NHS England North (Cumbria and North East) North of England Critical Care Network:

Transcription

1 NHS England North (Cumbria and North East) North of England Critical Care Network: Paediatric Critical Care Escalation Plan V4.1 Revised 14 December 2016

2 Document Management Document Ref. PCCEP 4.1 Type Specific Escalation Plan Document Title Version V4.1 Purpose/Description Document Author Document Sponsor Date revision process agreed by NT&W, DD&T & Cumbria LHRP s Superseded documents Circulation Review Period Last Reviewed December, 2016 Paediatric Critical Care Escalation Plan To provide an effective operational response across the health economy to unplanned increases in demand for Paediatric Intensive Care North of England Critical Care Network Dr Craig Melrose Medical Director NHS England North (Cumbria and North East) 11 TH February 2014 (DD&T), 4 th March 2014 (NT&W), 6 th March 2014 (Cumbria) 13 th October (NE), 13 th October North East Paediatric Critical Care Escalation Plan V st January 2014, All CEOs, Medical Directors and Directors of Nursing of all trusts providing in patient services, Consultants in charge Critical Care units, Clinical Directors of Paediatrics Three yearly (sooner in response to changes in national guidance or organisational responsibilities) Exercise Period Last Exercised Three yearly Version 4.0 finalised after Exercise Mother Goose 8 th May 2014 Linked Plans: North of England Critical Care Network Adult Critical Care Escalation Plan (ACCEP), September 2015 North of England Critical Care Network Ethical Framework for Utilisation of Critical Care in Response to Exceptional Demand, September 2015 North of England Critical Care Network Guidelines for Escalation of Ebola Virus Disease, September 2015 NHS England North (Cumbria and North East), Mass Casualty Response: NHS Tactical Command Framework (North East), June

3 NHS England North (Cumbria and North East), Public Health England North East Centre. Pandemic Influenza Operational Plan, November 2016 (Does not cover Cumbria) Contents Introduction Purpose Application Structure Activation 5 Section 1 Background 7 Section 2 Enabling measures 8 Section 3 Principles underpinning escalation plans 9 Section 4 Current PCC capacity (December 2016) 10 Section 5 Escalation levels 11 Appendices 1 Network Medical PCCU Leads NoECCN Personnel Contacts 17 2 Suggested terms of reference for the PCC Newcastle Hospitals Critical Care Control Group (PCC NHCCCG) 18 This plan has been developed by the North of England Critical Care Network (NoECCN) which includes all the paediatric critical care units in the North East and the two units in North Cumbria Hospitals NHS Trust. The Network is accountable to NHS England through NHS England North (Cumbria and North East) 3

4 Purpose The purpose of this plan is to provide an effective operational response across the North East and North Cumbria health economy to unplanned increases in demand for Paediatric Critical Care which are sufficient to require this coordinated response. The expected trigger for PCCEP is a surge in demand due to illness (e.g. pandemic influenza) or exceptional winter demand. It has not been designed as an immediate response to a mass casualty incident. Such an incident would initially be dealt with via the Mass Casualty Plans of the Major Trauma Centres (i.e. Newcastle Upon Tyne Hospitals (RVI) and James Cook University Hospital, Middlesbrough). Activation of PCCEP escalation however is likely to be required in the ensuing hours; timing of escalation will be dependant (but not exclusively) on; the number of casualties (children) requiring critical care and available PCC capacity. Application NHS England s requirements detailed within 1 the relevant document will be met by adoption of this plan by acute trusts, alongside the on-going review of internal trust plans for surge capacity within paediatric critical care. Structure Key enabling measures are highlighted in section 2. The key response section of the plan is section 5 which outlines escalation levels, triggers for further escalation and mitigation actions. Activation This plan will be activated in response to the triggers and levels identified in section 5.3. Escalation to Network Paediatric Critical Care Escalation Plan (PCCEP) level 2 is an internal decision made by the Paediatric Intensive Care lead consultant at the Great North Children s Hospital PCC unit Newcastle, in discussion with colleagues at Freeman PCCU and James Cook PCCU. The North of England Critical Care Network will be informed. Escalation to Network PCCEP level 3 is a decision of the On-call NHS England North (Cumbria and North East) Director, based on advice from the NoECCN (in hours) or the Intensive Care Consultants on call (out of hours). The NHS England North (Cumbria and North East) Director will inform the Clinical Commissioning Groups (CCGs). If NHS England North (Cumbria and North East) strategic command is already established, escalation will be a strategic command decision. Once the PCC Newcastle Hospitals Critical Care Control Group (NHCCCG) is established at PCCEP 3, it is the source of advice NHS England North (Cumbria and North East) and NHS strategic command if established. Escalation to Network PCCEP level 4 will in itself trigger the establishment of NHS strategic command, if this has not already been established in response to the underlying pressures/acute incident. This will usually be led by NHS England North (Cumbria and North East). 1 Management of surge escalation in critical care services: standard operating procedure for paediatric intensive care (NHS England 2013) 4

