Capacity and Escalation Plan for managing patient Flow in Powys Winter 2014

Capacity and Escalation Plan for managing patient Flow in Powys Winter 2014 Version 1.0 V1 issued V2 V3 V4 Ratified by: Lead Director Andrew Evans Operational Lead Jason Crowl Date Issued Review date Target Audience Executive Team Minor Injury Units Locality and Directorate wards and department On call managers DGH emergency plans serving Powys Care transfer co-ordinators Version control sheet Date Author Status Comment V1 13 September 2014 Sarah Southerby Closed V2 V3 V4 1

Powys Escalation Plan Contents Page Page I.0 Introduction 3 2.0 Aim 3 3.0 Objective 4 4.0 Powys Demographics 5 4.1 Emergency Admissions 5 4.2 Powys community hospitals Average Length of Stay 5 5.0 National Escalation Explanation of Levels 6 6.0 Capacity management 6 6.1 Operational Readiness 6.1 a Social Services 6.1b Reablement capacity 6.1c Powys Bed Bundle & Discharge 6.1d Predicted bed capacity 6.1e Joint Arrangements 6.2 Core Actions Framework 10 6.3 Roles and Responsibilities 6.4 Estates and Facilities Management 6.5 Weekend and Bank Holiday Arrangements 6.6 Virtual VC/phone/meetings 6.7 Advising the Public 6.8 Internal escalation Risk and Mitigation 6.9 Key Pressures indicated for 2014 7.0 Powys Wide Responsibility Action Cards 14 7.1 Care Transfer Co-ordinator 7.2 Ward Manager 7.3 Medical Lead 7.4 Winter Snow surge CRT 7.5 Powys Health Board Executive 8.0 Appendices 8.1 Powys Bed State 20 2

1.0 Introduction Effective bed management practice will always aim to ensure that there are sufficient beds available to meet the demands placed on Powys Teaching Health Board for admissions from District General hospital sites across Wales. This is via agreed operational bed management procedures in partnership with Wales Ambulance Service Trust and the Local Authority and third sector partners. It is recognised however that there will be times when demand may exceed availability, particularly during seasonal fluctuations, such as winter pressures. In this circumstance, this plan will provide a framework for managing the situation. Powys works to the National Repatriation Policy which includes bed and staff escalation plans and also to Corporate plans such as the Civil Contingencies plan. This work enhances operational details at a local level. There is complementary work underway to support this plan. In partnership with the Local Authority and other stakeholders, Powys is reviewing and refreshing a number of policies relating to facilitated discharge. The Choice Policy and Admission and Discharge policy provide clarity of procedure which underpin patient expectation and staff behaviours as part of a robust and safe discharge process. These are currently out for consultation. The escalation plan is a stand alone document and separate to the joint unscheduled Care action plan. This plan contains programmes to positively influence and improve unscheduled care in its widest sense, including 10 High Impact Changes and very recently, Public Health Wales report on Acute Healthcare demand- opportunities and levers for change (October 2013). Some are highlighted within the Health Boards Three Year Plan which is being developed and implemented concurrently. Priority areas are Primary Prevention, extended WAST alternative Pathway design, Urgent Care, Long Term Conditions self management, Integrated Care for the Frail Elderly and mental health. Through Workforce and Organisational Development, professional skills and competencies are being aligned to meet the increasing demand which means utilising the workforce in a more flexible way. As the plan sits within the unscheduled work stream with an Executive Lead, it will have sign off by the local authority, WAST and third sector partners to offer assurances that there is clarity of accountability and robust Governance arrangements in readiness for demand and capacity escalation. 2.0 Aim The aim of the escalation plan is to provide a high level approach for effectively managing escalation to support neighbouring Health Boards and NHS Trusts in England to manage capacity across each health system. Actions will be detailed in a number of step by step procedures for Powys Health Board to adopt and implement. Each stakeholder will also hold a copy of this plan. To support external escalation, Powys has to ensure it can respond by having robust internal systems in place. This will enable local measures which are pro-active and can be made according to the level of demand being placed upon Powys. It identifies internal actions that need to be taken to create capacity across respective community hospital sites. 3

