Agnes Jones UnitService Description

May 2020

Version History

Version Date Author(s) Change Description

1.0 01-May-20Harry RourkePam StanfordBradley Palin

Initial draft for consideration at Covid-19 Executive Led Quality Assurance Review (QAR)

2.0 04-May-20Harry RourkePam StanfordBradley Palin

Medical Staffing updated based on feedback from QAR

Approvals

Committee Date

Covid-19 Executive Led Quality Assurance Review (QAR)01/05/2020

Clinical Reference Group05/05/2020

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Table of Contents

1. Introduction 32. Document purpose 33. Objectives of the unit 34. Description of the unit and service 35. Admissions criteria and transfer process 4

5.1 Inclusion criteria:- 45.2 Exclusion criteria:- 45.3 Access and Referral 55.5 Transport Arrangements 65.6 Documentation of Medically Optimised 7

6. Management of Covid-19 77. Staffing structure 7

7.1 Medical Staffing 77.2 Junior Medical Staffing 87.3 Nursing Staffing 87.4 Therapies Clinical Team Lead 97.5 Ward Pharmacists at Aintree and Royal Site 97.6 Discharge Coordinators/Case Managers Aintree and RLH Site 97.7 Referring Ward 10

8. Accessing support services 108.1 Pharmacy 108.2 Management of the Deteriorating Patient 118.3 Transferring deceased patients to the mortuary 138.4 Safeguarding 138.5 Imaging requests 13

9. Infection Prevention Control 1410. Operational Management 15

10.1 Visitor Policy 1510.2 Security 1510.3 Nurse call 15

11. Monitoring of Compliance 15Appendix 1: Medically Optimised Form 17Appendix 2: Ward Transfer Form 18Appendix 3: Admissions Criteria 19Appendix 4: Ward Telephone details 20Appendix 5: Site Map 21Appendix 6: Process to Transfer Patients for All Out of Hospital Care 22Appendix 7: Emergency Radio Operation – Agnes Jones unit 23

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1. Introduction

The Trust has temporarily commissioning part of the new Royal Liverpool University Hospital (RLUH) as a step down unit to provide an additional 69 beds initially and up to 150, of level 0 and 1 beds for patients zoned green and white. The wards are intended as a zone to decant patients who are medically fit for discharge. This will enable the Trust to commence some business as usual activity as part of recovery planning.

2. Document purpose

The aim of this document is to:-

1. Outline the Standard Operating Procedures [SOP] for the unit. 2. To define how the unit will operate and interact with other departments and teams within

the Trust.3. To give frontline staff manning the unit information in relation to agreed procedures and

processes.

Procedures contained within the SOP have been discussed and signed-off at directorate level.

3. Objectives of the unit

To provide care for patients To provide a continuation of patients rehabilitation and discharge planning To create acute bed capacity on the Royal and Aintree site

4. Description of the unit and service

The Agnes Jones Unit will provide an initial 69 level 0 and 1 beds for both medical and surgical patients identified as green Covid-19 patients from within Liverpool Hospitals NHS Foundation Trust. The patients will be assessed by parent teams and meet the admission criteria for the green wards.

The majority of patients are expected to be elderly, medically stable and recovering from Covid-19 infection and consist of a combination of patients requiring intermediate care and those ready for discharge. The predominant treatment goal will be mobilisation and discharge from hospital.

Only patients who are medically optimised and require minimum support will be suitable for transferring to the unit. “Medical optimisation” is defined as the point at which care and assessment can safely be continued in a non-acute setting. It is a decision that balances the acute care requirements of the patient, the typical desire of individuals to return to their home environment at the earliest opportunity, the potential harm associated with staying in hospital and the needs of other more acutely ill patients.

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The unit contains three wards which will open in phases:-

Stage 1A - Pink ward 1 opens with the first 21 beds Stage 1B - Purple ward 2 opens with 22 beds. Stage 1C - Yellow ward 3 opens with 26 beds.

5. Admissions criteria and transfer process

Patients can be transferred to the unit if they meet the following criteria:-

5.1 Inclusion criteria:- Green ward for patients from the yellow area who test negative but need to remain co-

located as they may have had contact with positive patients in the yellow area and may subsequently develop worsening or new symptoms.

Patient is aged 18 or over. A doctor who is a member of the patient’s clinical team has confirmed the patient is

medically optimised on the Royal Site, this must be documented in PENS. For patients to be transferred from AUH site, the Medically Optimised Form must be completed and signed by the medical team FY2 or above*.

