Emergency Care Network Capacity Management and Escalation Plan Action Cards December 2009 December 2010

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1 Coventry and Warwickshire Emergency Care Network Emergency Care Network Capacity Management and Escalation Plan Action Cards December 2009 December 2010 This aim of this plan is to provide a high level multiagency approach for effectively managing capacity within Acute Trusts across the health economy. It is designed to enhance the effectiveness of local procedures through the adoption of best practice and proactive management processes. It will also enable the provision of mutual aid by exception where a hospital may be under severe or extreme pressure due to excessive, unpredicted demand for services. This plan should be treated as a working document and will subjected to regular review. Escalation Levels There are four escalation levels with quantifiable core triggers which will be used to standardise the pressure rating and appropriate actions across the health economy. Trusts are required to identify which core triggers are applicable in any given situation above Level 1. Contact Details The following information is presented in order to assist with communication between organisations. Organisation Contact Details Organisation In Hours Out of Hours George Eliot Hospital University Hospitals Coventry and Warwickshire South Warwickshire General Hospitals Coventry and Warwickshire Partnership Trust NHS Coventry Coventry Community Health Services NHS Warwickshire ext Warwickshire Community Health Services Coventry and Warwickshire Urgent Care Hub Ambulance Control Coventry Emergency Planning Unit (EPU) Warwickshire Emergency Planning Unit (EPU) Conference Call Facilities NHS Coventry and NHS Warwickshire operate conference facilities for use at Level 3 and Level 4 of this Escalation Plan. Chair person and participant numbers are available via the PCT on call Directors or on call ERMA Chief Executive. Training and Support Further information or training in the use of this plan is available by contacting paul.devlin@nhsurgentcare.net. Prepared by: Paul Devlin Emergency Care Network Director 16 th December 2009 Authority: Coventry and Warwickshire Local Health Resilience Forum Approved by LHRF on 16 th December 2009.

2 AH&CS Team Leader - Facilitate safe and timely discharges in the normal way by liaising with hospital Discharge Teams. Attend the hospital top delays progress meetings and address any transfer issues. Be aware of hospital escalation levels and the need to increase the pace and provision of services at Level 2 upwards. Community Health Services - No action required beyond normal community hospital bed management, community nursing and intermediate care capacity management and liaison with Acute Trusts and Social Care. Be aware of escalation levels and actions above Level 1. Coventry and Warwickshire Emergency Care Network Capacity Management Level 1 Action Card Level 1 Normal Working (No negative triggers applicable) 1. A&E 98% Target being maintained 2. Availability of bed stock across main specialties 3. Cubicles available in A&E and main assessment areas 4. No trolley waits over 4 hours 5. Elective lists proceeding as scheduled 6. Multiple resuscitation bays available 7. Ambulance patients Transfer of care within 15 minutes Management - Hospital General Manager & Onsite Manager Transfer of care is complete when a clinical handover has taken place between the ambulance crew and a qualified nurse and the patient has been placed on a hospital trolley. General & Bed Ensure that all clinical and operational managers are actively using and complying with the Capacity Management Operational Framework. Bed meetings must be held in line with Trust procedures including manager of the day, capacity manager, bed managers, discharge liaison nurses and intermediate care. Ensure that adequate capacity is available to manage planned and unplanned demand for the day. Highlight any shortfalls in capacity to the Directorate General Manager as a matter of urgency. It is imperative to update the current hospital escalation level in the EMS by 08:00 each day and four hourly there after. Ensure that on day requests for ambulance transport are booked before 12:00 to avoid delayed discharges and transfers. Hold twice weekly top delays progress meetings to proactively manage patient flow through the hospital. Nurse Practitioner Provide a care coordination service at the request of community based healthcare professionals including ambulance crews for patients requiring non-emergency services. Senior Operations Assistant - Send an to a pre-determined distribution list of colleagues at 09:30 and 14:30 Monday- Friday detailing the EMS escalation level and most significant issue for each Acute Hospital and the Ambulance Service. Emergency Operations Centre Ensure that crews use the Urgent Care Hub for accessing non-emergency care. EOC Duty Officer Update EMS by 08:00 and four hourly each day. Select the appropriate escalation level and briefly describe the most significant issue relating to pressure in the Ambulance Service comments field within the system. Be aware of hospital escalation levels of Level 2 or above, the Care Coordination Centre (Hub) will advise as appropriate. HALO - Liaise with hospital bed managers, attend site meetings and aid ambulance turn around.

