02 Updated with comments from Alison ENHT Phil Lumbard 19.10.2015 03 Updated with comments received at the WSCC top exercise on 21st October 2015. Phil Lumbard 26.10.2015 04 Updated with changes from JB Jo Burlingham 02.11.2015 05 Grammatical and Format Changes Jane Wallis 30.11.2015 06 Updated following action & trigger updates from providers Phil Lumbard 17.12.2015 07 Reformatted and system updated Jo Burlingham / Jane Wallis 23.12.2015 08 EEAST triggers & action updated Phil Lumbard 11.1.2016 09 EEAST Reap levels updated Jane Wallis 09.05.2016 10 Updated triggers and actions for HCS Jane Wallis 24.05.2016 11 Updated triggers and actions for ENHT Jane Wallis 13.07.2016 12 Update: 12 hour breach reporting protocol Ambulance divert check lists HCS triggers and actions Updated system matrix Jane Wallis and Jo Field 10.08.2016 13 Updated Halo and Cohorting process on pages 36 and 37. Jane Wallis 24.08.2016 14 Updated to reflect NHS England Central Midlands Escalation Framework September 2016 Jo Burlingham 10.09.2016 15 Updated with changes from ENHT Jo Burlingham/ Barbara Harrison 30.09.2016 16 Updated with changes from EEAST Jo Burlingham/ Steve Davey 30.09.2016 17 Updated with changes from HCS Heidi Hall/ Jane Wallis 04.10.2016 18 Updated with changes from HUC Lucy Markham/Jane Wallis 05.10.2016 19 Updated with Acute in hours visiting service from HUC Jane Wallis 02.11.2016
ENHT Actions Alert Status Capacity Meeting Attendees Divisional Strategic Actions Medicine Emergency Care Surgical Specialties Women & Children Clinical Support Services Trust Status – Green Meeting Chair GM’s Surgery ED Op Lead Bed Managers Medical Bed Bleep Holder Surgical Bed Bleep Holder Nurse in charge ED OCM at 16.00 weekdays Ambulance Transport Discharge Lounge Paediatric Designate Critical Care Designate Imaging representative Pharmacy representative Maternity Designate Business as usual Matrons to assess and mitigate safe staffing levels for all areas for medicine Ensure patient safety and quality maintained (use of DL, AMU ward rounds continue, daily consultant ward rounds, escalate delays to WSCC, EDD’s updates on BIMS, outlier reviews) OOH matron to monitor safe staffing levels and attend 17:00 capacity meetings Flag potential 4 hour standard breach to site team at 3 hours and 3.5 hours in accordance with ED triggers. Notify WSCC Bed managers and Lead Nurse of any staffing or Operational issues which may impact on patient flow or safety. Maintain CDU ward round Maintain triage and DART Models of care. Business as usual Matrons to assess and mitigate safe staffing levels for all areas for medicine Ensure patient safety and quality maintained (use of DL, SAU ward round, prioritization of theatre list for next day, daily consultant ward rounds, escalate delays to WSCC, EDD’s updates on BIMS, outlier reviews) OOH matron to monitor safe staffing levels and attend 17:00 capacity meetings Daily morning Consultant Ward Rounds Promote pre morning discharges Escalate any delays or issues to Paediatric Clinical Coordinator Maintain CAU ward round SDM to see ED referrals in 30 minutes. Ensure Diagnostic Delays are highlighted in time for capacity meetings Have accurate daily data detailing equipment availability Ensure any pharmacy issues/ delays are escalated
Trust Status Amber Divisional Daily Leads Outliers reviewed by 12:00 Consider extra staffing support for key areas Instigate SAFER Bundle Senior ward nurses populate list of patients suitable for escalation areas Ensure planned elective admissions do not compromise emergency admissions WSCC and Divisional Leads to alert NSM, GM & CD to deteriorating position, Feedback to WSCC by the Divisional Senior Management Team as necessary. Review all MF patients for potential discharge Consider specialty support in ED departments and targeting direct admissions to Alert WSCC site Team of any potential or active Ambulance delays Ensure as many Swift beds are utilised as possible whilst adhering to the ward operational policy Senior ward nurses populate list of patients suitable for escalation areas Ensure planned elective admissions do not compromise emergency admissions WSCC NSM, GM & CD to deteriorating position Instigate SAFER Bundle Ensure planned elective admissions do not compromise emergency admissions Alert NSM, CD or GM to deteriorating position Consider additional staffing if required due to patient acuity Consider patient discharge home with Children’s Community Nurse support
Status Red As above plus: 3 NSM’s Deputy Director of Operations GM’s Divisional Directors In addition to the above : Consider cancelling planned routine elective admissions Identify planned activity- e.g. training that may need cancellations Maintain capacity e.g. Produce list of patients who fall just outside of I.C. beds admission criteria Consider additional bed capacity Consider cancelling OPD clinics to facilitate senior ward rounds Review nurse staffing across ALL Divisions with a view for re-deployments and additional capacity e.g. Prepare wards for full Code Crimson: Consider redeploying additional medical & nursing staff to support ED for specified periods i.e. CD of ED consultant is responsible for medical mobilisation action Consider cancelling planned routine elective admissions Identify planned activity- e.g. training that may need cancellations Maintain capacity e.g. Produce list of patients who fall just outside of I.C. beds admission criteria Consider additional bed capacity Consider cancelling OPD clinics to facilitate senior ward rounds Review nurse staffing across ALL Divisions with a view for re-deployments and additional capacity e.g. CNS to support to areas of greatest need Prepare wards for full Capacity Protocol: Consider cancelling planned & elective