Adult Outliers Policy
Version
3
Name of responsible (ratifying) committee
Operational Board
Date ratified
21 October 2105
Document Manager (job title)
Chief of Service Medicine and MOPRS
Date issued
08 December 2015
Review date
21 October 2016
Electronic location
Clinical Policies
Related Procedural Documents
Trust Escalation Policy, Trust Transfer Policy, Trust
Escalation Plan – internal, Trust Risk Assessment
Policy and Protocol, Trust Mixed Sex Accommodation
Policy
Key Words (to aid with searching)
Adult, Outliers, Policy
Version Tracking
Version
Date Ratified
2
03.09.2009
3
21.10.2015
Brief Summary of Changes
Removal of Mary Sherry name’s as co-author
Changes to location of added capacity
Changes to reflect the fact that Mary Sherry is no
longer with PHT
Changes made to times of Operations Meetings
Policy Rewritten
Adult Outliers Policy
Version: 3
Issue Date: 08 December 2015
Review Date: 21 October 2016 (unless requirements change)
Author
Maria Purse
Nichola Martin
Page 1 of 16
CONTENTS
QUICK REFERENCE GUIDE
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Introduction
Purpose
Scope
Definitions
Process
Duties and Responsibilities
Training Requirements
References and Associated Documentation
Equality Impact Statement
Further Information
Adult Outliers Policy
Version: 3
Issue Date: 08 December 2015
Review Date: 21 October 2016 (unless requirements change)
Page 2 of 16
QUICK REFERENCE GUIDE
This policy must be followed in full when developing or reviewing and amending Trust procedural
documents.
For quick reference the guide below is a summary of actions required. This does not negate the need
for the document author and others involved in the process to be aware of and follow the detail of this
policy.
Need for additional Bed Capacity
to maintain patient flow is
identified and agreed as per the
Escalation policy
Are there beds in funded areas suitable
to use for outliers?
Are there beds in unfunded areas
suitable to use for outliers?
NO?
NO?
YES?
YES?
Can’t Outlie
Following completed risk assessments
by ward teams (Appendix A), have suitable
patients been identified to outlie?
YES?
Suitable identified patients are ready to
be outlied to appropriate designated
beds
NO?
YES?
NO?
Review of ward lists
by NiC with
Matron/CSC
management team
member/DHM OOH.
Suitable patients
identified to outlie?
Prior to outlying:
 Explain rationale for move including providing a copy of the – ‘Why do I
need to move wards?’ leaflet to the patient.
 Contact relatives if agreed by patient.
 Adhere to the Trust Policy – Transfer of Patients
Patient transferred to new clinical area
Receiving ward to update PAS
Adult Outliers Policy
Version: 3
Issue Date: 08 December 2015
Review Date: 21 October 2016 (unless requirements change)
Page 3 of 16
1. INTRODUCTION
Portsmouth Hospitals NHS Trust (PHT) is committed to providing a high quality care
environment where patients and staff can be confident that best practice is being followed at all
times and that the safety of everyone is of paramount importance. The Trust strives to provide
care and treatment, which promotes high standards of privacy and dignity as well as clinical
care, throughout each patient’s individualised care pathway.
It is the clear intention of the Trust to remove the need for outlying patients wherever possible
over time. At the present time process changes are focused on patients having minimal moves
and only those clinically indicated (eg from an Assessment Area to an Inpatient Ward). On a
daily basis Clinical teams are expected to pursue actions to increase discharges rather than
using outlying to create capacity.
'Each ward and CSC have an agreed discharge target. The target is based on predicted demand
for each day of the week so achievement of the target is important and will reduce the need to
outlie into other specialities/ CSCs.
A correlation between increased mortality rates and the practice of outlying is emerging. In
addition, the risks of healthcare associated infection (HCAI) are greatly increased by extensive
movement of patients within the hospital, by very high occupancy rates and by an absence of
suitable isolation facilities (DoH 2003, Winning Ways; DoH 2005 Saving Lives). It is also a risk
that outlying increases length of stay which in its turn then blocks capacity. It is therefore
imperative that all actions are focused on reducing the need for outlying.
Therefore Portsmouth Hospitals NHS Trust seeks to make every effort to minimise the numbers
of patients who are outlied, but recognises that at times, when emergency admissions are high,
decisions to outlie may be necessary. This policy seeks to provide clear protocols and
procedures in order to minimise the known risks to the practice of outlying.
This policy should be read in conjunction with the policies and guidelines listed in
section 8 of this document.
2. PURPOSE
This policy is intended to ensure the safety, dignity and duty of care for both patients and staff
who are involved in the process of caring for adult patients in clinical environments outside their
own speciality and/or in additional or emergency capacity.
3. SCOPE
This policy applies to all staff who have contact with adult patients working within PHT,
including medical staff, nursing and midwifery staff, allied health professionals, medical
students, nursing and midwifery students, and other members of the multidisciplinary team
working with individual patients in wards, and departments. It also applies to any staff (clinical
and non clinical) who are either making decisions about the most suitable clinical areas for
patients to receive care and treatment or who are caring for patients outside of the expected
clinical speciality. This is a generic policy designed to assist those responsible for the delivery
of care to all adult patients. Individual speciality guidelines may also be required and should
also be followed, but are not included in this policy.
Adult Outliers Policy
Version: 3
Issue Date: 08 December 2015
Review Date: 21 October 2016 (unless requirements change)
Page 4 of 16
In the event of an infection outbreak, flu pandemic or major incident, the Trust recognises that it may
not be possible to adhere to all aspects of this document. In such circumstances, staff should take
advice from their manager and all possible action must be taken to maintain ongoing patient and staff
safety’
4. DEFINITIONS
PDD
OOH’s
CSC
Additional
Capacity
Use of beds which are Internal
either designated for transfer
flexible use or are
normally closed or used
for another purpose
Risk
Possibility of exposure to Ops Centre
a hazard & therefore the
chance of injury, ill
health, harm, damage or
loss
Outlying
Healthcare Professional
responsible for the
patients care and
treatment
Clinician
5.
Predicted
Date
of EWS
Discharge
Out of hours is identified RAG
as the time between
19:00 – 08:00 weekdays
and from 1900 Friday –
0800 on Monday
Single Sex
Clinical Service Centre
Accommoda
tion/
Facilities
Early Warning Score
Red, Amber, Green
risk rating
Men and women
have separate
sleeping areas (eg
single-sex bays) and
have separate toilets
and bathrooms
The movement of a
patient from one
ward or department
to another within
Trust clinical areas
and/or across PHT
sites.
Operations Centre
Transferring a patient
to a clinical area
outside
of
their
speciality
DUTIES AND RESPONSIBILITIES
Clinical teams, ward staff and CSC Boards are all responsible for ensuring that patient focussed
and safe decisions are made prior to moving patients to wards/departments outside of their
expected speciality area. Wherever possible, additional actions should be pursued as a priority to
avoid the need to outlie patients by increasing discharges to increase capacity.
Director of Operations (Unscheduled)



