Bed Management and Escalation Policy - Newcastle … · Page 1 of 47 The Newcastle upon Tyne...

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The Newcastle upon Tyne Hospitals NHS Foundation Trust

Bed Management and Escalation Policy

Version No.: 8.0

Effective From: 15 February 2016

Expiry Date: 15 February 2019

Date Ratified: 02 December 2015

Ratified By: Emergency Admission Steering Group

1 Introduction

This policy is written to clarify the requirements of patients who require inpatient elective and non-elective care in a ward based environment on all Trust hospital sites, and the role and responsibilities of Trust staff in this respect.

2 Scope

This policy is relevant to all staff employed by the Newcastle upon Tyne Hospitals NHS Foundation Trust and relates to all patients regardless of age. The policy recognises that not all staff groups in all disciplines will have direct involvement in bed management and escalation, however all members of staff have a responsibility to support this policy.

3 Aims

The aim of the policy is to: • Provide clear operational guidance for bed management and escalation by

utilising criteria within the North East Escalation Plan (NEEP) to determine day to day operating levels.

• Provide a safe operating framework for staff and reduce the levels of risk for patients

• Maintain the flow of patients through the Trust and maximise bed availability in order to effectively manage fluctuations in patient presentations

• Ensure that patients are allocated to the appropriate specialty and care is delivered in a timely way with minimal interruption and risk

• Provide clear guidelines for the Patient Services Coordinators Team to work within.

4 Duties

Structure and responsibilities

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4.1 Chief Executive

The Chief Executive has overall responsibility for the strategic direction and operational management of the Trust and takes overall responsibility for policy.

4.2 Trust Board

The Trust Board has a role in driving quality assurance and ensuring compliance with Trust policy.

4.3 Directorate Management Teams

Directorate Management Teams are responsible for ensuring that policy is implemented within their individual Directorates / departments.

4.4 Patient Services Manager and Patient Services Matron

The Patient Services Manager and Patient Services Matron are responsible for ensuring that operational aspects of the policy are implemented and managed by the Patient Services Coordinators in their role as bed managers.

4.5 Bed Managers (PSC)

Bed Managers responsibility includes:

• Operational responsibility for the management of beds within specific Directorates and oversight of all beds across the Trust

• Operationally responsible for bed management of the Great North Children’s Hospital. GNCH bed management guidelines (Appendix 1)

• Ensuring that an up to date bed state and record of patients waiting for admission ( elective and non-elective) is maintained

• Co-ordination of information for presentation at bed meetings for the Patient Services Matron

• Escalation of any potential issues to the Patient Services Matron • Providing the relevant information to the Bed Bureau to inform the

Flight Deck information to NEAS. 4.6 The Bed Bureau The Bed Bureau is the single point of contact for GP’s to arrange urgent Medical, Surgical and Paediatric admissions. The Bed Bureau requests Ambulance transport on behalf of the GP. The Bed Bureau collates the bed states on behalf of the PSC. 4.7 Nurse Specialist (Discharge)

The Nurse Specialist for Discharge responsibility includes:

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• Works with Primary and Secondary care colleagues optimise use of

available hospital and community bed capacity ensuring that discharge

planning is integral to the patient pathway.

• Work in conjunction with the Patient Services Coordinators to ensure

that clinical areas have a sound knowledge and use best discharge

practice standards

• To have a lead role in developing, maintaining and evaluating delayed

transfers of care including the implementation of the Community Care

act. To undertake review of delayed transfer of care information and

audit in order to inform future capacity and action planning processes.

5 Definitions

Escalation Escalation, for the purpose of this Policy identifies when there are increasing levels of demand in the Emergency Department/ Assessment Suite and/or lack of bed capacity and when specific responses are required. Boarder This term may be used when a patient is residing on a ward outside their admitting specialty. (Appendix 2). North East Escalation Plan (NEEP) NEEP is a common language used by all hospital and community organisations in the North East to identify the levels of activity pressure and escalation across the area. In producing this document the Trust has aligned this Policy to the North East Surge and Escalation Framework (Appendix 3). The Flight Deck Is a series of metrics submitted by Trusts from across the Region to the North East Ambulance Service (NEAS). The metrics include: • NEEP status • Empty bed numbers including critical care, surgery, medicine and maternity • Are there any diverts in place • Are there any bed closures • Length of waits to be seen in ED. The information collected is then shared across the Region. The NEAS use this information to facilitate decisions on diverts and deflections.

6 General Principles

6.1 Normal Working

Normal working is how the Trust operates on a day to day basis to ensure NEEP level 1 (see appendix 3). All Trust employees are required to actively contribute to the timely and safe care and appropriate placement of patients.

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6.2 Bed management process

The PSC ensures the principles and processes around the management of the Trust’s bed capacity is operationalised on a daily basis.

6.2.1 The Bed State

The PSC collates and documents on the bed monitoring proforma the: • Number of patients ‘boarded out’ or awaiting transfer to or from

other hospital sites. This is circulated daily to relevant clinicians. • Potential patients awaiting transfer out of the Critical Care Units. • Number of electives due to come in.

The Bed Bureau collates the bed state for the PSC at 1200h 1800h and 2200h which is recorded on the proforma. This will include:

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

• Number of patients expected to be discharged that day. • Number of patients waiting for isolation facilities. It is the responsibility of ward staff to provide accurate and timely information.

6.2.2 Patients Awaiting Admission

All Medical and Surgical urgent GP referral are streamed either through the Assessment Suite or Ambulatory Care Unit at the RVI. The PSC will be informed of patient admissions and demand for beds by the Nurse Co-ordinator in ED, Nurse Co-ordinator in Assessment Suite and Directorate Waiting List Managers.

6.2.3 The Flight Deck

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

6.2.4 Boarding’ of Patients

When bed pressures continue is may be necessary to ‘board’ patients to another ward. In the context of this policy, a ‘boarder’ is defined as ‘a patient residing on a ward outside their admitting specialty’. The boarding of patients should be avoided as far as possible. However, there are times when such activity becomes a necessary part of managing emergency admissions and maintaining a supply of appropriate beds. The decision to board patients will be co-ordinated by the PSC. While there are no protected beds within the hospital all beds that are planned for elective admissions later that day or the following day should be last in line to board to.

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The clinical teams on the base wards remain responsible for identifying patients that are suitable to be moved elsewhere. It is acknowledged that, at times, there will be no patients that are deemed suitable. Under these circumstances the clinical teams will be expected to make decisions based on their professional judgement, to identify patients to move. (Appendix 2 Boarding Guidelines).

6.3 Requesting and Receiving Diverts from other Trusts

6.3.1 Requesting a Divert

Newcastle upon Tyne Hospitals does not divert patients and a divert request can only be authorised by the Chief Executive. When the Trust is at NEEP 4 the Trust may need to request a divert to another hospital. The requirement to consider this should be escalated by the Patient Services Manager or Senior Manager on call to the Director on Call. The regional divert policy should be consulted in relation to this.

6.3.2 Receiving a Divert

The following guidelines outline the Newcastle upon Tyne Hospitals NHS Foundation Trust’s internal procedure for when a request is made to the Trust from another Trust for support with respect to the deflection of emergency activity from one hospital to another. This may be due to: • Pressures on bed capacity, resulting in a request for an

organisation to accept GP admissions on a case by case basis; • When an accident and emergency department is experiencing

significant pressures on service delivery and require support on a time limited basis. (This includes issues with ambulance turnaround delays).

