rcht capacity management escalation plan · pdf filercht capacity management escalation plan...

RCHT Capacity Management Escalation Plan

v6.12

January 2018


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Table of Contents 1. Introduction ……………………………………………………………………………….. 3 2. Purpose of this Policy ……………………………………………………………………. 3 3. Scope ……………………………………………………………………………………… 4 4. Definitions/Glossary ……………………………………………………………………… 4 5. Ownership and Responsibilities ………………………………………………………… 5 6. Capacity Management Escalation Plan ………………………………………………... 8 RCHT Escalation Criteria ………………………………………………... 8 RCHT Escalation Actions/Responsibilities …………………………… 10 7. Dissemination and Implementation …………………………………………………… 22 8. Monitoring Compliance and Effectiveness …………………………………………... 22 9. Updating and Review …………………………………………………………………... 22 10. Equality and Diversity ……………………………………………………………… ….. 22 Appendix 1. Governance Information ……………………………………………………….. 23 Appendix 2. Initial Equality Impact Assessment Screening Form ………………………... 25 Appendix 3. CCG Chaired Call Agenda and Example of Multi Agency Gold Strategic Level Calls Agenda ………………………………………………….. 27 Appendix 4. Checklist for Opening of Additional Capacity Ward ………………….……… 29 Appendix 5. Standard Operating Procedure – Nurse allocated to care for Patients in the corridor of the Emergency Department ……………………… 33


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1. Introduction 1.1. The Royal Cornwall Hospitals NHS Trust (RCHT) needs to be able to

plan for and respond to a wide range of incidents and emergencies that could affect health or patient care. This plan looks at consequence management of high demand for services – surge management.

1.2. Under the Civil Contingencies Act 2004, NHS organisations must show that they can deal with these incidents while maintaining services to patients. This work is referred to in the health community as Emergency Preparedness, Resilience and Response (EPRR). This is supported by the Health and Social Care Act 2012.

1.3. NHS organisations must be able to maintain continuous levels of key or critical services when faced with disruption from high levels of demand or capacity management issues.

1.4. Business Continuity Management (BCM) provides organisations with a framework for identifying and managing risk that could disrupt normal service – this includes Surge Management.

1.5. This policy incorporates the escalation status setting, bed capacity and trigger points and action plans for the whole Trust to provide a safe emergency service whilst ensuring the maintenance of priority elective activity.

1.6. Emergency care activity often experiences peaks and troughs and it is important that patients requiring admission receive that care by the right clinician in an environment conducive to their well being.

1.7. This plan provides a consistent and co-ordinated approach to the management of pressures at RCHT and emergency care systems, where escalation points have been applied.

1.8. This plan is designed for managers and clinicians involved in managing capacity and patient throughput at a time of excess demand on RCHT.

1.9. This version supersedes any previous versions of this document.

2. Purpose of this Policy

2.1. The establishment of an effective escalation policy will contribute towards the following:

Early identification of capacity problems. Proactive rather than reactive response actions. Clear and concise actions. Defined responsibilities.


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2.2. The plan aims to maintain high standards of patient safety, patient experience and performance against key waiting time and quality standards of care.

2.3. The capacity management escalation plan enables RCHT to deal with fluctuations in demand and capacity so that it can manage associated clinical risks within acceptable limits. The plan is designed to help mitigate the risk of further escalation and ensure an appropriate response from key members of the health community to contribute to a reduction in escalation status.

3. Scope

3.1. This document applies to all RCHT staff.

3.2. The strategic aims are:

Right care, right place. To maintain patient safety and minimise risk. To maintain ambulance handover in a timely manner. To deliver essential patient care. To maximise safe patient discharges and transfers. To be flexible and response to abnormal variations. To monitor, manage and mitigate pressures. To maintain service provision. To enable capacity to be increased. To pull patients through the system, not push.

4. Definitions/Glossary

4.1. Escalation is a set of procedures set in place to deal with potential problems with a surge in demand for services.

4.2. This plan is based on identifying four statuses based on pre-determined triggers as follows:

GREEN (OPEL 1)

Low levels of pressure. Relevant actions taken in response if deemed necessary. No support required from partners.

AMBER (OPEL 2)

Moderate pressure with performance deterioration. Escalation actions taken in response with support required from partners.

RED (OPEL 3)

Severe pressure with significant deterioration in performance and quality. Majority of escalation actions available are taken in reponse

and increased support required from partners.

BLACK (OPEL 4)

Extreme pressure with risk of service failure. All available escalation actions taken and potentially exhausted. Extensive support and

intervention required.


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4.3 Abbreviations

ED Emergency Department

EDD Estimated Discharge Date

EPRR Emergency Preparedness, Resilience and Response

GP General Practitioner

IT Information Technology

KCCG Kernow Clinical Commissioning Group

NIV Non-invasive ventilation

OCM On Call Manager

OPEL Operational Pressures Escalation Level

RAT Rapid Assessment and Treatment

SIRI Serious Internal Reportable Incident

SOP Standard Operating Protocol/Procedure

SWASFT South Western Ambulance Service NHS Foundation Trust

TTO To Take Out (prescription)

5. Ownership and Responsibilities

5.1. In each NHS organisation the Chief Executive is responsible for ensuring that there is a Business Continuity Strategy in place based on the principles of risk assessment, cooperation with partners, emergency planning, communicating with the public and sharing information. (NHS Commissioning Board Business Continuity Management Framework: Service Resilience 2013). This includes management of surge conditions.

