operational procedure and guidance transfer and handover ... · operational procedure and guidance...

Attachment 16 TNMC appendix 3

Operational Procedure and Guidance

Transfer and Handover of Patients Procedure and Guidance Document

Summary Procedure to ensure that every transfer and handover must be conducted safely, with dignity and with the agreement of all parties, as stated in the Trust-wide Policy and Procedure.

This document must be read in conjunction with the

Transfer and Handover of Patients Trust-wide Policy and Procedure

Document Detail

Document Type Operational Procedure and Guidance Document Document name Transfer and Handover of Patients Procedure and Guidance Document Document location GTi Clinical Guidance Database Version 10.0 Effective from July 2015 Review date July 2018 Owner Eileen Sills, Chief Nurse/Chief Operating Officer Prepared by V. 7 : D. Parker, ACN ;C. Spencer, Acting ACN; Dr S Bruemmer-Smith, Consultant ICU and Dr Guy

Glover, Consultant ICU, (Critical Care/Appendix 5 and flowcharts) V 8 : Revised by C. Spencer, C.Hamm, J. Hamilton and M. Jubb V.10 : Revised by J. Hamilton

Approved by, date TNMC, July 2015 Superseded documents

Transfer of Patients Procedure and Guidance Document V 9.0

Related documents

Transfer Of Patients Trust Wide Policy And Procedure Patient Placement Policy

Keywords Patient Transfer, Patient transport, Patient Handover Relevant external law, regulation, standards

Blood Safety and Quality Directive 2005 DH ‘Dignity Challenge’ NCEPOD 2005 NMC Standards for Medicines Management 2008 The Law on Child Car Seats http://www.childcarseats.org.uk/law/index.htm NMC : The Code of Conduct, 2015

Date Change details Approved By

14 01 10 Transfer of Patients policy Procedure and Guidance V6

21 10 10 Transfer of Patients Policy Procedure and Guidance V7

February 2014 Minor changes in wording regarding students transferring patients & escorts TNMC

July 2015 Revision of Paragraph 4.4.1

TNMC

Change History

Transfer + handover of patients procedure/guidance document : July 2015 1

http://www.childcarseats.org.uk/law/index.htm


Transfer and Handover of Patients Procedure and Guidance Summary

Patient Transfer Risk Assessment: The underlying principle of every transfer and handover is that it must be conducted safely and with effective communication. The Transfer and Handover of Patients Procedure and Guidance must be followed at handover of care between shifts, and out of hours. It should also be followed when transferring patients between wards, to other departments, between sites and to community settings. For patients being transferred for investigations or procedures the Transfer checklist of a patient for investigation/Procedure should be completed. Prior to requesting aid with patient transfer, an up to date assessment of the patient must be undertaken and the need for a registered nurse escort assessed using the Patient Transfer Guidelines. Patient’s current medication regime and additional needs must be conveyed to the receiving clinical area including notification of infectious conditions.

As with all transfers and in accordance with hospital policy, patients must have an identity band and where appropriate allergy band in place prior to transfer and must be appropriately dressed/covered to maximise their personal dignity.

Patient’s requiring continuous nursing care at Level 3 (ICU) should have medical staff in attendance upon transfer. Discharge and step down from critical care to ward areas should be avoided between the hours of 22.00 and 07.00 due to evidence that this adversely affects patient outcomes and increases readmission rates. Where possible this should take place before 16.00.

Patient Transport Assessment: The PTS Assessment Booking Form must be completed by the health professional in charge of the patient. No patients should be transferred outside the hospital unless they are fully dressed or appropriately covered if on a stretcher.

Bariatric Patients: To minimise or eliminate foreseeable handling risks to staff and patients, staff must ensure that specialist advice, equipment and aids for the bariatric patient are available to aid transfer.

Babies and Children: The law requires children travelling in cars to use an appropriate child restraint or adult seat belt, if they are available. Expressed breast milk should be checked by two people independently, one of whom must be a registered Trust Nurse/midwife.

Medicines brought in with Patients: Encouraging patients to use their own medicines minimises cost and improves safety. If the patient is admitted the medicines should be labelled with the patients name and moved with the patient to the assessment unit or the appropriate ward. If the patient is not admitted the medicines should be handed back to the patient.

Site Nurse Practitioners All transfers from ward to ward, in and out of hours are co-ordinated by the Site Nurse Practitioners to ensure safe, timely and appropriate transfer and handover.

Nursing and Midwifery Students must not transfer patients alone when a registered nurse or midwife is required.


The Transfer and Handover of Patients Procedure and Guidance Document provides guidance to ensure that every transfer and handover is conducted safely and with dignity.

Page

Transfer and Handover of Patients Procedure and Guidance 1 Summary

Contents: 2 Introduction 3

1 Responsibilities of Registered Ward Nurses / Midwives 3 2 Responsibilities of the Site Nurse Practitioner 4 3 Assessment of Transfer Risk 4

3.1 Patient Transfer Risk Assessment 4 3.2 Bariatric Patients 5 3.3 Booking Patient Transport 5

3.3.1 High Dependency Journeys LAS 5 3.3.2 Patient Transport Assessment 6 3.3.3 Out of Hours Arrangements 6

4 Assessment of Escort Need 6 4.1 When Qualified Nursing/Midwifery Staff Must Accompany Patients 6 4.2 Transfer of Critical Care Patients 7 4.3 Nursing Assistants 7 4.4 Student Nurses 8 4.5 Other Support 8

5 Babies & Children 8 6 Responsibility of the Nurse/Midwife Escort 9 7 Patients Arriving From Other Hospitals with a Nurse Escort 9

7.1 Patient Journey Process 10 7.2 Responsibilities of the Nurse Escorting Patients to Guy’s And St 10

Thomas’ 7.3 Responsibilities of Staff in the Discharge Lounge/ Transport Waiting 10

Area 7.4 Responsibilities of the Site Nurse Practitioner 10

8 Frequent Transport Users 11 9 Patient Transport Scheme 11

10 Tracking and Movement of Patient Health Records 11 11 Documentation 11 12 Supply of Medication 12

12.1 When Patients Bring Medicines into Hospital 12 13 Transfer of Blood Components 12 14 Transfer of expressed breast milk (EBM) 13

Appendices: Appendix 1 Patient Transfer Handover Guidelines 14 Appendix 2 Transfer checklist 16 Appendix 3 Information for Inter-Hospital Patient Escorts 17 Appendix 4 Patient Transport Contact Numbers & General Information 18 Appendix 5 PTS Assessment / Booking Form 19 Appendix 6 Critical Care Inter And Intra Hospital Transfers 20 Appendix 7 Inter- hospital transfer checklist


Introduction

The underlying principle of every transfer and handover is that it must be conducted safely and with effective communication between all parties. The key to safety is thorough risk assessment and communication. All patients undergoing transfer must be risk assessed for clinical need during transfer by a nurse/midwife who must also take responsibility for communicating information relating to the patient and their care needs to the receiving area. The registered nurse/midwife who is currently accountable for the care of the patient has a duty to ensure that appropriate information and handover is provided to enable this to happen.

The Transfer and handover of Patients procedure and guidance must be followed when: • Handover of care between shifts • Hand over of care out of hours • Temporarily transferring patients to departments within the Trust • Transferring patients ward to ward • Transferring patients across site between Guys’ Hospital and St Thomas’ Hospital • Transferring patients to community settings • Receiving patients from other hospitals to undergo investigative procedures (including X- ray, ultrasound department) medical consultation or relocation.

