Royal Devon & Exeter NHS Foundation Trust Operational Capacity and Resilience Plan

Transcription

1 Royal Devon & Exeter NHS Foundation Trust Operational Capacity and Resilience Plan Operational Capacity & Resilience Plan 2017/18 Page 1 of 45

2 Full History Status: Draft or Final To be used in conjunction with: NHS England Operational Pressures Escalation Levels Framework. In consultation with Divisional Leads Senior Delivery Team Operational Capacity Steering Group Eastern Devon A&E Delivery Board Approval required from Royal Devon and Exeter NHS Foundation Trust Board Approved by the Trust Board 25/10/2017 Contact for Review: Peter Adey Chief Operating Officer Phil Luke Divisional Director, Operations Operational Capacity & Resilience Plan 2017/18 Page 2 of 45

3 CONTENTS 1. INTRODUCTION OBJECTIVES OWNERSHIP AND MAINTENANCE... 6 PART ONE 2. THE 2017/18 RD&E WINTER PLAN OVERVIEW CONTEXT AND STRATEGIC APPROACH MODELLING OF DEMAND THE 2017/18 TRUST-WIDE PLAN ANTICIPATED IMPACT OF THE 16/17 WINTER BED CAPACITY PLAN COMMUNICATION OF THE PLAN RISKS THAT COULD IMPACT UPON THE DELIVERY OF SERVICES TRUST-WIDE ISSUES PART TWO 3. OPERATIONAL CAPACITY MANAGEMENT & ESCALATION THE DAILY PROCESS OF OPERATIONAL CAPACITY MANAGEMENT AND ESCALATION ESCALATION STATUS DEFINITIONS, TRIGGERS AND ACTIONS THE RED ESCALATION TEAM (RET) GUIDELINES FOR OPENING ADDITIONAL INPATIENT AREAS DURING ESCALATION ACTIONS REQUIRED BEFORE DECLARING OPEL CRITICAL INCIDENT PROCESS EXTERNAL REPORTING AND ESCALATION STATUS OTHER TRUST ISSUES INDIVIDUAL ACTION CARDS FOR SPECIFIC ROLES APPENDICES APPENDIX 1: RED ESCALATION TEAM CHECKLIST APPENDIX 2: GUIDELINES FOR OPENING UP ADDITIONAL BED CAPACITY APPENDIX 3: OPENING EXTRA CAPACITY CHECKLIST APPENDIX 4: NHS ENGLAND (SOUTH) SURGE MANAGEMENT FRAMEWORK E EXTRACT APPENDIX 5: CANCELLING ELECTIVE PATIENT GUIDANCE Operational Capacity & Resilience Plan 2017/18 Page 3 of 45

4 APPENDIX 6: ACTIONS TO CONSIDER DURING A CRITICAL INCIDENT WHEN AT... OPEL APPENDIX 7: COMMUNITY SERVICES DIVISION ESCALATION ACTIONS AT OPEL 2, 3 & Operational Capacity & Resilience Plan 2017/18 Page 4 of 45

5 1. INTRODUCTION This Operational Capacity and Resilience Plan (OCRP) sets out the following: Part one - An overview of the 2017/18 RD&E winter bed capacity plan. Part two - How the Trust will operationally manage bed capacity throughout the forthcoming year, including key escalation triggers and actions to be taken in times of increasing pressure on the system. The plan is focussed on the following three areas: Keeping People Healthy at Home Maintaining Urgent Care provision within the hospital Increasing hospital resilience and improving operational efficiency Section two details the internal escalation processes which support the three areas of focus. Much of the processes detailed in this section are unchanged from last year as the approach has proved to be a successful way of mobilising the Trust to respond decisively in times of escalation. In particular, this section sets out: A greater emphasis on mobilising hospital resources to discharge patients when in escalation A higher threshold for opening up additional inpatient bed capacity A higher threshold for cancellation of elective capacity in order to create capacity for medical outliers The OCRP has been developed and written with reference to the NHS England Operational Pressures Escalation Levels Framework (October 2016) and in line with the STP s development of a consistent approach to escalation across Devon. It should be noted that the OCRP shares common actions with the Emergency Preparedness, Resilience and Response (EPRR) framework, however, they are not interchangeable. EPRR escalation should be considered separate from the framework described in this document. The OCRP forms part of the system-wide plan covering Eastern Devon which is aimed at building and maintaining resilient health and social care pathways across all services. It has been developed to link with other key organisations including NEW Devon Clinical Commissioning Group (CCG), South West Ambulance Service Foundation Trust (SWAST), Northern Devon Healthcare Trust (NDHT), Devon Doctors On-Call (DDOC), Primary Care, Devon Social Services (DCC) and Devon Partnership Trust (DPT). In addition to the above, this plan is closely aligned with the Integrated Care Model work stream of the Devon System Transformation Programme. Whilst winter is a period of increased pressure to the Health Community, establishing sustainable year-round delivery requires capacity planning. It is essential that the health economy has a clear understanding of how much capacity will be required to ensure that the whole health system achieves and maintains safe and effective patient care. Detailed demand and bed capacity modelling has been undertaken to support safe effective care for emergency and elective patients. The effectiveness of this plan requires all partner organisations to have robust and consistent plans in place that are responsive with sufficient capacity to support Operational Capacity & Resilience Plan 2017/18 Page 5 of 45