All patients’ next of kin have been advised that transfer to the unit is part of their treatment pathway and have been given ‘Your Discharge from Hospital Patient leaflet’ in line with the Merseyside Transfer of Care and Choice Policy.

Patients with a diagnosis of dementia or delirium will be considered if: -o They do not pose a potential safety hazard to themselves or other patients.o Patients are known to the Mental Health Team – the transferring ward team would

have already liaised, confirmed and ensured documentation confirms that they are in agreement with the transfer from the acute bed base.

o It is documented that the patient’s consultant is in agreement with the intention to transfer.

Patient who are palliative and assessed as having less than 3 months to live will be considered as long as they do not have any specialist needs.

Any patients with potential DOLS patients would be reviewed on a case by case basis.

5.2 Exclusion criteria:- If the patient is due to be discharged home or to a community bed within the next 48

hours. The patient, having been formally risk assessed, poses a potential safety hazard to self

and others. Patient assessed as requiring acute medical care. Patient has specialist palliative care needs. Patient is on dialysis. Patient who require total parenteral nutrition (TPN). Patient has outstanding diagnostic investigations required that cannot be undertaken at

the unit.

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Nausea vomiting and diarrhoea associated with an infection. Patients with nausea vomiting and diarrhoea associated with their condition and manageable in the community can be transferred please seek advice from IPC Team.

Covid-19 status that is red or yellow.

*Medically Optimised Form can be completed by FY1 if directed by the patient’s consultant and if the FY1 is part of the home team. The Medically Optimised Form should only be completed out-of-hours in exceptional circumstances and by StR grade or above.

5.3 Access and Referral The Lead Nurse and Therapy Lead for the unit will control access to the wards, utilising the inclusion and exclusion criteria and, where indicated, carry out a risk assessment to ensure the safety of patients and staff. The dependency level of the admitted patients will be monitored by the nursing and therapy staff in order to ensure that a safe environment and safe staffing levels are maintained.

If Aintree/Royal site is under pressure and a patient is required to be transferred outside of the agreed process, a risk assessment must be completed and an incident form submitted to Datix by the ward staff.

Process for Referral and Transfer to the unit in hours (08.00-17.00) is as follows:-

Patient identified as meeting the criteria for the unit via MDT daily Board Round discussion. Lead Nurse/Therapy Lead/Co-ordinator can also utilise daily RFD database provided by Discharge Planning Team to identify appropriate patients.

A member of the patient’s clinical team at Aintree/Royal must complete the Transfer referral form.

A member of the staff (Lead Nurse/Co-ordinator) will liaise with the named coordinator on the Aintree/Royal site to review the worklist and accept the referral if there is agreement with the transfer.

If the bed is not immediately available, the patient will be put on the Pending List. The unit staff will inform the named coordinator on the Royal/Aintree site once a bed becomes available. Patients will also be accepted from the RFD list.

For transferred from AUH, once the bed is available the medically optimised form must be completed by a doctor who is a member of the patients clinical team, the completed signed form is filed in the patient’s notes. Please see Appendix 1.

Prior to transfer the referring ward must follow and complete the Transfer Form, Please see Appendix 2.

The referring wards nursing team to print a MAC list from EPMA (Aintree), place this in the patients notes to be transferred.

The referring ward must inform the patient and or next of kin (NOK). The referring ward at Aintree must ensure the patients case notes, nursing

documentation and MAC list is transferred with the patient to Ward. The patient will need to be discharged from Aintree SIGMA and readmitted to the PAS

system at RLH by the receiving Ward Clerk. Once the patient is discharged their notes need to be booked out from the unit to clinical

coding at Aintree on SIGMA case note tracking system (CNT). For transfers from RLH, it should be clearly documented in PENS that the patient is

medical optimised. The transfer is completed in line with ward transfer processes in IPM

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Process outside of hours (17.00- 08.00)

If Aintree/Royal site is under pressure and a patient is required to be transferred outside the hours of 08.00 and 17.00 this has to be escalated to the on-site team who will seek advice from the patients’ clinical team prior to any transfer and notify Silver Command.

The patient must still meet the admission criteria for the ward.

If the patient is transferred, a risk assessment must be completed and an incident form submitted to Datix by ward staff at the unit.

5.4 Documentation Process for the Transfer of Patient Notes for Patients Transferring from Aintree

Notes must be tracked out on Sigma Case Note Tracking (CNT) to the unit – either Pink ward 1, Purple ward 2 or Yellow ward 3.

All the patients notes (nursing, case notes and MAC list) need to be placed in a sealed envelope and transfer with the patient.

