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Guidetopatienttransfer

Principlesandminimumrequirements
fornon-timecriticalinter-hospital
patienttransfer
RevisedDecember2012

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This document is available as a PDF on the internet at:
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Copyright, State of Victoria, Department of Health, 2012
This publication is copyright, no part may be reproduced by any process except
in accordance with the provisions of the Copyright Act 1968.
Authorised and published by the Victorian Government, 50 Lonsdale Street, Melbourne.
Except where otherwise indicated, the images in this publication show models and
illustrative settings only, and do not necessarily depict actual services, facilities or
recipients of services.
December 2012 (1211033)
GUIDE TO PATIENT TRANSFER
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A
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The development of this Guide to patient transfer: principles and minimum requirements for
nontime critical inter-hospital patient transfer was prepared by Alice Gleeson and overseen by the
VQC Patient Transfer Group. The group consists of two VQC members and members of relevant
stakeholder groups. The VQC acknowledges the valuable contribution made to this work by the
non-VQC members.
VQC Patient Transfer Group members
Dr Simon Fraser (Chair)* Senior Paediatrician and Chief Medical Ofcer, Latrobe Regional Hospital
Dr Robert Grenfell* GP, National Director, Clinical Issues, Heart Foundation
Mr Wallace Crellin Consumer representative
Dr Emma Mooney Doctors-In-Training, The Australian Medical Association Victoria
Mr Dean Jones Director, Inpatient Access, Eastern Health
Mr Ian Williams Acting Manager, Non-Emergency Services, Ambulance Victoria
Ms Belinda Westlake Health Information, Quality and Risk Manager, Moyne Health Service
Ms Lesley Hawes LAOS Statewide Coordinator, General Practice Victoria
Ms Tricia Elliot Patient Flow Coordinator, Bendigo Health
(*denotes VQC members)
GUIDE TO PATIENT TRANSFER
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Inter-hospital transfers are an important and necessary part of the Victorian healthcare system. Moving patients
from one hospital to another is vital to ensure they receive the right care, in the right place at the right time.
The Victorian Quality Council developed this guide following feedback from the sector on the need for
standardised principles and minimum requirements for nontime critical patient transfer.
The guide is informed by:
a literature review of current national and international best practice
an investmentlogic mapping workshop to defne transfer problems and strategic interventions
wide stakeholder consultation through executive directors, directors and managers within the Department
of Health, CEOs of public and private health services, Adult Retrieval Victoria, private and public transport
providers, quality managers and directors, access managers and the Australian Commission on Safety and
Quality in Health Care.
The guide includes principles, minimum requirements and an assessment tool for key phases of the transfer
process, but it does not attempt to address all the issues for specic transfer settings and patient groups at
individual health services. The guide is intended to help executives and senior managers to enhance, develop
and implement local policies and procedures for nontime critical inter-hospital patient transfer.
The principles, minimum requirements and assessment tool are designed to work together to promote
a culture of personal accountability, teamwork and effective communication to ensure patient safety and
continuity of care throughout the patient-transfer journey. We anticipate that a culture of safety and continuity
of patient care across the delivery system will result in fewer adverse events, higher quality and safer care, and
an improved patient experience.
Dr Sherene Devanesen
Chair
Victorian Quality Council
P
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GUIDE TO PATIENT TRANSFER
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ACKNOWLEDGEMENTS
PREFACE
INTRODUCTION 4
PURPOSE 5
SCOPE 5
AIM 5
ASSOCIATED RELEVANT LEGISLATION AND POLICIES 5
KEY PRINCIPLES 6
REQUIREMENTS FOR INTER-HOSPITAL PATIENT TRANSFER 7
APPENDICES 11
Appendix 1: Checklist 12
Appendix 2: Assessment tool 13
Appendix 3: Glossary 16
Appendix 4: VQC Inter-Hospital Transfer Patient Transfer Form 18
Appendix 5: VQC Inter-Hospital Transfer Patient Transfer Form instructions for use 20
REFERENCES AND RESOURCES 23

