Borders Community Hospital Admission Policy

The Board has four Community Hospitals:

Hawick Community Hospital – 23 beds: Medical cover is provided by Teviot Medical Practice 01450 370999 & O’Connell Street Medical Practice, 01450 372276, both in Hawick for the Teviot Locality.

HayLodge Community Hospital, Peebles – 23 beds: Medical cover is provided by Hay Lodge Health Centre Peebles (Tweed Practice 01721 720601 & Neidpath Practice 01721 720380) & St Ronan’s Medical Practice in Innerleithen 01896 830203

Kelso Community Hospital – 23 beds: Medical cover is provided by Kelso Medical Group Practice for the Cheviot Locality. 01573 224424

Knoll Community Hospital, Duns – 23 beds: Medical cover is provided by a Community Geriatrician and GPST1 doctor for the Berwickshire Locality. Call Knoll CH ward on 01362 885000

Community Hospitals Inclusion Criteria

• Rehabilitation (home and secondary care)
• Step up care from home
• Step down from secondary care
• End of Life care (home and secondary care)
• Supporting Pathways 3 and 4 (following the Pathways Based Planning Model, NHS Scotland), the Community Hospitals can provide an inpatient facility to enable people to recover and re-able after an acute episode. It can also allow people time to adjust to a care environment where a realistic assessment of long-term needs can be made.
• Non-specialist End of Life care is also provided following Pathway 4 of the Pathways Based Planning Model, NHS Scotland.
• Pain management.
• Oral antibiotic treatment.
• Subcutaneous fluids treatment.

Home must always be considered the preferred place for care and treatment. Step ups and step downs into a Community Hospital must be as part of an agreed pathway, not as the default position. Patients need to be aged 18 years or over, medically stable and consent to step up/step down has been given by the patient/family.

For NHS Borders Community Hospital beds, these fall into four main categories as identified within the earlier definition:

Rehabilitation (from home or secondary care)

• The provision of safe local observation and a suitable environment for patients who are medically stable but require further rehabilitation prior to returning safely to their home or future placement (Pathway 2). The timeframe for rehabilitation is assessed on an individual person-centered basis/clinical need.
• Patients who require further therapy that cannot be provided through delivery of services in the community, but whose needs do not require the facilities and specialist services available from an Acute General Hospital.
• The provision of multidisciplinary assessment where this cannot be delivered at home.
• Non-weight bearing or partially weight bearing patients who have clear goals established which will enable them to return home.

Step up care from home

• Patients who require nursing care and treatment to avoid admission to an acute hospital. This would include conditions which can be safely managed in the community hospitals e.g. urinary tract infections or chest infections.
• The patient has medical, therapy or nursing needs that require 24-hour healthcare intervention that is a level that cannot be provided in the patient’s own home or social care but can be managed outside of the acute environment.
• Medicines management/monitoring

Step down from secondary care

• Patients who are medically stable and clinically safe enough to be managed in a nurse-led care environment with General Practitioner medical support and limited diagnostic facilities available for the continuation of their treatment.
• The patient has medical, therapy or nursing needs that require 24 hour healthcare intervention that is a level that cannot be provided in the patient’s own home or social care.
• Patients who are stable with a delirium with potential for further recovery and have a treatment plan.
• Patients with complex discharge planning where this is better achieved closer to home. E.g. patients requiring home visits/environmental visits.
• Patients requiring Hospital Based Complex Clinical care (HBCCC). Community Hospitals are the most appropriate place these patients if their care needs cannot be managed in any other setting out with hospital. There needs to be a 6 week review of this at MDT meetings.

End of Life care (from home or secondary care)

• The provision of end of life care where the Community Hospital is the patient’s/family’s preferred place of death.
• The provision of end of life care where symptom control is complex and requires nursing input at a level which would not be able to be met at home (this excludes specialist palliative care)

Patients who have specific care issues must be discussed with the nurse in charge on duty before the step up/step down can be accepted as this may depend on the skill set of the nurses working at the time.

