Learning outcomes
By the end of this section, you should know how to:
▪ prepare the patient and carer for transfer to another care setting
▪ complete patient transfer documentation.
Background knowledge required
Carers and Disabled Children Act 2000
Revision of local policy on the transfer of patients
Achieving Timely ‘Simple’ Discharge from Hospital: A Toolkit for the Multidisciplinary Team (Department of Health 2004)
Discharge from Hospital: Pathway, Process and Practice (Department of Health 2003a).
Indications and rationale for patient transfer
Healthcare reform has resulted in a much greater focus on the appropriate use of the services available for patient care. Thus, the patient may be transferred between institutional and community settings within the statutory health and social care agencies or in the voluntary or private/independent sectors, as is judged appropriate for his or her individual needs and benefit.
Outline of the procedure
‘Patient transfer’ (rather than discharge) is the term used in this section as it demonstrates a continuum rather than a cessation of care. The procedure may be simple or complex, depending on the needs of the patient and carer. The systematic approach to care – namely assessment, planning, implementation and evaluation – may, however, be used as a framework for the patient transfer process:
▪ the assessment phase involves the collection of data pertinent to the patient and/or carer. A variety of sources may be used to build up a holistic picture of the patient and the caring environment. Some of this information will already have been collected during the patient admission assessment
▪ the planning stage utilises the assessment data to provide a plan of transfer. Liaison with other agencies to request and discuss their input will also be carried out at this stage of the process
▪ the implementation phase involves putting the plan into action and completing patient transfer documentation
▪ the evaluation stage of the transfer procedure is essential in order to assess the effectiveness of the process and to identify any difficulties or problems.
General principles will be given, followed by guidelines for planning and implementing the transfer process. Some of the guidelines may not be applicable to patients transferring from community to institutional settings.
Transfer and discharge to and from hospital can be a distressing time for individuals, their families and friends (Department of Health 2003a). As health professionals it is important that nurses develop and adapt practice and respond to the ever-changing needs of the service provided (Department of Health 2004). The multidisciplinary team can make a significant difference to the speed and quality of the patient journey (Department of Health and Royal College of Nursing 2003). A crucial factor in planning transfer and discharge is the process of communication, co-operation and collaboration between health and social care, the multidisciplinary team, patients and relatives (Hoban 2004, Lees 2004).
Principles
▪ the patient and carer should be involved in all stages of the transfer process, enabling a consideration and discussion of their needs prior to the transfer plan being completed and implemented (Department of Health 2004, Lees & Holmes 2005). Older people, in particular, often find it a major life transition, particularly when it means having to move home or establish new routines (Lishman 2003)
▪ patient transfer is normally a multidisciplinary procedure that may involve social, voluntary and independent care agencies as well as different healthcare professionals, ensuring a holistic approach to patient transfer
▪ good communication is an essential part of the patient-transfer process as poor communication patterns affect continuity of care on transfer from community to institutional settings as well as from institutional to community care (Department of Health 2004)
▪ it is essential that there be early involvement of and liaison with staff from the receiving care setting (which may be a hospital ward, an intermediate care facility, a nursing home or the patient’s own home). Some areas have a designated liaison nurse who provides a link between institutional and community care to promote continuity of care (Hoban 2004, Lees 2004)
▪ the multidisciplinary team can speed up the transfer process and manage the care pathway to an expected or predicted date of transfer, including weekends (Department of Health 2004)
▪ with the development of hospital at home and supported discharge teams, patients may be transferred to where their individual needs can be appropriately met (Department of Health 2004)
▪ an evaluation system should be in place to judge the effectiveness of the patient transfer process (Rudd & Smith 2002).
Planning patient transfer
▪ discuss care needs with the patient and carer to ascertain their views and requirements, and involve them in the decision-making process
▪ information related to risk factors should be recorded and shared between care settings (e.g. the patient being at risk of falls or any sensory deficit that may put the patient at risk)
▪ plan and initiate any teaching programmes for the patient and/or carer. Examples include a self-medication programme for patients being transferred from institutional to community care (Banning 2004) and a moving and handling teaching session for carers to prepare the patient and carer for tasks that they will be required to undertake in the community
▪ consult, liaise with and refer to the appropriate care agencies (health, social, voluntary or independent). If the patient has complex care needs, it may be necessary to invite all the relevant personnel, including the patient and/or carer, to a case conference to ensure that support services are in position prior to transfer (Department of Health 2003b)
▪ order any equipment or patient aids (e.g. moving and handling equipment or oxygen cylinder) to ensure that the receiving care setting meets the patient’s needs
▪ if the patient has complex needs and is being transferred from institutional care, it is valuable to organise a home-assessment visit prior to transfer. This will involve the patient, carer and district nurse as well as other relevant personnel such as the liaison nurse, occupational therapist, physiotherapist and social care staff to enable the patient’s needs to be assessed within his or her own environment and to enable an assessment of the carer’s ability to provide care
▪ arrange for transport between care settings to ensure that the transport is appropriate for the patient’s needs
▪ information related to any infection that may put the patient, carers or other healthcare personnel at risk should be recorded. If appropriate, the MRSA status of the patient should be given (see ‘Isolation nursing’, p. 187)
▪ order a small supply of continence, dressing or medicinal products to ensure that products are available for the immediate transfer period
▪ assess the patient’s ability to administer medication. If deficits are identified, a teaching programme may have to be initiated for the patient and carer, and/or patient compliance devices can be introduced. This should be carried out in conjunction with the pharmacist to check that the patient and carer are able to administer the medicines correctly
▪ consult with the carers about access arrangements to the patient’s home on the day of transfer to enable access arrangements to be made in advance of the transfer
▪ give an approximate expected time of arrival to the patient, carer and any other personnel who require this information (for example, the district nurse and home help, or the continuing care facility) to enable the caring network to be organised.
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
