CHHS18/139

Canberra Hospital and Health ServicesOperational ProcedureUniversity of Canberra Hospital (UCH) - Patient Escort and Transport Contents

Contents....................................................................................................................................1

Purpose.....................................................................................................................................3

Alerts.........................................................................................................................................3

Scope........................................................................................................................................ 3

Section 1 – Escorting patients within UCH (Intra-Hospital).......................................................4

Medical Officer Escort Criteria..............................................................................................4

Registered Nurse Escort Criteria...........................................................................................4

Documenting the decision not to escort the patient............................................................5

Hydrotherapy/Therapy Spaces outside the Inpatient units..................................................5

Section 2 –Inter-facility Transport from UCH to another hospital............................................5

For Clinical Deterioration:.....................................................................................................5

Section 3 – Transfer of Patients to UCH....................................................................................6

Transfer Procedure...............................................................................................................6

Section 4 – Transfer of Patients for appointments...................................................................7

Transfer Procedure for appointments...................................................................................7

Section 5 – Patient Transport....................................................................................................7

RACC Patient Transport Bus..................................................................................................7

Section 6 – Other transport options..........................................................................................8

Emergency Transport............................................................................................................8

Non-Emergency Patient Transport (NEPT)............................................................................8

Patient Transport Vehicle (PTV)............................................................................................8

Government Car/Taxi/Private Car.........................................................................................8

Section 7 – Medical Emergency during transport.....................................................................8

Implementation........................................................................................................................ 9

Related Policies, Procedures, Guidelines and Legislation.........................................................9

References................................................................................................................................ 9

Definition of Terms...................................................................................................................9

Doc Number Version Issued Review Date Area Responsible PageCHHS18/139 1 27/04/2018 01/07/2019 RACC 1 of 10

Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register

CHHS18/139

Search Terms.......................................................................................................................... 10

Doc Number Version Issued Review Date Area Responsible PageCHHS18/139 1 27/04/2018 01/07/2019 RACC 2 of 10

Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register

CHHS18/139

Purpose

This operational procedure outlines the requirements for intra-facility nurse escort, inter-facility escort, and patient transport options of inpatients at the University of Canberra Hospital (UCH) within the rehabilitation units: To ensure that patients are transported safely and efficiently within the hospital campus To ensure that patients are transported safely and efficiently externally to the hospital

This operational procedure does not limit patients moving freely about the hospital or external to the hospital if they are safe to do so.

This operational procedure should be applied when a patient is: Moving from one destination to the other for a clinical investigation or therapy When a clinical handover would be expected.

This policy does not apply to Gate Leave for patients. This policy does not apply to patients within the UCH Adult Mental Health Rehabilitation Unit.

Back to Table of Contents

Alerts

1. Every patient to be transferred from a hospital to the RACC units at UCH will be required to have a clinical screen prior to transfer to ensure they still meet the admission criteria and requirements for medical stability. This clinical screen can be undertaken by the RACC Medical Officer, Canberra Hospital Acute Subacute Early Rehabilitation Service (CHASERS) team, Rehabilitation Care Coordinator, Clinical Nurse Consultant (CNC) or After Hours Hospital Manager (AHHM).

2. UCH will have contracted staff providing ward/patient support services and portering. The terms Patient Support Officer and wardsperson may be read as interchangeable through the document.

Back to Table of Contents

Scope

This document applies to all UCH staff, working within their scope of practice: Medical Officers Registered and Enrolled Nurses Assistants in Nursing Allied Health Allied Health Assistants Administration Officers Patient Support Officers

Doc Number Version Issued Review Date Area Responsible PageCHHS18/139 1 27/04/2018 01/07/2019 RACC 3 of 10

Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register

CHHS18/139

Back to Table of Contents

Section 1 – Escorting patients within UCH (Intra-Hospital)

Within UCH there are minimal destinations to escort a patient to. The likely destinations are Inpatient units, Medical Imaging, Hydrotherapy and to a Car Park for further transport via a vehicle.