6 surges in demand and that deliver effective patient flow throughout the year. The Eastern Devon A&E Delivery Board will monitor whole system compliance and partnership working OBJECTIVES The objectives supported by the OCRP fall under the Trust s first strategic goal, the sound delivery of existing services and are as follows: Minimise hospital stay Maximise care at home and by community services Care for specialty patients in specialty beds Minimise cancellations of elective procedures due to bed capacity constraints Deliver resilience whilst maintaining financial balance Understanding of and compliance with the system-wide escalation process Supporting our staff by providing a clear plan as well as clear guidance of what to do in times of escalation 1.2. OWNERSHIP AND MAINTENANCE Executive Director Lead Peter Adey Chief Operating Officer Capacity Management Lead Phil Luke Divisional Director, Operations The Operations Board overall has responsibility and oversight of the plan, which it carries out through a sub group named the Operational Capacity Steering Group. The OCRP is intended to be a live document which will be subject to amendments in the light of new guidance and operational changes. All changes of the OCRP need to be approved by a quorum of the Operational Capacity Steering Group. Version control and governance of the OCRP will remain the responsibility of the Operations Support Unit. This plan will be distributed to individuals on the Director, Manager and Senior Nurse on-call rotas and the Site Management Office. The approved plan will be available on the Trust s Intranet HUB. This plan will also be distributed to partner organisations in the local healthcare community including NEW Devon CCG and the Devon A&E Board. Divisions have the responsibility for communicating and adhering to their specific plans. Operational Capacity & Resilience Plan 2017/18 Page 6 of 45

7 2. THE 2017/18 RD&E WINTER PLAN PART ONE 2.1. OVERVIEW This section of the 2017/18 Operational Capacity and Resilience Plan (OCRP) sets out the plan to ensure sufficient bed capacity to safely care for our patients over the winter period. The following information is provided in the sections below: Context and strategic approach. How the demand for beds was modelled. The 2017/18 Trust-wide bed capacity plan including the anticipated impact. Trust-wide improvement plans Risks that could impact upon the delivery of services. The potential impact of the stated risks. The delivery of this plan is closely interlinked with the aims, objectives and implementation of the Integrated Care Model work stream of the Devon System Transformation Programme. The focus of the OCRP is to ensure that there is sufficient bed capacity for the Trust to provide safe, high quality inpatient care, whilst undertaking the elective activity required to fulfil its contractual commitments. The 16/17 plan included changes to community services following their joining the Trust services in October The 17/18 plan goes further than this and takes more of a system-wide approach to supporting patient flow, recognising the key role that partner agencies such as social care and private providers of domiciliary care play in the resilience of acute and community services CONTEXT AND STRATEGIC APPROACH The 2016/17 OCRP encompassed a number of significant changes to services within the acute and community services, which aimed to transform some elements of the service delivery model whilst providing resilient operational capacity over the winter period. Much of that work has been implemented and continues to be in operation, including: Significant changes in community services The Acute Care of the Elderly Unit The Ambulatory Care Unit Educational support for therapy staff Considerable work on shifting the organisational mind-set from beds to home and from acute to community Last year s approach was broadly successful, and delivered increased levels of patient flow, reduced hospital escalation levels and a considerable reduction in cancelations of elective surgery due to bed capacity. The diagram below showing Operational Pressure escalation Levels (OPEL) for the past three years shows the significant improvement. Operational Capacity & Resilience Plan 2017/18 Page 7 of 45

8 The 2017/18 OCRP therefore aims to build upon the success of last year s plan, continuing and further developing key initiatives which supported the improved position, whilst adding new approaches to strengthen resilience further. Although the position in terms of escalation is clearly much improved, the period of escalation to OPEL 3 (red) in January 2017 is an important feature, which the 17/18 plan takes steps to avoid. The 17/18 plan also takes into account the changing local and national context, which includes the following key features: Year on year rising demand for emergency care An increasingly older, more frail population A constrained financial environment The shift in the care delivery model for community services from a bed based model to one delivered to a greater extent through community teams working together to keep people safe and well in their own homes. This includes the introduction of the Single Point of Access which provides a key role in co-ordinating community service delivery to avoid hospital admissions and support timely discharge. Greater understanding of and collaboration with the commissioning and provision of domiciliary care A growing evidence base that unnecessary hospitalisation can adversely affect patients through loss of independence, muscle atrophy and the risk of hospital acquired infections Greater opportunities through collaboration with partner organisations, catalysed by the Devon System Transformation Programme On-going changes to the commissioning of acute services, where finances are no longer linked to individual episodes of patient care for the majority of activity 2.3. MODELLING OF DEMAND Methodology In order to forecast the scale of demand for bed capacity this winter, the Trust Discrete Event Simulation (DES) bed capacity model has been used. The model was developed internally and its use for winter bed planning has been validated by the Academic Health Sciences Network (AHSN) in previous years. The bed model is based on adult inpatient admissions on the Wonford site only and uses the 2016/17 length of stay profiles. The length of stay profiles were adjusted to account for Yealm Operational Capacity & Resilience Plan 2017/18 Page 8 of 45

