Guide to Patient Transfer_ Web_ Revised Dec 2012

8/11/2019 Guide to Patient Transfer_ Web_ Revised Dec 2012

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Guide to patient transferPrinciples and minimum requirementsfor non-time critical inter-hospitalpatient transfer

Revised December 2012


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If you would like to receive this publication in an accessible format,please phone 03 9096 1388 using the National Relay Service13 3677 if required, or email [email protected]

This document is available as a PDF on the internet at:www.health.vic.gov.au/qualitycouncil

Copyright, State of Victoria, Department of Health, 2012

This publication is copyright, no part may be reproduced by any process exceptin accordance with the provisions of the Copyright Act 1968 .

Authorised and published by the Victorian Government, 50 Lonsdale Street, Melbourne.

Except where otherwise indicated, the images in this publication show models andillustrative settings only, and do not necessarily depict actual services, facilities orrecipients of services.

December 2012 (1211033)


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GUIDE TO PATIENT TRANSFER

1

A c k

n o w l e d g e m e n t s

The development of this Guide to patient transfer: principles and minimum requirements for nontime critical inter-hospital patient transfer was prepared by Alice Gleeson and overseen by the VQC Patient Transfer Group. The group consists of two VQC members and members of relevantstakeholder groups. The VQC acknowledges the valuable contribution made to this work by thenon-VQC members.

VQC Patient Transfer Group members

Dr Simon Fraser (Chair)* Senior Paediatrician and Chief Medical Ofcer, Latrobe Regional Hospital

Dr Robert Grenfell* GP, National Director, Clinical Issues, Heart Foundation

Mr Wallace Crellin Consumer representative

Dr Emma Mooney Doctors-In-Training, The Australian Medical Association Victoria

Mr Dean Jones Director, Inpatient Access, Eastern Health

Mr Ian Williams Acting Manager, Non-Emergency Services, Ambulance Victoria

Ms Belinda Westlake Health Information, Quality and Risk Manager, Moyne Health Service

Ms Lesley Hawes LAOS Statewide Coordinator, General Practice Victoria

Ms Tricia Elliot Patient Flow Coordinator, Bendigo Health

(*denotes VQC members)


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Inter-hospital transfers are an important and necessary part of the Victorian healthcare system. Moving patientsfrom one hospital to another is vital to ensure they receive the right care, in the right place at the right time.

The Victorian Quality Council developed this guide following feedback from the sector on the need forstandardised principles and minimum requirements for nontime critical patient transfer.

The guide is informed by:

a literature review of current national and international best practice

an investmentlogic mapping workshop to de ne transfer problems and strategic interventions

wide stakeholder consultation through executive directors, directors and managers within the Departmentof Health, CEOs of public and private health services, Adult Retrieval Victoria, private and public transportproviders, quality managers and directors, access managers and the Australian Commission on Safety andQuality in Health Care.

The guide includes principles, minimum requirements and an assessment tool for key phases of the transferprocess, but it does not attempt to address all the issues for specic transfer settings and patient groups atindividual health services. The guide is intended to help executives and senior managers to enhance, developand implement local policies and procedures for nontime critical inter-hospital patient transfer.

The principles, minimum requirements and assessment tool are designed to work together to promotea culture of personal accountability, teamwork and effective communication to ensure patient safety andcontinuity of care throughout the patient-transfer journey. We anticipate that a culture of safety and continuityof patient care across the delivery system will result in fewer adverse events, higher quality and safer care, andan improved patient experience.

Dr Sherene Devanesen Chair

Victorian Quality Council

P r e f a c e


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ACKNOWLEDGEMENTS

PREFACE

INTRODUCTION 4

PURPOSE 5

SCOPE 5 AIM 5

ASSOCIATED RELEVANT LEGISLATION AND POLICIES 5

KEY PRINCIPLES 6

REQUIREMENTS FOR INTER-HOSPITAL PATIENT TRANSFER 7

APPENDICES 11

Appendix 1: Checklist 12

Appendix 2: Assessment tool 13

Appendix 3: Glossary 16

Appendix 4: VQC Inter-Hospital Transfer Patient Transfer Form 18

Appendix 5: VQC Inter-Hospital Transfer Patient Transfer Form instructions for use 20

REFERENCES AND RESOURCES 23

C o n t e n t s


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4

Inter-hospital patient transfer is a frequent and important part of the Victorianhealthcare system. It falls into two broad groups: time-critical emergencytransfers and nontime critical (non-emergency) patient transfers. Patientsare transferred between hospitals for numerous reasons, most frequentlyto access specialised inpatient care not available at the hospital where theyare admitted (forward transfer), to return to a hospital from which they werepreviously transferred (back transfer), and to coordinate resources acrosshealth services (Victorian Quality Council 2009).

Introduction


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Inter-hospital patient transfer involves the movementof a patient from one hospital to another; it alsoinvolves the transfer of information and professionalresponsibility and accountability for patient carebetween individuals and teams within the overallsystem of care (Victorian Quality Council 2008a).

The Victorian Quality Council (2008a; 2008b)has identied many issues with patient transferprocesses, including:

dif culties with referral and transport processes

poor selection of receiving hospitals incomplete documentation of transfer

poor or delayed communication (clinical handover) .

Poor patient transfer processes are associated withdelayed or loss of continuity of care, duplicationof services, increased costs and adverse eventsincluding patient death (Department of HumanServices 2009; Department of Health 2009).

To improve the standard of patient transfer, the Victorian Quality Council developed this guide in orderto standardise the process across the state, so that

all Victorians can receive the high-quality healthcarethey need, where and when they need it.

Purpose The guide outlines patient-transfer principles andminimum requirements, and includes an assessmenttool (see Appendix 2).

The purpose of the guide is to help hospital staff:

improve local processes and policies for nontimecritical inter-hospital patient transfer

assess their current patient-transfer systemsand processes

support the implementation, auditing andenhancement of patient-transfer processes

promote a culture of safety and continuityof care throughout the interhospital patienttransfer process.

Scope These principles and minimum requirements applyto nontime critical patient transfers between

hospitals, primarily for admitted patients.

While many of the principles and minimumrequirements will apply to all patients, hospitals shouldtailor processes for specic transfer settings, patientgroups and their local situation.

The document is for all public and private hospitalexecutives and senior managers of clinical teams(medical, nursing, allied health and designatedpersons) responsible and accountable for planning,developing and implementing policies and proceduresfor nontime critical inter-hospital patient transfers.

Aim The aim of the guide is to standardise patient transferprinciples and minimum requirements in order to:

strengthen personal accountability, teamwork andeffective communication

ensure patient safety and continuity of carethroughout the patient-transfer journey.

