Antonis Hannides

Dr  Simon  Fox  QC 
Assistant Coroner 
Area of Avon 
The Coroner's Court 
Old  Weston  Road 
Flax  Bourton 
BS48  1UL 

9th  January 2020 

Dear  Dr  Fox, 

Spire 
Bristol Hospital 

Red land Hill 

Durdham Down 

Bristol 

B56 6UT 

Tel 0117 980 4000 

Fax 0117 974 3203 

www.spirebristol.com 

INQUEST  INTO THE  DEATH  OF MR ANTONIS  HANNIDES 
RESPONSE  TO  REGULATION  28  REPORT TO  PREVENT  FUTURE  DEATHS 

I am  writing  in  response  to  your  Regulation  28  Report  dated  11.11.19  following  your 
Inquest  into  the  death  of Mr  Antonis  Hannides,  who  underwent  hernia  repair  surgery 
at Spire  Bristol  Hospital  ("the Hospital") on 21.03.19. 

MATTERS  OF  CONCERN 

1.  No 

formal  system  at  Spire  Bristol  for  seeing  patients  who  re-attend 

unexpectedly after discharge. 

2.  No  formal  system  at Spire  Bristol  for  ensuring  full  and  comprehensive  record 

keeping  in accordance  with GMC  and NMC  guidance. 

3.  No  formal  system  for  ensuring  that  consultants  are  informed  immediately of 

any patient who  re-attends unexpectedly after discharge. 

SPIRE'S  RESPONSE 

FORMAL  SYSTEMS  IN  PLACE  AT  SPIRE  BRISTOL  FOR  PATIENTS  WHO  RE-ATTEND 
UNEXPECTEDLY AFTER DISCHARGE. 

It is  anticipated that some patients who  have  undergone treatment at a  Spire Hospital 
may  contact  the  Hospital  with  enquiries  about  their  care  after  discharge.  As  such, 
Spire  Healthcare  has  an  Admission  and  Discharge  policy  (in  place  at  the  time  of  Mr 
Hannindes'  admission)  which  outlines  a  number  of  key  steps  that  must  take  place  as 
part  of  any  patients'  discharge  planning  process, 
to  ensure  that  patients  are 
supported  after they  leave  hospital  and  are aware  of  how  to seek advice  if  they  have 
concerns. 

At  the point of discharge,  all  patients will  receive a detailed discharge summary  (with 
a  copy  sent  to  their GP).  The  summary  includes  details  of  how  the  patient  (or  their 

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 carer)  can  get  in  contact  with  their  Spire  Hospital  should  they  have  any  concerns 
regarding  their  recovery  or  discharge,  together  with  relevant  contact  telephone 
numbers that provide 24  hour access to a qualified  member of nursing staff. 

The  policy  also  outlines  a  formal  process  nursing  staff  should  follow  in  the  event  a 
patient  (or  their  carer)  contacts  a  Spire  hospital  with  an  enquiry  about  their  care 
after discharge.  All  enquiries  are  first  assessed  by  a  nominated,  qualified  member of 
the  Hospital  nursing  team,  who  will  make  an  assessment  (a  triage)  of the  next  steps 
required  and  depending upon  the patient's clinical  needs.  Nursing  staff are supported 
in  their  triage  assessment  by  comprehensive  guidance  in  the  policy  on  appropriate 
sign-posting  for  medical  assessment,  including  escalation  to  the  Registered  Medical 
Officer (RMO)  and treating consultant,  where appropriate. 

In  light  of  the  concerns  raised  at  the  Inquest,  Spire  Healthcare  has  updated  its 
National  Clinical  Admission  and  Discharge  policy  (copy  enclosed  at  Appendix  A)  to 
ensure  that the existing  triage  process  applies  equally  to  patients  who  unexpectedly 
re-attend  the  hospital  (as  happened  in  Mr  Hannindes'  case).  In  such  circumstances, 
the  policy  provides  that  the  patient  must  be  reviewed  by  an  RMO.  The  patients' 
consultant must be informed of their attendance post-discharge and  the RMO  or nurse 
reviewing  the  patient  must  document  that  the  consultant  has  been  notified  (and 
when),  and  whether advice  has  been sought  from  the  consultant.  Where  advice  was 
not  specifically  sought  before  providing  care,  for  example  as  a  result  of  minor 
concerns,  the reasons for  not doing so should  also  be documented.  The  policy  requires 
that any  patient that has  attended the hospital  must  be contacted within  24  hours  of 
attendance  by  the  RMO  and  the  follow  up  call  must  be  documented  in  the  patient's 
medical  records.  Post-discharge  re-attendances will  be  reported  onto Spire's incident 
management  database  to  ensure  the  hospital  tracking  of  the  patient's  outcome  and 
any  learning as a  result 

Any  patients  who  unexpectedly  present  to  a  hospital  post-discharge  with  seriously 
concerning  symptoms  would  be  immediately  escalated  to  the  operating  surgeon  by 
the RMO  for advice. 

In  addition  to the  enhancing its  National  policy  for  handling  in-person  post-discharge 
enquiries,  Spire  Healthcare has also:-

1.  Updated its  RMO  Handbook  (copy enclosed  at Appendix  B)  to emphasise the RMOs' 
key  responsibilities,  aligning these to the escalation  requirements in the Admission 
and  Discharge  policy. 

2.  Been  working  together  with  its  corporate  provider  of  RMOs,  NES  Healthcare,  on 
the  dissemination  of  the  learning  from  the  sad  events  following  Mr  Hannindes' 
death.  NES  have  provided  all  of  their  RMOs  with  a  copy  of  "how  to  be  an 
excellent  RMO"  on  induction  (copy  enclosed  at Appendix  C). 
In  addition  to  this 
the  learnings  from  this  case  have  been  provided  to  all  RMOs,  across  the  Spire 
network,  via  a  clinical  update issued  by  NES  on  5th  December 2019  (copy  enclosed 
at Appendix D).  The  update identified learning points including that:-

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 1.  A  full  clinical  assessment  should  be  undertaken  of  patients  who  re-attend 

unexpectedly following  discharge and fully  documented; 

2.  For  patients  who  re-attend  the  Hospital  unexpectedly  following  discharge 
there is  a  process  in  place  and  it should  be  documented  to  follow  up  with  the 
patient 

3.  RMOs  should  always  make  good  clinical  notes  in  the  patient  care  records.  If 
the  patient's  medical  records  are  not  immediately  available,  a  record  of  the 
examination  should  be  made  and  placed  within  a  temporary  folder.  All 
documentation  should  then  be  merged  with  the  original  medical  records  as 

· soon  as  possible. 

5. 

4.  RMOs  should  inform  the  Consultant  of  all  patients  who  return  to  the  Hospital 
for  a  review.  The  patient's  consultant  should  be  contacted  immediately  and 
the attendance documented. 
If  the  patient's  NEWS  score  is  7  or  more,  the  patient  must  be  reviewed  by  a 
Consultant and  a detailed entry should  be  made in  the clinical notes. 
If  the  patient's  Consultant  is  unavailable  or  if  there  is  a  delay,  the  RMO  can 
arrange to transfer a deteriorating patient to an  appropriate  NHS  Hospital.  The 
Consultant should  be kept informed. 

6. 

7.  Do  not delay taking action with any  deteriorating patient. 

FORMAL  SYSTEMS  AT  SPIRE  BRISTOL  FOR  ENSURING  FULL  AND  COMPREHENSIVE 
RECORD KEEPING  IN ACCORDANCE  WITH GMC AND NMC  GUIDANCE. 

All  nursing  and  medical  staff  at  Spire  Bristol  are  subject  to  professional  and 
contractual obligations  to  maintain  good  record  keeping  standards.  Those  obligations 
are  detailed  in  Spire's  Patient  Records  policy  (which  was  in  place  at  the  time  of Mr 
Hannindes'  care,  a  copy  of  which  is  enclosed  at  Appendix  E)  and  provides  that  "an 
entry  should  be  made  in  the  healthcare  record  whenever  a  patient  is  seen  by  a 
clinician  or  member of staff.  All  clinicians  and  healthcare  professionals  must make 
clear,  accurate  and contemporaneous  records  relating  to  their patients.  The  record 
must  contain  regular  and  timely  progress  notes,  observations  and  consultation 
reports  made by such  professionals.  In  addition  to  Spire  Healthcare's  requirements, 
clinicians  and  healthcare  professionals  may  formally  be  required  to  do  so  by  their 
professional  regulatory body."  All  RMOs  practising at Spire  are  provided  with  a  copy 
of Spire's  RMO  Handbook,  and  an  induction  pack  (copy  enclosed  at appendix  F)  which 
outline  further  the  obligations  with  regard  to  good  medical  record  keeping  and 
adherence to Spire's  Patient  Records  policy.  Spire  Bristol  undertake  routine  audits of 
record  keeping  standards  at  the  hospital  in  keeping  with  the  Spire  Patient  Records 
policy.  An  additional  audit  has  been  added  to the  local  2020  schedule  that will  focus 
specifically  on  the  standard  of  documentation  in  the  medical  records  where  patients 
have  re-attended the hospital following their discharge. 

All  employed  staff  at  Spire  Bristol  are  required  to  complete  mandatory  on-line 
information  governance  training  at  induction  and  then  on  an  annual  basis  as  a 
reminder of their  responsibilities  to  adhere to Spire's  patient records  policy  and  good 
medical  record  keeping  practices.  Similarly,  as  part  of  their  mandatory  training 
programme,  and  before starting with  any Spire  Hospital,  all  NES  RMOs  are  required to 

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 also  complete  online  training  modules  via  the  NES  website,  which  includes  record 
keeping  standards  and  escalation  to  consultants  Appendix  G details  the  training  that 
NES  RMO's  are  required  to  complete.  Evidence  of  completion  is  provided  to  the 
hospital  prior  to  the  RMO  commencing  their  placement,  which  was  received  for  the 
RMO  concerned. 

As  identified  above,  in  light  of  the  concerns  raised  at the  inquest,  Spire's  Admission 
and  Discharge  policy  and  RMO  Handbook  have  been  updated  to  remind  staff  of  the 
requirements  and  standards  of good  medical  record  keeping  practices  and  explicitly 
how  post-discharge enquiries should  be  recorded.  This  policy requires that any  clinical 
encounter  with  the  patient  must  be  comprehensively  documented  in  the  patient's 
records  by  the  clinical  staff  involved  in  the  patients'  care.  In  situations  where  the 
patient's  notes  are  not  immediately  available,  for  example  as  a result  of any  out  of 
hours  query  (or  in  Mr  Hannindes'  case  as  a result  of an  un-expected  presentation  to 
outpatients),  then  a temporary set  of records  will be  created  by  the team  involved in 
the  care  of  the  patient,  and  merged  as  soon  as  possible  with  the  original  patient 
records.  At  Spire  Bristol  there  is  a  folder  that  is  held  on  the  ward  for  temporary 
records  and  the  medical  records  department  collect  this  daily  and  any  temporary 
records  are  merged with the full patient record. 

