Monitoring Information. Agenda item: 8.2, Public Board meeting Date: 29 October Title: Capacity Plan and Escalation Framework 2014/15

Agenda item: 8.2, Public Board meeting Date: 29 October 2014 Title: Capacity Plan and Escalation Framework 2014/15 Prepared by: Presented by: Diane Ody, General Manager Peter Adey, Operations Director Em Wilkinson-Brice, Chief Nurse/Chief Operating Officer Responsible Executive: Summary: Em Wilkinson-Brice, Chief Nurse/Chief Operating Officer The Capacity Plan and Escalation Framework 2014/15 outlines the plan to support the expected increase in demand over the winter period and an escalation process if at any time demand exceeds capacity. Actions required: Status (*): The Trust Board is requested to approve the Capacity Plan and Escalation Framework 2014/15. Decision Approval Discussion Information x History: Link to strategy/ Assurance framework: The issues discussed are key to the Trust achieving its strategic objectives. Monitoring Information Please specify CQC standard numbers and tick other boxes as appropriate Care Quality Commission Standards Outcomes Monitor Service Development Strategy Local Delivery Plan Assurance Framework Equality, diversity, human rights implications assessed Other (please specify) Finance Performance Management Business Planning Complaints Capacity Plan and Escalation Framework 2014/15 29 October 2015 1 of 3

1. Purpose of paper The Royal Devon and Exeter NHS Foundation Trust Capacity Plan and Escalation Framework 2014/15 (RD&E Plan) outlines the Trust s response to an increase in demand and summarises how the operational teams will enhance their services to deal with the expected increase. 2. Background The RD&E Plan underpins year round operational resilience and is aligned to the guidance from NHS England Operational Resilience and Capacity Planning for 2014-15. The RD&E Plan will work in association with the whole system Operational Resilience Plan and is be implemented in line with other health and social care provider plans including Devon Doctors on Call, South West Ambulance Foundation Trust, North Devon Healthcare Trust (East Devon Community Services), Devon Partnership Trust and Devon County Council Social Services. The primary aim of the Plan is to be able to respond to increases in activity and demand maintaining service provision and ensuring safety of patients and staff at all times throughout the year. The plan builds on the key lessons learned over the last few years in terms of what worked well and areas requiring improvement. 3. Analysis As in previous years, bed modelling has been undertaken to identify the scale of the schemes required to meet the forecast demand for bed capacity this winter. The RD&E plan is reliant on other Health and Social care providers delivering their winter plans for increasing capacity to manage admission avoidance and improving flow to onward care across the whole system. The Board of Directors will be aware that there is a concern regarding the system wide planning arrangements and assumptions and a defecit in capacity provision remains. These concerns have been escalated to the NEW Devon CCG and the NHS England Area Team. Capacity Plan and Escalation Framework 2014/15 29 October 2015 2 of 3

4. Resource/legal/financial/reputation implications Funding has been approved for the RD&E service developments to support the plan. This includes opening an additional 13 in-patient beds and increasing staffing levels in the Emergency Department. Where required additional staff are being recruited or changes to working patterns agreed. 5. Link to BAF/Key risks The RD&E Capacity Plan is recorded and reviewed on the Corporate Risk Register. The Capacity Plan provides assurance that within predicted patient flow we can meet the demand. The main risk to the plan is the resilience in the provision of community capacity. RD&E staff continue to work with other providers to develop pathways of care that reduce the need for patients to be transferred to community hospitals and avoid admission to the acute hospital. Whilst there is evidence of non-bed-based models of care, such as Hospital @ Home and Early Supported Discharge for Stroke Patients, the system remains largely reliant on bed-based provision and therefore the stated fragility of community hospital resilience represents a risk for the winter when there is an increase in demand. 6. Proposals The Trust Board are requested to receive, note and endorse the contents of the Capacity Plan and Escalation Framework 2014/15. Capacity Plan and Escalation Framework 2014/15 29 October 2015 3 of 3

Approved by: Royal Devon & Exeter NHS Foundation Trust Board Date: 29 th October 2014 Page 1 of 88

Full History Status: Draft or Final Version Date Author (Title not name) 1.1 Sept 14 GM Operations Draft 1.1 29 October 2014 Approved Status To be used in conjunction with: NEW Devon CCG Escalation Framework V7September 2013 NHS England South Escalation Framework May 2013 Version 2.0 In consultation with Divisional Leads Senior Delivery Team Approval required from Royal Devon and Exeter NHS Foundation Trust Board Contact for Review: Peter Adey Operations Director Diane Ody General Manager Approved by: Royal Devon & Exeter NHS Foundation Trust Board Date: 29 th October 2014 Page 2 of 88

CONTENTS 1. INTRODUCTION... 6 AIMS... 7 OBJECTIVES... 7 OWNERSHIP AND MAINTENANCE... 7 RISKS THAT COULD IMPACT DELIVERY OF SERVICES... 8 POTENTIAL IMPACT OF RISKS ON SERVICES... 8 2. MODELLING DEMAND AND CAPACITY... 9 3. DIVISIONAL PLANS... 11 MEDICIAL SERVICES DIVISION... 11 SURGICAL SERVICES DIVISION... 13 SPECIALIST SERVICES DIVISION... 13 TRUSTWIDE ISSUES... 17 4. OPERATIONAL MANAGEMENT... 19 PATIENT FLOW MANAGER... 19 DAILY PERFORMANCE AND PRESSURE INDICATORS... 19 ROUTINE BED MEETINGS... 20 INTERNAL PATIENT TRANSFERS... 21 SPECIALIST AREAS... 22 5. CAPACITY ESCALATION FRAMEWORK... 23 TRUST ALERT STATUS & INTERNAL CAPACITY PRESSURES... 23 EXTERNAL REPORTING... 23 ESCALATION LEVELS / ALERT STATUS... 24 EXTERNAL ESCALTION PROCESS... 24 COMMUNICATION WITH STAFF AND PUBLIC... 25 INTERNAL MANAGEMENT OF ESCALATION... 25 SUMMARY ESCALATION TRIGGERS & ACTIONS TO MAINTAIN FLOW... 27 CAPACITY MANAGEMENT DECISION ALGORITHM... 31 CAPACITY MANAGEMENT DYNAMIC RISK ASSESSMENT... 32 6. ACTION CARDS FOR TRUST LEVEL ROLES... 33 ACTION CARD: PATIENT FLOW MANAGER / SITE PRACTITIONER... 33 ACTION CARD: SENIOR MANAGER ON CALL... 34 ACTION CARD: SENIOR NURSE ON CALL... 35 ACTION CARD: OPERATIONS DIRECTOR / DEPUTY / ON CALL DIRECTOR... 36 ACTION CARD: CHIEF OPERATING OFFICER... 37 Approved by: Royal Devon & Exeter NHS Foundation Trust Board Date: 29 th October 2014 Page 3 of 88

ACTION CARD: MEDICAL DIRECTOR... 38 CAPACITY ESCALATION ACTIONS: INPATIENT AREAS... 39 7. ACTION CARDS FOR DIVISIONAL ROLES... 40 ACTION CARD: DIVISIONAL DIRECTOR / DIVISIONAL BUSINESS MANAGER MEDICAL SERVICES DIVISION... 40 ACTION CARD: ASSISTANT DIRECTOR OF NURSING / DEPUTY MEDICAL SERVICES DIVISION... 41 ACTION CARD: ASSOCIATE MEDICAL DIRECTOR MEDICAL SERVICES... 42 ACTION CARD: CLUSTER MANAGERS MEDICAL SERVICES DIVISION... 43 ACTION CARD: SENIOR NURSE/ CNA BLEEP 202 MEDICAL SERVICES DIVISION... 44 ACTION CARD: WARD CONSULTANT MEDICAL SERVICES DIVISION... 46 ACTION CARD: DIVISIONAL DIRECTOR / DIVISIONAL BUSINESS MANAGER SURGICAL SERVICES DIVISION... 47 ACTION CARD: ASSISTANT DIRECTOR OF NURSING / DEPUTY SURGICAL SERVICES DIVISION... 48 ACTION CARD: CLUSTER MANAGER SURGICAL SERVICES DIVISION... 49 ACTION CARD: ASSOCIATE MEDICAL DIRECTOR SURGICAL SERVICES DIVISION... 50 ACTION CARD: DIVISIONAL DIRECTOR / DIVISIONAL BUSINESS MANAGER SPECIALIST SERVICES DIVISION... 51 ACTION CARD: ASSISTANT DIRECTOR OF NURSING / DEPUTY SPECIALIST SERVICES DIVISION... 52 ACTION CARD: CLUSTER MANAGER SPECIALIST SERVICES DIVISION... 53 ACTION CARD: ASSOCIATE MEDICAL DIRECTOR SPECIALIST SERVICES DIVISION... 54 ACTION CARD: LEAD NURSE PAEDIATRIC UNIT - SPECIALIST SERVICES DIVISION... 55 ACTION CARD: MATERNITY UNIT AND INTEGRATED SERVICES... 56 ACTION CARD: SENIOR MANAGER NEONATAL INTENSIVE CARE - SPECIALIST SERVICES DIVISION... 58 ACTION CARD: CHIEF PHARMACIST - SPECIALIST SERVICES DIVISION... 59 ACTION CARD: HEAD OF THERAPIES - SPECIALIST SERVICES DIVISION... 60 ACTION CARD: RADIOLOGY SERVICES MANAGER - SPECIALIST SERVICES DIVISION... 61 ACTION CARD: JOINT DIRECTOR OF INFECTION CONTROL - SPECIALIST SERVICES DIVISION... 62 ACTION CARD: HEAD OF FACILITIES MANAGEMENT - OPERATIONS SUPPORT UNIT... 63 8. MONITORING OF THE PLAN... 64 Approved by: Royal Devon & Exeter NHS Foundation Trust Board Date: 29 th October 2014 Page 4 of 88

9. APPENDICES... 65 APPENDIX 1: SIGNIFICANT INCIDENT GUIDANCE... 65 APPENDIX 2: NHS SOUTH OF ENGLAND ESCALATION FRAMEWORK EXTRACT... 69 APPENDIX 3: NHS ENGLAND SOUTH SYSTEM ESCALATION TRIGGERS... 72 APPENDIX 4: ESCALATION COMMUNICATIONS FLOW CHART... 75 APPENDIX 5: RDE CAPACITY PRESSURES MEETING AGENDA... 76 APPENDIX 6: ED CAPACITY MANAGEMENT & ESCALATION PLAN... 77 APPENDIX 7: BRAMBLE ESCALATION PLAN... 80 APPENDIX 8: NEONATAL UNIT ESCALATION PLAN... 84 APPENDIX 9: OPENING EXTRA ADULT CAPACITY CHECKLIST... 88 Approved by: Royal Devon & Exeter NHS Foundation Trust Board Date: 29 th October 2014 Page 5 of 88

1. INTRODUCTION The Royal Devon and Exeter NHS Foundation Trust (RD&E) Capacity Plan and Escalation Framework outlines the operational plans that have been agreed to manage demand throughout the year; there has been a particular focus on planning for the expected increase in demand for non-elective admissions over the winter period. The plan has been developed and written with reference to the Operational Resilience and Capacity Planning for 2014/15, guidance prepared by NHS England, the NHS Trust Development Authority, Monitor and the Association of Directors of Adult Social Services, and the NEW Devon Clinical Commissioning Group Escalation Framework September 2013 and NHS England South Escalation Framework May 2013 Version 2.0. The RD&E Plan has been developed to link with the other key organisations, the NEW Devon Clinical Commissioning Group (CCG) South West Ambulance Service Foundation Trust (SWAST), Northern Devon Healthcare Trust Mid, Exeter and Eastern Devon Services (NDDH), Devon Doctors On-Call (DDOC), Primary Care, Devon Social Services (DCC) and Devon Partnership Trust (DPT). Whilst winter is a period of increased pressure to the Health Community, establishing sustainable year-round delivery requires capacity planning to be on-going and robust. This approach moves towards year-round operational resilience underpinning the development of this year s Plan. It is essential that the health economy has a clear understanding of how much capacity will be required to ensure that the whole health system achieves and maintains safe and effective patient care. The RD&E Plan forms part of the Local Healthcare Economy (LHE) plan which is aimed at managing patient pathways across all services. Extensive demand and bed capacity modelling for the RD&E has been undertaken to ensure that the agreed plans are sufficient to meet the projected demand for services. The RD&E need to take into account the assumptions of other providers within the LHE regarding their plans to achieve admission avoidance and reducing delays to patients requiring onward care. The effectiveness of this Plan requires all partnership organisations to have robust and consistent plans in place that are responsive with sufficient capacity to support surges in demand and that deliver effective patient flow throughout the year. The System Resilience Group (SCG) will monitor whole system compliance and partnership working. As a service provider in isolation the Trust cannot safely provide sufficient capacity to meet this demand, whilst ensuring both patient safety and staff wellbeing, without the reassurance that robust, sufficient and consistent capacity is provided by other Health and Social Care providers. Date: 29 th October 2014 Page 6 of 88

AIMS The principal aim of this Plan is to ensure that the Trust has sufficient capacity to meet forecast demand for its services. Actions identified in this plan will support clinical services throughout the year to deliver safe patient care through operational resilience including periods where we experience surges in demand for services. OBJECTIVES To ensure the Trust understands predicted emergency and elective activity during seasonal pressures and provide sufficient capacity to maintain safe, efficient and effective patient care. The Trust-wide approach must deliver the following: Forecast effective demand and capacity planning at Trust aggregate and Divisional level. Efficient utilisation of internal and external bed capacity. Clear communications (internal & external). Clear understanding of escalation triggers and response. Accurate performance indicator reporting internally and externally. Understanding and compliance with Whole Systems escalation process (operational management). Staff knowledge and understanding of Plan through Divisions. Deliver resilience whilst maintaining financial balance. OWNERSHIP AND MAINTENANCE The development of the Capacity Plan and Escalation Framework will remain an iterative process as further information becomes available. CAPACITY MANAGEMENT EXECUTIVE LEAD: Em Wilkinson-Brice Chief Nurse/Chief Operating Officer DEPUTY: Peter Adey Operations Director The Operational Capacity Steering Group has responsibility and oversight of the Plan. The Plan will be reviewed and updated annually by the Group and presented to the Board of Directors for approval. Changes to the Plan may be requested at any time based on organisational changes, actual incidents or any other factors. All major changes need to be approved by a quorum of the Operational Capacity Steering Group. Version control and governance of the Plan will remain the responsibility of the Operations Support Unit. Date: 29 th October 2014 Page 7 of 88