5 Further escalation to Network PCCEP level 5 or 6 will be determined by the NHS strategic command structure. NB: Significant pressures within Paediatric Critical Care may trigger activation of the Network ACCEP at the appropriate escalation level. De-escalation decisions are made by the group responsible at the higher level, for example at PCCEP level 3 the Newcastle Hospitals Critical Care Control Group would determine de-escalation to PCCEP 2. This will be based on clinical advice. Section 1: Background This North East Paediatric Critical Care Escalation Plan (PCCEP) is informed by the lessons learned regionally and nationally from managing the delivery of Paediatric Critical Care (PCC) during the pandemic of influenza A (H1N1) in The North East Paediatric Critical Care Escalation Plan (PCCEP) was developed in tandem with the North East Adult Critical Care Escalation Plan (ACCEP) to ensure compatibility. Both the PCCEP and ACCEP are underpinned by the revised Ethical framework for utilisation of critical care in response to exceptional demand. These were all published as working documents by mid December 2010 to support response to the emerging pressures on critical care. The final V1.0 plan incorporated the lessons learned, in particular from the formal debrief meeting on 8 March Further major revision V 2.0 was required in March 2013 and V 3.0 in January 2014 in response to changes in NHS structures. Minor revision Dec 2016 to include North East Children s Transfer and Retrieval (NECTAR). This plan (V4.0) was revised to incorporate further changes in NHS Structures and lessons learnt from exercise Mother Goose which tested the North East Paediatric Critical Care Escalation Plan (PCCEP) on May 8 th

6 Section 2: Enabling measures actions required During the pandemic of influenza A (H1N1) in 2009, a number of enabling measures were put in place to deliver the required increase in paediatric critical care capacity. Some of these were fully implemented but others were not once the lower than expected impact of the second wave became apparent. In order to maintain surge capacity these enablers will need to be maintained, held on standby or retained as procedures to be reactivated. Actions for the critical care network and for trusts in relation to internal plans for surge capacity/major incidents are highlighted in this section. 2.1 Enabling measures In order to maintain surge capacity these enablers (identified during the pandemic) will need to be maintained, held on standby or retained as procedures to be reactivated: Increasing the workforce by identification of staff who could be trained or retrained to work in PCC. Provision of training (content and materials). A standard operating procedure for a single regional point of contact (NECTAR) for advice and admission to/discharge from PCC (wherever PCC is delivered) which includes (with initiation as escalation triggers met): o Contact process for clinical advice (utilising NECTAR telephone number ). o Maintenance of a line list of all children in region where PCC advice sought with recording of decisions and outcome. o Maintenance of a line list of all treated cases with location, supervision and outcome. o Terms of Reference for the PCC Newcastle Hospitals Critical Care Control Group (PCC NHCCCG) which includes senior clinical representation from the Great North Children s Hospital PCCU, Freeman PCCU and James Cook (STH) PCC team - teleconference via NECTAR 6

