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

When the bed pressures are exceptional and to maintain flow of patients to ensure safety of all, it may be necessary to “board” patients to another ward outside the admitting specialty. We do not take this decision lightly. On an individual and organisational level, we know boarding carries worse outcomes.

Evidence shows:

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

All of this places further pressures on the system creating further difficulty in keeping people safe.

Purpose

This standard operating procedure is intended to support safe and effective patient flow during periods when inpatient capacity is under pressure.

Scope

Applicable to the BGH, this SOP is intended to provide guidance on boarding of patients (out with the speciality under which they are being cared for), for nursing staff, midwifery staff, medical staff, hospital managers and bed management staff.

Communication

Senior Charge Nurses (SCN), senior medical staff and clinical nurse managers will disseminate this standard operation procedure within their areas of responsibility.

Definitions

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

Precautions

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

At the Daily MDT on all wards:

• An Expected Date of Discharge (EDD) should be documented on Trak.
• Management plan & factors needed for discharge - ideally Criteria Led Discharge (CLD) to ensure timely, safe discharge home.

Suitability for boarding for all patients to be updated daily as part of board round: Red (never), Orange (if pushed) and Green (can board) and why status chosen and by whom documented on Trak on floor plan notes.

For patients needing boarding:

• Completed nursing transfer letter / SBAR on Trak floor plan (+ Print off of notes).
• Inform receiving ward when leaving previous ward. Receiving ward to review patient within 30 minutes of arrival.

Boarding

• Should not be from MAU/ED/AAU.
• Should not occur if marked frailty or cognitive impairment.
• Should only occur between 07.30 – 20.00.

Criteria for boarding patients to Paediatrics (Ward 15):

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

Considerations when boarding patients to Paediatrics (Ward 15):

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

Responsibilities when boarding patients to Paediatrics (Ward 15):

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

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

The host/speciality team will:

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

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

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

NB – SAERS – We need to ensure that any SAERs / Adverse Events that are related to boarding of patients out with their speciality area are reviewed at Q level rather than at service or board level.

Following a meeting held on 22nd January 2010 attended by:

Dr Andy Duncan (HCS for Paediatrics)
Dr Simon Watkin (HCS for Medicine)
Lesley Horsburgh (Senior CN, Paediatrics/SCBU)
Mr Jacques Kerr (HCS for Emergency Medicine)

It was decided that the in-patient management of intoxicated adolescents should be guided by the following protocol. After further review (2017, 2019) this protocol remains as follows:

• Any young person, regardless of age, must be initially managed according to Advanced Paediatric Life Support and European Paediatric Life Support protocols; where the child / young person has any compromise of airway, breathing or circulation then he or she should be assessed by a senior doctor / APNP from paediatrics and anaesthetics and be admitted to an appropriately staffed high dependency unit, such as ICU. The paediatric consultant will be called to attend if appropriate.
  • Always be mindful of all possible substances taken that are contributing to the intoxicated state and consult TOXBASE to be advised of ongoing management and potential problems that may be encountered.
  • Further advise on novel psychoactive substances that may have been taken and their effects can be found on the Neptune clinical guidelines.

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

• Children aged 13 and under will be admitted to the paediatric ward (15) under the care of the paediatric team.
• Children aged between 14 and 15 should be referred to the paediatric doctor / APNP on call (bleep 6015) who will make a rapid assessment of the child and decide on the most appropriate admission decision. Factors that will be taken into consideration are:
  • Current behaviour; if demonstrated or anticipated aggressive tendencies that are inappropriate to manage on ward 15 where there are younger children present.
  • Developmental age (both mental and physical) of the young person.
  • Previous history (e.g. chronic medical conditions that have necessitated previous hospital admission).
  • Any individual of 16 years or over should be admitted under the care of adult medicine (usually ward 6 / MAU). However, individuals who are well known to the paediatric unit with chronic health conditions and who have not transitioned to adult services should be discussed with the Consultant Paediatrician - On Call prior to an admission decision.

If it is deemed not appropriate to admit the young person to ward 15, the young person will be admitted under the care of paediatrics and boarded to an acute adult ward (usually ward 6 / MAU). There will be ongoing review by the paediatric team until discharge as per the standards for boarding patients out of speciality above.

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

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

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