All patients requiring transport within the hospital campus will be escorted by an appropriately qualified person, unless an escort is deemed unnecessary according to the criteria within this policy and the professional judgement of the Medical Officer, Registered Nurse or CNC who is responsible for the patient.

The Medical Officer or Registered Nurse who is responsible for the patient or the CNC will make the decision and take responsibility regarding the need for an escort, the skill level of the escort and the number of people required to perform the escort safely (i.e. Medical Officer, Registered Nurse, Registered Midwife, Enrolled Nurse, Patient Support Officer or Allied Health).

Medical Officer Escort CriteriaA patient must have a Medical Officer escort if one or more of the following criteria is met: Patient has a Modified Early Warning Score (MEWS)/ Early Warning Score (EWS) ≥6 Any patient transported as a result of a Medical Emergency/ Hospital Emergency

Response Officer (HERO) call Any clinical instability as decided by the Medical Officer attending the patient.

Registered Nurse Escort CriteriaA patient must have a nurse escort if one or more of the following criteria is met: Patient has a MEWS/EWS in the range of 3-5 Patient has received intravenous narcotics or sedation in the previous one (1) hour Patients has intravenous infusions with medications added in progress Patient has drains in situ Patient has a tracheostomy Patients with an altered Glasgow Coma Score (GCS), combative, physically restrained or

requiring 1:1 nursing for any reason The sending nurse is unable to give a handover to a Nurse over the phone in the

receiving area The patient is in a hard collar or needs spinal precautions The patient has received a drug that has potential effect on central nervous system e.g.

Morphine, Fentanyl, taking in to account the clinical situation. Patients who take these drugs orally or in a transdermal patch on a daily and long term basis for chronic pain may not need an escort.

The patient has communication barriers, e.g. deaf, blind, mute or speaks limited English

Doc Number Version Issued Review Date Area Responsible PageCHHS18/139 1 27/04/2018 01/07/2019 RACC 4 of 10

Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register

CHHS18/139

Documenting the decision not to escort the patient Document the decision in the patient’s clinical record if the patient is assessed as not

requiring a nursing or medical escort Document the name of the nurse that has received the handover over the telephone in

the receiving area.

Hydrotherapy/Therapy Spaces outside the Inpatient units If a patient is approved to use hydrotherapy as part of their therapy program and they do

not meet any of the above criteria then they may be escorted to Hydrotherapy by Allied Health Professionals, Allied Health Assistants or the Patient Support Officer.

If a patient is approved to attend other therapy spaces outside the inpatient units, such as the computer room, as part of their therapy program and they do not meet any of the above criteria then they may be escorted to by Allied Health Professionals, Allied Health Assistants or the Patient Support Officer.

This decision does not need an entry in the clinical record at each event.

Back to Table of Contents

Section 2 –Inter-facility Transport from UCH to another hospital

Note: Where possible the patient and or the patient’s family must be consulted and consent obtained at each stage of the transfer process.

For Clinical Deterioration: 1. The decision to transfer a patient to another hospital is made after:

Consideration of the level of definitive clinical care, equipment and infrastructure required to care for the patient;

An assessment of the potential risks and benefits to the patient is made; The Senior Treating Doctor, or equivalent, of UCH has been consulted and involved in

the decision; and The accepting Specialist at the receiving hospital has been consulted and confirmed

they are accepting care, AND the bed management unit at the receiving hospital has confirmed that a bed is ready and its location.

In the event that transfer to an emergency department(ED) is intended, then the Senior Doctor in that ED must be contacted to discuss, and confirm acceptance. The patient should be transferred to the closest clinically appropriate ED.

2. Responsibility for the care of the patient prior to transfer remains with the: Senior Treating Doctor whose care the patient has been admitted under

3. Prior to transfer, the referring Senior Treating Doctor will: Contact Senior Specialist in the receiving Admitting Team Determine transfer urgency rating in consultation with the receiving Specialist

4. The Medical Officer, UCH Assistant Director Of Nursing (ADON), CNC or AHHM will: Contact receiving hospital’s bed management to arrange a bed

Doc Number Version Issued Review Date Area Responsible PageCHHS18/139 1 27/04/2018 01/07/2019 RACC 5 of 10

Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register

CHHS18/139

Contact ACT Ambulance Service to arrange transport for any patient that requires clinical support en route. See section 5 and 6 for alternative transport options or

Contact appropriate transport options if patient travelling interstate. 5. It is the responsibility of the Medical Officer, Registered Nurse and Allied Health

professional to give a clinical handover to the corresponding accepting team or inpatient unit.

