Discharge or transfer of patients from St John’s hospice inpatient unit procedure

1 Aim

This procedure is to provide additional guidance to the trusts admission transfer and discharge manual whose aim is to provide core guidance which is applicable to all services. This procedure represents best practice in relation to the safe and appropriate transfer and discharge of patients from St John’s hospice inpatient unit:

to ensure a safe, timely and effective discharge or transfer from the hospice or internal transfer for all patients
to ensure the patient is always treated as an individual with due regard shown to their personal choice, cultural characteristics and dignity
to take into consideration any advance care plan and preferred place of care or death (see advance statements and advance decisions to refuse treatment policy)

2 Scope

This procedure is applicable to all staff within St John’s hospice inpatient unit who are involved in the discharge and transfer of patients. All appropriate staff must be aware of the policy and ensure that they:

complete trust approved training relevant to their role
adhere to the admissions, transfer and discharge manual
report any discharge and transfer related clinical incidents via the trust incident reporting system

3 Link to overarching policy

Admission, transfer and discharge manual

4 Procedure

Preparation to enable safe and effective discharge which will support continuity of care, wellbeing or a peaceful death in their preferred place of care.

4.1 Multi-disciplinary team

Is responsible for:

deciding and communicating when a patient is medically fit for discharge and documenting the decision clearly within the electronic medical notes and on the discharge planning template
discussing if additional teams are required after discharge for example, new referral to the community specialist palliative care team, or discharge information if already known to the team
deciding the appropriateness of transferring patients to other areas as either being part of the patient’s pathway or within their best interests
discussing this date of discharge or transfer with the patient and, where appropriate, their family or those named as closest to them
take into consideration any advance care plan, any advance decision to refuse treatment and preferred place of care or death (see advance statements and advance decisions to refuse treatment policy)

4.1.1 Medical staff

Are responsible for:

assessing and prescribing any medication the patient requires for discharge or transfer at least 24 hours prior to discharge. Use the trust approved method, as agreed by the medicines management committee (see safe and secure handling of medicines manual, RDaSH controlled drugs St John’s hospice SOP, controlled drugs (RDaSH care groups community service, physical health SOP)
write To take out’s (TTOs) for any patient attending an appointment external to the hospice. Supply enough medication to last the duration of time away from the inpatient unit and ensure a copy of the inpatient medical notes are sent with them
completed TTO form or printout to be given to ward clerk to copy, scan and email to Doncaster Royal Infirmary (DRI) pharmacy and a copy to be put in discharge folder in the ward nurses’ office and saved to communications and letters in the patient’s medical notes
if the patient has a NOMAD ensure that an FP10 form is completed 48 hours prior to discharge and given to the family. A copy of the FP10 must be scanned into the communication and letters section of the patient’s medical notes:
- all patients who meet the fast track criteria (last 12 weeks of life) should be discharged with pre-emptive medications, as per national guidance. Write the instruction to administer the ‘as required’ pre-emptive medications on the trust approved non-syringe driver form, and if applicable, the instruction to administer a syringe driver. Give the forms to the nurse in charge to send to single point of access (SPA)
- for all fast track patients, and patients with complex medication regimes, write, the general practitioner (GP) out of hours’ information form and give to the nurse in charge to email to FCMS out of hours GP service
for patients on long term oxygen therapy (LTOT) or oxygen for palliative use, if it is a new or adjusted prescription the prescriber (who is authorised to prescribe oxygen) must complete the home oxygen order form (HOOF) as well as the initial home oxygen risk mitigation form (IHORM), if a new prescription. All information, assessment guidance and order forms, there is also a guide: A guide to The home oxygen service. liaise with the local home oxygen service in RDaSH via single point of access on 01302 566999 if required. Bayswater automatically notify the RDASH Home Oxygen team of any new prescriptions or adjustments
where appropriate and possible, provide the patient with the date for any required follow up appointment for attendance to consultant’s outpatient clinics within St John’s Hospice prior to leaving the ward. Send appointment letter as soon as appointment is arranged if discharged first
document all the above in the patient’s electronic medical records and on the discharge planning template
within 24 hours of discharge write a detailed discharge letter to the GP and copy other services as appropriate for example, oncology, Community Specialist Palliative Care team. Offer a copy to the patient
if appropriate, ring the GP and discuss any complexity in discharge, symptom management and prescribing decisions for example, complex regimes and shared care protocols
during an episode of inpatient care a need may arise to transfer a patient to another care setting either within or outside the trust. There is a need for good communication between the trust and the receiving hospital or unit. Photocopies or printouts of the relevant records must be provided and a formal documented letter or handover of care between the trust and receiving service

A detailed record is to be made in the patients transfer letter of:

all information provided to the receiving service
the date on which it was provided
who provided it
any additional information requested prior to the transfer
discussion with the patient and carers about the planned transfer
if applicable, the ReSPECT and do not attempt cardiopulmonary resuscitation (DNACPR) information
rationale for transfer

