02 Updated with comments from Alison ENHT Phil Lumbard 19.10.2015 03 Updated with comments received at the WSCC table 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 index 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/ 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 20 Incorporated OPEL guidance Phil Lumbard Sept 2017 Final OPEL version Phil Lumbard Nov 2017 21 Update with new EEAST Plan Phil Lumbard/Jane Wallis 09.11.2017 21 Update HCT DTC ranges and NSHE patient handover protocol Phil Lumbard Nov 2017 Trial
APPENDIX 1 - East & North Hertfordshire NHS Trust Escalation Triggers and Actions ENHT Dashboard Metrics OPEL 1 OPEL 2 OPEL 3 OPEL 4 Ambulance Handover >15 mins 15-59 60-119 minutes 120+ DTA Patients Waiting to be Admitted < 60 minutes 60 - 120 minutes 121 - 239 minutes >=240 minutes A&E 4 Hour Target >=92% 85.0% - 91.9% 60% - 84.9% <=59.9% Occupancy <93% 94%-96% 97%-99% 100%+ Stranded Patients <45 45 to 69 70 to 89 90+ Medical Staffing Rota No concerns Moderate concerns Severe concerns Extreme concerns Nursing Staffing Rota No concerns Moderate concerns Severe concerns Extreme concerns
ENHT ED Escalation protocol Department time before escalation and action Bronze Silver Gold Platinum Delays in triage 20 minutes after arrival escalate after 20 minutes 20 minutes to action Escalate 40 minutes from commencement if delays continue 20 minutes to action Escalate after 60 minutes from commencement if delays continue 20 minutes to action Escalate after 80 minutes from commencement if delays continue informed of delays greater than 80 minutes Delays in ambulance off load greater than 30 minutes escalate after 30 minutes 15 minutes to action Escalate 45 minutes from commencement if delays continue 15 minutes to action Escalate after 60 minutes from commencement if delays continue 15 minutes to action Escalate 75 minutes from commencement if delays continue informed of delays greater than 75 minutes Delays in diagnostics greater than 60 minutes escalate after 60 minutes 15 minutes to action Escalate after 75 minutes from commencement if delays continue 15 minutes to action Escalate after 90 minutes from commencement if delays continue 30 minutes to action Escalate after 120 minutes from commencement if delays continue informed of delays greater than 120 minutes Delays in patients seen by speciality greater than 30 minutes following referral escalate after 30 minutes 15 minutes to action Escalate after 45 minutes from commencement if delays continue 15 minutes to action Escalate 60 minutes from commencement if delays continue 30 minutes to action Escalate after 90 minutes from commencement if delays continue informed of delays greater than 90 minutes Delays in bed allocation greater than 30 minutes DTA escalate after 30 minutes 15 minutes to action Escalate after 45 minutes from commencement if delays continue 15 minutes to action Escalate after 60 minutes from commencement if delays continue 30 minutes to action Escalate 90 minutes from commencement if delays continue informed of delays greater than 90 minutes Delays in patients being transferred to ward within 30 minutes of bed allocation escalate after 30 minutes 15 minutes to action Escalate after 45 minutes if delays continue 15 minutes to action Escalate after 60 minutes if delays continue 30 minutes to action Escalate after 90 minutes if delays continue informed of delays greater than 90 minutes Delays in patients seen by Mental Health greater than 60 minutes after initial referral escalate after 60 minutes 30 minutes to action Escalate after 90 minutes from commencement if delays continue 30 minutes to action Escalate after 120 minutes from commencement if delays continue 30 minutes to action Escalate after 150 minutes from commencement if delays continue informed of delays greater than 150 minutes
HCT Actions Alert Status wide and Capacity Meeting actions HCT Actions by service line Bed bases and Bed Bureau Integrated community Adult Specialist services (inc Neuro) Children’s services Corporate services Trust Status – OPEL 1 Business as usual conference calls including daily reporting DGM’s monitor daily bed situation and operational issues throughout the day. IDT/discharge team have a good understanding of the predicted levels of demand and monitor community bed and ICT capacity. Bed states available via the Business Intelligence Portal and Bed Bureau. Bed Bureau team proactively review bed and community capacity in conjunction with operational managers. Active monitoring of infection control issues Maintain timely updating of information systems Ensure all pressures are communicated regularly to all local partner organisations, and communicate all escalation actions taken Proactive public communication strategy eg. Stay Well messages, Con calls – Bed bureau to represent HCT on conference calls DToC con call – held once a week for each side of the county and chaired by Patient flow manager including a lead executive Sit rep release (0930) Produce once a day capacity reports / sit rep via bed bureau to include staffing, bed state, etc. Appropriately structured for internal and external distribution. Business as usual management of patients at ward level including management of DTOCs Ensure all planned discharges to community beds and teams occur. LM’s monitor capacity and demand daily ensuring safe staffing levels met Forward planning rosters for weekends and bank holidays declaration of capacity status Integrated Community Team capacity communicated weekly to DGM via locality managers, with any teams reporting Amber to be escalated immediately to DGM DToC con call – held once a week for each side of the county and chaired by Patient flow manager including a lead executive Business as usual management of patients at ward level including management of DTOCs
SURGE LEVEL 3 - BLACK Action Who 1 Arrange conference call with Gold, EOC Silver, RCC, Senior Clinician, TACAD [call must be recorded via EOC line, time and extension noted] Teleconference 03303360670, Participant PIN: 706170 RCC (Strategic Commander to chair and authorise actions below) 2 Review Level 2 (Red) actions Strategic Commander 3 Consider on site Gold Cell (confirm attendees) RCC with Resilience Manager on Call 4 Call in additional staff to EOC and operations EOC and Operational Tactical 5 Call in additional clinical support to each EOC (see Appendix 2 for guidance on role) Strategic Commander 6 Consider increasing ECAT ring back time of C2 to 40 minutes, C3 to 180 minutes, C4 to 240 minutes EOC Tactical 7 Consider moving all appropriate Category 2-4 calls into ECAT (see script in Appendix 1) agree advisory delay time for category. EOC Tactical 8 Clinical review of back up requests (e.g. potential transport options) EOC Tactical 9 All HCPs referrals to be clinician reviewed (preferably hot transfer from call handler) EOC Tactical 10 Consider implementing “Do Not Send’ to Category 3 and 4 (see script in Appendix 1) with exclusion criteria (Appendix 3) Strategic Commander 11 Consider implementing “Do Not Send’ to Category 3 and 4 (see script in Appendix 1) without exclusion criteria (Appendix 3) Strategic Commander 12 Implement Category 2, 3 and 4 script for call handlers given potential delays (see Appendix 1) agree advisory delay time for category. EOC Tactical 13 Urgent Script (high demand and delay script) – agree advisory time EOC Tactical 14 Review welfare of unassigned events and consider a need to modify process with non-clinicians undertaken initial welfare Strategic Commander 15 Consider removal of breakpoints to improve immediate resource availability Strategic Commander 16 Consider suspension of end of shift process Strategic Commander 17 Prepare to invoke EEAST Major Incident Plan Strategic Commander 18 Send system wide notification of Surge Black Status (pre agreed script/distribution list) RCC 19 Record actions in appropriate log RCC 20 Inform DEOs and Clinical Coordinators / Senior EOC Clinicians RCC
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 Where the system is under extreme pressures and where the DCO Team Director believes: Pressures will require a co-ordinated response; or To reduce risks 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 their 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 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 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 other 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 – 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 >12hr plus any clinical harm impact and report on mitigations that were put in place. 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 place.