5.2. Role of the Chief Operating Officer

The Chief Operating Officer is the nominated executive director for and has overall responsibility for patient flow within the Trust and is responsible for ensuring that: Plans are in place to manage disruptions to services – internal or external

– that require special provision to be made. Plans are written and published to ensure business continuity for any

emergencies that may impact on Trust activity. Business continuity plans are kept up to date and include escalation

issues. The Trust is compliant with all legislation relevant to EPRR. The plans are exercised appropriately. Trust staff are familiar with the plans for their particular work area and are

familiar with the Trust’s core plan.

5.3. Role of the Associate Directors

Associate Directors are responsible for ensuring that: A lead is identified for each division/department to include escalation

(surge) in their Business Continuity Plans with area specific action plans linked to this document. This should include non-clinical areas that can support in times of red or black status.


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During heightened escalation levels manage the escalation actions for the Divisions.

Support patient flow within their divisions, focussing on future requirements, such as planning for tomorrow’s discharges.

5.4. Role of Site Coordinators

Site Coordinators are responsible for: Day to day management of patient flow. Undertaking actions contained within this plan.

5.5. Role of On Call Manager/Head of Patient Flow

Monday – Friday, 08.00 – 16.00 hours – Head of Patient Flow. Out of hours – On Call Manager as per the rota.

The On Call Manager/Head of Patient Flow is responsible for: Supporting patient flow. Ensure the actions in this plan are carried out by On Call Manager or are

delegated to relevant divisional lead to undertake. Recording and documenting the current hospital status. Undertaking the role of tactical commander (if Critical Incident is declared)

5.6. Role of the Clinical Directors

The Clinical Directors are responsible for: Ensuring their Consultants are aware of and adhere to this plan.

5.7. Role of Ward Consultant and Medical Teams

The Ward Consultant and Medical Teams are responsible for: Timely review of patients and ensuring the patient records are updated

regularly with Estimated Discharge Date (EDD) and clear medical discharge/management plans recorded

Reviewing all outliers in a timely manner.

5.8. Role of Senior Nurses/Matrons

The Senior Nurses/Matrons are responsible for: Pro actively actioning issues identified within their area of responsibility. Providing support and advice to ward teams to support them in

management of effective discharges.

5.9 Role of Ward Managers

The Ward Managers are responsible for: Ensuring that accurate, timely information about capacity is communicated

with the Bed Managers. Ensuring that their staff are working to this plan.


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Ensuring that all patients have an Estimated Day of Discharge (EDD).

5.10 Role of Named Nurses

The Named Nurses for each patient are responsible for: Pro active management of individual discharge arrangements and for

escalating issues as appropriate.

5.11 Role of Emergency Planning Lead

The Emergency Planning Lead is responsible for: Reviewing the Trust’s Capacity Management Escalation Plan. Supporting Business Continuity Leads with the development of their area’s

escalation plan. Reviewing the response to incidents to ensure learning points are shared

and included in future planning.

6. Capacity Management Escalation Plan

RCHT ESCALATION CRITERIA

GREEN (OPEL 1) AMBER (OPEL 2) RED (OPEL 3) BLACK (OPEL 4) By default Escalation if 5 trigger

points met Escalation if 5 trigger points

met Escalation if 5 trigger

points met

PATIENT SAFETY RATED

(HIGH TO LOW)

CRITERIA

GREEN x AMBER x RED x BLACK x

1 Receiving care in the ED corridor

Less than 5 patients receiving care in the ED corridor

5 or more patients receiving care in the ED corridor

2 Length of wait to be seen in ED

Less than 1 hour 1-2 hrs 2-3 hrs Over 3 hours

3 Critical Care/CCU capacity

No level 2 or 3 bed available for any potential admission

Level 2 or 3 patient outside of Critical Care/CCU without admission plan

4 Staffing levels (RNs) No gaps – next shift

< 4 gaps 4-8 gaps >8 gaps

5 Medical bed occupancy 80-85% 86-89% 90-92% 93% or more

6 Escalation Beds Open Escalation Beds Open (Newlyn Unit)

7 Elective Cancellations Cancellation of cancer and/or urgent patients on the day

Cancellation of cancer and/or urgent patients on the day


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CRITERIA

GREEN x AMBER x RED x BLACK x

8 Number of patients waiting for inpatient beds in ED, AEC or St Mawes Lounge

0 waiting more than 4 hrs

Less than 3 patients waiting more than 4 hrs

More than 3 patients waiting more than 4 hrs or 1 patient waiting over 8 hrs

More than 5 patients with no plan waiting more than 4 hrs and more than 1 patient waiting over 10 hrs

9 Business Continuity (defined as IT or utilities failure/severe weather event)

Incident affecting significant area of the site but with quick resolution or affecting non-critical area of the site with immediate resolution unlikely

Incident affecting a significant area of the site with immediate resolution unlikely

10 Outliers (including any additional capacity in use)

<10 10-25 26-39 ≥40

11

Ward closures due to infection

Less than 2 bays closed on different wards

2 or more bays on different wards closed

2 wards closed

12 Admissions higher than discharges (unable to be assessed fully at weekends)

For preceding day

2 days in a row 3 days in a row

13 Total number of discharges (assess at 12.15 and 16.00 hrs only)

100 or more planned, later or query discharges

75-99 planned, later or query discharges



14 Number of reportable delayed discharges and community bed waiters

Less than 15 16-25 26-39 40 or more


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RCHT ESCALATION ACTIONS/RESPONSIBILITIES

GREEN (OPEL 1) Action

Ref ED

Action Ref

All Wards Action Ref

All Doctors Action Ref

Site Co-ordinator

Action Ref

On Call Manager/ Head of Patient Flow

ED1 Monitor number of arrivals per hour and triage status.