This Plan will be distributed to individuals on the Director, Manager and Senior Nurse On Call Rotas and the Site Management Office. The approved Plan will be available on the Trust s Intranet IaN This Plan will also be distributed to the NEW Devon CCG. Divisions have the responsibility for communicating and adhering to their specific plans. RISKS THAT COULD IMPACT DELIVERY OF SERVICES The following risks have been identified which, if materialised, could impact on service delivery: Sustained increase in non-elective admissions above predicted numbers. Staff resilience to manage capacity pressures over a long period of time. An increase in delayed discharges, if community services cannot meet the demand. This includes community hospital capacity, social services and support care at home. Continued increase in Emergency Department attendances causing difficulty in meeting Emergency Department targets. Unplanned absence of staff e.g. relating to increase in infections: flu, D&V, industrial action and closure of schools, causing child care problems for staff. Increase demand for services due to higher level of infection within the Healthcare community. Adverse weather conditions. Partner agencies unable to cope with increased demand and patients diverting to RDE. A change in the baseline provision of community health and social care services from previous years levels. Outbreaks of Norovirus impacting on bed availability. Patient transport resilience is compromised. POTENTIAL IMPACT OF RISKS ON SERVICES The list below outlines the potential impact on services in the event of significant pressure affecting patient flow as described above. Cancellation of elective admissions due the number of emergency admissions and/or delays in patients waiting for onward care, therefore, unable to meet RTT and Cancer waiting times. Adverse patient impact on cancelling elective work. Risk of failure of 18 week RTT and ED 4hr target and consequent regulatory performance failure. Failure to meet ambulance handover times. This will affect both quality and safety for patients. Possible increase in length of stay. Rebooking will create capacity problems at a later stage. Declaration of black escalation status which could result in divert of non-elective admissions. Additional financial expenditure risk. The RD&E Capacity & Escalation Framework has a comprehensive risk assessment which is recorded and reviewed on the Corporate Risk Register. Date: 29 th October 2014 Page 8 of 88

nning 2. MODELLING DEMAND AND CAPACITY ( As in previous years, comprehensive bed modelling has been undertaken to identify the scale of the demand for additional services required to meet the forecast demand for bed capacity this winter. The modelling is based on adult inpatients on the Wonford site only and based on three bed-pools of Medicine, Surgery and Trauma & Orthopaedics. The graph below illustrates the predicted high bed occupancy levels for the Trust based on the actual activity variances seen between Apr-Jul 2013/14 and 2014/15 (non-elective medical growth was capped at 7.5%) whilst the length of stay was profiled on 2013/14 levels. The growth assumptions used in the bed-modelling are based on the first four months of actual activity with non-elective medical activity capped at 7.5%: The modelling has been used to assess the impact on the Trust-wide and Divisional schemes to provide resilience throughout winter. Date: 29 th October 2014 Page 9 of 88

Example of this work: Modelling of the medical bed pool determined that a number of additional medical beds were required to provide resilience during the winter period. The model was used to assess the impact of the proposed schemes and this evidence resulted in the decision to have a 28-bed swing ward and 11 beds from Wynard ward convert to medicine over the winter period. The models with and without the additional bed capacity are shown below. a) Medical bed pool maintained at current levels b) Medical bed pool with an additional 39 beds Date: 29 th October 2014 Page 10 of 88

3. DIVISIONAL PLANS MEDICIAL SERVICES DIVISION Bed Capacity and Swing Ward Arrangements The modelling work demonstrates that the Medicine bed-base needs to increase over the winter period to manage the demand. The plan makes provision for a swing ward in two areas creating an additional 39 beds for medical patients over the winter. There is an acknowledgement that this arrangement needs to be continued into the Spring period and therefore the swing ward arrangements will be in place from December 2014 until June 2015. A 28 bedded surgical ward will be run as a medical ward with consistent Consultant cover. An additional 11 bedded area is also planned. The combination of these two areas should reduce the need for any additional medical outliers and will enable the medicine team to focus the right resource to ensure that there is effective patient care in these areas. The medical model of care has been agreed with the consultants across the division to ensure that there is maximum opportunity to have timely ward rounds and maintain an improved length of stay. The nursing workforce has been recruited and alongside this recruitment the team have made provision for practice facilitator posts to support new recruits and overseas nurses in their new roles. Therapy provision has been prioritised and there will be a robust model of therapy support that reflects the complex needs of medical patients in these areas. Emergency Department The Emergency Department continues to review emergency care pathways for our patients to reduce delays and maximise the opportunity for admission avoidance. The Emergency Department team have undertaken a significant amount of work to ensure that the service is adequately resourced and that workforce capacity matches required demand. Additional resource has been planned for the winter period which will include additional Nurse Practitioners to extend the hours of the service and reduce the queue for minor injury patients during the night. The team are implementing a Rapid Assessment at Triage process, which will put Consultants at the start of the patient journey in the Majors area. Ambulance Handovers Medical Services has a comprehensive plan that has been developed with South West Ambulance Service to manage the handover of patients. The joint action plan has agreed escalation triggers to manage times of service pressure. Date: 29 th October 2014 Page 11 of 88

Front Door Services The Medical Services Division continues to work closely with health and social care community partners to maximise the opportunity to improve the opportunity to reduce overnight admissions through the Front Door Service. The model below outlines the pathway: Dementia Training Hospital at Home New rehab(yealm) (Yealm) EMI Link EDI Patch Geriatrician Care 7/7 working TWM standards New stroke Hospital at Home Planned ambulatory care The full multi-disciplinary team is in place with GP s having direct access to Consultant Geriatricians and Physicians to maximise the opportunity for advice and guidance. The team is fully functioning, working across traditional boundaries with the aim to return patients to their usual place of residence as soon as possible. The team includes: Consultant geriatrician Consultant physician Older peoples mental health worker Onward care team Age UK Specialist nurses An extension of the provision of ambulatory care is being under-taken, with a greater number of pathways implemented. To reflect the seasonal demand and case-mix, the staffing levels in the front door service team have been reviewed. For the winter period the team will implement the role of a physician s assistant to maximise the opportunity for rapid diagnostics and early senior decision-making. In addition to the current team there will be greater support for patient moves to reduce delays in transferring patients to x-ray or to inpatient wards. 7/7 Consultant Provided Care Last year the majority of specialties within the medical division implemented seven day working, which was hugely successful in reducing variation in healthcare provision and improving patient flow. The division are building on this success for the winter and will implement a 7/7 working arrangement for Cardiology and Gastroenterology. Date: 29 th October 2014 Page 12 of 88

SURGICAL SERVICES DIVISION The Division has developed the plans to ensure good patient flow is maintained throughout the winter period 2014-15. The actions listed below are designed to release pressure following the holiday periods and create medical capacity during the key pressure months of winter. It is accepted that the winter swing wards will likely continue into April and May 2015 and is being planned for accordingly. Surgery As at 01 October the additional bay on Dart Ward was deemed as normal capacity and no longer classed as escalation beds. As at 01 October the division will allocate a daily manager to assist with the flow of patients through the division and assist with any pressing decisions relating to bed capacity. Additional CEPOD lists will be put in place on the first Saturday of each month between October 2014 and March 2015 to clear any emergency case backlogs and to aid throughput on the Mondays following. During December Capener will open as a Urology ward creating 13 additional beds this will support the need for Dart Ward becoming the swing ward and used as Medical Ward, but will remain under the nursing leadership of the Surgical Services Division. Continue to develop STaAU during the winter period following Consultant recruitment. Trauma & Orthopaedics 22-24 December: Day Case only through Orthopaedics. 22 December onwards: Tavy Ward will reduce occupancy to either swing to temporary medical capacity over the Christmas period or to reduce down completely in reserve. Additional Fracture clinics and Trauma lists will take place on the 2 Mondays following the Christmas and New Year bank holidays to clear any trauma backlog. SPECIALIST SERVICES DIVISION Paediatrics Paediatrics has a well-developed plan when capacity pressure affects the flow of patients; see Appendix 7 for the full plan. Imaging & Pathology 7/7 CT Service Following successful pilots, the 7/7 CT service has been funded on a recurrent basis. A new Consultant and associated clinical staff have now been appointed to ensure the continuation of this service, providing the following benefits: Supports earlier discharge planning. Reduced LoS for patients who historically would have waited until CT was available the following week. Date: 29 th October 2014 Page 13 of 88

Improved patient flow within CT; avoiding backlogs and unnecessary build-up of appointments requiring clearing early into the next week. Support Medicine s own 7/7 winter planning proposal initiated over the winter period. 7/7 MRI Service The 7/7 MRI service will be maintained by increasing to an established 7/7 working model from the end of September 2014. The 2 MRI scanners will then run 08:00 to 20:00 seven days a week. The Division also has a contract with Alliance Medical for the provision of a mobile MRI scanner 4 days a month. With this mobile option, the numbers of days can be varied and is funded by clinical Divisions to help improve their RTT position and/or cover increased referrals. This provides the following benefits: Ensures maintenance of the current service provision to meet demand. Provides greater flexibility with sufficient staffing resources. Reduces overtime costs reinvest into additional staffing costs. Reduces in Alliance Medical costs reinvest into additional staffing costs. In line with diagnostic action plan, reduces cancer turnaround times for imaging to 7 days and improve reporting times. 7/7 Pathology Service Blood Sciences and Microbiology both provide a 7/7 service as necessary to meet existing demand. The Microbiology service cover increases to meet the need depending on infection control rates within the hospital e.g. Norovirus outbreak. Therapies Physiotherapy and Occupational Therapy will provide enhanced cover across inpatient services over the weekend. An enhanced Physiotherapy service will deliver early assessment of mobility, ongoing rehabilitation to prevent patients from deteriorating, or to accelerate the progression patients have achieved during the week, in order to facilitate timely discharge, and will participate in Board Rounds where appropriate (AMU), following up requests identified from wards. Occupational Therapy will support discharges over the weekend and prevent delays in determining discharge destinations, ensuring functional assessments are completed promptly. Infection Control The Trust takes a proactive approach to managing infection control issues via the Trust s Infection Control Team. The Trust has a dedicated infection control ward, Torridge, where the care of all patients diagnosed with symptomatic Clostridium Difficile Infection is managed. However, the negative pressure isolation rooms are also used for the admission of adult patients suspected or confirmed on admission as having easily transmissible infections e.g. viral gastroenteritis. Education and training of staff continues to be provided to raise awareness of the importance of recognising potentially infectious patient on admission, management of patients who have to be admitted and outbreak control measures. Please refer to the following policies for further information: Date: 29 th October 2014 Page 14 of 88

Infection Control policy Patient Placement Policy Major Outbreak Plan Ward Closure Due to Suspected or Confirmed Outbreak of Infection Viral Gastroenteritis Guidance Source Isolation Policy Seasonal Flu Plan Pandemic Flu Plan Women s Health The Gynaecology Ward will be used for women only but will accommodate female patients from other Divisions i.e. surgical patients and the planned use of 11 beds for medical patients from December 2014 to June 2015. Pharmacy Weekend working is well established. KPIs for prescriptions will be maintained and FP10 are available out of hours from Site Team. OPERATIONS SUPPORT UNIT Discharge of Complex Patients Patient Transfer System: The Operations Support Unit continues to make improvements to the Onward Care referral system (Patient Transfer System database) including: Ward Matrons/Sisters all have access to the database to ensure accurate and timely information. There is a simplified form for referral to the OCS. There is an electronic form for referral to Community Nursing Services that is sent to one central hub and there is ongoing development for electronic referral to Community Therapy services. Additional improvements to support transfers: Transfer Coordinators have extended their hours to include Saturday s and Sundays to facilitate community transfers. The VBM (Virtual Bed Meeting Conference Call) continues Monday to Friday for early identification of community capacity and to facilitate timely transfer and at the weekends a Community Matron will identify patients who can be transferred to Community Hospitals. During escalation, the Discharge Lead will participate in the Community VBM call and work with the Transfer Coordinators and the wards to support early and timely discharge Onward Care Service The Onward Care Service has increased staffing which includes nursing capacity to undertake face to face assessment on all new referrals which will reduce delays in placing patients on appropriate lists. The increase in Occupational Therapists will further support admission avoidance and is now a seven day service supporting the ACE team as well as focusing on front door services in ED and AMU. Date: 29 th October 2014 Page 15 of 88

Complex Care Teams (CCT) working with the RDE have developed a PULL pathway. If a patient is known to the CCT they will contact the appropriate ward at the RDE and liaise to support early discharge. Two local schemes operate in Exeter and Exminster. Acute Community Team (ACT) and Hospital at Home (H@H) continue and provide both hospital prevention and early supported discharge Site Practitioners Funding has been agreed for additional support from the site team at night, and enables two practitioners to support the wards. One staff member will be mainly managing patient flow, the other will support the wards in a senior clinical role. An additional member of staff for the site team has been rostered to work Sunday afternoons. Patient Transport / Ambulance Liaison SWAST providers of Emergency Ambulance Services: The Trust has established liaison arrangements with South Western Ambulance Service NHS Foundation Trust (SWAST). Contact is made between the Ambulance Trust and Trust Site Practitioners once a day and more frequently when on Red alert. Discussion focuses on the Trust s forecast operational pressure and any ambulance handover delays. When triggered by the Capacity Pressures Escalation Plan, SWAST can provide an Emergency Care Practitioner/Paramedic Manager to be based in the Emergency Department to co-ordinate ambulances off loading, and manage non-urgent referrals in. If the RD&E is in escalation and capacity is severely compromised a telephone conference will take place with the wider Healthcare Community. Any outcome from this conference call regarding possible divert, SWAST would be part of the decision making process. NSL Providers of Non-Urgent Patient Transport: Wherever possible, Patient Transport (against the criteria) to support discharge or transfer to a community resource, should be booked the day before discharge, to support the planning of journeys and resources. Where this cannot be achieved, Patient Transport for discharges may be booked on the day, but clear instructions must be provided regarding the patients Ready to Collect time; NSL s standard waiting time is a maximum of 15 minutes. A planning assumption has been made that NSL s performance will manage capacity and that unexpected increase in demand can be covered by utilising ad-hoc private resources as and when required. The use of a dedicated discharge vehicle has improved discharge from the ED/wards and the process for booking transport following the identification of a bed at a Community Hospital has changed to improve timing of discharge. Emergency Preparedness and Business Continuity The Trust s Emergency Preparedness Plan sets out the arrangements for responding to any major incident. The Trust has a Strategic Business Continuity and Recovery Plan. The plan is on the Trust s intranet site. Date: 29 th October 2014 Page 16 of 88