6. The Medical Officer will be required to complete the discharge summary. The Registered Nurse will be required to fill in the patient transfer form. If a patient is being transferred to Canberra Hospital then their clinical record may

be sent with the patient. The policy for transport of clinical records should be followed (see Clinical Records Management Policy).

7. If the patient is being transferred to Calvary Public Hospital, Bruce or another hospital, provide copies of appropriate documentation to accompany the patient, which must include the following: patient notes as appropriate details for next of kin emergency contact details investigation results physiology records contact details of referring and receiving doctor.

Considerations: Ensure the transfer is made in a timeframe that is appropriate to the degree of clinical

urgency, as the system permits, source appropriate modes of transport and provide an accurate estimated time of the patient’s arrival

Determine the appropriate form of clinical transportation and level of supervision for the patient in consultation with the receiving Senior Treating Doctor and retrieval service or the Ambulance Service Clinician, as appropriate

If agreement cannot be reached regarding the transfer urgency of a patient the referring Senior Treating Doctor will refer this matter to their clinical line management

Ensure transfer is approved at both the referring and receiving hospitals prior to transfer.

Back to Table of Contents

Section 3 – Transfer of Patients to UCH

Transfer Procedure1. The decision to admit/transfer a patient will be made following the UCH: Admission and

Eligibility Operational Procedure2. The transferring hospital should follow their patient transport policy 3. UCH will have a limited capacity to facilitate transport from another hospital to UCH via

the UCH Patient Transport Bus, please see section 54. Assessment for patient suitability for the UCH Patient Transport Bus will be made during

the clinical screen prior to transfer and in collaboration with the referring medical team

Doc Number Version Issued Review Date Area Responsible PageCHHS18/139 1 27/04/2018 01/07/2019 RACC 6 of 10

Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register

CHHS18/139

5. Once the patient has been deemed as suitable, the UCH ADON, AHHM or CNC of receiving ward will negotiate an admission time with the transferring ward

6. If UCH is able to assist with transferring the patient to UCH, in a UCH vehicle, the Canberra Hospital Access Unit and transferring ward will be notified by the UCH ADON, AHHM or CNC. The transport of patients from other health facilities to UCH for admission will remain the responsibility of the sending facility.

7. If UCH is able to assist with transferring the patient to UCH, the provision of an escort to accompany the patient will be negotiated with the Access Unit depending on which hospital has capacity to provide one.

Back to Table of Contents

Section 4 – Transfer of Patients for appointments

Transfer Procedure for appointments1. The decision to transfer a patient for an appointment off-site will be made, after

assessment of the potential risks and benefits to the patient via a consultative discussion with the Medical Officer and multi-disciplinary team

2. The type of transport that is suitable for each patient should be determined by the Medical Officer and documented in the clinical record

3. Prior to leaving the inpatient unit the patient should have a MEWS recorded and the Medical Officer or the CNC will make the decision and take responsibility regarding the need for and professional level of an escort.

Back to Table of Contents

Section 5 – Patient Transport

RACC Patient Transport BusRACC has a patient transport bus (PTB) and driver that is available during business hours.

The PTB has capacity to transport seated patients and one patient in a wheelchair. A patient’s suitability for the PTB should be determined by the Medical Officer and

documented in the clinical record. All inpatients who are transported via the PTB must have a clinical staff member in

attendance in the back of the bus as the driver does not have sufficient visibility over the patient and should not be distracted from driving.

The staff member must be current in Basic Life Support and have had orientation to the PTB.

The clinical staff member may be a Registered Nurse, Enrolled Nurse, Assistant in Nursing, Allied Health Professional, Allied Health Assistant or Medical Officer.

