Same Day Emergency Care (SDEC) Operational Policy V1.0 … · 2019. 2. 8. · Same Day Emergency...

Same Day Emergency Care (SDEC) Operational Policy

V1.0

December 2018

Same Day Emergency Care (SDEC) Operational Policy V1.0 Page 2 of 30

Process Flow Chart

Hours of Operation: Monday –Sunday 08:00 – 20:00

Patient presents at ED

ED Consultant/Acute GP conducts Rapid Assessment & Treatment (RAT) in order to

stream patient or streamed from minors to primary care GP

Patient streamed to either: SDEC (AGP) or SDEC (Medics)

Primary care (GP)

Patient seen within SDEC as per SOP

Patient booked in on Oceano

Notes:

Primary Care patients streamed

to SDEC remain subject to the 4 Hour Standard.

Oceano must be updated in real time

to ensure this activity is recorded

Patients streamed

to SDEC and identified as

requiring SDEC will require a discussion with medical bleep holder 3002 and be

discharged from OCEANO and

admitted onto PAS/SwiftPlus

Patients seen in

SDEC are not subject to the 4 Hour

Standard however waiting times will still be monitored. Swiftplus must be

updated in real time to ensure this

activity is recorded.

Weekend resources on MAA are reduced

and will require a discussion with

bleep holder 3002 to confirm

capacity/resources are available

ED GP available:

Friday 18:00-00:00 Saturday 15:00-

22:00 Sunday 15:00-22:00

Acute GP available:

Monday-Friday 08:30-18:30

Saturday 09:00-17:00

Sunday 09:00-17:00

These hours are currently being

extended

Patient discharged where possible nurse led – Home

Admitted to inpatient ward MAA / Base ward

Full clinical clerking completed (RATS streamed) and patient

observations/ bloods/ECG/ X-ray (as appropriate) completed

Attendance updated on Oceano

Patient referred by

own GP

Patient triaged by Acute GP

Ambulant admission to SDEC

to either AGP or Acute Medicine

At SDEC Reception the Patient is booked in on Adastra (AGP) PAS/SwiftPlus (SDEC) or remain on

OCEANO for primary care streamed

Patient seen by Acute Medical team:

Pull from ED / Push from

MAA

Non Ambulant patient for admission

Patient to MAA (if no flow they

should go to ED)


Table of Contents

Same Day Emergency Care flow chart…………………….……………………….…… 2

1. Introduction ……………………………………………………………… 5

2. Scope ………………………….. …………………………………………… 5

3. Location ………………………………………………………………… 5

4. Ownership and Responsibilities ………………………………………… 5

4.1 Medical Responsibility ………………………… 5

4.2 Acute GP …………………………………………………… 6

4.3

4.3

ED GP ………………………………………………

Nurse Staffing and Responsibility ……………………………

6

6

4.4 Healthcare Support Worker (HCSW)/General Assistant ……… 7

4.5 Ward Clerk ……………………………… 7

4.6 Therapy Support ……………………………… 7

5. Standards and Practice ………………………………… 7

5.1

5.2

Operational standards ……………………………

AGP Referral to SDEC …………………………

7

8

5.3 Method of Transfer from GPs to AEC or ED……………… 8

5.4 Streaming from Emergency Department ……. …………..…… 9

5.5 Method of Assessment on SDEC Unit ……………… 9

5.6 Discharges from the SDEC Unit ……………………… 10

5.7 18.30 hours AGP Transfer/Acute Medical Unit Transfer ……… 10

5.8 21.00 hours Hospital at Night (H@N) Handover …………… 10

5.9

5.10

Medical Follow-up Appointments in SDEC …………………

Acute GP follow up appointments in SDEC …………

10

10

5.11 Patient Assessment and Management Process …………… 10

5.12 SDEC Hours of Operation …………………………… 11

5.13 Criteria to Access SDEC ………………………… 11

5.14 Services Supporting SDEC ……………………… 12

5.15 Specialist Clinics ………………………………… 12

5.16 Medicines Management ……………………………… 12

5.17 Infection Control ……………………………… 13

6. Dissemination and Implementation ………………………… 14

7. Monitoring Compliance and Effectiveness ………………… 14

8. Updating and Review ………………………………………. 15

9. Equality and Diversity ………………………………… 16


Appendix 1. Governance Information …………………………… 17

Appendix 2.

Appendix 3.

Appendix 4.

Appendix 5.

Appendix 6.

Appendix 7 :

Initial Equality Impact Assessment Form …………………

Same Day Emergency Care flow chart ………………………

SDEC Escalation Checklist ………………………

SDEC Administration Guidelines ………………………

SDEC Team Training Plan ……………………………

SDEC Model …………………………

20

24

25

27

28

30


1. Introduction

1.1. This procedure sets out the arrangements for the safe and appropriate referrals of patients to Same Day Emergency Care (SDEC) within the Trust ensuring staff involved understand roles, responsibilities, accountability and mode of operation.

2. Purpose of this Policy/Procedure

2.1. The aim of SDEC is to maximise access to same day services, encompassing both primary care streaming and acute same day emergency care, but also with the potential to include out of hours services in due course. 2.2. The benefits of SDEC include:

Ensure right care in the right place, at the right time.

Improve patient experience and satisfaction, enabling patients to return home same day.

Reduce overnight admissions and pressure on acute and community inpatient wards.

Improve patient flow through whole system.

Provide specialist assessment for elderly and frail patients and improve ability to provide same day emergency care for this patient cohort.

Reduce activity in the Emergency Department (ED).

2.3. Quality operational standards will be used to ensure a governance framework from which to measure effectiveness. The standards include a triage assessment within 15 minutes and consultation with a clinician within 30 minutes of arrival (see section 5).

