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Bed Management and Escalation Policy v4 Policy No: OP33 Version: 4.0 Name of Policy: Bed Management and Escalation Policy Effective From: 28/09/2015 Date Ratified 17/07/2015 Ratified PQRS Committee Review Date 01/07/2017 Sponsor Director of Nursing, Midwifery and Quality Expiry Date 16/07/2018 Withdrawn Date Unless this copy has been taken directly from the Trust intranet site (Pandora) there is no assurance that this is the most up to date version This policy supersedes all previous issues

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Bed Management and Escalation Policy v4

Policy No: OP33

Version: 4.0

Name of Policy: Bed Management and Escalation Policy

Effective From: 28/09/2015

Date Ratified 17/07/2015

Ratified PQRS Committee

Review Date 01/07/2017

Sponsor Director of Nursing, Midwifery and Quality

Expiry Date 16/07/2018

Withdrawn Date

Unless this copy has been taken directly from the Trust intranet site (Pandora) there is no assurance that

this is the most up to date version

This policy supersedes all previous issues

Bed Management and Escalation Policy v4 2

Version Control

Version Release Author/Reviewer Ratified

by/Authorised

by

Date Changes

(Please identify

page no.)

1.0

Jan 2006

TFP Jan 2006

2.0

Sept 2008

Divisional

Managers

SafeCare

Council

Sept 2008

3.0

August

2010

Divisional

Managers

SafeCare

Council

11/10/2009

4.0 08/10/2010 CC Divisional

Manager

SafeCare

Council

11/10/2009

5.0

28/09/2015

Pam Naylor PQRS

Committee

17/07/2015

Bed Management and Escalation Policy v4 3

CONTENTS Page

1 Introduction .................................................................................................................................. 5

2 Policy scope .................................................................................................................................. 5

3 Aim of policy ................................................................................................................................. 5

4 Duties (Roles and responsibilities) ............................................................................................... 5

4.1 Board of Directors ........................................................................................................... 5

4.2 Chief Executive ................................................................................................................ 6

4.3 Director on Call ............................................................................................................... 6

4.4 Associate Directors .......................................................................................................... 6

4.5 Service Line Managers ..................................................................................................... 6

4.6 Medical Staff .................................................................................................................... 6

4.7 Bed Managers .................................................................................................................. 6

4.8 Matrons ........................................................................................................................... 7

4.9 Night Site Manager .......................................................................................................... 7

4.10 Ward Sister/Charge Nurse ............................................................................................... 7

4.11 Accident and Emergency Sister/Charge Nurse and Clinical Lead .................................... 7

4.12 Members of Staff ............................................................................................................. 7

5 Definitions .................................................................................................................................... 7

6 Main Body of the policy ................................................................................................................ 8

6.1 Normal Working .............................................................................................................. 8

6.2 Bed management process ............................................................................................... 9

6.2.1 Bed Meetings ......................................................................................................... 9

6.2.2 Bed State ............................................................................................................... 9

6.2.3 Patient’s Awaiting Admission ................................................................................ 9

6.2.4 The Flight Desk ...................................................................................................... 9

6.3 Early Supported Discharge and Alternatives to Admission ............................................. 9

6.4 ‘Boarding’ of Patients ...................................................................................................... 10

6.5 Trigger levels and escalation ........................................................................................... 11

6.5.1 Alert Levels (NEEP) ................................................................................................ 11

6.5.2 Triggers for Escalation .......................................................................................... 11

6.5.3 Action Cards ........................................................................................................... 11

6.6 Requesting and receiving Patients Divert from other Trusts .......................................... 12

6.6.1 Requesting a Divert ............................................................................................... 12

6.6.2 Receiving a Divert .................................................................................................. 12

6.6.3 Durham .................................................................................................................. 12

6.7 Ambulance Handover Delays ......................................................................................... 12

6.8 Winter Resilience Plan ..................................................................................................... 12

7 Training ......................................................................................................................................... 12

8 Equality and diversity ................................................................................................................... 13

9 Monitoring compliance with the policy ....................................................................................... 13

10 Consultation and review ............................................................................................................... 13

11 Implementation of policy (including raising awareness) ............................................................. 13

12 Associated Policies ....................................................................................................................... 13

13 Appendices ................................................................................................................................... 13

Bed Management and Escalation Policy v4 4

APPENDICES

Appendix 1: QE Quick Triggers for Alert Levels ................................................................................... 14

Appendix 2: North East Escalation Plan (NEEP) ................................................................................... 15

Appendix 3: ED Specific Triggers and Actions ...................................................................................... 32

Appendix 4: ECCA Escalation Triggers and Actions ............................................................................ 33

Appendix 5: Action Cards .................................................................................................................... 36

- Actions for the Bed Managers ............................................................................... 36

- Actions for Duty Matron (Cover 7.30am – 5pm) ................................................... 38

- Actions for the Duty Matron (Cover 5 - 8.30pm) .................................................. 41

- Actions for the Service Line Manager and Senior Manager on Call ...................... 42

- Actions for the Senior Manager on Call from 5pm and Weekends ....................... 44

- Actions for the Senior Manager on Call from 5pm ................................................ 45

- Actions for the Acute Response Team Band 7 Role (Cover 20:00pm – 08:00am) 46

- Actions for the Director on Call ............................................................................. 48

- Action for the Medical Teams, Consultants and Clinical Leads ............................. 50

Appendix 6: Standard Operating Procedures ...................................................................................... 52

- Monitoring A&E Ambulance Handover Breaches

- Escalating A&E Ambulance Handover Breaches

Appendix 7: Winter Resilience Plan ..................................................................................................... 53

Bed Management and Escalation Policy v4 5

Bed Management and Escalation Policy

1. Introduction

This policy aims to provide clear operational guidance for bed management and escalation and

incorporates the escalation status, bed capacity and emergency trigger points and associated

action’s required in response to operational pressures. This will provide a safe operating

framework for staff and reduce the levels of risk for patients.

Maintaining flow of patients through the Trust is key to maximising bed availability in order to

effectively manage fluctuations in workload. As a key principle Gateshead Health NHS Foundation

Trust will not close to emergency admissions. When hospital resources are stretched e.g. shortage

of beds, exceptionally high attendances in the Accident and Emergency Department hospital

remains the safest place for seriously ill people. Closure of the hospital will only be on the

instruction of the Director on Call and will result in the declaration of a Major Incident.

2. Policy Scope

This policy applies to all members of staff of Gateshead Health NHS Foundation Trust. The policy

recognises that not all staff groups in all disciplines will have direct involvement in bed

management and escalation, however all members of staff have a responsibility to support this

policy.

3. Aim of the Policy

This policy aims to provide clear guidance to those directly involved in bed management and

escalation; the establishment of an effective policy and framework which will contribute to the

following:

• Early identification of capacity problems

• Proactive rather than reactive response

• Concise and clear actions

• Defined responsibilities

This policy will enable the Trust to deal effectively with fluctuations in demand and capacity so that

it can manage associated risk within acceptable limits. The policy is designed to mitigate the risk of

further escalation and ensures an appropriate response from key staff members to contribute to a

reduction in escalation status.

The policy aims to ensure that every emergency admission is allocated a bed within four hours and

no elective admission is cancelled because of lack of bed availability. Effective communication and

teamwork is crucial to the implementation of this policy requiring regular dialogue with nursing

staff, medical staff and managers.

The policy aims to maintain high standards of patient safety, patient experience and performance

against key waiting time and quality standards of care.

4. Duties (Roles and Responsibilities)

4.1 Board of Directors

The Trust Board is responsible for ensuring that there is a robust system of Corporate

Governance within the organisation. This includes having a systematic process for the

development, authorisation and management of policies.

Bed Management and Escalation Policy v4 6

4.2 The Chief Executive

The Chief Executive is ultimately responsible for ensuring effective Corporate Governance

within the organisation and therefore supports the Trust wide implementation of this

policy.

4.3 Director on call

The Director on Call is responsible for setting up Gold Command at NEEP 5, to support with

diverts where required and to facilitate discussions with regards to Ambulance queuing in

exceptional circumstances.

4.4 Associate Directors

Associate Directors are responsible for ensuring that the systems and processes are in place

so that this Policy is implemented effectively within the individual Business Units. They are

responsible for developing the annual corporate winter plan.

4.5 Service Line Managers

Service line Managers are responsible for ensuring that systems are in place so the Bed

Management and Escalation Policy is implemented effectively within individual service

lines:

• Ensuring systems are in place to manage patient access effectively

• To ensure day-to-day capacity is available for the individual specialty

• To ensure a forward thinking and planning approach for the provision of patient

care services.

• Making the decision to open extra beds or a ward if the trigger level of bed

availability within the Trust is not achieved.

• Participate in Senior Manager on call rota escalating issues to the Director on Call

as required.

When Senior Manager on Call work with the Bed Manager / Night Site Manager and Duty

Matron to ensure effective use of beds is maintained and that patients are not kept in

Accident and Emergency for any longer than necessary.

4.6 Medical Staff

Medical staff are responsible for ensuring that the elements of the SAFER bundle are

implemented. This includes ensuring that discharge planning arrangements are robust and

in line with the Trust Discharge Policy (OP13) including setting a discharge date for all

patients. In addition, collaborating with the ward nursing team to identify patients who are

appropriate to be ‘boarded’ to other specialties if required; organising additional ward

rounds during periods of Escalation at NEEP 4; fast tracking assessments in Accident and

Emergency as appropriate and explore alternatives to admission (e.g. rapid access to the

next available clinic).

4.7 Bed Managers

Bed Managers are responsible for:

• Operational responsibility for the daily management of beds

• Ensuring that an up to date bed state and record of patients waiting for admission

is maintained

• Co-ordination of information for presentation at bed meetings

• Escalation of any potential problems to the Duty Matron

• Completion and delivery of Flight Deck information to NEAS.

Bed Management and Escalation Policy v4 7

4.8 Matrons

The Matron’s role is to proactively action issues identified within their area of

responsibility. They are available to provide support and advice to the ward team and to

support the team in the management of effective discharge. They will provide support and

advice to ward staff when they experience difficulty in identifying patients suitable for

boarding.

The Duty Matron will facilitate and coordinate bed meetings and actively manage within

this policy escalating to the Service Line Managers, Associate Directors as set out in

appendix 5.

4.9 Night Site Manager

The Night Site Manager is responsible for the overnight site management of the hospital

and delivery of services and ensuring any issues are escalated to the Service Line Manager

on call.

