Division A Standard operating procedure

Surgical assessment unit

Division A

Cambridge University Hospitals NHS Foundation Trust Page 1 of 20

Surgical assessment unit (SAU) on ward D6 Version 2; Approved April 2021

Standard operating procedure

Surgical assessment unit (SAU) on ward D6

Key messages

Surgical Assessment Unit (SAU) is an assessment unit to provide General Surgery and Urology care. During the 3rd wave of the COVID 19 pandemic it has moved again, to WARD D6 to support the Trust reorganisation and support the Emergency Department (ED) by taking additional speciality surgical patients

From February 22nd 2021 onwards this unit is located on WARD D6.

Patients from ED and GP referrals should be Covid-19 RAG green

ED patients should be swabbed in the department but do not need to be POC negative to transfer to SAU if RAG green

RAG amber patients should not be placed in beds on SAU but into consulting rooms until negative POC swab is returned

All admissions to SAU, via GP or ED, must be agreed by the relevant on-call team:

o GI Surgery Upper GI (UGI), Lower GI (LGI), HPB, Breast

ED referrals SPR on-call- bleep 1560316, Core Trainee on bleep 1560534, On call Consultant (Switch board), EGS Consultant (switchboard)

GP referrals to Consultant Emergency General Surgery (EGS) phone 07864 972392 (outside normal working hours and at weekends bleep the on-call team)

o Urology - Consultant on-call in hours, and out of hours the Urology registrar on-call (via Rotawatch)

o Vascular Surgery – Vascular SPR (Rotawatch) or consultant (rotawatch)

o ENT – ENT on call SHO (bleep 157573), or if unavailable, SpR (mobile via switch).

o OMFS – Contact OMFS CT or SPR (Rotawatch/ switch board)

o All other enquires co-ordinated through

SAU nurse coordinator phone 07707292969

WARD D6 phone 274679

All attendances to SAU via 111, GP or ED must be agreed by the on-call surgical speciality team


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1. Scope

For use within SAU on WARD D6, the Emergency Department (ED) and the Operations Centre.

2. Purpose

The purpose of this Standard Operating Procedure is to outline the pathway, processes and admission criteria for Surgical Assessment Unit (SAU) on WARD D6 during the COVID 19 pandemic. This document has been developed by Specialty Leads for EGS, Upper and Lower GI Surgery, Urology, Vascular surgery, ENT, OMFS, Associate Director of Operations (ADO), Divisional Head of Nursing (DHoN), Matrons, Operational Managers and associated Support Services.

3. Definitions

ADO Associate Director of Operations CFD Clinically Fit Date DFM Daily Facilitated Meeting DHoN Divisional Head of Nursing ED Emergency Department EGS Emergency General Surgery FY1 Foundation Year 1 (junior doctor) GP General Practitioner GUTS GI Urgent Theatre Session HCA Healthcare Assistant LoS Length of Stay MDT Multidisciplinary Team PFM Patient Flow Manager POC Point of Care RN Registered Nurse SAU Surgical Assessment Unit SPR Specialist Registrar ENT Ear, Nose and Throat OMFS Oral and Maxillofacial surgery NEWS National Early Warning Score CT Computerised Tomography

4. Introduction

This Standard Operating Procedure covers all patient areas within SAU on WARD D6. Floor plan of WARD D6 is shown in Appendix One.

Robust processes and pathways are required for the management of patients within SAU, in order to provide and maintain specialist and high quality patient


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care, during the COVID 19 pandemic. SAU will enable review, admission, treatment and discharge of patients that meet the relevant admission criteria.

5. Responsibilities

Clinical and nursing responsibilities The overall clinical responsibility for the area lies with the Clinical Directors and Surgical Speciality leads in EGS, Upper and Lower GI Surgery and Urology, in conjunction with the DHoN and Matron for SAU/WARD D6.

Individual speciality teams are responsible for the timely review and treatment of patients admitted under their care.

