Network repatriation protocol

• The policy will ensure that all patients are repatriated to their local health care provider when they are medically fit for transfer or have completed specific treatment at one of the MTCs.
• It will ensure that all relevant parties are aware of their specific roles and responsibilities; and prevent delays to patient transfer.
• It will provide clear guidance for action and escalation when there are delays in the repatriation process.

The South East of Scotland Major Trauma Network service requires clear guidelines for:

• The repatriation of patients from the Major Trauma Centre (MTC) at Royal Infirmary of Edinburgh (RIE) and Royal Hospital for Children and Young People (RHCYP) to Trauma Units (TU) within the region.
• The repatriation of patients from the Major Trauma Centre at RIE and RHCYP to community services. 
• The repatriation of patients from the Major Trauma Centre at RIE and RHCYP to Hospitals and Facilities out of area.
• The repatriation of non South East of Scotland residents from the Major Trauma Centre at RIE and RHCYP to Trauma Units within their residential area.
• The repatriation of South East of Scotland residents being cared for outside of the region in other Major Trauma Networks back to the South East of Scotland.

Repatriation refers to a patient returning to a centre that is local to them once specialist treatment has been completed in the MTC and they are able to complete their in-patient stay at a local TU closer to home.  Alternatively, it also refers to a patient that has been admitted to an MTC in another region or even another country returning to the South East of Scotland region.

Effective repatriation will maximize bed availability and thereby maximize accessibility of specialist services.  Unnecessary delays can be both inconvenient and distressing for patients and relatives. Swift repatriation will also allow TUs to arrange Social Care packages and access to local community services for the patient locally prior to discharge. Repatriation must occur in a timely manner to ensure the best use of bed capacity across the region and allow for patient recovery in a Unit closer to home.

This policy is activated once the lead clinician involved in the patient’s care has concluded that either:

• Specialist care in a South East of Scotland MTC is no longer required and the best interests of the patient would be to continue as an in-patient at the TU local to them or;
• Medical care is still required but the interests of the patient and their family would be for that to be closer to their place of residence e.g. repatriation from another Regional Major Trauma Network or another country.

Once the decision to repatriate a patient has been made then the patient should be transferred within 48 hours.

The Policy recognises that for patients being repatriated from other Major Trauma Networks around the country to the South East of Scotland transfers will be facilitated by the MTC who is responsible for arranging a direct transfer to the most appropriate site within the Network.

Appendix 2 referred to in the above image can be viewed here.

• The MTCs are committed to providing care to major trauma patients who may bypass TU or local hospitals. As such, it is critical that there is a robust and reliable process for repatriation to other hospitals within the region.  As such, a principle of automatic acceptance for repatriations should be approved by the regional TUs who will be responsible for co-ordination of the repatriation of the patient to the relevant area within their Health Board.
• Once the lead clinician involved in a major trauma patient’s care, in conjunction with the multidisciplinary team (MDT) has made the decision that care in the MTC is no longer required but a further in-patient stay is necessary before discharge then it is their responsibility to refer (or delegate referral) to a local Trauma Unit.  This must take into account suitability of the Trauma Unit to provide the required care and rehabilitation.
• Each Regional Trauma Unit and MTC will nominate a single point of contact (SPOC) to whom all referrals will be made.
• Referrals can be made between the hours of 9am – 5pm, 7 days a week and must be accepted by the responsible SPOC.
• All referrals should result in a transfer within 48 hours.  It is the responsibility of the SPOC to make a referral to the relevant most appropriate clinical team within the TU and facilitate a handover between the teams.  If the receiving team believes they are not the appropriate team for a transfer then it is the responsibility of the receiving SPOC to facilitate identification of the correct team.  This should not delay transfer.  The referrals are to be automatically accepted and there is no scope for rejection of a referral in the same way there is automatic acceptance of trauma patients into the MTC.
• The MTC should complete the Trauma Rehabilitation Prescription / Plan document a detailed handover to be sent with the patient prior to transfer.
• Where possible, the referring clinical team at the MTCs should attempt to identify possible future repatriations and be in contact with the Trauma Unit SPOC to allow for planning.  This would not trigger the 48 hour transfer rule but allow the Trauma Unit time to prepare for when the formal referral is being made.
• Transport must be requested by the transferring MTC as soon as a bed has been allocated by the receiving Board.
• All requests for Scottish Ambulance Transport must be made as soon as possible.  The Scottish Ambulance Service cannot guarantee same day transport for short notice requests.

• Transferring patients directly to the regional TUs from outside of the region may prove to be difficult due to differing services across the region and lack of clear policy for inter-regional transfers.
• All referrals for major trauma patients from outside of the region, including all centres in Scotland and outwith should be made to the regional MTCs and not directly to a TU.  The Regional MTCs will then be responsible for co-coordinating the ongoing management across the Region.
• For all referrals, the same principle of automatic acceptance and 48 hours transfer target is maintained, however it is recognized that negotiations with the healthcare systems in other countries maybe somewhat protracted.  Furthermore, where an insurance company is part of the process this may increase delays further, therefore, where possible, it is beneficial to undertake both parts of the process in unison.
• MTCs and TUs will have a single point of contact (SPOC) to whom all repatriations will be discussed. The switchboards of the MTC are to be made aware of the SPOC.

• Transferring patients from MTCs in the South East of Scotland to areas outwith the region will be managed in the same way as 'Repatriation from South East of Scotland MTCs to regional boards' described above.

• Specialist Rehab Units within Community Services will require to be managed differently.

• All referrals are to be made by the Major Trauma Centre Single Point of Contact to the Trauma Unit Single Point of Contact between the hours of 9am – 5pm, 7 days per week.
• The same day the Major Trauma Centre makes the referral they must also be informed of the receiving Consultant and Specialty.  If this does not happen then this must be escalated as per the diagram below.
  
  • If bed allocation has not occurred within 12 hours then the Site Senior Manager is to be informed.
  • If bed allocation has not occurred within 24 hours then the Site Director is to be informed. 
  • If bed allocation has not occurred within 48 hours then the Site Executive Director must be informed.
• If transport is requested but does not arrive the appropriate escalation policy must be followed.

•   Where the timescales outlined in the policy are not met details of the receiving hospital and specialty, along with the reason for the reason for the length of delay, will be held within the MTC senior management team.  Where recurrent problems are encountered, the referring Hospital will be provided with this information and asked to implement appropriate action to prevent further delays.  In some cases this information will be forwarded to specialist network teams for comment.
• Where frequent delays occur with local Boards, the Chief Operating Officers will address this with their senior management and clinical teams.