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Referrals
Referral form – Sylvan Ward

Nurse on St Nicholas Hospice Care Sylvan Ward

Call our 24/7 advice line for health care professionals and families if you need support with symptom management and end of life care - 01284 766133.

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Referral form – Sylvan Ward

What we do

Manage symptoms that are complex and have been difficult to control at home
Help people adapt to changes so that they can go back home
Provide care at the end of life when it is not possible to die at home

We advise using Google Chrome or Microsoft Edge when using the online referral form, instead of Internet Explorer.

Step 1 of 4

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Date
DD slash MM slash YYYY
Reason for referral(Required)
- Symptom management for uncontrolled or complicated symptoms that have not responded to initial treatment(s)
- Social Crisis – please note we can offer short stays (usually around 7 days) to support carer breakdown, and we may set a discharge date on arrival
- Patient’s preferred place to die
Please note Sylvan Inpatient Ward is a short stay unit.
Please complete this form to the best of your ability; incomplete or inaccurate forms will result in a delay in admission.
Please note that inpatient requests are discussed at 0930 each morning, they are allocated on clinical need and not length of time on the waiting list.
Please be aware that if a patient declines a bed they will be removed from the bed waiting list.
Please discourage patients from bringing in unlabeled, or unprescribed medications.
Is the patient known to St Nicholas Hospice Care(Required)
- Yes
- No
Please stop form and call Clinical admin on 01284 702525 in hours or 01284 766133 out of hours to discuss with a triage nurse.
Referrer details
Name(Required)
First Last
Job title
Telephone number(Required)
Email(Required)
Enter Email Please confirm Email
Patient details
NHS number(Required)
If unknown, please insert 0000000000
Name(Required)
First Last
Date of birth(Required)
DD slash MM slash YYYY
Address(Required)
House name/number and street Address Line 2 Town County Post Code Country
Telephone number(Required)
GP practice(Required)
If other, please state:
Please contact the GP to find out where the patient's local hospice is.
Contact St Nicholas Hospice Care's Clinical Admin team on *** if there is a specific reason you still wish referral to be considered, e.g. moving in with a relative and changing GPs.

Does the patient have mental capacity to consent to the referral?(Required)
- Yes
- No
Is this a best interest decision?(Required)
- Yes
- No
Please do not continue with this form and instead call our Community team on 01284 702525 or 01284 766133 out of working hours.
If patient has mental capacity, are they aware of the referral?(Required)
- Yes
- No
- No capacity
Please do not continue without consent for referral.
Next of kin details
Is Next of Kin known?(Required)
- Yes
- No
Name(Required)
First Last
Is the Next of Kin's address and telephone number the same as the patient's?
- Yes
- No
Address(Required)
House name/number and street Address Line 2 Town County Post Code Country
Telephone number(Required)
Relationship(Required)
Medical details
Primary Diagnosis(Required)
Is the patient aware of the diagnosis?(Required)
- Yes
- No
Other relevant conditions
Allergies

Present location of patient(Required)
If the patient is coming from a hospital ward please ensure nurse to nurse handover prior to any acceptance of patient. Please call 01284 766133 ensuring a rapid COVID 19 test has been done and results obtained BEFORE transfer to the Hospice.
- Home
- Hospital
- Care home
Please state which hospital(Required)
- West Suffolk Hospital
- Addenbrookes Hospital
- Colchester Hospital
- Ipswich Hospital
- Royal Papworth Hospital
Please state which care home(Required)
If other, please state:
Please call our Clinical Admin team on 01284 702525, as we may not be able to accept the patient as they are out of our catchment area.
Advance care planning
My care wishes folder?(Required)
- Yes
- No
DNACPR?(Required)
If no we will discuss resuscitation status with the patient and their family on admission, please make them aware
- Yes
- No
Reason for referral (i.e. pain management/nausea/EOLC and details of what has been tried)(Required)

Other agencies involved
Community nursing team
Consultant
Specialist nurse
CHC funding application made
- Yes
- No
What has been asked for, when and by whom?(Required)
Potential risks
Safeguarding concern / alcohol and drug dependency / potential verbally aggressive behaviours from patient or family / estranged family members(Required)
- Yes
- No
Please provide details(Required)
Potential infection risk(Required)
i.e. known MRSA, active Covid symptoms, Diarrhoea and / or sickness?
- Yes
- No
- Unknown
Please state(Required)
- C DIFF
- MRSA
- COVID-19
- Other
If other, please state
COVID 19 vaccinated(Required)
- Yes
- No
- Unknown
History of loose stools?(Required)
- Yes
- No
- Unknown
Has a stool sample been sent?(Required)
- Yes
- No
- Unknown
Falls risk(Required)
- Yes
- No
- Potential
Please provide details such as previous fall history, dizziness, unsteady gait, postural hypotension drop, multiple medications(Required)
Cognition
- Alert and orientated
- Confused
- Agitated
- Drowsy
- Other
What is the patient’s mobility?
- Independent
- Assistance of 1
- Assistance of 2
- Bed Bound / Hoisted
- Unknown
Are there any dietary requirements we need to be aware of? E.g. Food allergies, supplement drinks which require refrigeration
- Yes
- No
- Unknown
Please provide details(Required)
Pressure areas
- No pressure area damage, and not currently at risk
- No current pressure area damage, but is at risk
- Pressure areas are already suffering damage
- Unknown
Please provide details such where there is a vulnerability, grade of sore (if present), treatment plans such as referral to tissue viability(Required)
Is the patient a smoker/uses a vape?
- Yes
- No
- Unknown
Please advise patient that we have oxygen on-site and have smoking and vaping restrictions because of this.
Does the patient use CBD products?
- Yes
- No
- Unknown
Please advise patient CBD products must state on them that they contain less than 0.2% of THC to be allowed on site.
Is the patient on oxygen therapy?
- Yes
- No
- Unknown
Please provide details such as device used and litres and advise patient about our restrictions with smoking and vaping(Required)
Is the patient on a current syringe driver?
- Yes
- No
- Unknown
Please provide details of current medications and doses so we can ensure we have stock on order(Required)
Is the patient on current chemotherapy?
- Yes
- No
- Unknown
Please provide details(Required)
Does the patient require any specialist equipment? E.g. a bed extender (for patients over 6ft) or a bariatric bed (for patients weighing over 227kg) or a pressure relieving mattress for current pressure area damage?
- Yes
- No
- Unknown
Please provide details(Required)
Does the patient require transport to the Hospice?
- Yes
- No
- Unknown
Do they require:
- Ambulance stretcher
- Ambulance chair
Any other comments – such as family/patient expectations
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Getting Help

Referrals
Overview of the Hospice’s services
Managing symptoms
Preparing for end of life
Support Groups and Activities
Emotional and wellbeing support
Help at home
Care on Sylvan ward
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Advice line:

01284 766133

Supporter Care:

01284 715566

Donation Centre:

01284 747622

St Nicholas Hospice Care,
Hardwick Lane,
Bury St Edmunds,
Suffolk,
IP33 2QY

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