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5

ACC.5

Transfer of

Patients

*** ER.P.004 Patient Referrals and

Transfers.pdf (dsah.sa)

2

4

6

Admission to the Hospital

ACC.2

Discharge, Referral, and Follow-Up

ACC.4

ACC.6

Transportation

Boarding Patient in ER

Boarded Patient – is defined as a patient who remains in the ER department after the patient has been admitted under an MRP, but has not been transferred to in patient unit or Intensive Care Unit due to unavailability of bed.

Long Stay Patient - This refers to the patient who may need to stay in ER for more than six (6) hours.

1. For Boarding patients in ER department:

1.1 In case of delay of admission due to unavailability of bed, the

patient and family should be informed of delay.

1.2 The patient and family should be given the option to either

wait or to transfer to another facility.

1.3 Any boarding patient who is critically ill should be stabilized

within the hospital’s scope before any transfer to another

facility.

2. ER boarding from Out Patient Department or to a referred Specialty

2.1 Any patient from OPD needing ER observation, shall be carried out

by ER staff nurses and be under the supervision of On-call under the

Most Responsible Physician.

2.2 Any ER patient referred to a specialty will be the responsibility of the

MRP or designee and the ER nurse.

2.3 The same treatment and nursing care is expected to be provided to all

boarding patients.

3. ER boarding of Labor and Delivery Cases

3.1 Full term or preterm with active labor pain should not be kept as a

long stay in ER.

3.2 If and only during full bed capacity of L and D is achieved, the patient

will be examined in the ER-DR and coordinated timely with the OB

on call to examine patient and prepare for any emergency or imminent

delivery.

3.3 Coordination with the Nursery or NICU should also be done

accordingly to the prenatal history.

4. ER boarding of critically ill patients

4.1 All critically ill patients boarding in ER should be kept under the care of and observation of the ER

nurse.

4.2 In the event that the department gets busy and cannot manage to take care of ICU patient,

arrangement with Nursing Supervisor is done to allocate an ICU nurse with RT if needed to take

care of the patient until a bed is available in ICU.

4.3 An immediate back up plan within the 6 hour period shall be done by MRP, Duty Manager and ER

Physician in charge to decide to transfer the patient to another facility.

4.4 The MRP or designee shall be responsible with the patient in coordination with the ER nurse in

charge when the staffing permits.

4.5 Any Pediatric ICU patient is admitted under ICU temporarily to provide critical care and may

arrange transfer to other facility as needed.

ER Criteria for Admission and Discharge

> All patients coming to the ER for treatment or consultation must be considered an emergency

case and prioritized according to CTAS form: CN/001-V1 and Triage and Priority of Care

Policy and Visual Triage for Acute Respiratory Infection

> Patient may be discharged from the Emergency Room for the purpose of:

1. Admission of Patient to the floor

2. Transfer to another Hospital

3. Direct Home Discharge

4. Discharge against Medical Advice

Discharge Criteria - ICU

1. Physical Status has stabilized

2. Physiological status has deteriorated and active interventions are no longer considered

3. Stable Hemodynamic parameters

4. Stable respiratory status (patient extubated with stable arterial blood gases) and airway patency

5. Oxygen requirements not more than 60%

6. Intravenous inotropic support, vasodilators, vasopressors drugs are no longer required.

Patient on low dose inotropic support may be discharged earlier if ICU bed is needed.

ADMISSION AND DISCHARGE CRITERIA IN NICU

> ADMISSION TO NICU SHALL BE LIMITED TO:

1. Babies delivered in DSAH with birth weight more than 500 gram and more

than 23 weeks gestational age

2. DSAH shall only accept after full medical report and agreement between outside

Consultant neonatologist and chief of Pediatrics/NICU according to availability of

service, nursing and equipment.

3. In case of approval the baby will be admitted to isolation room and repeat sepsis

screening and transfer to main NICU after negative sepsis screening.

Criteria for Admission to Intermediate Care:

1. Low Birthweight – under 2500 gm. (Some babies 2000 and 2500 gm may be able to go directly to Nursery. This will depend upon the clinical assessment

of the baby after stabilization. Only normal babies go to Nursery.)