3. Scope

3.1. SDEC is part of the Emergency Care Stream and is primarily for the use of adult medical patients who have been referred either directly by their GP’s or through the Acute GP (AGP) service or patients streamed from ED who are clinically appropriate. ED will retain clinical responsibility for their patients in SDEC.

3.2. The prompt supply of inpatient beds, transport and diagnostics capacity is vital to facilitate the SDEC function and every effort must be made by the Trust’s patient flow team to facilitate persistent capacity and rapid turnover of patients through SDEC and Medical Assessment Area (MAA). This is important to avoid congestion within SDEC and MAA and the loss of the ability of these areas to function as assessment areas during their hours of operation.

4. Definitions / Glossary - Location, Layout and Utilisation

4.1. SDEC is located adjacent to ED and Imaging services on the ground floor of Trelawny Wing. The unit has a separate entrance along from ED; it shares a reception desk with Imaging and has its own patient waiting area.


4.2. SDEC has 4 consulting rooms, 1 treatment room and a flexible treatment bay equipped with 3 assessment trolley spaces and 4 lounge chairs. In addition, the unit has clinical office space, a drugs preparation room and Unit Managers Office. 4.3. The consulting rooms must be kept free to support the ability to maintain flow in the unit. Patients will be asked to wait in the waiting area if they are not being actively seen. The flexible trolley/chair spaces are to be used only for patients under the management of SDEC. The treatment chairs can be used for stable patients for delivery of IV fluids, infusions, antibiotics and other oral medications that do not require monitoring. The trolleyed area can be used for assessment of patients not fit to sit or are required to lie during treatment or procedures. 4.4. In line with privacy and dignity requirements in a mixed bay area all patients should be fully dressed and not in night clothes. 4.5. For patient’s well-being cold food, tea, coffee, water and snacks will be available to patients throughout their stay in SDEC.

5. Ownership and Responsibilities

5.1. Medical Responsibility The overall clinical responsibility for standards and clinical care of medical patients resides with the Acute Medical Unit (AMU) Consultant Acute Physician when that person is present and is supervising / participating in the Unit. All medical, GP expected or ED referred patients presenting to the SDEC, will be placed under the care of the team the patient is referred to: a Consultant Acute Physician, the AGP or ED Consultant. When the Consultant Acute Physician or AGP leaves then a hand over will take place with the duty registrar and Medical Consultant on call. ED patients will remain under the care of the ED Consultant. The AMU team will support both ED and SDEC and ensure cover is provided. 5.2. Acute GP

The AGP service are the “gatekeeper” for all GP referred patients, assessing and treating patients that fall within the “low risk” criteria of ambulatory care and provide onward referral to the SDEC, ED, community services, hot clinics, West Cornwall Hospital (WCH) or appropriate service. The AGP will also assess and treat those patients that are streamed to primary care from ED. The overall clinical responsibility for standards and clinical care of the AGP patients seen in SDEC will reside with AGP.

The AGP Healthcare Assistant (HCA) will operate within SDEC under the supervision of the AGPs, to their agreed competencies in accordance with their job description.

AGP referrals for medical patients to be assessed in SDEC are made by generic e-mail. The referrals are then communicated by the ward clerk to the SDEC Nurse in Charge.

The overall clinical responsibility for patients seen by the AGP team resides with the AGP clinical lead. The AGP clinical lead is accountable to the Cornwall Foundation Trust (CFT) primary care director.


5.3. ED GP The ED GP will assess and treat those patients that fall within the minor illness / primary care criteria of SDEC streamed from ED. The overall clinical responsibility for standards and clinical care of the ED GP patients seen in SDEC will reside with ED. 5.4. Nurse staffing and Responsibility SDEC will be staffed by a Senior Nurse and Emergency Medical Technician (EMT) to Rapidly Assess and Treat (RAT) patients on arrival plus 2 registered nurses and an EMT weekdays and 1 registered nurse on weekends to manage the treatment and care of patients through in the unit. See training needs plan Appendix 6.

5.4.1. The senior nurse manager is responsible for the SDEC Unit as a whole, supported by the Clinical Matron and will ensure safe nurse staffing levels at all times escalated through twice daily safer care meetings if appropriate. 5.4.2. There will be an identified Nurse in Charge (NIC) for every shift and designated and clearly identifiable nurses on duty for the Unit and they have responsibility for:

Completion of the appropriate admission documentation for the individual patient and the recording of basic and relevant observations in the first instance;

The day to day running of the SDEC including its organisational aspects and delivery of nursing care;

Ensuring a smooth flow of patients through the unit and co-ordinating the movement of patients to other areas within the Trust;

Gaining extra support from the site team should there be a high level of activity witnessed;

Managing escalation within the unit in accordance with the escalation checklist (see appendix 4);

Keeping white boards and SWIFTPLUS updated and ensure OCEANO is updated;

Providing activity / performance reports and information as required. 5.4.3. The nursing staff will work with agreed competencies as outlined in their job descriptions

5.5. Healthcare Support Workers (HCSW) / General Assistant Healthcare Support Workers (HCSW)’s and General Assistants will operate within the SDEC Unit under the supervision of the senior Nurse in Charge to agreed competencies in accordance with their Job Description. 5.6. Emergency Medical Technicians (EMT) EMTs are staff trained to carry out ECG’s, Venous Blood Gases, cannulation and Venepuncture. 5.7. Ward Clerk The ward clerk will work under AMU but will be available on the SDEC from 0900 to 1800 hours and will provide administrative support to the unit. The ward clerk will be responsible for:

Ensuring all referrals from AGP are received either through generic e-mail or paper copies by hand – the generic e-mail account must be checked every 15-minutes;


Ensuring all medical expected patients are registered into the medical take list on referral;

