Patient flow procedure

1 Aim

An inpatient admission to hospital may be an essential component to a person’s treatment and recovery to safely facilitate their care. The trust recognises that admission to hospital can be a stressful experience for the person, their family, friends and carers. Every effort is therefore made to ensure that the person’s admission is timely, purposeful, supportive to their needs, aimed towards their recovery, with privacy and dignity in mind and for no longer than clinically necessary.

Bed capacity both within the trust, and nationwide, is in high demand, so the management of resources must be effective and adopt a consistent approach with clear understanding of the roles and responsibilities of all involved.

The aim of this procedure is to provide clinical colleagues with a clear framework for the optimal use and safe and effective management of the trust’s beds within the adult and older person’s mental health inpatient services, both during times of ‘business as usual’ and periods of high demand within a care group or trust and country wide. It also describes the operation, roles and responsibilities of the Rotherham, Doncaster, and South Humber (RDaSH) NHS Foundation Trust’s Patient Flow team.

2 Scope

This procedure applies to adult and older person’s mental health inpatient services within the trust. The following services have their own procedures and are excluded from the scope of this procedure:

physical health wards
St John’s hospice
neuro rehabilitation services
intermediate care services
forensic services
mental health rehabilitation services
drug and alcohol rehabilitation (New Beginnings)

3 Link to overarching policy, and or procedure

Admission, transfer and discharge manual including patient flow and out of hours (OOH) procedures

4 RDaSH mental health and older person’s bed capacity

The trust has three adult mental health in-patient sites comprising psychiatric intensive care and acute services, with a current total of 104 beds and a further 63 older person’s mental health beds across the Rotherham, Doncaster and North Lincolnshire care groups.

The current configuration of RDaSH adult and older person’s mental Health beds can be found in appendix J RDaSH adult and older person’s mental health bed capacity.

5 The role and function of the Patient Flow team

The role of the Patient Flow team is to work with clinical teams and operational managers to make the most effective and efficient use of in-patient resources in agreed inpatient pathways.

The Patient Flow team will have bed management responsibility for all adult and older person’s mental health inpatient pathways in RDaSH in collaboration with clinical teams, operational managers and on-call colleagues.

The Patient Flow team operates a 7-day service with identified bed management cover for all adult and older person’s in-patient wards in scope across the whole 24-hour period.

The Patient Flow team currently consists of:

1 head of patient flow
1 patient flow clinical service manager
6 patient flow duty managers
1 patient flow officer
6 patient flow co-ordinators
1 patient flow administrator

The head of patient flow will have overall management and responsibility for patient flow in RDaSH to ensure that the highest standards of patient flow are provided to help solve immediate operational problems. The head of patient flow will work closely and proactively with the care groups to ensure a central and coordinated approach to patient flow.

The patient flow clinical service manager and patient flow duty manager will be active and core to resolving any issues that arise relating to patient flow, which can include, though not limited to – sourcing a bed (and issues related to this), difficulties with patients who are clinically ready for discharge (CRFD) but delayed, approving any referrals for trust out of area (OOA) placements and maintaining governance and oversight of those patients sent OOA both internal and external to the trust.

The primary responsibilities of the Patient Flow team are to:

identify an appropriate bed when a patient requires admission to hospital
coordinate transfers between the adult and older person’s mental Health wards
arrange all internal and external trust repatriations to the adult and older person’s mental health beds
monitor all patient admissions to RDaSH beds within scope and liaising with other trusts, ensure any non RDaSH patients are returned to their locality as soon as possible
liaise with the Infection Prevention and Control team for support in managing patient placements or transfers for patients with infections
assist and predict flow through the in-patient pathway and escalate any concerns to the clinical teams and operational managers as and when necessary
maintain proactive oversight of length of patient stay and support clinical teams to identify any potential barriers to discharge upon admission and escalate any concerns regarding those patients CRFD but delayed resolving any issues as swiftly as possible
produce patient flow or bed management related reports, sharing these with clinical teams, operational managers and senior leaders as and when required
ensure good governance and oversight of patients sent OOA both internal and external to the trust and ensure these patients are repatriated as soon as practically possible. This does not replace the clinical responsibility when a patient has a care co-ordinator or lead professional assigned

It is not appropriate for wards to arrange transfers or repatriations between themselves as colleagues may be unaware of all associated clinical issues and other potential transfers or admissions that may take priority.

On occasion, patients require ward transfer for reasons not related to locality, for example, clinical reasons, safeguarding reasons. The Patient Flow team will facilitate and authorise all transfers of this kind, taking into consideration clinical presentation, safeguarding advice, interventions used and the needs of potential receiving wards.

6 Principles of good patient flow management

There are some key principles for good bed management which are outlined below:

where possible, all patients should be admitted to their home locality
a patient should be admitted to a ward that provides the least restrictive level of care necessary
discharge planning should commence at the point of admission
a full review of patient needs and care (including activities of daily living (AODL), and infection prevention and control) should be taken into consideration when planning admission, transfer or discharge
admission, transfer, leave and discharge information must be kept up to date on SystmOne to ensure that bed occupancy can be accurately monitored. Any patient going on leave from the ward, should be recorded immediately, and updated as soon as they return
any patient who has been admitted from OOA or overseas should be repatriated at the earliest opportunity
the facilitation of early discharge by the Home-Based Treatment and Community teams should be prioritised where it is safe and appropriate to do so
concerns regarding bed access pressures and those patients experiencing delays and the reasons for this, should be monitored in daily meetings and escalated accordingly to the senior leadership team and partner organisations

Please refer to the SystmOne in-patient guides (staff access only) (opens in new window) via the following link for advice and further guidance.

7 Routes into hospital

There are only 3 lawful ways in which an assessing professional can admit a patient to hospital (without the intervention of the courts):

under the Mental Health Act (MHA) 1983 including community treatment order (CTO) and Ministry of Justice (MOJ) recalls
informally (the patient gives fully informed consent)
under the Mental Capacity Act (MCA) 2005, in limited circumstances

Where a patient lacks the capacity to consent to being admitted for care and, or treatment and they do not object to this and to any treatment they will receive for mental disorder, the patient can be admitted under either the MHA or via The MCA under best interests, but the deprivation of their liberty will need to be authorised by a deprivation of liberty safeguards (DoLS) authorisation. However, consideration should be given as to the overarching need for admission, for example, care and treatment for mental disorder, and balance which regime (MHA or DoLS) is the least restrictive. See MCA deprivation of liberty (DoL) policy for further guidance.

Note, an assessing professional is defined as a consultant, a section 12 doctor, an approved mental health professional (AMHP), a Community Treatment team (CTT) clinician of band 6 or above, a member of the home-based treatment, crisis resolution or Hospital Liaison team.

7.1 Assessments under the Mental Health Act

Assessments under the Mental Health Act will be completed by two doctors, one of whom must be section 12 approved and an AMHP.

The Patient Flow team will not allocate or book beds prior to a face-to-face assessment being made including MHA assessments. The only exception where RDaSH patient flow will reserve a bed in advance of a MHA assessment will be for an MoJ or CTO recall, or in extraordinary circumstances where the presenting urgency and risk has been escalated by the AMHP lead or service manager and this has been agreed by the head of patient flow (or the silver on call manager out of hours).

