Referral, Discharge and Conveyance Policy
Document Number
007/002/015
Version:
V3.00
Name of originator/
Andy Collen
author:
Consultant Paramedic/Head of Clinical
Development
Policy: Approved by:
RMCGC
Date approved:
27/10/15
Date issued:
Oct 2015
Date next review due:
Oct 2018
Target audience:
Replaces:
V2.00
Equality Analysis Record
Approved EA submitted
Dated: Sept 13
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Referral Discharge and Conveyance Policy
Contents
1
Introduction ..................................................................................................... 3
2
Aims and Objectives ...................................................................................... 5
3
Definitions ....................................................................................................... 9
4
Responsibilities .............................................................................................. 9
5
Competence .................................................................................................... 9
6
Monitoring ..................................................................................................... 10
7
Audit and Review.......................................................................................... 10
8
Associated Documentation ......................................................................... 11
9
Document Control ........................................................................................ 12
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Referral, Discharge and Conveyance Policy
1
Introduction
1.1.
South East Coast Ambulance Service NHS Foundation Trust (the Trust)
has recognised that for many patients the traditional default of
conveyance to A&E is not an appropriate model for a modern ambulance
trust. Nationally, ambulance services have seen activity shift to seeing
more patients with urgent, unscheduled or undifferentiated care needs,
and this has led the Trust to develop systems to manage this more
effectively.
1.2.
The Trust still manages large numbers of patients with life-threatening
and life-changing conditions and strives to support modern healthcare
networks and take these patients to centres of excellence – often
regionally.
1.3.
The main principles underpinning the document are:
1.3.1.
To define what the Trust means by referral, discharge and conveyance
1.3.2.
To define the systems and processes that inform our clinicians to make
the correct decision to refer, discharge or convey.
1.3.3.
The systems that safeguard patients when they are not conveyed.
1.4.
Policy Statement
1.5.
The intention of this policy is to evidence the Trust’s commitment to
ensuring that it delivers high quality patient care whilst minimising waste
and promoting efficiency.
1.6.
The Trust strives to meet and exceed national and international best
practice. The ambulance performance standards introduced in April 2011
mean that the Trust must ensure that it not only responds quickly, but
arrives with a clinician that is able to promote good patient outcomes. This
may mean treating the patient at home or conveying to a hospital.
1.7.
This policy will direct staff and a team within the Trust to ensure that the
patients care disposition is correct and that the management of care is
done safely, focussing on a high-quality patient experience.
1.8.
The management of risk and evidencing of a governance-led approach to
how the Trust plans and delivers care is vital. The Trust is committed to
ensuring that this is always paramount.
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Referral, Discharge and Conveyance Policy
1.9.
The Trust believes in fairness and equality, and values diversity in its role
as both a provider of services and as an employer. The Trust aims to
provide accessible services that respect the needs of each individual and
exclude no-one. It is committed to comply with the Human Rights Act and
to meeting the Equality Act 2010, which identifies the following nine
protected characteristics: Age, Disability, Race, Religion and Belief,
Gender Reassignment, Sexual Orientation, Sex, Marriage and Civil
Partnership and Pregnancy and Maternity.
1.9.1.
If a contractor carries out functions of a public nature then for the duration
of the contract, the contractor or supplier would itself be considered a
public authority and have the duty to comply with the equalities duties
when carrying out those functions.
1.10.
The Trust bases its clinical practice on evidence-based standard
pathways of care, developed into bespoke local or regional pathways
where appropriate.
1.10.1.
Where this differs from practice adopted by other providers, approval is
made in accordance with the Trusts governance arrangements
1.10.2.
The Scope of Practice and Clinical Standard Policy (SoPCS) states the
responsibilities of each clinical grade of staff. Full implementation of
pathways by staff is dependent on their scope of practice, staff should
implement pathways as permitted under their scope of practice where
clinically appropriate.
1.10.3.
Within the Conveyance, Handover and Transfers of Care Procedure,
Discharge Procedure and Referrals Procedure, there is further specific
guidance related to each relevant domain.
1.11.
The Trust will support staff to make the correct clinical decision, where
there is evidence that the decision was based upon appropriate scope of
practice, commensurate to education, training, qualification and
experience, and where applicable national or local guidelines have been
followed.
1.11.1.
Staff must always follow guidelines and local policies and procedures in
order to minimise the risk to patients, but also risk to themselves should
there be an unanticipated event lead to a diminished outcome for the
patient.
