Portsmouth Hospitals NHS Trust. Surge and Escalation Management Plan

Transcription

1 Prtsmuth Hspitals NHS Trust Surge and Escalatin Management Plan April 2013

2 Table f Cntents 1.0 INTRODUCTION Purpse f the Plan and Indicatrs Definitin Scpe Risk factrs Whle System Factrs MANAGING SURGE Management arrangements Assessment, mnitring and infrmatin cascade Situatin reprting Alerting ther rganisatins Rle f Cmmunity Partners Cntingency/Flex Capacity Optins/Queue Management Declaring Black Status Stand Dwn/Deescalatin prcedure Recvery Management ESCALATION STATUS LEVEL 1 - GREEN Summary and Actin LEVEL 2 - AMBER Summary and Actins LEVEL 3 - RED Summary and Actins LEVEL 4 - BLACK Summary and Actins Further Trust Actins Internal Cntrl Re-directin Optins Re-directin Actins EMERGENCY SURGE Summary Declaratin f an emergency Hspital Cntrl Rm (HCR) Emergency Surge Capacity Optins Emergency Surge Capacity Actins COMMUNICATIONS Summary ADVICE TO MANAGERS AND STAFF General guidance Redeplyment 335 Versin 1 April 2013 Page 2 f 60

3 Versin Cntrl This dcument is a cntrlled dcument. It replaces all previus versins. Upn signff f this versin, all previus versins shuld be remved frm use and destryed r archived. This dcument will be updated annually r as a result f lessns learnt fllwing an activatin r exercise f this plan. The issue date is shwn in the fter. Versin Histry Versin Title Versin Date Status Number 0.1 Surge Management Plan April 2013 Draft Versin 1 April 2013 Page 3 f 60

4 Versin 1 April 2013 Page 4 f 60 PORTSMOUTH HOSPITAL NHS TRUST 1.0 Intrductin 1.1 Purpse f the Plan The purpse f this Plan is t allw Prtsmuth Hspitals Trust t: Create additinal capacity fr an increase in demand created by any additinal pressures Create emergency capacity fr surge in demand Manage patient flw away frm the admissins pathway during these events Define triggers fr activatin f escalatin and surge management activity. T ensure escalatin Triggers are nted and crrect actin is taken T ensure the Trust achieves the Operatinal Standards mapped ut belw: INDICATOR OPERATIONAL STANDARD Fur hur emergency access standard 95% Ambulance turnarund time Ttal discharges by 1600 Daily In patient Discharges Cancelled Electives N. f High care / Resus beds available in Emergency Dept. Patient Flw Standards Delayed Discharges Maximum 15 minutes 80% f ttal discharges Equal t r greater than admissins <1% Trust wide 1 r mre Crrect patient t crrect bed first time Limit maximum number f patient ward mves t 4 50 clinically stable

5 Versin 1 April 2013 Page 5 f 60 PORTSMOUTH HOSPITAL NHS TRUST 1.2 Definitin Fr the purpses f this plan, escalatin is an anticipated increase in the number f patients r a delay in the availability f beds requiring additinal capacity t be created in the hspital. This may be caused by a number f factrs as detailed in sectin 1.4. External trigger pints fr activatin f the escalatin arrangements are: Increased demand Calls t SCAS increase as such that attendances t the Emergency Department rise Patient attendances abve the seasnal nrm Increase in demand fr cmmunity and primary care services Issuing f a weather alert likely t increase attendances Decreased supply Critical Care capacity drps belw 1 available space in ITU with n patients ready fr transfer t wards r high care areas, Resus is full DTOCs reach 5% mre than nrmally accepted Discharge vlumes are belw thse required t meet admissins Beds/wards clsed due t utbreak f D&V and cmmunity illness Waiting Times Perfrmance against fur hur peratinal standards falls belw 95% fr 2 days Significant risk f patients waiting mre than 6 hurs in Emergency Department Staffing Actual r predicted sickness, absence r vacancy levels reach a level where patient safety will be cmprmised. In turn this will trigger the Trust Escalatin status t change. The triggers and subsequent actins are detailed frm sectin 2. Surge is an anticipated increase in the number f patients caused by a single Incident r a Majr Incident which will cause extreme pressure t the system. This cupled with additinal beds already being in use will trigger Surge Management.

6 Versin 1 April 2013 Page 6 f 60 PORTSMOUTH HOSPITAL NHS TRUST 1.3 Scpe This plan deals with the respnses required t manage the expected r unexpected increase in demand caused either during a related majr incident r thrugh an increase in nrmal activity cmbined with ther factrs preventing discharge f patients. 1.4 Risk factrs The fllwing factrs increase the risk f there being a surge in demand fr services: Severe winter weather Heatwave cnditins A Majr Incident with severe and multiple casualties Pandemic influenza r ther infectius disease utbreaks Disruptin t cmmunity care and/r scial care services Extended Bank Hliday Weekends causing increased demand n bth Acute Trust and OOHs services 1.5 Whle System Factrs Increased activity in the acute care setting culd subsequently result in a delay in the cmmunity and scial care settings as the demand fr their services increase. Cmmunicatin f a surge and the pening f escalatin capacity with these grups will be essential fr a return t nrmality fllwing the surge. Failure t ntify the fllwing grups may further increase the surge in demand by creating feedback int the acute setting where patients are unsupprted n discharge: Intermediate Care Cmmunity Nursing Scial Services Integrated Discharge Bureau