The assessing team should inform the Patient Flow team at the earliest opportunity of a planned MHA assessment pending including time of assessment and potential clinical needs. This allows the Patient Flow team to plan for a potential admission. At this stage, the Patient Flow team will not advise regarding the location of beds, but they may provide guidance on if a bed may be available within RDaSH if felt appropriate.

7.1.1 Gatekeeping

Prior to any bed being sourced, the admitting professional must ensure that all the necessary steps in the gatekeeping process have been followed.

The process of gatekeeping in mental health is the screening and approving of the decision to admit a patient into hospital. It also includes an assessment of the individuals needs and consideration of whether any identified risks and or the treatment required can be managed in the community.

A gatekeeping assessment ensures that patients are treated in the least restrictive environment possible and provides assurance that trust inpatient bed capacity is being used appropriately.

Admission to a hospital in-patient bed will only be supported where there are no safe alternatives for care or treatment within the community.

The gatekeeping process will determine if the patient’s treatment pathway is an adult or older person’s mental health ward due to frailty or physical ability.

The identified gatekeepers for adults of working age are:

Doncaster, Intensive Home-Based Treatment team.
Rotherham, Crisis team, Intensive Home-Based Treatment team and the Hospital Liaison team.
North Lincolnshire, Crisis Resolution and Home Treatment team and Hospital Liaison team.

The gatekeeping process differs for older adults. In these cases, the consultant, care coordinator or duty worker in the Older Person’s Community Mental Health team will “gatekeep”. If outside normal working hours or a transfer from the general hospital, this process may also involve the hospital liaison or Crisis team.

Once the gatekeeping process has been completed, and if a hospital admission is purposeful and required, a phone call should be made by the gatekeeper to the Patient Flow team so that a bed can be identified following discussion around the person’s needs and requirement for admission.

7.1.2 Gatekeeping for admissions under the MHA

Where a person has been assessed under the MHA and deemed appropriate for admission (either detained or to be admitted informally), this will act as the completed gatekeeping process. However, the MHA assessing team must contact the relevant gatekeeper for the patient’s locality to inform them of the assessment and to ensure involvement in the discussion for this to count as having been appropriately gate kept.

7.1.3 Gatekeeping for admissions when the patient is being admitted informally

No person can be admitted informally to an inpatient bed without having first been gate kept for admission and this decision must be clearly documented on the template on SystmOne.

Documented assurance must also be provided which shows that alternatives to admission have been explored and an admission to hospital is purposeful and the least restrictive option for the patient. This will be reviewed by the Patient Flow team prior to allocation of a bed.

Where possible a gatekeeper will be present at any 136 assessments to consider alternatives to admission when someone does not require detention under the MHA.

Note, for more information and guidance relating to gatekeeping, please refer to section 5 of the Admission to adult and older persons mental health service inpatient wards procedure.

8 Sourcing a bed

Prior to any bed being requested, the admitting professional must ensure that all the necessary steps in the gatekeeping process outlined above have been completed. If gatekeeping has not been completed and is required for admission the admitting professional will be advised to complete this task before the patient is added to the to come in list.

Once a need for admission has been identified, the patient flow bed manager will be responsible for finding a bed. To request a bed the admitting professional is required to phone the Patient Flow team on 03000 211 850.

Only requests received via a phone call will be accepted. At the time of requesting the bed the admitting professional will be expected to provide the following information as part of the request and record on SystmOne:

patient name, NHS number and date of birth
current location
legal status of the patient (MHA or informal, MCA Consent (MCA1)
the type of bed which is required, for example, adult acute, psychiatric intensive care unit (PICU), organic, functional (if a PICU bed is required, section 9.3 of this procedure will be followed)
the purpose of admission, diagnosis (if known) and the expected aims and outcomes of admission as jointly agreed by the admitting professional, the patient and their family, friends and carers (where appropriate)
medical fitness and placement considerations, for example, physical health needs, language or cultural issues safeguarding concerns and legal issues
the expected time of the patient’s arrival on the ward, how they will arrive and who will be accompanying them

The risk assessment is also to be updated by the admitting professional on SystmOne. In some cases, such as a MHA assessment which has been completed by an AMHP or if the patient is in an OOA location, it is recognised that this may not be completed. In this circumstance, the AMHP report will suffice, along with a verbal handover of any risk details or the originating areas documentation.

Prior to admission to a mental health inpatient setting, an assessment of a patient’s physical health care needs (including relevant blood tests and physical examination for patients over the age of 65) must take place, as it may be clinically necessary for them to be admitted to a general hospital in the first instance. This may require use of MHA (1983) to detain the patient to the acute general hospital. Prior to transferring to a mental health inpatient bed from an acute general hospital setting, a final physical healthcare review must have taken place within 24 hours to ensure the patient is medically fit and the receiving team are informed of any specific physical healthcare needs or adaptations required to support the patient on arrival and throughout their stay.

The patient flow bed manager will then advise the admitting professional of the bed availability and liaise with the ward to confirm admission. It is the responsibility of the admitting professional to contact the nurse in charge of the ward where the patient will be admitted to provide a thorough and comprehensive handover prior to the patient arriving at the ward.

9 Bed allocation

On notification that a patient requires admission into a RDaSH bed, the patient flow bed manager will determine the named Integrated care board (ICB) for the patient in the electronic patient record (SystmOne). This can be located within the general practitioner (GP) details section of the patients record.

Admission should only be agreed if the patient’s ICB is within the RDaSH footprint unless a pre agreement or extenuating circumstance has been discussed with the head of patient flow, for example, the person being admitted is a colleague of another trust or mutual aid arrangements have been approved.

Where the ICB is unclear, or there is a discrepancy please refer to the “who pays guidance” which will support decision-making regarding admissions. A copy of the who pays guidance (opens in new window) can be found through the link.

Once the patient has been confirmed as an RDaSH ICB funded patient. The patient flow bed manager will take clinical and demographic details to allocate an appropriate clinical pathway bed for that patient to be admitted.

The decision on pathway allocation will usually be reached through discussion of clinical needs with referrers, but final decision on pathway allocation rests with the patient flow bed manager (in consultation with the relevant inpatient team as and when necessary) as they have all the up-to-date knowledge of bed state and associated issues across the trust.

The patient flow bed manager will utilise a standard approach to ensure that patients are allocated beds in their own locality or close to that locality and that admissions are allocated evenly across the trust’s resources.

In the first instance, admission should be directed towards an available bed within the relevant care group, dependent upon risk assessment and suitability. The patient flow bed manager will be responsible for liaising with the nurse in charge (NIC) of the relevant ward and agreeing admission considering any issues or concerns re acuity, safeguarding, infection prevention and control and safe staffing levels.

In circumstances where the person to be admitted is or has been a member of the armed forces, the trust should comply with the Armed Forces Covenant (opens in new window).

