v London Health Sciences Centre Policy: HALLWAY TRANSFER PROTOCOL Policy Owner: _| Vice President, Mental Health, Emergency Services and Corporate Access & Flow | [SLT Sponsor: | Vice President, Mental Heath, Emergency Services and Corporate Access & Flow Approval By: Executive Council Approval Date: | January 31,2018 | Original Effective Date: Revised Date: Reviewed Date: Related Policy at St. Josoph’s: !tis the intent that placing patients in the hallway will be a short term measure to assist in managing the ‘needs of patients in London Health Sciences Centre (LHSC) during periods of full capacity and in response to a Code Gridlock. Clinical Inpatient Units will endeavour to place patients from the hall into suitable rooms as soon as possible. Hellway refers to any unconventional lacation that is able to ‘accommodate a bed or stretcher ‘The Hallway Transfers Protocol does not apply to the Children’s Hospital or the Inpatient Mental Health Program. TRIGGERS By 0800 hours daily, the Patient Access Team will complete an assessment of access and flow within the organization. When the following criteria are met, tie Palient Access Team will invoke the Hallway Transfer Protocol. The Hallway Transfer Protocol will also be invoked when a Code Gridlock has been triggered University Hospital Victoria Hospital Emergency Hallway Transfers from the ED will | Hallway Transfers from the ED wil Department (ED) occur when one or more of the ‘occur when one or more of the following erteria are met: following criteria are met + Middle or Back Bubble is ull |. Middle or Back Bubble is full Breventing patients in the Front |” preventing patents in the Front Bubble who have been Bubble who have been assessed assessed and dispositioned fiom | and elspositioned from being being moved feed *+ More than 3 admitted patients |. More than 10 admitted patients | ftom the Cinical Neurosciences |* fom the Mesicine Program Progrem * More than 4 admitted patients: + More than 3 admitted patients from the Surgical Program tom te Gardelogy Fogiam |More than 6 sated patentsirom the Medicine Program + More than 4 admitted patients {rom the Surgical Program Critical Care Hallway Transfers from the Medical | Surgical Intensive Care Unit (MSICU) will occur when: ‘+ More than 8 patients ready to transfer to the Clinical Inpatient Unit without bed assignments Post Anesthetic Care | Hallway Transfers from PACU will Unit (PACU) | occur when one or more of the following criteria are met: + More than 50% of the bays with patients without bed assignments + No PACU bays available and no predicted discharges from FACU within the next 30 minutes CRITERIA FOR PLACEMENT IN HALLWAY Hallway Transfers from the Critical Care Trauma Center (CCTC) will | occur when, + More than 5 patients ready to transfer to the Clinical Inpatient Unit without bed assignments Hallway Transfers from PACU wil ‘occur when one or more of the following criteria are met More than 50% of the bays with Patients without bed assignments + No PACU bays available and no predicted discharges from PACU within the next 30, minutes Patients not suitable for placement in a hallway care spot are those that: + Require isolation + Require suction + Are not alert and are uncooperative + Are currently flagged for violence or have a history of violence + Are having chest pain + Are on active telemetry + Ase actively receiving hazardous drugs + Require 02 > 4 litres per minute by nasal prong (NP) consistently for 4 hours + Are Palliative and have immediate needs for additional comfort or compassion + Have a need for frequent toileting or perineal care + Require special devices or equipment (ie. CPAP, dialysis, patient lit anticipated prior to room, placement) + Require invasive procedures (ie. Thoracentesis, lumbar puncture, chest tube placement) ordered to be completed on ward prior to anticipated roam placement (excluding ambulatory hemodialysis) + Have a confirmed discharge anticipated in the next 12 hours (for within ward hallway placement) + Are having active seizures + Have instability of the spine that has not been cleared by x-rays + Arewanderers ‘There will be a minimum of 1-2 hallway patients per Clinical Inpatient Team. The care team must have the appropriate skill set to care for the needs of the patients, ziENVIRONMENTAL CRITERIA ‘The Manager of the Clinical Inpatient Unit is accountable for ensuring the following Environmental Criteria and Fire Regulations are met prior to the transfer of hallway patients: + Allhallway patients must have a distinctive method of calling staff for assistance + Environmental assessment of unit must be done to create a safe and dedicated space for placement of patient prior to transfer + All placements of patients must be on one side of hallway along with all other items in the hall + IV pumps and other equipment must be out of the