W1 Declare bed availability to Clinical Site Co-ordinators and/or Bed Managers.

D1 Write up TTOs before moving on to next patient.

SC1 Request Hospital Onward Care Team / SWASFT attend the bed meetings.

ED2 If more than 15 patients for 2 hours in a row, review current staffing and front-load senior assessment/ treatment.

W2 Set EDD within 1 day of admission and escalate any internal delays to patient journey through the discharge hub.

D2 Book all investigations before moving on to the next patient.

SC2 Identify all patients for repatriation and ensure plans are in place for their transfer with the receiving hospital.

ED3 If appropriate, doctors to see patients directly.

W3 Ensure discharges are achieved at the earliest opportunity with transport booked ideally pre-booked 24hrs in advance with all information required to complete the booking to prevent delays in discharge.

D3 Write and review EDD.

SC3 Confirm availability of transport for patient discharge.

ED4 If Decision Time is less than 2 hours, monitor wait to be seen and number of arrivals.

W4 Ensure staffing is reviewed at 8:30 and 15:30 SAFER Care meetings.

D4 Ensure that medical cover is provided for all patients outlying from speciality bed base.

SC4 Monitor and escalate staffing level issues.

ED5 If trolley wait is less than 30 minutes, monitor anticipated

W5 Ensure utilisation of discharge lounge.

SC5 Utilise Marie Therese beds with suitable patients.


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bed requirements from within department and estimated discharges from wards.

W6 Review all discharge plans for patients with and without CSD >7days.

W7 Work to the golden patient principles.

AMBER (OPEL 2) (Ensure actions at previous level have been completed) Action

Ref ED

Action Ref

Matrons/Ward Action Ref

Clinical Directors Action Ref

Site Co-ordinator

Action Ref


ED1 If Wait to be Seen is more than 1 hour, review teams in minors and majors and realign to demand. Ensure RAT is running and escalate speciality SOPs if required.

W1 Attend all bed meetings, undertake required actions and liaise with Site Co-ordinators.

C1 Ensure that consultants are completing e-discharge to provide parameters for nurse led discharge.

SC1 Liaise with ED nurse in charge, senior ED doctor (Consultant or Registrar if out of hours) to determine which escalation actions are required.

OCM1 Ensure speciality teams are supporting the take team and ED appropriately.

ED2 If wait for triage is more than 15 minutes, review staffing across department and move staff to triage to improve.

W2 Support wards to ensure delays in diagnostics are identified and escalated, prioritising those for discharge critical patients.

C2 Reviewing inpatient lists with their Consultants to discuss and enact any alternatives to ongoing inpatient stay or ways to accelerate the inpatient

SC2 Clinical Site Co-ordinator, in consultation with the On Call/Duty Manager, to open additional capacity and out-lie patients if required.

OCM2 Liaise with Onward Care Team to identify patients whose discharges are delayed or require input to support timely discharge and support wards to enable safe and effective patient discharge. Escalate


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pathway. external actions as required.

W3 Escalate those patients medically fit for discharge.

C3 Ensure speciality teams are supporting the take team and ED appropriately.

SC3 Ensure that RCH therapies are briefed to identify patients who require POC or step down beds.

W4 Ensure wards have identified all possible discharges and they are working on all actions to achieve them.

C4 Clinicians to prioritise discharges and accept outliers from any ward as appropriate.

SC4 Request facility teams prioritise cleaning and patient transfer.

W5 Escalate diagnostic, cardiac and other speciality delays.

C5 Contact on-take and ED on-call Consultants to offer support to staff and to ensure that specialty patients in ED are assessed rapidly.

SC5 Liaise with wards, bed managers and onward care team to ensure timely discharges. Reiterate use of discharge lounge to wards.

W6 Identify all those patients who need repatriation and ensure Clinical Site Co-ordinators are aware. Ensure a transport request is raised once handover with hospital has been carried out but prior to bed being

C6 Undertake additional ward rounds to maximise rapid discharge of patients.

SC6 Liaise with pharmacy to ensure TTOs are completed without delay.


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available so finance can be agreed with receiving CCG.

RED (OPEL 3) (Ensure actions at previous level have been completed) Action

Ref ED

Action Ref

Matrons/Ward Action Ref

Consultants Action Ref

Site Co-ordinator

Action Ref


ED1 If Resus is full and more patients are expected and unable to be accommodated in ED then invoke contingency plan.

W1 Resolve delays in patients transferring to base wards including WCH and St Michael’s.

C1 On take, surgical, trauma and ED on call Consultants to ensure patients in ED are assessed rapidly.