Associated relevant legislationand policies

This document should be used in conjunction withthe following legislation and policies:

1. Australian Commission on Safety and Qualityin Health Care (ACSQHC) National Safety andQuality Health Services Standards (NSQHSS),Standard 6: Clinical handover

2. Australian Commission on Safety and Qualityin Health Care OSSIE Guide to clinical handover

improvement

3. Charter of Human Rights and Responsibilities Act 2006

4. Health privacy principles extracted fromthe Health Records Act 2001

5. Health Records Act 2001 (Vic)

6. Mental Health Act 1986 (Vic)

7. Safe transport of people with a mental illness.Chief Psychiatrists guideline 2011

7. Non-Emergency Patient Transport Act 2003

8. Non-Emergency Patient TransportRegulations 2005


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Requirements for inter-hospital patient transfer The following section identies the action steps and minimum requirements for each phase of the transferprocess for nontime critical inter-hospital patient transfer. These are a guide only and are not intended to beall-inclusive. It is expected that hospitals will develop their own action steps and minimum requirements forspecic transfer settings and patient groups. While a systematic approach to the process of patient transferis essential, some of the phases and action steps may occur simultaneously when necessary.

Requirements for key phases of the inter-hospital patient transfer (IHPT)process for nontime critical patients

IHPT phase Action steps Minimum requirements

Determinethe clinicalappropriatenessand necessity forpatient referraland transfer

Assess the patients clinicalcondition

Ensure the necessary andappropriate investigationsare carried out

Establish if the patientshould be transferred, andif an escort is required

Identify any likely risksto the patient that mayresult from, or during, thetransfer

Ensure that the patientagrees to the transferand that advance caredirectives (ACDs) arerespected

Involve a senior clinicianor designated responsibleperson in the decision totransfer

All patients are assessed on admission, and regularlythereafter, to identify and plan for:

- appropriate ongoing care and discharge

- additional health and social care needs on discharge

- referral or inter-hospital transfer as required.

Ongoing care occurs in an appropriate place as close to thepatients home as possible.

The decision to transfer must involve the patient, next ofkin or the substitute decision maker (SDM), and a seniorexperienced clinician or the designated responsible person.

The patient has the right to receive treatment and transferfor treatment, or refuse one or both.

Each hospital has a documented Patient Medical Assessment Protocol to include speciality-specic criteriafor patient referral or transfer.

Each hospital has a documented Patient Transfer Policythat identies:

- roles and responsibilities of the referring and receivinghospital, the designated persons and transport provider

- designated roles that are responsible for the referral ortransfer decision and the various steps of the transferprocess

- the documentation required to accompany the patient.Note: if the patient has advance care directives, ornot for resuscitation, limitation of medical treatment orinvoluntary treatment orders, copies of these documentsmust accompany the patient so that treatment remainsconsistent with their terms.

All staff must be aware of their roles and responsibilities inrelation to patient referral or transfer.

All staff undertaking patient transfers should have theappropriate qualications, competencies and training inpatient transfer. This includes training in relation to:

- patient assessment, monitoring, treatment and evaluationto determine the clinical appropriateness of the transferand the level of care needed during transfer

- responsibilities in relation to patient transferdocumentation, referral, delegation, clinical handoverand privacy

- non-emergency patient transport providers and policies.


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Requirements for key phases of the inter-hospital patient transfer (IHPT)

process for nontime critical patients

IHPT phase Action steps Minimum requirements

Determinethe referraldestination andacknowledgeacceptance ofthe referral

Determine the appropriatereceiving hospital

Consult with the receivingteam about the referraland bed availability

Ensure the referral isaccepted by the receivinghospital team

Ensure that there is ashared understanding of

the purpose (diagnosis,investigation, treatmentor second opinion) andexpectation of the referral

Agree on arrangementsfor the transfer, arrival,repatriation and feedback

Escalate to a seniorclinician when: unable tosecure an appropriatereferral destination; abed is not available atthe receiving hospital

within a clinically relevanttime, when the transfer isdelayed or the patient isdeteriorating

Ensure that the receivingteam names, positiontitle, contact numbersand all issues arising aredocumented

Determining the appropriate receiving hospital will requireconsideration and assessment of the:

- patients current condition and degree of clinical urgency

- reason for the transfer to include the intervention requiredby the patient

- capability and capacity of the referring hospital

- capability and capacity of the potential receiving hospital

- geographical proximity or distance

- needs and consent of the patient, next of kin or SDM

- established referral relationships or inter-hospital patient transferagreements.

Whenever possible, inter-hospital patient transfer agreements shouldbe in place to facilitate timely transfer of patients.

This is especially recommended in locations where patients withcomplex problems are regularly transferred to a speci c hospital.

Inter-hospital transfer agreements where they exist should bedocumented to enable staff to:

- easily contact the relevant service providers

- identify role delineation between hospitals and repatriation of patientagreements, which may include transport charging arrangements

- identify clinical handover requirements for the receiving hospital,transport provider and the patients GP

- identify the appropriate escalation process if: a bed is not availableat the receiving hospital; there is a disagreement regarding thetransfer or if the patient is deteriorating

- identify the designated roles (position titles and contact details)responsible for the transfer decision and the various steps of thetransfer process

- identify a mechanism for evaluating the transfer process for ongoingquality and safety improvement.

Prepare thepatient fortransfer

Involve the patient, nextof kin and/or SDM

Obtain informed consentfor the inter-hospital

transfer and consent forsharing patient informationwith the receiving team,transport provider and thepatients GP

The patient, next of kin or the SDM is given adequate and timelyinformation about ongoing care, including: the reasons for transfer; thematerial risks and likely bene ts; the procedures involved; expectedoutcomes; transport options and support available; and the need

to share the patients information with the receiving team, transportprovider and the patients GP.

The information provided is documented in the medical record.

The clinician or designated person is responsible for obtaining anddocumenting the consent to transfer and share patient information.If circumstances do not allow for this then both the indications fortransfer and the reason for not obtaining consent is documented in themedical record.

The patient, next of kin or SDM is provided admission or transferinformation in a format that meets their needs.

A copy of the inter-hospital transfer form could be provided to thepatient if requested.

The interpreter is involved as required

The patients vital signs should continue to be monitored regularly toensure early recognition of clinical deterioration and the need for thetransfer to be escalated.


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process for nontime critical patientsIHPT phase Action steps Minimum requirements

Coordinatelogistics forpatient transfer

Determine the modeof transport

Coordinate the appropriatetransport

The mode of transport is determined by the referring hospital clinicianor designated person in consultation with the receiving hospitalclinician or designated person, the patient, and the transport provider.