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Inter-hospital patient transfer is a frequent and important part of the Victorian
healthcare system. It falls into two broad groups: time-critical emergency
transfers and nontime critical (non-emergency) patient transfers. Patients
are transferred between hospitals for numerous reasons, most frequently
to access specialised inpatient care not available at the hospital where they
are admitted (forward transfer), to return to a hospital from which they were
previously transferred (back transfer), and to coordinate resources across
health services (Victorian Quality Council 2009).
Introduction
GUIDE TO PATIENT TRANSFER
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Inter-hospital patient transfer involves the movement
of a patient from one hospital to another; it also
involves the transfer of information and professional
responsibility and accountability for patient care
between individuals and teams within the overall
system of care (Victorian Quality Council 2008a).
The Victorian Quality Council (2008a; 2008b)
has identied many issues with patient transfer
processes, including:
diffculties with referral and transport processes
poor selection of receiving hospitals
incomplete documentation of transfer
poor or delayed communication (clinical handover) .
Poor patient transfer processes are associated with
delayed or loss of continuity of care, duplication
of services, increased costs and adverse events
including patient death (Department of Human
Services 2009; Department of Health 2009).
To improve the standard of patient transfer, the
Victorian Quality Council developed this guide in order
to standardise the process across the state, so that
all Victorians can receive the high-quality healthcare
they need, where and when they need it.
Purpose
The guide outlines patient-transfer principles and
minimum requirements, and includes an assessment
tool (see Appendix 2).
The purpose of the guide is to help hospital staff:
improve local processes and policies for nontime
critical inter-hospital patient transfer
assess their current patient-transfer systems
and processes
support the implementation, auditing and
enhancement of patient-transfer processes
promote a culture of safety and continuity
of care throughout the interhospital patient
transfer process.
Scope
These principles and minimum requirements apply
to nontime critical patient transfers between
hospitals, primarily for admitted patients.
While many of the principles and minimum
requirements will apply to all patients, hospitals should
tailor processes for specic transfer settings, patient
groups and their local situation.
The document is for all public and private hospital
executives and senior managers of clinical teams
(medical, nursing, allied health and designated
persons) responsible and accountable for planning,
developing and implementing policies and procedures
for nontime critical inter-hospital patient transfers.
Aim
The aim of the guide is to standardise patient transfer
principles and minimum requirements in order to:
strengthen personal accountability, teamwork and
effective communication
ensure patient safety and continuity of care
throughout the patient-transfer journey.
Associated relevant legislation
and policies
This document should be used in conjunction with
the following legislation and policies:
1. Australian Commission on Safety and Quality
in Health Care (ACSQHC) National Safety and
Quality Health Services Standards (NSQHSS),
Standard 6: Clinical handover
2. Australian Commission on Safety and Quality
in Health Care OSSIE Guide to clinical handover
improvement
3. Charter of Human Rights and Responsibilities
Act 2006
4. Health privacy principles extracted from
the Health Records Act 2001
5. Health Records Act 2001 (Vic)
6. Mental Health Act 1986 (Vic)
7. Safe transport of people with a mental illness.
Chief Psychiatrists guideline 2011
7. Non-Emergency Patient Transport Act 2003
8. Non-Emergency Patient Transport
Regulations 2005
GUIDE TO PATIENT TRANSFER
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Key principles
The following key principles will support decision
making and safe systems to ensure continuity
of care during a nontime critical inter-hospital
patient transfer.
The key principles of patient transfer are:
1. The decision to transfer a patient between
hospitals is based on the patients condition
and consent, the capability and capacity of
the referring hospital to provide the necessary
care for the patient, and the receiving hospitals
capability and capacity to provide appropriate
and safe care.
2. All health professionals involved will ensure that
the transfer is timely and that the patient is cared
for in such a way as to maintain: patient safety;
the necessary treatment and care; contact with
appropriate staff; patient dignity; respect for
individual needs, including cultural, ethnic and
religious needs; patient condentiality; and the
safety and wellbeing of the staff involved.
3. All health professionals involved will act
in accordance with their accountability and
in a collaborative and coordinated manner.
4. The decision to transfer a patient is the
responsibility of the attending clinician
or designated person at the referring hospital
and should involve a senior clinician or
designated person.
5. The attending clinician or designated person
at the receiving hospital must agree to accept the
patient prior to transfer.
6. The receiving hospital will not refuse the patient
transfer if it is medically indicated and the
receiving hospital has the capability, capacity
or responsibility to provide care for the patient.
7. The patient, next of kin or the substitute decision
maker (SDM) will provide informed consent for
the transfer, and for sharing of information.
8. Clinical handover will occur before the transfer,
to ensure all relevant information is exchanged
between designated persons at the transferring
and receiving hospitals and the transport provider.
9. The attending clinician or designated person
at the referring hospital will ensure that copies
of all appropriate and pertinent records are
transferred with the patient.
10. The attending clinician or designated person
at the receiving hospital will ensure that copies
of all appropriate and pertinent records have
been transferred with the patient.
11. The receiving hospital will, where appropriate and
when agreed, ensure the patient is transferred
back to the referring hospital in a timely, orderly
and safe fashion, with accurate and complete
clinical handover.
12. Hospital clinical governance and leadership
will implement, audit and enhance transfer
processes to ensure a culture of safety and
continuity of care.
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Requirements for inter-hospital patient transfer
The following section identies the action steps and minimum requirements for each phase of the transfer
process for nontime critical inter-hospital patient transfer. These are a guide only and are not intended to be
all-inclusive. It is expected that hospitals will develop their own action steps and minimum requirements for
specic transfer settings and patient groups. While a systematic approach to the process of patient transfer
is essential, some of the phases and action steps may occur simultaneously when necessary.
Requirements for key phases of the inter-hospital patient transfer (IHPT)
process for nontime critical patients
IHPT phase Action steps Minimum requirements
Determine
the clinical
appropriateness
and necessity for
patient referral
and transfer
Assess the patients clinical
condition
Ensure the necessary and
appropriate investigations
are carried out
Establish if the patient
should be transferred, and
if an escort is required
Identify any likely risks
to the patient that may
result from, or during, the
transfer
Ensure that the patient
agrees to the transfer
and that advance care
directives (ACDs) are
respected
Involve a senior clinician
or designated responsible
person in the decision to
transfer