2. Prematurity – 36 weeks gestation or less. (For babies between 35 and 36 weeks gestation, criteria as in (1) apply.)

3. Any respiratory distress causing concern

4. Infection – suspected on clinical grounds or history, or confirmed, PROM

5. Gastrointestinal problems

6. Metabolic problems

7. CNS problems

8. Malformations

9. Jaundice requiring Phototherapy

Admission & Discharge Criteria in PICU

Patients of the following Categories must be admitted to PICU:

1. ER cases from Triage of 1 or 2

2. Apparent lie-threatening event (ALTE)

3. System

4. Surgical

Discharge/Transfer Criteria:

1. Stable hemodynamic parameters

2. Stable respiratory status (patient extubated with consistently stable

arterial blood gases) and airway patency. Post extubated patients should be

observed in PICU for 24hrs prior to transfer

3. Intravenous inotropic support, vasodilators and antiarrhythmic drugs

are no longer required

4. Neurological stability

5. Medical treatment is of no further benefit and therefore only palliative care is to be provided

ADMISSION AND DISCHARGE GUIDELINES IN NURSERY

ADMISSION TO NURSERY SHALL BE LIMITED TO:

- Well babies recently born at DSAH.

- Nursery should not be an overflow to NICU by any mean (e.g. admission of a growers.

or any old stable whose mother was discharged home and he/she still need to stay in the hospital.

ADMISSION TO NURSERY FROM OUTSIDE DSAH:

- Babies delivered before arrival to DSAH but cord aseptically cut in DSAH.

Criteria for Discharge:

1. Neonatal medical readiness. Successful cardiorespiratory adaptation to extra

uterine life, with normal, stable heart and respiratory rates.

2. Infant is maintaining temperature in an open crib

3. Infant is feeding well enough to meet the caloric intake needs for growth

4. Voided and at least one stool per day have passed.

5. If circumcision performed, no excessive bleeding at the site.

6. Vaccination and screening care

7. Discharge teaching is complete and parents demonstrate ability to

take care of the infant at home.

8. Follow-up

Patient Discharge Policy

> Adults may be discharged alone, unless their medical condition dictates otherwise.

> Child dependents may be discharged into the care of any individual (preferably a relative who is

known to the patient) who comes to collect them and who can provide identification (ID card,

Passport) and an address.

> New-born infants may be discharged only after matching the identification information on the

mother’s bracelet and noting the identity and method of verification (e.g. ID card, passport) of the

individual who comes to collect the infant and mother

> Patients given narcotics are not allowed to drive themselves, and preferably should be

accompanied when discharged.

Patients will be discharged under one of the following circumstances: -

1. Medically-advised discharge;

2. Discharge against medical advice (DAMA);

3. Transfer to another medical facilities;

Procedure:

1. A consent for discharge against medical advice should be completed and

signed by the patient and/or relatives.

2. The attending physician shall write prescriptions for patients to take home as

necessary.

3. An occurrence Variance Report shall be filled in by the primary Nurse, notification

to Nursing Supervisor and be sent to Quality for collation of data.

4. A referral to Social Services.

5. Patients who have a known family Physician is involved in the event they consent

for DAMA, Family Physician shall be informed and may be able to expound better

the risks involved and may persuade the decision to be otherwise.

6. A communication with the Duty Manager and Social Services are done in

case that the patient exhibits being a threat to self or to others.

7. A communication with Infection Prevention and Control (IPC) department is

done in case that the patient has an infectious disease that may cause harm

and spread of infection.

8. The patient is discharged from the system following the discharge process.

Discharged Against Medical Advice - DAMA

DAMA – Discharge against medical advice – when the patient leaves the

Hospital upon his/her own desire and responsibility against Medical advice of

the Physician

AMA – Against Medical Advice – when a patient refuses/declines a care of

treatment, investigations that are essential but will not hinder the normal

discharge of the patient. (Refusal of Care)

The following are not candidate for admission into the Newborn Nursery.

1. Symptomatic infants

2. Infants requiring IV fluids

3. Infants requiring blood transfusion

4. Infants with hypoglycemia

5. Infants requiring surgical intervention

6. Infants who require monitoring (cardiorespiratory, O2 saturation etc.)

7. Term infant with birth weight <1800 gm. should be admitted in NICU/

SCBU during the 1st 24 hours of life.

