northern staffordshire system escalation plan€¦ · should pressures arise. ems level 4 should be...

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Northern Staffordshire

System Escalation Plan

(Health and Social Care)

April 2015

Review Date: July 2016 or in response to post event learning or material changes to the urgent care system

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Foreword In the winter of 2015 - 2016 we faced one of our most challenging times with high demands on services within health and social care. There were a number of reasons including an increased number of patients needing care within the community or the acute hospital, alongside the other pressures we face during the winter period. Following winter we have looked at what we could do better; one aspect is to make sure we are all very clear on what we need to do at times of increasing demand for our services, how we need to operationally manage those demands and making sure our leaders know what is expected of them. To build on our existing partnership working we continue to strive to improve the way we jointly work; as a result we have reviewed our, ‘System escalation Plan’ which is set out in this document. It is important that we provide the best care and experience possible for the local population and to make sure our staff continue to enjoy coming to work, even when we are faced with challenging circumstances. We therefore support this System Escalation Plan in a step forward to improving the experience of patients and their families and also to support the working lives of our staff. Signed: Mark Hackett, UHNM Stuart Poynor, SSoTP Caroline Donovan, NSCHT

Anthony March, WMAS Dr Andy Bartlam, Stoke CCG

Dr Julie Oxtoby, North Staffs CCG John van de Laarschot, Stoke City Council

John Henderson, Staffordshire County Council

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Version History Log

This area should detail the version history for this document. It should detail the key elements of the changes to the versions.

Version

Date implemented

Description of significant changes

Intentionally left blank

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Contents FOREWORD .................................................................................................................................................................. 1 1. INTRODUCTION .................................................................................................................................................... 4 1.1. PURPOSE ........................................................................................................................................................ 4 1.2. BACKGROUND .................................................................................................................................................. 5 1.3. LESSONS LEARNT .............................................................................................................................................. 6 2. TRIGGERS ............................................................................................................................................................. 7 2.1. ESCALATION LEVELS AND TRIGGERS ....................................................................................................................... 7 2.2. WHAT IS EMS?................................................................................................................................................ 7 2.3. EMERGENCY AMBULANCES ................................................................................................................................. 8 2.4. WEST MIDLANDS EMS TRIGGERS ........................................................................................................................ 9 3. LEADERSHIP ........................................................................................................................................................ 10 4. COMMAND AND CONTROL ................................................................................................................................ 10

4.1. When would we use ‘Command and Control’ principles? ................................................................... 10

4.2. What do we mean by ‘Command and Control’? ................................................................................... 10

4.3. ‘Command and Control’ roles .................................................................................................................. 10

4.4. ‘Command and Control’ SILVER & GOLD MEETING AGENDA ....................................................... 12 5. COMMUNICATION ............................................................................................................................................. 12 6. INFECTION CONTROL .......................................................................................................................................... 12 7. ROLES AND RESPONSIBILITIES ............................................................................................................................ 12 7.1. SHARED RESPONSIBILITY ................................................................................................................................... 12 7.2. CHIEF OPERATING OFFICERS / GOLD COMMANDERS (STRATEGIC LEADER): .................................................................. 12 7.3. SILVER COMMANDERS: .................................................................................................................................... 12 7.4. CLINICAL COMMISSIONING GROUPS: ................................................................................................................... 13 8. ASSURANCE FRAMEWORK ................................................................................................................................. 13 9. ACTION CARDS LEVEL 1 ...................................................................................................................................... 14 10. ACTION CARDS LEVEL 2 ...................................................................................................................................... 19 11. ACTION CARDS LEVEL 3 ...................................................................................................................................... 24 12. ACTION CARDS LEVEL 4 ...................................................................................................................................... 30 13. NON-URGENT PATIENT TRANSPORT ACTIONS (NSL) ........................................................................................... 35 15. REGIONAL CAPACITY MANAGEMENT TEAM (RCMT) ACTIONS ........................................................................................... 36 14. AREA TEAM – PRIMARY CARE ACTIONS .............................................................................................................. 38 15. NHS111 ACTIONS ................................................................................................................................................ 38 16. STAFFORDSHIRE DOCTOR URGENT CARE ACTIONS ............................................................................................. 40 17. APPENDIX 1 EMS TRIGGER 3, 10 AND 14-SPECIFIC ACTION CARD ....................................................................... 41 ACTIONS TO BE CARRIED OUT IF TRIGGERS 3, 10, 14 ARE REPORTED AT LEVEL 3 OR 4 WITHIN THE EMS LEVEL ....................................... 41 18. APPENDIX 2 SILVER CONFERENCE CALL AGENDA ................................................................................................ 43 19. APPENDIX 3 GOLD CONFERENCE CALL AGENDA ................................................................................................. 45 20. APPENDIX 4 GOLD AND SILVER ‘COMMAND AND CONTROL’ AGENDA ............................................................... 47 21. APPENDIX 5 SILVER SITUATION REPORT SITREP FOR GOLD ................................................................................ 49 22. APPENDIX 7 CONFERENCE CALL CODE OF CONDUCT .......................................................................................... 51 23. APPENDIX 8 AUDIT TOOL .................................................................................................................................... 52 24. APPENDIX 9 UHNM FULL CAPACITY PROTOCOL .................................................................................................. 53 25. APPENDIX 10 OTHER ORGANISATIONS - FULL CAPACITY PROTOCOLS ................................................................ 62 GOLD: EXECUTIVE ON-CALL (ON-CALL) SILVER: SENIOR MANAGER (ON-CALL) BRONZE: SERVICE MANAGERS ............ 64 26. APPENDIX 11 CCG CHECK LIST ............................................................................................................................ 70

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1. INTRODUCTION

1.1. Purpose

This is a health and social care plan which sets out the process for escalation when there is increased demand for health and/or social care services across the Local Health and Social Care Economy (LHE). This escalation plans sits in support of additional plans, such as Winter Resilience and Capacity & Demand modelling and Major Incident Response. The plan is supported by a programme of system wide education and will be subject to annual testing through exercise and audit. In support of this plan, an accountability and audit framework has been developed (appendix 8) to support the continued drive for excellent patient experience and services in North Staffordshire The Northern Staffordshire partnership within the LHE includes health and social care, voluntary services and includes primary care and out of hours services, demonstrating an integrated approach to effectively maintain quality, supporting parts of the system which may be under pressure at a point in time. The focus of the plan is to achieve level 1 consistently as a system and to de-escalate quickly should pressures arise. EMS level 4 should be seen as a “never event” and all actions focused on returning / maintaining EMS level 1.

The standard is to have a robust escalation system to support sufficient and safe service capacity across the health and social care system, including:

Providing transfers of care for the patient in the most appropriate setting. Supporting best practice in Infection Prevention and single sex accommodation Supporting staff by clearly setting out roles and expectations Delivering the A&E 4 hour wait and other emergency metrics Keeping Delayed Transfers of Care (DToC) at a minimum The number of patients assessed and waiting for services is kept to a minimum Delivering speciality compliant 18 week pathways Support effective use of ambulance services Avoid system failures that result in penalties Shared risk management across the whole system Shared responsibility across the system for effective patient flow

Specifically this plan will outline the arrangements regarding:

Structured system wide escalation & de-escalation Timely response Roles and responsibilities Leadership Action cards Accountability and Assurance

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1.2. Background

The Plan framework provides a consistent and co-ordinated approach to the management of pressures in Northern Staffordshire and is designed to ensure the system is process driven and not person dependent.

Planning arrangements for the Northern Staffordshire health and social care economy and has been prepared in conjunction with the following partner organisations:

Stoke-on-Trent Clinical Commissioning Group (SOTCCG)

North Staffordshire Clinical Commissioning Group (NSCCG)

Staffordshire and Stoke on Trent Partnership Trust (SSOTPT)

University Hospitals of North Midlands (UHNM)

Stoke-on-Trent City Council

Staffordshire County Council

North Staffordshire Combined Healthcare (NSCH)

West Midlands Ambulance Service (WMAS) This escalation plan sets out the procedures across the LHE to manage day to day variations in demand across the health and social care system as well as the procedures for managing significant surges in demand by having a clear escalation and de-escalation plan where everyone knows what they should be doing and when, taking responsibility for their individual and organisational actions and contributing to a shared risk management approach across the system. This plan will not specifically detail any requirements under the Emergency Preparedness, Resilience and Response guidelines although, of course, there may be interconnection between processes depending on the nature of the incident / emergency. At the point of which a Major incident is declared please refer to the relevant organisations Major Incident Response and Recovery Plan.

EMS level 4 should be seen as a ‘never event’ and all actions focused on maintaining EMS Level 1.

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1.3. Lessons Learnt As part of the Lessons learnt following winter 2014 -15, 15 key points have been agreed; this plan meets recommendations 6 and 15 as set out below:

KEY POINTS

1. Plan to empty capacity across the system routinely particular in advance of predicted periods of increased demand.

2. Capacity plan to be discussed at SRG with a view to developing capacity planning over a rolling

period.

3. There should be a QIA on the actions taken during the Major Incident with a view to understanding how to use the QIA to assess decisions in the future.

4. Major Incident plans / actions need to be brought into alignment with escalation and de-escalation

plans across the system.

5. An agreed process around assessment of patients waiting social care discharge needs to be agreed.

6. All organisations need to bring their escalation actions in line and a system wide plan with actions

needs to be in place for routine service developments.

7. A system wide communications plan needs to be in place to ensure clear wide system messages, including; communication to the public and external organisations.

8. The consultant based in the Ambulance control room worked well along with clinical triage in 111

– placements needs to be reviewed to provide evidence of this working well and whether something can be provided longer term. The impact on having a GP based at the Walk In Centre also needs to be reviewed to see if this is having enough of a positive impact and whether this service should be continued.

9. Ambulance Services and UHNM Emergency Department Representatives to see if there are any

better ways to manage patients waiting assessment in ambulance triage and to improve ambulance turnaround times, (queues).

10. Education around the discharge process and thresholds needs to be potentially changed along

with what services are available in the community to support clinical decision making during the discharge process.

11. There needs to be clear system wide structure to command and control during times of significant

increase in demand not just in escalation.

12. There needs to be better integration of primary care within agreed plans for example staffing resources.

13. Timely interaction and a consistent focus required to maintain pace of decision making and acting,

this should be developed within the system wide plan.

14. HR colleagues to develop a system wide workforce plan to support greater resilience across the health and social care system.

15. An economy wide Gold and Silver training programme needs to be developed to include the use of the agreed system wide actions / protocols, including structure of conference calls to ensure consistency of approach against a set of escalation and de-escalation metrics.

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2. TRIGGERS

2.1. Escalation levels and triggers

Escalation levels are determined by the regional capacity Escalation Management System (EMS) with pre-determined triggers. However, we recognise limitations in the system in that not all partners currently use or are able to use EMS; this leaves the focus of the response being driven by the acute hospital status. Nonetheless, a rise in EMS levels can be seen as a symptom of whole system pressures and we will therefore focus on strengthening escalation actions with clear leadership against the acute hospital triggers.

2.2. What is EMS?

EMS is a bespoke, dynamic regional health economy escalation management system. The system is designed to work with health economies nationally. The tool is an interactive secure NHS website for all acute trusts and local health economy (LHE) partners to report escalation levels during the day. The site provides a helicopter view of pressure across health economies to all users. It is populated locally, using regionally agreed escalation triggers and is key to all managers in call when accessing regional pressure.

LEVEL 1 Normal Pressure

LEVEL 2 Moderate Pressure

LEVEL 3 Significant Pressure

LEVEL 4 Extreme Pressure

There are two mandatory update periods for acute trusts, 07:30 - 09:30 and 14:30 -16:30 to update EMS daily. However, the system should be updated as and if the position changes by the Site Mangers at RSUH and County sites. The EMS functionalities underpin the surge planning strategy for all health and social care partners. This allows transparency across the whole LHE and is led by the Regional Capacity Management Team (RCMT). Within each EMS level are a set of triggers that, depending on the inputted response, determine the EMS level. The summary of those triggers is circulated to partners. For example, it is possible to be on Level1/2/3 but still have key triggers reported at level 3 or 4. This summary should form a part of the LHE conference calls and focus on de-escalating triggers at level 3 and 4 within the EMS Level. A measure of success of the actions taken will be lower reported levels. In Northern Staffordshire analysis shows that the following triggers are run at a consistently high level:

Trigger 3 Expected Capacity deficit

Trigger 10 Planned additional bed capacity occupancy

Trigger 14 Number of patients Medically Fit for Discharge

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Example, of trigger levels reported at EMS level 2:

FOR ACTION CARDS SEE SECTION 9 PAGE 14 It is this summary that will now help to focus the actions within each level, as well as the overarching action cards. There are specific LHE action cards for these triggers 3, 10 and 14 are reported at level 3 or 4. (Appendix 1)

2.3. Emergency Ambulances The Northern Staffordshire LHE works in partnership with West Midlands Ambulance Service

NHS Foundation Trust (WMAS) but it worthy to note that WMAS is a regional ambulance service and has its own escalation system actions; WMAS Resource Escalation Action Plan (REAP). There is a need to be mindful that WMAS as a regional service may escalate even though the pressures are outside of Staffordshire.

Furthermore, WMAS has developed its Strategic Surge Management Plan to ensure that the

expected high standards and safe delivery of services are maintained throughout the whole of the winter period of 1 November – 31 March. This period represents the ‘winter period’ when demand for ambulance services is traditionally at its highest. However, the response actions in this plan can be used at any time when a demand spike is expected or experienced.

WMAS has developed this plan to outline the actions that will specifically be undertaken by the Trust to maintain business continuity, provide support to local Health Economies and support the national Department of Health strategy. Where events are foreseeable the Trust will put in place necessary arrangements; however some events and changes in demand are unexpected and require appropriate management and coordination arrangements.)

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2.4. West Midlands EMS Triggers

1 No current risk of a patient waiting more than 4 hours to be seen in ED 1 Risk of one or more patients waiting more than 4 hours in ED within the

next hour.

1 One or more patients waiting more than 4 hours a decision is unlikely to

be made for the next hour.

1 One or more patients waiting more than 4 hours and a decision is unlikely

to be made for the next 4 hours.2 Transfer of Ambulance patient care is shorter than 15 minutes. 2 Transfer of Ambulance patient care is between 15 and 30 minutes. 2 Transfer of Ambulance patient care is between 31 and 60 minutes. 2 Transfer of Ambulance patient care is longer than 60 minutes.

3 Expected admission capacity greater than or equal to expected admission

demand for the next 24 hours.

3 There is an expected admission capacity deficit of less than 10% of

expected demand for the next 24 hours.

3 There is an expected capacity deficit of between 10% and 20% of expected

demand for the next 24 hours.

