NHS England South Escalation Framework

NHS England South Escalation Framework

Escalation Framework NHS England South First published: April 2013: Version 1.0 Updated: May 2013: Version 2.0 Prepared by Gail King, Head of EPRR, Thames Valley Area Team and Catherine Hartz, EPLO, Buckinghamshire & Berkshire CCGs

Contents 1. INTRODUCTION... 1 2. GUIDANCE FOR USE OF THE NHS ENGLAND-SOUTH ESCALATION FRAMEWORK... 1 3. NHS ENGLAND SOUTH EXPECTATIONS OF LOCAL HEALTH ECONOMIES (LHES)... 2 4. MANDATORY PROCEDURES ON DECLARATION OF BLACK STATUS... 3 4.1 AT SINGLE ORGANISATIONAL LEVEL... 3 APPENDIX 1... 7 ESCALATION COMMUNICATION FLOW CHART... 7 APPENDIX 2... 8 ESCALATION STATUS TRIGGERS... 8 APPENDIX 3A... 12 ACTIONS TAKEN AT AMBER (LEVEL 2)... 12 APPENDIX 3B... 14 ACTIONS TAKEN AT RED (LEVEL 3)... 14 APPENDIX 3C... 17 ACTIONS TO BE TAKEN BEFORE ESCALATING TO BLACK (LEVEL 4)... 17 APPENDIX 3D... 19 ACTIONS TO BE TAKEN AT BLACK (LEVEL 4)... 19 APPENDIX 4 IMPLEMENTATION OF A DIVERT... 21 APPENDIX 5 SIRI GUIDANCE... 22 APPENDIX 6... 26 KEY DEFINITIONS... 26 APPENDIX 7... 28 REVERSE TRIAGE ALGORITHM... 28

1. Introduction This NHS England-South Escalation Framework sets out the procedures across NHS England-South to manage day to day variations in demand across the health and social care system as well as the procedures for managing significant surges in demand. The purpose is to ensure that all partners, health and social care have a mechanism to access additional short term capacity in the right part of the system when demand peaks. This framework provides a consistent and co-ordinated approach to the management of pressures in NHS England-South s acute and emergency care systems, where local escalation triggers have already been applied and yet the pressure on capacity and the need to mitigate against the possibility of compromising patient care, require additional support from other service providers, including those which cross Clinical Commissioning Group (CCG) and Area Team boundaries. This framework is designed for managers and clinicians involved in managing capacity and patient throughput at a time of excess demand on NHS emergency and acute care services. This document is to be circulated to all staff who participate in such events, to provide a practical working reference tool for all parties, thereby aiding co-ordination, communication and implementation of the appropriate actions in each organisation. 2. Guidance for use of the NHS England-South Escalation Framework 1. Use of this escalation framework is triggered where a Local Health Economy (LHE) experiences pressure such that despite all actions by the whole system to reduce that pressure external assistance is needed. 2. This should only be in the most exceptional circumstances. 3. Each system must define and agree triggers, actions, roles and responsibilities throughout the escalation process including those which trigger a request for external assistance. 4. The point at which a LHE deems that external assistance is required must be clearly defined and fully understood by all relevant managers and clinicians. 5. Only when all de-escalation measures have been exhausted, will organisations act from a position of last resort in response to the most unusual and exceptional pressures to access capacity beyond LHE boundaries. In such circumstances decisions must be made with the overall best interests of patients and service users as the top priority. Page 1 of 26

6. The trigger for request for external assistance will be the declaration by the LHE of whole system Black status. 7. The implementation of external support must be agreed by all relevant parties, following which the LHE shall inform its own Area Team. 8. Contact with the local Area Team will be initiated and maintained by the executive director on call for the lead commissioners of the LHE. 9. Following a divert the LHE to which assistance was given must raise a Serious Incident Requiring Investigation (SIRI) and undertake a full investigation, root cause analysis and lessons learnt exercise. 3. NHS England South expectations of Local Health Economies (LHEs) Individual LHEs are expected to manage the escalation and de-escalation processes at local level and this framework does not seek to prescribe the detail of escalation processes and management. Whole systems teleconferences can be a useful way to co-ordinate a response to an escalating situation and can be managed at the discretion of individual organisations. The scheduling of these can be part of business as usual systems resilience processes or when deemed necessary. It must be noted however that escalation to Black status or the threat of such escalation at LHE or organisational level automatically triggers mandatory action within this framework. Please refer to section 4 below. The following points should be addressed as part of the process of system resilience and escalation framework planning: 1. Each LHE partner organisation within a LHE must have a robust, up-to-date local escalation plan signed off at Board level which dovetails into up-to-date overarching LHE wide plans. 2. Each acute trust is also required to have an ambulance services handover plan and to comply with its obligations under the plan. 3. Escalation planning must also form an integral part of system resilience and winter planning of all partner organisations in the LHE, throughout all community and hospital care settings, with due regard for emergency, elective and on-going patient / service user care. 4. It is expected that all local escalation plans will have clearly defined escalation triggers, with actions to be taken to avoid the need for escalation and to enable deescalation as quickly as possible. Example triggers (including to Black status), actions and further information for escalation in the Green-Amber-Red range are available in the appendices of this document. It should be noted that these are not exhaustive and are for information only; they are not prescriptive. Please note that Page 2 of 26