Spire  Bristol has  undertaken a number of local actions to share  learning from this  case 
with  respect to record  keeping  practices including:-

1.  Shared  learning sessions  reiterated the process that should  a patient re-attend the 
hospital,  whether  expected  or  unexpected,  that  a  temporary  file  must  be  made 
and  the  assessment,  findings,  plan  and  advice  given  must  be  documented  on 
clinical  continuation  sheet.  This  file  must  then  be  placed  in  the  ward  folder  for 
collection and merging with the patient's medical records. 

2.  Shared  learning  sessions  from  the incident  were  provided  to all  clinical  staff as  a 

priority to reiterate the NMC  standards of documentation .. 

3.  The  RMO  involved  in  Mr  Hannindes'  care  has  been  asked  to  complete  her  own 

reflection of the case  for her appraisal to be discussed  with her supervisor. 

I  hope  that  my  response  and  the  actions  outlined  therein  provides  assurance  to  HM 
Coroner  and  Mr  Hannides'  family  that  the  Hospital  have  taken  on  board  and  acted 
upon  the concerns  which  have  been  raised. 

Interim Hospital Director 
Spire  Bristol Hospital 

Appendices  Evidence of actions taken 

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 Appendix A:  Spire's Admission  and  Discharge  policy 
Appendix B:  Spire's RMO  Handbook 
Appendix  C:  NES  guidance on  "how to be an  excellent RMO" 
Appendix D:  Clinical Update from NES  to RMOs  5.12.19 
Appendix  E:  Spire's Patient Records  policy 
Appendix F:  Spire RMO  induction 
Appendix G:  NES  mandatory training for RMOs 

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SPIRE HEALTHCARE 

ADMISSION AND 
DISCHARGE  POLICY 

Spire  Healthcare 

Ref: 

Clinical Policy 07 

Issued By: 

Approved By: 

Clinical Governance 
Director 

Policy Approval Group

Date: 

January 2020 

Applies to sites: 

All hospitals and clinical
sites 

Applies to staff 
groups: 

All relevant hospital staff 

ADMISSION AND  DISCHARGE  POLICY 

CONTROLLED  DOCUMENT 

CLINI 07 
Issued by:  Clinical  Governance Director  Next Review: January 2023 

Issue Date: January 2020 

Issue no:  12 

Page 1  of 32 

 TABLE  OF  CONTENTS 

1.0 

2.0 

3.0 

4.0 

5.0 

6.0 

7.0 

8.0 

9.0 

Introduction 

Duties and  responsibilities 

Definitions of patient groups 

Bookings 

Clinical  risk assessment 

Preparation  for admission 

Admission 

Paediatrics 

Discharge planning  - clinical 

10.0 

Discharges by Ward  Clerk 

11.0 

Transfers 

12.0 

Extended  stays 

13.0 

Managing  Post  Discharge  Enquiries 

14.0 

Post  Discharge Ward/Outpatient Attendance 

15.0 

Emergency readmissions 

16.0 

Monitoring the effectiveness of admissions  and  discharges 

Appendix  1 

Patient self-discharge against medical  advice procedure 

Appendix  2 

Patient self-discharge form 

Appendix 3 

Follow  up telephone  consultations form 

Appendix 4 

Follow  up telephone  assessment protocol 

Appendix 5 

Patient transfer variance  sheet 

Appendix  6 

Inter-Healthcare Infection Control Transfer Form 

Appendix  7 

Framework for Managing  Post-discharge  Calls  from 
Concerned  Patients 

Page 

3 

3 

3 

3 

4 

5 

5 

8 

9 

10 

10 

11 

11 

13 

14 

14 

15 

16 

17 

18 

23 

27 

28 

CLINI 07 
Issued by:  Clinical Governance Director  Next Review: January 2023 

Issue Date: January 2020 

Issue no:  12 

Page 2  of 32 

 1.0  INTRODUCTION 

This  policy  sets  out  Spire  Healthcare's  requirements  in  relation  to  the  admission  and 
discharge  of patients and  should  be  used  in  conjunction  with  locally  determined  processes 
and  work  instructions.  The  standards  for  pre-operative  assessment  are  outside  the  scope 
of this document and detailed  in  CLINI 81. 

2.0  DUTIES AND  RESPONSIBILITIES 

The  Hospital  Director  is  ultimately  responsible  for  ensuring  that  the  hospital  meets  the 
required  standards  of clinical  care,  in  many  cases  this  is  delegated  to  the  Head  of Clinical 
Services. 

The  Head  of  Clinical  Services  (Matron)  is  responsible  for  ensuring  clinical  standards  in 
relation  to  the  admission  and  discharge  of  patients,  for  ensuring  staff  are  adequately 
skilled  and  for monitoring the effectiveness of care. 

All  registered  practitioners  must  participate  in  the  admission  and  discharge  processes  in 
line  with  care  pathways  and  local  protocols  and  ensure  that  patients  are  assessed, 
admissions  are  appropriate and  discharge needs  are  considered  and  provided. 

All  staff  are  required  to  play  their  part  in  the  patient  journey,  to  ensure  that  hospital 
protocols are followed  and  report problems  if they arise. 

Admitting  consultants are  responsible  for the  admission  and  discharge  of patients  in  their 
care  in  accordance with  the standards defined in  the Consultants' Handbook. 

3,0  DEFINITIONS OF  PATIENT GROUPS 

Inpatient - a  patient who  is,  or expected to stay  overnight 

Daycase  - a  patient  undergoing  a  procedure  who  is  expected  to  be  discharged  on  the 
same  day (i.e.  without overnight admission) 

Surgical  - a  patient  undergoing  primary  surgical  care,  admitted  under  a  surgeon  with 
practising  privileges 

Medical  - a  patient  undergoing  primary  medical  care,  admitted  under  a  physician  with 
practising  privileges 

in  a  planned  way  in 
a  patient  transferred  to  another  unit 
Planned  transfer  -
circumstances  predictable  on  admission  or  being  moved  for  reasons  other  than  an 
escalation  of treatment that cannot be  provided by the admitting  unit. 

,Emergency  or  unplanned  transfer  - a  patient  transferred  to  another  unit  at  short 
notice  for an  escalated  level  of treatment that cannot be  provided in the admitting unit. 

Discharge - a patient undergoing  planned  discharge 

Self  discharge  - a  patient  who  wishes  to  be  discharged  despite  medical  advice  to  the 
contrary 

4.0  BOOKINGS 

in-patient)  are  accepted  from  doctors  with 
Requests  for  admission  (day  case  and 
practising  privileges  at  the  hospital  or  their  secretaries.  Alternatively,  patients  may  be 
accepted  as  an  NHS  referral  within  agreed  protocols.  Bookings  will  only  be  accepted  on 
presentation of a fully completed  booking  form  sent to the admission  office. 

Bookings  for  patient  admission  to  the  hospital  for  theatre  surgical  procedures  will  be 

CLINI 07 
Issued by:  Clinical Governance Director  Next Review: January 2023 

Issue Date: January 2020 

Issue no:  12 

Page 3  of 32 

 provided  with  a minimum  of 7 days' notice and  will  be  processed  by the admissions  office. 

Late  bookings  for  admission  for surgical  procedures  (less  than  7  days)  will  be  authorised 
by  a  member  of  the  Theatre  Senior  Team  and  Senior  Nurse  on  duty  once  due 
consideration  has  taken  place  regarding: 

• 

• 

• 

• 

• 

• 

• 

• 

• 

the clinical  urgency of the case 

the  number of cases  already booked  for that session 

the complexity of the cases booked  on  that session 

the availability of theatre/ ward  staff and  experience required 

the availability of instrumentation /  equipment 

the availability of a bed/ critical  care provision 

the ability to undertake any necessary clinical  and  financial  risk assessments 

the availability of a  pre-operative assessment appointment 

the  pre-operative testing  requirements  and the time taken  to receive test results, 
ensuring that all  necessary test results  will  be  received  prior to surgery 

GPs  who  contact  the  hospital  directly  regarding  a  request  for  an  immediate  consultation 
and  possible  admission  will  discuss details with  the Senior Nurse  on  duty. 

If considered  an  appropriate  admission  for  the  hospital,  the  Senior  Nurse  on  duty  will 
contact a  consultant to accept the  patient's care. 

Any  emergency  admission  will  not be  accepted  until  an  appropriate  consultant has  agreed 
to  discuss  the  case  directly  with  the  GP  prior to  acceptance  and  be  present to  assess  the 
patient on  arrival  at hospital. 

Payor  status  needs  to  be  established  before  any  admission  and  insurance  authorisation 
confirmed  as  appropriate.  For  Inclusive  Care  patients,  payment  is  required  in  full  prior to 
admission.  Self-pay patients must pay an  agreed  sum  as  an  initial  deposit. 

5.0  CLINICAL RISK ASSESSMENT 

Each  patient  will  be  assessed  clinically  prior  to  admission  and  in  consideration  of  the 
'Elective  Surgical  Admission  Criterion  Policy.  Patients  will  be  assessed  prior  to  surgery  as 
detailed  in  the  Pre-operative  Assessment  Standards,  Policy  and  SOP.  A  Pre-Admission 
Medical  Questionnaire  PAMQ)  will  be  completed  for  all  patients  ahead  of  admission  and 
discharge  planning  should  be  considered  at  this  stage,  especially  requirements  for  home 
care  packages or periods  of convalescence 

A 'Weekly  Planning  Meeting' should  be  held to  ensure  that  patients  at  increased  risk  have 
been  assessed,  optimised  and  a  plan  is  in  place  and  communicated  to  all  relevant 
departments and  the Head  of Clinical  Services (Matron) as  appropriate. 

Patients with a  diagnosis of Cancer 

•  Evidence  of a Cancer MDT  recommendation  must be  available prior to any patient with  a 

new or current diagnosis of cancer  being  admitted  for treatment with  surgery, chemotherapy 
or radiotherapy at a Spire  facility 

Pro.cess  for confirming  MDT  prior to admission 

•  The  new or recurrent cancer diagnosis  and  proposed  treatment must be  confirmed  on  the 

Booking  form  by the treating consultant 

•  All  patients  receiving  curative treatment for a new or recurrent cancer diagnosis must attend 

for POA 

CLINI 07 
Issued by:  Clinical Governance Director  Next Review: January 2023 

Issue Date: January 2020 

Issue no:  12 

Page 4  of 32 

 •  The  POA  RN  must confirm  that the MDT documentation  relating to the treatment is  available 

• 

in  the medical  records 
In the event that the  MDT documentation is  not available the  POA  RN  must complete  a 
clinical  incident report  on  Datix and  alert the  Head  of Clinical  Services (Matron) 

•  Where  patients have  been  escalated  to the Head  of Clinical  Services, the Head  of Clinical 
Services  should  discuss this with  the  relevant MAC  representative.  The Head  of Clinical 
Services  may approve  on  an  exceptional  basis if they believe: 

o  An  MDT discussion  as taken  place  and the documentation is  not yet available.  These 
cases  must be  followed  up to ensure that this received  post treatment or delaying 
treatment would  place the  patient at unacceptable clinical  risk and the patient will 
subsequently be  discussed  at an  appropriately configured  MDT meeting following 
treatment and this evidence  will  be  made available. 

o  Approvals  by exception  should  be  detailed  on  a standard  template as  per the  Cancer 

Standards Policy Appendix 4  and  a copy  added  to the Datix report. 