3 There is an expected capacity deficit of more than 20% of expected

demand for the next 24 hours.4 Elective work proceeding as planned. 4 Up to 10% of elective and urgent inpatient work cancelled on the day. 4 10% to 90% elective and urgent inpatient work cancelled for the next 24

hours.

4 More than 90% elective work including oncology patients cancelled for the

next 24 hours.5 Patients subject to a decision to admit not at risk of 8 hour trolley waits. 5 Risk of one or more patients subject to a decision to admit at risk of

waiting 8 hours on a trolley in the next 2 hours.

5 One or more patients subject to a decision to admit now waiting longer

than 8 hours on a trolley.

5 One or more patients subject to a decision to admit now waiting longer

than 8 hours on a trolley and at risk of waiting longer than 12 hours.

6 Medical outliers form less than 0.5% of total inpatient population. 6 Medical outliers form between 0.5% and 1% of total inpatient population. 6 Medical outliers form between 1% and 3% of total inpatient population. 6 Medical outliers form more than 3% of total inpatient population.

7 Cubicles in A&E are less than 80% occupied. 7 Cubicles in A&E are 80% -100% occupied. 7 All Cubicles in A&E are full and patients are waiting in planned overflow

areas.

7 All Cubicles in A&E are full and patients are expected to wait in unplanned

overflow areas.8 More than 1 resuscitation bay available for immediate use. 8 Only 1 resuscitation bay available for immediate use. 8 No formal resuscitation bay available in A&E for the next 30 minutes. 8 No formal resuscitation bay available in A&E for next hour.

9 Beds in Assessment Areas are less than 90% occupied. 9 Beds in Assessment Areas are 90%-99% occupied. 9 No Assessment area beds for up to 3 hours minimum. 9 No Assessment area beds for more than 3 hours.

10 Planned additional bed capacity on standby. 10 Planned additional bed capacity open and less than 80% occupied. 10 Planned additional bed capacity open and more than 80% occupied. 10 All planned additional bed capacity open and full; unplanned capacity in

use.11 No loss of admission bed capacity due to infection control measures. 11 Partial or whole ward closed to admission or discharge due to infection

control measures.

11 More than one ward closed to admissions or discharge due to infection

control measures with local restrictions on visiting.

11 More than one ward closed to admissions or discharge and whole

Hospital closed to visitors due to infection control measures.12 Critical care capacity less than 80% occupied. 12 Critical care capacity is 80%-100% occupied. 12 All formal critical care capacity occupied and planned overflow areas in

use.

12 All formal critical care capacity occupied and planned overflow areas in

use. Potential transfers identified but unresolved.13 Gender specific beds available as planned. 13 Patient moves required, expected within 1hr. 13 Patient moves required, expected within 4hrs. 13 Patients waiting for appropriate gender beds; non-planned or available.

14 Medically Fit for Discharge cases form less than 9% of the inpatient total. 14 Medically Fit for Discharge cases form between 9% and less than 11% of

the inpatient total.

14 Medically Fit for Discharge cases form between 11% and 13% of the

inpatient total.

14 Medically Fit for Discharge cases form more than 13% of the inpatient

total.

(Minimum of two triggers applicable) (Minimum of two triggers applicable) (Triggers 1 to 3 are mandatory) (Triggers 1,2 & 3 are mandatory)

1 Community bed availability is > 5% 1 Community bed availability is < 5% 1 No community bed capacity 1 No community bed capacity

2 No operational issues 2 Discharges are planned for today 2 Anticipated discharges by next day 2 All additional capacity is open

3 Planned admissions > 5% 3 Planned admissions < 5% 3 Planned admissions by next day 3 No anticipated discharges within 48 hours

4 Emergency direct admission being refused (Optional trigger)

1 100% of patients are treated and discharged with in 2 hrs 1 98% of patients are treated and discharged between 2 to 3 hrs 1 95% of patients are treated and discharged between 3 to 4 hrs 1 Time taken to treat and discharge any patients is > 4 hrs

1 All rostered staff working 1 Staffing levels at > 90% of rostered availability. Skill Mix appropriate 1 Staffing levels at 80 - 90 % of rostered availability. Skill Mix tolerable 1 Staffing levels at < 80% of rostered availability. Skill Mix inappropriate

2 New referrals accepted 2 New referrals accepted through prioritising care 2 Prioritising routine care and only responding to urgent new referrals 2 Only urgent complex and high priority care can be delivered

3 Can respond to normal request in 2 working days 3 Unable to respond to routine referrals in 2 working days 3 Urgent response will be within 4 hours. Routine Responses will be

rescheduled

3 Emergency visits only. Business continuity plan enacted

4 Updating of administration within the day. Staff breaks possible,

representation at meetings, and working to normal hours. Patient records

and activity are recorded.

4 Reduced time for office work and documentation, review all meeting

requests. Normal working hours need to be extended. Back log of activity

being recorded

4 Staff breaks not accommodated and working over contracted hours in

excess of 2 hours Study leave, training and courses cancelled. Only patient

records completed

4 Agreed overtime to complete patient related tasks

5 Able to deliver routine, essential and critical services. 5 Complex & Palliative care prioritised over routine services. 5 No routine visits or assessments undertaken. 5 Complex patient care only undertaken - potential risk to patient safety

6 No adverse weather conditions or planned major disruptions 6 Short term disruption expected <24hrs 6 Medium term disruption expected. > 24 hours < 48hrs 6 Long term disruption expected. > 48 hours

(Normal working - all triggers apply) (3 out of 4 triggers apply) (4 out of 5 triggers apply) (2 out of 3 triggers apply)

1 Red response for cluster is > 75% 1 Red response for cluster is < 75% for the cluster 1 Red response < 65% for the cluster 1 Red response is < 60% for the cluster

2 No out of time referrals for the cluster 2 RRV's are waiting > 15 minutes for back up in the cluster 2 RRV's waiting >30 minutes for back up on the cluster 2 Empty status plan for the cluster

3 WMAS reporting REAP level 1 or 2 WMAS reporting REAP level 1 or 2 3 5 or less out of time referrals in the cluster 3 6 or more out of time referrals in the cluster 3 WMAS reporting REAP level 4 or 5

4 Hospital Turn round issues have been escalated to Senior 4 Hospital Turn round times escalated to Director/SHA level within the

Management level within the Cluster Cluster

5 WMAS reporting REAP level 2 or 3 5 WMAS reporting REAP level 3 or 4

1 Call volume within forecast 1 Call volume 20% above forecast 1. Call volume 20-50% above forecast 1 Call volume > 50% above forecast

2 Staff redeployed to meet demand 2. Extra resource deployed to meet demand 2 Able to only deliver urgent care

(Minimum of two triggers applicable) (Minimum of two triggers applicable) (Minimum of two triggers applicable) (Minimum of two triggers applicable)

1 Normal staffing levels available 1 <70% of normal staffing levels available 1 <60% of normal staffing levels available 1 <50% of normal staffing levels available

2 Normal amount of referrals received eg. Section 2 referrals 2 >10% increase of the normal amount or referrals eg. Section 2 referrals 2 >20% increase of the normal amount of referrals eg. Section 2 referrals 2 >40% increase of the normal amount of referrals eg. Section 2 referrals

3 <10% above the normal amount are unable to progress 3 >10% above the normal amount are unable to progress 3 >20% above the normal amount are unable to progress 3 >40% above the normal amount are unable to progress

4 Normal team caseload levels 4 10% above normal team caseload levels 4 20% above normal team caseload levels 4 40% above normal team caseload levels

5 All cases have been assessed within 24hrs of an active 5 >5% of cases which have not been assessed within 24 hrs of the active 5 >10% of cases which have not been assessed within 24 hrs of the 5 >15% of cases which have not been assessed within 24 hrs

Section 5 referral Section 5 referral (not due to external factors) active Section 5 referral (not due to external factors) of the active Section 5 referral (not due to external factors)

Level 4 - Extreme PressureAcute

Community Providers

Community Beds

Community Providers

Community Beds

Community Providers

Community Beds

Community Providers

Community Beds

Acute

Level 1 - Planned Operational Working Level 2 - Moderate PressureAcute

Level 3 - Severe PressureAcute

Urgent Care Centres/Minor Injury Unit/ Walk In Centre

Community Services


Community Services


Community Services

WMAS

OOH

Hospital Social Care Services


Community Services

WMAS

OOH


WMAS

OOH


WMAS

OOH


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3. LEADERSHIP

4. COMMAND AND CONTROL

4.1. When would we use ‘Command and Control’ principles?

In the event that emerging pressures show either no sign of de-escalation after 4 hours nr EMS level 4, the system will run on, ‘Command and Control’ principles this will be approved agreed by the Gold commander only.

4.2. What do we mean by ‘Command and Control’?

Command and control is the means by which a commander recognises what needs to be done and sees to it that appropriate actions are taken. This means that the Silver commander/s will take operational control and responsibility reporting to Gold. No component part within organisations should then make unilateral decisions on matters relating to capacity but can seek authorisation by Silver. RSUH control room function will change and each day run from 08:00 to 20:00 hours (extended on instruction of the Gold Commander).

NSCHT will run on Command and Control as instructed through Strategic Commander [On Call Executive]. The hours of Operation will vary depending on the issues and actions required. Detail will be agreed through the Strategic LHE structure

4.3. ‘Command and Control’ roles To Note – Silver / Gold/ Bronze roles do not reflect any hierarchical existing job titles or roles and cannot be overruled during the incident management process without the commanders’ approval. Day to day job titles stay outside of the incident management command and control structure. 4.3.1 GOLD Commander - STRATEGIC.

Oversee the strategic provision of healthcare services across the organisation, coordinate communication with other organisations Directs and monitor delivery of agreed actions and give overall strategic direction. Do not take on the role of Silver who is operationally in charge.

At UHNM supported with on-site presence from:

Gold level senior nurse and Gold level senior medic. Communications lead.

LEVEL 1 Normal Pressure

LEVEL 2 Moderate Pressure

LEVEL 3 Significant Pressure

LEVEL 4 Extreme Pressure

Management: Operational Managers/Site Manager

Management: Heads of Service/ Assistant Director/Deputy

Management: Assistant/Associate Director level/Silver

Management: Director/COO/Gold

Assurance to: Heads of service Assistant/deputy

Assurance to: Assistant/Associate Director level

Assurance to: COO/Director

Assurance to: Chief Executive/CCGs GOLD may give instruction to enact UHNM and Full Hospital Protocol RSUH site only)

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At SSoTP supported with on-site presence from: Strategic Lead for Unplanned Care Chief Operating Officer for the North

At WMAS supported by;

Silver SOC Commander Silver on call on-site

4.3.2 SILVER Commander – TACTICAL.

At UHNM Silver will:

Co-ordinate the Incident Control room function via the Incident coordination centre, Springfield building.

Chair tactical meetings (Silver Update meetings, conference calls) ensuring setting and delivery of agreed actions

Report to Gold and keep Gold briefed at agreed timelines. Take whole organisational responsibility for tactical (operational) management. Out of hours the role of Silver role is fulfilled by the Site Manager until the on-call manager

(Silver) arrives on-site. At SSoTP supported with on-site presence from:

Strategic Lead for Unplanned Care Chief Operating Officer for the North

At WMAS Silver will; Liaise with On-site Bronze officer (HALO or ASO) Liaise with EOC Duty Officer Communicate to Gold when required.

4.3.3 BRONZE Commander/s – OPERATIONAL

At UHNM: Associate Directors are responsible for ensuring UHNM Bronze command posts are set up and function from 08:00- 20:00 with a named Bronze commander (unless instructed by Silver) to extend hours, in:

Emergency department Medicine Division Surgery Division Specialised Division Women’s & Children’s and Clinical Support Services

The Director of Operations or Deputy is responsible for setting up Bronze: Capacity Team control room

Each the control room must be manned for the period set out unless formally stood down by Gold. Others may be required to support as requested by Silver/Gold Commander, for example, Infection Prevention, Corporate Services. This request will be determined by emerging pressures.

At level 3 additional meetings may be called by the COO or Director of Operations (Gold). At SSoTP supported with on-site presence from:

Strategic Lead for Unplanned Care Chief Operating Officer for the North

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At WMAS:

HALO will be on site within the department

Area Support Officer will communicate with HALO and on call Silver as required.

City Social Care, North Staffordshire combined Healthcare Trust will take instruction from their Gold commanders on setting up and running a command and control structure.

4.4. ‘Command and Control’ SILVER & GOLD MEETING AGENDA

To support Silver and Gold commanders during command and control template agenda are set out in appendix 4.

5. COMMUNICATION

The LHE Communication Team will issue press statements but only when these have been agreed by all organisations. If, however, escalation procedures have been invoked to the point of declaring a major incident, the issue of press statements will be a decision taken by the Gold Commanders.

6. INFECTION CONTROL Specialist infection prevention and control advice should be sought as part of the day to day capacity and demand management decision making processes within each organisation; Infection Prevention teams discussing directly with each other on cross-organisational issues and advising their respective Capacity management teams.

7. ROLES AND RESPONSIBILITIES

7.1. Shared responsibility Each organisation has a responsibility to maintain patient safety across the local health and social care system; this includes supporting the maintenance of a fully functioning Emergency Department and other Emergency Portals and timely response to surge. Health and social care partners in North Staffordshire will take a shared risk approach by not letting all the clinical and organisational risk sit within one point within the health and social care system, taking timely actions.

7.2. Chief Operating Officers / Gold commanders (Strategic leader): Provide strategic leadership for effective patient flow.

Ensure internal escalation plans are in place and followed.

Ensure system wide actions are in place and followed.

Do not run the incident response

7.3. Silver Commanders: Responsible for running the incident response

Briefing up

Ensuring actions are being taken

Provide assurance to Gold that all actions at the respective level have been done.

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Providing timely briefing to Gold prior to conference calls.

Carrying out Gold instruction

Appropriate and timely escalation to Gold or external colleagues

7.4. Clinical Commissioning Groups: Receive assurance that the agreed actions have been taken

Respond to requests for commissioning needs

Contribute to the strategic and tactical leadership of the incident at Silver and Gold level

8. ASSURANCE FRAMEWORK

Standard Assurance Evidence

The health and social system in Northern Staffordshire will provide a joint response to increases in patient demand to ensure that no single part of the system experiences severe disruption.

A system wide escalation plan is jointly developed

Ratified plan in place

All relevant staff receive training on the system wide escalation plan

Training records

The plan is tested annually Exercise date is set and SRG receive post exercise report

The plan is reviewed annually or in response to lessons learnt

Updates are received by SRG

Operational implementation

Quarterly audit will be conducted using the audit form in appendix 8

Audit feedback: 1st level - individuals 2nd level - line managers 3rd level - System issues to SRG

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9. ACTION CARDS LEVEL 1

LEVEL 1

NORMAL WORKING

Action Cards

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EMS Level 1 – UHNM Responsible Ensure all internal escalation plan actions have been completed ADs/Director of Ops

All wards are to identify their target number of discharges (as minimum) and contact there Divisional Patient Flow lead NO LATER than 8.15 am with patient details

Ward Managers

Bed Meeting Attendance as set out by each Division Patient Flow leads

Clinical Site Manger to ensure all wards aware of the EMS Level by sending IT notification.