Prior to leaving the inpatient unit the patient should have a MEWS recorded and the Medical Officer or the CNC will make the decision and take responsibility regarding the professional level required for an escort.

To book the RACC PTB:

Doc Number Version Issued Review Date Area Responsible PageCHHS18/139 1 27/04/2018 01/07/2019 RACC 7 of 10

Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register

CHHS18/139

CNC or Team Leader to contact the UCH Nursing Support Officer and advise of time that the transport is needed, destination and what escort will be provided.

UCH Nursing Support Officer will liaise with driver to confirm transport.

Back to Table of Contents

Section 6 – Other transport options

Emergency TransportFor emergency situations such as a Code Blue, or for urgent hospital transfers, the ACT Ambulance Service should be contacted on 0-000 for assistance with transferring the patient to another hospital.

Non-Emergency Patient Transport (NEPT)For non-emergency patient transfers, the ACT Ambulance Service may be called on 02 6200 4126 for assistance to transfer the patient to another hospital or to an appointment.

Patient Transport Vehicle (PTV)For patients who require transport via the PTV this can be booked via the Canberra Hospital Access Unit on extension 43247 during business hours or 42654 after hours.

Government Car/Taxi/Private Car Patients may travel via government car or via taxi with a clinical staff member with

approval by the Medical Officer Patients may travel via private car with their family to appointments or between

hospitals with approval by the Medical Officer Prior to leaving the inpatient unit the patient should have a MEWS recorded and the

Medical Officer or the CNC will make the decision and take responsibility regarding the professional level required for an escort.

Back to Table of Contents

Section 7 – Medical Emergency during transport

If a medical emergency or code blue occurs during transit then the driver will:1. Stop the vehicle in a safe location2. Assess the patient and call ACTAS3. Commence Basic Life Support as appropriate and as able.

Back to Table of Contents

Implementation

This procedure will be communicated to staff on orientation to UCH and be available on the Policy Register.

Doc Number Version Issued Review Date Area Responsible PageCHHS18/139 1 27/04/2018 01/07/2019 RACC 8 of 10

Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register

CHHS18/139

Back to Table of Contents

Related Policies, Procedures, Guidelines and Legislation

Policies Clinical Records Management Policy

Procedures UCH: RACC Admission and Eligibility Operational Procedure Clinical Handover Procedure Inter Hospital Transfer – Non Critical Patients Patient Escort and Transport within Canberra Hospital campus

Legislation Health Records (Privacy and Access) Act 1997 Human Rights Act 2004 Work Health and Safety Act 2011

Back to Table of Contents

References

1. Statutory Rules 2016: Non-Emergency Patient Transport Regulations 2016, Victoria2. Non-emergency patient transport: Clinical practice protocols: Victoria State Government3. Service Specifications for Transport Providers: Non-Emergency Patient Transport, NSW

Government4. Non-Emergency Patient Transport Ambulance Service Policy, ACT Ambulance Service

Back to Table of Contents

Definition of Terms

CHASERS: Canberra Hospital Acute Subacute Early Rehabilitation Service

Gate Leave: When a patient is granted short term leave from the hospital. This leave may be overnight. The patient remains an admitted patient of the hospital during this time.

Inter-Hospital Transfer: Transfers that occur between two hospitalsIntra-Hospital Transfer: Transfers that occur within a hospital

Back to Table of Contents

Search Terms

UCH, Transport, Escort, Nurse Escort, RACC, Inter facility, Intra facility, Transfer

Doc Number Version Issued Review Date Area Responsible PageCHHS18/139 1 27/04/2018 01/07/2019 RACC 9 of 10

Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register

CHHS18/139

Disclaimer: This document has been developed by ACT Health, Canberra Hospital and Health Services specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.

Policy Team ONLY to complete the following:Date Amended Section Amended Divisional Approval Final Approval 18/04/2018 New Document Linda Kohlhagen, ED

UCHCHHS Policy Committee

This document supersedes the following: Document Number Document Name

Doc Number Version Issued Review Date Area Responsible PageCHHS18/139 1 27/04/2018 01/07/2019 RACC 10 of 10

Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register