3.0 Objective The objective of this escalation plan is to provide: A focussed and timely Powys response to predicted and actual capacity mismatch being experienced in wider NHS organisations. The plan will build on an integrated response from all departments within community hospital sites and community services Strengthened close working with partner agencies such as social services and the third sector. Robust and resilient internal operational procedures to ensure it can respond to the external escalation experienced in district general hospitals Assurance that its actions are enabling and effective The Winter Pressures plan for Powys is accountable to and governed by the Unscheduled Care Board and is based on four principle components- planning, communication, prevention and response. This paper forms part of the larger Winter pressures plan. During the Seasonal presentations event in September 2013, Powys underwent a peer review and the areas identified through the review are being progressed through the USCB Operational Group; the Integrated Care Pathways for Older Peoples Commissioning Board; the Transformation Board and within the maturity Matrix work stream carried out at a local level within the localities. They will not be addressed in this particular paper. 4.0 Powys Demographics Powys covers a quarter of the land mass of Wales ( 5,196 square km) is the most sparsely populated LHB area. It is the only LHB whose boundaries are coterminous with a single local authority. Around 135,200 individuals are registered with Powys thb general practices with a Welsh residence and a further 3,300 individuals with an English residence are also registered with the LHBs practices. Current projections see a rise in the older population from 13,000 in 2006 to 28,000 in 2013 which equates to 18% of the population. The increase in numbers is likely to cause a rise in chronic conditions. Older people living alone may place a greater demand on personal social services. 42.4% of older people in Powys live alone. Meeting the needs of these individuals will be a key challenge for the local health boards. In the current economic climate, the relative increase in economically dependent and in some cases, care dependent populations will pose particular challenges to communities. A decline in the number of informal carers is likely to increase and demand on statutory health and social services. They may be caring for people with multiple and increasingly complex needs 1. ( 1 taken from Public Health Wales Public Observatory 2001 censes data). 4

4.1 Emergency Admissions of Powys registered patients by Welsh and English providerssource NWIS APC 4.2 Powys community hospitals Average Length of Stay 5

5.0 National Escalation Levels Level 1 Steady state Ensure all standard operational procedures are functioning as efficiently as possible to maintain flow Level 2 Amber low Moderate pressure Respond quickly to manage and resolve emerging pressures that have the potential to inhibit flow. Initiate contingencies. Level 3 Amber high Level 4 Level 5 Reap escalation levels relevant for WAST Level 6 Reap escalation levels relevant for WAST Severe pressure Extreme pressure Critical Service Failure De- escalate when applicable Prioritise available capacity in order to meet immediate pressures. Put contingencies into action and bring pressures back with in organisational control. De- escalate when applicable Ensure all contingencies are fully operational to recover the situation. Executive command and control of the situation. Deescalate when applicable The above table is taken from the National and Emergency Pressures Escalation and de-escalation Plan November 2011. It identifies the four escalation levels for Health Boards and WAST in Wales. These levels and the triggers which support them will be used to determine the appropriate response to escalation and de-escalating emergency pressures and the actions necessary to protect core services, in order to supply the best possible level of service within resources available. There is also the following link for on call mangers and execs on call review the all Wales position http://www.howis.wales.nhs.uk/emergencypressures/statuslevel/index.cfm 6.0 Capacity Management Powys has to be ready to respond to escalation triggers from a number of different Health Boards and has to align itself to respond to peak pressures experienced in neighbouring DGHs and across the border in England. Powys is therefore, heavily reliant on the neighbouring Health Boards to share their bed status information. District General Hospitals neighbouring Powys borders: Morriston Hospital Royal Shrewsbury Hospital The Heath (UHW) Prince Charles Hospital Nevill Hall Hospital Hereford County Hospital Princess Royal Hospital Bronglais Hospital Glangwili Hospital Powys is in a strong position to support the DGHs by repatriating Powys patients back into Powys quickly and safely. Condition specific admissions can also be identified to assist in managing peak demand by ensuring Powys mobilises specialist nurses and /or specific clinical skills and 6