The principles of which are:

the armed forces’ community should enjoy the same standard of, and access to healthcare as that received by any other UK citizen in the area they live
family members should retain their place on any NHS waiting list, if moved around the UK due to the service person being posted
veterans should receive priority treatment for a condition which relates to their service, subject to clinical need
those injured in service should be cared for in a way that reflects the nation’s moral obligation to them, by healthcare professionals who have an understanding of the armed forces culture

In practice point 3 above means that if you have two patients with the same level of clinical need, but the mental disorder of one is caused by service, they should be given priority for the bed. Point 4 means that a patient can request to be admitted under a team or clinician with armed forces expertise or decline to be repatriated away from such.

Patients must always be cared for in an environment that meets their clinical needs and is safe for all. In most cases, adults under 65 years of age are admitted to an adult mental health ward. Adults over 65 years of age are usually admitted to an older person’s mental health ward. However, there may be situations where it is more appropriate to admit to an alternative ward. There must be sound, clinical rationale for this, and it will be recorded on the patient electronic record (using the clinical frailty scale on SystmOne).

Some clinical examples may be.

a person over the age of 65 but currently under the care of an adult mental health community team
a person under the age of 65 but who meets the frailty criteria as proposed by the admitting professional and approved by the patient flow team in relevant consultation with the inpatient clinical team

Patients under 65 should not be admitted to an older person’s ward purely to manage bed pressures and the converse is true of people over 65 being admitted to an adult ward as doing so can introduce unnecessary risks to both patients and colleagues.

9.1 Frailty criteria

When there are concerns relating to frailty, to assist with determining which inpatient service to admit a patient to, the admitting professional should refer to the Rockwood frailty scale (appendix U). This is an easy-to-use guidance tool to support decision-making which covers general principles of frailty and its applicability to under 65’s which are typically seen in an older adult population. We will the tool to determine environmental suitability for the most appropriate inpatient care, rather than the nature of other interventions, which are individually care planned.

Patients who score 5 or below should be considered appropriate for admission to a ward for adults of working age (under 65 years) and patients scoring 6 should be considered appropriate for admission to a ward for older adults (over 65 years).

In addition to the bed referral form, the patient flow bed manager will complete the frailty score and enter this on SystmOne, taking all necessary clinical information from the admitting professional. In hours, patient flow will liaise with the relevant clinical team regarding the score and a joint decision will be made. Out of hours this will be discussed with the nurse in charge of the ward ensuring the nurse has all the relevant clinical information re that patient so that an appropriate decision can be made.

If there is a dispute regarding the frailty score or concern regarding the purpose or appropriateness of the admission to the identified ward, in hours the inpatient responsible clinician or relevant deputy will be consulted and where necessary a multi-disciplinary team (MDT) discussion will take place between the inpatient and community teams before the bed is allocated. Out of hours, the patient flow duty manager will liaise with the on-call consultant and a joint decision will be made considering all the relevant clinical information.

Following admission, if the appropriateness of the bed allocation is disputed by the inpatient clinical team, the patient electronic record will be reviewed and the bed management form on SystmOne referred to as this will provide the rationale for the admission. Where necessary a joint MDT discussion in hours will then take place between the relevant service and where necessary the patient will be reassessed and transferred to the most appropriate environment. Any lessons learnt will then be shared and actioned accordingly.

9.2 Admission and transfer of people living with dementia

Out of hours a person living with dementia presenting in acute onset crisis must have a physical health care review in the most appropriate setting prior to any assessment under the mental health act to rule out any physical causes for deterioration. The patient flow bed manager will seek assurance from the admitting professional and check the patient’s electronic record (where applicable) that all necessary physical healthcare investigations have been completed and that the patient is medically optimised for admission before a bed is allocated. This applies for all patients living with dementia regardless of setting.

Admission to hospital or transfer between inpatient services for those patients with a diagnosis of dementia should occur as a planned purposeful admission or transfer within core working hours of the specialist community or mental health team to avoid unnecessary harm and destabilisation. People living with dementia should not be transferred at night unless there is a risk to self or others and this rationale is evidenced within the patient electronic record.

Some clinical examples may be:

the patient in accident and emergency (A and E) and has 2 medical recommendations for detention and an AMHP has completed the application (if a bed has been identified)
the patient is in a care home and continues to present with behaviours which challenge and cannot be managed safely
the patient is at home, there are significant safety risks, and the patient has 2 medical recommendations for detention and an AMHP has completed the application (if a bed has been identified)

Any referrals relating to inpatient admission for a person living with dementia under the age of 65, must have a frailty assessment completed to determine the most suitable environment. A diagnosis of dementia does not automatically mean a bed will be allocated on an older person’s ward.

9.3 Consideration of bed allocation on a PICU ward

When a clinical team feels that transfer of an existing inpatient to PICU is clinically necessary, or when a patient is assessed and due to their risk requires admitting directly to a PICU ward, part A of the PICU referral form will be completed on the patient electronic record by the admitting professional or MDT representative who will then notify the Patient Flow team that this has been completed.

The Patient Flow team will ensure all the necessary information is contained in the referral form and will inform the relevant PICU ward that the referral requires screening, and the outcome will be recorded in part B of the referral form. It will be usual for clinicians in the receiving pathway to agree any such referrals to a PICU environment.

The Patient Flow team will maintain oversight of any transfer to a PICU ward. The exception to this, is when patient need, and safety will be compromised if the transfer is not made immediately. A copy of the PICU referral form and PICU flow chart (staff access only) (opens in new window).

9.4 Dispute resolution

Within normal working hours, disputes within Adult and Older Person’s Mental Health Services over admission where a bed is available should be referred to the Head of Patient Flow for a final decision. Disputes between services should be escalated to the Patient Flow Clinical Service Manager in the first instance to arrange an urgent conference call between Modern Matrons or Service Managers to reach an agreement. If the dispute remains unresolved, it should be escalated to the relevant Care Group Senior Leadership Team and Head of Patient Flow.

Out of ordinary working hours, disputes should be reported to the silver on-call manager via the patient flow duty manager. The final decision rests with the silver and gold on-call manager, with clinical advice from the on-call consultant if needed.

10 Action if or when all inpatient beds are occupied

Due to the nature of adult mental health and older person’s mental health care provision, there will be occasions where the demand for inpatient beds outweighs the number of beds that are available. During normal working hours, modern matrons and ward managers are responsible for monitoring ward occupancy levels and liaising with the Patient Flow team.

To assist with sourcing an inpatient bed when there is no availability, the following steps should be taken.

10.1 Consideration of patient transfer

If the patient to be admitted, or a patient who is already on the ward can be transferred to another ward on site, within the locality or the wider trust based on meeting the frailty criteria and clinical judgement then this should be actioned. This would then make a bed available for the patient requiring admission.

Consideration of transfer to another ward or locality to create capacity must only be done where clinically indicated. Clinically indicated transfers may include:

a patient who has been referred for, or would benefit from, transfer to a rehabilitation and recovery ward
a patient who meets the admission criteria to an adult or older person’s ward
admission to a crisis house is deemed appropriate

The following should be considered:

the legal status of the patient
the patient’s view on the transfer
the receiving wards clinical view on the suitability of transfer
the patient’s risk profile
the impact on the patient’s recovery and the views of family or carers
any safeguarding issues
any infection prevention and control issues

The transfer of a patient will be coordinated by the Patient Flow team however, it is the responsibility of the ward manager or NIC to ensure all relevant information is handed over to the receiving ward, including all identified risk factors by completing the trust patient transfer checklist. The nurse in charge will send the checklist to the receiving ward who will complete the receiving ward section.