9 ward s transition into the stroke rehabilitation unit which was previously located at Ottery St Mary Community Hospital. For the demand assumptions, the activity profiled by month from the 2017/18 Demand Planner was used. The model generates a bed demand profile for the bed-pools of Medicine, Surgery, Trauma & Orthopaedics and Gynaecology which are combined to produce an aggregate bed demand. Following the changes to community beds in August 2017, the model assumes no further change to existing community bed capacity or current levels of social care, intermediate or nursing home provision. Work is currently underway to explore a wider approach to the modelling of community capacity and demand, which would include domiciliary care provision however this work is complex and at an early stage. It is anticipated that next year s plan will include this wider forward look Outputs of the Bed Modelling The graph below shows the output of the bed modelling for the Medical bed pool, which faces the highest pressure during the winter period if no management interventions are made. The activity profiles used in the Bed model have been taken from the Trust Demand Planner. For the Medical bed pool the combined activity in elective and emergency admissions represented a 1.7% growth compared to 2016/17 contract. Shortfalls of medical beds are shown in red with surpluses in green, illustrating that without significant intervention the number of medical patients will significantly exceed the number of available medical beds, which would result in large numbers of medical outliers in surgical wards and inevitably lead to large scale cancellation of elective activity. The modelling of the Medical bed pool suggests that in order to meet demand during the winter period, an average of 45 additional medical beds are required if operated at 100% occupancy, or to enable a 90% occupancy rate an additional 86 medical beds are required. It is important to note that because the model uses historical data any high variations in demand or length of stay will also be reflected in the forecast. The following section shows the planned interventions to mitigate against the anticipated bed capacity shortfall, as well as the expected impact that this will have on capacity. Operational Capacity & Resilience Plan 2017/18 Page 9 of 45

10 2.4. THE 2017/18 TRUST-WIDE PLAN In response to both the challenges and opportunities provided by this changing context, the 2017/18 winter bed capacity plan has three key elements: Keeping people healthy at home Maintaining urgent care provision within the hospital and the wider system, especially domiciliary care provision Increasing hospital resilience and improving operational efficiency Continuing the journey of changing the culture and behaviours around discharge and keeping patients in hospital The plan is summarised as an illustration on page 17 as part of the communication plan for staff, and a table showing the headline, description and lead division on page 15. A summary of the key elements of the plan is provided below Keeping People Healthy at Home Enhancing community based services, including those provided by the domiciliary care market, is a critical factor in reducing unnecessary hospitalisation and supporting people in their normal place of residence for longer. This aims to either reduce the need for hospital admission, or will facilitate a more effective discharge resulting in a shorter length of stay. The key elements of this part of the winter plan are as follows: Your Future Care - Further development of community services in line with the Your Future Care Model to provide greater support to patients to reduce unnecessary admissions and support patients on discharge. This will improve patient outcomes, reduce length of stay and reduce Delayed Transfers of Care (DTOC). Primary care - Joint working between primary care out of hours services and the Trust s clinicians to help primary care maintain patients in the community if there is no requirement for them to be admitted. SPOA - Greater use of the Single Point of Access (SPOA) by community teams to help avoid admissions and to ensure discharge referrals are made to the onward care teams in a timely manner. Domiciliary care market sufficiency - Work to support the domiciliary care market to ensure that patients needs are met on discharge and that services are available for them in a timely manner. A new contract, due to be issued in October 2017, aims to provide domiciliary care providers surety of their income such that they can increase their staffing levels in advance and provide a more consistent service. Overall this approach is expected to increase domiciliary care capacity by 400 hours per week from December 2017 and 800 hours per week by February Voluntary sector support for homeless patients - A grant has been secured to support a local voluntary sector organisation which specialises in the care of homeless people with the specific aim of avoiding hospital admission and supporting discharge. Care home education - By providing education to Care Homes, they will be better placed to support their residents in their home environment without needing to escalate their care to an acute setting. This will result in better quality of life for individuals and lower admissions to the Trust. Flu vaccination programme - Supporting the local flu vaccination programme, both within the hospital and around the wider community, with a particular focus in 17/18 on vaccinating people in residential and nursing homes. Operational Capacity & Resilience Plan 2017/18 Page 10 of 45