competencies for improved patient management and care. This optimises discharge plans and improves patient flow. 6.1 Operational Readiness The escalation process has to be lead and is the responsibility of everyone within the health board to be aware of the escalation system and respond accordingly to the actions necessary to maintain patient flow throughout the 24/7 period. The aim of approaches used in Powys such as Community Resource Teams, virtual wards and joint health and social care models is to keep as many people out of hospital or residential or nursing homes as possible, or delay their need for them. The south Locality s virtual ward is having success and is working well and similar models are being rolled out in the other two 2 locality/shires. During external escalation, action will be locally managed within the localities by the management teams whose operational procedures may differ due to their separate internal structures and processes. The Powys wide framework is below and optimises the opportunity to maintain a steady state within the community hospitals. There is similar plan for daily dialogue with Care Transfer coordinators who are based in our neighbouring Health Boards to maintain flow. While there are no acute beds in Powys, it will be helpful to explain what arrangements we have in place with our neighbouring Health Boards and alternative providers, so that we are assured there is sufficient capacity within the system to manage Powys residents, particularly during times of pressure. 6.1a Social Services Readiness Within the Local Authority, Social Care Provider Managers have two types of contingency plan in place. Firstly in severe weather, the localities/shires have a high risk register that identifies vulnerable adults who need access to essential social care intervention and the Fleet services ensures transport and carers reach them to prevent deterioration in their care needs and reduce risk of a hospital admission. They will provide geographically isolated clients respite opportunities in urgent cases. Secondly, in community hospital situations where social care packages are required to support discharges, Health operational leads will have weekly or as appropriate, daily dialogue with social services to understand the situation and reduce any potential delays to care packages being agreed and placed. Operational rotas have been completed for Xmas and New Year- no authorised leave is signed off where staff rota levels fall below an agreed indicator. Additionally, all staff complete available and none available rota days and may be called in to work in severe surge/pressure circumstances through negotiation and agreement. Other service areas will review their current caseloads and with client agreement and consent, staff can be deployed into pressure areas to meet demand on a temporary basis, whilst other support is maintained by phone or a lower level of worker where appropriate. All levels of staff step out of their roles to enable operational services to remain responsive. Services at the disposal of the provider manager include: Home support services, Day centres, Warden Services, Shared lives service where staff are diverted on a temporary basis. Agency staff can also be called upon if services are at saturation point and a critical level is reached. 7

6.1b Reablement services readiness Social services have completed a recruitment programme to increase the number of Reablement Support Workers and are employing assessors who will support the trained therapists which will increase therapist capacity to meet high demand. In situations of surge capacity, clients on the caseload are reviewed and additional staff will be deployed from services outlined above and with client consent, double packages will be shared with domiciliary care on a temporary basis, to release additional capacity. External Agency staff can be called upon and placed into services to work along side regular staff to create additional experienced reablement service capacity until de escalation. Third sector agencies such as Care and Repair will prioritise all essential minor adaptations to support hospital discharge and prevention of admission as part of winter planning and from community equipment service perspective it already has criteria and priorities in place to support hospital discharges. 6.1c Implementation of Powys Community Hospital Bed Bundle - to increase capacity Implementation of the Bed Bundle across Powys ensures that patients are admitted according to the agreed Powys Clinical Operating Framework (Policy CP003). This is to ensure that valuable NHS clinical beds are used appropriately and every opportunity is used to support the patient with their care with the improved community infrastructure. All patients have an agreed Estimated Date of Discharge recorded on a live database-myrddin. This enables improved discharge planning it can be viewed by senior managers from anywhere in Powys. On the day of discharge patients will vacate their bed by 11:00. This is to allow the area to be cleaned and made ready for the next patient. The aim is to bring the admission times for more patients into the day time period when appropriate staff are on duty. Patient discharges will be managed in line with the Revised Powys Discharge Policy. Discharge planning starts on admission and the expected date of discharge will be proactively managed against the patient care plan. Patient s response to treatment will be reviewed on a daily basis and the likely impact upon the EDD will be documented in the patient care/medical record and any revised discharge dates will be updated on Myrddin. This will reduce unnecessary bed days and planned discharges will take place over a 7 day week. The Bed Bundle supports managing the expectations of patients regarding their placement of choice in line with the new Powys Choice policy. The policy is there to help and inform the Multidisciplinary teams with managing expectations of patients and the obligations of patients and families. 6.1d Predicted capacity readiness Powys teaching Health Board is different to other, acute focussed Healthy Boards, with the majority of patients in our community hospitals being step down rather than step up, meaning that the creation of additional bed space in Powys will have very limited impact on reducing acute care admissions. In addition to this, Powys has limited capacity to create more bed capacity at short notice due to both the physical constraint on space in most of our hospitals, and also to the fact that the staff and skills base deployed in Powys does not easily allow for additional clinical staff capacity to be procured. For this reason Powys has focussed more on implementing services that reduce unscheduled care demand rather than on increasing capacity. Our success in this can be seen in the smaller number of acute admissions per head of population in Powys, and the lower number of ambulance conveyances in Powys per head of population than in other areas of the country. 8

