ADULT PATIENT FLOW AND ESCALATION POLICY · proactive response to surge in non-elective activity is fundamental to ensure patient safety. This policy details the procedures for ensuring

Title: Adult Patient Flow & Escalation Policy Version: 2.0 Issued: November 2018 Page 1 of 60

ADULT PATIENT FLOW AND ESCALATION POLICY

POLICY

Reference

CPG-TW-APF&EP

Approving Body Urgent & Emergency Care Divisional Clinical Governance Meeting

Date Approved

22nd November 2018

Issue Date

26th November 2018

Version

2.0

Summary of Changes from Previous Version

Revised escalation triggers

Alignment of escalation triggers to OPEL Framework

Revised action cards

Supersedes

v1.0, Issued 8th November 2016 to Review Date June 2018

Document Category

Clinical

Consultation Undertaken

Patient Flow Group

Date of Completion of Equality Impact Assessment

November 2018

Date of Environmental Impact Assessment (if applicable)

Not Applicable

Legal and/or Accreditation Implications

None identified

Target Audience

All staff

Review Date

December 2020 (ext2)

Sponsor (Position)

Chief Operating Officer, Simon Barton

Author (Position & Name)

Deputy Chief Operating Officer, Denise Smith

Lead Division/ Directorate

Corporate

Lead Specialty/ Service/ Department

Operations

Position of Person able to provide Further Guidance/Information

Chief Operating Officer

Associated Documents/ Information Date Associated Documents/ Information was reviewed

Medical Outlier Ward Pairings

Clinical Site Management Team SOP

Opening of Additional Bed Capacity (incl Bed Escalation Plan)

Available separately via the Medical Division intranet

Review Date: April 2020

Review Date: October 2020

http://sfhnet.nnotts.nhs.uk/content/showcontent.aspx?contentid=32200

http://sfhnet.nnotts.nhs.uk/content/showcontent.aspx?ContentId=49556




CONTENTS

Item Title Page

1.0 INTRODUCTION 3

2.0 POLICY STATEMENT 3

3.0 DEFINITIONS/ ABBREVIATIONS 4

4.0 ROLES AND RESPONSIBILITIES 5

5.0 APPROVAL 6

6.0 DOCUMENT REQUIREMENTS 6.1 Normal working 6.2 Escalation 6.3 Escalation triggers 6.4 Escalation actions 6.5 Outlying patients 6.6 Opening additional capacity 6.7 Closing additional capacity

6-8 6 6 7 7 7 8 8

7.0 MONITORING COMPLIANCE AND EFFECTIVENESS 9

8.0 TRAINING AND IMPLEMENTATION 10

9.0 IMPACT ASSESSMENTS 10

10.0 EVIDENCE BASE (Relevant Legislation/ National Guidance) and RELATED SFHFT DOCUMENTS

10

11.0 KEYWORDS 10

12.0 APPENDICES (list) 10

Appendix A Capacity and Flow Meetings SOP 11-16

Appendix B OPEL Framework 17

Appendix C Trust Escalation Triggers 18

Appendix D Emergency Department Escalation Triggers 19

Appendix E Action Cards 20-57

Appendix F Additional Capacity 58

Appendix G Equality Impact Assessment 59-60


1.0 INTRODUCTION Emergency Department (ED) attendances and non-elective patient admissions to the Trust, which can be unpredictable in nature, pose a challenge to the Trust on a daily basis. The proactive response to surge in non-elective activity is fundamental to ensure patient safety. This policy details the procedures for ensuring safe and effective utilisation of in-patient beds to ensure patients, who require admission are admitted to the right bed, at the right time first time. 2.0 POLICY STATEMENT

All emergency patients requiring an admission are transferred to bed within four hours of attending (ED), unless there is a valid clinical reason to remain in ED.

Elective admissions will not be cancelled due to lack of bed availability unless in accordance with this escalation policy.

All available capacity at SFH will be used efficiently and effectively to ensure that the right patient is placed in the right bed and at the right time.

All patients from assessment areas will be pulled into the correct specialty beds as soon as possible. When this process no longer complements emergency flow, as a last resort, additional capacity and outlying capacity will be used to maintain flow throughout the hospital.

The above objectives rely on the following assumptions:

Divisional Management Teams will manage their own emergency and elective

demand

Wards will ensure that they are aware of the expected emergency demand and have

daily plans to manage this

The movement of patients will comply with the Trust infection control policies.

It is the responsibility of all SFH staff engaged in acute, adult care to ensure the

actions detailed in this plan are undertaken and supported

Divisions will have operational action plans in place to support this policy and the

Trust during the stages of escalation.

These procedures relate to acute and adult capacity only. Paediatric and Maternity

capacity will be managed by the Women’s and Children’s Divisional Management

Team.


3.0 DEFINITIONS / ABBREVIATIONS

AECU Ambulatory emergency care unit

AHP Allied health professional

BAU Business as usual

BOC Bronze on call

BRAG Black, red, amber, green

CCG Clinical Commissioning Group

COO Chief Operating Officer

DCOO Deputy Chief Operating Officer

DGM Divisional General Manager

DNM Duty Nurse Manager

DTA Decision to admit

DTOC Delayed transfer of care

EAU Emergency Assessment Unit

ED Emergency Department

EDAS Early Supported Discharge Service

EDD Expected date of discharge

EMAS East Midlands Ambulance Service

IDAT Integrated Discharge and Assessment Team

NEMS GP out of hours provider

PC24 Primary Care 24

SAFER Patient flow bundle incorporating 5 elements of best practice

SAU Surgical assessment unit

SOC Silver on call

TCI To come in


4.0 ROLES AND RESPONSIBILITIES Responsibility The management of all bed capacity is the responsibility of the Chief Operating Officer and

this responsibility is disseminated through a Silver/Gold on call structure, which is in place at

all times in the Trust.

Expectations of each role are outlined in the action cards at Appendix E.

The management of patient flow, during working hours, remains the responsibility of the

Duty Nurse Manager (DNM) and the Divisional Management Teams.

The DNM is accountable for the management of flow ‘Out of Hours’ and has designated

authority to work in conjunction with the Silver and Gold on call as required. The day to day

process and roles and responsibilities of these individuals are outlined below:

Roles

DNMs Acts as Site Manager co-ordinating effective flow across each hospital site. Reports back to Silver/Capacity and Flow Matron if actions are not completed or are insufficient to meet demand.

Silver on Call Senior Managers’ within the Trust provide the ‘Silver on Call ‘role, 24 hours a day, 7 days a week. The role of the ‘Silver on Call’ is to provide Senior Leadership to help deliver the timely flow of patients through the Trust, supporting the decision making process and troubleshooting as required. During an incident, ‘Silver on Call’ has overall responsibility for co-ordination of the Senior Managers, Nurses and AHP’s within the Trust

Capacity and Flow Matron

Manages the capacity and flow team to ensure the timely flow of patients through the Trust. Holds the Divisional teams to account in delivering their plans as outlined in this policy. Assess whether the divisional plans are sufficient to ensure flow or if escalation is required.

Gold on Call The primary role of ‘Gold on Call’ is to give strategic direction to the ‘Silver on Call’. The Chief Operating Officer or the Deputy Chief Operating Officer is ‘Gold on Call’ Monday to Friday, 0800-1800. ‘ Out of Hours’ is the ‘Executive Gold on Call’


5.0 APPROVAL The policy has been consulted on at the Patient Flow Group and approved by the Urgent and Emergency Care Divisional Clinical Governance Group. 6.0 DOCUMENT REQUIREMENTS 6.1 Normal working All Trust staff are required to actively contribute to the timely and safe discharge of patients from hospital. An expected date of discharge (EDD) is to be set within 24 hours of a patient’s admission to help co-ordinate and plan for discharge in a timely manner. The patient’s discharge planning is to commence upon the admission of the patient. Medical staff must ensure that ward and board rounds are complete in a timely manner on a daily basis and patients for discharge identified. Potential and definite discharges should be declared to the Site Managers at the earliest opportunity. Ward staff should make appropriate use of the Discharge Lounge to ensure that beds are released to accept acute admissions. Normal working includes:

Completed morning ‘Board Rounds’

Completing ward rounds before 12:00 using SHOP (Sick, Home, Others, Plan)

Setting a patient’s clinically agreed EDD within 24 hours of admission

Commence discharge planning upon the patient’s admission

Informing Pharmacy of a patient’s discharge at least the day before discharge

Ensure the patient is assessed and is fit for transport in a timely manner

Ensure transport is booked as soon as possible, preferably the day before discharge

Identifying discharges the day before discharge and proactively move ‘Golden Patients’ from the wards to the discharge lounge at 8am on day of discharge

Identifying patients for step down to MCH/Newark

Proactively identifying patients for Newark and MCH wards

Proactively review all of the patients with a LOS of over 7 days on a daily basis 6.2 Escalation Non elective capacity and demand inequity, which may be caused by means of a surge of emergency admissions or a failure to deliver sufficient discharges, undermines the Trust’s ability to deliver to its operational standards and to care safely for individual patients in the correct environment. Assumptions are made that the Trust does not close for emergency admissions and will not be able to divert acute workload to another acute provider unless authorised by the Chief Operating Officer or Deputy Chief Operating Officer in hours and the ‘On Call Gold’ out of hours. This should only happen in accordance with escalation status and subsequent action cards.


