Page 7. DEFINITIONS Page 7. ORGANISATIONAL STRUCTURE AND KEY DUTIES Page 7. ROLES AND RESPONSIBILITIES Page 7. PROCEDURE Page 16. TRAINING Page 16. REFERENCES AND ASSOCIATED DOCUMENTATION Page 17. EQUALITY IMPACT ASSESSMENT Page 17. MONITORING COMPLIANCE WITH PROCEDURAL DOCUMENTS Page 18. APPENDIX A - PHT Trust Escalation Status and Triggers Page 20. APPENDIX B - Definitions and Explanations of Abbreviations Page 22. APPENDIX C - Organisational Structure and Key Duties Page 24. APPENDIX D - Roles and Responsibilities of Staff Page 31. APPENDIX E - Identifying and Managing OPEL 4/Black Status Page 33. APPENDIX F - Definition of System Escalation Status for A&E Delivery Boards Page 34. APPENDIX G - Emergency Department Trigger Tool & Escalation Plan Page 35. APPENDIX H - Management of Patients Held within Ambulance Handover and in Ambulances Page 37. APPENDIX I - Quick Use Action Cards Page 51. APPENDIX J – CSC Escalation Plans Page 102. APPENDIX K – Action Card Medical Staffing Out of Hours Page 104. APPENDIX L:- Command and Control in Critical Incident Page 105. APPENDIX M – Requesting an Ambulance Divert Page 106. APPENDIX N - Partner Escalation Triggers Page 110. APPENDIX O – Partner Escalation Actions Page 118. APPENDIX P - Patient A&E Wait Reporting Procedure (NHS England) Page 120. APPENDIX Q - Standardised Agenda and Reporting Template for Teleconference Page 121. APPENDIX R - Risk Assessment tool for inpatient moves Page 122. APPENDIX S - Cardiac Day Unit Standard Operating Procedure Page 127. APPENDIX T - Renal Day Unit Standard Operating Procedure Page 133. APPENDIX U – CHAT-Recovery Standard Operating Procedure Page 138. APPENDIX V – 1-up beds local SOPs and risk assessments Page 146. EQUALITY IMPACT SCREENING TOOL QUICK REFERENCE GUIDE This policy must be followed in full when developing or reviewing and amending Trust procedural documents. For quick reference the guides below is a summary of actions required. This does not negate the
Escalation Status Service Managed Unfunded Supplementary Capacity General Unfunded Escalation Capacity Use of unfunded capacity augments funded service/general capacity described Total Unfunded Capacity Open Cumulative Additional Capacity Staffing Plan Green (Opel 1) Funded capacity 0 0 Normal staffing plan * Up to a maximum of Area Bed spaces* Area Bed spaces* Amber (OPEL 2) CDU 4 C6/7 4 4 Additional staffing organised by CSC Red (OPEL 3) CDU 5 C6/7 14 18 Additional staffing organised by CSCs RDU 4 G6-9 Recovery 7 Surgical bed base D8 Amb 2 D8 bed base Black (OPEL 4) CDU 6 C6/7 19 37 As above plus: Research nurses; facing corporate; Cancelling meetings and training; Volunteers RDU 6 G6-9 Recovery 9 Surgical bed base A6 Amb 1 A6 bed base AOS Amb 2 F5-7 D8 Amb 4 D8 bed base AMU AEC 3 AMU G5 Endo 2 Medical bed base 1-up beds 4 Funded bed base ADDITIONAL CAPACITY BELOW ONLY TO BE CONSIDERED ON INTERNAL INCIDENT AND AGREED BY PHT GOLD COMMAND Internal Critical Incident CDU 10 C6/7 22 59 As on Black RDU 7 G6-9 A6 Amb 2 A6 bed base AOS Amb 4 F5-7 Recovery 12 Surgical bed base AMU AEC 5 AMU D Level endoscopy 9 Medical Bed Base Capacity Ladder - areas described at each escalation level provide a menu of flexible options according to variable service needs; services may choose to use their own supplementary capacity at lower escalation levels and in greater numbers than described below at their own discretion; the use of unfunded capacity including 1-up beds must be supported by a standard SOP for each area and an associated risk assessment tool used for each individual patient.