• When a request to deflect activity is made, communication should take place between the Director on call at the Trust making the request and the Director on-call at the receiving Trust. The manager on-call may communicate with the Trust making the request on behalf of the Director on-call, if this has been agreed between the two parties beforehand. The manager on-call at the receiving Trust should then keep the Director on-call at the receiving Trust updated with regards to the likely time frame for receiving patients from another Trust or the number of patients that it has been agreed will be deflected. Within Newcastle Hospitals, the Director or manager on-call should then communicate the request to the relevant staff including the ED Consultant and RVI PSC to establish the Trust’s capacity and capability to accept the request for deflection.

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The ED Consultant may also wish to contact the relevant clinician at the requesting Trust to discuss the reasons for their Trust making the request to deflect emergency activity. This internal procedure for when a request is made to receive patients from another Trust is detailed in the deflect flow chart which includes the lines of communication and who is responsible for recording the details of the patients accepted into the Trust via the deflection procedure. The North East Divert Policy can be found in Appendix 5 which provides the guidelines NEAS work to when they are making the decision to deflect ambulances from the nearest ED.

6.3.3 Trigger levels and Escalation

Triggers Triggered by

1. ED/PED waiting time >2.5 hrs

ED/PED Nurse co-ordinator & Consultant to discuss and trigger

2. AS > 8-10 patients waiting to be clerked

AS Nurse co-ordinator and Consultant to discuss and trigger

3. When the number of expected emergency admissions exceeds capacity

PSC Matron

ROLES: In hours: Escalate to Directorate Manager 1. Directorate Manager: on receiving a escalation/surge call the Directorate

Manager determines how best to action within the Directorate Management Team and collates information from ED/AS Consultant and PSC.

2. Matron responsible for flows and nursing issues 3. Clinical Director responsible for action by medical staff OOH: escalate to PSC 1. On receiving a surge call the PSC depending on the cause may decide to take

no further action if after analysis and taking a hospital wide view they are of the opinion that the surge will resolve

2. Escalates to the Senior Manager on Call (SMoC) if a. PSC team feel they are unable to deal with the issue b. Policy indicates SMoC be informed c. Situation requires escalation such as a business continuity incident.

3. Escalates to the Assistant Medical Director a. If it is patient safety issue b. If it is a system capacity issue c. If it is a case of mobilising additional medical staff NB: some of these issues can be dealt with remotely by telephone.

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Action by Directorate Management Team or Senior Management Team Assess the situation. Discuss with ED consultant who will be the point of reference of current pinch points. The PSC should also give you an up to date report of the bottlenecks. Ask for help as required. Appendix 5 is an action plan for the common issues/bottlenecks faced.

7 Training

The Trust will ensure that the Patient Services Coordinator team have the skills and knowledge to undertake the bed management role through the provision of on-site training. In particular, participation in training programme relevant to their role arising out of a Major Incident.

8 Equality and Diversity

The Trust is committed to ensuring that, as far as is reasonably practicable, the way we provide services to the public and the way we treat our staff reflects their individual needs and does not discriminate against individuals or groups on any grounds. This policy has been appropriately assessed.

9 Monitoring

Standard / process / issue Monitoring and audit

Method By Committee Frequency To provide a report in the trends of ED attendances and emergency admission. The level of patient boarding outside their speciality and review of waiting times and targets

Report Emergency Care Facilitator

Emergency Admissions Steering Group

Annually

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Appendix 1 Great North Children’s Hospital Bed Management 1. Introduction These guidelines outline the main responsibilities in relation to Bed Management arrangements within Children’s Services and include the role of the coordinator in hours and senior nurse in Children’s Services out of hours. Lines of communication within the Directorate and the Trust are outlined in order to facilitate the delivery of efficient and effective services for children. The critical success factors include collaborative working, communication and the provision of accurate information. 2. Bed Capacity and Patient Flow Management Bed management responsibilities will be undertaken by the Patient Services Co-ordinator (PSC). Out of hours at night Hospital at Night Nurse Practitioner will co-ordinate bed management.

2.1 Capacity

Children’s Services Bed capacity is as follows: Wards, GNCH • Ward 1a - Medicine (renal, gastro) – 22 beds • Ward 1b – Neuro-sciences – 13 beds • Ward 2a - Medicine (respiratory, ID, general paeds) -18beds currently

flexing to accommodate Long Term Vent • Ward 2b – Medical day case unit • Ward 3 - Children’s Bone Marrow Transplant Unit – 10 beds • Ward 4 - Oncology and Teenage Cancer Unit –20 beds • Ward 6 - Emergency Assessment Unit (total capacity 24, 12 inpatient

overnight) • Ward 7 - Renal Dialysis Unit (7 clinical spaces) 3 days/week • Ward 8 –Surgical Day Unit (Mon – Fri –21spaces) • Ward 9 – Surgery 20 beds • Ward 10 – Orthopaedics 15 beds • Ward 11 - Burns and Plastics – 15beds • Ward 12 - Paediatric Intensive Care Unit (11 flexing) • Ward 14 - Paediatric Oncology Day Unit (Mon – Fri 22 spaces).

2.2 Key Bed Management responsibilities

• To understand the bed capacity in the Directorate by receiving accurate bed states from the Bed Bureau.

• Bed states will be undertaken at 12:00hrs; 16:00hrs & 20:00hrs by the Bed Bureau who will contact each ward. The nurse in charge of each ward is responsible for ensuring that an accurate bed state is communicated including the number of vacant beds at the time of

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request and any predicted ‘later’ beds. The Bed Bureau will pass this information on to the PSC

• To take action to address any shortfall in bed capacity against requirement. Where a gap exists between capacity & demand solutions must be identified in order to ensure safe patient placement.

• Review expected capacity on each ward including confirmation that existing patients have been reviewed and confirm any discharges.

Ascertain admissions and transfers from:

• PICU • Paediatric ED / Children’s Emergency Assessment • Day Units – patients requiring overnight stay following procedure • Elective / Waiting List admissions (both Medical & Surgical) including

DOSA • Transfers from other Trusts • All admissions must be arranged through the PSC • In hours any escalation of bed pressures must be reported to the Matron

/ Directorate Manager for Children’s Services as well as any relevant Paediatric Consultant on-call. The PSC will provide relevant information in relation to: • bed availability, • expected admission and discharges, • current pressures,

2.3 Patient Admission Pathways

Single Point of Access • All GP referrals, transfers from North and South of Tyne, ‘Open Access’

patients will all be admitted via Children’s Emergency Assessment Unit (Paed E/D) •Patients will be either be discharged from PaedED, transferred to long or short stay in CEAU or transferred directly to base ward

• Adolescent Admissions / Young People up to their 16th Birthday • These patients should only be admitted to an adult ward if their clinical

condition dictates or if the patient requests to go to an adult ward. This decision should be made in agreement with the Paediatric Consultant or appropriate Specialist on-call. Some surgical children may require an adult surgeon for their condition but can be admitted to a paediatric ward for joint care. There may be rare circumstances when they need to be nursed in adult area. Matron, senior nurse must be made aware. Young People older than 16 years

• New surgical referrals will generally not be taken by the Paediatric surgeons and will be referred to the adult surgical team. If appropriate the patient can be admitted to a paediatric ward for nursing care. All young people between the ages of 16 – 18 years old should be assessed individually and a decision made as to how appropriate their placement on a paediatric ward is.

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Child and Adolescent Mental health Services • There should generally be no new referrals to Children’s Services for

young people over their 16th birthday – however the same considerations should be taken into account as above.

