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
Surgical assessment unit
Division A
Cambridge University Hospitals NHS Foundation Trust Page 2 of 20
Surgical assessment unit (SAU) on ward D6 Version 2; Approved April 2021
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
Surgical assessment unit
Division A
Cambridge University Hospitals NHS Foundation Trust Page 3 of 20
Surgical assessment unit (SAU) on ward D6 Version 2; Approved April 2021
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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Surgical assessment unit (SAU) on ward D6 Version 2; Approved April 2021
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
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Surgical assessment unit (SAU) on ward D6 Version 2; Approved April 2021
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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Cambridge University Hospitals NHS Foundation Trust Page 6 of 20
Surgical assessment unit (SAU) on ward D6 Version 2; Approved April 2021
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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Cambridge University Hospitals NHS Foundation Trust Page 7 of 20
Surgical assessment unit (SAU) on ward D6 Version 2; Approved April 2021
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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Division A
Cambridge University Hospitals NHS Foundation Trust Page 8 of 20
Surgical assessment unit (SAU) on ward D6 Version 2; Approved April 2021
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:
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Surgical assessment unit (SAU) on ward D6 Version 2; Approved April 2021
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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Surgical assessment unit (SAU) on ward D6 Version 2; Approved April 2021
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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Cambridge University Hospitals NHS Foundation Trust Page 11 of 20
Surgical assessment unit (SAU) on ward D6 Version 2; Approved April 2021
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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Surgical assessment unit (SAU) on ward D6 Version 2; Approved April 2021
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
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Cambridge University Hospitals NHS Foundation Trust Page 13 of 20
Surgical assessment unit (SAU) on ward D6 Version 2; Approved April 2021
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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Division A
Cambridge University Hospitals NHS Foundation Trust Page 14 of 20
Surgical assessment unit (SAU) on ward D6 Version 2; Approved April 2021
Appendix One: Floor plan for SAU on WARD D6
Surgical Assessment Unit
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Division A
Cambridge University Hospitals NHS Foundation Trust Page 15 of 20
Surgical assessment unit (SAU) on ward D6 Version 2; Approved April 2021
Appendix Two: SAU ED Pathways
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Surgical assessment unit (SAU) on ward D6 Version 2; Approved April 2021
Appendix Three: ED and GP Pathway for GI Surgery
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Surgical assessment unit (SAU) on ward D6 Version 2; Approved April 2021
Appendix Four: ED and GP Pathway for Urology
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Surgical assessment unit (SAU) on ward D6 Version 2; Approved April 2021
Appendix Five: ED and GP Pathway for Vascular Surgery
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Surgical assessment unit (SAU) on ward D6 Version 2; Approved April 2021
Appendix Six: ED and GP Pathway for ENT
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Surgical assessment unit (SAU) on ward D6 Version 2; Approved April 2021
Appendix Seven: ED and GP Pathway for OMFS