4.10 Ward Sister/Charge Nurse (delegated to Nurse in Charge)

The Ward Sister/Charge Nurse is responsible for ensuring staff understand the Bed

Management and Escalation Policy and the Discharge Policy. They will work proactively

with the medical staff to ensure the elements of the SAFER bundle are implemented to

identify patients who are ready for discharge, appropriate for boarding and ensuring staff

understand that at times wards will be expected to:

• Take boarders

• place boarders in an appropriate part of their ward following an infection control

risk assessment

• Move staff to another area to support the delivery of clinical care

The ultimate responsibility for providing accurate bed state updates rests with the Ward

Sister/Charge Nurse (or nominated deputy). This is best facilitated by keeping Medway as

up to date as possible with changes in patient movement and all wards should be working

to achieve this on a 24 hour basis. They must keep the appropriate Matron aware of any

concerns about staffing and/or the implementation of this policy.

4.11 A&E Co-ordinator and Clinical Lead

The A&E Co-ordinator and Clinical Lead are responsible for ensuring that the person ‘in

charge’ is identified on each shift to provide regular updates on current occupancy, and

expected admissions and discharges over the next 2 to 4 hours. The A&E co-ordinator in

charge of each shift is responsible for reporting to the Duty Matron any patient who has

been in the department for 2.5 hours, for whom there is no imminent plan and who looks

like they will be in the department over 4 hours unnecessarily, and efforts made to ensure

a safe and effective plan is put in place.

4.12 All members of staff are required to support this Policy whether or not they are directly

affected by bed management and escalation.

5. Definitions

Escalation

Escalation, for the purpose of this Policy identifies when there are increasing levels of demand in

the Emergency Department/Emergency Assessment Unit and/or lack of bed capacity and specific

responses are required.

Boarder

This term may be used when a patient is residing on a ward outside their admitting specialty.

Bed Management and Escalation Policy v4 8

Action cards

Key staff members have action cards (within this policy) which provide them with actions that they

should undertake at a particular escalation status level.

North East Escalation Plan (NEEP)

NEEP is a common language used by all hospital and community organisations in the North East to

identify the levels of activity pressure and escalation across the area. In producing this document

the Trust has aligned this Policy to the North East Surge and Escalation Framework (Appendix 2).

SAFER Bundle – The SAFER bundle is a set of recommended good practice actions to be taken on a

daily basis to support good patient flow.

S – Senior review of all patients before mid-day

A – All patients to have an expected date of discharge

F – Flow of patients, wards to pull patients from assessment units to wards before 10am

E – Early discharge, 33% of patients from base wards to be in discharge lounge with to take out

(TTO’s) medications and letter before mid-day

R – Review of all patients with extended length of stay (10-14 days) to have a management plan

Gold Command

Gold Command is introduced at NEEP Level 5, or at NEEP 4 to prevent NEEP 5 status being reached.

This involves a decision being made by the Director on Call in liaison with the Senior Manager on

Call. Identified staff will be required to report to a designated area to oversee all actions in respect

of escalation. This is part of our major incident plan.

HALO

The Hospital Ambulance Liaison Officer (HALO) is a member of staff from the North East Ambulance

Service who works very closely with the A&E Co-ordinator to support the levelling of activity across

the local area.

The Flight Deck

Is a series of metrics submitted by Trusts from across the Region to the North East Ambulance

Service (NEAS). The metrics include:

• NEEP status

• Empty bed numbers including critical care, surgery, medicine and maternity

• Are there any diverts in place

• Are there any bed closures

• Length of waits to be seen in A&E

The information collected is then shared across the Region. The NEAS use this information to

facilitate decisions on diverts and deflections.

6. Main Body of the policy

6.1 Normal Working

Normal working is how the Trust operates on a day to day basis to ensure NEEP level 1 (see

appendix 1). All Trust employees are required to actively contribute to the timely and safe

care of patients and implementation of the SAFER bundle.

Bed Management and Escalation Policy v4 9

6.2 Bed management process

Every morning there is a report and bed state email handover from the Night Site Manager

to key personnel and a verbal handover to the Duty Matron and Bed manager.

6.2.1 Bed meetings

Bed meetings are held at 9am, 1pm and 4.30 pm with Business unit staff. Frequency

of meetings may change when the Trust is on NEEP 3 & 4 at the discretion of the

Duty Matron.

6.2.2 The Bed State

Throughout the day the bed state will be updated using the bed monitoring

proforma. This will include:

• Number of empty beds by ward, specialty, male/female and side wards.

• Number of patients expected to be discharged that day.

• Number of patients ‘boarded out’ or awaiting transfer to other hospital

sites.

• Number of beds occupied by patients awaiting arrangements for discharge

and the reasons for these delays.

• Number of patients waiting for isolation facilities.

• Potential patients who will be ready to come out of Critical Care the next

day.

• Number of electives due to come in the next day.

• Numbers of in-patients admitted following an agreed Durham divert.

It is the responsibility of ward staff to provide accurate and timely information.

6.2.3 Patients Awaiting Admission

The Bed Manager will be informed of patient admissions and demand for beds by

the Nurse Co-ordinator in A&E, waiting list managers, member of staff taking GP

referral calls and Matrons.

All patients arriving by ambulance will arrive at the ambulance entrance and will be

streamed (initial assessment and directed to appropriate care setting) by the A&E

co-ordinator. GP referrals will be streamed direct to EAU unless there is no capacity

(in which case they will be streamed to appropriate pathway in EAU), unless they

require immediate resuscitation, or can be appropriately managed in Majors.

6.2.4 The Flight Deck

Information to be submitted three times a day at 11am, 4pm and 8pm by the Bed

Manager.

6.3 Early Supported Discharge and Alternatives to Admission

Several services have been developed to provide an alternative to hospital admission and

support early discharge:

• All specialist nurses – work to provide early supported discharges and prevent

unnecessary admissions where appropriate.

• CROP team can facilitate a discharge and provide interim support whilst awaiting

more formal care packages to start.

• Rapid Response Domiciliary Care Team

• Gateshead Immediate Care Team

Bed Management and Escalation Policy v4 10

A site wide Multi-Disciplinary meeting takes place every day at 12.30pm to identify patients

who are awaiting discharge and to ensure all actions are in place to help people to be

discharged from hospital.

6.4 ‘Boarding’ of Patients

When bed pressures continue is may be necessary to ‘board’ patients to another ward. In

the context of this policy, a ‘boarder’ is defined as ‘a patient residing on a ward outside

their admitting specialty’. The boarding of patients should be avoided as far as possible.

However, there are times when such activity becomes a necessary part of managing

emergency admissions and maintaining a supply of appropriate beds. The decision to

board patients will be co-ordinated by the Duty Matron. While there are no protected beds

within the hospital all beds that are planned for elective admissions later that day or the

following day should be last in line to board to.

The clinical teams on the base wards remain responsible for identifying patients that are

suitable to be moved elsewhere.

It is acknowledged that, at times, there will be no patients that are deemed suitable. Under

these circumstances the clinical teams will be expected to make decisions based on their

professional judgement, to identify patients to move.

In the event of patients being ‘boarded’ the Named Nurse or nurse in charge will explain

this to the patients and relatives, if possible, in a manner appropriate to the patient’s

individual needs accessing the support of the interpretation services or support worker if

required.

If the relatives are not present it is the responsibility of the Named Nurse or nurse in charge

to notify the ‘next of kin’ / ‘person to notify’ of the patient’s transfer and ensure that this is

documented.

The Bed Manager will liaise with the Matron from the Division to which patients are

boarded at the regular bed meetings. The Bed Manager should inform the appropriate

wards of the arrangements to transfer or ‘board’ a patient. As stated above Ward Staff on

the transferring ward will remain responsible for providing necessary clinical detail to

facilitate arrangements. When it is necessary to board from one specialty to another it is

best practice to allocate a single bay to accommodate the patients from the boarding

specialty whenever possible. Advice must be sought from the Infection Prevention and

Control Team for any patient/s with a known or suspected infection.

The boarding of patients should take place between the hours of 09:00 and 22:00 each day

wherever possible. Only in exceptional circumstances will the moving of patients occur

outside these hours or during protected mealtimes. No patient should, during their stay, be

boarded out more than once. This does not include any subsequent transfer to the care of

another Consultant or Specialty, for a clinical need, or repatriation to original base ward in

exceptional circumstances.

The dignity and quality of care given to the patient will be maintained throughout the

transfer or ‘boarding’ process (OP29). Staff must use their professional judgment when

attempting to move patients who would be clearly distressed by the move e.g. patients

with learning difficulties or there is knowledge that the family have raised strong concerns.

When patients are boarded out from the specialty, which would normally receive the

admission, it becomes the responsibility of the receiving ward and patient’s consultant

team to ensure they receive the same standard of care. Junior medical teams on receiving

Bed Management and Escalation Policy v4 11

wards are expected to support the care of patients who have been moved from their base

ward. If needed, advice can be sought from the specialty Matron.

Circumstances such as skill mix, infection status on the receiving ward should be taken into

consideration.

The numbers of patients boarded into different specialties will be reported on a daily basis

through the SITREP report in line with DH guidance.

When transferring (either within Gateshead Health NHS Foundation Trust or to another

hospital / organisation) ‘boarding’ or receiving a patient all nursing documentation must be

updated.

It is the responsibility of the Named Nurse to make an assessment of the patient’s needs to

determine if an escort is required to accompany / stay with the patient when they are being

transferred to another ward, department or site within Gateshead Health NHS Foundation

Trust in line with the Internal Transfer/Escort Policy (OP84)

6.4 Trigger levels and Escalation

6.5.1 Alert Levels (NEEP)

The following alert levels will be used to help communicate the escalation status

and guide people to the correct actions. This is based on a number scale that

reflects the level of risk to patient safety and the extent to which patient

experience may be compromised (as outlined below).

6.5.2 Triggers for escalation

Appendix 1 Trigger/alert levels are identified in (quick reference guide).

Appendix 2 outlines the Trust NEEP levels and escalation framework agreed by

Trust Board in line with North East Surge and Escalation Framework

Appendix 3 local triggers for Accident & Emergency

Appendix 4 local triggers Emergency Assessment Unit

Please refer to guidance, when appropriate, for actions specific to other

departments – Maternity, Critical Care Escalation Plans.

6.5.3 Action cards

The Action cards highlight actions to be taken by key individuals in the event of

increasing pressure and when triggers are causing any concern.

To patient safety and experience

Moderate

Risk

3

Low Risk

2

High

Risk

4

Service

Failure

6

Low Risk

1

Critical

5

Bed Management and Escalation Policy v4 12

Following the identification in a rise in the Escalation/NEEP Alert levels within the

NEEP escalation framework and local triggers for Accident & Emergency (Appendix

3) and Emergency Assessment Unit (Appendix 4), actions identified in the suite of

Action Cards (set out in appendix 5) will be followed by all key personnel.