8. Readmission for any reason after discharge

Criteria for admission to Nursery:

1. Newborns should be at least 35 weeks and weighing >1800 grams who remain physiologically

stable for direct admission into newborn nursery. Newborns less than 35 weeks gestational age

should be initially admitted in intermediate care (SCBU) or NICU depending on the infant

condition.

2. Infant of Diabetic Mother (IDM), including insulin dependent gestational diabetes to

monitor blood sugar as per Hypoglycemia Algorithm.

3. Stable infant with congenital anomalies which does not need close cardiorespiratory monitoring.

4. Infant with mild respiratory distress who requires oxygen less than 30% and have no other reasons

for admission to level2, can have an observation period for 2

hours ad per Senior Specialist Neonatologist order.

5. Large for Gestational Age (LGA) with birth weight >4000 grams.

6. Term > 37 weeks with PROM > 18 hours who is asymptomatic and without history of chorioamnionitis

Criteria for Discharge: NICU

1. The baby is steadily gaining weight for one week

2. The baby is sucking full requirements.

3. The baby is able to maintain his or her temperature in a cot in a normal household

environmental temperature especially in winter.

4. No Oxygen, No Apnea for at least 72 hours

5. No Antibiotics

6. Parents must be willing and happy to take the baby home and they have to

demonstrate adequate parenting skills.

7. There should be adequate follow up services, either in Hospital or through

neonatal home care nurses.

8. Neonate should be Free of the original cause of admission

Criteria for Admission to NICU:

1. Birthweight less than 1800 gm.

2. Gestation less than 35 weeks.

3. Requirement for any form of Assisted Ventilation: Nasal Cannula, CPAP, Ventilator.

4. Exchange transfusion.

5. Respiratory problems.

6. Cardiovascular problems.

7. CNS problems.

8. Any other baby whose clinical condition is such that baby cannot be appropriately

cared for in intermediate care.

9. Congenital anomalies causing derangement in physiology and vital signs.

Admission Criteria - ICU

> Establishment of:

1. Priority: Priority 1, 2, 3 & 4

2. Diagnosis: Severe Potential or Actual Life Threatening

3. Objective Parameters: Vital Signs/Laboratory Values Radiograph

4. Physical Findings: Acute Onset

> Admission to the ICU requires written order after approval of the

ICU consultant.

Patient Admission Policy

> Admission decision can only be made by a consultant physician or senior specialist referred to as MRP, or by CMO confirmation in case the consultant is not on duty.

> Admission Types: Elective, Emergency, Transfer, Unplanned

> Financial Categories: Cash, Insurance & Emergency Cases

DISCHARGE PLANNING

Discharge Planning - is the process by which the patient is

assisted to develop a plan of care for ongoing

maintenance and improvement of health care even after

he/she maybe discharged from the acute care setting.

Patient Transportation via DSAH Ambulance

> DSAH Ambulance services are provided on a 24/7, patients are accompanied by a Physician, Paramedic, Nurse, or designee according to the need and patient’s

condition.

> DSAH ambulance will be active for any outpatient or inpatient transfer of patients

> Patient discharges who require discharge by ambulance is permitted, to follow the

request completion within 1 hour of moving and settle medical service charges.

> Obtain doctor’s written order ---> CHARGE to notify NSV --->NSV to nofity Duty

Manager

DISCHARGE PLANNING

> All patients will be screened for discharge planning needs during the admission process by the MRP and admitting nurse.

> A completed Discharge Instruction from the patient’s medical record and a

patient copy with explanations provided by Clinical staff shall be given to the

patient at the time of discharge.

PATIENT DISCHARGE INSTRUCTIONS

PATIENT DISCHARGE INSTRUCTION -

Any directions that the patient must

follow after discharge to attend to any

residual conditions that need to be

addressed personally by the patient,

home care attendants, and other

clinicians on an outpatient basis.

