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Sunday, January 7, 2018

Blue Ribbon Patients: A Tool to Protect from Unnecessary Transitions

by Rick Strang (@rickstrang)

Bed pressures in busy hospitals often means that less acute patients are moved to different wards in order to make space for patients admitted from the emergency department. We are often faced with some difficult decisions in our current NHS. 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. It is also quite common for these moves to 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. Indeed, they will often require sitting down and 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. The Blue Ribbon Patient sticker idea came out of that.

The scheme is not exclusive to EoL patients, although it predominantly affects them and was started particularly for them. For example, we had an elderly man who had been profoundly deaf since childhood with several other very complex needs on one of the wards. As he became better he was likely to get moved. However, some of the staff had learned to sign and he had built up an important trusting relationship. Moving him and starting again wasn’t going to be helpful so he was made a Blue Ribbon patient.

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.

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.

The Blue Ribbon Patient scheme is integral to our Transfer of the Dying Patient policy.

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 RN is Emergency Care Improvement Lead at Isle of Wight NHS Trust in England. When not involved in all types of emergency care Rick is usually finding innovative ways to avoid household chores.

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