Internal Patient Transfer Escort Policy - · PDF filePatient Transfer and Escort Policy v2...
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Patient Transfer and Escort Policy v2
Policy No: OP84
Version: 2.0
Name of Policy: Internal Patient Transfer and Escort Policy
Effective From: 07/09/2015
Date Ratified 12/08/2015
Ratified SafeCare Council
Review Date 01/08/2017
Sponsor Director of Nursing, Midwifery and Quality
Expiry Date 11/08/2018
Withdrawn Date
Unless this copy has been taken directly from the Trust intranet site (Pandora) there is no assurance that
this is the most up to date version
This policy supersedes all previous issues
Patient Transfer and Escort Policy v2 2
Version Control
Version Release Author/Reviewer Ratified
by/Authorised
by
Date Changes
(Please identify page no.)
1.0
19/09/2014 Faye Butler SafeCare
Council
10/09/2014
2.0 07/09/2015 Julie Jones /
Caroline Lane
SafeCare
Council
12/08/2015 Adding in reference to
SBAR transfer form
Patient Transfer and Escort Policy v2 3
Contents
Section Page
1 Introduction .................................................................................................................................. 4
2. Policy scope .................................................................................................................................. 4
3. Aim of policy ................................................................................................................................. 4
4 Duties (roles and responsibilities) ................................................................................................ 4
5 Definitions of terms ...................................................................................................................... 5
6 Process for transfer ...................................................................................................................... 6
7 Providing an escort for transfer ................................................................................................... 7
8. Training ......................................................................................................................................... 8
9. Equality and diversity ................................................................................................................... 8
10. Monitoring compliance with the policy ....................................................................................... 8
11. Consultation and review .............................................................................................................. 9
12 Implementation of policy ............................................................................................................. 9
13 References .................................................................................................................................... 9
Appendices
Appendix 1 (In-patient SBAR Transfer form) ............................................................................................ 10
Appendis 2 (Critical Care transfer form) ................................................................................................... 11-12
Appendix 3 (Antenatal & Postnatal Handover of Care) ............................................................................. 13-15
Appendix 4 (Patient Escort QE Site Quick Reference Guide) .................................................................... 16
Patient Transfer and Escort Policy v2 4
Patient Escort Policy
1 Introduction
Gateshead Health NHS Foundation Trust is committed to the provision of high quality health care in
all aspects of its services to patients and staff. There are many occasions when a patient needs to
be transferred in the hospital to other wards or departments and which may require escort. This
policy is therefore intended to offer safeguards and guidance to ensure staff and patient safety
throughout the transfer process.
2 Policy scope
This Policy applies to all “health care professionals” working within Gateshead Health NHS
Foundation Trust involved in the assessment of patients to determine the need for escort during
transfer within the hospital. It provides clear guidance and instruction to all staff with regard to the
transfer and escort of adult and paediatric patients within and across the Queen Elizabeth Hospital
site.
All staff using this policy should ensure that the basic principles of respect, explanation, privacy and
dignity apply to all patients in the transfer setting. They must use this policy in conjunction with a
range of existing good practice guidance from professional bodies and existing Trust policy with
particular reference to:
• Bed management, patient transfer and escalation plan (OP33)
• Safeguarding patient privacy and dignity (OP29)
• Manual handling policy (RM06)
• Control of infection policy (IC01)
• Personal protective equipment (IC02)
• Hand hygiene policy (IC04)
• Safeguarding adults policy (OP75d)
• Safeguarding children policy (OP75a)
• Resuscitation policy (RM27a)
Outside of this policy is the transfer of children as there is a Regional Policy for this. When
transferring paediatric patients to longer term care, usually at either Newcastle Upon Tyne
Hospitals or City Hospitals Sunderland, this policy should be followed.
The escort section of the policy should be followed for all patients within QE Gateshead, including
paediatric, maternity services and mental health.
3 Aim of policy
The key aims of this policy are to ensure the safe transfer of patients between wards and
departments. In addition it will support the safety of those patients who will be spending time in
other departments away from their ward base with or without an escorting healthcare professional
or assistant. It will also provide clear guidance for staff that will ensure staff and patient safety. It
applies to all transfers, both in and out of normal working hours.
4 Duties - roles and responsibilities
The Trust Board:
The Trust has ultimate responsibility for providing effective healthcare services to patients. They
are responsible for ensuring there is support available to ensure the safety and wellbeing of
patients in our care.