CSM

Real time bed state using WIS within the wards to be updated Nurse in charge

Bed meetings to be held three times a day, see section see section 6. Capacity Team

CSM to proactively manage the bed stock, placing patients in appropriate bed in a timely manner.

CSM

Ward Manager to make sure that each patient has a predicted date of discharge. Escalate any delays in diagnostic tests & inform of potential suitable outliers etc. Ward Manager to ensure that patients are being moved in a timely manner and expediting discharges. Ensure that the discharge lounge is utilised for appropriate patients. Ensure compliance with discharge bundles.

Matrons/ Ward Manager

Make sure that patients are referred to other members of the MDT in a timely fashion

Ward Manager

Support maintaining A&E 4 hour standard. All

Complex Discharge Co-Ordinator to update plan for every delayed transfer of care.

Complex Discharge Co-ordinator

CSM to produce over-arching plan after 3.30pm bed meeting for out of hours.

CSM

Ward Managers and Matrons to identify patients who when medically stable/suitable could be transferred to UHNM at home.

Ward Leads/Matrons

Matron to follow up staffing shortfalls and to produce a plan for any staffing issues OOH

Matrons/Associate Chief Nurses

All areas to plan and prepare for sudden increase in demand by maintaining patient flow and ensuring timely discharge & transfers

ED, Ward Mangers

EMS LEVEL 1 – SSOTP Responsible Patient Flow All wards are to identify their number of discharges and contact the Patient Flow lead NO LATER than 8.15 am with patient details, this is then to be forwarded to the hub co-ordinator

Ward Managers

All step up/step down services to confirm their discharges no later than 8.30am to the Hub Co-ordinator

Team Leaders/Silver Co-ordinator

The hub co-ordinator to ensure all service managers are aware of the EMS Level by sending IT notification.

Hub-Co-ordinator

Internal Conference call - participants: Chair: Silver Commander/Co-ordinator/Area Manager/Community Hospital Manager Participants: Community Hospitals Rep, IC Capacity/LIS capacity rep, UHNM interface rep, hub co-ordinator Template to be completed and circulated with actions

Silver commander/co-

ordinator

Community Hospitals Patient Flow Coordination Team Manager to proactively manage the bed stock, placing patients in appropriate beds in a timely manner.

Patient Flow Coordination Team

Manager

16

EMS LEVEL 1 – SSOTP Responsible All side room usage to be reviewed Community Services Team leaders to proactively manage capacity in accepting patients in a timely manner liaising with the hub co-ordinator

All Ward Managers/Clinical Leaders to make sure that each patient has a predicted date of discharge. Escalate any delays & inform of potential suitable exit strategies etc. Ward Manager to ensure that patients are discharged before lunch and provide exception reports where this does not happen.

Managers/Clinical Leaders

Make sure that patients are referred to other members of the MDT in a timely fashion and escalate any delays

Ward Managers

Community Hospitals Patient flow co-ordinator to update plan for every delayed transfer of care for escalation to Patient Flow Coordination Team Manager


Manager

Community Hospitals Ward Managers to identify patients who could be transferred to Intermediate Care at home. Intermediate Care Team leaders to identify patients who could transfer to domiciliary care services

Ward Leads/Matrons

Ward Managers/Team Leaders to follow up staffing shortfalls and to produce a plan for any staffing issues OOH

Ward Managers/Team Leaders

All areas to plan and prepare for sudden increase in demand by maintaining patient flow and reviewing all IC restrictions and ensuring timely discharge & transfers

Ward Mangers

17

EMS Level 1 – WMAS Responsible WMAS operational resources to pass details patients on to hospital system.

Operational crews

Handover and offload within 15 mins of arrival and promptly return to vehicle to make ready for availability to EOC.

Operational crews

Maintain contact with resources at Acutes, ensuring timely handovers and bed availability

HALO/BRONZE Hospital Officer

Consider utilising spare stretchers to clear resources within 30 minutes and liaise with hospital desk regarding recording of this.


Utilise “Patient Release” button functionality in CAD Online – achieving at least 95% completion compliance


Liaise with Hospital Desk to maintain resource overview EOC Duty Manager

Monitor performance and activity identifying early pressure points EOC Duty Manager

Update escalation management system website regarding outstanding workload

EOC Duty Manager

Monitor turnaround times; consider level 2 if trigger point reached 4 hourly

EOC Duty Manager

Send estimated time to clear message to resources at 20 Minutes Hospital desk

Contact HALO’s for appraisal of situation on-site at Acutes, identifying early pressure points

Hospital desk

If no HALO on site liaise directly with hospital and EOC Duty Manager to ensure ASO/BRONZE Officer responded if required

Hospital desk

Maintain Control Log and EMS entries Hospital desk

Offer advice regarding activity across other Acute Trust sites to manage flow of patients.

Hospital desk Supervisor

Liaise with On-site HALO or BRONZE Officer (if present) Hospital desk Supervisor

Provide Gold functions [Strategic] if required on Call Assistant Chief Officer

Provide Silver functions [Tactical] if required Manager on call

Review and monitor weekly delays

Heads of Directorate or designated other

Ensure all admissions to adult acute wards are “gate kept” Head of Directorate - Adult Inpatients or designated other

EMS LEVEL 1 – CITY SOCIAL CARE Responsible Normal working

Team Manager

North Staffordshire Discharge Policy utilised

Team Manager

Social care to arrange discharges within agreed timescales

Team Manager

Report any problems / issues with delays/access to services to UHNM

Team Manager

Update CDS to reflect current patient status.

Team Manager

Attend MDT / MFFD meetings.

Team Manager

Ensure all teams are aware of the EMS level.

Team Manager

Track bed availability across the independent sector/local authority

Team Manager

18

EMS LEVEL 1 – CITY SOCIAL CARE Responsible Track in house/independent sector domiciliary care

Team Manager

EMS LEVEL 1 – CCG City/North/South Responsible

Provide First Responder and Gold functions First Responder and Gold

Monitor system information Urgent Care Team and First Responder

Ensure admission/attendance avoidance schemes are operating fully Urgent Care Team and First Responder

19


LEVEL

2 Moderate Pressure

Action Cards

20

EMS LEVEL 2 – UHNM Responsible

Actions as in Level 1 and 2 ALL

Confirm all internal level 1 & 2 actions have been completed Ads/Director of Ops

Designated Patient Flow Manager from each Division with information of all patient delays in ED and knowledge of bed allocation / pharmacy / diagnostic delays.

Clinical Site Team

Clinical area reps to collect information of all patient that every action has been taken previously to escalate delay direct to the service involved, & update plan for every patient- info to be brought to Patient Flow Meetings and plans agreed to fast-track patients.

Ward Managers & Discharge team

To consider any clinical staff on office days, meetings, study days/ sessions etc., are to return to shop floor to assist in patient flow issues, review board rounds and facilitate discharges where ever practical. Where unable – cover is to be arranged to ensure board / ward round activity is carried out in a timely manner.

Directorate Managers / Clinical Lead

Consider review of patients brought in the day before surgery Directorate Mangers to inform teams of increasing pressure, requesting support in assessment reviews

DMs

Review all capacity and activity with a view to using staff in areas of pressure

Patient Flow Manager and Matron

Utilisation of Discharge Lounge – use for patients waiting discharge to make capacity and ensure is used safely by default.

Patient Flow Manager / Ward Manager

Review any patient waiting solely for diagnostics or investigations and consider discharge with appropriate follow – up with Clinicians

Ward Manager/Matron

Consider alternative f l e x i b l e transport solutions. Head of Patient Transport

Discuss with ambulance transport to prioritise discharges if needed. CSM

Discuss with theatres/surgical teams to ensure patients are taken to theatre in priority order as per Theatres operation procedures

Theatres DM

Delayed discharges to be escalated to Patient Flow Manager & addressed with relevant MDT

Discharge team

Where Wards target possible discharges are not met, Directorate Manager and Matron of area to review with Wards and implement action plan to ensure discharge targets are achieved within Division.

Matrons / DMs

Information and update to be provided to Bed Manager / Patient Flow Coordinator continually both prior to and after Capacity Meeting.

Matrons/ DMs

Deputy /Divisional AD to update at Capacity Meeting ADs / Deputies

10 ‘Golden patients’ identified Matrons / DMs

EMS LEVEL 2 – SSOTP Responsible

Actions as in Level 1, with items detailed in addition ALL

Patient Flow As in level 1 with the addition of escalation to COO with any areas where there is an issue with patient flow including information of all patient delays in all critical services.

Service Managers

Internal Conference call – participants as in level 1 but escalation to COO any Silver

21


capacity issues. All actions to be fed through to LHE Silver conference call

Commander/Co-ordinator

Health Economy Conference Call Participants: Silver commander, hub coordinator

Silver Commander/Co-

ordinator

Ward managers to ensure board / ward round activity is carried out in a timely manner and all actions to be recorded.

Ward Managers

Review all capacity and activity Patient Flow

Manager and Matron

Discuss with UHNM Silver ambulance transport arrangements to prioritise discharges if needed.


Manager

Delayed discharges to be escalated to Patient Flow Manager Discharge team

Information and update to be provided to Bed Manager / Patient Flow Coordinator continually both prior to and after Capacity Meeting.

Matrons/ DMs

Intermediate Care Coordinators to be based at RSUH during the weekends Silver Commander

Attendance at all board rounds required by : As in level 2 with the addition of a Service Manager/Matron for all community hospitals with knowledge of bed allocation and delays.

All those with action cards

Ensure real time bed state through utilisation of CDS, & adjust frequency of conference calls as required, all capacity to be held by the hub coordinator.

Patient Flow Manager/ward nurse

in charge

Internal Conference call – participants: Chair: COO Participants: Silver Commander/Coordinator/Area Manager/Community Hospital Manager, Community Hospitals Rep, IC Capacity/LIS capacity rep, Unmet demand/EMS level rep, hub coordinator, Urgent Care Lead Template to be completed and circulated with actions

COO

LHE Conference Call Participants: Urgent Care Lead, Silver Commander, hub-coordinator. Actions to feed internal communication plan for SSOTP

Urgent Care Lead

Gold Commander to review the LHE situation with the Urgent Care Lead to determine if further escalation is likely. If so, command and control to be commenced to try and prevent further escalation

Gold Commander

Service Manager with appropriate knowledge of any operational issues for their area and action plans for any identified delays / issues to join conference call

Service managers/Team

Leaders

Review all level 2 actions Service Managers and Matrons are to work together to review all actions taken in level 2 and agree plan for targets not achieved. Actions to be fed to silver commander

Patient Flow Manager / Service

manager /

Community Services Managers are to ensure regular communication is provided to the Silver On-Call Manager and the Bed Manager / Patient Flow Manager to feedback and update throughout the day

Intermediate Care Managers/LIS

Managers/ Acute Social Care

Manager

Lead Nurses to provide information on elective and day case admissions Lead Nurse

Consider use of escalation beds On Call Silver/On Call Gold

Prepare for use of escalation capacity Gold Commander

22


Review all activity in community Services / Bed Provision in Community Hospitals/Brighton House

Community Teams

Communication pressures to the public Communications

Matrons/Team Leaders/Neighbourhood managers to review staffing levels and produce a plan for any shortfalls to cover gaps

Urgent Care Lead

Contact Gold commander for decisions of flexing service criteria, focus to be on moving patients safely through the system.

Urgent Care Lead

Internal Communications to be cascaded in preparation for further escalation Gold commander

Area Managers to meet with domiciliary care providers to discuss step down plan

Area Managers

Trusted assessors deployment for critical services to attend UHNM (ICT triage)

Silver Commander

All capacity for SSOTP to be centrally held by the hub Urgent Care Lead

EMS LEVEL 2 –WMAS Responsible

If unable to offload within 15 minutes notify HALO/BRONZE Officer (if on site – if not liaise directly with EOC) and prepare for cohorting onto spare stretcher(s) where appropriate.

Operational Resources

Maintain regular contact with EOC and BRONZE Officer on arrival to ensure robust communication.

Operational Resources

Make contact with lead nurse (or site specific/relevant contact) and Manager identifying any issues and determine plan for onward flow.


Utilise spare stretchers to release resources HALO/BRONZE Hospital Officer

Liaise with Acute Site Capacity Manager regarding any potential issues which will require further escalation.


Maintain regular communication with Hospital Desk Team providing on site intelligence of current and forthcoming expected events


Ensure appropriate patients are sent via triage/Main Waiting room (where appropriate) and walk-in centres to release resources


Contact Acute on call Manager to ascertain action plan for >30 min delays

SOC Commander (if on duty) Silver Commander

If no resolution contact Acute AND CCG on call Directors stating there are now PATIENT SAFETY issues in the department and through our reduced ability to respond due to delays

SOC Commander (if on duty) Silver Commander

Monitor turnaround times; consider level 3 if trigger points reached 4 hourly

EOC Duty Manager

Liaise and agree action plans with SOC Silver Commander – if between 0000-0800hrs liaise with Area Silver on call and EOC Silver Commander on call.

EOC Duty Manager

Contact crews after 20 minutes where there is no HALO on site, if HALO on site contact them directly and confirm update of situation, if no HALO or crew response, contact via hospital department making contact with crew.

Hospital Desk

Ensure that any resources not handed over or unable to do so are identified and escalated appropriately either to HALO to deal on site or capacity manager.

Hospital Desk

Liaise with EOC Duty Manager to respond Bronze Manager to potential problem site where there is no HALO present.

Hospital Desk

Maintain Control Log and EMS entries for WMAS Hospital Desk

23

EMS LEVEL 2 –WMAS Responsible

Inform SILVER; SOC Commander if on duty or On Call Silver if not.

Hospital Desk Supervisor

Liaise with EOC duty Manager and monitor overall situation across locality including outstanding workload and consider benefit of deflecting 999 resources inbound to lower activity Trust following discussion and agreement with WMAS SILVER – PROVIDING THIS WILL NOT NEGATIVELY IMPACT ON OPERATIONAL SERVICE DELIVERY as required


Contact on site / on call managers at Acutes and negotiate resolution.