The mode of transport selected will be based on patient acuity,clinical condition, medical needs, legal status under the Mental Health

Act 1986, distance or geographical proximity, and availability andtimeliness of transport resources.

The mode of transport may include public ambulance, privatenon-emergency patient transport (NEPT), or private or volunteercar transportation.

The designated person should ensure the transfer transport isarranged as soon as a date of transfer is known and if possible thatthe transfer is arranged to take place during business hours.

When booking the transport, the designated person should:

- be aware of the scope of practice for NEPT providers in relation topatient acuity, and when NEPT is permitted and not permitted forpeople with mental illness

- ensure that the transport provider is informed (where appropriateto meet patient safety needs and respect for patient condentiality)of the patients condition, acuity, weight, pick up time and location,and any special requirements that the patient may have such as IVinfusion, interpreter, wheelchair, sight, speech or hearing difculties,or escort requirements.

Hospitals should have a documented index of local transportresources to include:

- names and contacts details of transport agencies

- hours of service

- wait time and requirements for booking transport providers

- transport options provided by each transport agency along withestimated transit time for transport options

- NEPT providers scope of practice

- transfer equipment available/required or accommodated.

Involve the designatedpersons and relevantmultidisciplinary teammembers with planning forthe transfer of the patient

The designated person should ensure that all:

- multidisciplinary team members involved in the patient care arenotied of the intended transfer to enable planning as a team for

the transfer of responsibility and accountability for all aspectsof patient care.

Ensure the patient is readyfor transfer

A patient is ready for transfer when:

- a clinical decision has been made that the patient is suitable fortransfer AND

- the receiving hospital has accepted the patient transfer AND

- the patient, next of kin or SDM has consented to the transfer andsharing of information AND

- all key information on reason for transfer, patient discharge diagnoses,treatment or shared care plans, scheduled follow-up referrals andappointments, medications, investigation results and those pending havebeen accurately and completely documented and communicated to thereceiving hospital, the transport provider and the patients GP AND

- all relevant key information, documentation and required medicationshave been collated to transfer with the patient

- the multidisciplinary team has decided the patient is ready fortransfer AND

- strategies are in place for a safe patient transfer.


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process for nontime critical patientsIHPT phase Action steps Minimum requirements

Coordinateclinical handoverto:

the transportprovider

the receivinghospital team

the patientsGP

Coordinate clinicalhandover of the patient,that is the communication(verbal and written)process to transferprofessional responsibilityand accountability forpatient care to thereceiving hospital/transportprovider

Ensure that accurate,complete and appropriatekey information is providedto the designated personat the receiving hospital/ transport provider prior topatient transfer

Complete documentationand clinical handover

Ensure that all keyinformation is transferredwith the patient

To ensure the transfer of accountability and responsibility for all aspectsof patient care, clinical handover should include:

preparation for handover using a structured standardised processto ensure that timely, relevant, unambiguous, consistent handoverand communication across the whole spectrum of health careproviders is achieved

nomination of when, how and who will be involved in the handover

patient, next of kin or SDM and multidisciplinary team involvementas appropriate

the provision of verbal and documented key information on: reason

for transfer, patient discharge diagnoses, shared care treatmentplans, scheduled follow-up referrals and appointments, medications,investigation results and those pending prior to patient transfer

the key information shared should be accurate, complete andappropriate to enable ongoing care and to prevent unnecessary repeatof tests or investigations

direct communication, where appropriate from clinician to clinician,clinician to GP, nurse to nurse, nurse to transport provider, allied healthto allied health personnel to ensure continuity of patient care andenable the receiver to assume responsibility for patient care

use of the patient medical record to facilitate cross-checking of theinformation documented and handed over.

Repatriate thetransferredpatient

Determine repatriation ofpatient arrangements

When a clinical assessment determines that the transferred patientcould appropriately be cared for at the original referring hospital andif the patient is stable enough and consents to transfer, the patientshould be repatriated.

When initiating the inter-hospital patient transfer it is preferable to:

- establish the repatriation arrangements,and

- the mechanism and timing of follow-up and feedback about theoutcome of the transfer from the receiving hospital.

Initiate post-transferfollow-up communicationwith the receiving hospitalwhere appropriate

When repatriation is necessary, post transfer communication betweenthe sending and receiving hospital is preferable to enhance :

information sharing on the patient outcome

shared responsibility for the patient-transfer process

the provision of feedback or complaints on the clinical appropriateness

of the transfer and the quality of the transfer process collaboration between hospitals.

Evaluate theinter-hospitalpatient transferprocess forongoing qualityand safetyimprovement

Establish and maintain adocumented process forreviewing nontime criticalinter-hospital patienttransfer

Regularly review inter-hospital patient transfer processes by:

- reviewing feedback obtained from patient, next of kin or SDM,receiving hospital, transport providers and GPs

- involving the patient, next of kin or SDM and multidisciplinary teamin reviews and improvement activities

- documenting problems identied and the actions takento address problems

- communicating the actions taken to address problemsto all relevant stakeholders

- monitoring the volume of inter-hospital patient transfers to enable

appropriate allocation of resources.


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A GUIDE TO USING DATA FOR HEALTH CARE QUALITY IMPROVEMENT

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Appendices


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Appendix 1: Checklist

Determine the clinicalappropriateness andnecessity for patientreferral and transfer

Phases Action steps

Determine thereferral destinationand acknowledgeacceptanceof the referral

Prepare the patientfor transfer

Coordinate logisticsfor patient transfer

Coordinate clinicalhandover to: the transport

provider the receiving

hospital team the patient's GP

Repatriate thetransferred patient

Evaluate theinter-hospital patienttransfer process for

ongoing quality andsafety improvement

Has the patients clinical condition been assessed? Have the necessary and appropriate investigations been carried out? Does the patient need to be transferred? Does the patient require an escort? Has the likely risks that may result from or during the patient transfer been identified? Has the patient agreed to the transfer and are advance care directives respected? Has a senior clinician or designated person been involved in the decision to transfer?

Has the appropriate referral destination or receiving hospital been determined? Has the receiving team acknowledged acceptance of the patient referral? Is there a shared understanding of the purpose and expectation of the referral? Have arrangements for the transfer, arrival, repatriat ion and feedback been agreed? Is escalation to a senior clinician necessary? Has the receiving team names, position title, contact numbers and issues

been documented?

Has the patient,next of kin or substitute decision maker been involvedin decision making?

Has informed consent for the transfer and consent for sharing patient informationwith the receiving team, transport provider and patient's GP been obtained?

Has the appropriate mode of transport been determined and coordinated? Has the designated person and relevant multi-disciplinary team members been

involved with planning for the transfer of the patient? Is the patient ready for transfer?