> Upon discharge, all patients should receive a completed ‘’Patient Discharge

Instruction Form’’

Patient Discharge Policy

nurse will send a discharge alert to Billing Department

The physician will write discharge order and discharge medication

Home Medications are by the pharmacist

and or the nurse

Discharge & follow-up instructions are given to the patient and his family

Patient will be escorted to the door by nurse or porter

Admission and discharge officers will discharge patient from DMS after settlement of bill

> Abdominal pain discharge instruction

> Bronchial asthma discharge instruction

> Croup discharge instruction

> WOUND CARE INSTRUCTION

> Urinary tract infection instruction

> Post head trauma instruction: concussion

Discharge Summary

Discharge Summary: a report that summarizes all diagnostic, surgical, and

pathological findings for the patient.

> Discharge Summary must be completed upon discharge.(Not exceed 24 hours) by

the treating Consultant

> The complete discharge summary is prepared for all inpatients, and a copy of

the discharge summary is contained in the patient’s medical record.

OUT ON PASS POLICY AND PROCEDURE

Out on Pass - A patient on pass is an inpatient who is temporarily absent from a ward, by

arrangement, for 24 hours or more because: (s) he has been allowed to go home

temporarily, or (s) he has been transferred to another hospital and is expected

to return.

> A written physician’s order is required stating the exact time and date allowed to leave the hospital.

1. The maximum time allowed in DSAH for out on pass is 24 hours.

2. Female patients are accompanied by a responsible family member.

3. The out on pass form should be completed before the patient leaving the hospital.

> Explain/Vitally Stable/Give medicine/Notify Billing, NSV and Physician

> If in case patient did not return on time report immediately to the attending physician, notify the

Nursing Supervisor & the Duty Manager. Initiate OVR.

Left without being Seen and Left without Notification

> Left without being seen - LWBS - is a healthcare term to designate a patient encounter that ended with the patient leaving the healthcare setting before the patient could be seen by a certified Physician.

> Left without notifications/Absconded – is a term for a patient leaving the hospital premises after being assessed by Physician but there is no order of discharge by MRP. A patient who left hurriedly and secretly to escape the Hospital.

> The nursing staff should notify the Physician & Charge Nurse ----> NSV

> Assigned nurse should document in the patient’s medical record the date and time the patient left.

> ER/OPD reception should be notified that patient left the unit without being treated so that proper cancellation and discharge is done in the system.

> In cases of admitted patients who leave without notification/absconded, Duty Manager is informed.

> Family Physician/IPC/Duty Manager & Social Service --------> OVR

Patient Transportation via DSAH Ambulance

> For any Emergency Transport, ER staff, Paramedics should be available within maximum 15 minutes of transfer order Communicate with Duty Manager and Nursing Supervisor.

> An Ambulance Request shall be completed by requestor indicting full assurance to settle financial cost after ambulance transport, cosigned by Duty manager and Paramedic on duty and Staff Nurse on duty. Refer to Agreement for Ambulance Service: PAR/003-V1

Thank you and Good Luck to Everyone!

1

3

ACC.3

Screening for Admission to the Hospital

ACC.1

Continuity of

Care

ACC.1

Screening for Admission to the Hospital

Patient Screening Policy

> Types of Sceening:

1. Emergency: Visual Triage, Triage (CTAS)

2. Outpatient: With/Without Appointment

3. Transferred patients from outside facility

4. Direct Admission

NURSING INITIAL ASSESSMENT AND REASSESSMENT OF PATIENT

> Nursing assessment is performed by nursing staff qualified

by aducation, licensure and years of experience in the area

of practice.

> At the time of admission, all patients will have an initial

physical, psychological and social status assessment

completed by a registered nurse

>NURSING INITIAL ASSESSMENT documentation completed

within 4 hours from admission

Triage and Priority of Care

> Visual Triage – to identify immediately a sick patient. Devised to screen patients with risk of respiratory symptoms and classify risks of MERS-CoV using the screening tool of Ministry of Health

> Respiratory triage area: area at entrance of ER where screening for respiratory disease takes place

> CTAS – Canadian Triage Acuity Scale – a model of sorting of patients

using level from level 1 to level 5 based on their urgency.

