Silver Tactical Objective 3 – Outcomes

This objective has seven key outcomes

Describe an integrated whole system COVID-19 Tactical Operating

Model (TOM)

Describe Capacity Modelling Requirements

Describe the capacity escalation plans within the Tactical Operating

System (TOM)

Ensure the operational delivery of the Tactical Operating System

Deliver a performance and activity dashboard of the Tactical Operating

Model (TOM)

Utilise local outbreak data and system intelligence to coordinate the

TOM model review, pathway decision algorithm revision and activation

of contingency plans.

Tactical Operating Model

The Tactical Operating Model has been developed across our system integrating the

health and care services in the community, NHS24 stream, COVID-19 Assessment

Hubs and the Hospital COVID-19 Response. The high-level schematic is illustrated

below. The essential intervention or pathway points are described together with the

key metrics required to track our local outbreak and establish critical ‘Decision Points

(DP)’ for action:

Model starting assumption parameters for first wave of infection burden and

impact

These have been generated from all currently available Local, National, and

International modelling together with guidance from Scottish Government on

planning requirements. These starting parameters are used to generate all predicted

activity data for each part of the model.

Model Planning Assumptions Population Infection Burden (First Wave)

20%

Growth Trajectory doubling line 3 days (reducing 3/52 after Lockdown) Population Symptomatic Rate 65% Normal Hospitalisation Acuity Rate 4.4% of infected population Intensive Care Conversion Rate 13% of hospitalised cases Overall Infection Mortality Rate 1.2% Hospital Length of Stay 7 Days general COVID-19 Ward Intensive Care Length of Stay 10 Days + 6 Days post ITU

High Level schematic Tactical Operating Model (TOM)

Decision Points Related to Tactical Operating Model

Throughout the outbreak it is essential to monitor progress in real time and have set

three sets of critical Decision Points (DP). The first set of DPs will trigger escalation

points for the provision of increased capacity ahead of need within each service

element of the Tactical Operating Model (TOM). The second set of DPs will trigger

escalation to our COVID Clinical Board to examine decision points within the TOM

and to consider model readjustment or protocol review. The third set of DPs will

trigger contingency arrangements where we project that our system will become

overwhelmed.

DP Capacity - To increase service capacity ahead of need

DP Clinical Board - Model Behaviour showing significant deviation

DP Contingency - System overload predicted or near capacity overload

Data Check Points

The Tactical Operating Model has four key data points where information must be

available to understand the whole care pathway, respond where needed and

escalate in line with our three types of decision points.

Public Health and Social Care

o Illness Burden

o Clinical Input Requirements

o Social Care Burden

o Palliative Care Burden

NHS24 COVID Line

o Primary Contact Point for escalation of Clinical Deterioration

COVID Care Hub + Primary Care

o Assessment of Clinical Deterioration in Community

o Evaluating need for Secondary Care

o Evaluating need for addition social care input

o Evaluating need for Palliative Care

General Hospital and Intensive Care

o Evaluating Hospital Sector requirements

o Considering escalation to Critical Care

o Identifying recovery stream

o Considering palliative and symptomatic care pathways

o Recruiting for research

o Controlling realistic escalation to critical care

o Delivering appropriate clinical interventions

Patient and Population Intervention Points

Every element of the pathway is critical to ensure we offer a co-ordinated and

effective response. The burden on any one section is interdependent on every other

part of the pathway. Our approach must be co-ordinated and requires both a Clinical

Decision Advisory Board to support pathway algorithms and choices as well as a

capacity and escalation process that synchronises our response.

Public Health Messaging

(Lead Bronze Team – Public Health)

The overall pressure on the COVID-19 pathway is principally driven by the infection

burden within the community. Stringent community lockdown reducing social contact

should reduce peak infection burden and slow trajectory of demand within 3 weeks.

All points in the pathway should promote the guidance as described on the NHS

Inform website. Public Health measures will also include the identification of cases in

the community (key workers and public) and appropriate trace and contact work to

limit further transmission and to inform the outbreak model.

Care in the Community, Anticipatory Care Planning and Palliative Care

(Three Lead Bronze Teams HSCP (Aberdeen, Aberdeenshire and Moray))

This includes already recognised frailty groups held within primary care together

with high consequent risk individuals that will be captured in the ‘Shielding

Vulnerable Patients’ work established by Scottish Government. This will be

coordinated by a local cell that will be responsible for managing support and care

delivery for this group. The first step is to update all ‘Key Information Summaries’

(eKIS) and where possible develop Anticipatory Care Plans (ACP) using a newly

generated national guidance documentation. Updating plans with a specific intention

of considering individual’s wishes and the risk associated with co-morbidities will

provide extremely useful information to channel appropriate patients early in the

illness pathway and avoid unwanted hospital admission and focus on patient choice

and symptomatic care. Furthermore, analysis of current community care needs will

be essential both to ensure delivery of critical care packages are maintained as

staffing comes under pressure and in response to the expected community burden of

additional care needs for vulnerable groups becoming unwell and requiring

enhanced community care package input.