5.1  Financial Risk Assessment 

A  financial  risk  assessment  will  be  undertaken  for  each  patient  (as  detailed  below).  All 
insured,  inclusive care  and  self-funding  patients are required to sign  a hospital  registration 
form  accepting  financial  liability.  NHS  patients  are  requested  to  complete  a  registration 
form  to  ensure  all  data  is  correct  and  the  data  protection  notice  is  signed,  but  not  for 
financial  liability. 

All  non-NHS  patients  are  requested  to  provide  credit  card  or  debit  card  details  to  cover 
any  insurance  excesses,  take  home'drug  costs  and  sundry  charges  not  covered  by  their 
insurer  or  included  within  their  package  of  care.  Credit  card  details  are  acceptable  from 
the  patient or carer. 

a) 

Insured  Patients  - With  the  exception  of  oncology  - pre-authorisation  checks 
will  be  carried  out for insured  patients.  If authorisation  is  not provided  by  the  insurer, 
the  patient  should  be  advised  about  Inclusive  Care.  Admission  cannot  take  place 
without  guaranteed  payment  by either the  insurance company or advance payment of 
the inclusive care  package. 

b) 

Inclusive  Care  Patients  - Full  payment  is  required  prior  to  admission.  The 
procedure  will  be  re-scheduled  if the  payment has  not  been  received. 

c)  Self-funding  Patients - An  amount of money equivalent to inclusive  care  package  is 
required  prior  to  admission.  The  patient  will  be  kept  informed  of  costs  throughout 
their stay and  further monies requested  as  appropriate. 

d)  NHS  Patients  - Credit  or  debit  card  information  would  only  be  suggested  to 
patients  on  the  day  of  admission  to  cover  sundries  or  phone  calls  but  not 
requested  as a  mandated  requirement.  Patient journey details  are  maintained  for 
management of potential  breach  dates 

e)  Medico-Legal  patients - an  inclusive care  price  is  calculated  with  the  understanding 
that  a  refund  will  be  made  if the  full  amount  not  used  or if more  funds  are  required, 
This  can  be  guaranteed  by  a solicitor's  letter as  signed  guarantor which  is  acceptable 
with the deposit of the inclusive care price. 

f) 

Immediate/Late  bookings  (less  than  72  hours)  must 
Immediate/Late  Bookings  -
be  pre-authorised  as  a  priority  once  the  booking  has  been  approved  by  the  Senior 
Nurse  and  Theatre  Manager.  A  deposit  must  always  be  requested  for  'out  of  hours' 
bookings,  this  will  be  refunded  to  insured  patients  on  confirmation  of  authorisation 
from the insurance company.  If a  patient needs  admission 'out of hours' and  claims  to 
be  covered  by  insurance,  but  this  cannot  be  checked  until  a  later  date,  they  must  be 
treated  as  self-pay  patient  until  authorisation  is  confirmed  by  taking  a  deposit  or 
guaranteed credit card  payment in  the interim. 

CLINI 07 
Issued by:  Clinical Governance Director  Next Review: January 2023 

Issue Date: January 2020 

Issue no:  12 

Page 5  of 32 

 6.0  PREPARATION  FOR ADMISSION 

Beds  are  allocated  by the Senior Nurse on  duty or via  the  bed  management system. 

On  receipt  of  a  booking  form,  availability  of  theatre  time  and  bed/area  should  be 
assessed. 

After  pre-authorisation  checks,  care  pathways  and  labels  will  be  produced  (showing  full 
patient  demographics)  and  the  patients'  medical  record 
folder  will  be  prepared  for 
admission. 

Theatre  scheduling  booking  forms  will  be  passed  to  the  admissions  office  once  a  patient 
has  been  appropriately  pre-operatively  assessed.  A  theatre  schedule  will  be  built  to  the 
time  slot  available  /  allocated  to  the  surgeon.  Staff,  bed  availability  and  specialist 
equipment  requirements  will  be  assessed  at  the  weekly  bed  management  /  scheduling 
meeting.  Any proposed  late additions to the theatre schedule will  be discussed  with  the 

theatre  manager  and  senior  ward  nurse.  Theatre  scheduling  will  consider  the  complexity 
of procedure,  patient  condition,  whether an  in  patient  or day  case  procedure  and  the type 
of anaesthetic. 

7 .0  ADMISSION 

A  patient's  admission  will  be  conducted  quietly  and  efficiently  taking  due  care  and 
attention  of  any 
religious  and  cultural  beliefs  maintaining  privacy,  dignity  and 
confidentiality  throughout.  A  sensitive  approach  will  be  maintained  whilst  gathering  and 
imparting  all  the  necessary  information, ensuring that the  patient is  made  to feel  welcome 
and  at ease. 

7.1  Timing of Admission 

It is  recommended,  whenever it is  practical  to do so,  that admission  times are  split  for 
morning,  afternoon  and  evening  operating  lists.  For example: 

•  06:30 admission  for a morning  operating  list beginning  at 08:00 

•  11:00 admission  for an  afternoon  list beginning at 13:00 

•  15:00 admission  for an  evening  list beginning  at 17:00 

Splitting  admission  times  allows  better  management  of  pre-operative  fasting  times  and 
supports  maximising  bed  occupancy.  However,  this  must  be  balanced  with  the  need  for 
adequate  time  to  complete  admission  processes  (including  consent)  and  for  anaesthetists 
to assess  patients prior to arrival  in  the anaesthetic room 

For all  day operating  lists,  split admission  times must be  in  place 

7.2  Administration 

With  the exception  of emergency cases,  all  patients will  receive  an  Admission  Pack 
containing  relevant  details and  information  prior to admission. 

Patients  will  be  greeted  on  their  arrival  by  reception  staff.  Details  (including  identity)  of 
the  patient  will  be  confirmed  by  requesting  the  patient  to  state  their  full  name,  date  of 
birth  and  current  address.  These  should  be  checked  against Spire's  patient  administration 
system. 

Patient  Reported  Outcomes  questionnaires  will  be  issued  as  appropriate  (if  not  already 
done  so  at  pre-operative  assessment)  and  any  relevant  payments  requested  (including 
credit card  details) to cover sundry items and  insurance excesses. 

Registration  forms  must  be  reviewed  by  the  patient  and  signed.  Any  changes  to  details 
must be amended  on  the system  and  will  need  to  be  communicated to the ward when  care 

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 pathways and  labels have been  produced  prior to admission. 

Reception  is  responsible  for  ensuring  the  patient  is  collected  and  escorted  to  their  room 
without  undue  delay  (typically  within  fifteen  minutes  of  the  patient  making  themselves 
known  to the hospital  unless circumstances dictate a longer waiting time) 

The  ward  receptionist/  HCA  will  collect the relevant notes from  the  ward station  and 
escort the patient to their allocated  room  or clinical  treatment area. 

Once  in  the  room  or ward,  it is  the responsibility  of the person  escorting  the patient to 
ensure they are familiar with  all  of the facilities available: 

,  Nurse call  system 

•  Fire  Procedure 

•  Hostess call  system 

•  TV  controls 

•  Lights 

•  Telephone 

•  Use  of mobile phones 

•  Toilet facilities 

•  Lounge  (if applicable) 

•  Visiting times 

•  Telephone number for ward /  room  for relatives to call  in 
•  Confirm  if patient has  any electrical  equipment.  If yes,  please follow  work instruction  -

'Procedure for patient and  staff's own  electrical  equipment'. 

•  Safe storage of valuables  in  a safe with  receipt  (patients should  be  discouraged from 

bringing valuables into hospital) 

The  nursing  staff must be  informed that the  patient has  arrived  and  is  in  their room. 

The admission  details will  be  entered  onto Spire's  patient administration system. 

7.3  Nursing 

a)  Prior to the  admission, the admitting nurse will  check the room/ area to ensure the 

following: 

,  The  room  or area  is clean,  warm and  fit for purpose  e.g.  alcohol  gels,  gloves, 

towels tissues, vomit bowl,  gown, disposable pants  are available 

•  Appropriate  moving and  handling  equipment is  in  place  (e.g.  hoist) 

•  Ensure  relevant environmental  risk assessment is  carried  out e.g.  for paediatric 

admission  or cot  sides assessment 

•  Ensure the nurse  call  system is  in  working order. 

•  Ensure the oxygen  and  suction equipment is  in  working order and  non-breathable 

mask, oxygen  tubing and  yankeur sucker are  available. 

b)  The  named  nurse  will  greet the  patient  within  fifteen  minutes  of their  arrival  into  the 

room  I area. 

c)  All  information gained either verbally or written  prior to admission  must be  included 

on  the relevant hospital  admission forms and  Patient  Record. 

d)  The  nurse  will  complete/update  the  care-pathway  with  the  patient,  recording  all 
details and  identifying any changes to clinical  condition  since  questionnaire completion 
or  pre-admission  assessment.  Appropriate  escalation  of  this  information  needs  to  be 
considered. 

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 e)  All  patient  risk assessments must be  completed  by a  Registered  Nurse 

f)  Allergies  must be  recorded  on  the patient  Drug  Prescription  and  Record  and a  warning 
sign  placed  on  the  front  of the  Patient  Record  folder.  Relevant .clinical  and  catering 
staff must be  made aware of any  problems  highlighted  including allergies. 

g)  VTE  risk  assessment  is  to  be  recorded  on  the  Drug  Prescription  Chart  and  where  a 
patient is  identified  at risk of VTE  this must escalated  to the admitting consultant. 

h)  Confirmation  must  be  sought  by  the  nurse  that  the  patient  has  followed  any  pre-

admission  instruction  e.g. 'no food/drink for a  certain  period'. 

i) 

Legible ID  bands  recording  the  patient's full  name,  date  of birth,  hospital  number and 
their consultant's name must be  attached to all  patients. 

•  White ID  Band  - All  patients 

•  Red ID band  when  Allergies have  been  identified 

j)  Any  medication  brought  into  the  hospital  by  the  patient  must  be  handed  to  the 
admitting  nurse  to  liaise  with  the  hospital  pharmacist  and  then  locked  in  a  secured 
area.  Their  usual  medications  should  be  prescribed 
as 
appropriate.  Self administration  document  must be completed  for appropriate patients 

timely  manner 

in  a 

k)  The  named  nurse  will  ensure  the  patient  has  received  all  relevant  information 

regarding their care. 

I)  A  pregnancy test will  be  offered to all  appropriate  patients prior to treatment/ surgery 

/  investigation  as  per Spire policy. 

m)  If the  pregnancy test is  declined the consultant must be  informed and  course  of action 
documented  as  a  variance.  Positive  pregnancy  tests  must  be 
reported  to  the 
consultant  immediately  and  planned  procedure  suspended  until  reviewed  by  the 
consultant. 

n)  Any  response to a relative's  request for information  must first be  authorised  by the 

patient. 

o)  Confirmation will  be  sought and  documented  by the nurse that discharge home 
arrangements made by the  patient are  suitable for their requirements e.g.: 

1.  Accompanied  home by a  responsible adult and  for  24 hours following  a general 

anaesthesia 

2.  Suitable transportation  home 

3.  Carer arrangement made where relevant  as  per pathway. 

8.0 PAEDIATRICS 

The  minimum  age  at which  children  will  be  admitted  to  a  Spire  hospital  for .sill  procedures 
is  three  years  (with  exception  of  Manchester  Hospital  and  Leeds  Hospital  ONLY).  Please 
refer  to  Clinical  Policy  11  - Care  of  Children  Policy  which  defines  children  as  individuals 
between the ages of O and  15 years up to the day  before  their 16th birthday. 