All patients are assessed on admission, and regularly
thereafter, to identify and plan for:
- appropriate ongoing care and discharge
- additional health and social care needs on discharge
- referral or inter-hospital transfer as required.
Ongoing care occurs in an appropriate place as close to the
patients home as possible.
The decision to transfer must involve the patient, next of
kin or the substitute decision maker (SDM), and a senior
experienced clinician or the designated responsible person.
The patient has the right to receive treatment and transfer
for treatment, or refuse one or both.
Each hospital has a documented Patient Medical
Assessment Protocol to include speciality-specic criteria
for patient referral or transfer.
Each hospital has a documented Patient Transfer Policy
that identies:
- roles and responsibilities of the referring and receiving
hospital, the designated persons and transport provider
- designated roles that are responsible for the referral or
transfer decision and the various steps of the transfer
process
- the documentation required to accompany the patient.
Note: if the patient has advance care directives, or
not for resuscitation, limitation of medical treatment or
involuntary treatment orders, copies of these documents
must accompany the patient so that treatment remains
consistent with their terms.
All staff must be aware of their roles and responsibilities in
relation to patient referral or transfer.
All staff undertaking patient transfers should have the
appropriate qualications, competencies and training in
patient transfer. This includes training in relation to:
- patient assessment, monitoring, treatment and evaluation
to determine the clinical appropriateness of the transfer
and the level of care needed during transfer
- responsibilities in relation to patient transfer
documentation, referral, delegation, clinical handover
and privacy
- non-emergency patient transport providers and policies.
GUIDE TO PATIENT TRANSFER
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Requirements for key phases of the inter-hospital patient transfer (IHPT)
process for nontime critical patients
IHPT phase Action steps Minimum requirements
Determine
the referral
destination and
acknowledge
acceptance of
the referral
Determine the appropriate
receiving hospital
Consult with the receiving
team about the referral
and bed availability
Ensure the referral is
accepted by the receiving
hospital team
Ensure that there is a
shared understanding of
the purpose (diagnosis,
investigation, treatment
or second opinion) and
expectation of the referral
Agree on arrangements
for the transfer, arrival,
repatriation and feedback
Escalate to a senior
clinician when: unable to
secure an appropriate
referral destination; a
bed is not available at
the receiving hospital
within a clinically relevant
time, when the transfer is
delayed or the patient is
deteriorating
Ensure that the receiving
team names, position
title, contact numbers
and all issues arising are
documented
Determining the appropriate receiving hospital will require
consideration and assessment of the:
- patients current condition and degree of clinical urgency
- reason for the transfer to include the intervention required
by the patient
- capability and capacity of the referring hospital
- capability and capacity of the potential receiving hospital
- geographical proximity or distance
- needs and consent of the patient, next of kin or SDM
- established referral relationships or inter-hospital patient transfer
agreements.
Whenever possible, inter-hospital patient transfer agreements should
be in place to facilitate timely transfer of patients.
This is especially recommended in locations where patients with
complex problems are regularly transferred to a specifc hospital.
Inter-hospital transfer agreements where they exist should be
documented to enable staff to:
- easily contact the relevant service providers
- identify role delineation between hospitals and repatriation of patient
agreements, which may include transport charging arrangements
- identify clinical handover requirements for the receiving hospital,
transport provider and the patients GP
- identify the appropriate escalation process if: a bed is not available
at the receiving hospital; there is a disagreement regarding the
transfer or if the patient is deteriorating
- identify the designated roles (position titles and contact details)
responsible for the transfer decision and the various steps of the
transfer process
- identify a mechanism for evaluating the transfer process for ongoing
quality and safety improvement.
Prepare the
patient for
transfer
Involve the patient, next
of kin and/or SDM
Obtain informed consent
for the inter-hospital
transfer and consent for
sharing patient information
with the receiving team,
transport provider and the
patients GP
The patient, next of kin or the SDM is given adequate and timely
information about ongoing care, including: the reasons for transfer; the
material risks and likely benefts; the procedures involved; expected
outcomes; transport options and support available; and the need
to share the patients information with the receiving team, transport
provider and the patients GP.
The information provided is documented in the medical record.
The clinician or designated person is responsible for obtaining and
documenting the consent to transfer and share patient information.
If circumstances do not allow for this then both the indications for
transfer and the reason for not obtaining consent is documented in the
medical record.
The patient, next of kin or SDM is provided admission or transfer
information in a format that meets their needs.
A copy of the inter-hospital transfer form could be provided to the
patient if requested.
The interpreter is involved as required
The patients vital signs should continue to be monitored regularly to
ensure early recognition of clinical deterioration and the need for the
transfer to be escalated.
GUIDE TO PATIENT TRANSFER
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Requirements for key phases of the inter-hospital patient transfer (IHPT)
process for nontime critical patients
IHPT phase Action steps Minimum requirements
Coordinate
logistics for
patient transfer
Determine the mode
of transport
Coordinate the appropriate
transport
The mode of transport is determined by the referring hospital clinician
or designated person in consultation with the receiving hospital
clinician or designated person, the patient, and the transport provider.
The mode of transport selected will be based on patient acuity,
clinical condition, medical needs, legal status under the Mental Health
Act 1986, distance or geographical proximity, and availability and
timeliness of transport resources.
The mode of transport may include public ambulance, private
non-emergency patient transport (NEPT), or private or volunteer
car transportation.
The designated person should ensure the transfer transport is
arranged as soon as a date of transfer is known and if possible that
the transfer is arranged to take place during business hours.
When booking the transport, the designated person should:
- be aware of the scope of practice for NEPT providers in relation to
patient acuity, and when NEPT is permitted and not permitted for
people with mental illness
- ensure that the transport provider is informed (where appropriate
to meet patient safety needs and respect for patient condentiality)
of the patients condition, acuity, weight, pick up time and location,
and any special requirements that the patient may have such as IV
infusion, interpreter, wheelchair, sight, speech or hearing difculties,
or escort requirements.
Hospitals should have a documented index of local transport
resources to include:
- names and contacts details of transport agencies
- hours of service
- wait time and requirements for booking transport providers
- transport options provided by each transport agency along with
estimated transit time for transport options
- NEPT providers scope of practice
- transfer equipment available/required or accommodated.