Model Assumptions to guide planning The highest burden of illness will be in the elderly (70+ years) Community spread will be even across all age groups Symptomatic rate in the elderly (70+ years) 66% Rate of severe symptoms (70-80) 24% and (80+) 27% Rate of Critical illness (70-80) 43% and (80+) 71% Admission rates (70-80) 30% and (80+) 9.3% Infection Fatality Ratio (70-80) 5.4% and (80+) 9.3% Care Needs in Community increased in relation to illness severity and non-admission

Further work has commenced cross referencing this with distribution of elderly in

each HSCP together with their individual home situation and care needs. This will

allow a projected increased care requirement for all those remaining in the

community. Baseline data modelling of actual admission rates for this population

demographic will be collated from the first few weeks of our own outbreak data. The

mortality data can also be used to inform the community potential palliative care

needs. To look at this from another perspective we can estimate total mortality for

the outbreak and assume that at least 50% of this will occur in the community. Using

the total population estimates and data on in hospital mortality we can derive a

projected total mortality profile.

NHS24 Connection

(Lead through National Team with Local Bronze Team Lead – Moray HSCP)

The feed from NHS24 will almost certainly change as we move into higher volume

symptomatic likely COVID associated calls. NHS24 have set up a regular national

call in and a specific feedback route. We do not currently have an automatic model

data feed from NHS24 information or an agreed set of metrics from each call. This

would be very valuable for rapid learning during early phase of operation.

Primary Care COVID-19 assessment Hubs

(Lead Bronze Team – Moray HSCP)

The COVID-19 Hub model is intended as an advanced triage system that brings

together primary and secondary care expertise with the possible addition of face to

face assessment, physiological measurements and near patient testing data. The

intention is to maximise the opportunity to maintain an individual in the community

with appropriate support and care. In practical terms it should reduce the expected

admission rate into hospital (4.4% of infected individuals).

The first stage uses telephone and ‘near me’ consultation supported by secondary

care advice. Outcomes from this initial Multi-Professional Team assessment will

include:

999 to Hospital Direct to Hospital Admission Transfer to Non-COVID-19 pathway of care Home management on expected palliative care pathway Home management for mild/moderate symptoms Home management for mild/moderate symptoms with increased need for

additional support. Home Visit by mobile support unit Further Face to Face assessment in COVID-19 assessment Hub

Those who need an additional face to face assessment will attend the community

Assessment Hub. This may result in a similar range of actions although the

expectation would be that most mild/moderate cases would have been identified at

the first stage. Data modelling has been developed at a National level, but early

indications are that this significantly underestimated the call burden. Current baseline

data from the two weeks of operation has been used to generate a profile of demand

and staff time requirements. The initial assumption is that most COVID-19 related

admissions will pass through the Hub system. There remains the possibility that

direct 999 calls or self-presentation could be a significant stream of activity.

Furthermore, case identification whilst in an inpatient environment requiring Non-

COVID-19 related care looks also to be significant.

System information on the COVID-19 Hub activity will be critical to understanding our

local position. We have defined a minimal set of outcome measures to collect and

are working with the Adastra system owners to develop a data stream of activity.

Predicted COVID-19 Hub Activity for NHS Grampian

This is based on the symptomatic case growth projections set against the current

COVID-19 call activity and assuming 65% of COVID-19 patients with an acuity that

would lead to hospital admission would come through the Hub. This is set against

the predicted admissions from the hospital-based model of expected presentations

at an acuity requiring hospital care. Staff requirements are based on the need to run

two Hub locations and support general calls with an average time of 23 mins as well

as more advanced calls and face to face assessments. These figures will be revised

as analysis of the patient outcomes from the Hub are concluded.

Decision Points for escalation of service provision and contingency.

Given the exponential nature of the growth curves for Hub activity as well as the

uncertainty around baseline data we need to operate a completely new approach to

capacity management and activation of contingency measures. Three set of

Decision Points need to be incorporated at this level.

DP Capacity - To increase service capacity ahead of need based on 70%

utilisation of capacity.

o TOM 2 - 10 Clinical Staff per Shift

o TOM 3 - 15 Clinical Staff per Shift

o TOM 4 - 20 Clinical staff per Shift

DP Clinical Board - This is the activation of a review of the model predictions

and organisation of the Hub model in response to deviation from the predicted

model trajectory.

DP Contingency - This is the activation of plans when it appears system

overload is not far away. This may be triggered within the Hub against an

inability to manage predicted demand or through a downstream trigger.

Hospital based COVID-19 Care

(Lead Bronze Team – Acute Sector)

The point of hospital entry is intended as the definitive pathway into secondary care

with further opportunities to escalate to intensive care if appropriate. The NHS

Grampian single designated portal of entry will be at the Aberdeen Royal Infirmary.