Handover of care takes place between shifts to ensure effective communication of clinical care. Each ward has an established process for verbal handover to meet the needs of the patients and ward team and this takes place at the commencement of each shift and covers each patient, highlighting any particular care issues. In the event of the registered nurse from the previous shift not being available to handover it is the responsibility of the registered nurse in charge to handover to the incoming nurse. When patients are transferred verbal handover is given this can be by telephone or in person

Inpatient transfer from Guy’s to St Thomas’ for acute or urgent medical, cardiac or surgical treatment requires risk assessment and expert advice. The duty SNP must be notified on bleep 1165 of any patient who is:

• being transferred from Guys for acute or emergency treatment or advice • Any patient who is being transferred with a PAR score of ≥ 2. • Any out of hours transfer.

The Hospital at Night Team Handover Protocol provides further details and advice for clinical teams making transfer decisions. Discharge and step down from critical care to ward areas should be avoided between the hours of 22.00 and 07.00 due to evidence that this adversely affects patient outcomes and increases readmission rates (National Confidential Enquiry into Patient Deaths, 2005). Ill or vulnerable patients moving wards should be transferred before 20.00hrs. Such patients may be: Level 2/3 (HDU/ICU) patients, patients with a tracheostomy or patients with additional needs because of learning disability, mental health issues, behavioural issues etc. Where possible it is advisable that patients are transferred by 16.00.

1. The Responsibilities of Registered Ward Nurses and Midwives

Prior to the transfer, the patient’s current medication regime and additional needs such as communication, language support and feeding must be conveyed by phone or in person to the receiving clinical area. This should also include notification of infectious conditions/contacts e.g. MRSA, varicella, to ensure proper management of the patient and protection of the staff and other patients. Patients known to have MRSA carriage will be accepted providing the receiving area can make suitable arrangements for their isolation and management. Refer to Patient Placement and Infection and Prevention & Control Placement Protocol (2012). If Patient Transport is needed they should be informed of patients’ infection status.


1.1 Any procedure, which involves a patient being transferred from a ward, must be communicatedto the coordinator/shift leader of the ward team. The coordinator/shift leader must check that a bed is still available for the patient on the receiving ward or department prior to transferring the patient. The patient and/or relative /carer should be aware of any proposed transfer.

1.2 When transferring patients within the Trust ensure all relevant patient documentation are available for the transfer.

1.3 All patients must have an identity band and where appropriate allergy band in place prior to transfer.

1.4 The personal needs of the patient must be communicated e.g. language, British Sign Language (BSL), Makaton. The use of language support services and feeding issues must be communicated.

1.5 An appropriate carrier must be used if equipment is required during transfer e.g. oxygen carrier, drip stand.

1.6 Patients must be appropriately dressed/covered to maximise their personal dignity.

1.7 Discharge and step down from critical care to ward areas should be avoided between the hours of 22.00 and 07.00 due to evidence (NCEPOD, 2005) that this adversely affects patient outcomes and increases readmission rates. Ward or clinical area transfers should take place prior to 20.00 and where possible before 16.00. Out of hours the duty SNP will notify the accepting SpR/FY2 that inter or intra hospital transfer is taking place that day, however ward staff are responsible for notifying the appropriate team when the patient arrives.

1.8 The receiving ward must notify the SpR/FY2 when a patient has arrived from another hospital,

from a critical care area, or following intra-site transfer. This should be within 60 minutes of the patient’s arrival, or sooner if the patient is unwell.

1.9 The receiving ward or clinical area should liaise with Blood Bank to ensure that any blood or blood products to be transferred with the patient are correctly packed and that Blood Bank is aware of their transfer so that fate of these units can be verified. The receiving ward or clinical area must notify Blood Bank of any patients transferred from another hospital with blood prior to any transfusion to ensure that the blood has been packaged appropriately.

2. Responsibilities of the Site Nurse Practitioners

2.1 All transfers from ward to ward, in and out of hours are co-ordinated by the Site Nurse Practitioners to ensure safe, timely and appropriate transfer and handover.

3. Assessment of Transfer Risk 3.1 Patient Transfer Risk Assessment Prior to requesting aid with patient transfer, an up to date assessment of the patient must be undertaken using the Patient Transfer Guidelines (Appendix 1). This provides guidance and should be used to assess the level of support the patient requires. This should be applied to all patients being transferred to departments or clinical areas within the Trust (except the Discharge Lounge) and to all inter and intra hospital transfers. The assessment should be undertaken by the registered nurse/midwife responsible for the patient’s care or the nurse/midwife in charge of the ward and documented within the patient records.


Patient’s requiring continuous nursing care at Level 3 (ICU) and patients who are being ventilated or have compromised respiratory ability, should also have medical staff in attendance. In such cases, if a second porter is required to aid with transfer of these critically ill patients the nurse/midwife in charge must state the reason.

The registered nurse in charge of the ward will assess the portering requirements and the mode of transfer for the patient, e.g. trolley, wheelchair or bed. Wherever practical patients should either walk or be transported by wheelchair. The need for a registered nurse escort will be assessed using the Patient Transfer Guidelines. Clear indication must be given when booking a porter if a registered nurse escort will not be accompanying the patient. The registered nurse/midwife can transfer patient on beds without a porter if they have undertaken Moving and Handling training. When inpatients are being transferred, the registered nurse/midwife who is currently accountable for the care of the patient has a duty to ensure that adequate information and handover is given to enable this to happen.

For patients being transferred for investigations such as radiological procedures complete the Transfer checklist of a patient for investigation/Procedure (see Appendix 1). This should be completed by a qualified registered ward nurse and the collecting porter. If for the return journey the patient’s condition changes from the initial assessment this must be discussed and handed over to the ward team. The completed Transfer checklist of a patient for investigation/Procedure should be filed in the patient’s health record once the patient has returned to the ward. 3.2 Bariatric Patients To minimise or eliminate foreseeable handling risks to staff and patients, staff must ensure that specialist advice, equipment and aids for the bariatric patient are available to aid transfer.

All patients assessed as being in excess of 160Kgs/25stone, or with a Body Mass Index (BMI) in excess of 30+ will be classed as bariatric (25 to 30 BMI is overweight and 30 is obese). It should also be recognised that other individuals with lower weight and BMI’s may be considered for bariatric equipment depending on their weight distribution, height, size and immobility problems. It is essential that bariatric patients are treated with respect and dignity. In order to achieve this level of care extra resources will need to be deployed. 3.3. Booking Patient Transport To book patient transport contact the Patient Transport Assessment Team on Ext 82888.

Locations and hours of business:-

Guy's Hospital Ground floor, Guy's Tower

Monday to Saturday 7:00am- 10:00pm

St. Thomas' Hospital

Lower ground floor, Lambeth Wing (6:30am-10:00pm)

A & E Department (10:00pm-6:30am)

24 hours

Assessment Team 2nd Floor College House,St Thomas' Hospital

Monday to Friday 9:00am- 6:00pm


3.3.1 High Dependency Journeys - London Ambulance Service (LAS) All high dependency patient journeys must be booked by the user directly with the London Ambulance Service. This is necessary because the LAS will require specific details about the patient's condition that the department / ward are best placed to answer.

