patient flow internal escalation - wsh.nhs.uk15)304internalescalation.pdf · trust policy and...

Trust Policy and Procedure Document Ref. No: PP(15) 304

Policy Name Internal Escalation

For use in: All areas of the Trust

For use by: All Trust staff

For use for: Trust Wide

Document owner: ECOO

Status: Approved

West Suffolk Hospital NHS Foundation Trust

Patient Flow

Internal Escalation Policy and Plan

Source: COO Status: Approved Issue date: 7

th July 2015 Review date 7

th October 2016 Document Ref: PP(15) 304

Contents

Key Principles – ‘The 10 Golden Rules’ 3

1.0 Introduction 4

1.1 Aim 4

1.2 Objectives 4

1.3 Scope 4

1.4 Methodology 5

2.0 Patient Flow Team 5

2.1 Specific Incidents Requiring an Immediate Response 6

2.2 Operational Meetings 7

2.2.1 Handover Meetings 7

2.2.2 Operational Capacity Meetings 7

2.2.3 Standing Agenda for Capacity Meetings 8

2.2.4 The Capacity Report 9

3.0 Escalation Status 9

3.1 Escalation Process 12

3.2 Normal Working/Out of Hours 12

3.3 Escalation Actions 13

3.4 Capacity Meeting Attendees 14

4.0 Critical Care 15

5.0 Infection Control 15

6.0 Reporting – The Capacity Report 15

7.0 Communication 16

8.0 Internal Communication of Escalation Status 16

8.1 External Communication 16

9.0 Escalation & De-Escalation Actions 18

9.1 Escalation Actions & Authority 18

9.2 Actions Prior to Opening Escalation Areas 18

(Detailed in Action Cards) 18

9.3 Trust Escalation Flow Chart 19

9.4 De-Escalation 20

10.0 Plan Validation and Review 20

11.0 Black Escalation Process – Appendix 1 21

Action Cards For Trust Level Roles – Appendix 2 22

12.0 Trust Level Expectations – Appendix 3 40




Key Principles – ‘The 10 Golden Rules’

The ‘10 Golden Rules’ are critical to the Trust maintaining a high performing emergency pathway and effective capacity management regime for its patients – these are foundations upon which the trust builds effective and safe patient pathways and flows.

1. Patients who come into the hospital via the Emergency Department (ED) will be

subject to a system of rapid initial assessment and treatment by a senior clinician 2. GP referred patients should go to assessment areas directly; from there they will be

streamed to the appropriate ward or short stay area. The ED is strictly for diagnosis and routing of emergency patients only.

3. ED will have arrangements in place to assess emergency patients within an hour

and, if admission is obvious, a referral to the appropriate specialties should occur within 2 hours. No breaches will be caused by disputes between specialties about where a patient is to go. In the event of a dispute the ED Consultant will adjudicate in hours, the senior doctor out of hours.

4. We will not admit a patient likely to be able to go home or discharge a patient who needs urgent assessment/treatment in order to primarily avoid a transit time breach.

5. We will not admit patients for tests who are well enough to go home and return for

those tests - and we will ensure those tests are available when required. 6. Once a decision to admit is made, the patient will not be re-reviewed in the ED

causing them to stay in the department for longer than 4 hours from their time of arrival. Such patients will be reviewed on the assessment units unless there is a change in their condition.

7. The creation of capacity in admission/assessment areas is a trust priority. 8. Patients will be accepted on to the assessment units prior to full clerking. Initial

documentation will be carried out by ED, and be checked by the speciality registrar. 9. Discharge planning will begin at the time a decision to admit is made. Each patient

will have a discharge plan with a clearly defined predicted date of discharge given within 12 hours of admission to be agreed with the medical team. Plans for the discharge of elective patients should start at the pre-assessment stage. The patient and their carers, where appropriate, must be involved in all stages of the process.

10. Clinicians are responsible for ensuring the following takes place: Daily ward/board rounds with prompt decision making, immediate prescribing of TTOs and ordering of tests. Once a decision has been made, explicit notes made to indicate suitability for nurse-led discharge.




1.0 Introduction

The purpose of escalation is to ensure that decisions are made at the right level and those who need to be informed are made fully aware of circumstances in a timely manner. This policy recognises the effects that variation in demand and activity has on the effective operational management of the Trust, with enhanced focus on attendance and admission areas. It sets out the actions required across the Trust at each level of escalation to minimise the need to escalate further whilst at the same time seeking to return the Trust to ‘normal’ working as quickly and safely as possible. The plan seeks to ensure that patients receive the highest levels of care and experience whilst minimising risk. It also informs the wider Suffolk health economy of challenges facing the Trust due to high levels of activity and supports system wide actions to mitigate the effects of such pressures.

1.1. Aim

The aim of this plan is to measure the degree of operational pressure on the Trust and set out the actions required at each level of escalation to maintain patient safety, minimise risk and return the Trust to ‘normal working’.

1.2. Objectives Compliance with an effective escalation policy and plan will enable:

- the efficient use of beds and the early identification of capacity problems

- a proactive rather than reactive response, with defined responsibilities and clear, concise actions

- patients’ safety and clinical needs to be met appropriately and as effectively as possible

- compliance with national targets and fulfilment of contractual agreements with commissioners

1.3. Scope This Policy and plan applies to all areas of the Trust, be they directly clinical or support services (e.g. Facilities). The daily operation of the Trust in relation to clinical capacity management is governed by the Adult Bed Capacity Management Policy, a key element of which is the “10 Golden Rules”. These are key to the Trust maintaining a high performing emergency pathway for its patients and should be followed at all times The Trust has developed a series of escalation plans using a “traffic light” system approach. These outline the arrangements for managing pressure on bed capacity due to acute emergency demand and elective admissions to West Suffolk Hospital. The arrangements may also be invoked in response to:

Severe congestion in A&E Trust capacity status Staff shortages which limit or reduce capacity, or In accordance with specific Business Continuity plans

Each stage of the escalation plans outlines the roles and responsibilities of key personnel involved in facilitating patient flow. A Critical Capacity Incident Plan will be invoked when, despite the escalation procedures in this plan, the Trust has insufficient capacity to admit and/or treat emergency patients but where the designation of controlled areas for receiving injured casualties from a major incident is not required.




1.4. Methodology Departmental escalation plans are in place and their interaction is checked and tested (both jointly and severally) as part of the annual planning and review process. Nevertheless, there are overarching principles which are core to any Trust procedure:

1. Patients’ safety and clinical need will always be the overriding priority 2. Emergency admissions will be given priority in the allocation of beds 3. All patients will receive an equitable and professional service 4. All nurses have a responsibility to report accurate and timely bed availability to the Patient

Flow Team 5. Patients will not be transferred between wards unnecessarily, and transfers or discharges at

night will be avoided wherever possible 6. All elective surgical and medical admissions are admitted directly to the appropriate wards.

The waiting list office provides the planned admission lists each week. There are three categories of elective patients awaiting an in-patient spell:

‘Urgent’ (Cancer & other clinical urgent)

‘Long Waiters’

‘Routine’ (clinically non - urgent) Allocation of beds for elective admissions within the Trust:

Patients for admission ‘on day of surgery or treatment’ will be allocated beds as available in a timely way

Patients for admission ‘for next day surgery or treatment’ will be allocated beds according to availability

Where beds are not, or may not be available, priority will always be given to ‘Urgent’, ‘Long Waiters’ then ‘Routine’

Service Managers are responsible for their respective Departments during the day. However the Clinical Duty Manager is responsible for overall capacity and flow. Separate arrangements are in place for other issues of an immediate nature, such as Missing Persons or Major Incident.

