Latest revision as of 11:04, 3 September 2020

This topic is for IBID

iBID Referral

Referral fields provide information about the referrer and referring hospital, treatment the patient has received prior to arrival at the burn service, recording relevant members of staff and the decisions taken once the patient has arrived, through to the placement of the patient in the relevant ward.

Fields marked with two red stars are Key Performance Indicator (KPI) required fields, fields with one grey star are important and must be completed wherever possible. Failure to complete the marked fields will generate a validation error, information not present at the time of referral can be filled in once the information becomes available.

Referral Details

First Aid Given - Tick the box if any First Aid was given. If this box is ticked it will generate extra fields to allow further information regarding First Aid given prior to the referral.

First Aid Delay in Minutes:- Type in the time delay in minutes from the time of the burn injury to the time First Aid was given; this can be at the scene or upon arrival at the hospital.

First Aid Type:- Pick from the drop down list for type of First Aid.

First Aid Comments:- A searchable free type box for any additional details relevant to the treatment given to the patient.

The UK Tarn ID Reference:- If the UK TARN record reference number is known it should be entered in this field. UK TARN record reference number is used by the Trauma Audit and Research Network to calculate the likely rates of survival for particular injuries or combinations of injuries, taking into account age, gender and the patient’s physical response to their injuries.

Referred By:- What is the name of the referring service provider.

Referral Site:- Choose from the drop down menu list what best describes the service or source the initial referral come from. If any more accurate description is available that is not in the menu structure, this can be entered in the associated text box.

Referral Staff:- Type the name of the member of staff dealing with the case at the referring hospital.

Host Referral Site:- Choose a Referral Site from drop down list. For those users with relevant permissions, this field is editable and new referral sites can be added. Please see instructions below.

Referrer Telephone:- Type the telephone number of the person responsible for referring the patient to the host referral site.

Referrer Contact Details:- The referrer could be a district nurse or a GP for instance. This box allows you to enter as much information regarding the referrer as possible.

Referral Date:- This is an essential field for completion. This should be the first date at which contact was made with the burn service in order to make a referral rather than to ask for advice. There is an option to choose a date the calendar by clicking the calendar icon or free type in the the referral date box.

Referral Time:- This is an essential field for completion as this field is pivotal in the analysis and reporting of burn injuries, and should record the time the referral was made.

Referral Comments:- A searchable free type box that allows as much detail as possible regarding the referral be entered.

Adding a Host Referral Site

From the iBID Dashboard toolbar, select the "Tools" option.

Then select "Settings"

A system Settings Screen will open.

Click The "Manage Lookups" option form the options list on the left.

From the Manage Local Lookups List select "IBID Host Referral Site".

Click the "New" button if there is any information already present form a recent addition to the list.

Type the order the entry is to occupy in the lookup list, enter a lookup code and then the name of the Host Referral Site into the Description box.

Choose the "OK" button and the Host Referral Site Name will be entered in to the "List Contents" box.

Items in the List Contents box will now appear in the "Host Referral Site" drop down list.

Referral Assessment TBSA

Referral S & SD:- Enter the portion of the burn that is superficial (S) and superficial dermal (SD), as assessed by the referrer.

Referral DD & FT:- Enter the portion of the burn that is deep dermal (DD) and full thickness (FT), as assessed by the referrer.

Referral Total:- There is no need to type into this field as the information you have entered into two fields above automatically generates a total body surface area (TBSA) of burn injury.

Additional Referral Information

Enter any further details regarding the referral into free type box.

Treatment to date:- This is a free text field and you can fill in as much information as possible regarding the treatment the patient has received up to the point of referral.

Decision Support:- Choose from drop down list what best describes the how the decision to support the referral to the burn service was made.

Referral Justification

Referral Justification:- Choose the relevant tick box(es) that which best describes the justification for the referral of the patient to the burn service.

Referral Justification Text box:- Enter details and reasons why the patient should be referred.

Referral Accuracy:- Choose from drop down list and choose whether the referral was accurate or not accurate.

Transfer/Bed Info

NBBB Involved in Ref:- If the National Burn Bed Bureau (NBBB) were involved in the providing bed or transfer information click to put a tick box.

NBBB Bed Level:- Choose from the drop down list that which describes the level of care and monitoring requested for the patient on the referral transfer form. A full description of these menu items are available from the National Burn Care Review.

Initial Response:- All referrals once received should be recorded as either Accept or Refuse. The decisions about Accepting or Refusing a referral will be made by the clinical team at the burn service. This is a Key Performance Indicator (KPI) required field.