When patient has arrived at the unit, the notes should be accepted into the Ward on CNT.

Notes are for reference only; they should not be used for clinical noting. Notes should be securely stored. Once patient is discharged, notes should be booked out from the unit to the coding

department Aintree on case note tracking (CNT). Notes should be sent back to the coding department at Aintree by internal transport. Once clinical completed, Clinical Coding at Aintree to book the notes on CNT to Offsite

scanning. Notes will be collected by Capita and Scanned.

5.5 Transport Arrangements

AUH transfersThe transferring ward from Aintree will book the ambulance transport (likely to be through the private provider) via the discharge lounge on ext. 4485/7 as soon as they are made aware that a bed at the unit is available. Discharge lounge is open Monday-Friday, outside of the opening times for the Discharge Lounge; arrangements will be made via the Site Team.

Every effort must be made to arrange this within the hours of 08:00am-17:00pm. Transfers after 17.00pm are not acceptable please refer to point 5.3 for transfers planned after 17.00pm.

RLUH transfersThe transferring ward from RLUH will arrange for a porter on ext. 2010 to transfer patients as soon as they are made aware that a bed at the unit is available. Patients brought from RLUH will enter via the FM tunnel (connected to East of hospital). Entrance to the tunnel can be provided by unit security. They will then be brought via lift to Level 1 and be taken through the ED corridor, avoiding the staff area. A single staff entrance will be to the west. Two security staff will be present 24/7 and based in the ED security office.

Every effort must be made to arrange this within the hours of 08:00am -17:00pm. Transfers after 17.00pm are not acceptable please refer to point 5.3 for transfers planned after 17.00pm.

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Discharge transfersExisting Trust processes will apply for discharge transfers. This will include utilisation of the NWAS patient transport service and the Trusts privately contracted patient transport service.

Transfers can be arranged by contacting the Flow Team on #2314, between the hours of 07:30hrs - 21:00hrs.

The ambulance bays outside the ED entrance will be utilised for patient transport that will be manned by security 24/7.

Full process for transferring patients for all out of hospital care is included in Appendix 6.

5.6 Documentation of Medically Optimised

As per the definition above of ‘Medical Optimisation’, clinical teams must be aware that documenting that a patient is medically optimised in the case notes will be understood to be that the patient’s care and assessment could potentially safely be continued in a non-acute setting and that the patient is therefore fit to be transferred to the unit.

Clinical teams must therefore be clear when documenting that a patient is medically optimised and if the patient is not to be transferred to the unit, then this also must be clearly documented.

Clinical teams also need to ensure that if the patient’s condition changes and they are no longer medically optimised, the notes should reflect this.

6. Management of Covid-19

Patients will be predominantly green (post-Covid infection with limited risk of transmission) or green not positive.

Any WHITE patients will be separated from GREEN patients. Staff must change into scrubs before entering ward areas. National PPE guidelines will be followed. Staff will have a separate area where PPE can be relaxed. Any patient that shows signs of active Covid 19 infection must be transferred back to a

YELLOW acute ward immediately.

7. Staffing structure

7.1 Medical StaffingOut of hours if a patient becomes unwell, the medical doctor and the Advanced Nurse Practitioner (ANP) should be contacted on bleep.  

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There will be senior clinician review at the unit 5 days a week.   Those identified as requiring specialist review will be reviewed by a specialist medicine for the elderly consultant. A consultant level doctor will be present 08:00-17:00pm daily and on call by telephone 17:00-20:00pm, with 20:00-08:00ambeing covered by RLUH medical on call. 

7.2 Junior Medical StaffingThe unit requires 24/7 resident medical cover. A day shift will run with two junior doctors 7 days a week working 08:00-16:00pm. A twilight shift will run 14:00-22:00pm and a night shift 20:00-08:00am (resident with on call room). Overlap of shifts will ensure that there will always be two junior doctors present on the unit.

7.3 Nursing StaffingNursing for the unit will be senior nurse led, supported by B7/6 nurses in each 25-bed unit, with nursing ratios slightly higher than on an acute hospital ward and supported by increased HCAs and increased therapist ratios.

The following outline the key responsibilities of the nursing team

Matron or Lead Nurse Act as first point of contact for the Ward Manager to support the delivery of safe and

effective care of patients on the ward Manage governance and quality measures for nursing/ ward, in collaboration with

Therapies Team Lead for Royal/Aintree Support governance and quality measure for therapy/ ward, in collaboration with

Therapies Team Lead for Royal/Aintree Investigate critical incidents and complaints, with support from Ward Manager Liaise with relevant departments and services to support delivery of safe and effective

care on the ward; Professional Lead for Nurses on the ward.