2.0 Patient Flow Team The Patient Flow Team comprises of the Clinical Duty Manager (CDM) and Clinical Bed Coordinator (CBC) Teams, who are responsible for the effective day-to-day operational co-ordination of Trust-wide capacity management This includes monitoring and declaring the Trust Internal Escalation status and communicating it across the organisation. The Clinical Duty Manager and Clinical Bed Coordinator will be responsible for the collection and input of data which contributes to the determination of the Trust internal escalation status. This data will be entered on a four hourly basis at 08:00, 12:00, 15:00, 20:00 at which times the internal escalation status is reviewed. If workload is such that there is an increase in activity overall and multiple issues require action at the same time the CDM will notify the Senior Manager on Call (SMOC) and ask for assistance, agreeing shared actions to maintain safety and patient flow. For service specific issue the CDM will escalate directly to the relevant service manager for the area to resolve the problem.




2.1 Specific Incidents Requiring an Immediate Response The Clinical Duty Manager is responsible for maximising patient flow while maintaining patient safety and supporting the delivery of Trust targets. They will be the first point of contact for all escalation

issues. As well as the Executive on Call arrangements, a rota of Senior Managers is available to support the Clinical Duty Manager in the event that any of the following occurs:

Trigger are met which initiate a specific plan (such as ITs Disaster Recovery, Armed Response, Site Lock Down etc.)

A Major Incident or Major Incident Standby has been declared by another agency

A standby warning call is received from blue light agency or local authority

One or more core functions of the Trust (defined) is or could be jeopardised

Any on-going SIRI **

A missing patient has a score >100 confirmed by CDM - or any missing child

There is an imminent loss of any utility

Any confirmed fire or other serious incident on the site

A Command and Control response is mandated by NHSE or Commissioners

A situation generates Media interest beyond normal status checks

Any other serious situation

Short notice unfilled SpR shift i.e. sickness The Clinical Duty Manager will always call for support for any of the above.

If a Command and Control response is required, the Clinical Duty Manager will start a personal log. Clinical Duty Manager will arrange for the Hospital Control Centre to be set up and remain in the Control Room until relieved. Once Control staff arrive there should be a handover briefing and the Clinical Duty Manager will revert to providing proactive support for wards and departments and ensuring that all are aware of the current situation. Arrangements must be put in place for the CDM to provide regular reports on bed or staffing issues and to action as appropriate.

** Serious incidents requiring investigation are defined as incidents that occurred in relation to

NHS-funded services and care resulting in one of the following: • Unexpected or avoidable death of one or more patients, staff, visitors or members of the public,

and up to six months from discharge from services. • A scenario that prevents or threatens to prevent the Trust’s ability to continue to deliver

healthcare services, for example, actual or potential loss of personal/organisational information, damage to property, reputation or the environment, or IT failure; Acts or allegations of abuse (sexual, physical, psychological, theft, misuse or misappropriation of money or property and neglect or acts of omission which cause harm or place at risk of harm) of a service user; Adverse media coverage or public concern about the Trust or the wider NHS.

• One of the core set of “Never Events” as updated on an annual basis, for example, inpatient suicide using non collapsible rails; The admission of a child of 17 years, or under, to an adult psychiatric ward; significant healthcare associated infections (as defined by Health Protection Agency) i.e. an outbreak of infection, failure in decontamination or infected healthcare worker; The Anglia Health Protection Team should also be advised.

• Information Governance events. IG SIs are defined as “Any incident involving the actual or potential loss of personal information that could lead to identity fraud or have other significant impact on individuals should be considered as serious”




• Maternity, infant and child incidents as described in the NPSA National Framework for Reporting and Learning from Serious Incidents Requiring Investigation

2.2 Operational Meetings

At regular points throughout the day, meetings are held to receive handover between teams and to review current status and invoke relevant action cards.

2.2.1 Handover Meetings

At 08:00 and 20:00 the outgoing Clinical Duty Manager (CDM) will conduct a brief handover meeting in the Hospital Control Centre. This will be attended by the incoming CDM (bleep 888), the Surgical and Medical Bleep Holders 390 and 933 and Clinical Bed Coordinator (bleep 358). The Medical & Surgical Managers of the day will attend the 08.00 handover meeting only. The Senior Manager on Call (Silver) will attend the 08.00 meeting when on site or make arrangements to receive an update from the CDM as soon as possible after the meeting. The CDM will brief the Doctor’s Handover meeting at 08:30-09:00 about the Trust’s position and any specific input required of the Medical staff

2.2.2 Operational Capacity Meetings Operational Capacity Meetings will normally be held at 12:00, 15:00 and 17.30hrs in the Hospital Control Centre. These will be chaired by the CDM and attendance is dictated by Trust Capacity Status. The Senior Manager on call will attend all operational capacity meetings to gain an oversight of the organisation and provide support to the CDM. At Black escalation, the ECOO (or nominated deputy) will take over and Chair the meetings. Additional bed meetings may be convened when the Trust escalation status is at red or black. At the 15:00 meeting the initial Trust plan for the ‘out of hours’ period is to be agreed. The plan will also be confirmed at the 17.30 meeting if required. The Surgical Service Manager or nominated deputy for the surgical wards will attend the 15:00 meeting to review planned TCI activity for the following day and identify the potential for cancelling electives in the event capacity is required to meet anticipated or actual emergency demand overnight. Meetings should last no more than 15 minutes and will follow a fixed agenda (see below). The primary focus of the meeting will be to review and confirm plans for the next period, identify issues

impacting the safe and efficient patient flow through the Trust and agree and log actions, owners

and timescales to address. The development of plans and resolution of the issues must take place outside the meeting. All numerical data regarding capacity and current position MUST be reported to the Patient Flow team no later than 15 minutes prior to the meeting start. The ED Coordinator should arrive five minutes before the meeting time to input data to the Capacity Report




2.2.3 Standing Agenda for Capacity Meetings

1

2

3

Allocate an individual to log and allocate all actions on white board for review at next capacity meeting

Review of outstanding actions from previous meeting Patient safety issues requiring immediate action

4 Situation report (exception / issue reporting only) ED Review

Numbers in Department

Triage Delays

Any delays in waiting to be seen by a Doctor

Unvalidated Breaches

CDU status

Ambulance situation

Patients awaiting beds

Medical staffing issues

Other Capacity Review

AMU & Ambulatory Emergency Care capacity / issues

F7 Capacity/ Issues

SAU Capacity/ Issues

CCS capacity and step down

Stroke capacity

CCU capacity

Community bed availability

Overall Trust bed capacity including escalation

Other Areas for Review

Staffing

Discharge planning / Medically Fit

Support Services / Pharmacy/ Imaging/ EIT/ Therapies

Infection Prevention

5

Activity Forecast

Predicted emergency admissions & discharges

Planned elective activity

MTU planned activity and potential capacity

6 Agree plans and required actions for next meeting / overnight

7 8

Confirm internal escalation status and invoke action cards as appropriate Agree time of next capacity meeting