Adverse Weather Conditions The Trust receives warnings of severe weather from the Met Office. The Trust also receives additional information from a Met Office Adviser via the Local Resilience Forum if forecast weather has the potential to cause disruption. The Trust has plans for severe winter weather and heatwaves which can be found on the Emergency Preparedness page of IaN. The plans are reviewed each year against national guidance which corresponds to Met Office Cold Weather Alert and Heat Health Watch periods. The Cold Weather Alert period operates from 1 st November to 31 st March and the Heat Health Watch period operates from 1 st June to 15th September. This is Alert Level 1. During these periods the Trust receives twice weekly Met Office Weather Planning Advice and Alerts when threshold criteria are met. For the Cold Weather Alert period a Level 2 Alert is issued when temperatures are forecast to fall to 2 C or less and/or heavy snow and widespread ice is forecast. For the Heat Health Watch period a Level 2 Alert is issued when there is a 60% chance of daytime temperatures reaching 30 o C and night-time temperatures reaching 15 o C on at least two consecutive days. For both periods, a Level 3 Alert is issued when Level 2 criteria are reached and a Level 4 Alert is issued when the weather is so severe or prolonged that its effects extend outside health and social care and multi-sector response at national and regional levels would be invoked. The Operations Support Unit and Site Practitioners receive these warnings and escalate Level 2 and 3 Alerts to the General Manager, Operations Support, or out of ours to the On-Call Team. Services are then notified to take agreed actions contained in the Trust s Severe Winter Weather or Heatwave Plans. TRUSTWIDE ISSUES Annual Leave Divisions should ensure that throughout the winter months, annual leave provision across the Division and within wards / departments is closely monitored to ensure sufficient cover is maintained to support service continuity. This is particularly important during planned school holidays, where historically, patient flow pressures increase. Flu Vaccination Plan Seasonal flu is a highly infectious respiratory illness caused by a variety of different flu viruses. All health care workers are also offered flu vaccination, to protect staff and their families and to prevent the transmission of flu to patients and visitors who may be very vulnerable to flu. The vaccination programme at the RD&E is managed by the Occupational Health Service. Influenza Pandemic Plan Whilst influenza pandemics have been relatively infrequent however, a new pandemic Date: 29 th October 2014 Page 17 of 88

could emerge at any time. Plans for responding to any influenza pandemic are built on and enhance Trusts Plans and Divisional Business Continuity Plans. Domestic Services Specialist Cleaning Domestic Services have two additional Specialist Cleaners to be available over the next six months during the busy winter period. These additional staff will be available seven days per week and will occupy the 14:00-22:00 and 22:00-06:00 shifts to provide further support. A member of the Domestic Services Operational Team will attend bed meetings as required, in addition to a manager attending Outbreak meetings as these occur. This will ensure that the department maintains its close working links with the Site Practitioner and Infection Control teams and that up to date information on ward closures and cleaning requirements can be prepared and actioned. Date: 29 th October 2014 Page 18 of 88

4. OPERATIONAL MANAGEMENT This section of the plan outlines the arrangements in place and key actions to be taken by members of staff to effectively manage bed capacity to accommodate acute adult and paediatric emergency admissions. It is designed to ensure that potential risk to patients in terms of safety is minimised and that quality of care is maintained. The plan has been designed to ensure that both emergency and elective targets are achieved. This section outlines business as usual. Section 5 will outline the process when capacity is under pressure. PATIENT FLOW MANAGER Daily operational management is delegated to the Head of Access and Patient Flow and the Patient Flow Manager within the Operations Support Unit. The Patient Flow Manager and the Site Practitioners take an active role in co-ordinating bed management and supporting the Divisions to maximise available beds. The Patient Flow Manager is supported by the Cluster Managers and Senior Matrons from each Division. It is the responsibility of the Site Management Team to ensure that patients are allocated beds once the decision to admit is made and wherever possible in the correct ward for their clinical needs. It is their responsibility to maintain an overview of the Trust position at all times and to escalate issues to the Divisional Management Teams in hours and to the Senior Manager On-Call, as required, in accordance with this plan out of hours. The Patient Flow Manager/Site Practitioner must notify the Head Of Access and Patient Flow weekdays or the Senior Manager On-Call out of hours of any changes to the Trust status, and also inform members of the Operational Capacity Distribution List via e-mail as and when the status changes. DAILY PERFORMANCE AND PRESSURE INDICATORS The Trust has a daily bed forecast which indicates the current position using a barometer based on the previous 24hrs performance and the current pressure indicators for patient flow. The forecast is circulated across the organisation by 10:00 on week days. The Trust Barometer is a scoring system 0-100 used to indicate the days pressures. It also displays the previous days score by way of comparison. Date: 29 th October 2014 Page 19 of 88

The escalation status of the organisation is decided by the senior leadership team at the 08:45 Performance Meeting. Alongside the barometer, details of current capacity, the previous 24hrs performance, and the current pressure indicators are outlined. Previous 24hr Performance: Predicted & Actual Admissions. Predicted & Actual Discharges. ED Performance. Stroke & Cardiology Admissions & Waiting Lists. Pressure Indicators: 10 Day+ Stays. Medical Outliers. Onward Care Waiting Lists. Infection Control Issues. ROUTINE BED MEETINGS A routine bed meeting is held 7 days a week at 12:00 and 16:00 and at other times as the need dictates. This is led by the Patient Flow Manager or Deputy and focuses on the development of a robust plan to deal with any predicted shortfall between admissions and discharges. The meeting also reviews Emergency Department activity and performance to ensure compliance of the ED 4 hour wait quality indicator, any infection control issues and Trust wide staffing issues. The Patient Transfer Team (PTS) will be advised following the Community Virtual Bed meeting (VBM) each morning at 09.30 Monday to Friday of the patients who can be transferred to a Community Hospital to maximise patient flow. The PTS will advise the appropriate ward and book transport and ensure the ward has Community prescription Chart. Attendees at Bed Meeting (Monday to Friday) Required attendees of the Bed Meetings are: Patient Flow Manager (or deputy): chair Medicine representative Surgery representative Specialist Services representative ED representative On-Call Manager Infection Control representative AMU representative Agenda Review of current and future bed capacity by Division to include: Review of previous meeting s actions. Performance over the last 24 hours. Planned admissions. Forecasted non elective demand. Date: 29 th October 2014 Page 20 of 88

Planned discharges. Community bed / capacity review. Discharge constraint issues. Any other current operational issues. Escalation level. Attendance at the meeting and actions relating to the escalation level with timescales will be added to daily action log. Bed Meetings take place in the Site Management Office at 12:00 and 16:00. The Cluster Managers will review the outcome of the bed meetings and escalate actions as necessary. If the Trust escalation level is Amber or above, the relevant senior staff must attend as outlined in this plan. Out of hours (17:00 to 09:00 Monday to Friday / 24 hours at weekends / bank holidays) the Site Practitioner will ensure that the Senior Manager On-Call is kept up to date with the Trust s status. When the escalation status is Amber or above Capacity Pressure Meetings will take place, details are in Section 5. INTERNAL PATIENT TRANSFERS Ward to Ward Transfers Any decision to move patients from ward to ward or across the site must be discussed beforehand with the Patient Flow Manager or Deputy and be in line with the Trust Patient Placement Policy. Plans to move patients from the admission units or ED to the specified wards for their care must take place in a timely manner throughout the day. During times of pressure on capacity the escalation framework must be used to ensure patients are placed in the most appreciate ward as laid out the escalation section of this plan. This includes the need to minimise transferring patients for nonclinical reasons. All such moves will be discussed at the 12:00 Bed Meeting. Patient transfers should be completed by 21:00 and only in exceptional circumstances patient movements should take after this time including any transfers to community hospitals. All non-clinical moves will be recorded. Infection Control Precautions When identifying suitable beds for patients to be admitted into, infection control precautions must be adhered to at all times, according to the Trust s Infection Control Policy. All patients with a suspected infection must be isolated accordingly. If a side room is required for an emergency admission / patient requiring barrier nursing and one is not available, the Infection Control Team (in-hours) must be contacted to help clinical staff and Site Management to risk assess and/or identify which patients across the Trust may be transferred out of side rooms. Out of hours the On-Call Infection Control Nurse must be contacted. Updates on Infection Control issues are given to the Site Management Team at 09:00 each morning and when required at the 12:00 and 16:00 bed meetings. This will include an update on patient movement on the Infection Control Ward Torridge and plans for re-opening any wards with restricted access/closure to admissions. Date: 29 th October 2014 Page 21 of 88

SPECIALIST AREAS Cardiac Care Unit (CCU) In the event that the number of patients requiring cardiac monitoring exceeds the number of available monitored beds the situation is escalated to the Site Practitioner. Wherever possible, a bed will be made available on CCU or Taw Ward at all times. The Cardiologist On-Call can be contacted for advice regarding clinical prioritisation of transfers in and out of CCU. Renal Renal admissions requiring urgent dialysis will be admitted to Creedy Ward. If capacity is not available on Creedy Ward, this will be escalated to the Renal Consultant On-Call by the Site Practitioner and appropriate discharges or transfers out will be organised. Acute Stroke All acute stroke admissions must go directly to the Acute Stroke Unit (ASU). All patients undergoing stroke thrombolysis should go into a bed on the ASU. Should there be patients waiting for beds on the ASU, the patients in this area will be reviewed to ascertain if any patients who are not stroke patients can be moved to create capacity. If there are more than 4 patients waiting for 24 hours for acute stroke beds, then provision of re-designated extra stroke beds on Ashburn or Kenn Ward will be reviewed and a plan for increased cover by Stroke Nurse Practitioners and Stroke Consultant will be put in place. This will be a short term measure only to provide designated stroke capacity and an urgent review meeting will be called to look at opportunities for discharges from the existing bed stock to return internal capacity to meet demand. In order to enact the above the Site Practitioner will contact the Medicine 202 bleep holder (Monday-Friday) or the On-Call Stroke Consultant (weekend or out-of-hours). The subsequent actions for review will be led within Medicine and reported back to the bed meeting. Intensive Care Unit (ICU) Transfers out of ICU will be managed by the Site Management Team on a daily basis. ICU will determine the priority of transfers out of the Unit. Respiratory HDU (RHDU) Admission and transfers out of the RHDU beds will be managed by the Respiratory Consultants in conjunction with the Matron and the Site Practitioner. Should demand outstrip supply, the RHDU Operational Policy describing a detailed escalation plan, will be followed. This policy is held by RHDU. Date: 29 th October 2014 Page 22 of 88

5. CAPACITY ESCALATION FRAMEWORK TRUST ALERT STATUS & INTERNAL CAPACITY PRESSURES This section of the plan outlines the arrangements in place and key actions to be taken by members of staff to effectively manage bed capacity concerns have been identified in the daily performance data. It is designed to ensure that potential risk to patients in terms of safety is minimised and that quality of care is maintained. The plan has been designed to ensure that both emergency and elective targets are achieved. Capacity issues are measured at two levels: the overall Trust Alert Status and Internal Capacity Pressures. Trust/Divisional Pressure Indicators The Trust Performance & Pressure Indicator gives details of performance throughout the Trust and some specific specialty information that we know if performance is off target can contribute to the overall deteriorating position that affects patient flow. The information will be discussed at the 08:45 Daily Performance Meeting with Divisional Directors to ensure any actions necessary by Divisions can be communicated early in the morning and actions agreed. An update on the actions will be fed back at the 12:00 Bed Meeting and actions logged on the Action Log spreadsheet. The Trust will inform the CCG if the status is amber, red and possible black. The internal indicator will influence the Trust Level Status for external reporting. Trust Alert Status Each healthcare provider is required to assess their capacity position; there are four categories; green, amber, red and black. The daily assessment of the level is identified by using the definition from the NHS England South Escalation Framework (see the matrix on page 27). The aim is for each provider to remain on escalation level green. EXTERNAL REPORTING A data set has been agreed with the CCG to provide a daily status level and some individual level data. The information from the LHE is then put together and circulated so there is an understanding of the pressure and activity levels for each provider organisation. External reports will be verified by the Head of Access and Patient Flow or Head of Operational Performance. Winter Pressures SitReps will be reported to the DoH via Unify Monday to Friday. Starting November 2014, end date for these reports to be advised. The Operations Systems Manager has responsibility for producing and forwarding data for Winter SitReps (including Flu Reporting). The daily onward care list status will be reported to Community Teams, CCG and the Onward Care Team to ensure maximum use of capacity. Date: 29 th October 2014 Page 23 of 88

ESCALATION LEVELS / ALERT STATUS The NEW Devon CCG Escalation Framework September 2013 follows the NHS South of England Escalation Framework 2013 alert levels which comprise of 4 distinct levels. Escalation Levels GREEN AMBER RED BLACK Definition of Status Green: patient flow management The Local Health and Social Care System capacity is such that organisations are able to maintain patient flow and are able to meet anticipated demand within available resources. Commissioned levels of service will be decided locally. Amber: mitigation of escalation The Local Health and Social Care System starting to show signs of pressure. Focused actions are required in organisations showing pressure to mitigate further escalation. Enhanced co-ordination will alert the whole system to take action to return to green status as quickly as possible. Red: severe pressure and failure of actions Actions taken in Amber have failed to return the system to Green and pressure is worsening. The Local Health and Social Care System is experiencing major pressures compromising patient flow further urgent actions are required across the system by all partners. Black: whole system compromised All actions have failed to contain service pressures and the local Health and Social Care system is unable to deliver comprehensive emergency care. There is potential for patient care to be compromised and a serious untoward incident is reported by the system. Decisive action must be taken to recover capacity. EXTERNAL ESCALTION PROCESS The co-ordination of the tactical response to capacity pressures will be the responsibility of the Clinical Commissioning Group Director for Eastern Locality. Amber Status Where a healthcare provider moves to Amber alert status the Clinical Commissioning Group Director will convene a Tactical Capacity Pressures Meeting, the objective of which is to understand the cause of the increase in alert level and to take immediate Date: 29 th October 2014 Page 24 of 88

action to reduce the alert level back to its previous level. The General Manager Operations / On call level 1 will represent the Trust on the call. Red Status Declaration of red must be approved by the Operations Director or deputy. A declaration of red will instigate a tactical and executive conference calls convened by the CCG. The General Manager will represent the Trust at tactical level and the Operations Director will represent the Trust at executive level. Pre Black Status Where the Trust identifies the Escalation/Alert Status may reach Black, this escalation has to be agreed by the Chief Operating Officer or Operations Director. This must be immediately communicated to the Clinical Commissioning Group Director who is required to instigate a Cluster Conference Call to ascertain the whole community escalation level and agree what actions are required to reduce the level immediately. Internally a Significant Incident should be declared. The decision to escalate to Pre Black or Black status or the threat of such a decision automatically invokes a Significant Incident and mandatory actions within the framework. See Appendix 1 and Appendix 2. For full detailed information regarding the responsibilities of the Clinical Commissioning Group please refer to the NEW CCG Escalation Framework September 13. A copy of the plan is on the Capacity Shared Drive. COMMUNICATION WITH STAFF AND PUBLIC The CCG are responsible for communication of capacity issues across the LHE, this includes communication to the GPs other healthcare providers, press and the public. See Appendix 4 for the CCG Escalation Communication Flowchart. INTERNAL MANAGEMENT OF ESCALATION Plans are in place this winter as described in Section 3 however; there may be times when the Trust need to consider further steps to increase capacity for non-elective admissions. Any changes must form part of the escalation process and any decision which will impact elective work must be taken at Operations Director/Divisional Director level due the serious consequences on the RTT and waiting list positions. It is essential all other actions have been implemented prior to cancelling elective patients. Elective admissions should only be cancelled due to capacity issues if authorised by the Operations Director, General Manager or Divisional Director. Date: 29 th October 2014 Page 25 of 88