the decision to escalate to Black status or the threat of such decision automatically invokes mandatory action within this framework. Please refer to Section 4 below. 5. Special action will be required where an A&E department has to close (as opposed to not being able to receive new attenders) as it will not be able to offer resuscitation facilities. 6. There must be clear identification of the system leaders (including identification of organisation, role/s and responsibilities) who will oversee all levels of escalation, especially those where whole LHE action is needed to avoid or mitigate pressure, and where external support might be required. 7. Where an organisation and / or a LHE has undergone escalation of status it is expected that the executive directors of the lead commissioners shall lead the deescalation process once review shows suitably reduced pressure. Additional points for consideration: Timely and fit for purpose information is crucial to the management of the escalation and de-escalation process. Consideration must be given to the repatriation of patients transferred or initially taken to a receiving organisation. It is appropriate for an executive level director in each partner organisation to hold the responsibility for ensuring that escalation plans are actioned and reviewed. All escalation plans relating to a given LHE should be readily available to all relevant managers and clinicians. All should have a clear, current understanding of the processes. The impact on other A&E facilities due to the closure of a Minor Injuries Unit (from a knock on effect) must be considered. A stringent response to all ambulance handover delays is appropriate. 4. Mandatory procedures on declaration of Black status 4.1 At single organisational level 1. Prior to declaration of Black status, all actions must be taken to reduce pressure and all system partners must be fully involved in supporting the organisation at risk of this escalation. The expectation is that it would be extremely rare and the reasons exceptional for an organisation to declare Black status whilst any of the LHE partner organisations were reporting pressure less than Red level. 2. Prior to the declaration of Black status by an organisation the whole system must ensure that the following mandatory actions are implemented alongside all other locally defined actions: Page 3 of 26

a. Whole LHE All local Green-Amber-Red escalation actions in place Executive directors from all partners have been involved in discussion and agree with escalation status b. Commissioners Continue to co-ordinate communication and escalation response across the whole system Expedite additional capacity and increased support wherever possible (including voluntary and independent sector capacity) Make a risk based assessment of the best use of capacity and resource across the whole system and shift resources to best meet demand and maintain patient safety c. Acute Trust Routine elective admissions have been cancelled Urgent elective admissions have been reviewed and, where possible, rescheduled or cancelled d. Community care providers All possible capacity has been freed and redeployed to ease systems pressures e. Social Care Continue to expedite discharges, increase capacity and lower access thresholds to prevent admission where possible f. Primary Care All possible actions are being taken ongoing to alleviate system pressures g. Mental health trust Continue to expedite discharges, increase capacity and lower access thresholds to prevent admission where possible h. Ambulance trust Review current GP Admissions with GPs to ensure safe standards of care to patients Review on going 111 advice strategy Call in additional operational & communications centre staff and additional resources such as the voluntary aid societies, private ambulance services Review all long-distance inter-hospital transfers Ensure all Ambulance Trust PTS and private providers resources are directed to maintaining patient flow across the whole system. Ensure appropriate coordination with other PTS providers where other provision is commissioned Ensure direct communication between ambulance trust executive on call director and wider health system executives is under way Page 4 of 26

If emergency response is severely compromised consider use of Major Incident procedures Utilise actions from REAP plan to create capacity where possible i. PTS service Ensure all capacity is being utilised to alleviate system pressures 3. Where escalation to organisational Black status cannot be averted, the executive director on call for the organisation declaring Black status must immediately inform the executive director on call for the CCG. 4. The executive director on call for the CCG must then immediately inform the appropriate Area Team. 5. Immediately following declaration of Black status the following actions are mandatory, alongside other locally defined actions: a. Whole system: Continue to explore all local Green-Amber-Red escalation actions as well as those taken to avert further escalation to Black status and take decisive action to alleviate pressure Contribute to system-wide communications to update regularly on status of organisations (see flow chart) Provide mutual aid of staff and services across the local health economy as appropriate Post escalation: Contribute to the Root Cause Analysis and lessons learnt process through the SIRI investigation b. Commissioners Notify Area Team of alert status In conjunction with Ambulance Service and Acute Trust the commissioners act as the Hub of communication for all parties Ensure all system partners are informed of stand-down of Black status once this information is received from the organisation previously at Black status and oversee further de-escalation processes Post escalation: Lead and complete Root Cause Analysis and Lessons Learnt process in accordance with SIRI process c. Acute trust A&E consultant to be present in A&E department 24/7 Consultant Physician to be present on wards or in A&E department 24/7 Surgical consultant to be present on wards, in theatre or in A&E department 24/7 Assign appropriate qualified clinician to manage care of patients awaiting handover from ambulance service to enable ambulance crews to be released Executive director to be on site 24/7 Page 5 of 26