Has clinical handover of the patient, (verbal and written communication to transferprofessional responsibility and accountability for patient care) to the receiving hospitaland transport provider occurred prior to patient transfer?

Has documentation of clinical handover occurred? Have copies of all key information and documentation been transferred with the patient? Did the documentation tranferred include a doctor's letter that was cc'd to the GP?

When patient repatriation arrangements have been agreed, has post transferfollow-up communication with the receiving hospital been initiated?

Has a documented process for reviewing nontime critical inter-hospital patient

transfer been established and maintained?

Y/NY/NY/N

Y/NY/N

Y/NY/N

Y/NY/N

Y/NY/NY/N

Y/N

Y/N

Y/N

Y/N

Y/N

Y/N

Y/N

Y/NY/N

Y/N

Y/N

Y/N


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Appendix 2: Assessment tool The assessment tool will help executives and senior managers to examine inter-hospital patient transferprocesses, and identify priority areas for action to align them with the principles and minimum requirementsin this guide.

The assessment tool aims to ensure a culture of safety and continuity throughout the patient transfer process.

Topic Questions

Assessment

Yes WIP* No

Leadershipand patient IHTplanning

Is there a Patient Transfer Planning Group (PTPG) or equivalent in place withsenior executive, clinical, consumer and key stakeholder representation?

Does the PTPG or equivalent have terms of reference that clearly dene themembers roles, responsibilities and accountabilities?

Is there evidence of organisational leadership and governance aroundimplementing, reporting, monitoring and evaluating the patient transfer clinicalhandover process?

Is there an audit process in place to evaluate the inter-hospital transferprocesses, incidences, changes or interventions, and lessons learnt?

Does the audit process incorporate a peer review of the patient referral ortransfer for appropriateness, timeliness, transfer of information and patientsatisfaction?

Does the audit of inter-hospital transfer include reporting on reason for transferand volume of transfers by: transfers in and out; hospital or health service;speciality; transport provider (private, NEPT or Ambulance Victoria) and cost?

Are audit review recommendations actioned to ensure ongoing quality andsafety improvement and to reduce the risk of incidents recurring?

Are there systems and processes in place to share lessons learnt from goodand poor patient transfer practices, to identify system improvements andencourage a safety culture?


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Topic Questions

Assessment

Yes WIP* No

Documentation Does the workforce have easy access to a documented Patient Transfer Policy?

Was the Patient Transfer Policy developed in partnership with themultidisciplinary team, the patient and next of kin?

Is implementation of the Patient Transfer Policy being audited?

Is the Patient Transfer Policy reviewed regularly in accordance with theorganisations document review cycle?

Does the Patient Transfer Policy include:

key principles that apply when transferring patient care role and responsibility of the organisation for the provision of clinical

governance and leadership of patient transfer systems and processes role and responsibility in relation to implementation and evaluation of patient

transfer systems and processes roles and responsibilities of the designated persons responsible for

authorising the transfer and the various steps of the transfer process roles and responsibilities in relation to involving the patient, next of kin or SDM

in transfer decisions an escalation process in the event of: the patient deteriorating; a bed

not being available at the receiving hospital; or if there is a disagreementregarding the transfer

speci c transfer requirements for speciality patient groups such as children,mental health patients, renal dialysis patients, et cetera

steps taken to initiate a patient transfer to include key phases, action steps

and minimum requirements for a nontime critical patient transfer a list of the documentation required to be copied and transferred with the

patient to include mandatory documents such as ACD/NFR/limitation ofmedical treatment order/Mental Health Act paperwork when they exist?

inter-hospital transfer agreements, roles and responsibilities, contact details andtransport charging arrangements specically where the patient is repatriated

a process for accessing potential receiving hospitals an index of local transport resources a process for peer review and feedback on referral management to include

review of the appropriateness and timeliness of the referral, transfer ofinformation and patient satisfaction

the process for staff to report incidents and near misses relating to patient transfer reference and location of associated policies such as non-emergency patient

transport legislation and regulations, clinical practice protocols, MedicalRecords Act and privacy policies.

Communicationandcoordination ofinter-hospitalpatient transfer

Is there a designated role responsible for the coordination and communicationof inter-hospital patient transfers?

If so, is the role clear to all stakeholdersfor example, is the role published onthe hospital website or the hospital capability database?

Does the workforce have easy access to a structured clinical handover processfor inter-hospital patient transfer that includes: preparation, organisation, verbaland written documentation exchange, timing, environmental awareness andinvolvement of participants, and patient, next of kin or SDM?

Does the workforce have access to a range of tools to support effective inter-hospital transfer clinical handover such as the VQC Inter-Hospital Transfer Form(IHTF) or the Barwon-South Western Quality Advisory Group Transfer Envelope?

Is there evidence that the workforce is using the structured process and toolsfor inter-hospital transfer clinical handover?


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Topic Questions

Assessment

Yes WIP* No

Patient, next ofkin or substitutedecision makerinvolvement

Is there evidence that patient, next of kin or SDM is routinely involved in careplanning, and consent throughout the transfer process?

Is there evidence that patients rights and responsibilities in relation to patienttransfer are being complied with; for example, is there evidence that ACDs aretransferred with the patient?

Is there evidence that clear and accurate information is provided to patients,next of kin or SDM in an appropriate format to meet their needs, for example,a documented consent process?

Is patient satisfaction with the patient transfer process monitored?

Patient medicalassessment

Does the workforce have easy access to a documented Patient Medical Assessment Protocol?

Does the Patient Medical Assessment Protocol include:

specialty-speci c criteria for patient referral and transfer

speciality-speci c criteria for clinical escort requirements

triggers for referral on to other disciplines or hospitals

delegation and responsibility for referral and transfer?

Is there evidence that all patients are assessed on admission to ensure thatappropriate and timely ongoing care is available?

Training andeducation

Is there an education and training program on patient transfer available toclinical staff at orientation?

Does the training program include:

criteria for patient referral and transfer

key phases, action steps and minimum requirements for a nontime criticalpatient transfer

information on NEPT legislation, regulations and clinical practice protocols

information on selecting an appropriate receiving hospital?

Are arrangements in place for repeat training sessions at regular intervals?

Are staff competencies in relation to patient transfer, referral, clinical handover,documentation and patient medical assessment monitored?

*WIP: work in progress

Name Signature

Clinical area Date of assessment


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Appendix 3: Glossary

Term Denition

Advance care directive(ACD)

An advance care directive (ACD) is a document created by a patient while they arecompetent, which denes the medical treatment that they wish to refuse should theybecome incompetent in the dened circumstances.

An ACD can record the persons preference for future care and appoint a substitutedecision maker to make decisions about healthcare and personal life management.