7 Versin 1 April 2013 Page 7 f 60 PORTSMOUTH HOSPITAL NHS TRUST 2.0 Managing Escalatin 2.1 Management arrangements Escalatin will be managed by the Clinical Service Management team within hurs with the Duty Hspital Manager (DHM) supprting and the Duty Hspital Manager with the On Call Manager and Directr ut f hurs. Escalatin will be managed lcally by service leads ensuring that activity infrmatin is escalated t the daily bed meetings by the Patient Flw Managers. It will be necessary fr a nminated CSC Manager and/r Chief f Service t attend the bed meeting t assist with the management f surge. Bed meetings ccur at 09:45, 12:30, 15:00, 17:00 and 19:00 daily with further meetings held at request f the Duty Hspital Manager if required. The Trust will als participate in cnference calls which will be jined by all leads within the LHE. The frequency f which will be determined by the Escalatin Level. Cmmand and Cntrl Arrangements In the event f cmmand and cntrl arrangements being required it is expected that the Trust reprts its status t the Clinical Cmmissining Grup (CCGs) wh in turn will escalate t the NHS Cmmissining Bard area team fr Wessex (NHS CB). This means the CCGs will be the first pint f cntact. 2.2 Assessment, mnitring and infrmatin cascade Assessment will be carried ut n a daily basis at the bed meetings by reviewing the Emergency Department attendances, GP calls and admissins and the admissin numbers t each specialty. The Escalatin Status may need t adjust depending n the current psitin f the hspital. This will be mnitred by the DHM thrugh each day and the infrmatin surrunding this will be

8 Versin 1 April 2013 Page 8 f 60 PORTSMOUTH HOSPITAL NHS TRUST delivered within the Operatins reprts. If the demand n services affects particular CSCs significantly the DHM may cntact the relevant Managing Directr directly t infrm them. 2.3 Situatin reprting The escalatin status will be cmmunicated internally three times a day and externally nce a day unless the status changes, in which case a further escalatin status will be issued externally. 2.4 Alerting ther rganisatins The Trust will escalate t the CCGs if required. If the Hspital Status mves t Red then the Trust will need t assess the need fr rganising and chairing a whle system telecnference. If the Hspital Status mves t Black then the Trust will cntact the CCG Directr n Call. 2.5 Rle f Cmmunity Partners The fllwing rles and respnsibilities will be carried ut by the CCGs during the winter perid, and ther surge events: T lead the Cluster respnse t pressure surges n a daily basis in and ut f hurs Mnitr the daily situatin acrss the Cluster Be aware f measures taken by trusts t manage pressures and ensure timely implementatin Brker crss Cluster agreements fr the management f pressures Liaise with SCAS ver pressure levels, including the authrisatin f redirectins frm Emergency Departments where necessary Ensure Trusts investigate at a senir level the reasns fr redirectins Advise key leads within the LHE if there are actins that need t be undertaken r require apprval r brkerage During implementatin f central cmmand and cntrl mnitr the implementatin f centrally requested actins n the grund and escalate issues t

9 Versin 1 April 2013 Page 9 f 60 PORTSMOUTH HOSPITAL NHS TRUST Keep infrmed thrugh additinal briefings required t manage the situatin Ensure partners are wrking in an effective way tgether t manage demand and create capacity T vercme barriers t effective partner wrking and escalate t where this is nt pssible Brief barding Clusters n any issues which may impact n their management f pressure surges and patient redirectins beynd the Cluster brder. 2.6 Cntingency/Flex Capacity Optins/Queue Management The Flex Capacity ptins belw shuld be cnsidered after all apprpriate discharge measures have been carried ut as per the actin cards cntained in this plan. Each area has been RAG rated and risk assessed fr use. The aim must always be nt t queue hwever at such times f a large surge this may ccur. Staffing within the Emergency Department must be assessed as t whether they can supprt caring fr patients in the queue. The patient t nurse rati must be 4:1. If this cannt be supprted by the Emergency Department plans t seek supprt must be made via the ED Matrn and Head f Nursing and/r the Duty Hspital Manager. Staff frm ther areas acrss the Trust may be called upn t assist. A discussin als needs t take place with the MAU Cnsultant r ther Specialty Teams with regard t assisting the assessing f patients in ED and the Queue. 2.7 Escalatin/Declaring Black Status The Care Cmmissining Grups (CCGs) prvide the rute by which issues are escalated t. Hwever an external Trust status reprt must be issued daily and again if the status changes. The COO, On Call Directr r DHM must als remain in cntact with the relevant CCG t escalate any internal changes that they may be able t assist with. In the event f declaring Black Status a telephne call between the Trust COO r Duty Directr and the Chief Cmmissining Officer r CCG Directr On Call must take place t cnfirm the status. Out f Hurs this call must be between the Directrs n call fr the Trust and fr the Wessex area Cmmissining Bard.

10 Versin 1 April 2013 Page 10 f 60 PORTSMOUTH HOSPITAL NHS TRUST 2.8 Stand dwn/de escalatin prcedure The decisin t stand-dwn frm any f the alerting levels, r clse additinal capacity will be made by the DHM in cnjunctin with the Directr n Call r Chief Operating Officer, based upn demands, capacity and expected pressures. A discussin with the CCGs must take place befre de escalating frm Black. When deciding which additinal capacity shuld clse thse areas which pened with a higher risk scre attached t it shuld take pririty. Upn agreeing t stand-dwn, all managers activated r placed n stand by shuld be cntacted and std dwn, ther staff shuld be infrmed as necessary, and the Trust s alert status will be updated n the intranet. Other respnding agencies, will be infrmed as necessary. 2.9 Recvery management Return t nrmal business peratins fllwing the activatin f the Surge Management arrangements shuld cnsider the key aspects belw. In additin t this the recvery f ward space used fr escalatin shuld be returned t nrmal peratins at the earliest pprtunity especially where this impacts n perfrmance. A full debrief shuld be under taken t identify imprvements t the plan and prcedures. Key aspects & Cnsideratins Cause f the Surge Escalatin prcess and rder f pening Actins taken internally t the Trust Actins taken externally in supprt