A journey is deemed to be high dependency if the patient requires attention in excess of a stretcher to lay on with no other complications and 28% oxygen.

A high dependency journey may be booked with the LAS on the following telephone number: 0207 827 4525. It should be confirmed with the LAS that they are accepting the booking as a high dependency journey; otherwise the requesting area may be faced with a costly re-charge.

Additionally the LAS are contracted with this Trust to provide "front-line" high dependency ambulances to transfer between Guy's and St. Thomas' Hospital sites for certain specialities.

3.3.2 Patient Transport Assessment.

To ensure Patient Transport and Portering Services can provide safe and comfortable transport, the PTS Assessment Booking Form (Appendix 4) must be completed by the health professional in charge of the patient, except within Accident and Emergency Department where the nursing care plan will be used. If a nominated staff member is asked to book patient transport they must refer to this. The request form is then filed in front of the patient’s records and referred to when booking patient transport. Transport will use the information on the form to ensure appropriate transport is booked and a safe level of information is passed onto the ambulance/car personnel who will be transporting the patient. The form remains in the patient notes. No patients should be transferred outside the hospital unless they are fully dressed or appropriately covered if on a stretcher (except when due to medical reasons). 3.3.3 Out of Hours Arrangements Outside of hours and on bank holidays transport can be booked by dialing 0207 188-2888 (internal ext 82888).

For ambulance journeys (patients traveling in a wheelchair or requiring a stretcher) a crew will be on duty between 7.00 p.m. and midnight. After midnight the ambulance crew operates on an on- call basis. The agreed response time for an ambulance "out of hours" is within 2 hours.

For car journeys (walking patients) vehicles are available 24 hours a day with a response time of within 60 minutes.

An on call manager is available outside normal hours - contactable through the switchboard.

4. Assessment of Escort Need

It is recognised that the registered nurse/midwife in charge of the patients on-going care must ultimately decide on the level of escort, for patients leaving her/his area of responsibility. The Patient Transfer Handover Guidelines should be used in conjunction with other patient related information available at the time. The escort should be aware of all patient details and will be responsible for the communication and handover of these details to staff in the accepting department

Allied health professionals/therapy staff may accompany a patient from a ward to a particular therapy area for therapy intervention. In this case, the therapist will act as escort where appropriate. Occupational Therapists escorting patients from the hospital to their own home to undertake an assessment require a risk assessment as defined in the Occupational Therapy Home Assessment Policy which details the requirements for planning a Home Assessment including consideration of the type of transport required.


Occupational Therapy staff will use either the Trust’s taxi contract or ambulance service depending on the patient’s mobility /ability and medical status.

4.1 Qualified registered nursing/midwifery staff deemed competent at caring for the patient and care provision required and relevant experience must accompany patients in the following situations

The Trust recognises that it is the responsibility of the referring health provider to assess a patient’s escort requirements. A nurse/midwife escort is required for the following patients

1. Any patient with a NEWS score >= 5 or a single parameter scoring 3, agree need for transfer prior to patient leaving clinical area 2. All patients requiring Level 2 or 3 (Coronary, High dependency or Intensive) care.

Medical escort needed for level 3 patients in addition to qualified nurse/midwife.3. Any patient being ventilated or who requires assisted ventilation or has respiratory distress e.g.

CPAP, stridor, tracheostomy or artificial airway.4. Any patient requiring greater than 24% oxygen therapy.A HCA may accompany a patient who is receiving prescribed ≤ 24% oxygen therapy and with a PAR score ≤1 if they have passed the HCA competency in relation to oxygen therapy. 5. Any patient requiring an invasive procedure who may require sedation during investigations.6. Any patient who has been given an opiate medication within one-hour prior to transfer must be

assessed in relation to level of escort required.7. Any patient with on-going treatment in progress e.g. pain relief via PCA. 8. Any patient who has a chest drain in situ.9. Any patient with a CVP or arterial line in situ.10. Any patient who is having a blood transfusion, chemotherapy or on continuous intravenous

therapy that is of an opiate nature or other drug likely to alter patient’s physical state. Infusionscan only be stopped in exceptional circumstances and in consultation with medical staff and the patient.

11. Any patient who has altering degrees of consciousness.12. Any patient who is sectioned under the Mental Health Act or DOL or demonstrating aggressive

behaviour. 13. Vulnerable patients for example patients with safeguarding issues, learning disabilities, mental

health issues, challenging behaviour including those who are confused or are at risk of going missing.

14. Any patient at risk of falling 15. Patients returning from the operating theatre16. All patients under 16 must be accompanied by a clinical support worker, parent or guardian if

none of the above criteria apply. Parents of patients with chronic conditions such as long term tracheostomy, home oxygen, enteral feeds may accompany patients if they have been trainedand assessed as competent.

4.2 Transfer of Critical Care Patients (See Appendix 6) It must be the Consultant decision to transfer/discharge from Guy’s and St Thomas’ Hospital Critical Care Areas. See Appendix 5: Inter And Intra-Hospital Transfer Of Critical Care Patients and ICU Intranet Patient Transfer Guidelines

4.3 Nursing Assistants (NA)

An NA may accompany a patient who is receiving prescribed ≤ 24% oxygen therapy and with a NEWS score ≤ 1 if they have passed the HCA competency in relation to oxygen therapy and have received training updates.

It is important that Registered Nurses understand the principles of safe delegation as stated by the NMC (2015) Code of Conduct. The registered nurse is responsible for ensuring the criteria for delegation are met and is accountable if delegation is inappropriate.


NAs must work under the supervision of a healthcare professional. Being accountable for deciding to delegate the work to another person, Registered nurses must be sure that the person has the knowledge, skills and competence to undertake the delegated work. The RN is professionally accountable for delegating to a competent individual and ensuring the task is completed satisfactorily. If the NA fails to deliver care to a level for which he or she has been prepared and assessed as competent, the NA is accountable to his or her employer.

The responsibility for transfer remains with the Registered Staff Nurse/Nurse-in-Charge to sanction/delegate that the NA (who has passed their competences) has the permission to leave the ward with a patient on oxygen therapy.

4.4 Health Professionals in Training

4.4.1 Nursing and midwifery students

Nursing and midwifery students (Part 2 onwards) can accompany registered staff on intra-hospital transfers as this provides a valuable learning opportunity. They must not transfer patients independently where a registered nurse or midwife is required. This includes transfers to and from theatres.

If a registered nurse is not required to transfer the patient, nursing and midwifery students in the second year and above of their training, or are over eight months into their PgDip programme, can undertake the intra - hospital transfer of a patient independently.

In paediatric services a student may accompany a patient that would ordinarily be accompanied by a family member as long as the student has been deemed competent by a registered nurse. The registered nurse remains accountable for the student and the patient.

Nursing and midwifery students may go on an out of hospital transfer under the supervision of a registered healthcare professional where this is deemed appropriate. Please refer to the 'Scope of Practice for Nurses & Midwives in Training' document (LINK) for further clarification.

4.4.2 Other health professionals in training

Other health professionals in training will not escort patients outside of the hospital. Health Professionals in training may escort patients within the Trust if the experience contributes to them achieving their learning objectives and they are directly supervised by a registered nurse or midwife. They can not transfer alone patients returning from theatre or post anaesthesia. The mentor will maintain accountability for the patient’s care.