SC1 Liaise with wards on a patient by patient basis to ensure timely discharge.

OCM1 Request tactical conference call if required. Ensure that you join the call knowing what RCHT wants from health

partners (only where local provider to provider resolution has been insufficient).

ED2 If Wait to be Seen is more than 3 hours, review with Site Co-ordinator/On Call Manager – request additional doctors from specialities where possible. Ensure ED Consultant in charge is aware.

W2 Matrons to re-iterate to wards the requirement for patients for discharge to be sat out or sent to the discharge lounge and ensure they declare bed availability.

C2 Undertake extra post-take ward rounds including outliers.

SC2 Inform Acute Physician of the Day, Medical and Surgical Take Consultants of continuing pressures and actions.

OCM2 Ensure surgical and trauma areas have liaised with St Michael’s Hospital to source additional capacity subject to transfer criteria.

ED3 If Decision Time is more than 2 hours, doctor in charge to chase decision – delegate if necessary.

W3 Contact senior medical staff and request discharge reviews for appropriate patients.

C3 Identify further patients deemed suitable for discharge given current pressures

SC3 Identify additional beds that could be utilised with appropriate staff.

OCM3 Review and place on standby all relevant routine elective admissions. Liaise with the Associate Director (Surgery) and Consultants to


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being experienced.

prioritise theatre lists.

ED4 If Decision Time is more than 2 hours, check for imaging/lab delays and escalate speciality SOPs.

W4 Visit wards and conduct a board round with the nurse in charge to confirm current position including: - Swiftplus boards

up to date - bed availability

now and later - discharges today

and tomorrow including plans

- patients requiring intermediate care needs

- delays in assessments.

C4 Undertake daily Consultant ward rounds with every patient seen including outliers.

SC4 Ensure that adequate staffing is available – redeploy from appropriate areas.

OCM4 Request extra staffing in ED (GP, Nurse Practitioners and other hospital staff, such as Critical Care or CCU staff, paediatrics staff.)

ED5 If trolley wait is more than 30 minutes, escalate to Site Co-ordinator.

W5 Ensure telephone is answered to accept handovers and updates on operational position requirements.

C5 Senior Clinicians to actively scrutinise all GP requests for admission.

SC5 Admit suitable patients directly from ED to base wards.

OCM5 Enact process of cancelling day cases and staffing day beds (Newlyn) overnight if appropriate.

ED6 Less than 5 patients in the corridor, ED Band 7 to redeploy staff in ED to manage the corridor. If still not managed, escalate to ED Matron (or Divisional Nurse in their absence) to liaise with Site Co-

W6 Ensure wards have identified all possible discharges and they are working on all actions to achieve them.

SC6 Ensure patient transport is aware of likely requirements.

OCM6 Decide on which escalation beds to open.


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ordinator to check nursing staff available elsewhere for deployment (using SAFER). If redeployment not possible, escalate to Divisional Nurse to liaise with other Divisional Nurses and Deputy Director of Nursing for redeployment from Corporate Teams. Out of hours escalation is from ED Band 7 direct to Site Co-ordinator.

ED7 Less than 5 patients in the corridor, anticipate later requirements – request additional ED nurses and doctors.

W7 Speciality nurse to provide support to ED by assessing patients referred to relevant specialties.

ED8 Less than 5 patients in the corridor, create space to be seen using RATs bays. Patients not receiving direct care/treatment to wait in corridor.

W8 Review staffing levels over next 24/48 hours and ensure suitable staffing is in place.

W9 Liaise with Onward Care Team to


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identify patients whose discharges are delayed or require input to support timely discharge and support wards to enable safe and effective patient discharge.

RED (OPEL 3) (Ensure actions at previous level have been completed) Action

Ref On Call Executive

Exec1 Request a strategic conference call, where beneficial, to agree system wide actions (only where local provider to provider resolution has been insufficient). See Agenda – Appendix 3.

Exec2 If escalation into Black seems likely then prepare pre-emptive communication to prevent occurring. Making sure it is clear what response is required from staff. Ensure KCCG Director is aware of the RCHT


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operational pressures and likely escalation to Black.

Exec3 Liaise with IT and Estates to reschedule planned maintenance where work is likely to impact on capacity and flow.

BLACK (OPEL 4) (Ensure actions at previous level have been completed) Action

Ref ED Action

Ref All Wards Action

Ref Consultants Action

Ref Site

Co-ordinator

Action Ref


ED1 Liaise with SWASFT to see if a Paramedic crew can be released to manage the ambulance queue.

W1 Patients can be moved between wards during protected meal times.

C1 Request relevant on-call Consultants stay until 11pm. This is to support ED for admission avoidance and prioritise discharge review.

SC1 Using SAFER Care, utilise staff from other areas and redeploy to relieve key pressure points.

OCM1 Develop a plan of action, ensuring clear responsibilities and timeframes for completion.

ED2 Request ED Consultant to be present into the evening (11pm). Continuation post 11pm if ED not safe. Consider ED rota changes to ensure cover can be provided throughout the

W2 Matrons to identify patients to be moved to discharge lounge.

OCM2 Request medical division to send a senior medical consultant to be present at bed meetings.


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night.

ED3 Request Acute GP to work until 11pm.

