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Northern Territory Department of Health Library Services Historical Collection
DL HIST 362.11 ROY 1996
HISTORICAL ·, COLLECTION
00177
ADMISSION AND DISCHARGE
POLICY
ROYAL DARWIN HOSPITAL
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ROYAL DARWIN HOSPITAL
ADMISSION AND DISCHARGE POLICY AND eoo· KtNGS TO ELECTIVE SURGERY WAITING LISTS
1 1 FEB 2002 LIBRARY
Total commitment to quality patient care and service delivery through leadership, learning and the involvement of staff.
Endorsed by Hospital Executive Principal Author - Carrol Lynch Date July 1996 Review July 1997
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1.0 INTRODUCTION 11.1 Role of Bed Manager 1
1.2 General Information 1
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2.0 ADMISSION POLICY 22.1 Public Patients 2
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2.2 Private Patients 22.3 Emergency Admissions 2
2.4 Out of Hours.Admissions 3
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2.5 Admissions to Darwin Private Hospital (DPH) 32.6 Aerial Medical Patients 3
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2.6.1 Notification of Pending Admission 32.6.2 Direct Admission 3
2.6.3 Neonatal Cases 4
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3.0 ADMISSIONS GUIDELINES -INTERNAL 43.1 Emergency Department 4
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3.2 Admission to Specialised Areas 44.0 ADMISSIONS GUIDELINES - EXTERNAL 4
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4.1 Intrastate 44.2 Interstate 4
4.3 General Practitioner 4
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4.4 Visiting SpecialistI
5.0 DISCHARGE POLICY 55.1 Discharge Planning 5
5.2 Emergency Department 6
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5.3 Outpatients Department 65.4 Same Day Procedure Unit 6
5.5 Full Care Patient 6
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5.6 Referral to Discharge Planning Nurse 66.0 DISCHARGE GUIDLINES 7
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6.1 Discharge Planning 76.2 Discharge Summaries 7
6.3 Elective Patients 7
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6.4 Discharge Medications 76.5 Discharge to Self Care Centres 8
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6.5.1 Ongoing Care Required 86.5.2 Onging Nursing Care Not Required 8
6.6 Patient Assisted Travel (PATS) Reimbursement 8
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6.7 Weekend Referrals to Community Care Centres 96.8 Updating Patient Information System 9
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7.0 ELECTIVE SURGERY 7.1 Definition of Elective Surgery 7.2 Categories of Elective Surgery
7.3 Elective Surgery Booking Arrangements 7.4 Deferring Elective Surgery
7.5 Theatre Scheduling 7.6 Pre Admission Clinic
7.6.1 Clinical Investigations 7.6.3 Discharge Planning 7.6.4 Bed Availability 7.7 Theatre Lists
7.8 Same Day Procedure Unit Admissions
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1.0 INTRODUCTION
Bed Management at Royal Darwin Hospital has the following priorities:
. First, to provide access for emergency admissions.
. Second, to meet contractual obligations under the Medicare agreemen~ ie., admissions based upon clinical needs.
. Third, to ensure optimum use of human and material resources within budget allocation.
1.1 ROLE OF BED MANAGER
Royal Darwin Hospital has a Bed Management Co-ordinator (Bed Manager) who is responsible for the allocation of all beds.
The Bed Manager disseminates all information relating to the bed status within Royal Darwin Hospital. The Admissions Officer will be notified in the usual manner of all admissions, discharges and transfers.
The Bed Manager provides daily advice on the hospital's bed-state to the Divisional Heads on-call, so that informed decisions can be made regarding the admission of elective patients.
1.2 GENERALINFORMATION
Requests for admission must have estimated lengths of stay entered on the Request for Admission Form (HM 393).
When the demand for emergency beds exceeds availability, the reserved beds may be used as per the Surgical Bed Reservation Policy.
Where a non surgical patient is to be admitted to a surgical bed, the admission must be ratified on a consultant to consultant basis on each occasion.
Beds must not be held overnight for booked admissions due on the following day.
The General Manager has the discretion to purchase beds from Darwin Private Hospital.