The objectives of escalation are:

To ensure the safe and clinically appropriate placement of patients requiring an acute inpatient bed at all times, in line with infection control and mixed sex policies.

To minimise any potential risk to patients in terms of waiting times and cancellations.

To ensure patient flow into and out of ED is maintained to reduce the risks associated with overcrowding.

To maximise performance against the ED four hour standard. Patients should only be placed in clinical accommodation that is appropriately staffed and equipped to manage their presenting condition and this must be supported with an appropriate Medical, Nursing and AHP infrastructure. It is also the responsibility for all the Divisional Management Team to manage their clinical activity within their own bed base and to establish, implement and manage their own Divisional plans for each level of escalation. It is important that the Trust is able to assure its healthcare partners that all internal measures have been taken before escalating to the highest escalation status. 6.3 Escalation triggers SFH uses a Black, Red, Amber and Green (BRAG) escalation framework; this is aligned to the NHS Operational Pressures Escalation Levels Framework (OPEL), see Appendix B. The Trust escalation framework is included at Appendix C, three or more conditions triggers the escalation level. During normal working the Trust will function on escalation level green, indicating that there are no significant issues expected within the next 24 hours. It is when the Trust enters escalation level amber that this policy comes into effect. At this point the Site Management Team, On Call Teams and Divisional Management Teams will need to employ actions, supported by this policy that will help to regain control over the Trust’s flow and capacity. 6.4 Escalation actions Expected responses to each escalation are detailed in the action cards at Appendix E. 6.5 Outlying patients In the circumstances of OPEL 1 or OPEL 2 escalation outlying will not be necessary to maintain effective patient flow. On days when OPEL 3 or OPEL 4 alert is declared wards are to identify at least 2 patients who, in could be safely outlied into another specialty ward. The outlying of patients in such circumstances should be robustly assessed to ensure patient safety and experience is not compromised; any decisions taken to oulie patients must be taken in line with the Trust Patient Outlier Policy (for adult patients). Medical outlier ward pairings are available on the intranet.


A number of (specialty beds) are ring fenced and should not be used for outlying capacity unless at full capacity. These include:

Maternity

Paediatrics

2 x NIV (1 male bed, 1 female bed)

2 x Stroke (1 male bed, 1 female bed)

2 x #NoF (ward 12) (1 male bed, 1 female bed)

Elective Orthopaedics (ward 21)

Theatre recovery

Cath Labs

DCU (Day Case Unit) 6.6 Opening additional capacity Opening of additional beds requires progressively more resources, planning and managerial efforts. The decision to open additional capacity must not be undertaken lightly and will only be agreed by ‘Gold on Call’ through discussion with ‘Silver on Call’; consideration will be given to opening additional capacity will be made if the Trust is at escalation level OPEL 3 (RED) or OPEL 4 (BLACK). 6.7 Closing additional capacity When a decision is made to open beds or escalation areas a plan must also be in place for closing the beds or escalation area.


7.0 MONITORING COMPLIANCE AND EFFECTIVENESS

Minimum Requirement

to be Monitored

(WHAT – element of compliance or effectiveness within the document

will be monitored)

Responsible Individual

(WHO – is going to monitor this element)

Process for Monitoring

e.g. Audit

(HOW – will this element be monitored (method

used))

Frequency of

Monitoring

(WHEN – will this element be monitored (frequency/

how often))

Responsible Individual or Committee/

Group for Review of Results

(WHERE – Which individual/ committee or group will this be reported to, in what format

(eg verbal, formal report etc) and by who)

Compliance with Action Cards Chief Operating Officer

Observation Ad hoc – quarterly as a minimum

Patient Flow Group Divisional Performance Review Group Meetings

Compliance with Capacity and Flow Meeting SOP

Chief Operating Officer

Observation Ad hoc – quarterly as a minimum

Patient Flow Group Divisional Performance Review Meetings

Title: Adult Patient Flow and Escalation Policy Version: 2.0 Issued: November 2018 Page 10 of 60

8.0 TRAINING AND IMPLEMENTATION Training and implementation will be undertaken as follows:

Dissemination and cascade to all corporate teams via the Chief Operating Officer

Dissemination and cascade to all Clinical Divisions via the Patient Flow Group

All new staff participating in the Duty Nurse Manager, Silver and Gold on call rota will be trained in this policy by the Capacity and Flow Matron

The policy will be available on the Trust intranet under the Silver / Gold Resource page section

9.0 IMPACT ASSESSMENTS

This document has been subject to an Equality Impact Assessment, see completed form at Appendix G

This document has not been subject to an Environmental Impact Assessment 10.0 EVIDENCE BASE (Relevant Legislation/ National Guidance) AND RELATED

SFHFT DOCUMENTS Evidence Base:

Good practice guide: Focus on improving patient flow (NHS Improvement, July 2017) Related SFH Documents:

Major Incident Plan

Women’s and Children’s Escalation Policies

Emergency Department Escalation Policy

Infection Prevention and Control Policy

Patient Outlier policy

Ward pairings 11.0 KEYWORDS Bed Management; Gold; silver; bronze; on-call; Capacity and flow; Outlier; outlying; outlay; black alert; red; amber; escalate; ward pairings; 12.0 APPENDICES

Appendix A Capacity and Flow Meetings SOP

Appendix B OPEL Framework

Appendix C Trust Escalation Triggers

Appendix D Emergency Department Escalation Triggers

Appendix E Action Cards

Appendix F Additional Capacity

Appendix G Equality Impact Assessment


APPENDIX A CAPACITY & FLOW MEETINGS STANDARD OPERATING PROCEDURE This SOP is a guide to the expectations and information to be discussed in each Capacity & Flow meeting. It does not exclude the raising of other issues and attendees should feel able to raise any issues that they are concerned about or need help with. The overall objective of these meetings is to ensure patient get safe access to the care that they need. In terms of meeting attendance it should be read in conjunction with the Trusts escalation policy. Etiquette – start on time, no use of phones, action oriented, no specific patient discussions unless repatriations or safety issue. Chair – dependent on escalation status, as detailed below:

Monday – Friday (excl Bank Holidays)

8.00am 11.00am 2.00pm 5.00pm

OPEL 1 COO / CAPACITY

AND FLOW MATRON

DUTY NURSE MANAGER

DUTY NURSE MANAGER

CAPACITY AND FLOW MATRON


AND FLOW MATRON

CAPACITY & FLOW MATRON




AND FLOW MATRON




OPEL 4 COO COO COO COO

Time Objective Running order/information

0800

Debrief from night shift

Agreed actions to be taken to maintain patient safety, experience and quality between 0800 and 1100 Capacity & Flow meeting

Review and agree escalation status – if the escalation is ‘Black’ then a plan to immediately unblock majors/resus will be discussed and agreed

All Divisions

Staffing risks for the day that cannot be managed within Division

EAU/SSU

No. of patients awaiting post-take on EAU

Overview of the 3 longest waiting patients for EAU in ED including the plan if no capacity available

Identification of patients who have been on EAU for over 24 hours identifying the specialty they are waiting for

Clarity on number of patients waiting for medicine including how many have booked beds

Medicine

Planned discharges (PDDs) for the day

Identification from the PDDs of the expect number who can go to the discharge lounge

PDDS requiring transport with clarity on how many are pre-booked

Overview of elective patients TCI for medicine

Plan for the movement of patients identified the day before by the Division for early discharge (golden patients)