Involve the designated
persons and relevant
multidisciplinary team
members with planning for
the transfer of the patient
The designated person should ensure that all:
- multidisciplinary team members involved in the patient care are
notied of the intended transfer to enable planning as a team for
the transfer of responsibility and accountability for all aspects
of patient care.
Ensure the patient is ready
for transfer
A patient is ready for transfer when:
- a clinical decision has been made that the patient is suitable for
transfer AND
- the receiving hospital has accepted the patient transfer AND
- the patient, next of kin or SDM has consented to the transfer and
sharing of information AND
- all key information on reason for transfer, patient discharge diagnoses,
treatment or shared care plans, scheduled follow-up referrals and
appointments, medications, investigation results and those pending have
been accurately and completely documented and communicated to the
receiving hospital, the transport provider and the patients GP AND
- all relevant key information, documentation and required medications
have been collated to transfer with the patient
- the multidisciplinary team has decided the patient is ready for
transfer AND
- strategies are in place for a safe patient transfer.
GUIDE TO PATIENT TRANSFER
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Requirements for key phases of the inter-hospital patient transfer (IHPT)
process for nontime critical patients
IHPT phase Action steps Minimum requirements
Coordinate
clinical handover
to:
the transport
provider
the receiving
hospital team
the patients
GP
Coordinate clinical
handover of the patient,
that is the communication
(verbal and written)
process to transfer
professional responsibility
and accountability for
patient care to the
receiving hospital/transport
provider
Ensure that accurate,
complete and appropriate
key information is provided
to the designated person
at the receiving hospital/
transport provider prior to
patient transfer
Complete documentation
and clinical handover
Ensure that all key
information is transferred
with the patient
To ensure the transfer of accountability and responsibility for all aspects
of patient care, clinical handover should include:
preparation for handover using a structured standardised process
to ensure that timely, relevant, unambiguous, consistent handover
and communication across the whole spectrum of health care
providers is achieved
nomination of when, how and who will be involved in the handover
patient, next of kin or SDM and multidisciplinary team involvement
as appropriate
the provision of verbal and documented key information on: reason
for transfer, patient discharge diagnoses, shared care treatment
plans, scheduled follow-up referrals and appointments, medications,
investigation results and those pending prior to patient transfer
the key information shared should be accurate, complete and
appropriate to enable ongoing care and to prevent unnecessary repeat
of tests or investigations
direct communication, where appropriate from clinician to clinician,
clinician to GP, nurse to nurse, nurse to transport provider, allied health
to allied health personnel to ensure continuity of patient care and
enable the receiver to assume responsibility for patient care
use of the patient medical record to facilitate cross-checking of the
information documented and handed over.
Repatriate the
transferred
patient
Determine repatriation of
patient arrangements
When a clinical assessment determines that the transferred patient
could appropriately be cared for at the original referring hospital and
if the patient is stable enough and consents to transfer, the patient
should be repatriated.
When initiating the inter-hospital patient transfer it is preferable to:
- establish the repatriation arrangements,and
- the mechanism and timing of follow-up and feedback about the
outcome of the transfer from the receiving hospital.
Initiate post-transfer
follow-up communication
with the receiving hospital
where appropriate
When repatriation is necessary, post transfer communication between
the sending and receiving hospital is preferable to enhance :
information sharing on the patient outcome
shared responsibility for the patient-transfer process
the provision of feedback or complaints on the clinical appropriateness
of the transfer and the quality of the transfer process
collaboration between hospitals.
Evaluate the
inter-hospital
patient transfer
process for
ongoing quality
and safety
improvement
Establish and maintain a
documented process for
reviewing nontime critical
inter-hospital patient
transfer
Regularly review inter-hospital patient transfer processes by:
- reviewing feedback obtained from patient, next of kin or SDM,
receiving hospital, transport providers and GPs
- involving the patient, next of kin or SDM and multidisciplinary team
in reviews and improvement activities
- documenting problems identied and the actions taken
to address problems
- communicating the actions taken to address problems
to all relevant stakeholders
- monitoring the volume of inter-hospital patient transfers to enable
appropriate allocation of resources.
A GUIDE TO USING DATA FOR HEALTH CARE QUALITY IMPROVEMENT
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Appendices
GUIDE TO PATIENT TRANSFER
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Appendix 1: Checklist
Determine the clinical
appropriateness and
necessity for patient
referral and transfer
Phases Action steps
Determine the
referral destination
and acknowledge
acceptance
of the referral
Prepare the patient
for transfer
Coordinate logistics
for patient transfer
Coordinate clinical
handover to:
the transport
provider
the receiving
hospital team
the patient's GP
Repatriate the
transferred patient
Evaluate the
inter-hospital patient
transfer process for
ongoing quality and
safety improvement
Has the patients clinical condition been assessed?
Have the necessary and appropriate investigations been carried out?
Does the patient need to be transferred?
Does the patient require an escort?
Has the likely risks that may result from or during the patient transfer been identified?
Has the patient agreed to the transfer and are advance care directives respected?
Has a senior clinician or designated person been involved in the decision to transfer?
Has the appropriate referral destination or receiving hospital been determined?
Has the receiving team acknowledged acceptance of the patient referral?
Is there a shared understanding of the purpose and expectation of the referral?
Have arrangements for the transfer, arrival, repatriation and feedback been agreed?
Is escalation to a senior clinician necessary?
Has the receiving team names, position title, contact numbers and issues
been documented?
Has the patient,next of kin or substitute decision maker been involved
in decision making?
Has informed consent for the transfer and consent for sharing patient information
with the receiving team, transport provider and patient's GP been obtained?
Has the appropriate mode of transport been determined and coordinated?
Has the designated person and relevant multi-disciplinary team members been
involved with planning for the transfer of the patient?
Is the patient ready for transfer?
Has clinical handover of the patient, (verbal and written communication to transfer
professional responsibility and accountability for patient care) to the receiving hospital
and transport provider occurred prior to patient transfer?
Has documentation of clinical handover occurred?
Have copies of all key information and documentation been transferred with the patient?
Did the documentation tranferred include a doctor's letter that was cc'd to the GP?
When patient repatriation arrangements have been agreed, has post transfer
follow-up communication with the receiving hospital been initiated?
Has a documented process for reviewing nontime critical inter-hospital patient
transfer been established and maintained?
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N