11 Providing Resilient System-wide Urgent Care Provision A robust urgent care model is a cornerstone of the local system s ability to keep patients safe. For those patients who are admitted to hospital, early, senior, multidisciplinary review and intervention on entry to the urgent care system will help reduce their overall length of stay. The key elements of this part of the winter plan are as follows: Within the Trust Medical and nurse staffing - Increasing the level of medical and nursing staffing within the Emergency Department to provide more senior cover, later into the evening. o Two additional Emergency Department consultants have been recruited, which will increase general resilience and provides a consultant for minors patients until 10 pm on most days. o An additional nurse has been added to the ED nursing establishment 24/7. Clinical Nurse Specialists (CNS) on AMU in order to support the junior medical staff, two staff are being trained as CNSs. This will increase the resilience of the team overall and support good patient flow and discharge processes. Over time these staff will become highly experienced members of the team who, unlike the junior medical staff, will not change roles after 6 months, which will increase the resilience of the team. Specialty patients - Increased use of the surgical assessment unit and fracture clinic to ensure that surgical specialty patients who do not need to be seen or treated in ED are moved as quickly as possible. GP streaming - GP Streaming will ensure that those patients who have a primary care need or minor illness, rather than a medical need are streamed to either the WiC, Out of Hours DDOC appointment, or a same day primary care appointment. This will reduce the overall activity within the Emergency Department. ED therapist - The inclusion of a therapist within the ED 7 days per week to provide earlier assessment and treatment of a patient s therapeutic needs. This aims to help more patients to be discharged straight from the ED. For those patients who are admitted to the Trust, the early assessment will form a key part in the discharge planning process and should enable patients to be discharged earlier in the care pathway. Rapid transfer of patients requiring an inpatient psychiatric bed - The ED currently has access to a 24/7 Psychiatric Liaison service which ensures that all patients requiring a mental health assessment / treatment are able to access the services. Work is ongoing with Devon Partnership Trust to ensure that where an individual requires access to a mental health bed that the patient is able to transfer as soon as they are clinically safe for discharge. Clinical Decisions Unit - Long term plans are currently being developed to expand key elements of the Emergency Department, one element of which is the inclusion of a Clinical Decisions Unit (CDU.) This unit provides capacity for a cohort of appropriate patients requiring observation for longer than 4 hours but not admission to remain in a safe, supervised space. This is likely to reduce admissions as well as support an improvement in performance against the 4-hour ED standard, which is a key performance indicator for the Trust. Considerable work is currently underway to identify a way of bringing forward this one element of the ED expansion plan such that it could support better patient flow during the forthcoming winter period. Acute paediatrician An additional paediatrician will be recruited to provide early senior review of children in the ED. Detailed ED and Acute Medical Unit action plan - The ED action plan sets out how key actions will be taken to ensure that the ED is able to continue to meet the level of patient demand during the winter period. This includes increasing staffing levels in both departments during expected periods of peak demand. Extended opening hours for Assessment and Triage areas - The Trust will extend the opening of the Surgical Assessment Unit (SAU), Medical Triage Unit (MTU) and Operational Capacity & Resilience Plan 2017/18 Page 11 of 45

12 Paediatric Assessment Unit (PAU) to provide alternatives to the Emergency Department for patients requiring a period of assessment and treatment. This will reduce the level of admissions into the hospital Within the wider system Promoting the use of walk in centres (WICs) and minor injury units (MIUs) - By ensuring that the two Exeter WICs and the Honiton MIU are able to maximise the number of patients that they see, this will reduce pressure on the Emergency Department enabling them to focus on the patients that require emergency medicine. Supporting staffing resilience in MIUs and WICs aims to reduce the likelihood of service closures in peripheral units leading to increased attendances at the ED. Increased resilience of Devon Doctors on-call (DDOCs.) Planning via the local A&E Delivery Board is in place to ensure that DDOCs uplift their staffing at expected busy periods to ensure that the service does not become overwhelmed, leading to increased attendances at the ED. Choose Wisely campaign The Trust will co-ordinate with the CCG and Social Services to implement a comprehensive communication package informing patients of alternatives to the emergency department, especially the use of local pharmacies and primary care services Increased Hospital Resilience As well as interventions specifically aimed at the urgent care system, a series of changes to support patient flow through the wider hospital are planned. The key elements of this part of the winter plan are as follows: Additional beds for medical patients - 24 surgical beds are being set aside in order to accommodate medical patients over the winter period. Medical cover has been planned by linking medical wards with surgical wards, and additional therapy and pharmacy resource has been allocated to support the higher dependency of medical patients compared to surgical patients. 7-day services - The Trust has invested in increased weekend cover for the following services to help improve the level of patient flow and patient care at the weekend: o o o o o Therapy Pharmacy Cath Lab on key weekends where demand is expected to increase Echocardiography Consultant led ward rounds on surgical wards Ambulatory Care - By further developing the role of Ambulatory Care and Assessment services within the Trust, more patients will be able to have their care needs met without being cared for in a bedded ward. This will enable patients to avoid admission and / or be discharged earlier from the Trust. Near patient flu testing on ED, AMU, Yarty & Paediatric wards - will help patients with flu who require admission to be placed in side rooms so as to reduce the spread of infection across the hospital. Detailed planning of services over holiday periods careful planning to optimise the use of resources over the Christmas and half-term periods has been shown to significantly increase the resilience of the hospital and improve patient flow. Specific actions implemented within this planning include: o Reduction of elective inpatient activity in favour of increased day-case activity. Operational Capacity & Resilience Plan 2017/18 Page 12 of 45

