Internal Patient Transfer Escort Policy - · PDF filePatient Transfer and Escort Policy v2 Policy No: OP84 Version: 2.0 Name of Policy: Internal Patient Transfer and Escort Policy

Patient Transfer and Escort Policy v2

Policy No: OP84

Version: 2.0

Name of Policy: Internal Patient Transfer and Escort Policy

Effective From: 07/09/2015

Date Ratified 12/08/2015

Ratified SafeCare Council

Review Date 01/08/2017

Sponsor Director of Nursing, Midwifery and Quality

Expiry Date 11/08/2018

Withdrawn Date

Unless this copy has been taken directly from the Trust intranet site (Pandora) there is no assurance that

this is the most up to date version

This policy supersedes all previous issues

Patient Transfer and Escort Policy v2 2

Version Control

Version Release Author/Reviewer Ratified

by/Authorised

by

Date Changes

(Please identify page no.)

1.0

19/09/2014 Faye Butler SafeCare

Council

10/09/2014

2.0 07/09/2015 Julie Jones /

Caroline Lane

SafeCare

Council

12/08/2015 Adding in reference to

SBAR transfer form


Contents

Section Page

1 Introduction .................................................................................................................................. 4

2. Policy scope .................................................................................................................................. 4

3. Aim of policy ................................................................................................................................. 4

4 Duties (roles and responsibilities) ................................................................................................ 4

5 Definitions of terms ...................................................................................................................... 5

6 Process for transfer ...................................................................................................................... 6

7 Providing an escort for transfer ................................................................................................... 7

8. Training ......................................................................................................................................... 8

9. Equality and diversity ................................................................................................................... 8

10. Monitoring compliance with the policy ....................................................................................... 8

11. Consultation and review .............................................................................................................. 9

12 Implementation of policy ............................................................................................................. 9

13 References .................................................................................................................................... 9

Appendices

Appendix 1 (In-patient SBAR Transfer form) ............................................................................................ 10

Appendis 2 (Critical Care transfer form) ................................................................................................... 11-12

Appendix 3 (Antenatal & Postnatal Handover of Care) ............................................................................. 13-15

Appendix 4 (Patient Escort QE Site Quick Reference Guide) .................................................................... 16


Patient Escort Policy

1 Introduction

Gateshead Health NHS Foundation Trust is committed to the provision of high quality health care in

all aspects of its services to patients and staff. There are many occasions when a patient needs to

be transferred in the hospital to other wards or departments and which may require escort. This

policy is therefore intended to offer safeguards and guidance to ensure staff and patient safety

throughout the transfer process.

2 Policy scope

This Policy applies to all “health care professionals” working within Gateshead Health NHS

Foundation Trust involved in the assessment of patients to determine the need for escort during

transfer within the hospital. It provides clear guidance and instruction to all staff with regard to the

transfer and escort of adult and paediatric patients within and across the Queen Elizabeth Hospital

site.

All staff using this policy should ensure that the basic principles of respect, explanation, privacy and

dignity apply to all patients in the transfer setting. They must use this policy in conjunction with a

range of existing good practice guidance from professional bodies and existing Trust policy with

particular reference to:

• Bed management, patient transfer and escalation plan (OP33)

• Safeguarding patient privacy and dignity (OP29)

• Manual handling policy (RM06)

• Control of infection policy (IC01)

• Personal protective equipment (IC02)

• Hand hygiene policy (IC04)

• Safeguarding adults policy (OP75d)

• Safeguarding children policy (OP75a)

• Resuscitation policy (RM27a)

Outside of this policy is the transfer of children as there is a Regional Policy for this. When

transferring paediatric patients to longer term care, usually at either Newcastle Upon Tyne

Hospitals or City Hospitals Sunderland, this policy should be followed.

The escort section of the policy should be followed for all patients within QE Gateshead, including

paediatric, maternity services and mental health.

3 Aim of policy

The key aims of this policy are to ensure the safe transfer of patients between wards and

departments. In addition it will support the safety of those patients who will be spending time in

other departments away from their ward base with or without an escorting healthcare professional

or assistant. It will also provide clear guidance for staff that will ensure staff and patient safety. It

applies to all transfers, both in and out of normal working hours.

4 Duties - roles and responsibilities

The Trust Board:

The Trust has ultimate responsibility for providing effective healthcare services to patients. They

are responsible for ensuring there is support available to ensure the safety and wellbeing of

patients in our care.


