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SESLHD MHS PROCEDURE

COVER SHEET

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NAME OF DOCUMENT Patient Flow Operational Framework for Mental Health Service

TYPE OF DOCUMENT Procedure

DOCUMENT NUMBER SESLHDPR/245

DATE OF PUBLICATION March 2013

RISK RATING Medium

LEVEL OF EVIDENCE N/A

REVIEW DATE March 2016

FORMER REFERENCE(S) SESIMHS Patient Flow Operational Framework 015_10

EXECUTIVE SPONSOR or

EXECUTIVE CLINICAL SPONSOR

Dr Murray Wright, Director, SESLHD Mental Health Service

AUTHOR

Gayle Jones, A/ SESLHD MHS Access & Service Integration Manager

POSITION RESPONSIBLE FOR THE DOCUMENT

Gayle Jones, A/ SESLHD MHS Access & Service Integration Manager

KEY TERMS

Patient flow; access management; demand management; mental health access

SUMMARY

This document provides a framework for standardised patient flow operations in SESLHDMHS. Standardised operations aim to enhance mental health patients‟ experience and outcomes and as such this document should be used a s a reference tool by mental health staff.


Patient Flow Operational Framework SESLHDPR/245

Revision 0 Trim No. T13/5626 Date: March 2013 page 1 of 29 THIS DISTRICT DOCUMENT BECOMES UNCONTROLLED WHEN PRINTED OR DOWNLOADED UNLESS REGISTERED BY

LOCAL DOCUMENT CONTROL PROCEDURES

Table of Contents Introduction and Background…………………….………………………………… 2

SESLHD MHS Geography……………………………………………………………. 3

SESLHD MHS Inpatient Facilities……………………………………………………. 4

Patient Flow Coordination

The Role of the Patient Flow Coordinator………………………………………….. 6

PFC Communications Schedule……………………………………………………. 7

Capacity/Demand Profile Reports……………………………………………………. 8

LLOS Meetings, Second Opinion Policy, Demand Planning………..…………… 9

Weekend Demand Planning………………………………………………………….. 10

Collaborative Patient Flow Operations

The three R‟s of Patient Flow………………………………………………………. 11

Over Census / Over Numbers……………………………………………………… 12

Collaborative Patient Flow, After Hours Patient Flow …………………………… 13

Accepting Referrals of Patients for Mental Health Admission……………………. 13

Transfer of Care …………………………………………………………………….... 15

Repatriation of Out of District Patients – Establishing Catchment Area………….. 16

Repatriation Negotiation / Requesting Transfer to Alternate Facility..………..….. 17

Repatriation within SES LHD MHS, within NSW, Interstate and International……. 17,18

Inter-hospital Transfer Algorithm…………………………………………………… 19

Transport………………………………………………………………………………. 20

SESLHD MHS Priority Transport Options……………………………………………. 21

Referral to/from Private Hospitals…………………………………………………….. 22

Referral to Rehabilitation Services…………………………………………………. 23

Referral to Bloomfield Rehabilitation Services, Drug and Alcohol Services…… 24

Special Needs Referrals……………………..…………..………………………..….. 25

Appendix 1 - Useful Numbers……………………………………………………….. 26

Appendix 2 – Escalation Algorithm………….…………..………………………….. 27

Appendix 3 – Referral to IPCU/ MHICU Facilities Algorithm……………………..... 28

References and version control ……………………………………………………… 29





Introduction and Background This document provides a framework for standardised, district-wide, patient flow operations in South Eastern Sydney Local Health District Mental Health Services (SESLHD MHS). The framework applies to the management of operational patient flow for patients in SESLHD MHS and for patients who are being transferred to or from SESLHD MHS.

Aims Standardised patient flow operations aim to enhance mental health patients‟ experience and outcomes and as such this document should be used a reference tool by all mental health staff. Patient flow is a dynamic process not limited to business hours and this framework provides consistency of patient flow operations within and outside of business hours. This framework complements the processes outlined in the NSW Health Mental Health for Emergency Departments – A Reference Guide 2009.

Target Audience The framework is aimed at Sector Service Directors (SD), Clinical Operations Managers (COM), Inpatient Service Managers (ISM), Nursing Unit Managers (NUM), Patient Flow Coordinators (PFC), Nurses in Charge (NIC), Registrars and Consultant Psychiatrists and all other mental health staff involved in the patient flow process.

Patient Flow Philosophy The Garling Report (2008) identified the link between efficient use of inpatient beds and improvement in the quality of care provided to patients.* Persons requiring mental health inpatient care should receive timely and efficient access to the best possible care available. The core principle of patient flow is to provide sustainable access to inpatient beds and is identified as a State-wide standard. Consideration must be given at all times to ensure that people with a mental illness or mental health disorder “receive the best possible care and treatment in the least restrictive environment enabling the care and treatment to be effectively given", NSW Mental Health Act 2007.

What is Patient Flow? „Patient Flow‟ refers to the patient journey through a health service, in this instance the SESLHD MHS and predictable. SESLHD MHS operates at or near 100% bed occupancy most of the time therefore daily transfers of care out of mental health inpatient services must be planned to accommodate predicted daily admissions. Most admissions occur via the Emergency Department (ED). To achieve this KPI all patients requiring mental health admission should be transferred to an appropriate facility as soon as assessment and/or treatment processes are completed. It should be noted that some venues such as Prince of Wales (POW) Mental Health Service have points of admission that may bypass ED. For example Police / Community Mental Health Team (CMHT) presentations and patients sent directly from courts or prison for assessment can be transported directly to the Kiloh Centre. Multiple points of admission make patient flow coordination more complex and heighten the need for predictive and collaborative transfer of care planning around the clock.

* Final Report of the Special Commission of Inquiry Acute Care Services in NSW Public Hospitals Overview Peter Garling SC 27 November 2008, Pg. 30, (1.193)





SESLHD Geography

hern Network

Central Network

SESLHD Hospital and Health Service Sectors (*Mental Health Inpatient unit/s on site)

(+Mental Health assessment service in ED)

Northern Sector Southern Sector

Prince of Wales Hospital*+ St George Hospital*+

Royal Hospital for Women The Sutherland Hospital*+

Sydney Hospital The Garrawarra Centre

Sydney Eye Hospital Southern Network



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SESLHD MHS Inpatient Facilities

Acute Mental Health Inpatient Units (MHU) Site Name Total beds Bed Configuration Prince of Wales Hospital

Kiloh Centre 50 20 x observation, 30 x general acute

St George Hospital MHU 28 9 x observation, 19 x general acute including 6 SMHSOP beds

Sutherland Hospital Mental Health Inpatient Unit

28 10 x observation, 18 x general acute

Most MHU‟s provide both high-level acute (observation) and general acute care when community treatment is not possible due the patient‟s clinical condition. MHU‟s are declared under the NSW Mental Health Act 2007 (MHA) to accommodate people who are acutely unwell and require involuntarily treatment and care.