Heads of Departments Theatres General Manager Normal Working/Low Risk Normal Working/Low Risk Ensure that no patients discharge is delayed due to waiting for an assessment or test Review theatre capacity for emergency and elective lists, ensure plans in place to utilise resources effectively to avoid cancellations Moderate Risk - As above plus:- - Moderate Risk - As above plus:- - Review the level of activity, ensuring that any delays are escalated to CSC Escalation Lead to be resolved Remind requesters of suspended admission procedure Check right staff being available Check reporting capacity Check equipment capacity Review the level of emergency cases, ensuring that patients who require surgery today receive their treatment Consider with CSC’s if patients can move to day case surgery Facilitate the cancellation of non-urgent elective activity with CSC’s concerned being mindful of RTT targets Surgical specialties agree which patients can go to theatres and liaise directly with the Theatre Coordinator and the CHAT CSC Escalation Lead High Risk - As above plus:- High Risk - As above plus:- Discuss and plan for extended opening and enhanced cover with DHM and CSC lead for escalation Ensure extended opening and enhanced cover is provided to remove any delays if requested by DHM Establish additional lists to ensure back log is addressed Surgical specialties compile a list of those patients who are considered clinically urgent and must receive surgery on the day, and liaise directly with the Theatre Coordinator and the CHAT CSC Escalation Lead As lists are cancelled liaise with Matron (staffing) and release staff to wards DHM advised of the number of beds required to support this activity Very High Risk - As above plus:- Very High Risk - As above plus:- Black Provide additional staff to areas of need to assist with balancing safety Utilise recovery as an escalation area
At least 3 of the following apply:- ED is experiencing a peak of demand of 12-19 patients per hour (or more) for 2 consecutive Risk of ambulance arrivals not having 15 minute Assessment Ambulances being held for 15-30 minutes Failure to deliver PITSTOP process robustly to patients on majors Delays in initial assessment(clinical) over 60 minutes More than 21 patients in total in ED (/Majors 1&2/ /Resus) Unable to release the ambulance within 15 mins of arrival to ED Similar triggers apply to delays in Minors and Paediatrics. Triggers for delays in first and initial assessments combined with poor flow should be alerted to CIC and consultant/senior doctor and nurse in PED 1 available space in Resus 2 + registered short on a shift. Lack of SpR on early, late or night shift or more than 1 SHO absent from single shift Escalate any patients with delays in assessment over 15 mins to the NIC who will divert resources to meet 15-minute assessment Ensure Matron, DHM are aware of total number of patients in ED with DTAs Consultant in Charge will ensure: PITSTOP remains operational, junior doctors are supported in decision making, re-deployment of staff to meet demands Ensure PITSTOP does not delay ambulance offload when capacity across Majors A delay in referred patients being seen within 60 minutes are escalated to relevant on call consultant and Ops Centre notified Ensure all staff including FIT move suitable patients to the Discharge Lounge Consider flexing criteria for EDU to enhance performance and minimise risk Escalate through Matron/HON and staffing meetings if not filling with NHSP and consider requesting Agency usage. Consider requesting additional HCSW to replace 1 depending on skill mix. Increase ambulance streaming capacity Deployed additional staff and HCSW to ambulance streaming Medical staffing: ensure both ED and AMU juniors are seeing patients effectively. Support decision making across Majors NiC and CiC to ensure DATIX is used to record any clinical impacts on patients as per ED Trigger list for incidents, ambulance holds, or failure to meet assessment standards Additional nursing staff allocated to initiate early ECG and observations Review outcome of escalations
Bed Meeting Times Triggers Actions as above and the following Ops meetings and additional rounds in SAU and wards At 3 of the following apply:- Staffing ratio = Red Inability to admit to SAU / Wards or queue of patients to access Unable to accommodate SHCU / Critical Care repatriations Cancelling some elective activity Insufficient discharges confirmed/potential in place to support activity Convert SPA/Admin to direct clinical care sessions to enable further reviews of in patients Cease Elective operating / minimise to urgent cancer only Identify surgical patients to 1 up capacity Consider reducing threshold for discharge Review tomorrows elective activity and cancel as appropriate Review tomorrows routine / training / SPA times and convert as appropriate Conversion on SPA/Training/Admin time to Direct Clinical Care sessions When inpatient reviews have been exhausted, provide clinical support to ED in the event of queuing and attempt to turn patients around at earliest opportunity Bed Meeting Times Triggers Actions as above and the following Inability to outlie surgical patients Cancelling majority of elective activity Insufficient discharges confirmed/potential in place to support activity Identify further patients for additional areas to go 1 up All clinical staff on managerial sessions over 24-48 hours to be identified and deployed to clinical provision. Provide Senior Decision Maker to ED