Any request to divert patients from A&E must be initiated by the Acute Trust who having exhausted all internal divert options must contact the CCG to request a divert to neighbouring trusts whether these are in or out of region. Refer to divert flow chart Appendix 4 d. Ambulance trust Alert neighbouring trusts to seek appropriate support as dictated by circumstances of Black Alert Continue to make a risk based assessment of the best use of capacity and resource across the whole system and shift resources to best meet demand and maintain patient safety Review the escalation status every 2 hours and communicate this across the system 6. The organisation which has declared Black status must report a SIRI on the STEIS system. Page 6 of 26

Appendix 1 Escalation communication flow chart Page 7 of 26

Green (Level 1) Amber (Level 2) Appendix 2 Escalation Status Triggers Acute Trust Capacity available to meet expected demand Good patient flow through A&E and other access points A&E 4 hour target consistently being met Ambulance Service Offloading ambulances within 15 minutes. Ambulance call volumes within expected levels Resourcing Escalatory Action Plan (REAP) level 1 Community Care Primary Care Social Services Other Action Community capacity available across system. Patterns of service and acceptable levels of capacity are for local determination At least 5 of the following across the local Health system in more than one organisation Beds available, but short of beds in 1 main area * Anticipated pressure on maintaining A&E 4 hour target Anticipated pressure in facilitating ambulance handovers Discharges below expected norm Slow patient flow through A&E, Delays breaching 30 minute turnaround time Ambulance demand breaching predicted peaks REAP level 2 and 3 Some unexpected reduced staffing numbers (due to e.g. sickness, weather Patients in community and / or acute settings waiting for community care capacity Lack of medical cover for community beds Infection control issues Some unexpected reduced staffing numbers (due to e.g. sickness, weather Out of Hours (OOH) service demand within expected levels GP attendances within expected levels with appointment availability sufficient to meet demand GP attendances higher than expected levels OOH service demand is above expected levels Some unexpected reduced staffing numbers (due to e.g. sickness, weather conditions) Social services able to facilitate placements, care packages and discharges from acute care and other hospital and community based settings Patients in community and / or acute settings waiting for social services capacity Some unexpected reduced staffing numbers (due to e.g. sickness, weather conditions) NHS Direct and / or 111 call volume within expected levels Rising NHS Direct and / or 111 call volume above normal levels Surveillance information suggests an increase in demand Weather warnings suggest a significant increase in demand Monitor capacity across whole system and take routine action to manage demand and prevent escalation to Amber The system implements all necessary actions within organisations to increase capacity and improve flow Page 8 of 26

Assessment Units Some unexpected reduced staffing numbers (due to e.g. sickness, weather conditions) in areas where this causes increased pressure on patient flow Infection control issues conditions) conditions) At least 5 of the following across the local Health system in more than one organisation Red (Level 3) Actions at Amber failed to deliver capacity Lack of beds across the Trust Predicted discharges < expected admissions Significant failure of A&E 4 hour target Patients awaiting handover from ambulance service within 15 minutes significantly compromised Patient flow significantly Significant delay in handing over patients to acute trusts Hospital Ambulance Liaison Officer (HALO) implemented Ambulance response to emergency calls compromised REAP level 4 PTS at Red alert Significant unexpected reduced staffing numbers (due to e.g. sickness, weather Community capacity full Significant unexpected reduced staffing numbers (due to e.g. sickness, weather conditions) in areas where this causes increased pressure on patient flow Pressure on OOH/GP services resulting in pressure on acute sector Significant unexpected reduced staffing numbers (due to e.g. sickness, weather conditions) in areas where this causes increased pressure on patient flow Social services unable to facilitate care packages, discharges etc Significant unexpected reduced staffing numbers (due to e.g. sickness, weather conditions) in areas where this causes increased pressure on patient flow Surveillance information suggests an significant increase in demand 111 and / or NHS Direct call volume significantly raised with normal or increased acuity of referrals Weather conditions resulting in significant pressure on services Infection control Take cross-system actions throughout the local health economy to increase capacity, improve flow and avoid admissions Page 9 of 26

