ADULT OUTLIERS POLICY

Version / 5
Name of responsible (ratifying) committee / SMT
Date ratified / 11April 2018
Executive Owner / Chief Operating Officer
Document Manager (job title) / Associate Medical Director
Date issued / 23 April 2018
Review date / 22 April 2019
Electronic location / Clinical Policies
Related Procedural Documents / TrustCapacity Management Policy, Trust Transfer Policy, Trust Risk Assessment Policy and Protocol, Trust Mixed Sex Accommodation Policy, Full Capacity Policy
Key Words (to aid with searching) / Adult, Outliers, Policy

Version Tracking

Version / Date Ratified / Brief Summary of Changes / Author
5 / 11.04.2108 / Algorithm and risk assessment tools updated in line with Capacity Management Policy / Mark Roland
4 / 21.12.2016 / Policy reviewed for ratification at operation board
21/12/16
Additional information at SMT note reference to Recovery Outlier Risk assessment in related procedural documents / Nichola martin
Mark Roland
Zoe Hemsley
3 / 21.10.2015 / Policy Rewritten / Nichola Martin
2 / 03.09.2009 / Removal of Mary Sherry name’s as co-author
Changes to location of added capacity
Changes to reflect the fact that Mary Sherry is no longer with PHT
Changes made to times of Operations Meetings / Maria Purse

CONTENTS

1.INTRODUCTION

2.PURPOSE

3.SCOPE

4.DEFINITIONS

5.DUTIES AND RESPONSIBILITIES

6.PROCESS

7.TRAINING REQUIREMENTS

8.REFERENCES AND ASSOCIATED DOCUMENTATION

9.EQUALITY IMPACT STATEMENT

10MONITORING COMPLIANCE WITH PROCEDURAL DOCUMENTS

Appendix A: RAG Rating for Individual Patient Outlier Decisions

Appendix B: Individual Patient move risk assessment document

Appendix C: Patient Information Leaflet

EQUALITY IMPACT SCREENING TOOL

1.INTRODUCTION

Portsmouth Hospitals NHS Trust (PHT) is committed to providing a high quality care environment where patients and staff can be confident that best practice is being followed at all times and that the safety of everyone is of paramount importance. The Trust strives to provide care and treatment, which promotes high standards of privacy and dignity as well as clinical care, throughout each patient’s individualised care pathway.

It is the clear intention of the Trust to remove the need for outlying patients wherever possibleover time. At the present time process changes are focused on patients having minimal moves and only those clinically indicated (eg from an Assessment Area to an Inpatient Ward). On a daily basis Clinical teams are expected to pursue actions to increase discharges rather than using outlying to create capacity.

A correlation between increased mortality rates and the practice of outlying is emerging. In addition, the risks of healthcare associated infection (HCAI) are greatly increased by extensive movement of patients within the hospital, by very high occupancy rates and by an absence of suitable isolation facilities (DoH 2003, Winning Ways; DoH 2005 Saving Lives). It is also a risk that outlying increases length of stay which in its turn then blocks capacity. It is therefore imperative that all actions are focused on reducing the need for outlying.

Therefore Portsmouth Hospitals NHS Trust seeks to make every effort to minimise the numbers of patients who are outlied, but recognises that at times, when emergency admissions are high, decisions to outlie may be necessary. This policy seeks to provide clear protocols and procedures in order to minimise the known risks to the practice of outlying.

This policy should be read in conjunction with the policies and guidelines listed in section 8 of this document.

2.PURPOSE

This policy is intended to ensure the safety, dignity and duty of care for both patients and staff who are involved in the process of caring for adult patients in clinical environments outside their own speciality and/or in additional or emergency capacity.

3.SCOPE

This policy applies to all staff who have contact with adult patients working within PHT, including medical staff, nursing and midwifery staff, allied health professionals, medical students, nursing and midwifery students, and other members of the multidisciplinary team working with individual patients in wards, and departments. It also applies to any staff (clinical and non clinical) who are either making decisions about the most suitable clinical areas for patients to receive care and treatment or who are caring for patients outside of the expected clinical speciality. This is a generic policy designed to assist those responsible for the delivery of care to all adult patients. Individual speciality guidelines may also be required and should also be followed, but are not included in this policy.

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 infection control or EPR leads who will inform such plans to the DHM who will also be able to guide/advise. All possible action will be taken to maintain ongoing patient and staff safety’

4.DEFINITIONS

EDD / Expected Discharge Date / EWS / Early Warning Score
OOH’s / Out of hours is identified as the time between 19:00 – 08:00 weekdays and from 1900 Friday – 0800 on Monday / RAG / Red, Amber, Green risk rating
CSC / Clinical Service Centre / Single Sex Accommodation/
Facilities / Men and womenhave separate sleeping areas (eg single-sex bays) and haveseparate toilets and bathrooms
Additional Capacity / Use of beds which are either designated for flexible use or are normally closed or used for another purpose / Internal transfer / The movement of a patient from one ward or department to another within Trust clinical areas and/or across PHT sites.
Risk / Possibility of exposure to a hazard & therefore the chance of injury, ill health, harm, damage or loss / Ops Centre / Operations Centre
Clinician / Healthcare Professional responsible for the patients care and treatment / Outlying / Transferring a patient to a clinical area outside of their speciality

5.DUTIES AND RESPONSIBILITIES

Clinical teams, ward staff and CSC Boards are all responsible for ensuring that patient focussed and safe decisions are made prior to the Site Team moving patients to wards/departments outside of their expected speciality area. Wherever possible, additional actions should be pursued as a priority to avoid the need to outlie patients by increasing discharges to increase capacity.