1.11.2.
This policy does not, and will not, support negligent practice.
1.11.3.
Staff are responsible for acquainting themselves with the documents
which inform safe practice, profession standards and capability.
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Referral, Discharge and Conveyance Policy
2
Aims and Objectives
2.1.
Aims
2.1.1.
To provide a consistent approach to the conveyance of patients.
2.1.2.
To be an overarching policy for staff to be directed to more detailed
policies/procedures.
2.1.3.
To maximise our resources by ensuring the Trust operates efficiently.
2.1.4.
To promote the Trust as a provider, capable of managing emergency and
urgent care.
2.1.5.
To empower staff to make the correct disposition decision for the patient
2.2.
Objectives
2.2.1.
To convey patients who need to go to hospital in safety and comfort;
promoting recovery and rehabilitation, whilst preventing deterioration.
2.2.2.
To convey patients to specialist centres, such as major trauma centres,
primary percutaneous coronary intervention centres or stroke units
appropriately and rapidly.
2.2.3.
To ensure that the Trust meets its legal obligations.
2.2.4.
To ensure staff follow the appropriate scope of practice and maintain high
standards of clinical care.
2.2.5.
To ensure that the Trust achieves its strategic objectives, specifically:
2.2.5.1.
To deliver high-quality and appropriate care based on transparent and fair
rules with decisions devolved closer to patients;
2.2.5.2.
To provide care in the right setting;
2.2.5.3.
To improve clinical outcomes, safety and governance;
2.2.5.4.
To demonstrate intervention that supports an individual’s well-being;
2.2.5.5.
To reduce health inequalities across the dependent population;
2.2.5.6.
To ensure that services are delivered in the most efficient way possible;
2.2.5.7.
To deliver a timely, convenient and responsive access to care including
preventative interventions and diagnostics.
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Referral, Discharge and Conveyance Policy
2.2.6.
Support to clinical decision makers
2.2.6.1.
To engender a culture within the Trust of supporting staff to make the
correct disposition decision, and ensuring that staff feel supported, and
have access to support, to make these decisions.
2.2.6.2.
To have systems in place to ensure that where scope of practice and
guidelines have been followed, staff feel secure in making decisions (with
and/or without support), and which are defensible in the event of an
unanticipated outcome.
2.3.
Arrangements - Core requirements and instructions
2.3.1.
Referrals:
2.3.1.1.
Referrals can only be made where authorisation is given in the Scope of
Practice and Clinical Standards Policy for each grade of staff. Referrals
made out of scope of practice place the patient at risk and will leave the
clinician at risk of disciplinary action.
2.3.1.2.
Staff can seek advice and guidance from an authorised supervisor on
making referrals.
2.3.2.
Discharge (including self-discharge):
2.3.2.1.
Patients can only be discharged (as per the definition in 3.2) where the
clinician is authorised to do so in the Scope of Practice and Clinical
Standards Policy.
2.3.2.2.
Discharge is the clinical decision that carries most risk .Discharging a
patient means that their condition has been resolved or will be self
limiting. Staff not authorised to discharge patients, or where a discharge
has been deemed to have taken place, outside his/her scope, the clinician
(unless authorised) may be at risk of disciplinary action.
2.3.2.3.
Where a patient wishes to self-discharge, staff must assess the capacity
of the patient to make this decision in accordance with the Trust’s Mental
Capacity Act and Informed Consent Guidelines
2.3.2.4.
Staff not authorised to discharge are required to refer patients or provide
adequate follow up.
2.3.3.
Conveyance:
2.3.3.1.
With the exception of Community First Responders and Solo or Double
Crewed ECSWs, all clinical staff are authorised to convey any patient as
required.
2.3.3.2.
Staff must however consider the suitability for conveyance in context to
the needs of the patient and the opportunities to safely manage care in
the community (by referring to a PP or community service, for example).
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Referral, Discharge and Conveyance Policy
2.4.
Procedures
2.4.1.
There is a separate procedure for making referrals, discharging patients
and conveyance decisions.
2.4.2.
Whether a patient is being referred, discharged or conveyed, the following
key actions must be considered and/or complied with in order to validate
the decision.
2.5.
Consent and Capacity
2.5.1.
