Title: Adult Patient Flow & Escalation Policy Version: 2.0 Issued: November 2018 Page 1 of 60
ADULT PATIENT FLOW AND ESCALATION POLICY
POLICY
Reference
CPG-TW-APF&EP
Approving Body Urgent & Emergency Care Divisional Clinical Governance Meeting
Date Approved
22nd November 2018
Issue Date
26th November 2018
Version
2.0
Summary of Changes from Previous Version
Revised escalation triggers
Alignment of escalation triggers to OPEL Framework
Revised action cards
Supersedes
v1.0, Issued 8th November 2016 to Review Date June 2018
Document Category
Clinical
Consultation Undertaken
Patient Flow Group
Date of Completion of Equality Impact Assessment
November 2018
Date of Environmental Impact Assessment (if applicable)
Not Applicable
Legal and/or Accreditation Implications
None identified
Target Audience
All staff
Review Date
December 2020 (ext2)
Sponsor (Position)
Chief Operating Officer, Simon Barton
Author (Position & Name)
Deputy Chief Operating Officer, Denise Smith
Lead Division/ Directorate
Corporate
Lead Specialty/ Service/ Department
Operations
Position of Person able to provide Further Guidance/Information
Chief Operating Officer
Associated Documents/ Information Date Associated Documents/ Information was reviewed
Medical Outlier Ward Pairings
Clinical Site Management Team SOP
Opening of Additional Bed Capacity (incl Bed Escalation Plan)
Available separately via the Medical Division intranet
Review Date: April 2020
Review Date: October 2020
Title: Adult Patient Flow & Escalation Policy Version: 2.0 Issued: November 2018 Page 2 of 60
CONTENTS
Item Title Page
1.0 INTRODUCTION 3
2.0 POLICY STATEMENT 3
3.0 DEFINITIONS/ ABBREVIATIONS 4
4.0 ROLES AND RESPONSIBILITIES 5
5.0 APPROVAL 6
6.0 DOCUMENT REQUIREMENTS 6.1 Normal working 6.2 Escalation 6.3 Escalation triggers 6.4 Escalation actions 6.5 Outlying patients 6.6 Opening additional capacity 6.7 Closing additional capacity
6-8 6 6 7 7 7 8 8
7.0 MONITORING COMPLIANCE AND EFFECTIVENESS 9
8.0 TRAINING AND IMPLEMENTATION 10
9.0 IMPACT ASSESSMENTS 10
10.0 EVIDENCE BASE (Relevant Legislation/ National Guidance) and RELATED SFHFT DOCUMENTS
10
11.0 KEYWORDS 10
12.0 APPENDICES (list) 10
Appendix A Capacity and Flow Meetings SOP 11-16
Appendix B OPEL Framework 17
Appendix C Trust Escalation Triggers 18
Appendix D Emergency Department Escalation Triggers 19
Appendix E Action Cards 20-57
Appendix F Additional Capacity 58
Appendix G Equality Impact Assessment 59-60
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1.0 INTRODUCTION Emergency Department (ED) attendances and non-elective patient admissions to the Trust, which can be unpredictable in nature, pose a challenge to the Trust on a daily basis. The proactive response to surge in non-elective activity is fundamental to ensure patient safety. This policy details the procedures for ensuring safe and effective utilisation of in-patient beds to ensure patients, who require admission are admitted to the right bed, at the right time first time. 2.0 POLICY STATEMENT
All emergency patients requiring an admission are transferred to bed within four hours of attending (ED), unless there is a valid clinical reason to remain in ED.
Elective admissions will not be cancelled due to lack of bed availability unless in accordance with this escalation policy.
All available capacity at SFH will be used efficiently and effectively to ensure that the right patient is placed in the right bed and at the right time.
All patients from assessment areas will be pulled into the correct specialty beds as soon as possible. When this process no longer complements emergency flow, as a last resort, additional capacity and outlying capacity will be used to maintain flow throughout the hospital.
The above objectives rely on the following assumptions:
Divisional Management Teams will manage their own emergency and elective
demand
Wards will ensure that they are aware of the expected emergency demand and have
daily plans to manage this
The movement of patients will comply with the Trust infection control policies.
It is the responsibility of all SFH staff engaged in acute, adult care to ensure the
actions detailed in this plan are undertaken and supported
Divisions will have operational action plans in place to support this policy and the
Trust during the stages of escalation.
These procedures relate to acute and adult capacity only. Paediatric and Maternity
capacity will be managed by the Women’s and Children’s Divisional Management
Team.
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3.0 DEFINITIONS / ABBREVIATIONS
AECU Ambulatory emergency care unit
AHP Allied health professional
BAU Business as usual
BOC Bronze on call
BRAG Black, red, amber, green
CCG Clinical Commissioning Group
COO Chief Operating Officer
DCOO Deputy Chief Operating Officer
DGM Divisional General Manager
DNM Duty Nurse Manager
DTA Decision to admit
DTOC Delayed transfer of care
EAU Emergency Assessment Unit
ED Emergency Department
EDAS Early Supported Discharge Service
EDD Expected date of discharge
EMAS East Midlands Ambulance Service
IDAT Integrated Discharge and Assessment Team
NEMS GP out of hours provider
PC24 Primary Care 24
SAFER Patient flow bundle incorporating 5 elements of best practice
SAU Surgical assessment unit
SOC Silver on call
TCI To come in
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4.0 ROLES AND RESPONSIBILITIES Responsibility The management of all bed capacity is the responsibility of the Chief Operating Officer and
this responsibility is disseminated through a Silver/Gold on call structure, which is in place at
all times in the Trust.
Expectations of each role are outlined in the action cards at Appendix E.
The management of patient flow, during working hours, remains the responsibility of the
Duty Nurse Manager (DNM) and the Divisional Management Teams.
The DNM is accountable for the management of flow ‘Out of Hours’ and has designated
authority to work in conjunction with the Silver and Gold on call as required. The day to day
process and roles and responsibilities of these individuals are outlined below:
Roles
DNMs Acts as Site Manager co-ordinating effective flow across each hospital site. Reports back to Silver/Capacity and Flow Matron if actions are not completed or are insufficient to meet demand.
Silver on Call Senior Managers’ within the Trust provide the ‘Silver on Call ‘role, 24 hours a day, 7 days a week. The role of the ‘Silver on Call’ is to provide Senior Leadership to help deliver the timely flow of patients through the Trust, supporting the decision making process and troubleshooting as required. During an incident, ‘Silver on Call’ has overall responsibility for co-ordination of the Senior Managers, Nurses and AHP’s within the Trust
Capacity and Flow Matron
Manages the capacity and flow team to ensure the timely flow of patients through the Trust. Holds the Divisional teams to account in delivering their plans as outlined in this policy. Assess whether the divisional plans are sufficient to ensure flow or if escalation is required.
Gold on Call The primary role of ‘Gold on Call’ is to give strategic direction to the ‘Silver on Call’. The Chief Operating Officer or the Deputy Chief Operating Officer is ‘Gold on Call’ Monday to Friday, 0800-1800. ‘ Out of Hours’ is the ‘Executive Gold on Call’
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5.0 APPROVAL The policy has been consulted on at the Patient Flow Group and approved by the Urgent and Emergency Care Divisional Clinical Governance Group. 6.0 DOCUMENT REQUIREMENTS 6.1 Normal working All Trust staff are required to actively contribute to the timely and safe discharge of patients from hospital. An expected date of discharge (EDD) is to be set within 24 hours of a patient’s admission to help co-ordinate and plan for discharge in a timely manner. The patient’s discharge planning is to commence upon the admission of the patient. Medical staff must ensure that ward and board rounds are complete in a timely manner on a daily basis and patients for discharge identified. Potential and definite discharges should be declared to the Site Managers at the earliest opportunity. Ward staff should make appropriate use of the Discharge Lounge to ensure that beds are released to accept acute admissions. Normal working includes:
Completed morning ‘Board Rounds’
Completing ward rounds before 12:00 using SHOP (Sick, Home, Others, Plan)
Setting a patient’s clinically agreed EDD within 24 hours of admission
Commence discharge planning upon the patient’s admission
Informing Pharmacy of a patient’s discharge at least the day before discharge
Ensure the patient is assessed and is fit for transport in a timely manner
Ensure transport is booked as soon as possible, preferably the day before discharge
Identifying discharges the day before discharge and proactively move ‘Golden Patients’ from the wards to the discharge lounge at 8am on day of discharge
Identifying patients for step down to MCH/Newark
Proactively identifying patients for Newark and MCH wards
Proactively review all of the patients with a LOS of over 7 days on a daily basis 6.2 Escalation Non elective capacity and demand inequity, which may be caused by means of a surge of emergency admissions or a failure to deliver sufficient discharges, undermines the Trust’s ability to deliver to its operational standards and to care safely for individual patients in the correct environment. Assumptions are made that the Trust does not close for emergency admissions and will not be able to divert acute workload to another acute provider unless authorised by the Chief Operating Officer or Deputy Chief Operating Officer in hours and the ‘On Call Gold’ out of hours. This should only happen in accordance with escalation status and subsequent action cards.
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The objectives of escalation are:
To ensure the safe and clinically appropriate placement of patients requiring an acute inpatient bed at all times, in line with infection control and mixed sex policies.
To minimise any potential risk to patients in terms of waiting times and cancellations.
To ensure patient flow into and out of ED is maintained to reduce the risks associated with overcrowding.
To maximise performance against the ED four hour standard. Patients should only be placed in clinical accommodation that is appropriately staffed and equipped to manage their presenting condition and this must be supported with an appropriate Medical, Nursing and AHP infrastructure. It is also the responsibility for all the Divisional Management Team to manage their clinical activity within their own bed base and to establish, implement and manage their own Divisional plans for each level of escalation. It is important that the Trust is able to assure its healthcare partners that all internal measures have been taken before escalating to the highest escalation status. 6.3 Escalation triggers SFH uses a Black, Red, Amber and Green (BRAG) escalation framework; this is aligned to the NHS Operational Pressures Escalation Levels Framework (OPEL), see Appendix B. The Trust escalation framework is included at Appendix C, three or more conditions triggers the escalation level. During normal working the Trust will function on escalation level green, indicating that there are no significant issues expected within the next 24 hours. It is when the Trust enters escalation level amber that this policy comes into effect. At this point the Site Management Team, On Call Teams and Divisional Management Teams will need to employ actions, supported by this policy that will help to regain control over the Trust’s flow and capacity. 6.4 Escalation actions Expected responses to each escalation are detailed in the action cards at Appendix E. 6.5 Outlying patients In the circumstances of OPEL 1 or OPEL 2 escalation outlying will not be necessary to maintain effective patient flow. On days when OPEL 3 or OPEL 4 alert is declared wards are to identify at least 2 patients who, in could be safely outlied into another specialty ward. The outlying of patients in such circumstances should be robustly assessed to ensure patient safety and experience is not compromised; any decisions taken to oulie patients must be taken in line with the Trust Patient Outlier Policy (for adult patients). Medical outlier ward pairings are available on the intranet.