CAPACITY PRESSURE MEETINGS When capacity is at Amber, Red or Black an additional meeting with the Senior Management Team is required to plan what actions can be taken to reduce the level. This meeting will be instigated by the General Manager or Operations Director and must be attended by Divisional Directors and Assistant Director of Nursing level. See Appendix 2 for agenda template. Amber Status The meeting will be chaired by the General Manager or deputy. The meeting will take place at 12:30 or earlier if required with the Patient Flow Manager and senior representatives from each Division. Red Status The meeting will be chaired by the Operations Director or deputy. The meeting will take place at 12:30 or earlier if required with Divisional Directors and Assistant Director of Nursing and, if required, Associate Medical Directors. Pre Black Status / Black Status The meeting will be chaired by the Chief Nurse/Chief Operating Officer or deputy. Divisional Directors, Assistant Director of Nursing, Associate Medical Directors and Medical Director will attend, to assist with planning and agree actions to reduce the level. Out Of Hours Arrangements for Escalation Issues All actions will be co-ordinated through the On Call Director and the On Call Manager. Action cards Please see individual escalation action cards starting on page 36 for Trust level interventions. Patient Flow The flowchart on page 34 gives a process on possible areas to assess for increasing capacity on a temporary basis. Date: 29 th October 2014 Page 26 of 88

SUMMARY ESCALATION TRIGGERS & ACTIONS TO MAINTAIN PATIENT FLOW NHS England have defined escalation triggers for all helath and social care providers. See Appendix 3 for system escalation triggers. Below are the detailed triggers and actions for Acute Trusts GREEN Bed capacity within the Trust is able to maintain both emergency and elective activity. Good patient flow through ED and other access points with ED four-hour target consistently being met. Action Normal Operational Management. Daily operational meeting monitors performance and identifies any warning of deterioration of patient flow due to capacity. Bed meeting as described in this plan. Date: 29 th October 2014 Page 27 of 88

SUMMARY ESCALATION TRIGGERS & ACTIONS TO MAINTAIN PATIENT FLOW (continued) AMBER Pressures are increasing and the predicted or actual bed capacity may not meet demand in one main area. Discharges are below those expected including patients requiring Onward Care. There is an increase in patients on the Onward Care List who are medically fit. Anticipated pressure on maintaining ED four-hour target. Anticipated ambulance handovers with delays breaching 30-minute turnaround times. Some unexpected reduced staffing numbers (e.g. due to sickness, weather conditions) in areas where this causes increased pressure on patient flow. Infection control issues causing pressure on patient flow. Transport unable to support discharge. Escalation Actions The General Manager will provide capacity information to Commissioners to escalate to the whole healthcare community. Discuss actions at daily operational meeting to include: Ensure all patients have a senior review to expedite discharges. Contact OCT to identify blocks to Onward Care and escalate externally actions required. Maximise capacity by planning internal escalation plan re bed usage Refer to Capacity Management Decision Algorithm, Dynamic Risk Assessment and at end of this section. A Checklist for Opening Extra Adult Capacity is in Appendix 7. Identify and manage any delays in diagnostics. Confirm our position to the CCG. Manage any pressure indicators not within normal levels e.g. number of patients on CEPOD list, Trauma List & number of outliers. Review/Implement Ambulance Handover Plan (at Appendix 5). Instigate/participate in capacity pressures conference call with CCG and Providers. Follow Staff Escalation Plan. Ensure all areas review medical, nursing and A&C staffing levels for next 24-72 hours and that Bank/Agency requests are co-ordinated to ensure demands are prioritised. Ensure community beds are utilised. Participate in the System conference calls lead by the CCG. Advise NSL of pressures and the need for additional capacity to expedite discharges. Review on-site training and meetings and postpone if are staff required to cover absences or increase capacity. Consider the need for a Discharge Lounge. Liaise with Site Management for process to identify location, staffing and resource requirements. Date: 29 th October 2014 Page 28 of 88

SUMMARY ESCALATION TRIGGERS & ACTIONS TO MAINTAIN PATIENT FLOW (continued) RED Despite measures undertaken and all amber actions completed, pressures are continuing to increase. There is a lack of beds across the Trust due to high numbers of non-elective admissions. Predicted shortfall of beds for expected emergency and elective take High numbers of Medical, Surgical or Orthopaedic outliers All escalation beds are open. Day cases areas are being utilised for inpatients. MTU used overnight impacting on MTU ability to function High number of 10-day stays High number of patients on Onward Care List ICU having difficultly transferring patients in and out Discharges predicted to be lower than expected admissions. Onward Care not able to transfer medically fit patients to community care. Social Services unable to facilitate care packages for discharges. There is significant failure by ED in achieving the four-hour target and ambulance handover times within 15 minutes and response to emergency calls are severely compromised. Significant unexpected reduced staff numbers due to sickness or weather conditions are experienced. Infection control issues resulting in significant pressures on the system due ward closures. Escalation Action All listed at Amber. The Operations Director will provide capacity information to Commissioners to escalate to the whole healthcare community. The Operations Director will participate in the conference call with Commissioners and all local providers The outcome from the conference should identify actions that will increase will capacity across the LHE this could include: Increase provision for admission avoidance. Increase Primary Care. Improve the flow of patients from the Onward Care List to the community. Consider cancellations for non-urgent patients. Investigate further possibilities of increasing in patient capacity. A representative from each Division should be available as appoint of contact with the Site Team to manage flow. Request increase capacity for vehicles to support discharge Consider increasing senior medical cover in admission areas and front door services. Prioritise tests for patient awaiting discharge Date: 29 th October 2014 Page 29 of 88

SUMMARY ESCALATION TRIGGERS & ACTIONS TO MAINTAIN FLOW The Board of Directors considered and agreed, aligned to its stated Hierarchy of Priorities the following principles which provide a framework for decision making at preblack. Each situation is considered in its own right. Where cancellation of urgent patients is considered, senior clinical review of each patient is undertaken together with an assessment of risk. No urgent patient should be cancelled more than once. Consideration of the duty of care for patients within the RDE will be matched with consideration of the system s duty of care for the entire local population in terms of accessing urgent care. Continuous dialogue with CCG / other providers focused on achieving normal operating as soon as possible. PRE BLACK / BLACK Actions at Red failed to deliver capacity and there is system gridlock with no capacity across the acute trust or within the community. The Trust is unable to admit GP referrals. The Emergency Department and the medical triage Unit is unable to safely provide emergency care service. Ambulances are unable to off-load patients affecting their response to 999 calls. Routine elective work has already been cancelled. Reduced or insufficient staffing numbers are such that it compromises service delivery this could include inability to open inpatient beds in day case areas. Onward Care Services unable to transfer patients from Acute Trust Escalation Action and Mandatory Actions As actions listed in Amber and Red. The Chief Operating Officer / Operations Director would declare a Significant Incident. See Appendix 1 for guidance The Chief Nurse/Chief Operating Officer will provide capacity information to Commissioners to escalate to the whole healthcare community. The Chief Nurse/Chief Operating Officer and the Operations Director will participate in the conference call with Commissioners and all local providers Participate in peninsula wide conference call. Ensure all mandatory action actions are completed for Black status. Discuss possible divert with other healthcare providers, this must be agreed with the LHE. Further actions required Urgent elective admissions have been reviewed and, where possible, rescheduled or cancelled. Consider ED consultant to be present in ED department 24/7. Consider Medical consultant to be present on MTU 24/7. Consider Surgical consultant to be present on the wards, in theatre or in ED department 24/7. Consider cancelling outpatients to redirect staff to support inpatient work. Assign appropriate qualified clinician to manage care of patients awaiting handover from ambulance service to enable ambulance crews to be released Consider Level 1 or Level 2 On call to be on site 24/7. Any request to divert patients from ED 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. See Appendix 2 for full mandatory actions required across the LHE. Date: 29 th October 2014 Page 30 of 88

CAPACITY MANAGEMENT DECISION ALGORITHM (See the next page for Dynamic Risk Assessment Form) Date: 29 th October 2014 Page 31 of 88

CAPACITY MANAGEMENT DYNAMIC RISK ASSESSMENT Definition: Dynamic risk assessment is the continuous assessment of risk in the rapidly changing circumstances when there are operational capacity pressures in order to implement the control measures necessary to ensure an acceptable level of safety. This form should be used when assessing the need to open additional capacity Forms and a laminated copy of the NPSA 5x5 matrix are available in the Site Management Office. 1. 2. Issue/problem 3. 4. Cause(s) of the issue/problem 5. Options Considered Positives for this option Negatives for this option A NPSA 5x5 Score Select Yes/No B C D 4. Actions/tasks to be implemented as a result of this decision Date and time completed 5. Who was involved in this decision? (Name, Title and Role) Date: 29 th October 2014 Page 32 of 88

6. ACTION CARDS FOR TRUST LEVEL ROLES The following action cards outline the actions to be taken and individual responsible for staff when managing capacity at Trust level. ACTION CARD: PATIENT FLOW MANAGER / SITE PRACTITIONER GREEN Obtain a baseline of activity in ED from Patient First patients waiting for admission, status, and level of activity in each area. Check with ED Nurse in Charge for any issues relating to patients or staffing Review elective and predicted emergency admissions. Review number of expected discharges. Meet with Infection Control at 09:00 to discuss any significant issues for patient flow. Chair bed meetings, 12:00 and 16:00 to input and update status. Escalate to relevant Division contact any potential problems to patient flow: key contacts MTU and ED Nurse in Charge and the Cluster Manager. Monitor ED position in terms of the 4 hour wait. Support Medicine/MTU with allocation and timely transfers out of ED. AMBER Escalate to Head of Access and Patient Flow/ Divisional representatives. Chair meetings to review status of all inpatients with Senior Matrons from the Divisions. Initiate additional resources as required such as Portering and additional nursing cover. Inform Onward Care Team of position to expedite discharges and identify and manage delays. Advise Discharge lead to join VBM with community staff to ensure maximum discharge from the Onward Care list to the community. Support the area s most under pressure with a physical presence. Escalate potential breach situation to Head of Access and Patient Flow/ Divisional Teams/Senior Manager On-Call if it cannot be resolved in a timely way. Attend escalated bed meetings. Agree contingency actions aimed at reducing escalation level. Consider the option of opening extra beds if available. Refer to Capacity Decision Algorithm and Risk Assessment in Sections 6.3 and 6.4 Ensure these actions are carried out within each Division. RED Liaise with the Operations Director and General Manager Work closely with Divisional teams to investigate any blocks to discharge OOH liaises directly with On Call Level 1, Senior Manager and Senior Nurse. Initiate additional capacity pressure meeting at request of Operations Director. Provide up to date information to assist Chair of the capacity pressure meetings. Be clear where the blocks to flow are so that senior managers can support with additional resource or escalation. PRE-BLACK / BLACK All Local Green- Amber -Red escalation actions are in place. Black status can only be declared by the Chief Nurse/Chief Operating Officer Take direction from the Chief Nurse/Chief Operating Officer Support the Significant Incident as part of the Incident Control Team. Consider need to call in additional Site Team support. Provide data and attend escalated capacity pressure meetings.. Agree and implement contingency actions aimed at reducing escalation level. Date: 29 th October 2014 Page 33 of 88

ACTION CARD: SENIOR MANAGER ON CALL GREEN Take handover from previous manager. Ensure you are aware of escalation status following distribution of the bed forecast. Attend 16:00 Bed Meeting to ascertain the overall Trust situation and plan. Take update from the Site Management Team Manager at 18:30. Keep Level 1 On-Call updated of any potential problems. AMBER Support the Site Management Team with any escalation to Medical or Nursing teams. Ensure that plans from the Bed Meetings are being enacted in a timely way, follow up any outstanding actions. At the weekend, lead a Bed Meeting with the Site Management Team and Senior Nurse On-Call at 12:00 on Saturday and Sunday. Keep in regular contact with the Site Practitioner during the whole shift (day or night). RED Remain on site weekday evening or attend site on a weekend day until 16:00 or later if required. Attend Capacity Pressure Meetings. Agree contingency actions aimed at reducing escalation level. Ensure Action Plan is communicated and agreed as robust by the Level 1 On-Call. Support the Site Practitioner to maintain patient pathways by escalating any potential/actual blocks transport, portering, business continuity issues, staffing both medical and nursing. Maintain patient safety. Liaise with other agencies i.e. DDOC and SWAST to ascertain the local picture. Work closely and keep the Level 1 On-Call informed at all stages of escalation, particularly if the site is experiencing on-going periods of increased activity. Support the Site Management Team and Divisions in opening extra capacity. PRE-BLACK / BLACK All Local Green- Amber -Red escalation actions are in place. Attend and remain on site until the situation can be stabilised. Work closely to support the Operations Director or On-Call Level 1 Support the Site Team and Divisions to open up additional beds across the Trust. Support the Significant Incident as part of the Incident Control Team. Risk assess patient moves with medical and nursing staff. Attend capacity pressure bed meetings. Agree contingency actions aimed at reducing escalation level. Complete any actions from the Capacity Pressures Meeting. Communicate with external agencies for support as agreed with the Chair of the Capacity Pressure meeting. Participate and provide data for any Cluster Capacity Pressure Conference Call/Meeting. Ensure compliance with mandatory procedures on declaration of Black Status. Date: 29 th October 2014 Page 34 of 88