Registering all patients and booking them onto the unit on PAS and SWIFTPLUS;

Print patient stickers and making up patient notes;

Discharging and transferring patients as required;

Keeping all paperwork filed appropriately;

Ordering for the unit;

Dealing with general enquiries. 5.8. Therapy Support Therapy support is available by switch via bleep. The service is available from 08.30 to 17.00 hours, Monday-Friday, and fits with the team cover and weekends/Bank Holiday via a rota. Weekends are currently 08.30 to 17.00 hours as part of the ED, AMU and SDEC cover. 5.9. SDEC MDT SDEC operates an MDT approach to the management of the unit which is an

integrated clinical team. The core team compromises of:

SDEC Nurse in Charge

Acute Physician

Acute GP

Advanced Nurse Practitioner

5.9.1. Other key members of the MDT which the core team are able to call

upon are:

Therapist

Specialties as required e.g. frailty, chest pain etc

Onward care

Community services

ED clinicians as required

5.10. A safety brief will be given at the start of each day by the NIC. Board rounds involving the nurse in charge, AGP and Acute Medicine doctor will take place at 12:00, 15:00 and 18:00 or as requested by the NIC, to ensure timely escalation, prioritisation of investigations and best deployment of the team. These rounds will be focussed and standardised with clear information requirements. The MDT will use the board rounds to identify their case load to ensure patients are being assessed, diagnosed and treated by the right clinician, at the right time, on the same day. Teams will be asked by the NIC to attend board rounds as required. The SDEC escalation checklist must be completed to ensure SDEC does not become crowded or unable to manage workload (see appendix 4).

6. Standards and Practice

6.1. Operational Standards for the SDEC Unit

Task Role Timeframe Time required (min)

‘Meet-and-greet’ Senior nurse Upon arrival 5

Observations: NEWS Senior nurse Upon arrival 15

Initial assessment and tests ordered

Senior Nurse or Consultant or

15 minutes after arrival

10


Registrar

‘Bloods’ EMT 15-30 minutes after arrival

5

Consultation with clinician

Any of: • Consultant • Registrar • AGP • Senior Nurse • Junior doctor

30 minutes after arrival

20

Review test results (where appropriate) and final sign-off

Consultant or SpR Median time: 4h 10

Generation of SDEC discharge letter

Any clinician, countersigned by Consultant/Registrar

15 minutes after final sign-off

10

For admitted patients: Decision To Admit

Any clinician 60 minutes after request

Total time 75

6.1.1. The SDEC unit will see patients who will have justified clinical need to be in the unit for more than 4 hours, e.g. for blood test for troponin, scans and following reviews. The patient should not be moved from SDEC if the setting is best suited to patient’s needs even if it means a stay of longer than 4 hours. However, the anticipated mean length of stay should not be greater than 6 hours.

6.2. AGP Referral to SDEC Following consultation by AGP with the community GP, the AGP will advise attendance to either SDEC if the patient is ambulant or MAA if not.

A referral is sent via e-mail to the medical admissions generic e-mail account;

The ward clerk must check the e-mail account every 15minutes for any new referral;

The referral is printed and patient entered onto the medical on take register;

The patient details are checked on PAS and updated or registered as required;

The referral, wristband and printed patient labels are placed into a temporary set of patient notes;

If the patient is to present in SDEC, the temporary set of patient notes is taken to the Nurse in Charge in SDEC;

If the patient is to present to MAA, the temporary set of patient notes are taken to the MAA reception in preparation for the patient arrival. 6.3. Method of Transfer from GPs to SDEC or ED

6.3.1. This process is summarised in the flow chart in Appendix 3. If the decision is made to assess the patient in SDEC the AGP should ask the GP to advise the patient:

That they could be in the SDEC Unit for several hours but we will be aiming for same day anticipated discharge. Conversely the patient needs to be aware that they may need to be admitted;

To bring all current medication;

Space in the SDEC Unit is limited and where possible to be accompanied by one person;

To go directly to the SDEC Unit.


6.3.2. The AGP will forward all relevant information to the SDEC Unit for patient to be placed on the medical take register:

Demographic details of the patient;

Patient contact details;

Problem or provisional diagnosis warranting the review;

A referral including patient summary and past medical history;

Method of transport e.g. self, hospital transport, ambulance etc;

In view of the acute nature of the visit it is not essential that pre-existing notes are available but upon request every effort will be made to obtain them within the shortest time possible;

On arrival all patients and carers will be informed that they have been referred for assessment but that the aim is for same day anticipated discharge. They will also be informed that hospital admission is also a possibility;

An information leaflet will be provided.

6.4. Streaming from ED

6.4.1. The process for streaming from ED is summarised in the flow chart in Appendix 3. 6.4.2. Patients for SDEC can be transferred from ED either by the SDEC NIC ‘pulling’ patients through proactively monitoring of patients in the ED or by ED clinicians ‘pushing’ patients to SDEC. The absence of appropriate space in SDEC to pull a patient from ED will be escalated in line with the escalation checklist. 6.4.3. Patients will be referred through bleep 3002 for those requiring medical review or ext 3566 for those requiring AGP; 6.4.4. Patients will present with a full set of observations and RATS form including a provisional diagnosis (or differential) and a proposed management plan. Suitability for the SDEC will be documented and thus become the responsibility of the referring doctor until patient transfer; 6.4.5. A formal handover will occur between the referring doctor and the ‘on call team’ and a final decision can then be taken regarding suitability; 6.4.6. The transfer will occur as rapidly as possible in order to achieve the 4 hour target; 6.4.7. The Nurse in Charge will operate a positive pull approach when capacity within SDEC allows, assessing the suitability of clinically stable, ambulant ED patients for transfer to SDEC to continue their management plan. All patients should have a set of nursing observations completed prior to transfer; 6.4.8. ‘Deferred’ referrals may be accepted by the AGP or medical 3002 bleep holder for return to the SDEC for assessment and/or diagnostics the following day. There is a diary in SDEC to register patient details and the acute medical notes should be left with the SDEC ward clerk or ED ward clerk Out of Hours;


6.4.9. ED patients requiring completion of care and nurse led discharge will be referred to the NIC to confirm appropriate and accepted and remain under the care of ED. The patients will be discharged from OCEANO and admitted on PAS under SDEC; 6.4.10. Patients referred for primary care review with be through ext 3566 to confirm capacity to receive the patient, these patients will remain on OCEANO and the “4 hour clock”. 6.4.11. The SDEC unit should not be used under any circumstances as a method of transferring patients from ED purely in order to circumvent the 4-hour waiting target.