Elective patients planned for medicine for the day


Surgery

Confirmation of admitting capacity for SAU & Trauma – if there is not capacity clarity on plan to create admitting capacity

Elective patients scheduled for the day (DC/IP) including any identified for ITU

Womens & Childrens

Confirmation of admitting capacity for Gynae/Maternity/Paeds – if there is not capacity clarity on plan to create admitting capacity

Elective patients scheduled for the day (DC/IP) including any identified for ITU



1100

Follow up of actions agreed at 0800

Agreed actions to be taken to maintain patient safety, experience and quality between 0800 and 1100 Capacity & Flow meeting

Review and agree escalation status

All Divisions

Staffing risks for the day/night that cannot be managed within Division

Escalations for other Divisions (eg imaging, therapies)

Overview of repatriations in/out of the Trust Emergency department

Overview of the department including the status and plan for patients who breach in the next hour

Reporting of the waiting time to be seen and plans to reduce should it be in excess of 2 hours for majors

Clarification of capacity in resus/majors

Overview of ambulances currently waiting or that have been waiting in the past hour and whether they have been handed over before 30 minutes

Identification of what support if any is required EAU/SSU




Medicine

Clarity on patients discharged by 1100

Patients in the discharge lounge from medical base wards

Overview of potential discharges identifying what the patient needs to be discharged

Transport pre-booking and ambulance risks to be managed

Surgery


Confirmation of plan for any surgical/T&O patients in ED to be brought in prior to breach time

Confirmation of bed capacity for all elective patients Women’s & Children’s

Confirmation of admitting capacity for Gynaecology/Maternity/Paediatrics – if there is not capacity clarity on plan to create admitting capacity

Confirmation of plan for any Gynaecology/Paediatric patients in ED to be brought in prior to breach time

Confirmation of bed capacity for all elective patients Diagnostics & Outpatients

Pick up any escalations (eg imaging, therapies etc)

Infection control update (if required)



1400


Agreed actions to be taken to maintain patient safety, experience and quality between 1500 & 1800 Capacity & Flow meeting


All Divisions

Staffing risks for the day/night that cannot be managed within Division

Escalations for other Divisions (eg imaging, therapies)

Overview of repatriations in/out of the Trust Emergency department

Overview of the department including the status and plan for patients who breach in the next hour








Medicine

Clarity on patients discharged by 1400

Number of patients in the discharge lounge from medical base wards including the total number through for medicine today so far

Overview of potential discharges identifying what the patient needs to be discharged

Transport pre-booking Surgery



Confirmation of bed capacity for all elective patients Women’s & Children’s


Confirmation of plan for any Gynaecology/Paediatric patients in ED to be brought in prior to breach time

Confirmation of bed capacity for all elective patients Diagnostics & Outpatients

Pick up any escalations (eg imaging, therapies etc)

Infection control update (if required)



1700


Agree clear plan to give patients safe and quality access to beds for the night


All Divisions

Staffing risks for the night/day that cannot be managed within Division

Escalations for other Divisions (eg imaging, therapies) Emergency department

Overview of the department including the status and plan for breaches in the next hour








Medicine

Over view of forecast and clarity of plan for balance including any help required

Clarification of risks to discharge for the rest of the day (i.e. ‘re-beds’)

PDDs for the next day along with the number if pre-booked transport

Identification of patients for discharge before 1000 the following day (golden patients)

Review of elective patients TCI for medicine for the next day Surgery



Confirmation that all elective patients have either been admitted to beds or will have a bed available

Elective TCIs for tomorrow including the Day case/Inpatient split and any that need critical care

Women’s & Children’s



Confirmation that all elective patients have either been admitted to beds or will have a bed available

Elective TCIs for tomorrow including the Day case/Inpatient split and any that need critical care

Diagnostics & Outpatients

No required unless any issues to pick up



1945 – handover & bed state

Handover between Silvers (telephone)

DNM handover

Final days bed state

Confirmation of plan to maintain flow and patient safety overnight

Escalation and management of any staffing gaps


APPENDIX B OPEL FRAMEWORK

NATIONAL DESCRIPTOR SUGGESTED TRIGGERS

GREEN (OPEL 1)

The local health and social care system capacity is such that organisations are able to maintain patient flow and are able to meet anticipated demand within available resources. The Local A&E Delivery Board area will take any relevant actions and ensure appropriate levels of commissioned services are provided. Additional support is not anticipated.

Demand for services within normal parameters

There is capacity available for the expected emergency and elective demand. No staffing issues identified

No technological difficulties impacting on patient care

Use of specialist units/beds/wards have capacity

Good patient flow through ED and other access points. Pressure on maintaining ED 4 hour target

Infection control issues monitored and deemed within normal parameters

AMBER (OPEL 2)

The local health and social care system is starting to show signs of pressure. The Local A&E Delivery Board will be required to take focused actions in organisations showing pressure to mitigate the need for further escalation. Enhanced co-ordination and communication will alert the whole system to take appropriate and timely actions to reduce the level of pressure as quickly as possible. Local systems will keep NHS E and NHS I colleagues at sub-regional level informed of any pressures, with detail and frequency to be agreed locally. Any additional support requirements should also be agreed locally if needed.

Anticipated pressure in facilitating ambulance handovers within 60 minutes

Insufficient discharges to create capacity for the expected elective and emergency activity

Opening of escalation beds likely (in addition to those already in use)

Infection control issues emerging

Lower levels of staff available, but are sufficient to maintain services

Lack of beds across the Trust

ED patients with DTAs and no action plan

Capacity pressures on PICU, NICU, and other intensive care and specialist beds (possibly including ECMO)

RED (OPEL 3)

The local health and social care system is experiencing major pressures compromising patient flow and continues to increase. Actions taken in OPEL 2 have not succeeded in returning the system to OPEL 1. Further urgent actions are now required across the system by all A&E Delivery Board partners, and increased external support may be required. Regional teams in NHS E and NHS I will be aware of rising system pressure, providing additional support as deemed appropriate and agreed locally. National team will also be informed by DCO/Sub-regional teams through internal reporting mechanisms

Actions at OPEL 2 failed to deliver capacity

Significant deterioration in performance against the ED 4 hour target (e.g. a drop of 10% or more in the space of 24 hours)

Patients awaiting handover from ambulance service within 60 minutes significantly compromised

Patient flow significantly compromised

Unable to meet transfer from Acute Hospitals within 48 hour timeframe

Awaiting equipment causing delays for a number of other patients

Significant unexpected reduced staffing numbers (due to e.g. sickness, weather conditions) in areas where this causes increased pressure on patient flow

Serious capacity pressures escalation beds and on PICU, NICU, and other intensive care and specialist beds (possibly including ECMO)

Problems reported with Support Services (IT, Transport, Facilities Pathology etc.) that can’t be rectified within 2 hours

BLACK (OPEL 4)

Pressure in the local health and social care system continues to escalate leaving organisations unable to deliver comprehensive care. There is increased potential for patient care and safety to be compromised. Decisive action must be taken by the Local A&E Delivery Board to recover capacity and ensure patient safety. All available local escalation actions taken, external extensive support and intervention required. Regional teams in NHS E and NHS I will be aware of rising system pressure, providing additional support as deemed appropriate and agreed locally, and will be actively involved in conversations with the system. Where multiple systems in different parts of the country are declaring OPEL 4 for sustained periods of time and there is an impact across local and regional boundaries, national action may be considered.

Actions at OPEL 3 failed to deliver capacity

No capacity across the Trust

Severe ambulance handover delays

Emergency care pathway significantly compromised

Unable to offload ambulances within 120 minutes

Unexpected reduced staffing numbers (due to e.g. sickness, weather conditions) in areas where this causes increased pressure on patient flow is at a level that compromises service provision / patient safety

Severe capacity pressures on PICU, NICU, and other intensive care and specialist beds (possibly including ECMO)

Infectious illness, Norovirus, Severe weather, and other pressures in Acute Trusts (including A&E handover breaches)

Problems reported with Support Services (IT, Transport, Facilities Pathology etc.) that can’t be rectified within 4 hours


APPENDIX C TRUST ESCALATION TRIGGERS (Level will be determined by 3 or more indicators in a block triggering)

GREEN (OPEL 1) AMBER (OPEL 2) RED (OPEL 3) BLACK (OPEL 4)

EAU capacity ≥ 12

SAU capacity ≥ 6

EAU capacity ≥ 8

SAU capacity ≥ 4

EAU capacity ≥ 4

SAU capacity ≥ 2

No assessment or base ward capacity across the Trust

2 male & 2 female speciality beds in Cardiology, Stroke, NIV, #NOF

1 male & 1 female speciality beds in Cardiology, Stroke, NIV, #NOF

No speciality beds No speciality beds

Waiting lists placed Waiting lists placed Potential cancellation of routine, elective surgery

Routine, elective surgery suspended and risk of on the day cancellations

Sufficient capacity to meet predicted demand

Able to accommodate predicted demand through utilisation of all available capacity

Significant risk that available capacity will not meet predicted demand

Insufficient capacity to meet predicted demand and risk of patients waiting in ED overnight

No. of patients to step down ICCU ≤ 2

No. of patients to step down from ICCU 2 - 4

No. of patients to step down from ICCU ≥ 4

No Capacity or flow from ICCU

No extra capacity open No extra capacity open Extra capacity open due to bed pressures.