These specific care issues include:

• Patients requiring nasogastric feeding
• Patients requiring vac therapy for wound management
• Patients with PEG/RIG tube
• Patients requiring isolation facilities
• Patients requiring specialist size equipment e.g. bariatric equipment
• Management of patients requiring additional support to meet their care and safety needs (Enhanced Care Observation). Additional staff may be required to ensure patient safety.

Any issues and risks must be recorded as part of the handover documentation. These include:

• Any patient where specialised nursing or higher than usual levels of nursing is required.
• Patients with cognitive impairment, dementia or patients with a learning disability - a management plan is required prior to transfer to enable the ward staff to receive the patient to manage their mental health needs. A risk assessment should be initiated by the referring clinician to identify if it is appropriate to move patient with cognitive issues and or sensory issues which may mean that a move to another environment would be likely to significantly increase the chance of further confusion and impair timely discharge.

• People under the age of 18 years
• Antenatal, postnatal or maternity cases
• Those with acute mental health problems
• Patients requiring / undergoing alcohol/drug detoxification or who are actively using alcohol and drugs which affect their behavior or their ability to actively engage in their care
• Respite Care
• Patients with naso-gastric tubes without a treatment plan
• Patients who cannot self-manage a Tracheostomy
• Patients that are not medically stable and/or clinically safe for transfer (those patients that require access to 24/7 medical supervision and specialist consultant input beyond what is provided to the Community Hospitals)
• Late notice referrals for end-of-life care to avoid death in transit
• Step ups from the community and ED who are medically stable but without physical health/rehabilitation needs but require 24-hour care in a place of safety.
• Patients who require intravenous therapy.
• Patients who have already been assessed for a long-term care need and are identified as a delayed discharge.

Any patient who is ready to return to a community Hospital following a stay in the BGH can return without seeking new acceptance from a GP as long as their needs continue to meet the Community Hospital inclusion criteria on page 6 and there has been no significant change in their medical condition.

Patient Prioritisation

The Community Hospitals will accept in priority order from the waiting lists:

1. Step up and step down patients for Palliative care.
2. Step ups from the community and Emergency Department (ED) who are medically stable and for rehabilitation.
3. Step downs from an inpatient bed in the acute (BGH) who are medically stable and clinically safe for transfer and for rehabilitation.

Any step up/step down that the Nurse in Charge is unsure about should be discussed with:

• In hours (Monday to Friday, 9am to 5pm) – Relevant GP/Medic, Clinical Nurse Manager.
• Out of hours (evenings & weekends) – P&CS On-Call Manager

Direct GP Step Ups from Home In Hours (Monday to Friday, 9am to 5pm) - Hay Lodge & Hawick CHs.

• Step up would be by agreement between referring GP and CH Senior Charge Nurse/Charge Nurse) with full accompanying documentation as expected for admission to the BGH. Referring GP should include full summary, initial assessment and expected actions.
• All patients admitted should bring their own medication into hospital The medicine chart (Kardex) will be completed within 6 hours of admission by the responsible GP or a designated other.
• If no bed is available for direct admission, then the ward staff should add the patient to the CH waiting list.
• Staff from all referring agencies are responsible for ensuring that the admission criteria is met.
• The nurse in charge will work closely with the referring GP and will accept the patient providing the referral criteria is met, staff have the appropriate competencies to care for the patient and a suitable bed is available.
• Prior to admission a formal handover will be taken and fully documented.
• If the nurse in charge in the community hospital has any concerns regarding the admission of a particular patient, they must discuss their concerns with the referrer and if necessary, escalate these concerns as follows:
  • In hours (Monday to Friday, 9am to 5pm) – Relevant GP/Medic, Clinical Nurse Manager
  • Out of hours (evenings & weekends) – P&CS On-Call Manager
• The requirements of single sex accommodation will be robustly adhered to.