A  pre-admission  assessment  must  be  arranged  with  the  Registered  Sick  Children's  Nurse 
(RSCN)  for all  children. 

An  appropriate  risk  assessment  of patient,  room  and  equipment  must  take  place  and  be 
clearly documented within  the patient's care  pathway 

Bookings  for  children  cannot  be  confirmed  without  confirmation  that  an  RSCN  will  be 
available throughout the duration of the child's stay. 

Children  will  only  be  admitted  under the  care  of a  consultant  who  meets  their practicing 

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 privileges requirements  for CYP  patients. 

9.0 DISCHARGE  PLANNING  - CLINICAL 

The  discharge  plan  will  commence  at the  beginning  of the  patient  episode  of care.  Liaison 
will  take  place  between  the  consultant  and  other  members  of  the  clinical  team.  The 
discharge  arrangements  set  out  below  apply  whether  within  or  outside  normal  working 
hours.  Additional  discharge  arrangements  for  all  patient  groups  are  specified  in  the 
relevant treatment care  pathways. 

Community  liaison  and  Occupational  Therapy are  contacted  /  involved  when  necessary  as 
per the patient's care  pathway. 

The  consultant  and  clinical  team  will  identify  the  discharge  date  in  line  with  the  relevant 
care  pathway;  agree  the  expected  clinical  outcomes  on  discharge  and  any  follow  up  care 
arrangements to be  made. 

The  consultant  will  be  notified  of  any  variances  that  might  affect  the  planned  discharge 
date  as  they  arise.  If the  patient  does  not  achieve  the  expected  clinical  outcome  this  will 
be  reviewed. 

All  inpatients  will  be  discharged  by  10:00am on  the  morning  of their discharge  if clinically 
appropriate.  The  discharge  time  for  day-care  patients  will  depend  on  the  rate  of  their 
recovery  and  should take account of discharge criteria  within  the relevant care  pathway. 

Patients  will  not  be  routinely  discharged  after  22:00  unless  the  patient  expresses 
otherwise;  exception  late  evening  discharges  will  be  risk  assessed  to  take  account  of 
carers at home and the patient signs to say they are happy to  be  discharged  at thattime. 

Patients  that  have  been  admitted  as  a  day  case  and  received  sedation  /  general 
anaesthetic  must  only  be  discharged  if they  are  accompanied  home  and  have  someone 
with  them to stay overnight. 

Patient information  (including  written  information) and advice  on  follow  up/wound  care  will 
be  given  to  the  patient  and/or  their  carer  on  discharge  together  with  relevant  contact 
telephone  numbers  for  24  hour  access.  There  should  be  a  clear  protocol  in  place  for 
managing  post-discharge calls  (see  appendix 8)  and  telephone enquiries from  patients  (or 
their carers)  must be  assessed  by a nominated, qualified  member of the nursing team. 

Where  required,  an  outpatient  follow-up  appointment  will  be  made  prior  to  discharge  or 
sent to the patient's home  address following  discharge. 

For  ALL  NHS  patients there  must either be  a planned  face  to face  out-patient follow  up  by 
a  Clinician  or  a  telephone  review  within  6  weeks  of  discharge,  unless  otherwise  agreed 
with  the  relevant  commissioner.  A  protocol  for follow  up  telephone  review  for  all  patients 
has  been  developed  and  is  included  in  appendix 4  and  5. 

The  discharge  plan  will  be  documented  in  the  patient's  hospital  record  and  should  include 
a record  of any communication  with  community services. 

A  copy  of  the  completed  discharge  summary  must  remain  in  the  Patient  Record  with 
copies given to  patient and  faxed/sent to GPs. 

ALL  patients  should  be  given  their own  personal  copy  of their Discharge  Summary  on  the 
day of discharge which  should  be  discussed  with  the patient face to face 

Discharge medication  should  be  explained  and  written  information  given to patient. 

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 10.0 DISCHARGES BY WARD CLERK 

All  sundries and  phone bills should  be  checked  and  ready for payment prior to discharge 

Wherever  possible,  all  out-patient  follow  ups  should  be  arranged  where  indicated  with 
written  confirmation  for patient 

Once  the  nurse  responsible  for  discharging  the  patient  has  completed  her  entries  in  the 
Patient  Record,  the  Ward  Clerk  must  ensure  that  the  Patient  Record  is  filed  in  correct 
order and  details of discharge are  entered on  Spire's patient administration  system ..  See 
Clinical  Policy  08  - Patient Records  policy 

All  NHS  contract  patients  managed  under HRG4  at tariff must have their  notes  presented 
to the  Clinical  Coding  Service  immediately  after discharge to  ensure  the  episode  is  coded 
and  the  data  entered  into  Spire's  patient  administration  system  for  month  end  reporting 
and  billing. 

11.0 TRANSFERS 

Transfers  in  - are  processed  as  per  the  admission  process  but  include  a  telephone 
nursing  assessment  with  the  hospital  the  patient  is  moving  from,  including  a  MRSA  risk 
assessment  and  subsequent  screening  and  isolation  until  it  is  confirmed  that the  patient 
is  MRSA  negative. 

Internal  transfers  - conversion  from  day-case  to  unplanned  inpatient  - are 
arranged  in  accordance  with  the  instruction  of the  consultant  and  senior  nurse  on  duty 
and  following  liaison  with  the  relevant  departments. 

External  transfers  - booked  transfers  are  arranged  as  per  the  discharge  process  but 
include  the  arrangement  of transport  and  escort  as  required.  As  appropriate,  a  copy  of 
relevant  documentation  should  be  sent  with  the  patient.  The  Patient  Record  must  be 
updated to include  details of the transfer and  the  reason  for transfer must be  recorded  in 
the  relevant section  of Spire's patient administration system. 

Emergency  transfers  - arranged  following  consultation  with  the  attending  consultant 
and  senior  ward/theatre  nurse  who  will  liaise  with  the  accepting  hospital  as  per  the 
agreed  local  transfer  policy.  Relevant  documentation  will  be  photocopied  and  sent  with 
the  patient.  Transport  and  accompanying  clinical  staff  will  be  arranged  as  required  as 
per UK  Resuscitation  Council  Guidelines.  An  Serious Adverse  Event  Notification  Form  and 
datix  form  must  be  completed  and  the  reason  for  transfer  recorded  in  the  relevant 
section  of Spire's patient administration  system. 

All  unplanned and  emergency transfers to level  2  /  3  care  - will  be  followed  up on 
a  daily  basis  by  a  designated  member  of  the  senior  clinical  staff  who  will  contact  the 
establishment  where  the  patient  has  been  transferred  and  document  the  details  of the 
enquiry  into the  patient  record.  This  daily  contact  must  be  continued  until  the  patient  is 
deemed  'safe'  or 'out of critical  danger'.  A  standard  variance  tracking  sheet  is  available 
to  support  this  process  and  is  included  at  appendix  6.  The  Patient  Record  must  be 
updated to include details of transfer. 

Out of hours transfers 

Hospitals  must  have  out  of hours  transfer  arrangements  with  local  healthcare  providers 
and  local  processes  must be  followed  in  the event that this is  required. 

Documentation 

Documentation  that  accompanies  a  transfer  should  be  adequate  to  ensure  that  the 
receiving  unit have a  history  of treatment  provided  where  this  is  relevant to the ongoing 
care.  In  many  instances  local  transfer  arrangements  may  require  the  completion  of  a 
transfer form  and these  should  be  completed  where  required. 

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 A  Serious Incident Requiring Investigation (SIRI) notification should  be sent 
to IRWG following all  transfers out. 

12.0  EXTENDED STAYS 

Any  extended stay must be  recorded  as  a variance  in  Care  Pathway with the clinical 
reason 

For  insured  patients,  extended  stays  are  monitored  daily  and  communicated  with  the 
relevant  insurance  company  where  required  to  obtain  authorisation  for  the  extended 
stay. 

For self pay  patients,  extended stays are  monitored  daily and  hospital  fees are secured 
appropriately. 

The  clinical  governance team  regularly audit extended stays to identify any developing 

trends. 

NHS  Patients  - extended  stays  are  monitored  daily  and  information  provided  to  the 
appropriate  PCT  according  to  the  contractual  agreement.  All  details  of  complications 
must  be  entered  into  Patient  Record  to  ensure  the  Coding  Administrator  can  record  the 
cause of the extended  stay. 

13.0  MANAGING POST DISCHARGE ENQUIRIES 

13.1  On  discharge,  patients must be provided  with  information  on  how to contact the  hospital 
(24  hour number)  and  advised  to  do  so  if they  have  concerns  regarding  their  recovery 
or  discharge  arrangements.  Additionally  consultants  may  also  provide  patients  with 
direct contact information. 

13.2  Telephone  enquiries  from  patients  (or their  carers)  must  be  assessed  by  a  nominated, 
qualified  member  of  the  nursing  team  who  has  the  appropriate  competency  for 
managing  post  discharge  enquiries,  available  on  the  intranet.  The  purpose  of  this 
assessment  (triage)  is  to  signpost  patients to  the  appropriate  level  of care,  and  not to 
make  a  clinical  diagnosis.  However,  a  qualified  nurse  may  give  the  patient  (or  their 
carer)  advice,  provided  the  advice  given  is  within  their  professional  scope  of  practice 
and  current knowledge. 

13.3  The  principles for effective  post discharge call  management are: 

• 

• 

• 

• 

Information gathering  - actively hearing  what the  patient does and  doesn't say 

Understanding - interpreting the main  reason  for the call  amongst all  the 
information  the caller may give you 

Agreeing  - reflecting  back to the caller the main concern  and  agreeing the 
next course of action 

Appendix 7  must  be  used  for all  post-discharge enquires  documenting the 
Situation,  Background, Assessment and  Response. 

13.4  Passi ble  Outcomes 

The  outcome of a call  can  be  classified  as: 

A.  Contact 999 for ambulance  (to NHS Trust emergency department) 

B. 

Immediate return to the Spire hospital  - for review by RMO  /  Consultant 

C.  Advice given and patient to attend hospital tomorrow morning - for 

review by Nurse/RMO 

D.  Advice given and follow-up call to be made within  24 hours 

E.  Advice given and advice to be peer reviewed by senior nurse with  24 hours 

- may include attending a  GP routinely, or attending next planned 

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 out-patient appointment 

F.  Advice given and patient advised to call  back if problem persists 

G.  Advice given and no further intervention required 

H.  Other disposal  (not covered by categories A - E) 

13.5  Assessment  Criteria 

A. 