6.5. Method of Assessment on SDEC

6.5.1. The assessment process must be explained to the patient and their relatives/carers etc. It must be made clear that following a number of designated procedures a decision will be made regarding admission to hospital or discharge. If the patient is to be admitted to a bed, one will be found in the most suitable environment; 6.5.2. Prior notice complete with referral must be given to the NIC as soon as available and the NIC will confirm the referral is recorded on the medical on take register; 6.5.3. Upon acceptance to the unit a patient is not to wait for more than 15 minutes for triage which includes - observations ECG, Bloods, ordering of x-rays and nursing assessment in SDEC; 6.5.4. A patient is to wait for no longer than 1 hour before they receive a medical assessment and a management plan which is to be communicated to them and accompanying persons if appropriate; 6.5.5. A patient is to wait for no longer than 4 hours from their arrival onto the unit before an admission/discharge decision made. SwiftPlus must be updated on times seen and decision; 6.5.6. If the NIC of the unit experiences any difficulties they will inform the most senior person available (i.e. Consultant Acute Physician, AGP or Medical Registrar); 6.5.7. Nursing staff will facilitate the management plan and make prompt referrals to support services where required; 6.5.8. A cohort of patients will be independently managed by nurse practitioners on the unit; 6.5.9. The nursing staff will safely discharge patients when blood results become available (for example troponin), provided the medical plan is carefully documented and includes the words ‘Nurse Led Discharge’;


6.5.10. All admissions, transfers and discharges must be recorded electronically on OCEANO, PAS/SwiftPlus or Adastra.

6.6. Discharges from the SDEC Unit

6.6.1. On discharge patients will be provided with a Nurse Led Discharge summary; 6.6.2. A full Discharge Summary will be communicated with the GP by the Acute Physician within 24-48 hours for patients under their care; 6.6.3. The AGP will provide a discharge summary generated from Adastra; 6.6.4. ED will generate a discharge summary from OCEANO.

6.7. 18.00 hours AGP Transfer/AMU Handover

6.7.1. To support the safe transfer of patients at 18.00 hours when the AGP finishes and the on call medical consultant starts the following is required: 6.7.2. At 17:30 hours a handover meeting will be held in the SDEC office with the following staff:

Acute Physician

SDEC Nurse Practitioner/Nurse in Charge

General Medicine on-call Consultant

On-call registrar 6.7.3. The 17:30 hours meeting will be documented by the Nurse Practitioner/Nurse in Charge. A safety review will be made for all patients on the unit with assurances that a plan is in place for every patient and can be delivered within the opening hours of the unit.

6.8. 19.00 hours Handover At 19.00 hours the Nurse in Charge (NIC) will attend the clinical site office to update the Clinical Site Team of the current position and management plans for the patients in the SDEC Unit. Plans must be made for all patients to ensure the unit closes at 20:00 hours. 6.9. Medical Follow-up Appointments in SDEC If patients are to be reviewed in the SDEC as follow-ups in order to review progress or results of investigations then they are given a time and date prior to them leaving the unit. All follow-up appointments will be booked using the appropriate clinic codes 6.10. Acute GP follow up appointments in SDEC If patients are to be reviewed in the SDEC as follow-ups in order to review progress or results of investigations then they are given a time and date prior to them leaving the unit. All follow-up appointments will be booked using Adastra. When a patient attends for a follow-up appointment the clinical record will be completed on Adastra and an electronic discharge summary sent to the patient’s own GP.


6.11. Patient Assessment and Management Process

6.11.1. A structured approach to patient assessment is essential in determining case management decision making. In particular the following criteria need to be considered:

Presenting complaint;

Associated co-morbidities and complications;

Illness severity as judged by clinical assessment, National Early Warning Score (NEWS) and specific risk assessment tools e.g. Rockall Score, where appropriate;

Social circumstances. Thus, community-based support means will need to be considered rather than opting for the default position of hospital admission. 6.11.2. The management plan should be focussed, well documented and have clearly specified points of action. In particular, for patients that are discharged, indicators of deterioration and the need to seek medical advice should be documented. 6.11.3. It is of pivotal importance that the outcome is communicated back to the referring or responsible General Practitioner. Consequently a copy of the discharge letter will be given to the patient (depending on sensitivity of medical details contained within) and a second copy will be e-mailed to the general practice on discharge or the following morning.

6.12.SDEC Hours of Operation

6.12.1. The service will be delivered Monday to Sunday 08.00 hours – 20.30 hours. There is an AGP presence in SDEC from 08.30 hours -18.30 hours Monday to Friday and 09:00 hours to 17:00 hours at weekends. 6.12.2. No new patients will be accepted to the unit after 19.00 hours to allow completion of the clinical episode and safe and timely closure of the unit. The SDEC will close at 20.30. 6.12.3. The clinical site team will be informed as soon as a bed is required to facilitate admission to either AMU or the base wards. At 20.00 there will be no patients left in SDEC with all patients either discharged or admitted. If patients are waiting at end of day, clerked patients will be sent to MAA/AMU, if there is no flow patients will be sent to ED not clerked.

