Patient Flow, Bed Management and Escalation Policy 5 · 2019-04-02 · Bed Management and Escalation policy v5 6 Transfer The physical movement of a patient and their care from one

Policy for the development, management and authorisation of policies v8

Policy Title

Patient Flow, Bed Management and Escalation Policy

Policy Number

OP33

Version Number

5.0

Ratified By

EPRR committee

Date Ratified

07/03/2019

Effective From

02/04/2019

Author(s) (name and designation)

Claire Ellison, Patient Flow Co-ordinator Andy Hall, Patient Flow Team

Sponsor

Claire Coyne, Director of Clinical Support and Screening Services

Expiry Date

01/03/2022

Withdrawn Date

Unless this copy has been taken directly from Pandora (the Trust’s Sharepoint document management system) there is no assurance that this is the most up to date version This policy supersedes all previous issues

Bed Management and Escalation policy v5 2

Version Control

1.0

Jan 2006

TFP Jan 2006

2.0

Sept 2008

Divisional Managers

SafeCare Council

Sept 2008

3.0

08/10/2010 CC Divisional Manager

SafeCare Council

11/10/2009

4.0 28/09/2015

Pam Naylor PQRS Committee

17/07/2015

5.0

02/04/2019 Andy Hall/Claire Ellison

EPRR committee

(via Chairmans Action)

07/3/2019 Title updated. Pge 5-Roles and responsibilities updated Page 18 OPEL framework and Levels replaces NEEP Page 21 Infection control section updated Page 28 Management process includes site huddle agenda


Contents Section Page 1 Introduction ...................................................................................................................... 4 2. Policy scope ....................................................................................................................... 4 3. Aim of policy...................................................................................................................... 4 4 Duties (roles and responsibilities) ..................................................................................... 5 5 Definitions ......................................................................................................................... 8 6 Main Body of the policy .................................................................................................... 17

6.1 Principles ............................................................................................................... 17 6.2 Access to Inpatient Beds and Services .................................................................. 18 6.3 Discharge Planning ................................................................................................ 21 6.4 Management Processes ......................................................................................... 28 6.5 Escalation process ................................................................................................. 32

7. Training ............................................................................................................................. 33 8. Diversity and inclusion ...................................................................................................... 33 9. Monitoring compliance with the policy ............................................................................ 34 10. Consultation and review ................................................................................................... 34 11 Implementation of policy (including raising awareness) .................................................. 34 12 Associated documentation (polices) ................................................................................. 34


Policy Title 1 Introduction This policy provides clear operational guidance for the management of bed capacity to optimise patient safety and experience during all working conditions in line with the trust’s ICORE values. Maintaining the flow of patients through the Trust is essential to optimising availability of hospital beds to manage surges in demand. It is a key principle of Gateshead Health NHS Foundation Trust that the hospital will not close to emergency admissions; the hospital remains the safest place for seriously unwell people even when beds are scarce. The hospital can only be closed on the instruction of the Director on-call and will result in the declaration of a Major Incident. This policy includes:

The principles of patient flow through the hospital and the link with organisational values.

Roles and responsibilities relating to patient flow, admissions and discharge.

Roles and responsibilities relating to patient flow, internal escalation and de-escalation (including staffing)

24 hour timetable for managing inpatient capacity and demand.

Process for escalations both inside and outside of the organisation.

Terms of reference for the site handovers held twice daily and site bed meetings held four times daily.

Terms of reference for management of the hospital site and patient flow out of hours.

Terms of reference for the multi-agency surge meetings.

Governance and record keeping for monitoring the impact of actions taken.

2 Policy scope This policy applies to all members of staff of Gateshead Health NHS Foundation Trust. The policy recognises that not all staff groups in all disciplines will have direct involvement in bed management and escalation, however all members of staff have a responsibility to support this policy.

3 Aim of policy

This policy aims to provide clear guidance to teams and individuals directly involved in management of capacity and demand throughout the hospital and to support the trust to achieve the following:

Early identification of potential problems with capacity

Proactive rather than reactive response

Concise and clear actions

Defined responsibilities


Establishment of a culture of reflective practice and continuous improvement

Behaviours consistently in line with the trust’s ICORE values

This policy will enable the Trust to deal effectively with fluctuations in capacity and demand so that clinical risks can be minimised as far as possible. The policy aims to ensure that every patient who requires an emergency hospital admission is allocated a bed within four hours and no elective admission is cancelled due to lack of bed availability. Successful implementation of this policy requires effective engagement between all members of the multi-disciplinary team and senior managers. This policy aims to maintain high standards of patient safety, patient experience, staff health and wellbeing as well as the organisation’s performance against key waiting time and quality standards in all eventualities and to support a return to normal working practices at the earliest opportunity after times of particular pressure.

4 Duties (roles and responsibilities)

Definition

Outpatients Patients referred by a general practitioner (GP) or other health care professional for clinical advice or treatment for which they do not require an inpatient bed overnight.

Inpatients Patients who require admission to hospital for treatment and are intended to remain in hospital for at least one night.

Day Cases Patients who require admission to the hospital for treatment and require the use of a trolley or bed but who are not intended to stay in hospital overnight.

Discharge The formal release of a patient at the conclusion of a hospital stay or series of treatments. This may incorporate the transfer of care to another provider.

Delayed Transfer of Care (DTOC)

A delayed transfer of care occurs when an inpatient is unable to move on to the next stage in their journey when they become physiologically ready to do so.

Long Stay Patient A patient occupying an inpatient bed for 7 days or more.

Very Long Stay Patient.

A patient occupying an inpatient bed for 21 days or more.

Boarder The term ‘Boarder’ describes a patient receiving inpatient care from a ward other than the speciality of the consultant responsible for their care (for example, a medical patient on a surgical ward would be defined as a medical boarder).


Transfer The physical movement of a patient and their care from one place to another, either internally between wards or externally between organisations.

Medway Medway is the electronic system used to record all admissions, transfers and discharges within the organisation.

EMIS EMIS is the electronic system used to record all consultations and interventions by primary care providers in Gateshead.

Care First Care First is the electronic system used by Gateshead social services to record all consultations and community care plans for Gateshead residents.

Expected Date of Discharge (EDD)

The EDD is the date and time that a patient is expected to be discharged from the organisation. The EDD should be set on admission, reviewed daily and updated as required to provide an accurate indication of when each bed in the hospital will become available for use by another patient.

SAFER Best practice approach to ensuring excellence in patient flow; S = Senior Review every morning, A = All patients with EDDs within 14 hours of admission, F = Flow maintained out of ED, EAU and Critical Care, E = Early Discharges (i.e. 35% in the morning and R = Regular Review of Stranded Patients to identify opportunities for discharge.

A&E Breaches Patient attendance to A&E exceeding 4hrs without admission or discharge.

