Transfer Policy

Version

Name of responsible (ratifying) committee

Patient Safety Working Group

Date ratified

16 February 2012

Document Manager (job title)

Operations Centre Manager

Date issued

29 February 2012

Review date

December 2014 (unless requirements change)

Electronic location

Management Policies

Related Procedural Documents

Discharge Policy, Patient Identification Policy

Key Words (to aid with searching)

Transfer; safe; timely comfortable transfer of patients;

external; internal; inter-hospital; Care; Medical
treatment; Health and safety; Occupational health and
safety; Clinical guidelines; Clinical procedures;
Administration

In the case of hard copies of this policy the content can only be assured to be accurate on the date of issue marked on the
document.
For assurance that the most up to date policy is being used, staff should refer to the version held on the intranet

Transfer Policy.
Issue 2.
29 February 2012
(Review date: December 2014 (unless requirements change)
Page 1 of 12

CONTENTS

QUICK REFERENCE GUIDE.............................................................................................................. 3

1.

INTRODUCTION........................................................................................................................... 3

2.

PURPOSE.................................................................................................................................... 3

3.

SCOPE......................................................................................................................................... 3

4.

DEFINITIONS............................................................................................................................... 3

5.

DUTIES AND RESPONSIBILITIES..............................................................................................3

6.

PROCESS.................................................................................................................................... 3

7.

TRAINING REQUIREMENTS.......................................................................................................3

8.

REFERENCES AND ASSOCIATED DOCUMENTATION.............................................................3

9.

EQUALITY IMPACT STATEMENT...............................................................................................3

10. MONITORING COMPLIANCE......................................................................................................3

Appendices
Appendix A: Transfer Checklist

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29 February 2012
(Review date: December 2014 (unless requirements change)
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QUICK REFERENCE GUIDE

For quick reference the guide below is a summary of actions required. This does not negate the need
those involved in the process to be aware of and follow the detail of this policy.
1. Transfers should normally occur between 08:00 and 22:00
2. A transfer checklist must be completed by the transferring and receiving nurse
3. All other relevant documentation must accompany the patient
4. The need for an escort must be assessed
a. Level 1, 2, 3 patients and patients whose respiratory or cardiovascular systems are
unstable must be accompanied by a registered healthcare professional
5. The need for any equipment to accompany the patient
intravenous infusions, pressure relieving aids

must be assessed e.g. oxygen,

6. All medicines and personal property must accompany the patient

7. The receiving ward must be made aware of any infection risk
8. Patients must be handed over to, and welcomed onto, the receiving ward
9. There must be adequate, appropriate and timely communication between transferring and
receiving staff and with the patient, relative or carer
10. Out of hours transfers (22:00 08:00) must be avoided unless the patients condition or
operational demands of the organisation dictate.

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29 February 2012
(Review date: December 2014 (unless requirements change)
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1. INTRODUCTION
Portsmouth Hospitals NHS Trust (the Trust) recognises that there is frequently a requirement to
transfer patients internally and externally to other healthcare providers: for the purposes of the
provision of clinical care, undertaking investigations and to facilitate patient flow. This policy
aims to facilitate the safe, timely and comfortable transfer of patients, by stipulating the types of
transfers and the escort required.
An internal transfer takes place when a patient remains under the care of Trust Health
Professionals and who is not removed from the Patient Administration System (PAS).
Patients who may require transfer within the Trust include:

Transfers to departments for investigations.

Transfers from the Emergency Department
Transfers between wards
Transfers between sites.

The principal responsibility of all staff is to maintain patient wellbeing, provide optimal care
during the period away from the principal care area/ward, report and document outcomes and
action taken.

2. PURPOSE
The purpose of this policy is to provide direction, guidance and the underlying principles for
staff to support safe and appropriate transfer of patients.
The key to safety is through risk assessment and communication. All patients undergoing
transfer must be risk assessed for clinical need during transfer by a registered nurse/midwife
who must take responsibility for providing the verbal handover of the patient to the receiving
area.

3. SCOPE
This policy applies to all groups of patients requiring transfer and to all staff who are involved in
those transfers.
In the event of an infection outbreak, flu pandemic or major incident, the Trust recognises
that it may not be possible to adhere to all aspects of this document. In such circumstances,
staff should take advice from their manager and all possible action must be taken to
maintain ongoing patient and staff safety

4.