11 Versin 1 April 2013 Page 11 f 60 PORTSMOUTH HOSPITAL NHS TRUST 3.0 Escalatin Status 3.1 Summary Activity/capacity imbalance undermines the Trust s ability t deliver t its peratinal standards, and t care safely fr individual patients. The escalatin prcess is the mechanism fr sharing capacity pressures at times f difficulty. The triggers fr escalatin mechanisms t these emergency pressures are utlined belw. It is t be assumed that the hspital des nt clse t emergency admissins and will nt be able t divert acute wrklad t anther acute prvider unless in an event f an internal r external majr incident. It is imprtant that Trust is able t assure healthcare partners that all internal measures have been taken befre escalating t the highest escalatin status. There are fur categries f escalatin: Green, Amber, Red and Black. Specific trigger pints fr these are defined in the tables belw. Quick use Actin Cards will be made accessible. Green and Amber are used t define nrmal levels f activity. Cmmunicatin f internal capacity pressures will be in the frm f the Escalatin reprt issued internally and the daily capacity meetings. Actins taken in amber will be as abve, with specific attentin t individual areas f pressure, but it is nt intended that amber status shuld result in any actin likely t be disruptive t nrmal patterns f activity. Amber status represents busy, but within nrmal bundaries. Red is t be used as the next escalatin status and senir managers within CSCs will agree an internal actin plan. This will include reviewing all admissin and discharge decisins, t review current bed base and unfunded capacity. In line with this the Duty Hspital Manager will be expected t alert relevant partners and escalate t the relevant Management Teams.

12 Versin 1 April 2013 Page 12 f 60 PORTSMOUTH HOSPITAL NHS TRUST T declare black escalatin within the Trust all triggers must be checklisted. A telephne call t cnfirm will take place between the COO f the Trust and the Chief Cmmissining Officer in hurs and the Duty Directr fr the Trust and CCGs ut f hurs. Agreed Cnference call times will be activated and all measures t prevent escalatin this far will have been taken. In additin t these internal meetings between the Chief Operating Officer, On Call Manager and Directr with all Senir Managers frm CSCs will discuss whether there is a requirement t declare internal Majr Incident, cancel Elective cases and adjust threshld fr discharge further. Regular Cnference Calls with partners must be maintained.

13 Versin 1 April 2013 Page 13 f 60 PORTSMOUTH HOSPITAL NHS TRUST 4.0 Level 1 - Green Escalatin Level Level 1 Green: Nrmal Triggers: At least 3 f the fllwing apply :- N risk f breaching - patients discharged, transferred r mved t ward within 3 hurs f arrival N ambulance queues - ambulances able t unlad and turn arund within 15 minutes + Day starts with predicted balance f n mre than: Minus 15 ( Medicine/DMOP) Minus 10 (Surgical Div) and minimum f 6 Mau and 2 SAU beds and capacity will meet expected demand Flw is prgressing smthly in ED with capacity at all times fr resus and majrs Staffing levels manageable including flexing staff t fill gaps Anticipate discharge targets Actins PHT HOSPITAL WIDE Operatins Centre:- T maintain an accurate Trust wide bed state and Hspital Ops meetings t assess the hspital psitin and t determine actin required f CSCs and departments: Meetings at: 0945, 1230, 15:00, 17:00, 19:00 Hspital Status will set escalatin level, 2 status 1000 and 19:00 will update the psitin. Patient Flw C-rdinatrs:- t wrk with wards t ensure that flw is maintained, discharge targets are met, discharge lunge is maximised, diagnstics are prgressed and patients are transferred frm ED and assessment areas in timely manner t ensure that available beds are filled within a maximum f 30 minutes f ntificatin and escalate if nt Duty Hspital Manager:- t versee whle hspital and lcal health ecnmy psitin and cmmunicate with wards, department and divisinal teams the actin that are required t keep flw ging/tackle any slw dwn in flw. This will include ptential t escalate internal delays (e.g. TTOs, CT, endscpy, transprt, whitebard patients) t maintain flw and r external delays (repatriatins, cardiac t SUHT etc) t cmmunicate with On Call Manager and/r On Call Directr if there is any risk that the escalatin level will nt be maintained and it is necessary t mve t the next level Specialty Wards NiC r Ward Manager:- t ensure that patients are admitted in time fr space t be created in assessment areas s that patients can be transferred frm ED all patients t have an EDD within 12 hurs f arrival n ward and a cnfirmed treatment plan. Ensure updates f patient planning status bards and visual hspital review EDD fr current and next day and ensure that they take the necessary actin t achieve their target fr

14 Versin 1 April 2013 Page 14 f 60 PORTSMOUTH HOSPITAL NHS TRUST will be met and n mre than 10 utliers Less than 10 additinal care spaces in use Medical staff:- beds fr the day and enabling actins fr the fllwing day s discharges, this is t include beds fr elective patients ensure all next day discharges are reprted t the Operatins Centre by 17:00 the previus day t ensure that all actins reviewed fr all patients and chased up including tests, test results/reprts, dctr reviews, therapy treatment if risk that discharge target will nt be met fr day cmmunicate with medical and management teams t crrect this t ensure that ptential discharges are flagged up t the medical teams and reviewed first n the ward rund and that actins t discharge are carried ut prmptly t ensure full use f the discharge lunge in the discharge f their patients and prvisinal transprt bkings are made t ensure that available beds are declared t Patient Flw C-rdinatrs in a timely manner and filled within 30 minutes t identify minimum f 1 patient fr discharge/transfer t discharge lunge by 1000 and t achieve all mrning discharges by 1300 hrs by 1300 hrs t have the capacity either available r imminent t meet the expected admissins fr the day and t have made all mves t create the capacity cmpleted by 2200 hrs Ensure all Green Crss frms are submitted daily t the IDB t review all patients, update estimated discharge dates and take actins t prgress care r achieve discharge fr current and next day spell summaries, TTOs t be written up fr any patient and transprt requested if required with a ptential discharge with 48 hurs. t identify patients wh culd utlie if further capacity is required Discharge Planning team/integrated Discharge Bureau:- t ensure that all wards are carrying ut necessary tasks fr the discharge f patients with cmplex needs i.e. making sure the need r referrals are identified and that referral are made t ensure that all actins are taken t achieve predicted discharges fr patients with cmplex needs fr the current and next day and later in the week t ensure that cmmunity beds are cnsidered as an ptin fr patient transfer and reprted daily in the Operatins Centre meeting; wards t liaise with Cmmunity Hspitals/Cmmunity Intermediate Care Schemes t transfer patients and supprt this prcess if required T ensure all Medically Fit fr Discharge and Discharge ready patients are identified and actins t prgress are