6.6 Requesting and Receiving Diverts from other Trusts

6.6.1 Requesting a Divert

When the Trust is at NEEP 4 the Trust may need to request a divert to another

hospital. The requirement to consider this should be escalated by the Duty Matron

or Service Line Manager to Associate Director during office hours or Senior

Manager on Call to Director on Call out of hours. The regional divert policy should

be consulted in relation to this.

6.6.2 Receiving a Divert

• Any request to receive a divert should be made to a Service Line Manager in

Medicine (in hours) or Senior Manager on Call out of hours .

• Discussion should then take place with the on site team which may include

Bed Manager, Duty Matron, SLM, Consultant in charge of A&E, A&E nurse

co-ordinator before making a decision to accept patients.

• It is advised a fixed number of patients to accept should be agreed with a

built in review rather than a time period. Close monitoring is required to

assess the impact on our internal patient flow.

• Refer to North East Divert Policy (NEAS- May 2015)

• Escalate or further discuss with Associate Director (in hours) or Director on

Call (out of hours).

6.6.3 Durham

• We currently have an agreement with Durham CCG with regards to diverts

– refer to NDCCG Local Divert Policy (June 2015). This will be a NEAS direct

contact to the Service Line Manager in medicine (in hours) or Senior

Manager on Call (out of hours). Discussion with Associate Director (in

hours) or Director on Call (out of hours) can take place if required.

• When making decisions to request or accept a divert the Flight Deck

information may be of some help.

• Patient level details are required for Durham diverted patients in order to

ensure they are correctly logged on Medway.

6.7 Ambulance Handover Delays

Queuing of ambulances at A&E should be avoided whenever possible and proactive

management is required to ensure kept to a minimum. Appendix 6 outlines key actions to

be taken and how ambulance handover delays should be monitored.

6.8 Winter Resilience Plan

Every year additional measures are put in place for the winter months. Appendix 7 outlines

the current Winter Resilience Plan.

7. Training

Training with regards to this policy will take place at Site Training days, at Matron and Ward

Manager days, the Service Line Manager forum and the Central Management team time out.

Bed Management and Escalation Policy v4 13

8. Equality and diversity

The Trust is committed to ensuring that, as far as is reasonably practicable, the way we provide

services to the public and the way we treat our staff reflects their individual needs and does not

discriminate against individuals or groups on any grounds. This policy has been appropriately

assessed.

9. Monitoring Effectiveness of this Policy

To ensure the effectiveness of this policy the following indicators will be monitored:

• Number of 4 hour A&E waits

• Number of 12 hour A and E breaches

• Number of black (over 1 hour) Ambulance handover delays.

• Number of Ambulance handover delays above 30 minutes

• Number of diverts to other hospitals requested

• Number of cancelled operations as a result of bed pressures

10 Consultation and review

A Kaizen event was held with a number of stakeholders including Medical Staff, in order to engage

a broad spectrum of staff in the development of this policy. This was followed up with a series of

discussions to finalise actions. The implementation and effectiveness of the policy will be reviewed

through Performance Board Reports and annually at the Annual Winter Review event.

11 Implementation of policy (including raising awareness)

The policy will be implemented immediately and awareness will be raised at Matron /Ward

Manager Away Days, SLM forum, CMT time out, and Consultants’ meetings.

12. Associated Policies

This policy must be read in conjunction with the following Gateshead Health NHS Foundation Trust

Policies:

• Privacy and Dignity:

• Infection Prevention and Control Policies (IC1 – 26)

• Safeguarding Patients’ Privacy & Dignity (OP29)

• Patients’ Access Policy (OP12)

• Discharge Policy (OP13)

• Resuscitation Policy (RM27a and RM27b)

• Records Management Policy (OP10)

• Critical Care Escalation Policy

• Maternity and Special Care Baby Unit Escalation Policy

13 Appendices

Bed Management and Escalation Policy v4 14

Level A&E (see Appendix 3) EAU (see Appendix 4) Back of House

1 • Business as Usual • Business as Usual • Business as Usual

2

• 1 patient spending more than 4 hours in the

ED (avoidable)

• 1 resus space and 1 majors space

• Time from DTA to admission 1-2 hours

• 1-2 ambulance handovers > 15 minutes

• Pts on trolley >8hrs

• 0 cubicle availability 0-

1hrs

• Beds not available to receive non elective patients (ie less than one male

and one female bed available for each non elective receiving areas)

• Insufficient capacity identified in bed meeting for TCIs either medicine or

surgery

• Between 1 – 5 outliers in other specialties

• No critical care bed immediately available

• Ward staffing below agreed levels by 1 – 3 nursing staff across the site and

is judged to present a low risk to patient safety

3

• Multiple patients spending more than 4

hours in the ED (avoidable)

• 0 resus spaces and 0 majors spaces

• Time from DTA to admission 2-4 hours

• 4-8 patients stacking in the ED awaiting

admission

• 2 ambulance handovers > 15 minutes

• Pts on trolley >12hrs

• 0 cubicle availability

between 1-4hrs

• Insufficient capacity to accommodate non clinically urgent TCIs in either

medicine or surgery

• 5 – 14 outliers

• No critical care bed available and no plan in place for one to become

available in the next four hours

• Ward staffing is below agreed levels by 4 – 6 nursing staff across site and is

judged to present a moderate risk to patient safety

4

• Multiple patients spending significantly

longer than 4 hours in the ED

• No capacity to receive patients

• Time from DTA to admission >4 hours

• >8 patients stacking in the ED awaiting

admission

• Ambulances queuing to handover

• Pts on trolley >24hrs

• 0 cubicle availability

>4hrs

• Insufficient capacity to accommodate TCIs in either medicine or surgery

who are clinically urgent

• >15 outliers in other specialties

• Ward staffing is below agreed levels by 7+ nursing staff across site

• No critical care bed available, no place in place for one to become available

in the next four hours and no scope for escalation of critical care capacity

5

• Pts on trolley >36hrs

• 0 cubicle availability

>8hrs

• Negative bed state in either medicine or surgery with escalation areas open

& continued A&E/EAU triggers

• Ward staffing is below agreed levels by 7+ nursing staff across the site and

is judged to present a high risk to patient safety

6 • •

QE TRIGGERS FOR ALERT LEVELS (Quick Reference Guide) Appendix 1

15

*ED consultant when present in the ED. ED middle grade at other times.

Surge and Escalation Framework for : GATESHEAD HEALTH NHS FOUNDATION TRUST

Version number: 3.0 Date created: July 2015 Author: Pam Naylor

Glossary of Terms/Abbreviations:

NEEP – North East Escalation Plan NEAS: North East Ambulance Service NECS: North East Commissioning Service

DEP – Department Escalation Plan REAP: Regional Escalation Action Plan DM: Duty Matron

NECS: Clinical Commissioning Group AD: Associate Director ED: Emergency Department

OOH: Out of Hours DOC: Director on Call CD: Clinical Director

SMOC: Senior Manager on Call ART: Acute Response Team

Trigger Level Action Communication Command and control Impact Implications?

• What needs to

have happened

(actual), or be

about to

happen

(prospective

trigger)?

• Are these

internal

organisational

triggers, or

external ones

i.e. across the

NECS?

• NHS North East

Escalation Plan

(NEEP) level

• Description of

what is happening

in the organisation

or service at this

level

• What will be done to

mitigate the raised level

of pressure as a result of

moving to this level?

• Who by? When?

Where?

• What will be

communicated

intra and/ or inter

organisationally?

• Who by? When?

• What command and

control

arrangements will

be in place?

• Who has the

authority and

responsibility to

trigger?

• When and where

will it be triggered?

• Are these different

in hours and out of

hours?

• Expected

impact of

these

actions

• Any

implications

of these

actions on

other

organisations

Appendix 2

16

Surge and Escalation Framework for : Gateshead Health NHS Foundation Trust

Version number: 3.0 Date created: July 2015 Author: Pam Naylor Glossary of Terms /Abbreviations: NEEP – North East Escalation Plan NEAS: North East Ambulance Service NECS: North East Commissioning Service ED: Emergency Department DEP – Department Escalation Plan REAP: Regional Escalation Action Plan CD: Clinical Director DM: Duty Matron NECS: Clinical Commissioning Group AD: Associate Director ART: Acute Response Team SMOC: Senior Manager on Call OOH: Out of Hours DOC: Director on Call

Trigger Level Action Communication Command and control Impact Implications?

• What needs to have happened (actual), or be about to happen (prospective trigger)?

• Are these internal organisational triggers, or external ones i.e. across the NECS?

• NHS North East Escalation Plan (NEEP) level

• Description of what is happening in the organisation or service at this level

• What will be done to mitigate the raised level of pressure as a result of moving to this level?

• Who by? When? Where?

• What will be communicated intra and/ or inter organisationally?

• Who by? When?

• What command and control arrangements will be in place?

• Who has the authority and responsibility to trigger?

• When and where will it be triggered? • Are these different in hours and out

of hours?

• Expected impact of these actions

• Any implications of these actions on other organisations

• The Trust is operating at “normal service” 16 beds funded for winter contingency are available at NEEP level 1

Influencing factors (changes to the following):

• Premises • Workforce • IT • Resources, assets, utilities

and supplies

• Surge in demand

• Queuing ambulance

NEEP 1

Normal (white)

NOTE –PROVISIONAL DATA- STILL MODELLING

G& Acute Baseline:

Total beds available - 603

Of which is core bed stock – 442 ( in Winter)

Acute - 442

Maternity – 16 Paediatrics - 8

Of which are

• The organisations plans are in place for winter, escalation and surge.

• Daily operational meeting with clinical team within surgical business unit to assess elective for the day and capacity for emergency admissions.

• The Patient Flow Co-ordinator, DM and ARTOOH must monitor and report any surges in activity and report to DM’s and SLM’s if their Directorate is under pressure prior to or at the daily patient flow meetings.

• Patient flow meetings to be attended by the on call manager and

• A copy of the organisation winter plan communicated to NECS.

• Trust winter plan and escalation plan available on intranet site.

• Participate in the daily situation reporting (11am) during the winter monitoring months published on the winter planning and surge management website.

• Participate in daily teleconferencing during the winter reporting period chaired by North of

• Operational Patient Flow meetings x 3 daily - See bed meeting standard operating procedure.

• The patient flow co-ordinator with the Duty M has overall responsibility for managing the surge and capacity within the organisation

• Overnight this responsibility lies with ARTOOH and Senior Manager on Call

• Communication with AD/DOC as required.