2.2.4 The Capacity Report

08:00 Bed Capacity PositionDay Month Year

Status None11 October 2013

Physician 0 Elderly 0 Exec 0

Surgeon 0 Gynae 0 Manager 0

08:00 ED Green

Beds Black

Emergency Department Today

Attendances Number of 4 hr breaches Outliers

68 1 Med in Surg 4 Closed beds empty 32

Surg in Med 1

ED Cubicles in use/currently in department Total 5 TCI Today Cancelled 1

TOTAL Not Triaged See & Treat Minor Major Resus

29 1 12 9 5 2 Clinically stable 0 Medically Fit 0

Decision to admit

Med1 Community Beds

Surg2 Available Referrals

Paeds15 Nursing 0 0

Speciality redirections Residential 0 0

Ambulance's held No / max time 0 0

Nursing Shifts Not Covered

Bed State Empty Def / Lat Poss

Registered Unregistered

Med 2 0 Early 0 0

Surgery/Trauma 4 0 Late 0 0

0 Night 0 0

Bed Capacity 6 0 0 Alerts & Messages

Theatres All theatres closed due to generator failureITU 4

CCU 3

Paediatrics 15

Infection Control G9 Closed due to Norovirus and Swine Flu.Forecast Position

Forecast admits Admits to date Current bed state Forecast

Med 52 17 2 -37

Same Sex Breaches All wards - to accommodate emergency patients from EDSurgery/Trauma 63 5 4 -62

Gynae 0 0

Discharge Indicators

TOTAL 115 22 6 -87

Figure4: Bed Capacity Report (under development)

The completed Trust Capacity Report is issued at 0800, 1200, 1600 and 2000.

3.0 Escalation Status The Trust Escalation status is an indicator of the operational pressure that the Trust is under and will rise and fall in a controlled manner based on prevailing and anticipated pressures. Responsibility for the declaration of escalation status varies according to the level The internal escalation status is a component part of the county and region wide Escalation status. Where requested, organisations within the health economy will take supportive actions commensurate with the escalation level of the Trust declaring the highest status. The escalation status is based on a scale that reflects the level of risk to the Trust’s ability to provide services, and the extent to which patient safety and experience may be compromised – see figure 1.




This status setting applies to the Trust’s overall capacity, and excludes paediatrics and maternity services. There are three triggers to help determine the escalation status and appropriate response: (1) bed capacity; (2) pressure in the emergency department and (3) staffing levels. The Trust’s escalation status will be reviewed at periodic intervals throughout the day at the planned capacity review meetings. The Trust escalation status is determined by assessing a number of key performance metrics on an on-going basis. These metrics assess both current and anticipated operational pressures. Appendix 2 describes the nature of likely pressure as Capacity pressure increases. Data will be input to the Trusts Capacity Report against a series of indicators. These will be weighted according to a matrix and a Trust ‘score’ generated which will suggest an overall status.

SUMMARY ESCALATION LEVELS / ALERT STATUS

ESCALATION

STATUS

ESCALATION MEASURE /

TRIGGERS

RESPONSIBILITY

‘GREEN’

Bed capacity within the Trust is able to maintain both emergency and elective capacity. Deliver emergency care services across the system. Good patient flow through ED and other access points with ED four-hour target consistently being met.

Managed by the Patient Flow Team at all times

‘AMBER’

Pressures are increasing and the predicted or actual bed capacity may not meet demand in one main area. Discharges are below those expected. Anticipated pressure on maintaining ED four-hour target and in facilitating ambulance handovers with delays breaching 30-minute turnaround times. Constituent parts of the health economy are experiencing similar pressures; this is reported by WSCCG and via EEAST CAMS in the daily capacity meetings and corrective action identified. Some unexpected reduced staffing numbers (e.g. due to sickness, weather conditions) in areas where this causes increased pressure on patient flow. Infection control issues causing pressure on patient flow. The actions to be taken aim to bring trusts and the system back to a ‘Green’ position.

Managed by the Patient Flow Team with support from the Clinical Divisions. OOH support from Senior Manager on Call and Executive Director On-call




‘RED’

Despite measures undertaken, pressures are continuing to increase. There is a lack of beds across the Trust with discharges predicted to be lower than forecast and admissions. There is significant failure by ED in achieving the four-hour target and ambulance handover times within 15 minutes and response to emergency calls are severely compromised. Community services may not be able to transfer medically fit patients to community care. Social services may be unable to facilitate care packages for discharges. Significant unexpected reduced staff numbers due to sickness or weather conditions are experienced. There may be infection control issues resulting in significant pressures on the system. The actions taken aim to bring the Trusts and the system back at least to an ‘Amber’ position.

Managed by the Patient Flow Team, supported by the Senior Manager on Call and Executive Director On-call. Attendance as per action cards External communication ECOO /Deputy OOH support from Senior Manager on Call and Executive Director On-call

Black

Actions at ‘Red’ failed to deliver capacity and there is system gridlock with no capacity across the acute trusts or within the community. The Trust is unable to admit GP referrals. The Emergency Department is unable to safely provide emergency care service. Ambulances are unable to offload patients affecting their response to 999 calls. Elective work is cancelled. Unexpected reduced staffing numbers are such that this causes increased pressure on patient flow to such a level that it compromises service provision/patient safety. The Trust is experiencing severe operational challenges despite implementation of agreed actions with little or no likelihood of improvement within the next 4 hours. The Executive Medical Director and Executive Chief Nurse and/or ECOO are likely to believe that the clinical safety of patients has become compromised, and/or staffing levels and skill-mix is unsafe to care for patients.

TRUST BLACK escalation status can only be declared by the Executive Chief Operating Officer/ Deputy (in hours) or the Executive on-call (out of hours) following consultation with the Clinical Duty Manager Managed by the ECOO/Deputy or Executive on Call at all times




At TRUST BLACK status, the ECOO/Deputy will constantly review the situation and determine if an internal critical capacity incident should be declared. When the critical internal capacity incident is stood down, the ECOO/Deputy will determine which level of escalation the Trust should revert to. It is anticipated that at TRUST BLACK escalation status, significant input will be required from the wider health economy to return the Trust to operational normality. Routinely there should be: At least daily teleconference calls involving NHSE Area Team, CCG Exec on Call, East of England Ambulance Service Trust, Adult Social Care and Community

3.1 Escalation Process 3.2 Normal Working

All Trust members of staff are required to actively and continuously contribute to the timely and safe discharge of patients from hospital. Medical staff should ensure that board or ward rounds for discharge decision/planning have been completed during the morning; Medically fit and Clinically Stable patients should be identified within this process. Confirmed and Potential Discharges should be declared to the bed coordinators at the earliest opportunity. Ward staff should make appropriate use of any identified discharge waiting areas to ensure that beds are freed up to accept acute admissions as soon as possible. Providing timely bed availability information to the Clinical Bed Coordinator is key to the Trust’s ability to manage beds successfully and to cope with increased demand. Currently this information is obtained direct from ward staff, including the following:

“beds available now to be used”

“definite discharges - beds later”

“potential discharges - beds later”

Ward staff will ensure that the ward whiteboards are constantly updated and will also provide information for the Trust’s electronic systems, including each patient’s anticipated discharge arrangements. Beyond Green Level 1, ward staff or the shift co-ordinator will, without delay, bleep to inform the Clinical Bed Coordinator of:

1. Any additional definite or potential beds becoming available in between Clinical Bed Coordinator rounds

2. Any unexpected discharges (for example deaths) Trust medical and surgical staff will respond to requests from Patient Flow or Trust managers to review patients and, wherever possible, expedite their discharge. As pressures increase, clinicians may have to prioritise both admissions and those already admitted.