Even given these limitations, Powys has created 6 step up assessment beds, 3 in the North and 3 in the South, 6.1e Joint Arrangements and Escalation In the North Locality, there is a local planning arrangement with both Bronglais General hospital and Shrewsbury and Telford Hospitals including the management teams and Wye Valley Trust has an escalation pathway in progress with the mid locality. Across Powys generally, the Care transfer Co-ordinators are based in the main A and E departments and act as the key communicator between the DGHs and Powys. The Local authority, Primary Care and WAST are aware of our plans through a variety of communication strands such as: information sharing, GP Forums/Cluster meetings, local USC operational meetings, the Virtual ward model and Senior Management Team meetings which occur on a regular basis. The relevant people within WAST, Local Authority and the NHS are aware and understand the escalation plans on a national level and key leaders in each organisation have been clearly identified in Appendix 8.2. 6.2 Core Actions Framework Action Who Effect Use of rolling 6 week predictive tool to forecast demand for bed occupancy Information team Across all sites collect daily and weekly beds status reporting HSAG Hospital Status at a Glance MIP myrddin in Powys Any of the 3 Care Transfer Coordinators can call operational phone/virtual VC/meetings using the list in section 6.2 below Facilities and estate Heads of service to re- prioritise work to ensure domestic services are reprioritised to support internal escalation Timely intervention to check chase and challenge discharges / LOS Estimated discharge dates and times recorded for every patient and identified at ward level Utilisation of an effective workforce plan that provides adequate levels of competent staff and the correct skill mix over 24/7 Ability to access clinical and social services staff with decision making authority 24/7 Care transfer coordinators Care Transfer coordinators Senior Nurse Clinical leads across all sites Ward managers with MDT processes Ward managers and community managers Clinical leads and senior staff Improved process to manage demand Have up to date capacity and identify opportunity to resolve issues on levels of occupancy Internal escalation responds to external escalation Have access to prompt cleaning and re- hanging of curtains after D&V outbreaks and infection control policies can be swiftly followed Maintain patient flow Planned patient flow Resilient and flexible staffing providing continuity of care Permit safe discharges during escalation Access to equipment and 9