Psychiatric Emergency Care Centres (PECC’s)

St George 6 PECC beds

Prince of Wales 4 PECC beds

PECCs provide rapid access to mental health assessment and short stay admissions up to 72 hours. Patients referred to PECC must have a clearly defined admission / transfer of care pathway documented including the plan and expected date of discharge from hospital (EDD). Patients must have a manageable level of risk in all domains including suicide, self harm, aggression, sexual safety and absent without leave. Admissions are direct from the ED following mental health assessment and authorisation by the Medical Superintendent or delegate. Appropriate patients may be transferred from an acute mental health inpatient facility to PECC and on occasion at some facilities may be admitted direct from the community to PECC.

Mental Health Rehabilitation Units (MHRUs)

Site Name Beds + Configuration Prince of Wales MHRU 14 non acute beds - non-declared Sutherland MHRU 20 non acute beds - declared

Several Mental Health Rehabilitation Units (MHRUs) are also available in SESLHD. These non-acute facilities provide a range of programs to support patients to develop or regain skills for living independently or in supported accommodation. Where capacity exists during times of peak bed demand a MHRU bed may be considered as a temporary venue for limited number of „transition‟ patients from an acute facility. Careful consideration should be given to the use of MHRU beds for this purpose due to the disruption to patients involved. Wherever possible, patients who have already been referred to and/or are awaiting a MHRU bed and who have minimal risk factors should be considered. MHRUs may also provide venue for completion of Clozapine titration for suitable patients.





Specialist Mental Health Service for Older People (SMHSOP) – acute

beds Site Name Total beds Configuration Prince of Wales Euroa 6 (declared) + 2 Neuro-Psychiatry beds (non declared) St George MHU 6 allocated within the MHU (declared) Sutherland MHU 6 allocated within the MHU (declared)

SMHSOP provides specialist mental health assessment and treatment for older people with acute mental illness. Patients with a primary organic or physical health condition leading to disturbed behaviour are generally outside the referral criteria for SMHSOP. Where capacity exists SMSHOP beds may be considered during periods of peak bed demand as temporary venue for limited number of „transition‟ patients from an adult acute facility. This strategy should only be used at times of peak demand and after all other strategies to increase acute bed capacity have been exhausted. In general only patients who are close to the admission age and with minimal risk factors should be considered for transition placement.

Tertiary Intensive Psychiatric Care Units (IPCU or MHICU)

Hornsby MHICU Northern Sydney Central Coast Area Health Service Cumberland IPCU Sydney West Area Health Service Concord IPCU Sydney South West Area Health Service

SESLHD MHS does not currently have an IPCU/MHICU planning has commenced for a 12 bed facility to be commissioned January 2013. SES shares access to tertiary IPCU / MHICU beds in the facilities above with all other Local Health Districts in NSW. See Appendix 3 for Referral Algorithm.

Tertiary Child & Adolescent MHS Inpatient Units (CAMHS)

– acute beds Shellharbour Acute Shellharbour Hospital

Gna Ka Lun Acute Campbelltown Hospital Redbank House Acute, incl Child & Family Westmead Hospital Nexus Unit Acute John Hunter Hospital Sydney Children’s Acute - non declared Randwick Hospital Campus

The 8 beds available at Sydney Children‟s Hospital are not declared under the Mental Health Act 2007(MHA) so are unable to accommodate patients detained involuntarily. SESLHD MHS can make referrals to the declared tertiary CAMHS beds listed above.





Patient Flow Coordination

The Role of the Patient Flow Coordinator (PFC)

The PFC is the central point of contact for information and access to Site/Sector mental health beds in SESLHD during business hours Mondays to Fridays. After hours and on weekends, the role is delegated at each site for continuity of patient flow coordination. More details about after hours coverage is provided on page 13.

PFC Contact

Numbers Northern Sector Prince of Wales Ph: 0411 653 463

Southern Sector St George / Sutherland Ph: 0411 658 967

The core responsibility of the PFC is to be aware of current capacity and demand within their sector at all times. Capacity refers to the number of mental health inpatient beds physically available to accommodate patients requiring admission. Demand refers to the number of patients from all sources (including ED, Police, Community Mental Health, other inpatient services and other MHS) that require admission at any given point in time. To remain abreast the PFC must review relevant databases, attend clinical meetings and liaise continuously with NUMs, ED clinicians, inpatient clinicians, Community Mental Health Teams (CMHT) and peer PFCs (general and MH) to collect information such as:

Number of patients physically present on the unit(s)

Number of patients on leave and for how long

Patients absent without leave (AWOL) and whether they are expected to return and if not, when the bed will be confirmed as available

Patients in ED awaiting assessment and/or likely to require admission

CMHT patients being assessed and likely to require admission

The PFC records capacity/demand details in twice-daily Profile Reports (see page 8). Updates are sent to clinical teams, District MH Access & Service Integration Team, Site/Sector MH Executives and other relevant stakeholders as required.

PFC’s should be especially alert for:

Avoidable admissions – ensuring admissions are consistent with the principle of least restrictive care as outlined in the MHA, 2007.

Out of District patients requiring repatriation to their local MHS.

Patients with private health insurance who may be transferred to a private facility.

Barriers to transfer of care or leave for a patient who is otherwise clinically ready.

Patients suitable for referral to Acute CMHT, MHRU, inpatient drug and alcohol services, NGO supported accommodation (such as NEAMI) or general aged care services.





Patients awaiting CTO hearings that could be placed on leave pending the hearing.

Planning for discharge and transfer of care is initiated as soon as possible after admission, including the allocation of an estimated date of discharge (EDD).

The PFC has a key role in tracking the patient journey. By attending daily ward and multidisciplinary team (MDT) clinical meetings, the PFC maintains awareness of all patients‟ progress and can facilitate the removal of any non clinical barriers to transfer of care such as accommodation, transport, or social issues in collaboration with the NUM, MDT and others.

Patient Flow Coordinator Communication Schedule

The aim of this PFC communication schedule is to ensure timely and regular exchange of information between the Sector PFC and the District Access & Service Integration Team. Ad hoc communications includes challenges to patient flow as they occur, e.g. access blocked patients in the ED, other issues enquiring escalation.