15 Versin 1 April 2013 Page 15 f 60 PORTSMOUTH HOSPITAL NHS TRUST underway Assessment Areas C-rdinatrs:- t ensure that GP referrals can be admitted directly t the unit t ensuring smth flw f admissin frm hme, t maintain space at all times t receive GP direct admissin and patients frm ED t ensure that actins are being fllwed up in all areas t prgress care and achieve discharges and transfers t wards t ensure all patients have a PDD within 12 hurs f arrival n ward and a cnfirmed treatment plan. t ensure patients are allcated t apprpriate empty staffed beds, liaising with specialties t priritise wrk f the transfer team and ensure available beds can be filled within a maximum f 30 minutes frm ntificatin re patient discharge t ensure that all patients cnfirmed as requiring an inpatient bed are transferred frm the assessment areas t the apprpriate inpatient ward by 2200 Emergency Department ED Crdinatr:- Ensure that first assessment times are met and patient pathways are managed within agreed standards Ensure that specialty referrals are made in a timely manner and within agreed standards Deply nursing and medical staffing acrss the department t ensure that patients can be dealt with within agreed standards, taking practive actin based n knwn arrival pattern, as well as current day s infrmatin frm the ambulance service Escalate as per trigger plans if space in the department becmes cmprmised and if there is any threat t the department s ability t be able t take handver f patients frm SCAS in 15 minutes. Mnitr requirement fr Queue Nurse. Diagnstics:- Imaging call fr patients based n clinical pririty and the requirement fr reprts t allw patient discharge and/r prgress in the treatment pathway. Requesting specialties liaise with DI t identify suspended admissin patients t return fr imaging at an utpatient appintment bked fr a later date. Pathlgy reprt bld test etc., results within target turnarund times as determined by categry f clinical requestr. Pharmacy

16 Versin 1 April 2013 Page 16 f 60 PORTSMOUTH HOSPITAL NHS TRUST Pharmacists t cver all wards ensuring that drug histries are taken n all patients and that all prescriptins are clinically safe. Pharmacists r technicians t highlight thse patients requiring cunseling r special help with their medicatins n discharge. Liaising with discharge planners and wards s that any ptential prblems relating t drugs n discharge are srted in advance f the discharge, particularly NOMADs. Balance pririties t ensure that dispensing TTOs is balanced with rutine wrking and training. Liaising with the Discharge Lunge t ensure that any TTOs nt prcessed in advance are sent t the crrect place. Infrm the Duty Hspital Manager f any staffing/it/prtering issues that culd affect the turn arund times fr TTOs. Ensure that drug trlleys used n verflw areas are replenished. Transprt Desk/Discharge Lunge Transprt C-rdinatr assigns patients t available vehicles s as t maximise capacity and prmpt transprt f the patient. Ensure additinal transprt requested if necessary fllwing authrisatin Suth Central Ambulance Service (SCAS) Cntrl Duty Manager - can be reached n hurs a day. Ensure drp ff f patients and clearance f ED department unlading bay as sn as pssible and r within 15 minutes f arrival Ensure prmpt pick up f patients frm ED fr transfer and r discharge if pssible within 15 minutes f arrival t cllect PHT escalatin reprt t be circulated daily t all teams and actins taken accrding t the status Cncerns/Issues t be fed back t PHT Whle System Partners T maintain Patient Flw and capacity

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18 Versin 1 April 2013 Page 18 f 60 PORTSMOUTH HOSPITAL NHS TRUST 5.0 Level 2 - Amber Level 2: Heightened (Internal Alert) At least 3 f the fllwing apply :- Risk f 3 hur breaches with patients waiting 90mins t 1st assessment r 180 mins with n decisin t discharge, treat r transfer Ambulances turn arund >15 minutes but < 30 mins Flw is manageable but ED is busy at times with build up f patients Day starts with predicted balance f n mre than: Minus 25 (Medicine/DMOP) Minus 20 (Surgical) Staffing levels f cncern sme redeplyment required Predictins indicate that discharge targets are in dubt and r utliers Less than 20 additinal care space in use PHT HOSPITAL WIDE - All actins in Level 1 plus Patient Flw C-rdinatr:- t cmmunicate psitin acrss all CSCs t the Management team and agree actins with them and at the Hspital Operatins meetings. t receive escalatin f any delays in patients treatment plans and take actins t address t liaise with specialties t target patients whse discharge culd be expedited t agree and facilitate the utlying f patients t create space n wards In all specialties divisinal teams and n call managers t be alerted and actins t imprve flw agreed and enacted Duty Hspital Manager:- t cmmunicate the psitin hspital wide and t primary and secndary care Duty Hspital Manager t cntact PTS prvider and assess certainty f transprt arrangements and t arrange additinal capacity if required including use f taxis t liaise with Patient Flw C-rdinatrs t assess ptential t utilise cmmunity beds t liaise with Discharge Planning team t explre expediting actins fr cmplex patients t ask facilities t expedite cleaning and transfers, including additinal prtering supprt t alert SCAS t ptential issue and agree ambulance liaisn cver t cntact GPs/OOH and ask t cnsider alternative pathways Duty Hspital Manager and Patient Flw C-rdinatrs t ensure beds are filled within 30 minutes Specialty Wards Senir Management Teams r Matrns:- t infrm senir Medical staff f the situatin ask them t cnsider additinal discharge decisins, agree these with them and expedite eg patients suitable fr discharge lunge, discharge pending diagnstics and utliers.