compromised A&E patients with DTAs and no plan Significant unexpected reduced staffing numbers (due to e.g. sickness, weather conditions) in areas where this causes increased pressure on patient flow conditions) in areas where this causes increased pressure on patient flow issues resulting in significant pressure on services Escalation Status Black indicates a failure to manage current demand and that help is being sought beyond the locality boundaries. Chief Executive (or Deputy) level involvement is required to escalate to Black alert all actions in Appendix 3C should be taken before escalating to BLACK At least 5 of the following across the local Health system in more than one organisation Black (Level 4) Actions at Red failed to deliver capacity No capacity across the Trust Emergency care pathway significantly compromised Unable to offload ambulances A&E patients with DTAs >8 hrs. Unexpected reduced staffing numbers (due to e.g. sickness, weather conditions) in areas where this causes increased pressure on patient Cat A response target < 70% Ambulance delays affecting response to 999 calls Ambulance handover of patients to acute trusts affecting response to 999 calls REAP level 5 and 6 (Note that CAD system is barometer for SCAS) No capacity in community services Unexpected reduced staffing numbers (due to e.g. sickness, weather conditions) in areas where this causes increased pressure on patient flow is at a level that compromises service provision / patient safety Acute trust unable to admit GP referrals Inability to see all OOH/GP urgent patients Unexpected reduced staffing numbers (due to e.g. sickness, weather conditions) in areas where this causes increased pressure on patient flow is at a level that Unexpected reduced staffing numbers (due to e.g. sickness, weather conditions) in areas where this causes increased pressure on patient flow is at a level that compromises service provision / patient safety Take decisive actions throughout the system to alleviate pressure Page 10 of 26

flow is at a level that compromises service provision / patient safety Unexpected reduced staffing numbers (due to e.g. sickness, weather conditions) in areas where this causes increased pressure on patient flow is at a level that compromises service provision / patient safety compromises service provision / patient safety * Main areas = medicine; surgery; trauma / orthopaedics, paediatrics, maternity Page 11 of 26

Appendix 3A Actions taken at Amber (level 2) This is an example action card which outlines the minimum expected levels of action at Amber (level 2) status. Illustration of minimum actions at alert status AMBER which may be taken to mitigate pressure prior to (and with the intention of avoiding) further escalation: WHOLE SYSTEM 1 Undertake information gathering and whole system monitoring as necessary to enable timely de-escalation or further escalation as appropriate COMMISSIONERS 2 Expedite additional available capacity in primary care, out of hours, independent sector and community capacity 3 Co-ordinate the redirection of patients towards alternative care pathways as appropriate 4 Co-ordinate communication of escalation across the local health economy (including independent sector, social care and mental health providers) ACUTE TRUST 5 Contact on-take and A&E on-call Consultants to offer support to staff and to ensure that specialty patients in A&E are assessed rapidly 6 Implement a See and Treat pathway if not already in place routinely 7 Undertake additional ward rounds to maximise rapid discharge of patients 8 Pharmacy services to prioritise TTOs for appropriate areas and ensure that medications are delivered to the wards without delay 9 Clinicians to prioritise discharges and accept outliers from any ward as appropriate 10 Facilities, porters or transfer teams to prioritise cleaning and transfers 11 Implement measures in line with trust Ambulance Service Handover Plan 12 Inform minors patients in A&E of pressures and potential delays and of alternative care pathways where appropriate 13 Ensure patient navigation in A&E is underway if not already in place 14 Identify and encourage utilisation of alternative care pathways for minors patients (e.g. OOH). 15 Arrange alternative forms of transport (private ambulance, taxi) to discharge patients. 16 Contact PTS provider(s) and appropriate ambulance service personnel to confirm that they are in liaison with their acute counterparts to prioritise discharges/transfers and minimise turn-round times for crews. Page 12 of 26