If the  patient  is  reported  to  be  experiencing  any  of  the  following  critical 
signs,  the  caller  must  be  advised  to  dial  999  to  request  an  emergency 
ambulance: 

•  Unconsciousness  or altered consciousness 

•  Sudden  onset chest  pain  suggesting  an  acute cardiac episode 

•  Facial  weakness;  arm  weakness;  slurred  speech  - symptoms suggesting a stroke 

•  Shortness of breath;  difficulty breathing 

•  Acute and  severe trauma,  including  head injury 

•  Heavy uncontrolled  bleeding 

•  Sudden  loss of vision  following  ophthalmic surgery 

•  Pain  score  of 4 or more despite prescribed analgesics 

•  Any  other condition  the nurse taking the call  believes to  be  life threatening 

B.  If the patient is  reported to be experiencing any of the following concerning 
signs the caller must be asked to attend the hospital as soon as they can for 
clinical assessment by a  senor nurse or RMO: 

•  Any  unwell  child 

•  Pain  score  2/3 despite  prescribed  analgesics  (including severe headache) 

•  Calf pain;  tenderness  and swelling  of the leg;  skin  discolouration that is  pale,  blue, 

or a reddish-purple  colour - symptoms indicating  a deep vein thrombosis 

•  Prolonged vomiting  and/ or diarrhoea 

•  Acute  urinary symptoms including retention 

•  Unusual  chest pain  (not crushing  chest pain) 

•  Persistent surgical  site  bleeding 

•  Abdominal  pain  not associated  with  primary surgery 

•  Escalating  wound  pain, swelling,  inflammation or discharge 

•  Fever and/or escalating  malaise 

•  Difficulty swallowing 

•  Confusion  or disorientation;  repeated  episodes  of dizziness 

•  Repeated  falls 

•  Patients  receiving  chemotherapy treatment with  an  elevated temperature 

•  Any other condition  the nurse taking  the call  believes to  be  particularly concerning 

At  the  end  of  any  call  involving  concerning  signs,  a  "worsening  statement"  should  be 
provided  - e.g. "if your symptoms  worsen  before  you  can  attend the hospital,  please  call 
us  back or contact 999" 

Once  critical  or concerning  signs  have  been  ruled  out,  there  may  be  occasions  when  the 
nurse  taking  the  call  needs  to  contact  the  treating  Consultant  before  providing  advice 
to the caller.  Examples include when  the patient is  experiencing: 

• 

Elevated  temperature 

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 •  Unrelenting cough 

• 

Emotional distress 

If this  is  the case,  at the end  of the call  the nurse should take at least one,  but preferably 
two  telephone  numbers  to  contact the  patient  back  once  advice  has  been  received  from 
the Consultant. 

The  Nurse  should  give  an  indication  as  to  how  long  the  caller  will  have  to  wait  e.g.  20 
minutes,  and  call  the  patient  back  even  if  it  has  not  been  possible  to  contact  the 
Consultant within  that timescale, to explain  this. 

Advice  and  reassurance  by  the  Nurse  taking  the  call  can  be  provided  in  situations 
that  would  ordinarily  be  expected  as  a  result  of treatment,  with  no  immediate  concerns, 
and  not requiring  any immediate  intervention, e.g. 

•  Discomfort controlled  by  pain  relief 

•  Nausea 

• 

• 

Tiredness 

Bruising and  or/ swelling  in  the surgical  area 

•  Constipation 

•  General  queries relating to discharge arrangements  (e.g.  follow-up appointments) 

The  advice  provided  could  include  arranging  a  GP  appointment  or  attending  the  next 
planned  out-patient appointment. 

At  the  end  of  any  call  involving  advice  and  reassurance  by  a  nurse,  a  "worsening 
statement"  should  be  provided  - e.g.  if  you  continue  to  be  concerned  please  do  not 
hesitate to call  us  back" 

NB:  If someone  calls  post discharge for advice  again  within  a  24 hour period,  they  must 
be  invited  to  attend  the  hospital  at  their  earliest  convenience  for  clinical  assessment  by 
the senior Nurse  or RMO. 

14.0  POST DISCHARGE WARD/OUTPATIENT ATTENDANCE 

N.B - it is rare that a  patient will attend the hospital post-discharge without first calling 
for advice,  but on these occasions  please follow the same instructions as if the patient 
had been advised to attend the hospital. 

Following  a post-discharge phone  call  a patient maybe advised to visit the hospital  for review.  The 
patient  must be  advised  which  department to attend and  inform the department and the  RMO  to 
expect the patient. 

Prior to the  patient's arrival ensure that the medical  records  are  available.  On  the rare occasion 
where the medical  records are  unavailable there  must be  a local  process  in  place to ensure that  a 
temporary set must  be  made and  merged  as  soon  as  possible  with the original  records. 

All  patients  re-attending  the hospital  must be reviewed  by the  RMO.  The  patient must be  fully 
assessed  and  documentation  must include: 

•  Date and time 
•  Presenting  symptoms 
•  Past medical  history (recent admission  and previous medical  history) 
•  Examination and findings 
• 
•  Confirmation that the consultant has  been  notified  and  when 
•  Whether advice  has  been  sought from  the consultant, if it has,  that advice should  be 

Impression 

documented.  If advice has not been  sought the reasons  for not doing  so  should  also  be 

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 documented. 

•  Plan  for the patient 
•  Outcome 

Any patient that has attended the  hospital  must be  contacted  within  24 hours of attendance by the 
RMO  and  the follow  up call  must be  documented  in  the medical  records. 

Any  patient that is  seen  at the hospital  must be  entered  onto  Datix in  the following  category 

Main  category - Discharge 
Sub-Category - Re-attendance following  discharge 

15.0  EMERGENCY READMISSIONS 

Priority  should  always  be  given  to  a  re-admission  i.e.  a  patient  who  has  recently  been 
discharged  but  needs  to  come  back  into  Hospital  urgently  for  further  treatment.  In  the 
rare  event that it is  initially  deemed  that  no  beds  are  available,  due  consideration  must 
be  given to  postponing  future  admissions  to  accommodate the  patient.  A  member of the 
Senior  Management  Team  must  be  consulted  in  any  situation  where  beds  are  not 
immediately available  for re-admissions. 

The  Nurse in  Charge  will  be  notified  of the patient's needs  by GP/Consultant 

The  Nurse  in  Charge  assesses  suitability  of the  patient's  condition  and  staffing  and  bed 
availability 

The  Consultant  will  accept  responsibility for the patient's admission 

The  Nurse  in  Charge  completes  a  booking  form,  which  is  taken  to  Reservations  / 
Bookings 

If 'out of hours', the ward  clerk will  carry out the administrative admission. 

The  Patient's  details  are  entered  onto  computer.  The  admission  should  be  recorded  as 
an  "emergency" in  the  relevant section  of Spire's  patient administration system. 

Patient records located. 

The  Patient (& GP  if GP  referral)  are contacted  with  details of Admission/Transport and 
expected time of arrival 

The  Ward  and  relevant department are  notified of re-admission. 

All  the appropriate  pre-authorisation checks  must be  made and  credit/debit card  details 
secured  unless reason  for admission  is covered  by Inclusive Care  Package. 

Patient Assessment 

All  patients that are readmitted  must be  assessed  and  a plan  of care agreed  by their 
consultant no  longer than  4  hours following  admission. 

16.0  MONITORING THE  EFFECTIVENESS OF ADMISSIONS AND  DISCHARGES 

Local  and  national  patient  surveys,  complaints,  incidents  reports  and  informal  feedback 
all  provide  information  on  the  effectiveness  of  admission  and  discharge  arrangements. 
These  are  all  monitored  in  line  with  the  requirements  of  the  Spire  Healthcare  Clinical 
Governance and  Quality Manual  (Clinical  Policy  1) 

CLINI 07 
Issued by:  Clinical Governance Director  Next Review: January 2023 

Issue Date: January 2020 

Issue no:  12 

Page  14 of 32 

 PATIENT SELF  DISCHARGE  AGAINST  MEDICAL ADVICE 

PROCEDURE 

Appendix 1 

In the event that a  Patient wishes to  be  discharged against medical  advice within a Spire 
Hospital  the Senior Nurse on  duty shall: 

1. 

ensure  that  the  patient  is  aware  of  the  medical  advice  that  he/she  should  not  be 
discharged and  the reasons  for that opinion 

2. 

inform the consultant responsible for the  patient's  care immediately 

3. 

4. 

5. 

6. 

7. 

8. 

9. 

obtain  the  patient's  written  statement  that  they  wish  to  be  discharged  against  medical 
advice  or,  if  the  patient  is  unable  or  unwilling  to  sign  such  a  statement,  record  all 
relevant  details  in  the  patient's  medical  record  to  be  witnessed  by  two  Healthcare 
Professionals  one  of  whom  should,  if  possible,  be  the  consultant  responsible  for  the 
patient's care 

inform  the  patient's  next  of  kin,  carer  or  other  appropriate  person  of  the  patient's 
discharge  against  medical  advice  providing  the  patient has  signed  his/her consent  to  this 
in  the  self-discharge  form  (Appendix  2).  Details  and  reasons  for  patient's  decision  to self 
discharge should  be  left to the  patient to explain  to the next of kin  if possible 

take  any  steps  to  delay  the  patient's  departure  which  are  appropriate  and  are  legally 
permitted 

in  the  case  of  NHS  patients,  inform  the  NHS  Contract's  Manager  as  soon  as  reasonably 
practical  of the patient's discharge against medical advice 

in  the  case  of a  NHS  patients,  inform the  patient's  GP  as  the  referring  clinician,  prior to, 
or immediately after, the  patient's discharge 

in  the  case  of  vulnerable  patients,  inform  the  police  and/or  other  support  agencies  as 
appropriate 

take  all  reasonable  practicable  steps  to  organise  the  discharge  as  if it  were  taking  place 
with,  rather than  against,  medical advice 

10.  update the discharge plan  and  patient record  appropriately 

11.  where  appropriate ensure  that IV cannula  is  removed  prior to  departure  with  agreement 

of the  patient 

12.  where  appropriate  ensure  patient  has  essential  medication  prior to  leaving  as  agreed  by 

consultant 

CLINI 07 
Issued by:  Clinical Governance Director  Next Review: January 2023 

Issue Date: January 2020 

Issue no:  12 

Page  15 of 32 

 SPIRE HEALTH CARE 

PATIENT SELF  DISCHARGE  FORM 

Appendix 2 

I. ..................................................................................... . 

(Printed 

patient 

name)  wish  to take  responsibility  for my own  discharge from  this Spire  Hospital, 

despite the  medical  and  nursing  advice I  have  been  given. 

I  consent to  my next of kin  or carer being  informed that I  have taken  my own 

discharge against medical  and  nursing  advice  (delete this section  if consent withheld). 

Date...............................................................  Time ............................................ . 