No transfers should take place between the hours of 10pm to 7am unless there is an exceptional circumstance which is recorded in the patient’s electronic patient record and agreed by the on-call consultant.

10.2 Use of a leave bed

If no patients are suitable for transfer, then the use of a leave bed will be considered.

Prior to patients going on leave, the clinical teams will consider the needs and risks of the patient to determine whether the bed can be utilised for another patient. If the clinical team have concern regarding the leave this should be classified as a red leave bed and the bed should not be used.

The criteria below is guidance for professionals as to when a bed should be recorded as red.

Leave bed should not be used:

for the first episode of leave
when the patient is on leave for less than 48 hours to their own home or a physical health acute hospital setting
when a patient is subject to MOJ restrictions
concerns are being expressed by family or carers or community team about risks or progress on leave that have not been addressed and resolved by the MDT
there has not been any verification of progress on leave from others involved in care where relevant
home environment or leave destination is not suitable for community management
when the view of the clinical team is that there is a significant risk that the patient may suddenly and unexpectedly return from leave

Things you might consider to determine significant risk may include:

previously failed leave
use of illicit substances that resulted in marked deterioration in mental state
refusal to return from previous leave
previous non engagement with agreed leave care plan
a notable deterioration in mental state during previous leave or an increase in self-injurious behaviour whilst on previous leave

All beds of patients that are utilising overnight leave must be clearly documented on the patient’s electronic record (SystmOne) by the ward MDT to assist the Patient Flow team in bed allocation and prevent unnecessary OOA admissions.

The Patient Flow team are to receive twice daily updates in the morning and afternoon handover meetings from the care groups regarding each current ward position to enable an understanding of the whole trust position.

10.2.1 Good practice guidelines relating to the use of leave and management of beds

The timing of leave should be carefully considered for factors including, but not limited to, the purpose of leave, the timing of clinical review upon return, the impact of missing therapeutic ward activity and availability of community support (including carers, family and community services).
Leave beyond 7 or more Days would be unusual, however instances where leave exceeds 7 or more days the use of the leave bed must be considered.
Where the patient on leave is detained under the MHA consideration should be given to any relevant restrictions and conditions around leave requirements and the implications of extending leave.
MDTs should extend existing leave periods or bring forward planned leave (unless there are any barriers preventing early leave) when it is appropriate to do so, to enhance bed capacity, ensuring that the patient, family or carer and relevant community team are able to offer additional support.

Other alternatives to create flow will be considered by the MDT and the following options should be explored and communicated where necessary to the Patient Flow team by the modern matrons:

extending existing leave periods where this is clinically safe and appropriate, ensuring that the patient, family or carer and relevant community team are aware and able to offer additional support
bringing forward planned leave where this is clinically safe and appropriate, ensuring that the patient, family or carer and relevant community team are aware and able to offer additional support
early discharge might be considered where clinically safe appropriate. Where a patient is subject to section 3, 37, 45, 47, 48 and has aftercare entitlement under section 117 of the MHA then a section 117 aftercare meeting should be arranged first

10.3 Out of area (OOA) placements, RDaSH patients

In extreme circumstances, when clinical demand for an in-patient bed exceeds the trust bed stock availability, RDaSH patients may need to be accommodated in an OOA hospital placement, either in an alternative NHS setting or in the private sector.

An OOA placement is defined when, a person with assessed acute mental health needs, who requires an inpatient care, is admitted to a unit that does not form part of their usual local network of services. This means an inpatient unit that does not usually admit people living in the catchment of the person’s local community mental health service, and where the person cannot be visited regularly by their families, friends, carers and loved ones, and care co-ordinator or Lead Professional to ensure continuity of care and effective discharge planning.

An RDaSH patient will ordinally be placed in an OOA NHS provider placement when mutual aid has been agreed from a neighbouring trust or due to the patient presenting in crisis to another NHS provider.

An RDaSH patient may be placed in a bed in the private sector if the trust have subcontracted the bed or, due to no bed availability, the trust have had to spot purchase a bed. The Patient Flow team will have the most up-to-date information for bed availability for private providers.

Once a potential bed has been identified, it will be the responsibility of the patient flow bed manager to contact the provider and complete the referral paperwork. It is the responsibility of the admitting professional to ensure that all supporting documentation, the risk assessment and AMHP report (where necessary) is up-to-date and accurate before the referral is sent for processing.

Within working hours (Monday to Friday, 9am to 5pm) the head of patient flow will be consulted and provide authorisation for any OOA placement. Outside working hours the patient flow duty manager will undertake the necessary assurance checks that all other available options have been exhausted, admission OOA is therefore appropriate and will be responsible for processing the referrals. The patient flow duty manager will inform the head of patient flow of the admission via email including the rationale for the decision and complete an IR1 the head of patient flow will share the rationale with the relevant care group leaders, the next working day.

Please see appendix L which outlines the process for arranging and authorising an adult mental health or older persons OOA placement.

The RDaSH Patient Flow team will inform the responsible ICB after placing an RDaSH patient OOA by completing the ICB notification template.

Once the patient has been admitted, it is the responsibility of the patient flow officer to complete the OOA placement questionnaire on SystmOne. For patients formally admitted under the MHA, the admitting professional must ensure that the MHA paperwork reflects the correct unit being admitted to.

Should a patient refuse an admission to an OOA placement then the involved clinical team in conjunction with the patient flow duty manager, matron or service manager should be involved in decision-making in regard to next actions. Consideration should be given to the patient’s capacity, their reason for refusal and the alternative safe strategies that can be utilised to support the patient until a local bed is available.

The Patient Flow team will maintain oversight of OOA placements to ensure that:

the OOA questionnaire’s on SystmOne are completed and accurate.
the OOA power BI dashboard on Re-portal is aligned to all known current OOA placements
contact is maintained with the clinical team of any patient in an OOA placement at least once a week
any patient that exceeds 30 days in an OOA placement will be visited by the Patient Flow team for the purpose of quality, assurance, and patient experience
senior managers within the trust are informed of the number of OOA placements and the plans to repatriate

Please see appendix Q adult mental health and older persons out of area (OOA) placement monitoring process for the oversight of the monitoring requirements for all patients placed in an OOA placement.

The Patient Flow team will be responsible for coordinating the return of any OOA hospital placement to an RDaSH bed or another clinical service at the earliest opportunity. Prior to the patient returning from OOA the Patient Flow team will liaise with the private provider to ensure the ward transfer checklist is completed and sent to the receiving ward before transport is arranged so the receiving clinical team has all the relevant clinical information regarding the patient and the repatriation confirmed. The transport will then be arranged by the ward currently caring for the patient and they will be responsible for providing a verbal handover to the receiving ward. The funding of transport will be the responsibility of the identified care group.