17 Notify CCG on-call Director to ensure that appropriate operational actions are taken to relieve the pressure 18 Utilise staff from other areas of service and deploy to relieve key pressure points 19 Maximise use of nurse led wards and nurse led discharges COMMUNITY CARE PROVIDERS 20 21 22 23 Escalation information to be cascaded to all community providers with the intention of avoiding pressure wherever possible. Maximise use of re-ablement beds Task community hospitals to bring forward discharges to allow transfers in as appropriate Additional ward rounds within community providers to expedite discharge and create capacity Community providers to lower admission/treatment thresholds wherever possible through implementation of previously agreed flexible working arrangements to alleviate pressure 24 Apply flexibility regarding beds and staffing to increase capacity where possible 25 Expedite rapid assessment by multidisciplinary team (MDT) including Social Services assessment SOCIAL CARE 26 27 Expedite care packages and nursing / EMI / care home placements Ensure all patients waiting within another service are provided with appropriate service Where possible, increase support and/or communication to patients at home to prevent admission. Maximise use of re-ablement beds PRIMARY CARE 25 Community matrons to support district nurses in supporting higher acuity patients in the community 26 In reach activity to A&E departments to be maximised 27 Alert GPs to escalation and request alternatives to A&E referral be made where feasible MENTAL HEALTH 28 Expedite rapid assessment for patients waiting within another service 29 Where possible, increase support and/or communication to patients at home to prevent admission AMBULANCE SERVICE 30 Review and reallocate resources to meet current emergency workload PTS SERVICES 31 Ensure current PTS capacity is fully utilised for patient discharge and transfer Page 13 of 26

Appendix 3B Actions taken at Red (level 3) This is an example action card which outlines the minimum expected levels of action at Red (level 3) status. llustration of minimum actions at alert status RED which may be taken to mitigate pressure prior to (and with the intention of avoiding) further escalation: WHOLE SYSTEM 1 All actions listed in appendix 3A 2 3 Utilise actions from organisational major incident/significant incident plans to create capacity Utilise actions from organisational business continuity plans to ensure continuity of service COMMISSIONERS 4 5 6 7 8 CCG to co-ordinate communication and co-ordinate escalation response across the whole system Notify CCG on-call Director who ensures appropriate operational actions are taken to relieve the pressure Escalation information to be cascaded to all primary care providers with the intention of avoiding admissions wherever possible Inform OOH providers of the current system-wide alert status and advise to recommend alternative care pathways Cascade current system-wide alert status to GPs and to 111 service and advise to recommend alternative care pathways including independent providers 9 Consider Continuing Healthcare funding to be agreed outside panel 10 Ensure that liaison between and within PTS services is robust and functioning well, especially where provided other than by the Ambulance service ACUTE TRUST 11 A&E consultant to be present in A&E department 24/7 12 Contact on-take and A&E on-call Consultants to offer support to staff and to ensure emergency patients are assessed rapidly 13 Senior Physician to be present in A&E 24/7 to monitor medical admissions 13 Reschedule or put on hold relevant routine elective admissions. For example cancelling routine audiology day cases is unlikely to impact on system pressures. The Trust must remain mindful of the need to maintain planned care targets and take ongoing action as necessary to ensure that there is no slippage against these. Page 14 of 26

14 Enact process of cancelling day cases and staffing day beds overnight if appropriate. 15 16 Place NHS patients on private patient ward(s) if there are empty nursed beds as appropriate. Ensure reverse triage has been implemented to support rapid discharge (See appendix 7) 17 Open additional beds on specific wards, where staffing allows. 18 A&E to open an overflow area for emergency referrals, where staffing allows. 19 20 21 22 23 Review and reschedule plans for scheduled maintenance where work is likely to impact on capacity or patient flow Consider extra staffing in A&E (GP, Emergency Care Practitioner / Advanced Nurse Practitioner and other hospital staff, such as ITU or CCU staff, paediatrics staff.) Liaise with ambulance service to ensure risk assessment and agreed clinical plan for any patients awaiting handover Bring in extra staff to radiology, pathology, pharmacy, occupational therapy etc. If appropriate deploy staff from other areas of service to relieve key pressure points Assign clinical staff to care for any ambulance patients waiting for space (in A&E, Assessment Units and other admission areas etc.) 24 Senior Clinicians to actively scrutinise all GP requests for admission 25 Alert Social Services on-call managers to expedite care packages 26 Notify CCG on-call Director so that appropriate operational actions as above can be taken to relieve the pressure. 27 Liaise with independent sector for the availability and use of private beds COMMUNITY CARE PROVIDERS 28 29 30 31 32 All community care teams to review all patients awaiting assessments in order to expedite discharge or transfer this to include in reach teams, deliberate self-harm, community hospitals Community providers to continue to undertake additional ward rounds and review admission and treatment thresholds to create capacity where possible Community providers to expand capacity wherever possible through additional staffing and services Community providers to consider the use of wider group of agencies to increase staffing capacity Patients waiting at home for admission to be referred to Community Teams (by in reach nurses) SOCIAL CARE 33 Social Services on-call Managers to expedite care packages 34 Social services to review all assessments in pipeline to expedite discharge Page 15 of 26