Y/N
Y/N


Y/N
Y/N
Y/N
Y/N
Y/N
GUIDE TO PATIENT TRANSFER
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Appendix 2: Assessment tool
The assessment tool will help executives and senior managers to examine inter-hospital patient transfer
processes, and identify priority areas for action to align them with the principles and minimum requirements
in this guide.
The assessment tool aims to ensure a culture of safety and continuity throughout the patient transfer process.
Topic Questions
Assessment
Yes WIP* No
Leadership
and patient IHT
planning
Is there a Patient Transfer Planning Group (PTPG) or equivalent in place with
senior executive, clinical, consumer and key stakeholder representation?
Does the PTPG or equivalent have terms of reference that clearly dene the
members roles, responsibilities and accountabilities?
Is there evidence of organisational leadership and governance around
implementing, reporting, monitoring and evaluating the patient transfer clinical
handover process?
Is there an audit process in place to evaluate the inter-hospital transfer
processes, incidences, changes or interventions, and lessons learnt?
Does the audit process incorporate a peer review of the patient referral or
transfer for appropriateness, timeliness, transfer of information and patient
satisfaction?
Does the audit of inter-hospital transfer include reporting on reason for transfer
and volume of transfers by: transfers in and out; hospital or health service;
speciality; transport provider (private, NEPT or Ambulance Victoria) and cost?
Are audit review recommendations actioned to ensure ongoing quality and
safety improvement and to reduce the risk of incidents recurring?
Are there systems and processes in place to share lessons learnt from good
and poor patient transfer practices, to identify system improvements and
encourage a safety culture?
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Topic Questions
Assessment
Yes WIP* No
Documentation Does the workforce have easy access to a documented Patient Transfer Policy?
Was the Patient Transfer Policy developed in partnership with the
multidisciplinary team, the patient and next of kin?
Is implementation of the Patient Transfer Policy being audited?
Is the Patient Transfer Policy reviewed regularly in accordance with the
organisations document review cycle?
Does the Patient Transfer Policy include:
key principles that apply when transferring patient care
role and responsibility of the organisation for the provision of clinical
governance and leadership of patient transfer systems and processes
role and responsibility in relation to implementation and evaluation of patient
transfer systems and processes
roles and responsibilities of the designated persons responsible for
authorising the transfer and the various steps of the transfer process
roles and responsibilities in relation to involving the patient, next of kin or SDM
in transfer decisions
an escalation process in the event of: the patient deteriorating; a bed
not being available at the receiving hospital; or if there is a disagreement
regarding the transfer
specifc transfer requirements for speciality patient groups such as children,
mental health patients, renal dialysis patients, et cetera
steps taken to initiate a patient transfer to include key phases, action steps
and minimum requirements for a nontime critical patient transfer
a list of the documentation required to be copied and transferred with the
patient to include mandatory documents such as ACD/NFR/limitation of
medical treatment order/Mental Health Act paperwork when they exist?
inter-hospital transfer agreements, roles and responsibilities, contact details and
transport charging arrangements specically where the patient is repatriated
a process for accessing potential receiving hospitals
an index of local transport resources
a process for peer review and feedback on referral management to include
review of the appropriateness and timeliness of the referral, transfer of
information and patient satisfaction
the process for staff to report incidents and near misses relating to patient transfer
reference and location of associated policies such as non-emergency patient
transport legislation and regulations, clinical practice protocols, Medical
Records Act and privacy policies.
Communication
and
coordination of
inter-hospital
patient transfer
Is there a designated role responsible for the coordination and communication
of inter-hospital patient transfers?
If so, is the role clear to all stakeholdersfor example, is the role published on
the hospital website or the hospital capability database?
Does the workforce have easy access to a structured clinical handover process
for inter-hospital patient transfer that includes: preparation, organisation, verbal
and written documentation exchange, timing, environmental awareness and
involvement of participants, and patient, next of kin or SDM?
Does the workforce have access to a range of tools to support effective inter-
hospital transfer clinical handover such as the VQC Inter-Hospital Transfer Form
(IHTF) or the Barwon-South Western Quality Advisory Group Transfer Envelope?
Is there evidence that the workforce is using the structured process and tools
for inter-hospital transfer clinical handover?
GUIDE TO PATIENT TRANSFER
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Topic Questions
Assessment
Yes WIP* No
Patient, next of
kin or substitute
decision maker
involvement
Is there evidence that patient, next of kin or SDM is routinely involved in care
planning, and consent throughout the transfer process?
Is there evidence that patients rights and responsibilities in relation to patient
transfer are being complied with; for example, is there evidence that ACDs are
transferred with the patient?
Is there evidence that clear and accurate information is provided to patients,
next of kin or SDM in an appropriate format to meet their needs, for example,
a documented consent process?
Is patient satisfaction with the patient transfer process monitored?
Patient medical
assessment
Does the workforce have easy access to a documented Patient Medical
Assessment Protocol?
Does the Patient Medical Assessment Protocol include:
specialty-specifc criteria for patient referral and transfer
speciality-specifc criteria for clinical escort requirements
triggers for referral on to other disciplines or hospitals
delegation and responsibility for referral and transfer?
Is there evidence that all patients are assessed on admission to ensure that
appropriate and timely ongoing care is available?
Training and
education
Is there an education and training program on patient transfer available to
clinical staff at orientation?
Does the training program include:
criteria for patient referral and transfer
key phases, action steps and minimum requirements for a nontime critical
patient transfer
information on NEPT legislation, regulations and clinical practice protocols
information on selecting an appropriate receiving hospital?
Are arrangements in place for repeat training sessions at regular intervals?
Are staff competencies in relation to patient transfer, referral, clinical handover,
documentation and patient medical assessment monitored?
*WIP: work in progress
Name
Signature
Clinical area Date of assessment
GUIDE TO PATIENT TRANSFER
16
Appendix 3: Glossary
Term Denition
Advance care directive
(ACD)
An advance care directive (ACD) is a document created by a patient while they are
competent, which denes the medical treatment that they wish to refuse should they
become incompetent in the dened circumstances.
An ACD can record the persons preference for future care and appoint a substitute
decision maker to make decisions about healthcare and personal life management.
Patients have the right to make decisions about their healthcare, now and for the future.
An advance care plan offers the patient an opportunity to say now what life-prolonging
medical treatment they would and would not want in the future.
Barwon-South
Western Region
Quality Advisory
Group Patient Transfer
Envelope
The Patient Transfer Envelope was developed by the Barwon-South Western Region
Quality Advisory Group. It is an easy-to-use and practical tool for packaging all the
relevant documents to be transferred with the patient. It is used only once and is
discarded when the patient or resident is admitted.
Clinical handover Clinical handover refers to the verbal and written communication process to transfer
professional responsibility and accountability for some or all aspects of care for a patient,
or group of patients, to another person or professional.
Delegation, referral
and handover (Medical
Board of Australia
2009)
Delegation involves you asking another healthcare professional to provide care on your
behalf while you retain overall responsibility for the patients care.
Referral involves you sending a patient to obtain opinion or treatment from another
doctor or healthcare professional. Referral usually involves the transfer (in part) of
responsibility for the patients care, usually for a defned time and for a particular purpose,
such as care that is outside your area of expertise.
Handover is the process of transferring all responsibility to another healthcare
professional.
Good medical practice involves:
taking reasonable steps to ensure that the person to whom you delegate, refer or
handover has the qualifcations, experience, knowledge and skills to provide the care
required
understanding that when you delegate, although you will not be accountable for the
decisions and actions of those to whom you delegate, you remain responsible for the
overall management of the patient, and for your decision to delegate.
always communicating suffcient information about the patient and the treatment they
need to enable the continuing care of the patient.
Hospital capability The hospitals ability to manage patients requiring specialised medical evaluation and
care. Requirements span the range of specialised medical and health services, and may
include operating theatres, diagnostic equipment or particular specialist staff.
Hospital capacity The hospitals operational ability to manage a volume of patients to include the number of
beds available and staffed.
Inter-hospital patient
transfer
Any patient transfer, after initial assessment and stabilisation, from and to another
hospital.
Non-emergency
patient transport
Non-emergency patient transport (NEPT) is available for patients who do not require a
time-critical ambulance response and who have been assessed by a medical practitioner.
NEPT is governed by an Act, regulations and clinical practice protocols.
The Department of Health is responsible for the development and implementation of:
Non-Emergency Patient Transport Act 2003
Non-Emergency Patient Transport Regulations 2005
Non-emergency patient transport: clinical practice protocols.
GUIDE TO PATIENT TRANSFER
17
Term Denition
Not for resuscitation
(NFR)
Not for resuscitation (NFR) is an order to prevent the use of cardiopulmonary resuscitation
(CPR) in situations where the patients heart stop or the patient stops breathing. The NFR
order is made when CPR is deemed medically futile or unwanted by the patient.
An NFR order is documented in a form which may be referred to as a Limitation
of Medical Treatment Form.
Nontime critical
patient transfer:
(non-emergency
patient)
-versus-
Time-critical patient
transfer
(emergency patient)
Nontime critical patient transfer occurs when a stabilised patient needs to be
transferred, either forward to a higher level of care or back to a lower level of care or
closer to home, and the attending clinician or designated person has determined that:
the patient transfer is not urgent and that the patient is stable to transfer
the patient is unlikely to require transfer or transport under emergency conditions
irrespective of their acuity (high, medium or low).
The nontime critical patient is also referred to as a non-emergency patient.
Time-critical patient transfer occurs when a patient requires emergency care at the
closest appropriate hospital in the shortest time possible to achieve early intervention and
stabilisation. This patient will require transfer and transport under emergency conditions.
The time-critical patient is also referred to as an emergency patient.
Receiving hospital A hospital to which a patient is transferred for treatment, ongoing care or investigations.
Referring hospital A hospital from which a patient needs to be transferred, that is, the hospital that identies
the need for and initiates the patient transfer.
Substitute decision
maker
A substitute decision maker (SDM) is appointed or identied by law to make substitute
decisions on behalf of a person whose decision-making capacity is impaired.
Types of inter-hospital
transfers
Forward transfer: a transfer to a higher level of care than that available at the referring
hospital, for treatment such as inpatient specialist treatment.
Back transfer: a transfer back to a lower level of service, usually following completion of
an episode of care, or return transfer (repatriation) of an inpatient to the primary hospital,
or transfer of a patient to another hospital for recovery.
Lateral transfer: a transfer to a hospital with the same level of care. This may occur
when the referring hospital facilities are unavailable.
Transfer for investigations: a transfer for investigations not available at the referring
hospital. The patient is usually transferred back to the referring hospital once the results
have been discussed with the doctor.
Victorian Quality
Council (VQC)
The Victorian Quality Council (VQC) is a ministerial advisory council that was established
in 2001. The VQC is responsible for fostering better quality health services in Victoria
by working with stakeholders to develop useful tools and strategies to improve health
service safety and quality.
VQC Patient Transfer
Group (PTG)
The VQC Patient Transfer Group was established in 2009 to improve and standardise
inter-hospital patient transfer processes.
VQC Inter-Hospital
Transfer Form (IHTF)
The VQC Patient Transfer Group developed and piloted a generic Inter-Hospital Transfer
Form (IHTF) for nontime critical patients.
The IHTF has been endorsed by the Secretary for Health and the full VQC for
implementation across all Victorian health services from January 2012.