19 Versin 1 April 2013 Page 19 f 60 PORTSMOUTH HOSPITAL NHS TRUST Medical staff:- t cmmunicate t all teams if discharge target are in dubt and review further actins t expedite t split fr early review f existing utliers and patients n specialty wards t review all patients n every ward and agree discharge plan t identify suitable utliers with the NiC NiC r Ward Manager t fllw up n actins frm patient review t increase discharges, prgress care and where pssible t mve patients t discharge lunge pending discharge. Discharge Planning Team/Integrated Discharge Bureau t review all patients n cmplex discharge list with Scial Services t see if plans can be brught frward Assessment Areas Crdinatrs:- MAU NiC/ Crdinatr :- T ensure GP call centre t wrk with GPs t agree patient admissin times based n clinical need T ensure medical teams review referrals and agree admissin criteria based n clinical need T ensure medical and nursing teams t expedite actins t create space in respect t (i) discharges (ii) transfers t wards this will include a review f the triage categries f patients ED C-rdinatr and ED Cnsultant in majrs:- t assess the situatin and expedite actins t ensure first assessment times and referrals times are adhered t and patients are seen rapidly review need fr See and Treat pathway if nt already in place t ensure that patients suitable fr discharge frm the department have all actins expedited t achieve this and early referrals t specialties are made t identify queue staff t lk after patients if at any time they cannt be handed ver within 15 minutes t cnduct Bard rund t ensure that referrals are made prmptly t specialties infrm Minrs patients f alternative care pathways ie Treatment Centre Diagnstics: As fr green status

20 Versin 1 April 2013 Page 20 f 60 PORTSMOUTH HOSPITAL NHS TRUST Diagnstic Imaging, Clinical Nutritin Nurses, and Patient Transprt Desk as fr green status. Pharmacy - t speed up turnarund times fr n the day discharge decisins Supprt Services: Facilities and prters t priritise cleaning and transfers Suth Central Ambulance Service (SCAS) Cntrl Duty Manager - can be reached n hurs a day. SCAS t attend PHT Emergency Department and liaise with ED crdinatr / Duty Hspital Manager re situatin and agreed actins t supprt. Cmmunity Care Prviders Scial Care Maximise use f re-ablement beds Task cmmunity hspitals t bring frward discharges t allw transfers as apprpriate Additinal ward runds within cmmunity prviders t expedite discharge and create capacity Cmmunity prviders t lwer admissin/treatment threshlds wherever pssible thrugh implementatin f previusly agreed flexible wrking arrangements t alleviate pressure Apply flexibility regarding beds and staffing t increase capacity where pssible Expedite rapid assessment by multidisciplinary team (MDT) including Scial Services assessment Undertake additinal ward runds Expedite care packages and nursing / EMI / care hme placements Ensure all patients waiting within anther service are prvided with apprpriate service Where pssible, increase supprt and/r cmmunicatin t patients at hme t prevent admissin. Maximise use f re-ablement beds

21 Versin 1 April 2013 Page 21 f 60 PORTSMOUTH HOSPITAL NHS TRUST 6.0 Level 3 Red Level 3 Heightened (LHE Alert) At least 3 f the fllwing apply :- ED full and ambulances cannt fflad within 30 minutes with ambulance queues Ttal ccupancy 100% with n spaces n MAU r SAU utlying patients (f any specialty) Trlley waits at 4 + hurs A&E majrs cubicles full Resuscitatin area available Minrs busy with 1.5 hr wait Mre than 3 patients kept at hme vernight unplanned Staffing shrtages in key areas Mre than 30 additinal care spaces in use PHT HOSPITAL WIDE All actins in 1 & 2 plus: Duty Hspital Manager / On Call Manager (ut f hurs):- t discuss mve t Red status with n call Exec t lead additinal Hspital Site status checks t agree expedited actins with all teams at agreed times t ntify cnsultant n call and n call manager f escalatin level t cmmunicate hspital psitin t all departments and request prmpt actin n all matters t d with flw t ensure that referrals fr diagnstics are priritised t liaise with ED and MAU n use f bank pl f staff and r additinal staff needed in pharmacy, imaging and r pathlgy. t make decisins in cllabratin with CSCs and On Call Directr abut pening f extra care spaces / additinal capacity fr a limited time (aim shuld be t clse within 48 hurs) t cntact CCGs and SCAS and ensure new escalatin reprt distributed t alert them t situatin and escalatin t red status and steps taken t address. t assess pssible divert ptins Exec n call t attend next Hspital Operatins meeting and r call extrardinary Hspital Ops meeting (s) thrughut the day t cmplete duty directr reprt and circulate t ntify partner rganisatin On Call Directr reference red status. t ensure all CSCs have cmmunicated escalatin level t their teams and assciated services and release staff frm nrmal duties t reslve patient flw Patient Flw C-rdinatr / Duty Hspital Manager (ut f hurs) t ensure that beds are filled within fifteen minutes t review elective admissins and if apprpriate pstpne in discussin with CSC Management Teams All CSCs t cmmunicate escalatin level t their teams and assciated services and release staff frm nrmal

22 Versin 1 April 2013 Page 22 f 60 PORTSMOUTH HOSPITAL NHS TRUST duties t reslve patient flw Specialty Wards HN r if nt present Matrn t review deplyment f nursing staff acrss each CSC t target pririty areas t review patients admitted tday fr prcedures tmrrw t find alternative accmmdatin r sent hme t identify staff / arrange fr staff t be available t pen extra care spaces review the need fr Queue nurses and need t deply additinal staff t ED t assist determine skill mix based n situatin Cnsultant medical staff will identify further actins that culd be taken t expedite individual patient discharge and imprve flw this includes lwering the threshld n patients t be discharged t review deplyment f medical teams t best affect patient flw and discharge, including ensuring that specific respnsibility fr reviewing utlying patients has been allcated. All CSCs t review ptential fr any ther frm f treatment fr electives ( i.e. day case) Assessment Areas MAU crdinatr ask GP call centre t ensure :- GP expected patients g t assessment areas GP call centre t wrk with SPA t increase utilisatin f cmmunity patients t care fr patients Medical and nursing teams t expedite further actins t increase discharges and/r transfers t wards. DMOP/ MAU Team:- t increase scrutiny f admissins and utilise SPA t divert admissins where clinically apprpriate cntact all cmmunity hspitals and feed infrmatin back t Ops Centre Cnsultants in MAU t wrk tgether t prgress patient flw t cmmunicate with cmmunity services as abve and reprt any prblems/ pprtunities t the Integrated Discharge Bureau Matrn MAU / Acute Team t scrutinise patient and send them hme if pssible thinking f alternatives t admissin Emergency Department ED crdinatr T assess the queue situatin and deply staff/assess need fr utside agencies t assist in the care f patients wh cannt be frmally handed ver including triage f patients in ambulances s treatment can cmmence