Advanced Nurse Practitioners Observe defined admission criteria and process. Work in partnership with the ward doctors if a patient becomes unwell and requires

transfer back to an acute bed. Out of hours will control the access to the ward utilising the inclusion and exclusion

criteria and where indicated carry out a risk assessment to ensure the safety of the patients and staff.

Ward Manager/ Therapy Team Lead Ensure daily SAFER Board Rounds are undertaken within the wards on a daily basis to

identify suitable patients for transfer to wards the unit. Liaise with the ward managers and Therapy Team from wards at Royal/Aintree site with

regards to pressures within the Trust and the ability to transfer patients from acute beds Liaise with Lead Nurse Aintree/Royal site on a daily basis or more frequently if

necessary to maintain an up to date list of patients that would be suitable to transfer to the unit when a bed becomes available.

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Assist Lead Nurse/Therapy Clinical Team Lead Royal/Aintree site in controlling the access to the ward utilising the inclusion and exclusion criteria and where indicated carry out a risk assessment to ensure the safety of the patients and staff.

Ensure that an incident form is submitted to Datix if a patient is required to be transferred without the full documentation completed or if the documentation is completed incorrectly/ by inappropriate grade of staff.

If a patient on one of the wards becomes unwell and requires an acute bed, liaise with the clinical throughput team to facilitate this within 4 hours to the Royal site if it is a medical deterioration.

Support all members of the multidisciplinary team.

7.4 Therapies Clinical Team Lead The Therapies Clinical Team lead will act as point of contact for the Therapy Team to support the delivery of safe and effective care of patients at the unit and will be responsible for:-

Managing governance and quality measures for therapy/ ward, in collaboration with Lead

Supporting governance and quality measure for the nursing/ward, in collaboration with Lead Nurse

Investigating critical incidents and complaints, with support from Ward Manager Liaising with relevant departments and services to support delivery of safe and effective

care on the ward. Overseeing completion of Healthcare Needs Assessment (HNA).

7.5 Ward Pharmacists at Aintree and Royal Site The Aintree Ward Pharmacist will ensure the medications are up to date; The Pharmacist supporting the unit is responsible for ensuring that the transcribed

medications are correct and accurate.

7.6 Discharge Coordinators/Case Managers Aintree and RLH Site Discharge Coordinators at Aintree/RLUH site to liaise with Case Manager/Ward Manager

at the unit on a daily basis and provide an update on any patients transferred; Once the patients are transferred to the unit, discharge planning will be undertaken in the

usual way by relevant members of the MDT, maintaining regular communication with both their patient and their families’ carers to ensure that the patients discharge happens as planned.

7.7 Referring Ward The referring team must follow and complete the Transfer Form, Appendix 2. The referring team must inform the patient and/or next of kin (NOK). The medical team of the referring team must complete the Medically Optimised Form,

Appendix 1. The nurse transferring the patient (Aintree) must print off the MAC list from EPMA The referring team must ensure that the patient’s (Aintree) case notes, nursing notes

and MAC list all transfer with the patient to the ward The referring team will ensure the case notes are tracked out to the unit/ward/s on

SIGMA CNT; The referring team will discharge the patient (Aintree) on SIGMA.

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8. Accessing support services

8.1 Pharmacy Ward stock top ups to medicines storage area will happen bi-weekly (or as required) Daily stock replenishment of the clean utility areas will take place, for ease of access for

staff on other areas away from the medicines storage area. New dispensing of all medicines for patients who are admitted will be placed in the

patient medicine lockers in each room for ease of administration and medicine rounds – all labelled for discharge to ensure rapid discharge processes.

Assessment of patient’s own medicines and confirmation of supplies at home will be completed if appropriate.

Drug histories will be taken for all patients who are admitted (if not done on other areas) Deliveries by pharmacy porters will occur on a regular basis throughout the day. 2 x ward technicians, 2 x Assistant Technical Officers and 1-2 x Pharmacists visible on

wards between 09:00am-17:00pm, Monday to Friday. Out of hours support by pharmacy from 17:00pm – 19:00pm will be provided for urgent

requests and discharge support (available from main pharmacy #2085) Monday to Friday.

Out of hours pharmacy support will be via the on-call pharmacist (accessed through the duty manager) between 19:00pm-09:00am, Monday to Friday

Weekend supplies – Between the hours 09:00am – 17:00am supplies of medicines will be via #2085.

Out of hours weekend supplies will be via the on call pharmacist (accessed through the duty manager).  