The Chief Executive:

The Chief Executive is ultimately responsible for ensuring effective corporate governance within the

organisation and therefore supports the Trust-wide implementation of this policy.

Trust Managers:

Managers are responsible for ensuring all members of staff understand how the In-patient Transfer

Policy applies to them and their patients. Managers are also responsible for ensuring that where

necessary, local procedures are developed, to support the implementation of this policy. Managers

should review the effectiveness of the implementation of this policy, and take appropriate remedial

action when they become aware of any acts or omissions that contravene it.

Healthcare professionals:

Once the decision to transfer a patient is agreed, it is the responsibility of the clinician in charge of

the patient to assess the needs of the patient and make an informed decision regarding their escort

needs during transfer prior to authorising their departure from the clinical area.

The healthcare professional is responsible for undertaking a pre transfer assessment before a

patient leaves a clinical area, this is to determine if a nurse escort is required, and to take

appropriate steps to obtain one, All healthcare professionals must therefore demonstrate an

appropriate understanding of the escort requirements and the procedure for reporting concerns.

All Nursing /Medical staff transferring /escorting patients:

• Familiarise themselves with this policy, its contents and appendices

• Ensure that prior to transferring or escorting a patient transfer they have been given

adequate information regarding the patient to be able to care sufficiently for them during

the process.

• Provide effective care for the patient during transfer by being aware of the patients’

condition and current needs.

• Maintain the patient’s dignity and respect throughout.

• Registered Nurses/Midwives are personally accountable for their own safe practice, actions

and omissions as outlined in the NMC Code.

• Medical staff are personally responsible for their own safe practice, actions and omissions

as outlined in GMC duties of a Doctor/ good medical practice.

• Nursing Assistants and Pre-registered nurses should only undertake patient transfer if basic

life support training is complete and up to date and when it has been deemed appropriate

to their duties by their Ward/unit manager. This can be delegated to the nurse in charge on

a day to day basis.

All non–clinical staff (e.g. porters) escorting patients:

• Familiarise themselves with this policy, its contents and appendices

• Ensure that prior to escorting a patient transfer they have been given any necessary

information regarding the patient to be able to safely transfer.(e.g. any infection control

risks, mode of transfer, escort requirements)

• Maintain the patient’s dignity and respect throughout.

• Familiarise themselves with emergency telephone numbers and location of receiving area.

5 Definitions of Terms

Clinician – any qualified member of staff with the knowledge, skill and competency to assess the

patients’ requirement for escort. Within this policy, clinician refers to all clinical staff including

doctors, nurses and midwives. Where it is stated the “clinician in charge” or the “clinician


coordinating” this refers to the person who is caring for the patient and responsible for making the

arrangements for transfer, in most cases this will be the registered nurse or midwife.

Transfer of care – when it is deemed appropriate to move the care of a patient from one area to

another based upon the needs of the patient receiving the right care in the right place.

Escort – defined as “to accompany a person for protection with regards to safety and psychological

wellbeing during transfer from one area to another.” (Oxford Illustrated Dictionary.)

The escorting member of staff has a responsibility to ensure that the patient is safe throughout the

transfer and that their immediate physical and psychological needs are met. Any person involved in

the transfer of a patient should have the necessary knowledge, skills and experience to be able to

achieve a safe transfer.

Health care professionals – any staff group responsible in the assessment process regarding the

decision to escort.

Levels of Care for Adult and Paediatric patients – this refers to the intensity of nursing care required

by the patient.

The following levels of care have been taken from the Intensive Care Society Standards (ICS)

published in 2002 and Paediatric Intensive Care Standards (2001):

• Level 0 Patients whose needs can be met through normal ward care in an acute hospital.

• Level 1 Patients at risk of their condition deteriorating, or those recently relocated from

higher levels of care whose needs can be met on an acute ward with additional advice and

support from the critical care team.

• Level 2 Patients who require more detailed observation or intervention. This may include

support for a single failing organ system or postoperative care, and those stepping down

from higher levels of care.

• Level 3 Patients who require advanced respiratory support alone, or basic respiratory

support together with support of at least two organ systems. This level includes all complex

patients requiring support for multi – organ failure.

6 Process for transfer

6.1 Patients’ should only be transferred between 09.00 hrs. – 22.00 hrs. with the exception of

those patients being transferred based on clinical need or from assessment units such as

Coronary Care, Critical Care or Accident and Emergency to a base ward. It is only in

exceptional circumstances that the transfer of patients will occur outside of these times

including protected meal times.