Paediatric surgical and medical patients Ensure Consultant completes ward rounds as and when required to review and discharge patients Consider cancelling OPD clinics to facilitate senior ward rounds Ascertain where cover can be obtained from neighbouring hospitals Status Black As above plus: 4 Director of Operations Partners from Health & Social Care In addition to the above : Cancel all activity discussion with CD and all lead clinicians Monitor status and activity in specialty Clinical Director & Lead clinicians informed of position, cascades agrees action plan with Clinical Leads Consider cancellation of study time for all ED staff Clinical Director & Lead clinicians informed of position, cascades and agree action plan with clinical Leads Consider cancellation of clinics and Clinical Director & Lead Clinicians informed of position, cascades and agrees action plan with Clinical Consider cancellation of clinics and redeployment of staff Additional Consultant lead rounds Cancellations of all non-emergency activity
areas to ensure service continuity Ensure workforce is used effectively in of greatest need , redeploying staff as necessary e.g. cancel clinics and redeploy staff as necessary Activate Code Crimson Coordinating the use of the CNS/Cooperate Nursing Functions to support Clinical areas Review and cancel non –urgent work to release staff Support the implementation of the full capacity protocol Encourage second consultant led ward rounds to further identify discharges Activate Code Crimson ED Consultants continued on-site presence Consider Ambulance Divert redeployment of staff Additional Consultant lead rounds Cancellations of all non-emergency activity
Alert Status ACTION PERSON RESPONSIBLE Bed Managers to confirm with team leaders or deputy team leaders in acute and older people that all actions outlined in the bed management roles and responsibilities have been taken. Bed Manager Appropriate staff are made aware of the increasing bed pressures either verbally or by email to Ward Consultants, Team Leaders, Modern Matrons, CATT Managers, CMHT managers. Bed Manager If appropriate actions have not been taken by individuals escalate to their line managers Bed Manager Modern Matron/Service line lead to ensure all planned discharges will be delivered or notify bed manager if there are any barriers to achieve planned discharge CATT team to be made aware of increasing bed pressures Modern Matron/Service line lead CATT managers Review the potential shortfall in the number of beds and confirm that all capacity has been utilised before triggering a status alert. Bed Manager Bed Managers to confirm with modern matrons in acute and older peoples that all actions outlined in the bed management duties and responsibilities have been taken. Bed Manager Ward consultants, team leaders and modern matrons are asked to ensure all discharge plans are expedited. Medical Lead for consultants Bed Manager for nursing staff CATT Team Managers and CMHT Managers are asked to ensure discharge plans are expedited. Bed Manager CATT team asked to see all proposed admissions in person before agreeing admission. Modern matron/service line lead Team leaders to update bed manager with confirmed plans and provisional plans Team leaders Service Line and Medical Leads aware of escalated bed pressures. Bed Manager If appropriate actions have not been the Service Line Leader (or deputy) for acute and older people will be informed. Bed Manager To plan in advance for increased escalation during out of periods, particularly weekends and public/bank holidays. Bed Manager/Service line lead
Bed Manager to confirm with modern matrons in and older peoples that all actions outlined in the amber escalation have been taken and ensure actions/support taken are confirmed back. Bed Manager All inpatient consultants and CATT/IOT Managers asked to urgently review service users for whom leave or discharge with intensive support may be appropriate. Service line lead / Clinical Director Clinical leads to review service users for whom leave or discharge with intensive support may be appropriate, if the above action is unsuccessful at providing additional capacity. Matrons/ Acute Service line lead Clinical Directors, Medical Leads, Service Line Leaders and Matrons aware of the need to implement high risk actions above. Feed back progress to bed manager/on call within 2 hours of the alert. Team Leader / Modern Matron Consideration given to breaching Same Sex Accommodation in a managed way. Lead Nurse / Acute Service Line Lead To plan in advance for increased escalation during out of hours and particularly weekends. To predict the length of the shortage of beds to inform directors. Bed Manager/Service Line Lead On call consultants must be consulted out of hours admissions during red bed alert periods On call managers Consider private sector hospital bed for admissions pending. Managing Director / Clinical Director Service line lead to confirm with all modern matrons and service leads in older peoples that all actions outlined in the red escalation have been taken. Acute Service line lead Clinical Directors to ensure that all inpatient consultants and CATT/IOT Managers have reviewed the inpatient caseload; must provide assurance that all current inpatients require admission on basis of risk Clinical Directors Agree if a bed management executive meeting needs to be convened – COO, Director of Quality and Safety , Medical Director in attendance with MDs and Clinical Directors. The decision will be based on the length of time the status is likely to remain black and will be convened if likely length is more than 3 days This can be a virtual meeting. Service line lead/Managing Director Bed Management Exec meeting to consider further purchase of private sector hospital beds, (possibly out of county for admissions pending). Managing Director / Chief Operating Officer