Recycling of medicines through green recycling unit. Controlled drug orders. Controlled drug destruction.

Administration of Medicines

The EPMA system on the Aintree and Royal site are separate systems, patients will be discharged from the Aintree EPMA and readmitted on the Royal site EPMA system

A MAC list will be printed by the referring nursing team prior to discharge and transferred with the patients notes to (if transferring from Aintree). Patients transferring from Royal site EPMA will remain unchanged

Medications supplied from Aintree pharmacy or brought in from home, must be sent with patient to the wards.

All patients medications will be administered from EPMA; Prescribing and dosing of warfarin will be based on Royal Liverpool University Hospital

guidelines.

8.2 Management of the Deteriorating PatientWhilst patients are being cared for at the unit will be deemed medically fit, there is the possibility they could deteriorate, or their Covid status change and as a result may require transferring to the main hospital site. Identification of such patients should be done as early as possible to allow safe transfer and minimise escalation of treatment on the wards.

The following outlines the process for managing deteriorating patients at the unit.

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At the time of opening the wards, it is possible the bleep system may not be fully operational. If this transpires, a dedicated radio hand set system will be in operation. Radios will be allocated to the bleep holders (Doctor, Nurse in Charge and AMP) – See appendix 7.

National Early warning Score (NEWS) Escalation Plan NEWS 1-2: Nurse in charge to be notified NEWS 3-4: Nurse in charge to be notified, Nurse Practitioner should be called to

assess NEWS 5-6: Nurse in charge to be notified, SpR and Nurse Practitioner to be

called to assess NEWS 7+: MET call as below All other actions as per ADT Dashboard

Medical Emergency Team (MET) Calls MET should be called in the following situations:

o When a patient’s NEWS score is 7 or more o Compromised airway, o Sign of anaphylaxis o Unconscious patiento Other significant concerns.

The MET covering this area will consist of the duty doctor, nurse practitioner and the senior nurse on duty as a minimum with additional staff being notified during normal hours. This team will be independent of the Royal Liverpool site team who will not be notified of a MET call to this area

The MET should be summoned by dialling ‘2222’ from any internal telephone. The Caller must state the name of the ward (i.e. colour) and room number

Transferring Patients to the Main Site, RLUH

The basis of a decision to transfer a patient is an assessment of the risks, benefits and urgency associated with each case. The decision to initiate transfer lies with the clinical team on site. Please see overleaf for specific actions.

Ward Nursing Staff Contact the Nurse Practitioner on bleep/radio system or if not already present. Assist with the ongoing management of the patient Ensure the patient’s relatives have been informed of the change in patient’s

condition Provide a nurse escort (registered nurse) for the transfer if required, as directed

by the Nurse Practitioner.

Doctor Attending the Patient

Make contact with one of the following in order to facilitate the transfer:

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o Compromised airway - Consultant Anaesthetist.o All other transfers - Medical Registrar bleep 4950 (24/7).o Co-ordinate the management and stabilisation of the patient until patient is

transferred. Notify the patient’s own consultant at the most appropriate time.

Nurse Practitioner

Assist the doctor in the ongoing management and stabilisation of the patient. Inform Patient Flow, RLUH of the impending transfer. Facilitate additional equipment as required. Arrange additional staff to assist with the transfer, this may require utilising staff from

other areas.

Consultant Anaesthetist Decide on the best course of action including attendance of anaesthetic team on

site, or emergency transfer to RLUH. Ensure appropriate staff have been informed and mobilised as necessary. Discuss with ITU Consultant on call if the patient requires critical care intervention.

Bed Manager Notify the appropriate area of the impending transfer. Notify additional personnel as requested by the site clinical lead.

8.3 Transferring deceased patients to the mortuaryMortality is expected to be low at the unit. In the event of a death, the following process will be followed:-

Ward Staff will prep the patient for transfer and arrange for a porter on ext. 2010 to transfer the patient to the mortuary.

RLH Porters will collect the patient and deliver to the Mortuary, via the FM tunnel (connected to East of hospital). Entrance to the tunnel can be provided by unit security.

Mortuary staff will receive and document the patient. Subject to capacity, patient may then be transferred via vehicle to the temp Mortuary

within the CSSB compound. This will be the decision of mortuary staff.

8.4 SafeguardingWhere a patient is subject to either an on-going safeguarding investigation, or if they are currently subject to a Deprivation of Liberty Safeguard (DoLS) urgent or standard authorisation, the safeguarding team must be made aware of the transfer to the unit and any subsequent discharge.