Director of Operations

  • Day to day operational management of patient flow and utilisation of bed capacity
  • Leadership of Operations Centre Team
  • Overall leadership and management of Trust bed stock, as delegated by Chief Operating Officer
  • Develop with CSC Management Teams plans and processes for the management of bed capacity that will reduce over time the need for outlying.
  • Hold delegated executive authority to place patients in the most appropriate beds and to access beds at times of increased demand

Duty Hospital Manager and Site Team:

  • Keep continually appraised of the whole hospital position in relation to capacity and demand and on any internal/external issues which might affect patient flow
  • Receive reports verbally or written from speciality and duty matrons in relation to current staffing issues
  • Keep the Deputy COOfully briefed of the hospital position and request authorisation to open additional capacity and outlie when required
  • Ensure that patient movement to outlying or unfunded capacity adheres to published SOPs
  • Ensure that any patient outlied has an individual risk assessment completed (Appendix B).

Out of hours on call team: On call Manager and On call Director

  • Promote the use ofall policies and procedures and seek assurance from Site Team.

CSC & Operational Management Teams

  • Ensure robust systems and processes are in place for capacity management within the CSC
  • Monitor and ensure action is taken on areas of identified risk
  • Provide timely and accurate information to appraise Duty Hospital Manager of current demand and capacity issues and work to prevent the need to move patients outside their speciality by maintaining effective flow
  • Maintain SOPs related to unfunded capacity provided by their services with regular safety and quality checks for those areas
  • Ensure that any patient outlied has an individual risk assessment completed (Appendix B).

CSC Chiefs of Service, Clinical Directors & Consultants:

  • Ensure capacity management is effective within own CSC’s / services
  • Ensure patients under their care have agreed written treatment plans and PDDs are in place
  • Adjust discharge thresholds where possible and appropriate in order to ensure that maximum bed capacity is created and to avoid the need to outlie
  • Ensure patients who have been outlied get prompt and appropriate medical assessment and interventions, and receive a medical review at least once in every 24 hour period over Monday to Friday period and as needed at weekends
  • As part of the patient medical review, ensure that patients are RAG rated for their appropriateness to outlie, using the set of criteria in Appendix A.
  • Ensure specialties have identified appropriate criteria for assisting with outlying decisions and that this is widely understood/communicated to all members of the healthcare team
  • Ensure that junior medical staff respond appropriately to calls concerning an outlier patient’s condition and that appropriate cover arrangements are in place in the case of a patient’s condition deteriorating or in a medical emergency
  • Allow for juniors to complete discharge letters/summary and TTO requests if asked to do so in the case of potential outlying.

Junior Doctors

  • Ensure daily medical review of patients who are being cared for in outlying areas
  • Respond promptly to ward requests to review outlying patients e.g. if EWS scores deteriorating.
  • Ensure patients who are outlied have appropriate treatment and medication regimes prescribed
  • Confirm and communicate PDD’s and whether patients remain medically fit for discharge or transfer in patient’s record.
  • Ensure discharge summary complete and TTO’s requested

Matron for CSC/Speciality:

  • Understand the daily position with regard to capacity, patient moves and outliers either at the morning CSC capacity meeting or by contacting clinical areas
  • Ensure that all wards/department shift leaders have complied with requirements to identify outliers
  • Ensure all patients are RAG rated using criteria in Appendix 1
  • Ensure that a review of all speciality outliers takes place at least every 24 hours Monday to Friday and at weekends if possible and definitely if clinically required
  • Identify staffing situation and requirements for any added capacity within the CSC
  • Support regular safety and quality checks for any unfunded areas in use
  • Ensure that any patient outlied has an individual risk assessment completed (Appendix B).

Duty Matron

  • Review nurse staffing situation for the evening, night and if possible early shift of the next day
  • Make decisions to move nursing staff to cover gaps which have arisen from the opening of additional capacity

Ward Sister/Charge Nurse/Senior/Staff Nurse in charge of clinical area with Senior Medical staff

  • Identify suitable outliers (normally 1 per ward/department at morning handover and a further 1 by 15.00) Confirm outliers list with medical teams during ward rounds
  • Ensure that any patient outlied has an individual risk assessment completed (Appendix B).
  • Ensure patients and their families/carers are kept fully informed of potential/actual decisions to outlie
  • Ensure the patient is giventhe leaflet entitled, ‘Why am I moving wards?’ at the time of known move
  • Ensure nurse in charge of receiving ward is given comprehensive handover of patients condition, care and treatment plans
  • The list of Suitable outliers to be sign off by Hon or Matron and list provided to the operation centre.