Level of Demand Level of Escalation Action to be taken Level 1 Home Visit- Routine Calls within 4 hours. Urgent visits within 1 No escalation required Calls to be Clinically assessed upon receipt to the car to ensure Calls are visited in order of priority ‘Arrived’ to be marked when arriving at patients address ‘En-route’ to be marked when moving to next visit Use all available resource to ensure even distribution of visits between cars Routine Calls about to breach should be comfort called by the driver and if any deterioration discuss with the Clinician who could review and speak to patient Urgent Visits about to breach should be comfort called by the driver Level 2 Home Visit- Routine Calls within 6 hours Urgent visits within 2 hours. No escalation required Calls to be comfort called by driver to advise of situation and to check for deterioration Continue to ensure even distribution of Comfort Calling should continue to take place for Routine Calls that have breached at least two hourly, and if any deterioration is noted the Clinician should review and speak to patient.* Urgent Visits about to breach should be comfort called by the driver * *Comfort calling can be undertaken by alternative Operational staff eg Receptionist central bookers or despatcher 3 Home Visit- Routine Calls over six hours. Urgent visits over 2 Despatcher (OOH Supervisor) to inform the Shift Manager. Ask existing staff if they could work on. Document all events in Shift Report. Despatcher (OOH Supervisor) to ensure comfort calling continues as per level one and two escalation ensure calls are documented, and patient deterioration is noted, consider GP second contact advice.* Send additional visiting GP & Driver Nominate senior Clinician to re-triage base appointments if available Comfort calling can be undertaken by alternative Operational staff eg Receptionist central bookers or despatcher Level 4
Under extreme pressure and where there is significant risk to multiple DTA +11hrs NHS England DCO Team Director On-call NHS England Regional Senior Manager On-call the system is under extreme pressures and where the DCO Team Director believes: Pressures will require a multi-area co-ordinated response; or To reduce to patients. Trust Director On-call Trust NHS Improvement Portfolio Director If a 12hr breach has occurred: In-hours (i.e. 9am -5pm Monday to Friday) Persons outlined in column B immediately informs respective regional body in Column C CCG Director On-call NHS England DCO Team Senior Manager On-call who will inform the NHS England Regional Senior Manager On call Summary of activity including: Location, number and length of each 12 hour breach Actions and activity undertaken Any other relevant observations 12 hour breaches must be reported as a Serious Incident (SI) on STEISS and a Root Cause Analysis (RCA) should be completed within agreed timeframes. An initial RCA must be completed within 24hrs and shared with Senior Clinical staff to prevent reoccurrence Initial RCA analysis to be completed on all 12hr breaches within <24hrs – and for this to be shared with the NHS England Regional Director of Delivery and NHS England Regional Team Senior Manager On call and NHS Improvement Portfolio Director Trust Director On-call Trust NHS Improvement Portfolio Director If a 12hr breach has occurred: Out of Hours (i.e. 5pm – 9am Monday to Friday, Weekends and Public Holidays) By 1100hrs the following CCG Director On-call NHS England DCO Team Senior Manager On-call who will inform the NHS England Regional Senior Manager On call Summary of overnight Location, number and Actions and activity Any relevant >12 hour breaches must be Analysis (RCA) should be within 24hrs and shared
working day the persons outlined in column B informs their respective regional body in Column C Initial RCA analysis to be completed on all 12hr breaches within <24hrs – and for this to be shared with the NHS England Regional Director of Delivery and NHS England Regional Team Senior Manager On-call and NHS Improvement Portfolio Director. Acute Trust Director On-call Trust NHS Improvement Portfolio Director FORMAL ACCOUNTABILITY PROCEDURE FOR A 12HR TROLLEY BREACH If a 12hr breach has been confirmed: In-hours (i.e. 9am -5pm Monday to Friday) Persons outlined in column B informs immediately their respective regional body in Column C NHS England DCO Team Director On-call NHS England Regional Director and the Regional Director of Delivery Inclusion of information in activity report Summary of numbers; details for all waits >12hr plus any clinical harm impact and report on mitigations that are in place. Acute Trust Chief Executive NHS Improvement Director of Delivery and Development Out of Hours (i.e. 5pm – 9am Monday to Friday, Weekends and Public Holidays) By 1100hrs the following working day the person outlined in column B informs their respective regional director outlined in Column C NHS England DCO Team Director On-call NHS England Regional Senior Manager On-call Inclusion of information in overnight activity report Summary of numbers; details for all waits >12hr plus any clinical harm impact and report on mitigations that were put in place. Acute Trust Chief Executive NHS Improvement Director of Delivery and Development Trust CEO is requested to personally telephone NHS Improvement Director of Delivery and Development in order to explain the reason for the breach, on the day it happens (or if a breach occurs out of hours an update is required the following morning by 11.00am). Summary of the numbers and details regarding any 12hr breaches plus any clinical harm impact and report on mitigations that were put in