4.5 Other Support

Trust volunteers and chaplaincy staff may escort patients who do not need a qualified member of staff accompanying them, for the purpose of spiritual care.

In addition to a nursing escort, a patient may be accompanied by a relative/friend if their medical condition warrants it. Escorts will be limited to one per patient.

5. Babies and Children

Regulations governing the use of child car seats came into force on 18 September 2006. The law requires children travelling in cars to use an appropriate child restraint or adult seat belt, if they are available (http://www.childcarseats.org.uk/law/index.htm). Child restraints are the collective term in the seat belt wearing legislation for baby seats, child seats, booster seats and booster cushions. In addition, the revised regulations also state that rear-facing baby seats MUST NOT be used in a seat protected by a frontal air-bag unless the air-bag has been deactivated manually or automatically.

http://www.childcarseats.org.uk/law/index.htm

Current guidance should be reviewed when making transport arrangements for children. For comprehensive guidance for children travelling in cars visit the road safety web-site: http://www.direct.gov.uk/en/Parents/Yourchildshealthandsafety/Roadandtravelsafety/DG_10037077

From 18 September 2006 In cars, vans and goods vehicles

Front Seat Rear Seat Who is responsible?

Driver Seat belt must be worn if available

Driver

Child up to 3 years* Correct child restraint must be used*

Correct child restraint MUST be used.* if one is not available in a taxi, may travel unrestrained.

Driver

Child from 3rd birthday up to 135cms in height (approx 4’5”) (or 12th

birthday whichever they reach first)**

Correct child restraint must be used***

Where seat belts fitted, correct child restraint MUST be used. Must use adult belt if the correct child restraint is not available: ‐ In a licensed taxi or private hire vehicle

‐ For a short distance for reason of unexpected necessity

‐ 2 occupied child restraints prevent fitment of a third.

A child aged 3 and over may travel unrestrained in the rear seat if seat belts are not available.

Driver

Child over 1.35 metres (approx 4ft 5ins in height)

or 12 or 13 years

Seat belt must be worn if available


Driver

Adult passengers (i.e. 14 years and over)



Passenger

6.0 Responsibility of the Nurse/Midwife Escort


6.1 Ensure the comfort and safety of the patient at all times. 6.2 A patient’s clinical need to be transferred is paramount and the nurse/midwife escort may need to request staff/general public to vacate a lift to move the patient comfortably and appropriately. 6.3 Carry emergency equipment as required.

http://www.direct.gov.uk/en/parents/yourchildshealthandsafety/roadandtravelsafety/dg_10037077/


6.4 Any patient requiring an interventional radiological procedure requires a qualified nurse escort. The escort should provide comfort, safety, privacy and dignity of patients at all times eg ensuring the patient is dressed appropriately for transfer. The escort should always act in a professional manner at all times focussing all their attention on the patient in their care. In the absence of an anaesthetist, level 2 and 3 patients must always have the qualified nurse escort stay with the patient. Adequate equipment and medication must be made available for the duration of the transfer and or procedure. The nurse/midwife escort is not required to stay with the patient during diagnostic tests or invasive investigation if appropriate nursing/health professionals are available to take over, having received handover. Where nursing/health professional staff are not available in the receiving Ward/Department the escort nurse must remain with the patient at all times. Where the patient is acutely unwell the escort nurse must remain with the patient at all times unless the receiving Ward/Department trained nurse can provide one to one nursing care solely for the patient at that time. If the nurse escort needs to remain for a period greater then 30 minutes, the escort nurse must call and inform the ward of the delay.

6.5 To establish the nearest phone and emergency numbers in case of emergency.

6.6 Provide care to the patient in accordance with Trust policy.

6.7 Ask for help if needed.

7. Patients arriving from other hospitals 7.1 Patients arriving with a nurse escort & patients awaiting transfer back to their inpatient bed elsewhere following treatment/procedures at Guy’s and St Thomas’ and those transferring to community settings.

If the patient is to travel outside the hospital, he/she will be transported in the most appropriate manner i.e. ambulance for medical need or contract taxi. It is recognised that the nurse in charge of the patient’s on-going care must ultimately decide on the appropriate transport in discussion with the Transport team.

The booking of the outward and return journeys on the same day is the responsibility of the referring hospital unless by prior arrangement with the Trust but the nurse in charge should check that this has been done. Patients should remain in the clinical area until they are recovered from their procedure and are fit for transfer back to their host Trust. At this point, the escort nurse from the host Trust resumes the duty of care to the patient. The patient remains within the clinical area until they are fit for transfer.

7.2 Patient Journey Process Patients should receive their procedure as early in the day as possible to enable full recovery and fitness for transport. Due consideration should be given to patients travelling long distances where early appointments may not be appropriate.

Escorts coming from outside the Trust/elsewhere should be handed the information leaflet Information for Inter-Hospital Patient Escorts (Appendix 2) and orientated to the area and other facilities (toilets for self and patient, refreshments, emergency procedure, sources of help and advice if needed).

Once the patient is fit for transfer, they should be sent to the Discharge Lounge (STH) / Transport waiting area (Guy’s) to await transport.


7.4 Responsibilities of the registered nurse escorting patients to Guy’s and St Thomas’ 7.4.1 Provide care for the patient as identified in the care plan from the host Trust and according to needs following the procedure they have received. 7.4.2 Ask for help when required.

7.4.3 Familiarise themselves with the emergency numbers and location of the phone in case of emergencies (information is in the Information For Inter-Hospital Patient Escorts leaflet).

7.4.4 Report any difficulties or untoward incidents to the nurse in charge of the area in which they are waiting or contact the SNP (via bleep desk 3026). 7.4.5 Contact their manager in the event that transport is delayed in order to arrange cover for them and that the host Trust can contact their transport team regarding the delay. 7.5 Responsibilities Of Staff In The Discharge Lounge/ Transport Waiting Area

7.5.1 Ensure that both the patient and the nurse escort have copies of information leaflets in an appropriate format. Information for inter-hospital patient escorts should be handed to the patient or carer/family member where appropriate.

7.5.2 The nurse in the discharge lounge must assess and book transport when patients are sent down on the day of discharge, if no transport has been booked.

7.5.3 Look after the patient if the nurse escort requires a break. 7.5.4 Arrange for the provision of food for the patient as required. 7.3.5 Ensure transport bookings are checked and that the patient and escort are expected transfers. 7.5.6 Liaise with the SNP if the patient and escort remain in the department at the time of closure. 7.6 Responsibilities of the Site Nurse Practitioner

7.6.1 Provide guidance and support if contacted by the escort nurse as required. 7.6.2 Where possible to avoid patient transfers after 20.00 hours. 7.6.3 If the patient deteriorates the SNP will provide support and assistance as required. 8 Frequent Transport Users

A risk assessment must be completed for all frequent users of transport e.g. dialysis patients, who access transport several times a week. This must be recorded within the patient’s records and transport notified. Re-assessment of ‘risk’ should be carried out every three months or if the patient’s health changes.

9 Patient Transport Scheme

This scheme aims to ensure that decisions about patients' eligibility for free transport are fair and consistent. A nurse-led team undertakes assessments so that they are consistent across the Trust - patients are fairly assessed against the same criteria regardless of where they are being treated.

Free transport will be provided for patients with a medical need.