Requests for admission from General Practitioners, Nursing Homes or Visiting Medical Officers must be directed to the Director of the Emergency Department between 0800 -1600 hours (Monday - Friday). After hours these requests should be directed to the senior Emergency Department Medical Officer on duty. Beds will be allocated by the Bed Manager during business hours and after hours by the Nursing Resource Consultant.
Notification of cancellation of a procedure will be undertaken by the Bed Man- ager for patients not yet admitted. The Bed Manager will, where possible, give the patient an alternative date for the procedure. If it becomes necessary to cancel a procedure for an inpatient, the Surgical Registrar will be responsible to advise the patient.
2.0 ADMISSION POLICY
2.1 PUBLIC PATIENTS
All public patients are to be seen and assessed by Emergency Department staff except:
a) Maternity cases over 20 weeks gestation and with maternity related conditions
(b) Paediatric patients referred by the Aerial Medical Service.
(c) Inter hospital transfers
Unless a patient seeks to be treated privately he/she comes under the care of Emergency Department Medical Officers who make the decision to refer the patient to the appropriate medical team or send the patient home.
2.2 PRIVATE PATIENTS
At any time a person may elect to be treated privately. If the nominated Specialist is available and has admitting rights to RDH, the request is legitimate.
Every attempt should be made to contact the nominated Specialist. If the patient is accepted as a private patient, he/she is admitted to the ward under that particular specialist. Only urgent procedures should be undertaken by staff in the Emergency Department. The patient is to be advised of a Specialist's decision to visit in Emergency Department.
When a nominated specialist cannot be contacted, the patient is offered status as a public patient. A patient has the right to leave the Emergency Department and make arrangements to contact the specialist privately or through their General Practitioner. It should be explained that admission as a public patient does not preclude a change to private status following admission.
2.3 EMERGENCY ADMISSIONS
Acutely ill and injured patients have a higher risk of morbidity and mortality if left untreated therefore, Emergency admissions take precedence over elective admissions.
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In the event of bed shortages for emergency admissions, elective admissions will be cancelled after consultation with the Surgical Divisional Head and the relevant Consultants.
2.4 OUT OF HOURS URGENT ADMISSIONS
The Senior Medical Officer will liaise with the Nursing Resource Consultant on bed availability. It is the admitting Medical Officer's responsibility to allocate the patient to the care of the appropriate Specialist and notify the relevant Registrar of the admission.
2.5 ADMISSION TO DARWIN PRIVATE HOSPITAL (DPH)
Patients can be admitted to Darwin Private Hospital if they elect to do so and if the Doctor of their choice accepts the admission and has admission rights at DPH. The same protocol for admission to RDH should be followed.
If a patient is to be admitted to DPH the accepting Specialist should notify the Nursing Supervisor at DPH to request bed allocation.
If the patient is well enough they can make their own way to DPH. Where necessary an unwell patient may be escorted to DPH by a Registered Nurse/
Patient Care Assistant from the Emergency Department of ROH.
2.6 AERIAL MEDICAL PATIENTS
Patients may be transferred for urgent admissions from their community by either routine air medical flights or emergency evacuations. Air Med Officers will notify the relevant specialty Registrar that they are transferring a patient to Royal Darwin Hospital.
2.6.1 Notification of pending admission
In all cases the Emergency Department must be advised of details of the impending admission including patient's name, date of birth, Hospital Record Number (if known), diagnosis, community and estimated time of arrival. This information is recorded in the Air Med journal kept within the triage area of the Emergency Department.
2.6.2 Direct Admission
The Medical Officer accepting a direct admission into the wards must contact the Bed Manager during business hours or the Nursing Resource Consultant after hours to request allocation of a bed. The location of the bed will be recorded in the Air Med journal so that the ambulance officers can ascertain the patient's destination prior to arriving at ROH.
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2.6.3 Neonatal Cases
Before neonates are transferred to RDH the Bed Manager during work ing hours or the Nursing Resource Consultant after hours must be advised to ascertain if there are facilities available within Special CareNursery to accommodate the baby.
3.0 ADMISSIONS GUIDELINES - INTERNAL
3.1 EMERGENCY DEPARTMENT
The nurse/ doctor or the reception staff seeking the admission will liaise with the Bed Manager/Nursing Resource Consultant for bed allocation. The admitting medical officer will complete the admission slip including the estimated length of stay and the name of the treating Consultant.