ACTION CARD: SENIOR NURSE ON CALL GREEN Take handover from previous On-Call Senior Nurse. Ensure you are aware of escalation status following distribution of the bed forecast. Attend 12:00 and 16:00 Bed Meeting to ascertain the overall Trust situation and plan. Receive handover from all Divisions at 16:00 bed meeting. Attend handover with Site Team at 20:00. Keep On-Call Manager updated of any potential problems. Where staffing issues pose any risk to patient safety/quality escalate to Deputy Director of Nursing. AMBER After 16:00 and at weekends Senior Nurse to identify any key actions to support discharge/patient flow. Support the Site Team with any escalation to nursing teams. Ensure that plans from the 16:00 and weekend Bed Meetings are being enacted in a timely way, follow up any outstanding actions. At the weekend, attend Bed Meeting with the Site Management Team and Senior Manager On-Call at 12:00. Remain on-site weekday evenings and weekend day shifts until handover to the night site practitioner or until the hospital is safe with a plan for how to cover predicted admissions and staffing issues. Where staffing issues pose any risk to patient safety/quality escalate to the Deputy Chief Nurse if unable to resolve. Out-of-hours assist in the review of all patients identifying possible patients for discharge or moving to a non-base area. This should be done in conjunction with ward teams to ensure safe moves are being planned and facilitated. Should the senior on call team need to plan to open extra beds review Trust wide staffing to plan to cover this extra capacity through the next 24-48 hours until Divisional teams can take this over. If staffing insufficient follow normal protocols for arranging extra staff. Notify the appropriate support services of any pharmacy or diagnostics issues resulting in delaying the discharge of patients. RED Senior Nurse On-Call to liaise with Senior Manager On-Call to identify any key actions to support discharge/patient flow. Senior Nurse On-Call during out of hours working to ensure visits to all clinical areas. Identify any staffing issues for the next 24-hour period and facilitate actions to rectify. Senior Nurse to escalate any clinical/staffing issues that pose a risk to patient safety to Deputy Chief Nurse. PRE-BLACK / BLACK All Local Green-Amber-Red escalation actions are in place. Senior Nurse On-Call remains on site until situation is de-escalated. If the situation occurs out of hours, be prepared to attend site to support patient safety/capacity. Work closely to support the Operations Director and On-Call Senior Manager. Support the Significant Incident as part of the Incident Control Team. Support the Site Management Team and Divisions to open up additional beds across the Trust. Risk assesses patient moves with medical and nursing staff and On Call Manager. Attend Capacity Pressure Bed Meetings. Agree contingency actions aimed at reducing escalation level. Complete any actions from the Capacity Pressure Meeting. Ensure compliance with mandatory procedures on declaration of Black Status Date: 29 th October 2014 Page 35 of 88

ACTION CARD: OPERATIONS DIRECTOR / DEPUTY / ON CALL DIRECTOR GREEN Obtain status from Patient Flow Manager/Bed Forecast. Ensure you are aware of escalation status following distribution of the Winter Pressures Dashboard. Ensure you are aware of escalation status following distribution of the bed forecast. Follow the escalation communication flow chart in Appendix 4 AMBER Keep updated from the Patient Flow Manager/Bed Forecast. Discuss with the General Manager, Operations any external escalation required. Gain understanding of the contingency action plan and ensure that it is robust. Give approval to open extra beds with extra staff if appropriate. Ensure Divisional Directors are completing Divisional plans. Consider plans where possible to increase in-patient capacity. Inform Chief Nurse/Executive Director of Service Delivery of alert status. Inform Clinical Commissioning Group Director or deputy of alert status. Ensure capacity pressures meeting have been convened and Chaired by either the Operations Director or Deputy RED Attend.12:00 and 16:00 Bed Meeting. Keep the Chief Nurse/Chief Operating Officer informed of alert status and actions being undertaken to reduce alert status. Ensure full impact assessment has been completed by divisions on issues causing the capacity i.e. high number of non-elective admissions. Review all possible capacity that could be used for in-patients and the impact on other activity i.e. day cases. Escalate status to the CCG, NDDH Community Services, DDOC & SWAST. Lead RD&E on conference call with the wider healthcare community. Chair Capacity Pressure Bed Meetings. With Divisions consider the impact of cancelling non urgent elective patients. PRE-BLACK / BLACK All Local Green-Amber-Red escalation actions are in place. Contact to be maintained by the Exec Director on call and the Clinical Commissioning Group Director. Support or lead the Significant Incident as part of the Incident Control Team. May need to call in additional flow team support. Work with the Medical and Associate Medical Directors to assess medical staff capacity. Discuss and consider cancellation of elective activity in order to create bed capacity to accommodate urgent care admissions. Ensure DD s attend Escalated Bed Meetings. Discuss and consider cancellation of elective activity in order to create bed capacity to accommodate non-elective admissions. Ensure compliance with mandatory procedures on declaration of Black Status. Any request to divert patients to another ED 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. Date: 29 th October 2014 Page 36 of 88

ACTION CARD: CHIEF OPERATING OFFICER GREEN Ensure you are aware of escalation status following distribution of the Winter Pressures Dashboard. AMBER Operations Director will keep you informed of escalation levels and actions to reduce level. RED Operations Director will keep you informed of escalation levels and actions to reduce level. Support any actions requiring liaison with the CCG and the LHE Authorise SITREP reports that contain adverse reporting. Inform Chief Executive of escalation status, external communications in progress and actions being taken to reduce escalation level. With the Medical Director, ensure that clinical risk across the Trust is kept to a minimum. PRE-BLACK / BLACK Ensure all Local Green-Amber-Red escalation actions are in place. Chair the Capacity Pressures Meeting at 12:30. Inform Chief Executive of black status. Declare and lead Significant Incident Inform Clinical Commissioning Group Director of black status. Lead RD&E on conference call with the wider healthcare community. Review all possible capacity that could be used for in-patients and the impact on other activity i.e. day cases. Discuss and consider cancellation of elective activity in order to create bed capacity to accommodate urgent care admissions. Request urgent conference call with the CCG and the LHE to agree capacity plans to meet demand. Prepare communication to the media as required. Ensure compliance with mandatory procedures on declaration of Black Status. Any request to divert patients to another ED 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. Date: 29 th October 2014 Page 37 of 88

ACTION CARD: MEDICAL DIRECTOR GREEN Ensure you are aware of Trust Status. AMBER All actions as per Green. Be aware of medical staffing issues within the Divisions. RED All actions as per Green and Amber. Medical Director (or nominated Associate Medical Director) to consider cancellation of leave in liaison with Associate Medical Directors to enable clinical care to be delivered. Liaise with ED Consultant and Consultant Physicians to consider staffing requirements and re-deployment of available general medical staff to the assessment and treatment of acutely ill patients and the discharge of medically fit patients. Ensure daily senior ward rounds are carried out and contact Associate Medical Directors for assurance that patients are being reviewed appropriately. With the Chief Nurse/Chief Operating Officer, ensure that clinical risk across the Trust is kept to a minimum. Report to the Level 1 On-Call any delays in the systems which are hampering ability to undertake assessments for admissions/discharges. Put plans in place to ensure that all ward patients are senior reviewed on a daily basis with a view to expediting discharge. In liaison with Associate Medical Directors and the Medical Director ascertain the requirement for additional medical staff to assist with the admission and discharge process. PRE-BLACK / BLACK All Local Green-Amber-Red escalation actions are in place. Ensure Medical Consultant present on wards or in ED 24/7. Work with the Operations Director to access medical capacity and planning. Support the Significant Incident as part of the Incident Control Team. Attend capacity pressure bed meetings. Discuss and consider cancellation of elective activity in order to create bed capacity to accommodate urgent care admissions. Contact Associate Medical Directors for assurance that patients are being reviewed appropriately. In conjunction with the Chief Nurse/Chief Operating Officer, ensure that clinical risk across the Trust is kept to a minimum. In liaison with Associate Medical Directors ascertain the requirement for additional medical staff to assist with the admission and discharge process. Report to the Operations Director any delays in the system which is hampering ability to undertake assessments for admissions/discharges. Ensure compliance with mandatory procedures on declaration of Black Status. Date: 29 th October 2014 Page 38 of 88

CAPACITY ESCALATION ACTIONS: INPATIENT AREAS AMBER All Ensure Board rounds take place each day and planned date of discharge updated Ensure transport options are explored early in the day i.e. by 10.30 Ensure discharge summaries are typed by mid-day Review all long-stay patients for alternative options for discharge Review patients listed for diagnostics consider home and back Ensure all patients have a senior review to expedite discharges Identify and escalate if additional support required from Pharmacy, Diagnostics or Therapies for the discharge of patients Review medical, nursing and A&C staffing for next 24-72 hours and escalate staffing issues Consider re-deployment of available staff to the assessment and treatment of acutely ill patients and the discharge of medically fit patients Identify the requirement for additional staff to assist with discharges Identify patients that could be outlied to non-base wards Ensure all outliers have been identified, reviewed and medical cover is in place Escalate any delays in the system which is hampering ability to undertake assessments for discharges RED Carry out Amber actions plus: Ensure that all patients are senior reviewed on a daily basis with a view to expediting discharge Senior Nurses to review all patients for discharge / process issues. Review to be documented. Any identified blockages to be escalated for potential resolution. Consider extending arrangements for daily review to include twice daily board rounds/additional ward rounds Senior nurses to attend board rounds Identify and escalate any medical, nursing and A&C staffing issues for the next 48 hour period Consultant/Registrar to be made aware of increasing bed pressures to facilitate discharge / identify those suitable for transfer PRE-BLACK / BLACK Carry out Amber and Red actions plus: Ascertain the requirement for additional staff to assist with the admission and discharge process across out of hours periods (7/7 working). Consider Consultant cover to be on-site 24/7 Support any action required from declaration of a Significant Incident Risk assesses patient moves with medical and nursing staff Date: 29 th October 2014 Page 39 of 88

7. ACTION CARDS FOR DIVISIONAL ROLES ACTION CARD: DIVISIONAL DIRECTOR / DIVISIONAL BUSINESS MANAGER MEDICAL SERVICES DIVISION GREEN Ensure you are aware of escalation status following distribution of the bed forecast. Ensure awareness of any capacity issues in the last 24 hours or anticipated. AMBER Ensure board rounds are occurring as planned. Liaise with the Associate Medical Director /Lead Clinician regarding any gaps in medical cover. Receive updates from Cluster Managers and Assistant Director of Nursing on flow issues within the Division. Review pressure on non-elective services. Ensure all outliers have been identified and medical cover is in place. RED Continue to undertake action in Amber Alert. Review elective admission profiles. Ensure a full impact assessment has been completed for your Division on capacity issues. Gain assurance regarding discharges and any blocks to patient flow. Attend Capacity Pressure Meetings to assist in Trust wide capacity planning. Gain a comprehensive understanding of medical staffing issues in relation to high numbers of patients. Participate in the decision on escalation process/plan to increase capacity throughout the Trust. Discuss and consider the impact of the cancelling some non-urgent elective patients, although the final decision should be made in conjunction with the Operations Director. PRE-BLACK / BLACK All Local Green-Amber-Red escalation actions are in place. Attend Capacity Pressure Meetings to assist in Trust wide capacity planning ensuring you have up to date information regarding your Division. Support the Significant Incident as part of the Incident Control Team. With the Associate Medical Director and Assistant Director of Nursing lead capacity planning within the Division. Attend all escalation community wide conference calls as requested by the Operations Director. Provide up to date capacity plans for your Division to the Operations Director. Agree and implement contingency actions aimed at reducing escalation level. Date: 29 th October 2014 Page 40 of 88

ACTION CARD: ASSISTANT DIRECTOR OF NURSING / DEPUTY MEDICAL SERVICES DIVISION GREEN Ensure you are aware of escalation status following distribution of the bed forecast. Ensure adequate staffing levels for activity. AMBER Attend 12:00 and 16:00 Bed Meeting to ascertain the overall Trust situation and plan. Where staffing issues pose any risk to patient safety/quality escalate to Deputy Chief Nurse. From the matrons identify any key actions to support discharge/patient flow. Support the Site Team with any escalation to nursing teams. Ensure that plans from the bed meetings are being enacted in a timely way, follow up any outstanding actions. Keep in regular contact with the Site Practitioner during the whole shift (day or night). Re review all patients identifying possible patients for discharge. This should be done in conjunction with ward teams. Open extra beds as notified by the Site Team arrange for the provision of extra staff if necessary. Notify the appropriate support services of any pharmacy or diagnostics issues resulting in delaying the discharge of patients. RED Continue to undertake action in Amber Alert. Assistant Director of Nursing to liaise with Cluster Managers to identify any key actions to support discharge/patient flow. Keep the Divisional Director informed of any capacity issues. Request Matrons to visits all clinical areas to identify any staffing issues for the next 24 hour period and facilitate actions to rectify. Escalate any clinical/staffing issues that pose a risk to patient safety to Deputy Chief Nurse/ and Divisional Director. PRE-BLACK / BLACK All Local Green- Amber -Red escalation actions are in place. Work closely to support the Operations Director or On-Call Level 1 and Senior Manager. Support the Significant Incident as part of the Incident Control Team. Support the Site team and Divisions to open up additional beds across the Trust. Risks assess patient moves with medical and nursing staff. Attend capacity pressure bed meetings. Agree contingency actions aimed at reducing escalation level. Complete any actions from the capacity pressure meeting. Ensure compliance with mandatory procedures on declaration of Black Status. Date: 29 th October 2014 Page 41 of 88

ACTION CARD: ASSOCIATE MEDICAL DIRECTOR MEDICAL SERVICES GREEN Ensure you are aware of escalation status following distribution of the bed forecast. Ensure awareness of any capacity issues in the last 24 hours or anticipated. Ensure board rounds are occurring as planned. AMBER All actions as per Green. Be aware of medical staffing issues within the Divisions. If extra capacity areas planned / opened plan and review consultant cover. Liaise with junior staffing leads and request re-deployment / extra junior cover as needed to support larger volumes of patients in non-base ward areas. Escalate the situation to Lead Clinicians / consultants of the week via email to their secretaries for immediate escalation. Review provision of board rounds for all inpatient areas and facilitate extra support to ensure this is effective and timely in all areas. Review the need for extra support in any single area that is experiencing or predicted to experience extreme pressure. Liaise with ED Consultant and Consultant Physicians to consider staffing requirements and re-deployment of available general medical staff to the assessment and treatment of acutely ill patients and the discharge of medically fit patients. If required attend capacity pressure meeting. RED All actions as per Green and Amber. On advice from Medical Director to consider cancellation of leave in liaison with Lead Clinicians to enable clinical care to be delivered. Liaise with ED Consultant and Consultant Physicians to consider staffing requirements and re-deployment of available general medical staff to the assessment and treatment of acutely ill patients and the discharge of medically fit patients. Ensure daily senior ward rounds are carried out and provide assurance that patients are being reviewed appropriately. Consider the benefit of cancelling routine outpatient activity to redeploy senior medical staff. With the Assistant Director of Nursing, ensure that clinical risk across the Division is kept to a minimum. Reports to the Level 1 On-call any delays in the systems which are hampering ability to undertake assessments for admissions/discharges. Put plans in place to ensure that all ward patients have a senior review on a daily basis with a view to expediting discharge. Ascertain the requirement for additional medical staff to assist with the admission and discharge process over the extended 24 hour period. PRE-BLACK / BLACK All actions as per Green, Amber and Red. Work with the Medical Director and on call / capacity team to access medical capacity and planning. Attend capacity pressure bed meetings. Discuss and consider cancellation of elective activity in order to create bed capacity to accommodate urgent care admissions. Support the Significant Incident as part of the Incident Control Team. Ensure information available to provide assurance that patients are being reviewed appropriately. In liaison with Lead Clinicians / consultant of the week ascertain the requirement for additional medical staff to assist with the admission and discharge process across out of hours periods (7/7 working). Report to the capacity / on call team any delays in the system which is hampering ability to undertake assessments for admissions/discharges. Ensure compliance with mandatory procedures on declaration of Black Status. Date: 29 th October 2014 Page 42 of 88

