ADULT TRANSFER POLICY
Version / 3Name of responsible (ratifying) committee / Professional Nursing and Midwifery Forum
Date ratified / 17 August 2017
Document Manager (job title) / Head of Nursing Medicine for Older People, Rehabilitation and Stroke Services
Date issued / 01 October 2017
Review date / 31 August 2019
Electronic location / Clinical Policies
Related Procedural Documents / Discharge Policy, Patient Identification Policy
Key Words (to aid with searching) / Transfer; safe; timely comfortable transfer of patients;
Version Tracking
Version / Date Ratified / Brief Summary of Changes / Author3 / 17.08.2017 / Policy rewritten / L Field
2 / 16.02.2012 / Update / Ops Centre Manager
CONTENTS
QUICK REFERENCE GUIDE 3
1. INTRODUCTION 4
2. PURPOSE 4
3. SCOPE 4
4. DEFINITIONS 4
5. DUTIES AND RESPONSIBILITIES 5
6. PROCESS 7
7. TRAINING REQUIREMENTS 10
8. REFERENCES AND ASSOCIATED DOCUMENTATION 11
9. EQUALITY IMPACT STATEMENT 11
10. MONITORING COMPLIANCE WITH PROCEDURAL DOCUMENTS 12
EQUALITY IMPACT SCREENING TOOL 13
APPENDIX1: PATIENT TRANSFER RISK ASSESSMENT 15
APPENDIX 2: TRANSFER AND DISCHARGE CHECKLIST 16
QUICK REFERENCE GUIDE
For quick reference the guide below is a summary of actions required. This does not negate the need for the document author and others involved in the process to be aware of and follow the detail of this policy.
1. Patients should expect to be transferred between the hours of 08:00 and 21:00 except where there is a clinical need.
2. Out of hours transfers (21:00 – 08:00) must be avoided unless the patient’s condition or operational demands of the organisation dictate. All out of hours moves are logged by the Operations Centre- except patients moved from the Emergency Department, Surgical and Medical Assessment Units except moves that are clinically justified.
3. The need for an escort must be assessed using the Patient Transfer Risk Assessment documentation (Appendix 1), which risk assesses which member of staff must escort the patient.
a. Patients who score 0 are suitable for Porter/ EMA only transfer
b. Patients who score 1 are suitable for Care Support Worker transfer.
c. Patients who score 2 must have a Registered Nurse on transfer.
4. There must be adequate, appropriate and timely communication between transferring and receiving staff and with the patient, relative or carer. This must include any infection control risks. For ward to ward transfers, the transferring ward should inform the patient’s next of kin of the move.
5. A transfer checklist must be completed by the transferring and receiving nurse (Appendix 2)
6. All other relevant documentation must accompany the patient
7. The need for any equipment to accompany the patient must be assessed e.g. oxygen, intravenous infusions, pressure relieving aids
8. All medicines and personal property must accompany the patient, using the correct policy for any Controlled Medication.
9. Patients must be handed over to, and welcomed onto, the receiving ward in a polite and courteous manner.
1. INTRODUCTION
Portsmouth Hospitals NHS Trust (the Trust) recognises that there is frequently a requirement to transfer patients internally and externally to other healthcare providers: for the purposes of the provision of clinical care, undertaking investigations and to facilitate patient flow. This policy aims to facilitate the safe, timely and comfortable transfer of patients, by stipulating the types of transfers and the escort required.
An internal transfer takes place when a patient remains under the care of Trust Health Professionals and who is not removed from the Patient Administration System (PAS).
Patients who may require transfer within the Trust include:
· Transfers to and from Departments for investigations.
· Transfers from the Emergency Department
· Transfers between wards
The principal responsibility of all staff is to maintain patient wellbeing and safety, provide optimal care during the period away from the principal care area/ward, report and document outcomes and action taken.
2. PURPOSE
The purpose of this policy is to provide direction, guidance and the underlying principles for staff to support safe and appropriate transfer of patients.
The key to safety is through risk assessment and communication. All patients undergoing transfer must be risk assessed for clinical need during transfer by a registered nurse/midwife who must take responsibility for providing the verbal handover of the patient to the receiving area.