Patients have the right to make decisions about their healthcare, now and for the future. An advance care plan offers the patient an opportunity to say now what life-prolongingmedical treatment they would and would not want in the future.

Barwon-SouthWestern Region

Quality AdvisoryGroup Patient TransferEnvelope

The Patient Transfer Envelope was developed by the Barwon-South Western RegionQuality Advisory Group. It is an easy-to-use and practical tool for packaging all the

relevant documents to be transferred with the patient. It is used only once and isdiscarded when the patient or resident is admitted.

Clinical handover Clinical handover refers to the verbal and written communication process to transferprofessional responsibility and accountability for some or all aspects of care for a patient,or group of patients, to another person or professional.

Delegation, referraland handover (MedicalBoard of Australia2009)

Delegation involves you asking another healthcare professional to provide care on yourbehalf while you retain overall responsibility for the patients care.

Referral involves you sending a patient to obtain opinion or treatment from anotherdoctor or healthcare professional. Referral usually involves the transfer (in part) ofresponsibility for the patients care, usually for a de ned time and for a particular purpose,such as care that is outside your area of expertise.

Handover is the process of transferring all responsibility to another healthcareprofessional.

Good medical practice involves:

taking reasonable steps to ensure that the person to whom you delegate, refer orhandover has the quali cations, experience, knowledge and skills to provide the carerequired

understanding that when you delegate, although you will not be accountable for thedecisions and actions of those to whom you delegate, you remain responsible for theoverall management of the patient, and for your decision to delegate.

always communicating suf cient information about the patient and the treatment theyneed to enable the continuing care of the patient.

Hospital capability The hospitals ability to manage patients requiring specialised medical evaluation andcare. Requirements span the range of specialised medical and health services, and mayinclude operating theatres, diagnostic equipment or particular specialist staff.

Hospital capacity The hospitals operational ability to manage a volume of patients to include the number ofbeds available and staffed.

Inter-hospital patienttransfer

Any patient transfer, after initial assessment and stabilisation, from and to anotherhospital.

Non-emergencypatient transport

Non-emergency patient transport (NEPT) is available for patients who do not require atime-critical ambulance response and who have been assessed by a medical practitioner.NEPT is governed by an Act, regulations and clinical practice protocols.

The Department of Health is responsible for the development and implementation of:

Non-Emergency Patient Transport Act 2003

Non-Emergency Patient Transport Regulations 2005

Non-emergency patient transport: clinical practice protocols .


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Term Denition

Not for resuscitation(NFR)

Not for resuscitation (NFR) is an order to prevent the use of cardiopulmonary resuscitation(CPR) in situations where the patients heart stop or the patient stops breathing. The NFRorder is made when CPR is deemed medically futile or unwanted by the patient.

An NFR order is documented in a form which may be referred to as a Limitationof Medical Treatment Form.

Nontime criticalpatient transfer:

(non-emergencypatient)

-versus-

Time-critical patienttransfer

(emergency patient)

Nontime critical patient transfer occurs when a stabilised patient needs to betransferred, either forward to a higher level of care or back to a lower level of care orcloser to home, and the attending clinician or designated person has determined that:

the patient transfer is not urgent and that the patient is stable to transfer

the patient is unlikely to require transfer or transport under emergency conditionsirrespective of their acuity (high, medium or low).

The nontime critical patient is also referred to as a non-emergency patient.

Time-critical patient transfer occurs when a patient requires emergency care at theclosest appropriate hospital in the shortest time possible to achieve early intervention andstabilisation. This patient will require transfer and transport under emergency conditions.

The time-critical patient is also referred to as an emergency patient.

Receiving hospital A hospital to which a patient is transferred for treatment, ongoing care or investigations.

Referring hospital A hospital from which a patient needs to be transferred, that is, the hospital that identiesthe need for and initiates the patient transfer.

Substitute decisionmaker

A substitute decision maker (SDM) is appointed or identied by law to make substitutedecisions on behalf of a person whose decision-making capacity is impaired.

Types of inter-hospitaltransfers

Forward transfer : a transfer to a higher level of care than that available at the referringhospital, for treatment such as inpatient specialist treatment.

Back transfer : a transfer back to a lower level of service, usually following completion ofan episode of care, or return transfer (repatriation) of an inpatient to the primary hospital,or transfer of a patient to another hospital for recovery.

Lateral transfer : a transfer to a hospital with the same level of care. This may occurwhen the referring hospital facilities are unavailable.

Transfer for investigations : a transfer for investigations not available at the referringhospital. The patient is usually transferred back to the referring hospital once the resultshave been discussed with the doctor.

Victorian QualityCouncil (VQC)

The Victorian Quality Council (VQC) is a ministerial advisory council that was establishedin 2001. The VQC is responsible for fostering better quality health services in Victoriaby working with stakeholders to develop useful tools and strategies to improve healthservice safety and quality.

VQC Patient TransferGroup (PTG)

The VQC Patient Transfer Group was established in 2009 to improve and standardiseinter-hospital patient transfer processes.

VQC Inter-Hospital Transfer Form (IHTF)

The VQC Patient Transfer Group developed and piloted a generic Inter-Hospital TransferForm (IHTF) for nontime critical patients.

The IHTF has been endorsed by the Secretary for Health and the full VQC forimplementation across all Victorian health services from January 2012.


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Appendix 4: VQC Inter-Hospital Transfer Patient Transfer Form

PlaceHealth

Service Logo Here

Transfer discussed withpatient Yes No

Date of transfer

Indigenous status (circle)

A / TSI ATSI / Unknown

Medicare no. ________________________ Pension / DVA no. ___________________

Private health insurance (PHI) fund___________________________

PHI no.

(Affix patient label here)Referring facility URN

Surname Given names

Address

Postcode DOB

Gender Male Female Allergies Nil known Yes (if yes list type, reaction and severity) Signature

General practitioner Yes No Unknown

GP name __________________________

GP phone no. ______________________

GP notified of transfer Yes No Unknown

Next of kin (NOK) / Carer / Substitute decision maker (SDM) (Circle)

Name _________________________________ Phone no. ______________________________Relationship to patient ________________________

NOK / Carer / SDM notified of transfer Yes No

I d e n

t i f y

Referring / authorising practitioner name

________________________________Referring unit _______________________Referrer phone/pager no. _________________

Referrer position (Consult / Reg / HMO / GP / RN / Other)

Referring ward

Name _____________________

Phone no. ___________________

Patient living arrangements

Living independently

Residential facility In-home support

Principal diagnosis / problem

Reason for transfer

Medical history / comorbidities

Observations at time of transfer: T _____ .P _____ B/P _____Respiratory management plan / O 2 requirements

Sp0 2 target O 2 rate O 2 device**If ETT record any difficulty with intubation.