Out of Hours

During out of hours periods the Trusts ability to escalate to the wider team is limited, i.e. those staff groups listed in section 3.3. However, if BLACK Trust status is declared by the Exectuve on-call (Gold), the following staff groups will be called to attend a ‘BLACK capacity’ meeting in the HCC.




The CDM (888) will be responsible for co-ordinating the aforementioned , and will call the following staff members:

1. Portering Supervisor 2. POD on-call 3. GOD on-call 4. AMU on site Consultant 5. General Surgery/Urology/Orthoapedics on-call 6. Medical SpR 7. Gold/Silver on-call

3.3 Escalation Actions

The following key members of staff have Action Cards which provide them with tasks that they should undertake at a particular escalation status level.

1. Switchboard 2. Clinical Duty Manager – Bleep 888 3. Senior Manager on Call 4. Executive Chief Operating Officer/ Deputy/ Executive Director on Call 5. Senior Nursing Staff 6. Director of Nursing/ Deputy 7. Ward Consultants / On Call Consultants 8. Clinical Director 9. Medical Director 10. Discharge Planning Lead 11. Divisional Management Representatives 12. Chief Pharmacist/ Deputy 13. Head of Therapies/ Deputy 14. Radiology Service Manager/Deputy 15. Facilities Representative

The role of nominated key members of staff in relation to Internal Escalation is to ensure that all actions documented within the relevant Escalation Action Cards are completed in a timely manner with any issues being reported back to the Patient Flow Team.




3.4 Capacity Meeting Attendees

Attendance at the capacity meetings is determined by the Trust escalation status according to the table below.

* In hours ONLY

Job Title / Role Green Amber Red Black Clinical Duty Manager X X X X

Clinical Bed Coordinator X X X X

Contracted Pool Co-ordinator / Nurse Staffing Bleep Holders

X X X X

Senior Manager on Call (Silver)

X X X

ED Shift Coordinator (at black Senior representative from ED)

X X X X

AMU Shift Coordinator(at black Senior representative from ED)

X X X X

Discharge Planning Team representative X X

Critical Care Nurse representative plus intensivist when on black

X X

Infection Prevention* (If any IPT issues) X X X X

ECOO (or Deputy)* X

Executive Director On Call (Gold)

X

Head of Pharmacy/ Deputy * On call Pharmacist out of hours

X X X

Medical & Surgical Service Managers, Deputy General Managers

X X

Medical Manager of the day* X X X X

Surgical Manager of the day* X X X X

Nominated Senior Nurse for each Division * X X

Director of Nursing/ Deputy*

X

Facilities Representative X

On call Consultants (PoD, GoD, AMU & ED)

X

Nominated Clinical Support Services Representative*

X X

Portering Supervisor – OOH only X X




4.0 Critical Care

Intensive Care capacity within the Trust and in the health system generally is both limited and volatile. The service has its own capacity and escalation arrangements drawn up with input from the Critical Care Network. However Critical Care is a key element of the Trust’s ability to function under pressure; therefore the Service Manager or Nurse in Charge should attend RED and BLACK Bed Meetings. The intensivist should attend Black capacity meetings

5.0 Infection Control The need to maintain the integrity of isolation areas and infection control and prevention measures can impinge heavily on the availability of beds. The Trust has a number of plans in place to deal with

specific diseases including Infectious Gastroenteritis (Norovirus) and viral respiratory illness. Infection Prevention Nurses will attend bed meetings in accordance with 3.3, unless beds are closed in which case they will attend every bed meeting. Their role at these meetings is to advise those responsible for flow and capacity.

6.0 Reporting – The Capacity Report A Capacity Report is circulated to key staff 4 times per day by the Patient Flow Team. This report

shows key information including escalation status, available capacity, bed status and operational issues as well as agreed actions. External status reporting during the winter period is done via use of the National UNIFY system and daily SITREPS.

SITREP This is reported on a daily basis in winter for the previous 24 hour period, giving a range of pre validated statistics; the Patient Flow Team will complete a template and submit to the information team for sign-off. The information required is specified by the DoH and NHSE and routinely includes:

cancellations,

12 hour waits in A&E,

clinical and non-clinical critical care transfers,

ambulance hand over delays,

beds available and used,

critical care capacity,

beds closed due to D&V and / or ‘Flu,

number of delayed transfers of care and

the operational status of hospital Any “serious operational issues” reported on the form must be signed off before publication by the ECOO or nominated Deputy before publication. This information is visible to all NHS organisations including CCG and NHS Area Team.




7.0 Communication 8.0 Internal Communication of Escalation Status The current internal escalation status will be shown permanently on the homepage of the intranet. The status box will include a link to the relevant escalation action cards and the Internal Escalation page which includes relevant documents and procedures. Changes to internal escalation status will be communicated though the Capacity Report by the Patient Flow team via email. It is circulated both within the Trust and to external organisations The Trust Capacity dashboard should be automatically updated at the same time on a 4 hourly basis. This will ensure all relevant stakeholders are aware of the status and the actions required of them as set out in their functional Escalation Action cards.

8.1 External Communication At all levels of escalation the Trust is required to maintain effective information flows across the wider health system. This is achieved through the use of Capacity Reports, SITREPS, and participation in daily operational teleconferences and at higher levels of escalation, strategic level teleconferences. Responsibilities for external communication are documented in the relevant Escalation Action Cards. These include informing the CCG and other external stakeholders of escalation to Red status and beyond. The Clinical Commissioning Group (CCG) holds responsibility for overseeing provider escalation plans and for ensuing that organisations respond appropriately to increased pressures in demand and capacity management. This includes participating in the provider led system wide strategic escalation conference calls, to improve flow and resilience across the urgent care system. The system providers will organise and hold strategic executive level conference calls as part of system resilience planning. A CCG led ‘exceptions only’ conference call involving the whole health and care system will be held on Monday’s and Thursday’s throughout the year. These calls will cover highlighted barriers to service delivery that require system wide escalation. During the winter period (November – March) the CCG will facilitate additional calls to ensure that capacity and demand is managed collectively. The CCG will complete and distribute the system SitRep after these calls A copy of the sitrep is included below to indicate the information which will be required for the teleconference




During periods of sustained escalation additional operational teleconference calls can be initiated by any provider by paging the CCG Director on Call. The escalating provider will be expected to lead this call.

To access the conference, each party dials the following details: Primary dial in number: 0844 800 3227or via mobile: 02034 639 740 At the prompt, enter Participant PIN code followed by the # key. Participant PIN code: 39 82 35 63 # Chair PIN code (CCG use only)




A teleconference agenda will be used to gather a full situation report from each provider during sustained escalation or when moving to Black Trust status.

9.0 Escalation & De-escalation Actions Full details of the actions to be taken across the Trust at each level of escalation can be found in the Internal Escalation Action Cards as per appendix 2. Each action card is written for a specific role within the organisation and details the actions to be taken at Amber, Red and Black status.

9.1 Escalation Actions and Authority The ECOO/deputy or Executive Director on Call will decide to open escalation beds. Once authorised the Patient Flow Team will be responsible for ensuring the clinical mix and sex of patients is appropriate within each newly opened area. The Patient Flow Team will liaise with base ward staff to identify suitable patients with an estimated length of stay of less than 48 hours who can be transferred to escalation areas. Patients transferred to outlying or escalation beds other than F8 should ideally be medically fit or at least very stable without requiring oxygen with MEWs at zero or with a definite discharge date for ‘tomorrow’.