Patients transferred from Aintree site on a DoLS, staff at the unit will be required to complete a new DoLS application. Advice can be sort from the safeguarding team. For patients transferring from the Aintree site, staff will need to contact the safeguarding team on the Aintree site and for patients transferring from the Royal site, staff will need to contact the safeguarding team based on the Royal site.

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8.5 Imaging requests

The X ray / US imaging room is located in room H01.RAE019 in Zone 1.

The room contact number is 11606 although this room will not be routinely staffed, if you need to contact a Radiographer contact the main hospital on:

Mon – Fri: 09:00 – 17:00 ext 2745Evenings and weekends: ext 2069

Imaging can be requested via the imaging request procedure outlines below.

The X-ray provision is a basic temporary solution, referrals should only be for CXR’s. Any other examinations should be referred to the main hospital for suitable imaging capabilities.

9. Infection Prevention Control

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The unit is identified as a Green zone, with Green wards for patients from the Yellow area within Aintree/Royal acute beds who test negative but need to remain co-located as they obviously may have had contact with positive patients in the Yellow area and may subsequently develop worsening or new symptoms. A patient in the Green wards who develops new or worsening symptoms should be swabbed immediately and then moved back to Yellow while awaiting the result. Ward staff must liaise with Royal Site Team on ext. 2261 to facilitate transfer to yellow ward within 4 hours of identification.

PPE for wards - surgical face mask when entering the ward (sessional use), apron +/- eye protection (sessional use) and gloves changed between patients. PPE will be updates as required and follow latest guidance.

The admitting ward should screen the relevant patients for MRSA and CPE in line with guidance. If screening has not been undertaken, this should be undertaken at the earliest opportunity either on the admitting ward or on arrival to the unit. Patients with positive results should be managed in accordance with IPC guidance.

There is no requirement to rescreen the patient prior to their transfer to the Agnes Jones Unit; patients with known infections should be isolated as per guidance. MRSA and CPE screening should be undertaken for patients every 30 days.

Patients should not be transferred from wards experiencing unresolved outbreaks of infection e.g. norovirus.

10. Operational Management

10.1 Visitor PolicyIn line with current Trust policy, no visitors will be allowed into the unit.

10.2 SecurityThe unit is confined deliberately to a single level. All patients entering by ambulance will be brought in via the ED department. Patients brought from the RLUH will enter via the FM tunnel (connected to East of hospital). They will then be brought via lift to Level 1 and be taken through the ED corridor, avoiding the staff area. A single staff entrance will be to the west. Two security staff will be present 24/7 and based in the ED security office.

10.3 Nurse callA wireless nurse call system will be in operation across the three wards, with base units located at each of the nurse stations. To enable a rapid response to call, the number of each unit correlates with patient room numbers. To ensure all calls are heard and responded to appropriately, there will be an increased and fixed staff presence at the nurse station.

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11. Monitoring of Compliance

Standard operating procedure authors must outline how the implementation of the procedure will be monitored i.e. through audit, review of incidents, via performance management routes, key performance indicators etc.

Minimum requirement to be monitored

Process for monitoring e.g. audit/ review of incidents/ performance management

Job title of individual(s) responsible for monitoring and developing action plan

Minimum frequency of monitoring

Name of committee responsible for review of results and action plan

Job title of individual/ committee responsible for monitoring implementation of action plan

Patient safety Review of incidents

Ward Manager Weekly

Weekly Safety Meeting

Divisional Governance

Completion of Forms/ Documentation

Review of incidents

Ward Manager Weekly

Weekly Safety Meeting

Divisional Governance

Appropriateness of transfers

Review of incidents

Ward Manager Weekly

Weekly Safety Meeting

Divisional Governance

Safeguarding

Review of incidents Ward

ManagerWeekly

Weekly Safety Meeting

Divisional Governance

eNEWS 2 NEWS Audit Ward Manager Weekly

Divisional Governance

Divisional Governance

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Appendix 1: Medically Optimised Form

Medically Optimised Form

This form is to be completed and signed by the medical team FY2 or above. It can be completed by FY1 if directed by the patient’s consultant and if the FY1 is part of the home team. The Medically Optimised Form should only be completed out-of-hours in exceptional circumstances and by a SPR grade or above.

Readiness For Discharge/Transition (from current level of care) Yes No Comments

1. Vital assessments within safe and/or expected range in last 24 hours (includes assessments of: vital signs, airway, oxygen saturation monitoring, neuro-vital-signs, colour-sensation-movement (CSM), seizure Activity, Intake/Output, mental status, level of consciousness (LOC), blood glucose, surgical site, wound, oedema, weight etc.).