EMS LEVEL 2 –NSCHT Responsible

As Level 1

Requests for beds for out of area patients to be escalated for a decision on every occasion

Clinical Co-ordinators/ Directorate Heads or designated other

On Call Managers to be aware of current bed state and staffing Clinical Co-ordinator through agreed e-mail alerts

EMS LEVEL 2 – MODERATE PRESSURE City Social Care Responsible

As level one plus Team Manager

Monitor system for early signs of blockage & address any blockages in the system

Team Manager

Review and ensure proactive functioning of hospital discharge systems and individuals

Team Manager

Assessment staff to operate discharge to assess model on identified wards Team Manager

Arrangement of appropriate discharges / return home

Team Manager

Update CDS to reflect current patient status. Social care representative to participate in daily conference call

Team Manager

EMS LEVEL 2 –CCG City/North/South Responsible

As Level 1

Expedite additional available capacity in NHS 111, out of hours and other relevant commissioned services

Urgent Care Team and First Responder

Co-ordinate communication of escalation across the local health economy Urgent Care Team and First Responder

Support partners to identify risks and address issues in the system Urgent Care Team and First Responder

24


LEVEL 3

SEVERE PRESSURE

Action Cards

25

LEVEL 3 – SEVERE PRESSURE UHNM Responsible

Ensure all internal level 1,2, 3 actions have been completed ADs/Director of Ops

Ensure real time bed state through patient Flow Mangers & adjust frequency of bed meetings as required.

Director of Ops

Bed Manager / Patient Flow Manager to feedback and update throughout the day (both prior to and after capacity meetings)

Patient Flow Manager / Directors of nursing / Specialty Managers

Plans agreed to fast-track patients. Details of all patients delays that are occurring on wards and ED e.g. pharmacy / diagnostics to be brought by Patient Flow Mangers to Bed Meetings and plans agreed to fast-track patients. Discharge teams to manage exit plan for DTOCs

Patient Flow Mangers/Complex Discharge Team

Call all available doctors to go to the Wards to assist as required. Any clinical staff that are on office days, meetings, study days / sessions etc. to return to shop floor to assist in patient flow issues, review board rounds and facilitate discharge. Monitor long LOS patients taking action against identified blocks

DM / Matron / Clinical Lead

Review of patients brought in the day before surgery Patient Flow Manager / Matrons

Lead Nurse to provide information on elective admissions expected Lead Nurse

Consider postponing elective surgery COO

Consider use of escalation beds Associate Director of medicine / COO

Review ICU Capacity and Theatre activity with a view to use staff in areas of pressure

ACN

Review community provision with complex discharge team and RAID for mental health capacity

Complex discharge team


Matrons and ACNs to review staffing levels and produce a plan for any shortfalls to cover gaps

ACN

Escalate to Chief Nurse where required ACN

Prepare wards to receive 1 additional patient Matron / DM / Ward Manager

LEVEL 3 –SSOTP Responsible

Attendance at all board rounds required by : As in level 2 with the addition of a Service Manager/Matron for all community hospitals with knowledge of bed allocation and delays.

All those with action cards

Ensure real time bed state through utilisation of CDS, & adjust frequency of conference calls as required, all capacity to be held by the hub coordinator.

Patient Flow Manager/ward nurse

in charge

Internal Conference call – participants: Chair: COO Participants: Silver Commander/Coordinator /Area Manager/Community Hospital Manager, Community Hospitals Rep, IC Capacity/LIS capacity rep, Unmet demand/EMS level rep, hub coordinator, Urgent Care Lead Template to be completed and circulated with actions

COO

LHE Conference Call Participants: Urgent Care Lead, Silver Commander, hub-coordinator. Actions to feed internal communication plan for SSOTP

Urgent Care Lead

Service Manager with appropriate knowledge of any operational issues for their area and action plans for any identified delays / issues to join conference call

Service managers/Team

Leaders

26

LEVEL 3 –SSOTP Responsible

Review all level 2 actions Service Managers and Matrons are to work together to review all actions taken in level 2 and agree plan for targets not achieved. Actions to be fed to silver commander

Patient Flow Manager / Service

manager /

Community Services Managers are to ensure regular communication is provided to the Silver On-Call Manager and the Bed Manager / Patient Flow Manager to feedback and update throughout the day

Intermediate Care Managers/LIS

Managers/ Acute Social Care

Manager

Lead Nurses to provide information on elective and day case admissions Lead Nurse

Consider use of escalation beds On Call Silver/On Call Gold

Prepare for use of escalation capacity Gold Commander


Community Teams


Matrons/Team Leaders/Neighbourhood managers to review staffing levels and produce a plan for any shortfalls to cover gaps

Urgent Care Lead


Urgent Care Lead

Internal Communications to be cascaded in preparation for further escalation Gold commander


Area Managers


Silver Commander

All capacity for SSOTP to be centrally held by the hub Urgent Care Lead

LEVEL 3 – WMAS Responsible

Liaise with Hospital Desk Team, SOC Commander and Duty Manager ensuring that appropriate arrangements if agreed to deflect patients are being taken (please refer to Management Level in adjacent box for SILVER involvement)

HALO/ BRONZE Hospital Officer

Ensure spare stretchers are being utilised within problem sites and arrange for further spares to be transported if appropriate.

HALO/ BRONZE Hospital Officer

Arrange for Spare Stretcher Capacity to be delivered to the Acute. HALO/ BRONZE Hospital Officer

Liaise with EOC and HALO / BRONZE on site making judgment decisions as to whether further response to acute is required.

SOC Commander if on duty SILVER Commander

Contact PCT on call Director to re-advise of prolonged/extreme pressure and no resolution


Advise on call WMAS GOLD if out of hours or responsible Director in hours for the relevant Trust if appropriate at which point level 4 is activated in liaison with EOC Duty manager.


Through liaison with Hospital Desk/Logistics Desk deploy Regional Spare Stretcher Capacity vehicle (using solo/nearest HALO)


Contact WMSHA On Call Director (remember SOC Commander acts under SOC Commander if

27

LEVEL 3 – WMAS Responsible

as the “operational facilitator for NHS West Midlands) to appraise of current situation and lack of resolution within Acute and PCT – advise of PATIENT SAFETY in jeopardy due to delays in Departments and WMAS reduction in resources available to respond as required

on duty SILVER Commander

Liaise with Hospital Desk Team, who will in turn liaise with SILVER involved to maintain overview 4 hourly

EOC Duty Manager

Log all actions in control log in conjunction with Hospital Desk Team. EOC Duty Manager

Direct all hospital turnaround/escalation calls to Hospital Desk Team EOC Duty Manager

Maintain liaison with BRONZE Commander, confirm contact with local SILVER

Hospital Desk

Confirm the call signs delayed with BRONZE Commander Hospital Desk

Maintain Control Log with updated situation as required Hospital Desk

Liaise with Duty Manager to respond Manager to potential problem site where there is no HALO present as required

Hospital Desk

At request of SILVER arrange deployment of Spare Stretcher Capacity (using solo/nearest HALO/BRONZE Officer) as required

Hospital Desk

Assess outstanding workload and consider opportunities to deflect resources inbound to lower activity Trusts ensuring overall situation of all sites is reviewed. If instigated this should be for a set agreed period of time only 4 hourly


Escalate any turnaround problems (vehicles delays in excess of 30 minutes unable to handover) to On Site Manager at Acute and agree resolution as required


Inform SILVER Commander who will liaise with HALO / Capacity Management and EOC and remain in contact, making decision to attend hospital if necessary as required


Liaising with acute trusts to ensure the EMS site has been completed and updated at an appropriate time frame conducive with the situation as required


28

LEVEL 3 – NSCHT Responsible

As Level 1 & 2

LHE Conference Call attendance Executive Director on call/Manager on Call

Available beds across the Trust identified and the On call manager informed Clinical Co-ordinator through agreed e-mail escalation route

Patients to be identified who could be transferred from the Harplands to lower dependency areas

Consultant Psychiatrists, Home Treatment Team and Outreach Team

Available substantive and Bank Staff to be identified Clinical Co-ordinator/ Temporary Staff co-ordinator

Identify corporate staff who are able to work in clinical areas Human Resources

RAID to ensure availability in Emergency portals to assess patients who could be admitted to mental health units or supported at home to be able to assess with 1hr of referral

Modern Matron/Team Manager

RAID to assess older people with mental health needs that could be managed at the Harplands or supported home with mental health team support

Modern Matron/Team Manager

LEVEL 3 – CITY SOCIAL CARE Responsible

As Level 2 plus

Same Day funding decisions. Team Manager/Strategic Manager

CHC applications agreed outside of panel.

Team Manager/CDAT

Discuss options of flexing service criteria to meet demand.

Strategic Manager

Specifically, consideration will be given to step down alternatives where capacity prohibits discharge to the identified destination. This will include Rowan Village ICT flats, Extra care additional community capacity (within a 3 mile radius) and interim placements where appropriate.

Team Manager/Strategic Manager

Identification of additional capacity to open and planning to action if level 4 Strategic Manager

Commissioners to contact Providers (domiciliary and 24 hr care) to request urgency in response and availability of additional capacity.

Strategic Manager

Increased frequency of Capacity and Demand meetings (domiciliary care)

Strategic Manager

Discharge to Assess to operate on an enhanced basis with a focus on proactive “pull” function.

Team Manager

Social care to ensure all bed capacity / stay at home schemes is used / criteria relaxed in line with Contract and CQC regulations

Team Manager/Strategic

29

LEVEL 3 – CITY SOCIAL CARE Responsible

Manager

Operational Managers to participate in conference calls. Team Manager/Strategic Manager

LEVEL 3 –CCG City/North/South Responsible

As levels 1 and 2

Continuing Healthcare funding to be agreed outside panel (where appropriate)


Flex service criteria, in agreement with relevant partners, in order to optimise system capacity


Brief CCG Gold to provide assurance that all appropriate commissioning actions are taken in a timely manner


Contact bordering CCGs to establish the actions that can be instigated to reduce pressure on the system


30


LEVEL

4 EXTREME

PRESSURE Action Cards

Level 4 should be seen as a ‘never’ event ‘HOSPITAL FULL’ PROTOCOL’

MAY BE ENACTED (ON RSUH SITE ONLY)THE INSTRUCTION OF THE COO OR NOMINATED

GOLD DEPUTY

31

‘LEVEL 4’ UHNM

Escalation – Additional Action

As actions listed in Level 1, 2 and 3 (Green, Yellow and Amber).

Ensure all mandatory action actions are completed for ‘RED’ status.

Cancel elective activity severity of reduction will be agreed at Capacity Meetings and authorised by the COO / Director of Operations

Mandatory Actions

Routine elective admissions have been cancelled.

All managers’ diaries to be cleared for 48 hours and complete focus must be to support de-escalation across the organisation, assisting other specialities if needed.

Urgent elective admissions have been reviewed and, where possible, rescheduled or cancelled.

ED consultant to be present in ED department

Medical consultant to be present on wards or in ED department

Surgical consultant to be present on the wards, in theatre or in ED department

Assign appropriate qualified clinician to manage care of patients awaiting handover from ambulance service to enable ambulance crews to be released

Executive / Director / Gold to be on site .(rota should be put into place for staff welfare)

Any request to divert patients from ED must be initiated by the Acute Trust who having exhausted all internal divert options must contact the CCG and potential divert trusts to request a divert to neighbouring trusts.

Gold to contact Gold of neighbouring trusts to agree divert arrangements

Consider cancelling leave in areas of significant pressure

All clinical staff in non-clinical roles should attend work in uniform and prepare to be deployed as needed.

Ads and ACNs to review what non-essential services can stop to redeploy staff or create capacity in line with the Trusts critical/essential services list appendix xx)

LEVEL 4 – UHNM. Responsible Review all actions at normal working levels 1, 2 and 3 2 hourly Patient Flow

Manager/ Specialty Manager

CMST / ADO to discus with COO / Director of Operations the need for a compulsory (Gold level) capacity meeting with the rest of the health economy. 2 hourly or more frequently as required

Director of Operations

Report pressures to the rest of the Executive / Director Team of actions being taken 2 hourly.

Associate Director of Medicine / COO

Review situation on a 2 hourly basis with bed meetings

COO/Additional attendance as set out in plan

Ensure all internal actions at level 1,2,3 and 4 are completed COO/Gold

Communications to be kept informed and prepare a press release detailing the internal pressures and what plans have been put in place to deal with the escalating situation.

COO/Communications team

To contact hospitals outside of the county to see if they can assist. COO/Gold

Ensure early hourly contact with (Silver) manager on call, who will inform the Gold on call

Site Manager

Gold to Gold communication with all partner organisations 4 hourly or more frequently as agreed by Gold

COO/Gold

Bed meetings and capacity meetings to be arranged as required COO/Gold

32

LEVEL 4 – UHNM. Responsible dependent on the pressures on site.

Ensure all actions are logged for later review and de-brief.

Silver and Gold

After four hours consider system wide instruction to run on command and control principles

COO/Gold

Consider approval to instigate Full Hospital Protocol COO/Gold.

LEVEL 4 SSOTP

Escalation – Additional Action

As actions listed in Level 1, 2 and 3 (Green, Yellow and Amber).

Ensure all mandatory actions are completed Mandatory Actions

Decisions regarding continuing day case activity to be made

All managers of critical services diaries to be cleared for 48 hours and complete focus must be to support de-escalation across the organisation, assisting other services if needed.

Contact HR to consider cancelling leave in areas of significant pressure

SSOTP call to action for clinically registered staff

Area Managers and Professional Leads to review what non-essential services can stop to redeploy staff or create capacity in line with the Trusts critical/essential services list

LEVEL 4 – SSOTP Responsible Review all actions at normal working levels 1, 2 and 3 Patient Flow

Manager/ Specialty Manager

Internal Conference Call Chair: COO Notes collected by urgent care administrator Participants: COO, Urgent Care Lead, Gold Commander, Silver Commander, Area managers, Community Hospitals Manager 2 hourly *Specialised COO and North Division COO to be present on the call

Urgent Care Lead

LHE Conference Call - Silver Participants: Urgent Care Lead, Silver Commander, hub co-ordinator

Urgent Care Lead

Consider implementing System Gold Commander and internal Gold Commander

Gold Commander

LHE Conference Call – Gold Participants: Gold Commander (Based at SSOTP command & control centre)

Gold Commander

Command & Control to be initiated 8am-8pm. EPRR to establish the processes for command and control. Urgent Care Lead to take on the role of Silver Commander and operationally manage the control room 2 hourly

EPRR/Urgent Care Lead

Urgent Care Lead/Gold Commander communicate the need for a compulsory (Gold level) capacity meeting with the rest of the health economy 2 hourly

Gold Commander/Urgent

Care Lead

Report pressures to the rest of the Executive / Director Team of actions being taken 2 hourly


Care Lead

Review situation in community hospitals and critical community services three times per day 2 hourly


Care Lead

33

LEVEL 4 – SSOTP Responsible Gold to Gold communication with all partner organisations – actions to be fed back through internal conference calls twice daily or as agreed


Care Lead

Communications to be kept informed and prepare a press release detailing the health economy pressures and what plans have been put in place to deal with the escalating situation.

COO/Communications team

Bed meetings and capacity meetings to be arranged as required dependent on the pressures on site.