Day to day operational management of patient flow and utilisation of bed capacity
Leadership of Operations Centre Team
Overall leadership and management of Trust bed stock, as delegated by Chief Operating
Officer
Adult Outliers Policy
Version: 3
Issue Date: 08 December 2015
Review Date: 21 October 2016 (unless requirements change)
Page 5 of 16


Develop with CSC Management Teams plans and processes for the management of bed
capacity that will reduce over time the need for outlying.
Hold delegated executive authority to place patients in the most appropriate beds and to
access beds at times of increased demand
Duty Hospital Manager:



Keep continually appraised of the whole hospital position in relation to capacity and demand
and on any internal/external issues which might affect patient flow
Receive reports from speciality and duty matrons in relation to current staffing issues
Keep the Director of Operations fully briefed of the hospital position and request authorisation
to open additional capacity and outlie when required
On Call Director:

Ensure all policies and procedures have been adhered to in the process of outlying
CSC & Operational Management Teams



Ensure robust systems and processes are in place for capacity management within the CSC
Monitor and ensure action is taken on areas of identified risk
Provide timely and accurate information to appraise Duty Hospital Manager of current
demand and capacity issues and work to prevent the need to move patients outside their
speciality by maintaining effective flow
CSC Chiefs of Service, Clinical Directors & Consultants:







Ensure capacity management is effective within own CSC’s / services
Ensure patients under their care have agreed treatment plans and PDDs in place
Adjust discharge thresholds where possible and appropriate in order to ensure that maximum
bed capacity is created and to avoid the need to outlie
Ensure patients who have been outlied get prompt and appropriate medical assessment and
interventions, and receive a medical review at least once in every 24 hour period over
Monday to Friday period and as needed at weekends
As part of the patient medical review, ensure that patients are RAG rated for their
appropriateness to outlie, using the set of criteria in Appendix A.
Ensure specialties have identified appropriate criteria for assisting with outlying decisions and
that this is widely understood/communicated to all members of the healthcare team
Ensure that junior medical staff respond appropriately to calls concerning an outlier patient’s
condition and that appropriate cover arrangements are in place in the case of a patient’s
condition deteriorating or in a medical emergency
Junior Doctors



Ensure daily medical review of patients who are being cared for in outlying areas
Respond promptly to ward requests to review outlying patients e.g. if EWS scores
deteriorating.
Ensure patients who are outlied have appropriate treatment and medication regimes
prescribed
Matron for CSC/Speciality:


Understand the daily position with regard to capacity, patient moves and outliers either at the
morning CSC capacity meeting or by contacting clinical areas
Ensure that all wards/department shift leaders have complied with requirements to identify
outliers
Adult Outliers Policy
Version: 3
Issue Date: 08 December 2015
Review Date: 21 October 2016 (unless requirements change)
Page 6 of 16



Ensure all patients are RAG rated using criteria in Appendix 1
Ensure that a review of all speciality outliers takes place at least every 24 hours Monday to
Friday and at weekends if possible and definitely if clinically required
Identify staffing situation and requirements for any added capacity within the CSC
Duty Matron


Review nurse staffing situation for the evening, night and if possible early shift of the next day
Make decisions to move nursing staff to cover gaps which have arisen from the opening of
additional capacity
Ward Sister/Charge Nurse/Senior/Staff Nurse in charge of clinical area with Senior
Medical staff





Identify suitable outliers (normally 1 per ward/department at morning handover and a further 1
by 15.00) and communicate this to the CSC silver command.
Confirm outliers list with medical teams during ward rounds
Ensure patients and their families/carers are kept fully informed of potential/actual decisions
to outlie
Ensure the patient is offered the leaflet entitled, ‘Why am I moving wards?’
Ensure nurse in charge of receiving ward is given comprehensive handover of patients
condition, care and treatment plans
Specialist Nurses
 Provide advice and guidance about speciality aspects of patient’s conditions to ward teams
caring for the patient.
Infection Prevention and Control Team member (Daily Duty Rota)


Contribute to decisions about outliers and ensure any proposed outlier moves are
appropriate, particularly for patients who are identified as having a high risk of infection
Make every effort to avoid transferring patients who are more likely to carry HCAI organisms
Therapists

Continue to provide therapy for patients under own speciality who have been outlied to
another speciality or hand patients over to the appropriate team for the outlying ward.
6. PROCESS
6.1 Risk
The central principle underlying outlying decisions is rooted in the management of risk. The
Trust’s Risk Assessment Policy explains that a risk assessment is no more than a careful
examination of what might cause harm to patients, staff, visitors and others. A risk assessment
provides a systematic and methodical tool for identifying risks, removing them where possible
or otherwise adopting all the control measures and precautions that are reasonable and
practical in the circumstances.
In circumstances where it is necessary to make decisions about outlying (i.e. limited bed
capacity to ensure appropriate and timely patient flow), the degree of risk needs to be clearly
identified. It is recognised that the best course of action is not to outlie, but where outlying
decisions are needed these must ensure the minimal risk to patients and staff.
Adult Outliers Policy
Version: 3
Issue Date: 08 December 2015
Review Date: 21 October 2016 (unless requirements change)
Page 7 of 16
6.2 Principles
The following principles govern decisions to outlie patients to areas outside of their expected
speciality:

All efforts must be made to ensure patients receive care and treatment in the most
appropriate clinical speciality area for their current condition.