Time Monday Tuesday Wednesday Thursday Friday Sat/Sun Time

0830 Email AM Profile Report to District Access & Service Integration Manager

0830

0930 Verbal, email or SMS update of ED Demand and placement plans

0930

1100 Verbal, email or SMS update from morning meetings

1100

1200 District MH Access Manager Telco with District Patient Access team: Provide specific

overview of Site Self Sufficiency / Placement Plans for ED Admissions MH Site Manager on-call

Telco with District Executive

on-call

1200

1400

Verbal, email or SMS update - pt flow challenges 1400

Email Weekend

Demand Plan

1500

1500 District MH Access & Service Integration Manager provides briefing & service overview to District Risk Manager and District Director SES LHD MHS on request 1500

1530 Email PM Profile Report to District Access Team Manager

1530

1550

Verbal, email or SMS update of any significant variance from 1530 report 1550

1630 Close of Business 1630





Site/Network Capacity/Demand (Profile) Reports

Sector profile reports are collated by PFCs and published at 0830hrs and 1530hrs daily via email to: Site Registrars, Consultant Psychiatrists, Team Leaders, MH Executives, NUM‟s, Allied Health, General Hospital Executives, District Risk Manager, District Access & Service Integration Team. The reports are a summary of current Site/Sector capacity and demand. In line with NSW Ministry of Health protocols the profile reports also indicate predictive patient flow for the next 24 and 48 hours. See sample profile report below.





Long Length of Stay (LLOS) meetings Long Length of Stay (LLOS) meetings are held weekly or fortnightly to discuss patients with length of stay in the MHU of greater than 28 days and in MHRU for patients reaching length of stay thresholds of 100, 150 and 180 days. Meetings should be attended by the Chief Psychiatrist, Social Workers, CMHT Team Leaders, NUM, ISM, Clinical Operations Manager, PFC and District Access and Service Integration Manager. Representatives from the District MH Rehabilitation Team attend the MHRU LLOS meetings. Patients are discussed from a MDT and holistic perspective, aiming to remove any barriers to transfer of care or leave.

Second Opinion Policy

The SESLHD MHS Policy Obtaining a Second Opinion from a Consultant Psychiatrist 2007/06 v5, outlines the length of stay thresholds for obtaining a second opinion:

Thresholds for Obtaining a Second Opinion

LOS >28 Days Flexible format, may seek opinion from another Consultant Psychiatrist within the unit or within the service

LOS >49 Days

Second opinion and face to face review to be sought from the Chief Psychiatrist / Medical Superintendent. Review may be conducted by the Chief Psychiatrist / Medical Superintendent of the treating facility or another facility

LOS >75 Days Automatic referral to Complex Care Committee

The thresholds should be routinely reviewed during LLOS meetings and action to obtain a second opinion initiated if required.

Demand Planning

The aim of demand planning is to maximise the use of mental health inpatient beds using a non-reactive, predictive approach to patient flow. The District MHS Access & Service Integration Manager is using historical data to generate Demand Prediction figures. Data is based on previous three month discharges and EDD as entered into the NSW Health Patient Flow Portal.

The figures should guide Site/Sector planning to enable mental health beds to be available as required. Proactive and predictive planning ensures site self sufficiency and reduces waiting time for patients in ED.

http://www.seslhd.health.nsw.gov.au/Policies_Procedures_Guidelines/Clinical/Mental_Health/documents/2007-06-ObtainingASecondOpinion.pdf






Weekend Demand Planning

As with patient flow and demand planning in general, weekend demand planning strengthens site capacity, maintains self-sufficiency and minimises reliance on neighbouring services over the weekends. Local site sufficiency plans are documented on the Weekend Demand Plan (WDP) template below to ensure sufficient capacity in line with predicted weekend demand.

Possible Saturday/SundayMonday

To

tal

OOA's / Outliers for repatriation

Venue Suitable for Sub Acute, PECC, MHRU, OPU transfer?

Planned D/C

Planned Leave & Return Date

Possibility for D/C or Leave

Planned D/C

Planned Leave & Return Date

Possibility for D/C or Leave

Obs Unit

M S – to PECC

JB

FM 6/7

4

Issues JB awaiting crisis accommodation

PECC ME to OPU

JC

2

Issues

Endorsement Endorsed by: Site Executive or delegate and Medical Superintendent or delegate.

Additional Resources to be accessed in cases of surge demand

Distribution List Distributed to: Weekend CNCs, On call Execs, On call Registrars and Consultants

Deployment of additional ward staff Consultant on notice to attend facility in person to assist in reviewing patients on ward and/or in ED ACT/CMHT on notice to attend facility to assist in identifying ward patients for potential leave/DC with intensive community support

The WDP flags those patients confirmed for leave or transfer of care over the weekend and identifies their expected day/time of departure. The WDP records the patient‟s full name, whether their care is being transferred or they are going on leave. If going on leave the WDP identifies when they are due to return. Any issues that may impede leave or transfer of care such as accommodation or transport issues are also highlighted.

Site self sufficiency is essential for efficient patient flow on weekends. The WDP identifies patients who can be temporarily and safely transferred at times of peak demand to venues such as MHRU, PECC or SMHSOP Units should capacity be available. The WDP also identifies patients who may be considered for transfer to alternate SES MHUs, MHRU‟s, PECC‟s or SMHSOP Units should local capacity be unavailable. The PFC prepares the WDP in collaboration with the NUM and MDT and has it signed off by a representative of the site mental health executive. The WDP provides a reference tool and enhances communication for weekend staff including after hours clinical teams. The WDP is displayed in each MHU and is emailed to the weekend site on call MH executive, on call registrar and Consultant Psychiatrist and the District MHS Weekend Access & Service Integration Team Manager.





Collaborative Patient Flow Operations Patient flow is a collaborative process incorporating both operational and clinical bed management. Effective patient flow entails collaboration and co-operation between the PFC and MDT. The role of PFC is to „coordinate‟ patient flow in partnership with the MDT.

The Three R’s of Patient Flow

Remember the Three R‟s before recommending placement of a patient:

Right Patient

Consider the patient‟s presenting issues, age, risk factors, illness, physical health, gender, history and social supports – do they need admission, what is the purpose of admission, is the admission planned, what is the expected date of discharge from the inpatient facility (EDD)?

Right Bed

Consider the environment you are recommending placement into, ward acuity/patient mix, sexual safety risks, staffing resource issues, clinical skill mix, specialist medical and multidisciplinary services, relationships or history with other patients or staff, physical security of the environment (e.g. risk of absconding, falls risk).