9.2 Actions Prior to Opening Escalation Areas (as detailed in action cards)

Additional ward / board rounds and consultant review of patients under their care, to assist

with earlier discharge and proper use of any discharge lounge facilities that are put in place.

Liaise with other local providers and commissioners to reduce pressure on the hospital.

All other demand reduction (such as cancellation of non-urgent elective activity) and capacity increase options around discharge have to be considered




9.3 TRUST BED ESCALATION FLOW CHART Follow the sequence unless authorised by the Chief Operating Officer

During escalation the following must be considered:

CAPACITY ISSUE

OUTLYING. The use of empty beds for outlying should be considered initially, and be based on actual bed capacity at 15.00hrs. Once outlying has occurred, capacity issues within

either Surgery or Medicine should be managed as follows:

MEDICINE

Establish todays & tomorrow MTU procedures

And consider deploying patients to DSU

SURGERY

Review tomorrow’s electives

1. Fill ALL Medical & Surgical beds

2. Fill Escalation beds on: F3 TAU x1, G1 Oncology assessment x1, G8 Stroke x2

3. Fill CDU beds

4. Contact the Executive on-call to discuss & agree next steps i.e:

o Fill F8 incrementally to a maximum of 26 beds

o Use 6 beds on MTU

o Beds in ED




9.4 De-Escalation In a de-escalation situation, the principle of completing all actions detailed on the action cards remains. This is essential in ensuring the Trust returns to ‘normal working’ as swiftly and safely as possible.

10.0 Plan Validation and Review a. Plan consultation & approval Prior to ratification, this plan has been circulated to key internal stakeholders for their input.

b. Training All staff with a role or potential role related to the Trusts internal escalation status will receive appropriate training and communication to enable them to effectively discharge their duties as set out in the plan.

c. Monitoring & review of plan The Internal Escalation Plan will be formally reviewed on an annual basis by the Emergency Preparedness Steering Group. In the event major amendments are required to the plan to incorporate relevant internal or external organisational and / or operational changes, the approval of the revised plan will replace the annual review.




11.0 Appendix 1 – Black Escalation Process

IN HOURS OUT OF HOURS

Yes Yes

No No

Triggers for BLACK

escalation

Clinical Duty Manager notifies

General Divisional Managers & ECOO or

Deputy contacted

Director On Call contacted

CEO contacts NHSE Area Team and CCG to

confirm escalation to BLACK

Director On Call contacts NHSE Area Team and

CCG to confirm escalation to BLACK

Intranet homepage updated to reflect BLACK escalation

status

Switchboard alert ‘Black’ status follow Action Card

Who reviews status, capacity, issues, actions

taken & in progress undertaken

BLACK escalation status declared

Declare BLACK?

Who reviews status, capacity, issues, and

actions taken & in progress undertaken

Declare BLACK?

BLACK escalation status declared

CEO informed by ECOO

ECOO convenes Critical Capacity Command

Agree immediate actions

Director On Call informs COO and agrees immediate actions

CDM ECOO CEO Dir On Call

ED on call,

ECOO & CDM Key




Appendix 2

ACTION CARDS FOR TRUST LEVEL ROLES

The following section contains all of the action cards for key individuals.

1. Switchboard 2. Clinical Duty Manager – Bleep 888 (Bronze) 3. Senior Manager on Call (Silver) 4. Executive Chief Operating Officer/ Deputy/ Executive Director on Call 5. Senior Nursing Staff 6. Director of Nursing/ Deputy 7. Ward Consultants/ On call consultants 8. Clinical Director 9. Medical Director 10. Discharge Planning Lead 11. Divisional Management Representatives 12. Chief Pharmacist/ Deputy 13. Head of Therapies/ Deputy 14. Radiology Service Manager/Deputy

15. Facilities Representative




ACTION CARD 1:

SWITCHBOARD

Group Call # Message Authorised by:

173 Trust Status AMBER Activate group call out to notify status in hours only

888

173 Trust Status RED Activate group call out to request bed meeting, stating time of meeting in hours only

888, SMOC ECOO or deputy

172 Trust Status BLACK/ INTERNAL CRITICAL CAPACITY

In hours - Activate group call out to request bed meeting and notifying time of meeting.

Plus:

ECOO/ Deputy

SMOC

On call director at any time

Director of Nursing/ Deputy

Medical Director

AMU Consultants

On call Intensivist

On call Consultants PoD, GoD, T&O, General Surgery

Facilities Representative

Out of hours – the following ONLY

Executive Director on call

Senior Manager on call

On call Intensivist

On call consultants PoD, GoD, T&O, General Surgery

Facilities Representative at any time

On call Pharmacist

ECOO or Deputy, Exec on-call

Black Call out as red list plus Deputy General Managers and General Managers




ACTION CARD 2: CLINICAL DUTY MANAGER (CDM) – Bleep 888

TRUST LEVEL

‘GREEN’

Take handover at start and end of shift and obtain a baseline of Trust capacity and activity in ED from the shift co-ordinator – patients waiting for admission, status, and level of activity in each area

Check with ED shift co-ordinator for any issues relating to patients, staffing or support required

Validate capacity report to enable the CBC to distribute at 08.00, 12.00, 15.00 & 20.00hrs

Chair all capacity bed meetings following the standard agenda in section 2.2.3

Escalate to relevant Divisional Manager any potential problems to patient flow: key contacts – AMU and ED shift co-ordinators

Escalate to SMOC where multiple issues require action simultaneously

Monitor ED position in terms of the 4 hour wait

Support timely transfers out of ED

With support from appropriate bleep holders ensure safe staffing across the site.

‘AMBER’

All actions as per Green

Activate Trust Level staff to initiate action Amber cards via switchboard

Escalate issues to Divisional representatives

Initiate additional resources as required such as Portering

Inform Discharge Planning Team of position to expedite discharges and identify and manage delays

Support the area’s most under pressure with a physical presence

Escalate potential breach situation to Divisional Teams/Senior Manager On-Call if it cannot be resolved in a timely way

Formulate clear decisions and agree actions aimed at reducing escalation level & document those actions in ‘action log’ for follow up at next capacity meeting




‘RED’

All actions as per Green & Amber

Activate Trust Level staff to initiate Red action cards via switchboard indicating time to attend capacity meeting

Liaise directly with the Senior Manager on-Call if issues unresolved at ward / department level

OOH liaise directly with Executive Director On Call

Initiate & chair additional capacity pressure meetings as required

Allocate a member of staff in attendance at capacity meetings to capture actions

Agree actions aimed at reducing escalation level & document those actions in ‘action log’ for follow up at next capacity meeting

Be clear where the blocks to flow are so that senior managers can support with additional resource or escalation

‘BLACK’

Black status can only be declared by CEO/ ECOO/Deputy COO /Executive Director on Call

All actions as per Green, Amber and Red

OOH liaise directly with Executive Director On Call and SMOC

Activate Trust Level staff to initiate Black action cards via switchboard indicating time of initial critical capacity meeting

Initiate action log and establish command structure in HCC, taking control until SMOC or nominated senior manager arrives

Provide data and attend escalated capacity meetings

Implement agreed actions aimed at reducing escalation level

Ensure areas most under pressure are supported personally or through delegation to others.