7 Section 3: Principles underpinning the escalation plan 3.1 Organisational principles That supporting the delivery of paediatric critical care is a shared responsibility of all NHS organisations (excluding mental health trusts) in the North East and North Cumbria. That for incidents which impact (or are likely to impact) on paediatric critical care capacity across the network, NHS England North (Cumbria and North East) will command the critical care response as described in section Clinical principles That PCC will be delivered to national clinical standards until fully staffed capacity is exceeded. That an escalation plan will be implemented to deliver PCC to children able to benefit which will balance increased capacity with the minimum possible reduction in standards of care. That as far as possible all children who require ventilation for more than 24 hours will be cared for within the current designated paediatric intensive care units. That all children under five years of age requiring PCC will be cared for within the current designated paediatric intensive care units (until PCCEP level 5 - see section 5.3). That all clinical decisions will be underpinned by the Ethical framework for utilisation of critical care in response to exceptional demand, which will be published alongside the two critical care escalation plans. 7

8 Section 4: Current PCC capacity (August 2014) Table 4.1: Current staffed PCC capacity Trust Beds Description PICU GNCH Freeman Ward 22 James Cook NuTH NuTH STH 13 staffed Physical space capacity18 (including 5 cubicles) 10 staffed Cardiothoracic 4 staffed Includes 1 cubicle physical capacity 7 Total 27 GNCH PICU is the regional general critical care unit which also supports paediatric surgery, paediatric medical subspecialties neurosurgery, specialist oncology and transplant work. There is physical capacity for 18 PCC beds. Current staffing is used flexibly to maintain up to 11 PCCU beds. The cardiothoracic unit offers specialist tertiary cardiac care and ECMO. JCUH Ward 22 PCCU (4 beds) at the James Cook University Hospital provides Level 2 critical care support. This means it can safely provide advanced ventilatory support, but not support for multisystem failure and in particular the unit does not provide renal support. There is physical capacity for 7 PCCU beds (Level 2). Surge capacity Surge capacity would be implemented as part of the agreed actions at specified escalation levels as described in section 5.4. PICU at the RVI is adjacent to paediatric theatres which gives potential for a further 10 critical care spaces. Plans are in place at James Cook University Hospital to provide additional critical care spaces using theatre and adjacent areas. 8

9 Section 5: Escalation: triggers, levels and actions 5.1 Assumptions That all clinical decisions will be underpinned by the Ethical framework for utilisation of critical care in response to exceptional demand. The PCCEP levels are defined in relation to a rapidly progressive increase in demand for PCC. The most likely scenario would be an outbreak of a serious communicable disease such as a pandemic influenza virus of greater severity than pandemic Influenza A (H1N1) The responses assume that there is similar pressure across the country. However, an acute incident (such as major accident or chemical poisoning involving many children) may require a short term response at a high PCCEP level. In most acute scenarios it is likely that children can be stabilised and relatively quickly transferred to other regions. The PCCEP actions relate to a situation where there is excessive demand for PCC but not for adult critical care. Where there is also excessive demand for adult critical care, actions will have to be modified. This is likely to cause more rapid escalation to a higher PCCEP level. 5.2 Network Escalation Decisions Escalation to Network Paediatric Critical Care Escalation Plan (PCCEP) level 2 is an internal decision made by the Paediatric Intensive Care lead consultant at the Great North Children s Hospital PIC unit, Newcastle in discussion with colleagues at Freeman PCC and James Cook. The North of England Critical Care Network will be informed. Escalation to Network PCCEP level 3 is a decision of the NHS England North (Cumbria and North East) Medical Director or Director on call, based on advice from the NoECCN (in hours) or the Paediatric Intensive Care Consultants on call (out of hours). If NHS England North (Cumbria and North East) strategic command is already established, escalation will be a strategic command decision. Escalation to Network PCCEP level 4 will in itself trigger the establishment of NHS strategic command, if it has not already been established in response to the underlying pressures/acute incident. This will usually be led by NHS England North (Cumbria and North East) Further escalation to Network PCCEP level 5 or 6 will be determined by the NHS strategic Command structure. De-escalation decisions are made by the group responsible at the higher level, for example at PCCEP level 3 the Newcastle Hospitals Critical Care Control Group would determine de-escalation to PCCEP 2.This will be based on clinical advice. 9