No further additional capacity to open

No outliers ≤ 5 outliers ≥ 8 patients outliers ≥ 16 outliers

Peripheral capacity utilised transfer list available

Peripheral capacity utilised – no list available.

Peripheral capacity utilised – long list waiting for beds/transfer

Peripheral capacity utilised – long list waiting for beds/transfer

No patients waiting for repatriation

Patients for repatriation waiting ≤ 48 hours

Patients waiting for repatriation ≥ 48 hours

Patients waiting for repatriation ≥ 48 hours


APPENDIX D EMERGENCY DEPARTMENT ESCALATION TRIGGERS (Level will be determined by 3 or more indicators in a block

triggering)

GREEN (OPEL 1) AMBER (OPEL 2) RED (OPEL 3) BLACK (OPEL 4)

Presentations ≤ 15 in previous 2 hours

Presentations 15 – 20 in previous 2 hours

Presentations 20 – 25 in previous 2 hours

Presentations ≥ 25 in previous 2 hours

≤ 30 patients in department ≤ 50 patients in department 50 – 80 patients in department ≥ 80 patients in department

Longest wait to be seen 90 min Longest wait to be seen 120 min Longest wait to be seen 180 min Longest wait to be seen 240 min

Ambulance handover ≤ 30 min Ambulance handover 30 – 60 min Ambulance handover ≥ 60 min Ambulance handover ≥ 120 min

DTAs within 2 hours DTAs 2 – 3 hours DTAs – 4 hours DTAs 4 hours and over

Patients in resus ≤ 2 Patients in resus 3 - 4 Patients in resus 4 - 6 Patients in resus ≥ 6

No patients waiting for admission bed to any speciality

≤ 4 patients waiting for an admission bed in any given speciality within 4 hour window

≥ 5 patients waiting for an admission bed over 4 hours potential to breach 8 hours

≥ 10 patients waiting for an admission bed over 4 hours potential to breach 12 hours

Number of patients in streaming <5

Number of patients in streaming >5 - 10

Number of patients in streaming >10

Number of patients in streaming >10

No risk of 4 hour beaches, excluding clinical exceptions

Risk of 4 hour breaches Risk of 8 hour breaches Risk of 10 hour breaches

Number of patients in department <30

Number of patients in department 30 - 50

Number of patients in department 50 +

Number of patients in majors 30 + with no trolleys to hand over crews.


APPENDIX E ACTION CARDS


GREEN (OPEL 1)

NORMAL WORKING INCLUDING:

Chair the capacity and flow meetings at 8.00am and 5.00pm

Ensure fully staffed rota in place for the capacity and flow team to ensure DNM on site 24/7

Ensure there is a fully staffed rota in place to enable the collation of capacity and flow information to support decision making

Work with Divisional Bronzes to ensure that accurate and up to date information is maintained in the capacity and flow room, for example regarding admissions / discharges / patient transport / waiting lists / repatriations / external capacity

Support effective use of the discharge lounge

AMBER (OPEL 2)

AS ABOVE PLUS:

Chair the capacity and flow meetings at 11.00am and 2.00pm (in addition to 8.00am and 5.00pm)

Assess where pressure point exists (e.g. plenty of beds but long waiting times in ED) and escalate to relevant Divisional Bronze and / or Silver as appropriate

Escalate to Divisional Bronze any problems related to divisional patient flow which cannot be resolved within the capacity and flow team

Ensure that IDAT are providing information to be used to manage patient flow out to the peripheral capacity and any access issues for community/transfer to assess beds are fed through to the commissioning teams

Ensure that the Capacity and Flow Team are maintaining accurate overview of Trust capacity and patient discharge / transfers

Ensure there is accurate and up to date information regarding the number of patients going through the discharge lounge and understand any constraints.

Submit OPEL status to the CCG

Join 2.30pm system call as necessary

RED (OPEL 3)

AS ABOVE PLUS:

Ensure ‘Discharge Team’ contact Social Services, Call For Care and Community Intermediate Care Team to proactively remove patients out of the Hospital, MCH and Newark

During the management of extreme capacity pressure assume the point of contact for capacity for Division during normal working hours to enable the Duty Nurse Manager to support clinicians in the discharge of patients and freeing of capacity.

Work with Senior East Midlands Ambulance service (EMAS) representative to ensure that Ambulance flow is managed through ED.

Work with senior team in agreement and enactment of the contingency plans.

Ensure effective handover of contingency plans occur to the out of hour’s team.

BLACK (OPEL 4)

AS ABOVE PLUS:

Maintain contact with EMAS to effectively manage the pressures.

Maintain a complete and accurate evaluation of patient admission, discharge and transfers, to be readily available upon request.

Maintain overview of patient discharge/transfer of patients to inform if de-escalation can occur.

Obtain an action plan from all Divisions via DGMs / Clinical Chairs to create capacity.


DUTY NURSE MANAGER

GREEN (OPEL 1)

NORMAL WORKING WHICH INCLUDES:

Chair the 11.00am and 2.00pm capacity and flow meetings

Record actions at the Capacity and Flow Meetings

Work with Divisional Bronzes to ensure an appropriate bed has been identified for all elective patients and there is emergency capacity available.

Ensure that the Discharge lounge has a list of predicted discharges to enable early flow from ward areas.

Work with the external providers to ensure repatriations have occurred as stated according to clinical need, infection control need.

Identify any blocks to patients flow (clinical or non-clinical) from admission to discharge and take appropriate action as necessary.

Liaise with NIC in ED/EAU to manage patient flow, agree immediate solution or plan for how long pressure is likely to incur. Escalate to ED NIC / Capacity and Flow Matron (Silver OOH) if pressure is likely to trigger an increase in escalation level

Support, as necessary, the ED NIC in managing avoidable delays that could result in a patient breach. Where necessary, agree actions with the ED NIC to resolve delays.

Identify any changes in hospital pressure or patient blocks within the system that could trigger an increased escalation level, work with Divisional Bronzes to plan for managing the pressure.

Escalate to capacity and flow Matron if any patients experience lengthy delays for psychiatric review in ED or EAU

Work with IDAT for an accurate picture of intermediate care beds for patient transfers.

To be aware of Infection Control issues within the Trust and community bed capacity. Ensure that patients are being placed appropriately and information is available during the Capacity and Flow Meetings around bed closures for infection reasons both within the Trust and outlying capacity.

Maintain an overview of patient waiting times in ED and ensure there is a clear plan to admit, discharge or transfer patients in a timely manner

Work with Medirest in identifying issues with cleaning of areas following infection/fogging /Portering Support and agree priorities with the Medirest Duty Manager.

Ensure accurate bed state available for each capacity and flow meeting

Ensure that support service heads e.g. Radiology, Pathology and Therapies are informed of current escalation and where appropriate agree a plan of action with the service.

AMBER (OPEL 2)

AS ABOVE PLUS:

Discuss with NIC in ED to identify flow issues and what further resource can be brought in to improve the situation.

Via Divisional Bronze, actively encourage utilisation of the discharge lounge during its opening hours

Identify any known constraints e.g. staffing, infection control and numbers of planned electives.