13 o Increased medical, nursing, therapy, portering, phlebotomy, site management and pharmacy support, both within the acute hospital and the community services. o Pre-authorised use of spot purchase to increase flow to nursing homes. o Contingency plans in place to enable escalation capacity to be used quickly and safely if required. Increased consultant physician an additional respiratory consultant has been appointed to provide senior medical capacity to care for additional medical patients. Implementation of a Consultant in Perioperative Medicine - A new post is being piloted with an ITU consultant working full time on the Surgical wards to support the care of acutely unwell patients and to improve the level of training and support to the junior medical staff caring for all surgical patients. Enhanced support care team This is a team who provide supportive care for patients both in hospital and at home with advanced cancer. Their work aims to work with patients to prepare for anticipated changes and identify alternatives to hospital admission. So far in 2017 this team has proved highly effective in reducing the need for beds on the Oncology Unit Changing Culture A range of good work to shift the emphasis of care from the acute sector to community services took place in 2016/17, which has been brought together into a single campaign named Your Road to Wellbeing, which the Trust launched in June This work seeks to empower patients and reinforce positive behaviours in staff relating to effective discharging of patients. The key themes of the campaign are shown in the graphics below which have been made available widely in both the acute and community inpatient sites. In order to ensure that this work is embedded fully into the organisation, across all divisions and professions, a senior nurse will be released from her normal role over a 6 month period to oversee this important cultural change programme. Operational Capacity & Resilience Plan 2017/18 Page 13 of 45

14 2.5. ANTICIPATED IMPACT OF THE 16/17 WINTER BED CAPACITY PLAN Using the same methodology applied to establish the demand for medical beds over the winter period, modelling of the anticipated impacts of the Trust wide plan has been completed. Each element has been quantified using existing baseline data, whilst building in assumptions of the impact of any change based on experience from other organisations and the judgement of the clinical teams. The graph below illustrates the impacts, with green showing surpluses of bed capacity and red showing deficits. The impact of the planned interventions provides an improvement from the position without interventions shown on page 9, in which a deficit of up to 86 beds could be seen throughout Q4. The winter plan enables a medical bed occupancy of % and is expected to be sufficient to effectively manage medical patients during Q3 and much of Q4. Whilst some elements of the 2017/18 plan will be measurable, it should be noted that learing from 2016/17 shows that it is impossible to determine the exact impact of some elements of plans that are implemented. Whether a higher level of discharges is due to cultural change, the ward optimisation programme, the impact of the work on perioperative medicine or indeed natural variation can be difficult or impossible to say. The measures are therefore considered to be a bundle approach, where a package of small positive changes lead to a significant shift in overall performance COMMUNICATION OF THE PLAN A significant communication plan will accompany the implementation of this OCRP. The key elements comprising the 2017/18 winter plan are summarised in the table below. In addition to this, an illustration showing the key elements of the 2017/18 plan has been provided on page 17. Following on from its successful implementation in 2016/17, this diagram has been updated to reflect the 17/18 plan but contains the same key cornerstones and the central message around supporting people in their own homes as the ultimate goal. These two resources combined will provide an accessible quick reference guide to support managers and clinical leaders across the Trust in briefing their teams at comms cells and team meetings regarding the 2017/18 plan. This will be circulated widely to the following groups: Operational Capacity & Resilience Plan 2017/18 Page 14 of 45

15 Senior clinical leaders with the Trust, including all consultants, ward matrons and senior leaders of therapy and pharmacy services. GPs and practice managers Partner organisations via the A&E Delivery Board Intervention Description Lead division Planned start date Increased Medical and Nursing Provision Keeping People Healthy at Home 2 additional ED consultants to provide cover later in the day Increase in nursing numbers of 1 RGN 24/7 Rostering of a B7 matron overnight to support good co-ordination of the ED and support for junior staff Medicine September 2017 July 2017 July 2017 GP Out of Hours Increased staffing at peak times Operations Oct 2017 Delayed Transfers of Detailed plan to support patients home in a Community June 2017 Care (DTOC) Plan supported way Daily MDT conference call covering every patient to reduce delays Single Point of Access (SPOA) Consolidation of the process for accessing services to avoid admission and support Community April 2017 Domiciliary Care Market Sufficiency 800 extra hours per week. Enhanced Community Response Enhanced community inpatient bed model Bay6 Homeless Charity WIC/MIU Resilience including Honiton Comms discharge Increase market provision and improve the labour market for the provision of domiciliary care Working with DCC to standardise & improve terms and conditions across Devon Development of a capacity & demand tool to improve planning for peak times Investment in community services to enhance the range and responsiveness of services available in peoples homes Enhancing the resilience and service delivered within the inpatient community units A contract with a local charity that provides practical support to homeless people, which will support discharge of this complex patient group Ensuring RD&E support the MUIs and WiCs to increase staffing resilience where possible GP Streaming Triage of ED attendances to direct appropriate patients to GPs to relieve pressure on ED minors Clinical Decision Unit (CDU) Availability of inpatient psychiatric beds Speciality Responsiveness Scoping the feasibility of adapting an area to function as a CDU to enable suitable patients to be kept for observation and avoid hospital admission A programme of work within DPT to release bed capacity to enable a responsive service for patients in ED or the wards who require admission to an IP psychiatric bed Increased use of the surgical assessment and fracture clinic to ensure that surgical specialty patients who do not deed to be seen or treated in ED are moved as quickly as possible Expanding the role of ACU to include more emergency care pathways Community Community Community Operations Medicine Medicine Medicine October 2017 September 2017 September 2017 September 2017 Ongoing Ongoing March 2018 DPT June 2017 Surgery July 2017 Ambulatory and Specialist September Assessment Services 2017 Operational Plan for ED A range of targeted uplifts to staffing levels on Medicine October Operational Capacity & Resilience Plan 2017/18 Page 15 of 45