way and close to wall to prevent any potential tripping hazards, + Patients must regularly be assessed for sleep deprivation in order to prevent an incident of violence from occurring, + There shail be no obstructions to egress out or fre equipment (Fire Regulation) + Wheels of bed must be lacked + There shall be no obstructions to fire cabinets or access to fire extinguishers (Fire Regulation) ‘+ The exit width of the doonways must be maintained as you look down the corridor both ways to the ‘ext exit in both directions (most double doors have one leaf swinging in either direction so itis the exit width of one door). This needs to be wide enough to take a bed, Hallway Transfer is a temporary measure and is not to be implemented on a permanent basis. As such, the following must be avoided + Anything within the stairwell ~ stairwells must not be used for storage of any type: ‘+ Anything that cuts across the exit door itself + Any hazardous goods such as spare O, cylinders — are protected as part of standard operating procedures. + Buildup of combustibles, over full efuse bin — more regular pickup + Any equipment that prevents the door from automatically closing on alarm CLINICAL INPATIENT UNIT ALGORITHM Patients for hallway placement will be considered in the following order: 1. Onservice, on program with discharges anticipated Off service. on program with discharges anticipated (On service, on program with no discharges anticipated Off service, on program with no discharges anticipated Off service, off program with no discharges anticipated TRANSFER OF A PATIENT FROM CRITICAL CARE, ED OR PACU TO CLINICAL INPATIENT UNIT HALLWAY + The Coordinator or Charge Nurse of the CCTC/MSICU, ED or PACU with complete the criteria Checkiist and sign off thatthe patient is appropriate for the hallway. *+ The Coordinator or Charge Nurse of the CCTC/MSICU, ED or PACU will advise the After Hours Coordinator of which patient(s) have met the criteria for transfer to @ Clinical Inpatient Unit hallway + The After Hours Coordinator will contact the Coordinator, Charge Nurse or In Charge Person from the ‘most appropriate Clinical Inpatients Unit and notify them that of hallway patient(s) being received from CCTCIMSICU, ED or PACU + The Transfer of Care (TOC) will proceed as usual + The After Hours Coordinator or Patient Access Clerk will indicate in Capacity Management that the 31Clinical Inpatient Unit is ready to accept the hallway patients. + The Coordinator or Charge Nurse of the CCTC/MSICU, ED or PACU will place and transfer request in Capacity Management and wil proceed with TOC as usual ‘TRANSFER OF A PATIENT FROM A BED IN THE CLINICAL INPATIENT UNIT TO THE HALLWAY + Each day by 1500 houts the Clinical Inpatient Unit Coordinator or designate will identify two patients who meet hallway criteria, + These patients will be placed in order of preference to move to hallway if triggers met. + This information will be sent to the After Hours Coordinators and Patient Access Clerk + The Clinical Inpatient Unit team will inform the patient and/or family that this move may occur + During regular business hours, the Clinical Inpatient Unit Manager and Director will be notified prior to the transfers occurring. Outside of regular business hours, on weekends and statutory holidays the ‘Manager and Director On Call wll be notified prior to the transfers occurring, except in instances when the unit on which the transfers are occurring nave a Leader On Call model PATIENT NOTIFICATION + During regular business hours, the Manager of the CCTC/MSICU, ED or PACU wil notify the patient and/or family that the patient is being transferred to a Clinical Inpatient Unit and that intial care will be provided in the hallway, and they will be placed in a room as scan as possible For patients already (on Clinical Inpatient Units, the Manager will notify the patient andior family that the patient is beng moved to the hallway for care. + Outside of regular business hours, the After Hours Coordinator will be responsible for the notification of the patient andfor family, + Patients awaiting discharge that are being moved to a hallway willbe informed of this potential early in the day or the previous evening, and then again at the time of transfer + Patients and/or families will be provided with a letter from the hospital indicating the need and circumstances required for hallway placement, HOSPITAL NOTIFICATION + An email alert will be sent by the After Hours Coordinator to staff and physicians in the hospital to indicate that a patient has been placed in 2 hallway, REFERENCES Clinical Inpatient Unit to Hallway Patient Transfer Letter Critical Care Unit to Hallway Patient Transfer Letter Emergency Department to Hallway Patient Transfer Letter Hallway Transfer Criteria Checklist Post Anaesthetic Care Unit to Hallway Patient Transfer Letter