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The Chief Executive:
The Chief Executive is ultimately responsible for ensuring effective corporate governance within the
organisation and therefore supports the Trust-wide implementation of this policy.
Trust Managers:
Managers are responsible for ensuring all members of staff understand how the In-patient Transfer
Policy applies to them and their patients. Managers are also responsible for ensuring that where
necessary, local procedures are developed, to support the implementation of this policy. Managers
should review the effectiveness of the implementation of this policy, and take appropriate remedial
action when they become aware of any acts or omissions that contravene it.
Healthcare professionals:
Once the decision to transfer a patient is agreed, it is the responsibility of the clinician in charge of
the patient to assess the needs of the patient and make an informed decision regarding their escort
needs during transfer prior to authorising their departure from the clinical area.
The healthcare professional is responsible for undertaking a pre transfer assessment before a
patient leaves a clinical area, this is to determine if a nurse escort is required, and to take
appropriate steps to obtain one, All healthcare professionals must therefore demonstrate an
appropriate understanding of the escort requirements and the procedure for reporting concerns.
All Nursing /Medical staff transferring /escorting patients:
• Familiarise themselves with this policy, its contents and appendices
• Ensure that prior to transferring or escorting a patient transfer they have been given
adequate information regarding the patient to be able to care sufficiently for them during
the process.
• Provide effective care for the patient during transfer by being aware of the patients’
condition and current needs.
• Maintain the patient’s dignity and respect throughout.
• Registered Nurses/Midwives are personally accountable for their own safe practice, actions
and omissions as outlined in the NMC Code.
• Medical staff are personally responsible for their own safe practice, actions and omissions
as outlined in GMC duties of a Doctor/ good medical practice.
• Nursing Assistants and Pre-registered nurses should only undertake patient transfer if basic
life support training is complete and up to date and when it has been deemed appropriate
to their duties by their Ward/unit manager. This can be delegated to the nurse in charge on
a day to day basis.
All non–clinical staff (e.g. porters) escorting patients:
• Familiarise themselves with this policy, its contents and appendices
• Ensure that prior to escorting a patient transfer they have been given any necessary
information regarding the patient to be able to safely transfer.(e.g. any infection control
risks, mode of transfer, escort requirements)
• Maintain the patient’s dignity and respect throughout.
• Familiarise themselves with emergency telephone numbers and location of receiving area.
5 Definitions of Terms
Clinician – any qualified member of staff with the knowledge, skill and competency to assess the
patients’ requirement for escort. Within this policy, clinician refers to all clinical staff including
doctors, nurses and midwives. Where it is stated the “clinician in charge” or the “clinician
Patient Transfer and Escort Policy v2 6
coordinating” this refers to the person who is caring for the patient and responsible for making the
arrangements for transfer, in most cases this will be the registered nurse or midwife.
Transfer of care – when it is deemed appropriate to move the care of a patient from one area to
another based upon the needs of the patient receiving the right care in the right place.
Escort – defined as “to accompany a person for protection with regards to safety and psychological
wellbeing during transfer from one area to another.” (Oxford Illustrated Dictionary.)
The escorting member of staff has a responsibility to ensure that the patient is safe throughout the
transfer and that their immediate physical and psychological needs are met. Any person involved in
the transfer of a patient should have the necessary knowledge, skills and experience to be able to
achieve a safe transfer.
Health care professionals – any staff group responsible in the assessment process regarding the
decision to escort.
Levels of Care for Adult and Paediatric patients – this refers to the intensity of nursing care required
by the patient.
The following levels of care have been taken from the Intensive Care Society Standards (ICS)
published in 2002 and Paediatric Intensive Care Standards (2001):
• Level 0 Patients whose needs can be met through normal ward care in an acute hospital.
• Level 1 Patients at risk of their condition deteriorating, or those recently relocated from
higher levels of care whose needs can be met on an acute ward with additional advice and
support from the critical care team.
• Level 2 Patients who require more detailed observation or intervention. This may include
support for a single failing organ system or postoperative care, and those stepping down
from higher levels of care.
• Level 3 Patients who require advanced respiratory support alone, or basic respiratory
support together with support of at least two organ systems. This level includes all complex
patients requiring support for multi – organ failure.
6 Process for transfer
6.1 Patients’ should only be transferred between 09.00 hrs. – 22.00 hrs. with the exception of
those patients being transferred based on clinical need or from assessment units such as
Coronary Care, Critical Care or Accident and Emergency to a base ward. It is only in
exceptional circumstances that the transfer of patients will occur outside of these times
including protected meal times.