35 Increase domiciliary support to service users at home in order to prevent admission PRIMARY CARE 36 OOH services to recommend alternative care pathways 37 In hours GP services to recommend alternative care pathways 38 Review staffing level of GP OOH service MENTAL HEALTH 39 To review all discharges currently referred and assist within whole systems agreed actions to accelerate discharges from acute and non-acute facilities wherever possible 40 Increase support to service users at home in order to prevent admission AMBULANCE TRUST 41 Review and reallocate resources to meet current emergency workload 42 Ensure usage of managers/officers, staff and community responders is maximised. 43 44 Ensure (in conjunction with other PTS providers if commissioned) current PTS capacity is fully utilised for patient discharge and transfer Maintain communication with GP, 111 and OOH services to review potential delays to patient admissions 45 Ensure all duty officers and directors are aware of current status levels. 46 47 Liaise with acute trust to risk assess and agree clinical plan for any patients delayed in being handed over to acute trust. Reinforce with ECPs and other A&E staff the need to use alternative care pathways whenever possible. 48 Utilise actions from REAP plan to create capacity where possible PTS SERVICE PROVIDERS 49 Ensure that capacity is fully utilised for patient discharge and transfer, and that liaison between different PTS providers and the Ambulance Service is functioning well Page 16 of 26

Appendix 3C Actions to be taken BEFORE escalating to Black (level 4) This is an example action card which outlines the minimum expected levels of action before escalating to Black (level 4). BEFORE REQUESTING ESCALATION FROM RED TO Black the following actions should have been completed:- WHOLE SYSTEM 1 All escalation actions listed in appendices 3A and 3B have been implemented 2 CEOs / Lead Directors have been involved in discussion and agree with escalation COMMISSIONERS 3 4 5 CCG to continue to co-ordinate communication and co-ordinate escalation response across the whole system Expedite additional capacity and increased support wherever possible (including voluntary independent sector capacity) Make a risk based assessment of the best use of capacity and resource across the whole system and shift resources to best meet demand and maintain patient safety. ACUTE TRUST 6 Routine elective admissions have been cancelled. 7 Urgent elective admissions have been reviewed and, where possible, rescheduled or cancelled. 8 Increase staffing in A&E to manage queue 9 Provide additional beds in A&E for patients 10 Provide 24/7 senior management support in A&E to manage situation COMMUNITY CARE PROVIDERS 11 All possible capacity has been freed and redeployed to ease systems pressures SOCIAL CARE 9 Continue to expedite discharges, increase capacity and lower access thresholds to prevent admission where possible. PRIMARY CARE 10 All possible actions are being taken on-going to alleviate system pressures MENTAL HEALTH Continue to expedite discharges, increase capacity and lower access thresholds to 11 prevent admission where possible Page 17 of 26

AMBULANCE TRUST 12 Review current GP Admissions with GPs to ensure safe standards of care to patients 13 Review on-going 111 advice strategy 14 Call in additional Operational & Communications Centre Staff and additional resources i.e. St Johns, private ambulance services, etc. 15 Review all long-distance inter-hospital transfers 16 17 18 Ensure all Ambulance Trust PTS resources are directed to maintaining patient flow across the whole system. Ensure appropriate co-ordination with other PTS providers where other provision is commissioned Ensure direct communication between acute trust on call Director, lead CCG commissioner and wider health system executives is under way If emergency response is severely compromised consider use of Major Incident/ Significant Incident procedures. 19 Utilise actions from REAP plan to create capacity where possible PTS SERVICES 20 Ensure all capacity is being utilised to alleviate system pressures Page 18 of 26

Appendix 3D Actions to be taken at Black (level 4) At Alert Status Black the following actions must be completed: WHOLE SYSTEM 1 2 3 Continue to explore actions in Appendices 3A, 3B and 3C and take decisive action to alleviate pressure Contribute to system-wide communications to update regularly on status of organisations (as per local communications plans) Provide mutual aid of staff and services across the local health economy as appropriate 4 Stand-down of Black alert once review suggests pressure is alleviating 5 Post escalation: Contribute to the Root Cause Analysis and lessons learnt process through the SIRI investigation COMMISSIONERS 6 Area Team notified of alert status and involved in decisions around support from beyond local boundaries 7 CCG report Serious Untoward Incident on the STEIS system 8 9 In conjunction with Ambulance Service and Whole System the CCGs act as the hub of communication for all parties Post escalation: Complete Root Cause Analysis and lessons learnt process in accordance with SUI process ACUTE TRUST 10 A&E consultant to be present in A&E department 24/7 11 Consultant Physicians to be present on wards and in A&E department 24/7 12 Surgical consultants to be present on wards in theatre and in A&E department 24/7 13 Assign appropriate qualified clinician to manage care of patients awaiting handover from ambulance service to enable ambulance crews to be released 14 GP to be present in A&E department 24/7 15 Executive director to be on site 24/7 16 Any request to divert patients from A&E must be initiated by the Acute Trust who having exhausted all internal divert options must contact the CCG to request a divert to neighbouring trusts whether these are in or out of region. Refer to Appendix 4 Implementation of a Divert Flow Chart AMBULANCE TRUST Page 19 of 26