Patients should be informed that they need to call 020 7188 2888 for patient transport services on both sites

10 Tracking and Movement Of Patient Health Records 10.1 In instances where health records are being moved between departments staff are

responsible for ensuring records are tracked appropriately. 10.2 The location of all patient health records must be recorded on the Trust wide tracking

system that is held on iPM. 10.3 Individuals or departments to whom patient records are booked are responsible for the safe

keeping of the folders and their contents and for making them available on request. Responsibility is discharged only when the case note location identified on iPM is changed to another user. If a user does not have access to iPM then they may have the case note location recorded by sending an e-mail to “case note tracking update”.


10.4 In normal circumstances the Health Records Portering service must be used to transport records from one from site to another.

10.5 In exceptional circumstances health records can be transferred on the staff bus. The health records must be put in a sealed envelope with a contact name, number and address and brought to the Health Records Library for transfer. The person named on the envelope will be contacted once the records have arrived at their destination.

10.6 Unaccompanied patients must not transfer their own records. This is to prevent loss or damage to the records.

10.7 Health records must not be removed from Trust premises in any other circumstances other than Outreach clinics unless they are required by the coroner or in court and the Head of Health Records must be informed of their removal. The secure transportation of such notes should be ensured. The records must be in a sealed envelope which must be addressed to an individual. A record of all the details relating to the health record as well as a contact telephone number must be recorded on iPM.

10.8 All other requests for access to patient’s health records must go through the Access to Health Records Department.

11 Documentation

11.1 The patient’s Health Record and relevant nursing handover documentation including language and personal support needs.

12 Supply of Medication Nursing/midwifery/medical staff in conjunction with the ward/unit pharmacist must make adequate arrangements for patients who require medication during the period away from the parent ward. If a patient is moved to another department, or to the Discharge Lounge ALL the patients own medicines plus any newly dispensed labelled medicines from the POD locker are put in a labelled green bag and moved with the patient. This should be communicated to the receiving nurse /midwife along with any instructions relating to the need to administer any medicines during the time they are in the new area. Medicines should be locked in the patient’s locker. Those medicines on the Critical drugs list for: Rapid Response Report NPSA/2010/RRR009 should be reviewed on patient transfer to avoid any delays or omissions. These include antibiotics, medication for thrombosis, Parkinson’s disease, epilepsy and diabetes.

12.1 When Patients bring Medicines into Hospital

The Trust has a policy of using patients own medicines, when they are appropriate. Encouraging patients to use their own medicines minimises cost and improves safety (as a more accurate drug history can be recorded than relying on the patient’s memory).

Ambulance staff and transport drivers, wherever possible should bring patients own medication into hospital. If a patient is admitted via the London Ambulance Service as an emergency from home the medicines should already be in a green bag. The medicines can then be checked and if suitable returned to the green bag.

If the patient is admitted the green bag containing the medicines should be labelled /written on with the patients name and moved with the patient to the assessment unit or the appropriate ward.

If the patient is not admitted the green bag with the medicines in should be handed back to the patient.

On admission to the ward/ unit the patient’s own drugs (PODs) are handed to the receiving nurse/midwife who will seek the patients consent to lock them in the POD locker ready for checking by the ward/unit pharmacist for their possible use whilst in hospital (NMC Standards for Medicines Management 2008)


13. Transfer of Blood Components 13.1 Transferring blood components a) When a patient is transferred across site or to another hospital or community setting: Blood components must not be transferred by clinical staff direct from the clinical area: The Blood Transfusion Laboratory must be contacted, who will then ensure that all necessary blood components are packaged correctly and that all the units can be traced in accordance with the Blood Safety and Quality Directive (2005).

b) When a patient is transferred within the same site: When red cells are transferred from one clinical area’s satellite blood fridge to another satellite blood fridge, within the same site, this should be carried out by the portering staff who will use a blood transport box to maintain the correct storage and handling conditions of the component. All other blood components transferred with the patient within the same site must be handled as per the Blood Transfusion Policy, and a full handover given to the receiving clinical staff.

13.2 Transfusing blood components a) Blood components that are being transfused at the point of transfer: the clinical staff transferring the patient must handover the details about length of time left to transfuse to the receiving clinical staff. b) Blood components that arrive with a patient from another hospital: these can only be transfused if they have been packed correctly and have the appropriate documentation accompanying them. Seek guidance from the blood transfusion laboratory before using any of these. The laboratory must also be informed if any have been transfused so that they can inform the referring hospital of the fate of the blood in accordance with the Blood Safety and Quality Directive (2005). c) When a patient is transferred to interventional radiology: When a patient is transferred for an angio procedure, the interventional x-ray staff will order red cells for the patient direct from the transfusion lab (an ‘angio pack’): Do not send the patient with any red cells from the ward/unit. 14. Transfer of Expressed Breast Milk (EBM) Expressed breast milk should be checked by TWO people independently, one of whom must be a registered Trust Nurse/Midwife and one other person, preferably the mother of the child. The milk should be transported in an insulated container that can be easily cleaned and then stored as per local policy on arrival.


Apppendix 1 Patient Transfer Handover Guidelines

Patients with the following criteria require a Registered Nurse / Midwife/ Therapist or Medical Staff Escort

• Any patient with a NEWS score >= 4, or a score of 3 or greater for any one parameter, agree need for transfer prior to patient leaving clinical area with Medical and Senior Nursing Colleagues • All patients requiring Level 2 or 3 (Coronary, High dependency or Intensive) care. Medical

escort needed for Level 3 patients • A patient being ventilated or requires assisted ventilation or has respiratory distress e.g.

CPAP, stridor, tracheostomy or artificial airway • Any patient requiring greater than 24% oxygen therapy.

An NA may accompany a patient who is receiving prescribed ≤ 24% oxygen therapy and with a PAR score ≤ 1 if they have passed the NA competency in relation to oxygen therapy

• Any patient requiring an invasive procedure who may require sedation during investigations • Any patient who has been given an opiate medication within one-hour prior to transfer must

be assessed in relation to level of escort required • Any patient with on-going treatment in progress e.g. pain relief via PCA. • Any patient who has a chest drain in situ • Any patient with a CVP or arterial line in situ

• Any patient who is having a blood transfusion, chemotherapy or on continuous intravenous therapy that is of an opiate nature or other drug likely to alter patient’s physical state. Infusions can only be stopped in exceptional circumstances and in consultation with medical staff and the patient

• Any patient who has altering degrees of consciousness

• Any patient who is sectioned under the Mental Health Act or DOL or demonstrating aggressive behaviours

• Vulnerable patients for example patients with learning disabilities, mental health issues,

challenging behaviour including those who are confused or are at risk of going missing • Any patient at risk of falling • Patients returning from the operating theatre • All patients under 16 must be accompanied by a clinical support worker, parent or guardian

if none of the above criteria apply. Parents of patients with chronic conditions such as long term tracheostomy, home oxygen, enteral feeds may accompany patients if they have been trained and assessed as competent

• Bariatric patients:To minimise or eliminate foreseeable handling risks to staff and patients, staff must ensure that specialist advice, equipment and aids for the bariatric patient is available to aid transfer. All patients assessed as being in excess of 160Kgs/25stone, or with a Body Mass Index (BMI) in excess of 30+ will be classed as bariatric