6.2 When a patient is being transferred from one clinical area to another within the

organisation, it is vital that the patient is placed according to clinical need, paying particular

attention to the issues related to infection control and privacy and dignity.

Prior to a patient being transferred the transfer must be discussed and explained to the

patient, relatives and carers as appropriate.

When a patient is transferred from one ward to another a short verbal handover,

conducted by a registered nurse, from the sending ward using the SBAR format, will be

completed. The handover will be received by a registered nurse completing In Patients

Transfer Form based upon a SBAR handover (Appendix 1). This must take place prior to

transfer and include a recent NEWS Score / observations taken.


When a patient is being transferred from the Critical Care Department to a base ward then

a Critical Care Transfer sheet must be completed by Critical Care staff (Appendix 2)

It is the responsibility of the nurse in charge / deputy to establish if an escort is required

based on the patients clinical and nursing needs.

For maternity services the transfer of patients should be documented on their own

documentation (Appendix 3a, 3b & 3c).

The boarding or outlying of patients should be avoided as far as possible; however there

are times when such activity becomes a necessary part of managing emergency admissions

and maintaining patient flow. The decision to board will be coordinated by the Duty

Matron and the Bed Management Team following discussion at the Bed Meetings held

daily. For further information refer to policy OP 33. Patients should only be subjected to

one additional move as a boarder or outlier during their hospital episode when this is not

directly related to their clinical management plan.

7 Providing an escort for transfer

7.1 Prior to the transfer of patients within the QE site, an assessment of potential risk, using

clinical judgement and policy guide must be undertaken to ensure the patient is escorted

and transferred safely without harm. This policy and its supportive appendices aim to

ensure safe and appropriate transfer and escort of a patient and reduce risks by:

• Providing guidance on patient assessment prior to transfer

• Provide guidance for making the correct decisions regarding appropriate escort and

mode of transfer

• Allocation of appropriate escort to maintain patient safety during transfer

7.2 The registered nurse must use their clinical judgement to make an appropriate assessment

of the patients’ clinical condition to determine if an escort is required and to ensure the

escort is able to care for the patient during transfer.

7.3 Nurses should use the quick reference guide (Appendix 4) to assist with making this

decision if required.

7.4 A registered Nurse Escort however MUST be provided if any of the following apply:

• The Patient is causing clinical concern

• The patient has had a recent NEWS/PEWS trigger

• The patient has a potential risk to airway

• E.g. post op / post procedure / post sedation / recent seizures or vomiting)

• The Patient has acute respiratory problems

• The Patient is dependent on continuous oxygen greater then 4L/min

• The Patient is receiving continuous high risk medication Infusions or treatments

• E.g. Blood / Opiates/ PCA / Epidural / Antibiotics / Insulin /Heparin / Potassium

based infusions

• The patient requires continuous cardiac monitoring

7.5 Appropriate monitoring must be able to continue during patient transfer in accordance

with the patient’s condition and plan of care.

7.6 Health care assistants are responsible for patients during transfer if they have accepted the

delegated task from a registered nurse.


7.7 A registered nurse should provide health care assistants undertaking transfer with a full

handover of any relevant patient needs/ issues prior to the transfer

7.8 Following the assessment of the patient the patient movement should be booked onto

portertrak for transfer. If the patient requires escort, ‘escort’ should be entered on the

system. ‘No escort’ should be entered if the patient has been assessed as not requiring an

escort. There is no need to stipulate qualified or unqualified on the system.

8 Training

Members of staff who make the decision to escort should have undergone appropriate support in

order to ensure that they develop the competencies required.

The policy will be promoted at ward and department local induction, to ensure that all members of

staff have an understanding of the role of the escort and how to access the policy.

9 Equality and diversity

The Trust is committed to ensuring that, as far as is reasonably practicable, the way we treat

members of staff and patients reflects their individual needs and does not discriminate against

individuals or groups on the grounds of any protected characteristic. . This policy is therefore

intended to offer safeguards to both patients and members of staff prior to transfer to another

ward or department.

In this way, the policy promotes equality of opportunity and values diversity. The policy adopts a

human rights approach by considering a wide variety of situations, and encourages supportive,

reasonable arrangements to promote fairness, respect, equality, dignity and autonomy.