Urgent care lead/Gold Commander

Ensure all actions are logged for later review and de-brief.

EPRR Lead

Consider approval from Gold Commander and relevant CCG’s to instigate Capacity Full Protocol 2 hourly

Gold

LEVEL 4 – WMAS Responsible Adopt Triage Sieving (Trauma)/MEWS Scoring (Medical) of Ambulance borne patients 2 hourly

HALO / BRONZE Commander

Act directly upon instructions from WMAS SILVER 4 hourly HALO / BRONZE Commander

Continue to provide on-site intelligence as requested and appropriate as to situation changes 2 hourly

HALO / BRONZE Commander

Attend site if no other officer on Ground (NOT SOC Silver) 2 hourly SOC Commander if on duty Silver Commander

Act as per level three actions and as per further instructions of GOLD Commanders 4 hourly

SOC Commander if on duty Silver Commander

Arrange (where appropriate) additional Officer/Manager/Clinician support to maintain patient and crew safety 2 hourly

SOC Commander if on duty Silver Commander

Review options to improve the situation, actions as required 2 hourly SOC Commander if on duty Silver Commander

Maintain contact with Regional Capacity Management On Call 2 hourly SOC Commander if on duty Silver Commander

Contact the CEO of Acute Trust and PCTs causing issue(s) 2 hourly SOC Commander if on duty Silver Commander

SOC Silver/On Call GOLD to contact SHA On Call Director as required SOC Commander if on duty Silver Commander

Ensure WMAS CEO appraised of the situation GOLD Commander

Consider an Ambulance CEO to Acute CEO, CCG CEO and NHS England Director conference call 2 hourly

GOLD Commander

Consider arrangements for contacting on call CEO’s for ERMA if unable to contact as above 2 hourly

GOLD Commander

Maintain resource overview 4 hourly EOC Duty Manager

Direct all calls from Acutes to SOC SILVER/HTDesk Team EOC Duty Manager

Retain focus on performance and EOC issues leaving all hospital problems to be dealt with by HTDesk / SILVER / GOLD levels.

EOC Duty Manager

Act as liaison to advise capacity at relevant hospitals liaising with on-site / on call manager 4 hourly


Escalate any issues (turnaround times in excess of 60 minutes) to Hospital Desk

34

LEVEL 4 – WMAS Responsible relevant Director at Acute Trust ensuring that action plan, exit plans are in place with agreed timescales 2 hourly

Supervisor

Respond to EMS updates from acute trusts declaring Level 3 or 4 2 hourly


Region-wide notification of ongoing situation through ring round to acute trusts / email notifications / early warnings 2 hourly


Consider deflect and ensure if Trusts are approaching Level 4 Divert correct criteria is met and all actions in place; ensure correct persons are involved in the agreement, i.e. Acute Trust Chief Executive, SHA and Ambulance GOLD 2 hourly


LEVEL 4 – NSCHT Responsible As Level 1, 2 and 3

Consider moving to Command and Control Executive on call

Engage additional workforce through Bank and Agency Clinical Co-ordinator/ Temporary Staff co-ordinator

Corporate staff who are able to work clinically should be contacted and allocated

On call manager / tactical commander

Transfer identified patients at the Harplands to other areas or Home as clinically appropriate

Consultant Psychiatrists, Home Treatment Team and Outreach Team

Transfer patients assessed as clinically appropriate from UHNM to Harplands or home with support from mental health services

RAID / Consultant Psychiatrists/ Modern Matrons

No out of area patients to be accepted for admission Heads of Directorate or designated other

LEVEL 4 – CITY SOCIAL CARE Responsible As level three plus:

Same day funding decisions.


Agreement outside of panel for CHC applications.

Team Manager/CDAT

Social care to ensure all bed capacity / stay at home schemes is used.

Team Manager

Placement Navigator to liaise with independent sector to identify available capacity and negotiate admission process.

Team Manager

Specifically, consideration will be given to step down alternatives where capacity prohibits discharge to the identified destination. This will include Rowan Village ICT flats, Extra care additional community capacity (within a 3 mile radius) and interim placements where appropriate.


Enhanced operation of Discharge to Assess model with focus on proactive pull function.

Team Manager

Social Care to spot purchase beds in the independent sector as appropriate and by exception. Tracking system to be implanted and exit

Strategic Manager

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LEVEL 4 – CITY SOCIAL CARE Responsible strategy to be identified for each individual.

Commissioners to contact Providers (domiciliary and 24 hr care) to request urgency in response and availability of additional capacity. Senior Manager/Regional Provider discussions to meet demand requirements

Strategic Manager

Daily senior Capacity and Demand review (domiciliary care).

Strategic Manager

Directors, supported by appropriate Senior Managers to participate in the Conference Call.

Strategic Manager

13. NON-URGENT PATIENT TRANSPORT ACTIONS (NSL)

Level 1

1. All patient transport requests to be dealt with within contractual targets 2. Monitoring and escalation by Patient Transport Booking Office UHNM 3. NSL Contract Manger contact with Patient Transport Booking Office via Head of Patient

Transport for Team Leader at 08:00 and 17:00 to review operational performance and to agree further necessary actions. presence at bed meetings

Level 2

1. All patient transport requests to be dealt with within contractual targets 2. NSL Contract Manager contact with Patient Transport Booking Office via Head of Patient

Transport or Team Leader at 08:00, 12:30 and 17:00 to review operational performance and to agree further necessary actions. presence at bed meetings

Level 3

1. All patient transport requests to be dealt with within contractual targets. Zero tolerance to delays. 2. Senior NSL manger on site 08:00 – 17:00 working with the Head of Patient Transport to

coordinate activity accessing additional resources if needed. 3. All delays in PTS provision escalated to Site Manger out of hours and to Head of Patient

Transport in hours

Level 4

LEVEL 4 – CCG CITY/NORTH/SOUTH Note CCG Gold to Chair LHE Conference calls

Responsible

As levels 1, 2 and 3

Make a risk based assessment of the best use of capacity and resource across the whole system. Shift resources to most effectively meet demand and maintain patient safety


Inform Area Team. CCG lead to take senior leadership role and Chair the Conference Calls/equivalent forums (ensuring plans are action oriented with all partners being clear of their responsibilities)


Mobilise Incident Response Centre (if appropriate) Urgent Care Team and First Responder

As levels 1, 2 and 3

Make a risk based assessment of the best use of capacity and resource across the whole system. Shift resources to most effectively meet demand and maintain patient safety


Inform Area Team. CCG lead to take senior leadership role and Chair the Conference Calls/equivalent forums (ensuring plans are action oriented with all partners being clear of their responsibilities)


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1. All patient transport requests to be dealt with within contractual targets 2. Senior NSL presence on site 08:00 – 20:00 if command and control instigated. 3. All delays in PTS provision escalated to Hospital on site manager 4. PTS Supervisor to be on site and aid transport process 5. Contract Manager to request out of area resource to be readied should escalation continue 6. NSL internal review meeting every 4 hours (internal) 7. ETA’s for all outstanding patient journeys to be provided to Head of Patient Transport

15. Regional Capacity Management Team (RCMT) Actions Level 1 – Normal working

Level 1

1. Ensure that EMS has been updated during the mandatory times of 07:30-09:30 and 14:30-16:30

2. Request Front door attendances from the previous day if not received for the Acute Trusts 3. Monitor daily activity 4. Produce a ‘Sit Rep’ to provide the region with a snap shot view of escalation levels and

areas of concern. 5. Contact the SOC for divert or deflect information and the SOC commander for the day 6. Provide additional sit reps if required. 7. Monitor EMS and CAD on line for activity levels and changes in the escalation level of

organisations 8. Respond to calls from Health Economies, WMAS and Major incident alerts 24/7.

9. Record all actions on RCMT data base Salesforce

Level 2

1. Liaise with WMAS for early signs of pressure at the front door, including CAD on line and the

hospital desk

2. Inform organisations of the position of neighbouring organisations by use of the Early

Situation report, EMS, email and telephone communications and the potential for further

escalation.

3. Provide information of predicted demand for the day for WMAS (extranet) and the Front

door.

4. Ensure that WMAS are providing crews with messages to use the alternative pathways.

5. Monitor community teams on EMS for indications of increasing pressure

6. Record all actions on Salesforce

7. Inform SOC of potential pressure points and actions taken

Level 3

1. Follow the above plus

2. Verify trigger points if required

3. Participate in any conference calls when invited to do so

4. Be available to discuss plans with representatives of the Health economy and provide

advice and assistance if required.

5. Advise of the position of neighbouring organisations and whether a deflect or divert is worth

consideration – contact WMAS to see if they are in a position to assist

6. Advise that the Chief Operating Officer or Director of Operations will need to negotiate with

their Acute colleagues to see if assistance is available and inform WMAS

7. Maintain communications and inform relevant organisations of any actions

8. Advise WMAS (SOC) of potential level 4

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9. Monitor situation

10. Record all actions on Salesforce

Level 4

1. 1. Update EMS to inform the region of details of the level 4 2. Inform SOC of all actions and assist with co-ordination across the Region 3. Participate in any conference calls as required 4. Ensure that all organisations involved are informed of de-escalation and gain a position

statement from them to ensure that they have coped with any additional activity 5. Continue to monitor the situation 6. Record all actions on Salesforce

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14. AREA TEAM – PRIMARY CARE ACTIONS

Level 1

Business as usual

Level 2

Business as usual

Level 3

1. Communication of escalation level received via the CCG’s communication process to be circulated to all members of staff within the practice

2. Ensure patients are directed to alternative locations other than A&E 3. Update of the system to be shared on internal practice screens for patients (detailing

alternatives to A&E)

Level 4

1. As above.

15. NHS111 ACTIONS

Level 1

1. Call Handler - No staffing issues 2. Clinician Handler - no staffing issues 3. Appropriate skill mix in place 4. Service Level at 95%+ 5. Abandonment rate <2% 6. Call reasons within usual pattern 7. There are no technical issues

Action:

Team leader will manage shift dynamically to ensure service performance is maintained to the maximum levels possible.

Hourly performance updates sent to all Operations managers.

Level 2

1. Call Handler - staffing levels >85% against roster 2. Clinician Handler - staffing levels >85% against roster 3. 10% clinicians front ending 4. Service Level 90-95% 5. Abandonment rate 2-5% 6. 10-20% calls within last 24 hours relating to reported outbreak 7. Telephony or IT issues with contingency plans implemented

Action:

Team Leader asks call handlers and clinical staff already on duty to extend their shift by

one or two hours until pressure has subsided

Suspension of discretionary breaks until service level has improved

Suspension of all non-clinical activities until service levels have improved

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Level 3

1. Call Handler - staffing levels 75-85% against roster 2. Clinician Handler - staffing levels 75-85% against roster 3. 10-20% clinicians front ending 4. Service Level 85-90% 5. Abandonment rate 5-7% 6. 20-50% calls within last 24 hours relating to reported outbreak 7. Both Telephony and IT issues with contingency plans implemented Action:

In addition to level 2

Suspension of any additional non-front line activities (e.g. call audits, governance activities, monitoring and other management activities) until service levels have improved

Team Leader to contact remote triage pool of Clinicians to request assistance

Team Leader sends a text alert to 111 call handlers and other clinicians to advise that the service is under pressure and to ask if anyone can provide any additional hours

Team Leader alerts the On Call Operations Manager that the service is under pressure and confirms actions taken. If clinical stack is at trigger levels, then team leader can request authorisation to stream appropriate cases to SDUC Out Of Hours service in batches, however, this can only occur if the Out Of Hours service has GP resource availability for telephone triage support, which will need to be confirmed by the team leader at the point of request to the on call manager. This can be reviewed each hour, and additional cases streamed if Out of Hours resource continues to be available.

Level 4

1. Call Handler - Staffing levels <75% against roster 2. Clinician Handler - Staffing levels <75% against roster 3. >20% clinicians front ending 4. Service Level <85% 5. Abandonment rate >7% 6. >50% calls within last 24 hours relating to reported outbreak 7. Site Closure with contingency plans implemented Action

In addition to level 3,

Team leader to contact Operations on call manager, who in turn will contact Staffordshire Urgent Care On Call Manager for awareness and onward communication.

The Staffordshire Urgent Care on call manager can then liaise with other local urgent care services to advise that NHS111 is under severe pressure and that additional activity may be experienced within their own service as a result of this pressure.

Team leader identifies call handlers and clinicians who are due on shift in the next 2-3 hours, and rings them directly to seek additional resource at short notice.

Team leader advises all Call Advisors that all Health Information enquiries are to be placed in the 111 Clinician queue for call back rather than being warm transferred, with patients advised accordingly that there may be a delay

Team leader seeks additional support from both SDUC and Adastra trained NDUC NHS111 Clinical Support Managers who may be able handle calls, either within the contact centre or remotely.

Team leader seeks additional support from other team leaders who may be able handle calls and support with other liaison tasks.

If clinical pressure is sustained, and following on from discussions with team leader, On Call Operations Manager contacts West Midlands Commissioners to establish whether the mutual aid arrangement with West Midlands Ambulance Service for clinical case sharing can be initiated.

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Once agreed, on-going case sharing arrangements can then be managed by the team leader group from both organisations until the pressure has returned to normal levels.

16. STAFFORDSHIRE DOCTOR URGENT CARE ACTIONS

Level 1

1. All GP OOH cases to be dealt with within KPI targets. 2. Monitor daily activity against forecast 3. Liaise with the NHS111 Team to understand NHS111 activity and respond to surge. 3. Attend SitReps as required. 4. SDUC On Call Rota available. 5. Respond to calls regarding escalation & Major incidents 6. Inform Clinicians of potential pressure points

Level 2

1. As above. 2. SDUC On call manager in contact with Executive on call to review operational performance and

to agree further necessary actions. 3. Protect ‘slots’ so that Primary care Patients can be deflected to GP OOH. 4. Monitor ‘emergent’ outcomes to ensure Clinicians are referring to A&E, 999 appropriately.

Level 3

1. As above. 2. Operations Manager On Call on site working with Front Line Team to additional resources if

needed. 3. All delays in GP OOH escalated to Executive on call in a timely manner 4. Further additional resource to be provided as agreed with Operations On Call Manager and Clinical on call Manager i.e. Provide additional Clinicians to support streaming and additional UCC Front of House appointments if there is capacity.

Level 4

1. As above. 2. LCD/Exec presence on site as required. 3. Further additional resource to be provided as agreed with Operations & Clinical On Call Manager e.g. provide taxi service to divert Patients away from A&E.