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A number of (specialty beds) are ring fenced and should not be used for outlying capacity unless at full capacity. These include:
Maternity
Paediatrics
2 x NIV (1 male bed, 1 female bed)
2 x Stroke (1 male bed, 1 female bed)
2 x #NoF (ward 12) (1 male bed, 1 female bed)
Elective Orthopaedics (ward 21)
Theatre recovery
Cath Labs
DCU (Day Case Unit) 6.6 Opening additional capacity Opening of additional beds requires progressively more resources, planning and managerial efforts. The decision to open additional capacity must not be undertaken lightly and will only be agreed by ‘Gold on Call’ through discussion with ‘Silver on Call’; consideration will be given to opening additional capacity will be made if the Trust is at escalation level OPEL 3 (RED) or OPEL 4 (BLACK). 6.7 Closing additional capacity When a decision is made to open beds or escalation areas a plan must also be in place for closing the beds or escalation area.
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7.0 MONITORING COMPLIANCE AND EFFECTIVENESS
Minimum Requirement
to be Monitored
(WHAT – element of compliance or effectiveness within the document
will be monitored)
Responsible Individual
(WHO – is going to monitor this element)
Process for Monitoring
e.g. Audit
(HOW – will this element be monitored (method
used))
Frequency of
Monitoring
(WHEN – will this element be monitored (frequency/
how often))
Responsible Individual or Committee/
Group for Review of Results
(WHERE – Which individual/ committee or group will this be reported to, in what format
(eg verbal, formal report etc) and by who)
Compliance with Action Cards Chief Operating Officer
Observation Ad hoc – quarterly as a minimum
Patient Flow Group Divisional Performance Review Group Meetings
Compliance with Capacity and Flow Meeting SOP
Chief Operating Officer
Observation Ad hoc – quarterly as a minimum
Patient Flow Group Divisional Performance Review Meetings
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8.0 TRAINING AND IMPLEMENTATION Training and implementation will be undertaken as follows:
Dissemination and cascade to all corporate teams via the Chief Operating Officer
Dissemination and cascade to all Clinical Divisions via the Patient Flow Group
All new staff participating in the Duty Nurse Manager, Silver and Gold on call rota will be trained in this policy by the Capacity and Flow Matron
The policy will be available on the Trust intranet under the Silver / Gold Resource page section
9.0 IMPACT ASSESSMENTS
This document has been subject to an Equality Impact Assessment, see completed form at Appendix G
This document has not been subject to an Environmental Impact Assessment 10.0 EVIDENCE BASE (Relevant Legislation/ National Guidance) AND RELATED
SFHFT DOCUMENTS Evidence Base:
Good practice guide: Focus on improving patient flow (NHS Improvement, July 2017) Related SFH Documents:
Major Incident Plan
Women’s and Children’s Escalation Policies
Emergency Department Escalation Policy
Infection Prevention and Control Policy
Patient Outlier policy
Ward pairings 11.0 KEYWORDS Bed Management; Gold; silver; bronze; on-call; Capacity and flow; Outlier; outlying; outlay; black alert; red; amber; escalate; ward pairings; 12.0 APPENDICES
Appendix A Capacity and Flow Meetings SOP
Appendix B OPEL Framework
Appendix C Trust Escalation Triggers
Appendix D Emergency Department Escalation Triggers
Appendix E Action Cards
Appendix F Additional Capacity
Appendix G Equality Impact Assessment
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APPENDIX A CAPACITY & FLOW MEETINGS STANDARD OPERATING PROCEDURE This SOP is a guide to the expectations and information to be discussed in each Capacity & Flow meeting. It does not exclude the raising of other issues and attendees should feel able to raise any issues that they are concerned about or need help with. The overall objective of these meetings is to ensure patient get safe access to the care that they need. In terms of meeting attendance it should be read in conjunction with the Trusts escalation policy. Etiquette – start on time, no use of phones, action oriented, no specific patient discussions unless repatriations or safety issue. Chair – dependent on escalation status, as detailed below:
Monday – Friday (excl Bank Holidays)
8.00am 11.00am 2.00pm 5.00pm
OPEL 1 COO / CAPACITY
AND FLOW MATRON
DUTY NURSE MANAGER
DUTY NURSE MANAGER
CAPACITY AND FLOW MATRON
OPEL 2 COO / CAPACITY
AND FLOW MATRON
CAPACITY & FLOW MATRON
CAPACITY & FLOW MATRON
CAPACITY AND FLOW MATRON
OPEL 3 COO / CAPACITY
AND FLOW MATRON
CAPACITY & FLOW MATRON
CAPACITY & FLOW MATRON
CAPACITY AND FLOW MATRON
OPEL 4 COO COO COO COO
Time Objective Running order/information
0800
Debrief from night shift
Agreed actions to be taken to maintain patient safety, experience and quality between 0800 and 1100 Capacity & Flow meeting
Review and agree escalation status – if the escalation is ‘Black’ then a plan to immediately unblock majors/resus will be discussed and agreed
All Divisions
Staffing risks for the day that cannot be managed within Division
EAU/SSU
No. of patients awaiting post-take on EAU
Overview of the 3 longest waiting patients for EAU in ED including the plan if no capacity available
Identification of patients who have been on EAU for over 24 hours identifying the specialty they are waiting for
Clarity on number of patients waiting for medicine including how many have booked beds
Medicine
Planned discharges (PDDs) for the day
Identification from the PDDs of the expect number who can go to the discharge lounge
PDDS requiring transport with clarity on how many are pre-booked
Overview of elective patients TCI for medicine
Plan for the movement of patients identified the day before by the Division for early discharge (golden patients)
Elective patients planned for medicine for the day
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Surgery
Confirmation of admitting capacity for SAU & Trauma – if there is not capacity clarity on plan to create admitting capacity
Elective patients scheduled for the day (DC/IP) including any identified for ITU
Womens & Childrens
Confirmation of admitting capacity for Gynae/Maternity/Paeds – if there is not capacity clarity on plan to create admitting capacity
Elective patients scheduled for the day (DC/IP) including any identified for ITU
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Time Objective Running order/information
1100
Follow up of actions agreed at 0800
Agreed actions to be taken to maintain patient safety, experience and quality between 0800 and 1100 Capacity & Flow meeting
Review and agree escalation status
All Divisions
Staffing risks for the day/night that cannot be managed within Division
Escalations for other Divisions (eg imaging, therapies)
Overview of repatriations in/out of the Trust Emergency department
Overview of the department including the status and plan for patients who breach in the next hour
Reporting of the waiting time to be seen and plans to reduce should it be in excess of 2 hours for majors
Clarification of capacity in resus/majors
Overview of ambulances currently waiting or that have been waiting in the past hour and whether they have been handed over before 30 minutes
Identification of what support if any is required EAU/SSU
Overview of the 3 longest waiting patients for EAU in ED including the plan if no capacity available
Identification of patients who have been on EAU for over 24 hours identifying the specialty they are waiting for
Clarity on number of patients waiting for medicine including how many have booked beds
Medicine
Clarity on patients discharged by 1100
Patients in the discharge lounge from medical base wards
Overview of potential discharges identifying what the patient needs to be discharged
Transport pre-booking and ambulance risks to be managed
Surgery
Confirmation of admitting capacity for SAU & Trauma – if there is not capacity clarity on plan to create admitting capacity
Confirmation of plan for any surgical/T&O patients in ED to be brought in prior to breach time
Confirmation of bed capacity for all elective patients Women’s & Children’s
Confirmation of admitting capacity for Gynaecology/Maternity/Paediatrics – if there is not capacity clarity on plan to create admitting capacity
Confirmation of plan for any Gynaecology/Paediatric patients in ED to be brought in prior to breach time
Confirmation of bed capacity for all elective patients Diagnostics & Outpatients
Pick up any escalations (eg imaging, therapies etc)
Infection control update (if required)
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Time Objective Running order/information
1400
Follow up of actions agreed at 1100
Agreed actions to be taken to maintain patient safety, experience and quality between 1500 & 1800 Capacity & Flow meeting
Review and agree escalation status
All Divisions
Staffing risks for the day/night that cannot be managed within Division
Escalations for other Divisions (eg imaging, therapies)
Overview of repatriations in/out of the Trust Emergency department
Overview of the department including the status and plan for patients who breach in the next hour
Reporting of the waiting time to be seen and plans to reduce should it be in excess of 2 hours for majors
Clarification of capacity in resus/majors
Overview of ambulances currently waiting or that have been waiting in the past hour and whether they have been handed over before 30 minutes
Identification of what support if any is required EAU/SSU
Overview of the 3 longest waiting patients for EAU in ED including the plan if no capacity available
Identification of patients who have been on EAU for over 24 hours identifying the specialty they are waiting for
Clarity on number of patients waiting for medicine including how many have booked beds
Medicine
Clarity on patients discharged by 1400
Number of patients in the discharge lounge from medical base wards including the total number through for medicine today so far
Overview of potential discharges identifying what the patient needs to be discharged
Transport pre-booking Surgery
Confirmation of admitting capacity for SAU & Trauma – if there is not capacity clarity on plan to create admitting capacity
Confirmation of plan for any surgical/T&O patients in ED to be brought in prior to breach time
Confirmation of bed capacity for all elective patients Women’s & Children’s
Confirmation of admitting capacity for Gynaecology/Maternity/Paediatrics – if there is not capacity clarity on plan to create admitting capacity
Confirmation of plan for any Gynaecology/Paediatric patients in ED to be brought in prior to breach time
Confirmation of bed capacity for all elective patients Diagnostics & Outpatients
Pick up any escalations (eg imaging, therapies etc)
Infection control update (if required)
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Time Objective Running order/information
1700
Follow up of actions agreed at 1400
Agree clear plan to give patients safe and quality access to beds for the night
Review and agree escalation status
All Divisions
Staffing risks for the night/day that cannot be managed within Division
Escalations for other Divisions (eg imaging, therapies) Emergency department
Overview of the department including the status and plan for breaches in the next hour
Reporting of the waiting time to be seen and plans to reduce should it be in excess of 2 hours for majors
Clarification of capacity in resus/majors
Overview of ambulances currently waiting or that have been waiting in the past hour and whether they have been handed over before 30 minutes
Identification of what support if any is required EAU/SSU
Overview of the 3 longest waiting patients for EAU in ED including the plan if no capacity available
Identification of patients who have been on EAU for over 24 hours identifying the specialty they are waiting for
Clarity on number of patients waiting for medicine including how many have booked beds
Medicine
Over view of forecast and clarity of plan for balance including any help required
Clarification of risks to discharge for the rest of the day (i.e. ‘re-beds’)
PDDs for the next day along with the number if pre-booked transport
Identification of patients for discharge before 1000 the following day (golden patients)
Review of elective patients TCI for medicine for the next day Surgery
Confirmation of admitting capacity for SAU & Trauma – if there is not capacity clarity on plan to create admitting capacity
Confirmation of plan for any surgical/T&O patients in ED to be brought in prior to breach time
Confirmation that all elective patients have either been admitted to beds or will have a bed available
Elective TCIs for tomorrow including the Day case/Inpatient split and any that need critical care
Women’s & Children’s
Confirmation of admitting capacity for Gynaecology/Maternity/Paediatrics – if there is not capacity clarity on plan to create admitting capacity
Confirmation of plan for any surgical/T&O patients in ED to be brought in prior to breach time
Confirmation that all elective patients have either been admitted to beds or will have a bed available
Elective TCIs for tomorrow including the Day case/Inpatient split and any that need critical care
Diagnostics & Outpatients
No required unless any issues to pick up
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Time Objective Running order/information
1945 – handover & bed state
Handover between Silvers (telephone)
DNM handover
Final days bed state
Confirmation of plan to maintain flow and patient safety overnight
Escalation and management of any staffing gaps
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APPENDIX B OPEL FRAMEWORK
NATIONAL DESCRIPTOR SUGGESTED TRIGGERS
GREEN (OPEL 1)
The local health and social care system capacity is such that organisations are able to maintain patient flow and are able to meet anticipated demand within available resources. The Local A&E Delivery Board area will take any relevant actions and ensure appropriate levels of commissioned services are provided. Additional support is not anticipated.