Patient Signature 

Patient Printed Name 

State if Patient was unwilling or 
unable to sign this Form 

Witness Signature 

Printed Name 

Nurse in Charge Witness Signature 

Nurse in Charge Printed Name 

Other Healthcare Professional 
Witness Signature 

Other Healthcare Professional 
Witness Printed Name and 
Designation 

CLINI 07 
Issued by: Clinical Governance Director  Next Review: January 2023 

Issue Date: January 2020 

Issue no:  12 

Page 16 of 32 

 Outpatient Telephone Consultations Form 

Appendix 3 

Patie;it Number: 

First Name: 

Last Name: 

Date of Birth : 

Sex: 

M/F 

Contact tel no.  : 

ITreatment /  Operation : 

Discharge Information (e.g.  any  relevant clinical  findings,  complications,  pending  investigations,  advice  given) 

Call  date and 
time 

Call  made By

Completed 

Unanswered 

Patient 
unavailable 
/  Voicemail 

Patient 
declines 
telephone 
consultation 

CALL 1 

CALL2 

CALL3 

What is Patients current level of pain? 

0  No  pain 
1 Mild  pain 
2  Unpleasant  pain 

r 
r 

3  Severe  pain 
4  Worst imaginable pain 

How does the patient describe their surgical wound: 
r 
r 
r 
r 

Clean  and dry 
Redness  around  wound  no oozing  of blood  or other discharge 
Redness  around  wound  and  oozing  of blood  or other discharge 
N/A  - no wound 

Has the patient returned to normal activities such as driving, work and shopping yet? 
(Details) 

Patient understanding of next steps (please state): 

Outcome of Call 

CJ No  further action  required 

CJ Further action  required  (please  state): 

Call  completed by: 

Signature: 

............................................................... Print Name : 

Date: 

............................................................... Designation: 

CLINI 07 
Issued by:  Clinical Governance Director  Next Review:  January 2023 

Issue Date: January 2020 

Issue no:  12 

Page  17 of 32 

 Outpatient Telephone Assessment Protocol 

Appendix 4 

SPIRE  HEALTH CARE  - FOLLOW UP  ENQUIRY TELEPHONE 
PROTOCOL 

Timing of consultations 

4  weeks  following  discharge 

Number of attempts at contact 

If  the  first  attempt  at  a  follow-up  phone  consultation  is  unsuccessful  (because  the  call  is 
unanswered,  the  patient  is  unavailable  or  the  time  of the  consultation  is  inconvenient),  two 
more attempts at contact will  be  made  (a  maximum of three) within the  period  up to  six weeks 
following  discharge.  Attempts  to  contact  the  patient  must  be  made  at  different  times  of  the 
day  (e.g.  am  and  pm  on  the  same  day)  and  the  three  attempts  at  contact  must  be  spread 
across  at  least  two  consecutive  days.  However,  if  the  patient  declines  a  consultation  at  the 
first  point  of  contact  by  telephone,  no  further  attempts  to  conduct  the  consultation  are 
required. 

Escalation Procedures 

Pain Score 

0  No  pain 

1  Mild  pain 

No  action  required 

No  action  required,  if pain  gets worse  advised  to contact hospital 

2  Unpleasant pain 

o/p review  by health  care professional 

3  Severe  pain 

o/p review  by health  care professional 

4  Worst imaginable  pain 

o/p review  by health  care professional 

Wound  Care 

•  Clean  and  dry 

No  action  required 

•  Redness  around  wound  no oozing of blood or 

o/p  review  by health  care  professional 

other discharge 

•  Redness  around  wound  and  oozing  of blood or 

o/p  review  by health  care  professional 

other discharge 

Return to normal activities 

Any problems  with  return  to normal  activities 

o/p review  by health care  professional 

Telephone Consultation  Format 

a.  Answer-phone 

If the phone rings  into answer phone, do  not leave  a message,  but call  back  another time 
(if less than three attempts to conduct the consultation  have been  made). 

CLINI 07 
Issued by:  Clinical Governance Director  Next Review: January 2023 

Issue Date: January 2020 

Issue no:  12 

Page  18 of 32 

 Outpatient Telephone Assessment Protocol 

Appendix 4 

b.  Someone else answers 

Hello,  is it possible to speak to Mr/Mrs...................... (include first name and surname) 

If no:  state  name  and  inform that you  will  phone  back at another time  (if less than three 
attempts  to  conduct  the  consultation  have  been  made).  It is  not  appropriate  to 
ask  for a  convenient  time,  as  the  person  answering  the  phone  may  ask  what  the 
call  is  about  and  it  is  not  in  the  patient's  interest  to  discuss  this.  If  the  person 
who  answers the  phone  presses for an  explanation,  ask them to inform the patient 
that {your name} called  and  that you  will  phone back at another time. 

If yes:  continue  conversation  with  patient (see  below) 

c.  When contact is made 

Hello,  is  that Mr/ Mrs............................... (include just surname) 

It's .................... ,  a member of the nursing team at (hospital name),  ringing as  we 
agreed,  is it all right to  talk? 

If no:  negotiate a convenient time to call  back 

If yes:  continue conversation 

Please  can  you  tell me your full name?  And what is your date of birth? 

•  If either is  NOT CONFIRMED:  come  out of assessment and  check  patients details 

against notes again  and  confirm address and telephone number. 

Please  can  you confirm  the password we  agreed with  you before  your discharge. 

•  If NOT CONFIRMED:  explain  that in  order to  maintain  patient confidentiality,  you  need 
to be  sure of the  identity of the  person  you  are  taking  to and  discontinue assessment. 
A face  to  face  outpatient follow-up will  need  to be  arranged  for these instances. 

•  If CONFIRMED:  (continue with  assessment) 

Pain  score using O - 4  pain  scale 

Firstly,  I  would  like to know  if following your procedure you  have been  comfortable. 

If the  patient answers no then ask the detailed question  below. 

I  need to ask you  some  questions  about any current pain  from your operation  site.  Would 
you  describe your pain  at the present time as: 

0 

1 

2 

3 

4 

No  pain

Mild  pain

Unpleasant paint 

Severe pain 

Worst imaginable pain 

If the  patient answers 0  (for example), there is no  need  to describe the scale  in  full. 

CLINI 07 
Issued by:  Clinical  Governance Director  Next Review: January 2023 

Issue Date: January 2020 

Issue no:  12 

Page  19 of 32 

 Outpatient Telephone Assessment Protocol 

Appendix 4 

Secondly, I  need  to ask you  about your surgical  wound.  How would  you  describe  it at 
the moment? 

•  Clean  and  dry 

• 

• 

Redness  around  wound  no oozing  of blood  or other discharge 

Redness  around  wound  and  oozing  of blood  or other discharge 

Finally,  I  need  to ask you  about returning  to normal  activities.  Since  your operation, 
have you  been  able to return  to work, start driving  again  and  undertake other everyday 
activities such  as  shopping? 

Do  you  have any other concerns  or questions? 

That  is the end  of the consultation.  I  am  happy to discharge you, if you  have any 
problems  in  the future  please contact your GP. 

Or 

Describe  alternative next steps. 

Thank you  for your time. 

CLINI 07 
Issued by:  Clinical Governance Director  Next Review: January 2023 

Issue Date: January 2020 

Issue no:  12 

Page 20 of 32 

 Outpatient Telephone Assessment Protocol  - Patient /  GP  letters 

Appendix 4 

{Patient Letter} 

Dear 

Re:  Telephone Follow Up Appointment 

As  part of your ongoing  care  following  your surgery  at .........  Hospital  you  were to be  contacted 
by  telephone.  On  three  separate  occasions  I  have  telephoned  your  number  and  have  been 
unable to make contact with  you. 

Your Consultant and  GP  have been  made aware of this. 

From  /  /  please  contact  your  GP  if you  have  any  further  queries.  In  the  meantime,  please 
contact me on  the above number if you  should wish  to discuss this further. 

Yours sincerely 

{GP Letter} 

Dear 

Re:  Patient Details 

The  above named  patient was  to  be  followed  up by telephone following  their .............................. 
surgery  at.........  Hospital.  I  have  been  unable  to  contact  this  patient  on  three  separate 
occasions,  including  the  date  and  time  we  agreed  with  them.  I  have  not  made  any  further 
appointments and  have sent a letter to the  patient informing them  of the above. 

From  /  /  the  patient has been  advised  to contact you  if they have  any further queries. 

Should you  be  aware of any changes  in  the  patients circumstances or require  any further 
information  please  do not hesitate to contact me on  the above number. 

Yours sincerely 

CLINI 07 
Issued by: Clinical Governance Director  Next Review:  January 2023 

Issue Date: January 2020 

Issue no:  12 

Page  21 of 32 

 Outpatient Telephone Assessment Protocol - Patient Information 

Appendix4 

Telephone Follow Up Appointment 

As  part  of  your  care  following  your................................. surgery,  you  will  be  followed  up  by 
telephone.  The  phone  follow-up  service  has  been  set  up  for  patients  like  you  who  require  a 
follow-up  appointment which  does not need  to  be  at the hospital  outpatient department. 

The follow  up appointment has been  made for you  on  .................. (date)  at........... (time). 

The  call  will  be  made  by  a  member of our nursing  team.  So  that  we  can  respect  your  right  to 
privacy,  we  will  provide  you  with  a  "password"  before  your  discharge  from  hospital.  Please 
keep this safe  as  we  will  need  to confirm  it with  you  at the time of the  follow-up phone call. 

Examples  of the questions you  will  be  asked  during the  phone  call  include: 

•  How would  you  rate your level  of pain  (from  your surgical  site)? 

•  How would  you  describe your surgical  wound? 

•  Have you  been  able to return  to your normal  activities such  as  driving, working  and 

shopping? 

Please  think about your responses to these  questions  prior to the call  to  enable  time to discuss 
any issues  you  may have. 

If you,  or the  nurse,  are  worried  about  any  problems,  you  may  have  to  attend  an  outpatient 
appointment  at the  hospital  to  undergo  further tests  or treatment.  If this  is  the  case,  we  will 
inform your GP of the outcome of the call. 

Should  you  have  any problems prior to your telephone  appointment please  contact the  hospital 
on  tel:  ............................. 

Please  inform  the  hospital  of  any  changes  in  your  personal  details  prior  to  your  follow-up 
appointment,  including  changes to your telephone number. 

If you  are  unavailable  to  talk  at the  time  of your telephone  appointment,  we  will  contact  you 
again  (up to three times) to conduct the assessment. 

CLINI 07 
Issued by:  Clinical Governance Director  Next Review: January 2023 

Issue Date: January 2020 

Issue no:  12 

Page 22 of 32 

 PATIENT TRANSFER VARIANCE SHEET 

Appendix 5 

I PATIENT TRANSFER 

Use one side  per variance

Patient is  to be transferred to another hospital due  unpJanned circumstances. 

Date 

Time

VARIANCE  OR PROBLEM

Give  brief detail of reason for transfer here and 
continue to document below and over page asrequired. 

ADDRESSOGRAPH 

Please  note:  All  patient  unplanned  transfers  are 
reportable  incidents.  An  adverse  event/  near 
miss form must be completed. 

In addition, a  designated member of senior 
clinical staff must contact the establishment 
where the patient has been  transferred on a 
daily basis  and the enquiry must be documented 
in  the patient record (see page 3). This contact 
must be  continued until the  patient is  deemed 
"safe" or out of critical danger 

The following detail is  required for audit. 