Safety, clinical efficacy and a positive patient experience are the goals of all outlier decision
making. Decisions to outlie must be based on the patient’s current clinical and mental health
needs, their level of acuity and dependency and the clinical capability of the receiving area.

All patients are to be RAG rated within 24 hours of admission and reviewed daily as to their
appropriateness to outlie. Appendix A details the clinical considerations that must be taken
into account when RAG rating patients as to their suitability to outlie. Red more than 1
criterion present, Amber 1 of the criteria is present, and green, none of the criteria are
present. Therefore Green rated patients are the most appropriate to outlie.

Decisions to outlie should always be taken in a manner that supports the achievement and
maintenance of patient’s individual needs, privacy and dignity, infection control status and
single sex ward requirements. Such decisions must be taken according to current infection
control policies and practice in order to reduce the risk of exposure to infection.

Patients who are placed outside of their normal specialty areas are entitled to the same level
of care and treatment that they would receive if cared for within their specialty areas. Every
effort will be made to ensure that outlying patients are reviewed by medical and/or nursing
teams from their specialty on a daily basis during Monday to Friday and as needed at
weekends.

It must be recognised that outlying patients may challenge some medical and nursing teams
and, particularly at times of high outlier numbers, the CSC Management Team must work with
specialty clinicians to agree how outlier patients will be supported medically. This may
require some flexibility between clinical teams if total patient numbers for a specialty are
particularly high.

Once it is deemed necessary to outlie, patient treatment plans must be updated including
pending investigations and discharge plans carefully documented in the patient’s health
records.

Clinical teams must be informed of patients who are actually outlied, with clear information
given on where the patient has been outlied to. The Patient Administration System must be
updated promptly by the receiving areas as this ensure that the patients’ medical teams will
be able to clearly locate their patients from the patient list printed by the team each morning.

The number of bed moves during each patient’s stay must be minimised. Ideally once a
patient has been outlied from their original ward they should not be moved again. If this is
necessary then careful dialogue must take place with the patient and care taken not to move
the patient again. Patient moves are monitored and presented to the Trust Board on a
monthly basis as part of the Quality report.

Regulations around single sex accommodation and facilities must not be breached and there
may need to be some cohorting of patients to achieve this.

Outlier decisions must be based on a full understanding of the current position regarding
whole hospital capacity and decisions made to balance the prevailing risk across the whole
hospital and between specialties
Adult Outliers Policy
Version: 3
Issue Date: 08 December 2015
Review Date: 21 October 2016 (unless requirements change)
Page 8 of 16

Relatives must be informed of all decisions to move patients. It is the transferring wards
responsibility to do this.

Prior to outlying all patients should be offered a copy of the ‘Why do I need to move wards
leaflet?’ (Appendix B)
6.3 Decision Making

Outlier decisions will be made according to all of the above points as well as within the
context of the achievement of the Trust’s objectives and standards.

As a minimum the decision to outlie must be documented in the patient’s notes by the Nurse
in Charge.

Staff should not be put at risk by being asked to care for patients in environments where there
is insufficient staffing, equipment or physical resources or where they do not have the
appropriate knowledge and skills for those patients’ conditions.

Normally patients are not to be admitted to an outlying area straight from the Emergency
Department or assessment area such as the Acute Medical Unit. If this is required then a full
risk assessment should be completed (Appendix A)

Staff involved in making decisions to outlie or open unfunded capacity will use the risk
assessment tools and be prepared to justify that all decisions were taken in a robust manner,
taking into account individual patient conditions as well as the overarching hospital capacity
situation.
6.4 Outlying Criteria

First option: Outlie patients from one speciality to another open and funded area,

Second Option Use additional capacity within an existing staffed bedded footprint.
Accommodate patients in wards where flexible beds are available and can be opened but
where additional staffing is not normally required or is minimal.