Demand for services within normal parameters
There is capacity available for the expected emergency and elective demand. No staffing issues identified
No technological difficulties impacting on patient care
Use of specialist units/beds/wards have capacity
Good patient flow through ED and other access points. Pressure on maintaining ED 4 hour target
Infection control issues monitored and deemed within normal parameters
AMBER (OPEL 2)
The local health and social care system is starting to show signs of pressure. The Local A&E Delivery Board will be required to take focused actions in organisations showing pressure to mitigate the need for further escalation. Enhanced co-ordination and communication will alert the whole system to take appropriate and timely actions to reduce the level of pressure as quickly as possible. Local systems will keep NHS E and NHS I colleagues at sub-regional level informed of any pressures, with detail and frequency to be agreed locally. Any additional support requirements should also be agreed locally if needed.
Anticipated pressure in facilitating ambulance handovers within 60 minutes
Insufficient discharges to create capacity for the expected elective and emergency activity
Opening of escalation beds likely (in addition to those already in use)
Infection control issues emerging
Lower levels of staff available, but are sufficient to maintain services
Lack of beds across the Trust
ED patients with DTAs and no action plan
Capacity pressures on PICU, NICU, and other intensive care and specialist beds (possibly including ECMO)
RED (OPEL 3)
The local health and social care system is experiencing major pressures compromising patient flow and continues to increase. Actions taken in OPEL 2 have not succeeded in returning the system to OPEL 1. Further urgent actions are now required across the system by all A&E Delivery Board partners, and increased external support may be required. Regional teams in NHS E and NHS I will be aware of rising system pressure, providing additional support as deemed appropriate and agreed locally. National team will also be informed by DCO/Sub-regional teams through internal reporting mechanisms
Actions at OPEL 2 failed to deliver capacity
Significant deterioration in performance against the ED 4 hour target (e.g. a drop of 10% or more in the space of 24 hours)
Patients awaiting handover from ambulance service within 60 minutes significantly compromised
Patient flow significantly compromised
Unable to meet transfer from Acute Hospitals within 48 hour timeframe
Awaiting equipment causing delays for a number of other patients
Significant unexpected reduced staffing numbers (due to e.g. sickness, weather conditions) in areas where this causes increased pressure on patient flow
Serious capacity pressures escalation beds and on PICU, NICU, and other intensive care and specialist beds (possibly including ECMO)
Problems reported with Support Services (IT, Transport, Facilities Pathology etc.) that can’t be rectified within 2 hours
BLACK (OPEL 4)
Pressure in the local health and social care system continues to escalate leaving organisations unable to deliver comprehensive care. There is increased potential for patient care and safety to be compromised. Decisive action must be taken by the Local A&E Delivery Board to recover capacity and ensure patient safety. All available local escalation actions taken, external extensive support and intervention required. Regional teams in NHS E and NHS I will be aware of rising system pressure, providing additional support as deemed appropriate and agreed locally, and will be actively involved in conversations with the system. Where multiple systems in different parts of the country are declaring OPEL 4 for sustained periods of time and there is an impact across local and regional boundaries, national action may be considered.
Actions at OPEL 3 failed to deliver capacity
No capacity across the Trust
Severe ambulance handover delays
Emergency care pathway significantly compromised
Unable to offload ambulances within 120 minutes
Unexpected reduced staffing numbers (due to e.g. sickness, weather conditions) in areas where this causes increased pressure on patient flow is at a level that compromises service provision / patient safety
Severe capacity pressures on PICU, NICU, and other intensive care and specialist beds (possibly including ECMO)
Infectious illness, Norovirus, Severe weather, and other pressures in Acute Trusts (including A&E handover breaches)
Problems reported with Support Services (IT, Transport, Facilities Pathology etc.) that can’t be rectified within 4 hours
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APPENDIX C TRUST ESCALATION TRIGGERS (Level will be determined by 3 or more indicators in a block triggering)
GREEN (OPEL 1) AMBER (OPEL 2) RED (OPEL 3) BLACK (OPEL 4)
EAU capacity ≥ 12
SAU capacity ≥ 6
EAU capacity ≥ 8
SAU capacity ≥ 4
EAU capacity ≥ 4
SAU capacity ≥ 2
No assessment or base ward capacity across the Trust
2 male & 2 female speciality beds in Cardiology, Stroke, NIV, #NOF
1 male & 1 female speciality beds in Cardiology, Stroke, NIV, #NOF
No speciality beds No speciality beds
Waiting lists placed Waiting lists placed Potential cancellation of routine, elective surgery
Routine, elective surgery suspended and risk of on the day cancellations
Sufficient capacity to meet predicted demand
Able to accommodate predicted demand through utilisation of all available capacity
Significant risk that available capacity will not meet predicted demand
Insufficient capacity to meet predicted demand and risk of patients waiting in ED overnight
No. of patients to step down ICCU ≤ 2
No. of patients to step down from ICCU 2 - 4
No. of patients to step down from ICCU ≥ 4
No Capacity or flow from ICCU
No extra capacity open No extra capacity open Extra capacity open due to bed pressures.
No further additional capacity to open
No outliers ≤ 5 outliers ≥ 8 patients outliers ≥ 16 outliers
Peripheral capacity utilised transfer list available
Peripheral capacity utilised – no list available.
Peripheral capacity utilised – long list waiting for beds/transfer
Peripheral capacity utilised – long list waiting for beds/transfer
No patients waiting for repatriation
Patients for repatriation waiting ≤ 48 hours
Patients waiting for repatriation ≥ 48 hours
Patients waiting for repatriation ≥ 48 hours
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APPENDIX D EMERGENCY DEPARTMENT ESCALATION TRIGGERS (Level will be determined by 3 or more indicators in a block
triggering)
GREEN (OPEL 1) AMBER (OPEL 2) RED (OPEL 3) BLACK (OPEL 4)
Presentations ≤ 15 in previous 2 hours
Presentations 15 – 20 in previous 2 hours
Presentations 20 – 25 in previous 2 hours
Presentations ≥ 25 in previous 2 hours
≤ 30 patients in department ≤ 50 patients in department 50 – 80 patients in department ≥ 80 patients in department
Longest wait to be seen 90 min Longest wait to be seen 120 min Longest wait to be seen 180 min Longest wait to be seen 240 min
Ambulance handover ≤ 30 min Ambulance handover 30 – 60 min Ambulance handover ≥ 60 min Ambulance handover ≥ 120 min
DTAs within 2 hours DTAs 2 – 3 hours DTAs – 4 hours DTAs 4 hours and over
Patients in resus ≤ 2 Patients in resus 3 - 4 Patients in resus 4 - 6 Patients in resus ≥ 6
No patients waiting for admission bed to any speciality
≤ 4 patients waiting for an admission bed in any given speciality within 4 hour window
≥ 5 patients waiting for an admission bed over 4 hours potential to breach 8 hours
≥ 10 patients waiting for an admission bed over 4 hours potential to breach 12 hours
Number of patients in streaming <5
Number of patients in streaming >5 - 10
Number of patients in streaming >10
Number of patients in streaming >10
No risk of 4 hour beaches, excluding clinical exceptions
Risk of 4 hour breaches Risk of 8 hour breaches Risk of 10 hour breaches
Number of patients in department <30
Number of patients in department 30 - 50
Number of patients in department 50 +
Number of patients in majors 30 + with no trolleys to hand over crews.
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APPENDIX E ACTION CARDS
CAPACITY AND FLOW MATRON
GREEN (OPEL 1)
NORMAL WORKING INCLUDING:
Chair the capacity and flow meetings at 8.00am and 5.00pm
Ensure fully staffed rota in place for the capacity and flow team to ensure DNM on site 24/7
Ensure there is a fully staffed rota in place to enable the collation of capacity and flow information to support decision making
Work with Divisional Bronzes to ensure that accurate and up to date information is maintained in the capacity and flow room, for example regarding admissions / discharges / patient transport / waiting lists / repatriations / external capacity
Support effective use of the discharge lounge
AMBER (OPEL 2)
AS ABOVE PLUS:
Chair the capacity and flow meetings at 11.00am and 2.00pm (in addition to 8.00am and 5.00pm)
Assess where pressure point exists (e.g. plenty of beds but long waiting times in ED) and escalate to relevant Divisional Bronze and / or Silver as appropriate
Escalate to Divisional Bronze any problems related to divisional patient flow which cannot be resolved within the capacity and flow team
Ensure that IDAT are providing information to be used to manage patient flow out to the peripheral capacity and any access issues for community/transfer to assess beds are fed through to the commissioning teams
Ensure that the Capacity and Flow Team are maintaining accurate overview of Trust capacity and patient discharge / transfers
Ensure there is accurate and up to date information regarding the number of patients going through the discharge lounge and understand any constraints.
Submit OPEL status to the CCG
Join 2.30pm system call as necessary
RED (OPEL 3)
AS ABOVE PLUS:
Ensure ‘Discharge Team’ contact Social Services, Call For Care and Community Intermediate Care Team to proactively remove patients out of the Hospital, MCH and Newark
During the management of extreme capacity pressure assume the point of contact for capacity for Division during normal working hours to enable the Duty Nurse Manager to support clinicians in the discharge of patients and freeing of capacity.