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17. APPENDIX 1 EMS TRIGGER 3, 10 and 14-SPECIFIC ACTION CARD Actions to be carried out if triggers 3, 10, 14 are reported at level 3 or 4 within the EMS level

EMS TRIGGER LEVEL Potential actions that can be taken by organisations involved in the process to respond to escalation of these triggers – other organisations unlikely to be involved at this stage due to escalation being against individual trigger

1 Each organisation working to normal daily actions as per their internal plans and system wide plan at level 1

2 Each organisation working to daily actions as per their internal plans and system wide plan at level 1 and 2

Level 3

Severe pressure, all organisations need to respond to increasing pressures to prevent escalation of the trigger. Success of the LHE actions will be measured by de-escalation of this trigger – target within 4 hours.

UHNM

Reinforce all actions at level 2

Details of all patients delays that are occurring e.g. pharmacy / diagnostics to be brought to Patient Flow / Bed Meetings and plans agreed to action.

Prepare for implantation of ‘l Full Capacity Protocol’ Dynamic risk assessment of problems and actions highlighted to Divisional Patient Flow Manager

Maintain ‘live’ status of demand from ED, critical care step down and elective admissions

Ensure full utilisation of the discharge lounge

Look at alternatives for patient assessment areas

Request medical support deployed to ED to review patients for admission

Assess potential for direct referral to wards

Support timely turnaround of WMAS ambulances

Prepare Divisional control rooms for use.

All diary commitments to be reviewed with primary focus on patient flow

Review non-critical clinical services with a view to stooping the function to redeploy staff

Consider divert between sites within UHNM or Staffordshire

Consider opening additional capacity

Review elective activity and consider cancelling / some

Review elective activity as instructed by the COO/Gold

SSOTP


Lead Nurses to provide information on elective and day case admissions

Consider use of escalation beds

Prepare for use of escalation capacity


Matrons/Team Leaders/Neighborhood managers to review staffing levels and produce a plan for any shortfalls to cover gaps


Internal Communications to be cascaded in preparation for further escalation



All capacity for SSOTP to be centrally held by the hub

WMAS


Liaise with Hospital Desk Team, SOC Commander and Duty Manager ensuring that appropriate arrangements to deflect patients are being taken (please refer to Management Level in adjacent box for SILVER involvement)

Assess outstanding workload and consider opportunities to deflect resources inbound to lower activity Trusts ensuring overall situation of all sites is reviewed. If instigated this should be for a set agreed period of time only

NSCHC


Join LHE conference calls

NHS 111

Reinforce actions at level 3

SDUC

Reinforce actions at level 3

Primary Care

Communication of escalation level received via the CCG’s communication process to be circulated to all members of staff within the practice

Ensure patients are directed to alternative locations other than A&E

Update of the system to be shared on internal practice screens for patients

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EMS TRIGGER LEVEL Potential actions that can be taken by organisations involved in the process to respond to escalation of these triggers – other organisations unlikely to be involved at this stage due to escalation being against individual trigger

(detailing alternatives to A&E)

LEVEL 4

Extreme pressure, all organisations need to respond to increasing pressures to ensure de-escalation of the trigger. Success of the LHE actions will be measured by de-escalation of this trigger – target within 4 hours.

UHNM Review all level1,2,3 actions

CMST / ADO to discus with COO / Director of Operations the need for a compulsory (Gold level) capacity meeting with the rest of the health economy.

Review situation on a 2 hourly basis with bed meetings and EMS trigger assessment.

Review all declared MMFD patients and those awaiting services with the LHE health and social care team to identify exit strategies for all patients.

Review elective activity.

Review opening of additional capacity

After four hours consider system wide instruction to run on command and control principles

Consider instigating Full Capacity protocol

SSOTP Review all level1,2,3 actions

Gold consider Command & Control to be initiated 8am-8pm

Urgent Care Lead/Gold Commander communicate the need for a compulsory (Gold level) capacity meeting with the rest of the health economy.

Consider instigating Full capacity protocol

2 hourly review of demand and capacity

WMAS Review all level1,2,3 actions

Arrange (where appropriate) additional Officer/Manager/Clinician support to maintain patient and crew safety

Establish capacity at relevant hospitals liaising with on-site / on call manager.

Escalate any issues (turnaround times in excess of 60 minutes) to relevant Director at Acute Trust ensuring that action plan, exit plans are in place with agreed timescales.

NSCHC Review all level1,2,3 actions

Consider moving to Command and Control

Transfer patients assessed as clinically appropriate from UHNM to Harplands or home with support from mental health services

No out of area patients to be accepted for admission

111 Review all level 1,2,3 actions

SDUC Review all level 1,2,3 actions

LCD/Exec presence on site as required.

Further additional resource to be provided as agreed with Operations & Clinical On Call Manager e.g. provide taxi service to divert Patients away from A&E.

Primary Care Review all level 1,2 3 actions

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18. APPENDIX 2 Silver conference call agenda Date: _________ Start Time: _________ End Time: ___________Note Taker : ____________ (Name) Call Chair: _________________(Name) Chair: UHNM Silver.

STAFF PRESENT ON THE CONFERENCE CALL:

ITEM NOTES

1.UHNM: A. Current EMS level B. Capacity deficit C. Any IC issues D. Any ‘hot-spots’ E. Report back on agreed actions from last call

2. SSoTP Provider A. Current EMS level B. Capacity report – intermediate care services

and bed based. C. Any IC issues D. Any ‘hot-spots’ E. Report back on agreed actions from last call

3. Social Care – County A. Capacity report B. Any IC issues C. Any ‘hot-spots’ D. Report back on agreed actions from last call

4. Social Care – City A. Capacity report B. Any IC issues C. Any ‘hot-spots’ D. Report back on agreed actions from last call

5. NSCHT A. Capacity report B. Any IC issues C. Any ‘hot-spots’

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D. Report back on agreed actions from last call

6. WMAS A. Current demand B. Any ‘hot spots’ C. Actions being taken to support flow D. HALO Cover E. Expected Amb demand for next 6 hours

Chair to summarise current priorities and facilitate formulation of actions.

Agreed Actions: (By whom and by when?)

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19. APPENDIX 3 Gold conference call agenda Date: _________ Start Time: _________ End Time: ___________ Note Taker : ____________ (Name) Call Chair: _________________ (Name)

STAFF PRESENT ON THE CONFERENCE CALL:

ITEM NOTES

1.UHNM: Current SitRep overview. Capacity deficit Any ‘hot-spots’ / emerging issues Report back on agreed actions from last call

2. SSoTP Provider Current SitRep overview. Capacity deficit overview intermediate care services and bed based. Any ‘hot-spots’ / emerging issues Report back on agreed actions from last call

3. Social Care – County Capacity report Capacity deficit overview intermediate care services and bed based. Any ‘hot-spots’ / emerging issues Report back on agreed actions from last call

4. Social Care – City Capacity report Capacity deficit overview intermediate care services and bed based. Any ‘hot-spots’ / emerging issues Report back on agreed actions from last call

5. NSCHT Capacity report Any IC issues Any ‘hot-spots’ / emerging issues Report back on agreed actions from last call

6. WMAS Current demand Any ‘hot spots’ Actions being taken to support flow

Chair to summarise current priorities and facilitate formulation of actions.

Agreed Actions: (By whom and by when?)

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NEXT CALL SCHEDULED FOR _________________________________________________

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20. APPENDIX 4 Gold and Silver ‘Command and Control’ Agenda

Initial Gold (Strategic) Briefing Agenda Date: Time: Location:

item Agenda Lead

1 Introductions Chair – introduce the Loggist and minute taker. Ask that all attendees speak clearly and avoid jargon. Check that everyone has signed the attendance list.

All

2 Urgent Business

All

3 Review of Representation Chair

4 Situation Update (two minute overview) Chair provides a brief summary of the incident thus far. Team members provide a short factual summary of current and emerging risks on the ground based on the most up to date information available

All

5 Strategic Objectives Agree tactical objectives. It is not likely you will have the Strategic objectives at this stage. If you do have them align the Tactical objectives with them.

All

6 Silver (Tactical) update on delivery of against Strategic Objectives All

7 Identify Actions

Chair

8 Review group representation

Chair

9 Summary of Decisions and Actions

Loggist

10 Time of next briefing

Chair

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Initial Silver (Tactical) Briefing Agenda Date: Time: Location:

Item Agenda Lead

1 Introductions Chair – introduce the loggist and minute taker. Ask that all attendees speak clearly and avoid jargon. Check that everyone has signed the attendance list.

All

2 Urgent Business

All

3 Situation Update (two minute overview) Chair provides a brief summary of the incident thus far. Team members provide a short factual summary of current and emerging risks on the ground based on the most up to date information available

All

4 Tactical Objectives Agree tactical objectives. It is not likely you will have the Strategic objectives at this stage. If you do have them align the Tactical objectives with them.

All

5 Identify Actions

Chair

6 Review group representation

Chair

7 Summary of Decisions and Actions

Loggist

8 Time of next briefing

Chair

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21. APPENDIX 5 SILVER SITUATION REPORT SitRep for GOLD

* WHEN RUNNING ON COMMAND AND CONTROL

Note: Please complete all fields. If there is nothing to report, or the information request is not applicable, please insert NIL

or N/A.

Organisation:

Date:

Name (completed by):

Time:

Telephone number:

Email address:

Authorised for release by (name & title):

Type of Incident (Name) EG Significant capacity / demand deficit

Teams reporting serious operational difficulties

Impact/potential impact of incident on services / critical functions and patients

Impact on other service providers

Mitigating actions for the above impacts

Impact of business continuity arrangements

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Media interest expected/received

Mutual Aid Request Made (Y/N) and agreed with?

Additional comments

Other issues

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22. APPENDIX 7 Conference call code of conduct

Principles:

This is a business call and as such excellent standards of business behaviour are expected.

A conference call is a meeting and formality is expected.

This is not a secure line and specific patient or staff details WILL NOT be discussed.

The Chair will act as a facilitator and will ensure the call will starts and finishes on time, follow the agreed agenda and finish within 30 minutes

This is partnership call where mutually agreed actions are facilitated to ensure timely system wide actions

Each caller will be invited to introduce themselves at the start of each call.

ALL those joining the call must declare themselves; if the Chair suspects no declared staff have joined the call must be ended and re-scheduled.

Managers are expected to follow the principles in the NHS Code of Conduct for Managers and lead by example.

CODE OF CONDUCT:

DO ensure that you are prepared have read the Hub briefing prior to the call DO conduct the call as a business meeting & start and finish on time DO show mutual professional respect and professionalism and listen to others & make others feel

their views are welcomed and valued DO protect privacy and treat others as they would wish to be treated DO ensure that you are in a quiet environment, minimising background noise. DO state your name before talking (don’t assume people recognise your voice). DO use clear language, checking understanding and providing explanation where needed. DO avoid interrupting others. DO be concise. DO summarise the agreed actions (remember this is about system actions not just your organisation) DO take responsibility for your organisations actions. DO ensure you hand over if you can’t join the next scheduled call. DO end the call properly summing up the agreed actions.

AND DO NOT talk over colleagues. DO NOT move into ‘story telling’ or let the call fall into ‘informality’. DO NOT talk /comment in the back ground. DO NOT discuss identifiable patient or staff details. DO NOT get emotive. DO NOT mute the button if you are likely to play ‘music’ to the con call. DO NOT overrun the allotted time. DO NOT answer your mobile or do emails during the call. DO NOT leave the call part way through; in an emergency please announce and apologise to the

meeting for your departure.

Review Date: January 2016

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23. APPENDIX 8 AUDIT TOOL

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24. APPENDIX 9 UHNM FULL CAPACITY PROTOCOL

FULL CAPACITY PROTOCOL Royal stoke Site

Hours of Operating: 0700hrs to 1700hrs

1. INTRODUCTION The maintenance of patient safety and the provision of high quality care is the aim for all NHS organisations. Organisational pressures and operational workload can limit the ability of key areas to provide this along with expected patterns of care. When this pressure stops normal daily functioning, it significantly increases the risk of a failure in care occurring. Hospitals with overcrowded Emergency Departments are overcrowded hospitals that have chosen to manifest the overcrowding in a single location1. Unlike many departments A&E is unable to close its’ doors when all available patient care spaces are occupied. The risk of serious incidents happening not only increases with every new patient that arrives but is concentrated in one area. Allocating extra patients to suitable wards shares this risk across the Trust and reduces it in A&E (ECIST 2011). This policy describes the process of sharing risk across the organisation when the A&E department has more patients than it can safely care for.

2. CONSEQUENCES OF OVERCROWDING

2.1 Sick people wait too long to receive emergency care There is evidence that boarded patients in the ED experience delays in their treatment, including significant time-sensitive interventions such as antibiotic administration in pneumonia 2, 3 Furthermore, new arrivals also wait longer for treatment, including the sickest patients needing urgent treatment, when there are boarding patients in the ED. This is due to increased demands on nursing and medical staff, already stretched to care for the patients who need ED care. 4, 5 Patients also wait longer for pain relief during times of overcrowding.6 2.2 Total length of stay for waiting patients is increased

It is obvious that being boarded on an ED corridor prolongs the stay in the ED, resulting in

patients exceeding the four hour access standard set by the government. What is less well known is that patients who experience a prolonged wait in the ED go on

to have an increased total length of stay (LOS), with all the costs and harm this entails.7, 8

2.3 Hospital Standardised Mortality Ratio Increases (RR 1.3) Evidence from the US, where publicly funded healthcare is exposed to many of the same circumstances and pressures as the NHS, is that the relative risk of death increases to 1.3 during overcrowding. This means an extra 30 deaths for every 100 expected, or a 30% increase. 9, 10 2.4 Increased numbers of patients leave without being seen

Patients who leave without being seen, coded as 'Did Not Wait' (DNW) are recorded as

one of the quality indicators of hospital care in the ED. The current standard, which UHNM meets, is fewer than 5% should leave in this way. The rate of patients choosing not to wait goes up when the ED is overcrowded. 11

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2.5 Medical errors increase Under pressure of time, and sometimes forced to provide elements of care in unsuitable environments such as ED corridors, ED clinicians have an increased error rate, including serious incidents (SIs). Half of all sentinel events leading to serious harm or death in the US occur in the ED, and as many as a third of them can be attributed to overcrowding. 12

2.6 Conversion of non-inpatient areas The conversion of non-inpatient areas into inpatient bed facilities can be considered as part of the Full Capacity Protocol but may not necessarily be an outcome after declaring a Full Hospital. In considering the use of non-inpatient areas (surgical day case, endoscopy suite) at the point of activating Full Capacity Protocol, Gold MUST consider the impact and patient safety risk to patients on a cancer and/or clinically urgent elective pathways.