OCM3 Ensure hospital status is cascaded to all areas in the hospital. Ensure that communication is clear around targets and actions for staff. Ensure it is updated for each day the trust remains in Black.

ED4 Inform Minors patients in ED of pressures and potential delays and of alternatives such as Minor Injuries Units and Urgent Care Centres.

OCM4 If Critical Incident is declared by Exec On-Call Director assume the role of Tactical Commander and lead the Incident Coordination Centre response.

OCM5 Request tactical conference call (if not already occurring and only where local provider to provider resolution has been insufficient). Ensure before you join the conference call that you know what actions you would like from partners to ease pressure on RCHT.

OCM6 Using SAFER Care ensure divisional nurses have specialist nurses and


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clinical educators supporting wards.

OCM7 Review urgent elective admissions where possible - reschedule or cancel.

OCM8 On Call Manager to stay on site until presence no longer deemed operationally beneficial.

BLACK (OPEL 4) (Ensure actions at previous level have been completed) Action

Ref On Call Executive

Exec1 Declare a Critical Incident where there is a clear benefit to aiding the response. Consider after 48hrs of continued Black Status. If declared, implement ‘command and control’ arrangements (including loggist) and assume role of Strategic Commander.

Exec2 Request a strategic conference call (unless already being conducted and only where


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local provider to provider resolution has been insufficient). See Agenda – Appendix 3.

Exec3 Ensure public and internal messages are being sent out by Communications Team. Ensure internal message is sent every day that the trust remains in Black and that it clearly states the targets and actions required to achieve them.

Exec4 If Critical Incident declared, Datix incident form to be completed and SIRI reported on STEIS.

Exec5 Cancel training and non-clinical duties where proportionate and will provide benefit. Link to SAFER Care for redeployment of staff.

Exec6 Executive Director to stay on site until presence no longer deemed


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operationally beneficial.

Exec7 Consider On-Call Manager shifts to be split into 12hr day and 12hr night shifts.

Exec8 Implement Full Capacity Policy if triggers are met.


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7. Dissemination and Implementation

7.1. All key relevant staff will need to be briefed by their managers on this plan and the relevant actions for their division/ward.

8. Monitoring Compliance and Effectiveness Element to be monitored

The plan will be monitored in it’s entirely as the trust moves between escalation levels.

Lead Emergency Planning Lead

Tool Debriefs or SIRIs (if Critical Incident declared) will be held and lessons identified incorporated into the plan.

Frequency The plan is constantly in use.

Reporting arrangements

Reporting of escalation or capacity management issues is through Trust Management Group.

Acting on recommendations and Lead(s)

The Trust Management Group will nominate a lead to undertake actions depending on their nature and the circumstances. They will monitor actions for any deficiencies and recommendations within reasonable time frames.

Change in practice and lessons to be shared

Shared learning will be via the debrief/SIRI process. Required changes to practice will be identified and actioned within an agreed timeframe. Lessons will be shared with all relevant stakeholders.

9. Updating and Review

9.1This document will be reviewed annually by the Emergency Planning Lead.

10. Equality and Diversity

10.1This document complies with the Royal Cornwall Hospitals NHS Trust

Equality and Diversity Statement which can be found in the ‘Equality, Diversity & Human Rights Policy’ or on the Equality and Diversity website.

10.2Equality Impact Assessment

The initial Equality Impact Assessment screening form is located at Appendix 2.


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Appendix 1. Governance Information

Document Title RCHT Capacity Management Escalation Plan v6.12

Date Issued/Approved: 31 January 2018

Date Valid From: 31 January 2018

Date Valid To: 30 January 2021

Directorate / Department responsible (author/owner):

Matt Overton, Emergency Planning Lead

Contact details: 01872 250000

Brief summary of contents To provide guidance for dealing with escalation events leading from a surge in demand.

Suggested Keywords: Escalation, capacity management. green status, amber status, red status, black status

Target Audience RCHT PCH CFT KCCG

Executive Director responsible for Policy: Chief Operating Officer

Date revised: 31 January 2018

This document replaces (exact title of previous version):

RCHT Capacity Management Escalation Plan v6.11

Approval route (names of committees)/consultation:

Trust Management Group / A&E Delivery Board

Divisional Manager confirming approval processes

Rab McEwan, COO

Name and Post Title of additional signatories

‘Not Required’

Signature of Executive Director giving approval

{Original Copy Signed}

Publication Location (refer to Policy on Policies – Approvals and Ratification):

Internet & Intranet

Intranet Only

Document Library Folder/Sub Folder Chief Operating Officer/Emergency Planning

Links to key external standards NHS England EPRR Core Standards


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Related Documents:

NHS Commissioning Board Business Continuity Management Framework (service resilience) 2013 NHS England South Central Escalation Framework v2.0 RCHT Business Continuity Strategic Plan v2.4 CCG Whole System Escalation Plan v10 Escalation Plan – Child and Maternity

Training Need Identified? No

Version Control Table

Date Version

No Summary of Changes

Changes Made by (Name and Job Title)

4 June 14 6.3 Document revised following winter 2013/14

period and subsequent learning Simon Wilkins, Emergency Planning Lead

July 14 6.4 Document revised following consultation Simon Wilkins, Emergency Planning Lead