10 Monitoring compliance with the policy

Standard/process/issue Monitoring and audit

Method By Committee Frequency

Policy complies with OP27 –

Policy for the development,

management and

authorisation of policies and

procedures

OP27 Checklist Upon Review

Staff are aware of the policy

and able to implement it

effectively

Refer to Training

and Local

Induction.

Annual

review

Informal feedback from

patients and carers about

patient escort issues

Discussed in the

PALS / Complaints

quarterly analysis

reports

PALS &

Complaints

Manager

Quarterly

Compliance into the

completion of SBAR In

Patient Transfer Forms

Audit Matrons SafeCare Annual

review

Review of incidents

occurring regarding the

transfer of patients

Trend monitoring Matrons SafeCare Quarterly


11 Consultation and review

The policy was developed using best practice guidelines, in consultation with key staff groups and

following a pilot of the Quick Reference Guide (Appendix 1).

12 Implementation of policy

This policy will be circulated by the Trust Secretary as detailed in OP27 Policy for the development,

management and authorisation of policies. Individual healthcare professionals have a responsibility

to ensure they understand the role of the nurse escort and take appropriate steps to implement

this policy effectively, including reporting any concerns as appropriate.

Managers are responsible for ensuring all members of staff understand how the Patient Escort

Policy applies to them and their patients. Managers are also responsible for ensuring that where

necessary, local procedures are developed, to support the implementation of this policy. Managers

should review the effectiveness of the implementation of this policy, and take appropriate remedial

action when they become aware of any acts or omissions that contravene it.

13 References

• Internal Patient Transfer and Escort Policy (March 2009) The Royal Free Hampstead NHS Trust

• Patient Escort Policy (January 2011) County Durham and Darlington NHS Foundation Trust

• Clinical Policy for the Safe Transfer and Escort of Patients Heart of England NHS Foundation

Trust (April 2012)

14 Appendices

Appendix 1: SBAR Inpatient Transfer Form

Appendix 2: Critical Care transfer tool

Appendix 3: Maternity Handover Forms (a – Antenatal handover, b – Delivery suite to SCBU, c –

Delivery suite to Postnatal)

Appendix 4: Patient Escort (QE Site) – Quick reference guide


Appendix 1


Appendix 2



Antenatal Handover of Patient Care (SBAR) To be completed for all transfers between AN and LW

(Except planned low risk IOL & early labour admissi ons)

Please tick appropriate boxes (√) or circle correct answer

SBAR report Antenatal Handover Situation Reason for transfer:

Current antenatal issues (summary):

Background Gravida: Para: Gestation : weeks Midwifery led Consultant led Significant medical history: Yes No please state: Significant Obstetric history: Yes No please state: Obstetric Risk Assessment: High Low Thromboembolism: High Low

Assessment BP: Pulse: bpm Temp: °C Resps: rpm Previous MEOWS trigger: Yes No Abdomen: Foetal heart: bpm CTG interpretation: Urinalysis : Uterine Activity: Vaginal Loss: discharge / amniotic fluid Colour: Bloods: taken and / or results:

Recommendations Antenatal care plan: including observations and foetal monitoring Further tests / treatments required: Identified indications for medical review:

Signature of person transferring patient: Signature of person receiving patient: Date and time of transfer:

Appendix 3a


Delivery Suite to Postnatal Handover of Baby’s Care (SBAR) - Only to be completed if baby is transferred immed iately to SCBU

Please tick appropriate boxes (√) or circle correct answer

SBAR Report Postnatal Handover Situation Date of Delivery: Time of delivery:

Delivery: Normal � Ventouse � Forceps � Elective LSCS � Emergency LSCS � Reason: Reason: Baby: Postnatal � SCBU � Paediatric Alert? Yes � No � details:

Background Gestation: weeks Mother’s blood group: Antibodies: Baby’s blood group: Antibodies: Family issues identified: Yes � No � AN2: Yes � No �

Assessment Bloods taken / results: Swabs taken / results: Initial Assessment: Colour: Skin: Eyes: Mouth: Cord: Passed meconium? Yes � No � Passed urine? Yes � No � Skin to skin � Breast fed � Length of feed: mins Artificially fed � mls ID bracelet x 2 present and correct? Yes � No � Temperature on transfer: ˚C Birth weight: _______kg

Recommendations Routine postnatal care? Yes � No � Further tests / treatments required: Identified indications for medical review: Is there an Individual Management Plan in place? Pl ease document plan on page 4. If baby requires regular observations (Meconium, GBS) ensure that observation chart is up to date PRIOR to transfer to PN ward.