Third option: Open additional capacity in agreed locations which will normally require
additional staffing, as set out in the Trust Escalation Policy.
.
Adult Outliers Policy
Version: 3
Issue Date: 08 December 2015
Review Date: 21 October 2016 (unless requirements change)
Page 9 of 16
6.5 Actions:
The following decision tree details the actions associated with outlying patients
outside their normal specialty:
Need for additional Bed Capacity
to maintain patient flow is
identified and agreed as per the
Escalation policy
Are there beds in funded areas suitable
to use for outliers?
Are there beds in unfunded areas
suitable to use for outliers?
NO?
NO?
YES?
YES?
Can’t Outlie
Following completed risk assessments
by ward teams (Appendix A), have suitable
patients been identified to outlie?
YES?
Suitable identified patients are ready to
be outlied to appropriate designated
beds
NO?
YES?
NO?
Review of ward lists
by NiC with
Matron/CSC
management team
member/DHM OOH.
Suitable patients
identified to outlie?
Prior to outlying:
 Explain rationale for move including providing a copy of the – ‘Why do I
need to move wards?’ leaflet to the patient.
 Contact relatives if agreed by patient.
 Adhere to the Trust Policy – Transfer of Patients
Patient transferred to new clinical area
Receiving ward to update PAS
Adult Outliers Policy
Version: 3
Issue Date: 08 December 2015
Review Date: 21 October 2016 (unless requirements change)
Page 10 of 16
7. TRAINING REQUIREMENTS