22 Aug 14 6.5 Document revised following consultation at Operational Management Group

Simon Wilkins, Emergency Planning Lead

17 Sept 14 6.5 Minor amendments to reflect changes in day time On Call Manager/Medical Division Manager responsibilities

Simon Wilkins, Emergency Planning Lead

23 Mar 16 6.6 Review following Black Status Significant Incident declaration


18 Jul 16 6.7 Minor amendments following 3 month trial of v6.6.


17 Oct 16 6.8 Amendments following Black Status debrief and addition of Early Warning System.


13 Dec 16 6.9 Early Warning System triggers amended. Matt Overton, Emergency Planning Lead

14 Aug 17 6.10 Addition of Appendix 6. Matt Overton, Emergency Planning Lead

01 Dec 17 6.11 Removal of section 5.12, 7, appendix 5. Escalation Triggers and appendix 3 updated based on Whole System Escalation Plan v10


31 Jan 18 6.12 Outliers and DTOC triggers altered based on agreement between COO, CCG and NHS England.


All or part of this document can be released under the Freedom of Information

Act 2000 This document is to be retained for 10 years from the date of expiry.

This document is only valid on the day of printing

Controlled Document

This document has been created following the Royal Cornwall Hospitals NHS Trust Policy on Document Production. It should not be altered in any way without the

express permission of the author or their Line Manager.


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Appendix 2. Initial Equality Impact Assessment Form

Are there concerns that the policy could have differential impact on: Equality Strands: Yes No Rationale for Assessment / Existing Evidence

Age

Sex (male, female, trans-gender / gender reassignment)

Name of service, strategy, policy or project (hereafter referred to as policy) to be assessed: RCHT Capacity Management Escalation Plan

Directorate and service area: Corporate – Emergency Planning

Is this a new or existing Policy? Existing

Name of individual completing assessment: Matt Overton

Telephone: 07818 581950

1. Policy Aim* Who is the strategy / policy / proposal / service function aimed at?

To provide guidance for the whole Trust to manage a capacity or escalation event.

2. Policy Objectives*

To provide information and support managers in managing an escalation event.

3. Policy – intended Outcomes*

● Clear actions to follow ● Clear trigger points ● Capacity and escalation managed

4. *How will you measure the outcome?

● Debriefs and SIRIs ● Audit of plan

5. Who is intended to benefit from the policy?

Patients, staff, health partners and the public.

6a) Is consultation required with the workforce, equality groups, local interest groups etc. around this policy? b) If yes, have these *groups been consulted? c). Please list any groups who have been consulted about this procedure.

No

7. The Impact Please complete the following table.


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Race / Ethnic communities /groups

Disability - learning disability, physical disability, sensory impairment and mental health problems

Religion / other beliefs

Marriage and civil partnership

Pregnancy and maternity

Sexual Orientation, Bisexual, Gay, heterosexual, Lesbian

You will need to continue to a full Equality Impact Assessment if the following have been highlighted:

You have ticked “Yes” in any column above and

No consultation or evidence of there being consultation- this excludes any policies which have been identified as not requiring consultation. or

Major service redesign or development

8. Please indicate if a full equality analysis is recommended. Yes No

9. If you are not recommending a Full Impact assessment please explain why.

The plan is designed to ensure all patients are managed safely and does not look at different groups.

Signature of policy developer / lead manager / director Matt Overton

Date of completion and submission 23 March 2016

Names and signatures of members carrying out the Screening Assessment

1. 2.

Keep one copy and send a copy to the Human Rights, Equality and Inclusion Lead,

c/o Royal Cornwall Hospitals NHS Trust, Human Resources Department, Knowledge Spa, Truro, Cornwall, TR1 3HD A summary of the results will be published on the Trust’s web site. Signed _______________ Date ________________


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Appendix 3.

CCG Chaired Call Agenda

Item Objective Process Presenter

1 Confirmation of Chair and Loggist

Agree appropriate Chairperson and a Loggist

Verbal Chair

2 Reason for the Call Shared understanding of reason for the call

Verbal Chair

3 Introductions (All to state name and organisation)

Confirm attendance and appropriate representation

Verbal All

4 Confirmation of Alert Level Shared understanding and summary of current position

Verbal Chair

5 Actions arising from previous meeting

Confirm that agreed actions have been completed

Verbal Update

Chair

6 Partner asks and discussion To clearly articulate what is required from system partners to de-escalate

Verbal Update

All

7 Summary of agreed actions Summary of action log ahead of formal record being produced for next meeting

Discussion Chair & Loggist

8 AOB For urgent issues/discussion

Discussion All

9 Decisions requiring escalation to Multi Agency Gold Strategic Level

Clearly define greatest areas of danger decisions which need Executive level and discussion and action

Discussion All

10 Time of next meeting To note timing of next meeting

Discussion Chair


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Example of Multi Agency Gold Strategic Level Calls Agenda

Item Objective Process Presenter

1 Confirmation of Chair and Loggist

Agree appropriate Chairperson and a Loggist

Verbal Chair

2 Reason for call Shared understanding of reason for call

Verbal Chair

3 Introductions (All to state name and organisation)

Confirm attendance and appropriate representation

Verbal All

4 Actions arising from previous meeting

Confirm that agreed actions have been completed

Verbal Update

Chair

5 Consideration of decision requested by executive call

Reach common understanding of greatest dangers in the system

Discussion Chair/All

6 Agreement of decisions made and summary of actions

Decide on key actions required to de-escalate

Verbal update

All

7 AOB For urgent issues/discussion

Discussion All

8 Time of next meeting To note timing of next meeting

Discussion Chair


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Appendix 4. Checklist for Opening of Additional Capacity Ward (insert ward names and number of beds/bays/side rooms) Authorised by: Context, rationale and admission protocol agreed with Executive Team: Date: Time:

Completed by: Name: Signature: Date: Time:

Action/Works Required Risk/Assurance Responsible Action RAG Notes and Contacts

Allocate responsibility to person overseeing and managing ward area.