Right Time

Consider whether the patient has any physical complaint which requires investigation and resolution prior to transfer, how does the patient feel about going to a particular ward, are there staff available to admit the patient, is transport available or additional escort staff available, has the bed become physically vacant (even if the bed is not yet physically available, the patient may, in an emergency, be moved to the unit while the bed is being prepared).

It is important to note that admission or transfer should not be delayed for the sake of staff convenience e.g. meal breaks, clinical hand over for example. Mitigation strategies should be implemented to ensure patient‟s transfer is not delayed other than for safety reasons.





Over Census / Over Numbers

Over Census refers to the census report taken at midnight every night. There may be at times more patients listed as admitted to the unit than there are formal beds. As such the report seeks to capture the actual head count of patients at midnight and excludes patients on overnight or extended leave. In extreme and rare circumstances where SESLHD MHUs surge to over census capacity, the situation must be approved by the Service Director or delegate or the on call MH Executive after hours and additional staffing resources must be sourced.

Over Numbers refers to circumstances where there are physically more patients than beds on a unit at a particular point in time. This can include:

Patients returning from leave whose beds have been used.

Day patients awaiting or recovering from ECT.

Patients commencing Clozapine who are undergoing initial dose monitoring.

Patients on the unit awaiting CTO hearing.

Patients brought directly to the unit (eg Kiloh) by Police or CMHT awaiting assessment.

Over numbers or over census admission can compromise patient care and place undue pressure on staff. The aim of efficient patient flow is to avoid over numbers and over census by anticipating demand and ensuring there is sufficient capacity to accommodate actual or predicted admissions.

In the event that a MHU goes over numbers or over census the following actions should occur without delay:

Inform the Duty Consultant Psychiatrist/ Registrar as soon as it is known that the unit will be over numbers or over census.

Inform the site Executive or on call MH Executive after hours and District MH Access & Service Integration Team (within office hours).

Discuss with the site Nurse In Charge (NIC) any patients who may be suitable for review for leave, transfer or discharge.

Identify any patients who may be suitable for temporary transition placement in MHRU, PECC, SMHSOP Unit.

Identify patients who may be supported by CMHT whilst on leave from the unit.

Contact peer PFCs during business hours to establish alternate site bed capacity and seek assistance with alternate placement for suitable patient. After hours this may require direct contact with each facility.

Over numbers/over census situations can be stressful and place teams under significant pressure. It is imperative for all parties to remain open and supportive and communicate transparently to preserve goodwill. Operational patient flow management is the administrative tasks associated with accessing a mental health inpatient bed and includes:

Bed finding and/ or negotiations within and between services regarding bed availability.





Repatriation and identifying suitable patients for clinical review, leave, transfer or admission to a private facility.

Clinical patient flow and bed management involves the clinical review and decision making process to determine whether any additional acute beds can be made available including:

Review of out of district patients / out of sector patients for repatriation.

Review of patients who may be considered for transfer and admission to a private mental health facility.

Review of patients on leave for extension of leave.

Review of appropriate patients for early transfer of care with additional supports or overnight leave with acute CMHT follow-up. This includes reviewing bed allocations and transfer of care status of patients, status of patients on leave, voluntary patients requesting to have care transferred or patients who have supportive family and/ or community networks.

After Hours Patient Flow

Each site has a role designated to co-ordinate patient flow after hours (evenings and overnight including weekends). At times of peak demand t h e On-call Consultant Psychiatrists can support the patient flow process by advocating for access to alternate venues if needed e.g. by discussing assessment and management of an individual patient with the Consultant Psychiatrists on call at another hospital. Where site bed capacity is nil and Consultant Psychiatrist to Consultant Psychiatrist negotiation for alternate site placement has been unsuccessful, negotiations may be escalated to the on call MH Executive for peer discussion and resolution. The hospital After Hours Nurse Manager is another valuable resource for advocating and facilitating strategies to generate additional bed capacity after hours.The SESLHD MHS After Hours patient flow coordination contact list is below:

Accepting Patients for Mental Health Admission





From ED

Acceptance of patients for admission is a collaborative process between the Mental Health clinician assessing the patient in the ED, duty Consultant Psychiatrist / ED Consultant Psychiatrist or Registrar and the PFC or after hours delegate. Important factors to consider include:

Is there a less restrictive alternative to admission? Can the patient go to a private hospital or drug and alcohol rehabilitation centre, be transferred to CMHT follow up, are they suitable for a brief PECC admission?

Is there a documented admission plan?

Has the patient had a physical health assessment clearing them for a MH admission?

Has the medical assessment and treatment in ED been completed? To minimise the risk of medically compromised patients being transferred to a MH bed, the ED medical staff are required to document in the medical record that there are no further investigations or treatments pending subsequent to a thorough physical examination. Prior to patients being transferred from ED the patient must be de-cannulated, ECG leads removed (ligature risk) and extubated at least 24 hours previously.

Is the medical record complete? MH-OAT Assessment module (A1), treatment plan for admission, medication chart including PRN‟s and depots, MHA original papers, blood pathology forms for example.

Acceptance of patients for admission is also a collaborative process between the PFC and the MHU or PECC NUM or NIC. A patient may have been assessed as suitable for a sub acute unit for example but following clinical handover it may be apparent the patient requires placement on an acute unit. Negotiation must take place with the NIC to establish the time for transfer into the MH bed. There may be times when it is necessary for the NUM or NIC to defer transfer at a particular time due to acuity. Other factors include staffing resources. It is therefore essential for the PFC to maintain regular contact with the NUM or NIC to communicate information about Police / Ambulance / CMHT presentations, unit acuity and staffing, AWOL‟s, transfers of care and leaves.

Direct Presentations

When patients present directly to the unit with Police, Ambulance or CMHT it is imperative to assess whether they are intoxicated. An Alcolmeter is available on each acute unit to measure alcohol intoxication. Patients should be observed for evidence of other intoxication such as illicit or prescribed substances e.g. pinpoint or dilated pupils, high pulse / respirations. If a patient is found to be intoxicated they must be transferred to the ED immediately for monitoring and medical assessment.

From General Hospital

The Consultation Liaison (CL) Teams will inform the PFC of any patients in a general hospital bed awaiting Mental Health admission. The same criteria as per ED apply. It is imperative all medical investigations and treatments have been completed and the patient has been reviewed





by CL team for the least restrictive care option prior to transfer to MHU.