Ambulance Breaches

An ambulance breach is said to have occurred when the emergency department is unable to take over the care of a patient and release the ambulance crew to attend other jobs within 15 minutes of their arrival. Ambulance breaches between 30-59 minutes are recorded and reported to NHS Improvement on a daily basis.

Black Breaches (Ambulance)

A ‘black breach’ is said to have occurred when the emergency department is unable to take over the care of a patient and release the ambulance crew to attend other jobs within 60 minutes of their arrival. There is an escalation flow chart to be followed if black breaches occur.

Mixed sex breaches Patients identified for step down from critical care to a ward should be moved within 4 hours (measured from 12pm on the day). A mixed sex breach is said to have occurred if the patient is unable to move to a base ward and remains in critical care next to a patient of the opposite gender.

Emergency Patients with an unplanned admission to the hospital irrespective


Admissions of their route of admission.

Elective Admissions Patients who have been admitted to the hospital to receive planned interventions.

Cancellation of Admission

Cancellation of a patient’s elective admission to hospital due to insufficient bed capacity, patient preference or clinical need.

Decision to Admit (DTA)

The time at which a patient in the emergency department is identified as requiring an inpatient bed.

12 Hour Trolley Breach

A 12 Hour Trolley Breach is said to have occurred when a patient in the emergency department has been unable to be admitted to the hospital within 12 hours of their DTA time. Reportable to Department of Health

Urgent Operation The definition of ‘Urgent Operation’ is one that should be agreed locally in light of clinical and patient need. However, it is recommended that the guidance as suggested by the National Confidential Enquiry into Patient Outcome and Deaths (NCEPOD) should be followed. Broadly these are:

Immediate – (A) life-saving or (B) limb or organ saving intervention. Operation target time within minutes of decision to operate.

Urgent – Acute onset or deterioration of conditions that threaten life, limb or organ survival. Operation target times within hours of decision to operate.

Expedited – Stable patient requiring early intervention for a condition that is not an immediate threat to life, limb or organ survival. Operation target time within days of decision to operate.

Elective – Surgical procedure planned or booked in advance of routine admission to hospital.

Flight Deck Real time ambulance data and local Trust’s OPEL levels.

UEC-RAIDR UEC-RAIDR (frequently referred to as ‘Radar’) is a smartphone app from which the Flight Deck for all trusts across the region can be viewed to enable quick assessment of regional capacity and demand.

Blue Sphere Blue Sphere is an electronic database used in the trust to manage theatre capacity for planned and unplanned surgeries.

DST Decision Support Tool.

Situational Report (SITREP)

A sit rep must be submitted before 10am each morning recording the previous day’s activity. On weekdays this is done through the


command centre on Pandora and on weekends this is done directly to NHS Improvement.

Operational Pressures Escalation Level (OPEL)

OPEL is a nationally agreed benchmark to standardise how operational pressures are quantified by acute healthcare providers and the risk posed to organisational performance.

Length of Stay (LOS)

LOS is the total time a patient spends as a hospital inpatient.

ED Emergency Department.

ACC Ambulatory Care Centre.

EAU Emergency Assessment Unit.

SSU Short Stay Unit

Senior Decision Maker

An appropriately trained healthcare professional to capable of making the final decision about whether to admit or discharge a patient.

5 Definitions

Role Responsibilities

Chief Executive

Overall accountability for the implementation of this policy.

Executive and Operations Directors

Responsible for the strategic management and implementation of this policy. In the event that it is not possible for the hospital to provide safe levels of care even after having implemented all possible actions in this policy it is the responsibility of the director to declare a major incident and close the hospital to any further admissions. Other responsibilities:

Ensure Clinical Directors and Service Managers are aware of and follow agreed policies and SOPs.

Understand actions to be taken in escalation and carry these actions out.

Ensure that all staff within their directorate have the appropriate training and competencies to be safe and effective in their roles.

Identify and resolve any barriers to patient flow from within their directorates and support colleagues to do the same.

Strategic decision making in the directorate and across the organisation to achieve continuous improvement.

Demonstrate courage and leadership in line with the trust’s ICORE values to resolve any barriers to achieving optimal patient flow.


Associate Directors Responsible for ensuring that appropriate systems and processes are in place to support the implementation of this policy within their business unit. Other responsibilities:

Hold teams and individuals within the business unit to account to ensure compliance with this policy and with best practice.

Demonstrate courage and leadership in line with the trust’s ICORE values to resolve any barriers to achieving optimal patient flow.

Development of the annual winter plan.

Medical Directors (MDs)

Accountable for the medical management of patient flow.

Clinical Directors (CDs) Ensure rota in place to deliver consultant cover to all ward areas 24 hours per day 7 days a week all year around.

Ensure robust arrangements are in place to provide consultant cover for all inpatients during periods of consultant annual leave or sickness.

Ensure clarity over skills required to be designated to Senior Decision Maker in their clinical service.

Ensure a robust process is in place for a prompt and appropriate response to ward referrals. Trainees delegated to see referrals should be ST3 and above and must indicate which Consultant they are representing when communicating outcome.

Consultants Ensure daily review of all inpatients under their care by appropriate Senior Decision Maker.

Ensure all patients have a clinical criteria led discharge plan which is reviewed daily.

Support patient flow by undertaking risk assessments of patients under their care to identify the most clinically appropriate patients for boarding as required.

Senior Decision Makers Ensure daily participation in Board Rounds and timely reviews to ensure that all patients have a clear treatment and discharge plan in place.

Other Junior Medical Staff and/or Specialist Nurse Teams

Responsible for their own clinical practice in relation to the clinical care of patients: Other responsibilities:

Ensure all investigations are requested during ward rounds using a one-stop approach to facilitate diagnosis, treatment and early discharge.

Ensure completion of discharge scripts are prioritised over other tasks and completed the day before EDD whenever


possible.

Ensure electronic discharge summaries are completed and sent to GP on the day of discharge.

Ensure consultants or other senior decision makers are aware of changes in patient status in real time.

Service Line Managers (SLMs)

Responsible for ensuring that the areas for which they have responsibility follow this policy and associated SOPs. Other responsibilities:

Accountable for ensuring that all staff in their service line have appropriate competencies to fulfil their job role safely and effectively.

Responsible for effective engagement with all relevant stake holders internally and externally.

Responsible for ensuring all clinical care provided within their service lines conforms to the best evidence currently available.

Responsible for reducing unwarranted variation in practice within their service lines.

Responsible for supporting Ward Managers to be accountable for ward processes to support patient flow.

Responsible for authorising availability of additional resources as requires (for example, extra ambulance transport and locum staff)

Responsible for liaison with senior managers in neighbouring hospitals to manage divert requests (inbound and outbound).

Patient Flow Manager Responsible for the operational management of the patient flow team and identifying areas that require change to support improvements in patient flow throughout the organisation.