16 Intervention Description Lead division and AMU days of predictable high volume for urgent care ED Therapist 7/7 A senior therapist to provide early Specialist assessment and treatment of patients Services therapeutic needs, freeing up other ED staff Increased Hospital Resilience Planned start date 2017 Additional medical beds (24 Beds) including additional respiratory, therapy and pharmacy cover 7 Day Cover: Therapy Pharmacy Cath Lab Echocardiography Extended opening of SAU, MTU, PAU Near patient flu testing on ED, AMU, Yarty & Paediatrics Culture Change: Your Road to Wellbeing campaign Provision of 24 beds within surgical wards that can be used for medical patients Additional Medical staff to support care Additional therapy and pharmacy available to support the higher acuity of these patients Additional physiotherapists, occupational therapists & pharmacists at weekend An inpatient echocardiography list every Saturday An additional cath lab list on key weekends around holiday periods to manage expected peaks in demand SAU extended from 2000h 2200h MTU extended from h, staffed 24/7 to avoid frequent need to find agency staff at short notice. PAU extended from /7 Testing non-elective patients preadmission to avoid cross contamination Material publicising empowering messages to patients and staff A prolonged period of engagement with staff across the Trust to change attitudes and behaviours from a focus on acute care to getting people home Patient video to be shown to most inpatients Surgery / Medicine Specialist Services Medicine Surgery Medicine Specialist Services Specialist Services October 2017 October 2017 November 2017 December 2017 Operations June 2017 and ongoing Operational Capacity & Resilience Plan 2017/18 Page 16 of 45

17 Operational Capacity & Resilience Plan 2017/18 Page 17 of 45

18 2.7. RISKS THAT COULD IMPACT UPON THE DELIVERY OF SERVICES The 2017/18 winter bed capacity plan has elements not contained in previous years and, whilst there is an evidence base behind each element of the plan, there is always a risk that they will not deliver the forecasted benefits. The figures used in the bed capacity modelling show benefits which are expected by the clinical and managerial teams to be the most likely case. Inevitably some elements may not deliver the full anticipated benefits, whilst others may over deliver. With regards to assessing the level of risk The Operational Capacity Steering Group will monitor the implementation and impact of the different elements of the programme such that changes can be made to address any shortcomings as they arise Other risks In addition to the risks around the delivery of the plan itself, the following risks have been identified which, if materialised, could impact on service delivery more generally: Sustained increase in non-elective admissions above predicted numbers Continued levels / increase in Emergency Department attendances causing difficulty in meeting Emergency Department targets Unplanned absence of staff from issues such as an increase in infections or industrial action Increased demand for services due to higher level of infection within the Healthcare community Adverse weather conditions Partner agencies unable to cope with increased demand resulting in patients diverting to RDE A change in the baseline provision of community health and social care services from previous years levels Outbreaks of Norovirus or any other infection control issues impacting on bed availability Patient transport resilience is compromised The Plan has a risk assessment which is recorded and reviewed on the Corporate Risk Register Potential Impact of Risks on Services The list below outlines the potential impact on services in the event of significant pressure affecting patient flow as described above. Potential adverse patient safety and quality impact on cancelling elective work Cancellation of elective admissions due to the number of emergency admissions and/or delays in patients waiting for onward care, therefore unable to meet RTT and cancer waiting times, and associated loss of STF income Risk of failure of the 4-hr A&E target, consequent regulatory performance failure and associated loss of STF income Failure to meet ambulance handover times. This will affect both quality and safety for patients. Declaration of OPEL4 escalation status which could result in divert of non-elective admissions Additional exposure to financial expenditure risk Reputational impact from regulators and local media as a result of failure to deliver targets and potential adverse patient outcomes Operational Capacity & Resilience Plan 2017/18 Page 18 of 45