Prioritisation for Admission

When there are patients in the ED and General Hospital awaiting mental health placement at the same time, especially when bed capacity is limited, priority for placement should be negotiated with the hospital Patient Flow Manager in consultation with the Mental Health Clinical Operations Manager and Duty Consultant (or delegate)

Transfer of Care

Discharge from an acute care facility is not the end point in the continuum of care for most people accessing acute care services, hence, “transfer of care” is a term adopted by NSW Ministry of Health to demonstrate that care continues beyond the hospita l setting. In the context of Mental Health, transfer of care ensures the safe, effective and efficient movement of people with mental health problems between inpatient settings to the community or alternative care settings. T he decision to transfer c a r e o f a patient should be made by the MDT in consultation with the patient and carers wherever possible. Planning for transfer of care optimises the patient journey and ensures timely service. The section below is consistent with PD2011_015 Care Co-ordination: Planning from Admission to Transfer of Care in NSW Public Hospitals.

On Arrival to the Inpatient Unit

On arrival to the unit (or as soon as practicable) each patient should receive information on the Expected Date of Discharge (EDD) outlining expected date and time of departure from the unit / clinical area and the expectations around transportation.

The Registrar under whom the patient is admitted should allocate and verify the EDD within 48 hours of admission, wherever possible.

Within 48hrs of admission the EDD should be communicated to the MDT. The EDD should be based on the patient‟s presenting clinical signs and symptoms, historical length of stay, psychosocial and non-clinical factors that may influence length of stay where known.

A transfer of care risk assessment should be conducted and the admission / transfer of care checklist commenced within 48hrs of admission.

The EDD should be verified by the Consultant Psychiatrist at the patient‟s first MDT clinical review and the date relayed to the patient and family / carer as soon as is practicable.

Each patient should be actively involved in their own transfer of care planning wherever possible.

Prior to Transfer of care

On the EDD the departure time from the ward should be no later than 1000hrs.

Transfer of care medications should be ordered and stored in the clinical area at least 12hrs prior to 1000hrs on the EDD.

Transportation bookings and arrangements should be confirmed within 24-48hrs prior to transfer of care. It is usually the patient‟s / carer‟s responsibility to arrange their transportation home, however exceptions can be made in consultation with the NUM / MH Executive, particularly if EDD will be unduly compromised.





All items on the transfer of care checklist should be completed prior to transfer of care, including notification of NGO‟s, case managers, GP‟s etc.

Repatriation of Out of District Patients Establishing Catchment Area Establishing catchment area usually comes down to confirmed residential address. However, this can be unclear for a variety of reasons including:

The patient has just been released from prison.

The patient has been admitted directly from the airport.

The patient is homeless.

The patient has an AVO preventing them returning to their accommodation.

The patient has a breakdown of relationship preventing them returning to their accommodation.

When the address is unclear other factors may be taken into consideration to determine which catchment area the patient is best serviced by such as:

Has the patient had any previous psychiatric treatment, if so where and how recently?

Does the patient have relatives or support networks? If so where?

Where does the patient want to live?

Does the patient have an identified care provider or a case manager?

Does the patient have a complex medical condition requiring local specialist care?

Repatriation Negotiation

Repatriation negotiation occurs between Site/Sector PFCs in the first instance. This can be escalated to Site/Sector Registrars, Consultant Psychiatrists and/or Service Dirceors if there is uncertainty about suitability of a patient for repatriation. If the issue remains unresolved and is impacting on patient flow, escalation to the District Access & Service Integration Manager may be required. It is useful to confirm all negotiations via email with relevant parties to avoid misunderstandings. When negotiating repatriation the requesting service must fax copies of the following to the receiving venue:

MH-OAT Assessment module (A1) or A4 plus another recent A1 if available (usually in medical record). Confirmation of address of relatives / carers, or most recent residential address.

Mental Health Act papers / recent clinical nursing notes / current risk assessment / Plan for admission/medication chart.

Details of case manager if available, and whether the patient is known to the Acute Care Team.





Requesting Transfer to Alternate Facility

When requesting temporary transition placement (e.g. to PECC or SMHSOP Unit) to enable capacity for acute patient flow or when repatriating a patient the following process is required:

Telephone contact PFC to PFC (weekdays 0800-1630hrs), or between afterhours Site/Sector patient flow delegate roles and/or on call Registrars to discuss request for placement.

Faxing of MH-OAT assessment, risk assessment and additional modules where necessary, medication charts, MHA papers, progress notes and any transfer of care summaries from previous admissions.

Once paperwork has been received and thoroughly reviewed the referring Duty Registrar is required to discuss the referral with the accepting Duty Registrar.

Should the patient provisionally be accepted for transfer this should be discussed with the Consultant Psychiatrist or on call MH Executive to ensure that the transfer is appropriate.

The referring venue is responsible for ensuring all required information is forwarded (see page 20). The receiving venue is responsible for reviewing the paperwork prior to accepting the patient, ensuring the patient is clinically appropriate and if appropriate satisfying themselves that the patient is a resident of their catchment area. Where transfer request cannot be resolved at local level, escalation to Service Director or On-call Executive may be required (see Appendix 2).

Repatriating within SESLHD MHS

Where a patient is from within SESLHD catchment area negotiations for inter-Site/Sector transfers are undertaken by the relevant PFCs. District Access & Service Integration Team is kept informed of progress.

Repatriating within NSW

Negotiations for repatriation of patients who are from outside of SESLHD MHS are between local PFC and other receiving MHS PFC, NUM, NIC or on call Registrar / Consultant Psychiatrist dependent on local practices.

NSW Metro PFC Contact Numbers

South Western Sydney LHD Ph: 0425 237 499

Central Coast & Northern Sydney LHDs Ph: 0404 830 169

Sydney West LHD Ph: 9840 3864

Illawarra Shoalhaven LHD Ph: 0403 571 299

St Vincent‟s Hospital Ph: 0416 141 026

Nepean Blue Mountains LHD Ph: 0434 396 111

Repatriating Interstate

There are various factors to be considered when transferring a patient interstate. Is the patient suitable for transfer in terms of risk and clinical presentation for example? Logistically how will the patient be transferred e.g. air, train, relative/carer assistance, hospital vehicle and escort. Mental





Health Act status – each jurisdiction has its own MHA and patient‟s status may become altered once over the border. The issue is complex and requires direct involvement of the site Chief Psychiatrist, sector Director of Operations and/or SESLHD MHS Director.

