2. Scope. 3. Purpose

Transcription

1 1. Introduction This policy is developed to provide clear operational guidance for Escalation within UL Hospitals group. The policy describes the escalation status; bed capacity and Emergency Department(ED) trigger points, and associated actions required in response to emergency pressures. The policy outlines how this process will be managed and clarifies roles and responsibilities of staff to support the day to day operational management within the group. The policy also reinforces the need to maintain good communication with staff across the system, patients and their carers. 2. Scope This policy will apply to all individuals within the Trust who are involved in providing services to patients, adult, paediatrics with the exception of Maternity services. The Chief Operations Officer the Directorate teams and the Bed manager will review the allocation of beds annually, as part of the business planning process. Specific admission and transfer criteria e.g. Critical Care Services (CCS) may supplement the basic principles outlined in this policy. 3. Purpose The establishment of an effective escalation policy is designed to support the following: 1. Early identification of capacity problems and associated risks 2. Proactive rather than reactive response 3. Concise and clear actions 4. Defined responsibilities The escalation policy enables the UL hospital group to provide a comprehensive response to fluctuations in demand and capacity so that it can manage associated clinical risk within acceptable limits. The policy is designed to mitigate the risk of further escalation and ensures an appropriate response from key staff members throughout the group to contribute to a reduction in escalation status. The policy aims to maintain high standards of patient safety, patient experience and performance against key waiting time and quality standards of care.

2 4. Escalation Activity/capacity imbalance, whether through a surfeit of emergency admissions, or planned attrition of the acute base, undermines the group s ability to deliver to its operational standards, and to care safely for individual patients. Acute and community capacity is seen as a continuum, with a constant flow of patients between care settings according to need. The escalation process is the mechanism for sharing capacity pressures at times of difficulty The triggers for escalation mechanisms to these emergency pressures are outlined below, and detailed in appendix 1. It is expected through collaborative working with community services and others that a comprehensive capacity management system will be finalised and agreed. This will involve some further adjustment of the triggers. In the interim, the Chief Operations Officer and the Directorate Teams will work to ensure that the escalation status levels and triggers are closely linked with community services, ambulance services, and elderly community hospitals, to optimise use of capacity in all areas. Assumptions are made that as University Hospital Limerick as it is the only model 4 hospital in the group that the hospital does not close to emergency admissions and will not be able to divert acute workload to another acute provider unless authorised by the CEO in consultation with the National Director for acute hospitals: for example, in the case of an internal critical incident or external major incident. It is important that the group is able to assure healthcare partners that all internal measures will be employed before considering that action 5. Key Priniciples The key principles underpinning this policy are: 5.1 All actions will be implemented across the group, regardless of time of day or day of week to maintain or return the group status to green and prevent further escalation of area status based on agreed triggers and associated actions. 5.2 Triggers indicating a continuing risk when all action has been taken will be escalated to the relevant personnel via the appropriate escalation channels into the Capacity meetings. 5.3 Ward and department status will be formally monitored 6 times a day, regardless day of week and discussed at the site planning meetings held at 09.15, 10.30, 14.00, and The overall group status will be agreed at these meetings once all mitigating actions are agreed. 6.0 Escalation Status Levels A traffic light system based on a status Green, Amber, Red will be used to communicate the escalation status. This is based on a numbered scale that reflects the level of risk to patient safety and the extent to which patient experience may be compromised. The escalation status refers to group sites only

3 6.1 Status Schema Level Capacity and Escalation Levels GREEN ESCALATION LEVEL 1 Optimum working AMBER ESCALATION LEVEL 2 Persistent excess pressure requiring significant action to address demand / congestion RED ESCALATION LEVEL 3 Servere and/or prolonged pressure requiring maximum action and support from internal / external agencies to address demand / congestion BLACK ESCALATION LEVEL 4 The Group is in a critical position and the ED or other departments are clinically unsafe In the event of escalation to Black status the operational ADON/site manager or / On Call Manager/ Executive (Out of Hours) consider declaring an internal significant incident. The Communications team should be informed at Black escalation and if an Internal Significant Incident is being considered or declared. Escalation conditions are described in detail in appendix 1 and escalation actions in action cards section in appendix 6.2 Internal Significant Incident An Internal Significant Incident is defined as any occurrence that presents serious threat to the health of the patients within the group, disruption to service or causes (or is likely to cause) to require special arrangements to be implemented. Within the group an Internal Significant Incident can be declared by the Chief Operating Officer or CEO when escalation actions taken at levels 1-3 have not satisfactorily resolved the pressure in one or more services. The loss of a key service, as examples ED, ICU/ theatres may also necessitate enactment of an Internal Incident. By contrast a Major Emergency, is the Group responding to an event outside of the Group that is or likely to affect the health of the community, this can only be enacted by our external 999 partners most often notified by Ambulance Services.