Planned Step Down In Hours (Monday to Friday, 9am to 5pm) – Hay Lodge, & Hawick CHs from other hospitals.

• Step down would be by agreement between the referring medic/GP and the GP covering the respective Community Hospital
• Contact the Community Hospital Nurse in Charge advising of GP acceptance providing:
  • Name, age and address of patient
  • Patient’s GP name
  • Diagnosis of patient
  • Treatment required and management plan
• Staff from all referring agencies are responsible for ensuring that the Community Hospital inclusion criteria are met.
• Take a handover ensuring it is detailed and the patient has a plan using the Patient Telephone Handover SBAR.

The transferring unit/ward will be asked to provide:

1. A nursing transfer letter- to include a full summary of the patient’s medical condition.
2. An immediate discharge letter from the department, which includes a history of treatment and investigations undertaken and the patient’s current physical and cognitive function.
3. A completed rehab /clinical management plan to include MDT goals and rehabilitation aims.
4. Confirmation of all outstanding clinical investigations and any outpatient appointments including transport arrangements.
5. Hospital patient records/notes
6. Medication Kardex (to cover any remaining OOH period),
7. DNACPR (If required)
8. A fully completed Treatment Escalation Plan (TEP)
9. A necessary supply of non-stock medication
10. Record of any information shared with patients and family about the patient’s condition and prognosis.
11. All of the patients belongings.

• A courtesy phone call will be requested to indicate that the patient is in trans
• Agree when the patient can be admitted. If no bed is available for direct admission then the ward staff should add the patient to the CH waiting list.
• If the nurse in charge has any concerns regarding the admission of a particular patient, they must discuss their concerns with the referrer and if necessary, escalate these concerns as follows:
  • In hours (Monday to Friday, 9am to 5pm) – Relevant GP/Medic, Clinical Nurse Manager.
  • Out of hours (evenings & weekends) – P&CS On-Call Manager.
• Remain in communication with the relevant GP/ANP/DN/Ward to ensure the patient’s journey is managed and step downs are effectively and safely planned.
• The requirements of single sex accommodation will be robustly adhered to.

Planned Step Ups to Kelso CH & Knoll CH, Duns - In and Out of Hours.

All step ups to Kelso CH & Knoll CH, Duns will be agreed following the Standard Operating Procedure – Kelso & Knoll Step Up Patients from Home.

This SOP was created in conjunction with this policy and should be consulted together when arranging/discussing step ups to Kelso & The Knoll Community Hospitals. See appendix 2.

Medical Practitioner

The admitting Medical Practitioner will as part of the admission process- (this applies to all Community Hospital contracted GPs, medics, & BECS GPs for all admissions to Community Hospitals whether from home, via triage or stepped down from the acute hospitals):

• Examine and write up any medication and care documentation for patients within 4 hours of admission if direct admissions from the Community or A&E.
• Step downs from other hospital wards to be clerked in the next working day (unless a detailed medical care plan and required documentation does not arrive with the patient; or the nurse in charge has a clinical concern regarding the patient).
• Medic will attend or advise on the patient within an agreed timescale according to the urgency indicated by the referral supported by other factors such as the NEWS2 score. This may necessitate urgent referral back to the acute hospital or a paramedic response if required.

Nurse

• Nursing staff will report missing documentation, inform medic of arrival for in hour’s step downs and respond as appropriate to any deterioration or unstable patient.
• Complete admission documentation including completion of all assessments as appropriate. Review any existing DNACPR and Treatment Escalation Plans notifying the medical practitioner of outstanding tasks.
• Continue rehabilitation plans until an MDT assessment can be completed.
• Post admission, patients will undergo a MDT assessment and the identified pathway will be reviewed and recorded for quality purposes.
• Nursing staff will complete a Datix for any exceptions to this policy or internal Standard Operating Procedures.
• The nurse in charge will escalate incidents to the Clinical Nurse Manager or On Call Manager as appropriate.