Work with Senior East Midlands Ambulance service (EMAS) representative to ensure that Ambulance flow is managed through ED.
Work with senior team in agreement and enactment of the contingency plans.
Ensure effective handover of contingency plans occur to the out of hour’s team.
BLACK (OPEL 4)
AS ABOVE PLUS:
Maintain contact with EMAS to effectively manage the pressures.
Maintain a complete and accurate evaluation of patient admission, discharge and transfers, to be readily available upon request.
Maintain overview of patient discharge/transfer of patients to inform if de-escalation can occur.
Obtain an action plan from all Divisions via DGMs / Clinical Chairs to create capacity.
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DUTY NURSE MANAGER
GREEN (OPEL 1)
NORMAL WORKING WHICH INCLUDES:
Chair the 11.00am and 2.00pm capacity and flow meetings
Record actions at the Capacity and Flow Meetings
Work with Divisional Bronzes to ensure an appropriate bed has been identified for all elective patients and there is emergency capacity available.
Ensure that the Discharge lounge has a list of predicted discharges to enable early flow from ward areas.
Work with the external providers to ensure repatriations have occurred as stated according to clinical need, infection control need.
Identify any blocks to patients flow (clinical or non-clinical) from admission to discharge and take appropriate action as necessary.
Liaise with NIC in ED/EAU to manage patient flow, agree immediate solution or plan for how long pressure is likely to incur. Escalate to ED NIC / Capacity and Flow Matron (Silver OOH) if pressure is likely to trigger an increase in escalation level
Support, as necessary, the ED NIC in managing avoidable delays that could result in a patient breach. Where necessary, agree actions with the ED NIC to resolve delays.
Identify any changes in hospital pressure or patient blocks within the system that could trigger an increased escalation level, work with Divisional Bronzes to plan for managing the pressure.
Escalate to capacity and flow Matron if any patients experience lengthy delays for psychiatric review in ED or EAU
Work with IDAT for an accurate picture of intermediate care beds for patient transfers.
To be aware of Infection Control issues within the Trust and community bed capacity. Ensure that patients are being placed appropriately and information is available during the Capacity and Flow Meetings around bed closures for infection reasons both within the Trust and outlying capacity.
Maintain an overview of patient waiting times in ED and ensure there is a clear plan to admit, discharge or transfer patients in a timely manner
Work with Medirest in identifying issues with cleaning of areas following infection/fogging /Portering Support and agree priorities with the Medirest Duty Manager.
Ensure accurate bed state available for each capacity and flow meeting
Ensure that support service heads e.g. Radiology, Pathology and Therapies are informed of current escalation and where appropriate agree a plan of action with the service.
AMBER (OPEL 2)
AS ABOVE PLUS:
Discuss with NIC in ED to identify flow issues and what further resource can be brought in to improve the situation.
Via Divisional Bronze, actively encourage utilisation of the discharge lounge during its opening hours
Identify any known constraints e.g. staffing, infection control and numbers of planned electives.
Assess where pressure point exists (e.g. plenty of beds but long waiting times in ED) and escalate to relevant Divisional Bronze
RED (OPEL 3)
AS ABOVE PLUS:
Via Divisional Bronze, ensure all clinical teams are aware of level of escalation and taking actions in line with their action cards
Ensure that PC24 are aware of level of escalation and understand capacity and capability to provide additional support
Contact Hospital Transport to discuss the prioritisation of inpatient discharges and ensure they follow their own escalation process in
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the event of capacity pressures
Ensure Silver on call/Matron for capacity and flow is kept informed of the plans/progress
Discuss with capacity and flow matron (Silver on call OOH) the potential requirement of escalation capacity and understand the state of readiness of this capacity (in line with SOP)
BLACK (OPEL 4)
AS ABOVE PLUS:
Maintain a complete and accurate evaluation of patient admission, discharge and transfers, to be readily available upon request.
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GOLD
THROUGHOUT Maintain oversight of Trust operational status and set any strategic objectives
GREEN (OPEL 1) NORMAL WORKING
AMBER (OPEL 2) NORMAL WORKING
RED (OPEL 3)
AS ABOVE PLUS:
Confirm and challenge Divisional plans if requested by capacity and flow matron (Silver OOH)
Consider rescheduling of elective admissions where appropriate
Consider utilisation of additional capacity
Consider outlying patients
Review any planned maintenance work where work is likely to impact on capacity or patient flow
Issue communications internally and externally, ensuring clinical leaders are aware and cascade to teams
Alert Social Care in conjunction with the CCG to expedite care packages
BLACK (OPEL 4)
AS ABOVE PLUS:
Chair Capacity and Flow Meetings
Ensure elective admissions have been reviewed and, where possible / appropriate, rescheduled or cancelled
Liaison with EMAS to request divert
Support Medical Director to rouse Consultants
Support Divisional Teams (walk areas in crisis)
Contact Chief Nurse and Medical Director to discuss Trust pressure
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SILVER
THROUGHOUT Maintain oversight of Trust demand, capacity, pressure points and escalation status Set any tactical actions
GREEN (OPEL 1)
NORMAL WORKING, INCLUDING:
Attend the 8.00am and 5.00pm capacity and flow meeting
AMBER (OPEL 2)
AS ABOVE PLUS:
Attend the 8.00am and 5.00pm capacity and flow meeting
Out of hours – see capacity and flow matron actions
RED (OPEL 3)
AS ABOVE PLUS:
Attend the 8.00am and 5.00pm capacity and flow meeting
Out of hours – see capacity and flow matron actions
BLACK (OPEL 4)
AS ABOVE PLUS:
Attend the 8.00am and 5.00pm capacity and flow meeting
Out of hours – see capacity and flow matron actions
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DIVISIONAL BRONZE - UEC
GREEN (OPEL 1)
NORMAL WORKING, INCLUDING:
Attend all Capacity and Flow Meetings, providing up to date information on flow positions and update of actions from previous meeting
AMBER (OPEL 2)
AS ABOVE PLUS:
Establish/collate any delays across division requiring resolution
Support with resolving delays to treatment / transfer / discharge
Support with resolving flow issues as identified during Bed Meetings.
Escalate issues to Specialty and Divisional Teams as required
Obtain list of patients meeting second criteria for SSU beds on EAU
Ensure ‘Board Rounds’ are completed (due twice a day)
Liaise with clinicians to support actions which maintain or restore patient flow.
RED (OPEL 3)
AS ABOVE PLUS:
Communicating information on ‘Alert Status’ and ‘Actions’ to staff and services within their Division
Ensure areas Action Cards are being followed
Work with Divisional Representatives to identify the patients who may be suitable for earlier discharge and ensuring appropriate Consultants are notified
Ensure consultants have reviewed patients who are query discharge promptly to see if can expedite their care/management plans
Ensure all patients reviewed by Senior Decision maker within 2 hours of admission (in hours 8am-8pm)
Identify any extra resources needed to help with transfers to expedite patient movement to and from EAU.
Review ‘Clinical Staff’ not currently based in clinical areas (i.e. Management Staff, Staff in training etc...) that could be redeployed to provide support to the response
BLACK (OPEL 4)
AS ABOVE PLUS:
Consider and identify staffing requirements for opening additional beds overnight/weekends on the discharge lounge.
Ensure all patients reviewed by Consultant prior to admission in hours. Middle Grades after hours.
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CLINICAL CHAIR – UEC *** Included within Divisional Leadership Action Card
GREEN (OPEL 1)
NORMAL WORKING INCLUDING:
AMBER (OPEL 2)
AS ABOVE PLUS:
RED (OPEL 3)
AS ABOVE PLUS:
BLACK (OPEL 4)
AS ABOVE PLUS:
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HEADS OF SERVICE - UEC
GREEN (OPEL 1)
NORMAL WORKING INCLUDING:
Be aware of Trust escalation status an ensure mechanisms in place within the service to cascade this to all clinical teams Emergency Department:
Ensure that senior streaming takes place
Ensure Emergency Care Standards are being followed
Acute Medicine:
Ensure that there is senior medical decision maker at the daily board round and that all clinical teams are working towards expected date of discharge (EDD)
Ensure that the principles of SHOP are followed on ward rounds
AMBER (OPEL 2)
AS ABOVE PLUS: Emergency Department:
Ensure that clinicians are using all possible methods for admission avoidance e.g. referring to AECU, Call for Care etc.
Advise UEC Bronze/Capacity and Flow team if there are any avoidable delays Acute Medicine:
Ensure that the medical teams are aware of all patients who are at their EDD and that activity is prioritised to facilitate discharge
Advise UEC Bronze/Capacity and Flow team if patients are at their EDD date but there are delays to discharge
Revisit patients who could be transferred to AECU to complete treatment before being discharged
Ensure that the medical teams identify patients who can be sent to SSU on second criteria
RED (OPEL 3)
AS ABOVE PLUS:
Consider cancellation of SPA activity to free up medical capacity to support patient flow and maintain safety
Consider the implications of a prolonged period of heightened escalation on all departments within the Division Emergency Department:
Consider prioritisation of patients requiring medical input. Holding a breach within ED for patients who may be able to be discharged later the same day to prioritise a patient requiring an extended period of acute medical input.
Acute Medicine:
A further senior review of patients will be requested. Along with the nurse in charge re-visit the board round to ensure that all plans each Consultant has put in place have been enacted and that patient discharge has been prioritised.
Any blocks to patient discharge are to be escalated immediately to UEC Bronze/Capacity and Flow team.
Identify patients that could be out lied within the hospital or to community setting e.g. transfer to assess or integrated care team.
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BLACK (OPEL 4)
AS ABOVE PLUS:
Gold on call will chair the capacity and flow meeting and may request attendance from senior decision makers as to what ward teams are doing to support the patient flow.
Stand down SPA activity (where appropriate) to free up medical capacity to support patient flow and maintain safety Emergency Department:
Ensure all admissions are screened by a consultant before admission (working with Acute Medicine as necessary) Acute Medicine:
Consider what additional medical support could be given to avoid admissions from ED
Consider post-taking of patients to occur within ED
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DIVISION OF URGENT AND EMERGENCY CARE
GREEN (OPEL 1)
NORMAL WORKING INCLUDING:
Be aware of the escalation level and pressure points within your area and ensure that all patient information has been communicated to the Flow coordinator/DNM as appropriate.
Ensure attendance of senior clinical decision makers at Board Rounds, EAU and Ward each morning. All patients should be discussed along with their EDD.
Ensure attendance of the Nurse in Charge of EAU to all the Capacity and Flow Meetings
Continually promote a culture to promote the discharge process from time of admission.
Monitor monthly capacity statistics and ensure relevant corrective action is taken where appropriate.