Appendix 1 cont’d Patient Transfer Handover Guidelines

Communication • Inform patient and ensure that needs are met e.g. language support, British Sign language

(BSL), Makaton etc • Check patient identity band present and correct • Inform Patient’s Significant other / Carer / Residential or Nursing Home if patient is leaving

the ward to go to another ward • Inform nurse in-charge of patient being transferred out • Confirm with receiving department / hospital acceptance of patient prior to leaving • Request porter and confirm time transfer required • Handover, verbally or in writing to the receiving area. • Convey patient’s infection status (if known) and current medication regime to the receiving

clinical area with the exception of emergency cases * • Convey patient’s infection status (if known) to patient transport with the exception of

emergency cases * • Convey the patient’s current medication regime to the receiving clinical area. The receiving

clinical area must ensure that medicines are available for the patient who has been transferred. Equipment

• Ensure all equipment required to aid transfer is in good working order • Patient in an Electronic functional bed with bed rails (if using bed for transfer • Check patient has all the medicines from their locker, in their green bag to take with them

Transfer of Patient Health Records Internal transfers The following documentation will accompany the patient as appropriate:

• The patient’s Health Record and relevant nursing documentation • Patient’s X-ray, Radiology and Ultrasound reports plus any other appropriate

documentation. • Drug prescription chart • If attending another department for a procedure, completed consent and operation checklist

Transferring Blood Components

When a patient is transferred across site: Blood components must not be transferred by clinical staff direct from the clinical area: The Blood Transfusion Laboratory must be contacted, who will then ensure that all necessary blood components are packaged correctly and that all the units can be traced in accordance with the Blood Safety and Quality Directive (2005).

When a patient is transferred within the same site: When red cells are transferred from one clinical area’s satellite blood fridge to another satellite blood fridge, within the same site, this should be carried out by the portering staff who will use a blood transport box to maintain the correct storage and handling conditions of the component. All other blood components transferred with the patient within the same site must be handled as per the Blood Transfusion Policy, and a full handover given to the receiving clinical staff. * For Critical Care patients only

Application of these guidelines is intended as a guide only it should not replace clinical judgment

Registered Nurse / midwife in charge needs to be made aware of all patient transfers, mode and support provided


Appendix 2 Transfer checklist of a patient for investigation / procedure

Collecting Porter/ Registered Nurse to complete: Mode of Transport: Please Complete of Affix Patient Label Surname: Forename:

Date of birth: Sex: Hospital Number: NHS Number:

Bed … Trolley … Chair … From ward/dept: Destination area:

Patient identity confirmed with patient and patient identity band present … To be completed by a Registered Nurse on the Ward: (Circle as appropriate) Patient mobility:

o Independent Yes No o Needs assistant Yes No o Identified as a risk of falling (Falls Assessment Completed) Yes No

If Yes, a nurse escort is required to escort the patient Is the NEWS score above 5 or a single parameter scoring 3 or more? Yes No If Yes, consider if it is appropriate for the patient to leave the ward. If appropriate a Registered nurse escort will be required to escort the patient. Does the patient require more than 24% Oxygen? Yes No If Yes consider if it is appropriate for the patient to leave the ward. If appropriate a Registered Nurse escort will be required to escort the patient. An NA may accompany a patient who is receiving prescribed ≤ 24% oxygen therapy and with a PAR score ≤ 1 if they have passed the NA competency in relation to oxygen therapy. Are there any Infusions/Transfusions/Catheters/Drains present? If Yes consider Yes No appropriateness of the transfer, making sure where transfer goes ahead equipment is safe. List infusions, blood transfusions, PCA-attach copy of infusion chart. Is the patient confused and/or at risk of wandering? Yes No If Yes, consider if it is appropriate for the patient to leave the ward. If appropriate an escort will be required. Does the patient require medication whilst away from the ward? Is Yes, send the patient with their medications and drug chart in a labelled pharmacy green bag, particularly if on the critical medicines list. Infection control: Are there any isolation precautions required? Yes No If Yes please state …………………………

Does the patient meet the Trust’s patient dress code? Yes No If No please discuss this with the patient before they leave the ward/dept. Has the patient any special communication needs? Yes No If Yes please state: ……………………………………………

Does this patient require a Nursing Assistant escort? Yes No Does this patient require a registered Nurse escort? Yes No

Outward journey Please print name & status with signature Qualified Nurse: ………………………… Porter: ……………………………………. Date: ……………… Time:………………

Return journey Has the patient’s condition changed from the above assessment?

Yes No If Yes, please contact the ward to discuss Name/Signature of person assessing:

Please file the completed checklist in the patient’s health records once returned to the ward

Appendix 3 Information for Inter-Hospital Patient Escorts

Welcome to Guy’s and St Thomas’ NHS Foundation Trust. This information sheet is for nurses who are escorting patients to and from our hospitals. The aim is to give you information to help you care for your patient during their visit. Primary responsibility for the patient’s care remains with you, but we will support and assist you in any way we can. Transport waiting area and Discharge Lounge When your patient has recovered from the procedure, you will be asked to wait for your transport either in the Discharge Lounge at St Thomas’ or in the clinical area or transport waiting area at Guy’s. If any of these areas are closed, the Site Nurse Practitioner (SNP) will arrange for you and your patient to wait in an area that allows you to continue to give your patient the care he or she needs.


If you are concerned about your patient’s condition at any time while you are waiting for transport, please ask the nurse in the area to help you contact the department where your patient was treated. If the department is closed, dial extension 3026 and ask the bleep operator to contact the Site Nurse Practitioner (SNP). • If it is a medical emergency - dial 2222 and state your location • In the event of a fire or security emergency - dial 3333 and state you location It is your responsibility to liaise with senior nurses in your base hospital if you are severely delayed in your return (in order to arrange relief or alternative arrangements).

Refreshments At St Thomas’: Main Entrance

• AMT Naturally Coffee • Marks & Spencer Store and Café • WH Smith • Shepherd Hall restaurant, ground floor, South Wing - offers a range of hot and cold snacks and meals (08:00 - 15:00)

Lambeth Wing: • Tom’s Café, Ground Floor

Evelina Hospital: • AMT Coffee, Ground Floor

At Guy’s: • AMT Coffee, main reception of Guy’s Tower - for drinks and snacks (24 hours)

If your patient would like refreshments, please ask the nursing staff in the area you are waiting in. A snack box can be provided if hot food is not available. The SNP is always available if you need support - dial extension 3026 and ask the bleep operator to contact the SNP.


Appendix 4 Patient Transport Contact Numbers & General Information

Locations and Hours of business:

Guy’s Hospital Ground floor, Tower Monday to Friday 7.30 a.m. and 10.00 p.m.

Guy’s Transport Office Ext. 82888 Fax 80074 St. Thomas’ Hospital

Lower ground floor, Lambeth Wing Monday to Friday

24hour St Thomas’ Transport Office Ext. 82888 Fax 84888

Contacts:

Imelda Brady Patient Transport Manager Ext. 84899 Fax 83545

Felicity Davies Discharge Lounge Ext. 82266 Out of hours arrangements: An on call manager is available outside these hours - contactable through the switchboard dial 0.

Please note from 6pm ambulances will be provided by agreed out of hours contractor with an agreed response time of up to 2 hours.

For car journeys (walking patients), vehicles are available 24 hours a day with a response time of within of up to 2 hours.