Ophthalmology There may the rare occasion when a child is admitted with an eye injury that requires close monitoring with specialised equipment at regular intervals. If the injury is to the extent that the portable equipment will not be sufficient to appropriately monitor, then the child will need to be admitted to the adult Ophthalmology ward. Ward 20 staff will contact the coordinator / senior nurse to organise this. In these circumstances a decision needs to be made by the Matron or Senior Nurse if a paediatric nurse is required to nurse the patient, this will be depend on age, size and maturity. Emergency Department Waiting Time Standard

• Potential breaches must be brought to the attention of the PSC by the Emergency Department staff. This must be documented on the ‘Breaches’ sheet. Every attempt must be made to avert the ‘breach’ by admitting patients directly to the base wards from PED or transferring to ward 6 pending bed where clinically appropriate. Breaches forms must be stored with bed states.

Cancellations • No elective patients are to be cancelled without authorisation from the

Directorate Management Team. Any agreed cancellations must be documented by the ward cancelling the patient using the electronic cancelled operations database. The Directorate Office Manager will maintain a database to log all cancellations due to none clinical reasons.

2.4 Boarders

• A proactive approach must be maintained to ensure the most effective

utilisation of the beds across the Directorate. • Patients must be identified well in advance of beds being all utilised for

the purposes of boarding to other wards. Generally it will require medical patients to be boarded to other paediatric wards within the Directorate.

• A clinical decision to board a patient must be made in consultation with the relevant Clinician in charge of the patients care prior to moving the patient.

• Wards should adopt a ‘traffic light’ system for the early identification of potential boarders. Green - Can move to other area Amber – Possibly can move to other area, if essential. Red – Cannot be boarded out

• Babies who have not received all their immunisations should be nursed in a cubicle unless that is over ridden by Paediatric Consultant on call. Boarding Exceptions

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The following clinical considerations must be taken into account when identifying patients to be boarded:

• Ward 11: no confirmed pseudomonas, a known infection (Strep or staph) • Ward 10: no patients with: a known infection (Strep or staph) • Oncology Boarders: Each individual patient will be assessed by the

clinician for their suitability to be boarded outside of the specialty. Criteria would include age/maturity, treatment/stage of treatment, general condition and psycho-social situation.

• The clinician will advise nursing staff on the need for a cubicle for oncology patients. Patients requiring chemotherapy would not normally be nursed outside of the oncology unit. However, if necessity arises cases must be discussed with the Consultant Paediatric Oncologist. NB: There may be rare occasions when young people over 18 years of age require admission. These patients must be admitted to the Teenage Oncology Unit on ward 4 and a younger patient identified to board out. Ward 4 should only be used for boarding into by exception following full explanation to the child and parents of the nature of the clinical conditions accommodated on the ward.

• PICU: To be used in extreme circumstances i.e. by exception. When there is no available bed within the Directorate and PICU have capacity whilst still maintaining an Intensive Care service. Boarders must be transferred out of PICU and onto a paediatric ward at the earliest opportunity. Clinical care for the patient will be provided by the appropriate specialty i.e., the patients Consultant team; Nursing care will be provided by PICU staff.

• Ward 3 (Bone Marrow transplant Unit) – patients boarded here must not be infected.

2.5 Escalation Procedures

2.5.1 Opening additional capacity

• The decision to cancel elective admissions can only be made by:

In and Out of hours: on call Consultant and CD • The decision to open additional beds can only be made by:

In hours: Clinical Director and Matron,

Out of hours: The PSC must discuss the bed situation with the On Call General Paediatric Consultant and Senior Nurse CEAU It may be necessary to provide an additional nurse to enable additional beds to open and this decision will be made by the on-site PSC and on-call Consultant. Out of hours, the PSC should inform the on-call manager of this decision.

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2.5.2 Deflection of Out of Area patients • The Trust will always receive Paediatric Emergency patient’s

self- presenting to the Paediatric Emergency Department or arriving by Ambulance.

• Emergency GP referrals • The Great North Children’s Hospital will always accept

emergency GP referrals from Newcastle, Northumberland, North Tyneside and Gateshead where an inpatient hospital stay is needed.

• If the Paediatric Directorate is experiencing pressures on bed capacity or sustained levels of demand in the Emergency Department then it may be necessary to consider deflection of further Out of area GP referrals.

• The decision to deflect GP referrals will be made by the Clinical Director or Assistant Medical Director (Out of Hours)

• Only non-specialist GP referrals from South of Tyne (beyond Gateshead) can be considered for deflection. The referring GP from Out of Area should be advised to contact the local admitting Paediatric Hospital. Note: This does not mean that the hospital will be closed or will not accept admissions.

• The trigger for consideration of this level of escalation is when the bed capacity required to accommodate admissions exceeds the available bed capacity (This excludes PICU and ward 3 (Oncology) capacity.

2.5.3 Actions to be taken when this trigger is indicated in order to avoid the

need to deflect GP emergencies include: • Ensure Children’s Acute Nursing Initiative Team (CANI) have

reviewed all patients for potential discharge with support at home.

• Identify appropriate boarders to create capacity in medicine or surgery depending on demand.

• Consultant teams to conduct extra ordinary ward rounds to identify discharges or transfers back to local DGH as appropriate.

• Consideration of elective activity cancellation, including current inpatient and next day activity.

• Consider staffing uncommissioned beds to increase capacity. This can be done by releasing staff from areas where patients have been cancelled or by calling staff in to do extra shifts.

• Areas where this can be done are, ward; 2, CEAU, 9, 10 • Day units can be considered 7, 8 – they do not have beds they

have trolleys and dialysis chairs. • Consideration of converting Daycase capacity to inpatient

capacity. • Open additional capacity with nursing resource. • A regional bed state may be required and a decision to deflect

may be required. • Deflection to Sunderland may be explored (see 2.5.1).

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2.6 Escalation policy for ED referrals to paediatric medical staff • Children requiring specialist paediatric opinion must be referred by ED

team in a timely fashion, ideally within 2 hours of their arrival in PED/ED

• Child referred to paediatric SpR/middle grade and time of referral noted on ED card

• Referral accepted and estimated time of attendance given • Paediatric middle grade may designate F2/SHO to attend if admission

seems likely • Paediatric middle grade to attend first if specialist opinion is required • If admission is deemed likely by either ED or paediatric team, notify

paediatric bleep holder to arrange bed • If, following timely referral, paediatric team attendance is delayed and 4

hour wait limit in ED is likely to be breached, the on call paediatric consultant should be contacted with sufficient time for remedial action on their part (ideally greater than 45 minutes before breach). There may be circumstances when admission of the child is inevitable and the paediatric team have not been to see the child in a timely manner. In these circumstances direct admission to the ward before review by the paediatric team is possible.

Before leaving the ED department a PEWS assessment must be completed and a management plan should be verbally agreed with the paediatric middle grade doctor. The doctor responsible for the care of the patient must be clearly identified and a timescale for initial medical assessment and Consultant review documented. It is the responsibility of the receiving ward staff to ensure that a senior clinical review takes place including escalation to Consultant level if this does not occur. The clinical team are responsible for handing over the need for review to the team taking over the patients’ care.

2.7 Bed Closure

• It is not acceptable for a ward to refuse a patient due to staffing

problems. If pressures on staffing arise, the ward must ensure the issues are addressed as soon as possible in order to avoid an impact on admissions.

• Consideration for bed closures within the Directorate may emerge for a number of reasons, for example, increase in patient workload, a reduction in nurse staffing levels, and/or skill mix considered insufficient to accommodate patient workload. Bed closures will only be considered after all other strategies have been explored.

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• In the event that there is an increase in patient workload, and nurse staffing or skill mix is insufficient to meet demand the ward must liaise with the Directorate Matron and the following will be considered:

• Review of patient dependency against staff/skill mix to assess and confirm level of resources required,

• Look for suitable patients to transfer / board to other wards, • Assess whether any patients are suitable for discharge, • Move staff within the Directorate as appropriate.