Intravascular access Site and date of insertion No access Peripheral venous line (1) ... Peripheral venous line (2) ... Peripheral venous line (3) ... Central venous line . Other .

IV fluids Yes No

Mental / cognitive / behaviour No issues Cognitive impairment Post-traumatic amnesia Verbal aggression Delirium Physical aggression Sleep disturbance Resistive to care Dementia Absconding risk Depression Wanderer Acquired brain injury Harm to self Harm to others

Other _________________________

Current cognitive state ________________Glasgow Coma score

Continence No issues Faecal continence Urinary continence Indwelling catheter Intermittent catheter Stoma / colostomy

Time last voidedDate bowels last opened

Date IDC inserted

S i t u a

t i o n

Legal status

Not applicable Voluntary patient Involuntary patient Forensic patient Security patient

Nutrition and swallowingFasting: Yes No

Time of last intake ________Diet: Normal Diabetic Renal Soft

Puree Minced NBM

Fluids __________________Supplements ______________Restrictions _______________Safe swallow strategies: ________Medication Crushed WholeEnteral feeding NG PEG

Regime and feed sent Yes No

Dentures Yes No

Weight

CommunicationInterpreter required

No Yes Primary language spoken

Patient transfer form (inter-hospital) Nontime critical patients Facility name

P a t i en

t t r an sf er f or m

MRn

o.

F o r m

v e r s

i o n n o . &

d e s

i g n

d a

t e


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Patient transfer formFacility name Date Page 2

(Affix patient label here)Referring facility URN

Surname Given names

Address

Postcode DOB

Gender Male Female

B a c

k g r o u n

d

Specialty-specific information

Alerts none _____________________

Alerts bariatric patient _____________________

Alerts falls risk _____________________

Alerts infectious risk _____________________

Alerts pressure ulcer risk _____________________

Alerts smoker _____________________

Advance care directives Yes No Unknown

NFR / limitation of medical treatment order

Yes No Unknown Alerts other:

A c c o m p a n y i n g

P t .

Personal Accompanying Sent withitems N/A patient familyClothing Glasses Dentures Hearing aid Medications

Equipment __________________ _ _

Valuables List valuables_____________________________________

___________________________________________ ___

Other

If an air-ambulance transfer, luggage has to be less than 5 kgs

Patient ID band on patient Yes

Attached copy of documentation: ( where applicable )Doctors letter Cognitive assessment tool

Allied health letter *Advance care directives

Observation chart Nursing care plan / pathway

Medications chart Fluid balance chart

IV orders Behaviour management plan

Wound chart *Involuntary treatment order*NFR / limitation of medical treatment order

Investigation results: X-rays ECG Pathology reportOther

* Where these exist, a copy must accompany the patientReceiving facility (RF) Appropriate time for transfer agreed Yes No

RF name RF ward name

Acceptance by receiving medical practitioner Yes No

Date TimeReceiving medical practitioner / unit name

_____________________________Receiving practitioner / unit phone no. and pager

Acceptance by receiving facility bed coordinator Yes No

Date TimeReceiving bed coordinator name

_________________________________________Receiving bed coordinator phone no. and pager

Treating allied health contact details (if applicable)Discipline Name Pager/phone Discipline Name Pager/phoneOccupationaltherapist

Dietitian

Physiotherapist Socialworker

Speechpathologist

Other

Form completed by (print name and job designation ) : Signature:

Patient transport provider (TP) service name _____________________ Date and time booked

Handover received Yes No Accompanying documentation received Yes No

Receiving transport provider name (print) Signature

R e s p o n s i

b i l i t y

Handover provided : by referring staff Yes No : by TP Yes No .

Accompanying documentation provided Yes No Accompanying items checked Yes No

Receiving clinical staff name (print) SignatureFax the form to receiving hospital prior to patient transfer. A copy should accompany the patient and the original form should be filed in the patient medical record.

P a t i en

t t r an

s f er f or m


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Appendix 5: VQC Inter-Hospital Transfer Patient Transfer Forminstructions for use

VQC inter-hospital patient transfer form

Instructions for use

The Victorian Quality CouncilThe Victorian Quality CouncilThe Victorian Quality CouncilThe Victorian Quality CouncilSafer, better healthcare for all Victorians

www.health.vic.gov.au/qualitycouncilwww.health.vic.gov.au/qualitycouncilwww.health.vic.gov.au/qualitycouncilwww.health.vic.gov.au/qualitycouncil

December 2012

IntroductionIntroductionIntroductionIntroduction

The Victorian Quality Council (VQC) inter-hospital transfer form aims to improve standardisation of clinical handover anddocumentation for nontime critical inter-hospital patient transfers.

The Department of Healths Secretary and the VQC endorsed the implementation of the form by all Victorian healthservices from January 2012.

The form will help to:

ensure pertinent and accurate patient information is exchanged between the referring and receiving facility and thetransport provider

standardise the terminology and the minimum data sent and expected by health services during patient transfer reinforce the need to transfer professional responsibility and accountability by identifying key responsible people at

the sending and receiving hospitals and the transport provider service replace the multitude of transfer forms with varying information currently being used by Victorian health services complement the Guide to patient transfer: principles and minimum requirements .

TTTTypypypypeeeessss of of of of patient tpatient tpatient tpatient transfersransfersransfersransfers coveredcoveredcoveredcovered

The form isisisis intended for use in nontime critical transfers involving:

adult inter-hospital transfers transfers between acute health services transfers provided by both private and public transport providers.

The form is nois nois nois notttt intended for use in transfers involving:

time-critical patients specialist patient transport services such as Adult Retrieval Victoria, trauma retrievals, Newborn Emergency Transport

Service (NETS), Victorian Paediatric Transport Service (PETS) and Perinatal Emergency Referral Service (PERS).

The form maymaymaymay be used in transfers involving:

inter-campus transfers, such as between hospitals in a health service hospitals and other facilities, such as between hospitals and rehabilitation centres, aged care facilities or GP

surgeries.

However, you may need to modify the form for inter-campus, rehabilitation or aged care transfers (see Appendix 1).

Transfer processTransfer processTransfer processTransfer process Confirm that the patient is to be transferred. Identify if the patient fulfils the criteria for the intended use of the form. Complete the form. All sections must be completed. A copy of the form should be faxed to the receiving hospital prior to patient transfer, a copy should accompany the

patient during transfer and the original form should be filed in the patient medical record.

LocalLocalLocalLocal modificationsmodificationsmodificationsmodifications to theto theto theto the f ff formormormorm

The dataset contained in the VQC form is the minimum data that all hospitals should provide and receive whenundertaking a patient transfer. This dataset or its location under the sections should not be changed.