Free transport will continue to be provided for patients with a medical need.

Patients should be informed that they need to

call 020 7188 2888 for patient transport services on both sites.


Appendix 6 Patient Details

PTS Assessment / Booking Form Mr/Mrs/Ms/Miss:

A patient can only be assessed for PTS if they have no alternative means of transport to get them to or from hospital. Patient to score 4 points or more to be eligible for PTS - only one score from each category.

Criteria Points Fitness 1. No SOB or exercise restrictions Y/N 2. Limited 50 - 200 metres walking Y/N 3. Limited 0 - 50 metres walking Y/N Mobility 4. Walks unaided Y/N 5. Needs walking stick / zimmer Y/N 6. Travels in wheelchair Y/N 7. Stretcher Y/N Senses 8. All senses Y/N 9. Deaf / Registered Blind Y/N 10. Needs carer to action medical treatment Y/N

Mental Function 11. Learning disability/dementia/confusion Y/N General Health 12. Chronic ill health Y/N 13. Acute ill health Y/N 14. Leg(s) in full p.o.p. cast Y/N 15. Major surgery in the last 6 weeks Y/N

Surname:

Forename:

Telephone No.

Hospital No.

D.O.B.

Address from:

Post Code Address to:

Post Code

Appointment Date:

Appointment Time:

O/P Admission Single / Repeat Booking

Start Date:

Discharge Transfer

End Date:

16. Condition / procedure precludes driving Y/N TOTAL □ Escort: Y/N Escorts are only for those patients less than 16 years of age, are required to interpret or action medical treatment or where a patient may be confused. Name of person applying for assessment if different from patient:

Repeat Booking tick Accordingly Monday □ Tuesday □ Wednesday □ Thursday □ Friday □ Saturday □ Sunday □

Patient Mobility:

W1 Walker Car Suitable □ C1 Chair Single Crew Ambulance □

Relationship: C2 Chair Double Crew Ambulance□ C3 Chair Wheelchair Bound □

Contact Telephone No. S Stretcher Needs to lay down □ Requires O2 Y/N Quantity: Barrier nurse/Reverse barrier nurse Y/N

Assessment completed by: Notes Name: Signature:


Appendix 7

PRINCIPLE ISSUES:

Inter and Intra-hospital Transfer of Critical Care Patients

The transport of critically ill patients has logistical and clinical difficulties. Priority should be given to assessing potential risk, optimising physiological stability and ensuring preparedness for any likely event during the transfer. Classification of levels of patient care:

Level 0 - Needs can be met through normal ward in acute hospital Level 1 - Patients at risk of deteriorating, needing a higher level of care or

recently relocated from a higher level. Needs met on an acute ward with additional support

Level 2 - Patients needing more detailed observation / intervention. After

major surgery or with single organ failure

Level 3 - Patients requiring advanced respiratory support or basic

respiratory support with other organ system failure. Includes all complex patients in multi-organ failure

Common indications for transfer:

• Intra-hospital o Radiology o Operating theatre o Admission / discharge from A&E / HDU / ward

• Inter-hospital o Transfer between STH / Guy’s o Retrieval / repatriation from /

to regional hospitals o Transfer for specialist services eg. neurosurgery

Please refer to the document ‘Transfer and Handover of Patients - Procedure and Guidance’ for generic information on good practise in patient transfer. This appendix is a supplement with specific information for the critical care directorate

1. Communication and documentation

• Decision for transfer must be made by a critical care consultant in liaison with the parent / consulting team(s) and senior nursing staff

• Confirm transfer with receiving team and document contact name / number

• Communicate clinical history, drug history, infection status and active clinical problems

• Confirm bed / staffing availability at receiving site

• Liaise with portering staff / ambulance service (see ambulance transfer guide) as appropriate, communicating degree of urgency and other special requirements

• Communicate ETD / ETA, updated if any delays and confirm immediately prior to departure

• Documentation including case notes / discharge summary / PACS CD / investigation results / consent form / MRI checklist should be transferred with the patient as required

• A record of the transfer should be made using the dedicated ‘Critical Care Transfer Form’ - to be filed in the patient notes and carbon copy in dedicated box for audit purposes

• Next of kin (NOK) should be informed of all inter-hospital transfers and intra- hospital transfers where appropriate

2. Equipment and monitoring

• Equipment should be equivalent in function to that available within the

ICU environment (see suggested equipment list)

• The shift manager should delegate an individual to check transfer equipment

at the beginning of each shift and it should be rechecked prior to transfer

• Monitoring should adhere to the AAGBI standard [4] with attention paid to portability and battery life

• Transfer shelving stacks and pre- packed transfer bags are available and

are recommended. • Consider duration of transfer with respect to requirements for oxygen /

drugs and battery life • Draeger Oxylog 3000: battery life 4 hrs, internal gas consumption 0.5l/min


• Viasys Vela: battery life 6hrs. Note high gas consumption due to bias flow

(add 10l/min to MV) 3. Personnel

In discussion with the senior nursing / medical staff, the following recommendations are made. A Nurse led transfer service will be developed in 2011 - 12 and this guideline will be updated accordingly in time. Until such time:

• Level 1 - minimum one nurse with at

least six months experience • Level 2 - minimum one nurse with a

post-registration critical care course or a minimum of 18 months of experience in critical care and the ILS course

• Level 3 - minimum of two personnel one of whom must be a medical practitioner. They should have appropriate training in intensive care medicine, anaesthesia or other appropriate acute specialty. They should be competent in resuscitation, airway management, ventilation and other organ support. Previous experience and training of transportation in a supernumerary capacity should have been undertaken demonstrating competence in transport medicine and they should be familiar with transport equipment. This will commonly be a trainee. The accompanying person should have appropriate experience - Band 6 / post-registration critical care qualification recommended (or may be an ODP) - but ultimately at the discretion of the senior nursing / medical staff.

• The critical care department is responsible for providing the medical staff to conduct the majority of transfers, however in certain circumstances the assistance of the anaesthesia department may be requested (bleep 0153). The on-call consultant should provide advice and assistance where required

• Physiologically stable patients, self ventilating via a tracheostomy may be transferred by a nurse alone, provided they have appropriate experience - Band 6 / post-registration critical care qualification recommended - but ultimately at the discretion of the senior nursing / medical staff.

• It is the responsibility of the operator looking after the airway (anaesthetist

or senior nurse for bed-to-bed transfers) to re-establish the patient on mechanical ventilation after any transfer. Ensure that anaesthetic cover is present on ICU when transferring between bed spaces

• During transfers for interventions the transferring staff should remain with

the patient at all times unless care has been explicitly handed over to eg. the anaesthetic team

4. Logistics

• Non-emergency patient transfer should be avoided out of hours wherever possible. Consideration should be given to availability of staffing and disruption to other critical care services

• The nurse in charge should liaise with portering staff / ambulance service

• The decision for use of blue lights / sirens rests with the ambulance service after advice from the transferring staff. In general, priority should be given to safety and smoothness of transfer rather than absolute speed

• It is not the responsibility of ambulance crew to return medical and nursing escorts. If necessary alternative transport should be arranged by the nurse in charge of the transferring unit

• Relatives should not travel in the ambulance with escort personnel


BLOOD PRODUCTS:

Refer to GST ‘Blood Transfusion Clinical Policy: procedure and guidance document’

Summary: • Intra-hospital transfer

o Blood products other than those for immediate use during transfer should not be transferred between clinical areas by clinical staff. Products attached to patient require full handover to receiving staff

• For patients going to theatre i) request transfusion lab to send products to receiving site satellite fridge OR ii) request porter transfer of blood products from ICU satellite fridge to the receiving area in blood transport box OR iii) anaesthetic team request products from transfusion lab as per normal procedure.