If bed closure is inevitable this will be undertaken by the Directorate / Manager/Matron who will complete a Bed closure request form( having discussed the circumstances with the site Head of Nursing, and forward to the Matron for Patient Services. The on-call Paediatric Consultant will be advised of the decision. The period of closure will be specified and review times agreed • Out of hours, the senior nurse will liaise with the on-call consultant and

Patient Services Co-ordinator for authorisation to close beds if all other avenues have failed. The decision to close the beds will be made by the on-call Senior Manager.

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Appendix 2

DIRECTORATE PATIENT SERVICES-BOARDERS

Daily Function Management of boarders

(green)

Increased Pressure

(amber)

Escalation Plan (Red)

Useful Contacts

Patients are classed as boarders when they are residing in a ward outside their admitting specialty. Each ward should identify, daily, patients who are suitable to board into other specialties clinical areas. Identification of boarders should be the responsibility of the medical staff. Patients should not be boarded without approval by the medical staff to ensure that they are fit to board. Ideally patients should be from base wards awaiting discharge within 48hrs, this may not always be possible but other factors such as bed pressures and the lack of identification of other boarders should be taken into account. Other patients suitable for boarding include those who are Medically/surgically stable and mainly self-caring. Infected patients or those with disability or cognitive impairment should not be boarded.

Boarding capacity at FH will be up to 12 medical patients. NEEP Level 2.

Emergency admissions should be boarded only after Consultant review as to the suitability of the patient to board. They should have minimal medical or chronic problems. During increased bed pressures the boarding of patients after 22.00hrs may occur. Receiving wards must be made aware of late transfers and if boarding is cross site then the approval of the medical director must be

Increased pressure on beds/capacity may result in an Increase in boarding capacity at FH. This should happen following a discussion with the Medical Director and matron Patient Services. Identification of wards to be used for boarding will be done by PSC FH and Matron Patient Services. NEEP Level 3&4 Infected patients may have to be boarded after liaising with the Medical registrar and

Matron Patient Services 29460 PSC RVI 24300 PSC FH 26623 Nurse Specialist Discharge 48900 Patient Services Manager 48963

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When placing patients as boarders the following must be considered The receiving ward must have the relevant nursing and clinical skills to care for the patient. Location and normal activity of the ward where boarders may be placed. Preserving special care areas CCU etc. Waiting list admissions and the preserving of elective activity. Returning of boarders to their base wards may be needed to accommodate elective activity. Daily senior review by the patient’s consultant or allocated team must be undertaken to ensure a clinical care plan is in place to progress the care of the patient. See exhibit (1) for base ward allocation for boarders Only by exception will a patient be moved more than once for a non-specialty clinical need. The patients consultant/allocate team must be involved in the decision making process. Boarding should take place between 09.00-22.00

sought. PSC’s to ensure that boarders are reviewed daily and plans made for their ongoing care. Contacting individual directorates if their boarders remain high.

Infection Control. Patients who are suitable to board may be placed in areas such as the Cardio block at FH if clinically safe to do so. Elective activity of base wards may be cancelled due to high levels of boarded patients. PSC’s to ensure that boarders are reviewed daily and plans made for their ongoing care. Involving Nurse Specialist for Discharge if necessary

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PSC’s will update lists of boarders daily and distribute to all relevant Directorates, Consultants Heads of Nursing, Medical Directors, Matron for Patient Services and Patient Services Manager

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Appendix 3

Level Acute and Community Trust Local Authority Out of Hours Ambulance Service

Escalation Plan level

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

Are these internal organisational triggers, or external ones

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

Who by? When? Where?













Escalation

level 1 Normal (White)

Acute Baseline: Total beds available - ?

Of which is core bed stock - ?

Acute - ? Maternity - ? Paediatrics - ?

Of which are escalation beds - ?

ITU/HDU capacity – ? Indicative numbers: UHND ? ITU, ? HDU DMH ? ITU, ? HDU Average daily A&E attendances

Monday - ?

Tuesday – ? Wednesday –? Thursday – ? Friday – ? Saturday –? Sunday – ?

Actions

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

Daily operational meeting with clinical team to assess elective programme and predicted emergency activity for the day (8am)

To participate in the daily situation reporting (11am) during the winter monitoring months, published on the winter planning and surge management website

Participate in daily teleconferencing during the winter reporting period, chaired by North of England Commissioning Support Unit on behalf of the CCG

See and treat in place

Adult Social Services influencing factors and triggers No trigger required for escalation to ‘normal’ level. De-escalation triggers will be reverse of the following.

Actions

Full range of services operating normally

Refine and revise BCPs and escalation plans

Identify vulnerable users (without known relatives, living alone, over 75’s with pre-existing health conditions, mental illness, dementia)

Triggers factors for escalation

To be added by Trust

Actions

Service normal operating level of activity and capacity

Reference Health on call Business continuity plan. Increased demand Weekly and daily activity is reviewed and adjustments are made to shifts accordingly. Additional staffing added into the system when required with the length and coverage of shifts. OOHs operate a flexible workforce.

Influencing Factors to escalate to REAP 2


Actions

Ensure staff who are absent due to sickness are made aware that they should maintain regular contact with their line manager and ensure RTW is completed ASAP following return

Ensure maximum cover of core fleet

Ensure RRV’s are at their agreed designated standby points

Actively liaise with EOC on ambulance station cover

Actively engage local Staff Side Representatives

Monitor and manage annual leave

Monitor and manage mobilisation times

Monitor and manage job cycle times

Monitor and manage activation times

Monitor and manage staff hours

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Ambulatory care capacity – ? capacity. Indicative number: ? places. Average daily Acute admissions

Monday – ? Tuesday - ? Wednesday – ? Thursday – ? Friday – ? Saturday – ? Sunday – ?

Average daily discharges:

Monday – ? Tuesday – ? Wednesday – ? Thursday – ? Friday – ? Saturday – ? Sunday – ?

Average length of stay – ? Average number of daily discharges – ? During NEEP level 1, the organisation will be providing a full elective programme: Average daily electives:

Monday – ? Tuesday – ? Wednesday – ? Thursday – ? Friday – ? Saturday – ?

Sunday – ?

Triggers factors for escalation


Ward /Board rounds 7 days a week

Agreed number of daily discharges to be progressed

Bed Predictor tool to be used at 12 mid-day and 3pm.

Patient flow meeting minimum x 2 (revised patient flow model) 9.30-12.00-16.00 and 20.30

Action planning must follow the patient flow meetings action plan to be in place for the evening

The Patient Flow manager must monitor and report any surges in activity and report to matrons and GM’s if their Directorate is under pressure at the daily patient flow meetings.

Patient flow meetings to be attended by the on-call manager and alert any issues to the Director on Call via the telephone or E mail.