GUIDE TO PATIENT TRANSFER
18
Appendix 4: VQC Inter-Hospital Transfer Patient Transfer Form

Place
Health
Service Logo Here
Transfer discussed with
patient Yes No
Date of transfer
Indigenous status (circle)
A / TSI
ATSI / Unknown

Medicare no. ________________________

Pension / DVA no. ___________________
Private health insurance (PHI) fund
___________________________
PHI no.
(Affix patient label here)
Referring facility URN
Surname Given names
Address
Postcode DOB
Gender Male Female
Allergies Nil known Yes (if yes list type, reaction and severity) Signature
General practitioner Yes No Unknown
GP name__________________________
GP phone no. ______________________
GP notified of transfer Yes No Unknown
Next of kin (NOK) / Carer / Substitute decision maker (SDM) (Circle)
Name _________________________________
Phone no. ______________________________
Relationship to patient________________________
NOK / Carer / SDM notified of transfer Yes No
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Referring / authorising practitioner name
________________________________
Referring unit _______________________
Referrer phone/pager no. _________________
Referrer position (Consult / Reg / HMO / GP / RN / Other)
Referring ward
Name _____________________
Phone no.___________________
Patient living arrangements

Living independently

Residential facility

In-home support
Principal diagnosis / problem

Reason for transfer
Medical history / comorbidities

Observations at time of transfer: T_____.P_____ B/P _____
Respiratory management plan / O2 requirements
Sp02 target O2 rate O2 device*
*If ETT record any difficulty with intubation.
Intravascular access Site and date of insertion
No access
Peripheral venous line (1) ...
Peripheral venous line (2) ...
Peripheral venous line (3) ...
Central venous line .
Other .
IV fluids Yes No
Mental / cognitive / behaviour
No issues
Cognitive impairment Post-traumatic amnesia
Verbal aggression Delirium
Physical aggression Sleep disturbance
Resistive to care Dementia
Absconding risk Depression
Wanderer Acquired brain injury
Harm to self Harm to others
Other _________________________
Current cognitive state ________________
Glasgow Coma score
Continence
No issues
Faecal continence
Urinary continence
Indwelling catheter
Intermittent catheter
Stoma / colostomy
Time last voided
Date bowels last opened
Date IDC inserted
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Legal status
Not applicable
Voluntary patient Involuntary patient
Forensic patient Security patient
Nutrition and swallowing
Fasting: Yes No
Time of last intake________
Diet: Normal Diabetic Renal Soft
Puree Minced NBM
Fluids__________________
Supplements ______________
Restrictions _______________
Safe swallow strategies:________
Medication Crushed Whole
Enteral feeding NG PEG
Regime and feed sent Yes No
Dentures Yes No
Weight
Communication
Interpreter required
No Yes
Primary language spoken
Patient transfer form (inter-hospital)
Nontime critical patients Facility name

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GUIDE TO PATIENT TRANSFER
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Patient transfer form
Facility name Date Page 2
(Affix patient label here)
Referring facility URN
Surname Given names
Address
Postcode DOB
Gender Male Female
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Specialty-specific information
Alerts none _____________________
Alerts bariatric patient _____________________
Alerts falls risk _____________________
Alerts infectious risk _____________________
Alerts pressure ulcer risk _____________________
Alerts smoker _____________________
Advance care directives Yes No Unknown
NFR / limitation of medical treatment order
Yes No Unknown
Alerts other:
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Personal Accompanying Sent with
items N/A patient family
Clothing
Glasses
Dentures
Hearing aid
Medications
Equipment __________________ _ _
Valuables
List valuables_____________________________________
___________________________________________ ___
Other
If an air-ambulance transfer, luggage has to be less than 5 kgs
Patient ID band on patient Yes
Attached copy of documentation: ( where applicable )
Doctors letter Cognitive assessment tool
Allied health letter *Advance care directives
Observation chart Nursing care plan / pathway
Medications chart Fluid balance chart
IV orders Behaviour management plan
Wound chart *Involuntary treatment order
*NFR / limitation of medical treatment order
Investigation results: X-rays ECG
Pathology report
Other
* Where these exist, a copy must accompany the patient
Receiving facility (RF) Appropriate time for transfer agreed Yes No
RF name RF ward name
Acceptance by receiving medical practitioner Yes No
Date Time
Receiving medical practitioner / unit name
_____________________________
Receiving practitioner / unit phone no. and pager
Acceptance by receiving facility bed coordinator Yes No
Date Time
Receiving bed coordinator name
_________________________________________
Receiving bed coordinator phone no. and pager
Treating allied health contact details (if applicable)
Discipline Name Pager/phone Discipline Name Pager/phone
Occupational
therapist
Dietitian
Physiotherapist Social
worker

Speech
pathologist
Other
Form completed by (print name and job designation ) : Signature:
Patient transport provider (TP) service name _____________________ Date and time booked
Handover received Yes No Accompanying documentation received Yes No
Receiving transport provider name (print) Signature
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Handover provided: by referring staff Yes No : by TP Yes No .
Accompanying documentation provided Yes No Accompanying items checked Yes No

Receiving clinical staff name (print) Signature
Fax the form to receiving hospital prior to patient transfer. A copy should accompany the patient and the original form should be filed in the patient medical record.
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GUIDE TO PATIENT TRANSFER
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Appendix 5: VQC Inter-Hospital Transfer Patient Transfer Form
instructions for use

VQC inter-hospital patient transfer form
Instructions for use

The Victorian Quality Council The Victorian Quality Council The Victorian Quality Council The Victorian Quality Council
Safer, better healthcare for all Victorians
www.health.vic.gov.au/qualitycouncil www.health.vic.gov.au/qualitycouncil www.health.vic.gov.au/qualitycouncil www.health.vic.gov.au/qualitycouncil
December 2012

Introduction Introduction Introduction Introduction
The Victorian Quality Council (VQC) inter-hospital transfer form aims to improve standardisation of clinical handover and
documentation for nontime critical inter-hospital patient transfers.
The Department of Healths Secretary and the VQC endorsed the implementation of the form by all Victorian health
services from January 2012.
The form will help to:
ensure pertinent and accurate patient information is exchanged between the referring and receiving facility and the
transport provider
standardise the terminology and the minimum data sent and expected by health services during patient transfer
reinforce the need to transfer professional responsibility and accountability by identifying key responsible people at
the sending and receiving hospitals and the transport provider service
replace the multitude of transfer forms with varying information currently being used by Victorian health services
complement the Guide to patient transfer: principles and minimum requirements.

T TT Typ yp yp ype ee es ss s of of of of patient t patient t patient t patient transfers ransfers ransfers ransfers covered covered covered covered
The form is is is is intended for use in nontime critical transfers involving:
adult inter-hospital transfers
transfers between acute health services
transfers provided by both private and public transport providers.

The form is no is no is no is not tt t intended for use in transfers involving:
time-critical patients
specialist patient transport services such as Adult Retrieval Victoria, trauma retrievals, Newborn Emergency Transport
Service (NETS), Victorian Paediatric Transport Service (PETS) and Perinatal Emergency Referral Service (PERS).