Patient Flow Lead Responsible for optimising patient flow through the hospital the day. Other responsibilities:

Operational management of available bed capacity.

Coordination of the patient flow admin team.

Identify and escalate any obstacles affecting patient flow to the appropriate individual or team.

Ensure appropriate SLM and senior nurse are kept informed of any issues affecting patient safety or the organisation’s capacity to accommodate emergency admissions.

Liaise with the senior nurse on duty to make optimal use of available staffing resources for the patients in the hospital at the time.

Ensure the resilience bulletin is updated throughout the day all relevant pressures and actions.

Ensure compliance with mandatory data collection and reporting such as daily sit rep.


Senior Manager On-Call / SLM on-call

Senior manager on-call / SLM on-call to support patient flow out of hours between 17:00 – 09:00 between Monday to Friday and 24/7 at weekends. 24/7 responsibility in the event of a major incident or in the absence of the Head of Patient Flow.

Responsible for authorising availability of additional resources as requires (for example, extra ambulance transport and locum staff).

Responsible for liaison with senior managers in neighbouring hospitals to manage divert requests (inbound and outbound).

Ensure the director on-call is kept informed of any issues affecting patient safety or the organisation’s capacity to accommodate emergency admissions.

Director On-Call The director On-Call has the overall responsibility for the organisation whilst on call. Also responsible for maintaining the organisations normal services at an appropriate level during an incident.

Senior Nurse on Duty

The senior nurse on duty is responsible for managing nurse and auxiliary staffing across the organisation and supporting the patient flow lead to assess the risks and benefits of escalation areas.

Matrons Responsible for staffing, quality and performance in a group of clinical areas. Other responsibilities:

Accountable for monitoring the delivery of discharge targets.

Accountable for managing and as appropriate, escalating issues that impact on patient flow in real time.

Accountable for ensuring that all nursing staff understand and implement this policy.

Accountable for performance managing issues relating to nursing, brought to their attention via the patient flow manager.

Accountable for supporting the process for managing discharges for DTOC and long-stay patients.

Accountable for ensuring Ward Managers/Nurse in Charge operationalise the SOP.

Ensuring and monitoring safe staffing levels within their clinical areas.

Ward Manager/Nurse in Charge

Accountable for ensuring that daily board rounds take place by 09:30 each morning following the trust’s protocol.


Accountable for ensuring that all patients on the ward have an EDD set and that this is reviewed regularly to ensure it remains an accurate reflection of each patient’s likely discharge date.

Ensuring that every patient has an active management plan, and that appropriate escalation takes place for any issues.

Ensuring that patients are pulled through to every available bed within 30 minutes of vacation and Patient Flow are always aware of empty beds in real time.

Ensuring that an accurate and proactive management plan is in place for every patient to avoid delays in patient flow including clinical criteria for discharge.

Ensuring and monitoring safe staffing.

ED Nurse Co-ordinator

Ensuring that the escalation process for ED is followed.

Ensuring patients are referred to sub-specialties immediately following decision.

Escalating an unmanageable increase in demand.

Continuous proactive review in conjunction with the ED patient flow support and lead Consultant.

Establish board rounds when department is in escalation to develop the plan for managing patients with a long wait, plan to ensure access to resus.

Ensuring; capacity issues are dealt with, waits for assessment and assessing ambulance turnaround issues.

Ensuring continuous dialogue is maintained with EAU and patient flow team so that they understand expected demand.

Ensure in hours that the patient flow team are aware of any 3-4 hour trolley waits.

Ward Nursing Staff Ensure rapid and effective delivery of nursing care to expedite discharges.

Ensure each patient has an EDD in place on Medway.

Facilitate discharges so that they take place early in the day to ensure beds are available for new patients.

25% of patients discharged by 10am.

35% of patients discharged by 12 noon.

Ensure that the patient flow team are kept up to date in Patients must be transferred to the Discharge Lounge unless they do not meet the criteria (Infected, Cognitive Impairment or end of life patients).

All discharge checklist actions are completed as soon as possible.

SLM for Therapy Services

Responsible for the provision of therapy services in the hospital. Other responsibilities:


Accountable for monitoring the delivery of therapy services (Physiotherapy, occupational therapy and dietetics) throughout the organisation.


Accountable for ensuring that all therapists understand and implement this policy.

Accountable for performance management issues relating to therapists brought to their attention via the Patient Flow Manager.

Accountable for supporting the process for managing delayed discharges for all patients who have a length of stay of >6 days.

Responsible for the deployment of therapy staff to areas of priority at times of escalation.

Responsible for effective rapid response of therapist to facilitate safe discharge from agreed areas.

Responsible for delegating accountability for therapy services to head of departments within service line as required ensuring continuation of services.

Head of Physiotherapy Responsible for the provision of physiotherapy services in the hospital. Other responsibilities:

Accountable for monitoring the delivery of physiotherapy services throughout the organisation.


Accountable for ensuring that all physiotherapists understand and implement this policy.

Accountable for performance management issues relating to physiotherapists brought to their attention via the Patient Flow Manager.


Responsible for the deployment of physiotherapy staff to areas of priority at times of escalation.

Responsible for effective rapid response of physiotherapist to facilitate safe discharge from agreed areas.

Responsible for accepting accountability for therapy services as delegated by service line manager when required.

Head of Occupational Therapy

Responsible for the provision of Occupational Therapy services in the hospital. Other responsibilities:


Accountable for monitoring the delivery of occupational therapy services throughout the organisation.


Accountable for ensuring that all occupational therapy understand and implement this policy.

Accountable for performance management issues relating to occupational therapy brought to their attention via the Patient Flow Manager.


Responsible for the deployment of occupational therapy staff to areas of priority at times of escalation.

Responsible for effective rapid response of occupational therapy to facilitate safe discharge from agreed areas.


Head of Nutrition and Dietetics

Responsible for the provision of Nutrition and Dietetics services in the hospital. Other responsibilities:

Accountable for monitoring the delivery of nutrition and dietetic services throughout the organisation.


Accountable for ensuring that all dietitians understand and implement this policy.

Accountable for performance management issues relating to the nutrition and dietetic team brought to their attention via the Patient Flow Manager.


Responsible for the deployment of nutrition nurses and dietitians to areas of priority at times of escalation.

Responsible for effective rapid response of nutrition nurses and dietitians to facilitate safe discharge from agreed areas.


Ward Physiotherapist Responsible for their own clinical practice in relation to physiotherapy: Other responsibilities:

Ensure rapid and effective delivery of physiotherapy assessment and treatment in line with current best practice.


Proactively work to overcome any barriers to discharges from acute hospital care.

Arrange appropriate aftercare for any patients with ongoing rehabilitation needs that could be met outside of hospital.


Responsible for escalating any delays in patient length of stay to head of physiotherapy.