Under no circumstance will the admitting clerk enter an estimated length of stay. In the absence of an estimated length of stay the admission clerk will return the admission slip to the admitting Medical Officer for completion.
3.2 ADMISSION TO SPECIALISED AREAS
Admissions to Isolation Paediatrics, Coronary and Intensive Care Units and the Maternity wards are to follow the appropriate ward admission protocol.
4.0 ADMISSIONS GUIDELINES - EXTERNAL
4.1 INTRASTATE
All patient transfers from intrastate hospitals must be accepted by the relevant RDH Registrar.
Before accepting admissions the Registrar must check bed availability with the Bed Manager or Nursing Resource Consultant after hours.
4.2 .INTERSTATE
NOTE: Any patient requiring ventilation cannot be accepted without first consulting with the Nursing Resource Consultants to ascertain the availability of a ventilator and staff to operate same.
Admissions and transfers from interstate must not be accepted unless the Divisional Head has agreed to accept the admission.
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All admissions must be referred to the Bed Manager or Nursing Resource Consultant ( after hours) for bed allocation before accepting the patient.
4.3 GENERAL PRACTITIONER
Requests from General Practitioners for immediate admission of patients are to 1 be referred to the Director of the Emergency Department (Monday - Friday) or after hours to the Senior Medical Officer on duty in the Emergency Department.
All patients referred by General Practitioners must be assessed by the Emergency Department Medical Officer who will decide if the patient is to be admitted or discharged home. In cases where the patient is not admitted the General Practitioner must be advised by the attending Emergency Department Medical Officer.
4.4 VISITING SPECIALIST
Visiting Specialist will contact the "on-take" Specialist Consultant prior to directing the patient for admission. During business hours the accepting Consultant will advise the Bed Manager of the requirement to admit a patient (after hours the Nursing Resource Consultant).
The Bed Manager/Nursing Resource Consultant will allocate a bed in the receiving ward, then advise the Emergency Department Patient Services Receptionist of the anticipated arrival of the patient and the ward in which a bed has been allocated. Upon the patient's arrival, the ward staff will advise the Resident Medical Officer to admit the patient.
If the admission cannot be delayed for 24 hours the Visiting Specialists will contact the Director of the Emergency Department who will advise the Bed Manager of the request for admission. The Bed Manager will liaise with the Specialist to admit the patient at the appropriate time according to urgency.
DISCHARGE POLICY
5.1 DISCHARGE PLANNING
Discharge Planning is an integral part of planned care for all patients irrespective of whether they are to stay for one day or longer.
In order to allow the Bed Manager/Nursing Resource Consultant to plan admissions ALL full care patients, except those awaiting Patient Assisted Transport are to be discharged before . J 000 hours.
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5.2 EMERGENCY DEPARTMENT
A full assessment of the patient's needs for home and the required community support should be identified before discharge, with appropriate arrangements made. When community sexvices are required by patients, the Emergency Department staff should contact the Discharge Planning Nurse.
All discharge patients should receive clear communication (verbal and/ or written) on their condition and any required follow-up arrangements. When there is doubt as to the patient's level of understanding written instructions must be provided.
Whenever possible referring General Practitioners, Nursing Homes or Community Care Centres are to be advised of patient discharges.
5.3 OUTPATIENTS DEPARTMENT
In the case of attendances to the Emergency and Outpatient Departments, a written communication should be provided in instances where it is necessary in the interest of safe, ethical and efficient ongoing management of patients.
5.4 SAME DAY PROCEDURE UNIT
All day care patients will be discharged from the Same Day Procedure Unit no later than 2100 hours. Prior to discharge all patients will be given written confirmation of follow-up appointments and directions for wound care/
management as required.
The Nursing Resource Consultants are to be contacted to allocate a bed should a patient require to be admitted overnight.
5.5 FULL CARE PATIENT
Hospital clinicians in the Northern Territory have professional responsibility to provide a written communication or discharge summary for every inpatient separation from hospital. This summary facilitates the safe, ethical and efficient management of patients following discharge.