2. Voiding, quantity sufficient (could include long term catheter). Manageable in the community.

3. Nausea, vomiting and diarrhoea associated with their condition not associated with an infection controlled or manageable in the community, please seek advice from IPC Team.4. Pain controlled/manageable with oral meds, transdermal patch, or manageable in the community.

5. Passing flatus/stool or diarrhoea not associated with an infection controlled or manageable in the community.6. Tolerating fluids/tube feedings/) or manageable in the community.

7. Oxygen saturation greater than or equal to 90% on Room Air or in alignment with patient’s comorbidities and/or diagnoses, back to baseline or manageable in the community.8. Lab Values within acceptable ranges in last 24 hours, or improving over the past 48 hours.9. Monitored drug levels (including half-life/clearing levels if applicable) within therapeutic/safe range or manageable in the community.

10. Cardiac status within safe and expected range in last 24hrs (includes absence of; ischemic cardiac changes, unstable angina, unexpected or hemodynamically significant arrhythmias). Chest pain controlled by oral/sublingual/patch meds.11. All investigations available , reported and acted upon

Doctors Name:

Signature: Date

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Appendix 2: Ward Transfer Form

We need to review

Once it has been confirmed that there is a bed available for your patient please complete the following checklist

Confirm the following criteria has been met

□No medical needs requiring intervention only available on Royal or Aintree Site

□No dementia/confusion unless agreed by the clinical team looking after the patient

□Consultant has given permission to transfer the patient to Project X

□Transfer medical and nursing notes from Aintree site to the Project X site, including relevant passports – i.e. catheters, LD

□Inform relatives

□Inform Patient (Please provide patient leaflet)

□Verbal handover to Ward nursing staff Ext ……

□Medication - AUH patients to transfer with a MAC list

□Medications supplied from Aintree Pharmacy or brought in from home sent with patient to Project X.

□Transfer relevant passports e.g. catheter

□If the patient requires an outpatient appointment please arrange this prior to the transfer

□Identify if there are any ongoing safeguarding concerns and whether a DoLS was in place on the transferring ward. Transfer relevant info.

Printed Name

SignatureDate

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Patient Details:

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Appendix 3: Admissions Criteria

Admissions Criteria for the Transfer of Patients from Aintree/Royal Site to Pink ward 1, Purple ward 2 and Yellow ward 3

Patients can be transferred if they meet the following criteria: -

Inclusion Criteria: - Green ward for patients from the Yellow area who test negative but need to remain co-

located as they obviously may have had contact with positive patients in the Yellow area and may subsequently develop worsening or new symptoms.

 At times of severe pressure with capacity, flexibility of the catchment area maybe employed, however, there would be an aim to select appropriate patients i.e. on the borders of the catchment area.

Patient is aged 18 or over A doctor who is a member of the patient’s clinical team has confirmed the patient is

medically optimised. The Medically Optimised Form completed and signed by the medical team FY2 or above*

All patients next of kin have been advised that transfer to Project X is part of their treatment pathway and have been given Your Discharge from Hospital Patient leaflet in line with the Merseyside Transfer of Care and Choice PolicyPatients with a diagnosis of dementia or delirium will be considered if: -- They do not pose a potential safety hazard to themselves or other patients- Patients who are known to the Mental Health Team current ward team would have

already liaised, confirmed and ensured documentation confirms that they are in agreement with the transfer

- It is documented that the patients consultant is in agreement with the intention to transfer

Patient who are palliative and assessed as having less than 3 months to live will be considered as long as they do not have any specialist needs

Any patients with potential DOLS patients would be reviewed on a case by case basis.Exclusion Criteria: - If the patient is due to be discharged home or to a community bed within the next 48

hours The patient, having been formally risk assessed, poses a potential safety hazard to self

and others Patient assessed as requiring acute medical care Patient has specialist palliative care needs Patients who are on dialysis Patients who require total parenteral nutrition (TPN) Patient has outstanding diagnostic investigations required that cannot be undertaken at

the Project X site Nausea vomiting and diarrhoea associated with an infection. Patients with nausea

vomiting and diarrhoea associated with their condition and manageable in the community can be transferred please seek advice from IPC Team.

