Nursing, Midwifery and AHP Board

05-10-2018

Issue date:

5TH October 2018

Review date: October 2020

Job title of author responsible for the document/ author name:

Minor amendment made – Meg Haselden, Corporate Matron

Division & Specialty/ Department/ Service responsible for reporting the status of the document

Corporate/ Nursing – Practice Development Team

Document Sponsor:

Medical Director; and

Chief Nurse

Superseded document(s): (Ref No., Version number, previous title if changed, date issued – review date)

CPG-TW-AHP, v1.0 ISS 12 Nov 2015 – RV Oct 2018.V2.0 13th November 2017.

Version History and Practice Changes/ Amendments

Issue Date Version Comments

05-10-2018 2.1 Minor amendment made to Appendix B

13-11-2017 2.0 Flow charts included to aide visual assistance for staff whilst out in clinical practice.

Amended ED/ MIU-UCC Accountability Transfer Handover document included into the appendices.

10-11-2015 1.0 NEW – Not Applicable

Distribution (Circulation):

This document will be accessible via the Trust’s intranet.

Communication:

Information regarding the initiation and subsequent updates of this document will be communicated via the earliest weekly Trust staff bulletin/ nursing bulletin and/ or other agreed communication method.

Accountability Handover Policy For Registered Health Care Professionals · Accountability Handover...

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