Community Partnership Adult Social Services Manager to participate in daily patient flow teleconference

SAFER bundle principles in place: S senior review of

all patients before mid-day

A all patients to have an expected date of discharge

Utilisation of overtime as required

Monitor and manage predicted staffing

Ensure routine management/ALO presence at hospitals as required

Monitor and manage EOC staffing

Monitor and manage PTS and Intermediate Tier staffing and deployment

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Influencing Factors to escalate to escalation level 2

To be added by Trust as these will vary

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

E early discharge, 33% of patients from base wards to be in discharge lounge with to-take-out (TTO’s) and letter before midday

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

Escalation level 2

Concern (green)

Consideration to be given to the following triggers and influencing factors to activate escalation level 3


3 or more of the following indicators are hit: Indicators


Actions

Participate in daily teleconferencing during the winter reporting period, chaired by North of England Commissioning Support Unit

NECS team to inform CCG (in-hours) and general manager for emergency medicine to inform CCG on call (out of hours) of increased NEEP level

Manager on call /patient flow manager to declare escalation level 2 to Director on call

Director on call to authorise escalation level 2

Report the escalation of escalation level 2 level to the NECS


Combined impact of staff absence and client activity increase at equivalent to 10%

At least one service area affected

Residential care capacity at 90% for specific client groups

Dom Care contract at

Actions

As normal but prioritising workload if necessary

BCP / escalation plans reviewed

Decision Maker

Service Manager


To be added by organisation

Actions Weekly and daily activity is reviewed and adjustments are made to shifts accordingly. Additional staffing added into the system when required with the length and coverage of shifts. OOHs operate a flexible workforce.

Consideration to be given to the following triggers and influencing factors to activate REAP level 3


Actions

Consider opening Area Major Incident Suites (Formerly known as AOCC)

Increase local monitoring at Area level to ensure efficiency

Look at predicted solo staff and pair up in advance. (this includes staff moving location)

Review non-essential training and consider re-schedule options

Review predicted RRV cover and fill in all gaps. Use solo as necessary

Increase focus on Control staffing ensuring adequate ratio of call takers and dispatchers

Review all second clinical and non-clinical staff and consider recalling

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Surge and Escalation team

Safer bundle in place

2 hourly dashboard via patient flow i.e. capacity ED/performance /discharges/elective programme

Create additional temporary capacity (additional capacity strategy policy) (work force strategy)

Consider the boarding of patients (boarding policy)

Front of house model to navigate away from ED if in escalation (require ED escalation plan)

Senior nurse and ED consultant in ED to sift and sort

All GP referrals to be discussed with acute care physician (pathway in place)

Prioritise elective programme for the week using the prioritisation tool in anticipation for escalation level 3

Initiate ward/board round if not already in progress.

Identify patients for boarding

Request from ambulance service pre-alert of all ambulance attendance to ED/EAU.

Inform Communication Team of Escalation and prepare pre-written and pre- agreed

90% capacity

Consider allocating shifts to all non-operational staff (e.g. non-operational Clinical Practice Trainers)

Consider the role of Urgent Care Services/PTS and how they can assist with Red calls

Monitor all planned events and resource requirements and available intra area assistance

Consideration of existing BCM plans; Review Directorate/Department BCM SitRep (submitted following Escalation Change) and ensure recovery actions are identified and in place

Control to routinely contact all CFR schemes and request their availability

Consider issuing message to the media about inappropriate use of service

Inform all stakeholders of any changes in Trust Escalation Plan levels so assessment of their own needs/pressures can be identified as part of the early warning systems

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communications to be sent out to public primary care ,community ,ADSS ,WIC social media

Trust internal divert to allow equidistant attendance and admissions across the two sites

Review rota’s with a view of cancellation of study leave based on individual assessment of both course and staff.

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

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

Activate capacity and workforce strategy at escalation level 2

111 – GP urgent slots accessible (for further discussion and exploration)

Escalation Level 3

Pressure (amber)



Ensure all actions at the escalation level 2 have been implemented before escalating to escalation level 2 Actions

Participate in daily teleconferencing


Combined


BCP / escalation plan in action


To be added

Ensure all actions at the escalation level 2 have been implemented before escalating to escalation level 2 Actions Weekly and daily activity is reviewed




Establish GOLD command team to manage recovery &

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3 of the following indicators are hit. Indicators:


during the winter reporting period, chaired by North of England Commissioning Support Unit

NECS team to inform CCG (in-hours) and general manager for emergency medicine to inform CCG on call (out of hours) via Carlton Clinic Switchboard of increased NEEP level

Director on call to authorise escalation level 3

ED Senior Dr fronting triage if ED under pressure.

Expectation that all actions from escalation level 2 have been considered and implemented.

Safer principles applied – includes step up of additional ward/boards rounds

Start boarding patients

1 hourly capacity and demand dash board in place (patient flow model)

Additional bed capacity created as per additional capacity strategy at escalation level 3 and work force strategy at escalation level 3

Relaxation of 48hour discharge rule to nursing and residential homes

If ED in escalation to refer to ED

impact of staff absence and client activity increase at equivalent to 20%

Residential bed capacity at 95% for specific client groups

Dom Care contract at 95%

Disruption to more than one service

Only mandatory training to take place

Cancel non-essential meetings

Prioritise work appropriately

Coordinate leave – cancel if necessary

Daily monitor of all providers

Provide lists of vulnerable clients

Client reviews deferred

Commissioning team closely monitoring of independent sector care homes / domiciliary care contract (identify vacancies / capacity issues)

Decision Maker

Head of Service

by organisation

and adjustments are made to shifts accordingly. Additional staffing added into the system when required with the length and coverage of shifts. OOHs operate a flexible workforce.

declare ‘Major Incident Standby’ and implement relevant business continuity arrangements

Identify the number and location of PTS resources required to support the A & E operation – PTS management to provide resources where possible

Station Management Teams to establish list of staff available for overtime and use appropriately

Consider providing appropriate clinical training staff for operational shifts

Cancel non-existing meetings

Non Ops CPTs and Service Delivery Managers to staff vehicles where possible (Ambulance or RRV)

PTS Managers who can be released without generating a negative impact on PTS core activity to be deployed to busy A & E Departments as Ambulance Liaison Officers (ALO’s)

Establish GOLD command team to manage recovery & declare ‘Major Incident Standby’ and implement relevant business continuity arrangements

Identity the number and location of PTS resources required to support the A & E operation – PC management to

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escalation policy

Revised criteria for discharge home as opposed to community beds

Review elective in-patient and outpatient programme. Consideration for reduction or cancellation. This requires a 48hour plan

Consideration of mutual aid request

Activate capacity and workforce strategy at escalation level 3

Obtain from ambulance forecast position of activity for next 4 hours

Turn 111 DOS to amber (for further discussion and exploration)

provide resources where possible

Station Management Teams to establish list of staff available for overtime and use appropriately

Consider providing appropriate clinical training staff for operational shifts

Cancel non-essential meetings

Non Ops CPTs and Service Delivery Managers to staff vehicles where possible (Ambulance or RRV)

PTS Managers who can be released without generating a negative impact on PC core activity to be deployed to busy A & E Departments as Ambulance Liaison Officers (ALO’s)

Review resource cover at external events

Consider extended hours of Fleet Support Services

Control to rigidly maintain RRV development to standby points and monitor re-deployment following meal

Issue messages to the media, key stakeholders and service users

Consider Operational Managers deploying to AS1 incidents

Stringent local monitoring of all instances causing vehicle downtime e.g. VOR, Medicine issues, meal breaks

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Consider placing operational management liaison in Control

Consider staffing additional RRVs

Ensure health control desk liaise with ALOs and feed information into the MI suites and ROCC

Consider appropriate clinical staff for operational cover Cat A cover

Inform CCGs/NHS England – North Region of current service delivery pressure level

Consider requesting intra area mutual aid

Consider providing accommodation for personnel/finance requirements

Consider relocating vulnerable key assets/functions (vehicles/personnel) in line with relevant BCM plans

Escalation Level 4 Severe

Pressure (red)


4 or More of the following are met



Participate in daily teleconferencing during the winter reporting period, chaired by North of England Commissioning Support Unit

NECS team to inform CCG (in-hours) and general manager for


Combined impact of staff absence and client activity increase at equivalent to 30%

Residential bed capacity


Risk assess all workload and categorise

Prioritise statutory work such as MCA, safeguarding and hospital discharges / First Contact

Transfer staff from non critical areas and limit or close those services


To be added by organisation





Consider Declaration of a ‘Major Incident’. Advise NHS England and Trust Board

Appropriate Clinical Training staff to be re-deployed to staff vehicles

Review planned leave and negotiate rescheduling with staff

Defer all operational training days for

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emergency medicine to inform CCG on call (out of hours) via Carlton Clinic Switchboard of increased NEEP level

Establish internal command and control Director on call to lead the meeting plan of action to be agreed and implemented

Cancellation of all electives with the exception of priority 1

Significant reduction/cancellation of outpatient activity.