This limit on hospital entry sites is essential to reduce transfer of critically ill patients

who are COVID positive as this is difficult and resource intensive. Furthermore,

multiple sites increase COVID positive traffic in our system and contributes to

increasing infectivity ratio R. It also gives the opportunity to focus vulnerable non-

COVID activity in a more protected environment or offer step down recovery and

rehabilitation. Detection of COVID positivity in other NHS Grampian hospital sites will

also occur and in principle these patients should transfer to ARI at the earliest

opportunity where escalation to intensive care would be considered appropriate if the

need arose. Some patients in other hospital locations may have a clear ceiling of

care already established which would preclude the need to ITU availability and in

these cases within hospital cohorting or isolation is a possible option. Activity

projection with current model:

Hospital General Care

This offers hospital level supportive care, recruitment to intervention studies until

specific therapeutic regimes are available, complication management facilities and

assessment for escalation to ITU following risk-based assessment of benefit.

Discharge for recovery will be the most common outcome with palliative care both in

hospital and after discharge. Capacity requirements are variably predicted to rise

very significantly. The outbreak metrics are essential for understanding our local

outbreak. Possible measurements are detailed below.

Predicted in Hospital COVID-19 Activity for NHS Grampian

This assumes that Aberdeen Royal Infirmary will remain the single planned portal of

entry for COVID possible and confirmed COVID inter-hospital transfers. The figures

are based on the starting parameters detailed above and relate to COVID confirmed

rather than COVID possible activity. The gap between these two metrics could be

substantial and may have significant implications for planning front door and transfer

services.

Decision Points for escalation of service provision and contingency.

Given the exponential nature of the growth curves for hospital utilisation of inpatient

facilities we need to operate a completely new approach to capacity management

and activation of contingency measures. Two sets of Decision Points need to be

incorporated at this level.

DP Capacity - To increase service capacity ahead of need based on 70%

utilisation of capacity. The TOM has three tiers of service expansion and as

we near the maximum capacity of a given tier we need to prepare for the next

operational step. These figures do not include the assessment and front door

areas which will need to be sufficient to manage the daily expected load and

the undifferentiated COVID-19 possible cases. o TOM 2 - Prepared capacity of 200 COVID-19 General Beds in ARI o TOM 3 - Prepared capacity of 300 COVID-19 General Beds in ARI o TOM 4 - Prepared capacity of 400 COVID-19 General Beds in ARI

DP Contingency - This is the activation of plans when it appears system

overload is not far away. The trigger in the bed capacity step up model is

when TOM 4 is at 75% utilisation and the last 50 reserve beds are brought

into service.

Intensive Care

(Lead Bronze Team – Acute Sector)

Worldwide experience has often focused on the Intensive Care ventilatory capacity

pressure with evidence of high rates of physiological deterioration particularly in the

elderly. We have been asked to plan for a four-fold increase in our ITU capacity

against a baseline of 16 General ITU and 6 Cardiac ITU beds. The outbreak metrics

related for ITU care will be particularly important. Both conversion rate to ITU care

from the General Wards and the Length of Stay in ITU have a dramatic effect on ITU

capacity requirements. The role of ECMO is not yet fully established but will

necessitate higher resource requirements.

Predicted conversion from General COVID care to ITU combined with expected

length of stay in ITU describes predicted utilisation.

Decision Points for escalation of service provision and contingency.

Given the exponential nature of the growth curves for hospital utilisation of inpatient

facilities we need to operate a completely new approach to capacity management

and activation of contingency measures. Two set of Decision Points need to be

incorporated at this level.

DP Capacity - To increase service capacity ahead of need based on 75%

utilisation of capacity. The TOM has three tiers of service expansion and as

we near the maximum capacity of a given tier we need to prepare for the next

operational step. These figures do not include the General ITU which is

relocated in TOM 2 to Green Zone 106 (14 Beds Protected for General ITU

care of Non-COVID patients). o TOM 2 - Prepared capacity of 21 COVID-19 ITU Beds in ARI o TOM 3 - Prepared capacity of 38 COVID-19 ITU Beds in ARI o TOM 4 - Prepared capacity of 71 COVID-19 ITU Beds in ARI

DP Contingency - This is the activation of plans when it appears system

overload is not far away. The trigger in the bed capacity step up model is

when TOM 4 is at 75% utilisation and contingency plans need to be reviewed

and considered.

Stepdown and Recovery pathways at Home, in Community and Hospital

Facilities

(Lead Bronze Team – Aberdeenshire HSCP)

The need for rehabilitation and recovery is reported to be significant and provision of

this may be useful to ensure flow through the system and care closer to home.

Hospital related COVID-19 care will be primarily established in the Aberdeen Royal

Infirmary but once patients are well enough to manage in a lower care environment

and the risk of subsequent deterioration is very low then transfer to other inpatient

facilities or home with enhanced rehabilitation is an option that should help maintain

central capacity. The clinical model is under rapid development and will follow

shortly.