6.2 When a patient is being transferred from one clinical area to another within the
organisation, it is vital that the patient is placed according to clinical need, paying particular
attention to the issues related to infection control and privacy and dignity.
Prior to a patient being transferred the transfer must be discussed and explained to the
patient, relatives and carers as appropriate.
When a patient is transferred from one ward to another a short verbal handover,
conducted by a registered nurse, from the sending ward using the SBAR format, will be
completed. The handover will be received by a registered nurse completing In Patients
Transfer Form based upon a SBAR handover (Appendix 1). This must take place prior to
transfer and include a recent NEWS Score / observations taken.
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When a patient is being transferred from the Critical Care Department to a base ward then
a Critical Care Transfer sheet must be completed by Critical Care staff (Appendix 2)
It is the responsibility of the nurse in charge / deputy to establish if an escort is required
based on the patients clinical and nursing needs.
For maternity services the transfer of patients should be documented on their own
documentation (Appendix 3a, 3b & 3c).
The boarding or outlying of patients should be avoided as far as possible; however there
are times when such activity becomes a necessary part of managing emergency admissions
and maintaining patient flow. The decision to board will be coordinated by the Duty
Matron and the Bed Management Team following discussion at the Bed Meetings held
daily. For further information refer to policy OP 33. Patients should only be subjected to
one additional move as a boarder or outlier during their hospital episode when this is not
directly related to their clinical management plan.
7 Providing an escort for transfer
7.1 Prior to the transfer of patients within the QE site, an assessment of potential risk, using
clinical judgement and policy guide must be undertaken to ensure the patient is escorted
and transferred safely without harm. This policy and its supportive appendices aim to
ensure safe and appropriate transfer and escort of a patient and reduce risks by:
• Providing guidance on patient assessment prior to transfer
• Provide guidance for making the correct decisions regarding appropriate escort and
mode of transfer
• Allocation of appropriate escort to maintain patient safety during transfer
7.2 The registered nurse must use their clinical judgement to make an appropriate assessment
of the patients’ clinical condition to determine if an escort is required and to ensure the
escort is able to care for the patient during transfer.
7.3 Nurses should use the quick reference guide (Appendix 4) to assist with making this
decision if required.
7.4 A registered Nurse Escort however MUST be provided if any of the following apply:
• The Patient is causing clinical concern
• The patient has had a recent NEWS/PEWS trigger
• The patient has a potential risk to airway
• E.g. post op / post procedure / post sedation / recent seizures or vomiting)
• The Patient has acute respiratory problems
• The Patient is dependent on continuous oxygen greater then 4L/min
• The Patient is receiving continuous high risk medication Infusions or treatments
• E.g. Blood / Opiates/ PCA / Epidural / Antibiotics / Insulin /Heparin / Potassium
based infusions
• The patient requires continuous cardiac monitoring
7.5 Appropriate monitoring must be able to continue during patient transfer in accordance
with the patient’s condition and plan of care.
7.6 Health care assistants are responsible for patients during transfer if they have accepted the
delegated task from a registered nurse.
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7.7 A registered nurse should provide health care assistants undertaking transfer with a full
handover of any relevant patient needs/ issues prior to the transfer
7.8 Following the assessment of the patient the patient movement should be booked onto
portertrak for transfer. If the patient requires escort, ‘escort’ should be entered on the
system. ‘No escort’ should be entered if the patient has been assessed as not requiring an
escort. There is no need to stipulate qualified or unqualified on the system.
8 Training
Members of staff who make the decision to escort should have undergone appropriate support in
order to ensure that they develop the competencies required.
The policy will be promoted at ward and department local induction, to ensure that all members of
staff have an understanding of the role of the escort and how to access the policy.
9 Equality and diversity
The Trust is committed to ensuring that, as far as is reasonably practicable, the way we treat
members of staff and patients reflects their individual needs and does not discriminate against
individuals or groups on the grounds of any protected characteristic. . This policy is therefore
intended to offer safeguards to both patients and members of staff prior to transfer to another
ward or department.
In this way, the policy promotes equality of opportunity and values diversity. The policy adopts a
human rights approach by considering a wide variety of situations, and encourages supportive,
reasonable arrangements to promote fairness, respect, equality, dignity and autonomy.
10 Monitoring compliance with the policy
Standard/process/issue Monitoring and audit
Method By Committee Frequency
Policy complies with OP27 –
Policy for the development,
management and
authorisation of policies and
procedures
OP27 Checklist Upon Review
Staff are aware of the policy
and able to implement it
effectively
Refer to Training
and Local
Induction.