ACTION CARD: CLUSTER MANAGERS MEDICAL SERVICES DIVISION GREEN Ensure you are aware of escalation status following distribution of the bed forecast. Ensure awareness of any capacity issues in the last 24 hours or anticipated. Ensure ward rounds are occurring as planned. Liaise with Medical Staffing regarding any gaps in medical cover. Ensure all outliers have been identified and reviewed. AMBER Actions at Green. Ensure Lead Clinician of the week and all teams are aware of capacity issues across the Trust. Actively assist in expediting any complex discharges escalated by the wards. If any internal capacity pressure in own service escalate to On-Call team with plan for resolution. Assist with any other actions requested post bed meetings and ensure Divisional Director and the Divisional Business Manager are briefed on the situation and any outstanding issues. Designated Cluster Manager to attend extra capacity meeting if required RED Continue to undertake action in Green and Amber Alert. Request that all consultant teams re-assess their specialty for further potential discharges or outliers. Consider implementing deployment of additional staff identified to open any additional bed spaces which can be converted for appropriate patient use e.g. Day-case unit, Discharge Lounge etc. Ensure lead clinicians in Medicine, Management Team, ED, MTU/AMU and Wards are all aware of escalation level within Medicine/Trust. Review all actions are being taken to provide extra service to return all areas of speciality to normal level of service, if any blocks are identified escalate these to Divisional Director. Attend Capacity pressure meeting if requested to do so by your Divisional Director. PRE-BLACK / BLACK All Local Green- Amber -Red escalation actions are in place. Cancel all non-urgent management activity and routine meetings and redeploy management team to support wards and in discharging, outlying and transferring patients. Undertake any actions required from the declaration of a Significant Incident. Agree and implement contingency actions aimed at reducing escalation level. Ensure compliance with mandatory procedures on declaration of Black Status Date: 29 th October 2014 Page 43 of 88

ACTION CARD: SENIOR NURSE/ CNA BLEEP 202 MEDICAL SERVICES DIVISION GREEN All Senior Nursing staff to ensure they are aware of escalation status following distribution of the bed forecast. All Senior Nurses to visit clinical areas to review next 48 hours staffing, any clinical concerns and that plans are in place for board rounds to happen and planned date of discharge to be updated after this. Collate Divisional staffing and ensure all areas have adequate staffing levels for activity. Attend 12:00 and 16:00 bed meeting. Escalate any unresolved issues to specialist areas for resolution and to brief Assistant Director of Nursing / Divisional Director if any concerns arisen. AMBER As per Green and: Where staffing issues pose any risk to patient safety/quality escalate to Lead Nurse who will review and if necessary escalate to Deputy Chief Nurse for Trust wide action. All senior matrons to work with Ward Matrons to identify any key actions to support discharge/patient flow any blockages to be escalated to central team. Support the Site Team with any escalation to nursing teams. Ensure that plans from the bed meetings are being enacted in a timely way, follow up any outstanding actions. Keep in regular contact with the Site Practitioner during the whole shift (day time via holder on CCU overnight). Matrons to re-review all patients identifying possible patients for discharge or moving to non-base ward to facilitate safe transfers. Matrons to escalate any blockages to Senior Nurses and CM s. Review to be documented on Medicine Escalation form (to be attached as appendix) and reviewed by Senior Matron and relevant issues escalated to site practitioners. Senior Nurses (where possible) to attend board rounds. If decision made by On-Call team to open extra capacity C.N.A to review staffing over the next 24 hours and arrange for the provision of extra staff if necessary. Extra areas opening to be escalated to Lead Nurse to risk assess planned area and staffing model. C.N.A. or Senior Nurse to assist in setting capacity areas up to receive patients. Notify the appropriate support services of any pharmacy or diagnostics issues resulting in delaying the discharge of patients. RED Continue to undertake action in Green and Amber Alert. Assistant Director of Nursing to liaise with Senior Matrons and Cluster Manager to identify any key actions to support discharge/patient flow. Keep the Divisional Director informed of any capacity issues. Assistant Director of Nursing to attend 12:00, 16:00 and any extra capacity meetings. Senior Nurses to cancel all non-essential work to return to clinical areas. Senior nurses to attend board rounds. Senior Nurses to review all patients for discharge / process issues. Review to be documented on Medicine Escalation form (to be attached as appendix) and returned to lead site practitioner for central review of any identified blockages and to plan for potential resolution. Senior Matrons to ensure visits to all clinical areas to identify any extra staffing issues for the next 48 hour period and facilitate actions to rectify. Assistant Director of Nursing to escalate any clinical/staffing issues that pose a risk to patient safety to Deputy Chief Nurse / and Divisional Director. Date: 29 th October 2014 Page 44 of 88

PRE-BLACK / BLACK All Local Green- Amber -Red escalation actions are in place. Continue to undertake action in Green Amber and Red Alert. Assistant Director of Nursing/Senior Nurses to work closely to support the Operations Director or On-call Level 1 and Senior Manager. Undertake any actions from declaration of a Significant Incident Support the Site team and Divisions to open up additional beds across the Trust. Risk assesses patient moves with medical and nursing staff. Attend capacity pressure bed meetings. Agree contingency actions aimed at reducing escalation level. Complete any actions from the capacity pressure meeting. Ensure compliance with mandatory procedures on declaration of Black Status. Date: 29 th October 2014 Page 45 of 88

ACTION CARD: WARD CONSULTANT MEDICAL SERVICES DIVISION GREEN Attend 08:30 AMU Morning Report and review patients on AMU as necessary. Undertake ward board round (5/7) with a focus on discharge planning and identifying discharges. Other ward duties, including patient review, as required. Review outlier patients as required. AMBER All actions as per Green. Take particular steps to ensure that outliers have been reviewed in a timely way. Escalate concerns about delayed discharges or blockages in the system to the Senior Matron. Expedite discharges Consider whether additional support is necessary (e.g. medical, therapy staff). If required attend capacity pressure meeting. RED All actions as per Green and Amber Consider extending arrangements for daily review to include twice daily board rounds/additional ward rounds. PRE-BLACK / BLACK All actions as per Green, Amber and Red. Work with the Associate Medical Director and on call / capacity team to access medical capacity and planning. In liaison with Associate Medical Director ascertain the requirement for additional medical staff to assist with the admission and discharge process across out of hours periods (7/7 working). Report to the capacity / on call team any delays in the system which is hampering ability to undertake assessments for admissions/discharges. Ensure compliance with mandatory procedures on declaration of Black Status. Date: 29 th October 2014 Page 46 of 88

ACTION CARD: DIVISIONAL DIRECTOR / DIVISIONAL BUSINESS MANAGER SURGICAL SERVICES DIVISION GREEN Ensure you are aware of escalation status following distribution of the bed forecast. Ensure awareness of any capacity issues in the last 24 hours or anticipated. AMBER As Green and: Ensure Lead Clinician and all teams are aware of capacity issues across the Trust. If any internal capacity pressure in own service escalate to on call team with plan for resolution. Ensure board rounds are occurring as planned. Liaise with the Associate Medical Director /Lead Clinicians regarding any gaps in medical cover. Receive updates from the Cluster Managers and Assistant Director of Nursing on flow issues within the Division. Review pressure on non-elective services. Review impact on elective workload RED Continue to undertake action in Amber Alert. Review elective admission profiles. Ensure an impact assessment has been completed for your Division on capacity issues. Gain assurance regarding discharges and any blocks to patient flow. Attend Capacity Pressure Meetings to assist in Trustwide capacity planning. Gain a comprehensive understanding of medical staffing issues in relation to high numbers of patients. Participate in the decision on escalation process/plan to increase capacity throughout the Trust. Discuss and consider the impact of the cancelling some non-urgent elective patients, although the final decision should be made in conjunction with the Operations Director. PRE-BLACK / BLACK All Local Green- Amber -Red escalation actions are in place. Attend Capacity Pressure Meetings to assist in Trustwide capacity planning ensuring you have up to date information regarding your Division. Support the Significant Incident as part of the Incident Control Team. With the Associate Medical Director and the Assistant Director of Nursing lead capacity planning within the Division. Attend all escalation community wide conference calls as requested by the Operations Director. Provide up to date capacity plans for your Division to the Operations Director. Date: 29 th October 2014 Page 47 of 88

ACTION CARD: ASSISTANT DIRECTOR OF NURSING / DEPUTY SURGICAL SERVICES DIVISION GREEN Ensure you are aware of escalation status following distribution of the bed forecast. Ensure adequate staffing levels for activity. AMBER Attend 12:00 and 16:00 Bed Meeting to ascertain the overall Trust situation and plan. Where staffing issues pose any risk to patient safety/quality escalate to Deputy Chief Nurse. From the matrons identify any key actions to support discharge/patient flow. Support the Site Team with any escalation to nursing teams. Ensure that plans from the bed meetings are being enacted in a timely way, follow up any outstanding actions. Keep in regular contact with the Site Practitioner during the whole shift (day or night). Re review all patients identifying possible patients for discharge. This should be done in conjunction with ward teams. Open extra beds as notified by the Site Team arrange for the provision of extra staff if necessary. Notify the appropriate support services of any pharmacy or diagnostics issues resulting in delaying the discharge of patients. RED Continue to undertake action in Amber Alert. Assistant Director of Nursing to liaise with Cluster Managers to identify any key actions to support discharge/patient flow. Keep the Divisional Director informed of any capacity issues. Request Matrons to visits all clinical areas to identify any staffing issues for the next 24 hour period and facilitate actions to rectify. Escalate any clinical/staffing issues that pose a risk to patient safety to Deputy Chief Nurse/ and Divisional Director. PRE-BLACK / BLACK All Local Green- Amber -Red escalation actions are in place. Work closely to support the Operations Director or On-Call Level 1 and Senior Manager. Support the Significant Incident as part of the Incident Control Team. Support the Site team and Divisions to open up additional beds across the Trust. Risks assess patient moves with medical and nursing staff. Attend capacity pressure bed meetings. Agree contingency actions aimed at reducing escalation level. Complete any actions from the capacity pressure meeting. Ensure compliance with mandatory procedures on declaration of Black Status. Date: 29 th October 2014 Page 48 of 88

ACTION CARD: CLUSTER MANAGER SURGICAL SERVICES DIVISION GREEN To continue with normal day to day duties. Ensure awareness of the Trust escalation status and any impact on patient flow. Ensure theatres are running to maximum capacity to maintain CPOD and NCPOD lists. AMBER Assist the Assistant Director of Nursing/Senior Nurse in redeployment of staff to maximise effective working. Ensure board rounds are occurring as planned. Liaise with the Associate Medical Director /Lead Clinicians regarding any gaps in medical cover. Receive updates from other Cluster Managers and Assistant Director of Nursing on flow issues within the Division. Review pressure on non-elective services. Ensure all outliers have been identified and medical cover is in place. RED Continue to undertake action in Amber Alert. Inform Consultant/Registrar of increasing bed pressures to facilitate discharge / identify those suitable for transfer. Liaise with Site Management team to ensure they are aware of situation and gain support where able. Identify potential non-urgent electives for next day and take information to bed meeting. PRE-BLACK / BLACK All Local Green- Amber -Red escalation actions are in place. Undertake any actions required from declaration of a Significant Incident. If a decision is taken to cancel elective surgery to organise cancellation contacts to be made with patients, ensure that only appropriate patients are cancelled. Liaising with Consultants regarding any cancellations required. Ensure compliance with mandatory procedures on declaration of Black Status. Date: 29 th October 2014 Page 49 of 88

ACTION CARD: ASSOCIATE MEDICAL DIRECTOR SURGICAL SERVICES DIVISION GREEN Ensure you are aware of Trust Status. AMBER All actions as per Green. Be aware of medical staffing issues within the Division. RED All actions as per Green and Amber. Cluster Managers to liaise with Lead Clinicians with regard to prioritising possible elective cancellations although no cancellations due to bed capacity can be completed without the agreement of the Operations Director. Liaise with ED Consultant and Consultant Physicians to consider staffing requirements and re-deployment of available general medical staff to the assessment and treatment of acutely ill patients and the discharge of medically fit patients. Ensure daily senior ward rounds are carried out. If required attend capacity pressure meeting. Ensure adequate plans for medical care of escalation beds. PRE-BLACK / BLACK All local Green- Amber -Red escalation actions are in place. Support the Significant Incident as part of the Incident Control Team. Attend escalated bed meetings. Discuss and consider cancellation of elective activity in order to create bed capacity to accommodate urgent care admissions. In liaison with the Medical Director ascertain the requirement for additional medical staff to assist with the admission and discharge process. Ensure compliance with mandatory procedures on declaration of Black Status. Date: 29 th October 2014 Page 50 of 88

ACTION CARD: DIVISIONAL DIRECTOR / DIVISIONAL BUSINESS MANAGER SPECIALIST SERVICES DIVISION GREEN Ensure you are aware of escalation status following distribution of the bed forecast. Ensure awareness of any capacity issues in the last 24 hours or anticipated. AMBER As Green and: Ensure Lead Clinicians and all teams are aware of capacity issues across the Trust. If any internal capacity pressure in own service escalate to on call team with plan for resolution. Ensure board rounds are occurring as planned. Liaise with the Associate Medical Director/Lead Clinician regarding any gaps in medical cover. Receive updates from Cluster Managers and Deputy Chief Nurse/Head of Midwifery on flow issues within the Division. Review pressure on non-elective services. RED Continue to undertake action in Amber Alert. Review elective admission profiles. Ensure an impact assessment has been completed for your Division on capacity issues. Gain assurance regarding discharges and any blocks to patient flow. Attend Capacity Pressure Meetings to assist in Trust wide capacity planning. Gain a comprehensive understanding of medical staffing issues in relation to high numbers of patients. Participate in the decision on escalation process/plan to increase capacity throughout the Trust. Discuss and consider the impact of the cancelling some non-urgent elective patients, although the final decision should be made in conjunction with the Operations Director. PRE-BLACK / BLACK All Local Green- Amber -Red escalation actions are in place. Support the Significant Incident as part of the Incident Control Team. Attend Capacity Pressure Meetings to assist in Trust wide capacity planning ensuring you have up to date information regarding your Division. With the Associate Medical Director, Head of Midwifery and Assistant Director of Nursing lead capacity planning within the Division. Attend all escalation community wide conference calls as requested by the Operations Director. Provide up to date capacity plans for your Division to the Operations Director. Date: 29 th October 2014 Page 51 of 88