International Repatriation

A patient may require transfer to their residence overseas. Where relevant the patient‟s travel insurance may cover the cost of repatriation. Alternatively the family/ carers may be able to escort the patient. Where unclear it is useful to contact the relevant Embassy/ Consulate to advise what repatriation options can be provided. For example Switzerland has an excellent retrieval process where a team will be sent to escort the patient back to Switzerland. Retrieval agencies generally quote tens of thousands of dollars to assist in the repatriation of a patient to their place of origin. Such an agency is SOS International, Ph: 9372 2400.

International repatriation requires a MDT approach to consider risk factors and clinical presentation. Airlines require an assessment form confirming suitability of the patient to fly, usually obtainable via their websites.





Inter-hospital Transfer Algorithm

Team identifies the need to transfer a patient to another venue following comprehensive clinical assessment, medical review & detailed risk assessment.

Business Hours After Hours

Current documentation to be compiled at this stage:

Complete MH-OAT assessment Risk assessment & additional modules Care plans

Management plans etc Historical information Medication / PRN charts 7 days progress notes

Original legal papers plus S78, 80 & 81 where required.

Referring team contacts Patient Flow Coordinator (PFC) via routine process to communicate requirement for transfer of patient & provides all paperwork.

On-Call Registrar / CNC alerts NIC, On-Call Consultant, On-Call Executive of transfer requirement. NIC/ CNC faxes paperwork and phones to confirm receipt of fax.

Requesting site PFC alerts Duty Registrar / Consultant, site Executive & District Access Team of transfer requirement, faxes all relevant documentation to receiving venue & checks receiving venue has received the fax.

Registrar at receiving venue reviews relevant paperwork.

Duty Registrar at receiving venue reviews relevant paperwork in consultation with PFC / NUM / site Mental Health Executive.

Clinical discussion occurs between referring venue & receiving venue Registrars & On- Call Consultant Psychiatrist where necessary.

Clinical discussion occurs between referring venue & receiving venue Registrars & Duty Consultant Psychiatrist where necessary.

After clinical discussion the decision to transfer a patient to another venue is made in consultation with the Medical Officers, Nurse in Charge / CNC, On-Call Executive and after hours Nurse Manager.

After clinical discussion the decision to transfer a patient to another venue is made in consultation with Medical Officers, NUM‟s, PFC & Executive. A clinical handover must precede or coincide with the patient‟s arrival at the receiving venue.

Ref: Inter-hospital Transfer of Mental Health

Inpatients including ED, PECC, MHRU, OPU and MHU facilities Document No: 002_10

Once the decision to transfer has been made, appropriate transport can be booked and it is imperative the original Mental Health Act paperwork accompanies patient and nursing clinical handover takes place. A clinical handover must precede or coincide with the patient‟s arrival at the receiving venue





Transport When transferring a patient to another unit the following should be collated prior to transfer:

Original MHA papers must accompany the patient. Photocopies should be kept in the

patient medical record.

A current Section 78 form for transfer should be completed and original to accompany patient.

Copies of the recent clinical notes from the medical record, MH-OAT assessment, risk assessments and additional modules where necessary, medication chart, investigations, and other relevant assessments or correspondence.

Any medications or belongings such as money, cards cigarettes and lighters.

Scheduled patients must be risk assessed by the attending medical officer and a collaborative transport and escort plan formulated. Clinical handover must be given at the receiving destination.

SESLHD MHS Priority Transport Options The patient‟s risk status will determine the most suitable means of transport. Risk status should include risk of AWOL, self harm, harm to others, sexual safety, patient‟s current mental state, willingness to be transported and historical risk factors. The following is a repertoire of transport options in escalating order for consideration and collaborative discussion in line with risk assessment:

1. Hospital Transport with nurse escort 2. Hospital transport driver (overtime) and hospital car with nurse escort 3. Hospital car with Health and Safety Assistant (HASA) as the driver with nurse escort 4. Hospital car with two nurse escorts (one driving) 5. Networked hospital transport service with nurse escort 6. Networked hospital transport driver and hospital car with nurse escort 7. If the transfer is a repatriation arrange to use the donor site transport service 8. Consider admitting a high risk patient to the local MHU and transferring a low risk patient via

hospital car with ward staff or taxi and ward staff to another sector hospital 9. Consider delaying transport until acuity settles in 24 hrs 10. Consider temporarily placing a stable low risk patient in a transitional PECC bed to facilitate

high risk MHU admission 11. Consider assertive CMHT engagement to expedite low risk MHU patient transfer of care to

community to facilitate capacity to accept high risk admission 12. Contact Consultant Psychiatrists to review Mental Health inpatients to create capacity 13. Consider occupying medical / surgical bed for low risk voluntary patient to facilitate high risk

patient admission to MHU 14. Consider buying a private hospital bed for low risk admission to facilitate capacity 15. NSW Ambulance / Hospital Security Officer with nurse escort 16. NSW Ambulance / Overtime Hospital Security Officer with nurse escort 17. NSW Ambulance / Casual Pool Hospital Security Officer with nurse escort 18. NSW Ambulance / Sector Security Officer with nurse escort 19. NSW Ambulance / NSW Police where a public safety issue is identified in consultation with Site/

District Mental Health Executives, Security Manager and / or Corporate Service Manager





Hospital Vehicle/ Taxi

Based on risk and following discussions with Consultant Psychiatrist and Clinical Operations Manager voluntary patients may be transferred in the ward car driven by nursing staff. Taxi vouchers can also be obtained from the NUM to transfer a patient to another hospital or home if nurse escort not required. If the patient requires an escort in the taxi a return taxi voucher for the nursing staff will be required. The destination of the taxi voucher must be completed in advance to prevent misuse of the vouchers.

Ambulance

St Vincent‟s Hospital Transport Ph: 8382 2141

NSW Ambulance Bookings Ph: 131 233

NSW Ambulance Liaison Officer Ph: 0407 296 254

NSW Ambulance Senior Operations Manager Ph: 8396 5150

Medical Retrieval Unit Ph: 9553 2222

*St Vincent‟s Transport can transfer patients within New South Wales and interstate. To organise transfer contact ph:8382 2238.

Aero-medical Transport of Patients

Where distance prohibits the use of a motor vehicle, aero-medical transport may be considered. Medical Retrieval Unit (ph: 9553 2222) is the central booking point for medical retrieval or long distance patient transport (for patients requiring air transport). However if Air Ambulance declines the transport, St Vincent‟s Transport (above) will organise transport with Wing-away. Patients who are Involuntary under the MHA can be transported but must be adequately settled. Wing-away have nurses who conduct a transport risk assessment prior to accompanying the patient on the flight.