5.6 REFER-RAL TODISCHARGE PLANNING NURSE
It is the responsibility of both the admitting Medical Officer and Nurse within the pre-admission clinic and the ward, to use the Discharge Planning Screening Tool in the Discharge Planning Manual to identify those patients who need referrals to Discharge Planning Nurses for co-ordination of services required following discharge.
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6.0 DISCHARGE GUIDELINES
6.1 DISCHARGE PLANNING
Well planned discharges will only occur when the patient is reviewed by the Medical Officer during each ward round, with the patient's progress towards discharge being both discussed and documented in the medical records. The estimated Length of Stay (LOS) for each patient entered onto the Hospital Information System (Care Sys) must be reviewed during ward rounds.
In order to maintain an accurate bed state, any changes which are likely to lengthen or reduce the period of hospitalisation (LOS), must be adjusted by the ward clerk in Care Sys. Relevant information must be conveyed to the Discharge Planning Nurse for action.
The day before the expected date of discharge the Medical Officer, responsible for the patient's management, is to review the case and confirm that discharge will occur as planned or re-estimate the expected discharge date.
6.2 DISCHARGE SUMMARIES
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All patients discharged from ROH must have discharge summaries.
Additional information relating to discharge summaries is contained in Territory Health Services 'Written Communications for Inpatient and Outpatient Separations from Northern Territory Hospitals' May 1996.
ELECTIVE PATIENTS
Elective patients should be provided with an expected discharge date prior to admission or be informed at least one day prior to discharge so that appropriate transport/personal arrangements can be made by family/ friends.
DISCHARGE MEDICATIONS
To enable prescriptions to be safely prepared and ready for discharge they are, where possible, to reach Pharmacy at least one day prior to discharge.
Pharmacists will bring ·medications to the patient and explain administration directions and potential side effects, as required by law. Only in an emergency should prescriptions be sent to Pharmacy on the day of discharge. There is a minimum of one hour required to prepare and dispense discharge prescriptions.
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6.5 DISCHARGE TO SELF CARE CENTRE 6.5.1 Ongoing Care Required
Patients transferred to Self Care Centre who require ongoing nursing care must be referred to the Discharge Planning Nurse as soon as the required care is identified. Patients requiring post acute nursing care within Self Care Centre are to be referred and reviewed by the Post Acute Nursing Service before discharge.
Written referrals for simple dressings, medications and follow up appointments must be finalised by ward staff prior to transfer so the information can be relayed to Casuarina Community Care Centre.
The Discharge Planning Nurse communicates all details of required follow up care to the Self Care Centre and the Casuarina Community Care Centre before the patient transfer occurs.
A summary of the care given within the Self Care Centre and any subsequent changes to that care must be communicated to the appropriate Community Care Centre by the Casuarina Community Care Centre staff.
The Discharge Planning Nurse will fax discharge summaries with appropriate follow up arrangements to Casuarina Community Care Centre and the patients appropriate rural health clinic and DMO.
Casuarina Community Care Centre will forward any additional information to the health centre when the patient is discharged home.
In addition to the designated medications supplied on discharge, rural patients must be given sufficient medications to last for their stay in Self Care Centre.
6.5.2 Ongoing Nursing Care Not Required
Transfer to the Self Care Centre of patients who do not require Community Health services is arranged by the ward staff who contact the Self Care Centre manager.
6.6 PATIENT ASSISTED TRAVEL(PATS) REIMBURSEMENT:
If the patient is entitled to PATS funded repatriation, Hospital Patient Travel will make all travel arrangements. If travel is delayed and outside hostel accommodation is required, notify Patient Travel who will make the arrangements. Where possible details of a patient's homeward travel arrangements will be communicated, by telephone or facsimile, to the relevant Community Health Centre by the Patient Travel Clerk.
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6.7 WEEKEND REFERRALS TO COMMUNITY CARE CENTRES
Weekend referrals to the Casuarina Community Care Centre are sent by ward staff in same manner as all other Community Care referrals (refer to Discharge Planning Manual).
6.8 UPDATING PATIENT INFORMATION SYSTEM
During business hours the ward clerk must enter all discharges into the computer immediately following the patient being discharged from the ward. After hours the Patient Care Assistant or Nurse is to perform this task.