Notes: -*Medically optimised form can be completed by FY1 if directed by the patient’s consultant and if the FY1 is part of the home team. The medically optimised form should only be completed out-of-hours in exceptional circumstances and by StR grade or above

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Appendix 4: Ward Telephone details

Ward Telephone List for Pink ward 1, Purple Ward 2 and Yellow Ward 3

Room Number Room Name Phone number Ward/AreaH01.EAC019 Staff touch base 11619 PinkH01.EAC016 Office 1 person 1512826520 PinkH01.EAC026 Staff base 11614 PinkH01.EAC033 Staff base 11610 PinkH01.EAC028 Office 2 person 1522826521 PinkH01.EAM001 Staff base 11617 YellowH01.EAM037 Staff base 11612 PurpleH01.EAM082 MDT room 1512826522 OfficeH01.EAM083 Interview room 11623 OfficeH01.EDS006 Ultrasound room 11606 X-RayH01.EDS007 Office 1 person 11620 OfficeH01.EDS008 Office 8 person 11607

116091160211603116001160811611

Office

H01.ESA028 Staff base 11613 YellowH01.ESA034 MDT room 3 people 11622

11621Office

H01.ESA039 Staff touch base 11601 Discharge LoungeH01.ESA041 Staff base 11615 YellowH01.ESS001 Staff base 11605 YellowH01.FMZ106 Medicine Store 11624 Yellow

Red Emergency Phones

Room Number Room Name Phone Number Ward/AreaH01.EAC026 Staff base 6569 PinkH01.EAM001 Staff base 6568 YellowH01.EAM037 Staff base 6570 Purple

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Appendix 5: Site Map

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Appendix 6: Process to Transfer Patients for All Out of Hospital Care (including to Care Homes/Hubs, domiciliary care, supported living, sheltered housing)

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Usual discharge process to be followed including: arranging TTO medication, transport and completion of discharge checklist.

If a Care Home/Provider accepts transfer of the patient before the result is available,this must be discussed and approved at Divisional level and by IPC. Please discuss with the relevant Discharge

coordinators/Case Managers for the ward in the first instance.

In order to identify that swab is for a discharge to out of hospital care, requestor must indicate "Pre Discharge Swab" in the clinical details section of the order comms request.

Patients can be discharged once the following are satisfied:Confirmed or High Clinical Suspicious Covid-19 - Red WardClinical Improvement (afebrile > 48 hours and stable or improving respiratory function). At least 14 days post inital positive swab. A repeat Covid-19 swab test is required on Day 12 following initial positive swab result.If repeat swab result is negative and clinical assessment is in agreement, the patient should be stepped down to a green ward. As a general rule, patients cannot be discharged from a red ward. For exceptional circumstances or if care home/provider can faciliate/is pushing for discharge from a red ward, this must be discussed and approved at Divisional level and by IPC. If repeat swab result is positive, the patient should remain on a red ward and be re-tested in a further 7 days for reswab, i.e. Day 19 from original (12+7). If still positive at Day 19, reswab every 72hrs until negative.

Non Covid-19 pathway - White WardA Covid-19 swab test is still required prior to planned transfer.A negative swab result in the past 48 hours. If patient is re-swabbed and result is positive , the patient should move to a red ward and follow the process for Confirmed or High Clinical Suspicious Covid-19 patients.

Previously Suspected COVID-19, confirmed Negative swab - Green WardAsymptomaticA negative swab result in the past 48 hours. If patient is re-swabbed and result is positive, the patient should move to a red ward and follow the process for Confirmed or High Clinical Suspicious Covid-19 patients.

A Health Needs Assessment form is completed if indicated and sent to SPC to source placement/care plan etc.

Patient identified as RFD and agreed discharge plan. Patient/Next of Kin provided with Patient Discharge Choice Leaflet A and B2.

Appendix 7: Emergency Radio Operation – Agnes Jones unit

The Emergency radios will be in operation on the Agnes Jones Site until the bleep system has been installed. This SOP has been written for members of the Medical Emergency Team and the following should be noted:

Placing a MET call in response to a patient’s condition: Members of staff who require the MET should dial ‘2222’ from any internal phone

as per trust policy. Members of the MET should also dial ‘2222’ should anaesthetic assistance be

required.

Daily system tests: At the start of each shift, the radio should be checked to ensure:

o The radio is switched on and the volume adjusted

o The radio should be on channel 7

The call centre will perform twice daily radio tests at approximately 10am and 10pm

Upon receiving the test call the user should acknowledge the test by responding via the radio as below.

Receiving an emergency call: Upon receiving a ‘2222’ call the call centre will repeat the information over the

radios a number of times.

If the information is not clear the user can either radio back to the call centre or alternatively dial ‘2222’ from an internal phone and ask for clarification

Please note when using the radio to send a message the user must not begin the message until after the beeps.

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