Ward Occupational Therapist

Responsible for their own clinical practice in relation to Occupational Therapy: Other responsibilities:

Ensure rapid and effective delivery of occupational therapy assessment and treatment in line with current best practice.

Proactively work to overcome any barriers to discharges from acute hospital care.

Arrange appropriate aftercare for any patients with ongoing rehabilitation needs that could be met outside of hospital.


Responsible for escalating any delays in patient length of stay to head of physiotherapy.

Chief Pharmacist Responsible for provision of pharmacy services throughout the hospital: Other responsibilities:

Accountable for managing the pharmacy department and, as appropriate, escalating issues that could impact on turnaround times of discharge prescriptions.

Accountable for ensuring all of the pharmacy team are adhering to this policy and locally agreed SOPs.

Accountable for ensuring both the clinical pharmacy team and dispensary are prioritising discharge prescriptions.

Ward Pharmacist Responsible for their own clinical practice in relation to pharmacy: Other responsibilities:

Ensure discharge prescriptions are prioritised (this includes reviewing patient’s own drugs and one stop dispensing).

Maintain good communication with nursing and medical staff to be able to plan in advance for future discharges.

Prioritise patients for medicines reconciliation and clinical chart checks.

Pharmacist prescribers to assist with writing discharge


prescriptions within their own competence.

To check clinical appropriateness and accuracy of prescribing.

Responsible for coordinating the use of pharmacy services to optimise patient flow.

Radiology Responsible for their own clinical practice in relation to radiology: Other responsibilities:

Accountable for monitoring the delivery of radiology services.

Accountable for managing and as appropriate, escalating radiology issues that impact on patient flow in real time.

Accountable for ensuring the radiology team are adhering to SOPs and this policy.

Accountable for performance, managing issues relating to radiology brought to their attention via the Patient Flow Manager.

Accountable for ensuring the radiology service is prioritising discharge dependent imaging requests.

Responsible for coordinating the use of radiology services to optimise patient flow.

Pathology Responsible for their own clinical practice in relation to pathology: Other responsibilities:

Accountable for monitoring the delivery of pathology services.

Accountable for managing and, as appropriate, escalating pathology issues that may impact on patient flow in real time.

Accountable for ensuring the pathology team are adhering to SOP’s and this policy.

Accountable for performance, managing issues relating to pathology brought to their attention via the Patient Flow Manager.

Accountable for ensuring the pathology service is prioritising discharge dependant pathology testing.

Responsible for coordinating the use of pathology services to optimise patient flow.

Clinical Support Lead Responsible for their coordinating all resources within the clinical support directorate to support patient flow on the day. Other responsibilities:

Responsible for attending the bed meetings to identify any opportunities for re-allocating resources within the clinical support directorate to improve patient flow (e.g. to arrange for investigations to be changed to urgent).

Responsible for escalating any issues within the clinical support directorate that may affect patient flow to the patient


flow lead.

Discharge Liaison Nursing Team

Responsible for their own clinical practice in relation to discharge planning of individual patients: Other responsibilities:

Collate information and facilitate daily management of DTOCs and Stranded Patients, including external responses.

Ensure assessments, care plans, care support and equipment is in place to facilitate rapid discharges for patients requiring end of life care outside of hospital.

Rapidly assess patients requiring enablement care in the community by the PRIME team to avoid delays to discharge.

Discharge Co-ordinators

Responsible for their coordinating administrative tasks associated with discharge planning for patients on their designated ward. Other responsibilities:

Responsible for proactively making referrals to therapy services, social services and any other services required to ensure a timely discharge from inpatient care.

Responsible for escalating any barriers to patient discharge to ward staff and the patient flow team as required.

Patient Flow Administrators

Responsible for completing administrative tasks associated with the optimisation of patient flow throughout the hospital on the day. Other responsibilities:

Responsible for liaison with the emergency department, EAU and all ward areas to provide an accurate real-time picture of the current state of patient flow within the organisation.

Responsible for collating information relevant for patient flow and other operational meetings as required.

Responsible for identifying common problems and ‘bottlenecks’ in patient flow throughout the organisation.

Responsible for escalating any issues affecting patient flow to the patient flow lead each day.

Responsible for supporting the trust’s digitisation program to enable access of real-time data on bed availability.

Corporate Volunteers The Corporate Volunteering workforce will be deployed to deliver simple non-clinical support services. At times of significant operational pressure, they will be used as additional resources to support operational delivery without compromising patient safety and security. Each corporate employee will provide their services for one day per month to a pre-agreed ward or service area. Training will be a mandatory requirement and will be renewed annually. No Corporate volunteer will participate until they have been trained.


The type of tasks a Corporate Volunteer is likely to complete include: talking to/reading with patients; accompanying patients around the hospital; nutritional and hydration awareness; wayfinding services; general administration (e.g. filing, answering phones). Corporate volunteers will not be involved in direct patient care or clinical roles.

Discharge Lounge Responsible for proactively identifying patients that are suitable for the discharge lounge.

Responsible for booking transport for all patients ready to leave hospital.

Responsible for escalating any issues impacting on patient flow to the patient flow lead.

6 Main Body of the policy

OPEL (Operational Pressures Escalation Levels)

Level 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.

Level 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.

Level 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

Level 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.

6.1 Principles The objective of patient flow is to enable all patients to get into the right place at the right time to be seen by the right clinicians for their needs. In essence, good patient flow enables good patient care.


There have been multiple studies which show that good patient flow is equivalent to increased capacity. Therefore, it is imperative that patient flow is a core element of our management processes. Everybody at all levels of the organisation has a responsibility to optimise patient flow.

The performance of the Emergency Department is one measure of how well the whole health and social care system functions during times of pressure.

Good patient flow is dependent on the delivery of the following:

Ensuring all patients are in the right place at the right time to receive the care they need.

Daily Senior Decision Maker (Consultant) – Patient Reviews.

Adherence to OPEL Escalation Policy

Early identification of the patients expected date of discharge (EDD).

Early escalation of any delays in investigations/diagnostics and/or treatments

Proactive management of ALL discharges.

Proactive management of admissions, transfers and repatriation of patients out with clinical specialty.

Good communication at all levels of the organisation.

Ensuring decisions are made on robust and reliable information.

The ability to respond to surges in demand.

Effective infection control.

Repatriation of out of area patients.

6.2 Access to Inpatient Beds and Services Adult patients may be admitted via:

Emergency Department admission.

Direct admission from a General Practitioner (GP) as agreed with Senior Clinician.

Assessment Units (Surgical and Medical).

Planned urgent case where the patient has been assessed.

Internal transfer from another specialty, including Critical Care.

Direct admission from an Outpatient Clinic.

Elective admission from a non-urgent waiting list.