Annual
review
Informal feedback from
patients and carers about
patient escort issues
Discussed in the
PALS / Complaints
quarterly analysis
reports
PALS &
Complaints
Manager
Quarterly
Compliance into the
completion of SBAR In
Patient Transfer Forms
Audit Matrons SafeCare Annual
review
Review of incidents
occurring regarding the
transfer of patients
Trend monitoring Matrons SafeCare Quarterly
Patient Transfer and Escort Policy v2 9
11 Consultation and review
The policy was developed using best practice guidelines, in consultation with key staff groups and
following a pilot of the Quick Reference Guide (Appendix 1).
12 Implementation of policy
This policy will be circulated by the Trust Secretary as detailed in OP27 Policy for the development,
management and authorisation of policies. Individual healthcare professionals have a responsibility
to ensure they understand the role of the nurse escort and take appropriate steps to implement
this policy effectively, including reporting any concerns as appropriate.
Managers are responsible for ensuring all members of staff understand how the Patient Escort
Policy applies to them and their patients. Managers are also responsible for ensuring that where
necessary, local procedures are developed, to support the implementation of this policy. Managers
should review the effectiveness of the implementation of this policy, and take appropriate remedial
action when they become aware of any acts or omissions that contravene it.
13 References
• Internal Patient Transfer and Escort Policy (March 2009) The Royal Free Hampstead NHS Trust
• Patient Escort Policy (January 2011) County Durham and Darlington NHS Foundation Trust
• Clinical Policy for the Safe Transfer and Escort of Patients Heart of England NHS Foundation
Trust (April 2012)
14 Appendices
Appendix 1: SBAR Inpatient Transfer Form
Appendix 2: Critical Care transfer tool
Appendix 3: Maternity Handover Forms (a – Antenatal handover, b – Delivery suite to SCBU, c –
Delivery suite to Postnatal)
Appendix 4: Patient Escort (QE Site) – Quick reference guide
Patient Transfer and Escort Policy v2 10
Appendix 1
Patient Transfer and Escort Policy v2 11
Appendix 2
Patient Transfer and Escort Policy v2 12
Patient Transfer and Escort Policy v2 13
Antenatal Handover of Patient Care (SBAR) To be completed for all transfers between AN and LW
(Except planned low risk IOL & early labour admissi ons)
Please tick appropriate boxes (√) or circle correct answer
SBAR report Antenatal Handover Situation Reason for transfer:
Current antenatal issues (summary):
Background Gravida: Para: Gestation : weeks Midwifery led Consultant led Significant medical history: Yes No please state: Significant Obstetric history: Yes No please state: Obstetric Risk Assessment: High Low Thromboembolism: High Low
Assessment BP: Pulse: bpm Temp: °C Resps: rpm Previous MEOWS trigger: Yes No Abdomen: Foetal heart: bpm CTG interpretation: Urinalysis : Uterine Activity: Vaginal Loss: discharge / amniotic fluid Colour: Bloods: taken and / or results:
Recommendations Antenatal care plan: including observations and foetal monitoring Further tests / treatments required: Identified indications for medical review:
Signature of person transferring patient: Signature of person receiving patient: Date and time of transfer:
Appendix 3a
Patient Transfer and Escort Policy v2 14
Delivery Suite to Postnatal Handover of Baby’s Care (SBAR) - Only to be completed if baby is transferred immed iately to SCBU
Please tick appropriate boxes (√) or circle correct answer
SBAR Report Postnatal Handover Situation Date of Delivery: Time of delivery:
Delivery: Normal � Ventouse � Forceps � Elective LSCS � Emergency LSCS � Reason: Reason: Baby: Postnatal � SCBU � Paediatric Alert? Yes � No � details:
Background Gestation: weeks Mother’s blood group: Antibodies: Baby’s blood group: Antibodies: Family issues identified: Yes � No � AN2: Yes � No �
Assessment Bloods taken / results: Swabs taken / results: Initial Assessment: Colour: Skin: Eyes: Mouth: Cord: Passed meconium? Yes � No � Passed urine? Yes � No � Skin to skin � Breast fed � Length of feed: mins Artificially fed � mls ID bracelet x 2 present and correct? Yes � No � Temperature on transfer: ˚C Birth weight: _______kg
Recommendations Routine postnatal care? Yes � No � Further tests / treatments required: Identified indications for medical review: Is there an Individual Management Plan in place? Pl ease document plan on page 4. If baby requires regular observations (Meconium, GBS) ensure that observation chart is up to date PRIOR to transfer to PN ward.