• May be able to offer mutual aid to other organisations.

17

escalation beds -

Critical care capacity - 12

Level 1 -

Level 2 - 6

Level 3 - 6

High dependency unit – 6 (Level 2)

Average daily A&E attendances

Monday - 332

Tuesday - 298

Wednesday - 280

Thursday - 281

Friday - 271

Saturday - 310

Sunday - 325

Ambulatory care capacity – 10 patients

Average daily Acute admissions

Monday - 83

Tuesday - 79

alert any issues to the Director on Call via the telephone or E mail.

• Bed Predictions to be used at Bed Meetings..

• Action planning must follow the patient flow meetings and an action plan developed for evening/overnight.

• The Ward Manager/ senior nurse is responsible for 24/7 staffing cover for their area concerns must be raised through the Matron and the SLM if necessary.

• Late staffing issues to be highlighted at Patient Flow Meetings and resolution facilitated by Duty Clinical Matron.

• Patients identified for discharge to be taken to the discharge lounge as early as possible in the day even if the relatives are attending to take home.

• Test escalation areas are fit for purpose i.e. alarms and equipment are in good working order

• ED Co-ordinator to front all majors/resus triage.

• Board rounds on all wards.

• SAFER bundle principles in place

S – Senior review of all

England Commissioning Support Unit on behalf of the CCG.

• Flight deck information complete at 11am, 4.30pm and 8pm.

• Any escalation of NEEP levels to be communicated to the on call NECS Manager via the teleconference or directly.

• The organisations internal infrastructure Director/Senior Manager on Call system in place.

• Patient Flow Team presence on site 8am – 8pm 7 days a week.

• Duty Matron on site 8am-8pm 7 days a week

• SMOC • Daily analysis of

ED 4 hour breaches with issues communicated to relevant specialties,

• Daily Discharge facilitation meetings.

• The organisations internal on call

18

Wednesday - 74

Thursday - 74

Friday - 78

Saturday - 62

Sunday - 60

Average daily discharges required (Acute)

Monday - 80

Tuesday - 88

Wednesday - 83

Thursday - 78

Friday - 90

Saturday - 52

Sunday - 40

Average length of stay –

Elective (minus Daycase) – 3.5

Non-Elective – 5.0

During NEEP level 1, the organisation will be providing a full elective

patients before mid-day

A – All patients to have an expected day of discharge

F – Flow of patients, wards to pull patients from assessment unit to wards before 10am

E – Early discharge – 33% of patients from base wards to be in discharge lounge until TTO’s and letter before mid-day

R – Review all patients until extended length of stay (10-14 days) to have a management plan.

infrastructure is in place

• Weekly operational delivery group meetings

• Regular winter / surge planning meetings

19

programme:

Average daily electives required

Monday - 111

Tuesday - 127

Wednesday - 123

Thursday - 126

Friday - 112

Saturday - 25

Sunday - 7

Consideration to be given to the following Triggers to activate NEEP level 2

Three or more of the following indicators are hit.

INDICATORS

A&E

• 1 patient spending more than

4 hours in the ED (avoidable)

• 1 resus space and 1 majors

space

• Time from DTA to admission

1-2 hours

• 1-2 ambulance handovers >

15 minutes

NEEP 2 Concern

(green)

ALL ACTIONS AT NEEP 1 IN PLACE

Command and control - communications

• At the teleconferences NEAS/OOH via NECS to be informed of growing pressures within the Acute Trust

• Duty Matron to request additional matron, SLM support and support services representation at bed meetings.

• Team briefed of capacity issues all matrons/senior nurses to attend their respective areas to assess and to actively create capacity;

• Inform Communications

All communication within NEEP 1 will have been activated

All command and control actions in NEEP 1 will have been activated.

• Impact on

• May not be able to offer mutual aid.

• May not be able to attend external meetings

• May impact on NEAS

• Risks to KPI’s

20

EAU

• Pts on trolley >8hrs

• 0 cubicle availability 0-1hrs

Back of House

• Beds not available to receive

non elective patients (ie less

than one male and one

female bed available for each

non elective receiving areas)

• Insufficient capacity identified

in bed meeting for TCIs either

medicine or surgery

• Between 1 – 5 outliers in

other specialties

• No critical care bed

immediately available

• Ward staffing below agreed

levels by 1 – 3 nursing staff

across the site and is judged

to present a low risk to

patient safety

• No critical care beds available

at present and no movement

identified in the next few

hours.

Team of Escalation and ask for appropriate screen saver launch.

• Critical Care network to be informed if no beds and none imminent.

Ambulance queuing/ demand on A&E department

• ED Co-ordinator or ED Senior Dr

fronting triage

• Senior decision makers to front all services (minors and majors category) e.g. Consultant in Ambulatory care

• Ensure ED is adequately staffed with a transfer nurse and porters.

• Mobilisation of additional resources to assist with transfer of patients.

• Duty matron to liaise with A&E co-ordinator and consultant to activate A&E escalation plan.

Bed availability

• Identify patients to be moved to different speciality wards.

• Discuss with Bed Manager opening and staffing additional escalation beds

• Test escalation areas are fit for purpose i.e. alarms

• Early comms out to clinical teams re pressure being experienced..

• Enhanced liaison with co-ordinator on A&E & EAU.

• Communication to NECS & other organisations on teleconference call..

• Flight deck information complete at 11am, 4.30pm and 8pm.

Matron/SLM other commitments

• May impact on staff being able to attend meetings.

21

and equipment are in good working order

• Request additional consultant led patient reviews on all wards to identify patients suitable for discharge.

• Patients identified for discharge to be taken to the discharge lounge as soon as possible even if the relatives are attending to take home.

• Delays with discharge letter and pharmacy to be identified and to be given priority following discussion with medical teams to be coordinated by Ward Teams / Duty Matron.

• Community on call manager to liaise with Trust on call manager to ensure appropriate discharge and continuing to support patients within their own home to avoid unnecessary admissions.

• Elective teams to risk assess the continuity of the elective activity.

• Matron / SLM for elective care, Women’s and Children’s’ services and perioperative service manager to liaise with booking team to review lists of TCIs for the following day.

• Consideration of elective work in relation to back up for Critical Care

• Command and control will be as at NEEP 1.

• Consider SLM/SMOC presence at patient flow meetings if potential to escalate to NEEP 3.

22

• Identify 2 potential boarders on each ward by 1pm Patient Flow meeting.

Workforce

• At the discretion of Duty Matron the following to be in attendance at Patient Flow Meetings or contact made with: Clinical Support Services

Domestic Monitoring

IPC Nursing Team

Discharge Nurses

Ensure Staff Breaks are coordinated to allow sufficient flexible rest periods.

Consideration to be given to the following Triggers to activate NEEP level 3

Three or more of the following indicators are hit.

TRIGGERS

A&E

• Multiple patients

spending more than 4

hours in the ED

(avoidable)

• 0 resus spaces and 0

NEEP 3 Pressure

(amber)

Expectation that all actions from NEEP 2 have been considered and implemented. All available capacity opened and patients boarded

Command and control - communications

• At teleconference and through the SITREP report escalation of NEEP level to the NECS manager/ CCG on-call manager out of hours • Inform Communications

All communication within NEEP 1 and 2 will have been activated .

All command and control actions in NEEP 1 and 2 will have been activated.

• Impact on Matron/SLM/ AD other commitments

• Impact on study leave attendance

• Impact on meeting attendance

Risks to:

• Elective activity • KPI’s • Normal service

delivery

May impact on:

• NEAS • Ability to

repatriate from other hospitals

• Will have great difficulty in offering mutual aid

23

majors spaces

• Time from DTA to

admission 2-4 hours

• 4-8 patients stacking in

the ED awaiting

admission

• 2 ambulance handovers

> 15 minutes

EAU

• Pts on trolley >12hrs

• 0 cubicle availability

between 1-4hrs

Back of House

• Insufficient capacity to

accommodate non

clinically urgent TCIs in

either medicine or

surgery

• 5 – 14 outliers

• No critical care bed

available and no plan in

place for one to become

available in the next

four hours

• Ward staffing is below

agreed levels by 4 – 6

nursing staff across site

and is judged to present

a moderate risk to

patient safety

• No critical care beds

available and no

potential movement

identified over the next

few hours with difficulty

Team of Escalation for a bulletin to go to all staff re NEEP levels

• Director on call and Associate Director be informed of escalation to NEEP level 3

• Team briefed of capacity issues all matrons/senior nurses and SLM’s to attend their respective areas to assess and to actively create capacity;

• Request from NEAS pre-alert of all ambulances attendance to EAU if A&E under pressure

• Consider requesting HALO

• Critical Care network to be informed if no beds and none imminent by Critical Care

• Identify hot spots/process/patient flow pressure points for individual Directorates to be reported to the Patient Flow Team.

• Elective

Ambulance queuing/ busy A&E department

• Senior decision makers to front all services - minors and majors category

• Physician of the day/week to assist with assessment of patients in A&E for suitability of referral or discharge

• Patient flow co-ordinator

• DM to trigger NEEP 3.

• May need to request mutual aid from elsewhere.

24

transferring level 3

patients out because

regional position has

worsenend.

• Physician of the day/week to contact all medical consultants via voice bleep to advise of increased escalation

• Physician of the day/week to attend Bed Meetings to gain full briefing

• Physician of the day/week to consider moving junior staff to support pressure areas

• Physician of the day/week to ensure all sub specialty referrals are seen early in the day

• Physician of the day/week to consider cancelling elective activity for the afternoon and following day

• Refer to A&E escalation plan

Bed availability

• Additional escalation beds to be opened as documented in the winter plan.

• Additional consultant led patient reviews on all wards to identify patients suitable for discharge.

• Review of delayed discharges and accelerate discharge plans where possible involving Social Services and other relevant organisations.

to inform ward teams of increasing pressure.

• Patient flow co-ordinator to inform DM of increasing pressure.

• DM/ART OOH to inform SLM/SMOC of increasing pressure

• Voice over - bleep voice alert to all medical consultants to inform of escalation to NEEP 3. (See medical team action card in Escalation Policy.)

• Flight deck information complete at 11am, 4.30pm and 8pm

• DM to co-ordinate additional patient flow meetings when required.

• SLM/SMOC to attend 9am patient flow meetings.

• SMOC to attend additional patient flow meetings where required.

• SLM/SMOC to keep AD/DOC informed of situation.

25

• Request acceleration of patients waiting repatriation to other hospitals.

• Wards to prioritise the patients for radiology / scanning and pharmacy if this is all they are waiting for before they are discharged and to ensure Patient Flow Team informed.