6.13.Clinical Exclusion Criteria for Referral to the SDEC –

If a patient is medically unstable they will be transferred to ED / Resus

If the patient’s clinical condition presents a cross-infection risk for the patient or others

If a patient is non-ambulant and unable to be safely managed in the unit

If a patient is under the age of 16 years

6.13.1. These exclusions are subject to change and will be reviewed and updated accordingly according to staff and service development.


6.13.2. In addition, there are exclusion criteria for each condition specific pathway. 6.13.3. SDEC is not a waiting area for inpatient beds

6.14.Condition Specific Criteria for Referral to the SDEC

6.14.1. Condition specific exclusion criteria are integral to each of the Ambulatory Care Pathways that have been developed. 6.14.2. The unit is focussed on maximising opportunity of medicine SDEC first. Same day emergency care pathways have been implemented and further pathways are in development - as a minimum, the conditions which should be referred to the SDEC Unit are some of those listed in the Directory of Ambulatory Emergency Care for Adults:

Acute Headache

Anaemia

Asthma

Cellulitis

Chest Pain

Community Acquired Pneumonia (Well)

DVT

Fall, including Syncope/Collapse

LRTI within COPD

PE

6.14.3. This list will be continually under review, surgical SDEC to follow as developed.

6.15.Services Supporting SDEC

6.15.1. Diagnostics All imaging requests are to be made through Order Communications (Comms) and discussed with a Radiographer/ Radiologist as required. Imaging requests are managed with the same urgency as in ED. Time to imaging and reporting are monitored and included in monthly performance reports. 6.15.2. Pathology All pathology requests are to be made through Order Comms and discussed with a pathologist as required. Pathology requests are managed with the same urgency as ED. 6.15.3. Pharmacy During opening hours patients will take To Take Out’s (TTO’s) from Electronic Prescribing and Medicines Administration (EPMA) to Lloyds (as ED patients already do).

6.15.3.1. SDEC to use TTO packs where possible. If not possible, use FP10HNC prescriptions which can be taken to a community pharmacy.


6.15.3.2. For all other situations, the on call pharmacist would need to be contacted. This is the same as the current arrangements in ED. 6.15.3.3. ED has FP10HNC pads which are stamped with ED which could be used for SDEC patients.

6.15.4. Mental Health Access The Mental Health Liaison Team are available through switchboard 6.15.5. System Support The following systems are to be updated to support the smooth running of the unit and ensure appropriate monitoring and reporting:

OCEANO (ED)

PAS (Acute Medicine)

Swiftplus

Maxims

Adastra (AGP) All staff will be given appropriate training and competency sign off for the systems used. The AGP will maintain the Adastra system for all AGP only patients. In order to ensure flow and an overview of all patients in the Unit the following white boards will be used and maintained by the Nurse in Charge:

Patients expected

Patients in the department 6.15.6. Patient Records All medical patients will have notes made up and these will accompany the patient in the Unit. To ensure confidentiality and ease of access one locked notes trolley is to be used and based in the treatment bay. Nursing records are to be maintained at all times.

6.16.Medicines Management

6.16.1. To ensure medicines are handled and administered properly, the Medicines Policy sets the standards and procedures required to ensure the safe and secure handling of medicines. Among the procedures described are the prescribing, administration, recording, ordering and storage of medicines. This is supplemented by policies such as the Policy for Self-Administration of Medicines (SAM) by Competent Patients, the Delayed and Omitted Medicines Procedure, the Policy for the Rules Relating to All Activities Involving Controlled Drugs, the Antibiotic Stewardship Protocol, Clinical Guidelines for Ward Medicines Management, Guidance on Governance Arrangements Relating to Medicines, Injectable Medicines Policy, Non-medical Prescribing Policy and the Policy for the Prescription and Administration and Monitoring of Oxygen in Adults.


6.16.2. If patients managed in the SDEC are not intended to stay for more than 4-6 hours full medicines reconciliation will not usually be performed by pharmacy unless specifically requested by the clinicians. Designated pharmacists and ward pharmacy technicians are attached to the Acute Medical Unit (AMU) but will not normally review patients on the SDEC Unit unless specifically requested. A regular pharmacist service will be allocated to SDEC to include a clinical pharmacist and technician visiting the SDEC for a period of time. Their role mainly involve medicines reconciliation and general medication-related advice where needed. 6.16.3. If a supply of medication is needed on discharge, either a TTO pack will be issued from the SDEC or a TTO will be generated from EPMA which should be taken to Lloyds Pharmacy. Out of Hours (after 18.00 hours), either a TTO pack will be issued from the SDEC or an FP10 (HNC) prescription will be issued which can be taken to a community pharmacy for dispensing.

6.17.Infection Control It is important that this policy is read in conjunction with the Infection Prevention and Control Policy. Any changes to the unit or process must be discussed with Infection control to ensure compliance.

7. Dissemination and Implementation

7.1. Training requirements for Medical Unit staff:

IV additives course

Cannulation and phlebotomy

Mentorship

Trust mandatory study days

Ionising Radiation Medical Exposures (IRMER) course

X Ray requesting

Immediate Life Support (ILS)

Maxims Order Comms

ECG + interpretation

Other courses identified for the role in the job description. 7.2. Dissemination to Trust staff:

Presentations to senior managers and Clinicians

Attendance at ward meetings

Education on daily ward visits

Presentation of AEC activity at Educational meetings. It is the responsibility of Division of Medicine, ED and WCH to ensure that;

staff are aware of any new or newly revised policies;

Policies are appropriately filed and that old ones are removed and destroyed (keeping one copy for archiving purposes on shared drive).