This is to ensure timely admission and discharge from this area, tailored to the needs of the patients and the service.

All permanent ward staff, bank staff and members of the MDT caring for patients, or providing support services within SAU on WARD D6 , have a responsibility to familiarise themselves with, and adhere to, this Standard Operating Procedure.

Operational responsibilities The area will be under the Clinical Governance and Management structure of the Digestive Diseases Directorates within Division A. Escalation will be via Division A Bronze Command and the Trust’s Silver Command if required.

Patient Flow Manager/ Operations Centre responsibilities Onward placement of patients will be the responsibility of the Patient Flow Manager and the Operations Centre. Escalation, if required, should be via the Division A Manager of the Day (weekdays) or Operational Matron (weekends and out of hours).

Further day-to-day responsibilities are outlined in section 13.

6. SAU Admission Criteria for GI Surgery

The SAU is a service delivered by the on-call GI surgical team to provide co-ordinated care by dedicated Consultant support via the EGS service. It is also serviced by the Urology team led by their Consultant on-call. The admission criteria for SAU is detailed below.

All attendances to SAU via 111, GP or ED must be agreed by the on-call surgical team


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Via GP:

GP referrals will be directed to a member of the on-call team using a direct dial number to a mobile phone or bleep (via Rotawatch). If appropriate or necessary due to staffing constraints, this will default to the reception desk of WARD D6 (274679)

After the referral is accepted, GPs may email additional patient data (without identifiers, ie name) to [email protected] if no letter is available

Patients will be admitted directly from the GP referral unless unstable (NEWS2 score of 5 or greater), in which case they may be re-directed to ED

Via ED:

Patients will be admitted from ED as acute attendances

ED referrals should be made to the General Surgery Registrar on-call

ED referrals to Urology should be made via the Urology on-call team as on Rotawatch

The ED referral pathway is outlined in Appendix Two.

Patient groups will include General Surgery (Upper GI, Lower GI, HPB and acute Breast) and Urology

Exclusion criteria:

There are some exclusion admission criteria for SAU patients as detailed below:

Children under the age of 16yrs

Surgical Specialities outside of the agreed pathways within this policy

Patients already occupying an inpatient bed

There is currently no provision for ambulance crews to convey patients without a GP referral to the SAU

7. Urology admission protocol

In normal working hours – GP & ED Referrals to Urology Consultant on call(via switch)

OOH ( nights and weekends) GP &ED referrals to SpR (mobile via switch) or, if unavailable consultant on call

mailto:[email protected]


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If deemed appropriate we will accept for direct transfer and assessment on the SAU currently on WARD D6.

All accepted referrals to be called through to the SAU lead nurse on 274679 or mobile 07707292969 by the Urology surgery team.

8. Vascular surgery admission protocol

ED Referrals / transfers from ED or from spoke hospitals within the vascular surgery network to SpR (mobile via switch) or, if unavailable, consultant on call.

GP referrals to SpR(mobile via switch) or, if unavailable consultant on call

If deemed appropriate we will accept for direct transfer and assessment on the SAU currently on WARD D6.

All accepted referrals to be called through to the SAU lead nurse on 274679 or mobile 07707292969 by the Vascular surgery team

Cases that we would need to assess primarily in ED o Acute aortic conditions o Acute limb ischaemia o Acute haemorrhage

Examples of cases appropriate for the SAU o Chronic critical limb ichaemia o Diabetic foot ulceration and other infected ulcers o Post-operative complications (eg wound infections)

9. ENT admission protocol

ED referrals to SHO (bleep 157573), or if unavailable, SpR (mobile via switch).

GP referrals to SHO (bleep 157573), or if unavailable, SpR (mobile via switch).

If deemed appropriate we will accept for direct transfer and assessment on the SAU currently on WARD D6. Otherwise patients will be directed to the Emergency Department for assessment.