MSK CSC Escalation Plan Bed Meeting Triggers Actions to maintain position and prevent deterioration 0730 & 1330 Plus 0800 Trauma meeting At least 3 of the following apply:- Bed capacity Trauma / Elective Unfunded beds closed Ability to maintain Fast capacity Outliers not impacting on activity EDDs in to support demand of 10 Staffing ratio = Green Wards review outliers - check teams have seen patients and escalate to Ops Team if not Utilise Discharge Lounge for all patients (except meeting exception criteria) Maintain Patient Flow Bundle SAFER principles Identify ‘early bird’ patients for tomorrow Ensure appropriate referrals are made timely Review all patient journey boards and RAG rating of patients Escalation of remaining EDDs Ability to pull from ED in line with Professional Standards Utilisation of QA@Home Keep Bedview updated real-time Full use of IDS Pathway Bed Meeting Triggers Actions as above and the following 0730 & 1330 Silver to attend Plus 0800 Trauma meeting At least 3 of the following apply:- Staffing = Amber 7 - 9 EDDs in place to support demand Elective demand more than capacity (skill/beds) Review elective cases – identify potential cancellations Consider conversion to DSU Escalation of patients awaiting OOA repatriation Extra Senior decision maker Ward rounds and / or further clinical reviews to be requested Adjust criteria for admissions
HIGH RISK CSC Bed Meeting Times Triggers Actions as above and the following 07.30 Board Round MFU 07:45 Handover 08:00 Elective Meeting 08:00 – 08:45 Ward Round 13:00 – 14:00 Post Op 17:00 – 18:00 Ward Round At 3 of the following apply:- Staffing ratio Red EDDs not sufficient to accommodate demand. No Escape Bed No nurse for the emergency treatment room Increased demand through Treatment More than 2 ECO required Surgical flow to link with CSC Silver Bleep 0192. Consultant contacted Flex Discharge Criteria Consider Elective Programme R2G update and escalate Staffing 4+2 Treatment room nil cover HIGH RISK CSC Bed Meeting Times Triggers Actions as above and the following 07.30 Round MFU 07:45 Nurse Handover 08:00 Elective Meeting 08:00 – 08:45 Ward 13:00 – 14:00 Post Op 17:00 – 18:00 Ward Round At least 3 of the following apply:- No ECO available No treatment EDDs not sufficient to accommodate demand. No Escape Bed Increased demand through Treatment Not able to accommodate ITU demand No capacity to repatriate from trusts Cease Supernumerary shifts Re allocate SPA to support the ward SMT to cancel meetings to support Consultant informed / reviews Routine Elective Cancelled Review case mix across Treatment / Clinic environment No treatment room staff. Bed Meeting / Huddle Triggers Actions to maintain position and prevent deterioration
Create list of escalations. 1500 Review all PDDs Identify planned discharge times Ensure flow to DC lounge Create list of escalations. Identify birds for next day, EDD for tomorrow and outlier lists MFFD between 41-70 (for the Trust) 1 CCU bed/1 Resp High Care bed Staffing = Amber Flow rep for CSC will work with Ops Centre to identify potential outliers Ensure CoS, GM and HoN aware if potential to deteriorate to OPEL 3 Bed Meeting Triggers Actions as above and the following Twice daily operational meetings chaired by Silver 1100 Review of all PDDs and MFFD Identify planned discharge times Ensure flow to DC lounge Create list of escalations. 1500 Review all PDDs Identify planned discharge times Ensure flow to DC lounge Create list of escalations. At least 3 of the following apply:- Bed capacity – EDD’s <34 discharges Risk of single sex breaches Outliers 16 – 20 MFFD between 71-100 (for the Trust) No CCU capacity No Resp High Care bed Staffing ratio = Red As per OPEL 2 PLUS: Non patient facing nurses work to support where feasible Matrons to attend board rounds/ward areas at start of day or when OPEL 3 declared to ensure areas fully supported and escalations being made and acted upon Silver to clear diary to support flow, wards and ops centre and manage escalations GM or HoN to support Silver at Trust Ops meetings Silver to review elective demand and risk assess cancellations with relevant clinical teams When inpatient reviews have been exhausted, provide clinical support to ED in the event of queuing and attempt to turn patients around at earliest opportunity Allocate / book staff for CDU if agreed at Trust Ops meetings
Identify Early birds for next day, EDD for tomorrow and outlier lists GM or HoN attendance indicated Senior Team to support Silver, flow and clinical teams with escalations, operational planning, decision making and wider communication. Ensure robust management of any IDS delays, provide timescales for feedback of actions, hold to account and escalate to Ops Lead of any external concerns GM/HoN/CoS to ensure all CDs, Consultants and Senior decision makers are aware of escalation status and plans to mitigate At 3pm meeting review elective demand for following day (Inc. CDU) and discuss as part of 16:00 ops meeting Bed Meeting Triggers Actions as above and the following Twice daily operational meetings chaired by GM, HoN or Matron 1100 Review of all PDDs and MFFD Identify planned discharge times Ensure flow to DC lounge Create list of escalations and agree actions. 1500 Review all PDDs Identify planned discharge Ensure flow to DC lounge Create list of escalations and agree actions. Identify Early birds for When Trust declares OPEL 4 status, or for the CSC IF at least 3 of the following apply:- Bed capacity – EDDs less than 15 discharges Outliers 20+ MFFD >101 (for the Trust) No CCU bed No Resp High Care bed As per OPEL 3PLUS: Cancel all non urgent / routine elective inpatient work GM/HoN/CoS to ensure all Consultants and Senior decision makers are aware of deterioration of escalation status and plans to mitigate CoS or On call Consultant to attend 1600 ops meeting if able or send a deputy HoN/General Manager/CoS to review planned leave for next 48 hrs and are accountable for deciding what study leave is required and what should be cancelled. Consultants to provide additional ward team support. When inpatient reviews have been completed, provide clinical support to AMU and ED to support admission avoidance. SMT to cancel all meetings to support Consultant lead informed / reviews Review case mix across Treatment / Clinic environment
