Boarding patients outwith specialty in the Borders General Hospital (including Protocol for management of intoxicated adolescents/young people)

ISD Scotland defines boarding as a ‘Patient who occupies a borrowed bed outwith speciality is described as boarding’

NHS Borders recognises that boarding patients results in reduced quality of care and has negative outcomes for patients. Evidence shows that patients experience:

• poor patient experience;
• increased length of stay;
• increased readmissions;
• increased medication omissions;
• increased morbidity and mortality

However, at times of high patient admissions and exceptional bed pressures, it may be necessary to board appropriately risk assessed patients to reduce the overall risk.

Communication

Senior Charge Nurses (SCN), senior medical staff, and Clinical Nurse Managers will disseminate this standard operation procedure within their areas of responsibility.

Definitions

A boarding patient is a patient who is accommodated in an area outwith the speciality responsible for their care.

Precautions

To enable appropriate boarding of patients it is necessary to complete the risk assessment form to meet the required criteria of the receiving ward.

All patients must be routinely risk assessed according to the boarding criteria below;

• All patients should have their boarding level (green, amber or red) considered by the MDT at the Board round. This needs only to be documented in the patient’s AUPR at the time of boarding the patient.
• Any patient that is allocated for boarding must be agreed by their Responsible Consultant and Senior Charge Nurse (or depute).
• A patient with red status would ideally Not be boarded.
• A patient should ideally only board once during their admission. If the patient is being considered for boarding repeatedly a further risk assessment should be done each time.
• No patient should be moved out of MAU until they have been reviewed by a consultant, and a clear plan documented in the post-take ward round notes.

Timing of boarding

The Site position is discussed at the 08:30 and 14:00 Safety Briefings. In times of increased pressure, additional meetings may be triggered.

Early identification of patients suitable to board will facilitate flow within the Emergency Department to admitting wards. All patients identified to board should be moved by 20:00, and no boarding should occur after 22:00.

MAU boarding

There is an increased risk in boarding from MAU. Boarding should only occur if all other boarding options have been exhausted.

If boarding from MAU is necessary, then the medical consultant responsible for the patient (or if out of hours the Medical Registrar on call) should be involved in the clinical decision to board.

Criteria for boarding patients to Paediatrics (Ward 15)

• Appropriate age/pubertal stage–16yrs would be considered the normal maximum although there may be scope to admit those of 17yrs should a suitable bed space/ accommodation be available within the ward. 
• it would not be suitable to board young people under the influence of drugs/alcohol who may pose risk to infants and children (see appendix on the management of intoxicated young people) 
• risk assessment must be undertaken prior to boarding on Ward 15 

Considerations when boarding patients to Paediatrics (Ward 15)

• There is no separate gender accommodation on Ward 15 apart from the use of cubicle 
• en-suite facilities are only available in the HDU cubicles 

Responsibilities when boarding patients to Paediatrics (Ward 15)

Ward 15 medical and advanced nurse practitioner team can assist with:

• Cannulation and collection of blood samples or investigations ordered by the host team
• Immediate reviews in the event of acute deterioration/pain assessment
• Review of hydration and prescribe routine IV maintenance fluids
• Discharge paperwork with the exception of discharge medications 

The host/specialty team will:

• Fully clerk newly admitted patients
• Prescribe initial medication
• Prescribe and review ALL medication
• conduct daily patient review to make treatment/discharge decisions
• order radiology and other complex investigations

N.B The points above relate to patients boarded in Ward 15 aged 16 and over and are not part of the existing Shared Care Guidelines for under 16s with surgical or orthopaedic conditions.

Criteria for boarding paediatric patients (under 16 yrs) to other wards 

• Need for inpatient admission with no space within ward 15 
• Risk assessment must be undertaken prior to boarding outwith Ward 15 

Considerations when boarding paediatric patients outwith Ward 15 

• Parents be allowed to stay with patients where possible 
• Boarding outwith Ward 15 is for the shortest time possible 
• Consideration given to boarding wards environment, set up and population mix and its suitability for children 

Responsibilities when boarding paediatric patients outwith Ward 15 

The Boarding medical/ANP team can assist with: 

• Cannulation and collection of blood samples or investigations ordered by the host team for suitable older patients when agreed with the paediatric team 
• Immediate reviews in the event of acute deterioration/ pain assessment 
• Discharge paperwork with the exception of discharge medications  

The Ward 15/Paediatric team will:

• Fully clerk newly admitted patients 
• Prescribe initial medication 
• Prescribe and review ALL medication 
• Review of hydration and prescribe routine IV maintenance fluids 
• Take blood samples/cannulation 
• conduct daily patient review to make treatment/discharge decisions 
• order radiology and other complex investigations 

Responsibilities when boarding patients to Ward 7 or Ward 9

Medical boarders should never be boarded into the elective six bedded bay in Ward 9 or boarded in Ward 17.