Specialist Nurses

  • Provide advice and guidance about speciality aspects of patient’s conditions to ward teams caring for the patient.

Infection Prevention and Control Team member (Daily Duty Rota)

  • Contribute to decisions about outliers and ensure any proposed outlier moves are appropriate, particularly for patients who are identified as having a high risk of infection
  • Make every effort to avoid transferring patients who are more likely to carry HCAI organisms

Therapists

  • Continue as planned to provide therapy for patients under own speciality who have been outlied to another speciality or hand patients over to the appropriate team for the outlying ward.

6.PROCESS

6.1 Risk

The central principle underlying outlying decisions is rooted in the management of risk. The Trust’s Risk Assessment Policy explains that a risk assessment is no more than a careful examination of what might cause harm to patients, staff, visitors and others. A risk assessment provides a systematic and methodical tool for identifying risks, removing them where possible or otherwise adopting all the control measures and precautions that are reasonable and practical in the circumstances.

In circumstances where it is necessary to make decisions about outlying (i.e. limited bed capacity to ensure appropriate and timely patient flow), the degree of risk needs to be clearly identified. It is recognised that the best course of action is not to outlie, but where outlying decisions are needed these must ensure the minimal risk to patients and staff.

6.2 Principles

The following principles govern decisions to outlie patients to areas outside of their expected speciality:

  • All efforts must be made to ensure patients receive care and treatment in the most appropriate clinical speciality area for their current condition.
  • Safety, clinical efficacy and a positive patient experience are the goals of all outlier decision making. Decisions to outlie must be based on the patient’s current clinical and mental health needs, their level of acuity and dependency and the clinical capability of the receiving area.
  • All patients are to be RAG rated within 24 hours of admission and reviewed daily as to their appropriateness to outlie. Appendix A details the clinical considerations that must be taken into account when RAG rating patients as to their suitability to outlie. Red more than 1 criterion present, Amber 1 of the criteria is present, and green, none of the criteria are present. Therefore Green rated patients are the most appropriate to outlie.
  • Decisions to outlie should always be taken in a manner that supports the achievement and maintenance of patient’s individual needs, privacy and dignity, infection control status and single sex ward requirements. Such decisions must be taken according to current infection control policies and practice in order to reduce the risk of exposure to infection.
  • Any patient being considered for outlying must have an individual risk assessment completed prior to a decision being made to move them (Appendix B).
  • Patients who are placed outside of their normal specialty areas are entitled to the same level of care and treatment that they would receive if cared for within their specialty areas. Every effort will be made to ensure that outlying patients are reviewed by medical and/or nursing teams from their specialty on a daily basis during Monday to Friday and as needed at weekends.
  • It must be recognised that outlying patients may challenge some medical and nursing teams and, particularly at times of high outlier numbers, the CSC Management Team must work with specialty clinicians to agree how outlier patients will be supported medically. This may require some flexibility between clinical teams if total patient numbers for a specialty are particularly high.
  • Once it is deemed necessary to outlie, patient treatment plans must be updated including pending investigations and discharge plans carefully documented in the patient’s health records.
  • Clinical teams must be informed of patients who are actually outlied, with clear information given on where the patient has been outlied to. The Patient Administration System must be updated promptly by the receiving areas as this ensure that the patients’ medical teams will be able to clearly locate their patients from the patient list printed by the team each morning.
  • The number of bed moves during each patient’s stay must be minimised. Ideally once a patient has been outlied from their original ward they should not be moved again. If this is necessary then careful dialogue must take place with the patient and care taken not to move the patient again. Patient moves are monitored and presented to the Trust Board on a monthly basis as part of the Quality report.
  • Regulations around single sex accommodation and facilities must not be breached and there may need to be some cohorting of patients to achieve this.
  • Outlier decisions must be based on a full understanding of the current position regarding whole hospital capacity and decisions made to balance the prevailing risk across the whole hospital and between specialties
  • Relatives must be informed of all decisions to move patients. It is the transferring wards responsibility to do this.
  • Prior to outlying all patients should be offered a copy of the ‘Why do I need to move wards leaflet?’ (Appendix B)
  • Maintain SOPs related to unfunded capacity provided by services with regular safety and quality checks for those areas

6.3 Decision Making

  • Outlier decisions will be made according to all of the above points as well as within the context of the achievement of the Trust’s objectives and standards.
  • Any patient being considered for outlying must have an individual risk assessment completed prior to a decision being made to move them and this should be documented in their case notes (Appendix B).
  • Staff willnot be put at risk by being asked to care for patients in environments where there is insufficient staffing, equipment or physical resources or where they do not have the appropriate knowledge and skills for those patients’ conditions.
  • Normally patients are not to be admitted to an outlying area straight from the Emergency Department or assessment area such as the Acute Medical Unit. If this is required then a full risk assessment should be completed (Appendix B)
  • Staff involved in making decisions to outlie or open unfunded capacity will use the risk assessment tools and be prepared to justify that all decisions were taken in a robust manner, taking into account individual patient conditions as well as theoverarchinghospital capacity situation.

6.4 Outlying principles