10 5.3 Role of the PCC Newcastle Hospitals Critical Care Control Group There will be Terms of Reference for the PCC Newcastle Hospitals Critical Care Control Group (PCC NHCCCG) which includes senior clinical representation from the Great North Children s Hospital PICU, Freeman PCCU and James Cook PCC team (usually by teleconference) in relation to PCC issues. At specified escalation levels (usually PCCEP 3 and above), in relation to PCC across the Network, the paediatric intensive care clinicians on the Newcastle Hospitals CCCG will: o Make decisions on escalation in keeping with this plan. o Report daily or more frequently as required through the Network Critical Care Control Group (NCCCG) if it has been established to address adult critical care capacity. o Make decisions in relation to admission and discharge criteria in keeping with this plan. o Support clinicians in making individual case decisions. o Monitor cases being managed outside of the PCC units. 5.4 Network PCCEP triggers levels and actions Network PCCEP level 1 Current position and response to expected pressures Children stabilised in outlying units if presented there. Clinical advice on resuscitation and stabilisation by NECTAR to staff in outlying units. Retrieval by team from NECTAR When under pressure, consultant to consultant discussions across the GNCH units to move staff to support admissions. If still under pressure, consultant to consultant discussions between GNCH PICU, Freeman PCCU and JCUH PCCU to maximise staffed capacity. Possible triggers to PCCEP level 2 Unusual case mix. Increasing numbers of admissions (above usual seasonal activity) with same diagnosis. Responses to expected pressures have not enabled admission of urgent surgical cases that require post-operative PCC. Children requiring PCC are being ventilated in non-pcc areas. Transferring children out of region 10

11 Network PCCEP level 2 All current staffed PCC capacity is occupied and children requiring PCC are being ventilated temporarily in resuscitation areas or in adult critical care facilities or children require urgent surgery which will need postoperative PCC. Actions Priority is to fully staff all current PCC beds and maximise capacity for admissions. 1. Inform NoECCN 2. Consider the following and flag that some/all of these may need to be implemented at 24 hours notice: o Activation of PCC Newcastle Hospitals Critical Care Control Group (PCC NHCCCG). o Older children requiring short term ventilation (less than 24 hours) only, to be retained in district general hospitals (DGH)/adult critical care unit, subject to individual case discussion via NECTAR. o Telephone supervision to DGH/adult intensive care unit o NECTAR capability overwhelmed DGHs to make provision for transfer (if bed available). o Review paediatric elective surgery requiring PCC, cancelling on basis of lower clinical need. o Review elective paediatric cardiothoracic surgery, cancelling on basis of lower clinical need. o Deferral of other specialist services based on clinical decisions through the CCCG. In relation to quaternary services, this will require national discussion. o Transfers from out of region for general PCC will no longer be accepted except for specialist/quaternary services where these are continuing. o Post-operative neonatal cases to be returned to neonatal intensive care. Possible triggers to PCCEP level 3 Underlying problem continues. Actions have not reduced pressure. Not able to transfer out of region as no capacity in other regions. Network PCCEP level 3 All current PCC based ventilatory capacity utilised. Some older children requiring short term ventilation being cared for in district general hospitals (DGH s)/adult critical care unit, subject to individual case discussion via NECTAR. 11

12 Priority is to fully staff all current PCC beds and maximise capacity for admission for children able to benefit 1. Progressive implementation of all PCCEP level 2 actions. 2. PCC NHCCCG meeting daily. o Stringent review of all children being managed in DGHs/adult critical care as to whether now require admission to PCCU. o Stringent review for all current general, surgical and cardiothoracic PCC patients in region and decisions re limiting the degree or duration of further support, balancing need for individual on-going care with e.g. need for capacity for PCC after urgent elective surgery. o All non-emergency procedures (including neonatal and cardiothoracic) on children which require PCC to be considered together for prioritisation in relation to critical care capacity. o Reports daily or more frequently to NoECCN/ NHS England North (Cumbria and North East) Medical Director or to NCCCG (if established) or NHS Strategic command (if established). 3. Stand by arrangements to open additional beds at GNCH and JCUH. 4. Progressive cancellation of all elective paediatric surgery (at JCUH and later at GNCH) to free medical and nursing paediatric anaesthetic staff to staff additional capacity. 5. Transfers from out of region no longer accepted. Possible triggers to PCCEP level 4 Underlying problem continues. Actions have not reduced pressure. Increasing numbers of children ventilated in district general hospitals. Network PCCEP level 4 All current PCC based ventilatory capacity utilised. Older children requiring short term ventilation being cared for in district general hospitals (DGH)/adult intensive care unit, subject to individual case discussion via NECTAR. Children with ability to benefit from PCC are still awaiting admission. Priority is to fully staff all current PCC beds, progressively open additional capacity and maximise capacity in PCC centres for younger children able to benefit. 1. PCC NHCCCG meeting daily. 2. Reporting to agreed timescales to NHS strategic command (via NCCCG if established) 12