23 Versin 1 April 2013 Page 23 f 60 PORTSMOUTH HOSPITAL NHS TRUST t wrk with ambulance liaisn fficer n management f ambulance queue, acuity, deplyment f resurce SCAS prvide cntinued liaisn supprt splitting crews where apprpriate t remain aware f situatin and nn cnveyance f the patient t hspital if apprpriate Cnsultant/Registrar t scrutinise admissin decisins and ensure all apprpriate actins are being taken t prgress care Diagnstics Imaging as fr amber plus:- ptential capacity fr extra three dimensinal imaging checked and scheduled fr later deplyment as available. Requesting specialties/discharge planners liaise with Diagnstic departments re result - dependent discharges. Pharmacy Ensure extra drug trlleys are mved t apprpriate areas in a timely way Re-allcate staff as required t maintain the flw f TTOs t allw discharges Patient Transprt Desk Assess the likelihd f later discharges, verify that transprt capacity is available and cnsider rdering extra if apprpriate. Suth Central Ambulance Service (SCAS) Cntrl Duty Manager t be ntified n hurs a day and nce an ambulance fficer nsite they becme the first pint f cntact fr liaisn and actin with SCAS :- Ensure deplyment f SCAS PHT Emergency Liaisn Officer t PHT ED department t assess and help with patient flw Review and reallcate resurces t meet current emergency wrklad Ensure usage f managers / fficers, staff and cmmunity respnders is maximised Maintain cmmunicatin with GP and OOH services t review ptential delays t patient admissins Ensure all duty fficers and directrs are aware f current status level Reinfrce with ECPs and ther ED staff the need t use alternative care pathways whenever pssible Cmmunity Care Prviders Review all patients awaiting assessments in rder t expedite discharge r transfer this t include in reach teams, deliberate self-harm, cmmunity hspitals

24 Versin 1 April 2013 Page 24 f 60 PORTSMOUTH HOSPITAL NHS TRUST Undertake additinal ward runds and capacity where pssible expand capacity wherever pssible thrugh additinal staffing and services Cnsider the use f wider grup f agencies t increase staffing capacity Refer patients waiting at hme fr admissin t Cmmunity Teams (by in reach nurses) OOHs 111 t cnfirm staffing levels and pssible challenges OOHs t review staffing level f GP Out f Hurs service and cmmunicate any pssible challenges Scial Care On-call Managers t expedite care packages Review all assessments in pipeline t expedite discharge Increase dmiciliary supprt t service users at hme in rder t prevent admissin

25 Versin 1 April 2013 Page 25 f 60 PORTSMOUTH HOSPITAL NHS TRUST 7.0 Level 4 - Black 7.1 Summary This sectin details the necessary arrangements fr the re-directin f patients ut f care pathways int mre suitable arrangements during times f extreme pressure. A checklist t cnfirm status must be cmpleted and filed and the COO r Duty Directr must cnfirm Black status with Chief Cmmissining Officer r equivalent. Level 4 Internal Incident (SHA level) alert At least 3 f the fllwing apply :- Ttal ccupancy 100% with n spaces n MAU and SAU and Mre than 40 utlying patients r Cumulative trlley waits indicating ptential t breach 70 fr the week 10 r mre ambulances being held fr ver 30 minutes (at any ne time) N space in resuscitatin area r Majrs cubicles in ED Over 5 patients left at hme unplanned vernight r accumulatin f patients PHT HOSPITAL WIDE - All actins in 1, 2 & 3 plus Duty Hspital Manager / On Call Manager (ut f hurs) :- T ensure that pririty is given t clearing resuscitatin area in ED and ensure further risk assessment f patients at hme, expediting admissin t hspital if required Specialty patients t be transferred frm Observatin area t specialty area T liaise with Suth Central Ambulance Liaisn Officer and Chief Operating Officer / On Call Directr t keep them infrmed f the situatin Duty Hspital Manager / On Call Directr (ut f hurs) t cntact CCGs Chief Executives t review any ther ptins and t keep them appraised f the situatin. Nn frntline clinical staff (eg Crprate clinical staff) )t be fcused n all aspects f clinical wrk that will help t imprve patient flw t be agreed with Duty Hspital Manager All remaining electives t be further reviewed by CSC Managers and r relevant surgens and cnsideratin given t cancellatin. t make decisins abut pening f extra care spaces / additinal capacity fr a limited time aim shuld be t clse within 48 hurs) Heads f Nursing t undertake risk assessment f areas f increased capacity and ensure all steps up t Escalatin Red have been taken in particular t ensure the threshlds fr discharge have been lwered and fr admissin have been raised Clinical Directrs :- t ensure that Cnsultant Medical staff review all patients and identify blcks as abve. Cnsultant staff t be arranged t take GP referrals COO:-

26 Versin 1 April 2013 Page 26 f 60 PORTSMOUTH HOSPITAL NHS TRUST waiting at hme during the day Staffing shrtages in all areas Mre than 40 additinal care spaces in use will request an urgent meeting/cnference call (within 2 hurs) f the Lcal Health Ecnmy with representatives frm each area, SCAS and SS Diagnstics Imaging and Pathlgy: requesting specialties liaise with diagnstic departments regarding apprpriate priritisatin f patients, and prvisin f discharge - critical reprts. Pharmacy Senir staff ensure that wrkflw thrugh the dispensary is maintained and prvisin f TTOs priritised apprpriately. Patient Transprt liaise clsely with suppliers t maximise capacity and mve patients prmptly. Suth Central Ambulance Service (SCAS) Cntrl Duty Manager t be ntified n hurs a day and nce an ambulance fficer nsite they becme the first pint f cntact fr liaisn and actin with SCAS :- Review current GP admissins with GP s t ensure safe standards f care t patients Call in additinal peratinal and cmmunicatins centre staff and additinal resurces eg St Jhns, private ambulance services etc Review all lng distance inter hspital referrals Direct cmmunicatins between SCAS and PHT NHS Trust Duty Directr If emergency respnse is severely cmprmised cnsider use f Majr Incident prcedures What is the current demand and capacity? 2. Can 111 redirect t alternative prviders ther than ED? What is the capacity OOH 1. within service / any gaps in service prvisin? ISTC 2. What is the current demand and capacity? 3. Can ED redirect t ISTC?