No bed should be left empty for longer than 30 minutes- empty beds should be communicated to the patient flow via vocera.
Ensure the DNM is provided with all information as appropriate.
AMBER (OPEL 2)
AS ABOVE PLUS:
Communicating information on ‘Alert Status’ and ‘Actions’ to staff and services within the Division
Supporting staff in the Division in their response
Ensure information has been made available for capacity and flow meetings as required
To ensure Lead Nurse/Shift Lead accurately and responsibly report all patient activity within their ward/areas to the Bed Management team without delay
Following communications from DNM ensure all ward Consultants have been contacted and Trust pressures discussed, report any identified issues to the Matron for Capacity and Flow or Silver on call.
Ensure all extra ordinary information is communicated via Lead Nurse/Shift Lead at Capacity Meetings i.e. Infection Control Outbreaks, staffing issues etc.
RED (OPEL 3)
AS ABOVE PLUS:
At least one member of the Divisional Leadership Team (Clinical Chair, DGM and/or HoN) to attend the Capacity and Flow Meeting (in hours) ensuring key messages / actions are cascaded to clinical teams
Clinical Chair to support any actions speaking to staff and clinical teams as required
Ensure areas Action Cards are being adhered to
Matrons to support clinical areas as required/needed e.g. assist in driving discharge plans for patients at ward level
Ensure patients have been identified for extra capacity areas as appropriate
Review ‘Clinical Staff’ not currently based in clinical areas (i.e. Management Staff, Staff in training etc...) that could be redeployed to provide support to the response
If staffing adequate (using all staff available through redeployment) create and co-ordinate ‘Transfer Teams’ to enable rapid movement of patients to ward beds.
Arrange review of any patients, who have not been seen by a Senior Decision maker within 2 hours
Ensure plans in place for all patients who are being discharged are actioned (Commissioning use of taxis, as appropriate to support
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increased discharges if ambulance service and third party providers cannot provide sufficient capacity)
HoN to ensure all appropriate ‘Discharges’ are moved to the discharge lounge.
Consider any requests or opportunities to provide mutual aid to other Divisions
Consider the implications of a prolonged period of heightened escalation on all departments within the Division
Consider cancellation of SPA activity to free up medical capacity to support patient flow and maintain safety
Lead the Divisional response to Full Capacity Protocol if implemented
BLACK (OPEL 4)
AS ABOVE PLUS:
Ensure all SPA activity is stood down across the Division to free up medical capacity to support patient flow and maintain safety
Contact all Medical Teams and Clinicians on SPA to review patients
Cancel ‘Training’ (as appropriate) to free up staff for clinical areas
Work with Clinical teams in your area to create capacity by expediting immediate discharges
Ensure immediate transfer of identified patients to the Discharge Lounge
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Acute Emergency Care Unit (AECU)
GREEN (OPEL 1)
NORMAL WORKING INCLUDING:
AECU to review white board and pull all appropriate patients from ED into AECU
AMBER (OPEL 2)
AS ABOVE PLUS:
Liaise with NIC on EAU and SSU to revisit patients who could be transferred to AECU to complete treatment before being discharged
RED (OPEL 3)
AS ABOVE PLUS:
A further senior review of patients will be requested. Along with the nurse in charge re-visit the board round to ensure that all plans each Consultant has put in place have been enacted and that patient discharge has been prioritised.
Any blocks to patient discharge are to be escalated immediately to UEC Bronze/Capacity and Flow team.
BLACK (OPEL 4)
AS ABOVE PLUS:
Consider cancelling planned activity to create capacity for non-elective activity from ED.
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EAU AND SSU
GREEN (OPEL 1)
NORMAL WORKING INCLUDING:
Nurse in Charge of EAU to attend all the Capacity and Flow Meetings
Nurse in Charge of SSU to attend 11am Capacity and Flow Meetings
Ensure that there is senior medical decision maker at the daily board round and that all clinical teams are working towards expected date of discharge (EDD)
Ensure that the principles of SHOP are followed on ward rounds
Ensure all patients who can attend the Discharge Lounge do so
Ensure flow is maintained by declaring beds within 15 minutes of becoming vacant.
Ensure actions arising from bed meetings are completed
Ensure juniors complete investigations and TTO’s in timely manner
AMBER (OPEL 2)
AS ABOVE PLUS:
Revisit patients who could be transferred to AECU to complete treatment before being discharged
Coordinate a re-review of all patients identifying possible patients for discharge
Expedite any investigations and highlight delays
RED (OPEL 3)
AS ABOVE PLUS:
EAU fill in only the important/bare minimum section the nursing admission documentation if the bed is available within the next few hours e.g. bed is assigned allowing the patient to leave ASAP freeing up the bed on EAU.
A further senior review of patients will be requested. Along with the nurse in charge re-visit the board round to ensure that all plans each Consultant has put in place have been enacted and that patient discharge has been prioritised.
Any blocks to patient discharge are to be escalated immediately to UEC Bronze/Capacity and Flow team.
Identify patients that could be out lied within the hospital or to community setting e.g. transfer to assess or integrated care team.
Consider any requests or opportunities to provide mutual aid to other Divisions
Consider the implications of a prolonged period of heightened escalation impacting on the ward, looking at resources and ensuring a staffing plan is in place
BLACK (OPEL 4)
AS ABOVE PLUS:
Provide additional medical support to avoid admissions from ED
Consider post-taking of patients to occur within ED
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Discharge Lounge
GREEN (OPEL 1)
NORMAL WORKING INCLUDING:
Pulling patients from wards, offering to collect, pack patients
Liaise with wards the day prior to discharge to arrange transfer time
AMBER (OPEL 2)
AS ABOVE PLUS:
Any delays to patient discharge are to be escalated immediately to UEC Bronze/Capacity and Flow team.
RED (OPEL 3)
AS ABOVE PLUS:
No additional specific actions
BLACK (OPEL 4)
AS ABOVE PLUS:
No additional specific actions
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Emergency Department
GREEN (OPEL 1)
NORMAL WORKING INCLUDING:
Ensure senior streaming is taking place
Ensure Emergency Care Standards are being followed
AMBER (OPEL 2)
AS ABOVE PLUS:
Liaise with UEC Bronze to escalate any delays/issues
RED (OPEL 3)
AS ABOVE PLUS:
Maximise use of Ambulatory areas Consultants overseeing patient selection where necessary
Review resourcing within the department e.g. consider asking doctors/ACPs/ENP/RN/HCAs to stay later beyond shift time.
Follow appropriate departmental escalation SOPs e.g. Greater than 3 hour wait to be seen
Review ‘Clinical Staff’ not currently based in clinical areas (i.e. Management Staff, Staff on SPA, Staff in training etc...) that could be redeployed to provide support to the response
NIC to attend the Capacity and Flow Meetings, ensuring key messages / actions are cascaded to clinical teams
Consider the implications of a prolonged period of heightened escalation on all departments within the Division
ED consultant to stay later and make a plan before leaving of what to do with middle grade, nurse in charge and site co-ordinator.
Articulate clearly what help is needed from within and external to the division e.g. Specialities to come and see appropriate patients i.e. Orthopaedic team to see hip injuries, ICU nurses can assist in resus and for transfers etc.
Review all patients on a trolley to ensure they are not ‘fit to sit’
Establish whether PC24 can support streaming at the front door
To ensure only urgent treatments are given within ED, ensuring patients are not delayed from transferring for non-urgent treatments that can take place on a ward
Utilise all existing/available space within Department e.g. including resus where appropriate
Consider prioritisation of patients requiring medical input. Holding a breach within ED for patients who may be able to be discharged later the same day to prioritise a patient requiring an extended period of acute medical input.
BLACK (OPEL 4)
AS ABOVE PLUS:
Ensure all admissions are screened by a consultant before admission (working with Acute Medicine as necessary)
Ensure all clinical staff on none clinical duties support patient flow and maintain safety
Review and arrange requirements for patients staying in the department for extended periods of time e.g. obtaining physical beds to transfer from trolleys, staff identified to enable care and comfort rounds etc.
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DIVISIONAL BRONZE - Medicine
GREEN (OPEL 1)
NORMAL WORKING, INCLUDING:
Attend all Capacity and Flow Meetings, to manage actions and update of actions from previous meeting
Collate golden patient and TCI list for next day
AMBER (OPEL 2)
AS ABOVE PLUS:
Attend all Capacity and Flow Meetings, to manage actions and update of actions from previous meeting
Eliminate any blockages to discharge
Escalate issues to Specialty and Divisional Teams
Obtain list of patients to be ‘Outlied’ from Specialty Wards
Ensure all patients reviewed by senior decision maker within 12 hours of admission
Identify any ward beds not used and consider opening additional beds overnight/weekends
Ensure additional ‘Board Rounds’ are completed
RED (OPEL 3)
AS ABOVE PLUS:
Communicating information on ‘Alert Status’ and ‘Actions’ to staff and services within their Division
Work with Divisional Representatives to identify the patients who may be suitable for earlier than discharge and ensuring appropriate Consultants are notified
Ensure all patients reviewed by Senior Decision maker within 2 hours of admission
Collate list of TCI’s for the remainder of the day and following day
BLACK (OPEL 4)
AS ABOVE PLUS:
Ensure all patients reviewed by Consultant prior to admission
Ensure additional bed stock is opened and safely staffed
Routine elective admissions are likely to have been cancelled and urgent elective admissions must be reviewed
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CLINICAL CHAIR - Medicine
GREEN (OPEL 1)
NORMAL WORKING INCLUDING:
Be aware of Trust escalation status and ensure mechanisms in place within Division to cascade this to all clinical teams
AMBER (OPEL 2)
AS ABOVE PLUS:
Ensure service line actions are being completed, including any additional actions arising from Capacity and Flow Meetings
RED (OPEL 3)
AS ABOVE PLUS:
Attend the Capacity and Flow Meetings, ensuring key messages / actions are cascaded to clinical teams
Consider any requests or opportunities to provide mutual aid to other Divisions
Consider the implications of a prolonged period of heightened escalation on all departments within the Division
In conjunction with Gold, review elective activity, including clinical prioritisation
Consider cancellation of SPA activity to free up medical capacity to support patient flow and maintain safety
Lead the Divisional response to Full Capacity Protocol if implemented
BLACK (OPEL 4)
AS ABOVE PLUS:
Ensure all SPA activity is stood down across the Division to free up medical capacity to support patient flow and maintain safety
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HEADS OF SERVICE - Medicine
GREEN (OPEL 1)
NORMAL WORKING INCLUDING:
Be aware of Trust escalation status an ensure mechanisms in place within the service to cascade this to all clinical teams
Ensure that there is senior medical decision maker at the daily board round and that all clinical teams are working towards expected date of discharge (EDD)
Ensure that there is a mechanism for pulling patients through from the admission areas who are waiting for beds on your ward (SHOP, Review of Results, Admission Avoidance)
AMBER (OPEL 2)
AS ABOVE PLUS:
Ensure the team the medical teams are aware of all patients who are at their EDD and that activity is prioritised to facilitate discharge.