ACTION CARD: ASSISTANT DIRECTOR OF NURSING / DEPUTY SPECIALIST SERVICES DIVISION GREEN Ensure you are aware of escalation status following distribution of the bed forecast. Ensure adequate staffing levels for activity. AMBER Attend 12:00 and 16:00 Bed Meeting to ascertain the overall Trust situation and plan. Where staffing issues pose any risk to patient safety/quality escalate to Deputy Director of Nursing. From the matrons identify any key actions to support discharge/patient flow. Support the Site Team with any escalation to nursing teams. Ensure that plans from the bed meetings are being enacted in a timely way, follow up any outstanding actions. Keep in regular contact with the Site Practitioner during the whole shift (day or night). Re review all patients identifying possible patients for discharge. This should be done in conjunction with ward teams. Open extra beds as notified by the Site Team arrange for the provision of extra staff if necessary. Notify the appropriate support services of any pharmacy or diagnostics issues resulting in delaying the discharge of patients. RED Continue to undertake action in Amber Alert. Assistant Director of Nursing to liaise with Cluster Manager to identify any key actions to support patient flow. Keep the Divisional Director informed of any capacity issues. Request Matrons to visits all clinical areas to identify any staffing issues for the next 24 hour period and facilitate actions to rectify. Escalate any clinical/staffing issues that pose a risk to patient safety to Deputy Director of Nursing/ and Divisional Director. PRE-BLACK / BLACK All Local Green- Amber -Red escalation actions are in place. Work closely to support the Operations Director or On-Call Level 1 and Senior Manager. Support the Significant Incident as part of the Incident Control Team. Support the Site team and Divisions to open up additional beds across the Trust. Risk assessed patient moves with medical and nursing staff. Attend capacity pressure bed meetings. Agree contingency actions aimed at reducing escalation level. Complete any actions from the capacity pressure meeting. Ensure compliance with mandatory procedures on declaration of Black Status. Date: 29 th October 2014 Page 52 of 88

ACTION CARD: CLUSTER MANAGER SPECIALIST SERVICES DIVISION GREEN To continue with normal day to day duties. Ensure awareness of Trust escalation status AMBER As actions in Green. Liaison with Site Management team to ensure they are aware of the current bed pressures. Assist the Assistant Director of Nursing/Senior nurse in Redeployment of staff to maximise effective working. Ensure board rounds are occurring as planned. Liaise with the Associate Medical Director /Lead Clinician regarding any gaps in medical cover. Receive updates from Department Managers and the Assistant Director of Nursing on flow issues within the Division. Review pressure on non-elective services. Ensure all outliers have been identified and medical cover is in place. RED Continue to undertake action in Amber Alert. Inform Consultant/Registrar of increasing bed pressures to facilitate discharge / identify those suitable for transfer. Liaise with Site Management Team to ensure they are aware of situation and gain support where able. Identify potential non-urgent electives for next day and take information to bed meeting. Assist with identifying priorities for cancellation (non-urgent/urgent) elective patients as potential cancellation, patients can only be cancelled for capacity issues without the agreement of the Operations Director. Consider increasing staffing if problem on Friday or W/E in cooperation with Assistant Director of Nursing /Matron. Following authorisation to use bank/agency staff, book accordingly. PRE-BLACK / BLACK All Local Green- Amber -Red escalation actions are in place. If a decision is taken to cancel elective surgery to organise cancellation contacts to be made with patients, ensure that the appropriate patients are cancelled only. Undertake any actions required on declaration of a Significant Incident. Liaising with Consultants regarding any cancellations required. Ensure compliance with mandatory procedures on declaration of Black Status. Date: 29 th October 2014 Page 53 of 88

ACTION CARD: ASSOCIATE MEDICAL DIRECTOR SPECIALIST SERVICES DIVISION GREEN Ensure you are aware of Trust Status. AMBER All actions as per Green. Be aware of medical staffing issues within the Divisions. RED All actions as per Green and Amber. Cluster Managers to liaise with Lead Clinicians with regard to prioritising possible elective cancellations. Patients can only be cancelled for capacity issues with the agreement of the Operations Director. Liaise with ED Consultant and Consultant Physicians to consider staffing requirements and re-deployment of available medical staff to the assessment and treatment of acutely ill patients and the discharge of medically fit patients. Ensure daily senior ward rounds are carried out. If required attend capacity pressure meeting. Ensure adequate plans for medical care of escalation beds. PRE-BLACK / BLACK All Local Green- Amber -Red escalation actions are in place. Attend escalated bed meetings. Discuss and consider cancellation of elective activity in order to create bed capacity to accommodate urgent care admissions. Support the Significant Incident as part of the Incident Control Team. In liaison with your Associate Medical Director and the Medical Director ascertain the requirement for additional medical staff to assist with the admission and discharge process. Ensure compliance with mandatory procedures on declaration of Black Status. Date: 29 th October 2014 Page 54 of 88

ACTION CARD: LEAD NURSE PAEDIATRIC UNIT - SPECIALIST SERVICES DIVISION GREEN A representative of the Bramble nursing team will attend the daily bed meeting 12:00 Monday Friday. The Site Practitioner Team will phone Bramble twice a day during office hours, to check bed availability. AMBER If, at any point, the number of available beds are reduced to 6 or the number of cubicles to 2, the Bramble bleep holder should: Inform Site Practitioner Team on bleep 217. Inform Assistant Director of Nursing and/or Senior Nurses on bleep 586, (In hours only). Identify cause of pressure. e.g. increase in admissions. Unable to discharge patients. Staffing problems. In conjunction with medical staff review the issues to create capacity. RED If bed capacity has still not improved: Matron/ Assistant Director of Nursing to inform Site practitioner. Inform Divisional Director. Lead nurse/matron to liaise with On-Call Consultant Paediatrician to decide action plan. The Bramble bleep holder and the Paediatric SpR should review the current situation, considering moving adolescents to adult wards and inform ED. If the situation is unchanged then inform the Consultant Paediatrician who should contact on-call manager (bleep via the switchboard). Together an action plan should be agreed, which should include communication with other local Children Units. In addition, the On-Call Manager, in discussion with the On-Call Level 1, should develop an action plan, reference elective admissions to Bramble for the following day. They should then advise the nursing staff, who can inform the parents when they phone the ward at 07:00 to check bed availability. PRE-BLACK / BLACK Before a decision is agreed to divert children to other Trusts, the On-Call Manager should discuss the proposed plan with the On-Call Director. Ensure compliance with mandatory procedures on declaration of Black Status. Date: 29 th October 2014 Page 55 of 88

ACTION CARD: MATERNITY UNIT AND INTEGRATED SERVICES GREEN Service delivery as normal agreed staffing compliment for early, late and nights AMBER Labour ward or AN / PN ward Contact the hospital midwifery manager or the on call midwifery manager to assist with staffing coordination. If there appears to be an issue of Safety call the Supervisor of Midwives on call (via labour ward / switchboard). DAY Review AN / PN staffing consider numbers and complexity- reallocate midwives or support staff as able. Call in all integrated midwives. Divert possible work to FMAU. Any midwives on pay back day to be diverted to where required. Any non-essential community work to stop. Consider discharging women to birth centres. Follow homebirth / birth centre flow chart. NIGHT Call in fostered on call integrated midwives. Integration If problem covering home birth see - Homebirth / Birth Centre Flow Chart. Review AN / PN staffing consider numbers and complexity- reallocate midwives or support staff as able. Contact the integrated midwifery or community or the on call midwifery manager to assist with staffing co-ordination. DAY Any midwife on pay back to be diverted to where required. Consider cancelling any non-essential work e.g. postnatal visits. NIGHT Call in fostered on call integrated midwives. If problem covering home birth see - Homebirth / Birth. Review AN / PN staffing consider numbers and complexity- reallocate midwives or support staff as able. Community If no women labouring in birth units or home consider deploying all available staff as required to RD&E site. Ensure community midwife is allocated to low risk labouring women or to work on AN / PN area. Homebirths And Low Risk Birth Units All off duty is centralised on the labour ward to enable ease of cover. In the event of a problem contact the Community / Integrated Midwifery Manager or the on-call Midwifery Manager to co-ordinate cover. Review the overall number of women in the birth units and those in active birth Those in active labour will be prioritised. Maternity Support Workers Ensure MSW kept in Okehampton to coordinate phones. Divert all available staff as able / required. Discharge women if no MSW available in unit. If unable to cover births safely consider transfer in and use of the Exeter Low Risk Birth Unit or Call the ON-CALL Supervisor of Midwives and ask them to cover as the second on call Midwife, or release appropriate staff from RD&E. If a woman refuses to be transferred from home or birth centre discuss with the midwifery manager on-call. Midwives Review the overall on call provision. Date: 29 th October 2014 Page 56 of 88

Reallocate total midwifery resource considering the demand for women in active labour and logical geography for staff. Aim for equitable provision. If unable to cover births safely consider transfer in and use of the Exeter Low Risk Birth Unit or Call the ON CALL Supervisor of Midwives and ask them to cover as the second on call Midwife, or release appropriate staff from RD&E. If a woman refuses to be transferred from home or birth centre discuss with the midwifery manager on call. RED As Amber PRE-BLACK / BLACK Full closure Reopening Reverse the process contacting those above particularly the units that have assisted and ambulance control Date: 29 th October 2014 Page 57 of 88

ACTION CARD: SENIOR MANAGER NEONATAL INTENSIVE CARE - SPECIALIST SERVICES DIVISION GREEN Routine activity is carried out patients assessed and seen promptly. Neonatal unit have beds/spaces for admissions expected. Transitional Care Cots available. Discharges occur without delays. Adequate skilled staffing to care for all levels of babies. Capacity to move patients from delivery suite to neonatal unit. AMBER Delay in or lack of discharges and/or Unable to admit 2 new ITU babies. Limited resource of equipment to support potential neonatal admissions. Staffing skill mix inadequate to deal with patient numbers or dependencies. NNU co-ordinator to understand why patients are not getting discharged promptly and highlight issues causing delay to the appropriate people. Transfer appropriate babies to postnatal ward. Consider equipment available liaising with medical electronics department if necessary and NNU assistants to ensure equipment available is ready for use. NNU co-ordinator to liaise with consultant on call for NNU to review situation, formulate and agree a plan for potential admissions. NNU co-ordinator to consider staffing and activity for the next few shifts increasing numbers if possible. NNU co-ordinator to liaise with NNU or Bramble Ward Matrons who should look across child health for appropriate staff to help NNU. NNU co-ordinator to liaise with Labour suite co-ordinator who will consider use of midwifery staff on NNU to free up staff. NNU co-ordinator to inform Matron/ Senior Matron/ Assistant Director of Nursing of potential problems or Site Practitioner out of hours. NNU co-ordinator to communicate status to Neonatal Network and ascertain cot availability in Network. RED Only one space available to assess and admit patients in neonatal unit. Lack of available cots in neonatal unit for admissions expected. Lack of intensive care equipment available. Nursing/ medical staff insufficient in number or skill mix to safely care for further admissions. Unit closed due to infection as directed by Consultant Microbiologist. Ensure actions from previous status are exhausted complete a WAT. NNU consultant to liaise with Obstetrician on call to formulate and agree a plan for future potential admissions considering transfers in utero to other units. NNU co-ordinator and consultant to review all patients to consider potential of transfers to Bramble ward/ postnatal/ community maternity units. Inform On-Call Manager who will brief Executive Director On-Call. Document if unsafe conditions are experienced and complete incident report. PRE-BLACK / BLACK All actions as above Date: 29 th October 2014 Page 58 of 88

ACTION CARD: CHIEF PHARMACIST - SPECIALIST SERVICES DIVISION GREEN Expedite TTOs for patients being discharged AM ward round. Chief Pharmacist receives bed state updates and reviews status. Normal department activity continues AMBER All actions as per Green. Inform Discharge bleep holders (Pharmacist and Pharmacy Technician) of Amber status. Alert Clinical Pharmacists to Amber status. Clinical Pharmacists and Pharmacy Technicians will prioritise discharge work on the wards. RED All actions as per Green and Amber. Inform all Section Heads, Discharge Bleep Holders (Pharmacist and Pharmacy Technician) and Clinical Pharmacists of Red status. Clinical Pharmacists and Pharmacy Technicians will prioritise discharge work on the wards. Review training activity and cancel if required. Staff re-directed to essential duties in the department. Assess requirement for additional Pharmacist and Pharmacy Technician to cover Discharge Bleep Service. Outpatient capacity redirected to cover inpatient services. Review late night cover & advise team of Red status. PRE-BLACK / BLACK All Local Green Amber Red escalation actions are in place. All Section Heads informed of black status. Discharge Bleep Holders (Pharmacist and Pharmacy Technician) will be alerted to black status. Clinical Pharmacists will be alerted to black status. Clinical Pharmacists and Pharmacy Technicians will prioritise discharge work on the wards. All training activity cancelled and staff re-directed to essential duties in the department. Additional Pharmacist and Pharmacy Technician allocated to cover Discharge Bleep Service as required. Outpatient capacity redirected to cover inpatient services. Review late night cover and provide additional resource beyond 18:00 as required. Review of staffing required for EPS activity Redirect staff to other duties, if required, and where possible. Date: 29 th October 2014 Page 59 of 88

ACTION CARD: HEAD OF THERAPIES - SPECIALIST SERVICES DIVISION GREEN Head of OT & PT will review the daily bed status. PT & OT clinical leads will co-ordinate joint therapy teams as per normal structure. AMBER All actions as per Green. Head of OT & PT will review the daily bed status and highlight to Clinical Leads any areas of concern. Liaise with Patient Flow Manager of any area of concern. Staff will be reallocated if necessary decision by Head of OT & PT / Clinical leads. Problem of staff shortages within teams review all caseloads and prioritise across in-patient service (all Divisions). RED All actions as per Green and Amber. Head of OT & PT will review the daily bed status and attend 12:00 bed meeting. Teams to get handover / attend all board rounds redirect staff to cover as necessary. 09:00 meet with Clinical Leads to review all staffing levels. Cancel IST / other training / attendance at LDS courses etc. Agree early supported discharge to community to facilitate discharges. Review out-patient caseloads reallocate / cancel 50% patients. PRE-BLACK / BLACK All Local Green- Amber -Red escalation actions are in place. Teams to get handover / attend all board rounds redirect staff to cover as necessary. 09:00: meet with Clinical Leads to review all staffing levels. Cancel IST / other training / attendance at LDS courses etc. Re-prioritise patient caseloads. Cancel junior physiotherapist MSK out-patient lists, plastics and rheumatology to freeup OTs to focus on discharge. If continues with unacceptable low staffing for in-patient services consider: 1. Locum cover / bank staff. 2. Cancel all out-patient slots. Date: 29 th October 2014 Page 60 of 88