27 Versin 1 April 2013 Page 27 f 60 PORTSMOUTH HOSPITAL NHS TRUST Cmmunity (SHFT and Slent HCC and PCC) 1. Hw many cmmunity beds are available? 2. Where are cmmunity beds available? 3. What is the staffing status? 4. Hw many extra ward runds are taking place? 5. Are there any package f care issues if s what actins have taken place? 6. Cnsider relaxatin f cmmunity bed admissin criteria where apprpriate MAJOR INCIDENT As per Majr Incident Plicy

28 7.2 Further Trust Actins Actins Establish permanent cmmand and cntrl in Operatins Centre Identify suitable lead fr situatin (Directr n Call), if nt being led by Chief Operating Officer Fllw prcess fr requesting Ambulance Redirectin if deemed apprpriate Pull staff frm ther services t supprt Emergency Department and Discharge prcesses and ensure all clinical staff have clear diaries t allw them t supprt Ensure frequent clinical safety assessments are cnducted Open and Staff additinal cntingency beds Request the spt purchasing f beds within Nursing Hmes t supprt discharge Cnsider scale back f nn essential functins acrss all services t create capacity and staffing Use f crprate (staff nt nrmally in clinical rles) nursing staff t supprt care where necessary Ensure all staff are made aware f pressures, and need t priritise discharge Re review f all Elective activity 7.3 Internal Cntrl Upn reaching a bed crisis level, there shuld be a mve t centralised cntrl r escalatin f bed meetings t identify business cntinuity measures t be used t supprt nging pressure management. Internal cntrl arrangements shuld take the frm f additinal bed meetings, which fcus n the issue f capacity. Or the use f the Operatins Centre t centrally cllate infrmatin, reflecting the structures used t respnd t a Majr Incident as detailed in the Emergency & Majr Incident Plan r thse f the Overarching Business Cntinuity Plan. A bed crisis is t be cnsidered an Emergency under these arrangements and will nt be declared a Majr Incident. All staff shuld be made aware f the arrangements and may need t supprt pressures management by mving away frm their usual daily rutine. Versin 1 April 2013 Page 28 f 60

29 7.4 Re-directin Optins Ambulance Redirectin An ambulance redirectin may be requested. This shuld be agreed with SCAS and with the receiving hspital/s. The request fr a hspital re-directin will be balanced against the impact this will have n the surrunding hspitals and verall pressures in the cluster. Any re-directin will be time limited and prvide a pressure ease n the Accident and Emergency Department, it will nt thugh prevent self presenters attending the hspital. Primary Care It is als pssible t request primary care supprt, with the stepping up and redirectin f patients where their clinical need allws int primary care services, either in t primary care walk-in centres and general practices. 7.5 Re-directin Actins The fllwing actins shuld be taken when arranging a hspital re-directin. Actins Ensure SCAS is aware f situatin and visits site On-Call Directr t cntact On-Call Directrs fr SCAS and neighburing Trusts and request redirectin SCAS On-Call requests redirectin frm alternative site with agreement f receiving site and the Ambulance Service. SCAS cnfirms the request t On-Call Directr The On-Call Directr cnfirms with the Duty Hspital Manager Versin 1 April 2013 Page 29 f 60

30 8.0 Emergency Surge 8.1 Summary Surge caused as a result f a single incident that verwhelms nrmal surge management prcesses r ccurs during a time when all additinal bed capacity has been activated. This will usually be pened nly in the event f a Majr Incident and as a temprary slutin. 8.2 Declaratin f an emergency In the event that an Emergency r Majr incident needs t be declared due t the impact f an incident n the trust services the Chief Executive, r deputy, will declare an emergency r majr incident with guidance frm the Emergency Planning Manager. In such an event the actins f this plan maybe superseded by thse f the Emergency & Majr Incident Plan. 8.3 Hspital Cntrl Rm (HCR) During an emergency respnse the Incident Cntrller will decide if the HCR is t be established r if the incident will be handled using existing wrking methds, shuld the Hspital Cntrl Rm be required details can be fund in the Emergency and Majr Incident Plan. The main rle f the HCR during an emergency will be t c-rdinate the respnse f all services and issue cmmunicatins relating t the current status f the hspital including capacity. The Incident Cntrller will decide if Bed Meetings will becme part f the cntrl rm functins r remain separate. In either case beds will be managed by the bed crdinatr. 8.4 Emergency Surge Capacity Optins The fllwing utline the ptins fr managing emergency surge in the hspital, cnstraining factrs will include staffing availability, length f surge and type f surge: Suspensin f Day Cases t create capacity Suspensin f Elective Prgramme Redirectin f mre patients Expansin f discharge lunge eligibility criteria, and frmatin f patient bservatin area Opening additinal capacity, r creating capacity utside f nrmal areas (may exceed time f surge t establish) Versin 1 April 2013 Page 30 f 60

31 8.5 Emergency Surge Capacity Actins Upn declaratin f a Majr Incident. Initiate actins fr Amber and Red, and actins fr Black Identify services t be suspended/capacity t be pened Identify and call in supprt staff All areas t initiate Majr Incident Cards Ensure clinical safety assessment is cnducted n all areas pened All clinical and nn clinical teams t fcus n discharge and creating capacity Versin 1 April 2013 Page 31 f 60