Ensure leadership and responsibility is understood.

Medicine Divisional Management Team/ On Call Manager

Assign Ward Manager Advise that this should be person who will manage set up and activity on ward

Ward Sister/Charge Nurse and Matron check intended environment, do risk assessment for: cleaning, facilities (see below), equipment and supplies, consider previous usage of area and potential concerns that may arise.

Ensure anticipated Patient Safety Potential Cross Infection Non Compliance with DSSA.

Medicine Divisional Management Team, On Call Matron and Manager Infection Control Team

Matron and Ward Manager to visit environment. Discuss and record works required. Complete Risk Assessment and Infection Control DSSA Risk Assessment. Involve Infection Control Team.

Consider anticipated workflow and ambulance of Client group i.e. Ward to be “well” medical female only? Infection Control Ext 4969.

Budget number and authorised signatories.

Maintain financial control with workflow responsibilities.

Medicine Divisional Management Team Finance

Matron to arrange budget for new area

Ward area, nurses station, toilets, bathrooms and treatment areas, sluice, kitchen to be cleaned. Curtains changed on windows and between bays if required.

Control of Infection and breach in DSSA.

Cleaning Team (Hotel Services)

Set up pre clean and regular clean while area in use

Consider use of curtaining and screens to ensure Privacy and Dignity. Hotel Services Ext 2468.

Telephone and computers – ensure dedicated phone line and IT access/PAS. Agree Ward Clerk provision to support nursing team and flow.

Workflow communication, ensure ability to obtain emergency assistance and patient location. (Swiftplus board).

Ward Sister/Charge Nurse

Advise IT to amend PAS. Ensure dedicated telephone line, IT and support to anticipated flow. Ensure Switchboard informed of number and opening.

Ensure ward has Ward Clerk cover/shares with another ward. Set up new area on PAS. CITS Ext 1717.


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Staffing (nursing) Immediate

Lead Matron to ensure appropriate staffing levels and skill mix have been agreed and are in place. Redeploy staff from other areas of the hospital, cancel training and deploy staff consider non critical activity which could be cancelled and staff redeployed. Offer overtime to staff Maintain safe FML, service delivery and skill mix. Planned opening Lead matron to look at staffing through overtime to staff, Kernowflex, block booking agency staff and offering temporary contracts.

Matron and Kernowflex with Site Team support.

Create off duty for area based on 2 x trained, 3 x HCA (2 + 2 + 1 Housekeeper) day and night

Ensure the skill mix is based on at least 1 trained regular (RCHT) staff member. Consider moving staff from other medical wards to ensure this. KernowFlex Ext 2649.

Staffing (doctor) Ensure a lead consultant is identified for patients to come under. Ensure junior doctors are identified to review patients.

Lead Consultant medicine

Assign consultant and doctors to cover escalation beds.

Call Bells, Oxygen and Suction Responsive care. Ward Sister/Charge Nurse, Estates/ Medical Physics

Ensure each bed space has access to working call bells, oxygen and suction

Estates Ext 3400 Medical Physics Ext 2490

Furniture Lack of facilities for basic patient needs. Quality environment to deliver care. Patient comfort and safety.

Medicine Divisional Management Team Hotel Services

Each bed space to have 1 x bed, 1 x locker, 1 x table, 1 x patient chair and access to working oxygen and suction.

Equipment Library via netpage. Hotel Services Ext 2468


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CD Cupboard Facility for safe storage of Controlled Drugs.

Medicine Divisional Management Team/ Pharmacy

Ensure availability of keys. Once identified, basic stocks to be provided by Pharmacy.

Pharmacy Ext 2592

TR Room/cupboards and drug trolley – medicines fridge bulk fluids

Security of medicines/ availability of trolley/locks on cupboards

Pharmacy/Matron/ Ward Sister/Charge Nurse

Ensure availability of keys once area fit for purpose. Basic stock to be provided by Pharmacy. Treatment area to be stocked.

Pharmacy Ext 2592

Stores and storage CSSD – sterile services

Adequate stock required to deliver basic nursing care

Supplies Department/Matron/ Ward Sister/Charge Nurse

Ensure all stock available with top-up provision.

Supplies 01209 310053 Sterile Services Ext 2816

Sluice Safe disposal of body fluids. Ward Sister/Charge Nurse and Estates

Check that disposal unit is working. Area is decluttered. Commodes are cleaned and ready to use. Pulp products restocked.

Estates Ext 3400

Kitchen Unable to cater for patient nutritional needs if items not available.