The patient is to be transferred to: 

the  NHS  Another independent  provider 

The patient is to transferred to: 

critical  care level  2 

critical  level  3 

other ward/unit (not level  2  or 3 care)

Please indicate the MAIN reason  for the transfer: 

Unplanned  transfer to  ITU

Unplanned  transfer to HDU

Unplanned  transfer for Inpatient treatment

Unplanned  transfers due to Consultant request where  no  other reason  is indicated

Other (please  state): 

Time of actual transfer: 

Who has authorised the transfer? 

How is the patient being transferred: 

By 999 ambulance 

By  private ambulance  (paramedic crew) 

By  private ambulance (non-paramedic crew) 

other (please  give details)

Where is the patient being transferred to? (Give  hospital and  unit/ward) 

Who is escorting the patient?  (Name,  profession  and  qualification) 

Observations and vital signs recorded  prior to transfer:  (use space  below  if required) 

CLINI 07 
Issued by:  Clinical Governance Director  Next Review: January 2023 

Issue Date: January 2020 

Issue no:  12 

Page  23 of 32 

 PATIENT TRANSFER VARIANCE SHEET 

Appendix 5 

I PATIENT TRANSFER 

Use one side per variance 

Patient is to be transferred to another hospital due unnlanned circumstances 

Name and signature of person completing this sheet: 

Date 

Time 

Variance /  Problem 

I 

Addressograph 

Date 
&time 

Report /  Action 

Sign 

Outcome/Progress Evaluation 

Sign 

Date 
& 
time 

Variance/ problem  resolved: 

Yes/ No  (if no continue on another sheet) 

CLINI 07 
Issued by: Clinical Governance Director  Next Review: January 2023 

Issue Date: January 2020 

Issue no:  12 

Page 24 of 32 

 PATIENT TRANSFER VARIANCE SHEET 

Appendix 5 

I PATIENT TRANSFER 

Use one side per variance 

Patient is to be transferred to another hospital due unplanned circumstances. 

Date 

Time

Variance /  Problem

Record  of daily contact with accepting 
hospital to monitor patient progress 

Addressograph 

Date 
&time 

Report /  Action 

Sign 

Outcome/Progress Evaluation 

Sign 

Date 
& 
time 

Telephone call 
made to 
accepting 
hospital to 
monitor patient 
progress 

Telephone call 
made to 
accepting 
hospital to 
monitor patient 
progress 

Telephone call 
made to 
accepting 
hospital to 
monitor patient 
progress 

Variance/ problem  resolved: 

Yes /  No  {if no continue on another sheet) 

CLINI 07 
Issued by: Clinical  Governance Director  Next Review: January 2023 

Issue Date: January 2020 

Issue no:  12 

Page 25 of 32 

 PATIENT TRANSFER VARIANCE SHEET 

Appendix 5 

I PATIENT TRANSFER 

Use one side per variance 

Patient is to be transferred to another hospital due unplanned circumstances. 

Please continue overleaf if required 

Date 

Time 

Variance /  Problem 

Addressograph 

Date 
&time 

Report /  Action 

Sign 

Outcome/Progress Evaluation 

Sign 

Date 
& 
time 

Variance/ problem  resolved: 

Yes  /  No  (if no continue on another sheet) 

CLINI 07 
Issued by: Clinical Governance Director  Next Review: January 2023 

Issue Date: January 2020 

Issue no:  12 

Page 26 of 32 

 INTER-HEALTHCARE  INFECTION  CONTROL TRANSFER FORM 

Patient/Client details:  (insert label  if available) 

Consultant : 

Appendix 6 

Name: 

Address: 

NHS Number: 

Date of Birth : 

Receiving facility - hospital, ward, care home, 
district nurse 

Contact no. : 

Is the ICT /  ambulance service 
aware of transfer? 

Yes/ No 

GP: 

Current patient /  client location : 

Transferring facility - hospital, ward, care home, 
other: 

Contact No.  : 

Is the ICT aware of transfer? Yes/ No 

Is this patient /  client an infection risk? 

Please tick most appropriate box and give confirmed 
or suspected organism 

Confirmed risk 

Confirmed risk 

Confirmed risk 

No known risk

Organism:

Organism:

Organism:

Patient /  client exposed to others 

with infection e.g. D&V 

Yes/ No 

If patient /  client has diarrhoeal illness, please indicate bowel history for last week : 
(based  on  Bristol stool form  scale) 

Is the diarrhoea thought to be of an  infectious nature? Yes  /  No 

Relevant specimen results (including admission screens - MRSA, glycopeptide-resistant enterococcus 

SPP, C.  difficile, multi resistant Acinetobacter SPP)  and treatment information including antimicrobial 

therapy: 

I s,ec,mee  • 

Date: 

Result  : 

Treatment information : 

Other information : 

Is the patient /  client aware of their diagnosis /  risk of infection? 

Does the patient /  client require isolation? 

Yes/ No 

Yes/ No 

Should the patient /  client require isolation, please phone the receiving  unit in advance 

Name of staff member completing form : 

Print Name: 

Contact No. : 

For further advice, please contact your infection control team /  adviser 

CLINI 07 
Issued by: Clinical Governance Director  Next Review: January 2023 

Issue Date: January 2020 

Issue no:  12 

Page 27 of 32 

 FRAMEWORK FOR MANAGING  PHONE CALLS  FROM 
CONCERNED  PATIENTS 

Appendix 7 

1.  Establish  rapport with the caller 

• 

Introduce yourself to the caller and  advise them on  the direction the call  will take 

•  Establish  who  is on  the phone - patient,  relative, third  party,  e.g.  nursing home 

•  Rule out any critical  signs  requiring  immediate intervention 

2.  Once,  critical  signs  have been  ruled  out, establish  reason for the call 

•  What has  led the patient to call? 

• 

If the  patient is  not calling  themselves,  ask to speak to them  in person 

•  What has changed  and  what is  their norm? What makes their symptoms better or 

worse? 

•  Take a brief account of the enquiry,  using the  patient's reported  words wherever 

possible. 

•  Rule  out any concerning  signs  requiring  the patient to attend the hospital  for clinical 

assessment by  a senior nurse or RMO 

3.  Once  concerning  signs have  been  ruled  out.  consider involving the RMO and the 

patient's consultant 

•  Reflect  information  gathered back to caller /patient to ensure that you  have picked 

up the correct information 

4.  Recommendations 

• 

Involve caller/patient in  your decision  making: 

•  Discuss  outcome  with  caller/patient and  gain  agreement for decision. 

•  Explain  rationale for the  decision  you  have reached 

5.  Provide worsening statement 

6.  Complete the post-discharge call  record sheet in full  for each and every call where 

advice is  provided. Sign, date and  time. 

7.  Notify Consultant of contact from patient if advice has not already been sought. 

CLINI 07 
Issued by:  Clinical  Governance Director  Next Review:  January 2023 

Issue Date:  January 2020 

Issue no:  12 

Page  28 of 32 

 POST-DISCHARGE CALL  RECORD SHEET (Incoming Calls) 

Appendix 7 

Please follow each step in  order as it is set out in this form 

Are you  a qualified  nurse  with  at least 6  months experience in  post  D  Yes  D  No 
Have  you  successfully completed  a competency assessment in  managing  post-discharge calls  D  Yes  D  No 

To  proceed  further you  must have  answered "Yes" to  both  of the questions above.  You  must otherwise  pass 
the call  to a more experienced  colleague. 

Date .............................. . 

Caller name: .................................................................................. 

Time ........................... .. 

Patient 

state relationship below) 

Patient's name:....................................................................  Date  of Birth: ........................................................ . 

Telephone  number: ................................................................  Consultant: ............................................................ 

Why  are  you  calling? 

Is the  patient 
reported  to be 
experiencing  any 
of these critical 
signs? You  must 
specifically  ask 
each  question. 

Unconsciousness  or altered  consciousne 
Sudden  onset chest pain  suggesting  an  acute cardiac episode 
Facial  weakness;  arm weakness;  slurred speech 
Shortness of breath;  difficulty breathing 
Acute  and  severe trauma,  including  head  injury 
Heavy uncon 
Sudden  loss of vision  following  ophthalmic surgery 
Pain  score 4  despite  prescribed  analgesics 

(please state below) 

- symptoms suggesting a stroke 

P.9.t~.~x. .~.9.!1~.i.\!\?!"!..Y.\?~..
If any apply advise caller to dial 999 to request an emergency ambulance 

!!!Y.~..!~.!!f.~..t.~.r!i.1:l.t!in.i.!19.................................................. . 

Date  of admission:  ................................................  Date of discharge:  .......................................................... . 

Details of original  admission  (e.g.  procedure performed): 

Please  describe the enquiry in  more detail  using the patient's reported  words wherever possible 
(e.g. "it's a sharp stabbing  pain") Please  continue  on  a separate sheet if necessary,  using a patient 
address label: 

·················•·•········································································································································································· 

., ........................................................................................................................................................................................... . 

................................................................................................................................................................................................ 

............................................................................................................................................................................................. 

CLINI 07 
Issued by:  Clinical Governance Director  Next Review: January 2023 

Issue Date: January 2020 

Issue no:  12 

Page 29 of 32 

 
 
 Is the  patient reported to 
be  experiencing  any of 
these  concerning  signs? 

A 

endix 7 

Any  unwell  child 
Pain  score  2/3 despite  prescribed  analgesics  (including severe headache) 
Calf pain;  tenderness  and  swelling  of the leg;  skin  discolouration that is 
pale,  blue, or a  reddish-purple  colour - symptoms indicating a  deep vein 
thrombosis 
Prolonged  vomiting and/ or diarrhoea 
Acute  urinary symptoms including  retention 
Unusual  chest  pain  but not crushing 
Persistent surgical  site  bleeding 
Abdominal  pain  not associated  with  primary surgery 
Escalating  wound  pain,  swelling, inflammation or discharge 
Fever and/or escalating  malaise 
Difficulty swallowing 
Confusion  or disorientation;  repeated  episodes  of dizziness 
Repeated falls 
Patients  receiving  chemotherapy treatment with an  elevated temperature 
Other condition  you  believe  is  particularly concerning  (please  state below) 

If any apply advise please ask the patient to attend the hospital for 
clinical assessment by a  senior nurse or RMO 
You  may give the  patient advice  provided  the advice you  give is within your professional  scope  of practice 
and  current  knowledge.  Please  summarise the advice given: 

Was the Consultant contacted  for advice BEFORE  patient attends hospital? 

No  D  Yes  (Please state below advice given by Consultant): 

Date and time of call  to consultant: ........ /  ........ /  20 ....... 

If the Consultant was not contacted  before advising the patient, please make sure the 
Consultant is notified that their  atient has called and what advice has been given. 

Final  disposal 

Follow  up call 

999 Ambulance 
Attend  hospital  immediately for review  (attach  records) 
Advice  given  and  patient to attend  hospital tomorrow morning for revieN 

( attach  records) 

Advice  given and  follow-up  call  required  within  24 hours 

D  Advice  given and  advice to be  peer reviewed  by senior nurse within  24 
hours 
D  Advice  given and  patient advised to call  back if problem persists 
n  Advice  given and  no further interventions  required 
D  other disposal  (please state 
below) .................................................................................................................................. . 

