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Veterans Program
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Navigating MyCare
for a transfer from K or L wing to and from acute care

It is Sunnybrook’s policy to ensure that all transfers of Kilgour and George Hees Wing residents to and from acute care at the hospital occur in a coordinated manner with good communication between transferring and accepting staff so that these residents receive appropriate care during and around transfers.

Your care pathway

1

Transfer of residents from K or L wing to acute care

Non-emergency transfers

  • The physician from the acute care service writes an order to transfer the resident to acute care. If the resident is going for surgery, pre-op orders are to be written prior to the transfer. These orders are approved and co-signed by the long-term care attending physician.
  • Confirmation of an available bed through Patient Flow in acute care is required prior to transferring the resident to acute care. Patient Flow will co-ordinate with the acute care unit and notify the long-term care unit when the bed is available.
  • After the order to transfer has been written and an acute care bed is available, the long-term care unit will call Patient Registration giving details of the transfer, i.e. to which service and when the treatment/surgery is to be done.
  • The transfer from long-term care to acute care is considered a discharge and admission.
  • All portions of the long-term care chart must accompany the resident to acute care. The chart is kept intact for referral purposes. When the resident is discharged back to long-term care, the long-term care chart accompanies the resident back to the same bed/unit.

Emergency transfers

  • The long-term care attending physician or on-call physician ensures that the resident or substitute decision maker consents to transfer to the Emergency Department. If the substitute decision maker is not available, the plan of care as outlined in the Advance Directive or Treatment Plan is followed and the substitute decision maker is notified by the physician or nurse (as delegated) as soon as possible. The physician writes an order or gives a telephone order to transfer the resident to the Emergency Department.
  • The nurse calls 911 to arrange urgent ambulance transfer to the Emergency Department.
  • The long-term care attending physician or on-call physician calls the Emergency Department physician or triage nurse giving the details of the emergency and the intention to send the resident to emergency.
  • The nurse attends to the resident and provides appropriate care to the resident while awaiting ambulance transfer.
  • The nurse (or physician if present) gives the ambulance attendant the history of the reason for transfer and the resident's long-term care chart.
  • The resident is transferred to emergency by ambulance. This transfer is not considered a discharge from Kilgour or George Hees Wing until the medical status of the resident is assessed and the need for admission to acute care determined. If the resident requires admission to acute care, he/she will be discharged from Kilgour or George Hees Wing and admitted to acute care.
  • The resident's bed in Kilgour or George Hees Wing will be held for the resident during the acute care admission.
2

Return of residents from acute care back to K or L wing

Return from the Emergency Department (ED) with no admission to acute care

  • After assessment and management in the ED, the ED Physician, on determining that the resident does not require acute care admission, will transfer the resident back to his/her long-term care unit with a copy of the ED record.
  • Changes to orders recommended by the ED Physician will be written by the ED Physician in the Doctor's Orders section of the long-term care chart. These orders will be approved by the attending or on-call physician by telephone order prior to implementing. If there is a significant change in the health status of the resident or the treatment plan, the ED physician or consulting physician will notify the long-term care attending or on-call physician by telephone.
  • Since transfers back to long-term care from the ED without an acute care admission are not re-admissions, a re-admission note by the physician is not required.
  • The attending physician should be notified non-urgently of the resident's transfer back to Kilgour or George Hees Wing.
  • The receiving unit will notify the Substitute Decision Maker (SDM) of the transfer back to Kilgour or George Hees Wing and any recommended changes to the care plan.

Return to K or L wing after admission to acute care

  • When a long-term care resident is medically stable and ready to return to long-term care from acute care, the acute care attending physician completes a discharge summary.
  • Transfers will normally occur Monday to Friday between 8 a.m. and 3 p.m. It is the responsibility of the acute care attending physician to obtain agreement from the patient's attending physician in long-term care and the Patient Care Manager (or delegate) of the receiving unit prior to arranging for the transfer of the patient back to the long-term care unit. If the long-term care attending physician is not available, the on-call physician is called. This is done between the hours of 8 a.m. and 3 p.m. Monday to Friday, even if the transfer back is anticipated for after hours or on the weekend. This approval process is to ensure that adequate resources are available on the resident's long-term care unit in order to provide appropriate care.
  • When necessary, the primary nurse, Patient Care Manager or delegate of the long-term care unit will do an assessment of the patient, in person or by telephone, to determine the availability of equipment and/or nursing expertise to manage the returning resident, prior to agreeing to the transfer back to long-term care. If an assessment is necessary, this would be done between the hours of 8 a.m. and 4 p.m. Monday to Friday.
  • If a resident is from a Level 2 nursing unit in long-term care but can no longer be managed on a Level 2 nursing unit, the Veterans Admissions Specialist is consulted by the Patient Care Manager or delegate of the resident's long-term care unit to find an appropriate bed on a Level 3 unit.
  • If a transfer is anticipated between the hours of 3 p.m. to 8 a.m. Monday to Friday or on weekends/holidays, it will be pre-approved by the attending physician and patient care manager or delegate in long-term care to ensure conditions are met, and an appropriate plan communicated to the receiving staff and on-call physician.

Return to K or L wing after admission to acute care

  • If the bed in acute care is required for another patient on an urgent basis, after hours transfers are permitted without pre-approval provided the conditions below are met. All after hours transfers require the following conditions to be met:
    • The resident is medically stable, (e.g. no requirement for daily blood work or daily medical assessments, no deterioration in health status that has not been assessed and managed to ensure stability).
    • The resident does not have a new care requirement involving nursing skills and/or expertise beyond the training of available staff in long-term care.
    • The on-call physician for Kilgour and George Hees Wings is notified and agrees to accept responsibility for medical care. The Medical Director On-Call for Sunnybrook will be consulted if there is concern about the appropriateness of the transfer by the on-call physician.
    • The nursing Team Leader on the receiving unit is notified and if the nursing Team Leader has concerns that inadequate staffing will create a safety risk for the resident or other residents on the unit, the Shift Manager will be required to approve the transfer.
    • The acute care attending physician or delegate writes transfer orders for the continuing care of the patient and notifies the family or Substitute Decision Maker of the transfer. The on-call physician may give a telephone order to continue the orders written by the acute care attending physician or delegate. These orders must be co-signed within 24 hours of re-admission.
    • All medications necessary for the patient until the next regular business day must accompany the patient as the K-Wing Satellite pharmacy is not open after regular business hours. If the resident is receiving an IV solution that is not routinely stocked in the Veterans Centre, this IV solution must accompany the resident in sufficient quantities to last until the next business day.
  • The transfer of the patient from acute care to long-term care is considered a discharge and re-admission. When the resident arrives back in Kilgour or George Hees Wing, it is the responsibility of the long-term care attending physician or on-call physician to examine the resident, review and co-sign the orders and write a re-admission note within 24 hours.
3

Health record data of resident returning to K or L wings

How to access health record data

  • All portions of the patient record are to accompany the patient to long-term care. The acute care chart is prepared as if being sent to Health Data Resources (HDR). This acute care chart is to be sent with the resident to long-term care.
  • This chart will remain on the nursing unit for ten (10) days following the transfer. The acute care stay record will then be forwarded to HDR for chart completion purposes and will be returned to the long-term care nursing unit only if requested. The acute care Discharge Summary will be filed in the long-term care chart.
  • The long-term care in-patient binder will accompany the resident to acute care, remain in acute care with the resident during his/her acute care stay and accompany the resident back to the long-term care unit.