Assess where pressure point exists (e.g. plenty of beds but long waiting times in ED) and escalate to relevant Divisional Bronze

RED (OPEL 3)

AS ABOVE PLUS:

Via Divisional Bronze, ensure all clinical teams are aware of level of escalation and taking actions in line with their action cards

Ensure that PC24 are aware of level of escalation and understand capacity and capability to provide additional support

Contact Hospital Transport to discuss the prioritisation of inpatient discharges and ensure they follow their own escalation process in


the event of capacity pressures

Ensure Silver on call/Matron for capacity and flow is kept informed of the plans/progress

Discuss with capacity and flow matron (Silver on call OOH) the potential requirement of escalation capacity and understand the state of readiness of this capacity (in line with SOP)

BLACK (OPEL 4)

AS ABOVE PLUS:

Maintain a complete and accurate evaluation of patient admission, discharge and transfers, to be readily available upon request.


GOLD

THROUGHOUT Maintain oversight of Trust operational status and set any strategic objectives

GREEN (OPEL 1) NORMAL WORKING

AMBER (OPEL 2) NORMAL WORKING

RED (OPEL 3)

AS ABOVE PLUS:

Confirm and challenge Divisional plans if requested by capacity and flow matron (Silver OOH)

Consider rescheduling of elective admissions where appropriate

Consider utilisation of additional capacity

Consider outlying patients

Review any planned maintenance work where work is likely to impact on capacity or patient flow

Issue communications internally and externally, ensuring clinical leaders are aware and cascade to teams

Alert Social Care in conjunction with the CCG to expedite care packages

BLACK (OPEL 4)

AS ABOVE PLUS:

Chair Capacity and Flow Meetings

Ensure elective admissions have been reviewed and, where possible / appropriate, rescheduled or cancelled

Liaison with EMAS to request divert

Support Medical Director to rouse Consultants

Support Divisional Teams (walk areas in crisis)

Contact Chief Nurse and Medical Director to discuss Trust pressure


SILVER

THROUGHOUT Maintain oversight of Trust demand, capacity, pressure points and escalation status Set any tactical actions

GREEN (OPEL 1)

NORMAL WORKING, INCLUDING:

Attend the 8.00am and 5.00pm capacity and flow meeting

AMBER (OPEL 2)

AS ABOVE PLUS:


Out of hours – see capacity and flow matron actions

RED (OPEL 3)

AS ABOVE PLUS:



BLACK (OPEL 4)

AS ABOVE PLUS:




DIVISIONAL BRONZE - UEC

GREEN (OPEL 1)


Attend all Capacity and Flow Meetings, providing up to date information on flow positions and update of actions from previous meeting

AMBER (OPEL 2)

AS ABOVE PLUS:

Establish/collate any delays across division requiring resolution

Support with resolving delays to treatment / transfer / discharge

Support with resolving flow issues as identified during Bed Meetings.

Escalate issues to Specialty and Divisional Teams as required

Obtain list of patients meeting second criteria for SSU beds on EAU

Ensure ‘Board Rounds’ are completed (due twice a day)

Liaise with clinicians to support actions which maintain or restore patient flow.

RED (OPEL 3)

AS ABOVE PLUS:

Communicating information on ‘Alert Status’ and ‘Actions’ to staff and services within their Division

Ensure areas Action Cards are being followed

Work with Divisional Representatives to identify the patients who may be suitable for earlier discharge and ensuring appropriate Consultants are notified

Ensure consultants have reviewed patients who are query discharge promptly to see if can expedite their care/management plans

Ensure all patients reviewed by Senior Decision maker within 2 hours of admission (in hours 8am-8pm)

Identify any extra resources needed to help with transfers to expedite patient movement to and from EAU.

Review ‘Clinical Staff’ not currently based in clinical areas (i.e. Management Staff, Staff in training etc...) that could be redeployed to provide support to the response

BLACK (OPEL 4)

AS ABOVE PLUS:

Consider and identify staffing requirements for opening additional beds overnight/weekends on the discharge lounge.

Ensure all patients reviewed by Consultant prior to admission in hours. Middle Grades after hours.


CLINICAL CHAIR – UEC *** Included within Divisional Leadership Action Card

GREEN (OPEL 1)


AMBER (OPEL 2)

AS ABOVE PLUS:

RED (OPEL 3)

AS ABOVE PLUS:

BLACK (OPEL 4)

AS ABOVE PLUS:


HEADS OF SERVICE - UEC

GREEN (OPEL 1)


Be aware of Trust escalation status an ensure mechanisms in place within the service to cascade this to all clinical teams Emergency Department:

Ensure that senior streaming takes place

Ensure Emergency Care Standards are being followed

Acute Medicine:

Ensure that there is senior medical decision maker at the daily board round and that all clinical teams are working towards expected date of discharge (EDD)

Ensure that the principles of SHOP are followed on ward rounds

AMBER (OPEL 2)

AS ABOVE PLUS: Emergency Department:

Ensure that clinicians are using all possible methods for admission avoidance e.g. referring to AECU, Call for Care etc.

Advise UEC Bronze/Capacity and Flow team if there are any avoidable delays Acute Medicine:

Ensure that the medical teams are aware of all patients who are at their EDD and that activity is prioritised to facilitate discharge

Advise UEC Bronze/Capacity and Flow team if patients are at their EDD date but there are delays to discharge

Revisit patients who could be transferred to AECU to complete treatment before being discharged

Ensure that the medical teams identify patients who can be sent to SSU on second criteria

RED (OPEL 3)

AS ABOVE PLUS:

Consider cancellation of SPA activity to free up medical capacity to support patient flow and maintain safety

Consider the implications of a prolonged period of heightened escalation on all departments within the Division Emergency Department:

Consider prioritisation of patients requiring medical input. Holding a breach within ED for patients who may be able to be discharged later the same day to prioritise a patient requiring an extended period of acute medical input.

Acute Medicine:

A further senior review of patients will be requested. Along with the nurse in charge re-visit the board round to ensure that all plans each Consultant has put in place have been enacted and that patient discharge has been prioritised.

Any blocks to patient discharge are to be escalated immediately to UEC Bronze/Capacity and Flow team.

Identify patients that could be out lied within the hospital or to community setting e.g. transfer to assess or integrated care team.


BLACK (OPEL 4)

AS ABOVE PLUS:

Gold on call will chair the capacity and flow meeting and may request attendance from senior decision makers as to what ward teams are doing to support the patient flow.

Stand down SPA activity (where appropriate) to free up medical capacity to support patient flow and maintain safety Emergency Department:

Ensure all admissions are screened by a consultant before admission (working with Acute Medicine as necessary) Acute Medicine:

Consider what additional medical support could be given to avoid admissions from ED

Consider post-taking of patients to occur within ED


DIVISION OF URGENT AND EMERGENCY CARE

GREEN (OPEL 1)


Be aware of the escalation level and pressure points within your area and ensure that all patient information has been communicated to the Flow coordinator/DNM as appropriate.

Ensure attendance of senior clinical decision makers at Board Rounds, EAU and Ward each morning. All patients should be discussed along with their EDD.

Ensure attendance of the Nurse in Charge of EAU to all the Capacity and Flow Meetings

Continually promote a culture to promote the discharge process from time of admission.

Monitor monthly capacity statistics and ensure relevant corrective action is taken where appropriate.

No bed should be left empty for longer than 30 minutes- empty beds should be communicated to the patient flow via vocera.

Ensure the DNM is provided with all information as appropriate.

AMBER (OPEL 2)

AS ABOVE PLUS:

Communicating information on ‘Alert Status’ and ‘Actions’ to staff and services within the Division

Supporting staff in the Division in their response

Ensure information has been made available for capacity and flow meetings as required

To ensure Lead Nurse/Shift Lead accurately and responsibly report all patient activity within their ward/areas to the Bed Management team without delay

Following communications from DNM ensure all ward Consultants have been contacted and Trust pressures discussed, report any identified issues to the Matron for Capacity and Flow or Silver on call.

Ensure all extra ordinary information is communicated via Lead Nurse/Shift Lead at Capacity Meetings i.e. Infection Control Outbreaks, staffing issues etc.

RED (OPEL 3)

AS ABOVE PLUS:

At least one member of the Divisional Leadership Team (Clinical Chair, DGM and/or HoN) to attend the Capacity and Flow Meeting (in hours) ensuring key messages / actions are cascaded to clinical teams

Clinical Chair to support any actions speaking to staff and clinical teams as required

Ensure areas Action Cards are being adhered to

Matrons to support clinical areas as required/needed e.g. assist in driving discharge plans for patients at ward level

Ensure patients have been identified for extra capacity areas as appropriate

Review ‘Clinical Staff’ not currently based in clinical areas (i.e. Management Staff, Staff in training etc...) that could be redeployed to provide support to the response

If staffing adequate (using all staff available through redeployment) create and co-ordinate ‘Transfer Teams’ to enable rapid movement of patients to ward beds.