ELECTIVE SURGERY
7.1 DEFINITION OF ELECTIVE SURGERY
7.2
Elective surgery is surgery which, although deemed necessary by the treating clinician, can be delayed for at least twenty-four hours.
CATEGORIES OF ELECTIVE SURGERY
All elective surgical patients will be admitted according to the Northern Territory Clinical Urgency Classification System, as follows: progress of disease; pain or distress; disability or dependence on others; and interference of disease with normal occupation.
Category 1 (urgent) - admission within 30 days.
Category 2 (semi-urgent) - admission within 90 days.
Category 3 (non- urgent) - admission within 12 months.
Whilst public and private patients will be listed for elective surgery primarily on the basis of clinical urgency the following factors are to be taken into consideration in the development of surgical operating lists.
• special needs such as the requirement to travel long distances for treatment .
• length of time on the waiting list.
• previous delays (re-scheduling of patients should be avoided wherever possible and should not occur more than twice for the same patient).
• organisational needs such as available resources.
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7.3 ELECTIVE SURGERY BOOKING ARRANGEMENTS
All elective surgical bookings will be entered into the computer by outpatient clerical staff following each outpatient clinic. The Medical Officer requesting a booking for a patient is to include full particulars, on the progress sheet and complete Request for Admission Form (HM 393), indicating estimated length of stay.
It is the responsibility of this Medical Officer to ensure that the patient is fully aware of the procedure for whi~h he/she is being referred and that informed written consent has been obtained for the procedure.
The Nurse working in the clinic is to check that all relevant information is documented before sending the chart to the clerical staff for data entry. If the information is incomplete the chart is returned to the Medical Officer to be completed.
Urgent cases are given priority according to principal diagnosis and urgency rating by the referring Medical Officer. When bed availability is limited the Bed Manager, in consultation with the Divisional Heads (Surgical & Medical) will cancel elective admissions in order to admit patients requiring emergency medical treatment.
7.4 DEFERRING ELECTIVE ADMISSIONS
After conferring with the Divisional Head and the relevant Consultant concerned, the Bed Manager will, where necessary, defer elective admissions from 1500 hours one day prior to admission. Where possible the patient shall be given a new admission date. Patients are not to be rescheduled for their procedure on more than two occasions.
7.5 THEATRE SCHEDULING
The patient is contacted by the Operating Theatre Scheduler being given details of elective admission date and an appointment to attend the Pre-Admission Clinic.
7.6 PRE ADMISSION CLINIC
Unless alternative arrangements are made all patients for elective surgery are to attend the pre admission clinic at least one week prior to the date of admission.
At the pre-admission clinic a member of the respective surgical team will review the patient and determine if the procedure is still required. Discharge planning needs will also be determined at this time.
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7 .6.1 Clinical Investigations
Routine investigations ordered in the pre-admission clinic must have the planned operation/procedure recorded on the request form. Results of investigations ordered in the preadmission clinic are to be reviewed by the anaesthetist on the following day then immediately sent to medical records for filing in the patient's medical records.
7 .6.2 Consent to Operation
Pre-Admission Clinic staff will check that the consent form has been signed by the patient, and contact the appropriate Medical Officer if incomplete.
7 .6.3 Discharge Planning
All patients identified in the pre-admission clinic as those requiring discharge planning (ie., referral to Community Health or other specialty services) are to be referred to the Discharge Planning Nurse at that time.
7 .6.4 Bed Availability
At the pre-admission clinic the patient is to have their date and time for procedure confirmed and be requested to contact the Bed Manager between 2 PM and 4 PM one day prior to admission to confirm the availability of a bed and the appropriate time for admission.
7.7 THEATRE LISTS
Each theatre list may contain one only full care elective admission. Elective admissions may occur on the day of surgery or on one day before if extensive pre-operative preparation is required.
When the Operating Theatre List is being compiled the Operating Theatre Scheduler will check to determine that each patient has been seen by an anaesthetist in the pre-admission clinic
Unless prior arrangements have been made, :patients who fail to attend the pre-admission clinic are excluded from the Operating Theatre List.
7.8 SAME DAY PROCEDURE UNIT ADMISSIONS
Patients admitted as day cases will be admitted according to the Unit Protocol, following assessment at the pre-admission clinic.
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