DEFINITIONS
Diagnostic/Treatment Transfer: the movement of a patient from one service to another within
the Trust for an assessment/diagnostic procedure or treatment
Escort: any member of staff who is involved with escorting patients and who has the relevant
knowledge and skills to provide a high standard of care during the transfer; to ensure patient
safety is not compromised. An escort can be:

Registered professionals, doctors, registered nurses and midwives, operating

department practitioners

Non registered professional, healthcare assistants and other clinical support workers

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29 February 2012
(Review date: December 2014 (unless requirements change)
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External transfer: the temporary movement of a patient to an acute care environment service
external to the Trust, e.g. for investigations or interventions that, for whatever reason, cannot be
provided by Portsmouth Hospitals NHS Trust. This should not be confused with a discharge, as
the intention is that, once the investigation or intervention has been completed, the patient will
return to our care.
Internal transfer: the movement of a patient from one clinical area to another within the Trust.
For example:

For investigations
From the Emergency Department
Between wards
Between sites

Patient groups:
Adults
Level 0 Patients whose care can be met through normal ward care in hospital
Level 1 Patients at risk of their condition deteriorating, or those recently relocated from higher
levels of care, whose needs can be met on an acute ward with additional advice and support
from the critical care team
Level 2 Patients requiring more detailed observation or intervention including support from a
single failing organ system or postoperative care and those stepping down from higher levels
of care
Level 3 Patients requiring advanced respiratory support alone or basic respiratory support
together with support of at least two organ systems. The level includes all complex patients
requiring support for a multi organ failure
Out of Hours: a transfer that occurs between 2200 and 0800

5.

DUTIES AND RESPONSIBILITIES

The Operations Centre Manager is responsible for resolving any operational issues relating to
the transfer of patients, as escalated by the clinical team
The Matron is responsible for:

The day to day operational management of the Transfer Team and the development of
transfer processes to ensure they remain responsive to the changing needs of the Trust.
Escalating any unresolvable matters associated with patient transfer to the Director of
Nursing (or nominated deputy); in particular those matters relating to patient care,
patient safety and other quality issues
Escalating any operational issues related to transfer to the Operations Centre Manager
In association with members of the Transfer Team, carrying out education amongst
Trust staff to ensure they have the appropriate skills and knowledge to implement safe
patient transfer
Receiving information on all adverse incidents and near misses relating to patient
transfer
In association with members of the Transfer Team, undertaking an annual review of this
policy, to ensure it continues to meet the operational needs of the Trust and its patients.
Developing and implementing an action plan with defined timescales to address any
changes to the transfer process, as highlighted by review of the policy and/or trends
identified through adverse incidents and near misses.

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29 February 2012
(Review date: December 2014 (unless requirements change)
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Escalating any problems with the implementation of the action plan to the Emergency
Pathway Manager

Duty Hospital Manager: out of hours and in the absence of the Operations Centre Manager or
Matron/Hospital at Night service, the Duty Hospital Manager has responsibility for managing
any issues relating to patient transfer and for providing support and guidance
Transfer Team report directly to the Matron and are:

Employed to undertake the majority of internal transfers, with the support of clinical
teams and the Portering Services. The exceptions to these transfers are those required
by child health, obstetric and critical care service patients

In association with the Matron, responsible for carrying out education amongst Trust
staff to ensure they have the appropriate skills and knowledge to implement safe patient
transfer

In association with the Matron, responsible for reviewing and continually developing this
policy, to ensure it continues to meet the requirements of the Trust and its patients
The registered nurse on the Transfer Team will, in conjunction with the registered nurse
caring for the patient in the clinical area, undertake a risk assessment to ascertain by
whom the transfer should be undertaken.

Nurse Escort regardless of status, is responsible for:

Positively identifying the patient to be transferred

Ensuring all relevant documentation is completed and transferred with the patient
Confirming the correct destination for the transfer
Monitoring the status of the patient during the transfer, using the appropriate monitoring
devices
Taking all appropriate action, should the patients condition change

Ward Managers are responsible for:

Ensuring their teams are aware of the requirements of this policy

Ensuring there are operational systems in place within their teams to fulfill the
requirements of this policy at local level
Reporting any transfer issues to the relevant Modern Matron, for support to ensure the
ongoing safety of their patients

Ward Clerk
Ward Clerks are responsible for copying the patients health record, the booking of transport
and any other required administrative duties to support safe patient transfer

6.

PROCESS
Internal Transfers
Internal transfers normally take place between 08:00 and 22:00
6.1 Staffing
6.1.1 The Transfer Team will carry out the majority of transfers, within hours

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(Review date: December 2014 (unless requirements change)
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6.1.2

Porters will support the transfer process with requests submitted via the Helpdesk
(ext 6321). Urgent transfers must be requested as such, as a response time of 5
minutes from portering services is required

6.1.3

All staff involved in the transfer process are required to follow infection control
practice guidance related to protective equipment and hand hygiene

6.1.4

Ward staff are responsible for ensuring patients are suitably dressed and blankets
provided if necessary, to ensure comfort and maintain privacy and dignity

6.1.5

The receiving ward/department must ensure that a member of staff is available to

receive the patient and take handover from escort if necessary.