Prior to a detained patient being returned from OOA the patient flow bed manager will notify the appropriate RDaSH MHA office of the proposed transfer and check that all the necessary paperwork relating to the section along with the form H4 to formally transfer detention under the MHA has been completed and will accompany the patient.

Note, the objectives set out in the NHS Five Year Forward View (2015) and NHS Long Term Plan (2019) states that out of area placements will essentially be eliminated for acute mental health care for adults by 2021.

Some patients choose to have their care facilitated out of area or require a specialist placement to meet their needs, for example, secure, male only or locked rehab services. As RDaSH is not commissioned to provide these services they are outside the scope of this procedure.

10.4 No trust or private provider bed availability

Where there are no trust or private provider beds available nationally, within hours, the head of patient flow will escalate to the Care Group Senior Leadership teams and the chief operating officer.

Out of hours, the silver on-call manager should escalate to the gold on-call manager who will then contact the ICB or NHS England to seek advice.

Should we have a patient who requires admission, and a bed cannot be identified by following the guidance in section 10.1 to 10.3 above, admission to a red leave bed or holding the patient (under section 140) in the health based place of safety (section 136 Suite) will be considered.

10.5 Use of a red leave bed

In extreme and exceptional circumstances and only when all the options outlined in the sections above have been explored and unsuccessful, the decision to admit a patient to a red leave bed may be made. Authorisation to do so has to be provided by the relevant Care Group Senior Leadership team (in hours) or the gold on-call via the silver on-call manager out of hours in consultation with the on-call consultant.

Admission to a red leave bed will only occur when there are no suitable beds available trust wide and should consider the following:

identified levels of clinical risk and the impact on these if admission is not facilitated
the patient’s liability to detention under the MHA
family and social support and level of carer burden if the admission is not facilitated

If the decision is made to admit a person to a red leave bed, there should always be at least one red leave bed remaining across the trust. If a red leave bed is admitted into, an IR1 should be completed by the receiving ward.

10.6 Section 140 Provision

10.6.1 Section 140 definition

Integrated care systems or local commissioners at place and local authorities are responsible for commissioning mental health services to meet the needs of their areas.

Under section 140 of the Mental Health Act 1983, local commissioners at place have a duty to notify local social services authorities (LSSAs) in their areas of arrangements which are in force for both:

the reception of patients in cases of special urgency
the provision of appropriate accommodation or facilities specifically designed for patients under the age of 18

The act refers to reception into a hospital, not specifically to a bed.

10.6.2 Special urgency definition

The term ‘special urgency’ is a situation where a person experiencing a mental disorder is so acutely unwell that failure to urgently admit the person to hospital under the MHA or an excessive wait for a bed could cause significant harm, trauma, health issues or potential death of the patient, those assessing the patient or other members of the public.

The need for special urgency must be based on a current medical examination by a section 12 approved doctor or other doctor in consultation and agreement of a consultant psychiatrist (applicable to both detained and informal patients) due to their severe mental disorder.

The decision maker in respect of whether a case meets the “special urgency” criteria will be the section 12 doctor or consultant psychiatrist who may consult with the AMHP in cases of MHA assessments to determine urgency and risk. The assessment may also include consultation with the clinical colleagues normally involved in the person’s care, police or ambulance colleagues in attendance or crisis home treatment teams.

Where a MHA assessment is not required, the urgency and risk will be assessed through the gatekeeping process. In all cases this will be approved by the clinicians detailed above, following a current risk assessment.

The following is not an exhaustive list but is proposed as guidance for the identification of ‘special urgency’ for adults under section 140:

an episode of immediate life-threatening self-harm or severe suicidal intent and clearly identified severe mental disorder signs and symptoms
acute and severe mental disorder in a community setting with other high risk factors, for example living alone with lack of engagement with community teams, non-concordance with treatment including medication, self-neglect, active agitation and, or thoughts of self-harm or harm to others
patient with such severe mental disorder that they lack capacity to carry out activities of daily living including self-care and who present with severe self-neglect, for example showing features of dehydration or sustained food refusal
patient showing features of relapse of mental disorder and presenting with a serious risk of significant harm to others, with other high-risk factors including non-concordance with medication, disengagement from services, carrying weapons and, or making threats to harm others

If the criteria for special urgency is met, the admitting professional must advise the patient flow bed manager of the name of the doctor who has assessed and approved this. The rationale should also be in the electronic patient record (EPR).

Note, children and young people (under 18 years of age) are always assumed to be in ‘special urgency’ regardless of the situation, though decision-makers should always consider whether there are less restrictive options as alternatives to detention under the act.

10.6.3 Exclusion criteria

Where patients meet any of the criteria outlined in section 10.6.2 but are already in a place of safety, A and E or in police custody ‘special urgency’ may not apply if a clear plan is in place to manage risks to self and others.

Acute presentations requiring hospital admission or detention under the MHA would not, on their own, be deemed cases of ‘special urgency’.

10.6.4 Section 140 provision for adults or older persons

For the reception of adults and older persons in cases of special urgency, the inpatient wards as detailed in appendix J RDaSH adult and older persons mental health bed capacity are available.

If there are no available or appropriate beds within the above listed provision, it may be necessary to procure a bed with an alternative provider. This could be with an alternative NHS trust or with a private provider as detailed in section 10.3.

Where no bed can be sourced in a timely manner, the trust will receive adult or older person’s into the section 136 suites (subject to availability) in cases of special urgency as defined above.

10.6.5 Section 140 provision for children and young people under the age of 18

RDaSH is not commissioned to provide inpatient services for children and young people under the age of 18.

The commissioned inpatient services for children and young people in Doncaster, Rotherham and South Humber are as follows:

South Yorkshire ICB, The Becton Centre, Sheffield
North Yorkshire and Humber ICB, Inspire, Hull

Therefore, all under 18 admissions for the purpose of section 140 should be referred to these services.

11 Management of patient flow

11.1 Clinical responsibility

Once a patient has been admitted to another care group, their care becomes the responsibility of the clinical team on that ward and will remain with them until the patient is discharged or transferred back to their home locality. It is the responsibility of the care coordinator or lead professional from the patient’s home locality to maintain contact with the patient at least once a week, whilst they are on another care group’s ward.

For patients in OOA specialist placements, responsibility for liaison and clinical updates lies with the care coordinator or lead professional. All clinical updates and liaison are to be documented clearly on SystmOne.

11.2 Patients clinically ready for discharge (but delayed)

To ensure a collective understanding of what we mean by a delayed discharge and enhance partnership working across multiple organisations, NHS England has produced a national definition of ‘clinically ready for discharge’ for mental health inpatients, to replace the previous delayed transfer of care (DToC) reporting.

A patient is clinically ready for discharge (CRFD) when:

the MDT conclude that the person does not require any further assessments, interventions and, or treatments, which can only be provided in the current inpatient setting

To enable this decision:

there must be a clear plan for the ongoing care and support that the patient requires after discharge, which covers their pharmacological, physical health, psychological, social, cultural, housing and finances, and any other individual needs or wishes
the MDT must have explicitly considered the patient and their chosen carer(s)’ views and needs about discharge and involved them in co-developing the discharge plan
the MDT must also have involved any services external to the trust in their decision-making, for example, social care teams, where these services will play a key role in the person’s ongoing care

Working in collaboration with all relevant MDT’s, the Patient Flow team will maintain oversight of any patients identified as CRFD (but delayed) and ensure that patients are assessed for supported discharge on an ongoing basis. Suitable patients should be referred to home treatment or community teams according to the early discharge protocol.