3. PURPOSE 3.1 To safely recover the functioning of ED 3.2 To facilitate the egress out of ED for patients awaiting acute inpatient care 3.3 To maintain the safety of patients and staff in ED 3.4 To maintain the safety of patients and staff across inpatient wards

4. ACTIVATION OF THE FULL CAPACITY PROTOCOL (see Assurance Check List to be completed by Gold) Hours of Operating: 0700hrs until 1700hrs

In the event that capacity exceeds demand the Full Capacity Protocol will be activated when ALL the following 6 criteria are met: 1. The Trust escalation status is EMS Level 4 2. The Emergency Department escalation status is RED - 20 patients boarding in ED, 1 or more patient queuing in the corridor, inability to egress out of a full ambulance assessment within an hour (see table below) 3. No egress of boarding patients out of ED into inpatient beds within an hour 4. Emergency portals (CDU, AMU, SAU, FEAU, EAB) all full and no ability to create capacity within an hour 5. HALO confirmation that further 2 or more ambulance attendances expected within an hour and unable to operate DIVERT protocol 6. All protected specialty beds have been used (see appendix)

EMERGENCY DEPARTMENT

RAG RATNG

IMPACT ON PATIENT CARE MEASURES

Green Normal functioning <No delays in admissions to wards

Ambulance assessment capacity available

Amber

Functioning but under pressure

5-20 patients boarding in ED Ambulance assessment capacity available

Red

Not able to function. Department unsafe.

20 patients boarding in ED Ambulance assessment full (6 patients) with > 1 hour wait to transfer to majors cubicle and 1 or more patients queuing on the corridor

Black

Dangerous Normal care not possible

>25 patients boarding in ED Patients queuing on corridor with > 1 hour wait for transfer into ambulance assessment area

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5. DEFINTIVE ACTIONS The following actions, in no particular order, must be taken in addition to usual operating procedures. 1. Leadership

There will be three tiers of leadership for the operational delivery (Operational Leader Team) of the Full Capacity protocol following national standards of incident management:

Gold: Executive On-call (on-call) Silver: Senior Manager (on-call) Bronze: Duty Manager (resident)

In normal working hours, Gold Command would be the Chief Operating Officer or nominated deputy.

o Clinical Leadership

There will be nominated Consultant Leads to support the operational governance of delivery of the Full Capacity protocol.

All Consultant Leads will be informed of activation of the protocol and base themselves within

the areas of their responsibility.

Consultant leads: ED Consultant in Charge Specialty Consultants on-call (of admitting ward areas for extra patients) Acute Physician in Charge AMU Surgeon in Charge of SAU

2. The Senior Manager (Silver) should be present in the Trust within 30 minutes of

activation of the protocol. The Executive On-call will be responsible for the overall delivery of the Full Capacity Protocol, liaising with key team leaders and clinicians as necessary. The Senior Manager will liaise with the ED Lead Consultant. Who (Responsible Officer): Silver: Senior Manager Where: Site Office/Emergency Department When (Timeframe): 30 minutes

3. Delaying transfers of care from Paramedics to ED If there are more than 6 patients in Ambulance assessment then WMAS control will be alerted that there will be delays in transfer of care from paramedics to ED. In this situation, assistance should be requested from WMAS to provide further assistance so that a HALO or single crew can be identified to continue supervision of these patients, allowing other crews to be released.

Who (Responsible Officer): Silver Commander Where: Emergency Department When (Timeframe): As required

4. Conversion of non-inpatient areas For the purposes of this protocol the non-inpatient areas are Surgical Day Case Unit and Endoscopy Suite. The use of these non-inpatient areas should be considered by Gold before transferring additional patients to designated clinical escalation space.

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Consideration must be given to;

Impact on patient safety for those patients on a cancer or urgent elective pathway

Ability to exit out of these areas within 24 hours

Type of in-patient area converting in to (e.g. medical, surgical)

Safe Nurse staffing resource

Medical cover

Access to beds and other equipment required

Forecasted impact on recovery of NEL patient flow

5. Transfer of Patients to Wards whilst awaiting a Bed

In these extreme circumstances to mitigate the patient safety risk of those patients awaiting access to assessment in ED it will be necessary to transfer patients with a clear decision-to-admit to a ward without a bed being immediately available. The agreed risk assessed areas to safely take an additional patient are listed within this policy.

To do so however the following conditions must be met:

1. The Nurse-in-Charge of each ward area listed must be contacted by a member of the

Operational Leader team and asked to prepare for implementation of FULL CAPACITY PROTOCOL

2. The Consultant on-call for the receiving ward must be contacted by a member of the Operational Leader team and asked to attend the ward area within the next 30 minutes

3. The NIC and Consultant on-call will coordinate the identification of the most appropriate and suitable patients to be moved on to their ward areas. They are to do this through liaison with ED Clinical team and/or the relevant Emergency Portal Clinical Team.

4. Up to two patients per agreed ward areas will be allocated from the emergency portals. 5. It is the responsibility of the NIC and Consultant to identify a minimum of 2 patients on the

inpatient ward that can be managed safely within the non-clinical areas, to allow the safe management of the extra patients arriving on the ward from ED and/or another emergency portal.

6. When considering patients to move into designated clinical escalation space; only patients who are stable (MEWS less than 3), not acutely confused, not receiving oxygen, and not receiving continuous cardiac monitoring will be considered.

7. A ward nurse must be clearly identified to look after the patients in the agreed area whilst awaiting a bed. Staffing issues will be escalated within the current safe staffing SOP. This will remain the responsibility of the NIC to co-ordinate as within existing standard practice.

8. All patients’ privacy and dignity will be maintained at all times. 9. Any patient identified as needing to move into a non-clinical area will be spoken to directly

by the NIC and the situation clearly explained.

In Medicine, patients will be moved off AMU onto wards, releasing AMU capacity to accept patients from the ED. In Surgery, patients will be moved off SAU onto wards, releasing SAU capacity to accept patients from the ED. Other specialty wards will be allocated patients from the Emergency Portals as appropriate i.e. Orthopaedic patients from ED directly to Orthopaedic wards.

Portering Additional porters should be deployed to the Emergency Portals to assist with transfers across the Trust. This will be arranged by a member of the Operational Leader Team

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6. De-Escalation PROCESS Any area that reports a timeframe of De-Escalation that exceeds 6 hours will be prioritised for additional support from site management to assess what is required to maintain patient safety and safe staffing. If additional patients remain on a ward area without confirmed resolution for over 8 hours from admission on the ward area escalation MUST be made to the Gold on-call who will expedite a LHE resolution. 6.1 LHE Response Gold MUST inform LHE Gold on-call representatives to prepare to receive additional patients into community services within the next hour. These are those patients that have been identified as Medically Stable to transfer and require community service support on discharge. This will be co-ordinated through Silver to Silver communication. Expected De-Escalation timeframe will be assessed and reported into the Operational Leader Team by the Ward NIC and Consultant. 6.2 Specialty In-reach to the Emergency Portals Each specialty/directorate shall undertake an additional in-reach from a nominated clinical team member into the relevant Emergency Portals (AMU/SAU/FEAU/ED). Through liaison with the Nurse Co-ordinator they will work to; 1 expedite discharge where safe to do so, and 2 follow up via ambulatory care and/or clinic appointment, and 3 identify/prioritise their specialty TCIs.

6.3 Creation of additional discharges Every ward area with additional patients will have an additional Ward Round completed validating all medically stable patients, review of all patients with an EDD for the next 48 hours to identify opportunities to expedite discharge. The NIC will coordinate the required response to support the additional discharges e.g. TTOs, transport, communication with patient and relatives, arrangements for follow-ups by acute where required. 6.4 Discharge Lounge Where appropriate to do so, Discharge Lounge will extend opening times and prepare to PULL patients from wards into this area to create capacity as early as possible. 6.5 Diagnostic in-patient waits Diagnostic services will review all inpatient lists waiting for diagnostic test and liaise with the consultant referrer to expedite the test/result or arrange out-patient booking. Cancellation of ALL Consultant SPA activity The above additional clinical workload involving consultants will be expected to be shared between consultants via mechanisms such as an on-call rota and the cancellation of occasional sessions not requiring Direct Clinical Care. The Trust Medical Director (or deputy) however may judge that all such activity should be cancelled by all consultants such that all consultant expertise is diverted to direct patient care such as assisting colleagues with ward rounds, clinics or activity on the Emergency Floor. Post De-escalation Reviews

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24 hours following activation of Full Capacity Protocol all patients transferred into designated clinical escalation space must have a Senior Medical review as a priority to ensure there has been no impact on treatment and recovery. 7. Instigate Major Incident Plan In the event that activation and delivery of Full Capacity Protocol is unsuccessful in recovering safe, effective patient flow the Trust Major Incident Response Plan shall be activated Who (Responsible Officer): Gold on-call Where: Conference Room/Emergency Department When (Timeframe): As required

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Assurance Check List - To be completed by Gold On-call

Gold: (Name & Designation)…………………………………………………………………… Silver: (Name & Designation)………………………………………………………………… Bronze: (Name & Designation)………………………………………………………………

Criteria checklist to determine activation of FULL CAPACITY PRTOCOL

Yes/No GOLD Signature

1. The Trust escalation status is EMS Level 4

2. The Emergency Department escalation status is RED.- 20 – 25 patients boarding in ED, 1 or more patient queuing in the corridor, inability to egress out of a full ambulance assessment within an hour

3. No egress of boarding patients out of ED into inpatient beds within an hour

4. Emergency portals (CDU, AMU, SAU, FEAU, EAB) all full and no ability to create capacity within an hour

5. HALO confirmation that further 2 or more ambulance attendances expected within an hour and unable to operate DIVERT protocol

6. All protected specialty beds have been used

If ALL 6 criteria met – ACTIVATE FULL CAPACITY PROTOCOL

GOLD Action Log

Conversion of non-inpatient areas

For the purposes of this protocol the non-inpatient areas are Surgical Day Case Unit and Endoscopy Suite.

Impact on patient safety for those patients on a cancer or urgent elective pathway (Information to be given by AD Surgery or nominated rep) High/Low risk?

Forecasted impact on recovery of NEL patient flow – Immediate Positive Impact?

Type of in-patient service converting in to (e.g. medical, surgical)

Safe Nurse staffing resource sourced. (Supported by Chief Nurse or nominated senior nurse rep)

Medical cover sourced. (Supported by relevant AD)

Access to beds and other equipment required completed (Supported by Site Manager)

Ability to exit out of these areas within 24 hours confirmed

If conversion of non-inpatient areas can be delivered in line with all above actions – Proceed with operational delivery via nominated Divisional leads

If conversion of non-inpatient areas cannot be safely delivered and de-escalated in line with above actions –

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proceed to Operational actions to accommodate patients in designated clinical escalation space.

Operational actions to accommodate patients in designated clinical escalation space

ED senior clinical team informed and prepared

All relevant ward areas informed and prepared

All relevant consultants informed and requested to attend their ward areas

All clinical teams in emergency portals informed and prepared

Additional porters requested to attend emergency portals to support prompt and timely transfers

LHE response

Gold to LHE Gold alert has been sent and community services are preparing to receive patients within the next hour

Transfer of patients to inpatient ward areas

All relevant ward areas have begun transfer process

All patients requiring transfer in line with this protocol have been transferred

De-Escalation Process

All areas have confirmed predicted De-Escalation times (in hours)

LHE escalation made by Gold for additional support for areas unable to de-Escalate

Stand-Down

Protocol has been delivered

De-Escalation completed

Patient flow recovered

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References 1. Gilligan P, Quin G. Full capacity protocol: an end to double standards in acute hospital care

provision. Emerg Med J July 2011 Vol 28 No 7 2. QuickStats: Percentage of emergency department visits with waiting time for a physician of > 1 hour,

by race/ ethnicity and triage level – United States, 2003-2004. MMWR. 2006;55(16);463. 3. Pines JM, Hollander JE, Localio AR, et al. The association between emergency department crowding

and hospital performance on antibiotic timing for pneumonia and percutaneous intervention for myocardial infarction. Acad Emerg Med. 2006;13(8):873-878.

4. Pines JM, Hollander JE. Association between cardiovascular complications and ED crowding. American College of Emergency Physicians Scientific Assembly; October 8-11, 2007; Seattle, WA.

5. Dunn R. Reduced access block causes shorter emergency department waiting times: An historical control observational study. Emerg Med (Fremantle). 2003;15(3),232–238.

6. Hwang U, Richardson L, Livote E, Harris B, Spencer N, Sean MR. Emergency department crowding and decreased quality of pain care. Acad Emerg Med 2008; 15(12):1248-1255.

7. Richardson DB. The access-block effect: relationship between delay to reaching an inpatient bed and inpatient length of stay. Med J Aust. 2002;177(9):492-495.

8. Liew D, Kennedy MP. Emergency department length of stay independently predicts excess inpatient length of stay. Med J Aust. 2003;179(10):524-526.

9. Sprivulis PC, Da Silva JA, Jacobs IG, et al. The association between hospital overcrowding and mortality among patients admitted via Western Australian emergency departments. Med J Aust. 2006;184(5):208-212.

10. Richardson DB. Increase in patient mortality at 10 days associated with emergency department overcrowding. Med J Aust. 2006;184(5):213-216.

11. Richardson DB, Bryant M. Confirmation of Association between overcrowding and adverse events in patients who do not wait to be seen. Acad Emerg Med. 2004;11(5):462.

12. Weissman JS, Rothschild JM, Bendavid E, et al. Hospital workload and adverse events. Med Care. 2007;45(5):448-455.

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25. Appendix 10 OTHER ORGANISATIONS - FULL CAPACITY PROTOCOLS

SDUC – OOH Please refer to the Level 4 Action Card

SDUC – NHS111 Please refer to the Level 4 Action Card

Stoke City Council Please refer to the Level 4 Action Card

Staffordshire County Council Please refer to the Level 4 Action Card

WMAS Please refer to the Level 4 Action Card

NSCHT Please refer to the Level 4 Action Card

Primary Care Please refer to the Level 4 Action Card

(Based upon EMS Level 4 at UHNM)

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SSOTP Capacity Full Protocol

Hours of Operating: 0800hrs until 1800hrs

Activation of the Protocol This protocol will be commenced by the Gold Commander in the following situations:

Local Health Economy Level 3 plus the predicted deficit in capacity to meet demand in the next 12 hours

Local Health Economy Level 4 PRINCIPLES OF THE PLAN

Introduction

The management of patient flow across the community and ensuring the appropriate placement of patients is a challenging process. The purpose of this plan is therefore to:

Ensure that all capacity across the Partnership Trust is proactively managed in periods of escalation

Establish a common understanding of the process for escalation

Standardise the approach to ensure consistency and optimal use of bed based and non-bed based capacity.

Maintain the health and well-being of individuals within our care

To communicate the capacity full position to all staff and stakeholders

This plan is based on the philosophy that patient care will be delivered in the lowest dependency environment.

Maintaining the safety of patients, including protection from infection, and meeting individual clinical needs will be a paramount aim throughout their care episode.

The services covered in this document:

Community Hospitals

ILCT’s

Intermediate Care/CIS

Hospital Social Work Teams

Walk in Centres (Leek & Haywood)

Guiding Principles The Director of Operations is accountable for day to day operational delivery of the

services provided by the Partnership Trust.

