Most of us across acute care have been involved in late night bed pressures that call for that dreaded decision to need to move some patients around between wards. Typically we see the only beds available to be surgical ones whilst the demand is for acute medical beds. Moving acute medical patients directly to these outlying beds from the emergency department (ED) may present too much of a risk. Lower acuity patients from acute wards are therefore often sought out to be transferred into these surgical beds thus making way for the more acute ED demand. End of Life (EoL) patients seem particularly at risk of being moved, which can be very distressing for families, friends, the patient and the care teams.
Lucy, our End of Life Care Nurse Facilitator dropped into ED one morning after a particularly difficult night. She had a pretty obvious “enough now” demeanour about her and I could only agree. We knew that most of these moves occur into the night or at weekends. These periods are covered by site managers, bed managers and on-call clinicians rather than the usual ward teams and therefore their knowledge of the patients can be very limited. This will mean that they would need to spend time reading through the notes before making decisions. This is where we thought we may be able to have an impact by flagging clearly those patients whom we should not move. It took us a couple of hours to figure out the Blue Ribbon Patient scheme and we had stickers good to go by the end of that week.
The scheme is not exclusive to EoL patients (although it predominantly affects them and was started particularly for them) and we do use it for very vulnerable and/or complex patients too whose movement to other wards would be a regressive step. It is vitally important that “Blue Ribbon” doesn’t become a label for “going to die”. It just means, for a whole host of reasons, that this patient should not be moved. It’s also very important not to overuse the scheme. Patients must be carefully considered and nominated by a senior nurse or nurse specialist.
Blue Ribbon patients are notified to the Site Manager who keeps a “Blue Ribbon List” with her notes and Blue Ribbon patients are noted and discussed at Bed Meetings, reminding folks that they are not to be moved.
A key element of the scheme is to ensure that there is very senior input into a decision to move the patient. This makes sure we really, really are in last resort territory before a move is made. If there is a requirement to move a Blue Ribbon Patient for a non-clinical reason this must be agreed by the Head of Nursing or by the on-call Director if it is out of hours. Either the Head of Nursing or the On-call Director must then contact the family to explain the reasons for the move and apologise. We’ve deliberately made it a very senior responsibility as we view moving these patients as a very important decision if it has to happen.
All Blue Ribbon patients have the requisite sticker placed on the front of their notes and any care planning documentation. In this way, even clinicians unfamiliar with the patient are reminded that there are extenuating circumstances around this person that means that moving them to another ward is unlikely to be in their best interests.
Prompted by two quite difficult episodes involving the movement of dying patients we implemented this scheme rapidly; a two hour discussion with key teams and stickers back from the printers within 24 hours. That was six weeks ago. Since then not a single EoL patient has been moved despite ongoing bed pressures. We have stopped all non-clinical transfers for dying patients thanks to this scheme. It’s been quite a revelation and folks have really taken to it. It’s not complex or expensive to implement. It seems that sometimes simple just works!
Rick Strang @rickstrang (Emergency Care Improvement Lead) and Lucy Merry-Williams (End of Life Care Nurse Facilitator) – Isle of Wight NHS Trust