The nurse in charge of the Ward/Clinical Nurse Manager/GP/ANP/Consultant has the right to refuse the step up/step down of a patient when they feel that admission would not be in the best interests of the patient or compromise care given to existing patients. This decision will be made following discussion of the patient’s medical/social condition with appropriate health care team involved in the patients care and Clinical Nurse Manager / On Call Manager.

If the nurse in charge in the Community Hospital has any concerns regarding the step ups/step downs of a particular patient, they must discuss their concerns with the referrer and escalate these concerns to the Clinical Nurse Manager or On Call Manager. Patient Safety will remain paramount.

When stepping up/down patients/clients to another care setting it is vital to inform the receiving ward or unit if the patient has a laboratory confirmed infection or a suspected infection. If a patient/client being step down is suspected or confirmed as being infectious the nurse in charge must contact the Infection Prevention and Control Team (IPC) within normal working hours prior to the step down being carried out and BEFORE transport is arranged.

If advice is required out of hours, the On-Call Manager should be contacted, who can take advice via the On-Call Consultant Microbiologist.

If a patient is suspected or confirmed with COVID-19, follow IPC guidance on these patients in regard to testing and test results prior to step up/step down. Ensure the correct facilities are available to safely manage the patient once they arrive on the ward i.e. - Cohorted bays or side rooms.

• The discharge planning process should be commenced from admission in conjunction with the patient and family/carers.
• A planned discharge date (PDD) will be set within 48hrs of admission.
• The MDT will work with the patient and family towards the Planned Date of Discharge (PDD) Patients, family and carers should be involved and have timely and appropriate information in order to make an informed choice on their care following discharge. The involvement of the patient and family/carer is an integral and essential part of the discharge process.
• The ward staff will work closely with any existing Social Worker/Care Manager or lead professional involved in the patients care prior to admission; or refer to Social Work as soon as deemed appropriate by the MDT for assessment.
• Inpatient discharges should be planned to occur before 12 noon, on any day of the week, including weekends in order to safeguard vulnerable patients against the associated risks of late/out of hours discharges.
• The MDT will utilise the Discharge Checklist to ensure completion of the various components of discharge, e.g. tablets to take home, transport, referral to appropriate specialist professionals, provision of information and documentation to the Patient, GP and other key professionals and the provision of basic foods is available at home for the patient, prior to discharge.

 Key Points for Achieving Timely Discharge and Reducing Length of stay include:

• The discharge planning process should be commenced from admission in conjunction with the patient and family/carers.
• Patients who are identified as no longer requiring hospital-based care should be provided with the ‘Moving On from Hospital’ leaflet and appropriate letters as per the ‘Moving on from Hospital’ policy.
• Patients will be reviewed daily by the MDT, evaluating individual care plans that involve active therapy, treatment or opportunity for recovery in accordance with patient needs.
• The PDD will be pro-actively evaluated against the discharge plan on a daily basis as part of the Urgent & Unscheduled Care Collaborative – Discharge without Delay.
• The ward staff and community teams, Nursing and Therapy, will pro-actively work together to identify appropriate management strategies for the patient and to facilitate the smooth transition of care from hospital to home.
• Where the patient or carer appears to be reluctant to discharge, the nurse in charge will refer to the ‘Moving on from Hospital’ policy and issue the appropriate letter. The ‘Moving on from Hospital’ policy supports people’s timely, effective discharge from an NHS inpatient setting, to a setting which meets their diverse needs and is their preferred choice amongst available options. It applies to all adult inpatients in NHS Borders settings, and needs to be utilised before and during admission to ensure that those who are assessed as medically fit for discharge can leave hospital in a safe and timely way.

All breaches of policy will be reported as adverse events and subjected to a Significant Adverse Event Review (SAER) where multiple investigative methods will be utilised.

Knoll & Kelso Admission SOP

Kelso & Knoll Step Up SOP

Hay Lodge Admission Flow Chart

Admission to Hawick CH Flow Chart