17 18 Alert neighbouring trusts to seek appropriate support as dictated by circumstances of Black Alert Continue to make a risk based assessment of the best use of capacity and resource across the whole system and shift resources to best meet demand and maintain patient safety. 19 Review the escalation status every 2 hours and communicate this across the system AREA TEAM 20 Sign-off the use of support from beyond locality and/or regional boundaries 21 Assist in the management of communications and media handling 22 Post escalation: Involvement in and sign-off of SIRI investigation process Escalation Checklist Ensure all actions listed in 3A-3D have been completed in advance of requesting a divert. To be established by the Acute Trust prior to a divert request to the CCG Have whole systems teleconferences taken place and actions taken to relieve pressure? Is the safety and care of patients in the hospital compromised? Are you considering declaring an internal significant incident? Are ambulances stacking outside/been stacking throughout the day? Are contingency plans in place for staffing for the next 24hours and 48 hours? Page 20 of 26

Appendix 4 Implementation of a Divert Extraordinary pressures faced by acute trust. All internal and local escalation measures exhausted (If circumstances extreme, acute trusts may decide to declare an internal significant incident (following individual trust pathway) through CCG). Divert required. Organisational Black status declared* Acute trust Director on call contacts relevant CCG director on call. A dynamic risk assessment is undertaken across local health system. The acute trust agrees need for divert with CCG. Details of support required discussed and logged. Local system Black status declared* Formal request made to ambulance service by acute trust. Details of support required discussed and logged. Ambulance can support Ambulance cannot support Acute trust contacts neighbouring acute trusts to ascertain suitability and ability to support divert in liaison with the CCG Hospital support available Hospital support not available Acute trust to contact CCG director on call.an alternative action plan will be put in place by requesting hospital in conjunction with CCG. Internal and local escalation measures to be rechecked. Acute trust to follow significant incident pathway. Acute trust to update CCG with details of divert support offered. Diverting CCG to liaise directly with receiving CCG. Timing and stand-down procedure confirmed. Acute trust to inform other commissioners, other ambulance services, and relevant stakeholders informed with details agreed with hospitals. All details logged and information cascaded internally by trust comms team. Divert implemented. Acute Trust and CCG to consider 1:1 diverts of speciality patients to other acute trusts to alleviate pressure. Is time agreed for divert running out? Pressure alleviated? (Monitoring in line with timescales of divert) Acute trust to inform all relevant parties. Raise SIRI. Secure position. Seek further de-escalation Page 21 of 26 *It would of course be expected that the whole health economy would work together in the usual way to avert escalation and facilitate de-escalation at all levels. This flowchart does not indicate that the acute trust should wait until it declares Black status before contacting commissioners

Appendix 5 Serious Incidents Requiring Investigation (SIRIs) Information and Guidance for Area Team On-Call Directors This guidance is linked to the national SIRI Framework and the local Area Team Procedures for reporting and monitoring SIRIs. This document covers only Area Team directors on-call and relates to the Area Team procedure which states that: Criteria for informing the Area Team directly in the event of a Serious Incident Any serious incident being reported by a service commissioned by the Area Team, i.e. Primary Care provider, specialist services, offender healthcare services, screening and immunisation. Any serious incident occurring within a CCG. Any Never Events A serious incident within a CCG commissioned provider organisation where there may be media interest and/or where there are significant immediate healthcare or safety issues. Serious incidents requiring investigation should be reported on the Strategic Executive Information System (STEIS) within two working days of the incident being identified (by the organisation where the incident has occurred). In addition, organisations identifying a SIRI should also contact the relevant commissioner by telephone to enable, e.g. Major Incident Plans to be activated or media/ communication teams to be alerted (if applicable). SIRI calls may be received both in and out of hours and organisations/contractors have been instructed to contact the Area Team On-Call Director as the default number for both in and out of hours. Page 22 of 26