Chief Operating Officers are accountable for ensuring the capacity required to meet the escalated demand is in place.

The Urgent Care Lead is delegated the authority for the management of capacity/patient flow across the Partnership Trust by the Chief Operating Officer and the Divisions and is accountable for effective management of that flow in times of escalation.

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All Services are required to be fully engaged in communication of capacity information and in the decision-making process regarding patient flow.

At level 4 capacity will be managed hour by hour via a command and control centre to ensure:

Equitable access is given to all patients requiring the provision of a service within the Partnership Trust promoting the principles of patient safety and the management of risk.

Patients will be admitted into appropriately resourced clinical environments.

Single sex principles are adhered to.

Infection prevention and control principles are followed.

A proactive planned approach to patient flow is promoted.

DEFINTIVE ACTIONS The following actions, in no particular order, must be taken in addition to usual

operating procedures.

Leadership

Important To Note – Silver/Gold/ Bronze roles do not reflect any hierarchical existing job titles or roles and cannot be overruled during the incident management process without the commanders’ approval. Day to day job titles stay outside of the incident management command and control structure.

There will be three tiers of leadership for the operational delivery of the Full Capacity protocol following national standards of incident management:

Gold: Executive On-call (on-call) Silver: Senior Manager (on-call) Bronze: Service Managers

Gold Commander – Strategic

Oversee the strategic provision of healthcare services across the Partnership Trust and coordinates communication with other organisations.

Directs and monitors delivery of agreed actions and gives overall strategic direction to the situation.

Gold commanders do not take on the role of Silver Commander who is operationally in charge of the situation.

In normal working hours, Gold Command would be the Director of Operations or nominated deputy which could be a COO.

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Silver Commander – Tactical In times of command and control the Urgent Care lead would assume the position of

Silver Commander (Unless on annual leave or sickness leave) Silver will: o Co-ordinate the Command & Control room o Represent the Partnership Trust at LHE tactical meetings (Silver Update

meetings, conference calls) ensuring setting and delivery of agreed actions o which will then be cascaded throughout the relevant areas of the o organisation o Report to Gold and keep Gold briefed at agreed timelines. o Take whole organisational responsibility for tactical (operational) management.

If the command and control centre is required out of hours the role of Silver role is fulfilled by the On-Call Silver Commander pending the formation of a rota.

Bronze Commanders – Operational

Area Managers/Community Hospital Managers are responsible to for ensuring Bronze command posts are set up and function from 08:00- 18:00 with a named Bronze commander (unless instructed by Silver) to extend hours, in:

Community Hospitals

Intermediate Care

ILCT’s

LIS

Community Hospitals Social Work Team

RSUH Social Work Team

The Chief Operating Officers or Deputy is responsible for setting up Bronze:

Capacity Team control room

Each the control room must be manned for the period set out unless formally stood down by Gold. Others may be required to support as requested by Silver/Gold Commander, for example, Infection Prevention, Corporate Services. This request will be determined by emerging pressures.

Clinical Leadership There will be nominated Professional Leads to support the operational governance of

delivery of the Full Capacity protocol, all neighbourhood managers and team leaders will assist with prioritising community based patients.

All Professional Leads will be informed of activation of the protocol and base themselves within the areas of their responsibility and provide updates into the command and control centre.

Command & Control

The control room will be fully operational 8.00-18.00 Monday-Friday supported by the Gold Commander and Urgent Care Lead from LHE level 3 plus the predicted deficit in capacity to meet demand in the next 12 hours and throughout the period of utilising the Hospital Full Protocol. Members of the EPRR team will assist in assembling the control room and establishing the flow of information.

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Out of hours arrangements will be agreed and determined by the situation. Any decisions to extend the command and control centre will be the responsibility of the Gold Commander.

The Executive On-call will be responsible for the overall delivery of the Hospital Full Capacity Protocol, liaising with key team leaders and clinicians as necessary.

Action Cards will be activated to identify the steps which need to be taken (See Appendix XX)

Who (Responsible Officer): Silver: Strategic Urgent Care Lead Where: Control Room When (Timeframe): 30 minutes

Conversion of non-inpatient areas For the purposes of this protocol the non-inpatient areas are Cheadle Hospital (Ward

3), Scotia Day Case Unit, the inclusion of additional bed spaces on established wards and Day Case Transfusion beds.

The use of these non-inpatient areas should be authorised by Gold commander using the activation cards and action cards included as Appendix XX.

The order of the escalation capacity to be utilised (which needs to be confirmed):

o Day Case Transfusion Beds o Additional beds on wards (which breaches Infection Control Guidance) o Cheadle Hospital (Ward 3) o Scotia Day Case

Unit Consideration must be given to;

Impact on patient safety for those patients

Ability to exit out of these areas within 72 hours

Safe Nurse staffing and therapy resource

Accessibility for Social Care workers

Medical cover

Access to beds and other equipment required

Forecasted impact on recovery of patient flow

Transfer of Patients to Wards to Escalation Capacity

The agreed risk assessed areas to safely take patients are listed in the previous section within this protocol.

Prior to activation or the transfer of any patients the following conditions must be met:

1. The Nurse-in-Charge of each receiving area listed must be contacted by a member of the Operational Management team and asked to prepare for implementation of FULL CAPACITY PROTOCOL

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2. The receiving ward/service area must be contacted by a member of the Control Room

3. All transfers will be coordinated through the command and control centre in liaison with the RSUH Clinical Team.

4. When considering patients to move into designated clinical escalation space; only patients who are stable (MEWS less than 3), not acutely confused and not receiving oxygen will be accepted.

5. Staffing issues will be escalated within the current safe staffing SOP. This will remain the responsibility of the Nurse in Charge to co-ordinate as within existing standard practice. Advice will be available from the identified professional lead.

6. All patients’ privacy and dignity will be maintained at all times.

7. Internal transfers of patients will need to be considered based on clinical stability and the EDD.

24 hours following activation of Full Capacity Protocol all patients transferred into designated clinical escalation space must have a Senior Medical review as a priority to ensure there has been no impact on treatment and recovery.

Creation of additional discharges

Every area identified as part of the critical services list will have an additional Board Round completed by a critical friend validating all medically stable patients, review of all patients with an EDD for the next 48 hours to identify opportunities to expedite discharge.

The Bronze Commanders (Service Managers/Neighbourhood Mangers) will coordinate

the required response to support the additional discharges e.g. TTOs, transport, communication with patient and relatives, arrangements for follow-ups, step down into other services where required.


The Urgent Care Lead together with the Gold Commander (or nominated deputy) will be responsible for the de-escalation process and return of services.

Any area that reports a timeframe of De-Escalation that exceeds 24 hours will be prioritised for additional support from operational management team to assess what is required to maintain patient safety and safe staffing.

The Urgent Care Lead will be responsible for the incident debrief and review.

Instigate Next Steps

In the event that activation and delivery of Full Capacity Protocol is unsuccessful across the health economy in recovering safe, effective patient flow the Partnership Trust will take advice from EPRR for consideration prior to further action

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Assurance Check List - To be completed by Gold On-call

Gold: (Name & Designation)…………………………………………………………………… Silver: (Name & Designation)………………………………………………………………… Bronze: (Name & Designation)………………………………………………………………

Criteria checklist to determine activation of FULL CAPACITY PRTOCOL

Yes/No GOLD Signature

1. The RSUH Trust escalation status is EMS Level 4

2. The Community Hospitals Capacity status is RED.- All clinical capacity is full and no further discharges can be identified

3. Community Services Capacity status is red – all full and no ability to create capacity within an hour in the designated critical services

4. RSUH confirmation that 10 or more patients are medically stable and awaiting transfer to the Partnership Trust

5. RSUH confirmation that 5 or more patients waiting community services

6. If ALL 5 criteria met – ACTIVATE FULL CAPACITY PROTOCOL

GOLD Action Log

Conversion of non-inpatient areas For the purposes of this protocol the non-inpatient areas are Additional Bed spaces, Cheadle Hospital (Ward 3), Scotia Day Case Unit, additional ward spaces and transfusion beds.

Ability to exit out of these areas within 72 hours confirmed Medical cover sourced. (Supported by relevant COO) Access to beds and other equipment required completed (Supported by EPRR)

Plan to open first escalation area within 30 minute of protocol being initiated – Additional In-patient ward beds

No reduction in EMS level predicted for the next 4 hours? Community Hospitals remain RAG rated Red? Community Services Capacity Status remains red? Second escalation bed opening initiated Community Hospitals remain RAG rated Red? Community Services Capacity Status remains red? Third escalation bed opening initiated Community Hospitals remain RAG rated Red?

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Community Services Capacity Status remains red? Fourth escalation area opened

If conversion of non-inpatient areas can be delivered in line with all above actions – Proceed with operational delivery via nominated Divisional leads

If conversion of non-inpatient areas cannot be safely delivered and de-escalated in line with above actions – immediately inform AEO

Operational actions to accommodate patients in

designated clinical escalation space

Medical Director informed and prepared All relevant ward areas informed and prepared All relevant consultants informed and requested to attend their ward areas

All clinical teams informed and prepared Ambulance service informed and prepared

Transfer of patients to inpatient ward areas All relevant ward areas have begun transfer process All patients requiring transfer in line with this protocol have been transferred

Transfer of patients to community services All patients holding in intermediate care have been reviewed by a critical friend

Plans made to flex the criteria for Intermediate Care at home Non-critical services to be reviewed and rationalised in line with demands in urgent care

All step down patients to be accepted by 12 midday Risk assessments to be undertaken


LHE agreement to commence de-escalation process All areas have confirmed predicted De-Escalation times (in hours) LHE escalation made by Gold for additional support for areas unable to de-Escalate

Stand-Down

Protocol has been delivered De-Escalation completed Patient flow recovered

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26. APPENDIX 11 CCG CHECK LIST

CCG Checklist

The following provides a checklist of what tools are available to a CCG Director on call and a set of suggested

questions to ask providers should the Acute Trust escalate to an EMS level 4.

Tools Required

1) Ensure that you are receiving EMS alerts

2) Ensure that you are receiving daily situation reports from the Regional Capacity Management Team

3) Ensure that you are receiving the LHE information three times daily, before 10:00, 14:00 and 18:00.

Information

The EMS email alerts will provide a breakdown of the areas of pressure within the system. An example of

this is provided below:

Royal Stoke University Hospital is now at EMS LEVEL 3

Expected time to de-escalation reported as: Less than 2 hours

Trigger Number

Selected Trigger Trigger Level

1 No current risk of patients waiting more than 4 hours in ED 1

2 Transfer of Ambulance patient care is between 15 and 30 minutes. 2

3 There is an expected admission capacity deficit of less than 10% of expected demand for the next 24 hours

2

4 Elective work proceeding as planned. 1

5 One or more patients subject to a decision to admit now waiting longer than 8 hours on a trolley.

3

6 Medical outliers form between 0.5% and 1% of total inpatient population. 2

7 All Cubicles in A&E are full and patients are expected to wait in unplanned overflow areas.

4

8 No formal resuscitation bay available in A&E for next hour. 4

9 No Assessment area beds for more than 3 hours. 4

10 Planned additional bed capacity open and more than 80% occupied. 3

11 Partial or whole ward closed to admission or discharge due to infection control measures.

2

12 Critical care capacity is 80%-100% occupied. 2

13 Patient moves required, expected within 1hr. 2

14 MFfD cases form less than 9% of the inpatient total. 1

As a CCG Director this information is beneficial to ensure that actions being taken by the LHE are based

around the key areas of pressure.

If you need to chair a conference call due to an EMS level 4 escalation, the EMS alerts should provide the

basis of an agenda for discussions on this call.

By concentrating on the areas that are experiencing most pressure will provide clear direction and facilitate

de-escalation.

Questions to Ask

When an Acute Trust escalates to an EMS level 4, the CCG need to be assured that all relevant actions are

being taken by all provider organisations, please see below some suggested questions to ask so assurance

can be provided. You can adapt these questions around the areas of pressure highlighted in the EMS alert:

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Current Capacity:

1) What is the Simple and Timely discharge target for today and how many have they identified, actuals and predicted? UHNM

2) What is the complex discharge target for today and how many have they identified, actuals and predicted? SSoTP

3) Are PTS providing adequate support for planned discharges? CCG 4) What is the expected attendance and admissions for the rest of the day and what is the gap (deficit)

between admissions and discharges? UHNM and SSOTP 5) What community capacity is available today, beds and services? SSoTP 6) What is the current average turnaround time for ambulances, have there been any excessive waits,

for example over an hour? WMAS 7) What is the longest wait for a bed in A&E? UHNM 8) What staffing is in place to assist with the surge (UHNM and SSOTP), is there a HALO (Hospital

Ambulance Liaison Officer) on the front door? WMAS 9) What escalation beds are /could be opened over and above what is commissioned? SSoTP and

UHNM 10) Do you have any closed beds? UHNM & SSoTP 11) Are there any delays in Mental Health assessments? UHNM/SSoTP/NSCHT 12) Is the command and control structure active? CCG Gold * LHE Gold commanders 13) Is there a Director on-site and who is this? UHNM & SSoTP 14) Have all actions on the action cards been taken? 15) Is the ‘risk’ shared across all organsations? CCG 16) Does the plan support safety & operational functionality of A&E over the next 48 hours? CCG

Creating Capacity:

1) When was the last senior medical review (ward round) undertaken for each patient to encourage discharges? UHNM & SSoTP

2) What joint working is happening, for example are community staff onsite helping with pulling patients out of the hospital, has the working day been extended? SSoTP

3) Have third sector been approached to support, for example age concern and keeping people at home? CCG

4) What alternative pathways are being utilised? Can minors be directed elsewhere? ALL 5) Have electives been cancelled for the day? UHNM 6) Are there other apparent immediate blockers to discharge that need/can be addressed today? SSoTP

/City Social Care/UHNM 7) Can referral criteria be flexed in to community beds and or intermediate care teams and what will that

flexing mean for patient flow? SSoTP 8) Has a peripheral divert been considered? WMAS & UHNM 9) Are WMAS crews utilised the Telemed Desk and hub? WMAS

Forward Planning:

1) When are ward rounds planned for the next few days? 8am ward rounds? UHMN & SSoTP 2) What staffing is in place for the next few days to assist with de-escalation? UHMN/SSoTP/

NSCHT/Social Care 3) What plans are in place to ensure discharges before 11am over the next few days? UHNM & SSoTP 4) What are your predictions for the next few days and what plans have been put in place for any

surges? UHMN/SSoTP/ NSCHT/Social Care 5) What electives have been cancelled for the next few days? UHNM

Record Keeping It is important as a CCG Director on call, that you keep a record of the discussions and actions that have been agreed when an Acute Trust escalates to an EMS level 4, to ensure that any actions that have been agreed are discussed at the next meeting/conference call.

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