8. Monitoring Compliance and Effectiveness

Element to be monitored

Whole process monitoring

Lead Medicine Division – Associate Director and Clinical Director


Tool Emergency Assessment Checklists to ensure that all possible steps are being taken to improve and streamline the care of patients presenting to emergency care.

Internal audits

Incident reporting and monitoring

Complaints/Datix’s Outcome measures to be included:

Total activity

Quality operational indicators

Patient mortality over 28 days

Re-admission rates

Quality of patient experience including satisfaction surveys, Friends and Family

Number of patients managed with a ‘0’ day Length of Stay (LOS)

Number of patients discharged from unit

Diagnostic waiting times.

Frequency Weekly dashboard for exception reporting

Monthly Performance Assurance Framework (PAF)

Reporting arrangements

The results of the aforementioned monitoring methods will be presented, analysed and discussed at the 2-weekly operational meeting, monthly governance meeting and monthly Divisional Board, Quality, Performance and Compliance Board meeting. Actions, interventions and action plans resulting will be logged and implemented. Subsequently the operational policy can be amended as required.

Acting on recommendations and Lead(s)

The Nurse in charge is required to work closely with the Divisional Governance team and is responsible for the timely response to:

Complaints

Incidents [Datix, & Serious Incident’s (SI’s)]. Operational Management

Daily exception reporting and escalation if required

Weekly performance monitoring

Monthly SDEC Governance meetings

Change in practice and lessons to be shared

Required changes to practice will be identified and actioned within 3 months. A lead member of the team will be identified to take each change forward where appropriate. Lessons will be shared with all the relevant stakeholders

Joint reporting for Acute Medicine and AGP will form part of future developments with one a system approach

9. Updating and Review 9.1. This guidance will be reviewed at least yearly. 9.2. Version Control Table as part of the document control process.

10. Equality and Diversity


10.1. This document complies with the Royal Cornwall Hospitals NHS Trust service Equality and Diversity statement which can be found in the ‘Equality, Diversity & Human Rights Policy’ or the Equality and Diversity website.

10.2. The Initial Equality Impact Assessment Screening Form is at Appendix 2.


Appendix 1. Governance Information

Document Title Same Day Emergency Care (SDEC) Operational Guidelines V1.0

Date Issued/Approved: 14 August 2018

Date Valid From: December 2018

Date Valid To: December 2021

Directorate / Department responsible (author/owner):

Debra Shields, Deputy Associate Director Jane Michell/Ian Gillespie, Clinical Matron Sanjeev Gupta, Lead Consultant Amanda Dave, CFT service manager Lisa Paterson Lead Acute GP Toby Slade, Clinical Director ED and Acute Medicine

Contact details: 01872 258438

Brief summary of contents

This policy sets out the arrangements for the safe and appropriate referrals of patients to the AECU within the Trust. The policy is also intended to ensure that staff of RCHT and CFT clearly understand their responsibilities to ensure safe referral, admission and management of the patient.

Suggested Keywords: AEC/AECU/Ambulatory/Emergency Care/ Acute GP/ SDEC/ Same day Emergency Care

Target Audience RCHT CFT KCCG

Executive Director responsible for Policy:

Medical Director / Chief Operating Officer RCHT Primary Care Director CFT

Date revised: New Document

This document replaces (exact title of previous version):

New Document

Approval route (names of committees)/consultation:

Acute Medicine Governance Board CFT Governance Board

Divisional Manager confirming approval processes

Debra Shields RCHT Amanda Dave - CFT

Name and Post Title of additional signatories

Not required

Name and Signature of Divisional/Directorate Governance Lead confirming approval by specialty and divisional management meetings

{Original Copy Signed}

Name: Sanjeev Gupta

Signature of Executive Director giving approval

{Original Copy Signed}


Publication Location (refer to Policy on Policies – Approvals and Ratification):

Internet & Intranet Intranet Only

Document Library Folder/Sub Folder

Clinical

Links to key external standards

Related Documents:

Department of Health (2003). Emergency Care Checklists, London, The Stationary Office. Institute for Innovation and Improvement. Delivering Quality and Value. Directory of Ambulatory Emergency Care for Adults. Department of Health (2005). Our health, our care, our say, London. The Stationary Office. Royal College of Physicians. Acute medical care. The right person, in the right setting – first time. Report of the Acute Medicine Task Force. London: RCP, 2007.

Training Need Identified? Yes

Version Control Table

Date Version No

Summary of Changes Changes Made by (Name and Job Title)

15 Feb 18 1.0 Initial issue

Debra Shields, Deputy Associate Director Jane Michell, Clinical Matron David Friedericksen, Lead Consultant

All or part of this document can be released under the Freedom of Information Act

2000

This document is to be retained for 10 years from the date of expiry. This document is only valid on the day of printing

Controlled Document

This document has been created following the Royal Cornwall Hospitals NHS Trust Policy on Document Production. It should not be altered in any way without the express

permission of the author or their Line Manager.


Appendix 2. Initial Equality Impact Assessment Form

This assessment will need to be completed in stages to allow for adequate consultation with the relevant groups.

Name of Name of the strategy / policy /proposal / service function to be assessed Same Day Emergency Care (SDEC) Operational Guidelines V1.0

Directorate and service area: Medicine

Is this a new or existing Policy? New

Name of individual completing assessment: Debra Shields

Telephone: 01872 252787

1. Policy Aim* Who is the strategy / policy / proposal / Service function aimed at?

This policy sets out the arrangements for the safe and appropriate referrals of patients to the SDEC within the Trust. The policy is also intended to ensure that staff of RCHT and CFT clearly understand their responsibilities to ensure safe referral, admission and management of the patient. This in turn will reflect the need of the individual, their relatives and carers.