Arrange review of any patients, who have not been seen by a Senior Decision maker within 2 hours

Ensure plans in place for all patients who are being discharged are actioned (Commissioning use of taxis, as appropriate to support


increased discharges if ambulance service and third party providers cannot provide sufficient capacity)

HoN to ensure all appropriate ‘Discharges’ are moved to the discharge lounge.

Consider any requests or opportunities to provide mutual aid to other Divisions

Consider the implications of a prolonged period of heightened escalation on all departments within the Division


Lead the Divisional response to Full Capacity Protocol if implemented

BLACK (OPEL 4)

AS ABOVE PLUS:

Ensure all SPA activity is stood down across the Division to free up medical capacity to support patient flow and maintain safety

Contact all Medical Teams and Clinicians on SPA to review patients

Cancel ‘Training’ (as appropriate) to free up staff for clinical areas

Work with Clinical teams in your area to create capacity by expediting immediate discharges

Ensure immediate transfer of identified patients to the Discharge Lounge


Acute Emergency Care Unit (AECU)

GREEN (OPEL 1)


AECU to review white board and pull all appropriate patients from ED into AECU

AMBER (OPEL 2)

AS ABOVE PLUS:

Liaise with NIC on EAU and SSU to revisit patients who could be transferred to AECU to complete treatment before being discharged

RED (OPEL 3)

AS ABOVE PLUS:



BLACK (OPEL 4)

AS ABOVE PLUS:

Consider cancelling planned activity to create capacity for non-elective activity from ED.


EAU AND SSU

GREEN (OPEL 1)


Nurse in Charge of EAU to attend all the Capacity and Flow Meetings

Nurse in Charge of SSU to attend 11am Capacity and Flow Meetings


Ensure that the principles of SHOP are followed on ward rounds

Ensure all patients who can attend the Discharge Lounge do so

Ensure flow is maintained by declaring beds within 15 minutes of becoming vacant.

Ensure actions arising from bed meetings are completed

Ensure juniors complete investigations and TTO’s in timely manner

AMBER (OPEL 2)

AS ABOVE PLUS:

Revisit patients who could be transferred to AECU to complete treatment before being discharged

Coordinate a re-review of all patients identifying possible patients for discharge

Expedite any investigations and highlight delays

RED (OPEL 3)

AS ABOVE PLUS:

EAU fill in only the important/bare minimum section the nursing admission documentation if the bed is available within the next few hours e.g. bed is assigned allowing the patient to leave ASAP freeing up the bed on EAU.





Consider the implications of a prolonged period of heightened escalation impacting on the ward, looking at resources and ensuring a staffing plan is in place

BLACK (OPEL 4)

AS ABOVE PLUS:

Provide additional medical support to avoid admissions from ED

Consider post-taking of patients to occur within ED


Discharge Lounge

GREEN (OPEL 1)


Pulling patients from wards, offering to collect, pack patients

Liaise with wards the day prior to discharge to arrange transfer time

AMBER (OPEL 2)

AS ABOVE PLUS:

Any delays to patient discharge are to be escalated immediately to UEC Bronze/Capacity and Flow team.

RED (OPEL 3)

AS ABOVE PLUS:

No additional specific actions

BLACK (OPEL 4)

AS ABOVE PLUS:

No additional specific actions


Emergency Department

GREEN (OPEL 1)


Ensure senior streaming is taking place

Ensure Emergency Care Standards are being followed

AMBER (OPEL 2)

AS ABOVE PLUS:

Liaise with UEC Bronze to escalate any delays/issues

RED (OPEL 3)

AS ABOVE PLUS:

Maximise use of Ambulatory areas Consultants overseeing patient selection where necessary

Review resourcing within the department e.g. consider asking doctors/ACPs/ENP/RN/HCAs to stay later beyond shift time.

Follow appropriate departmental escalation SOPs e.g. Greater than 3 hour wait to be seen

Review ‘Clinical Staff’ not currently based in clinical areas (i.e. Management Staff, Staff on SPA, Staff in training etc...) that could be redeployed to provide support to the response

NIC to attend the Capacity and Flow Meetings, ensuring key messages / actions are cascaded to clinical teams


ED consultant to stay later and make a plan before leaving of what to do with middle grade, nurse in charge and site co-ordinator.

Articulate clearly what help is needed from within and external to the division e.g. Specialities to come and see appropriate patients i.e. Orthopaedic team to see hip injuries, ICU nurses can assist in resus and for transfers etc.

Review all patients on a trolley to ensure they are not ‘fit to sit’

Establish whether PC24 can support streaming at the front door

To ensure only urgent treatments are given within ED, ensuring patients are not delayed from transferring for non-urgent treatments that can take place on a ward

Utilise all existing/available space within Department e.g. including resus where appropriate

Consider prioritisation of patients requiring medical input. Holding a breach within ED for patients who may be able to be discharged later the same day to prioritise a patient requiring an extended period of acute medical input.

BLACK (OPEL 4)

AS ABOVE PLUS:

Ensure all admissions are screened by a consultant before admission (working with Acute Medicine as necessary)

Ensure all clinical staff on none clinical duties support patient flow and maintain safety

Review and arrange requirements for patients staying in the department for extended periods of time e.g. obtaining physical beds to transfer from trolleys, staff identified to enable care and comfort rounds etc.


DIVISIONAL BRONZE - Medicine

GREEN (OPEL 1)


Attend all Capacity and Flow Meetings, to manage actions and update of actions from previous meeting

Collate golden patient and TCI list for next day

AMBER (OPEL 2)

AS ABOVE PLUS:

Attend all Capacity and Flow Meetings, to manage actions and update of actions from previous meeting

Eliminate any blockages to discharge

Escalate issues to Specialty and Divisional Teams

Obtain list of patients to be ‘Outlied’ from Specialty Wards

Ensure all patients reviewed by senior decision maker within 12 hours of admission

Identify any ward beds not used and consider opening additional beds overnight/weekends

Ensure additional ‘Board Rounds’ are completed

RED (OPEL 3)

AS ABOVE PLUS:


Work with Divisional Representatives to identify the patients who may be suitable for earlier than discharge and ensuring appropriate Consultants are notified

Ensure all patients reviewed by Senior Decision maker within 2 hours of admission

Collate list of TCI’s for the remainder of the day and following day

BLACK (OPEL 4)

AS ABOVE PLUS:

Ensure all patients reviewed by Consultant prior to admission

Ensure additional bed stock is opened and safely staffed

Routine elective admissions are likely to have been cancelled and urgent elective admissions must be reviewed


CLINICAL CHAIR - Medicine

GREEN (OPEL 1)


Be aware of Trust escalation status and ensure mechanisms in place within Division to cascade this to all clinical teams

AMBER (OPEL 2)

AS ABOVE PLUS:

Ensure service line actions are being completed, including any additional actions arising from Capacity and Flow Meetings

RED (OPEL 3)

AS ABOVE PLUS:

Attend the Capacity and Flow Meetings, ensuring key messages / actions are cascaded to clinical teams



In conjunction with Gold, review elective activity, including clinical prioritisation



BLACK (OPEL 4)

AS ABOVE PLUS:



HEADS OF SERVICE - Medicine

GREEN (OPEL 1)


Be aware of Trust escalation status an ensure mechanisms in place within the service to cascade this to all clinical teams


Ensure that there is a mechanism for pulling patients through from the admission areas who are waiting for beds on your ward (SHOP, Review of Results, Admission Avoidance)

AMBER (OPEL 2)

AS ABOVE PLUS:

Ensure the team the medical teams are aware of all patients who are at their EDD and that activity is prioritised to facilitate discharge.

Advise capacity and flow team if patients are at their EDD date but there are delays to discharge.

Be aware of patients requiring admission to ward for procedures or planned admission

Revisit patients who are waiting for on-going investigation as to whether this could be done as an outpatient.

Ensure all electives are identified to Duty Nurse Manager

RED (OPEL 3)

AS ABOVE PLUS:


Any blocks to patient discharge are to be escalated immediately to patient Flow Coordinators or DNM.