Patients receiving care from Trust staff must be informed about the
treatment they require in a way that is acceptable to the patient in an
easily understandable manner. However, if they have capacity, patients
have the right to refuse to allow treatment to take place based on their
own beliefs and/or values, even if the decision seems unwise, irrational or
may cause them harm. Patients can only consent to treatment, or refuse
treatment if they have capacity to do this
2.5.2.
If a refusal of treatment may potentially result in serious harm to the
patient’s health, staff must undertake a capacity assessment. A person
lacks capacity if they are unable to make a particular decision because of
an impairment or disturbance of the mind or brain at the time the decision
needs to be made
.
2.5.3.
Clinicians must acquaint themselves with Trust documentation on consent
and capacity – see section 11.
2.5.4.
Patient safety
2.5.4.1.
Patient safety is paramount and where staff have arranged for follow up
care, they must ensure that the patient understands what to do if they
deteriorate.
2.5.5.
Handover
2.5.5.1.
When transferring care of a patient over to another clinician or
department, a detailed and accurate handover is vital to ensure the
transfer of care is safe. Staff must present accurate information on the
patient’s condition and document fully their findings on the patient clinical
record (and associated documentation).
2.5.6.
Record Keeping
2.5.6.1.
Staff must make accurate and detailed clinical records for all patients in
their care.
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Referral, Discharge and Conveyance Policy
2.6.
Emergency Operations Centre (EOC) actions
2.6.1.
EOC staff will keep all care records up to date in all the systems in use in
the control room.
2.6.2.
Where patients are not conveyed, EOC will update incidents logs to
reflect this where appropriate.
2.7.
Manual Handling
2.7.1.
Staff must comply with the requirements stated in the manual handling
policy and procedure at all times.
2.8.
Infection Control
2.8.1.
Staff must comply with the requirements stated in the Infection Control
Policy and Procedure at all times.
2.9.
Care pathways
2.9.1.
Below is a list of the care pathways available to Trust clinicians. Some
may not be directly available and will need approval or further
assessment by a senior paramedic or Clinical Advisor.
2.9.1.1.
Accident & Emergency
2.9.1.2.
End of life care
2.9.1.3.
Primary Percutaneous Coronary Intervention (pPCI)
2.9.1.4.
Stroke
2.9.1.5.
Major Trauma
2.9.1.6.
Primary Care
2.9.1.7.
Secondary Care specialists
2.9.1.8.
Tertiary Care
2.9.1.9.
Minor Injury/Urgent Treatment Centres/Walk in Centres
2.9.1.10. Ambulatory care pathways
2.9.2.
Where a patient is being conveyed, staff must ensure that the receiving
unit has the required levels of service to meet patient need (i.e. vascular
surgery).
2.9.3.
Where bypass arrangements are in place for certain types of patient,
conveyance to those units must be considered in the first instance even if
journey times are longer than a local unit. Evidence exists to support
regional centres of excellence and the Trust supports these pathways.
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Referral, Discharge and Conveyance Policy
3
Definitions
3.1.
Referral: This is where a patient care is passed from one clinician or
provider to another. In context to the Trust, this may be a referral between
a crew and Paramedic Practitioner (PP). Externally, it may be a PP
referring a patient to a hospital specialist or a crew referring a patient
back to primary care.
3.2.
Discharge: The Trust definition of discharge is the termination of care or
the end of the episode with no follow up for the patient. (Patients who
refuse care/transport and have capacity to do so are deemed to have
“self-discharged”).
3.3.
Conveyance: The movement or transport of patients from the scene of
an incident to a care facility or other place of safety..
3.4.
Managed conveyance: This is the conveyance rate which reflects the
incidents over which we influence the decision to convey. The managed
conveyance rate excludes transport requests such as GP Urgent
Journeys and Inter-hospital Transfers.
4
Responsibilities
4.1.
The
Chief Executive has ultimate responsibility for referral, discharge
and conveyance.
4.2.
The
Chief Clinical Officer has executive responsibility for referral,
discharge and conveyance.
4.3.
The
Consultant Paramedic/ Head of Clinical Development are
responsible for overseeing the policy on a day-to-day basis.
4.4.
The
Chief Operating Officer is responsible for ensuring that staffs work
in accordance with this policy.
4.4.1.
Managers must make documentation available to staff using the systems
available (such as team briefing folders) and review staff understanding of
key document through the PADR process.
5
Competence
5.1.
All staff in clinical roles has defined levels of training and education in
order to practice at grades with a variety of abilities and rights to use
alternative pathways.
5.2.