6.2 Escorts
6.2.1 The nurse-in-charge of the patients care will assess (Appendix A) if an escort is
required and record any such requirement in the patients health record. The
nurse-in-charge will remain accountable for the patients care at all times
6.2.2

The staff member acting as an escort must be competent to use any equipment
that is being transferred with the patient and ensure it has sufficient battery life for
the period of the transfer

6.2.3

All patients categorised as level 1, 2 and 3 require a registered professional escort

6.2.4

Escorts are required to ensure that the patients wellbeing is considered at all
times and must actively engage with the patient during the whole transfer process.

6.3 Communication
6.3.1 There must be adequate and effective communication between the transferring
and receiving ward/department
6.3.2

Ward to ward transfers between specialties will be facilitated by the nurse-incharge of the ward/department, the Duty Hospital Manager and Transfer Team

6.3.3

The nurse-in-charge of the patients care on the transferring ward must provide a
verbal telephone handover to the receiving nurse if not accompanying the patient.
Alternatively the nurse-in-charge of the transferring ward will hand over to the
Transfer Team who will then hand over to the nurse on the receiving ward

6.3.4

The escort and the ward/department where the patient is being transferred to,
whether permanently or temporarily for investigations/intervention, must be aware
of any current infection risk prior to transfer.

6.3.5

Patients will be informed at the earliest opportunity of the need for a transfer and
provided with an explanation of why the transfer is necessary.

6.3.6

With the consent of the patient, relatives, carers or others will be advised of
transfers to another ward. Note: it is not necessary to notify relatives, carers or
others when a patient is temporarily absent from the ward e.g. for diagnostic
investigations or interventions.

6.4 Documentation
6.4.1 The nurse-in-charge is responsible for ensuring that all appropriate health records
accompany the patient
6.4.2

The transfer checklist (Appendix A), which forms part of the nursing

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29 February 2012
(Review date: December 2014 (unless requirements change)
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documentation, must be completed by the nurse responsible for the patients care
at the time of the transfer
6.4.3

Patients must have an accurate patient identification band and on arrival in the
receiving ward the band must be removed and replaced with amended details: in
accordance with the Patient Identification Policy

6.5 Other
In general, when transferred, other than internally for investigations or interventions
6.5.1

All dispensed medications must accompany the patient.

6.5.2

All property must accompany the patient together with a completed property form.

6.5.3

The registered nurse is responsible for deciding if existing pressure relieving

equipment should move with the patient

Note: it may be that even for temporary internal transfers for investigations or
interventions that the nurse on the transferring ward may consider it necessary for
some medications and/or pressure relieving aids to accompany the patient.
6.6

Intravenous Infusions
6.6.1 All infusions containing drugs, including Potassium or TPN must be on an infusion
pump with appropriate battery life for the transfer and the registered professional
must have been trained and competent to use the equipment.
6.6.2

If the patient requires a continuous infusion or the infusion can not be stopped
during the transfer (advice sought from a doctor) the registered nurse responsible
for the assessment must clearly state, on the Transfer Checklist, the action
required for any ongoing intravenous infusion.

6.6.3

If close observation of the patient is required, or if drug administration is required,

a registered professional must always act as the escort for the patient. It is
acceptable for a non registered member of staff to escort a patient connected to
an IVAC infusion pump but ONLY when 0.9% saline or 5% Glucose/Dextrose
Saline or Hartmans is being administered. Non-registered staff are not allowed to
transfer patients receiving intravenous drug therapies and they are not allowed to
touch or use any infusion device. If a patient has been assessed as competent to
self administer medication by a registered professional and is using an ambulatory
infusion device then it is acceptable for a nonprofessional to act as an escort.
However, the device must have been checked by a registered professional prior to
commencement of the transfer, to ensure there is sufficient battery life and
medication for the duration of the escort.

6.7 Oxygen Therapy

6.7.1 If the patients respiratory or cardiovascular status is unstable a registered nurse
must always act as the escort for the patient.
6.7.2

The registered nurse making the assessment is responsible for ensuring that all
required information is given to the patients escort.