Date:  .............................  time: 

Have  symptoms  resolved  CJ Yes  CJ No 
Test results  given 
Treatment advice  given 
Advice  given  and  patient to attend  hospital  for review 
Advice  given  and follow-up  call  within  24 hours 
other 

CLINI 07 
Issued by:  Clinical  Governance Director  Next Review:  January 2023 

Issue Date:  January 2020 

Issue no:  12 

Page 30 of 32 

 I Signature: ........................................................................... . 

Date:  .............................  time:  ......................... . 

Appendix 7 

CLINI 07 
Issued by: Clinical Governance Director  Next Review: January 2023 

Issue Date: January 2020 

Issue no:  12 

Page 31 of 32 

 CLINI 07 
Issued by: Clinical Governance Director  Next Review: January 2023 

Issue Date: January 2020 

Issue no: 12 

Page 32 of 32 

 SPIRE HEALTHCARE 

Spire  Healthcare 

Ref: 

Clinical Poli<:y 18 

Issued By: 

Clinical Governance 
Director 

Approved By: 

Policy Approval Group 

Date: 

January 2020 

RMO  HANDBOOK 

Applies to sites: 

All hoi;;pitals 

Applies to staff 
groups: 

RMO's, SMT, Clinical HOD's 

RMO  HANDBOOK 

CONTROLLED  DOCUMENT 

Clinical Policy 18 
Issue: 11 
Issued by: Clinical Governance Director 

Issue Date: January 2020 
Next Review: January 2023 

Page 1  of 13 

 1.0  INTRODUCTION 

Welcome  to  Spire  Healthcare.  We  hope  that  you  will  enjoy  working  as  part  of  the 
If  you  have  any  problems  whilst  you  are  here,  please  do  not 
multidisciplinary  team. 
hesitate to bring  them to  Matron's/ Clinical  Service  Managers  attention. 

The  RMO  handbook  is  intended  to  give  a  brief overview  of the  hospital  and  those  policies 
and  procedures which  are the most relevant and  essential  to the role. 

Our prime concern  is for the safety of patients and  the policies  are in  place  to  protect both 
patients and staff.  Please  familiarise  yourself with them to avoid  any compromise. 

Matron  or a  senior  member  of the  clinical  team  will  greet  you  early  in  your  first  week  to 
introduce you  to all  heads of departments 

2.0  SPIRE  HEALTHCARE  THE  ORGANISATION 

Spire  has  37  hospitals  in  the UK  group  and  over 5000 of the  UK's  best consultants working 
in  hospitals - this  leads to 'centres for excellence' and  specialties for different hospitals. 

3.0  GENERAL  INFORMATION 

3.1  Appraisal/ Mentor 

You  will  be  assigned  a mentor who  either is  a  member, or has been  assigned  by  a member 
of the Medical  Advisory  Committee (MAC).  The  objectives of the  MAC  are: 

•  To  provide  a  forum  for  members  to  discuss  issues  affecting  the  hospital  and  its 

facilities. 

•  To  agree,  implement  and  monitor  measures  designed  to  facilitate  the  delivery  of 

appropriate and  effective  patient care. 

•  To  monitor  and  review  clinical  services,  providing  advice  to  the  hospital  Matron  as 

appropriate. 

•  To  provide  a  forum  for  educational  activities  for  members  and  to  assist  in  ensuring 

compliance  with  the new regulatory  environment. 

You  will  meet  with  your  mentor  and  Clinical  Services  Manager  on  a  quarterly  basis,  i.e. 
every  3  months,  regarding  your  progress  and  any  issues  or  concerns.  An  appraisal 
document will  be  completed.  One  copy  will  be  left in  the  hospital  and  another sent to the 
agency. 

Monthly  meetings  will  be  held  with  Matron  or a  designated  senior  member  of the  clinical 
team  to  discuss  incidents,  accidents,  clinical  issues  and  concerns.  At these  meetings you 
can  discuss  opportunities for observing  in  theatre. 

3.2 

Induction 

Using  the  checklists  at  appendix  lA and  1B,  an  induction  will  be  completed  and  retained 
as  a record  of compliance. 

3.3  Catering 

The  staff  dining  room  is  open  at  all  times  for  tea  and  coffee.  Please  check  with  the 
Facilities  Manager for usual  times for serving  meals 

You  will  not  be  charged  for meals whilst  on  duty.  Therefore  day  duty  includes  lunch  and 
dinner,  night duty includes breakfast only.  You  may need to pre-book your meal  order. 

Clinical  Policy  18 
Issue:  11 
Issued by:  Clinical Governance Director 

Issue Date: January 2020 
Next Review: January 2023 

Page  2 of 13 

 3.4  Do's and don'ts 

Do  wear smart clothes. 
Hospital  'scrubs' (theatre clothing) may be  worn  outside of the theatre department (at 
local  hospital  management  discretion).  Night-shift  RMO's  may  wear  scrubs  so  that 
they can  attend an  emergency immediately 

Do  wear a disposable apron  if performing  a clinical  task 

Do  wear identification 
Do  always introduce yourself formal!y to patients. 

Do  wear your bleep. 

Do  answer your bleep promptly. 
Do  always hand  over to the next RMO  all  patient conditions and outstanding work. 

Do  inform  Matron  of any anticipated  personal  visitors. 

Do  liaise  with  Matron  or designated  senior member of the clinical  team at least weekly 
- no appointment necessary. 
Do  enter documentation  in  patient  notes  and  remember  to  sign,  date  and  time  these 
entries 

x  Don't  keep  problems  to  yourself  -
member of the clinical  team. 

raise  concerns  with  Matron  or  designated  senior 

x  Don't leave the hospital  when  on  duty. 

3.5  Housekeeping 

The  bedroom  used  by the  night-duty  RMO  will  be  cleaned  by  housekeeping  staff who  will 
liaise to arrange a suitable time for this and this will  probably be  done twice  weekly. 

Please  note  that  all  private  telephone  calls  are  logged  as  you  are  liable  for  any  calls  you 
have made.  Calls  relating  to patient care  should  be  made  via  the ward  telephone. 

3.6  Mail 

Mail  will  be  left  at  main  reception  for  you  to  collect  or  within  a  designated  mail  box  / 
'pigeon-hole' 

3.7  Operational Policies 

You  must familiarise  yourself with  all  operational  policies  which  will  be  made  available  via 
Matron.  It is essential  that you  read  and  become familiar with  the following  without delay: 

•  Clinical  02  Control  of Infection  Manual 
•  Clinical  08  Patient  Records 
•  Clinical  12  Resuscitation  Policy 
•  Clinical  13  Management of Medicines 
•  Clinical  42  Chaperone  Guidelines 
•  FIN  03 
•  FIN  05 
•  HOP  03 

Policy  for Risk Assessment 

Duty of Candour Policy 

•  HR  04 

Health  and  Safety  Policy 
Confidential  reporting  of  concerns  by  staff  in  the  workplace  -
blowing' 

'Whistle 

In  addition,  the  RMO  section  of the  clinical  intranet  contains  other  guidelines  which  you 
must also  read  within  your first 48 hours: 
•  Spire Healthcare Confidentiality Policy and  Guidelines 

•  Spire  Healthcare  Data  Protection  Guidelines 

•  NES  Complaints Policy  (For RMO's  contracted  by  NES) 

Clinical  Policy  18 
Issue:  11 
Issued by: Clinical Governance Director 

Issue Date: January 2020 
Next Review: January 2023 

Page 3 of 13 

 3.8  Training /  Teaching 

If you  would  like  to  participate  in  teaching,  please  liaise  with  Matron  /  Clinical  Services 
Manager. 

4.0  RMO  DUTIES 

This  is  a  demanding  position  responding  to  many  requests  from  different  areas.  This  is 
expected  throughout  the  24hour  period.  Although  activity  is  obviously  quieter by  night  it 
should  be  noted  that  night  shift  is  a  working  shift  and  you  are  required  to  respond  to 
requests  in  professional  and  timely manner. 

4.1  Cardiac arrest/ Emergency 

•  You  must carry your pager at all  times. 

•  If an  arrest/ emergency occur within  the hospital,  you  and  the  emergency team  will  be 

contacted  via  the bleep  system. 

•  The  emergency  tone  will  sound  and  the  location  of the  arrest  will  be  displayed  or the 

pager will  speak the location. 

•  Crash  trolleys  are  located  in  various  areas  of the  hospital.  You  must  be  aware  of the 

location  of these trolleys. 

•  Please  note  that  the  nursing  staff  will  request  that  the  RMO  makes  a  medical 

assessment of any  patient scoring  4  or above. 

4.2  Medical  Certificates 

You  may be  requested  to sign  a  medical  certificate for patients on  discharge. 

4.3  Pain Control 

Pain  control  is  vital  to  good  patient  care.  You  need  to  be  aware  of  PCA  pumps  and 
Epidural  protocols - recovery staff can  assist you  with  any training  issues. 

4.4  Documentation 

• 

• 

• 

• 

• 

• 

• 

• 
• 

Please  ensure you  are familiar with  the GMC's  guidelines for good  record  keeping 

An  entry  must  be  made  into  the  medical  records  of  each  patient  every  time  an 
assessment  is  made  or  a  procedure  undertaken.  This  would  include  for  example 
changing  a venous cannula,  inserting a  catheter or attending the ward  round 

The  notes  should  be  accompanied  by  date,  time,  signature,  printed  name  and 
designation  in  black ink 

Each  inpatient  must,  as  a  minimum,  be  visited  once  a  day  and  a  medical  record 
entry made.  A  patient list can  be  obtained  from the ward  clerk 

Please  inform  the  Duty  Sister  or  the  patient's  nurse  when  changes  are  made  to 
treatment 

Patients  with  comorbidities  and  abnormal  blood  results  must  have  a  referral  for 
anaesthetic review prior to admission  fully documented in  the medical  records 
All  call  backs to the  hospital  post discharge and  advice given  must be  documented  in 
full  in  line  with  policy 
All  clinical  patient reviews  must be  documented  in  the  patient's medical  records 
Consultants  must be  informed  of patients if any  concerns  and  this fully  documented 
in  the  medical  records 

Clinical  Policy 18 
Issue:  11 
Issued by:  Clinical Governance Director 

Issue Date: January 2020 
Next Review: January 2023 

Page 4  of 13 

 • 

Where the clinical  notes of the  patient are  unavailable the documentation  is  held  in  a 
designated  folder  /  temp  set  of notes  and  sent  to  medical  records  to  be  included  in 
the  medical  file  of the  patient 

Death  Notification 
• 

The  Consultant  will  usually  complete  this  and  the  documentation  is  available  on  the 
ward 

Clinical Incident/Accident form 
• 

If an  accident  or  clinical  incident  occurs  with  a  patient  or member of staff and  you 
are  called  to  assist  then  you  will  need  to  participate  in  the  completion  of the  online 
Datix  form.  Please  ensure  you  meet  with  the  Clinical  Governance  Lead