2. Policy Objectives*

The arrangements for the safe and appropriate referrals of patients to the AECU within the Trust. The policy is also intended to ensure that staff of RCHT and CFT clearly understand their responsibilities to ensure safe referral, admission and management of the patient.

3. Policy – intended Outcomes*

Evidenced based standardised practice

4. *How will you measure the outcome?

Audit and review

5. Who is intended to benefit from the policy?

Patients, their relatives and carers

6a Who did you consult with b). Please identify the groups who have been consulted about this procedure.

Workforce Patients Local groups

External organisations

Other

√

Please record specific names of groups Medical Directorate

What was the outcome of the consultation?

Policy Agreed


Are there concerns that the policy could have differential impact on: Equality Strands: Yes No Unsure Rationale for Assessment / Existing Evidence

Age X

Sex (male,

female, trans-gender / gender reassignment)

X

Race / Ethnic communities /groups

X

Disability - Learning disability, physical impairment, sensory impairment, mental health conditions and some long term health conditions.

X

Religion / other beliefs

X

Marriage and Civil partnership

X

Pregnancy and maternity

X

Sexual Orientation, Bisexual, Gay, heterosexual, Lesbian

X

You will need to continue to a full Equality Impact Assessment if the following have been highlighted:

You have ticked “Yes” in any column above and

No consultation or evidence of there being consultation- this excludes any policies which have

been identified as not requiring consultation. or

Major this relates to service redesign or development

8. Please indicate if a full equality analysis is recommended. Yes No

x

9. If you are not recommending a Full Impact assessment please explain why.

No areas indicated

7. The Impact Please complete the following table. If you are unsure/don’t know if there is a negative impact you need to repeat the consultation step.


Signature of policy developer / lead manager / director Debra Shields, Deputy Associate Director Jane Michell/Ian Gillespie, Clinical Matron Sanjeev Gupta, Lead Consultant Amanda Dave, CFT service manager Lisa Paterson Lead Acute GP Toby Slade, Clinical Director ED and Acute Medicine

Date of completion and submission 22/11/2018

Names and signatures of members carrying out the Screening Assessment

1. Medical Services, Governance Lead 2. Human Rights, Equality & Inclusion Lead

Keep one copy and send a copy to the Human Rights, Equality and Inclusion Lead c/o Royal Cornwall Hospitals NHS Trust, Human Resources Department, Knowledge Spa, Truro, Cornwall, TR1 3HD This EIA will not be uploaded to the Trust website without the signature of the Human Rights, Equality & Inclusion Lead. A summary of the results will be published on the Trust’s web site. Signed__ Medical Services, Governance Lead Date____22/11/2018


Appendix 3. SDEC Flow chart

Patient presents at ED

ED Consultant/Acute GP conducts Rapid Assessment & Treatment (RAT) in order to

stream patient or streamed from minors to primary care GP

Patient streamed to either: SDEC (AGP) or SDEC (Medics)

Primary care (GP)

Patient seen within SDEC as per SOP

Patient booked in on Oceano

Notes:

Primary Care Patients streamed to SDEC GP remain

subject to the 4 Hour Standard.

Oceano must be updated in real time

to ensure this activity is recorded

Patients streamed

to SDEC– and identified as

requiring AEC will require a discussion with medical bleep holder 3002 and be

discharged from OCEANO and

admitted onto PAS/SwiftPlus

Patients seen in AEC are not subject to

the 4 Hour Standard however waiting times will still be

monitored. Swiftplus must be

updated in real time to ensure this

activity is recorded.

Weekend resources on MAA are

reduced and will require a discussion

with bleep holder 3002 to confirm

capacity/resources are available

ED GP available:

Friday 18:00-00:00 Saturday 15:00-

22:00 Sunday 15:00-22:00 Acute GP available:

Monday-Friday 08:30-18:30

Saturday 09:00-17:00

Sunday 09:00-17:00

These hours are currently being

extended

Patient discharged where possible nurse led – Home

Admitted to inpatient ward MAA / Base ward

Full clinical clerking completed (RATS streamed) and patient

observations/ bloods/ECG/ X-ray (as appropriate) completed

Attendance updated on Oceano

At SDEC Reception the Patient is booked in on Adastra (AGP) PAS/SwiftPlus (AEC) or remain on

OCEANO for primary care streamed

Patient referred by

own GP

Patient triaged by Acute GP

Ambulant admission to SDEC

to either AGP or Acute Medicine

Patient seen by Acute Medical team:

Pull from ED / Push from

MAA

Non Ambulant patient for admission

Patient to MAA (if no flow they

should go to ED)


Appendix 4. SDEC Escalation check list

Criteria

Green

Default

Amber

Two or more triggers

Red

Three or more triggers

Black

Two triggers Time to Triage

< 15 mins (average per hr)

15 – 30 mins (average per hr)

Monitor number of arrivals per hour

If more than 5 patients for 2 consecutive hours: review current staffing and front-load senior assessment/treatment

> 30 mins (average per hr)

Escalate to Matron

Double triage capacity using an additional RN and treatment room

Refer expected admission (from GP decision) direct to MAA or ED if MAA closed with no RATS

N/A

Wait to be seen by clinician

< 1hour

Monitor number of arrivals per hour and treatment status

> 1 hour and < 3 hrs

Review teams in ED, AGP and AMU (MAA) and realign to demand

Allocate docs/nurses to ensure flow is maintained

Escalate patients requiring admission

> 3 hours

Nurse in Charge to identify patients for immediate doctor review and request doctor from AMU if necessary

If OOH, assess if Consultant advice/attendance is needed

Escalate to site co for MAA capacity available - patients should be transferred to MAA for review

> 4 hours

Escalated to Consultant and Matron in hours or Site Co out of hours for immediate response

Matron / Site Co to discuss with AD Medicine or SMOC to gain senior clinician support

Time to Decision

< 2 hours Monitor wait to be seen and number of arrivals.