ACTION CARD 3: SENIOR MANAGER ON CALL (SILVER)

TRUST LEVEL

‘GREEN’

Receive exception report handover from previous SMOC at 08:00 handover meeting or via telephone

Attend if on site or call extension 3365 at 08:00 handover to gain an oversight of the organisation and decisions being made

Support and be available to the CDM to resolve issues they may have

Attend all in hours capacity meetings

‘AMBER’


Support the Patient Flow Team with any escalation issues to Medical or Nursing teams

Resolve issues which have not been dealt with by the respective divisional managers

‘RED’

All actions as per Green and Amber

Support the Patient Flow Team to maintain patient pathways by escalating/addressing any potential/actual blocks for example; transport, portering, business continuity issues as requested by the CDM

Attend capacity meetings as requested via CDM /ECOO/ Deputy COO/ Executive on Call

Review elective surgical & MTU next days planned activity

‘BLACK’

All Actions as per Green, Amber, Red

Attend and remain on site until the situation can be stabilised

Take over control of HCC and consider the following:

o Remain in HCC and delegate actions as appropriate

o Requirement for additional phone lines and computers

o Appoint scribe to capture events and actions

o Gather Sitrep to support team briefing

Make arrangements for alternative support/ SMOC cover if situation is ongoing

Work closely to support the Executive Chief Operating Officer/ Deputy/Executive on Call

Action requests made from ECOO/ Deputy/Executive on call




ACTION CARD 4:

EXECUTIVE CHIEF OPERATING OFFICER (ECOO)/ DEPUTY ( IN HOURS)

EXECUTIVE DIRECTOR ON CALL ( OUT OF HOURS)

TRUST LEVEL

‘GREEN’

Normal working – ensure you are aware of trust escalation status

Ensure you are awareness of any capacity issues in the last 24 hours

‘AMBER’


‘RED’


Consider escalation to CCG. Executives on call/Escalation lead

Respond to requests from operational staff

Attend capacity meetings in hours and support operational teams to resolve issues affecting patient flow.

Authorise opening of escalation capacity if required

Authorise cancellation of routine elective activity if required

Consider/request local ambulance diverts

‘BLACK’

All actions as per Green and Amber, Red

Attend and chair all capacity meetings

Work closely with SMOC and CDM to allocate actions as appropriate

Consider

o Do you need to call in additional staff/ resources particularly out of hours

o Available additional nursing/medical staff options( cancelled theatre lists/ clinics)

o Redeploy medical and nursing staff on non-clinical activities

o Consider the potential to cancel elective admissions in consultation with SMOC and 888

o Use facilities representative to support logistics and supplies issues

o Advise AMU and ED consultants of situation and promote alternative pathways and APS




Inform CCG Executive on call / Escalation Lead of status and request system wide teleconference – issue invitation to attend site and support capacity meetings

o Consider external communications to GPs and out of hours services

o DTOC and medically fit numbers

o Community bed capacity – spot purchases

o HALO support from ambulance service

Request Ambulance divert from Neighbouring Trusts

Inform ambulance control of black escalation status

Maintain regular communications with all external agencies

Aim to reduce Trust escalation status




ACTION CARD 5:

SENIOR NURSING STAFF

TRUST LEVEL

‘GREEN’

Normal working ensure you are aware of Trust Status

Respond to escalation requests from the CDM as required.

Ensure good working practices are being followed in all wards in relation to patient flow/ safety

‘AMBER’

Actions as per Green

Provide senior support to nursing teams across the divisions as requested.

Escalate any clinical/staffing issues that pose a risk to patient safety to Deputy Director of Nursing if unresolved

‘RED’

Actions as per Green and Amber

Attend Capacity Bed Meetings in hours as detailed in point 3.3

Support ward teams to ensure safe moves are being planned and facilitated

Escalate any clinical/staffing issues that pose a risk to patient safety

Should the Trust need to plan to open extra beds review staffing with divisional staff bleep holders to plan to cover this extra capacity through the next 24-48 hours

If staffing levels are insufficient follow normal protocols for arranging extra staff

Consider cancellation of non-effective shifts across the divisions

‘BLACK’

All Local Green-Amber-Red escalation actions are in place

Support patient safety/capacity as required

Support the teams and Divisions to open up additional beds across the Trust. Risk assess patient moves with medical and nursing staff as requested

Complete any actions from the Capacity Bed Meetings

Cancel non- effective shifts if not already done.

Provide physical presence on wards to support staff and patients




ACTION CARD 6:

DIRECTOR OF NURSING/DEPUTY

TRUST LEVEL

‘GREEN’


‘AMBER’


Respond to actions as requested by ECOO or Deputy to reduce level of escalation

Notify the appropriate support services of any pharmacy or diagnostics issues resulting in delaying the discharge of patients

‘RED’


Respond to escalated requests from the Head of Nursing on any clinical/staffing issues that pose a risk to patient safety

Support any actions requiring liaison with WSCCG in liaison with the ECOO With the Medical Director, ensure that clinical risk across the Trust is kept to a minimum

‘BLACK’


Attend capacity meetings in hours

Respond to escalated requests from ECOO




ACTION CARD 7:

WARD CONSULTANTS / ON CALL CONSULTANTS

‘GREEN’


Undertake ward & board rounds with a focus on discharge planning

Other ward duties, including patient review, as required

Review outlier patients as required

‘AMBER’


Take particular steps to ensure that outliers have been reviewed in a timely fashion

Escalate concerns about delayed discharges or blockages in the system to the Senior Matron

‘RED’


There is an urgent requirement to expedite discharges and engage in reducing capacity pressures

Implement arrangements for daily review to include twice daily board rounds/additional ward rounds where possible

‘BLACK’


Capacity issues causing major operational difficulties presenting risks to patients safety– There is a need for emergency measures to be put into place to manage the situation and to ensure patient safety

Work with the Clinical Director and management team to proactively undertake actions to expedite safe discharges and improve capacity

Report to the capacity / on call team any delays in the system which are hampering ability to undertake assessments for admissions/discharges

Note: At ‘Black’ the AMU consultant should be responsible for actions at the front door i.e. in ED or AMU. PoD should be responsible for any actions involving the wards such as improving the discharges. PoD / GoD would not be called to ED unless the AMU consultant feels they need additional consultant help in which case the AMU consultant should call PoD themselves




ACTION CARD 8:

CLINICAL DIRECTOR

‘GREEN’


Ensure awareness of any capacity issues in the last 24 hours

‘AMBER’


Be aware of medical staffing issues within the Divisions.

‘RED’


Ensure daily senior ward rounds are carried out and provide assurance that patients are being reviewed appropriately

Put plans in place to ensure that all ward patients are ‘senior reviewed’ on a daily basis with a view to expediting discharge

Ascertain the requirement for additional medical staff to assist with the admission and discharge process over the extended 24 hour period.