Initial Action:- Menu items available for this field are based on the option chosen in the Initial Response field. If in Initial Response you choose Accept, options in Initial Action are: Accept for Admission or Accept for Assessment. If you choose Refuse in Initial Response, options available in Initial Action are: Refuse no bed or Refuse no staff. This is a Key Performance Indicator (KPI) required field.

Transport Type:- Enter the type of transport predominantly used in transferring the patient to the burn service from either the scene of the accident or from the Emergency Department.

No. of Journeys:- Enter the number of journeys the patient made from the scene of the incident to arrival in the burn service eg; scene of incident to ED, ED to burn service equals 2 journeys.

Reason For Transfer Delay:- This is a free text field for you to state the reason for the delay in transferring the patient to the burn service. If there was no delay in transfer, there is no need to complete this field.

Outreach Team (BORT - Burns Outreach Team)

The Burns Outreach Team provides a multi-disciplinary assessment for patients referred to the Outreach service. Delivery of care by the Outreach Team can be done in a variety of settings such as in, out patient clinics, visits to the patient's home or seeing a patient on a hospital ward. The Outreach Team provide all aspects of burn wound management, scarring and aftercare support and education for professionals providing a service to burn injured patients.

The section below can be used to record information about a patient in two ways. First by the Burns Outreach Team:

Date of First OR (Outreach) Visit:- Enter the date the patient's first visit to the burns outreach service.

Where First Seen:- Where within the burn service was the patient first seen? Choose from the drop down list what best describes where the initial assessment by the Burns Outreach Team took place. For example; if the patient was seen in the clinic choose clinic on site, if seen in their own home choose home, if seen on a ward within your own hospital choose hospital was on site

DNA (Did Not Attend) Appointment:- If the patient did not attend their appointment click into the box to put a tick.

The second way in which to use this section other than for Burns Outreach is to record where a patient has been first seen by members of the burns clinical team prior to the patient being admitted onto the burns ward.

Date of First OR (Outreach) Visit:- Leave this blank if the patient was not seen by the Burns Outreach Team.

Where First Seen:- Choose from the drop down list what best describes where the patient has been seen and assessed by members of the burns team. For example, if a patient with a major burn was seen by the burns clinical team in the Emergency Department, record this as ED on site. If the patient was seen on the burns ward as they are admitted enter hospital ward on site, if the patient is seen as on the ward as there is no out patient clinic available, click on burn ward attender

DNA (Did Not Attend) Appointment:- If the patient has been referred for admission, leave this field blank.

Attendance

This section requires completion for both a Burns Outreach referral or a referring for admission, as the fields are Key Performance Indicator (KPI) required date and time fields.

In the event the patient has been assessed by members of the burns clinical team for admission, enter the date assessed. The date in the Assessment Date field can be different to that entered in the Admission Date field because a patient can be assessed in the Emergency Department first but then not be admitted to the Burns Service for some time after that.

Assessment time:- Enter the time the patient was assessed.

Once the Referral fields have been completed and if the patient has been accepted for admission, the Admission fields need to be completed. For further information on Admission fields please follow link to iBID Admission

Editor Types

Date Editor

Can free type date or select from drop down calender. Enter "Today" or press "Clear to exit without entering data.

Time Editor

Can free type time or use scroll bars at the right of data field.

Date & Time Editor

Free type date dd/mm/yyy and time 00.00, or drop down list. Choose "today" button if event was day of inputting data or "Clear to exit field without data entered.

Drop Down / Lookup List

The Lookup List is a collection of common names, places, catagorys, or other types of information that can help you choose a required field. Click on the down arrow to the right of the data field, highlight the relevant information to enter.

Staff Drop Down / Lookup List

Populated by staff names entered as "Users" in Administration.

'Yes/No/(Don't Know Drop Down

A special kind of drop down list to allow a clearer selection of yes, no & don't know when compared to the tick box. Used predominantly in the iBID editors, but due to roll out to all data-entry fields. Input via keyboard can be acheived by pressing Y or N on the keyboard.

Tickbox

Checked - Positive with a known value = 1.

Unchecked - Negative with a known value = 0.

Gray - Don't know with a value = null.

Please note: Check boxes are grey (Unknown) by default.

Postcode Editor (2 part)

Free type 1st part of postcode letters and numbers.

Free type 2nd part of postcode numbers and letters.

Text Field

A free type field to enter as much detail as possible.

(Note: Max 255 characters)

Memo Field

A free type field to enter as much detail as possible (Unlimited chars)

Automatically Filled in Fields

Sometimes shaded, Aquila will fill in these fields automatically from the data entered in previous fields.