Wales wide conference calls for external escalation Community services/virtual ward/crt to be informed of any escalation Medical practices to be informed of any escalation Social services to be informed of any escalation De-escalation function 6.3 Roles and Responsibilities Directors on call at Gold level Operational lead/lead nurses Locality Operational lead Senior Management Team Leads Operational leads from DGHs to Powys Health Board or transfer coordinators to notify localities residential care placements Alert Maintain flow Maintain flow Maintain flow Disinvestment of additional resource Once the external escalation level is known, Powys internal processes commence. Both clinical and management team engagement across all sites is important to ensure internal pro-active approach to effective flow and capacity. Internal escalation process is operational through Locality and shire structures. Early escalation of capacity problems from the care transfer coordinators or their representatives is key to enabling Powys to increase awareness to ensure patient flow is efficient and can respond to the need for increased capacity to repatriate Powys patients from the DGHs. Responsibility cards for some specific roles are available at the end of this section. The key staff members are as follows for four escalation levels: Escalation Levels 1 and 2 A locality operational manager Care Transfer coordinator Ward manager Local Authority- social care manager Escalation Levels 3 (in hours) Locality operational team Care transfer co-ordinator Ward Manager Local Authority- shire manager Clinical Leads from community hospital sites with Facilities and Estates representation CRT operational lead and primary care Lead Escalation Level 4 (in hours) A locality operational manager Care Transfer coordinator Ward manager Local Authority- shire manager Clinical Lead from community hospital sites with Facilities and Estates representation CRT operational lead and primary care lead Health Board Executive 10

Director on call Care Coordination Centre Escalation Level 3 and 4 (OOH) Care Coordination Centre Locality/clinical/ senior lead on call OOH Providers (Shropdoc and Primecare) Ward Manager Local Authority social services OOH service 6.4 Estates and facilities management The preparation and cleaning of bed areas is undertaken by Hotel services and is managed through the ward managers in liaison with locality business managers at locality level. In situations where ward closure for contagious outbreaks such as D and V has occurred and subsequently assessed by Infection control, the preparation work for radiator cover removal and curtain removal with re-hanging is handled by the estates department in these situations as curtains require high level ladders. The works request help desk internal 2401 is for all works requests, routine or urgent. Following a review of delays causing beds to stay closed due to the high level ladder work to enable cleaning, the current SLA is being reviewed to include bed preparations to be escalated as a priority and will be identified as a red flag action and carried out urgently in the same day. This is in line with the recently reviewed D and V Policy which sets out clear response times for ward deep cleaning and re-opening within 24 hours. 6.5 Weekend and Bank Holiday Arrangements To ensure appropriate levels of discharges will be maintained over the Christmas and New Year period, including weekends, the following assurances are in place. Powys will move to weekend/bank Holiday discharges from level 2 escalation to contain capacity and ensure flow. Localities are moving to have staff with appropriate competencies on duty over these days. In the Mid locality, MIU staff with additional skills will support the ward nurses. A weekend/bh rota will be distributed to ensure that accountable clinical decision makers are on duty to admit and discharge patients, outside the usual MDT process. The senior nurse on the on-call rota system will also be alerted. Within the local authority, there is flexibility for social care to respond at evenings and weekends through the out of hour s system that is in place. If the service has advanced knowledge they can prepare the OOHs service to set up discharges at weekends or BHs where there is need to have a care package set up. This is very responsive and means that social services are able to set up the package on Friday for a discharge if appropriate later that night or Saturday. In addition, Social services have moved to an Emergency Duty Team in 2014 so there is a dedicated service which should provide more capacity and a more robust service out of hours. 11