Activate capacity and workforce strategy at escalation 4

Activate surge management agreement with LA/Social Care

Consider financial framework

Obtain from AMBULANCE TRUST forecast position of activity for next 4 hours

Turn 111 DOS to red (for further discussion and exploration)

at 99% overall

Dom care contract at 99%

Disruption in most services

Cancel annual leave where possible

Head of Service to brief Director / Chief Executive

Cancel validation panel for all but high risk cases

Inform CQC of likely impact on care services

Preparations for Incident Room

Website updated with relevant information

Decision Maker Head of Service

existing staff but ensure consideration of mandatory training requirements in line with BCM Plans (including recovery strategies where appropriate)

Defer all non-escalation plan related meetings

Consider deploying all clinically trained non Operational staff (e.g. HCG, Community Liaison Officer etc)

Consider recalling all externally seconded staff

All non – essential vehicle maintenance/repair to be re-scheduled

All staff deficiencies and projected resources to be reported to the Area Major Incident Suite (formerly known as the AOCC)

A & E Operational Managers to be allocated shifts in a staff support role covering 24 hours. Request support from PTS Management in supporting this capability

Consider contacting Acute Trusts with a view to reducing planned clinics in conjunction with PTS

Liaison with CCG’s to explore options for additional support

Consider sending a Silver level liaison to Police controls to review police requests and provide advice

Reinforce messages

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to the media about pressures and using the service wisely

Consider requesting other agencies to act as co-responders

Consider Mutual Aid options

Where appropriate consider contacting voluntary agencies for additional resources

Consider implementing a no send policy

Request mutual aid and support National Ambulance Coordination Centre

Consider extending clinically based telephone triage for all incidents

In conjunction with PTS Commissioners, cancel by agreement all PTS and non-essential work and redeploy resources to support PES Ops

Cancel all event cover

High profile media campaign to discourage inappropriate use

Use trainees to support operations

Open workshops at night to increase daytime fleet

All non-operational Managers with a lease vehicle to ‘book on’ with Control each morning and make themselves available to support operations

Carry cash float/Procurement Card to allow quick solutions

In conjunction with Department of Health,

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NHS North and National Ambulance Coordination Centre, ensure appropriate and common response and recovery strategies are effective and deliverable

Ensure effective and coordinated communications messages are cascaded and updated to reflect the situation

Ensure safety and integrity of all staff is maintained to assist recovery needs

Ensure support to National Mutual Aid Requirements are balanced against needs and capability across AMBULANCE TRUST region

Escalation Level 5

Critical (purple)

ACTIVATION OF MAJOR INCIDENT PLAN (as per policy)




Escalation Level 6

Potential Service Failure (black)

Core service delivery only

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







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Appendix 4


Deflection Communication/Process Flowchart

Request made to Trust to accept patient from other Trusts (i.e. NEAS deflect policy)

(N.B. this should be made by the requesting Trust’s Director on-call to the receiving Trust’s Director on-call).

Request may be received by ED consultant/PSC/NUTH Manager on

call/or other

Contact PSC (24300)

Establish: Reason for deflection/ Have they instigated their Trusts escalation

process/ How long is deflection expected to last for?

PSC to contact :On call manager/ED Consultant and establish Trust capacity and

capability position to receive patients. This should include ED and wider

acute bed capacity.

Decision not to accept

patients communicated to

other Trust. Decision may be

reviewed at later time.

Decision made to accept

patients via ED department

and/or for medical referrals to

AS.

Establish how long the deflection

will be in place or how many

patients can be accepted. It may

be acceptable to only accept

specific specialty patients e.g.,

surgical rather than all patient

conditions.

ED Consultant and RMO

to be informed of

deflection decision and

time frame.

Ensure sending Trust has

informed Ambulance Service of

time frame or how many patients.

PSC to record details of

patients accepted into Trust

via deflection.

Receiving ED Consultant to contact

relevant clinician at the deflecting hospital

to discuss rationale for request

Agreement as to whether the

trust can accept deflections

should be authorised at Director

level following discussion with

ED Consultant and on-call

manager. The Director level can

be either the Assistant Medical

Director on-call or the Director

on-call.

It must be made clear to the

requesting Trust’s Director that any

patients deflected must be repatriated

when clinically safe to do so.

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At the end of the agreed time or number of patients, normal operation will continue.

N.B. for regional specialties e.g. Neuro – deflection arrangements will be made

Doctor to Doctor and should not involve the Manager on call. The PSC may be

involved if beds are needed.

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Appendix 5

North East Divert Policy

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Contents

1. Introduction 5

2. Purpose 5

3. Principles 5

4. Process 6

5. Record of Agreement 7

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Version Control

Version No.

Amendment Date Author Approved

V 0.1 Initial Document Creation 12-12-14 N Kenny

V 0.2 Feedback from North East Acute Providers and Service Commissioners

09-03-15 G.Carton/M.Waugh

V.0.3 Request to simplify the policy as too complex

14-04-15 Stewart Findlay

V0.4 Comments from NEAS 28/4/2015 N Kenny/ Paul Liversidge

V0.5 Changes by North of England Commissioning Support Unit

12/5/15 Gill Carton/ Michelle Waugh/ Martin Johnson

V0.5 Flowchart included as ‘the policy’ and minor changes to the wording now included as an Appendix.

13.05.15 Gary Collier

V0.6 Guidance moved to separate document, strengthening of NEAS position and clinical safety first

14.05.15 Gary Collier

V0.7 Amendments and updates from Sunderland CCG

26.05.15 Martin Johnson

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Executive Summary

Each year we see an increased number of challenges to all health and social care

organisations that affect service delivery, including the balance of emergency and

elective activity; together with the flow of patients from admission to secondary care

through to discharge. These challenges may include severe weather, seasonal flu,

norovirus and public holidays.

Ambulance delays at Acute Trusts, the diversion of Ambulances or the closure of a

hospitals’ Emergency Department can result in an increased clinical risk to patients.

Delays increase pressure on other local services, increasing waiting times for

patients in both the hospital concerned and in neighbouring Trusts.

As a result this policy sets out the process to reduce Ambulance Delays and Diverts

by way of the following:

The flight desk must be completed by all Acute Trusts daily at 11am, 4pm and

8pm to inform safe divert, this will be discussed and agreed in contract

negotiations with each Acute Trust.

A divert maybe initiated by an Acute Trust or the North East Ambulance Trust

(NEAS) following discussions as per policy.

A penalty of £2,000 per case will be incurred by the referring organisation

whether that decision is taken by the referring organisation or the Ambulance

Service.

An incentive of £1,500 per case will be given to the receiving organisation

providing mutual aid.

The Ambulance Service will receive £500 for each case diverted.

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1. Introduction

1.1 This policy sets out the process for the implementation and management of ‘Diverts’. A ‘divert’ is defined as an agreed change to the original planned destination of a patient, resulting in the re-routing of an Ambulance. This includes EDs, Maternity unit, Assessment Units etc.