Review capacity for on the ward procedures and determine whether the procedure can wait or be done in an alternate setting

BLACK (OPEL 4)

AS ABOVE PLUS:

A further senior review of patients will be requested. Together with the nurse in charge, revisit the board round to ensure that all plans you have put in place have been enacted and that patient discharge has been prioritised

Identify patients that could be out lied within the hospital or to community setting e.g. transfer to assess

Gold on call will chair the capacity and flow meeting and may request attendance from senior decision makers as to what ward teams are doing to support the patient flow


DIVISION OF MEDICINE

GREEN (OPEL 1)



Ensure attendance of senior clinical decision makers at the Board Round each morning- all patients should be discussed along with EDD.



Develop and communicate plan for your ward.



AMBER (OPEL 2)

AS ABOVE PLUS:


Supporting staff in the Division’s in their response

Ensure ward information has been made available for capacity and flow meetings.


Following communications from DNM ensure all ward Consultants have been contacted and Trust pressures discussed, report any identified issues to the Matron for capacity and flow or Silver on call.


Plan required for the next morning

RED (OPEL 3)

AS ABOVE PLUS:

Clinical Chair, DGM and HoN to attend the Capacity and Flow Meeting (in hours)

Identify patients suitable for extra capacity areas

Review ‘Clinical Staff’ not currently based in clinical areas (i.e. Management Staff, Staff in training etc...) that could be redeployed to provide support to the response.

If staffing adequate (using all staff available through redeployment) create a ‘Transfer Team’ to enable rapid movement of patients to ward beds.

All Consultants requested to ensure patients have been reviewed for discharge and identified for the management of outliers in the preceding 8 hours, arrange review of any patients, who have not been seen by a Senior Decision maker within 2 hours

Ensure plans in place for all patients who are being discharged are actioned within two hours (Commissioning use of taxis, as appropriate to support increased discharges if ambulance service and third party providers cannot provide sufficient capacity)


Ensure SpRs provide support needed to ED

At the request of Gold, cancel elective activity to free up staff to support patient flow and maintain patient safety

BLACK (OPEL 4)

AS ABOVE PLUS:


Cancel any training to free up staff for clinical areas

SpRs and Consultants on site to liaise closely with ED to provide support

Work with Clinical teams in your area to create capacity by expediting immediate discharges.

Ensure immediate transfer of identified patients to the Discharge Lounge.


DIVISION OF MEDICINE WARD ACTIONS

GREEN (OPEL 1)





Identify golden patients and two potential outliers on each board round


AMBER (OPEL 2)

AS ABOVE PLUS:








RED (OPEL 3)

AS ABOVE PLUS:

Clinical Chair, DGM and HoN to attend the Capacity and Flow Meeting (in hours)

Clinicians will be asked to prioritise reviewing unwell patients first followed by golden patients and potential discharges prior to starting normal patient reviews or ward rounds

Immediate prescribing of TTOS

Identify and make clear plans for patients suitable for criteria led / nurse led discharges

Identify a minimum of 2 patients suitable to outlie into extra capacity areas


All Consultants requested to ensure patients have been reviewed for discharge and arrange review of any patients, who have not been seen by a Senior Decision maker within 2 hours





BLACK (OPEL 4)

AS ABOVE PLUS:







DIVISIONAL BRONZE - SURGERY

GREEN (OPEL 1)




AMBER (OPEL 2)

AS ABOVE PLUS:





RED (OPEL 3)

AS ABOVE PLUS:






Identify staffing for any ward stock not used and consider opening additional beds overnight/weekends

BLACK (OPEL 4)

AS ABOVE PLUS:



Review Routine elective admissions with consideration of cancellation to free staff



CLINICAL CHAIR - SURGERY

GREEN (OPEL 1)



AMBER (OPEL 2)

AS ABOVE PLUS:


RED (OPEL 3)

AS ABOVE PLUS:




BLACK (OPEL 4)

AS ABOVE PLUS:

Consider SPA activity being stood down across the Division to free up medical capacity to support patient flow and maintain safety

In conjunction with the DMT and Gold, review elective activity, including clinical prioritisation


HEADS OF SERVICE - SURGERY

GREEN (OPEL 1)




AMBER (OPEL 2)

AS ABOVE PLUS:


RED (OPEL 3)

AS ABOVE PLUS:





Review capacity for on the ward procedures and determine whether the procedure can wait or be done in an alternate setting.

BLACK (OPEL 4)

AS ABOVE PLUS:

A further senior review of patients will be requested. Together with the nurse in charge, revisit the board round to ensure that all plans you have put in place have been enacted and that patient discharge has been prioritised.



DIVISION OF SURGERY

GREEN (OPEL 1)






AMBER (OPEL 2)

AS ABOVE PLUS:



RED (OPEL 3)

AS ABOVE PLUS:

A member of the DMT to attend the Capacity and Flow Meeting (in hours)



Review ‘Clinical Staff’ not currently based in clinical areas (i.e. Management Staff, Staff in training etc...) that could be redeployed to provide support.

If staffing adequate (using all staff available through redeployment) create a ‘Transfer Team’ to enable rapid movement of patients from ward beds or from assessment unit to ward beds.

All Consultants requested to ensure patients have been reviewed for discharge in the preceding 8 hours


Divisional Nurses to ensure all patients for discharge are moved to the discharge lounge where the patient meets the discharge lounge criteria

Consider for all patients whether outpatient follow up and on-going management would be clinically safe and appropriate

BLACK (OPEL 4)

AS ABOVE PLUS:

A member of the DMT to attend the Capacity and Flow Meeting (in hours)

Contact all Medical Teams and Clinicians to review patients

Review training and SPA to free up staff for clinical areas



DIVISION OF SURGERY WARD ACTIONS

GREEN (OPEL 1)


Nurse in charge to be aware of the escalation level and pressure points within your area and ensure that all patient information has been communicated to the divisional Bronze and Flow coordinator/DNM as appropriate.

Ensure Daily Board Round each morning- all patients should be discussed. Escalate any issues to divisional Bronze and Flow coordinator/DNM as appropriate.

Promote a culture where the discharge process from time of admission.

Ensure Transport is booked for any patients with an expected discharge date & Utilise Discharge lounge for all appropriate patients.

Ensure any staffing shortfalls using Safecare are escalated to the respective Matron.

AMBER (OPEL 2)

AS ABOVE PLUS:


To ensure Nurse in charge (NIC) accurately reports all patient activity within their ward/areas to the Bed Management team.

Ensure any extra ordinary information is escalate to divisional Bronze and Flow coordinator/DNM as appropriate to be discussed at Capacity Meetings i.e. Infection Control Outbreaks, staffing issues etc.

RED (OPEL 3)

AS ABOVE PLUS:

Clinicians will be asked to prioritise reviewing unwell patients first followed by potential discharges prior to starting normal patient reviews or ward rounds

Request Drs to prescribe of TTOS as decision made to discharge time.

Review ‘Clinical Staff’ not currently based in clinical areas that could be redeployed to provide support to the response.

Ensure plans in place for all patients who are being discharged are actioned within two hours

BLACK (OPEL 4)

AS ABOVE PLUS:

After the request of Gold, be prepared to speak to patients and inform them if their surgery has been cancelled.

Consider Cancelling any training/meeting to free up staff for clinical areas to provide support if required.


DIVISIONAL BRONZE – WOMEN AND CHILDREN’S

GREEN (OPEL 1)


Attendance at the 8am and 5pm Capacity and Flow Meetings

AMBER (OPEL 2)

AS ABOVE PLUS:






Identify any ward beds not used and consider opening additional beds overnight/weekends


RED (OPEL 3)

AS ABOVE PLUS:




Identify staffing for any ward stock not used and consider opening additional beds overnight/weekends


BLACK (OPEL 4)

AS ABOVE PLUS:



Routine elective admissions are likely to have been cancelled and urgent elective admissions must be reviewed


CLINICAL CHAIR – WOMEN AND CHILDREN’S

GREEN (OPEL 1)



AMBER (OPEL 2)

AS ABOVE PLUS:


RED (OPEL 3)

AS ABOVE PLUS:

Attend the Capacity and Flow Meetings, ensuring key messages / actions are cascaded to clinical teams



In conjunction with Gold, review elective activity, including clinical prioritisation



BLACK (OPEL 4)

AS ABOVE PLUS:



HEADS OF SERVICE – WOMEN AND CHILDREN’S

GREEN (OPEL 1)





AMBER (OPEL 2)

AS ABOVE PLUS:


Advise capacity and flow team if patients are at their EDD date but there are delays to discharge.