• Interventional radiology is covered by the ‘angiopack’ as the unit does not have a satellite fridge. Contact transfusion lab with patient details and request ‘angiopack’. Products will be appropriately packed by the lab for storage up to 4 hours.

• Interhospital transfer (inc between

Guy’s / STH) o Blood products other than those for immediate use during transfer should not be transferred between clinical areas by clinical staff. Products attached to patient require full handover to receiving staff o Request transfusion lab to ensure blood products available at receiving site o If high probability of need for products during transfer inform transfusion lab who will package appropriately and issue transfer documentation

Blood products transferred with patient from elsewhere

• Inform transfusion lab, send unopened transport box to lab and take samples

for group and save • If products required immediately i) if packed correctly blood can be

transfused ii) if not packed correctly DO NOT TRANSFUSE - request crash blood

MRI transfers

• Critical care patients should only use the ECH MRI scanner (Ext: 89211) / Guy’s MRI (Ext: 84118) where an anaesthetic machine / monitoring exists

• MRI transfers should only be undertaken by senior medical / nursing staff with prior experience of MRI

• Contact ODP (STH: bleep 0177 or out of hours bleep 0185 / Guy’s via MRI Ext: 84118) and request assistance

• Complete MRI safety checklist for patient and staff - discuss with MRI for patients without capacity to complete

• Remove all metal objects from own person and patient

• The blue floor area in ECH MRI is outside the 5 Tesla area

• Use 3 IV extensions for all infusion pumps to enable pumps to remain outside 5 Tesla area

• Conduct patient transfer to MRI compatible trolley, monitoring, ventilator etc. in anaesthesia induction area / ECH scanning room in blue floor area. Ensure slave monitor in control room is functioning; set HR to sense from SpO as ECG is unreliable 2

• Confirm sufficient length of breathing circuit / IV lines for expected table movement

• Apply ear protectors even for sedated patients

• In liaison with MRI staff, in the event of an untoward event discontinue scan and return patient to outside 5 Tesla area for assessment and treatment


SPECIFIC CIRCUMSTANCES:

Neurosurgical transfers • See Reference 9 for comprehensive guidance • Initial referral should be to King’s College Hospital Neurosurgical SpR via switchboard. • Transfer is time critical with the aim of time from injury to surgery of < 4hours • Transferring staff should have knowledge and training in the care of patients with brain injury

Clinical guidelines for patients with severe head injury

• Indications for referral to neuro centre

o Post resuscitation GCS ≤ 8 / deteriorating GCS o Intra-cranial haematoma with mass effect o Diffuse brain injury with evidence of raised ICP o Compound / base of skull fracture o Progressive neurological signs / seizures without full recovery o Penetrating injury o CSF leak

• Indications for intubation

o GCS ≤ 8 / deteriorating GCS (ie. decrease in motor score ≥ 2) o Loss of protective laryngeal reflexes o Altered gas exchange

eg. PaO2 <13kPa on O2 PaCO2 >6 kPa or <4.0 kPa

o Threat to airway from trauma o Seizures

• The following should be addressed

o Maintain 20° head up tilt and avoid other causes of venous congestion o Following intubation maintain sedation +/- muscle relaxation o Avoid the internal jugular route for central venous lines o Maintain spinal precautions with three point

immobilisation and log rolling until spinal injury excluded

o Monitoring should include regular checks of GCS / pupils as appropriate o Avoid hypotonic fluids. o Reserve osmotherapy unless evidence of

severe intracranial hypertension and discuss with neurosurgeons

o The following targets are commonly accepted: ƒ PaO2 ≥ 13 kPa

� PaCO2 4.5 - 5.0 kPa � MAP ≥ 80mmHg � Hb ≥ 10g/dl � Glucose 4-8mmol/l � Normothermia

• Establishing cardio-respiratory stability should take precedence over immediate transfer to the neurosurgical unit


As with all transfers and in accordance with hospital policy patients must have identity (and allergy if required) bracelets in situ during transfer. Patient dignity should be maintained throughout the process.

Equipment list for critical care transfers ;

(these guidelines should be adapted for the individual requirements) • Portable mechanical ventilator …

• Oxygen cylinders (estimate requirements then multiply by two) …

• Portable suction …

• Syringe / volumetric pumps (with adequate battery capacity) …

• Self inflating bag, mask and ‘Waters’ circuit …

• Intubation and tracheostomy equipment …

• Venous access equipment …

• Chest drain equipment …

• Monitor (with adequate battery capacity / spare batteries) …

• Defibrillator …

• Drugs - sedation, analgesia, muscle relaxants, ino-pressors, others may include

electrolytes, insulin, mannitol etc. Minimise non-essential infusions where possible …

• Emergency resuscitation drugs …

• IV Fluids / blood products as per hospital policy …

• Documentation including case notes, discharge summary, PACS CD, investigation results,

consent form, MRI checklist as indicated …

• Mobile telephone, money and appropriate clothing …

Intra / Inter-hospital Critical Care Transport Checklist ;


CONSULTANT DECISION TO TRANSFER : with agreement of consulting team(s) and senior nursing staff

COMMUNICATE : with the following and document as appropriate • receiving site … / transferring staff … / porters … / London Ambulance Service … / NOK …

ASSESS STABILITY FOR TRANSFER • Determine patient level (1/2/3) and requirement for medical / nursing staffing to transfer … A ‐ Consider need for intubation. Assess ETT length, patency and secure tube … B ‐ Perform clinical exam and ABG. Stabilise on transfer ventilator. Consider mandatory mode … C ‐ Resuscitate if unstable. Additional IV fluids / vasoactive drugs available. Adequate IV access (peripheral line or vascath for CT contrast) … D ‐ Consider increasing sedation / muscle relaxation. Head injury guidelines met if appropriate … E ‐ Stop enteral feed / insulin, aspirate NGT, monitor glucose. Discontinue RRT and confirm electrolytes safe. Maintain normothermia … DO NOT TRANSFER IF PHYSIOLOGICALLY UNSTABLE UNLESS ABSOLUTELY NECESSARY.

ASSESS FULLY AND STABILISE AS REQUIRED

MONITORING • ECG / NIBP / Sa02 as minimum. Invasive monitoring as indicated …

• ETCO2 mandatory if invasive ventilation … EQUIPMENT see equipment list • Appropriate equipment available / checked (transfer stacks and bag recommended) …

• Consider transfer duration with respect to O2 / drugs / battery life …

• Ensure monitoring / tubes / lines / drains are secured … DOCUMENTATION as required • notes … / DC summary … / PACS CD & investigation results … / consent … / MRI

TRANSFER PATIENT

POST TRANSFER • Replace used equipment and reseal transfer bag with red safety tag• Plug in pumps, monitor & ventilator to recharge• Report faulty equipment to ICU technical support staff

COMPLETE CRITICAL CARE TRANSFER FORM - WHITE COPY IN NOTES / CC IN AUDIT BOX

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