19 2.8. TRUST-WIDE ISSUES Flu Vaccination Plan Seasonal flu is a highly infectious respiratory illness caused by a variety of different flu viruses. All frontline health care workers are offered flu vaccination, to protect staff and their families and to prevent the transmission of flu to patients and visitors who may be very vulnerable to flu. The vaccination programme at the RD&E is managed by the Infection Control Team and Occupational Health Service. This year, an extensive peer vaccination programme has been established in all wards and many clinical departments e.g. ITU, Emergency Department, Operating Theatres. The aim of the peer vaccination programme is to increase uptake of vaccine by frontline staff through local promotion of the benefits and making vaccination easily accessible in the clinical area thus negating the need for frontline staff to attend vaccination clinics provided by the Occupational Health Service Seasonal Flu Plan The Trust s Guidance for the Management of Seasonal Influenza is reviewed annually against national guidance and to incorporate any learning from the previous year s flu season. The plan is activated when Public Health England s national surveillance scheme indicates that influenza virus A or B is circulating and there is a substantial likelihood that people presenting with an influenza-like illness are infected with influenza virus, or once Flu is circulating in the community or initial cases are identified in hospital Influenza Pandemic Plan Whilst influenza pandemics have been relatively infrequent a new pandemic could emerge at any time. The Trust s response to an influenza pandemic will be based on this Framework and the Trust s Guidance for the Management of Seasonal Influenza and Influenza Pandemic Contingency Plan. Reference should also be made to the RD&E Business Continuity Strategic Response and Recovery Plan and individual Service Continuity Plans Domestic Services Specialist Cleaning Domestic Services have additional Specialist Cleaners to be available during the busy winter period. These additional staff will be available seven days per week and will occupy the 14:00-22:00 and 22:00-06:00 shifts to provide further support. A member of the Domestic Services Operational Team will attend bed meetings as required, in addition to a manager attending Outbreak meetings as these occur. This will ensure that the department maintains its close working links with the Site Practitioner and Infection Control teams and that up to date information on ward closures and cleaning requirements can be prepared and actioned Non-Emergency Patient Transport Services At times of escalation, information should be provided to First Care Ambulance and Devon County Council Patient Transport Advice Service about any likely increase in demand on Patient Transport Services (e.g. potential for increased discharges) Emergency Preparedness and Business Continuity The Trust s Emergency Preparedness Plan sets out the arrangements for responding to any major incident. The Trust has a Strategic Business Continuity and Recovery Plan. The plan is made available on the Trust s intranet site Adverse Weather Conditions The Trust receives warnings of severe weather from the Met Office. The Trust also receives additional information from a Met Office Adviser via the Local Resilience Forum if forecast weather has the potential to cause disruption. The Trust has plans for severe winter weather and heat waves which can be found on the Emergency Preparedness page of HUB. The plans are reviewed Operational Capacity & Resilience Plan 2017/18 Page 19 of 45

20 each year against national guidance which corresponds to Met Office Cold Weather Alert and Heat Health Watch periods. Operational Capacity & Resilience Plan 2017/18 Page 20 of 45

21 PART TWO 3. OPERATIONAL CAPACITY MANAGEMENT & ESCALATION This section outlines the day to day operational management processes in place to effectively manage bed capacity across the Trust. It is designed to be a useful source of reference for the operational teams responsible for ensuring that there is good patient flow throughout the hospital, as well as setting out the correct processes of escalation to follow in times of increasing pressure on bed capacity. The Trust approach to operational capacity management and escalation incorporates guidance from NHS England, detailed in their recent publication, Operational Pressures and Escalation Framework (October 2016.) This section sets out the following: The daily process of operational capacity management. Escalation triggers and actions. Red Escalation Team response. Guidelines for opening additional inpatient areas during escalation. Actions required before declaring OPEL 4. External reporting and escalation status. Other Trust issues. Individual action cards for operational capacity management and escalation THE DAILY PROCESS OF OPERATIONAL CAPACITY MANAGEMENT AND ESCALATION Daily operational management is delegated to the Trust Lead Patient Flow and Site Management Team, who take an active role in co-ordinating bed management and supporting the Divisions to maximise available beds. It is the responsibility of the Site Management Team to ensure that patients are allocated beds once the decision to admit is made and wherever possible in the correct ward for their clinical needs. It is their responsibility to maintain an overview of the Trust position at all times and to escalate issues to the Divisional Management Teams in hours and to the Senior Manager On-Call, as required, in accordance with this plan, out of hours. Routine bed meetings are held 7 days a week at 12:00 and 16:00 and at other times as the need dictates. This is led by the Trust Lead Patient Flow or Deputy and focuses on the development of a robust plan to deal with any predicted shortfall between admissions and discharges. The meeting also reviews Emergency Department activity and performance to ensure compliance of the ED 4- hour wait quality indicator, any infection control issues and Trust wide staffing issues. Bed meetings are attended by Trust-wide representatives and are to review the outcome and escalate actions as necessary. The Trust has a daily bed forecast which indicates the current position using a barometer based on the previous 24 hours performance and the current pressure indicators for patient flow. The forecast is circulated across the organisation by 10:00. Alongside the barometer, details of current capacity, the previous 24 hours performance, and the current pressure indicators are outlined. The bed forecast is updated at the midday bed meeting. Operational Capacity & Resilience Plan 2017/18 Page 21 of 45