Modification may be made to form, such as inserting your health service name, logo and a medical record number,formatting to comply with the Australian Standard 2828 for paper-based healthcare records or adding to the specialty-specific area if required.

If you wish to use the form for all transfers including aged care and inter-campus transfer, we have included suggestionsfor consideration in Appendix 1. An electronic copy of the form is available at: http://www.health.vic.gov.au/qualitycouncil


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VQC inter-hospital patient transfer form

Instructions for use



Section explanationsSection explanationsSection explanationsSection explanations

I d e n t i f y

I d e n t i f y

I d e n t i f y

I d e n t i f y

s e c t i o n

s e c t i o n

s e c t i o n

s e c t i o n

Referring facility URN:Referring facility URN:Referring facility URN:Referring facility URN: t ttthe patients unique record number (URN) at the referring facility. IndigenousIndigenousIndigenousIndigenous statusstatusstatusstatus: ::: an Aboriginal or Torres Strait Islander person is defined as a person of Aboriginal (A) (A)(A)(A) or

Torres Strait Islander (TSI)(TSI)(TSI)(TSI) descent, who identifies as being A AAA or TSITSITSITSI. Information on indigenous status iscollected by asking Are you of Aboriginal or Torres Strait Islander origin? and the response is recorded bycircling either: A or TSI; or Aboriginal and Torres Strait Islander (ATSI); or unknown.

AllergiesAllergiesAllergiesAllergies: ::: if allergies are known, list the allergen type, reaction and severity. Allergen types may includemedications, foods, inhalants, environmental substances, latex and other.

SubstituteSubstituteSubstituteSubstitute decision makerdecision makerdecision makerdecision maker (SDM):(SDM):(SDM):(SDM): an SDM may be appointed by the person, appointed for (on behalf of) theperson or identified as a substitute decision maker under the Guardianship and Administration Act 1986 .

S i t u

a t i o n

S i t u

a t i o n

S i t u

a t i o n

S i t u

a t i o n s e c t i o n

s e c t i o n

s e c t i o n

s e c t i o n

The situation section should include a comprehensive overview of admission diagnosis, relevant medical history,the reason for transfer, observations at time of transfer, respiratory treatment requirements and information onnutrition and continence, if applicable. SpOSpOSpOSpO 2222 targettargettargettarget: ::: refers to the acceptable patient oxygen saturation range when measured by a pulse oximeter.

ETTETTETTETT :::: refers to an endotracheal tube or breathing tube. Please note that any difficulty with intubation willneed to be recorded on the form and communicated during handover to the receiving hospital/facility

ForensicForensicForensicForensic patientpatientpatientpatient: ::: refers to a patient who is remanded, committed or detained in custody in an approvedmental health service by a supervision order under the Crimes (Mental Impairment and Unfitness to beTried) Act 1997.

SecuritySecuritySecuritySecurity patientpatientpatientpatient: ::: refers to a patient who is a prisoner detained in custody in an approved mental healthservice under s. 16 or 16A of the Mental Health Act 1986.

InvoluntaryInvoluntaryInvoluntaryInvoluntary patientpatientpatientpatient: ::: refers to a patient who is subject to an involuntary treatment order under s. 12 or 12AA

of the Mental Health Act 1986 . PrincipalPrincipalPrincipalPrincipal diagnosisdiagnosisdiagnosisdiagnosis: ::: refers to the condition that is established after investigation and responsible for the

patients admission to hospital. PastPastPastPast medicalmedicalmedicalmedical historyhistoryhistoryhistory / // / ccccomorbiditiesomorbiditiesomorbiditiesomorbidities: ::: refer to significant medical events, for example obesity and

comorbidities of hyperlipidemia, hypertension and type 2 diabetes.

B a c k g r o u

n d

B a c k g r o u

n d

B a c k g r o u

n d

B a c k g r o u

n d

s e c t i o n

s e c t i o n

s e c t i o n

s e c t i o n

The background section should include: aaaa specialtyspecialtyspecialtyspecialty- ---specificspecificspecificspecific areaareaareaarea that allows for the addition of specialty-specific information, such as dialysis

indication, commencement date, centre, type, frequency and schedule along with dialysis access type alertsalertsalertsalerts refer to known at-risk alerts. ... Tick known alerts, or tick none.

A c c o m p a n y i

n g

A c c o m p a n y i

n g

A c c o m p a n y i

n g

A c c o m p a n y i

n g

s e c t i o n

s e c t i o n

s e c t i o n

s e c t i o n

The accompanying section may be used as a checklist to remind you of the documentation that shouldaccompany the patient and personal items that may accompany the patient or be sent with the family. PersonalPersonalPersonalPersonal luggageluggageluggageluggage: ::: if the patient is an air-ambulance transfer, luggage has to be less than five kilograms. Documentation:Documentation:Documentation:Documentation: where an advance care directive, involuntary treatment order or not for

resuscitation/limitation of medical treatment order exists, a copy must accompany the patient.

R e s p o n s i b i l i t y



R e s p o n s i b i l i t y s e c t i o

n

s e c t i o n

s e c t i o n

s e c t i o

n

The responsibility section reinforces the need for the receiving clinician or designated person to accept thepatient prior to transfer and the need to transfer professional responsibility and accountability by identifying key

responsible people at the sending and receiving hospitals and the transport provider service.The responsibility section requires documentation to include: the receiving facility/ward name, medical practitioner, bed coordinator/designated person, treating allied

health contact details, and your name, job designation and signature the transport provider (if applicable ) to acknowledge receipt of a handover and documentation (please note-

transport providers do not accept responsibility for accompanying non-medical personal items ) the receiving clinical staff member to acknowledge receipt of a handover, accompanying personal items and

documentation. Handover should be provided by the designated person at the referring facility prior topatient transfer and by the transport provider (if applicable) at the time of transfer.

Implementing the formImplementing the formImplementing the formImplementing the form

Some recommendations for implementing the form include: identify key staff on each unit to support, monitor and manage the implementation of the form update the executive team regularly about the progress of the implementation so they can provide constructive

advice and support strategies for overcoming barriers identify key staff involved in the transfer process, such as nurse unit managers, discharge coordinators, access

managers, ward clerks and transport operators, and consult with them prior to its implementation so that they canoffer support and assistance.