What to do if a SIRI call is received Obtain minimum information: The organisation/practice/service reporting The name, designation and contact details of the person reporting The service involved and a summary of the incident A brief note of immediate actions taken by the organisation/service/practice Details of any media interest (or potential media interest) Details of any other agencies involved (e.g. police, fire service, local authority, etc.) Initiate any immediate action relating to patient safety and/or following Major Incident Plans In Ho If necessary, immediately alert the communications team.* Out of If necessary, contact the on-call communications manager. Pass the information as soon as practicable (and within the same working day) to the Directorate of Nursing On the next working day, alert the communications team* (if this is required) Or Patient Safety Lead Quality & Safety Manager *If urgent notification to communications is not required, this may be left for the Patient Safety Lead or the Quality & Safety Manager to follow up. Patient Safety Lead Denise Peett Tel: 01865 334612 E-mail: Denisepeett@nhs.net Quality & Safety Manager Christine Skeldon Tel: 01865 334639 E-mail: Christine.skeldon@nhs.net Page 23 of 26

Serious Incident Requiring Investigation (SIRI) Initial Notification Report via the Area Team On-Call Director Director receiving call Date call received Time call received Organisation/practice/ service reporting Details of the person reporting: Name Designation Contact details The Incident and immediate actions taken: Location or specific service involved Summary of incident Immediate actions taken by the organisation/ service involved Continued over. Page 24 of 26

Details of any media interest (or potential media interest Details of any other agencies involved (e.g. police, fire service, local authority, etc.) Actions taken by Area Team Director on Call: Has the Area Team Communications Team been informed? YES* NO Not Applicable *If yes name and contact details of communications team member Any other actions taken and contacts Page 25 of 26

Appendix 6 Key Definitions Complete Closure When an accident and emergency department is accepting no patients at all. This will happen in very extreme circumstances only, e.g. when an Internal Incident is declared, and not normally for reasons of capacity shortfall or escalation. Escalation Triggers All organisations have adopted the common triggers to ensure equity of pressure; capacity and access (see Appendix 2). Hospital Ambulance Liaison Officer (HALO) An operational management /supervisory presence within all major Emergency Department / Assessment Units during periods of high activity. The Hospital Ambulance Liaison Officer (HALO) role is to; provide an ambulance interface with managers within the ED, monitor A&E pressures and to facilitate the timely handover of patients, where possible assist in the monitoring and caring for queuing ambulance patients until hospital queue nurses are deployed and dynamically manage the early turnaround of ambulances. Local Health Economy A health and social care whole system grouping (usually geographically defined). This is likely (but not exhaustively) to comprise a number of CCGs, acute trust(s), social care organisations, mental health trusts, ambulance service and OOH providers. Where there is more than one CCG within an operational economy (e.g. one large acute Trust providing significant levels of service for a number of CCGs) there should be agreement of a lead CCG to co-ordinate communication and escalation within the system supported by other local CCGs. These responsibilities must be clearly identified within the local health economy plans. For local CCGs responsibilities regarding co-ordination and communication of escalation must be clearly defined and agreed. Major Incident Any event which presents a serious threat to the health of the community, disruption to the service, or causes (or is likely to cause) such numbers or types of casualties as to require special arrangements to be implemented by NHS Commissioning Board, Local Area Teams, NHS Trusts, ambulance services or CCGs. It is not normally expected that escalation would be a cause of a major incident as escalation is a result of general capacity and demand pressure rather than pressure caused by a specific event. However, there may well be actions that are common to escalation levels 3 and 4 and major incident plans and this should be considered Page 26 of 26

within local economy action cards. Partial Closure When an A&E department will accept only certain patients. Peripheral Divert Border patients are taken by the Ambulance Service to neighbouring organisations to alleviate capacity issues. Resourcing Escalatory Action Plan (REAP) The REAP plan is essentially a set of pre-agreed actions to manage escalating demand by increasing capacity. It is always in operation, normally at level one, but higher levels are triggered as demand increases. Responsible Person A senior employee authorised by the Chief Executive of an individual provider to implement agreed diversions and to notify relevant parties in accordance with this framework. The responsible person must have decision making ability and authority, and an organisation wide view. The responsible person may be specified as a post (e.g. Duty Accident and Emergency Consultant, Duty Director, Operations Director) if desired. 24/7 arrangements must be in place for this person s role to be covered in person or by a deputy with clarity regarding communication. There must be a clear communication link between the responsible person and the Chief Executive. Serious Incident Requiring Investigation Refer to Appendix 5 Page 27 of 26

Appendix 7 Reverse Triage Algorithm Risk of Medical Event Basis Triage Category Notes 1 - Minimum No anticipated medical event during next 72 hours Green Deemed medically fit /stable 2 - Low Calculated risk of non fatal medical event. Consider early discharge Green Consider discharge home with assistance 3 - Moderate Consequential medical event quite likely without critical intervention Yellow Discharge home not advisable 4 - High Patient care cannot be interrupted without virtually assured morbidity or mortality Red Highly skilled care required 5 - Very High Patient cannot be mover or readily transferred Red ITU care required Page 28 of 26

Page 29 of 26