All accepted referrals to be called through to the SAU lead nurse on 274679 or mobile 07707292969 by the ENT team

Examples of cases appropriate for the SAU o Otitis externa o Perichondritis o Facial cellulitis o Simple parotitis o Septal haematoma (if no head injury concerns or epistaxis)


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10. OMFS admission protocol

ED Referrals to OMFS CT/ SPR – switch board

GP referrals to OMFS CT/ SPR - switchboard

OMFS SAU admission criteria o Patient must be stable o NEWS <4 o Pain scores <5 o RAG: Green o No D&V o Able to walk to SAU o No exclusion criteria met

Examples of case appropriate for the SAU o Lacerations on pts aimed for discharge o Facial swellings – dental abscess (no airway compromise) o Dentoalveolar emergencies o Maxillofacial trauma – head injury excluded o Post operative complications/ advice o Dog / human bites

OMFS SAU admission exclusion criteria o Patient < 16yrs o Acute surgical presentation requiring resuscitation o Medical cause for presentation o Head injury/ C-spine concerns o Polytrauma o Elderly/ frail o Neck swelling and/ or airway compromise o Dental pain with no signs of sepsis- can be seen by pts dentist

11. Patient placement

Attendances can be same day for assessment and treatment, or deferred urgent review over the subsequent days. Facilities and/ or staff may vary at short notice according to the trust situation and this may need to change.

Admission on SAU should be for a maximum of 48 hours – this may need to extend in response to Trust bed state and pressure during the COVID19 outbreak

Patients would ideally be transferred for longer stay or post complex post-surgical care.

12. SAU capacity

SAU will consist of: 4 consultation rooms 20 bay beds


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2 side rooms 10 chairs

Maximum capacity The maximum capacity for SAU within WARD D6 is 19 bedded patients, 4 patients in assessment/consultation rooms and 6 in the waiting area

The decision that maximum capacity has been reached is made jointly by the Senior Nurse in Charge and on-call Consultant. The Nurse in Charge will inform the Operational Matron (707 bleep holder) of the change in status and give an approximate time frame to de-escalate.

13. Admissions to SAU beds on WARD D6

Sources of admission to SAU on WARD D6

GP referral to EGS team/ Consultant

111 referral to EGS team/ Consultant

Emergency department (all appropriate specialties)

Ambulatory returns, both operative and non-operative pathways

General Surgery clinic patients To ensure there is a clear process in place to maintain patient flow, there should be prompt clinical prioritisation of patients and escalation of any issues to the Senior Nursing team. The Senior Nursing team will also attend all necessary daily bed state huddles chaired by Operations Centre. There will be a daily safety huddle to review safe staffing, appropriate acuity and placement of patients –chaired by Matron, DHoN or Specialist Nurse Lead. The Nurse in Charge and a member of the clinical team from the ward is required to attend. A list of patients suitable for discharge/ transfer will be recorded on EPIC.

14. Standards required for patient placements

Length of stay (LoS)

The expected LoS for patients will be consistent, unless clinically indicated, with those set out in the relevant pathways

Venous Thromboembolism (VTE) assessment

A VTE risk assessment will be completed and prophylaxis (where appropriate) prescribed on all admissions


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EPIC status will be updated to reflect the assessment has been carried out

Respect documentation

This will be completed in line with trust guidelines

Discharge planning

A clinically fit date (CFD) will be documented in EPIC within 14 hours of admission for all patients

A formal discharge summary will be sent from EPIC to the GP within 24 hrs of discharge

The next of kin or relevant care agency (with the patients consent) will be informed of the patient’s admission and discharge

Same sex accommodation

SAU on WARD D6 will be compliant with same sex accommodation (SSA) policy, where this is not feasible all breaches will be managed, reported and recorded according to existing Trust policy during the COVID 19 pandemic

15. COVID-19 assessment of patients within SAU

In line with Trust guidance, patients attending SAU will be assessed for COVID-19 as follows:

GP/ 111 referrals will be COVID 19 assessed on arrival. If the questionnaire is positive they will be isolated (with scenario 1 PPE), tested and transferred to RED, AMBER, or GREEN as appropriate

RED patients will be transferred to the appropriate RED inpatient area

SAU will be a GREEN area using scenario 0 PPE – visor and mask for all patient facing team, apron and gloves for examination/ treatment

Location of transfer will be dependent on COVID 19 state, i.e. RED, AMBER, or GREEN

Admission process and COVID-19 screening for GP referrals

GP call received by GP liaison – ask screening questionnaire and redirect to GP referral phone

GP call to GP referral phone (held by clinical team or fixed phone in SAU)

Ask/ check COVID-19 screening questions:

http://merlin/Pages/Results.aspx?k=same%20sex%20policy%20SSA

http://merlin/Pages/Results.aspx?k=same%20sex%20policy%20SSA


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Respiratory Assessment: COVID-19 1. Does the patient have a persistent/continuous cough and/or raised

temperature? 2. Does the patient live with someone who is self-isolating and/or

exhibiting symptoms of COVID 19?

Take patient details (name, NHS number, specialty accepting) and inform the SAU team on 274679. Patient to attend SAU on WARD D6

Patient to bring all own medications and enter via WARD D6 entrance

No visitors may accompany any patients unless in possession of a carer’s passport

Attendance at SAU on WARD D6 Patient assessed by a COVID 19 triage nurse at entrance to unit (nurse in mask, gown and gloves with hat +/- visor) Repeat questionnaire:

COVID-19 screening questionnaire

1. Have any household contacts had a new persistent cough or high

temperature in the last 14 days? 2. Have you been admitted to hospital in the last 14 days? 3. Do you have ANY of the following NEW symptoms?

o Persistent Cough o High Temperature o Shortness of Breath o Sore throat or hoarseness of voice o Nasal congestion or runny nose o Wheezing or sneezing o Loss of sense of smell/taste o Muscle aches o Diarrhoea o Age of 70 years or older with acute confusion

If answers YES to above questions:

Nurse to arrange patient check in with admin – isolate in identified isolation room

Take COVID 19 nasal and throat swabs for SAMBA test

Full assessment and diagnosis +/- bloods, patient may be discharged if possible

If admission needed then transfer to ‘RED/AMBER’ ward (to be assigned)

If answers NO to above questions:

Admit to SAU on WARD D6 chairs via reception with admin team


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Review by Triage/ Clerking nurse in consulting rooms

Medical assessment/ admit to ward area / discharge according to clinic state

If unwell admit directly to WARD D6 SAU for assessment in bed space/ consulting room

NB – this guidance may change as COVID 19 incidence changes both in the community and the hospital

PPE

Scenario 1 PPE to be worn by front door triage nurse

Scenario O PPE to be worn by all other staff throughout the unit – currently Visor and Facemask

Plastic apron and non-sterile gloves to be worn for each patient contact on the ward (to protect staff and patient from non-symptomatic exposure)

Hand washing mandated between patients

NB – this guidance may change as COVID 19 incidence changes both in the community and the hospital

Donning and doffing area There is a donning and doffing area available for Scenario 0 PPE at the entrances to the ward.

16. Support Services Radiology Provision Radiology Department provision will be managed in the same context for SAU referrals as ED referrals. This will ensure rapid diagnostics to expedite care and discharge. This will cover all imaging modalities. The two current ‘next day’ USS slots will continue. If utilisation increased there is scope to negotiate an increase in dedicated USS slots. If capacity allows, patients should have imaging on the day to reduce the number of visits to the hospital. CT will delivered using the same level of prioritisation as the ED to minimise patients waits – please book and contact the radiology SPR. NB – CT Chest will no longer be done as routine for urgent scans and will need to be directly requested if required. This is open to change depending on Trust position.