The principle is that patients should be admitted to the right bed in the right specialty and at the right time to receive the care they need. If the optimum bed is not available when needed the patient flow administrator will liaise with the patient flow lead and the senior nurse on duty to make arrangements for the best alternative to consider boarding other patients to make capacity, opening escalation areas or admitting the patient to another clinical area.

Patients will be triaged in the emergency department by senior clinicians and identified for appropriate specialties. Referrals for assessment by surgical specialties are submitted electronically and specialty teams are required to complete their review within 60 minutes of referral. When patients are identified for admission under surgical care they will be transferred directly to surgical wards from the emergency department. Patients in the emergency department


identified as requiring further investigations or intervention under the care of medical consultants likely to take longer than four hours to complete will be transferred to EAU where an acute physician will determine if admission to a medical ward is required.

All patients will be deemed clinically stable prior to transfer from the emergency department.

Only relevant diagnostics and treatments will be carried out on EAU to support clinical decision making. Further investigations, treatments etc will be the responsibility of the receiving speciality.

It will not be necessary for the acute physicians to complete a formal referral to specialty teams prior to transfer to a medical ward.

There will be no requirement for specialty teams to review patients prior to transfer unless there is an urgent clinical need and it is essential for decision making.

The senior decision maker will not be required to discuss cases with the receiving teams, supporting the referrer decides process.

The following patient pathways should be adhered to and enforced. Capacity should be provided daily in each clinical area to accommodate non elective admissions Theatre Scheduling Process

Cancelling admissions on the day of surgery has a detrimental impact on patient experience, the Trust’s reputation and the key performance indicators for the organisation and should only be considered as a last resort when failing to cancel the surgeries would risk patient care. All cancellations of elective surgeries must be authorised by a director. The process for cancelling surgeries is outlined in the trust’s Operating Theatre Performance policy (OP 38) To minimise the impact of cancellations on patient care surgeries should be cancelled in the following order:

1. Elective patients without prior cancellations 2. Elective patients with prior cancellations 3. Elective patients at risk of breaching the 18 week pathway or other access targets 4. Inpatient who has already had clinical preparation (i.e. bowel prep). 5. Elective patients on cancer pathway 6. Life or limb emergency

Sequence Procedure For Theatre List Formation Where Appropriate

Additional Information

1. All theatre lists should be formed

starting with category 1 patients followed by category 2 patients and ended with category 3 patients.

Category 1

Day case

Latex allergy

Diabetic patient

Day case


Category 2

Inpatient cancer 62 day breach

Inpatient cancer 31 day breach

Inpatient requiring ambulance transport

Inpatient 28 day rebook breach

Inpatient 18wk routine

Inpatient planned case

Category 3

23hr patients

High risk patient

Gender

There should be no occasion when an inpatient is in mixed-sex accommodation unless this is required for clinical reasons (e.g. access to specialist beds such as intensive care). The risk of this happening should be mitigated by the use of single rooms and allocation of patients to bed bays. Age Children should not be admitted to adult beds and vice versa. In periods of high activity, patients between the age of 16 and 18 can be placed in a Paediatric bed, coordinated by the senior nurse on duty. Critical Care Discharge

08:00 – Critical care co-ordinator identifies probable patients for step down to base wards that day.

12:00 – Critical Care co-ordinator confirms patients suitable for step down to base wards that day which starts the 4 hour target.

16:00 – All patients identified for step down should be moved to their new ward before 16:00.

In order to avoid mixed sex breaches and create capacity for level 2 and 3 patients, it is essential that discharges from Critical Care have equal priority with patients awaiting beds within ED and that these discharges take place in hours.

Infection Control

The presence of patients with Norovirus or a Respiratory virus will have consequences for admission to that ward. The Infection Prevention and Control Team will provide advice and guidance on the management of individual patients and the affected ward with advice as necessary from the on call Consultant Microbiologist. A member of the Infection Prevention and Control Team will attend the daily bed meetings when requested by the patient flow lead, during periods of outbreak. Follow the link for Infection Control Policies (Link).

Infection Control Team Availability:

Infection Control Team available 8am – 5pm via Vocera ‘IPC Resilience’

Microbiologist On-Call available 24/7 via switchboard.

http://stas16/intranet/policies/policies/infection-prevention-and-control/


Patients may need to be cohosted or segregated to prevent the spread of infection. There may be occasions when beds in a bay remain empty due to the presence of infection; these will need to be reported on the daily SITREP information which is collated and distributed by the Patient Flow Team. Any decision to admit or move patients contrary to the Infection Control Policies would need to be risk assessed, documented and only commence following discussions with the Infection Prevention Team (in hours). A decision to carry out actions outside of policy would only be considered following review and discussion with managers and clinicians at the site bed meeting. Out of hours this would be with the SLM on-call, the responsible clinician and On-Call Consultant Microbiologist. An impact assessment would be required as an audit trail.

Bed Requirement Escalation Levels

At the 15:30 bed meeting the Patient Flow Lead and the Senior Nurse on duty will assess whether there are sufficient beds available and the availability of staffing to ensure flow is protected during the night.

At the 17:30 bed meeting it is the responsibility of SLM On-Call to ensure that an appropriate plan is in place to meet expected overnight demand.

The following table should be used as a guide for QEH:

Escalation Level Number of Beds available at 17:30

(ready and coming up)

Escalation Process

Medicine Surgery

Green >20 >20 No Escalation Required

Amber >10 >10 Escalation to SLM on-call

Red <10 <10 Escalation to director on-call

Based on predictive data, the Trust needs to achieve on average 70 inpatient discharges per weekday to accommodate admissions. Protected Beds

The organization will take all possible actions to accommodate patients requiring an unplanned admission to hospital. No beds will be protected from use in the event of an emergency but care should be taken to minimize impact on other hospital services.

A risk assessment should be carried out prior to using CCD and NIV

Order Ward Area Risk Assessment by Other Considerations

3 Ward 9 (NIV cubicle)

In hours Senior Nurse -Out of hours – Night site Manager

Ensure availability of critical care beds for any further patients requiring NIV. ( Actioned Opel 2 and above )

4 Critical Care In hours – Senior Nurse Critical Ensure all appropriate critically ill


Care Consultant Out of hours – Night site Manager + critical care consultant

patients are accommodated in critical care first. Consider regional Ccopela level (Actioned Opel 2 and above )

5 TCL1 (Elective Orthopaedics)

Director on-call Out of hours – Night site Manager + SLM on-call and director on-call

Patients with infections may pose a risk to patients with new elective joint replacements and should be a last resort. Admitting patients with infections to TCL1 will discontinue the elective program.