The Patient Flow team will work closely with patient flow co-ordinators on the wards to identify and solve issues preventing discharge from hospital.

MDT’s, care coordinator’s or lead professional’s and the Patient Flow team will work with all agencies involved with these patients to minimise delays and facilitate transfer as quickly as possible

12 Exceptional clinical issues relating to patient flow

12.1 Support for AMHPs and community teams when making decisions in situations where no beds are immediately available

This guidance is designed to provide support and information to AMHPs when making decisions in relation to scenarios where no bed is immediately available for a person being assessed under the MHA.

Each situation will differ and should be considered on a case-by-case basis. Support can also be sought via other AMHP colleagues, the AMHP Lead and other on-call colleagues if discussion and joint decision-making is required.

AMHPs have a legal duty to consider all requests for a MHA assessment under section 13 of the MHA.
A blanket stance of not acting on a request would be in breach of this duty; therefore, consideration and triage of the request must take place, whatever the resources. However, it may be necessary and justified in some circumstances to delay the interview element of the assessment, but this must not be solely down to the lack of a bed if, had there been one, it would have gone ahead. Examples of such circumstances to delay may be the person is likely to abscond, harm themselves or others as a result of the assessment. The reasons for the decisions to delay should always be recorded by the AMHP.
Once the need for a hospital admission has been established, it is important that all parties work cooperatively to help make the necessary arrangements for the patient. A bed will always be sourced for patients when needed, however if this is not immediately available, the AMHP, the assessing doctors and others involved in the process (including carers) should work together to formulate a safety plan to manage the risk whilst continued efforts are made to source an inpatient bed by the Patient Flow team.
The referrer and other relevant health colleagues (for example, care co-ordinator, Dr, Crisis and Home Treatment team) will need to retain their usual responsibilities for supporting the person whilst the request is considered and coordinated.
Part of the role of an AMHP (once a decision has been made to pursue hospital admission) is to make the necessary arrangements for the conveyance of the person to hospital. If a hospital bed is not immediately available, it will not be possible for the AMHP to complete the assessment process or indeed to make an application in respect of the involved patient. This also applies in cases of special urgency.
If there is significant concern or historical evidence that the act of carrying out a MHA assessment will trigger an extreme reaction (for example, aggression or violence) that would present a risk to those in attendance or the person themselves, then consideration should be given to request Police attendance or apply for a s135(i) warrant to manage the assessment in a more contained fashion, if the criteria for this are thought to be met.
The safety and well-being of the person and those around them is the responsibility of all those mental health and social care professionals involved in their care and support and these responsibilities do not end when a MHA assessment is requested or carried out.

12.2 Process to follow when a request for a MHA assessment is made or completion of a MHA assessment and no bed is currently available and one is not likely to be available imminently

A joint risk assessment of the situation for patients in the community and acute general hospital settings with the relevant health and social care colleagues involved in the patient’s care including AMHP’s, crisis, Home Based Treatment and Hospital Liaison teams will need to be undertaken.

Information from this risk assessment will be used to develop a safety plan which must be documented on the patient’s electronic record and shared with the relevant health and social care colleagues who will be supporting the person in the interim period. Details of the safety plan must be shared with the RDaSH Patient Flow team by the admitting professional and the relevant team who are providing support for the patient to maintain oversight of the safety plan in the interim period.

Decisions about what to inform the patient and where relevant their family, friend or carers at this time are to be considered on a case-by-case basis but where possible AMHPs should aim to be open and honest about what support is planned and how it will be monitored and coordinated. Contact details for the relevant services are to be shared or support or information. This needs to include advice to contact emergency services 999 if there is an immediate risk to life or limb.

The AMHP will ensure medical recommendations are stored safely where they can be accessed later:

for people on medical wards or in custody place within person’s notes
for people in the community, place with Crisis team or Home-Based Treatment team other 24hr accessible place (it is recommended to designate an agreed place in each locality for this purpose)
ideally also ensure copies are scanned up to the person’s record so they can be used electronically if required.

If the assessing AMHP is willing to be contacted outside their shift to make an electronic application in the event of a bed becoming available, then please make AMHP colleagues aware in order that they can avoid a repeat assessment and instead proceed on the basis of this application. There is no expectation for AMHPs to do this.

Feedback should be provided to AMHP team colleagues on the current situation and where the relevant information or papers can be found.

The type or level of mental health care available to the patient awaiting the allocation of a bed, cannot be insisted by the AMHP service. The law is clear that an AMHP cannot be expected to address the delay themselves, the responsibility rests with all mental health services. The AMHP service should work collaboratively with all parts of the service to minimise the risk and distress to the patient and others.

12.3 Unplanned admissions of non RDaSH patients

On occasion, patients from other NHS trust areas will present to RDaSH services and require hospital admission. If RDaSH services complete an assessment for a patient from another locality (outside RDaSH Trust), it is the responsibility of the admitting professional to liaise with patient flow who will then notify the relevant trust that we have assessed their patient and they require admission. The Patient Flow team will liaise with the admitting professional and the patients’ home area to make the most appropriate plan to meet needs and safety.

The patient should be admitted to their home area but when this is not possible or regarded as unsafe, in extreme and exceptional circumstances the patient will be admitted to a RDaSH bed (if available) and repatriated to their home area as soon as possible.

If the home area does not have a bed (assuming the person is fit to travel) and there is no bed available within RDaSH, the patient flow bed manager, will get written confirmation in an email that the patient’s home area will fund the bed. Attempts will then be made to source an OOA placement. As the admitting professional will be with the patient and having completed the most recent assessment, it may be necessary to contact the home area for collateral information. When completing the funding form all relevant details for the home area as this will go on the form for payment of the bed and any transport arranged.

The RDaSH Performance team will collect information on all OOA activity (incoming and outgoing) and report to relevant stakeholders on issues and trends.

The RDaSH Patient Flow team will liaise with the trust finance department to ensure that all recharges are accurately processed.

12.4 Non RDaSH patient in A and E

There may be an occasion whereby a non RDaSH ICB patient is assessed in A and E and requires admission. On this occasion it is the responsibility of the patient flow team to:

identify the appropriate patient flow or bed management team of the patient’s home locality and notify them of the patient requiring admission
the patient flow team will obtain the home locality’s bed management and escalation contact details and share this with the admitting professional and appropriate team within RDaSH and where necessary the local acute trust caring for the patient
share the contact details via the system co-ordination centre (SCC) for any escalations between the A and E department and the receiving trust to take place

When this is complete the patient flow team will relinquish their responsibilities.

It is the responsibility of the admitting professional to maintain contact with the identified trust regarding bed availability.