Domiciliary Care Managers have confirmed the winter planning and contingencies within the in house domiciliary care service for this winter and work has already commenced to decide Christmas rotas and staffing levels as well as the Powys wide Out of Hours rota for adult social care. We are also ensuring all front line staff are reminded and supported to have the flu jab if they choose to do so. 6.6 Virtual VC /phone /meetings Within the Health Board there is a daily, 10.30 bed management meeting. Where necessary, these will be held again at 16:00 hours during peak pressures. These are initiated by the Care Transfer Co-ordinators and involve conversation with those listed in section 6.2 at the current escalation level. The idea is to enable all the Localities to have ownership of any escalation and can be where information is shared to maintain a steady state. Issues such as staffing shortage, bed management, any locality risks which could impact on other areas and patient flow in the community or community hospital beds can be raised and supported with any appropriate actions between the localities. For external escalation, a national level call is operated by Welsh Government held at 11am and during OOH escalation at 10am and 6pm. There is a website also which will help identify and inform on current levels. http://www.howis.wales.nhs.uk/emergencypressures/statuslevel/index.cfm?reg=a&sort=hosp 6.7 Advising the Public Powys HB has to be pro-active in managing escalation. The population should have easy access to information which can provide advanced warning of a range of environmental situations such as extreme temperatures (hot or cold) pollen counts and flooding to alert them to be aware and take precautions. Reminders of pharmacy and MIU units opening hours will be available and short accurate regular messages will be shared on the Powys HB website on Choose Well, Keep Well this Winter, reminders for seasonal flu jabs, key contacts for advice and condition specific information from specialist nurses will also posted. General links to other sites such as fuel poverty information will also be posted. To increase public engagement longer term, we do have the health and social care partnership board for Older People; Learning Disability and Mental Health as well as carers support groups and services which will be more closely linked in as there are client/user representatives on these forums to share information within their communities and client groups. 6.8 Internal Escalation Risk and Mitigation Risk Lack of staff and transferability of staff across sites Loss of beds due to D&V etc and slow response to re-open beds Mitigation Operational managers agree to transfer staff during escalation WOD /HR policy review where locality is serving DGHs open additional beds Clarify roles of staff in cleaning and prioritising work programmes to meet operational demand work with Heads of service to implement this plan 12

Availability of social care packages Improve local commissioning or joint commissioning. 2014 Emergency Duty service for social care to ensure increased capacity and robust OOH service Loss of utilities to sites Redirect to other sites and operationally manage any issues. Maintain compliance work. Links with estates to prioritise work on the utility loss Seasonal flu outbreaks Flu campaign and staff immunisation programmes- offer to Severe weather, heat, drought, flooding, pollen counts and snow Poor information from providers Increased demand for equipment Poor transport arrangements for people ready for discharge to Powys social services staff Receive alerts and flag at risk patient groups Call in additional staff Cancel any training Localities to agree to work more closely to support Ensure the Care Transfer co-ordinators are the known link with DGHs and the locality Lead nurses as 2 nd cascaders Maintain store at appropriate level to meet anticipated demand Liaison with WAST with accurate patient assessment at time of conveyance and regular dialogue 6.9 Key pressures indicated for 2014/15 Desire to increase public engagement for future planning and service redesign Working differently to create capacity in elective and unscheduled care Capacity within social services Capacity within the localities More complex individuals will be cared for in the community setting or in their homes/usual place of residence Changing work patterns to meet needs of the population Development of a Powys wide communications Hub Public Health Improvement in key priority areas such as in primary prevention 13

7.0 Powys wide Responsibility Action Cards 7.1 Care Transfer Co-ordinator 7.2 Ward Manager 7.3 Medical Lead 7.4 Winter Snow- surge CRT 7.5 Health Board Executive Escalation Responsibility Action Cards 7.1 Escalation levels 1 and 2- Care Transfer co-ordinator takes on additional responsibilities during Escalation No. Individual Actions 1 Request daily escalation level from DGH in the morning and afternoon 2 Inform the community hospital wards in the locality of current level of escalation 3 Ensure there is access to update bed status from MIP for Powys bed availability- 4 Work with ward managers to have EDDs updates for the week/ month ahead 5 Routine issue resolution work 6 Inform CRT of transfers/repatriations to community services 7 Inform DGH pharmacy if TTOs are required for Powys patients to speed up the discharge process 8 Have information on hand re Powys capacity to refer on if escalation triggers to level 3 or 4 9 De-escalate as necessary and inform through the locality structures Escalation Levels 3 and to 4 1 Ensure escalation levels 1 and 2 have been exhausted 2 Inform Director on call escalation is moving from level 2 to level 3 Inform locality through specific locality structures for them to cascade 3 Work with ward Managers in community sites to ensure any changes to discharges or bed availability is known in advance 4 Inform WAST by calling 5 Ensure all patients have been reviewed by clinical decision maker 6 Using repatriation process, identify those patients who need repatriation during the day 7 Identify any blocks to patient flow into Powys and take action to resolve by directing others as necessary to manage the pressure 8 Check, chase challenge all Powys patients in DGH to be able to repatriate /pull back into Powys 9 Work with CRT leads to pull back patients known to their services if safe to do so 10 Request assistance if workload is overwhelming and for an extended period 11 De-escalate as necessary and inform through the locality structures 14