Closure of escalation areas

All escalation beds should be closed at the earliest opportunity. The closure of additional beds will be coordinated by the Patient Flow Lead and the senior nurse on duty after taking account of the up to date organizational position, the clinical needs of the patients requiring admission and the availability of staffing. Escalation beds should only opened after all existing beds have been used and should be closed as soon as beds become available within the standard bed stock. Staffing

It may be necessary to re-deploy staff from any profession to different clinical areas to their base in order to maintain patient safety. Ward managers and team leaders are responsible for escalating any issues with staffing levels that may impact on patient safety or patient flow for resolution by their respective managers who will in turn escalate any issues that persist to the patient flow lead and/or senior nurse on duty. Any gaps in medical cover should be escalated to the responsible SLM. Out of hours, all staffing issues will be addressed by the night site lead. Requesting a Consultant to Return to a Department/Ward At times of pressure, when the SLM and director on-call believe the organisation will be unable to maintain patient safety the director should contact the speciality consultants on-call and request that they review patients in the hospital to identify further patients who could be discharged to release capacity. Other senior medical staff may be asked to reprioritise clinical duties and assist with ward discharges when necessary. As guidance, the Consultant’s role will be to undertake the following duties:

Senior decision making/review of all patients to identify further discharges where safe and appropriate to do so.

Provide Clinical Leadership.

Provide direct clinical care to individual patients, however the role will not just be restricted to direct clinical care, the Consultant may be required to provide suitable supervision and support the rest of the team and also work with other specialties.

Ambulance Handovers

Handing a patient over from an ambulance to an ED is expected to take no more than 15 minutes. This is a national target that is measured and monitored daily. At times when the target is not being met, the ambulance service may introduce special measures to improve performance in co-


operation with the Trust. This would be arranged through either North East Ambulance Service. This usually takes the form of allocating a Hospital Ambulance Liaison Officer (HALO) to the ED.

6.3 Discharge Planning Timely discharge of patients provides the Trust with the capacity to admit. Expected Date of Discharge All patients are required to have an expected date of discharge (EDD) set within 12 hours of their arrival in the emergency department which should be recorded on MEDWAY. The EDD should be set on admission, reviewed daily and updated as required to provide an accurate indication of when each bed in the hospital will become available for use by another patient. When setting EDD clinicians should assume the optimal physiological recovery for every patient and should not assume any delays in care. Principles for the use of EDD:

Every patient should have an EDD completed within 12 hours of admission and reviewed within 12 hours of transfer to a base ward.

EDD should be reviewed each day by consultant or senior clinician at the board/ward round with input from the rest of the MDT.

EDD should only amend for clinical reasons but should be amended to ensure an accurate reflection of the patient’s likely discharge date.

All EDD’s should stipulate a date and time of discharge – evidence shows that by specifying a morning discharge, bed availability improves.

Where support following discharge is anticipated, arrangements should be put in place prior to the expected discharge date (i.e. before the patient is physiologically ready to leave the hospital) either through the trusted assessment process for PRIME or by referring to social services for an assessment of long-term care needs.

Medical discharge criteria should be documented by a senior clinician within 48 hours of admission and communicated to the ward team.

Functional discharge criteria should be documented by a nurse or therapist within 48 hours of admission and communicated to the ward team.

The criteria for discharge should be used to guide the discharge planning process and should be the minimum safe level that each patient requires for their needs to be met in the community and should not be a return to their previous level of function.

The ward team should be empowered to enact/progress discharges based on discharge criteria.

The MDT Ward Round

Principles of the MDT Ward Round:

Should take place every morning before 12 Noon.


Patients should be reviewed in priority order with the most unwell patients seen first, potential discharges second and then other patients.

In collaboration with the MDT the senior clinician should set or update the EDD for each patient on clinical grounds, set the priorities for each patient to progress their care (discharge medication, diagnostics, treatments, referrals), escalate any delays and consider if the patient’s continuing needs could be met through non-inpatient means.

The discharge criteria for each patient should be clearly documented in the patient’s notes to allow criteria led discharge and should include both medical and functional criteria.

After the ward round, the Ward Manger/Nurse in Charge should ensure that MEDWAY is fully updated and accurately reflects the patient’s current clinical status and discharge plan including their EDD

The Ward Manager/Nurse in Charge is accountable for ensuring that actions agreed for individual patients are completed to ensure daily progress towards discharge for each patient.

The ward manager/nurse in charge with the support of the discharge coordinators is responsible for ensuring that all delays in discharge are escalated to the discharge liaison team and/or patient flow team.

Delayed Transfers of Care (DTOCs) and Stranded Patients

The discharge liaison team will identify patients with delayed transfers of care (DTOC).

A delayed transfer of care from acute or non-acute (including community) care occurs when a patient is ready to depart from such care and is still occupying a bed. A patient is ready for transfer when:

A) A clinical decision has been made that the patient is ready for transfer AND B) A multi-disciplinary team decision has been made that the patient is ready for transfer

AND C) The patient is safe to discharge/transfer.

The discharge liaison team should collate this information to ensure that any delay is being proactively managed and, where necessary, to escalate any concerns to the patient flow lead / SLM / surge meeting. DTOCs and Stranded Patient information is collated daily via MEDWAY by the Informatics Team and reported to the Corporate Management Team.

Making a Bed Available

Everybody within the organization is responsible for taking all possible actions to facilitate safe discharges from all inpatient areas and for making the bed available for use by another patient in a timely way. The nursing staff on each ward are responsible for ensuring the patient flow team are kept up to date about the status of each discharge and the timescale each bed is likely to become available for the next patient to use. Any barriers to discharge or potential delays should be escalated to the patient flow team at the earliest opportunity.


Failure to declare an accurate EDD on MEDWAY, failure to declare a when a bed becomes available and failure to take all proactive steps to ensure the bed becomes available as early in the day as possible will be treated as a performance management issue for the staff concerned. Concerns will be escalated through the normal process in line with the Trust’s Performance Management Policy. Cleaning Arrangements

All beds and equipment must be cleaned between patients. The responsibility for cleaning lies with the nursing and auxiliary staff on each ward and the domestic services team provided by QEF.

Types of Cleans:

Internal Transfers

Discharges

Decontamination o Terminal Cleans o HP Cleans – C Diff/Pseudomonas/Multi Drug Resistant

Pseudomonas/MRSA/Other Reason

The table below specifies who is responsible for cleaning on site:

Cleaning Type Staff responsible

Internal Transfers Ward Nursing Staff/Auxiliaries/Housekeepers/

Domestic services

Discharges Ward Nursing Staff/Auxiliaries/Housekeepers/

Domestic services

Decontamination Domestic Services (QEF)

To request cleaning from Domestic Services, please contact ‘Domestic Response’ via Vocera or via Bleep 2396. At times when the cleaning of beds and equipment is critical to the timely movement of patients through the system and if there are competing demands for the cleaning capacity, the Patient Flow Lead will determine the order of priority and will liaise with the Domestic Supervisor, Infection Prevention and Control Team, Senior Nurse on duty and the SLM on-call as appropriate Discharge Routes Please see below for the various routes of discharge from the acute hospitals:

Home

Eastwood Intermediate Care

Residential Care (Assessment Bed)

Nursing Care (Assessment Bed)

Residential Care (Long-term placement)

Nursing Care (Long-term placement)


Repatriation to local hospital. Transport for Discharge

Day/Time Person responsible for booking transport

Contact

Monday – Friday (08:00 – 20:00)

Discharge lounge Vocera: ‘Discharge lounge’ or ‘Discharge lounge coordinator.’