• Ask Estates if there are any works that can be expedited should that free up bed capacity

• Consider a porter being assigned to patient flow Manager at a weekend

• Acute Care physician to be aware of potential (additional Consultant or Junior Medical support to be co-ordinated through the Medical Business Unit.

• Clinical Matrons and SLM’s to assist discharge co-coordinator/matrons/patient flow co-ordinator to influence all wards to encourage movement of discharged patients to the discharge lounge

• ACCEEP Critical Care plan will be triggered as per the regional ACEEP network agreement

• Daily Critical care command and control meetings will take place and plan for daily management of the

26

situation/pressures. • Community On Call

Manager will continue to liaise with Trust On Call Manager to ensure appropriate support for discharge and continuing to support patients within their own home to avoid unnecessary admissions.

• Consider additional weekend sessions for ultrasound and or CT as required

Workforce

• Review rotas with a view of cancellation of study leave based on individual assessment of both course and staff.

• Assess study leave – Business Units to identify case by case leave which can be cancelled and benefits provided to own or other areas.

• Close liaison with Nurse Bank – requesting additional bank staff where appropriate.

• Consider use of Practice Development Team Nurses / Specialist Nurses/ART to support ward areas.

• Consider the appropriateness of staff that are sent to help out on the ward. Ensure Staff Breaks are

27

coordinated to allow sufficient flexible rest periods.

Consideration to be given to the following Triggers to activate NEEP level 4

Three or more of the following indicators are hit.

• All actions from NEEP level 3 implemented with no significant improvement with capacity

• Critical Care patients exceed the physical bed spaces available of 17.

TRIGGERS

A&E

• Multiple patients spending

significantly longer than 4

hours in the ED

• No capacity to receive

patients

• Time from DTA to admission

>4 hours

• >8 patients stacking in the ED

awaiting admission

• Ambulances queuing to

4 NEEP

Severe Pressure

(red)

Expectation that all actions from NEEP 3 have been considered and implemented. All available capacity opened and patients boarded

Cancellation of all electives with the exception of priority 1.

Command and control - communications

• Continue managing situation as a surge and escalation incident.

• Through the daily teleconference and SITREP report escalation of NEEP level to the NECS manager/ CCG on-call manager out of hours

• Inform Communications Team of escalation

• Director on call to be informed of escalation to NEEP level 4

• Consider calling additional local teleconference with CCG, Local Authority, Community Services and NEAS

• At NEEP level 4 designated Director on Call, AD’s, and SLM’s to

All communication within NEEP 1,2 and 3 will have been activated.

• AD/DOC is to be kept informed of situation by SLM/SMOC

• DM/ART OOH to

All command and control actions in NEEP 1,2 and 3 will have been activated.

• Impact on Matron/SLM/ AD other commitments

• Impact on study leave attendance

• Impact on meeting attendance

• The need to cancel routine work will impact on KPI’s and reputation.

• Financial cost of additional resource brought in.

Risks to:

• Elective activity • KPI’s • Normal service

delivery

May impact on:

• NEAS • Neighbouring

Trusts • Ability to

repatriate from other hospitals

• Will not be able to offer mutual aid to other organisations.

• Will need to request mutual aid from other organisations.

28

handover

EAU

• Pts on trolley >24hrs

• 0 cubicle availability >4hrs

Back of House

• Insufficient capacity to

accommodate TCIs in either

medicine or surgery who are

clinically urgent

• >15 outliers in other

specialties

• Ward staffing is below agreed

levels by 7+ nursing staff

across site

• No critical care bed available,

no place in place for one to

become available in the next

four hours and no scope for

escalation of critical care

capacity

report to Gold Command. Activation of their Business Continuity Plans with regard to cancellation of elective procedures and continuity of core services.

• NEAS/OOH via NECS to be informed of growing pressures within the Acute Trust by the daily teleconference and SITREP

• Team briefed of capacity issues all matrons/senior nurses and SLM’s to attend their respective areas to assess and to actively create capacity

• Continued communication with NEAS re: pre-alert of all ambulances attendance to EAU

• Continued communication with Critical care network if no beds and none imminent

Ambulance queuing/ busy A&E department

• Senior decision makers to front all services - minors and majors category

• Physician of the day/week to assist with assessment of patients in A&E for suitability of referral or discharge

• Additional consultant to be commandeered to support the on call Consultant to be co-ordinated by the

ensure SLM/SMOC aware of situation and to request on-site presence when necessary.

• SLM/SMOC to request DOC to seek mutual aid.

• Flight deck information complete at 11am, 4.30pm and 8pm.

• SLM/SMOC to escalate to AD/DOC the need for setting up Gold Command.

• DOC to assess situation with SMOC and determine if on-site presence is required.

29

Medical Director • Request mutual aid from

neighbouring organisations in accordance with the Mutual Aid Policy

Bed availability

• Consider opening additional beds.

Produce list of potential elective cancellations which have been assessed on a case by case basis.

Cancellation of all electives with the exception of priority 1. Must take place when organisation at NEEP 4.

• Review of medical outpatients to be undertaken with potential to cancel non urgent outpatient appointments to free up medical consultants to attend ward rounds.

Workforce

• Assess study leave – Business Units to identify case by case leave which can be cancelled and benefits provided to own or other areas.

• Close liaison with Nurse

.

30

Bank – requesting additional bank staff where appropriate.

• Consider use of Practice Development Team Nurses / Specialist Nurses/ART to support ward areas.

• Consider the appropriateness of staff that are sent to help out on the ward. Ensure Staff Breaks are coordinated to allow sufficient flexible rest periods.

Consideration to be given to the following Triggers to activate NEEP level 5

Three or more of the following indicators are hit.

TRIGGERS

EAU

• Pts on trolley >36hrs

• 0 cubicle availability >8hrs

Back of House

• Negative bed state in either

medicine or surgery with

escalation areas open &

continued A&E/EAU triggers

• Ward staffing is below agreed

levels by 7+ nursing staff

across the site and is judged

to present a high risk to

patient safety

NEEP 5

Critical

(purple)

• ACTIVATION OF MAJOR INCIDENT PLAN (as per policy)

All communication within NEEP 1,2,3 and 4 will have been activated.

• On activation of major incident plan all stakeholders identified within plan will establish communications through command and control

All command and control actions in NEEP 1,2,3 and 4 will have been activated.

• Gold command at SHA

• Silver command NECS and Trusts

• Bronze command Trust

For discussion consideration of impact on:

• mental health • Primary Care

(via NECS) • Neighbouring

Trusts • Community

Directorate • GPs

• Risks to Targets

• Normal service delivery

• Elective activity

31

NEEP 6

Potential Service

Failure

(black)

• CONTINUE WITH MAJOR INCIDENT/BUSINESS CONTINUITY PLANS SIMULATNEOUSLY WITH STAND BY TO INITIATE RECOVERY PHASE ( as per policy)

• As NEEP level 5 • As NEEP level 5

For discussion consideration of impact on:

• mental health • Primary Care

(via NECS) • Neighbouring

Trusts • Community

Directorate • GPs

• Risks to Targets • Normal service

delivery • Elective activity

32

ED ED Specific Triggers ED Co-ordinator Actions ED Senior Doctor* Actions

Level 1

• functioning safety and 4 hour target consistently being delivered

• <40 patients in the ED

• 1 resus space and >2 majors spaces

• Time from DTA to admission < 1 hour

• No delays with ambulance handovers

• Adequate staffing in the ED

• Normal working practice

• Maintain lines of communication with duty

matron and bed manager

• Review staffing for next 24 hours

• Normal working practice

• Consider attending EAU handover at 8pm to touch

base

Level 2

At least

three

triggers to

be present

to trigger

this level

• 1 patient spending more than 4 hours in the ED (avoidable)

• 40-50 patients in the ED

• Influx of patients arrived or expected (>10 in 1 hour)

• 1 resus space and 1 majors space

• Patients waiting >2 hours to see a doctor

• Time from DTA to admission 1-2 hours

• 1-2 ambulance handovers > 15 minutes

• Borderline staffing in the ED

• Redeploy nurses to high pressure ED areas

• Alert EAU co-ordinator and request attendance to

jointly look at board, see if any patient can be

moved immediately

• Alert duty matron and request support in

addressing the delays in moving patients to

EAU/wards

• Address any nursing staffing shortfalls

• Redeploy doctors to high pressure ED areas

• Ensure that ED patients have early senior review

• Contact registrar or consultant of specialty teams if

there is a delay (>30 minutes) from specialty teams to

see patients in the ED

• Address any ED medical staffing shortfalls

• Re-triage all patients to potentially re-allocate to

different work streams

• Liaise with EAU consultant

Level 3

At least

three

triggers to

be present

to trigger

this level

• Multiple patients spending more than 4 hours in the ED (avoidable)

• 50-60 patients in the ED

• >10 pts arrived in ED per hour over 3 consecutive hours

• 0 resus spaces and 0 majors spaces

• Maximum of 4 in holding corridor

• Time from DTA to admission 2-4 hours

• 4-8 patients stacking in the ED awaiting admission

• 2 ambulance handovers > 15 minutes

• Significant staffing shortages in the ED

• As above plus:

• Request nursing staff support from other

departments

• Liaise with duty matron to identify specialty help

that could be utilised in the ED

• Clinical staff on non-clinical duties to support

patient care

• Minor injuries shift lead to look at ED queue to

see what could be pulled through to them

• Reception staff to inform patients on arrival of

waiting time

• Refer to Ambulance Handover SOP – Appendix 6

• As above plus:

• Identify patients that could safely be moved directly to

EAU/SSU/wards

• Re-review patients ? can patient go home rather than

admission

• Refer to Ambulance Handover SOP – Appendix 6

Level 4

At least

three

triggers to

be present

to trigger

this level

• Multiple patients spending significantly longer than 4 hours in the ED

• >60 patients in the ED

• >10 patients arrived in ED per hour over 4 consecutive hours

• No capacity to receive patients

• Time from DTA to admission >4 hours

• >8 patients stacking in the ED awaiting admission

• Ambulances queuing to handover

• Inadequate staffing in the ED

• As above plus:

• Create additional majors capacity by utilising

minors pods

• Utilise additional resus capacity

• Refer to Ambulance Handover SOP – Appendix 6

• As above plus:

• Clinical staff on non-clinical duties to support patient

care

• Consider curtailing WIC work and utilising cubicles

• Refer to Ambulance Handover SOP – Appendix 6

Appendix 3 ACCIDENT & EMERGENCY LOCAL ESCALATION PLAN

33

ECCA ESCALATION PLAN

ECCA Triggers for Alert levels ECCA Specific triggers ECCA Co-ordinator Actions ECCA Senior Doctor’s Actions