Advise capacity and flow team if patients are at their EDD date but there are delays to discharge.
Be aware of patients requiring admission to ward for procedures or planned admission
Revisit patients who are waiting for on-going investigation as to whether this could be done as an outpatient.
Ensure all electives are identified to Duty Nurse Manager
RED (OPEL 3)
AS ABOVE PLUS:
A further senior review of patients will be requested. Along with the nurse in charge re-visit the board round to ensure that all plans each Consultant has put in place have been enacted and that patient discharge has been prioritised.
Any blocks to patient discharge are to be escalated immediately to patient Flow Coordinators or DNM.
Identify patients that could be out lied within the hospital or to community setting e.g. transfer to assess or integrated care team.
Review capacity for on the ward procedures and determine whether the procedure can wait or be done in an alternate setting
BLACK (OPEL 4)
AS ABOVE PLUS:
A further senior review of patients will be requested. Together with the nurse in charge, revisit the board round to ensure that all plans you have put in place have been enacted and that patient discharge has been prioritised
Identify patients that could be out lied within the hospital or to community setting e.g. transfer to assess
Gold on call will chair the capacity and flow meeting and may request attendance from senior decision makers as to what ward teams are doing to support the patient flow
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DIVISION OF MEDICINE
GREEN (OPEL 1)
NORMAL WORKING INCLUDING:
Be aware of the escalation level and pressure points within your area and ensure that all patient information has been communicated to the Flow coordinator/DNM as appropriate.
Ensure attendance of senior clinical decision makers at the Board Round each morning- all patients should be discussed along with EDD.
Continually promote a culture to promote the discharge process from time of admission.
Monitor monthly capacity statistics and ensure relevant corrective action is taken where appropriate.
Develop and communicate plan for your ward.
No bed should be left empty for longer than 30 minutes- empty beds should be communicated to the patient flow via vocera.
Ensure the DNM is provided with all information as appropriate.
AMBER (OPEL 2)
AS ABOVE PLUS:
Communicating information on ‘Alert Status’ and ‘Actions’ to staff and services within the Division
Supporting staff in the Division’s in their response
Ensure ward information has been made available for capacity and flow meetings.
To ensure Lead Nurse/Shift Lead accurately and responsibly report all patient activity within their ward/areas to the Bed Management team without delay
Following communications from DNM ensure all ward Consultants have been contacted and Trust pressures discussed, report any identified issues to the Matron for capacity and flow or Silver on call.
Ensure all extra ordinary information is communicated via Lead Nurse/Shift Lead at Capacity Meetings i.e. Infection Control Outbreaks, staffing issues etc.
Plan required for the next morning
RED (OPEL 3)
AS ABOVE PLUS:
Clinical Chair, DGM and HoN to attend the Capacity and Flow Meeting (in hours)
Identify patients suitable for extra capacity areas
Review ‘Clinical Staff’ not currently based in clinical areas (i.e. Management Staff, Staff in training etc...) that could be redeployed to provide support to the response.
If staffing adequate (using all staff available through redeployment) create a ‘Transfer Team’ to enable rapid movement of patients to ward beds.
All Consultants requested to ensure patients have been reviewed for discharge and identified for the management of outliers in the preceding 8 hours, arrange review of any patients, who have not been seen by a Senior Decision maker within 2 hours
Ensure plans in place for all patients who are being discharged are actioned within two hours (Commissioning use of taxis, as appropriate to support increased discharges if ambulance service and third party providers cannot provide sufficient capacity)
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Ensure SpRs provide support needed to ED
At the request of Gold, cancel elective activity to free up staff to support patient flow and maintain patient safety
BLACK (OPEL 4)
AS ABOVE PLUS:
Contact all Medical Teams and Clinicians on SPA to review patients
Cancel any training to free up staff for clinical areas
SpRs and Consultants on site to liaise closely with ED to provide support
Work with Clinical teams in your area to create capacity by expediting immediate discharges.
Ensure immediate transfer of identified patients to the Discharge Lounge.
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DIVISION OF MEDICINE WARD ACTIONS
GREEN (OPEL 1)
NORMAL WORKING INCLUDING:
Be aware of the escalation level and pressure points within your area and ensure that all patient information has been communicated to the Flow coordinator/DNM as appropriate.
Ensure attendance of senior clinical decision makers at the Board Round each morning- all patients should be discussed along with EDD.
Continually promote a culture to promote the discharge process from time of admission.
Identify golden patients and two potential outliers on each board round
No bed should be left empty for longer than 30 minutes- empty beds should be communicated to the patient flow via vocera.
AMBER (OPEL 2)
AS ABOVE PLUS:
Communicating information on ‘Alert Status’ and ‘Actions’ to staff and services within the Division
Supporting staff in the Division’s in their response
Ensure ward information has been made available for capacity and flow meetings.
To ensure Lead Nurse/Shift Lead accurately and responsibly report all patient activity within their ward/areas to the Bed Management team without delay
Following communications from DNM ensure all ward Consultants have been contacted and Trust pressures discussed, report any identified issues to the Matron for capacity and flow or Silver on call.
Ensure all extra ordinary information is communicated via Lead Nurse/Shift Lead at Capacity Meetings i.e. Infection Control Outbreaks, staffing issues etc.
Plan required for the next morning
RED (OPEL 3)
AS ABOVE PLUS:
Clinical Chair, DGM and HoN to attend the Capacity and Flow Meeting (in hours)
Clinicians will be asked to prioritise reviewing unwell patients first followed by golden patients and potential discharges prior to starting normal patient reviews or ward rounds
Immediate prescribing of TTOS
Identify and make clear plans for patients suitable for criteria led / nurse led discharges
Identify a minimum of 2 patients suitable to outlie into extra capacity areas
Review ‘Clinical Staff’ not currently based in clinical areas (i.e. Management Staff, Staff in training etc...) that could be redeployed to provide support to the response.
All Consultants requested to ensure patients have been reviewed for discharge and arrange review of any patients, who have not been seen by a Senior Decision maker within 2 hours
Ensure plans in place for all patients who are being discharged are actioned within two hours (Commissioning use of taxis, as appropriate to support increased discharges if ambulance service and third party providers cannot provide sufficient capacity)
Ensure SpRs provide support needed to ED
At the request of Gold, cancel elective activity to free up staff to support patient flow and maintain patient safety
Title: Adult Patient Flow and Escalation Policy Version: 2.0 Issued: November 2018 Page 41 of 60
BLACK (OPEL 4)
AS ABOVE PLUS:
Contact all Medical Teams and Clinicians on SPA to review patients
Cancel any training to free up staff for clinical areas
SpRs and Consultants on site to liaise closely with ED to provide support
Work with Clinical teams in your area to create capacity by expediting immediate discharges.
Ensure immediate transfer of identified patients to the Discharge Lounge.
Title: Adult Patient Flow and Escalation Policy Version: 2.0 Issued: November 2018 Page 42 of 60
DIVISIONAL BRONZE - SURGERY
GREEN (OPEL 1)
NORMAL WORKING, INCLUDING:
Attend all Capacity and Flow Meetings, providing up to date information on flow positions and update of actions from previous meeting
Collate list of TCI’s for the remainder of the day and following day
AMBER (OPEL 2)
AS ABOVE PLUS:
Eliminate any blockages to discharge
Escalate issues to Specialty and Divisional Teams
Revisit patients who are waiting for on-going investigation as to whether this could be done as an outpatient.
Ensure all patients reviewed by senior decision maker within 12 hours of admission
RED (OPEL 3)
AS ABOVE PLUS:
Communicating information on ‘Alert Status’ and ‘Actions’ to staff and services within their Division
Work with Divisional Representatives to identify the patients who may be suitable for earlier than discharge and ensuring appropriate Consultants are notified
Ensure additional ‘Board Rounds’ are completed
Obtain list of patients to be ‘Outlied’ from Specialty Wards
Ensure all patients reviewed by Senior Decision maker within 8 hours of admission
Identify staffing for any ward stock not used and consider opening additional beds overnight/weekends
BLACK (OPEL 4)
AS ABOVE PLUS:
Ensure all patients reviewed by Consultant prior to admission
Ensure additional bed stock is opened and safely staffed
Review Routine elective admissions with consideration of cancellation to free staff
Ensure all patients reviewed by Senior Decision maker within 2 hours of admission
Title: Adult Patient Flow and Escalation Policy Version: 2.0 Issued: November 2018 Page 43 of 60
CLINICAL CHAIR - SURGERY
GREEN (OPEL 1)
NORMAL WORKING INCLUDING:
Be aware of Trust escalation status and ensure mechanisms in place within Division to cascade this to all clinical teams
AMBER (OPEL 2)
AS ABOVE PLUS:
Ensure service line actions are being completed, including any additional actions arising from Capacity and Flow Meetings
RED (OPEL 3)
AS ABOVE PLUS:
Consider any requests or opportunities to provide mutual aid to other Divisions
Consider the implications of a prolonged period of heightened escalation on all departments within the Division
Lead the Divisional response to Full Capacity Protocol if implemented
BLACK (OPEL 4)
AS ABOVE PLUS:
Consider SPA activity being stood down across the Division to free up medical capacity to support patient flow and maintain safety
In conjunction with the DMT and Gold, review elective activity, including clinical prioritisation
Title: Adult Patient Flow and Escalation Policy Version: 2.0 Issued: November 2018 Page 44 of 60
HEADS OF SERVICE - SURGERY
GREEN (OPEL 1)
NORMAL WORKING INCLUDING:
Be aware of Trust escalation status an ensure mechanisms in place within the service to cascade this to all clinical teams
Ensure that there is a mechanism for pulling patients through from the admission areas who are waiting for beds on your ward (SHOP, Review of Results, Admission Avoidance)
AMBER (OPEL 2)
AS ABOVE PLUS:
Ensure the team the medical teams are aware of all patients who are at their EDD and that activity is prioritised to facilitate discharge.
RED (OPEL 3)
AS ABOVE PLUS:
A further senior review of patients will be requested. Along with the nurse in charge re-visit the board round to ensure that all plans each Consultant has put in place have been enacted and that patient discharge has been prioritised.
Ensure that there is senior medical decision maker at the daily board round and that all clinical teams are working towards expected date of discharge (EDD)
Any blocks to patient discharge are to be escalated immediately to patient Flow Coordinators or DNM.
Identify patients that could be out lied within the hospital or to community setting e.g. transfer to assess or integrated care team.
Review capacity for on the ward procedures and determine whether the procedure can wait or be done in an alternate setting.