13 3. The principles of triaging are as above but greater stringency will be required in deciding which patients should receive PCC and the extent of the treatment interventions provided. 4. All previous escalation actions will be in place. The following to be implemented progressively as pressure increases: o Cancellation of all elective non-life threatening adult surgical and cardiothoracic surgery(staged approach and speciality dependent) o Anaesthetic and recovery staff to support PCC(as electives progressively cancelled) o Lowering of standards of care is the inevitable consequence of reduction in PCC trained nurse: patient ratios. Team clinical management with PCC trained nurses supervising anaesthetic and recovery staff. o Cancellation of annual leave (including study leave) for PCC trained medical, nursing and key support staff. 4. Decisions will be made in parallel in relation to the care which can be offered in neonatal intensive care units, in particular balancing post surgical care and duration of ventilatory and multi organ support. Possible triggers to PCCEP level 5 Escalation to PCCEP level 4 will in itself trigger the establishment of NHS England strategic command, if it has not already been established in response to the underlying pressures/acute incident. Further escalation to PCCEP level 5 or 6 will be determined by the NHS strategic command structure. Network PCCEP level 5 All current PCC based ventilatory capacity utilised. Older children requiring short term ventilation (less than 24 hours), being cared for in district general hospitals (DGH)/adult critical care unit, subject to individual case discussion via NECTAR. Many additional children now requiring transfer to PCC, including some currently ventilated in DGH/adult critical care units. Priority is to utilise all additional possible ventilated beds which can be used for children within the two current centres, for those children most likely to benefit. 1. PCC NHCCCG meeting once daily. 2. The following will be implemented progressively: Utilisation of Adult Critical Care (ACC) beds at GNCH and JCUH for progressively younger children (criteria based on age, weight and clinical complexity), allowing overview / supervision from PCC staff. This will require displacement of adult cases from GNCH and JCUH to 13

14 DGH Adult Critical Care Units (ACCU s) to ensure equity for adult patients. Utilisation of ACC beds at all DGHs for progressively younger children (criteria based on age, weight and clinical complexity), with supervision from PCC staff. Further reduction in PCC trained staff: patient ratios. Limiting of complexity and period of intensive care support to individual children. Possible triggers to PCCEP level 6 Further escalation to PCCEP level 6 will be determined by the NHS strategic Command structure. Network PCCEP level 6 All possible critical care capacity utilised. Children requiring ventilatory support cannot be admitted. Many very ill children on paediatric wards. This phase may also occur if critical infrastructure fails (E.g. no drugs available) or no staff available. If this situation is reached, the command structures may determine that intensive care can no longer be delivered and that staff should be redeployed to give lower levels of support to children. 14

15 Appendix 1 Single Point of Contact NECTAR Phone Number: Network Medical PCCU Leads PAEDIATRIC ICU Sue Jackson GNCH PICU RVI Newcastle Hospitals NHS FT Yam Thiru Freeman Hospital PCICU Newcastle Hospitals NHS FT Ginny Birrell James Cook University Hospital South Tees NHS FT Aravind Kashyap PCCU North East Children s transport and retrieval NECTAR NoECCN Personnel Contacts Newcastle Hospitals NHS FT North East & Cumbria Locality Table of NoECCN Personnel Contacts Normal Hours Monday to Friday Lesley Durham (Director) Dave Cressey (Medical Lead) Jan Malone (Administrator) Out of Hours (Monday-Friday) Weekends Consultant Intensivist on call (RVI Ward 18 Neuro-Trauma ICU) Tees Valley & South Durham Locality Julie Platten (Manager) Isabel Gonzalez (Medical Lead) Sarah Gray (Administrator) Consultant Intensivist on Call (JCUH GICU) Paediatric Critical Care Leads Iain Johnstone (Paediatric Medical Lead) / Lynda Pittilla (Paediatric Nurse Lead) Consultant Paediatric Intensivist on call GNCH PCCU (RVI Newcastle) Consultant Paediatric Intensivist on call JCUH PCCU North East Children s Transfer and Retrieval (NECTAR) Phone number