‘BLACK’


Capacity issues causing major operational difficulties presenting risks to patients. There is a need for emergency measures to be put into place to manage the situation and to ensure patient safety

Work with the Medical Director to access medical capacity and planning

Attend capacity bed meetings

Ensure information available to provide assurance that patients are being reviewed appropriately

In liaison with Lead Clinicians / consultant of the day/week ascertain the requirement for additional medical staff to assist with the admission and discharge process across out of hours periods

Report to the ECOO or Deputy any delays in the system which is hampering ability to undertake assessments for admissions/discharges




ACTION CARD 9:

MEDICAL DIRECTOR

‘GREEN’


‘AMBER’


Respond to actions as requested by ECOO or Deputy to reduce level to green status

Be aware of medical staffing issues within the Divisions

‘RED’


Capacity issues causing major operational difficulties – There is an urgent requirement to work across directorates to expedite discharges and engage in ‘Reducing capacity pressure

Liaise with CDs to put plans in place to ensure that all ward patients are ‘senior reviewed’ on a daily basis with a view to expediting discharge

‘BLACK’

All Local Green- Amber -Red escalation actions are in place

Capacity issues causing major operational difficulties presenting risks to patients – There is a need for emergency measures to be put into place to manage the situation and to ensure patient safety. All Local Green-Amber-Red escalation actions are in place

Work alongside ECOO or Deputy to access medical capacity and planning. Attend capacity pressure bed meetings

Contact Clinical Directors for assurance that patients are being reviewed appropriately

In conjunction with the Director of Nursing, ensure that clinical risk across the Trust is kept to a minimum

In liaison with Clinical Directors ascertain the requirement for additional medical staff to assist with the admission and discharge process




ACTION CARD 10:

DISCHARGE PLANNING TEAM LEAD

TRUST LEVEL

‘GREEN’


Provide information on discharge delays to support Suffolk system wide sitrep.

‘AMBER’


Respond to requests from operational managers

Collate information in preparation for escalated capacity meetings

Escalate discharge and medically fit delays at capacity meetings

‘RED’


Attend capacity meetings in hours

Attend system wide teleconferences as required.

‘BLACK’


Support ACS and ward areas in the risk management of expected discharges.

Facilitate use of any additional community capacity identified as quickly and safely as possible




ACTION CARD 11:

DIVISIONAL MANAGEMENT REPRESENTATIVE ( DGM /Service Manager)

‘GREEN’


‘AMBER’


Ensure ward and board rounds are occurring as planned

Liaise with Lead Clinician regarding any gaps in medical cover

Respond to issues from wards, CDM and CBC relating to flow within the Division

Ensure all outliers have been identified and reviewed by medical teams

‘RED’


Gain assurance regarding discharges and any blocks to patient flow

Attend Capacity Bed Meetings to assist in Trust wide capacity planning ensuring you have up to date information regarding your Division

Gain a comprehensive understanding of medical staffing issues in relation to high numbers of patients

Participate in the decision on escalation process/plan to increase capacity throughout the Trust

‘BLACK’


Respond to actions as directed by ECOO or Deputy

Provide up to date capacity plans for your Division to the ECOO or Deputy

Agree and implement contingency actions aimed at reducing escalation level

Implement actions required in relation to planned activity for the next 24-48 hrs




ACTION CARD 12: CHIEF PHARMACIST PHARMACY/ DEPUTY

‘GREEN’

Expedite TTOs for patients being discharged a.m. ward round Chief Pharmacist receives bed state updates and reviews status


‘AMBER’


Inform departmental staff of ‘‘Amber’ status

Alert Clinical Pharmacists to Amber status

Ensure ward based Pharmacists and Pharmacy Technicians are instructed to prioritise discharge work on the wards.

‘RED’


Review training activity and cancel if required

Re- Direct staff to essential duties in the department

Assess requirement to review late night cover & advise team of Red status

‘BLACK’


All departmental staff informed of black status

Clinical Pharmacists will be alerted to black status

Attend capacity meetings and provide update of TTO activity and departmental status




ACTION CARD 13:

HEAD THERAPIES/DEPUTY

‘GREEN’


‘AMBER


Ensure therapy teams are aware of Trust escalation status and highlight to Clinical Leads any areas of concern

Reallocate staff as necessary to prioritise patient flow

Review all caseloads and prioritise across in-patient service (all Directorates).

‘RED’


Attend capacity bed meetings as designated times & additional if requested to do so

Review any areas of concern following the regular bed meetings

‘BLACK’


Teams to get handover / attend all board rounds – redirect staff to cover as necessary

All training activity cancelled and staff re-directed to essential duties in the department




ACTION CARD14:

RADIOLOGY SERVICES MANAGER/DEPUTY

‘GREEN’


‘AMBER’


Radiology Services Manager will review the daily bed status and highlight any areas of concern

Staff will be reallocated within department to support service, if necessary – decision by Radiology Services Manager

In the event of staff shortages, review all workloads/ lists and prioritise in-patient examination

‘RED’


Attend capacity bed meetings as designated times & additional if requested to do so

Review any areas of concern following the regular bed meetings

‘BLACK’

All local Green- Amber -Red escalation actions are in place

Review working hours prioritise in-patient examination and patients waiting for discharge

If service continues with unacceptable low staffing consider using agency staff or offer overtime

Cancel mandatory training and attendance at LDS courses etc. Review working hours and also look at modality booked lists prioritise in-patient examinations and patients waiting for discharge.




ACTION CARD 15:

FACILITIES REPRESENTATIVE

TRUST LEVEL

‘GREEN’


‘AMBER’


Respond to requests from operational managers

Collate information in preparation for escalated capacity meetings

‘RED’


‘BLACK’


Attend capacity meetings

Support in the resolution of issues relating to estates and operational logistics e.g. Additional beds, laundry

Contact each ward to establish requirements

Note: Out of hours the Portering Superviser will be called when on BLACK.




12.0 Appendix 3 – Trust Level Expectations

LEVEL 1 STEADY STATE

INPATIENT WARDS ED, AMU & CRITICAL CARE PATIENT FLOW /

DISCHARGE Expectation Expectation Expectation

< 85% bed occupancy

Emergency admissions within forecast to 10%

Elective programme activity accommodated

Staffing levels by shift – core and actual within forecast <10%

No external influences present e.g. norovirus

Clinical Support Service provision normal with daily plans

ACS service provision normal

Transport service provision normal

100% EDD compliance for patients with LOS > 24hours

Capacity to cope with inbound screen. Attendances within forecast up to 10%

All ambulance arrivals are triaged with 15mins of arrival

No ambulance turnaround delays.

Compliance with button submit target >90%

Emergency Department is not below the safe minimum medical and nursing staffing level on any shift.

Waiting times less than 1hrs for first contact with assessing clinician for majors and ambulatory care.

Clinical pathways followed with stroke nurse available for specialist input.

100% of patients spend less than 4hrs in Emergency department from arrival to discharge/transfer.

50% of treatment areas within the Emergency Department available for use and 2 resuscitation bays available.

100% of discharge summaries completed in a timely manner

No psychiatric liaison service delays.

EAU trolley capacity– 5 trolleys

No area below safe minimum medical and nursing staffing level for

Predicted discharge exceeds required capacity to achieve a minimum of 25 beds and matches the predicted time of activity

Patients admitted into appropriate speciality beds

Workforce resources agreed in the ward/departments operational plans support service delivery

Discharge Planning Team, Rapid Response Team and Local Healthcare Teams dealing with referrals within their performance indicators

Less than 5 DTOC patients within the system




the next 24 hours

Clinical support provision normal

ACS service provision normal

Greater than 2 critical care bed available

< 25% of Emergency Department attendances resulting in admissions




LEVEL 2 (EARLY WARNING)

INPATIENT WARDS ED, AMU & CRITICAL

CARE PATIENT FLOW / DISCHARGE

Expectation Expectation Expectation

Bed occupancy >85% - < 90%

>0.8% - <0.9% of elective Operations cancelled

Number of emergency admissions to Trust 105 more than predicted

Staffing levels by shift – core and actual fall >10% - <24% ( Medical, Nursing, AHP’s, Clinical Support services OCS)

No external influences present e.g. norovirus

Transport service provision risks can be mitigated

Non Compliance with EDD for patients with LOS >24 hours by 10%

Demand at 10% more than predicted

>25% - <30% Emergency Department attendances resulting in admissions

Stretcher capacity is only able to accommodate inbound screen.

