St Andrews Hospice - Adult Service
Patient Referral and Admission Criteria
The following is intended to provide guidance to health professionals to enable appropriate patient referral to St Andrew’s Hospice Adult services.
It is, of course, not exclusive, and the clinical team are happy to advise further in uncertain situations including patients with known infections e.g.
C.Difficile and MRSA.
(NB: Throughout this document, where we refer to admission, this also includes attendance at the Day Therapy or Outpatient Clinics.)
Criteria for Determining the Most Appropriate Intervention, Including Face to Face Assessment
(Taken from the North East Yorkshire and Humber Clinical Alliance (NEYHCA) (Cancer) Referral, Admission and Discharge Criteria)
St Andrew’s Hospice provides interventions at different levels, according to the needs of the individual patient:
• Advice & support for generalist health and social care staff
• Single contact with patient for a specific problem
• Short term involvement for multiple problems
• On-going advice, support and involvement for complex issues.
In some circumstances it may be appropriate for professionals referring a patient with a basic palliative care problem to receive advice only via a
one off discussion between them and a specialist at the Hospice.
However, in cases that are particularly complex, such as severe symptom management problems or uncontrolled symptoms at end of life, it may be
appropriate for the patient to be referred for face-to-face assessment. In this instance, the professional is advised to first contact a member of the
Hospice Team. This member will then decide the appropriateness of face-to-face assessment on an individual case basis.
Referral Criteria
Referral for specialist palliative care can occur at any time in the pathway for patients with complex palliative care needs.
1. The service is available to people who have incurable, life limiting, malignant and/or non-malignant disease. Most patients will have advanced
progressive disease and the focus of treatment will have changed from curative to palliative. Some patients, who have complex specialist
needs, may be referred at an earlier stage in their illness. Palliative care may be necessary during periods of prognostic uncertainty, including
newly diagnosed people and when treatment fails.
2. General criteria for admission (NB: see above) are highlighted in the Referral Indicator Tool below, and it is essential on referral that the
referrer identifies the reason for referral and the current problems requiring specialist palliative care input. Specific disease related
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indicators can be found in Appendix 1.
3. The patient, patient’s GP and/or if appropriate their advocate should consent to the referral and admission to Hospice services.
4. Whilst admitted to the In-Patient service, patients can remain under the care of their own GP. However, some patients GP’s will relinquish
the medical care to be provided by the Hospice Medical Directors, this includes patients from out of the Grimsby/Cleethorpes area. Whilst
attending Day Therapy or Outpatient Clinics, the patient will remain under the care of their own GP.
5. Additional groups other than those highlighted in the Referral Indicator Tool may be referred and will be discussed individually by the multi
professional team as to the appropriateness of admission e.g.
 Patients who have progressive terminal disease with a longer prognosis than one year but who have complex needs
 Patients, who require specialist pain and symptom management at the time of diagnosis, yet are undergoing active treatments
such as chemotherapy and radiotherapy.
The focus of specialist palliative care is on patients with a short prognosis. However, it is recognised that there are ‘grey’ areas and members of the
clinical team will be happy to discuss such patients:
Inappropriate Referrals include:
 Patients with chronic stable disease or disability with a life expectancy of several years
 Patients with chronic pain problems not associated with progressive terminal disease
 Competent patients who decline referral or who are unaware of their underlying disease
 Competent patients who decline referral and where referral is made for family member support only
 Patients with diagnosed primary lymphoedema
Patients Who Lack Capacity
If a patient lacks the capacity to make a decision about referral and admission to Hospice services and there is no relevant Lasting Power of
Attorney or Court Appointed Deputy, the decision to admit the patient to Hospice services must be made in their best interests in accordance
with the Mental Capacity Act 2005 and the accompanying Code of Practice. This may necessitate a Best Interests meeting and may require the
involvement of an Independent Mental Capacity Advisor (IMCA). These reports must be made available on referral of the patient for specialist
palliative/Hospice care.
Patients referred for Hospice care will be admitted according to the urgency of their need and subject to capacity to admit. Where patients are
placed on a waiting list for admission, and urgent care/support is required from the Hospice, for example symptom management advice or
psychological support, a discussion will be held with the referrer to assess the level of need and to agree the interventions. There will be regular
contact with the referrer, during this period, and they will be asked to provide updates to the clinical team in relation to the patient’s condition and
need for admission.