16 Appendix 2: PCC NEWCASTLE HOSPITALS CRITICAL CARE CONTROL GROUP (PCC NHCCCG) Terms of Reference and Membership Purpose The PCC Newcastle Hospitals Critical Care Control Group (PCC NHCCCG) will be the command group for PCC across the north east once the relevant alert level is reached. Its purpose is to coordinate, monitor, and direct a region wide (North East and North Cumbria) response to an exceptional demand for paediatric critical care. [Depending on the cause of the pressure on PCC, the Trust Critical Care Control Group (CCCG) may also be coordinating the trust adult critical care response] Broad Remit of the Group To monitor and coordinate paediatric critical care patients, staffing (nursing, medical, and admin), disposables and equipment for critical care services across the network. To assess critical care demands and advise the Hospital Tactical Control Teams on the appropriate reallocation of staff, beds, equipment, disposables and drugs To monitor admissions, access and throughput to critical care beds and direct the appropriate expansion and cohorting across the NoECCN organisations To advise the Trust on any changes to normal critical care standards of care e.g. equipment and staffing To prioritise and direct the delivery of staff education and training to support the staffing requirements of critical care. To coordinate staffing rotas/off-duty and support the Hospital Tactical Control Team with organisation and coordination of critical care services throughout the Trust. To ensure the use of the regional Ethical framework for utilisation of critical care in response to exceptional demand which underpins all decisions at all times. (A multi-professional team with no less than two consultants will decide on the admission and access to critical care beds and limitation on treatment. When appropriate withdrawals of treatment will be discussed at the daily meeting and will be recorded in meeting notes) To maintain and review a log of ethical decisions To review all patients on the line list To perform a stringent review of all elective surgery requiring PCC, with a view to cancellation of surgery in accordance with the Trusts Major Incident Plan and the Network PCCEP level Facilitate early/appropriate discharge to ward areas where clinically feasible. To interact with and inform the North of England Critical Care Network and NHS England North (Cumbria and North East) on Trust Critical Care capacity and demand. 16

17 Provide appropriate representation (possibly at short notice) to represent the Trust on the Network Critical Care Control Group (NCCCG) in accordance with the Network PCCEP. Timing and Operation The Trust PCC NHCCCG will be convened in line with the Trusts Major Incident Plan and at Network PCCEP 3. A Chair will be identified who will have responsibility for the actions of the PCC NHCCCG. This would ideally be the duty PICU Consultant at the GNCH (RVI) or a designated deputy The establishment of Trust PCC NHCCCG may be at short notice and will be driver dependent The group will meet daily / weekly dependent upon on activity and driver to coordinate critical care activities The chair of the group will report to the Trust Hospital Control Team A teleconference facility will be provided for staff to dial in from their units. The dial in number is The conference call will be recorded and key decisions documented Membership The PCC NHCCG will be multi-professional Senior clinical representation from the Great North Children s Hospital PICU, Freeman PICU and James Cook PCC team (usually by teleconference) to include a Consultant Paediatric Intensivist and at least one other Paediatric Medical Consultant, NECTAR. Senior PCC Nursing staff and AHP s as appropriate Senior Pharmacist Senior Trust Manager / Emergency Planning Officer Senior Bed Manager Others as appropriate such as outreach for early discharge planning situations Ad hoc partners as appropriate Governance The PCC NHCCCG will be accountable to the Trust Tactical Command. Administration and Coordination Secretariat to PCC NHCCCG will be provided by a member of the Critical Care / Anaesthetic admin team or an appropriate person as designated by the chair of the group. 17