Be aware of patients requiring admission to ward for procedures or planned admission


Ensure all electives are identified to Duty Nurse Manager

RED (OPEL 3)

AS ABOVE PLUS:




Review capacity for on the ward procedures and determine whether the procedure can wait or be done in an alternate setting.

BLACK (OPEL 4)

AS ABOVE PLUS:

A further senior review of patients will be requested. Together with the nurse in charge, revisit the board round to ensure that all plans you have put in place have been enacted and that patient discharge has been prioritised.

Identify patients that could be out lied within the hospital or to community setting e.g. transfer to assess.



DIVISION OF WOMEN AND CHILDREN’S

GREEN (OPEL

1)






Develop and communicate plan for your ward.



AMBER (OPEL

2)

AS ABOVE PLUS:








RED (OPEL

3)

AS ABOVE PLUS:

DGM or HoN to attend the Capacity and Flow Meeting (in hours)



If staffing adequate (using all staff available through redeployment) create a ‘Transfer Team’ to enable rapid movement of patients to ward beds.

All Consultants requested to ensure patients have been reviewed for discharge and identified for the management of outliers in the preceding 8 hours, arrange review of any patients, who have not been seen by a Senior Decision maker within 2 hours


Divisional Nurses to ensure all ‘Discharges’ are moved to the discharge lounge.




BLACK (OPEL

4)

AS ABOVE PLUS:







Ward 25 – Acute Paediatrics

GREEN (OPEL 1)


Review white board and pull all appropriate patients from ED

AMBER (OPEL 2)

AS ABOVE PLUS:

Liaise with NIC on Ward 25 to review all EDD’s to ensure there is appropriate flow and capacity

RED (OPEL 3)

AS ABOVE PLUS:



BLACK (OPEL 4)

AS ABOVE PLUS:



Ward 14 – Gynaecology

GREEN (OPEL 1)


Review white board and pull all appropriate patients from ED

AMBER (OPEL 2)

AS ABOVE PLUS:

Liaise with NIC on Ward 14 to review all EDD’s to ensure there is appropriate flow and capacity

RED (OPEL 3)

AS ABOVE PLUS:



BLACK (OPEL 4)

AS ABOVE PLUS:



DIVISIONAL BRONZE – D&O

GREEN (OPEL 1)


Attendance at the 8am, 11am and 2 pm Capacity and Flow Meetings. To attend 5pm meeting if Divisional issues requiring escalation.

Expedite any imaging, diagnostics, pharmacy or therapy issues delaying discharges or flow

Escalation to flow meeting of areas of concern or potential risk

AMBER (OPEL 2)

AS ABOVE PLUS:

Attend Capacity and Flow Meetings as above

Continue to escalate any issues impacting on flow or discharges

Prioritise ward and ED patients as requested to support flow.

RED (OPEL 3)

AS ABOVE PLUS:

Communicate information on ‘Alert Status’ and ‘Actions’ to staff and services within their Division

Escalate to Divisional Management teams to consider relocating Therapy and Pharmacy staff to support ED and TTOs, additional diagnostics and releasing OP staff to those areas

Ward Therapists to prioritise discharges

Ward therapists escalate to Therapy managers any issues blocking discharges to seek solutions and escalate to other agencies

BLACK (OPEL 4)

AS ABOVE PLUS:

Attend 5pm Capacity and Flow meeting

Explore with HoN and OPD Matron if additional staff available in OPD to support wards

Escalate to Divisional Management team- consideration of cancellations of OPD activity

Escalate to Divisional Management team support staff working extended hours to support flow

Explore with HoN and Therapy managers cancellation of therapy OPD to support wards


CLINICAL CHAIR – D&O

GREEN (OPEL 1)


Be aware of Trust escalation status and ensure mechanisms in place within Division to cascade this to all clinical teams if necessary

AMBER (OPEL 2)

AS ABOVE PLUS:

Bronze to escalate to Clinical chair issues requiring their support to resolve)

RED (OPEL 3)

AS ABOVE PLUS:





BLACK (OPEL 4)

AS ABOVE PLUS:

Ensure all SPA activity is stood down across the Division to free up medical capacity to support patient flow and maintain safety where this supports flow and discharges


HEADS OF SERVICE – D&O

GREEN (OPEL 1)



AMBER (OPEL 2)

AS ABOVE PLUS:

Ensure medical teams respond to any escalations from the Capacity and flow meetings and adequate clinical support is available

RED (OPEL 3)

AS ABOVE PLUS:

Ensure medical teams are prioritising patients in ED and those for discharge

Consider extended or additional cover if required

BLACK (OPEL 4)

AS ABOVE PLUS:

Gold on call will chair the capacity and flow meeting and may request attendance from senior decision makers.

Respond to any requests for enhanced or extended service provision

Prioritise inpatient radiology vetting and reporting


DIVISION OF DIAGNOSTICS AND OUTPATIENTS

GREEN (OPEL 1)


AMBER (OPEL 2)

AS ABOVE PLUS:


Supporting staff in the Division in their response

Responding to patient delays impacting on discharge and flow.

RED (OPEL 3)

AS ABOVE PLUS:

Clinical Chair, DGM or HoN & AHP’s to attend the Capacity and Flow Meeting (in hours)

Review ‘Clinical Staff’ not currently based in clinical areas (i.e. Management Staff, Staff in training etc...) that could be redeployed to provide support.

Priority to be given to inpatients and ED.

Pharmacy to cancel all non-urgent activities to support additional discharges (wards and dispensaries)

Therapy and radiology to consider cancellation of OPD activity if required to support flow and discharges

At the request of Gold, cancel OPD activity to free up staff to support patient flow and maintain patient safety

BLACK (OPEL 4)

AS ABOVE PLUS:



Provide additional or extended services as required


APPENDIX F ADDITIONAL CAPACITY

Division Ward Core Escalation Total

UEC EAU 40 0 40

Ward 36 (SSU) 32 8 40

72 8 80

W&C Ward 14 13 0 13

Ward 25 30 0 30

NICU 10 0 10

53 0 53

Surgery Ward 11 24 0 24

Ward 12 24 0 24

Ward 21 16 0 16

Ward 31 24 0 24

Ward 32 24 0 24

ITU 11 3 14

123 3 126

Medicine Ward 22 24 0 24

Ward 23 23 0 23

Ward 24 24 0 24

Ward 34 24 0 24

Ward 41 24 0 24

Ward 42 24 0 24

Ward 43 24 0 24

Ward 44 24 0 24

Ward 51 24 0 24

Ward 52 24 0 24

Ward 53 29 0 29

268 0 268

Newark Sconce 24 0 24

MCH Chatsworth 16 0 16

MCH Lindhurst 24 0 24

MCH Oakham 24 0 24

88 0 88

TOTAL 604 11 615


APPENDIX G EQUALITY IMPACT ASSESSMENT FORM (EQIA)

Name of service/policy/procedure being reviewed: Adult Patient Flow and Escalation Policy

New or existing service/policy/procedure: Existing

Date of Assessment: November 2018

For the service/policy/procedure and its implementation answer the questions a – c below against each characteristic (if relevant consider breaking the policy or implementation down into areas)

Protected Characteristic

a) Using data and supporting information, what issues, needs or barriers could the protected characteristic groups’ experience? For example, are there any known health inequality or access issues to consider?

b) What is already in place in the policy or its implementation to address any inequalities or barriers to access including under representation at clinics, screening?

c) Please state any barriers that still need to be addressed and any proposed actions to eliminate inequality

The area of policy or its implementation being assessed:

Race and Ethnicity

None None None

Gender

None None None

Age

None None None

Religion None None None

Disability

None None None

Sexuality

None None None

Pregnancy and Maternity

None None None

Gender Reassignment None None None

Marriage and Civil Partnership

None None None

Socio-Economic Factors (i.e. living in a poorer neighbourhood / social deprivation)

None None None


What consultation with protected characteristic groups including patient groups have you carried out?

What data or information did you use in support of this EqIA?

As far as you are aware are there any Human Rights issues be taken into account such as arising from surveys, questionnaires, comments, concerns, complaints or compliments?

Level of impact From the information provided above and following EQIA guidance document Guidance on how to complete an EIA (click here), please indicate the perceived level of impact: Low Level of Impact For high or medium levels of impact, please forward a copy of this form to the HR Secretaries for inclusion at the next Diversity and Inclusivity meeting.

Name of Responsible Person undertaking this assessment: S Shaw

Signature:

Date: 19/11/2018


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