32 9.0 Cmmunicatins 9.1 Summary Belw are cmmunicatin actins that need t be cnsidered r taken in the event f a Surge, utside f the standard messages that wuld be issued as part f a respnse t an incident as utlined in the Emergency & Majr Incident Plan. Duty Hspital Manager t infrm key staff, including Carillin, f immediate ward changes e.g. pening and clsing f wards, restricted access t wards and any ther relevant infrmatin. Ging int weekends and evenings, ensure that reactive press lines have been agreed and the Cmmunicatins Officer has circulated. An On Call Cmmunicatins Officer is available OOHs. Use f cmmunicatin channels that reflect the urgency and frequency f messages especially where changes will impact n supprt services. General Managers t ensure that they take respnsibility fr cmmunicating key messages t their departments and services face t face if at all pssible d nt rely n t cmmunicate urgent and imprtant infrmatin - refer t actin lists. Hspital Twitter Accunt nw als available. Patient infrmatin will be cmmunicated using the website, switchbard message, and utpatient call centre system as required. This is nly likely t be needed in extreme circumstances/sudden nset surge. Jint cmmunicatins messages, and lnger term cmmunicatins planning and strategies, are develped and practiced with partners. The cmmunicatins team can be cntacted via the infrmatin in the cntacts sectin f the emergency management manual r switchbard. Versin 1 April 2013 Page 32 f 60

33 10.0 Advice t managers and staff PORTSMOUTH HOSPITAL NHS TRUST 10.1 General guidance Staff shuld where pssible make themselves aware f the actins and alert levels cntained in this plan, and knw the Trust alert level thrughut the day. This will enable individual staff and managers t take actin t relieve pressure n the Trust during surge effectively. In additin t these actins additinal tasks t alleviate pressure n specific services may be undertaken at the directin f the apprpriate lead r n-call Redeplyment During any surge event it may be necessary t redeply staff frm their usual rutine duties int ther services. In ding s the Trust will ensure that staff are redeplyed based upn their clinical skill set, and adequately supervised within the rle they are given. Managers and senir staff in the receiving area must ensure that any staff deplyed t them are made aware f any risks, given a cmplete health and safety briefing and are aware f whm t escalate prblems t. N member f staff that is redeplyed shuld be asked t cmplete tasks they are nt cmpetent in, r withut supervisin. Versin 1 April 2013 Page 33 f 60

34 Appendix 1 Flex Capacity Escalatin Beds pened as a change f designated functin frm day areas r unfunded inpatient bed spaces which are already based within funded ward areas. Thse spaces available clinically have been risk assessed, RAG rated and detailed belw. Escalatin Beds are a change f designated functin and cnfrm t Trust standard n risk assessment. T review utilisatin when all funded capacity is in use and cannt meet the frecasted demand. Escalatin Beds are a change f designated functin and cnfrm t Trust standard n risk assessment. Sme specified staffing levels may apply and/r equipment may need t be mved r sught. T review use f these when all Green Escalatin Beds are in use. Escalatin Beds are a change f designated functin and cnfrm t Trust standard n risk assessment. Specified staffing levels may apply and pening will impact n nrmal service delivery. Equipment will need t be sught and ther equipment mved. These beds are agreed via cnsultatin with the General Manager fr the Service and/r Directr n call. T review use f these when all Green and Amber beds are in use. Black Escalatin. Only t be cnsidered when in Black r Majr Incident. The pening f these will impact n service delivery and will require cancellatin f activity. Specified staffing levels will apply and equipment will need t be acquired. Cmmissining f areas may need t take place and discussin with Directr f Estates must take place if this is the case. These beds are agreed via cnsultatin with the General Manager fr the Service and/r Directr n call. T review use when all f the abve are pen and all ther measures have been taken t release capacity and failed. D8 weekend beds (8) D level Orthpaedics Beds E1 5 th Bed space ED Obs Ward ED Majrs Cubicles G5 Renal flex in all wards G2 cubicles Escalatin Areas Risk Scre Lw - 4 Versin 1 April 2013 Page 34 f 60

35 E6 Respiratry High Care Level 2 Patients nly PORTSMOUTH HOSPITAL NHS TRUST E1 Ambulatry cubicles Lw / Medium - 6 D3 Rm 18 Medium - 9 Renal Day Unit Cardiac Day Unit D5 - DOSA Medium / High - 15 Treatment Rms *NO CALL BELLS* High - 20 CHOC E1 Needs equipment E1 Treatment Rm E8 Wuld need t relcate Pharmacy Dispensary E7 Strage area D5 Wuld need t relcate Pharmacy Dispensary D8 Treatment Rm *N Call Bell* C7 Crnary Care Pacing Rm C6 Wuld need t relcate Cardilgy Research team and equipment C5 Wuld need t relcate the Gastr day case / treatments including the nurse led venesectin Service(Mn - Fri) Versin 1 April 2013 Page 35 f 60

36 E3 - Physi rm F3 Gym D6 Jint Schl MAU Ambulatry Very High - 25 Wuld require sme wrks t alter functin/recmmissining wrks, but pssible Day services wuld require relcatin prir t use Majr Incident Spaces:- G1 Waiting areas Recvery Areas Day Case Units Endscpy Theatres Old ED Majrs Areas used fr Offices r Training Rms Majr Incident spaces Flr Ward / Rm Additinal Impact Assessment Versin 1 April 2013 Page 36 f 60

37 Level Dept Care Space(s) G Renal Flex in all wards PORTSMOUTH HOSPITAL NHS TRUST 4 Fully serviced Nt available until August 2013 Renal Day Unit 5 Fully serviced Single Sex nly Nt available until August 2013 Training area G5 PP unit Variable. +/- clinic 3 Remval f kit and testing f gases/ cleaning/ beds etc Single sex nly Fully serviced Quality Cst Delivery Risk Scre Fully serviced Staff review needed Staff required ut f hurs 2x RNs If activity cancelled incme implicatins Staff required Financial Recharge fr Impact n day cases fllwing day Changed functin f rm requiring relcatin f equipment Impact n next day admissins x2=6 Versin 1 April 2013 Page 37 f 60