4.3 Ward coordinators and named nurses

Are responsible for:

on admission the admitting nurse must assess and identify any special requirements that may need to be considered to facilitate the patient’s discharge. Discharge documentation must be commenced on or as soon as possible after admission and all communication and action taken concerning discharge clearly documented in the medical notes and on the discharge planning template. Adhere to the admission, transfer and discharge manual
once a discharge date has been set, coordinate the discharge process, taking into account patient needs and wishes which may be included in advance care plan, any advance decision to refuse treatment or preferred place of care or death (see advance statements and advance decisions to refuse treatment policy)
if the patient needs equipment to go home then ensure timely referral to occupational therapy. Consider referral to the physiotherapist for mobility assessment and stair assessment, where applicable
commence the discharge check list prior to discharge
record and manage appropriately any delays in discharge or transfers of care as per the safe discharge and transfer of patients from the adult and older persons mental health service inpatient wards
allow opportunities for the different staff groups to discuss and agree the discharge care plan via various arenas such as case conferences, best interest meeting and internal and external Multi-disciplinary team meeting agendas
obtain clarity from patient, family or medical team on mode of discharge transport and document clearly in patient’s notes. Some patients may require a special ambulance (bariatric) or the ambulance service to access the property prior to discharge. This must be identified earlier to prevent a delayed discharge
make appropriate arrangements for the provision of any support services required in the community checking with the patient, family or carer that they know how to access these services in the event of an emergency
order medications to take home (TTOs) at least 24 hours prior to discharge
if the patient has a NOMAD (blister pack of medications provided by the pharmacy) ensure that an FP10 form is completed 48 hours prior to discharge and given to the family
cross reference prescribed discharge medication against medication delivered and the take home medication chart. Liaise with pharmacy or prescribing medic for discrepancies. Complete IR1 if deemed appropriate
provide the patient, family or carer with a TTOs both verbally and a copy of the TTO prescription
for fast track patients, email the pre-emptive instruction to administer (non-syringe driver form) and the syringe driver instruction (if applicable) to the single point of access (SPA) at doncaster.spa@nhs.net. For all fast track patients, and patients with complex medication regimes, scan and email the GP out of hours’
information form to FCMS out of hours GP service at ooh.doncaster@nhs.net
produce a discharge communication sheet for all appropriate services required (district nurses, Community Specialist Palliative Care team) to be involved in patient care. Complete any appropriate risk assessment
document all of the above clearly in the electronic medical records and on the discharge planning template
on transfer of patients to another care setting either within or outside the trust, co-ordinate transfer:
- organise transport
- ensure that written and verbal handover is given to the receiving organisation
- ensure that the relevant paperwork is collated and prepared for the transfer
- ReSPECT and DNACPR information, if applicable
- ensure that the patient and family or carers are aware of the transfer and the rationale
if the patient has an identified infection risk this must be discussed with the receiving service to allow them time to make any necessary arrangements for the management of the infection once the patient is discharged to their care. All relevant information must also be
documented on the patient’s transfer or discharge letter and care records updated accordingly

5 ReSPECT and DNACPR decision

ReSPECT and DNACPR status: it is the responsibility of the discharging clinician to ensure that the patient’s GP is informed of any ReSPECT discussion and DNACPR decision via the discharge letter and that all agencies involved in the patient’s care in the community are informed of the order. The ReSPECT and DNACPR form must be scanned into the medical record, in communications and letters, and titled ‘ReSPECT’ on discharge.

The ReSPECT and DNACPR decision must be reviewed before discharge. It may not be possible to review the DNACPR for out of hours’ transfers. At this point the review will be done by the accepting service.

The original ReSPECT and DNACPR form should be given to the patient or carer. Staff should ensure that the patient or carer is aware of and fully understands the form and decision.

All ReSPECT and DNACPR decisions must be documented on the ReSPECT or DNACPR template in the patient’s medical records.

6 Training implications

All staff, who in the course of their work, undertake duties in relation to the discharge or transfer of patients and in relation to this SOP to undertake training or supervision in the following:

medication management and administration
controlled drugs (CD)
healthcare record keeping

7 Links to any associated documents

Document control

Version: 3.1.
Unique reference number: 497.
Date ratified: 6 September 2022.
Ratified by: Clinical policies review and approval group.
Name of originator: Head of patient flow, nurse consultant in
specialist palliative care or clinical lead.
Name of responsible individual: Director or nursing and allied health professionals.
Date issued: 29 September 2022 (amendment).
Review date: May 2025.
Target audience: All medical, allied healthcare professionals and nursing staff working within St John’s hospice who are involved in referring, admitting and discharging patients.

Page last reviewed: April 23, 2024
Next review due: April 23, 2025

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