1.2 To ensure service equity to our patients in the North East, this policy has been developed to provide clear and consistent guidance to Acute Trusts and NEAS with regards to diverts to ensure optimal handover times supporting patient flow and patient safety.

1.2 The best practice standard for the timely clinical handover and turnaround times of a patient by an emergency ambulance crew to hospital staff is 15 minutes “Everyone Counts: Planning for Patients 2013/14”.

2.2 The North East Urgent Care System aspires to reduce Ambulance Diverts to a minimum.

2.3 The North East Urgent Care System regards Ambulance handover delays in excess of 30 minutes as a Never Event, and as such, do not expect patients to be subject to such delays.

2. Purpose

2.1 The purpose of this document is to ensure that NEAS, Acute Trusts, Clinical Commissioning Groups (CCG’s) and NHS England have a clearly defined and consistent approach to managing diverts to effectively assist and manage demand across the system. The overarching principle is the safety and dignity of patients.

3. Principles

3.1 A divert may be initiated by either an Acute Trust or NEAS.

3.2 Diverts must be agreed between the diverting trust, NEAS and the receiving Trust.

3.3 Where diverts are agreed between trusts, NEAS must be formally notified of the period of the divert and of conditions i.e. speciality divert etc.

3.4 Taking a patient to an alternative Emergency Department (ED) is only appropriate if:

o the closest receiving unit is physically incapable of providing the right care and resuscitation facilities within a physically safe environment or;

o demand and/or delays result in Ambulances queuing and existing escalation and surge management plans have not been effective.

o Patient safety is jeopardised if in the opinion of the paramedic, it would be safer to take patients to an alternative hospital.

o Agreed with NEAS.

3.5 This policy applies to all North East Acute Trusts and NEAS and will be reviewed annually. This policy does not apply to diverts from or to trusts

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outside the North East. This policy does not apply to the prior agreement in place between County Durham and Darlington FT and Gateshead Health FT.

4. Process

Any and all diverts must follow the Divert Process as detailed below.

Decision to

Divert

Consult Flight Desk to

identify alternative

capacity

PROVIDER TO PROVIDER

DISCUSSION

Diverter/Receiver/NEAS

DIVERT

AGREED? NO

DIVERT RECORDED &

INITIATED*

£2,000

PENALTY

APPLIED

PER CASE

YES

RECEIVING FT £1,500

INCENTIVE PAID PER

CASE

AMBULANCE £500

INCENTIVE PAID PER

CASE

Examples may include:

- NEEP 3+

- Queuing Ambulances

- Broken Equipment

- Staffing

Penalties and Incentives applied

per Case

* Where clinically safe to do so –

NEAS not to bypass nearest A&E

where it would risk patient safety

Details of Provider Staff

agreement and Times recorded

Following discussions with two

‘receivers’ with no success -

ESCALATE TO FT DIRECTOR ON

CALL

No available mutual aid available

- ESCALATE TO CCG DIRECTOR ON

CALL

Further guidance can be found within the embedded Guidance document.

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Supporting Doc V7.docx

5. Record of Agreement

This policy records the agreement between the Commissioners and the Providers, IN WITNESS OF WHICH the Parties have signed this Policy on the date(s) shown below.

SIGNED BY TITLE ON BEHALF OF (ORGANISATION)

DATE

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Appendix 5

Escalation Action plan

Issue Action In hours DM Out Of Hours, SMT

1. ED/PED waiting time >2.5 hrs

Analyse bottlenecks implement flow changes by allocating resource at pinch points in consultation with shift leaders. In cases of Acute Med/Paediatric surge contact the relevant Consultant on call for advice

Analyse bottlenecks implement flow changes by allocating resource at pinch points in consultation with shift leaders. Contact the duty consultant of the relevant specialty for advice.

2. ED/AS Staffing Nursing: allocate from other areas in consultation with matrons /PSC. Medical: HR has a distribution list (locum bank) and group messages can be sent asking for help.

Nursing: allocate from other areas in consultation with PSC. Theatres often have spare capacity. Medical: The PSCs have the Trust approved medical agency telephone numbers and can be given access to the locum bank distribution list to be used 24/7.

3. Patients awaiting CT Should be undertaken within 60 minutes of request

Explore reason. Do all CTs need to be done urgently? ED Consultant to discuss and prioritise CTs with radiology consultant.

Explore reason. Do all CTs need to be done urgently? ED Consultant to discuss and prioritise CTs with radiology consultant.

4. CT report Verbal report within 60 minutes of scan

Explore reason. ED Consultant to discuss and prioritise reporting with radiology consultant.

Explore reason. ED Consultant to discuss and prioritise reporting with radiology consultant.

Patients waiting blood results; if >1-2 hour

Explore reason: are bloods being done early in patient journey. Allocate resource at front end. Contact Labs to enquire if results can be expedited.

Explore reason: are bloods being done early in patient journey. Allocate resource at appropriately. Contact Labs to enquire if results can be expedited.

5. Fast track of medical admissions

When ED is busy but AS has capacity and only if medical emergency admissions are overwhelming ED capacity. All patients to be rapidly assessed by ED senior doctor to ensure stability & AS consultant must be

When ED is busy but AS has capacity and only if medical emergency admissions are overwhelming ED capacity. All patients to be rapidly assessed by ED senior doctor to ensure stability & AS consultant must be informed Identify medical admissions at ED triage and fast track to AS

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informed Identify medical admissions at ED triage and fast track to AS

6. ED Exit block due to increased waiting times on AS due to patient volume waiting to be seen

To reallocate senior and junior medical staff to help manage surge

1. AMD contacts AS consultant physician to discuss what is required.

2. AMD implements that one of the specialty rotas be called – suggest alphabetical order, and as we started with Gastro, next would be ID, then Diabetes, then Endo.

3. Additional Juniors to be recruited from BoH and FH

4. Awaiting bed Liaise with PSC to determine bottleneck and act accordingly If AS issue allocate resource appropriately, if BoH issue ensure discharges are actioned by requesting BoH review if capacity issue identify nursed capacity and board patients.

Nurse in Charge to liaise with Assessment Suite (AS) & Patient Services Coordinator (PSC). Emergency Department (ED) Consultant to be regularly made aware when capacity issues are affecting outflow from ED e.g 4 hrly. If wait > 4 hrs Matron and/or PSC to be advised of wait who will take action to expedite patient to bed by looking to move patients out of AS or base bed to accommodate ED patient. If wait > 8hrs then Nurse in Charge to inform ED Consultant and further discussion with PSC and Senior manager to take place. If a solution cannot be found to transfer the patient from ED then advice should be sort from the Clinical Director or Associate Medical Director OOH. The Trust Chief Executive is required to report any >12hr waits to the Department of Health.

5. Awaiting Speciality review

To ensure patients seen within 30 – 60 minutes of referral by senior decision maker

If not, Nurse in Charge to contact speciality; if still do not attend, Nurse in Charge to escalate to ED consultant who must escalate to Speciality Consultant. If specialty unable to attend arrange direct admission to base ward as agreed in the ‘Admitting rights to Specialty’ document.