The form may may may may be used in transfers involving:
inter-campus transfers, such as between hospitals in a health service
hospitals and other facilities, such as between hospitals and rehabilitation centres, aged care facilities or GP
surgeries.
However, you may need to modify the form for inter-campus, rehabilitation or aged care transfers (see Appendix 1).
Transfer process Transfer process Transfer process Transfer process
Confirm that the patient is to be transferred.
Identify if the patient fulfils the criteria for the intended use of the form.
Complete the form. All sections must be completed.
A copy of the form should be faxed to the receiving hospital prior to patient transfer, a copy should accompany the
patient during transfer and the original form should be filed in the patient medical record.
Local Local Local Local modifications modifications modifications modifications to the to the to the to the f ff form orm orm orm
The dataset contained in the VQC form is the minimum data that all hospitals should provide and receive when
undertaking a patient transfer. This dataset or its location under the sections should not be changed.
Modification may be made to form, such as inserting your health service name, logo and a medical record number,
formatting to comply with the Australian Standard 2828 for paper-based healthcare records or adding to the specialty-
specific area if required.
If you wish to use the form for all transfers including aged care and inter-campus transfer, we have included suggestions
for consideration in Appendix 1. An electronic copy of the form is available at: http://www.health.vic.gov.au/qualitycouncil

GUIDE TO PATIENT TRANSFER
21
VQC inter-hospital patient transfer form
Instructions for use

The Victorian Quality Council The Victorian Quality Council The Victorian Quality Council The Victorian Quality Council
Safer, better healthcare for all Victorians
www.health.vic.gov.au/qualitycouncil www.health.vic.gov.au/qualitycouncil www.health.vic.gov.au/qualitycouncil www.health.vic.gov.au/qualitycouncil

Section explanations Section explanations Section explanations Section explanations

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Referring facility URN: Referring facility URN: Referring facility URN: Referring facility URN: t tt the patients unique record number (URN) at the referring facility.
Indigenous Indigenous Indigenous Indigenous status status status status: : : : an Aboriginal or Torres Strait Islander person is defined as a person of Aboriginal (A) (A) (A) (A) or
Torres Strait Islander (TSI) (TSI) (TSI) (TSI) descent, who identifies as being A AA A or TSI TSI TSI TSI. Information on indigenous status is
collected by asking Are you of Aboriginal or Torres Strait Islander origin? and the response is recorded by
circling either: A or TSI; or Aboriginal and Torres Strait Islander (ATSI); or unknown.
Allergies Allergies Allergies Allergies: : : : if allergies are known, list the allergen type, reaction and severity. Allergen types may include
medications, foods, inhalants, environmental substances, latex and other.
Substitute Substitute Substitute Substitute decision maker decision maker decision maker decision maker (SDM): (SDM): (SDM): (SDM): an SDM may be appointed by the person, appointed for (on behalf of) the
person or identified as a substitute decision maker under the Guardianship and Administration Act 1986.
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The situation section should include a comprehensive overview of admission diagnosis, relevant medical history,
the reason for transfer, observations at time of transfer, respiratory treatment requirements and information on
nutrition and continence, if applicable.
SpO SpO SpO SpO2 2 2 2 target target target target: :: : refers to the acceptable patient oxygen saturation range when measured by a pulse oximeter.
ETT ETT ETT ETT : : : : refers to an endotracheal tube or breathing tube. Please note that any difficulty with intubation will
need to be recorded on the form and communicated during handover to the receiving hospital/facility
Forensic Forensic Forensic Forensic patient patient patient patient: :: : refers to a patient who is remanded, committed or detained in custody in an approved
mental health service by a supervision order under the Crimes (Mental Impairment and Unfitness to be
Tried) Act 1997.
Security Security Security Security patient patient patient patient: : : : refers to a patient who is a prisoner detained in custody in an approved mental health
service under s. 16 or 16A of the Mental Health Act 1986.
Involuntary Involuntary Involuntary Involuntary patient patient patient patient: :: : refers to a patient who is subject to an involuntary treatment order under s. 12 or 12AA
of the Mental Health Act 1986.
Principal Principal Principal Principal diagnosis diagnosis diagnosis diagnosis: :: : refers to the condition that is established after investigation and responsible for the
patients admission to hospital.
Past Past Past Past medical medical medical medical history history history history / // / c cc comorbidities omorbidities omorbidities omorbidities: :: : refer to significant medical events, for example obesity and
comorbidities of hyperlipidemia, hypertension and type 2 diabetes.
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The background section should include:
a aa a specialty specialty specialty specialty- -- -specific specific specific specific area area area area that allows for the addition of specialty-specific information, such as dialysis
indication, commencement date, centre, type, frequency and schedule along with dialysis access type
alerts alerts alerts alerts refer to known at-risk alerts. . . . Tick known alerts, or tick none.
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The accompanying section may be used as a checklist to remind you of the documentation that should
accompany the patient and personal items that may accompany the patient or be sent with the family.
Personal Personal Personal Personal luggage luggage luggage luggage: : : : if the patient is an air-ambulance transfer, luggage has to be less than five kilograms.
Documentation: Documentation: Documentation: Documentation: where an advance care directive, involuntary treatment order or not for
resuscitation/limitation of medical treatment order exists, a copy must accompany the patient.
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The responsibility section reinforces the need for the receiving clinician or designated person to accept the
patient prior to transfer and the need to transfer professional responsibility and accountability by identifying key
responsible people at the sending and receiving hospitals and the transport provider service.
The responsibility section requires documentation to include:
the receiving facility/ward name, medical practitioner, bed coordinator/designated person, treating allied
health contact details, and your name, job designation and signature
the transport provider (if applicable ) to acknowledge receipt of a handover and documentation (please note-
transport providers do not accept responsibility for accompanying non-medical personal items )
the receiving clinical staff member to acknowledge receipt of a handover, accompanying personal items and
documentation. Handover should be provided by the designated person at the referring facility prior to
patient transfer and by the transport provider (if applicable) at the time of transfer.
Implementing the form Implementing the form Implementing the form Implementing the form
Some recommendations for implementing the form include:
identify key staff on each unit to support, monitor and manage the implementation of the form
update the executive team regularly about the progress of the implementation so they can provide constructive
advice and support strategies for overcoming barriers
identify key staff involved in the transfer process, such as nurse unit managers, discharge coordinators, access
managers, ward clerks and transport operators, and consult with them prior to its implementation so that they can
offer support and assistance.
GUIDE TO PATIENT TRANSFER
22
VQC inter-hospital patient transfer form
Instructions for use

The Victorian Quality Council The Victorian Quality Council The Victorian Quality Council The Victorian Quality Council
Safer, better healthcare for all Victorians
www.health.vic.gov.au/qualitycouncil www.health.vic.gov.au/qualitycouncil www.health.vic.gov.au/qualitycouncil www.health.vic.gov.au/qualitycouncil