22 Out of hours (17:00 to 09:00 Monday to Friday / 24 hours at weekends / bank holidays) the Site Practitioner will ensure that the Senior Manager On-Call is kept up to date with the Trust s status ESCALATION STATUS DEFINITIONS, TRIGGERS AND ACTIONS NHS England has produced a framework for the classification of escalation levels, setting out the definition of Operational Pressure Escalation Levels (OPEL) 1-4. The definitions have been incorporated into the Trusts approach and are described in the table below. Definition of Escalation Statuses OPEL ONE OPEL TWO OPEL THREE OPEL FOUR Business as usual. Capacity is such that organisations are able to maintain patient flow and are able to meet anticipated demand within available resources. Commissioned levels of services will be decided locally. The local health system is starting to show signs of pressure. Focused actions are required in organisations showing pressure to mitigate further escalation. Enhanced coordination will alert the whole system to take action to return to green status as quickly as possible. Actions taken in Level 2 have not succeeded in returning the local health system to Level 1 and pressure is increasing. The Trust /system is experiencing major pressures compromising patient flow. Urgent actions are required across the local health system by all partners. Pressure continues to escalate leaving the local health system unable to deliver comprehensive emergency care. There is potential for patient care and safety to be compromised. A Serious Incident is reported by the affected organisation. Decisive action must be taken to recover capacity and ensure patient safety. A number of factors contribute to the overall escalation status of the organisation. These indicators have a high degree of interdependency and a degree of judgement is required as well as an understanding of the key escalation triggers. The escalation status of the organisation is decided by the divisional representatives at the 08:45 daily meeting using the triggers described in the table below as a guide. If an escalation level of OPEL 3 is required the Chief Operating Officer or Chief Executive must be informed. OPEL 4 can not be declared without agreement from the Chief Operating Officer or Chief Executive and the on-call director from the CCG. The tables overleaf describes the key actions which should be implemented according to the different escalation levels. Operational Capacity & Resilience Plan 2017/18 Page 22 of 45

23 Escalation Triggers These triggers are used by the hospital to determine escalation status and are consistent in definition (if not trigger value) with those used across the four acute systems within Devon. OPEL Level OPEL ONE OPEL TWO OPEL THREE OPEL FOUR OPEL Level OPEL ONE OPEL TWO OPEL THREE OPEL FOUR Patients in ED with DTA Resus Capacity No. in ED 12 hr breaches A&E Performance No. of ambulance handover delays > 60 mins Urgent ops cancelled (due to lack of capacity) Elective ops cancelled (due to lack of capacity) Outliers (excluding paediatrics) <5 NA <45 =0 >=90% =0 =0 =0 <20 >=5, <9 NA >=46 <60 =0 >=85%, <90% =0 =0 <5 >=20, <30 >=9, <12 NA >=60 <75 =1 >=80%, <85% >=1 =0 >=5 >=30 <40 >12 NA >=75 >=2 <80% SOP on =1 >5 >=40 Beds closed due to infection control G&A bed occupancy for acute hospital / community beds DTOC No. of patients waiting for triage No. patients waiting for a bed to be allocated No. of predicted discharges by 12 noon LoS (acute) over 7 days Community hospital OPEL status =0 <92% <40 <3 <5 >35 <200 OPEL 1 >=1 ward, 3 or more bays >=92%, <96% >=40, <50 >=3, <5 >=5, <8 >=35, <25 >=200, <230 OPEL 2 >6 bays >=96%, <98% >=50 <60 >=5, <8 >=8, <10 >=25, <20 >=230 <250 OPEL 3 >10 bays >=98% >60 >=8 >10 >20 >250 OPEL 4 If the average score of all the escalation triggers, when rounded equals 1 then the Trust is OPEL1 If the average score of all the escalation triggers, when rounded equals 2 then the Trust is OPEL2 If the average score of all the escalation triggers, when rounded equals 3 then the Trust is OPEL3 If either the level of Elective Operations Cancelled or Outliers (red above) are OPEL3 and two or more other triggers are at OPEL3 then the Trust will be OPEL3 If all metrics are at OPEL4 then the Trust is OPEL4 Operational Capacity & Resilience Plan 2017/18 Page 23 of 45

24 The Table below sets out the actions to be taken Escalation status OPEL 1 OPEL 2 OPEL 3 OPEL 4 Authorisation level Trust Lead Patient Flow (TLPF) Trust Lead Patient Flow Divisional Director - Operations Chief Operating Officer Key actions None required DD for Ops & TLPF to consider any of the actions below as proactive measures in response to individual pressures such as previous day high medical admissions. SNs to ensure all patients, including outliers, have had senior review. This may involve the conversion of consultant SPAs to ward rounds. Directed by AMD. Senior manager from 3 clinical divisions to attend 1200 bed meeting. Review of IP diagnostic & treatment waiting, CEPOD, Trauma, Endoscopy, Cardiology. Immediate plans to be implemented as required. Divisional senior managers to review all elective IPs to consider DC / ACU options. TLPF & DD for Ops to review hospital data to identify any surge / remedial actions required in specific departments. Trust Discharge Lead to review all patients moved from AMU to specialty wards without specialty review in past 24 hours to identify discharge opportunities. All actions above. Red Escalation Team established to coordinate the actions set out in Red Escalation Team Checklist (Appendix 1). Divisional Director for Operations, on-call director of nominated Divisional Director to lead the Trust-wide response. Staff freed up by cancellation of activity to be deployed to support discharge and safe ward care. All actions above. Critical incident declared by Chief Operating Officer or on-call director supported by senior manager as appropriate. Exec Director chairs Trust wide response meeting. Discuss cancellation of elective surgery including cancer and clinically urgent activity. Discuss creation of inpatient bed capacity through conversion of existing non-ip facilities. Consider deployment of ED physician in ED 24/7. Ensure that senior medic reviews Trust wide staffing to ensure safe levels. Consider on-call team to be resident and possibility of 2 nd on-call team created. Exec Director to participate in CCG & Peninsula conference call. Service diversions discussed. Operational Capacity & Resilience Plan 2017/18 Page 24 of 45