Hotel Services and Ward Sister/Charge Nurse

Items required for kitchen, fridge, microwave, toaster, kitchen trolley. Stores to provide basic food requirements. Ensure kitchen cleaned and decluttered.

(In absence of fridge, bread, milk, etc, can be stored in cold side of meal trolley). Hotel Services Ext 2468 or via Mullions

Crash Trolley and Defib Required for Emergency Resus. Skillmix – ensure all staff are aware of the Trust Resuscitation Procedures - lessons learned from SUI Feb 2011. This includes bank/agency/locum staff.

Medicine Divisional Management Team Resuscitation Team

Equipment essential prior to admission of first patient

Resuscitation Team advice. Need to ensure staff are familiar with Resus procedures. Agency to be supported by Trust trained staff on all shifts.

Equipment, linen and supplies to provide basic care. See Emergency Medical Beds Opening Requirements List

Ensure safe timely care delivery.

Medical Physics and Ward Sister/Charge Nurse

Use list as standard checklist

Ensure admission protocol is adhered to

Risk mitigation with regards to admission area purpose and agreed protocols.

Medicine Divisional Management Team and Clinical Director

Decision required and communicated to Site Co-ordination Team about suitability of transfers/admissions (guideline). Decision to be supported and sustained by clinical site and bed management team out of hours.

Patients to be selected by Ward Manager/Lead Nurse with co-ordination with site team at weekend.


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Signage and communication with all services

Ensure timely emergency response.

Medicine Divisional Management Team, Matron and Ward Sister/Charge Nurse, Health & Safety Team

Ensure Fire Safety/Resus Team are aware of area, its name and area, purpose – even if temporary. Put up temporary direction signs to alert staff and direct patients and visitors. All staff email/add to daily bulletin.

Fire Safety Ext 3400 Estates Ext 3400 Communications Ext 2934

Staffing (AHP and Medical). Ensure Support Services/medical teams aware of area and responsibility assigned for area

Risk to quality of care/patient flow by lack of support services to discharge elderly or unwell patients.

Medicine Divisional Management Team, Clinical Director or On Call Medical Team. AHP Leads. Health & Safety Team

Matron to ensure AHP and clinical team is engaged to new area.

Reference to Trust operational policy/national targets for care delivery.

Promote Productive Ward Working – ensure teams are assigned/colour-coded/flow recorded on whiteboard or Swiftplus

Prevent risk to delayed patient flow and discharge. Work area backlog/ avoidable delays.

Medicine Divisional Management Team, Matron and Ward Sister/Charge Nurse

Ensure facility to record patient status and security of notes and documentation – consider workflow.

Waste Management Safe working and patient environment.

Medicine Divisional Management Team, Matron and Ward Sister/Charge Nurse

Liaise with Waste Management to ensure prompt collection arrangements.

Waste Management Ext 3813

Other Ward Sister/Charge Nurse/Hotel Services

Check hand gel and soap/towel dispensers, waste bins.

Hotel Services Ext 2468

Other

Ward Sister/Charge Nurse

Notify Security and Post Room of changes.

Security Ext 2147/2229 Post Room Ext 3826

NB. Use with Ward Move Checklist, Ward Decant Checklist and Emergency Medical Beds Opening Requirements Checklist.

Risk Assessment should be signed and dated and delivered to Site Co-ordinators for filing.


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Appendix 5.

Standard Operating Procedure: Nurse allocated to care for patients in the corridor

of the Emergency Department

STANDARD OPERATING PROCEDURE

Title NN Nurse allocated to care for patients in the corridor of the Emergency

Department

Purpose

-To inform all qualified nursing staff of the standard operating procedure to be followed to ensure the timely and safe delivery of care to patients who arrive by ambulance to the Emergency Department who remain on the

corridor -To provide support and guidance for staff who have been asked to work in

ED at short notice

Scope

All patients who remain on the corridor after RATS assessment or patients

who have been triaged (walk in) who require observation and treatment that cannot be delivered in Minors.

Instruction

1. On arrival to ED the nurse will identify themselves to the

Nurse in Charge (NIC)

2. The NIC will complete the local induction checklist Discussion required regarding nurses

existing skill set and competencies to ensure most appropriate use of staff

3. The NIC will introduce the nurse to the senior nurse on RATS. The RATS senior nurse will give handover of the

patients that have been fully triaged and awaiting a cubicle

4.

The corridor nurse will complete the ED proforma and all the relevant risk assessments pertaining to the patient’s

condition. They will maintain clinical observations in accordance with NEWS status, and administer any

medications prescribed.

5.

Any patient who deteriorates whilst on the corridor should be escalated to the NIC and transferred to an appropriate area. The patient should be handed over to a registered

nurse in the receiving area

Discussion required regarding how card/patient arrive at location eg children’s,

resus


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6.

ALL patients who are on the corridor should be transferred from the ambulance trolley to an A&E trolley. If no trolleys

are available this should be escalated to the NIC.

7.

The Nurse in Charge will be responsible for identifying any patient waiting to come from the corridor into Majors and

liase with the RATS senior nurse.

The corridor nurse will then hand over the patient to the appropriate RN

8.

ESCALATION

Patients waiting on the corridor

More than 4 patients in the queue awaiting a cubicle

Inform the A&E co-ordinator

Inform the ED consultant