Appendix Appendix Appendix Appendix 1 11 1
Suggestions for Suggestions for Suggestions for Suggestions for modifications modifications modifications modifications to the to the to the to the form form form form
Some health services may wish to use the form for all transfers including aged care and inter-campus transfer. We have
included the following suggestions that may be added to the minimum dataset in the VQC form.
Neurological Neurological Neurological Neurological ( if applicable)
Conscious state: Conscious state: Conscious state: Conscious state: alert drowsy varies Mood Mood Mood Mood: normal agitated flat
Memory: Memory: Memory: Memory: normal short-term problems confused state MMSE MMSE MMSE MMSE.
Triggers: Triggers: Triggers: Triggers: ..
Intervention strategies: Intervention strategies: Intervention strategies: Intervention strategies: ....
Mobility/ Mobility/ Mobility/ Mobility/transfers transfers transfers transfers/ // /physical f physical f physical f physical function unction unction unction ( if applicable)
Mobility: Mobility: Mobility: Mobility: Independent Chair/bed bound Requires assistance no. of staff required
Bed mobility: turns sits
Weight-bearing status: none left right partial left right full left right
Ambulation. Endurance.
Aids Aids Aids Aids used used used used: : : : Walking stick/s Frame Wheelchair Prostheses ..
Transfers: Transfers: Transfers: Transfers: Independent Requires assistance no. of staff required
Aids Aids Aids Aids used used used used: :: : Slide sheet Lifter type................... Other transfer aids type ....................
Falls Falls Falls Falls risk risk risk risk ( (( (FR): FR): FR): FR): FR score Needs bed rails
Other Other Other Other safety requirements safety requirements safety requirements safety requirements: : : :
Personal Personal Personal Personal care care care care ( mark: A AA A = assistance needed; I II I = independent; D DD D = dependent; S SS S = supervision)
Bathing: Toileting: Dressing: Eating:
Skin Skin Skin Skin i ii integrity and ntegrity and ntegrity and ntegrity and wounds wounds wounds wounds ( if applicable)
Pressure areas: Braden score: Site(s): ..
Appearance: Stage: Dressing: .
Pressure mattress: Type: ....
Other wounds: Describe: ......
Sutures/staples: Date to be removed:
Communication/ Communication/ Communication/ Communication/sensory sensory sensory sensory ( if applicable)
Communication: Communication: Communication: Communication: Normal Follows directions Responds to non-verbals
Speech: Speech: Speech: Speech: Normal Impaired Aphasia: expressive receptive Sign language use
Vision: Vision: Vision: Vision: Normal Impaired Blind Artificial eye/s: right left Glasses
Hearing: Hearing: Hearing: Hearing: Normal Impaired Deaf Aid/s: right left
Long Long Long Long- -- -term plan term plan term plan term plan ( if applicable)
Yet to be determined Home independently / services / carer Respite care Hospice
Supported residential service Residential care: high-level (nursing home) Residential care: low-level (hostel)

Transitional care program: home based Transitional care program: residential
Other:
Enduring Enduring Enduring Enduring power power power power of of of of attorney attorney attorney attorney / // / administrator administrator administrator administrator/ / / / guardianship guardianship guardianship guardianship / / / / substitute decision maker substitute decision maker substitute decision maker substitute decision maker (SDM) (SDM) (SDM) (SDM) ( if applicable)
No Required Pending Yes
Name and contact details:

A GUIDE TO USING DATA FOR HEALTH CARE QUALITY IMPROVEMENT
23
23
References and
Resources
GUIDE TO PATIENT TRANSFER
24
References
Department of Health 2009, Limited adverse
occurrence screening (LAOS): annual report 200809,
State Government of Victoria, Melbourne.
Department of Human Services 2009,
Sentinel event program annual reports,
State Government of Victoria, Melbourne,
http://www.health.vic.gov.au/clinrisk/sentinel/ser.htm
Medical Board of Australia 2009, Good
medical practice: a code of conduct for doctors
in Australia, Medical Borad of Australia,
http://www.medicalboard.gov.au/Codes-
Guidelines-Policies.aspx
Victorian Quality Council 2009, Inter-hospital
patient transfer: a thematic analysis of the literature,
State Government of Victoria, Melbourne,
http://www.health.vic.gov.au/qualitycouncil/
downloads/interhospital_pt_litreview.pdf
Victorian Quality Council 2008a, Current
inter-hospital patient transfer practice,
State Government of Victoria, Melbourne,
http://www.health.vic.gov.au/qualitycouncil/
downloads/current_ihpt_surveyrpt.pdf
Victorian Quality Council 2008b, Themes from the
Victorian Quality Council Inter-hospital Patient Transfer
Workshop: group work summary, State Government
of Victoria, Melbourne.
Resources
Australian Charter of Healthcare Rights,
http://www.safetyandquality.gov.au/internet/safety/
publishing.nsf/Content/PriorityProgram-01
Charter of Human Rights
and Responsibilities Act 2006
http://www.legislation.vic.gov.au
Safe transport of people with a mental
illness. Chief Psychiatrists guideline.
http://www.health.vic.gov.au/mentalhealth/cpg/
safetransport.pdf
Clinical handover resources
Australian Commission on Safety and Quality
in Health Care, National Safety and Quality
Health Services Standards
http://117.53.168.228/implementation-toolkit-
resource-portal/interface/additional-clinical-handover-
resources/acsqhc-resources-and-publications.html
New South Wales Department of Health, Australian
Resource Centre for Health Innovations
http://www.archi.net.au/resources/safety/clinical/
nsw-handover
South Australia Department of Health,
Safety and Quality
http://www.sahealth.sa.gov.au/wps/wcm/connect/
Public+Content/SA+Health+Internet/About+us/
Safety+and+quality/Communications+and+teamwork/
Communication+and+teamwork
Western Australia Department of Health, Ofce
of Safety and Quality in Health Care
http://www.safetyandquality.health.wa.gov.au/
initiatives/clinical_handover.cfm
Queensland Department of Health, Patient Safety
and Quality Improvement Service
http://www.health.qld.gov.au/psq/handover/html/
ch_homepage.asp
Australian Medical Association 2006, Safe handover,
safe patients: guidance in clinical handover for
clinicians and managers, AMA, Canberra.
http://www.ama.com.au/node/4064
Victorian Quality Council handover resources
http://www.health.vic.gov.au/qualitycouncil/activities/
handover.htm
Legislation
Health Records Act 2001 (Vic)
http://www.legislation.vic.gov.au
Health Records Act: frequently asked questions
http://www.health.vic.gov.au/hsc/resources/faq.htm
Health Records Act: online training
http://www.health.vic.gov.au/hsc/training.htm
Health privacy principles,
extracted from the Health Records Act
http://www.health.vic.gov.au/hsc/downloads/
hppextract.pdf
Mental Health Act 1986 (Vic)
http://www.legislation.vic.gov.au
Non-Emergency Patient Transport (NEPT)
Act 2003, regulations 2005
http://www.health.vic.gov.au/nept/nept-rcpp.htm
Guidetopatienttransfer
Principlesandminimumrequirements
fornon-timecriticalinter-hospital
patienttransfer
RevisedDecember2012