Saturday – Sunday (12:00 – 20:00)

Patient Flow Team Vocera: ‘Patient Flow’ or ‘Bed manager’

Out of hours ED Reception

Requirements for arranging discharge are as follows:

Ward Nursing Staff – Staff should initially explore whether transport home could be provided by the patient, their family or friends as early in the patient’s hospital stay, as is both possible and appropriate. This is the Trusts preferred method of transport home.

Discharge Home Plan – To identify if patients are entitled to transport home please follow the eligibility criteria. Transport should be booked the day before discharge whenever possible.

Transport requirements – Staff should be clear on the patient’s mobility and resuscitation status and whether any equipment is going with them prior to booking transport.

Transfers or Discharges Out of Hours (10pm – 7am)

Discharges of patients from the inpatient bed base between 10pm and 7am should not usually occur. When this does occur, this should be supported by a nursing risk assessment with consideration for any safeguarding issues. Inter-hospital transfers should only occur during these time when there is a critical clinical need.

Actions/Escalations for Transfers or Discharges out of hours:

The following escalations need to occur and be documented in the patients’ record by the Nurse caring for the patient for any transfer or discharge between 10pm and 7am:

Patient has capacity and has consented to transfer.

Family are informed and consent to out of hours discharge.

Nursing risk assessment undertaken.

Inter-hospital transfers must be discussed with the Night Site Lead who will liaise with the SLM On-Call as required. Out of hours transfers should be avoided whenever possible when it is likely to have a detrimental impact on their clinical care such as people with dementia.

Discharge Lounge Discharge Lounge is available 5 days per week Monday – Friday 8am – 8pm.


Whenever possible the discharge lounge should be used to facilitate discharges and ensure base ward beds are made available for the next patient as early in the day as possible. The only patients that are excluded from using the Discharge Lounge are:

Patients with an infection.

Patients with cognitive impairment where the move to a new environment would be distressing.

Patients in the last days of life.

Patients can be accepted into the Discharge Lounge to wait for transport and medications. In periods of escalation patients can be transferred prior to prescriptions being written and a Junior Doctor would be required to attend the Discharge Lounge to complete their prescription within 30 minutes of transfer.

6.4 Management Processes

Decision Making

The system for managing operational pressures of demand and capacity is based on the system of Operational (i.e Patient Flow Lead / Senior Nurse / Night Site Lead), Tactical (i.e. Business Unit SLM / SLM on-Call) and Strategic (i.e. Director / Director on-call) decision making and the associated levels of Command and Control. The aim is to have emergency demand decisions managed operationally as far as possible. There may be a need to instigate Tactical and Strategic decision making if the services are under particular pressure; the mechanisms for this are set out below. Decision making will be based on information from the following set of sources, augmented by ad hoc information as necessary, and a proactive approach to planning each day.

24 Hour Timeline for Managing Capacity and Demand

The following timetable shows the key decision points where any interventions or actions required to support patient flow should be identified and reviewed. Between 07:30 – 20:30 the patient flow team will provide up to date information for consideration at each of these times. Outside of these hours the night site lead will take and collate their own information for consideration.

No Time Meetings/Handovers

1 07:30 Night Site Handover

2 09:30 Site Huddle Meeting



5 17:30 Site Huddle Meeting/ On-call check In

6 20:00 Night Site Manager/ Patient Flow Team Handover

*Additional meetings/telephone calls may be booked and times may be changed times can be changed according to Opel levels on the day.


Daily Bed Meetings At each bed meeting the following information should be reviewed for the medical and surgical business units individually and also the overall organizational position as well as other inpatient areas including critical care, paediatrics, maternity and SBU.

Current bed availability

Predicted bed availability today

Currently patients requiring admission

Patients predicted to require admission today

Predicted bed state the following morning

Operational performance against 4 hour ED target

Infection prevention and control issues

Actions identified/ Opel action cards followed Meeting Structures and Content Attendance is required from staff depending on Opel Levels

Title Description

07:30 – Handover from Night team 09:30 – Site Huddle 12:00 – Site huddle 15:00 – Site huddle 17:30 – Site huddle / On – call check In 20:00 – Site huddle

In attendance: Depending on Opel levels

Patient Flow Lead

Emergency Flow Administrator

Patient Flow Administrator (Wards)

Senior Nurse on Duty

Representative from medical and surgical business units

Clinical support lead

SLM on-call

Director on-call

Night site manager (depending on time)

The purpose of this meeting is to:

Report the current patient flow status of the Trust.

Assess progress against the required and expected discharges and admissions.

Provide an update against actions agreed at each site huddle

Ensure ED DTAs and Critical Care discharges are prioritised and allocated.

Review theatre schedule plan – ensure capacity for elective admissions.

Provide a plan to arrange cover for any gaps and pressures with staffing and act to re-deploy staff where appropriate.

Highlight any delays for access to diagnostics/treatments and procedures and allocate dedicated resource.

Agree plan for any portering and cleaning delays.

Agree plan for repatriations.


Ensure outliers process is adhered to.

Identify and collate a borders list if required

The outcome of the meeting is to:

Complete triggers of OPEL level for the organisation – communicate to key staff with expected actions.

Allocate responsibility for any tasks that require action to named individuals.

Ensure outliers process is adhered to.

Opel checklists must be followed

Daily operational Meetings Model

Operational Meetings will run to the following operating model:

RESPONSE

R Review – Actions from the previous meeting. If action(s) have not been completed then

the reason should be understood and a solution identified or escalated for resolution. A simple checklist should be used to do this. Agree who the chair is for the day/ meeting, this should be determined by the escalation status.

E Early – Senior Review in ED – review number of patients waiting longer than 1 hour to see

a clinical decision maker. ‘Assessment Unit’ – review number of patients waiting longer than 14 hours to see a Consultant.

S Streaming – Confirm patients are being streamed effectively based on principles.

P Plan – All patients in the ED at 2.5 hours or above require a definitive plan. Plans and times

for leaving the department for each patient should be written up, monitored and reviewed at the next meeting. In addition, any patient with a LoS > 6 hours in the ED requires a regular update to the Matron (in hours) or Night Site Lead (out of hours), using SBAR (situation, background, assessment & recommendation).

O Overview – Provide a clear description of the speciality capacity (bed and workforce) across

hospital through to 08:00 the following day. Highlight staffing deficiencies against agreed staffing levels and escalate within one hour if not resolved.