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Process for Referral – In Patient Unit
The following Referral Indicator Tool will assist in establishing the level of need the patient has for admission and can be used to identify a timescale
enabling the health professional making the referral to have a target date.
a. Referrals to the hospice should be made to the Adult Services In-Patient Unit on 01472 350908
b. Referrals can be made at any time. Relevant and up-to-date information will be collected by a staff member, who will also offer guidance on
additional support/advice as required.
c. Referrals will be received from any healthcare professional/patient/carer with the patient’s knowledge and consent.
d. Telephone referrals are accepted but must be supported by further clinical information which should be faxed to the unit on 01427 359525
e. The referral will be reviewed by the Hospice Clinical Team to assess whether it meets the criteria.
f. The patients GP will be contacted and consent will be sought prior to undertaking an assessment.
g. If appropriate, an assessment will be undertaken, within 48 hours, by the Adult Service Liaison Nurse or Senior Nurse.
h. GP Direct Admissions can be arranged following assessment by the General Practitioner of their patient who, they feel would benefit from
immediate admission to the Hospice.
i. Admissions are accepted dependant on available capacity.
j. Members of the clinical team determine the appropriate waiting list category. Admission often occurs within a day or two even if it is not
urgent.
k. Occasionally capacity problems mean that patients wait longer than the ideal and every effort is made to ensure that, if appropriate, the patient
and their family/carer are supported by alternative clinical services, who will initiate, for example, symptom management, until such time as an
admission can be arranged.
Respite Care within the Inpatient Unit
1. Due to capacity, a maximum of 8 weeks in any 12 months can be offered to patients over the age of eighteen who meet the criteria for
palliative care respite.
2. Palliative care respite admissions will be discussed with the patient and /or primary carer and wherever possible, planned in advance.
3. The patient will have been referred to the hospice and assessed by the Hospice Liaison Nurse.
4. Every patient receiving palliative care respite is reassessed during their stay prior to further respite being offered.
Process for Referral – Day Therapy
St Andrews Hospice Adult Services Day Therapy offers a range of services for patients with a diagnosis of an advanced, progressive, life-limiting
illness that have associated complex Palliative Care needs. All patients who meet the Hospice criteria have access to the Day Therapy service.
Sessions are held in the Adult Service Hospice building on a Monday, Tuesday, Thursday and Friday of every week.
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Process for Referral – Lymphoedema Service
St Andrews Hospice offers a range of lymphoedema treatments for patients with a diagnosis of lymphoedema linked to the disease related
indicators at appendix 1. Treatment is provided to patients who are diagnosed as having lymphoedema to reduce the effects of the condition and
to improve the patients overall quality of life.
In addition to the above the service also offers prevention, advice and support to community health professionals and specialist units within Diana
Princess of Wales Hospital to enable treatment to be provided to those patients who do not fit St Andrews Hospice criteria.
Process for Referral – Outpatient Services
St Andrews Hospice offers a range of services for patients with a diagnosis of an advanced, progressive, life-limiting illness that have associated
complex Palliative Care needs. All patients who fit the Hospice criteria have access to complementary therapy, family support and physiotherapy.
These services are provided to inpatients and also operate on an outpatient appointment basis.
How to refer to Day Therapy and Outpatient Services
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Referrals can be made by General Practitioners (GP), District Nurses (DN), hospital medical/surgical teams or by Macmillan/Specialist teams
in the community or hospital. Referrals may also be initiated by the patient, but this will be in consultation with their GP and key worker.
Patients referred for Day Therapy will be contacted within 48 hours of referral and assessed following consent from the GP.
Macmillan Specialist Nurse referrals are normally accepted without the need for initial nurse assessment.
Once the patient is accepted for Day Therapy, they are placed on the waiting list until the next session is available.
Once the patient has been assessed and it is found that they meet the Hospice criteria contact will be made by the outpatient service(s)
identified by the assessment to arrange an appointment.
Regular liaison with the patient will be maintained during this time.
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St Andrews Hospice Adult Services In-Patient Unit
Referral Indicator Tool
Reason for
Referral
Indicators
Prompt
Pain &
Symptom
Management
 Complex, unpredictable and rapidly
changing pain and symptoms that cannot be
managed in another care environment
 Unstable condition with sudden
exacerbation/ deterioration that requires
24/7 specialist assessment;
 Symptoms that cannot be alleviated by
treating the underlying disease
 Severe progression of illness over a few
months/weeks
Physical symptoms such as intractable vomiting
 Dying patient with specialist palliative care
needs
Deterioration in condition on a daily basis
Respite
 Temporary physical, emotional or social
care of a dependent person in order to
provide relief from caring to the primary
care provider
Patients requiring palliative care respite should
have specialist palliative care needs.
Emergency
Respite
 Respite as above, where there are critical
circumstances to respond immediately
Care in Dying
Spiritual distress and/or
psychological disturbances,
severe anxiety or depression
Response Time
Supported by NEYHCA
(Cancer) 2012
Urgent :
Whenever possible, admission to
happen within 24 to 48 hours
Prioritised by need and subject
to bed availability
Pain crisis
Rapidly progressive disease
Complex medication review and monitoring
When it is clear the patient is actively dying
Urgent:
Whenever possible, admission to
happen within 24 to 48 hours
Prioritised by need and subject
to bed availability
Routine:
Pre booked dates by
arrangement with patient,
family/carer
Urgent :
Whenever possible, admission to
happen within 24 to 48 hours
Prioritised by need and subject
to bed availability
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Admission:
St Andrew’s Hospice Adult Services in-patient unit is open 24 hours a day throughout the year. Admissions are accepted dependant on the
availability of medical support for the admission and morning admissions of the patient is encouraged to permit timely completion of the process.