Signature of person transferring baby: Signature of person receiving baby: Date and time of transfer:

Appendix 3b


Delivery Suite to Postnatal Handover of Mother’s Ca re (SBAR) To be signed by both the transferring midwife and t he receiving midwife

Please tick appropriate boxes (√) or circle correct answer SBAR report Postnatal Handover Situation Date of delivery: Time of d elivery :

Delivery: Normal Ventouse Forceps Elective CS reason: Emergency CS reason: Spontaneous Induced Analgesia if appropriate: Perineum: intact 1st 2nd 3rd 4th Episiotomy Sutured Yes No Drains: Yes No IVT type and rate: Estimated blood loss: mls

Background Gravida: Para: Gestation : weeks Risk assessment prior to labour: High Low If high, please state reason: Blood group: Antibodies: Rubella Immune Yes No Personal Issues identified: Yes No AN2 Yes No

Assessment BP / Pulse bpm Temp °C Resps bpm Previous MEOWS trigger Abdomen: Passed Urine: Yes No If no please record time of last void: (SRC insitu) (document time and volume of 1 st void in “P/N care” section on p.8) Lochia: Heavy / normal / light Bloods: taken and / or results:

Recommendations Risk assessment following delivery: High Low If high, please state reason: If high risk postnatally please document individual ised management plan on page 6-7 Further tests / treatments required: Identified indications for medical review:

Signature of person transferring patient: Signature of person receiving patient: Date & Time of transfer :

Appendix 3c


Appendix 4: Patient Escort (QE Site) - Quick Reference guide

This aims to guide staff with appropriate escort requirements and does not replace the clinical judgement and ultimate decision of the Registered Nurse

Assessment of Patient

Risk Minimum

Escort requirement Mode of transfer

Minimum

Skills required

• Maintaining own airway

• No Oxygen support required during transit

• Stable observations no NEWS triggers in last 4 hours

• No medical devices in progress during transfer

• Alert and orientated

Low

• Adults - Porter

• Children - HCA or Pre-

registered student Nurse

• Walk

• Wheelchair

• Bed/Cot

• Trolley

• Familiar with trust transfer policy

• Understands Transfer process.

• Clinical staff BLS/PLS

• Maintaining own airway

• Stable on Continuous Oxygen less than 4L/Min

• Stable observations no NEWS triggers in last 4 hours

• No medical devices that may require intervention during

transfer.

• Confused /disorientated

• High risk of falls / likely to wander

Med

• Adults - HCA, Pre-registered

student Nurse or Therapist &

Porter

• Children - Registered Paediatric

Nurse

• Wheelchair

• Bed/Cot

• Trolley

• Awareness of patient’s current clinical

condition and needs.


• Understands Transfer process.

• BLS / PLS

• Requires continuous cardiac monitoring

• Risk to airway (e.g. post op / post procedure / post sedation /

recent seizures or vomiting)

• Acute respiratory problems

• Requires continuous oxygen greater then 4L/min

• Recent NEWS trigger within the last 4 hours

• Continuous Infusions or treatments in situ

E.g. Blood /PCA/Epidural/Antibiotics/Insulin

• Patient causing clinical concern / increasing NEWS score

• Clinical challenging behaviour

High

• Adults - Registered Nurse/ and

Porter

• Children- Registered Paediatric

Nurse and HCA / Pre-registered

student +/- Medic if indicated

• For manifestations of aggression

consider security escort

• Bed/Cot

• Trolley

• Aware of patient’s current clinical

condition and needs.


• Understands Transfer process

• BLS / PLS

• Requires Invasive / Non Invasive Ventilatary Support

� Acute respiratory problems

• Unstable Circulatory System

• Complex Patients requiring support for multi organ failure

Critical

• Adults- Critical Care Clinician /

Practitioner and Critical Care

Nurse/ART Nurse +/- porter

• Children – PICU Retrieval Team

or Critical Care

Clinician/Paediatric Clinician &

Consultant/Middle Grade &

Registered Nurse

• Bed/Cot

• Trolley

• Aware of patients current clinical

condition and needs

• Appropriate Critical care skills


• Understands Transfer process

• ALS / PLS

Documents

Internal Patient Transfer Escort Policy - · PDF filePatient Transfer and Escort Policy v2 Policy No: OP84 Version: 2.0 Name of Policy: Internal Patient Transfer and Escort Policy