Departmental Induction
8. REFERENCES AND ASSOCIATED DOCUMENTATION





Portsmouth Hospitals NHS Trust Escalation policy
Portsmouth Hospitals NHS Trust. Transfer Policy
Portsmouth Hospitals Escalation Plan - internal
Portsmouth Hospitals NHS Trust Risk Assessment Policy and Protocol
Portsmouth Hospitals NHS Trust Mixed Sex Accommodation Policy
9. EQUALITY IMPACT STATEMENT
Portsmouth Hospitals NHS Trust is committed to ensuring that, as far as is reasonably
practicable, the way we provide services to the public and the way we treat our staff reflects
their individual needs and does not discriminate against individuals or groups on any grounds.
This policy has been assessed accordingly.
Our values are the core of what Portsmouth Hospitals NHS Trust is and what we cherish. They
are beliefs that manifest in the behaviours our employees display in the workplace.
Our Values were developed after listening to our staff. They bring the Trust closer to its vision
to be the best hospital, providing the best care by the best people and ensure that our patients
are at the centre of all we do.
We are committed to promoting a culture founded on these values which form the ‘heart’ of our
Trust:
Respect and dignity
Quality of care
Working together
Efficiency
This policy should be read and implemented with the Trust Values in mind at all times.
Adult Outliers Policy
Version: 3
Issue Date: 08 December 2015
Review Date: 21 October 2016 (unless requirements change)
Page 11 of 16
Appendix A – Risk Assessment for Individual Patient Outlier Decisions
CLINICAL CONSIDERATIONS
Please consider the following criteria and tick yes or no for each
Yes
No
Any confusional state or behavioural concerns
- Delirium, dementia, encephalopathy, learning disability
- Wandering behaviour
- This includes patients under DOLS or mental health act
Acutely unstable or deteriorating patient
- Particularly high risk if EWS>6
Patient requiring specialist medical or nursing knowledge
- For example: chest drains, telemetry, seizures, stroke care
End of life care
Patient already outlied once from baseline ward
Complex on-going discharge
- Including if CHC paperwork is incomplete
Are isolation precautions in place? i.e. C Diff diarrhoea
Date:
Name and Signature:
RAG rating patients as to their suitability to outlie. Red more than 1 criterion present; Amber
1 of the criteria is present; Green, none of the criteria are present. Therefore Green rated
patients are the most appropriate to outlie. Amber rated patients might be possible to outlie
but with increased risk, therefore assessed on a case by case basis if no other option
available. Red rated patients should not be outlied. If a decision to outlie an Amber or Red
rated patient then the person making the final decision and the reason for decision should be
given below.
Signature:
Name in print:
Date:
Reason:
IMPORTANT: - A full handover of patients should be given to the receiving ward
- All staff should follow the Trust Transfer Policy and fully complete the transfer check list
including the receiving ward updating PAS
RAG
Rating
- If the
patient is still required to move, the reason for this and the decision maker needs to be
clearly stated in the medical record.
- Patient consent to move should also be documented.
- Incident report/DATIX (Amber risk) should be completed by nurse in charge for all high risk
(Red rated) patients whom are outlied.
IMPORTANT A full Nursing and Medical handover of patients should be given to the receiving ward
IMPORTANT All staff should follow the Trust Transfer Policy and fully complete the transfer check list .
Adult Outliers Policy
Version: 3
Issue Date: 08 December 2015
Review Date: 21 October 2016 (unless requirements change)
Page 12 of 16
Appendix B – Patient Information Leaflet
Adult Outliers Policy
Version: 3
Issue Date: 08 December 2015
Review Date: 21 October 2016 (unless requirements change)
Page 13 of 16
10. MONITORING COMPLIANCE WITH PROCEDURAL DOCUMENTS
Minimum
requirement to be
monitored
Lead
Tool
Frequency of Report
of Compliance
Reporting arrangements
Lead(s) for acting on
Recommendations
To undertake a
risk assessment
for all patients
when considering
appropriateness
to outlie
Chief of
Service and
Head of
Nursing
Audit of all
Datix
completed
for patients
who are
assessed
as high risk
Quarterly
Policy audit report to:
Clinical Governance And
Quality Meeting
Chief of Service and
Head of Nursing
Report on all non
clinical
moves
over a 24 hour
period
General
Manager
for
Medicine
CSC
Tracking
and
data
collation by
all CSCs
Monthly
Policy audit report to:
Trust Board
Chief of Service and
Head of Nursing
Policy audit report to:
Chief of Service
Daily
weekday
senior review of
all
outlied
patients
Chief of
Service
Audit of
medical
notes for
20 outlied
patient a
Monthly
Patient
experience
survey to include
if informed of
rational
for
outlying and if
offer the leaflet
Patient
experience
lead
Survey
Quarterly
 Trust Governance and
Quality
Policy audit report to:
Trust Board
Chief of Service and
Head of Nursing
This document will be monitored to ensure it is effective and to assurance
compliance.
Adult Outliers Policy
Version: 3
Issue Date: 08 December 2015
Review Date: 21 October 2016 (unless requirements change)
Page 14 of 16
Equality Impact Screening Tool
To be completed and attached to any procedural document when submitted to
the appropriate committee for consideration and approval for service and policy
changes/amendments.
Stage 1 - Screening
Title of Procedural Document: Adult Outlier Policy
Date of Assessment
09/11/2015
Responsible
Department
Corporate
Name of person
completing
assessment
Nichola Martin
Job Title
Head of Nursing Medicine
CSC
Does the policy/function affect one group less or more favourably than another on the basis
of :
Yes/No
 Age
No
 Disability
Learning disability; physical disability; sensory
impairment and/or mental health problems e.g.
dementia
No
 Ethnic Origin (including gypsies and travellers)
No
 Gender reassignment
No
 Pregnancy or Maternity
No
 Race
No
 Sex
No
 Religion and Belief
No
 Sexual Orientation
No
Comments
Adults Only
If the answer to all of the above questions is NO,
the EIA is complete. If YES, a full impact
assessment is required: go on to stage 2, page 2
More Information can be found be following the link
below
www.legislation.gov.uk/ukpga/2010/15/contents
Adult Outliers Policy
Version: 3
Issue Date: 08 December 2015
Review Date: 21 October 2016 (unless requirements change)
Page 15 of 16
Stage 2 – Full Impact Assessment
What is the impact
Level of
Impact
Responsible
Officer
Mitigating Actions
(what needs to be done to minimise /
remove the impact)
Monitoring of Actions
The monitoring of actions to mitigate any impact will be undertaken at the appropriate level
Specialty Procedural Document:
Specialty Governance Committee
Clinical Service Centre Procedural Document:
Clinical Service Centre Governance Committee
Corporate Procedural Document:
Relevant Corporate Committee
All actions will be further monitored as part of reporting schedule to the Equality and Diversity
Committee
Adult Outliers Policy
Version: 3
Issue Date: 08 December 2015
Review Date: 21 October 2016 (unless requirements change)
Page 16 of 16