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Emergency Theatre Provision Patients requiring surgery on the GUTS list will be admitted to SAU on WARD D6 for GUTS ensuring a streamlined pre-operative assessment and maximised theatre utilisation. Provision of theatres may change during the COVID 19 pandemic recovery phase. Admin

SAU on WARD D6 will have a ward clerk available 08:00-20:00 everyday Non ward based Support Services

Pharmacy

Physiotherapy

Portering services

Housekeeping

Hotel services

Security

Infection control

Discharge planning

Specialist nurses

Pathology

Estates and facilities

Occupational therapy

Information technology

17. Responsibilities

SAU- Medical:

Senior cover will be provided by the appropriate On Call Speciality Consultant and their on-call team 24/7

Senior cover for GI surgical patients will also be provided by the EGS consultant Monday-Friday 07:30-17:30

On call junior cover may change in response to the COVID 19 outbreak

If a decision is made that further inpatient treatment is required, it is the responsibility of the primary team, nursing and Patient Flow Managers to ensure this is made in a timely fashion and an appropriate ward bed is identified


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In the event of medical patients being admitted to SAU beds, the primary team will be GI surgery with assistance from Gastroenterology

The day to day nursing responsibilities

The SAU nursing team will provide initial triage assessment and bloods/ ECG/ analgesia/ basic imaging requests according to enhanced skill mix

The nursing team will provide front door COVID triage and isolate as directed in the “WARD D6 SAU Admission process and COVID screening” protocol enclosed in this SOP

The Matron for SAU will have overall management responsibility for the area supported by the Senior Sister and Specialist Nurse Lead for SAU/ SACU

The Senior Sister will remain responsible for the co-ordinating of patient care and the timely progress of patients through their pathways

There will be a daily SAU safety huddle to review safe staffing, appropriate acuity and placement of patients –chaired by Senior Sister, Matron, Specialist Nurse Lead or Nurse in Charge

In the case of the deteriorating patient, the Rapid Response Team (RRT) should be called as per Trust policy

The Nursing model is reflected in the table below. These numbers support the ambulatory care element, enabling appropriate skill mix, appropriate patient placement, patient safety, experience and flow

Planned Staffing Early Shift Late Shift Night Shift

Registered 6 6 4

Unregistered 3 3 2

14. Infection control issues/ policy

The Trust’s infection control documents will be followed.

15. Monitoring compliance with and the effectiveness of this document

Daily reporting through Safety Huddle: Nurse in charge/Matron

Incident reporting: All Staff

Monthly incident review: Senior Sister / Matron

Twice daily walk rounds: Matron/Senior Sister

http://merlin/Pages/Results.aspx?k=infection%20prevention%20control%20policy&r=dmsowner%3D%22Infection%20prevention%20and%20control%20%28DIPC%29%22&start1=1


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Equality and diversity statement This document complies with the Cambridge University Hospitals NHS Foundation Trust service equality and diversity statement.

Disclaimer It is your responsibility to check against the electronic library that this printed out copy is the most recent issue of this document.

Document management Approval: Claudia Macfarlane and Rachael May – 1 April 2021

Silver command – 1 April 2021

JDTC approval: N/A

Owning department: Digestive Diseases

Author(s): Mr John Bennett, Gill Love, Christopher Gray

Pharmacist: N/A

File name: Surgical assessment unit (SAU) standard operating procedure D6 v2 Apr 2021

Supersedes: Version 1, September 2020

Version number: 2 Review date: April 2024

Local reference: Document ID: 101907


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Appendix One: Floor plan for SAU on WARD D6

Surgical Assessment Unit


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Appendix Two: SAU ED Pathways


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Appendix Three: ED and GP Pathway for GI Surgery


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Appendix Four: ED and GP Pathway for Urology


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Appendix Five: ED and GP Pathway for Vascular Surgery


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Appendix Six: ED and GP Pathway for ENT


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Appendix Seven: ED and GP Pathway for OMFS

Documents

Division A Standard operating procedure