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VQC inter-hospital patient transfer formInstructions for use



AppendixAppendixAppendixAppendix 1111

Suggestions forSuggestions forSuggestions forSuggestions for modificationsmodificationsmodificationsmodifications to theto theto theto the formformformform

Some health services may wish to use the form for all transfers including aged care and inter-campus transfer. We have

included the following suggestions that may be added to the minimum dataset in the VQC form. NeurologicalNeurologicalNeurologicalNeurological ( if applicable)

Conscious state:Conscious state:Conscious state:Conscious state: alert drowsy varies MoodMoodMoodMood: normal agitated flat Memory:Memory:Memory:Memory: normal short-term problems confused state MMSEMMSEMMSEMMSE.Triggers:Triggers:Triggers:Triggers: ..Intervention strategies:Intervention strategies:Intervention strategies:Intervention strategies: ..

Mobility/Mobility/Mobility/Mobility/transferstransferstransferstransfers/ // /physical f physical f physical f physical functionunctionunctionunction ( if applicable)Mobility:Mobility:Mobility:Mobility: Independent Chair/bed bound Requires assistance no. of staff required

Bed mobility: turns sits Weight-bearing status: none left right partial left right full left right Ambulation. Endurance.

AidsAidsAidsAids usedusedusedused:::: Walking stick/s Frame Wheelchair Prostheses ..Transfers:Transfers:Transfers:Transfers: Independent Requires assistance no. of staff requiredAidsAidsAidsAids usedusedusedused:::: Slide sheet Lifter type................... Other transfer aids type ....................

FallsFallsFallsFalls riskriskriskrisk ((((FR):FR):FR):FR): FR score Needs bed rails OtherOtherOtherOther safety requirementssafety requirementssafety requirementssafety requirements::::

PersonalPersonalPersonalPersonal carecarecarecare ( mark: A AA A = assistance needed; I III = independent; D DDD = dependent; S SSS = supervision)Bathing: Toileting: Dressing: Eating:SkinSkinSkinSkin iiiintegrity andntegrity andntegrity andntegrity and woundswoundswoundswounds ( if applicable)

Pressure areas: Braden score: Site(s): ..Appearance: Stage: Dressing: .Pressure mattress: Type: ....Other wounds: Describe: ......Sutures/staples: Date to be removed:Communication/Communication/Communication/Communication/sensorysensorysensorysensory ( if applicable)

Communication:Communication:Communication:Communication: Normal Follows directions Responds to non-verbals Speech:Speech:Speech:Speech: Normal Impaired Aphasia: expressive receptive Sign language use Vision:Vision:Vision:Vision: Normal Impaired Blind Artificial eye/s: right left Glasses Hearing:Hearing:Hearing:Hearing: Normal Impaired Deaf Aid/s: right left

Long Long Long Long----term planterm planterm planterm plan ( if applicable) Yet to be determined Home independently / services / carer Respite care Hospice Supported residential service Residential care: high-level (nursing home) Residential care: low-level (hostel)

Transitional care program: home based Transitional care program: residential Other:EnduringEnduringEnduringEnduring powerpowerpowerpower ofofofof attorneyattorneyattorneyattorney / // / administratoradministratoradministratoradministrator/ / / / guardianshipguardianshipguardianshipguardianship / / / / substitute decision makersubstitute decision makersubstitute decision makersubstitute decision maker (SDM)(SDM)(SDM)(SDM) ( if applicable)

No Required Pending Yes Name and contact details:


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References andResources


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ReferencesDepartment of Health 2009, Limited adverseoccurrence screening (LAOS): annual report 200809 ,State Government of Victoria, Melbourne.

Department of Human Services 2009,Sentinel event program annual reports ,State Government of Victoria, Melbourne,http://www.health.vic.gov.au/clinrisk/sentinel/ser.htm

Medical Board of Australia 2009, Good medical practice: a code of conduct for doctors in Australia, Medical Borad of Australia ,http://www.medicalboard.gov.au/Codes-

Guidelines-Policies.aspx

Victorian Quality Council 2009, Inter-hospital patient transfer: a thematic analysis of the literature ,State Government of Victoria, Melbourne,http://www.health.vic.gov.au/qualitycouncil/ downloads/interhospital_pt_litreview.pdf

Victorian Quality Council 2008a, Current inter-hospital patient transfer practice ,State Government of Victoria, Melbourne,http://www.health.vic.gov.au/qualitycouncil/ downloads/current_ihpt_surveyrpt.pdf

Victorian Quality Council 2008b, Themes from theVictorian Quality Council Inter-hospital Patient TransferWorkshop: group work summary , State Governmentof Victoria, Melbourne.

Resources Australian Charter of Healthcare Rights,http://www.safetyandquality.gov.au/internet/safety/ publishing.nsf/Content/PriorityProgram-01

Charter of Human Rights and Responsibilities Act 2006

http://www.legislation.vic.gov.auSafe transport of people with a mentalillness. Chief Psychiatrists guideline .http://www.health.vic.gov.au/mentalhealth/cpg/ safetransport.pdf

Clinical handover resources

Australian Commission on Safety and Qualityin Health Care, National Safety and QualityHealth Services Standardshttp://117.53.168.228/implementation-toolkit-resource-portal/interface/additional-clinical-handover-resources/acsqhc-resources-and-publications.html

New South Wales Department of Health, AustralianResource Centre for Health Innovationshttp://www.archi.net.au/resources/safety/clinical/nsw-handover

South Australia Department of Health,Safety and Qualityhttp://www.sahealth.sa.gov.au/wps/wcm/connect/ Public+Content/SA+Health+Internet/About+us/ Safety+and+quality/Communications+and+teamwork/ Communication+and+teamwork

Western Australia Department of Health, Ofceof Safety and Quality in Health Carehttp://www.safetyandquality.health.wa.gov.au/

initiatives/clinical_handover.cfm

Queensland Department of Health, Patient Safetyand Quality Improvement Servicehttp://www.health.qld.gov.au/psq/handover/html/ ch_homepage.asp

Australian Medical Association 2006, Safe handover, safe patients: guidance in clinical handover forclinicians and managers , AMA, Canberra.http://www.ama.com.au/node/4064

Victorian Quality Council handover resourceshttp://www.health.vic.gov.au/qualitycouncil/activities/

handover.htm

Legislation

Health Records Act 2001 (Vic)http://www.legislation.vic.gov.au

Health Records Act: frequently asked questionshttp://www.health.vic.gov.au/hsc/resources/faq.htm

Health Records Act: online traininghttp://www.health.vic.gov.au/hsc/training.htm

Health privacy principles,

extracted from the Health Records Act http://www.health.vic.gov.au/hsc/downloads/ hppextract.pdf

Mental Health Act 1986 (Vic)http://www.legislation.vic.gov.au

Non-Emergency Patient Transport (NEPT) Act 2003, regulations 2005 http://www.health.vic.gov.au/nept/nept-rcpp.htm


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Guide to Patient Transfer_ Web_ Revised Dec 2012

Documents

Transcript of Guide to Patient Transfer_ Web_ Revised Dec 2012