6. Awaiting discharge To ensure patients discharged within 4

If delays with ambulance Nurse in Charge to contact ambulance to

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hours expedite and to consider possibility of alternative transport with PSC

7. Patients in Observation for >6hours

To ensure patients have the appropriate management plan in place

Consultant/ Doctor in Charge to review patients in Observation ward at start of morning shift and also if patient has been in unit for >6hours

8. Patients booked for admission

To ensure admissions are appropriate

All admissions to be discussed with consultant or ED registrar

9. Orthopaedic Trauma Surge Escalation

Monitoring trolleys within ED should become operational and used to help with the management of surge activity. This will be managed as part of ED capacity under the coordination of the ED Consultant and assisted by the on-call Orthopaedic medical team. A nurse from Fracture clinic/ortho ward will be released to work within ED to assist with clinical care as appropriate. Plaster technicians will be available as per normal. An on-call nursing rota will be available during the Winter months from the beginning of November to the end of March. The on-call period includes 12:00 – 20:00 hrs Saturday and Sundays and BH. The rota will provide nurse cover to be available and called upon should a surge in acute trauma activity occur and time-limited support is required. The rota will be held by Trauma/orthopaedic bleep holder with the list of staff on-call available

Monitoring trolleys within ED should become operational and used to help with the management of surge activity. This will be managed as part of ED capacity under the coordination of the ED Consultant and assisted by the on-call Orthopaedic medical team. A nurse from Fracture clinic/ortho ward will be released to work within ED to assist with clinical care as appropriate. Plaster technicians will be available as per normal. An on-call nursing rota will be available during the Winter months from the beginning of November to the end of March. The on-call period includes 12:00 – 20:00 hrs Saturday and Sundays and BH. The rota will provide nurse cover to be available and called upon should a surge in acute trauma activity occur and time-limited support is required. The rota will be held by Trauma/orthopaedic bleep holder with the list of staff on-call available in the bleep folder. The on-call person should be utilised to staff the above area / or backfill depending on skills. The decision to call-in the nurse on the rota rests with the Orthopaedic bleep holder and RVI PSC.

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in the bleep folder. The on-call person should be utilised to staff the above area / or backfill depending on skills. The decision to call-in the nurse on the rota rests with the Orthopaedic bleep holder and RVI PSC.

If escalation measures within the department are unsuccessful, then the member of staff in charge of the A&E department should contact the Directorate Manager or Clinical Director in hours; Out of hours contact should be with the on-call Assistant Medical Director or on-call Senior Manager always ensuring that the site PSC is aware of the circumstances.

Utilisation of acute monitoring beds Current capacity: 9 Monitored beds in “monitoring area” on Assessment Suite 3 monitored beds (male bay) 3 monitored beds (female bay) 4 CPAU beds All emergency admissions which require monitoring require timely access to an emergency admissions monitoring bed. Patients requiring monitoring CPAU Monitored bed Chest Pain/ACS AS Monitored Bed to be utilised for:

Cardiac arrhythmia Collapse secondary to potential cardiac arrhythmia – AS monitored bed Unstable medical patient – determined by clinical acumen, MEWs, lactate –

(mandatory if MEWs >3 in any one category or >5 total, lactate >2/acidosis, deteriorating MEWs)

DKA Serious electrolyte disturbances Patients requiring administration of particular drugs necessitating cardiac

monitoring Toxicology patients (dependent on drug)

In the event of there being limited monitored bed availability on AS:

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PSC to inform AS Consultant if monitored bed capacity tight on AS. AS Consultant to review monitored patients and move appropriate patients to base ward/non-monitored beds.

If there are problems with patient flow in ED either for monitored or non-monitored patients, ED to contact AS Consultant to enable a more rapid Consultant review if required in ED. (ED clerk of the medical admissions document must be completed).

If there is still no monitoring capacity following the above actions:

CPAU may be used as overflow capacity in exceptional circumstances if all monitoring beds are full and no patients in these beds are fit to move.

If CPAU is full the CPAU Sister should look to transfer patients to RVI ward 49/CCU.

If RVI ward 49/CCU is full the Cardiology Consultant should be contacted by the CPAU nurse in order to review patients in CPAU with a view to freeing up capacity. If a timely review by the Cardiologist is not possible a review by the medical SpR should be considered in order to facilitate movement of patients from CPAU.

In addition:

AS Consultant to contact Critical Care to establish whether or not there is capacity on HDU to help meet demand of monitored patients.

Patients requiring increased monitoring should be escalated to HDU/ICU and not be transferred to AS. If HDU/ICU is full to capacity AS monitoring may be used in exceptional circumstances. This must be agreed by the AS Consultant who should liaise with the PSC to ensure patient flow will not be impeded.

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Equality Analysis Form A

This form must be completed and attached to any procedural document when submitted to the appropriate committee for consideration and approval.

PART 1 1. Assessment Date: 2. Name of policy / strategy / service:

Bed Management

3. Name and designation of Author:

Melanie Cunningham Patient Services Manager

4. Names & designations of those involved in the impact analysis screening process:

Melanie Cunningham

5. Is this a: Policy * Strategy Service

Is this: New Revised *

Who is affected Employees * Service Users * Wider Community

6. What are the main aims, objectives of the policy, strategy, or service and the intended outcomes? (These can be cut and

pasted from your policy)

26.11.2015

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To provide safe and effective bed management

7. Does this policy, strategy, or service have any equality implications? Yes * No

If No, state reasons and the information used to make this decision, please refer to paragraph 2.3 of the Equality Analysis Guidance before providing reasons:

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8. Summary of evidence related to protected characteristics Protected Characteristic Evidence, i.e. What evidence do you

have that the Trust is meeting the needs of people in various protected Groups

Does evidence/engagement highlight areas of direct or indirect discrimination? If yes describe steps to be taken to address (by whom, completion date and review date)

Does the evidence highlight any areas to advance opportunities or foster good relations. If yes what steps will be taken? (by whom, completion date and review date)

Race / Ethnic origin (including

gypsies and travellers)

Interpreter policy Patients would not be moved if staff were unable to communicate the need for the move.

No No

Sex (male/ female) Single sex accommodation policy.

No No

Religion and Belief Chaplaincy team available for support if required

No No

Sexual orientation including

lesbian, gay and bisexual people

Information about next of kin and person who the patient wishes staff to relate to transferred with patient

No No

Age Boarding guidelines referenced within this policy. This states that people with dementia will not be boarded

No No

Disability – learning difficulties, physical disability, sensory impairment and mental health. Consider the needs of carers in this section

Boarding guidelines referenced within this policy. This states that people with disabilities that would make it unsafe to move them will not be moved.

No No

Gender Re-assignment Moving patients is discussed No No

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with the nurse in charge any Transgender people who it would not be appropriate to move would not be moved.

Marriage and Civil Partnership

None relevant to this policy No No

Maternity and Pregnancy Moving patients is discussed with the nurse in charge any pregnant or nursing mothers who it would not be appropriate to move would not be moved.

No No

9. Are there any gaps in the evidence outlined above? If ‘yes’ how will these be rectified?

No

10. Engagement has taken place with people who have protected characteristics and will continue through the Equality

Delivery System and the Equality Diversity and Human Rights Group. Please note you may require further engagement in respect of any significant changes to policies, new developments and or changes to service delivery. In such circumstances please contact the Equality and Diversity Lead or the Involvement and Equalities Officer.

Do you require further engagement? Yes No *

11. Could the policy, strategy or service have a negative impact on human rights? (E.g. the right to respect for private

and family life, the right to a fair hearing and the right to education?

No

PART 2

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Name:

Melanie Cunningham

Date of completion:

09/12/2015

(If any reader of this procedural document identifies a potential discriminatory impact that has not been identified, please refer to the Policy Author

identified above, together with any suggestions for action required to avoid/reduce the impact.)

Bed Management and Escalation Policy - Newcastle … · Page 1 of 47 The Newcastle upon Tyne...

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Transcript of Bed Management and Escalation Policy - Newcastle … · Page 1 of 47 The Newcastle upon Tyne...