The accepting hospital will usually arrange to collect the patient from the destination airport. In exceptional circumstances Wing-away will also transfer from the airport to the destination hospital. In appropriate circumstances, provision may be made for a relative to accompany the patient on the flight. Authorisation must be obtained from the Sector Service Director and Chief Psychiatrist prior to organising the transfer.





Referral to Private Hospitals

Private psychiatric hospitals‟ admission criteria may vary slightly. In general these hospitals do not accept patients who are Involuntary under the MHA or have high levels of risk. Therefore patients must be voluntary prior to transfer and have current risk assessment demonstrating low-moderate levels of risk. Consideration must be given to risks such as suicidality, deliberate self harm, aggression, AWOL, sexual safety and self neglect. Private psychiatric hospitals also vary in their referral requirements. Essentially the same information is required as when negotiating repatriation:

MH-OAT assessment and risk modules (A1& A4).

Private Health Fund provider and number.

Evidence of address and phone number of patient.

Recent clinical notes from medical record / Current risk assessment / Psychiatric / Physical history / Plan for admission.

GP / Private Psychiatrist / Psychologist contact details / Next of kin / carer contact details.

Patients may not know their health fund reference numbers and it may be necessary to contact the health fund with the patient‟s name, date of birth, address so they can supply the health fund reference number. Patients who have health insurance may be required to pay an excess before they can be transferred to a private psychiatric hospital. This must be established before transfer takes place to ensure the patient is not put in financial difficulty.

Private Hospitals

Wandene (Kogarah) Ph: 8197 5800

Wesley Private (Ashfield) Ph: 9716 1400

St John of God (Richmond) Ph: 024570 6100

St John of God (Burwood) Ph: 9715 9200

Sydney Clinic (Bronte) Ph: 9389 8888

Northside Clinic (Greenwich) Ph: 9433 3555

Northside West Clinic (Wentworthville) Ph: 8833 2222

The Park Central Clinic (Campbelltown) Ph: 024621 9111

Southwest Clinic (Liverpool) Ph: 9600 4000

Accepting Referrals from Private Hospitals

Patients who experience a significant deterioration in their clinical condition while in a private psychiatric hospital may be Scheduled under the MHA, 2007 and require transfer to a public hospital. When this occurs the private hospital will contact the nearest declared MHU and notify them of the patient‟s pending transfer. Most often the patient is taken to ED for assessment prior to transfer to MHU. The same principle applies as for accepting patients from ED or the general hospital (see page 14).





Referral to Rehabilitation Services

SESLHD MHS MHRU Clinical Access Pathway

1. Consumer identified by treating team for MHRU Referral from acute inpatient setting (priority) or community. Informal visit to MHRU may occur at this point. *Referral to Bloomfield or other SESLHD MHS MHRU may occur at this point*

2. Referral completed by referring clinician and

sent to MHRU NUM

Referral incomplete or consumer needs do not match Rehabilitation service.

Referral complete and contains sufficient information

for assessment of urgency, risk, relevance and processing of referral in a timely manner.

Referrer contacted by MHRU to provide additional information and /or discuss possible alternative options.

MHRU assesses person within 2 weeks

*Bloomfield most suitable for consumer

*Other SESLHD MHS MHRU more suitable for consumer

Local MHRU suitable for consumer

Contact Bloomfield PFC

Referral negotiated directly between Sectors

Place available Place not available

MHRU NUM facilitates admission processes in

consultation with referrer/treating team, priority list adjusted accordingly.

Consumer prioritised on waiting list:

bed list + waiting list circulated

weekly by Sectors

MHRU NUM commences engagement process in consultation

with referrer/treating team – includes consumer visit(s) to MHRU

SESIMHS MHRU’s

POW

Ph: 9382 3798

Fax: 9382 4237

TSH

Ph: 9540 8200

Fax: 9540 8237



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Referral to Bloomfield Rehabilitation Services

Bloomfield is a specialist psychiatric facility based in Orange, NSW and includes several locked and declared rehabilitation units. The rehabilitation units at Bloomfield offer single gender accommodation for men and women and a limited number of long stay beds for patients deemed unsuitable for rehabilitation but for who all other placement options have been exhausted. The model at Bloomfield targets patients with higher acuity and more complex presentations than standard rehabilitation services. Beds are also available for patients undergoing Clozapine titration.

Once a patient has been assessed as suitable for referral to Bloomfield a referral form must be completed. This is a collaborative process between the MDT and PFC. The following documents are required for referral to Bloomfield:

Completed referral form, MH-OAT documentation, OT assessment / 7 days progress notes, medication chart.

Transfer of care summaries from previous non-acute admissions, clinical handover / referral letter and site ownership letter.

Bloomfield‟s allocation meetings take place on a Wednesday and the referral is processed within approximately a week. Once a patient has been accepted it may take a few more weeks before a bed comes available. However the date for transfer is generally indicated in advance to enable the patient and MHU to prepare.

Following acceptance by Bloomfield, if transport is required, St Vincent‟s Transport should be contacted at least 48 hours in advance. It is approximately a 10 hour round trip to Orange so the patient and escort are usually collected by Transport at 0700hrs. The NUM must be informed so that extra staff can be arranged if needed to cover the escort. All original MHA paperwork must accompany patient, along with a completed Section 78. Due to the remote location of Bloomfield Hospital it is essential patients have a supply of personal money, personal items and clothing upon transfer. The patient‟s family/carers should be given the contact details and address for Bloomfield.

Drug and Alcohol Services

There are drug and alcohol teams based at every hospital and at various community services throughout SESLHD to provide support and education to patients with addiction issues. Clinical Nurse Consultants specialising in Alcohol and Other Drugs can attend ED‟s and MHUs to assess and support patients with co-morbid mental health and drug and alcohol issues. There are various facilities for Drug and Alcohol rehabilitation in NSW. Alcohol and Other Drugs rehabilitation facilities in SES LHD include:

Sydney Hospital offers two inpatient rehabilitation beds for patients at risk of

seizure during alcohol withdrawal: 9382 7111.

The Langton Centre is a community based Drug and Alcohol service: 9332 8777.





Special Needs Referrals „Special Needs‟ refers to patients who may be unable to be treated in their local catchment due to actual or potential risk or conflict of interest. This can include patients who are employed within the hospital, a member of the local Police, Security or Ambulance Officers or relatives of patients or staff employed within the hospital. It can also relate to patients who have a clinical presentation that precludes admission to the local hospital, such as delusional thoughts regarding a member of staff or past threats of harm toward a staff member.

