Royal Cornwall Hospital

Truro

Cornwall TR1 3LJ

For Life-Threatening Emergencies Call 999

© 2023 by Acute GP Service, CPFT. 

Community Hospitals

 

 

    •    08:30 - 18:30 Monday to Friday, 09:00 – 17:00 weekends and bank holidays refer via the Acute GP service

    •    Step up admission from primary care to community beds are for: 

  • a defined PURPOSE: Rehabilitation, Respite, Palliative Care/Symptom Control (vs further investigation),

  • a Robust DIAGNOSIS* and Management plan appropriate for community care

  • CLEAR COMMUNICATED CONTEXT: normal level of function, capacity, PMHx, Meds/Allergies, Social situation (POC/family situation), rehab potential, special input need (bariatric, confusion, infection risk, nursing need)

  • Who assessed the patient, and when - is there an agreed, communicated ceiling of care?

  • FORWARD PLANNING: End of life care, just in case meds, syringe driver form, expected death form, TEP form

  • ADMISSION ARRANGEMENTS: transport, referring doctor letter, drug chart, handover phone calls to be agreed

   

         *This requires a robust diagnosis where further investigation is unlikely to impact management (off legs/confused

          ?cause are not appropriate)

    

    •    Temporary nightsitter placement: there is a budget for this through the relevant HOME FIRST service, but it currently                  follows an email tendering process that makes it unlikely to be helpful in the short-term as a viable alternative to                        admission

    •    Step Down admission from ED to community beds, requirements as above plus: MAC/MAP/TTOs

    •    Once the triage assessment has been made:

  • AGP contacts Onward Care

  • Discusses suitability of referral

  • Check availability and location of community bed ie ward and contact details (below)

  • Check level at which handover is required (Dr-Dr, Dr-Nurse in charge, Nurse-Nurse 

    •    Contact referring clinician with outcome of referral and agreed steps

    •    Referring clinician to hand over patient

    •    Referring clinician to arrange transport if the admission is going to be delayed for any reason

    •    Finally, for any admission AGP to consider whether their clinical notes should be made available to receiving ward (email addresses below). this is typically good practice.

    •    Ensure notes are robust, with a clear timeline and agreement as to areas of responsibility