7.2 Escalation Levels 1 and 2 Ward Manager takes on additional responsibilities during Escalation No. individual actions 1 Prepare information on bed status and EDD s for sharing and reporting Sit reps and MIP 2 Ensure Expected Discharge Dates and planned discharges are reviewed and patients have been reviewed by clinical lead with particular emphasis for patient discharges over the weekend (see 10 below) 3 Resolve any discharge issues re TTOs, equipment, WAST and other patient transport to expedite planned discharges 4 Be aware of changes in escalation levels 5 When booking transport, ensure accurate mobility status of the patient is known to reduce delays 6 Prioritise requests for bed admissions based on clinical need by working/meeting with the Care Transfer coordinator and lead medical clinician as necessary 7 Support the decision making process to contain capacity at current level 8 Liaise with CRT and other ward sites for their capacity status 9 Ask the question about the de-escalation status as necessary and inform through the locality and shire structures 10 At level 2 prepare a weekend rota plan to have senior staff who can discharge patients (accountability needs to transfer to?enp, Specialist nurses/therapists ) 11 Ward manager takes priority and control of facilities and ward cleaning management and liaises with facilities/estates to ensure additional staff are transferred in from other sites Ward Manager responsibilities at Escalation Levels 3 and 4 1 Ensure escalation levels 1 and 2 have been exhausted 2 Check bed status is up to date on MIP, Sitreps and prepare to inform Care Transfer coordinator of bed status at 10am and 4pm 3 Work with Medical lead, Social service (local team) and CRT to discharge or transfer appropriate patients on to create capacity 4 Implement weekend rota plan and disseminate 5 Ensure the staff has correct skill mix and staffing levels for additional admissions 6 Request that Continuing Health Care assessors reach same day scrutiny decisions to expedite discharges by prompt arrangement of community care packages 7 Request same day panel decisions from social services or delegate 8 Delegate some-one to keep Locality managers up to date with situation 9 Inform Estates that extra cleaning may be required immediately to resolve any infection control issues 10 Share with senior clinical staff list that escalation level 3 or 4 is in place in readiness for arranging admission or discharges 11 Let GPs, MIU s know escalation level 3 or 4 to mobilise in readiness 12 Work with Senior or Lead Nurses to prepare to open additional beds- await Director approval at 11am following the National Call 13 Ask the question about the de-escalate status as necessary and inform through the locality and shire structures 15

7.3 Escalation Levels 1 and 2 Medical lead GP/Consultant takes on additional responsibilities during Escalation No. Individual Action 1 Be aware of escalation levels 2 Normal working at level 1 3 Assess predicted capacity and demand for bed occupancy at escalation level 2 4 Work with ward staff to ensure EDD are reviewed 5 Work with staff to expedite and ensure TTOs Diagnostics letters are completed so planned discharges take place to contain capacity 6 Question de-escalation status Escalation at Level 3 and to 4 1 Ensure escalation levels 1 and 2 (3) have been exhausted 2 Work with the ward manager/team to identify potential discharges and suitable patients who could be transferred into primary or community services through the CRT 3 Work with other to enhance admission avoidance pathways with other service alternatives 4 Inform Care Transfer co-ordinator of additional bed capacity if the decision is to open surge beds 5 Increase MIU support if necessary 6 Keep informed and share with other GPs through all channels. Care Co-ordination Centre updates 7 Ask the question about the de-escalate status as necessary 16