If the patient is detained under section 136 and reaches 18 hours without a bed identified, escalation to the RDaSH patient flow team is required to discuss contingency planning and the options available until a bed can be sourced within the patient’s home locality.

12.5 Care of children and young person’s with a mental disorder

12.5.1 16 to 18 years

Whilst it is accepted that the admission of a young person to an adult mental health ward should not occur as the trust is not commissioned to provide these services, there may be exceptional circumstances in cases of urgent necessity and the absence of satisfactory immediate alternatives where in the short term, this may need to occur for a young person suffering from mental disorder between the ages of 16-18 years.

Prior to assessment the assessing team must refer to the Children and Young People’s Crisis team who operate 24 hours a day, 7 days a week and cover trust wide receiving referrals for young people under 18 presenting with a mental health concern, who may pose a significant risk to self or others. Referrals can be made 24 hours a day, 7 days a week by phoning single point of access (SPA) on:

03000 218996, option 2 (mental health services) followed by option 1 (urgent)

Please have all demographic information, circumstances of presentation and any other key information to hand.

Non-urgent phone number for professionals, Monday to Friday 9am to 5pm, 03000 213101.

During the assessment of any young person, to decide whether admission to an adult acute mental health ward is appropriate, the following must be considered:

under what grounds they will be admitted.
what, if any, treatment plan is appropriate; and
how any needs the young person has will be met during the admission.

An adult mental health ward will only be used if:

No specialist tier 4 child and adolescent bed can be secured

and

it is an emergency situation with admission to an adult acute mental health ward or the health-based place of safety (section 136 suite) being the only safe option

If the patient is not admitted under the MHA 1983 the patient’s capacity to consent to the admission must be considered. If the patient lacks capacity and the “acid test ” is met parental responsibility cannot be relied on to consent to the deprivation of liberty and an urgent application will need to be made to the Court of Protection to authorise the deprivation of liberty. The MCA lead or MHA Manager should be consulted in these cases.

The assessing team will contact the Patient Flow team and the child and adolescent mental health services (CAMHS) crisis and intensive community support service manager.

When making this call, the assessing service will provide the following details:

name of the patient
age of the patient
reason for admission
the child or young person’s ability to consent or not to the admission
details of any safeguarding children concerns
any identified risks
child protection status
the reason why an admission to an acute general hospital is not appropriate
the alternatives to admission to an adult acute mental health ward that have been explored and a rationale as to why these are not suitable or available

During core working hours, the CAMHS clinician must seek authorisation from the relevant Care Group Senior Leadership team to admit into an adult mental health bed or if deemed more clinically appropriate, the health-based place of safety (section 136 suite).

Out of hours authorisation will be sought from the gold on-call via the silver on-call manager to admit into an adult mental health bed or the health-based place of safety (section 136 suite).

In circumstances when this occurs an IR1 must be completed by the receiving ward or section 136 suite and the CQC notified (via the local MHA Office).

If the decision has been made to care for the child or young person in the health-based place of safety (section 136 suite), this will remain closed for the duration of the placement and the local police force notified of the closure (as per section 136 closure procedure).

12.5.2 Under 16 years

There should be no circumstance in which a patient under the age of 16 will be admitted to an RDaSH Adult mental health bed or the section 136 suite.

A patient under the age of 16 should be admitted to a tier 4 age appropriate CAMHS unit or the paediatric ward at their local Acute General Hospital Trust.

For further guidance regarding CAMHS admissions please follow the links below:

care and treatment of children under the age of 18 on adult acute mental health inpatient areas policy
children and young people’s mental health service (CAMHS) out of hours service standard operating procedure

12.6 Patients with a diagnosis of learning disability and or autism

12.6.1 Definition

A learning disability (LD) is currently defined by the DSM-V as limited functioning within social skills, conceptual skills and practical ability. With the ICD-11 stating ‘, a condition of arrested or incomplete development of the mind, which is especially characterised by impairment of skills manifested during the developmental period, which contribute to the overall level of intelligence, for example, cognitive, language, motor and social abilities.’

Within RDaSH, a LD is primarily assessed through Wais-IV testing, providing a comparative score against the global population, diagnostic testing can also be complemented by functional assessments for a more accurate representation of an individual’s needs. Therefore, someone with a LD may be eligible for specialist services with an IQ score of 70 and below, however, there should be consideration of the individual’s primary need to determine which service is the most appropriate to provide support and guidance states that there should be ‘inclusivity of mainstream mental health services for people with learning disabilities who have mental health problems”.

A LD can be classified as mild, moderate or severe.

Autism is a neurodiverse condition, with or without the presence of a LD. Someone with autism may have presented in crisis to the Community LD team or the Community Mental Health team, the process is the same irrespective of which team they have presented to.

12.6.2 Inpatient care

The transforming care agenda, building the right support and homes not Hospitals aims to enhance community capacity, thereby reducing inappropriate hospital admissions and subsequent length of stay and there are currently no local NHS provisions of assessment and treatment unit’s.

It is accepted that the admission of a patient with a primary diagnosis of LD and, or autism to one of the adult or older person’s mental health in-patient wards should not occur as the trust is not commissioned to provide these services. Should someone require a specialist admission, the ICB with support from the patient’s care co-ordinator will lead on the sourcing of a suitable bed.

However, there may be circumstances when an admission to an adult or older person’s mental health ward may be necessary, for example:

when mental health is presenting as the patient’s primary need
there is an increased risk of harm to self and others, which cannot be managed within a community environment
following a breakdown of the community placement and the patient being detained under the MHA
following a breakdown of the community placement and the patient being subject to an order of the Courts and, or DoLS

12.6.3 Pre-admission

Prior to admission to hospital a patient with a diagnosis of Learning disability and, or autism, who is thought to be at risk of a hospital admission, should already be known to local services and will be placed on the dynamic support register (DSR). If someone is presenting as ‘at risk of admission’ they would hold a red rating and throughout the period of admission, the person will remain on the DSR. The DSR will be held by the ICB with involvement from the LD community teams and be reviewed every 2 weeks in a multi-professional team meeting.

Prior to admission a local area emergency protocol (LAEP) should be implemented with recommended outcomes and contingency plans associated to the admission. The LAEP recommendations should be shared with the patient flow team and admitting ward, with a full care and treatment review (CTR) arranged by South Yorkshire ICB or Humber and North Yorkshire ICB. The LAEP process will consider if someone is suitable for a mental health inpatient environment or if they require specialist LD inpatient services.

12.6.4 Admission

Anyone with a diagnosis of a LD and, or autism who is detained under the MHA will be eligible for a CTR.

There may also be occasions when someone is unknown to local LD or mental health services, and this will be identified upon admission. A single access referral form should be completed to request support from the relevant community team.

Should someone be suspected of having a LD, diagnostic assessments would not be undertaken during a period of mental illness as this would invalidate the assessment, however they can be referred for future assessment when they are no longer presenting with an acute episode of mental illness.

At the point of and during subsequent admission, reasonable adjustments need to be implemented to ensure accessible care. These adjustments will be person specific, however will need to include easy read or accessible information regarding the legal framework they are admitted under.