The Adult Service is able to offer an emergency out-of-hours service for the direct admission of patients. However it should be noted that there is
no on-site medical presence at these times. The patient’s GP will be required to be available to come into the Hospice on the day of admission to
facilitate the prescription of medicines and care.
When a patient is admitted to the in-patient unit, a nursing and medical assessment will take place on the day of admission. Any previously
expressed preferences for care and/or treatment will be discussed as appropriate.
Discharge Criteria and Planning:
The Hospice is unable to accept patients for indefinite care and this should be made clear by the referrer to the patient and their family/carers
when admission to the unit is being discussed. Patients are likely to be discharged as soon as they can be suitably cared for by a non-specialist team
with the appropriate specialist support. This may be at the end of a pre-set duration of attendance, (NEYHCA (Cancer) 2012).
Most patients will be admitted for a period of assessment; length of stay will be dependent on complexity of need and with the exception of
patients who are in the last days/hours of life (unless this is the patients wish and can be supported), discharge planning commences on admission.
Discharge should only be made:
 Following discussions between the patient and appropriate family members, carers and relevant professionals
 If the patient’s condition stabilises or improves such that they or the Hospice team feel that input from the specialist palliative care service is
no longer required
 If the patient is no longer able to benefit from Specialist Palliative Care
The Hospice clinical team acknowledges the importance of Advance Care Planning (ACP) and recognises that patients may have preferences with
regard to their preferred priority of care/death. The in-patient unit is required to prioritise access to its service according to the complexity of
need and will always take preferences into account but there may be times when this may not be possible, due to the stage of the patients illness or
the capacity of the unit.
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Appendix 1 – Specific Disease Related Indicators (adapted from the GSF Prognostic Indicators 2008)
Look for two or more of the following
Heart Disease
NYHA Class III/IV heart failure, severe valve disease or
extensive coronary artery disease.
Breathless or chest pain at rest or on minimal exertion.
Cancer
Performance status deteriorating due to metastatic
cancer and/ or co-morbidities.
Persistent symptoms despite optimal palliative oncology
treatment or too frail for oncology treatment.
Persistent symptoms despite optimal tolerated therapy.
Systolic blood pressure <100mmHg and /or pulse > 100.
Kidney Disease
Renal impairment (eGFR <30 ml/min).
Stage 5 chronic kidney disease eGFR< 15ml/min
Cardiac cachexia.
Two or more acute episodes needing intravenous
therapy in past 6 months.
Conservative kidney management due to multi morbidity
Deteriorating on renal replacement therapy; persistent
symptoms and/or increasing dependency.
New life limiting condition or kidney failure as a
complication
Not starting dialysis following failure of a renal transplant
Respiratory Disease
Severe airways obstruction (FEV1<30%) or restrictive
deficit (vital capacity < 60%, transfer factor <40%).
Meets criteria for long term oxygen therapy (PaO2 <
7.3kPa).
Breathless at rest or on minimal exertion between
exacerbations.
Persistent severe symptoms despite optimal tolerated
therapy
Symptomatic right heart failure.
Low body mass index (< 21).
Liver Disease
Advanced cirrhosis with one or more complications:
 intractable ascites,
 hepatic encephalopathy,
 hepatorenal syndrome,
 bacterial peritonitis,
 recurrent variceal bleeds.
Serum albumin < 25g/l and prothrombin time raised or
INR prolonged
Hepatocellular carcinoma.
Increased emergency admissions for infective
exacerbations and/or respiratory failure.
Neurological Disease
Progressive deterioration in physical and/or cognitive
function despite optimal therapy.
Recurrent aspiration pneumonia; breathless or
respiratory failure.
Speech problems; increasing difficulty communicating;
progressive dysphagia.
Symptoms which are complex and difficult to control.
Dementia
Unable to dress, walk or eat without assistance; unable
to communicate meaningfully.
Increased eating problems; now needing pureed/ soft diet
or supplements or tube feeding.
Recurrent febrile episodes or infections; aspiration
pneumonia.
Urinary and faecal incontinence.
Lymphoedema associated with a condition above
Tissue swelling, pitting and non-pitting
Skin condition hyperkeratosis, papillomatosis (dry thickened warty bumpy) blistered, weeping broken or ulcerated
eczema
Subcutaneous tissue changes – fatty/rubbery, non-pitting or hard
Shape change of limb.
Cellulitis, also frequency of episodes
Associated complications of other aetiologies
Movement and function – impairment of limb or general function
Obesity
Reference
1. SPOTLIGHT: Palliative care beyond cancer: Recognising and managing key transitions in end of life care: Kirsty Boyd, Scott A Murray
BMJ | 25 September 2010 | Volume 341
2. The Gold Standards Framework (GSF) www.goldstandardsframework.nhs.uk
3. The GSF Prognostic Indicator Guidance Revised V5 Sep 2008
www.goldstandardsframework.nhs.uk/Resources/Gold%20Standards%20Framework/PrognosticIndicatorGuidancePaper.
4. North East Yorkshire & Humber Clinical Alliance Referral, Admission and Discharge Criteria2012
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