> Designates an acuity level after assessment and prioritizes patient according to acuity level

Level 1 – Immediate (continuous nursing care)

Level 2 – Emergent (Every 15 minutes)

Level 3 – Urgent (Every 30 minutes)

Level 4 – Less Urgent (Every 60 minutes)

Level 5 – Non Urgent (Every 120 minutes)

ADMISSION AND DISCHARGE CRITERIA IN NICU

> ADMISSION TO NICU SHALL BE LIMITED TO:

1. Babies delivered in DSAH with birth weight more than 500 gram and more

than 23 weeks gestational age

2. DSAH shall only accept after full medical report and agreement between outside

Consultant neonatologist and chief of Pediatrics/NICU according to availability of

service, nursing and equipment.

3. In case of approval the baby will be admitted to isolation room and repeat sepsis

screening and transfer to main NICU after negative sepsis screening.

Criteria for Admission to NICU:

1. Birthweight less than 1800 gm.

2. Gestation less than 35 weeks.

3. Requirement for any form of Assisted Ventilation: Nasal Cannula, CPAP, Ventilator.

4. Exchange transfusion.

5. Respiratory problems.

6. Cardiovascular problems.

7. CNS problems.

8. Any other baby whose clinical condition is such that baby cannot be appropriately cared

for in intermediate care.

9. Congenital anomalies causing derangement in physiology and vital signs.

Criteria for Admission to Intermediate Care:

1. Low Birthweight – under 2500 gm. (Some babies 2000 and 2500 gm may be able to go directly to Nursery. This will depend upon the

clinical assessment of the baby after stabilization. Only normal babies go to Nursery.)

2. Prematurity – 36 weeks gestation or less. (For babies between 35 and 36 weeks gestation, criteria as in (1) apply.)

3. Any respiratory distress causing concern

4. Infection – suspected on clinical grounds or history, or confirmed, PROM

5. Gastrointestinal problems

6. Metabolic problems

7. CNS problems

8. Malformations

9. Jaundice requiring Phototherapy

Criteria for Discharge: NICU

1. The baby is steadily gaining weight for one week

2. The baby is sucking full requirements.

3. The baby is able to maintain his or her temperature in a cot in a normal household

environmental temperature especially in winter.

4. No Oxygen, No Apnea for at least 72 hours

5. No Antibiotics

6. Parents must be willing and happy to take the baby home and they have to

demonstrate adequate parenting skills.

7. There should be adequate follow up services, either in Hospital or through neonatal

home care nurses.

8. Neonate should be Free of the original cause of admission

Patient Referrals and Transfers

- A structured handover tool is used for endorsement by nurses

1. Patient Transfer to another Hospital

1. Obtain doctor’s written order for transfer to another facility 5. Coordinate the needed transportation and resources

2. Secure a written acceptance documents from the receiving hospital 6. Transport patient by wheelchair or stretcher

3. Duty Manager liaise with receiving facility a written acceptance documents 7. Document in the patient medical record the Patient Transfer

4. Explain the necessity of transfer to the patient and relatives 8. A systemized handover process is done upon the transfer

2. Patient Referrals

1. Transfer order written stating the reason of transfer

2. Consultation form or documentation should be sent with brief history and for transfer of care stated in the reason

3. The receiving physician documents in patient medical record the acceptance of patient under his name

4. The admission office or ward clerk change the MRP after verifying the acceptance order and the time for transfer of care.

3. Intra-hospital transfer at the same level of care

- An order for transfer is written in the medical order that patient is discharged from the unit and is ready for transfer.

***Form

FORMS:

1. Adult Nursing

Admission Assessment

2. Pediatric Nursing

Admission Assessment

Related Policy:

1. Patient Admission Policy

2. Clinical Handover

3. ER Criteria for Admission and Discharge

4. ER.P.004 Patient Referrals and Transfers.pdf (dsah.sa)

NURSING INITIAL ASSESSMENT AND REASSESSMENT OF PATIENT

> Nursing reassessment must be performed on every shift with a frequency

dictatedby the patient’s condition, response to treatment, and physician’s

order.

> The registered nurse conducting the admission assessment or re-

assessment will take responsibility of his/ her own nursing findings.

> The registered nurse conducting the admission assessment or re-

assessment will ensure that critical findings are promptly relayed to

responsible person for immediate interventions.

JCI Re-Accreditation:

ACCESS TO CARE & CONTINUITY OF CARE (ACC)

Prepared by: Nursing Education

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