BLACK (OPEL 4)
AS ABOVE PLUS:
A further senior review of patients will be requested. Together with the nurse in charge, revisit the board round to ensure that all plans you have put in place have been enacted and that patient discharge has been prioritised.
Gold on call will chair the capacity and flow meeting and may request attendance from senior decision makers as to what ward teams are doing to support the patient flow.
Title: Adult Patient Flow and Escalation Policy Version: 2.0 Issued: November 2018 Page 45 of 60
DIVISION OF SURGERY
GREEN (OPEL 1)
NORMAL WORKING INCLUDING:
Be aware of the escalation level and pressure points within your area and ensure that all patient information has been communicated to the Flow coordinator/DNM as appropriate.
Continually promote a culture to promote the discharge process from time of admission.
Monitor monthly capacity statistics and ensure relevant corrective action is taken where appropriate.
Ensure the DNM is provided with all information as appropriate.
AMBER (OPEL 2)
AS ABOVE PLUS:
Communicating information on ‘Alert Status’ and ‘Actions’ to staff and services within the Division
Supporting staff in the Division’s in their response
RED (OPEL 3)
AS ABOVE PLUS:
A member of the DMT to attend the Capacity and Flow Meeting (in hours)
Ensure attendance of senior clinical decision makers at the Board Round each morning- all patients should be discussed along with EDD.
Identify patients suitable for extra capacity areas
Review ‘Clinical Staff’ not currently based in clinical areas (i.e. Management Staff, Staff in training etc...) that could be redeployed to provide support.
If staffing adequate (using all staff available through redeployment) create a ‘Transfer Team’ to enable rapid movement of patients from ward beds or from assessment unit to ward beds.
All Consultants requested to ensure patients have been reviewed for discharge in the preceding 8 hours
Ensure plans in place for all patients who are being discharged are actioned within two hours (Commissioning use of taxis, as appropriate to support increased discharges if ambulance service and third party providers cannot provide sufficient capacity)
Divisional Nurses to ensure all patients for discharge are moved to the discharge lounge where the patient meets the discharge lounge criteria
Consider for all patients whether outpatient follow up and on-going management would be clinically safe and appropriate
BLACK (OPEL 4)
AS ABOVE PLUS:
A member of the DMT to attend the Capacity and Flow Meeting (in hours)
Contact all Medical Teams and Clinicians to review patients
Review training and SPA to free up staff for clinical areas
SpRs and Consultants on site to liaise closely with ED to provide support
Title: Adult Patient Flow and Escalation Policy Version: 2.0 Issued: November 2018 Page 46 of 60
DIVISION OF SURGERY WARD ACTIONS
GREEN (OPEL 1)
NORMAL WORKING INCLUDING:
Nurse in charge to be aware of the escalation level and pressure points within your area and ensure that all patient information has been communicated to the divisional Bronze and Flow coordinator/DNM as appropriate.
Ensure Daily Board Round each morning- all patients should be discussed. Escalate any issues to divisional Bronze and Flow coordinator/DNM as appropriate.
Promote a culture where the discharge process from time of admission.
Ensure Transport is booked for any patients with an expected discharge date & Utilise Discharge lounge for all appropriate patients.
Ensure any staffing shortfalls using Safecare are escalated to the respective Matron.
AMBER (OPEL 2)
AS ABOVE PLUS:
Ensure ward information has been made available for capacity and flow meetings.
To ensure Nurse in charge (NIC) accurately reports all patient activity within their ward/areas to the Bed Management team.
Ensure any extra ordinary information is escalate to divisional Bronze and Flow coordinator/DNM as appropriate to be discussed at Capacity Meetings i.e. Infection Control Outbreaks, staffing issues etc.
RED (OPEL 3)
AS ABOVE PLUS:
Clinicians will be asked to prioritise reviewing unwell patients first followed by potential discharges prior to starting normal patient reviews or ward rounds
Request Drs to prescribe of TTOS as decision made to discharge time.
Review ‘Clinical Staff’ not currently based in clinical areas that could be redeployed to provide support to the response.
Ensure plans in place for all patients who are being discharged are actioned within two hours
BLACK (OPEL 4)
AS ABOVE PLUS:
After the request of Gold, be prepared to speak to patients and inform them if their surgery has been cancelled.
Consider Cancelling any training/meeting to free up staff for clinical areas to provide support if required.
Title: Adult Patient Flow and Escalation Policy Version: 2.0 Issued: November 2018 Page 47 of 60
DIVISIONAL BRONZE – WOMEN AND CHILDREN’S
GREEN (OPEL 1)
NORMAL WORKING, INCLUDING:
Attendance at the 8am and 5pm Capacity and Flow Meetings
AMBER (OPEL 2)
AS ABOVE PLUS:
Attend all Capacity and Flow Meetings, providing up to date information on flow positions and update of actions from previous meeting
Eliminate any blockages to discharge
Escalate issues to Specialty and Divisional Teams
Obtain list of patients to be ‘Outlied’ from Specialty Wards
Ensure all patients reviewed by senior decision maker within 12 hours of admission
Identify any ward beds not used and consider opening additional beds overnight/weekends
Ensure additional ‘Board Rounds’ are completed
RED (OPEL 3)
AS ABOVE PLUS:
Communicating information on ‘Alert Status’ and ‘Actions’ to staff and services within their Division
Work with Divisional Representatives to identify the patients who may be suitable for earlier than discharge and ensuring appropriate Consultants are notified
Ensure all patients reviewed by Senior Decision maker within 2 hours of admission
Identify staffing for any ward stock not used and consider opening additional beds overnight/weekends
Collate list of TCI’s for the remainder of the day and following day
BLACK (OPEL 4)
AS ABOVE PLUS:
Ensure all patients reviewed by Consultant prior to admission
Ensure additional bed stock is opened and safely staffed
Routine elective admissions are likely to have been cancelled and urgent elective admissions must be reviewed
Title: Adult Patient Flow and Escalation Policy Version: 2.0 Issued: November 2018 Page 48 of 60
CLINICAL CHAIR – WOMEN AND CHILDREN’S
GREEN (OPEL 1)
NORMAL WORKING INCLUDING:
Be aware of Trust escalation status and ensure mechanisms in place within Division to cascade this to all clinical teams
AMBER (OPEL 2)
AS ABOVE PLUS:
Ensure service line actions are being completed, including any additional actions arising from Capacity and Flow Meetings
RED (OPEL 3)
AS ABOVE PLUS:
Attend the Capacity and Flow Meetings, ensuring key messages / actions are cascaded to clinical teams
Consider any requests or opportunities to provide mutual aid to other Divisions
Consider the implications of a prolonged period of heightened escalation on all departments within the Division
In conjunction with Gold, review elective activity, including clinical prioritisation
Consider cancellation of SPA activity to free up medical capacity to support patient flow and maintain safety
Lead the Divisional response to Full Capacity Protocol if implemented
BLACK (OPEL 4)
AS ABOVE PLUS:
Ensure all SPA activity is stood down across the Division to free up medical capacity to support patient flow and maintain safety
Title: Adult Patient Flow and Escalation Policy Version: 2.0 Issued: November 2018 Page 49 of 60
HEADS OF SERVICE – WOMEN AND CHILDREN’S
GREEN (OPEL 1)
NORMAL WORKING INCLUDING:
Be aware of Trust escalation status an ensure mechanisms in place within the service to cascade this to all clinical teams
Ensure that there is senior medical decision maker at the daily board round and that all clinical teams are working towards expected date of discharge (EDD)
Ensure that there is a mechanism for pulling patients through from the admission areas who are waiting for beds on your ward (SHOP, Review of Results, Admission Avoidance)
AMBER (OPEL 2)
AS ABOVE PLUS:
Ensure the team the medical teams are aware of all patients who are at their EDD and that activity is prioritised to facilitate discharge.
Advise capacity and flow team if patients are at their EDD date but there are delays to discharge.
Be aware of patients requiring admission to ward for procedures or planned admission
Revisit patients who are waiting for on-going investigation as to whether this could be done as an outpatient.
Ensure all electives are identified to Duty Nurse Manager
RED (OPEL 3)
AS ABOVE PLUS:
A further senior review of patients will be requested. Along with the nurse in charge re-visit the board round to ensure that all plans each Consultant has put in place have been enacted and that patient discharge has been prioritised.
Any blocks to patient discharge are to be escalated immediately to patient Flow Coordinators or DNM.
Identify patients that could be out lied within the hospital or to community setting e.g. transfer to assess or integrated care team.
Review capacity for on the ward procedures and determine whether the procedure can wait or be done in an alternate setting.
BLACK (OPEL 4)
AS ABOVE PLUS:
A further senior review of patients will be requested. Together with the nurse in charge, revisit the board round to ensure that all plans you have put in place have been enacted and that patient discharge has been prioritised.
Identify patients that could be out lied within the hospital or to community setting e.g. transfer to assess.
Gold on call will chair the capacity and flow meeting and may request attendance from senior decision makers as to what ward teams are doing to support the patient flow.
Title: Adult Patient Flow and Escalation Policy Version: 2.0 Issued: November 2018 Page 50 of 60
DIVISION OF WOMEN AND CHILDREN’S
GREEN (OPEL
1)
NORMAL WORKING INCLUDING:
Be aware of the escalation level and pressure points within your area and ensure that all patient information has been communicated to the Flow coordinator/DNM as appropriate.
Ensure attendance of senior clinical decision makers at the Board Round each morning- all patients should be discussed along with EDD.
Continually promote a culture to promote the discharge process from time of admission.
Monitor monthly capacity statistics and ensure relevant corrective action is taken where appropriate.
Develop and communicate plan for your ward.
No bed should be left empty for longer than 30 minutes- empty beds should be communicated to the patient flow via vocera.
Ensure the DNM is provided with all information as appropriate.
AMBER (OPEL
2)
AS ABOVE PLUS:
Communicating information on ‘Alert Status’ and ‘Actions’ to staff and services within the Division
Supporting staff in the Division’s in their response
Ensure ward information has been made available for capacity and flow meetings.
To ensure Lead Nurse/Shift Lead accurately and responsibly report all patient activity within their ward/areas to the Bed Management team without delay
Following communications from DNM ensure all ward Consultants have been contacted and Trust pressures discussed, report any identified issues to the Matron for capacity and flow or Silver on call.
Ensure all extra ordinary information is communicated via Lead Nurse/Shift Lead at Capacity Meetings i.e. Infection Control Outbreaks, staffing issues etc.
Plan required for the next morning
RED (OPEL
3)
AS ABOVE PLUS:
DGM or HoN to attend the Capacity and Flow Meeting (in hours)
Identify patients suitable for extra capacity areas
Review ‘Clinical Staff’ not currently based in clinical areas (i.e. Management Staff, Staff in training etc...) that could be redeployed to provide support to the response.