4 7. Trigger Points The group has four categories of escalation: Green, Amber, Red and Black. Specific trigger points for these are defined in appendix 2, and will be subject to review and negotiation with healthcare colleagues and may be adjusted. The status level of the group will be declared in the daily site reports and at the daily Site planning meetings at 9.15, & hours. The status update will be shared with Ambulance services and with community care services. And will be declared by the Bed Manager by hrs. The operational ADON will maintain a daily log that will record the actions and decisions taken in line with each of the actions required as part of the escalation status levels ED triggers ED escalation is linked to the ED timeline (figure 2) and ED capacity triggers (figure 3) both essential for safe and effective care of patients in the department. Once an ED trigger has been met the Operational ADON must be informed. It is acknowledged that if there are multiple traumas it may not be possible for the Emergency Department nurse in charge to initiate this phone call and it can therefore delegated to another staff member. The Emergency Department nurse in charge/ed consultant must ensure that group escalation level and actions in train are communicated to the Floor Emergency Department Consultant, Nursing and radiology staff. Operational ADON will inform On-Call Manager or Directorate teams when triggers are activated and the situation cannot be resolved by the Operational ADON. The status of the ED should be reviewed every hour by the ED nurse manager / consultant lead. Professional judgement will need to be used to weigh measures associated with the timeline above and the capacity triggers below Additional Capacity The following areas have been identified for additional capacity in planned and unplanned escalation. The decision to open these areas should be planned in advance in consultation with the Assistant Directors of Nursing, and the Nursing Director. The opening of any areas out of hours should only be undertaken with the approval of the oncall executive director or Nursing director. The duty lead nurse should follow the reopening checklist if the ward is being opened at short notice. These areas will open as per agreed Escalation status. It is the responsibility of the CD s to communicate to the Consultants and the Site Manager coordinates the opening of these areas as per their action cards.

5 Figure 5: Additional capacity areas ite Beds Beds Beds HL 1 extra trolley put up on Wards: 1C, 1D, 1B, 2C, 3A, 3C, 3D, 4A, 4C, Trauma (as determined following fire consultant review) HL 1C Mon Fri 5 bedded unit to open 7 /7 2 nd extra trolley is put up on 1C, 1D, 1B, 2C, 3A, 3C, 3D, 4A, Trauma (as determined following fire officer review) Only urgent electives / Cancer patients HL AMU & SAU Protected AMU & SAU Protected HL Day surgery reviewed / cancelled to open additional 11 beds and 4 eye day beds. GH 4 extra beds Open 7 beds in old ICU. GH t Johns room 4 extra beds 4 extra beds Identify and transfer 4 emergency surgeries from UHL transferred to Croom elective list. t Ita s, St amillus, Hospital f the 1 extra rehab patient to each unit ssumption, St osephs ursing Home Purchase 15 beds x 12 weeks ( Winter eds period) 115k otal Number 32 beds 70 beds Assumption: 1B is open as a 30 bedded medical / ED landing pad Open 8 beds on 2 nd floor to accommodate medical discharge patients All elective surgery cancelled to give an extra 10 beds Identify 6 trauma patients who can be stepped down to Croom from the Trauma Ward (may require medical review while in Croom. To be arranged by CD) Internal incident called Additional resources 9.1 Cancellation of training The cancellation of training should be facilitated by the staff in the various education centres. The room booking process will identify training activity and meetings taking place. At all levels - the head of education centres for all clinical staff/ nominated deputy will ensure the registers of all staff in training sessions are completed.each register documents the name, job title, department and signature of those attending training. At Red - level 3, the manager/ nominated deputy should actively follow the process for all levels, and should share the Training Registers with the DON s and Operational Site

6 Team, this information will inform potential redeployment decision making. The Training Registers will be scanned and forwarded electronically or photocopied and the hard copies hand delivered to Chief DON s office ADON If requested, the manager/ nominated deputy should actively facilitate the cancellation of training sessions and meetings. Group staff will be required to attend training sessions in uniform where possible. All staff members have a responsibility to either attend training in uniform or to have access to their uniform. Directorates will review key clinical staff attending external network meetings, conferences and workshops and facilitate cancellation as appropriate. 9.2 An additional group of clinical staff in non-operational roles may be required to support Red/Black escalation, examples include; Divisional Specialist nurses Management roles The deployment of this group is enacted at the request of the Director of Nursing or Chief Operating Officer. 10. Communication The escalation status is communicated to staff throughout the organisation in a number of different ways. These methods recognise that not all staff will have the opportunity to regularly access s General Communication These forms of communication are designed to provide general information about the escalation status of the group. The Intranet/internet reports will be generated automatically and will be refreshed at 15 minute intervals Group Intranet/Ihub (internal communications) The Escalation status is displayed desk top of all computers, this is updated three times daily via the clinical site team automated system Flip Books Flipbooks will be displayed in all clinical areas within the group. Flipbooks will be updated by the ward clerks or nurse manager on every ward or department at 09.30, and The Flipbook should reflect the escalation status displayed on the global . The escalation status should be highlighted to the nurse in charge or head of department.

7 8.4. Escalation Global Site report The Site report will be sent by global by the Clinical Site Manager at 09.30, and daily to raise awareness of the escalation status, predicted demand, planned capacity and bed deficit. It also includes infection control updates related to ward closures etc. This is sent to key UHL staff, Community services and Ambulance services (sample in appendix 4) 9. Escalation Communication Process The following is a guide to the daily escalation process