North Wales Critical Care Network

Transcription

1 North Wales Critical Care Network CRITICAL CARE ESCALATION PLAN FOR SURGE REQUIREMENTS This document should be read in conjunction with the Network Emergency Planning Guidelines. Revised July

2 North Wales Critical Care Network Regional Adult Critical Care Escalation Plan for Surge Requirements Winter 2010 saw unprecedented demands on the Critical Care Units in North Wales from general seasonal pressures as well a significant number of influenza A (H1N1) patients. Unlike 2009 the worldwide numbers of H1N1 were not sizeable enough to be classified as pandemic. That said, UK wide the impact on Critical Care was far more significant requiring escalation and the cessation of elective surgery in most regions of the UK. Whilst there is guidance for a Flu Pandemic (North Wales Critical Care Escalation Plan & Triage Tool for Pandemic Flu-Executive Approved 2009) there is no guidance for Surge Planning due to more generic pressures. In December 2010 Paul Williams issued a letter requesting that Executive Directors review their organisational readiness, according to the principles agreed in the Critical Care Strategy for Wales. There is also an expectation from the Department of Health 1 of readiness should the need arise: Every NHS board should assure itself that the following strands of an effective response are in place and able to be deployed at short notice should the situation demand it: developed and tested clinically led surge plans, including for adult and paediatric critical care; This North Wales Critical Care Network Escalation Plan is informed therefore by the lessons learned regionally and nationally from managing the delivery of Critical Care during the pandemic of influenza A (H1N1) in 2009 and the demands from the same and other generic winter pressures in The purpose of this guidance is to provide an effective operational response across North Wales to unplanned increases in demand for Adult Critical Care where escalation is required (see North Wales Critical Care Network Emergency Planning Guidelines for guidance regarding Major Incidents). It is likely that this will be where neighbouring Critical Care Networks are experiencing similar demands and so the options to transfer out are limited. Where additional demand for Critical Care includes paediatric patients normal Critical Care admission practices should apply; please refer to Critical Care Admission and Discharge Protocol. In the first instance however contact NWTS on Activation As local and regional pressures dictate Senior Critical Care Clinicians will discuss the necessity to Escalate with Senior Managers of the CPG. A collaborative decision will be made. Certain officers i.e. Chief of Staff, Associate Chief of Staff (ACoS) and Clinical Director for Critical Care are empowered and have the authority to instigate the Critical Care Escalation Strategy; this is provided it is undertaken in collaboration with at least two of the aforementioned officers and after informing the Hospital Management Teams (HMTs) and Site Management Teams (ref: Critical Care Sub Committee s Terms of Reference). 2

3 Principles In expanding capacity, units should initially use the measures normally employed when demand for care outstrips supply in normal clinical practice. Escalation can mean escalating capacity into Level 2 beds i.e. within a critical care unit and/or escalating outside a critical care unit for example, into theatre recovery. If there is a local surge in the first instance, normal rules of transfer will apply the escalation of local plans should not be in isolation but taken on a Network/BCUHB basis. Established Critical Care patients will not be transferred where there is no clinical benefit to themselves to accommodate planned/elective/urgent suspected cancer admissions. Shared managerial and clinical responsibility is essential; daily status reports will be supported by frequent teleconferences between the units. o The frequency of the teleconferences will be determined at the time and between the managerial and clinical teams. Network support will be provided to ascertain the bed availability in the North West critical care units i.e. not just regions; this will include paediatric beds. The process for standing down elective activity is vital to any escalation of critical care activity (DoH ) o The agreement standing down/continuing elective surgery will be agreed in collaboration with the Surgical & Dental CPG and by senior members of the managerial and clinical teams. This may involve the AMDs of the HMTs. o This may be done on a daily basis or to cover a longer time frame. Delayed Transfers of Care (DToCs) from Critical Care will be proactively managed in collaboration with the Site Management Teams. Staffing levels and requirements will be decided on the daily teleconferences. The necessity for utilising and expediting overtime will be discussed with the ACoS (Nursing), or a designated deputy, on the daily teleconferences. Medical staffing levels will be co-ordinated by the Critical Care Consultant and Anaesthetic Department (Rota Coordinator) Consideration of continuation of surgery will need to be borne in mind where staffing levels and/or skill mix are decreased Additional (non-critical care) staff may be required to care for critical care patients; staff may be from theatres and/or theatre recovery for example. o Critical Care staff will be available for support and advice at all times. If/where Critical Care nursing staff rotate/move to another unit to help, orientation and ongoing support will be provided to mitigate any risks. The amount of additional equipment required, for example ventilators and haemofiltration machines, must recognise not only expanded capacity but also the need for cleaning between patients (turnover may be more frequent than in normal circumstances), servicing and unexpected malfunction. o Sharing/rotation of haemofiltration machines between patients, whilst not ideal, may be necessary o Consideration will be given to the process and movement safety of any equipment moved between units. Some ICU staff may be less familiar with the additional ventilators supplied AND they may be working in exceptional circumstances possibly with reduced skill-mix. There will be a requirement to significantly increase stocks of drugs and consumables at very short notice to accommodate surge capacity. 3