Signature of person transferring baby: Signature of person receiving baby: Date and time of transfer:
Appendix 3b
Patient Transfer and Escort Policy v2 15
Delivery Suite to Postnatal Handover of Mother’s Ca re (SBAR) To be signed by both the transferring midwife and t he receiving midwife
Please tick appropriate boxes (√) or circle correct answer SBAR report Postnatal Handover Situation Date of delivery: Time of d elivery :
Delivery: Normal Ventouse Forceps Elective CS reason: Emergency CS reason: Spontaneous Induced Analgesia if appropriate: Perineum: intact 1st 2nd 3rd 4th Episiotomy Sutured Yes No Drains: Yes No IVT type and rate: Estimated blood loss: mls
Background Gravida: Para: Gestation : weeks Risk assessment prior to labour: High Low If high, please state reason: Blood group: Antibodies: Rubella Immune Yes No Personal Issues identified: Yes No AN2 Yes No
Assessment BP / Pulse bpm Temp °C Resps bpm Previous MEOWS trigger Abdomen: Passed Urine: Yes No If no please record time of last void: (SRC insitu) (document time and volume of 1 st void in “P/N care” section on p.8) Lochia: Heavy / normal / light Bloods: taken and / or results:
Recommendations Risk assessment following delivery: High Low If high, please state reason: If high risk postnatally please document individual ised management plan on page 6-7 Further tests / treatments required: Identified indications for medical review:
Signature of person transferring patient: Signature of person receiving patient: Date & Time of transfer :
Appendix 3c
Patient Transfer and Escort Policy v2 16
Appendix 4: Patient Escort (QE Site) - Quick Reference guide
This aims to guide staff with appropriate escort requirements and does not replace the clinical judgement and ultimate decision of the Registered Nurse
Assessment of Patient
Risk Minimum
Escort requirement Mode of transfer
Minimum
Skills required
• Maintaining own airway
• No Oxygen support required during transit
• Stable observations no NEWS triggers in last 4 hours
• No medical devices in progress during transfer
• Alert and orientated
Low
• Adults - Porter
• Children - HCA or Pre-
registered student Nurse
• Walk
• Wheelchair
• Bed/Cot
• Trolley
• Familiar with trust transfer policy
• Understands Transfer process.
• Clinical staff BLS/PLS
• Maintaining own airway
• Stable on Continuous Oxygen less than 4L/Min
• Stable observations no NEWS triggers in last 4 hours
• No medical devices that may require intervention during
transfer.
• Confused /disorientated
• High risk of falls / likely to wander
Med
• Adults - HCA, Pre-registered
student Nurse or Therapist &
Porter
• Children - Registered Paediatric
Nurse
• Wheelchair
• Bed/Cot
• Trolley
• Awareness of patient’s current clinical
condition and needs.
• Familiar with trust transfer policy
• Understands Transfer process.
• BLS / PLS
• Requires continuous cardiac monitoring
• Risk to airway (e.g. post op / post procedure / post sedation /
recent seizures or vomiting)
• Acute respiratory problems
• Requires continuous oxygen greater then 4L/min
• Recent NEWS trigger within the last 4 hours
• Continuous Infusions or treatments in situ
E.g. Blood /PCA/Epidural/Antibiotics/Insulin
• Patient causing clinical concern / increasing NEWS score
• Clinical challenging behaviour
High
• Adults - Registered Nurse/ and
Porter
• Children- Registered Paediatric
Nurse and HCA / Pre-registered
student +/- Medic if indicated
• For manifestations of aggression
consider security escort
• Bed/Cot
• Trolley
• Aware of patient’s current clinical
condition and needs.
• Familiar with trust transfer policy
• Understands Transfer process
• BLS / PLS
• Requires Invasive / Non Invasive Ventilatary Support
� Acute respiratory problems
• Unstable Circulatory System
• Complex Patients requiring support for multi organ failure
Critical
• Adults- Critical Care Clinician /
Practitioner and Critical Care
Nurse/ART Nurse +/- porter
• Children – PICU Retrieval Team
or Critical Care
Clinician/Paediatric Clinician &
Consultant/Middle Grade &
Registered Nurse
• Bed/Cot
• Trolley
• Aware of patients current clinical
condition and needs
• Appropriate Critical care skills
• Familiar with trust transfer policy
• Understands Transfer process
• ALS / PLS