Any boarding patient with wound infection, ESBL, or MRSA requires a cubicle and should not be placed in 6-bedded rooms with surgical or orthopaedic patients.

Medical patients should not be mixed with elective arthroplasties due to the increased risk of wound infections.

All nursing home patients require a cubicle until their MRSA status is known. If a cubicle is not available, then the patient should be allocated a corner bedspace in a bay.

All boarding patients MRSA status should be known, checked and taken into consideration when deciding whether they are appropriate to board.

Responsible Consultant

All patients must have a clearly identified responsible consultant.

The consultants name and speciality must be recorded on Trak, and in the AUPR.

The consultant will be responsible for:

• Ensuring patients under their care are reviewed regularly as per plan with agreed boarding status.
• The ongoing management and clinical care of patients under their care who are boarding.

Senior Charge Nurse (or Deputy)

The Senior Charge Nurse should, along with ward medical staff, be responsible for the identification of suitable boarders using with the boarding criteria. They should ensure any patient identified for boarding is agreed with the senior medical team. The Senior Charge Nurse (or deputy) is responsible for the safe handover of patient to the boarding ward, and for ensuring the next of kin/family are aware of the move.

All transfers should comply with NHS Borders Safe Patient Transfer SOP.

If patients are boarding on a ward outwith specialty, the Senior Charge Nurse (or deputy) of the boarding ward must ensure that patients are reviewed timely and that priority should be given to the deteriorating patient, or patients awaiting discharge.

Site and Capacity Team

The Site and Capacity Team should use their clinical expertise to support staff in identifying suitable boarding patients.

They should ensure all patients identified to board have met the boarding criteria and has been agreed with the senior medical teams.

They are responsible for providing information to the boarding wards about patients transfers.

Managers

Clinical Nurse Managers and Clinical Service Managers are responsible for ensuring that staff understand their roles and responsibilities, and for monitoring compliance with this SOP. Nurse Managers are required to ensure safe staffing levels on wards to which patients are being transferred.

If there is difficulty identifying suitable patients to board, it is their responsibility to support ward staff in line with the boarding criteria.

• Nurse
• See medical SBAR (includes DNACPR & AWIC) Nutrition
• Mobility
• Skin
• Outstanding Tasks & Recommendations Falls
• 4AT

It was decided that the in-patient management of intoxicated adolescents should be guided by the following protocol:

• Any young person, regardless of age, must be initially managed according to Advanced Paediatric Life Support and European Paediatric Life Support protocols; where the child/young person has any compromise of airway, breathing, or circulation then they should be assessed by a senior doctor / APNP from Paediatrics and Anaesthetics, and be admitted to an appropriately staffed high dependency unit, such as ITU. The Paediatric Consultant will be called to attend if appropriate.

(Always be mindful of all possible substances taken that could be contributing to the intoxicated state, and consult TOXBASE to be advised of ongoing management and potential problems that may been countered.

Further advice on novel psychoactive substances that may have been taken, and their effects, can be found on the Neptune clinical guidelines)

In all other cases, where the child is stable but intoxicated from drugs or alcohol, and requires admission for observation: 

• Children aged 13 and under will be admitted to the paediatric ward (Ward 15) under the care of the paediatric team.
• Children aged between 14 and 15 should be referred to the Paediatric Doctor / APNP on call (bleep 6015) who will make a rapid assessment of the child and decide on the most appropriate admission decision. Factors that will be taken into consideration are: 
  • current behaviour; if demonstrated or anticipated aggressive tendencies that are inappropriate to manage on ward15 where there are younger children present 
  • developmental age (both mental and physical) of the young person 
  • previous history (e.g. chronic medical conditions that have necessitated previous hospital admission) 

Any individual of 16 years or over should be admitted under the care of adult medicine. However, individuals who are well known to the paediatric unit with chronic health conditions and who have not transitioned to adult services should be discussed with the Consultant Paediatrician on call prior to an admission decision. 

If it is deemed not appropriate to admit the young person to ward 15, the young person will be admitted under the care of paediatrics and boarded to an acute adult ward. There will be ongoing review by the paediatric team until discharge as per the standards for boarding patients out of Ward 15 above. 

All children and young people in this group must be risk assessed by the paediatric team to ensure there are no child protection issues. The paediatric doctor/ advanced nurse practitioner on call should be the first point of call on bleep 6015 if any issues arise. 

Children of any age that require admission to hospital will not be held in the Emergency Department, as this is not a place of safety and has limited facilities for inpatient observation. 

All children/young people admitted in an intoxicated state and their families should be signposted to support from Quarriers at time of discharge.