Level 1

• Business As Usual

• Ensure minimum of 3

spaces available at all

times

• Good flow of patients in

and out of department

• No delays with discharges

• Adequate staffing levels

achieved

• Normal working practice

• Maintain lines of communication with ED Co-ordinator, SSU Co-

ordinator, duty matron, emergency bed manager and Acute Physician

• Liaise with bed manager, SSU / ACC co-ordinator to plan to create space

• Normal working practice

Level 2

• <5 patients in

admissions requests

list on Medway

• potential limited space on

ECCA

• Staffing in line with

planned safe staffing levels

• Co-ordinator ensures spaces available to accommodate ALL impending

admission requests – transfers and discharges performed in a timely

manner and directs nursing staff and doctors to complete paperwork in

real time

• Actual staffing levels are suitable for department to function without

assistance from elsewhere

• Address any medical staffing issues

Level 3

• > 5 patients in

admissions requests

list on Medway with

limited space on

ECCA to

accommodate

• No current capacity for

patient requiring a bed

GP or A&E

• Greater than 5 patients

awaiting nurse assessment

As above plus

• If expected GP referral, Co-ordinator reads GP letter and assesses if

immediate bed required or suitable for ACC or ‘holding corridor’

• If suitable for ACC, co-ordinator contacts ACC Nurse in charge via vocera

and requests a transfer upstairs – staff member assigned to transfer

• If bed immediately required then identifies a patient to move elsewhere

– base ward /ACC/SSU and liaises with bed managers to locate available

space

• If bed not immediately required , assigns a staff member to ‘holding

corridor’ and performs a set of obs to ensure patient safety

• Co-ordinator contacts SSU co-ordinator and ACC nurse in charge via

vocera to assess if any staff could be released to supervise ‘holding area’

– if not then escalates to duty matron

• Duty matron to attend ECCA and assess

• Co-ordinator escalates to duty matron

• Duty matron attends ECCA and discusses situation with co-ordinator

• Duty matron and co-ordinator looked at staffing levels of all areas on

ECC via electronic staffing grid and staff requested from other areas to

help complete nurse assessments

• Duty matron to temporarily take over Co-ordinator role to free up co-

ordinator to nurse assess

As above plus

• Should A&E have x1 ambulance

delay then Acute Physician should

meet up with A&E Consultants and

identify patients to pull through

• Ensure medics are aware of joint /

shared roles and responsibilities to

assist with assessments of patie

Appendix 4

34

• Greater than 5 ECCA

patients awaiting junior

doctor clerking

• Greater than 5 patients

awaiting Consultant review

• Staffing levels below

planned levels and actual

levels are causing a backlog

in nursing assessments

taking place

• Co-ordinator escalates to Acute physician and duty matron and

discussion to take place with Acute physician from SSU

• Co-ordinator to contact duty matron and then to liaise with Acute

Physician for ECCA and Physician of the day from SSU

• ECCA co-ordinator to liaise with SSU &ACC co-ordinator’s and also A&E

co-ordinator to discuss staffing levels across the floor and then staffing

moved to where deficit is showing – duty matron informed as to

potential staff movement

• If ECCA bottleneck or potential –

ask wards with 3 or more doctors

present to send someone to ECCA

to assist with clerking – ask on call

doctors due to start at 5 pm to

leave base wards and attend ECCA

earlier

• Acute Physician contacts Dr’s Scott

/ Naryanan to request additional

consultant support – out of hours

patients can be moved to base

wards without a Consultant review

/ providing a registrar or band 7

from ART has reviewed patient. A

list should be made of such

patient’s on Friday / Saturday

nights for weekend Consultant

doing ward rounds on Saturday &

Sunday to review the patients’ on

the base wards the following day.

Base ward nurses should ensure

that if they are concerned about a

patient, ECCA are informed so that

the patient can be prioritised to be

seen.

Level 4

• > 5 patients in

admissions requests

• No space available in

‘holding area’ and no beds

available for immediate

As above plus

• EAU co-ordinator liaises with A&E co-ordinator to negotiate potential

space in majors until space in ECCA is available recognising the patient

MUST be filtered back through ECCA when space created.

35

list on Medway with

NO space on ECCA to

accommodate

transfer and patient arrives

into ambulance area who

requires ECCA

• Inadequate staffing in ECCA

despite attempts to be self

sufficient across ECC

• ECCA co-ordinator contacts duty matron who will liaise with bed

managers to assist with base wards identifying suitable space as quickly

as possible. A transfer list will be compiled from ECCA patients,

identifying who is ready to move first.

• SSU co-ordinator contacted to identify any patients who could wait in

ACC and release a bed then a suitable ECCA patient to transfer up

without review / clerk for this to be performed on SSU (in hours)

• ECCA co-ordinators to liaise with duty matron nd emergency bed

managers to request staff movements from other areas of the Trust i.e.

Clinical staff on non- clinical duties to support patient care

36

KEY PERSONNEL ACTION CARDS

Actions for the Bed Managers

Alert Level 1: Low risk to patient

safety and experience. Normal

Trust working is maintaining

patient flow

Alert Level 2: Moderate Risk to

patient safety and experience

Alert Level 3: High Risk to

patient safety and experience

Alert Level 4: Very High Risk to

patient safety and experience

Alert Level 5: Critical

Handover from the ART Team Undertake all actions identified

at Level 1

Undertake all actions identified

at Level 1

Undertake all actions identified

at Level 1

Support Gold Command

Walk around the wards to

establish bed status

Work closely with the Duty

Matron and Service Line

Manager

In liaison with the Duty Matron

and Service Line Manager

identify patients to be moved to

other areas

Ring around the wards to

establish the nurse staffing

levels

Work closely with the Duty

Matrons to identify critical care

potential

Ensure patients requiring

repatriation are identified at the

bed meetings and included in the

action plan

Take all decisions to admit, eg

GP referrals or admissions from

clinics, outliers and repatriations

Attend the bed meetings - 9.30

am, 1.30 and 4.45 pm and take

the information relating to bed

status. Email bed status after

the bed meetings

Identify predicted/potential

discharges across the site

Work closely with coordinators

on EAU, ED and short stay -

coordination in terms of what is

coming in

Appendix 5

37

Alert Level 1: Low risk to patient

safety and experience. Normal

Trust working is maintaining

patient flow

Alert Level 2: Moderate Risk to

patient safety and experience

Alert Level 3: High Risk to

patient safety and experience

Alert Level 4: Very High Risk to

patient safety and experience

Alert Level 5: Critical

Monitor patients in ED - coming

up to three or four hours -

working with ED Coordinator to

establish a plan

Collect the Boarders List

Communicate regularly with

Duty Matron

Handover to the Acute Response

Team (ART) at 8pm

Monitor and consider who is on

call – Vascular

In liaison with the Duty

Matron/Service Line Manager

manage the elective admissions

ensuring identification of beds

required for next day admissions

In liaison with the Duty Matron

and SLM ensure that all beds are

open

Work with Ward Managers to

identify patients for specialty

wards

Keep wards informed of current

NEEP status

38

Actions for the Duty Matron (Cover 7.30 am – 5.00 pm)

Alert Level 1: Low risk to patient

safety and experience. Normal

Trust working is maintaining

patient flow

Alert Level 2: Moderate Risk to

patient safety and experience

Alert Level 3: High Risk to

patient safety and experience

Alert Level 4: Very High Risk to

patient safety and experience

Alert Level 5: Critical

All actions included in Business

as Usual (BAU)

Ensure completion of all Level 1

/BAU actions

Ensure completion of all Level 2

actions

Review ensure plans are in place

to de-escalate to level 3

In liaison with the Director on

Call and the Senior Manager on

call instigate Gold Command

Participate in handovers with

ART team lead at 07.30

Review & ensure plans are in

place to de-escalate to level 1

Review & ensure plans are in

place to de-escalate to level 2

Cancel all non-clinically urgent

elective surgery in discussion

with SMOC/SLM’S/ Director on

Call

Call in all staff identified in this

Policy who have Action Cards

Chair and co-ordinate bed

meetings at 9.30, 1.30 and 4pm

as per agreed Standard

Operational Procedure (Appendix

1a)

Co-ordinate response to

increasing pressures across the

Trust

Initiate communication with

senior clinicians/Consultants to

expedite review of patients

Review forward staffing plans. In

conjunction with SMOC consider

cancellation of planned non-

clinical time / training for front

line staff and backfill onto areas

under pressure

Consider cancelling all outpatient

activity to provide additional

ward input in discussion with

SMOC / Director on Call

Continue to work with Gold

Command

Take lead in ensuring actions

from bed meetings are

completed

In liaison with ED co-ordinator

and Consultant activate ED

escalation plan – Appendix 3

Contact Nurse Bank to request

additional bank staff into areas

under pressure where

appropriate

Discuss with SMOC request for

mutual aid

Request site presence and

support of SMOC if not already in

attendance

Agree SITREP with Service Line

Manager in Medicine by 10am.

Discuss any escalation to Level 2

with SMOC

Request additional resources to

assist with transferring patients

to maintain patient flow

Chair and co-ordinate more

frequent bed meetings as

required

Discuss with SMOC / Director on

Call potential need to escalate to

level 5 and instigation of gold

command.

Raise any issues with Senior

Manager on Call or SLM by

EXCEPTION ONLY

Request additional Matron, SLM

support and Support Services

representation at bed meetings if

required

Consider request for mutual aid

with SMOC if appropriate

Request additional Consultant

led patient reviews for all

specialities under pressure to

In conjunction with SMOC

develop plan for drafting in

additional medical staff to

support areas under pressure

39

Alert Level 1: Low risk to patient

safety and experience. Normal

Trust working is maintaining

patient flow

Alert Level 2: Moderate Risk to

patient safety and experience

Alert Level 3: High Risk to

patient safety and experience

Alert Level 4: Very High Risk to

patient safety and experience

Alert Level 5: Critical

identify patient suitable for

discharge

Will be required to act as first

point of contact for requests for

mutual aid from other Trusts

with ED co-ordinator / Lead

Consultant and advise SMOC /

Director on Call

Escalate issues regarding delayed

discharges of medically fit

patients to SLM’s within Business

Units or SMOC

Discuss with SMOC and Director

On Call any agreement in

escalation to Level 4 with

review/agreement of plan

Redeploy nurses from non-ward

based areas.