3 AH&CS Team Leader - Expedite discharges by prompt arrangement of community care packages and through close liaison with the Intermediate Care Service, Continuing Healthcare and Assessment Team. Inform the Team Manager and General Manager of escalation to Level 2. Liaise regularly (in-between site meetings) with Discharge Team and Hospital Bed. Determine level of additional capacity required and escalate to Assistant Director in the event of shortfalls. Community Health Services Prepare to receive an increased number of ambulance patients that meet referral criteria. Director of Operations - Be prepared to join a conference call or hospital site meeting and facilitate further escalation processes if the situation deteriorates. Community Hospital Matrons - Confirm bed occupancy and predicted capacity. Expedite discharges through links with Acute Trust, Social Care and other community services. Intermediate Care - Increase liaison with all Hospitals to expedite discharges. Coventry and Warwickshire Emergency Care Network Capacity Management Level 2 Action Card Level 2 Moderate Pressure (Three Core Triggers Applicable) 1. A&E 98% Target maintained but breaches have occurred 2. No beds immediately available to meet emergency demand 3. 10% capacity available in A&E and assessment areas 4. Limited trolley waits over 4 hours occurring 5. Single resuscitation bay available 6. Staffing inadequate to open additional capacity 7. Ambulance patients Transfer of care >30 minutes Management - Hospital General Manager & Onsite Manager Bed/Capacity - Physically check the hospital bed occupancy by arranging visits to all wards and determine how many patients have not been reviewed by a senior physician so far today. Ensure that all patients are scheduled to receive a medical review as soon as possible (within 2 hours maximum). Update the hospital escalation level in EMS and outline specific pressures in the hospital comments field. Escalation to Level 3 is not possible until every patient has received a medical review by a senior physician and the actual capacity deficit is verified by the Chief Operating Officer. Expedite discharges through links with Ward, Pharmacy,, the Ambulance Service and Intermediate Care Teams. When booking ambulance transport ensure mobility requested is accurate in order to prevent delays. General & Clinical Directors Confirm that all patients have been reviewed by a senior physician in a timely fashion routinely before 12:00 each day or within 2 hours of reaching Level 2. Nurse Practitioner Prepare to receive increased levels of referrals from healthcare professionals including ambulance crews. Senior Operations Assistant - Send an to a pre-determined distribution list of colleagues at 09:30 and 14:30 Monday- Friday detailing the EMS escalation level and most significant issue for each Acute Hospital and the Ambulance Service. Emergency Operations Centre Emphasise the need for crews to use the Urgent Care Hub for accessing nonemergency care. EOC Duty Officer Initiate a peripheral (border) re-route for non-emergency 999 patients to a neighbouring hospital displaying a lower escalation level within the C&W locality. Operate for a period of up to 4 hours or until such time as all hospitals reach the same escalation level or delays offloading are experienced. Review after 2 hours. Inform Silver Commander of all issues impacting on response capability. HALO/Bronze Commander Attend site, validate hospital escalation level, and liaise with EOC Duty Office, Bed and aid ambulance turn around.