If staffing adequate (using all staff available through redeployment) create a ‘Transfer Team’ to enable rapid movement of patients to ward beds.
All Consultants requested to ensure patients have been reviewed for discharge and identified for the management of outliers in the preceding 8 hours, arrange review of any patients, who have not been seen by a Senior Decision maker within 2 hours
Ensure plans in place for all patients who are being discharged are actioned within two hours (Commissioning use of taxis, as appropriate to support increased discharges if ambulance service and third party providers cannot provide sufficient capacity)
Divisional Nurses to ensure all ‘Discharges’ are moved to the discharge lounge.
Ensure SpRs provide support needed to ED
At the request of Gold, cancel elective activity to free up staff to support patient flow and maintain patient safety
Title: Adult Patient Flow and Escalation Policy Version: 2.0 Issued: November 2018 Page 51 of 60
BLACK (OPEL
4)
AS ABOVE PLUS:
Contact all Medical Teams and Clinicians on SPA to review patients
Cancel any training to free up staff for clinical areas
SpRs and Consultants on site to liaise closely with ED to provide support
Work with Clinical teams in your area to create capacity by expediting immediate discharges.
Ensure immediate transfer of identified patients to the Discharge Lounge.
Title: Adult Patient Flow and Escalation Policy Version: 2.0 Issued: November 2018 Page 52 of 60
Ward 25 – Acute Paediatrics
GREEN (OPEL 1)
NORMAL WORKING INCLUDING:
Review white board and pull all appropriate patients from ED
AMBER (OPEL 2)
AS ABOVE PLUS:
Liaise with NIC on Ward 25 to review all EDD’s to ensure there is appropriate flow and capacity
RED (OPEL 3)
AS ABOVE PLUS:
A further senior review of patients will be requested. Along with the nurse in charge re-visit the board round to ensure that all plans each Consultant has put in place have been enacted and that patient discharge has been prioritised.
Any blocks to patient discharge are to be escalated immediately to UEC Bronze/Capacity and Flow team.
BLACK (OPEL 4)
AS ABOVE PLUS:
Consider cancelling planned activity to create capacity for non-elective activity from ED.
Title: Adult Patient Flow and Escalation Policy Version: 2.0 Issued: November 2018 Page 53 of 60
Ward 14 – Gynaecology
GREEN (OPEL 1)
NORMAL WORKING INCLUDING:
Review white board and pull all appropriate patients from ED
AMBER (OPEL 2)
AS ABOVE PLUS:
Liaise with NIC on Ward 14 to review all EDD’s to ensure there is appropriate flow and capacity
RED (OPEL 3)
AS ABOVE PLUS:
A further senior review of patients will be requested. Along with the nurse in charge re-visit the board round to ensure that all plans each Consultant has put in place have been enacted and that patient discharge has been prioritised.
Any blocks to patient discharge are to be escalated immediately to UEC Bronze/Capacity and Flow team.
BLACK (OPEL 4)
AS ABOVE PLUS:
Consider cancelling planned activity to create capacity for non-elective activity from ED.
Title: Adult Patient Flow and Escalation Policy Version: 2.0 Issued: November 2018 Page 54 of 60
DIVISIONAL BRONZE – D&O
GREEN (OPEL 1)
NORMAL WORKING, INCLUDING:
Attendance at the 8am, 11am and 2 pm Capacity and Flow Meetings. To attend 5pm meeting if Divisional issues requiring escalation.
Expedite any imaging, diagnostics, pharmacy or therapy issues delaying discharges or flow
Escalation to flow meeting of areas of concern or potential risk
AMBER (OPEL 2)
AS ABOVE PLUS:
Attend Capacity and Flow Meetings as above
Continue to escalate any issues impacting on flow or discharges
Prioritise ward and ED patients as requested to support flow.
RED (OPEL 3)
AS ABOVE PLUS:
Communicate information on ‘Alert Status’ and ‘Actions’ to staff and services within their Division
Escalate to Divisional Management teams to consider relocating Therapy and Pharmacy staff to support ED and TTOs, additional diagnostics and releasing OP staff to those areas
Ward Therapists to prioritise discharges
Ward therapists escalate to Therapy managers any issues blocking discharges to seek solutions and escalate to other agencies
BLACK (OPEL 4)
AS ABOVE PLUS:
Attend 5pm Capacity and Flow meeting
Explore with HoN and OPD Matron if additional staff available in OPD to support wards
Escalate to Divisional Management team- consideration of cancellations of OPD activity
Escalate to Divisional Management team support staff working extended hours to support flow
Explore with HoN and Therapy managers cancellation of therapy OPD to support wards
Title: Adult Patient Flow and Escalation Policy Version: 2.0 Issued: November 2018 Page 55 of 60
CLINICAL CHAIR – D&O
GREEN (OPEL 1)
NORMAL WORKING INCLUDING:
Be aware of Trust escalation status and ensure mechanisms in place within Division to cascade this to all clinical teams if necessary
AMBER (OPEL 2)
AS ABOVE PLUS:
Bronze to escalate to Clinical chair issues requiring their support to resolve)
RED (OPEL 3)
AS ABOVE PLUS:
Consider any requests or opportunities to provide mutual aid to other Divisions
Consider the implications of a prolonged period of heightened escalation on all departments within the Division
Consider cancellation of SPA activity to free up medical capacity to support patient flow and maintain safety
Lead the Divisional response to Full Capacity Protocol if implemented
BLACK (OPEL 4)
AS ABOVE PLUS:
Ensure all SPA activity is stood down across the Division to free up medical capacity to support patient flow and maintain safety where this supports flow and discharges
Title: Adult Patient Flow and Escalation Policy Version: 2.0 Issued: November 2018 Page 56 of 60
HEADS OF SERVICE – D&O
GREEN (OPEL 1)
NORMAL WORKING INCLUDING:
Be aware of Trust escalation status an ensure mechanisms in place within the service to cascade this to all clinical teams
AMBER (OPEL 2)
AS ABOVE PLUS:
Ensure medical teams respond to any escalations from the Capacity and flow meetings and adequate clinical support is available
RED (OPEL 3)
AS ABOVE PLUS:
Ensure medical teams are prioritising patients in ED and those for discharge
Consider extended or additional cover if required
BLACK (OPEL 4)
AS ABOVE PLUS:
Gold on call will chair the capacity and flow meeting and may request attendance from senior decision makers.
Respond to any requests for enhanced or extended service provision
Prioritise inpatient radiology vetting and reporting
Title: Adult Patient Flow and Escalation Policy Version: 2.0 Issued: November 2018 Page 57 of 60
DIVISION OF DIAGNOSTICS AND OUTPATIENTS
GREEN (OPEL 1)
NORMAL WORKING INCLUDING:
AMBER (OPEL 2)
AS ABOVE PLUS:
Communicating information on ‘Alert Status’ and ‘Actions’ to staff and services within the Division
Supporting staff in the Division in their response
Responding to patient delays impacting on discharge and flow.
RED (OPEL 3)
AS ABOVE PLUS:
Clinical Chair, DGM or HoN & AHP’s to attend the Capacity and Flow Meeting (in hours)
Review ‘Clinical Staff’ not currently based in clinical areas (i.e. Management Staff, Staff in training etc...) that could be redeployed to provide support.
Priority to be given to inpatients and ED.
Pharmacy to cancel all non-urgent activities to support additional discharges (wards and dispensaries)
Therapy and radiology to consider cancellation of OPD activity if required to support flow and discharges
At the request of Gold, cancel OPD activity to free up staff to support patient flow and maintain patient safety
BLACK (OPEL 4)
AS ABOVE PLUS:
Cancel any training to free up staff for clinical areas
SpRs and Consultants on site to liaise closely with ED to provide support
Provide additional or extended services as required
Title: Adult Patient Flow and Escalation Policy Version: 2.0 Issued: November 2018 Page 58 of 60
APPENDIX F ADDITIONAL CAPACITY
Division Ward Core Escalation Total
UEC EAU 40 0 40
Ward 36 (SSU) 32 8 40
72 8 80
W&C Ward 14 13 0 13
Ward 25 30 0 30
NICU 10 0 10
53 0 53
Surgery Ward 11 24 0 24
Ward 12 24 0 24
Ward 21 16 0 16
Ward 31 24 0 24
Ward 32 24 0 24
ITU 11 3 14
123 3 126
Medicine Ward 22 24 0 24
Ward 23 23 0 23
Ward 24 24 0 24
Ward 34 24 0 24
Ward 41 24 0 24
Ward 42 24 0 24
Ward 43 24 0 24
Ward 44 24 0 24
Ward 51 24 0 24
Ward 52 24 0 24
Ward 53 29 0 29
268 0 268
Newark Sconce 24 0 24
MCH Chatsworth 16 0 16
MCH Lindhurst 24 0 24
MCH Oakham 24 0 24
88 0 88
TOTAL 604 11 615
Title: Adult Patient Flow and Escalation Policy Version: 2.0 Issued: November 2018 Page 59 of 60
APPENDIX G EQUALITY IMPACT ASSESSMENT FORM (EQIA)
Name of service/policy/procedure being reviewed: Adult Patient Flow and Escalation Policy
New or existing service/policy/procedure: Existing
Date of Assessment: November 2018
For the service/policy/procedure and its implementation answer the questions a – c below against each characteristic (if relevant consider breaking the policy or implementation down into areas)
Protected Characteristic
a) Using data and supporting information, what issues, needs or barriers could the protected characteristic groups’ experience? For example, are there any known health inequality or access issues to consider?
b) What is already in place in the policy or its implementation to address any inequalities or barriers to access including under representation at clinics, screening?
c) Please state any barriers that still need to be addressed and any proposed actions to eliminate inequality
The area of policy or its implementation being assessed:
Race and Ethnicity
None None None
Gender
None None None
Age
None None None
Religion None None None
Disability
None None None
Sexuality
None None None
Pregnancy and Maternity
None None None
Gender Reassignment None None None
Marriage and Civil Partnership
None None None
Socio-Economic Factors (i.e. living in a poorer neighbourhood / social deprivation)
None None None
Title: Adult Patient Flow and Escalation Policy Version: 2.0 Issued: November 2018 Page 60 of 60
What consultation with protected characteristic groups including patient groups have you carried out?
What data or information did you use in support of this EqIA?
As far as you are aware are there any Human Rights issues be taken into account such as arising from surveys, questionnaires, comments, concerns, complaints or compliments?
Level of impact From the information provided above and following EQIA guidance document Guidance on how to complete an EIA (click here), please indicate the perceived level of impact: Low Level of Impact For high or medium levels of impact, please forward a copy of this form to the HR Secretaries for inclusion at the next Diversity and Inclusivity meeting.
Name of Responsible Person undertaking this assessment: S Shaw
Signature:
Date: 19/11/2018