In conjunction with Ward /

Department Managers, 1104 and

1200 Bleep holders identify

patients for boarding using

boarding criteria tools

Consider extended opening and

use of discharge hospitality

lounge

Required to act as first responder

in event of adverse / serious

untoward incident e.g. missing

patients, serious drug incidents,

MAJAX

Agree with SMOC the planned

order of escalation into other

wards / departments as set out

in the winter plan.

Appendix 7

Request Site Presence of Senior

Manager on Call if needed.

May be required to act as a first

point of contact for press

enquires and discuss with SMOC

/ Director on Call

Discuss with SLM’s / SMOC any

agreement in escalation to Level

3 with review/agreement of plan

Opening and staffing of

escalation beds / areas based

upon speciality requirements /

pressures

Discuss potential request for

mutual aid within specialities

with ED Consultant and SMOC

In conjunction with ward /

department managers ensure

that proactive discharge planning

is occurring e.g. EDD, discharge

plans, working with DLT / social

services

Communicate closely with SMOC

in hours and where necessary

escalate any issues causing

concern

Discuss with SMOC and Director

on Call any agreement in

escalation to Level 4 with review

/ agreement of plan

40

Alert Level 1: Low risk to patient

safety and experience. Normal

Trust working is maintaining

patient flow

Alert Level 2: Moderate Risk to

patient safety and experience

Alert Level 3: High Risk to

patient safety and experience

Alert Level 4: Very High Risk to

patient safety and experience

Alert Level 5: Critical

Agree communication plan for

evening with Senior Manager on

Call at 4.30pm bed meeting – NB

reporting should be by

EXCEPTION ONLY

Ensure completion of all Level 1

/BAU actions

In liaison with Surgical

Consultants, SLM’s and Theatres

prioritise elective admissions and

consider cancellation of non-

urgent cases.

Communicate closely with SMOC

and where necessary escalate

any issues causing concern

Participate in handover with ART

team lead at 20.00

Review & ensure plans are in

place to de-escalate to level 1

Where required provide

handover to Duty Matron for

following day via email or

telephone call

Co-ordinate response to

increasing pressures across the

Trust

In liaison with ED co-ordinator

and Consultant activate ED

escalation plan

Request site presence of SMOC

as necessary

Communicate closely with SMOC

out of hours and where

necessary escalate any issues

causing concern

41

Actions for the Duty Matron (Cover 5 - 8.30 pm)

Alert Level 1: Low risk to patient

safety and experience. Normal

Trust working is maintaining

patient flow

Alert Level 2: Moderate Risk to

patient safety and experience

Alert Level 3: High Risk to patient

safety and experience

Alert Level 4: Very High Risk to

patient safety and experience

Alert Level 5: Critical

All actions included in BAU Ensure completion of all Level 1

/BAU actions

Ensure completion of all Level 2

actions

Request site presence and

support of SMOC if not already in

attendance

In liaison with the Director on

Call and the Associate Director

for the Business Unit instigate

Gold Command

Agree communication plan for

evening with Senior Manager on

Call at 4.30pm bed meeting – NB

reporting should be by

EXCEPTION ONLY

Continue with identified Duty

Matron actions 07.30-17.00

Continue with identified Duty

Matron actions 07.30-17.00

Call in all staff identified in this

Policy who have Action Cards

Participate in handover with ART

team lead and Senior Manager on

Call at 20.00

Request site presence of SMOC

as necessary

Request site presence of SMOC as

necessary

Where required provide

handover to Duty Matron for

following day via email or

telephone call

Discuss with SMOC any

agreement in escalation to

Level 3 with review/agreement

of plan

Discuss request for mutual aid

within specialities with ED

Consultant and SMOC

May be required to act as first

point of contact for PALS and

Complaints

Communicate closely with

SMOC out of hours and where

necessary escalate any issues

causing concern

Discuss with SMOC and Director

on Call any agreement in

escalation to Level 4 with review /

agreement of plan

Required to act as first responder

in event of adverse/serious

untoward incident e.g. missing

patients, serious drug incidents,

MAJAX

Ensure completion of all Level 1

/BAU actions

Communicate closely with SMOC

and where necessary escalate any

issues causing concern

May be required to act as a first

point of contact for press

enquires and discuss with SMOC /

Director on Call

42

Actions for the Service Line Manager and Senior Manager on Call

Alert Level 1: Low risk to patient

safety and experience. Normal

Trust working is maintaining

patient flow

Alert Level 2: Moderate Risk to

patient safety and experience

Alert Level 3: High Risk to

patient safety and experience

Alert Level 4: Very High Risk to

patient safety and experience

Alert Level 5: Critical

SMOC to attend 4pm bed

meeting for handover into the

evening

Review and ensure plans are in

place to de-escalate to Level 1

Review and ensure plans are in

place to de-escalate to Level 2

Review and ensure plans are in

place to de-escalate to Level 3

Consider launching Gold

Command in discussion with

Associate Director and Director

on Call

Consider requests for mutual aid

with A&E/EAU co-ordinators.

Discuss with DoC if required

Agree and support as required

mobilisation plan for escalation

into the designated Escalation

areas

Initiative communications with

senior clinicians to expedite

review of patients

Cancel non-urgent elective work Site presence required

Contact ARTOOH between 9-

11pm for current situation

Discuss with Duty Matron/ART

escalation to Level 3 with

review/agreement of plan

In liaison with Duty Matron and

Surgical Consultants prioritise

elective admissions identifying

those who may be able to

attend as same day admissions

Site presence required

Handover issues to SMOC 9am at

weekends

Attend complex discharge

meeting (12.30 pm in the Agile

area) and support Duty

Matron/Patient flow in

accelerating all potential

discharges

SLM presence

Proactively inform CCG of

position and mitigating actions

Point of contact for press

enquiries, discuss with Director

on Call (all levels)

Consider cancelling of some

non-urgent elective work

Instigate requests for mutual aid

following discussion with DoC

Discuss with Matron/ART

escalation to L2

Agree and support as required

mobilization plan for escalation

into identified areas

Contact Local Authority and

Social Care with a view to

commissioning additional

community beds to accelerate

discharges

43

Alert Level 1: Low risk to patient

safety and experience. Normal

Trust working is maintaining

patient flow

Alert Level 2: Moderate Risk to

patient safety and experience

Alert Level 3: High Risk to

patient safety and experience

Alert Level 4: Very High Risk to

patient safety and experience

Alert Level 5: Critical

Discuss with Duty Matron/ART

escalation to Level 4 with

review/agreement of plan

Consider launching gold

command in discussion with

Director on Call

On site presence at request of

Duty Matron/ART

44

Actions for Senior Manager on Call from 5pm and weekends

Alert Level 1: Low risk to patient

safety and experience. Normal

Trust working is maintaining

patient flow

Alert Level 2: Moderate Risk to

patient safety and experience

Alert Level 3: High Risk to

patient safety and experience

Alert Level 4: Very High Risk to

patient safety and experience

Alert Level 5: Critical

Participate in handover with

Duty Matron at 8 pm

Consider site presence at request

of Duty Matron/ART

Participate in 8 pm Handover

Meeting

Discuss with Director on Call

request for mutual aid

In liaison with the Director on

Call and the Duty Matron Unit

instigate Gold Command

Appropriate handover to Senior

Manager on Call 9 am Saturday

and Sunday

Discuss with Duty Matron/ART

escalation to Level 3 with review

and agreement of plan

At 9 am on a Saturday and

Sunday Senior Manager to Senior

Manager On Call telephone

handover

Consider launching Gold

Command in discussion with

Director on Call

Site presence required

Consider requests for mutual aid

with A&E/EAU coordinators and

Duty Matron/ART and advise

Director on Call for decision (at

all levels)

In liaison with the Duty Matron

devise and implement a plan to

reduce further risk

On site presence Site presence required

Point of contact for press

enquiries, discuss with Director

on Call (at all levels)

Consider site presence at request

of Duty Matron/ART

Discuss with Director on Call

request for mutual aid

Discuss with Duty Matron/ART

escalation to Level 4 and inform

Director on Call with

review/agreement of plan

Point of contact for press

enquiries – liaise with Director on

Call relating to these

45

Actions for the Senior Manager on Call (from 5 pm)

Alert Level 1: Low risk to patient

safety and experience. Normal

Trust working is maintaining

patient flow

Alert Level 2: Moderate Risk to

patient safety and experience

Alert Level 3: High Risk to

patient safety and experience

Alert Level 4: Very High Risk to

patient safety and experience

Alert Level 5: Critical

Participate in handover with

Duty Matron at 8 pm

Consider site presence at

request of Duty Matron/ART

Participate in 8pm handover

meeting

Discuss with Duty Matron/ART

escalation to Level 4 and inform

Director on Call with

review/agreement of plan

In liaison with the Director on

Call and the Duty Matron Unit

instigate Gold Command

Appropriate handover to Senior

Manager on Call 9 am Saturday

and Sunday

Discuss with Duty Matron/ART

escalation to Level 3 with review

and agreement of plan

At 9am on a Saturday and

Sunday Senior Manager to

Senior Manager on Call

telephone handover

Point of contact for press

enquiries – liaise with Director

on Call relating to these

Site presence required

Consider requests for mutual aid

with A&E/EAU coordinators and

Duty Matron/ART and advise

Director on Call for decision (at

all levels)

In liaison with the Duty Matron

devise and implement a plan to

reduce further risk

On site presence

Point of contact for press

enquiries, discuss with Director

on Call (at all levels)

Consider site presence at

request of Duty Matron/ART

Discuss with Matron/ART

escalation to Level 2

46

Actions for the Acute Response Team Band 7 Role (Cover 20:00pm – 08:00am)

Alert Level 1: Low risk to patient

safety and experience. Normal

Trust working is maintaining

patient flow

Alert Level 2: Moderate Risk to

patient safety and experience

Alert Level 3: High Risk to

patient safety and experience

Alert Level 4: Very High Risk to

patient safety and experience

Alert Level 5: Critical

Joint handover with the Bed

Manager and Duty Matron

Identify potential outliers, plan

to potentially transfer to other

specialties

Report escalation of NEEP level

to the Senior Manager on call

Undertake all Levels 1, 2 and 3 Constant communication with

Duty Manager, Director on Call

Agree overall alert status level

for the Trust

Transfer outlier to given wards

in a timely manner ,preferably

before 22:00

Working with Senior Manager on

Call

Identify any areas for

intervention or where extra

resource is required and agree

and arrange

A&E clinician, and Consultants on

Call

Establish any Staffing issues Ensure ECC is adequately staffed

with a transfer nurse and porters

Liaise with Ward Teams to

identify all patients who can be

transferred to non- medical

wards

Preparation of escalation areas

to open ensuring adequate staff

for overnight but also plans to

staff these areas for the morning.