4 AH&CS Team/Service Manager Confirm availability of community beds and care packages, verify level of deficit then brief the relevant Assistant Director/AD on call of specific issues and potential solutions. Relevant Assistant Director/AD On Call Receive a briefing from the relevant Service Manager then join the health economy conference call and agree extraordinary actions to recover the situation. Liaise with the commissioning team to identify sources of additional capacity. Source appropriate providers, in partnership with PCTs. Community Health Services Prepare to receive an increased number of ambulance patients that meet referral criteria. Review the split of designated "admission prevention" and "rehabilitation" beds. Implement simplified access criteria, enhancing admission avoidance and palliative care services. Director of Operations Participate in an urgent conference call and/or participate in the hospital emergency discharge-planning meeting and agree extraordinary action to recover the situation. PCT Director on Call - Participate in an urgent conference call and/or participate in the hospital emergency discharge-planning meeting and agree extraordinary action to recover the situation. Coventry and Warwickshire Emergency Care Network Capacity Management Level 3 Action Card Level 3 Severe Pressure (Four Core Triggers Applicable 1, 2 and 3 compulsory) 1. A&E 98% Target lost for the day 2. All patients waiting 4 hours or more to be admitted 3. No capacity in the A&E or assessment areas for 2 hours 4. Trolley waits over 4 hours occurring in most (>50%) cases 5. No resuscitation bays available, all used for critical care 6. Potential 12 hour trolley wait breaches 7. Ambulance patients Transfer of care >45 minutes Management - Hospital Chief Operating Officer/On Call Dir. Chief Operating Officer/On Call Executive Director Ensure that General have accurately reviewed their bed capacity and confirm that all patients have been reviewed by a senior physician prior to escalating to Level 3. Contact the Ambulance Divisional Commander/On Call Silver via Control and jointly authorise escalation to Level 3. Update the hospital escalation level in EMS then inform the Chief Operating Officer/on call Director from the neighbouring hospital of the Level 3 situation and active ambulance divert. Activate the hospital business continuity plan and amend routine working practices to accommodate excessive demands on service. Maintain an issue log to capture causation and events. Convene a health economy conference call between Chief Operating Officers, Directors of Operations, Ambulance Commander and Local Authority Assistant Director for Community Services. Verify the issues and immediate requirements then agree a series of extraordinary actions to recover the situation. De-escalation criteria must be agreed and used as a measure of recovery. Nurse Practitioner Prepare to receive increased levels of referrals from healthcare professionals including ambulance crews. Senior Operations Assistant - Send an to a pre-determined distribution list of colleagues at 09:30 and 14:30 Monday- Friday detailing the EMS escalation level and most significant issue for each Acute Hospital and the Ambulance Service. EOC Duty Officer With the exception of Blue Light transports to hospital by air or land; divert 1 ambulance per hour (2 for UHCW 1 North & 1 South) for a period of up to 4 hours to a neighbouring hospital within the C&W locality with a lower escalation level until such time as all hospitals reach the same level or delays offloading are experienced. Record reasons for divert in incident CAD notes. Diverts are subject to operational pressures. Review after 2 hours. HALO/Bronze Commander Attend site, validate hospital escalation level, and liaise with EOC Duty Office. PTS Manager Attend hospital discharge lounge and aid patient transport process. Divisional/Silver Commander Participate in the health economy conference call. Brief the Gold Commander if the situation is likely to be prolonged or deteriorate.

5 Relevant Assistant Director/AD On Call - Brief Service and Director of Social Care. Agree a series of interventions over and above normal service provision to rapidly increase the level of support to the health economy. Join the health economy conference call and attend the Trust Situation Control Group meeting. Agree and implement further extraordinary actions to recover the situation or confirm that a local resolution is not possible. Director of Operations/On Call Director - Agree a series of interventions over and above normal service provision to increase the level of support to the health economy. Attend the Trust Situation Control Group meeting, agree further extraordinary actions to recover the situation or confirm that a local resolution is not possible. PCT Chief Executive/On Call Chief Exec Convene a LHE conference call as soon as possible with Operations Directors from health and Social Care, Ambulance Divisional Commander and PCT Director on call where a Level 4 situation is likely to last longer than 4 hours. This group is responsible for taking tactical control and providing a health economy wide response to resolving the situation through a series of mutual aid and shard risk. Coventry and Warwickshire Emergency Care Network Capacity Management Level 4 Action Card Level 4 - Extreme Pressure (Five Core Triggers Applicable 1, 2, 3 & 4 compulsory) 1. No capacity in A&E or assessment areas for 2-4 hours 2. Trolley waits over 4 hours occurring in all cases 3. No resuscitation bays available, all used for critical care 4. Ambulance patients Transfer of care >60 minutes 5. A&E 98% Target under threat for the week 6. No beds available in any area for at least 4-6 hours hour trolley wait breaches have occurred Management 1-4 Hours - Hospital Chief Operating Officer/On Call Exec. Dir. > 4 Hours PCT Chief Exec/On Call Chief Exec Chief Operating Officer/On Call Executive Director Confirm that all actions points at level 1-3 have been carried out. Contact the Ambulance Divisional Commander/On Call Silver via Control and jointly authorise escalation to Level 4. Update the hospital escalation level in EMS then inform the Chief Operating Officer/on call Director from the neighbouring hospital of the Level 4 situation and additional ambulance divert. Set up an on site Situation Control Group to take tactical control and address significant issues through a series of extraordinary actions over and above those contained in the normal business continuity plans. Maintain a log of all proceedings detailing the triggers for escalating, critical issues, actions taken, deescalation criteria and duration of situation. Review 2 hourly. Convene a further health economy conference call as detailed in Level 3. Brief colleagues on critical issues, principle risks and immediate requirements. Escalate to the PCT Chief Exec/On Call ERMA Chief Exec if Level 4 is likely to last longer than 4 hours. All Level 4 situations will be reviewed by the Local Health Resilience Forum. Nurse Practitioner Prepare to receive increased levels of referrals from healthcare professionals including ambulance crews. Senior Operations Assistant In addition to the scheduled EMS Update s at 09:30 and 14:30 Monday-Friday, send an additional informing colleagues of a Level 4 situation detailing the date and time updated along with most significant issues. EOC Duty Officer With the exception of Blue Light transports to hospital by air or land; divert 2 ambulances per hour (4 for UHCW 2 North & 2 South) for a period of up to 4 hours to a neighbouring hospital within the C&W locality with a lower escalation level until such time as all hospitals reach the same level or delays offloading are experienced. Record reasons for divert in incident CAD notes. Diverts are subject to operational pressures. Review after 2 hours. Inform Bronze and Divisional/Silver Commander. Maintain a HALO or Bronze Commander presence at hospital site. Divisional Commander/On Call Silver - Participate the health economy conference call, provide tactical support and brief the Gold Commander. Operate from Silver Cell if 2 or more sites reach Level 4.

6 The following framework should be used as a best practice guide to ensure that colleagues are clear about their role in undertaking effective capacity management duties. Capacity Management Operational Framework Acute Hospitals Action Who Effect Use of a six week rolling average predictor tool to forecast demand for unplanned care Daily and weekly performance reviews Rapid intervention of senior medical staff following triage of patients in A&E (SIFT) General and Bed General and Bed Clinical Directors and General Improved processes for managing demand Identify lessons learnt and reinforce positive aspects Improved patient flow through A&E and 4- hours Provision of an acute psychiatric liaison service within A&E Head of Adult Mental Health Timely assessment and reduced A&E breaches Estimated day and time of discharge recorded for every patient Ward Active case management of patients and reduced length of stay Threshold monitoring for potential breaches (A&E, ambulance turnaround, elective cases and length of stay) Hospital site meetings held throughout each day ensuring the availability of adequate bed capacity and essential logistic supplies Consistent use of the Escalation Management System (EMS) and Network Capacity Management Plan Requests for ambulance transport booked 24 hours in advance in the majority of cases. On day bookings placed by 12:00. Provision of diagnostic and therapy services working seven days per week in primary and secondary care Active management of 10+ day length of stay cases Joint health and social care meetings held 2 times per week to review patients requiring continuing care Utilisation of an effective workforce plan that provides adequate levels of competent staff and the correct skill mix at all times General and Bed General, Bed and On Site Mangers Bed, On Site and Ambulance Control Ward managers and Bed managers General and Urgent Care Commissioners Matrons, Intermediate Care Team and Bed Bed and Social Care General, HR and Matrons Rapid response and intervention to address performance issues Maximum potential for delivery and appropriate risk management Communication of capacity pressures across the organisation and economy Timely transfer or discharge of patients along with improved bed availability Improved flow, management of demand and bed occupancy Reduced length of stay and increase bed availability Proactive timely transfer of care, reduced length of stay and bed availability Resilient and flexible staffing arrangements providing continuity of care