No Critical care bed available No patients ready for transfer to ward Patients referred and awaiting admission Cancellation of Critical Care elective patients No repatriations possible Non-clinical transfer possible Staffing ratio = Red All non-ward based Nursing staff to provide support All clinical staff on managerial sessions over 24-48 hours to be identified and deployed to clinical provision. CHAT Escalation Plan Escalation Status Capacity Plan Staffing Consequences & Risks No outliers overnight As per rotas Normal theatre activity with all lists running CHAT silver will confirm elective bed availability to D & E-Level Coordinators & TAS following 8 a.m. bed meeting. Day Surgery & TAS open. No outliers overnight As per rotas Normal theatre activity with all lists running CHAT silver will confirm elective bed availability to D & E-Level Coordinators & TAS following 8 a.m. bed meeting. Day Surgery & TAS open. RED Maximum of 7Outliers overnight. All patients to be risk assessed as suitabal as to CHAT outlier SOP. 1Trust RN from appropriate Surgical CSC &1CSW Surgical CSC’s to review bedbase with potential cancellation of some routine cases at the 8am bed meeting. CHAT Silver will confirm changes with D & E coordinators & TAS. Plan for day cases to commence lists. Recovery plan to support overnight patients. Maximum of 9 post-operative surgical patients 2xTrust RN from appropriate Surgical CSC & 1xCSW Surgical CSC’s to review bed base with the view to cancel all routine cases and review clinically urgent cases and confirm with CHAT Silver at the 8am Bed meeting.
management team before transferring new or additional patients to Recovery Theatre and Anaesthetic staff redeployed to Recovery and clinical areas outside Theatres Decisions informed by senior clinicians from theatres and surgery considering risk to clinically urgent, cancer wait patients and capacity for emergency patients Consideration to the risk to Critical Care expansion area in Paediatric Recovery if used for outlying of surgical and medical patients There is risk of prolonged occupation of recovery, because of poor selection of outlier patients, to the capacity to treat inpatient and day cases on both E and D level (typically 50% of day cases are patients being investigated or treated for cancer) EXTERNAL MAJOR INCIDENT Theatres and Recovery used to the needs of and risk to the hospital Implement MI Plan Life and Limb surgery only – urgent senior clinical review by all surgical specialties to prioritise cases. Regular review of emergency capacity on the day and for next 48 hours by senior clinicians from Surgery and Theatre
Radiology team may be asked to assist with portering B7 or Supt will inform radiologists that will be double IP lists for reporting on hotseat reporting work list Escalation email sent out from Clinical Director to clinicians to request careful consideration of referrals Head of Department - Pathology Head of Department - Pharmacy Normal Working/Low Risk Normal Working/Low Risk Usual Pathology activity undertaken. Training, appraisals, quality systems and regulatory preparation. Prioritisation according to workload outstanding and emergency/inpatient demand Usual pharmacy processes undertaken. Clinical and dispensary services. Training, appraisals, quality systems and regulatory preparation. Prioritisation according to workload outstanding. Moderate Risk - As above plus: Moderate Risk - As above plus: Usual Pathology activity undertaken. Training, appraisals, quality systems and regulatory preparation. Prioritisation according to workload outstanding and emergency/inpatient demand Usual pharmacy processes undertaken. Clinical and dispensary services. Training, appraisals, quality systems and regulatory preparation. Prioritisation according to workload outstanding. High Risk - As above plus: High Risk - As above plus: Pathology activity undertaken. Training, appraisals, quality systems and regulatory preparation would be reviewed. Non-essential meetings cancelled. Prioritisation according to workload outstanding and emergency/inpatient demand including discharge dependent tests. pharmacy processes undertaken. Clinical and dispensary services. Reduction in training, appraisals, quality systems and regulatory preparation according to priority. Meetings suspended. Prioritisation and redistribution of pharmacy staff according to workload outstanding. Internal and External Black Very High Risk - As above plus: Internal and External Very High Risk - As above plus: Usual Pathology activity undertaken. Priority given to inpatient and emergency demand including discharge dependent activity. Increased management oversight within the laboratory. All non patient facing activities suspended. Pharmacy staff reallocated to high pressure areas within the Trust where possible in order to support safety and flow.