Support Gold Command

Looking at predicted/potential

discharges across the site

Keeping in close touch with the

EAU coordinator and A & E

coordinator to enable prediction

of patient flow

If possible to allocate help from

other departments to support

ECC with Transfers

Contact the Medical Lead to gain

additional input from the medical

staff

Emergency list of elective

patients and telephone numbers

to prepare for potential

cancellation of procedures.

Monitoring patients in ED -

coming up to three or four hours

- working with the ED

Coordinators

In liaison with A&E activate the

A&E Escalation Plan (see

Appendix 3)

Ensure that all beds are open and

utilised

Staff to be prepared to inform

patients that there may be

decisions made to discharge

those patients whose elective

surgery is planned for the next

day

Collect a Outliers List from base

wards

Consider opening and staffing

additional escalation beds

Work with medical teams and

nursing staff to identify further

discharges for am

Contact should be made with

Duty Manager and Director on

call for support and guidance

potential requests for divert.

47

Alert Level 1: Low risk to patient

safety and experience. Normal

Trust working is maintaining

patient flow

Alert Level 2: Moderate Risk to

patient safety and experience

Alert Level 3: High Risk to

patient safety and experience

Alert Level 4: Very High Risk to

patient safety and experience

Alert Level 5: Critical

Communication with EAU and

Short Stay to establish if any

patients can be transferred to

other specialty wards as outliers

In the Request additional

consultant led patient reviews on

all wards to identify patients

suitable for discharge

To collect data regarding elective

admission in each area and

ensure this is communicated to

Bed Managers and Duty Matron

in am

Ensure any decision relating to

divert is discussed with Senior

Manager on Call, Director on call

A&E Clinician, A &E coordinator.

Looking at predicted/potential

discharges across the site

Ensure all identified patients for

discharge have plans in place to

ensure speedy transfer to the

Discharge Lounge for the

opening in the am

Liaise with all high patient flow

areas frequently including areas

such as Critical Care , Maternity ,

Theatres and Paediatrics

regarding acuity and dependency

of patients

Visit all Wards and identify areas

which may be struggling

including visiting A&E

Coordinating response to

increasing pressures across the

site

Communication across the site to

advise all areas and staff who are

on duty.

Communication in am to Bed

Manager and Duty Matron

Facilitation of conversations

between clinicians to ensure that

the patient flow continues

Electronic Morning report to be

sent with relevant information

Contact Senior Manager on Call

following regarding bed status

early evening

Communication in am to Bed

Manager and Duty Matron

Electronic Morning report to be

sent with relevant information

regarding trust Status and Issues

overnight

48

Actions for the Director on Call

Alert Level 1: Low risk to patient

safety and experience. Normal

Trust working is maintaining

patient flow

Alert Level 2: Moderate Risk to

patient safety and experience

Alert Level 3: High Risk to

patient safety and experience

Alert Level 4: Very High Risk to

patient safety and experience

Alert Level 5: Critical

Business as usual Business as usual Expect an update from Senior

Manager on Call re current status

and plans in place

Site presence may be required

following discussion with the

SLM On Call

Following discussion with the

Senior Manager on Call

Implement Gold Command’ –

site presence required

Respond to any issues escalated Support with any issues as

needed

SMOC will make decisions re

receiving diverts but may require

advice/support

Establish base in Bed Bureau for

Gold Command

Support with Mutual Aid

requests from our Trusts to

others

If we are receiving a divert

ensure this is discussed with

SMOC, A&E Consultant and

Co-ordinator and Duty Matron

Set up Control Team

• Medical Director

• Associate Director

• Duty Matron/ARTOOH

• Senior Manager on Call

• Bed Manager

• A&E Consultant or

representative

• Consultant Physician on Call

• Consultant Surgeon on Call

Use Flight Deck information to

aid decisions re from whom to

contact re Mutual Aid

Check all non-urgent elective

activity is cancelled as

appropriate

Plan of action to be developed

- To include releasing clinical

staff from non-clinical duties

- Cancel all but essential

elective activity

- Re direction Walk-in activity

from A&E Minors

Prepare to support requests for

diverts from other Trusts – refer

to Flight Deck information

- Agree communications plan

- Discussion with

CCG/NECS/Local Authority/

Community Services Lead

49

Alert Level 1: Low risk to patient

safety and experience. Normal

Trust working is maintaining

patient flow

Alert Level 2: Moderate Risk to

patient safety and experience

Alert Level 3: High Risk to

patient safety and experience

Alert Level 4: Very High Risk to

patient safety and experience

Alert Level 5: Critical

Contact NEAS Duty Manager to

notify the position at the Trust

and advise the Trust is looking to

divert elsewhere Advise NEAS of

any agreements made with

regards to diverts

Prepare to request divert to

other Trusts

Consider communication with

CCG/NECS/ Local Authority/

Community Services Leads if

situation is ongoing and

burdening NEEP 5

50

Actions for the Medical Teams, Consultants and Clinical Lead

Alert Level 1: Low risk to patient

safety and experience. Normal

Trust working is maintaining

patient flow

Alert Level 2: Moderate Risk to

patient safety and experience

Alert Level 3: High Risk to

patient safety and experience

Alert Level 4: Very High Risk to

patient safety and experience

Alert Level 5: Critical

Ward Consultant/Medical Team

Actions (standard expected

practice):

Business as usual

Lead Consultant in speciality

communicates the situation and

actions required. Consultants in

teams with inpatients, and with

the relevant ward manager/s.

Once communication is received

from designated bed

manager/coordinator ensure this

is communicated to all medical

consultants via voice bleep

Once communication is received

from designated bed

manager/coordinator ensure this

is communicated to all medical

consultants via voice bleep

Once communication is received

from designated bed

manager/coordinator ensure this

is communicated to all medical

consultants via voice bleep

Support Gold Command – on site

presence required

Ensure daily consultant or SpR

ward round in the morning as

per SAFER Flow Bundle:

Discuss with other consultants in

sub-speciality AND ensure a

consultant-led or SPR led ward

round takes place on the base

ward in the morning

Where possible attend bed

meeting(s) to get full briefing

Attend bed meeting(s) to get full

briefing

If above not possible ensure SpR-

led ward round with report to

consultant

Liaise with Business Unit Lead to

check on medical staffing levels

within the department and

identify any potential gaps

Liaise with the Business Unit

Lead or deputy to re-deploy

medical staff if needed

S – Senior Review – Aim for

senior review of all patients on

base wards by midday

Ensure every patient has an

‘early’ discharge plan with

criteria for nurse-led discharge

documented if appropriate

Check that all actions above have

been taken and review as

necessary

Contact colleagues to discuss if

any support is needed to ensure

above actions are completed

o Aim to see potential

discharges after

sick/unstable patients

Highlight patients waiting for

social services sort out and

medically fit on Medway and to

ward manager

Update duty matron by

telephone

Discuss cancelling elective

activity with sub-speciality

colleagues and divisional team

51

Alert Level 1: Low risk to patient

safety and experience. Normal

Trust working is maintaining

patient flow

Alert Level 2: Moderate Risk to

patient safety and experience

Alert Level 3: High Risk to

patient safety and experience

Alert Level 4: Very High Risk to

patient safety and experience

Alert Level 5: Critical

o Hand Over Form (HOF)

completed real time

Liaise with AC if there are any

inpatients on your ward suitable

for this pathway

If junior staffing levels allow

consider offering help to other

areas like EAU

o Identify patients likely to go

home the following day and

update EDD for all patients

Contact other sub-speciality

consultants by phone if any

patients on the ward are waiting

for another consultant’s opinion

(includes on EAU & SSU)

Ensure all sub-speciality referrals

are seen early in the day

A – All patients should have an

EDD

Consider cancelling elective

activity for the afternoon and

following day if possible

o Aim to set EDD within 24

hours of arrival on base ward

o Communicate this date to

patient and relatives/carers

52

Standard Operating Procedure

Monitoring A&E Ambulance Handover Breaches

• A&E Co-ordinator to monitor handover breaches on designated proforma

• Proforma to be scanned and sent to Pam Naylor / Chris Wright on a daily basis by Night

Site at 4.00am with 4 hour breach sheet

• Night Site Team and Bed Managers, during the day, to detail on bed report

o Number of Ambulance Handover delays 15-30 minutes

o Number of Ambulance Handover delays 30-60 minutes

o Number of Ambulance Handover delays over 1 hour (black breaches)

• NEAS provides the electronic information about Ambulance Handover delays to our

Information Department

• Information Department to send this information to Chris Wright / Pam Naylor for

validation against the proforma completed by A&E Co-ordinator

• Number of Ambulance Handover delays performance and subsequent action planning to

be discussed at monthly Emergency Care Service Line meeting attended by Senior staff

within the service

• Issues / concerns to be escalated to Associate Director

Appendix 6

53

Standard Operating Procedure

Escalating A&E Ambulance Handover Breaches

• A&E Co-ordinator to monitor capacity in Department against expected arrivals

• If capacity is not sufficient to meet expected demand contact Bed Manager to inform

and further assess nature and origin of patients coming in to decide plan for movement

of patients requiring admission

• If no patients deemed ready to move A&E Co-ordinator and Bed Manager to speak to

shop floor Consultant and agree most suitable to be moved

• If not able to create immediate capacity due to pressure on EAU spaces, A&E Co-

ordinator/ Bed Manager to contact Duty Matron / Night Site to initiate plans for freeing

up beds

• Any Ambulance Handover waits that have gone above 15 minutes A and E Co- ordinator

to contact Bed Manager and Duty Matron / Night Site if not already involved. Discussion

to also take place with Senior Doctor.

• Any waits above 30 minutes, Duty Matron / Night Site to attend, if not involved already,

and liaise with Co-ordinator and Senior Doctor to agree plans

• Senior Manager on Call to be informed if breaches above 30 minutes are anticipated.

SMOC to check all appropriate escalation actions across the patient pathways and above

actions have taken place. Work with on- site teams to develop on- going plan- consider

opening additional capacity, requesting mutual aid (use Flight Deck information to help

inform).

• SLM/ SMOC to be informed if any black breaches (over 1hr) anticipated.

• If anticipated to be an on- going situation SMOC to discuss the situation with the

Ambulance service to flag the pressures. SMOC to contact Associate Director/ Director

on Call to advise of situation and further discuss request of Mutual aid/ on- going plans.

• If any black breaches occur Duty Matron / Night Site and SLM / SMOC to write report to

outline events and to record any learning. This should be submitted to Associate

Directors with SLMs and Matrons copied in for discussion at Business Unit Boards and at

Board to Board meetings.

Appendix 6