3. SCOPE
This policy applies to all groups of patients requiring transfer and to all staff who are involved in those transfers.
‘In the event of an infection outbreak, flu pandemic or major incident, the Trust recognises that it may not be possible to adhere to all aspects of this document. In such circumstances, staff should take advice from their manager and all possible action must be taken to maintain ongoing patient and staff safety’
4. DEFINITIONS
Diagnostic/Treatment Transfer: the movement of a patient from one service to another within the Trust for an assessment/diagnostic procedure or treatment
Escort: any member of staff who is involved with escorting patients and who has the relevant knowledge and skills to provide a high standard of care during the transfer; to ensure patient safety is not compromised. An escort can be:
· Registered professionals, doctors, registered nurses and midwives, operating department practitioners
· Non-registered professional, healthcare assistants and other clinical support workers
· Non-clinical members such as Porters, Emergency Department Medical Assistants (E.M.A) supporting the Emergency Department, the Acute Medical Unit and the Diagnostic areas ( they are not in Radiology or Cardiology).
External transfer: the temporary movement of a patient to an acute care environment service external to the Trust, e.g. for investigations or interventions that, for whatever reason, cannot be provided by Portsmouth Hospitals NHS Trust. This should not be confused with a discharge, as the intention is that, once the investigation or intervention has been completed, the patient will return to our care.
Internal transfer: the movement of a patient from one clinical area to another within the Trust. For example:
· For investigations
· From the Emergency Department
· Between wards
Patient groups:
Adults- using the Transfer Risk Assessment
Patients who score 0 are appropriate for Porter/ EMA only transfer- this includes patients who do not have any oxygen requirements, have maintenance intravenous fluids only , not a falls risk or confused, Early warning score of ≤ 3, and who does not have owned controlled medications.
Patients who score 1 are appropriate for Care Support Worker transfer- this includes patients on oxygen ≤ 28%, and who may be confused, lack capacity (including those under Deprivation of Liberty orders).
Patients who score 2 must have a Registered Nurse to transfer them- this includes patients being transferred to a High Care area or Intensive care and those who have a Early warning score of ≥ 3.
Out of Hours: a transfer that occurs between 2100 and 0800
5. DUTIES AND RESPONSIBILITIES
The Head of Nursing for Medicine for Older People, Rehabilitation and Stroke Services in association with the relevant CSC teams and the Duty Hospital Manager is responsible for undertaking an annual review of this policy, to ensure it continues to meet the operational needs of the Trust and its patients, including making any appropriate changes as a result of the outcomes of safety learning events investigations.
The Duty Hospital Manager is responsible
· The day to day operational management of the Transfer Team and the development of transfer processes to ensure they remain responsive to the changing needs of the Trust, including booking the team via NHS Professionals and monitoring fill rate and escalating any unfilled shifts to the Duty Matron.
· Escalating any unresolvable matters associated with patient transfer to the Clinical Services Centre Silver bleep holder (during working hours), Out of Hours to the Duty Matron or Hospital @Night team, specifically those matters relating to patient care, patient safety and other quality issues
· Escalating any operational issues related to transfer to the General Manager-Operations.
· Receiving information on all adverse incidents and near misses relating to patient transfer and supporting the CSC teams with any associated investigations.
Registered Nurse with responsibility for the patient who is to be transferred will complete the risk assessment (Appendix 1) to identify which staff member is required to support the patient transfer, from non-clinical member, health care assistant and registered nurse. The risk assessment will be included in the patients’ medical records.
As part of the transfer process between wards or the Emergency Department they will be responsible for;
· Ensuring that the patient is aware of the transfer and include the patient’s next of kin with the consent of the patient (where applicable).
· Ensuring that relevant patient details are handed over to the receiving ward prior to or as part of the transfer process.
· Ensuring that patients’ property is transferred with them and documented.
· Completing the transfer checklist.