6.7.3

Prior to commencement of the transfer, the registered nurse must check and
ensure there is sufficient oxygen in the cylinder required for the full duration of the

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29 February 2012
(Review date: December 2014 (unless requirements change)
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transfer.
6.8 Tissue Viability
6.8.1 All patients must have a documented, up to date, Waterlow Assessment prior to
transfer
6.8.2
6.9

The registered nurse is responsible for deciding if the patient requires pressurerelieving equipment during transfer

External Transfers
All conditions and arrangements relating to internal transfers apply, plus
6.9.3 Only a copy of the health record must accompany the patient: the original must be
retained by the Trust
6.9.4 If an escort is to accompany the patient, confirmation of the return journey
arrangements for the escort must be made by the nurse-in-charge of the
transferring ward

6.10 Maternity Transfers

All maternity transfers are considered as emergencies and the maternity service works in
partnership with South Central Ambulance Trust to achieve rapid and seamless transfer
processes.
The guidelines on transfer can found on the Maternity Services Departmental webpage.
The guideline covers the transfer of mothers, babies and neonates, including process,
responsibilities, communication pathways and documentation.
6.11 Transferring the Critically Ill Patient
The transfer of critically patients is governed by the policy and procedures produced by
the Wessex Critical Care Network.
Inter-hospital transfer guidance is available on the Critical Care Departmental webpage
6.12 Out of Hours Transfers
Out of hours transfers are those that occur between 22:00 and 08:00 hours. The
arrangements as described above apply to transfers out of hours. However, it is
recognised that such transfers are far from ideal and will be avoided unless the:
6.12.1 The patients condition deteriorates, necessitating a transfer out of hours
6.12.2 The operational demands of the organisation make such a transfer unavoidable.
If an out of hours transfers is necessary
6.12.3 The nurse-in-charge of the transferring ward must risk assess all patients, to
determine which patient is in the most favourable clinical condition for transfer.
The assessment must include, but is not necessarily limited to:

Dependency of patient
Instability of condition
Behavioural risks and concerns

6.12.4 The on-call registrar/consultant may be called to identify or review patients for
suitability to transfer if the nursing teams need confirmation of suitability or are
unable to identify safe, suitable patients from a clinical perspective.
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6.12.5 The nurse-in-charge must inform the Duty Hospital Manager who will support the
transfer
6.12.6 Any decision to transfer out of hours must be clearly documented in the patients
health record
6.12.7 The relatives will be informed as soon as possible in hours, unless the patient
requests otherwise or there is an overriding clinical reason for informing them out
of hours. Any decision to notify relatives, carers or others out of hours is the
responsibility of the patients clinician

TRAINING REQUIREMENTS
7.1

Members of the Transfer Team, in conjunction with the Lead Nurse Clinical Practice, are
responsible for educating staff, temporary or substantive, to ensure they have the
required knowledge and skills to allow the safe and timely transfer of all patients across
general clinical areas

7.2

Staff from the Department of Clinical Care are responsible for educating staff in the care
and transfer of patients in and out of the Department

7.3

Carillion Management Team are responsible for training and supervising porters involved
in the transfer of patients

REFERENCES AND ASSOCIATED DOCUMENTATION

External
Medical Stability and Safe to Transfer: Department of Health (2003) www.dh.gov.uk
The transfer of frail older NHS patients to other long stay settings: Department of
Health (1998) www.dh.gov.uk
Ensuring the Effective Discharge of Older Patients from NHS Acute Hospitals. The
Stationery Office. www.nao.org.uk
Internal
Patient Identification Policy
Discharge Policy

EQUALITY IMPACT STATEMENT

Portsmouth Hospitals NHS Trust is committed to ensuring that, as far as is reasonably
practicable, the way we provide services to the public and the way we treat our staff reflects
their individual needs and does not discriminate against individuals or groups on any grounds.
This policy has been assessed accordingly

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Issue 2.
29 February 2012
(Review date: December 2014 (unless requirements change)
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10 MONITORING COMPLIANCE
As a minimum the following will be monitored to ensure compliance
Minimum requirement
to be monitored

Lead

Tool

Frequency of
Report of
Compliance

100% of transfers meet

the requirements specific
to each patient group

Operations
Centre Manager

Random audit of 50
sets of medical
records

Annually

100% of documentation
that
accompanies
a
patient
when
being
transferred is accurately
completed

Operations
Centre Manager

Random audit of 50
sets of medical notes

Annually

100% of out of hours

transfers comply with the
requirements
of
this
policy

Operations
Centre Manager

Random audit of 30
sets of medical notes
for patients transferred
out of hours

Annually

Reporting arrangements

Policy audit report to:

Page 11 of 12

and

Midwifery

Operations Centre Manager /

CSC Heads of Nursing

Midwifery

Operations Centre Manager /

CSC Heads of Nursing

Midwifery

Operations Centre Manager /

CSC Heads of Nursing

Policy audit report to:

Transfer Policy.
Issue 2.
29 February 2012
(Review date: December 2014 (unless requirements change)

Nursing
Committee

Nursing
and
Committee

Policy audit report to:

Nursing
and
Committee

Lead(s) for acting on

Recommendations

Appendix A
TRANSFER CHECKLIST

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29 February 2012
(Review date: December 2014 (unless requirements change)
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