N Numbers – Every inpatient area should be clearly able to define the numbers of planned

discharges and time. All relevant inpatient wards should pull a patient from EAU before 10:00 and confirm that they have achieved this. If not, the reasons should be updated at the 12:00 meeting.


S Senior – Daily Consultant review of every inpatient should be monitored and assurance

provided by Centres. Any internal/external waits that are impacting on discharge/patient flow across inpatient wards over the next 24 hours should be raised and a plan agreed accordingly.

E Escalation – Status confirmed and actions agreed. Actions will be reported to the

responsible officer at the next site meeting. Ensure communication, escalation status and plans are communicated to all wards/departments and health and social care partners.

The Trust is a 24/7 provider, not a 9 – 5 Monday to Friday provider and so must define a clinical plan that can be executed to deliver care into the following morning.

Attendance at bed meetings

Bed meeting attendance is set but additional people may be asked to attend in times of pressure or to help address a specific issue or delay. At OPEL 2 each business unit is required to send a representative to the bed meetings as well as a representative from the Emergency Department. At OPEL 3 on-call managers are expected to attend meetings in person. At OPEL 4 a Command and Control Structure will be established.

The Patient Flow Team may also require input from the following teams:

Informatics Team

Pharmacy

Therapies

Transport

Estates and Facilities

Human Resources

Communications Team

Social Work

At this point external partners will be involved to support in ensuring capacity is created for the organization.

Weekend and Bank Holiday Arrangements

No Time Meetings/Handovers

1 07:30 Handover between Night Site Lead / Patient Flow Team

2 09:30 Bed Meeting

3 12:00 Bed Meeting

4 15:00 Bed Meeting

5 17:30 Bed Meeting

6 20:00 Handover between Patient Flow Team / Night Site Lead

7 22:00 Telephone update Night Site Lead / SLM on-call


A weekend plan will be agreed every Thursday at the 15.00 meeting, identifying any actions required to maintain services. Bank holiday plans will be developed and shared 2 weeks prior to the bank holiday, to ensure required resources are available to provide cover. 6.5 Escalation Dealing with Demand which Exceeds Normal Capacity

Excess demand for Trust services can be dealt with through; admission avoidance, increased discharges, flexing or changing the bed capacity, the use of theatres, change to staffing, or a combination of these. If these measures are taken, there must be a recovery plan via the Command and Control Structure for returning the Trust to the equilibrium position in which the demand is managed within the core bed base and the normal use of theatres and staff at the earliest opportunity.

Dealing with Potential for a Breach of the 4 Hour Emergency Care Standard

It is a national requirement that all patients attending via an ED should be admitted, treated or discharged within four hours and that the operational standard is that this should be achieved in 95% of cases.

It is imperative that when managing the Emergency Care Standard the Patient Flow Team fully understands the cause of the potential breach. The cause might include:

Increased demand

Decreased capacity

Process or system failure

Increased patient acuity

The correct identification of the cause will ensure that the appropriate and supportive intervention is provided.

Any patient waiting 6 hours without a plan with the potential to become a 12 hour wait should be escalated to the Matron or SLM for the emergency department in hours or to the Night Site Lead out of hours. In the event that any patient has waited more than 10 hours in the emergency department the Matron and SLM for emergency care should be informed in hours and the Night Site Lead out of hours. Mutual Aid

Across the North East, it has been agreed that mutual aid from neighboring trusts will be requested at Opel 3 and should not be the first response in times of pressure. Mutual aid should be requested by the SLM for medicine (in hours) or SLM on-call (out of hours) following a risk assessment showing that the hospital is unable to cope with current demand and there is no potential of recovery within the next 60 minutes. Regional Divert policy can be located within Command Centre informatics system.


Medical Team Responsibilities Regarding Boarders

Boarders will be reviewed daily by a suitable clinician (doctor or nominated nurse or allied health professional) to ensure no delay occurs in the patient’s care pathway.

It is the responsibility of the medical staff working on wards receiving outlier patients to provide the ‘day to day’ care for outlying patients (eg: cannulas, bloods, and prescription charts). Command and Control to Support Managing Flow Command and Control Meetings At high OPEL level 2 a Command and Control structure will be established and led by the Associate Director in- hours, On-call Director out of hours. The Patient Flow Lead and the SLM on-call will be in attendance 7 days per week. The Command and Control structure will be established in ‘Gold Command.’ Gold command is located on the ground floor between the Health Records department and the endoscopy department. The Command and Control structure will take priority over other bookings in this room. In high OPEL 2, consideration is needed for all meetings and training to be cancelled and all resources directed towards recovery of the trust’s position.

Major Incidents

In the event of a Major Incident, the Director on-call and SLM on-call have 24/7 responsibility for the organization or until the incident Command structure arrive on –site. Major incident policy and action cards must be followed.

7 Training

Training with regards to this policy will take place at Site Training days, at Matron and Ward Manager days, the Service Line Manager forum and the Central Management team time out. The trust will ensure the Patient flow team have the skills and knowledge to undertake the bed management role through provision of On-site training, in particular new pathways and resilience work streams.

8 Diversity and inclusion

The Trust is committed to ensuring that, as far as is reasonably practicable, the way we provide services to the public and the way we treat staff reflects their individual needs and does not unlawfully discriminate against individuals or groups on the grounds of any protected characteristic (Equality Act 2010). This policy aims to uphold the right of all staff to be treated fairly and consistently and adopts a human rights approach. This policy has been appropriately assessed.


9 Monitoring compliance with the policy

To ensure the effectiveness of this policy the following indicators will be monitored: Number of 4 hour A&E waits

Number of 12 hour A and E breaches

Number of black (over 1 hour) Ambulance handover delays.

Number of Ambulance handover delays above 30 minutes

Number of diverts to other hospitals requested

Number of cancelled operations as a result of bed pressures

10 Consultation and review

The implementation and effectiveness of the policy will be reviewed through Performance Board Reports and annually at the Annual Winter Review event.

11 Implementation of policy (including raising awareness)

The policy will be implemented immediately and awareness will be raised at Matron /Ward Manager Away Days, SLM forum, CMT time out, and Consultants’ meetings.

12 Associated documentation

This policy must be read in conjunction with the following Gateshead Health NHS Foundation Trust Policies: Privacy and Dignity:

Infection Prevention and Control Policies (IC1 – 26)

Safeguarding Patients’ Privacy & Dignity (OP29)

Patients’ Access Policy (OP12)

Discharge Policy (OP13)

Resuscitation Policy (RM27a and RM27b)

Records Management Policy (OP10)

Critical Care Escalation Policy

Maternity and Special Care Baby Unit Escalation Policy

Opel documents / Control and Command centre

Documents

Patient Flow, Bed Management and Escalation Policy 5 · 2019-04-02 · Bed Management and Escalation policy v5 6 Transfer The physical movement of a patient and their care from one