> 4 hrs

Doctor in Charge to chase decisions – delegate if necessary.

Check for imaging/lab delays and inform Site coordinator

Escalate admissions awaiting review

> 6 hours

Escalated to Consultant and AD Medicine in hours and SMOC out of hours for immediate response

N/A

Transfer delays

< 15 mins Ensure timely discharge preparation: SBARD, notes prepared

15 mins – 30 mins

Escalate to Site Co-ordinator

Request transfer support if multiple beds available simultaneously

> 30 mins

Escalated to Matron in hours and Site Co out of hours for immediate response

Matron / Site Co to work with teams to divert resource to support transfers

N/A

Number of patients in SDEC

< 12 patients 6 in lounge

> 12 patients

2 waiting for a bed -

> 4 patients waiting for admission

> 4 waiting for admission for more

than 1 hour


6 in waiting room 1 waiting for a bed

escalate to Site Co-ordinator

Maintain space to be seen using. Patients not receiving direct care/treatment to wait in waiting room

Queue patients out to beds (seen and sorted) to reduce queue in

Restrict access to new admissions

Transfer new arrivals to MAA

If MAA full, RAT patient and send to ED for clerking (record on OCEANO the time of arrival to SDEC and triage information)

Record any risk on DATIX

Escalate to Site-Co

Site Co to transfer patients immediately

At close of unit (20:00) patients to be sent to MAA/AMU if there is no flow to AMU patients to be sent to ED (not clerked)

Escalated to Consultant and Matron in hours and Site Co out of hours for immediate response

Matron to discuss with AD for medicine or on call manager to agree plan to recover or restrict unit activity

Comments & Actions - Please explain and demonstrate below what actions have been taken. For example:

Who have we escalated to? If so what was the outcome?

Have we called specialities? If so what specialities and what was the outcome?

What have we done differently within the department?

Have we re-organised staff according to need?

Have any doctors worked extra hours? If so what was the outcome?

Comments & Actions detail

Names of all that completed escalation

Date and Time


Appendix 5. SDEC Administration Guidelines The Unit will accept patients from 08.00 until 19.00 hours. GP patients arriving after 19.00 hours will be directed to ED if they are unable to be processed within the timeframe of SDEC hours. However, if a suitable ambulatory patient arrives in ED before 19.00 hours they will be sent to SDEC (this will be agreed between the nurse co-ordinator and the medical staff). The Unit will close at 20.00 hours and all patients will be transferred out of the Unit by this time. (The nursing staff will use Swiftplus). The allocated SDEC ward clerk will work from 09.30 –19.00 hours starting on AMU 2 until 09.30. Cover will be provided between the AMU 1 and SDEC ward clerk as required. The Acute GPs will e-mail referrals to a generic e-mail address. The ward clerk must check the GP referral admission e-mail account every 15 minutes. On referral receipt the ward clerk must process them immediately and place the patient on the medical take register. – predoc, create a temporary folder and request main notes. The completed notes MUST be hand delivered to AEC or ED reception (depending on where the patient is to present) once they have been made up. The ward clerk will admit the patient on their arrival to SDEC. If the patient changes location in the Unit, Swiftplus will be updated accordingly. The nursing staff will keep the ward clerk informed of the patient’s location. Patients will either be transferred to MAA/AMU, the base wards or discharged home and it will be the responsibility of the ward clerk to tidy the notes for discharge. The notes will go to the AMU Secretaries for discharges summaries to be dictated. The main notes must be forwarded to the secretary as appropriate if they arrive after the patient has left the Unit or follow the patient to the ward if they are admitted. At times of short notice leave SDEC, AMU1 and AMU2 administrative staff will be required to flex across all areas to ensure cover is provided where the need is greatest. Priority will be given to where patients are presenting. Processes will be constantly reviewed and issues addressed as they arise. There will be periodic admin reviews in line with SDEC reviews.


Appendix 6: SDEC Team Training Plan

Requirement Delivery Numbers Support Barriers Cost Measures of

Success

Triage Training Study day All trained staff and AP

Unit Manager Rota Gaps and frequency of training

In house RCHT staff costs

All staff competent in triage staff able to meet triage standards

Immediate Life Support ( ILS)

Study day All band 5 nurses

Unit Manager Rota Gaps frequency of training

In House RCHT Staff costs

All staff achieve competence

Advanced Life Support (ALS)

Study day All band 7/6 Nurses

Unit Manager Rota Gaps In house RCHT staff costs

All staff achieve competence

Intravenous additives competent

Study day and learning pack

All trained nurses

Unit Manager Rota Gaps and frequency of training


All staff achieve competence delivery of drugs on time

Cannulation and phlebotomy

Study day and learning pack

All trained and band 4/3

Unit Manger Rota Gaps and frequency of training


All staff achieve competence, patients have bloods taken in a timely manner

PCA Trained Study day and online training

All trained staff Unit Manager Rota Gaps and frequency of training


All staff achieve competence, safe delivery of analgesia

Medical Devices Departmental training

All staff Unit Manager nil departmental All staff achieve competence, safe use of equipment

Nurse requested In house ( part of All trained staff Unit manger Rota gaps In house RCHT All staff achieve


chest x ray triage training) frequency of training

staff costs competence, timely requesting of chest x rays

EPMA In house on line All trained staff Unit Manger Nil departmental All staff achieve competence, safe administration of medication

Maxims In house on line All staff Unit manger nil Departmental All staff achieve competence, ability to order and view test results

Oceano In house On line All staff Unit Manager nil Departmental All staff achieve competence and able to discharge patients on system


Appendix 7. SDEC Model

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