More than 1 patient unable to be triaged within 15mins

Ambulance turnaround time not delivered by <27% - >24%

Compliance with button submit target not delivered <90% - >81%

30% of treatment areas in Emergency Department available for use.

Waiting times identified to be increasing for first contact with decision making clinician for both majors and ambulatory care with 1 patient in excess of 60min criteria

>2 98% performance target breaches anticipated in Emergency Department

The stroke service is unable to support the dept

Inability to complete >95% of discharge summaries in timely manner

Psychiatric liaison

Predicted discharge is less than required to achieve 85% bed occupancy

Patients admitted to appropriate speciality beds

Workforce resources agreed in the ward/departments operational plans support service delivery

Discharge Planning Team, Rapid Response Team and Local Healthcare Teams dealing with red and amber referrals within their performance indicators but green referrals building up

Transport service provision normal

>5 -<9 DTOC patients within the system




service normal with no contributing delays to 98% performance breaches.

Active trauma call in progress/expected.

2 critical care beds available

EAU trolley capacity is 2-3 trolleys

Risks associated for patient safety in relation to physical resources can be mitigated ( Medical, Nursing AHP’s, Clinical Support services OCS)




LEVEL 3

INPATIENT WARDS ED, AMU& CRITICAL CARE PATIENT FLOW /DISCHARGE


Bed occupancy >90% - <98%

>0.9% - <1% Elective operations cancelled

Emergency admissions at >15% - <19% more than predicted

Staffing levels by shift – core and actual fall >24% - <25% ( Medical Nursing AHP’s, Clinical Support services ISS)

External influences present that can affect patient flow e.g. norovirus, adverse weather conditions

Transport service provision cannot be rectified within the day

Non-compliant with EDD for patients with LOS >24hours by 30%

Demand at >15% - <19% more than predicted

.30% - < 35% ED attendances resulting in admission

Insufficient capacity to cope with inbound screen.

Ambulance turnaround time not delivered by <48% - >42%

Compliance with button submit target not delivered <80% - >75%

Waiting time >60mins for first contact with decision making clinician in majors and >2.5hrs in ambulatory care

No majors cubicles available for assessment and triage of clinically deteriorating patients

Key clinical equipment fully utilised or unavailable

No immediate identification of bed availability.

Emergency department patients not receiving regular observations in accordance to triage status.

Increasing risk to patients and staff as numbers of patients awaiting assessment increase.

2 resuscitation beds out of the 3 in active use.

>4 98% performance target breaches anticipated in emergency department.

Psychiatric liaison service delays

Predicted discharge is less than required to achieve .>85% - ,90% bed occupancy

Beds available do not match speciality demand and no repatriation is possible

Workforce resources agreed in the ward/departments operational plans do not support service delivery

Discharge Planning Team, Rapid Response Team and Local Healthcare Teams dealing with red within their performance indicators but amber and green referrals delayed

Transport service provision compromised

>10 - <15 DTOC patients within the system




contributing to 98% performance breaches.

One critical care bed available

Risks associated for patient safety in relation to physical resources cannot be mitigated – core residual risk 15-20 (Medical Nursing AHP’s, Clinical Support services OCS)




LEVEL 4

INPATIENT WARDS ED, EAU & Critical Care PATIENT FLOW /

DISCHARGE


Bed occupancy >98%

All possible elective admissions deferred. Elective operations cancelled >1%

Emergency admissions at >20% more than predicted

No patient flow

Any untoward incident that affects patient flow

Staffing levels by shift – core and actual fall >25% ( Medical Nursing AHP’s, Clinical Support services ISS)

External influences present that can affect patient flow e.g. norovirus, adverse weather conditions

Transport service provision cannot be rectified within the day

Non-compliant with EDD for patients with LOS >24 hours by 50%

Demand at 20% more than predicted

>35% Emergency Department attendances resulting in admission

Insufficient capacity to cope with inbound screen.

Ambulance turnaround time not delivered >48%

Compliance with button submit target not delivered by <75%

Waiting time >60MINS for first contact with decision making clinician in majors and >2.5 hours in Ambulatory care.

No majors cubicles available for assessment and triage of any patients – unable to offload

Emergency Department patients not receiving regular observations in accordance to triage status.

Increasing risk to patients and staff as numbers of patients awaiting assessments increase.

All 3 resuscitation beds in active use.

>6 98% performance target breaches occurring or anticipated in Emergency Department.

No specialist service support available to support dept

Psychiatric liaison service delays contributing to 98% performance breaches.

Zero critical care bed

No further discharges identified within 48 hours

Discharge Planning Team, Rapid Response Team and Local Healthcare Teams not dealing with red, amber and green within their performance indicators.

Transport service provision compromised

>15 DTOC patients within the system




availability

No immediate information re bed availability for EAU or specialist beds

Risks associated for patient safety in relation to physical resources cannot be mitigated – core residual risk 15-20 ( Medical Nursing AHP’s, Clinical Support services OCS)

Version Control

Version Number Date of Release Details

Version 1 12 November 2013 Approved by Operational Steering Group 11 November 2013

Version 1.1 25 November 2013 Amendment approved by Operational Steering Group 25 November 2013

Version 1.2 17 December 2013

Amendments approved by Operational Steering Group 9 December 2013

Version 1.3 02 December 2014 Document Review

Version 1.4 21 January 2015 Amendments to previous version made

Version 1.5 9th July 2015 Document review and amendments made

Version 1.6 19th February 2016 Document review and amendments made

Contributors The following people have contributed to the development of this plan

Name Role / Organisation

Jon Green Executive Chief Operating Officer

Annie Campbell Deputy General Manager

Helen Beck Deputy Chief Operating Officer

Pam Chrispin Medical Director




Related documents

Plans / polices / procedures to be read in conjunction with this plan

Adult Bed Capacity Management Policy

ED Internal Escalation Plan

County-wide Escalation Plan

Major Incident Policy

Ambulance Turnaround Protocol (NHSE)

12 hour waits (NHSE)

Ambulance Divert Protocol (NHSE)

Author(s): Version 1.2 Gerald Kelly – Patient Access Development Manager. Version 1.3, 1.4 & 1.5 Annie Campbell – Deputy General Manager, Emergency Access, Medical Division

Other contributors:

Detailed on page 42 of the policy

Approvals and endorsements: Operational Steering Group

Consultation: Operational Steering Group

Issue no: 2

File name: S:\CHIEF OPERATING OFFICER\Internal Escalation Plan

Supercedes: PP(13) 304

Equality Assessed Yes

Implementation Trust wide, Intranet, and website

Monitoring: (give brief details how this will be done)

Operational Steering Group

Other relevant policies/documents & references:

Adult Bed Capacity Policy

Additional Information: N/A

patient flow internal escalation - wsh.nhs.uk15)304internalescalation.pdf · trust policy and...

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