The Scope of Practice & Clinical Standards Policy defines the
competency and referral rights for all staff employed by the Trust in
clinical roles.
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Referral, Discharge and Conveyance Policy
6
Monitoring
6.1.
This policy will be monitored by the
Clinical Governance Working
Group or
appropriately delegated committee. This will be achieved by
quarterly reports from the
Consultant Paramedic/Head of Clinical
Development containing incidence of practice outside the definitions laid
out in this document.
6.2.
The
Consultant Paramedic/Head of Clinical Development will be
responsible for ensuring adherence to the policy by reviewing internal
reporting systems (i.e. risk registers).
6.3.
Any non-compliance or deviation from this policy that results in an
adverse outcome for a patient will be dealt with in accordance with the
Incident Reporting Procedure and referred to the Professional Standards
Department.
6.3.1.
All staff and managers are responsible for reporting incidences of practice
operating outside the definitions laid out in this document.
6.3.2.
Reporting will be done through the usual Trust systems of incident
reporting, such as:
6.3.2.1.
Patient Advise and Liaison Service (PALS)
6.3.2.2.
IWR1 report forms
6.3.2.3.
Serious Incidents Requiring Investigation report
7
Audit and Review
7.1.
The
Consultant Paramedic/Head of Clinical Development will review
the implementation of this policy on a yearly basis and/or in response to
incidents of non-compliance. A report will be sent to the Clinical
Governance Working Group.
7.2.
This document will be reviewed every three years or sooner if new
legislation, codes of practice or national standards is introduced.
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Referral, Discharge and Conveyance Policy
8
Associated Documentation
8.1.
Scope of Practice & Clinical Standards Policy
8.2.
Response & Incident Resourcing Policy
8.3.
Conveyance, Handover and Transfers of Care Procedure
8.4.
Referral Procedure
8.5.
Discharge Procedure
8.6.
Mental Capacity Act and Informed Consent Guidelines
8.7.
Information Governance Policy
8.8.
Health Records Management Policy
8.9.
Safeguarding Policy
8.10.
Infection Prevention and Control Policy
8.11.
Manual Handing Policy
8.12.
Patient Clinical Record
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Referral, Discharge and Conveyance Policy
9
Document Control
Manager Responsible
Name:
Andy Collen
Job Title:
Consultant Paramedic/Head of Clinical Development
Directorate:
Clinical
Committee to approve
Risk Management and Clinical Governance Committee
Version No. V2.01
Final / Draft
Date: 27/10/15
Approval
Person/ Committee
Comments
Version
Date
Andy Collen
Updated template
V2.01
Oct 15
Preparation for re-ratification by
CQWG and RMCGC
Andy Collen
Minor revisions to text to ensure EA
V2.00
5/09/2013
compliance.
Equality Analysis
Comments and revisions
V2.00
20/08/201
Reference Group
3
Andy Collen
Amendments to final version
V2.0
15/11/12
RMCGC
Approved pending minor revision
V1.06
06/11/12
relating to deviation from standard care
pathways
CGWG
Tele conference recommended for
V1.05
22/10/12
approval at RMCGC subject to minor
changes
Andy Collen
Final version for submission (as per
V1.04
13/10/12
v1.03 but without tracked changes)
Andy Collen
Updated following comments
V1.03
13/10/12
Barbara Tree
Comments and update
V0.01
11/10/12
John Griffiths
Comments
V1.02
11/10/12
Andy Collen
Addition of revised monitoring table
V1.02
5/10/12
Clarification on decisions to refer,
discharge or convey
Temporary
No changes made to this document
V1.01
20/6/12
withdrawal April
prior to republication
2012
RMCGC
For Approval
V0.02
10/11/11
Clinical Governance Approved with minor changes
V0.01
25/10/11
Working Group
(included in this version)
Jo Byers
First Draft
V0.01
18/9/11
Andy Collen
First Draft
V0.01
14/9/11
Circulation
Records Management Database
Date:
Internal Stakeholders
External Stakeholders
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Referral, Discharge and Conveyance Policy
Review Due
Manager
Period
Every three years or sooner if new
Date:
legislation, codes of practice or
national standards are introduced
Record Information
Security Access/ Sensitivity
Public domain
Publication Scheme
Yes
Where Held
Records Management database
Disposal Method and Date
Supports Standard(s)/KLOE
Care Quality Commission
IG Toolkit
Other
(CQC)
Criteria/KLOE: Name core service area and
CREWS elements
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Document Outline