In circumstances where the patient is admitted following the breakdown of a community placement either under the MHA or subject to an order of the Court or DoLS, the following actions must be taken:

the trust MHA manager should be notified, at the earliest opportunity to ensure that the appropriate legal framework is in place and where necessary that the trust solicitors are consulted
escalation to the chief operating officer, in order that there is senior oversight of the case within the trust
regular update meetings are held with the appropriate ICB representatives, local authority representatives, placement representatives and ward manager or modern matron, in order to ensure either the patient returns to the placement, or that an alternative placement can be found

The local community LD team(s) will liaise with the ward manager to confirm the in-reach support requested during admission, on a needs-led basis. This will then be discussed with the crisis and intensive support team (Doncaster) or the relevant clinical pathway (mental health pathway or positive behaviour pathway) for Rotherham or North Lincolnshire for agreement. Any disputes will be escalated to the relevant service manager or modern matron.

In-reach support will not ordinarily include the community team working on an inpatient ward.

12.7 Restricting of beds and requests to close a ward

There may be occasions when due to clinical issues relating to safety, a request is made to restrict beds or close a ward to admissions. All requests to restrict beds should be directed to the care group leadership team by the ward. If the restriction is agreed, the care group will inform the Patient Flow team.

Please refer to appendix T which outlines the governance process for an adult and older person’s mental health ward closure.

In the event of a critical or major outbreak that causes the closure of multiple wards the chair of the trust’s Outbreak Control team will notify the accountable emergency officer (AEO) and directors of all the care groups. Please refer to the outbreak of infection management procedure for information.

12.8 Short term sickness or absence cover arrangements for the patient flow officer and duty manager

In the event there is short term absence of the patient flow officer, the patient flow duty manager, will be responsible for bed managing throughout the period of absence.

If there is short term absence of the patient flow duty manager, the following action will be taken:

a review of the patient flow roster will be completed by the patient flow clinical service manager to identify any potential shift swaps or change in working patterns to fill vacant shifts
offer of flexible or home working to be explored
offer of overtime or bank to band 7’s across the trust or person with relevant experience to fill any operational cover required
offer of overtime or bank to band 4 or person with relevant experience to fill any out-of-hours bed management cover required

If the above has been explored and there is still no patient flow duty manager cover, in hours (9am to 5pm) the patient flow clinical service manager will cover the role of the patient flow duty manager throughout the period of absence.

If the absence occurs out of hours, it is the responsibility of the patient flow duty manager to inform silver on call of the absence.

The bed management duties will then be delegated to the nurse in charge or unit co-ordinator (where applicable) of each care group (Doncaster, Rotherham and North Lincolnshire). Silver on call will be required to answer all operational calls throughout the period of absence.

The care group bed manager will be the first point of contact to ascertain bed availability and coordinate any admission to hospital that is presented to them by the out of hours admitting professional.

This can include but is not limited to:

liaising with other care group bed managers to ascertain bed availability and coordinate admissions
supporting the admitting professional with liaising with other trust bed management teams to ensure anyone that falls outside the scope of RDaSH’s footprint is admitted to the appropriate NHS trust (see section 9)
processing referrals into RDaSH PICU beds (see section 9.3)
completing and sending referrals to OOA placements where necessary (see section 10.3)

At the end of the out of hours period it is the responsibility of the care group bed manager to e-mail the patient flow inbox rdash.patient-flow-team@nhs.net with any action taken overnight, and any tasks to be carried forward into the following shift.

13 Governance, learning and escalation

13.1 Governance

To ensure good governance, maintain effective communication and escalate concerns relating to patient flow proactively, the following meetings are in place:

a daily on call morning handover (Monday to Friday at 9.15am)
a daily on call afternoon handover (Monday to Friday at 4pm)
weekend planning (every Friday at 11am)
weekly care group multi-agency clinically ready for discharge (but delayed)
bi-monthly trust wide clinically ready for discharge (but delayed) oversight
bi-monthly trust OOA oversight
ICB system pressures calls, once a week as a minimum and stepped up as and when required

Ad hoc meetings will also be convened with clinical teams and partnership agencies where necessary to discuss complex cases.

13.2 Learning and continuous improvement

With the aim of identifying future learning needs for individuals, teams and the trust whilst also highlighting areas of good practice, the Patient Flow team will undertake case reviews to examine situations that have caused a disruption in patient flow in RDaSH.

All case reviews will be completed with input from clinical colleagues or teams and the findings will be used to support and transform the patient flow within RDaSH by identifying areas of process development and prevent future disruptions in service.

On completion each case review will be tabled and presented at the relevant care group quality and assurance meeting for discussion and subsequent sign off. Following sign off, anonymised themes regarding lessons learnt and actions identified will be shared at trust level within the trust organisational learning forum.

As part of the patient safety incident response framework (PSIRF) and to enhance our governance relating to patient care, experience and risk management, colleagues will complete IR1’s to identify opportunities for learning and further development of the service.

The Patient Flow team will complete an IR1 relating to an adverse healthcare event, admission or transfer or discharge planning issues, due to lack of bed availability in the following circumstances:

when a patient is sent inappropriately OOA
if a patient in A and E has been waiting for a mental health bed for over 12 hours
if a patient in the community (who will be being supported by a community team) has been waiting for a mental health bed over 24 hours
if a patient has been admitted to the 136-suite due to lack of bed availability elsewhere or for the purpose of section 140

The Patient Flow team will also support colleagues as required by facilitating debriefs to discuss clinical and operational issues and enable continuous improvement.

13.3 Escalation

The following escalation and governance process for patient flow with agreed authorisation and escalation criteria has been approved and implemented regarding managing beds within working hours.

Outside business hours, the existing on-call management structure will remain responsible for the management of patient flow including all necessary escalations and authorisations.

Patient flow escalation framework (staff access only) (opens in new window)

14 Appendices

Please see admission, transfer and discharge manual including patient flow and out of hours (OOH) procedures webpage for appendices attached to this procedure.

Appendix J Adult and older persons mental health bed capacity
Appendix K Ward transfer checklist
Appendix L Adult mental health and older persons process for arranging and authorising out of area placements
Appendix M Mutual aid contact details
Appendix N Private providers contact details
Appendix O ICB notification and funding form submission details
Appendix P Out of area patient ICB notification form
Appendix Q Adult mental health and older persons out of area (OOA) placement monitoring process
Appendix R How to document clinical updates
Appendix S Escalation procedure
Appendix T Ward closure procedure adult and older adults mental health
Appendix U Rockwood frailty scale

Document control

Version: 2.2.
Unique reference number: 1017.
Approved by: Clinical policies review and approval group.
Date approved: 29 November 2023.
Name of originator or author: Head of patient flow.
Name of responsible individual: Chief operating officer
Date issued: 3 April 2024 (minor amendment).
Review date: 31 December 2026.
Target audience: Clinical colleagues working in the adult mental health and older person’s mental health inpatient services, community, hospital liaison, crisis, and home-based treatment teams, on-call managers and AMHP’s for reference.
Description of change: Minor amendment to sections, 7.1.1, 8, and 10.3.

Page last reviewed: November 14, 2024
Next review due: November 14, 2025

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