4 o At the earliest opportunity the Business Support Partnership (BSP) will be notified that additional stock levels may be required. o [Extra] Close liaison with the Critical Care Pharmacists will be sought with the potential of increasing the stock levels of frequently used drugs. The following phased response is dependant on the additional equipment (as detailed) being available to expand capacity at the time of need as described. Critical Care Phased Response Green Level 1 (Normal effect on Yellow Level 2 (Moderate effect on Normal working Critical Care beds available Elective/planned admissions requiring Critical Care continuing Transfers accepted Early signs of difficulty Normal Critical Care bed stock full (or nearing full regionally) Non-urgent surgery, requiring Critical Care, cancelled Careful consideration required for urgent planned/elective surgery No capacity for receiving transfers. Amber (Severe effect on Severe/prolonged excess pressures requiring significant additional management Normal Critical Care bed stock full and into surge capacity Decision of proceed with urgent surgery taken on a regional basis. Careful consideration required for continuing (non-icu) routine in-patient surgery. Red Level 4 (Major disruption to Extreme pressures requiring immediate and significant actions All surge beds and normal beds full (at 100% surge or beyond) No ventilation capacity available All ventilated admissions will require transfer out This is phased response which will be dictated by local needs at any given time. If there is a local surge in the first instance, normal rules of transfer will apply the escalation of local plans should not be in isolation but taken on a Network/BCUHB basis (see principles). In order to maximise critical care capacity as described it is essential to prioritise patient flow to and from units. Patients requiring discharge from a critical care facility must take precedence above all other patient flow issues. 4

5 Regional Escalation Plan The provision of Critical Care beds in the Network will be maximised in a series of stepped phases. It is expected that the situation will change across each phase and a degree of clinical discretion will be required. Green Level 1 Green Level 1 (Normal effect on Normal working Critical Care beds available Elective/planned admissions requiring Critical Care continuing Transfers accepted Hospital Level 2 Total capacity capacity Wrexham Maelor Glan Clwyd 6 4* 10/9 Bangor Network Total 17 16/15 33/32 *Glan Clwyd reduce L2 capacity at weekends to 2x L2 with an additional 1x L2 bed if required Total capacity 17 No effect on existing North Wales critical care capacity, staffing ratios or working practices. Yellow Level 2 Yellow Level 2 (Moderate effect on Early signs of difficulty Normal Critical Care bed stock full (or nearing full regionally) Non-urgent surgery, requiring Critical Care, cancelled Careful consideration required for urgent planned/elective surgery No capacity for receiving transfers. Hospital Convert Level 2 Wrexham Maelor Glan Clwyd Bangor Network Total Increased Total Total beds capacity 25 All funded beds are open nurse patient ratio 1:1 Where possible Level 2 beds are converted to. Numbers of staff required adjusted to meet demand. (May need some increase if some Level 2 beds to be kept open) Minimal disruption to emergency services or urgent oncology surgery Reduction of some elective surgery to commence with proviso that there will be no Level 2 support for non-urgent surgery in critical care It is essential to ensure that there are not any available beds in or out of the Network prior to opening surge capacity beds; ring ICBIS to check availability. 5

6 Amber [Into surge capacity] Amber (Severe effect on Severe/prolonged excess pressures requiring significant additional management Normal Critical Care bed stock full and into surge capacity Decision of proceed with urgent surgery taken on a regional basis. Careful consideration required for continuing (non-icu) routine in-patient surgery. Hospital Additional surge capacity Increased Total Wrexham Maelor Glan Clwyd Bangor Network Total Total beds capacity 34 All funded level 3 beds are open All Level 2 beds converted directly to (ratio of 1:1), where possible Emergency services preserved and continuing Additional staff will be needed from outside critical care; normal skill mix reduced Red Level 4 [Full or beyond surge capacity] Red Level 4 (Major disruption to Extreme pressures requiring immediate and significant actions All surge beds and normal beds full (at 100% surge or beyond) No ventilation capacity available All ventilated admissions will require transfer out No capacity for urgent (suspected cancer) cases ALL surge capacity beds open at Inadequate capacity to meet emergency need across North Wales. All critical care beds in use with no further escalation in critical care capacity possible. No further admissions to critical care possible. Should the National situation be at such surge/escalation capacity consideration might need to be given to triaging patients (see Critical Care Escalation Plan & Triage Tool for Pandemic Flu document). This will only be where and when precedence has been set Nationally. 6

7 References: 1. Department of Health (2010) The Operating Framework: for the NHS in England 2010/11 cuments/digitalasset/dh_ pdf 2. Department of Health (2010) Report of the Swine Flu Critical Care Clinical Group and Key Learning Points for Future Surge Planning; Report on behalf of the clinical group by Dr Judith Hulf CBE. H_