Emergency Department signposting/ redirection guidance

8. National Redirection Guidance Framework

The following steps are considered high impact changes. Evidence suggests these are the 4 component process steps that will have the greatest impact. Following the steps set out in each of these key component parts will ensure a safe and effective, consistent approach to signposting/redirection is in place. These should form the basis of local approaches.

Key approach considerations:

1) Trigger

2) Process

3) Clinical decision

4) Clinical guidelines

1) Trigger

Signposting/redirection is not appropriate for every patient presenting to the Emergency Department. A defined group of patients can be identified and considered for signposting/redirection, using a criteria based trigger. Suggested trigger criteria used to initiate a signposting/redirection assessment include, for example:

a) Illness or health problem normally seen and dealt with by the primary care team

b) Conditions with which citizens have already been seen by their own primary care team or have an ongoing treatment plan in place

c) Condition that has been present for more than 3 days

These criteria should be adapted and applied consistently in the context of local service requirements.

An example of assessment guidance for patients who present to the Emergency Department can be found in Appendix C.

2) Process

A standard system should be put in place so that those identified as ‘potential for signposting/ redirection’ have consistently applied the same process and messaging. The key to the success of the approach is consistency. The process must involve information, education and a review by an experienced Emergency Department clinician. Suggested process, scripting and patient information leaflet can be found in Appendix D and Appendix E.

3) Clinical decision

A clinical decision around appropriate signposting has to be made by an Emergency Department senior decision maker (with sufficient department experience).

Signposting/redirection will require the senior clinical decision maker to consider safeguarding and will require a working knowledge of available social care and community support services.

It should be acknowledged and accepted that the senior clinical decision maker is sufficiently experienced and therefore able to distinguish between those conditions requiring immediate attention and those which should be referred out with the Emergency Department. See Appendix F for an example signposting/redirection process.

4) Clinical guidelines

Best practice suggests there is a requirement for a number of underpinning protocols for frequent ‘non-emergency’ presentations or ‘primary care type’ presentations. These should be easily accessible and form part of training and development processes to ensure they are fully understood and utilised.

Peer review is recommended and protocols can be shared with other Boards which will ensure variation is minimised and does not undermine the key principles outlined in this guidance.

Clear documentation and guidance for staff applying the principles and written information for patients is essential.

Summary of 4 Key Components and Associated Requirements

1. Trigger

• Criteria based triggers identified at triage
• ‘Flow chart’ type protocols for agreed pathways for operational use

2. Process

• Standardised processes/standard operating procedures
• Monitoring of adoption/compliance
• Built into existing training and development
• Scripts to guide conversations for clinical staff
• Patient information leaflets detailing the approach

3. Clinical Decision

• Clinical decision peer support structure
• Information on safeguarding/contacts
• Knowledge of available health and social care services, directory of services in and out of hours
• Guidance on requirements to be considered a senior clinical decision maker
• Development opportunities to support learning

4. Clinical Guidelines

• Definitions for ‘non-emergency’ presentations or ‘primary care type’ presentations
• Regular peer review
• Review of clinical outcomes and information for improvement
• Overall guidance for staff to refer to detailing the rationale for signposting
• General information on appropriate use of services