When this situation occurs, the issue should be escalated to the Site / Sector Service Director to confirm whether transfer to another venue is required and to negotiate with another venue where appropriate. Should the matter not be resolved locally, the Area Access & Service Integration Team should be advised of the situation and the following information provided via email:

Name / MRN / Date of Birth / Address.

Special needs requirement, eg. Patient is RN working in the local hospital or patient a Police Officer working in local Area Command.

Patients‟ current mental state/ diagnosis / prognosis / history.

Patients MHA status.





Appendix 1

Useful Numbers

Services and Contacts Numbers District Access & Service Integration 9113 2468 / 0404 033596

0404 033 596 SHH Eloura East 4295 2546 SHH ED 4296 6666/switch

SHH Eloura West 4249 2549 Shoalhaven ED 4421 3111/switch

SHH Mirrabook 4295 2310 Milton ED 4454 9133/switch

TWH MHU 4253 4304 TWH ED 4222 5000/switch

TSH MHU 9540 7506 / 7485 TSH ED 9540 7115

STG MHU 9113 2559 STG ED 9113 1516

STG PECC 9113 1419 STG PECC Fax 9113 1499

POW General 9382 4319 / 4357 POW ED 9382 8400

POW Obs 9382 4333 / 4356 Kiloh Reception Fax 9382 4399

POW PECC 9382 7772 / 7770 POW Euroa (SMHSOP) 9382 3796

SVH Caritas 8382 1590 SVH ED 8382 2473

SVH PECC 8382 4090 SVH PECC fax 8382 4091

POW MHRU 9382 3798 NUM 9382 3495

TSH MHRU 9540 8200 NUM 9540 8231

SHH MHRU 4295 2357 NUM 4295 2352

Sydney Children‟s Child and Adolescent Ward (CAMHs) 9382 8283

TWH SMSOP Unit 4253 4465





Appendix 2:

SESLHD MHS Patient Flow Escalation Algorithm





Appendix 3:

Referral to IPCU / MHICU Facilities Algorithm

Patient presents with associated loss of capacity for self-control, with a corresponding increase in risk, which does not enable their safe, therapeutic management and treatment in an acute ward.

Treating team notifies PFC of need to refer patient for mental health intensive care.

PFC notifies site Executive and

MHS Access & Service Integration Manager

PFC faxes all documentation to receiving venue.

Documentation to be compiled at this stage:

Comprehensive Consultant psychiatrist assessment Risk assessment Care plans

Details of containment strategies trialled: management plans etc Historical information Medication / PRN charts 7 days progress notes Appropriate legal papers SES LHD MHS PFC contacts corresponding PFC to establish IPCU / MHICU bed availability and makes referral. PFC informs referring team of outcome.

Referring Consultant Psychiatrist contacts Chief Consultant of receiving venue to support request for higher level care and clinical / therapeutic / pharmaceutical discussion.

Bed available Bed unavailable

PFC to arrange appropriate transport and escort, ensure original MHA paper work and copies of notes etc accompany patient and escort is able to provide full clinical hand over.

If no bed available, referring site Service Director to contact site Service Director of Intensive Care Venue to ascertain if bed can be made available.

Bed available Bed unavailable

The referring venue has an obligation to ensure repatriation of the patient within 24hrs of notification by IPCU / MHICU of criteria for admission no longer applying

IPCU/MHICU Venues & Contacts

Sydney/ Sydney West (Concord)

Sydney West (Cumberland)

North Shore Central Coast (Hornsby)

Where no bed available, site Service Director to prepare brief of action so far for SES LHD MHS Director

PFC 0425 237 499

PFC 984 0386

PFC 0404 830 169

Revision 0 Trim No. Date: March 2013 Page 29 of 29 THIS DISTRICT DOCUMENT BECOMES UNCONTROLLED WHEN PRINTED OR DOWNLOADED UNLESS REGISTERED

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References

Garling, P. Final Report of the Special Commission of Inquiry. Acute Care Services in NSW Public Hospitals Overview 27 November 2008, pp. 30, (1.193) NSW Health Mental Health for Emergency Departments – A Reference Guide 2009 NSW Health Sustainable Access Plan 2004 Referral to Intensive Psychiatric Care Unit (IPCU) or Mental Health Intensive Care Unit (MHICU) Business Rule Document No: 004_10. April 2010 SESLHD Acute Patient Flow and Sustainable Access Management for Mental Health January 2013 Discharge/Transfer Planning For Adults & Children in Acute Facilities, SESLHD PD 107 August 2009 Inter-hospital Transfer of Mental Health Inpatients including ED, PECC, MHRU, OPU and MHU facilities SESLHD Document No: 002_10 Obtaining a Second Opinion from a Consultant Psychiatrist SESLHD PD 2007/07 v5 Revised

April 2012

8. Revision and Approval History

Date Revision no: Author and approval

22/11/2012 0

Updated and changed from previous SESIAHS Procedure. Gayle Jones, A/Access & Service Integration Manager, SESLHD MHS. Approved by SESLHDMHS Clinical Council.

http://internal.health.nsw.gov.au/pubs/2009/pdf/mh_emergency.pdf

http://www.seslhd.health.nsw.gov.au/Policies_Procedures_Guidelines/Clinical/Mental_Health/BR/AMHBR_004_10_Referral_to_Intensive_Care.pdf

http://www.seslhd.health.nsw.gov.au/Policies_Procedures_Guidelines/Clinical/Mental_Health/BR/AMHBR_004_10_Referral_to_Intensive_Care.pdf

http://www.seslhd.health.nsw.gov.au/Policies_Procedures_Guidelines/Clinical/Mental_Health/Guidelines/SESLHDGL022-MH-AcutePatientFlowSustainableAccessMgt.pdf

http://www.seslhd.health.nsw.gov.au/Policies_Procedures_Guidelines/Clinical/Mental_Health/Guidelines/SESLHDGL022-MH-AcutePatientFlowSustainableAccessMgt.pdf

http://www.seslhd.health.nsw.gov.au/Policies_Procedures_Guidelines/Clinical/Operations/Documents/PD-107-DischargePlanning.pdf

http://www.seslhd.health.nsw.gov.au/Policies_Procedures_Guidelines/Clinical/Operations/Documents/PD-107-DischargePlanning.pdf

http://www.seslhd.health.nsw.gov.au/Policies_Procedures_Guidelines/Clinical/Mental_Health/BR/AMHBR_002_10_Interhospital_Transfer_Patients.pdf

http://www.seslhd.health.nsw.gov.au/Policies_Procedures_Guidelines/Clinical/Mental_Health/BR/AMHBR_002_10_Interhospital_Transfer_Patients.pdf



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