Snow-Winter Surge- CRT 7.4 Escalation levels 1 and 2 CRT take on additional responsibilities No Action 1 Be aware of escalation levels outside Powys 2 In the days leading up to a significant snow event business continuity plans should be referred to and all vulnerable patients should be assessed with regards to their continuing care needs. Bids for emergency support from Powys County Council (PCC) are for emergency support only and so plans should consider avoiding the need for DNs to travel for routine treatments in such extreme environments. 3 Prioritise visits day before and continue to review vulnerable caseload 4 Maintain cover in affected areas where possible 5 Work with social care, therapy and reablement service to develop a contingency plans to attend high risk individuals jointly 6 Liaise with the county council to clear roads for key community nursing staff- to reach work if snowed in and have access through emergency planning programme 7 Draw up low risk individuals and have a phone list of those who can manage with a phone call 8 Some carers may need additional support- liaise with third sector for visits 9 Ensure adequate equipment is available in local stores 10 Identify any volunteer 4x4 car owners who could be available to the CRT Escalation level 3 and 4 1 Ensure escalation levels 1 and 2 have been exhausted 2 Review un-approved leave and all staffing levels and increase cover over the weekend period if necessary- inform Care Transfer co-ordinator of capacity 3 Undertake joint visits in 4x4 to contain capacity with PCC 4 Inform senior nurse/lead nurse of available capacity 5 Work with neighbour locality CRT for near border individuals who could be visited by another team 6 Specialist nurses can be asked to undertake community visits (on individuals not on their case load) to contain capacity 7 Staff will remain on duty to ensure patient safety until sufficient staff report for duty 8 Ensure resilience and continuity of the Evening service 9 Ask the question about the de-escalation after snow resolved 17

7.5 Escalation Levels 1 and 2 Powys Health Board Executive takes on additional responsibilities during Escalation No. Action 1 Normal Health Board communications apply 2 Where potential increases in pressure from DGHs is communicated from the hospitals directly or the care transfer co-ordinators, confirm the localities are aware 3 Ensure daily bed capacity is accurately reviewed and discharges expedited to contain capacity Level 2 Escalation 1 Confirm with localities that GPs, primary care, WAST, MIUs and CRTs are aware of status 2 Confirm with localities every patient has been reviewed by the Consultants/GPs 3 Confirm with localities accurate bed status and be aware of available capacity 4 Confirm extra staffing status for the weekend 5 Confirm care transfer co-ordinator is working with localities to repatriate Powys patients 6 Ask the question on de-escalation status as necessary and cascade Level 3 Escalation 1 Ensure escalation levels 1 and 2 have been exhausted 2 Executive informed and communicate with DGHs operational and on-call emergency managers as necessary 3 Confirm the wards are prepared to receive diverts from the DGH s 4 Confirm the staffing levels are skilled adequately, particularly during a weekend where community hospital discharges may be necessary 5 Confirm the CRT, Palliative Care teams and Specialist nurses have capacity 6 Confirm with senior nurses/lead nurses that Continuing Health Care assessors reach same day scrutiny decisions to expedite discharges by prompt arrangement of community care packages to contain capacity 7 Confirm all Powys patients that have been identified as safe to repatriate, have been pulled back into Powys 8 Confirm senior on call is aware 9 Demonstrate preparedness and support during national phone conferences 10 Disseminate communications via locality teams 11 Consider opening additional beds to create capacity and ensure staff can be available at short notice 12 Question de-escalation and share with localities Level 4 Escalation 1 The Executive now leads on operational planning of beds in Powys 2 Ensure escalation level 3 has been exhausted 3 Nominate a named individual for daily contact in each locality for cascading information and 2-4 hourly updates in communications and actions 4 Support operational managers and care transfer co-ordinators if prolonged escalation at this level 5 Agree to open additional beds in identified community hospitals and communicate to localities as necessary 6 Winter surge due to Snow- Direct communication with CRT operational lead for status reports 7 Decision to suspend training and study days if severe staff shortages or staff movement from other localities to support 8 Agree de-escalation level through national phone conference and communicate with localities 9 Learning through reflection /debrief with localities 18

Appendices 8.1 Illustration of a Powys daily Bed State 19

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