Transfer Team, who are usually temporary staff report directly to the Duty Hospital Manager and are:
· Employed to undertake the majority of internal transfers, with the support of clinical teams and the EMA team/Portering Services. The exceptions to these transfers are those required by child health, obstetric and critical care service patients
Registered Nurse Escort regardless of status is responsible for:
· Ensuring all relevant documentation is completed and transferred with the patient
· Confirming the correct destination for the transfer
· Monitoring the status of the patient during the transfer, using the appropriate monitoring devices
· Taking all appropriate action, should the patient’s condition change
Ward Managers are responsible for:
· Ensuring their teams are aware of the requirements of this policy
· Ensuring there are operational systems in place within their teams to fulfill the requirements of this policy at local level
· Reporting any transfer issues to the relevant Matron, for support to ensure the ongoing safety of their patients
Ward Clerks are responsible for:
· copying the patient’s health record, the booking of transport and any other required administrative duties to support safe patient transfer.
6. PROCESS
Internal Transfers
Internal transfers normally take place between 08:00 and 21:00
6.1 Staffing
6.1.1 The Transfer Team will carry out the majority of transfers, within hours
6.1.2 Porters (outside of ED and AMU) will support the transfer process with requests submitted via the Helpdesk (ext 6321). Urgent transfers must be requested as such, as a response time of 5 minutes from Portering services is required
6.1.3 All staff involved in the transfer process are required to follow infection control practice guidance related to protective equipment and hand hygiene and that patients dignity and comfort is maintained during the transfer process.
6.1.4 The receiving ward/department must ensure that the patient is welcomed on to the ward and that a member of staff is able to take handover from escort if necessary.
6.2 Escorts
6.2.1 The nurse/clinician in charge of the patient’s care will assess (Appendix A) if an escort is required and record any such requirement in the patient’s health record. The nurse/ clinician in charge will remain accountable for the patient’s care at all times
6.2.2 The staff member acting as an escort must be competent to use any equipment that is being transferred with the patient and ensure it has sufficient battery life for the period of the transfer
6.2.3 All patients who score ≥ 2 require a registered nurse escort
6.2.4 Escorts are required to ensure that the patient’s wellbeing is considered at all times and must actively engage with the patient during the whole transfer process.
6.3 Communication
6.3.1 There must be adequate and effective communication between the transferring and receiving ward/department
6.3.2 Ward to ward transfers between specialties will be facilitated by the nurse/ clinician in charge of the ward/department, the Duty Hospital Manager and Transfer Team
6.3.3 The nurse-in-charge of the patient’s care on the transferring ward must provide a verbal telephone handover to the receiving nurse if not accompanying the patient. Alternatively the nurse-in-charge of the transferring ward will hand over to the Transfer Team who will then hand over to the nurse on the receiving ward
6.3.4 The Patient Transfer Risk Assessment form must be completed for all ward to ward transfers to identify appropriate escort.
6.3.5 The escort and the ward/department where the patient is being transferred to, whether permanently or temporarily for investigations/intervention, must be aware of any current infection risk prior to transfer.
6.3.6 Patients will be informed at the earliest opportunity of the need for a transfer and provided with an explanation of why the transfer is necessary.
6.3.7 With the consent of the patient, relatives, carers or others will be advised of transfers to another ward. Note: it is not necessary to notify relatives, carers or others when a patient is temporarily absent from the ward e.g. for diagnostic investigations or interventions.
6.3.8 The nurse in charge of the clinical area is responsible for the safe transfer of their patients. If any other staff members make decisions about patients transfers without the agreement or knowledge of the nurse in charge a Safety Learning Event should be raised.
6.4 Documentation
6.4.1 The nurse/ clinician in charge is responsible for ensuring that all appropriate health records accompany the patient
6.4.2 The transfer checklist, which forms part of the nursing documentation, must be completed by the nurse responsible for the patient’s care at the time of the transfer
6.4.3 Patients must have an accurate patient identification band and on arrival in the receiving ward the band must be removed and replaced with amended details: in accordance with the Patient Identification Policy
6.5 Other
In general, when transferred, other than internally for investigations or interventions
6.5.1 All dispensed medications must accompany the patient.
6.5.2 All property must accompany the patient together with a completed property form.
6.5.3 The registered nurse is responsible for deciding if existing pressure relieving equipment should move with the patient
Note: it may be that even for temporary internal transfers for investigations or interventions that the nurse on the transferring ward may consider it necessary for some medications and/or pressure relieving aids to accompany the patient.