Appendix Q- Standardised Agenda and Reporting Template for Teleconference Appendix R – A PATIENT TRANSFER TOOL TO EVALUATE THE LEVEL OF RISK FOR INPATIENT MOVES TRUST STATUS: DATE: It is well documented that internal patient moves increases length of stay and has multiple risk factors associated with an elongated length of stay. To minimise against the potential risks to all parties involved in the transfer there must be a clear understanding of the need to move the patient using a systematic physical assessment, an assessment of the situation, confirm the routes of communication, documentation and identification of clinical equipment required to provide a safe transfer experience for patients and clinical staff. Name of Patient: DOB: Name of person requesting move: Could be DHM for escalation reasons Patient EWS Oxygen Requirements? O2%: Mask Type: O2 Flow: Other Equipment Required? Reason for Move: Clinical Requirement for this Patient? Please Detail: Clinical Requirement for another Patient Please Detail: Patient Condition: Yes No Comments: Elevated EWS with no management plan (CODE RED) Imminently dying/ Last few days of life / EOL pathway Dementia / cognitive impairment learning difficulties Patient under care of Safe guarding / DOLS/ MH Act Suspected / Known Infection Please detail the number of previous moves: Moves History: Risk Use score card overleaf to determine level of risk: Continue to move patient? Yes No Signed: Define main risk: Patient Communicated with? Yes No Signed: If the patient must be moved despite meeting any of the criteria above please provide explanation and detail risk mitigation below: Patient Medical Team Informed Yes No Time: Method: Who else was informed? e.g other staff / family / carer Time: Method:
Escalation of A5 care spaces Think Out of hours bleep appropriate Duty Matron/ H@N for support In hours Bleep 1443 – Silver and Matron/HoN Numbers Matron within hours bleep 1216 Duty Matron out of bleep 0119 H@N at bleep 0119 Do appropriate team member to inform them GAU is unable to take patients from ED. Bleep Numbers Ward Matron within hours bleep 1216 In hours inform HoN/GM Duty Matron out of hours bleep 0119 H@N at bleep 0119 Complete DATIX to identify patients in A5 care spaces only & all appropriate actions you have taken to manage the risk Complete DATIX detailing All risk assessment undertaken Actions taken by ward to maintain safety and dignity of the patients and for patients in A5 Care spaces Document All actions to be documented in patient notes EQUALITY IMPACT SCREENING TOOL 1 - Screening Title of Procedural Document: Trust Capacity Management Policy (inc. Escalation Measures)
Date of Assessment 08/01/18 Responsible Department Corporate Functions Name of person completing assessment M Roland Job Title Associate Medical Director – Operations Does the policy/function affect one group less or more favourably than another on the basis of : Yes/No Comments Age No Disability No Gender reassignment No Pregnancy and Maternity No Race No Sex No Religion or Belief No Sexual Orientation No Marriage and Civil Partnership No If the answer to all of the above questions is NO, the EIA is complete. If YES, a full impact assessment is required: go on to stage 2, page 2 More Information can be found be following the link below To be completed and attached to any procedural document when submitted to the appropriate committee for consideration and approval for service and policy changes/amendments