Hospital Avoidance Procedure
Approver
Operations Committee
Date Approved
23rd November 2010
Procedure
Hospital Avoidance Procedure
Original Issue Date
November 2010
Revision Date
Revised by
Director of Care
Next Revision Date
September 2013
Related Documents
Death and Dying, Gold Standard Framework
Location of Electronic Copy
Intranet
Location of Hard Copy
Signed:
Chief Executive:
Caroline Tiller
Page | 1 Hospital Avoidance Policy/Nov 2010/GSF/Sharon Hardy
The aim of this procedure is to operate within the Gold Standard
Framework (GSF) to assess and review changes in a service user’s
condition to avoid hospital admissions.
Hospital avoidance procedure
The team should support this procedure, select and use tools of GSF models
to suit the needs of the individual service user’s
Sending a resident to the hospital should not be considered routine practice,
but as a contingency measure only. Decisions should be made after
assessing the needs of the individual resident in open discussion with the GP,
family and the team.
The GSF co-ordinator and the Home Manager should ensure that in the case
of service users with Capacity - the advance care plans are discussed and
completed. All admission to the home should be completed and recorded
within a time frame of 6 weeks.
In the case of service user’s who are deemed or assessed to lack capacity to
understand the advance care planning – informed consent should be sought
from the family or next of kin. The best interest of the service user’s must be
considered at all times.
All current service user’s and new admissions should be placed on the GSF
register. This register should be reviewed monthly and as required with the
coding A.B.C.D. This information must be communicated to all staff involved
in the care of the service user’s including night staff. The coding assist the
Team to anticipate likely stages of illness and alert the team to the needs of
the individual resident.
Weekly meetings are to be held with the team and the GP to ensure effective
communication and better collaboration to prevent hospital admission and to
have anticipatory medication available as required. Meetings with families are
ongoing and must be promptly recorded.
The team should work closely with families to best meet the needs and choice
of the individual service user’s. Staff should record Do Not Attempt
Resuscitation (DNAR) discussions and communicate to the rest of the team.
To prevent crisis in the final days staff should adhere to the need support
matrix especially for service user’s who are coded C.
Page | 2 Hospital Avoidance Policy/Nov 2010/GSF/Sharon Hardy
The out of hours handover form should be completed by the team and sent to
the relevant emergency services when the resident is coded C.
Please refer to the stop and think prompt and action (GSF)
The GSF co-ordinator should hold a meeting with the night staff at least once
a month to ensure continuity of care.
The GSF Coordinator should ensure that the minimum care protocol is in
place during the dying phase to maintain care of a very high standard.
Regular audits and reflection to be carried out to improve the GSF
The changing needs of the service users must be assessed and documented
as required. Any external aid or support required must be obtained
immediately. E.g. local palliative care services, priest. Staff should be
familiar with the contact details for these services.
The GSF coordinator should ensure that all staff are trained in the GSF
programme. GSF professionals and support workers have personal
responsibilities and accountability to ensure that they are trained and to use their
knowledge and skills to anticipate physical symptoms and where possible by the
use of specialist devices resolve problems and reduce hospital admissions.
Develop an awareness of an illnesses that may require hospital admissions e.g.
Pneumonia, fractures, strokes, dehydration, acute toxic confusional states.
Ongoing training for the GSF must be accessible to all staff to uphold the
residents preferences, option, choices in how they choose to promote their end
of life.
Reducing the length of stay in hospital and encourage Rapid
discharge.
Aim
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To prepare the resident, families and staff for the discharge back to the care
home.
To facilitate a smooth transfer by ensuring appropriate equipments are in
place and the environment is prepared to receive the service user’s as
required. E.g. pressure mattress, commode, anticipatory medication etc.
To provide continuity of care via the home and the hospital through effective
communication, e.g. phone, email, resident’s notes/ advance care plans.
Planning process
Develop close links with the Ward staff, Social Workers, and discharge
coordinators of the hospital to enable effective transfer back to the home.
Share information with the hospital regarding the service users preferred
place of care and death. The staff at the home to ensure that the advance
care planning is sent to the hospital with the resident ( use bright coloured
paper to highlight)
When a resident is admitted ensure that details of their Advanced Care Plan
notes are transferred with them.
Visit the resident regularly and make the ward staff aware of who you are in
order to build familiarity.
Liaise with family regarding resident’s well being
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