ACTION CARD: RADIOLOGY SERVICES MANAGER - SPECIALIST SERVICES DIVISION GREEN Radiology Services Manager will review the daily bed status. Modality superintendents will co-ordinate to ensure all in patients are examined as per normal. AMBER All actions as per Green. Radiology Services Manager will review the daily bed status and highlight to Modality Superintendents any areas of concern. Patient Flow Manager will inform the Divisional Office or Radiology Services Manager directly of any delays in imaging. Staff will be reallocated within department to support service, if necessary decision by Radiology Services Manager / Modality Superintendents. Problem of staff shortages within modalities review all workloads/ lists and prioritise in-patient examination. Review work hours. RED All actions as per Green and Amber. 09:00: meet with Modality Superintendents to review all staffing levels and patients waiting. Radiology Services Manager will review the daily bed status and be informed of any areas of concern following the regular bed meetings attended by Divisional Director or deputy especially the 12:00 noon Bed Meeting. All modality Superintendents to be aware of hospital status and patients needing to be imaged and discharged and arrange lists and staff accordingly. Cancel mandatory training and attendance at LDS courses etc. Review working hours and also look at modality booked lists prioritise in-patient examinations and patients waiting for discharge. PRE-BLACK / BLACK All local Green- Amber -Red escalation actions are in place. Review working hours and also look at modality booked lists, prioritise in-patient examination and patients waiting for discharge. If service continues with unacceptable low staffing consider: 1. Calling staff in, using bank staff. 2. Cancel all out-patient slots being mindful of urgent patients and rebook accordingly. Date: 29 th October 2014 Page 61 of 88

ACTION CARD: JOINT DIRECTOR OF INFECTION CONTROL - SPECIALIST SERVICES DIVISION GREEN Daily review of single room utilisation on admission wards and Torridge ward twice daily communication with site management team. Review of all single room occupancy in Medicine, Surgery and Orthopaedics on Friday to facilitate placement of potentially infectious patients over weekend. On call advice available outside normal working hours regarding patient placement and movement from an infection control perspective. AMBER All actions as per Green. As above unless infection control issues arise i.e. outbreaks. Planned work e.g. non-essential teaching, will be postponed/cancelled to enable more frequent ward and ED visits to both affected and unaffected areas to facilitate decision making and planning for reopening of wards, putting restrictions in place, planning terminal cleaning etc. Attend all bed capacity meetings. RED All actions as per Green and Amber. As above and establish outbreak control group to co-ordinate outbreak control measures as per Major Outbreak Plan. Weekend working is considered to supplement on call service. PRE-BLACK / BLACK All Local Green- Amber -Red escalation actions are in place. As above plus weekend working and complete halt to provision of non-clinical infection control services to enable total focus on outbreak management and other reactive clinical priorities. Date: 29 th October 2014 Page 62 of 88

ACTION CARD: HEAD OF FACILITIES MANAGEMENT - OPERATIONS SUPPORT UNIT This action card summarises actions that you are required to undertake according to the Trust Emergency Pressures Escalation Policy. It highlights actions to be undertaken in addition to normal duties for Housekeeping, Linen Services, Non-Patient Transport, Portering, HSDU, Security, Catering / Patient Meal Service, Waste Management Security, Post and Accommodation. All actions for any previous levels must be taken before moving onto next level. Escalation for additional activity. GREEN To continue with normal day to day duties AMBER Notification of escalation to General Manager. Service Manager for Facilities to attend 12:00 and 16:00 bed meetings and communicate escalation state to all Facilities Departments, obtain strep on service provision and confirm ready state for additional equipment and resource. Facilities Service Manager to prioritise liaison with Site Management Team throughout the escalation period one Service Manager to remain available at all times. Porter supervisor to prioritise patient movements at the direction of the Site Management Team. House Keeping supervisor to prioritise cleans to release additional beds at the direction of the Site Management Team. Porter supervisor to liaise with the Site Management team to ensure they are updated of the available unused bed/mattress numbers. Where required increase staffing numbers to maintain activities in the identified areas to maximise bed capacity and patient flow. RED Continue to undertake action in Amber Alert. Service Manager for facilities to Redeploy staff to facilitate bed movements. Accommodation to be made available for staff required to remain on site. PRE-BLACK / BLACK All Local Green- Amber -Red escalation actions are in place. Attend escalated bed meetings Support the Significant Incident as part of the Incident Control Team. In liaison with General Manager of any issues affecting facilities services Ensure compliance with mandatory procedures on declaration of Black Status. Date: 29 th October 2014 Page 63 of 88

8. MONITORING OF THE PLAN In order to ensure compliance with the plan, the following will be monitored: Action log which forms part of the Bed Forecast. Ensure all actions are completed. Performance data that is presented at the Daily Performance Meeting with Divisional Directors. The data will be assessed to ensure there are no delays in patient flow and capacity is being managed.. Any escalation is managed as described in the plan. Review monthly actions against the alert status. The General Manager, Operations has the responsibility to review compliance with the plan. Any barriers to implementation of plan will be risk assessed and added to the risk register if necessary. Any changes required to the plan will be highlighted to the Senior Management Group. If the plan requires a major change, this will be presented to the Trust Board for approval. Date: 29 th October 2014 Page 64 of 88

9. APPENDICES APPENDIX 1: SIGNIFICANT INCIDENT GUIDANCE Definition Times of severe pressure, such as winter periods, a sustained increase in demand for services such as surge or an infectious disease outbreak that would necessitate the declaration of a significant incident however not a major incident; Any occurrence where the NHS funded organisations are required to implement special arrangements to ensure the effectiveness of the organisations internal response. This is to ensure that incidents above routine work but not meeting the definition of a major incident are managed effectively. Actions Notify the Clinical Commissioning Group and NHS England Area Team that the RD&E has declared a Significant Incident and an initial situation report Convene an Incident Control Team Use MDT Room (E235) or other room if not available (e.g. E230): o Incident Director - Chief Nurse/Chief Operating Officer or Operations Director (or On-Call Director if out of hours) o On-Call Manager and On-Call Senior Nurse (if out of hours) o Medical Director or Associate Medical Director o Medical, Surgical, Specialist Services and Operations Support representatives (one Decision Maker per Division plus one admin support if available) o Site Management o Infection Control o Communications Manager o Loggist (for Incident Director) o Control Team Administrator (if available) o Others as required (e.g. Transformation and OD, Finance, Estates, H&S) Refer to Capacity Pressures Meeting Agenda in RD&E Capacity & Escalation Framework Review Action Cards in RD&E Capacity & Escalation Framework and confirm that all actions have been carried out for Amber and Red Escalation/Alert Levels o Consider referring to Action Cards in Emergency Preparedness Plan Complete actions in Pre/Black in Summary Escalation triggers in Section 5 and Consider the following actions: Action Consider cancelling urgent elective /cancer admissions Benefit of undertaking this action Increased capacity for nonelective admissions by reducing demand on beds/ admissions. Free up clinical staff to support inpatients Increase availability of clinical and non-clinical staff to support medicine Risk of this action Impact on RTT Impact on cancer targets Increase in complaints Re-booking may create capacity problems at a later stage Freeing up some specialties may have limited benefits so would need to be assessed against potential reduction Date: 29 th October 2014 Page 65 of 88

Action Consider cancelling outpatient clinics Prioritise tests for patients awaiting discharge. Compromise on infection control principles would be considered for any closed (infected) areas on the basis of relative risk. Benefit of undertaking this action Clinical staff to support inpatient activity Facilitate earlier discharge Risk of this action of demand on beds Potential risk of clinical incident and consequent patient harm Increase in complaints Impact on RTT Re-booking will create capacity problems at a later stage Potential risk of clinical incident and consequent patient harm Possible increase LOS for some patients Delay in diagnosis for many patients which could result in harm Impact on elective patients Delays due to volume of diagnostic tests and investigations. Options could include: Establish cohort ward(s) if sufficient numbers of patients affected Transfer patients from one closed ward to empty beds on other closed wards to allow cleaning and reopening of beds (in conjunction with relevant specialty consultants to ensure that transfers are safe and on-going management of transferred patients agreed with receiving ward/specialty) Compromise single sex principle for inpatient areas Cancelling elective work and outpatients would free up staff to support in-patient areas Short term improvement in flexibility and use of beds Short term improvement in flexibility and use of beds Flexible staffing availability to staff additional areas Likely to increase spread of infection, thereby increasing capacity issues, increasing LOS and potential patient harm Staff moving between closed and open wards (or use of clean/ dirty staff) makes patient review more difficult. Increase length of infection outbreak Contractual fines Reduced patient satisfaction. Increase in complaints Staff resilience unable to maintain high level of activity Staff fatigue with potential errors Increase in staff sickness Impact on normal business Impact on staff Date: 29 th October 2014 Page 66 of 88

Action Consider using day case areas for inpatients e.g. Endoscopy Theatres recovery Transfer of medically stable patients to other acute providers South West Ambulance Service Trust maybe requested to take patients on locality borders to other hospitals if their care is not compromised Full Divert Close to emergency and elective admissions Benefit of undertaking this action Additional capacity Additional capacity Additional capacity Some reduction in ambulance attendances and GP referrals. Reduction in admissions requiring in-patient care Improve safety for existing patients Risk of this action competencies affected if training not carried out Impact on mandatory training targets Impact on RTT Increase in complaints Re-booking may create capacity problems at a later stage May not have capacity to staff areas appropriately Potential risk of clinical incident and consequent patient harm Increased complaints Other Acute Trusts unable to take additional patients Increased LOS due to dispersal of patients Potential risk of clinical incident and consequent patient harm Increase ambulance handover delays resulting in SWAST unable to maintain target times for 999 calls Pressure put on neighbouring Trust Reputational harm Potential risk of clinical incident and consequent patient harm Other Acute Trusts may be unable to take additional patients Limited benefits as patients with immediate life threatening conditions will have to come to RD&E Delayed GP referrals likely to come in over following days Pressure put on neighbouring Trusts Reputational harm Potential risk of clinical incident and consequent patient harm Ensure the welfare of responding staff is considered including: o Regular breaks o Provision of refreshments o Shifts are staffed to avoid people working excessive hours Date: 29 th October 2014 Page 67 of 88

Actions on Stand Down Notify staff (e.g. use Pillar Alert) Notify external organisations Assess the impact the incident has had on departments. Put in place arrangements to: o Co-ordinate the planned resumption of services to normal levels of activity o Plan staffing needs for next 24/48 hours o Plan bed management arrangements for next 24/48 hours If Outpatient and Inpatient appointments cancelled: o IM&T to be requested to send out a list with names of patients that were booked into Outpatient Clinics. All patients that are recorded as DNA, Cancelled or Attendance status unknown will need to be telephoned and offered another appointment. Patients recorded as attended need to be checked to see if they did receive their appointment. o In the case of Non-Consultant OPD appointments where it is not possible to ascertain which Division is responsible for the patient all Divisions will need to check complete lists to ensure patients are rebooked. o IM&T to be requested to send to send out a TCI list of patients due to be admitted on the date(s) of the incident. The same exercise will need to be applied. In addition the 28 day rebooking rule will apply. o In addition IM&T will check on a daily basis that missed appointments/admissions have been rebooked over the next week and any patients not rebooked to be referred to Divisions. Put in place arrangements for Incident Logs and other records to be copied and originals sent to the Site Management Office Ensure staff receive recognition (e.g..rde email, RDE News, Team Meetings) and are appropriately remunerated if they have worked additional or excessive hours (e.g. TOIL, overtime) Put in place arrangements for a post-incident review meeting. September 2014 Date: 29 th October 2014 Page 68 of 88

APPENDIX 2: NHS SOUTH OF ENGLAND ESCALATION FRAMEWORK EXTRACT. Mandatory procedures on declaration of Black status At single organisational level 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. 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: 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. 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. Acute Trust Routine elective admissions have been cancelled. Urgent elective admissions have been reviewed and, where possible, rescheduled or cancelled. Community Care Providers All possible capacity has been freed and redeployed to ease systems pressures. Social Care Continue to expedite discharges, increase capacity and lower access thresholds to prevent admission where possible. Primary Care All possible actions are being taken on-going to alleviate system pressures. Mental Health Trust Continue to expedite discharges, increase capacity and lower access thresholds to prevent admission where possible. Ambulance Trust Review current GP Admissions with GPs to ensure safe standards of care to patients. Review on going 111 advice strategy. Date: 29 th October 2014 Page 69 of 88

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. If emergency response is severely compromised consider use of Major Incident procedures. Utilise actions from REAP plan to create capacity where possible. PTS Service Ensure all capacity is being utilised to alleviate system pressures. 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. The executive director on call for the CCG must then immediately inform the appropriate Area Team. Immediately following declaration of Black status the following actions are mandatory, alongside other locally defined actions: 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. 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. 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 onwards, 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. 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 Date: 29 th October 2014 Page 70 of 88

divert to neighbouring trusts whether these are in or out of region. Refer to divert flow chart. 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. The organisation which has declared Black status must report a SIRI on the STEIS system. Date: 29 th October 2014 Page 71 of 88

APPENDIX 3: NHS ENGLAND SOUTH SYSTEM ESCALATION TRIGGERS Acute Trust Ambulance Service Community Care Primary Care Social Services Other Action Green (Level 1) Capacity available to meet expected demand Good patient flow through A&E and other access points A&E 4 hour target consistently being met Offloading ambulance within 15 minutes. Ambulance call volumes within expected levels Resourcing Escalatory Action Plan (REAP) level 1 Community capacity available across system. Patterns of service and acceptable levels of capacity are for local determination Out of Hours (OOH) service demand within expected levels GP attendances within expected levels with appointment availability sufficient to meet demand Social services able to facilitate placements, care packages and discharges from acute care and other hospital and community based settings NHS Direct and / or 111 call volume within expected levels Monitor capacity across whole system and take routine action to manage demand and prevent escalation to Amber At least 5 of the following across the local Health system in more than one organisation Amber (Level 2) Beds available, but short of beds in 1 main area * Anticipated pressure on A&E 4 hour target Anticipated pressure in facilitating ambulance handover Discharges below expected norm Slow patient flow through A&E, 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 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 conditions) 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 conditions) 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) Patients in community and / or acute settings waiting for social services capacity Some unexpected reduced staffing numbers (due to e.g. sickness, weather conditions) 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 The system implements all necessary actions within organisations to increase capacity and improve flow Date: 29 th October 2014 Page 72 of 88

Acute Trust Ambulance Service Community Care Primary Care Social Services Other Action 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 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. 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 toconditions) in areas where this causes increased pressure on patient flow 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 issues resulting in significant pressure on services Take cross-system actions throughout the local health economy to increase capacity, improve flow and avoid admissions Date: 29 th October 2014 Page 73 of 88

Acute Trust Ambulance Service Community Care Primary Care Social Services Other Action 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 at Red 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 flow is at a level that compromises service provision / patient safety 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 Unexpected reduced staffing numbers (due to e.g. sickness, weather conditions) in areas where this increases pressure on patient flow that compromises service provision / patient safety 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 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 Take decisive actions throughout the system to alleviate pressure Date: 29 th October 2014 Page 74 of 88

APPENDIX 4: ESCALATION COMMUNICATIONS FLOW CHART (FROM NHS ENGLAND SOUTH ESCALATION FRAMEWORK 2013) Date: 29 th October 2014 Page 75 of 88