Page 1 of 6 AGENDA ITEM: 5(d) SCBU Escalation Policy & Procedure
Page 2 of 6 The Special Care Baby Unit at Colchester General Hospital admits over 500 babies each year and has a capacity of 18 cots within SCBU and two for babies who require transitional care on the postnatal wards. Historically the Unit is subject to variations in workload and demand. This policy seeks to identify the course of action to follow when demand exceeds capacity. The escalation policy will be operationalised when 18 cots within SCBU are occupied, or the number of babies requiring high dependency care exceeds the number of appropriately skilled staff to care for babies safely. 1.a) If the above events occur, Sister/Nurse in Charge of SCBU will discuss situation with Matron Children s Services (Bleep 953), or if unavailable, will contact 722 bleep holder who will: b) Notify the on-call Paediatric Consultant and agree that SCBU will close to further admissions. The on-call Paediatric Consultant will speak to Consultant Obstetrician on call. c) Notify Assistant Head of Midwifery / 722 bleep. d) Assistant Head of Midwifery will notify the Supervisor of Midwives. e) Matron, Children s Services (or bleep 953) will notify: Office hours Out of office hours Directorate Manager E-mail Directorate Manager Senior Midwife (bleep 722) Senior Midwife (bleep 722) Duty Matron for acute site (bleep 333) Duty Matron (bleep 333) Bed Manager (bleep 700) Bed Manager (bleep 700) f) The Consultant Obstetrician will notify his/her team. g) The Assistant Head of Midwifery (bleep 722 ) will assess the situation within Delivery Suite and Antenatal areas. In consultation with obstetric team, will make arrangements to transfer babies in utero who are likely to require SCBU support, out to other hospitals. h) Sister/Nurse in charge of SCBU will complete an incident form. i) While the escalation policy is in operation: The clinical situation will be re-assessed three times daily at shift changeover and also as necessary, initiated and documented by the Sister/Nurse in charge of SCBU. 2. When the Unit has vacant cot(s) and safe skill mix of staff, planned admissions will be accepted. Points 1. a-f will be followed and documented within the format on SCBU. NB: Closure of SCBU is to prevent planned and preventable admissions. Emergency admissions may still occur and babies may have to transfer to other units as a result.
Page 3 of 6 All admissions to unit during closed! Status must be identified by completion of incident form stating why baby required admission. Agreed by: Lead Paediatrician Dr Mukerji... Lead Obstetrician, Mr J Evans-Jones... Directorate Manager, Mrs A Ferris... Matron, Children s Services, Ms K Johnson... Date: June 2004
Page 1 of 6 INSTIGATION Communication Channels for Instigation of the Escalation Policy for SCBU SCBU.complete Incident Form and Need to close to reassess at each shift change planned admissions MATRON, CHILDREN S SERVICES DIRECTORATE MANAGER (or bleep 953 out of hours) (email out of hours) PAEDIATRIC CONSULTANT BED MANAGER (on call) (bleep 700) SENIOR MIDWIFE (bleep 722) DUTY MATRON (bleep 333) PAEDIATRIC MEDICAL TEAM OBSTETRIC CONSULTANT (on call) DUTY MANAGER (via switchboard) OBSTETRIC MEDICAL TEAM ASSESS DELIVERY SUITE NOTIFY SUPERVISOR OF MIDWIVES AND ARRANGE PLANNED TRANSFERS OUT
Page 2 of 6 REVERSAL Communication Channels for Reversal of the Escalation Policy for SCBU SCBU Appropriate cots and skill mix available MATRON, CHILDREN S SERVICES DIRECTORATE MANAGER (or bleep 953 out of hours) (e-mail out of hours) TO INFORM CASCADE, SCBU OPEN PAEDIATRIC CONSULTANT BED MANAGER (on call) (bleep 700) ASSISTANT HEAD OF MIDWIFERY ( bleep 722 ) DUTY MATRON (bleep 333) PAEDIATRIC MEDICAL TEAM OBSTETRIC CONSULTANT (on call) DUTY MANAGER (via switchboard) OBSTETRIC MEDICAL TEAM NOTIFY DELIVERY SUITE NOTIFY SCBU OPEN SUPERVISOR OF MIDWIVES
Page 3 of 6 SCBU Documentation of Implementation of Escalation Policy DATE: /TIME: INITIATED BY: Person Notified in 1.a) SCBU Review 3 x daily at shift changeover only when escalation policy activated DATE 07.00hrs NAME STATUS and REASON 13.00hrs NAME STATUS and REASON 21.00hrs NAME STATUS and REASON When SCBU is safe to open. Follow point 2. DATE: TIME: INITIATED BY: Person notified in 1.a) PLEASE COMPLETE NEW FORM FOR EACH CLOSURE (send to Matron, Children s Services)