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Policy No: OP33 Version: 4.0 Name of Policy: Bed Management and Escalation Policy Effective From: 28/09/2015 Date Ratified 17/07/2015 Ratified PQRS Committee Review Date 01/07/2017 Sponsor Director of Nursing, Midwifery and Quality Expiry Date 16/07/2018 Withdrawn Date Unless this copy has been taken directly from the Trust intranet site (Pandora) there is no assurance that this is the most up to date version This policy supersedes all previous issues Bed Management and Escalation Policy v4

Version Control Version Release Author/Reviewer Ratified by/authorised by Date 1.0 Jan 2006 TFP Jan 2006 Changes (Please identify page no.) 2.0 Sept 2008 Divisional Managers 3.0 August Divisional 2010 Managers 4.0 08/10/2010 CC Divisional Manager SafeCare Council SafeCare Council SafeCare Council Sept 2008 11/10/2009 11/10/2009 5.0 28/09/2015 Pam Naylor PQRS Committee 17/07/2015 Bed Management and Escalation Policy v4 2

CONTENTS Page 1 Introduction... 5 2 Policy scope... 5 3 Aim of policy... 5 4 Duties (Roles and responsibilities)... 5 4.1 Board of Directors... 5 4.2 Chief Executive... 6 4.3 Director on Call... 6 4.4 Associate Directors... 6 4.5 Service Line Managers... 6 4.6 Medical Staff... 6 4.7 Bed Managers... 6 4.8 Matrons... 7 4.9 Night Site Manager... 7 4.10 Ward Sister/Charge Nurse... 7 4.11 Accident and Emergency Sister/Charge Nurse and Clinical Lead... 7 4.12 Members of Staff... 7 5 Definitions... 7 6 Main Body of the policy... 8 6.1 Normal Working... 8 6.2 Bed management process... 9 6.2.1 Bed Meetings... 9 6.2.2 Bed State... 9 6.2.3 Patient s Awaiting Admission... 9 6.2.4 The Flight Desk... 9 6.3 Early Supported Discharge and Alternatives to Admission... 9 6.4 Boarding of Patients... 10 6.5 Trigger levels and escalation... 11 6.5.1 Alert Levels (NEEP)... 11 6.5.2 Triggers for Escalation... 11 6.5.3 Action Cards... 11 6.6 Requesting and receiving Patients Divert from other Trusts... 12 6.6.1 Requesting a Divert... 12 6.6.2 Receiving a Divert... 12 6.6.3 Durham... 12 6.7 Ambulance Handover Delays... 12 6.8 Winter Resilience Plan... 12 7 Training... 12 8 Equality and diversity... 13 9 Monitoring compliance with the policy... 13 10 Consultation and review... 13 11 Implementation of policy (including raising awareness)... 13 12 Associated Policies... 13 13 Appendices... 13 Bed Management and Escalation Policy v4 3

APPENDICES Appendix 1: QE Quick Triggers for Alert Levels... 14 Appendix 2: North East Escalation Plan (NEEP)... 15 Appendix 3: ED Specific Triggers and Actions... 32 Appendix 4: ECCA Escalation Triggers and Actions... 33 Appendix 5: Action Cards... 36 - Actions for the Bed Managers... 36 - Actions for Duty Matron (Cover 7.30am 5pm)... 38 - Actions for the Duty Matron (Cover 5-8.30pm)... 41 - Actions for the Service Line Manager and Senior Manager on Call... 42 - Actions for the Senior Manager on Call from 5pm and Weekends... 44 - Actions for the Senior Manager on Call from 5pm... 45 - Actions for the Acute Response Team Band 7 Role (Cover 20:00pm 08:00am) 46 - Actions for the Director on Call... 48 - Action for the Medical Teams, Consultants and Clinical Leads... 50 Appendix 6: Standard Operating Procedures... 52 - Monitoring A&E Ambulance Handover Breaches - Escalating A&E Ambulance Handover Breaches Appendix 7: Winter Resilience Plan... 53 Bed Management and Escalation Policy v4 4

Bed Management and Escalation Policy 1. Introduction This policy aims to provide clear operational guidance for bed management and escalation and incorporates the escalation status, bed capacity and emergency trigger points and associated action s required in response to operational pressures. This will provide a safe operating framework for staff and reduce the levels of risk for patients. Maintaining flow of patients through the Trust is key to maximising bed availability in order to effectively manage fluctuations in workload. As a key principle Gateshead Health NHS Foundation Trust will not close to emergency admissions. When hospital resources are stretched e.g. shortage of beds, exceptionally high attendances in the Accident and Emergency Department hospital remains the safest place for seriously ill people. Closure of the hospital will only be on the instruction of the Director on Call and will result in the declaration of a Major Incident. 2. Policy Scope This policy applies to all members of staff of Gateshead Health NHS Foundation Trust. The policy recognises that not all staff groups in all disciplines will have direct involvement in bed management and escalation, however all members of staff have a responsibility to support this policy. 3. Aim of the Policy This policy aims to provide clear guidance to those directly involved in bed management and escalation; the establishment of an effective policy and framework which will contribute to the following: Early identification of capacity problems Proactive rather than reactive response Concise and clear actions Defined responsibilities This policy will enable the Trust to deal effectively with fluctuations in demand and capacity so that it can manage associated risk within acceptable limits. The policy is designed to mitigate the risk of further escalation and ensures an appropriate response from key staff members to contribute to a reduction in escalation status. The policy aims to ensure that every emergency admission is allocated a bed within four hours and no elective admission is cancelled because of lack of bed availability. Effective communication and teamwork is crucial to the implementation of this policy requiring regular dialogue with nursing staff, medical staff and managers. The policy aims to maintain high standards of patient safety, patient experience and performance against key waiting time and quality standards of care. 4. Duties (Roles and Responsibilities) 4.1 Board of Directors The Trust Board is responsible for ensuring that there is a robust system of Corporate Governance within the organisation. This includes having a systematic process for the development, authorisation and management of policies. Bed Management and Escalation Policy v4 5

4.2 The Chief Executive The Chief Executive is ultimately responsible for ensuring effective Corporate Governance within the organisation and therefore supports the Trust wide implementation of this policy. 4.3 Director on call The Director on Call is responsible for setting up Gold Command at NEEP 5, to support with diverts where required and to facilitate discussions with regards to Ambulance queuing in exceptional circumstances. 4.4 Associate Directors Associate Directors are responsible for ensuring that the systems and processes are in place so that this Policy is implemented effectively within the individual Business Units. They are responsible for developing the annual corporate winter plan. 4.5 Service Line Managers Service line Managers are responsible for ensuring that systems are in place so the Bed Management and Escalation Policy is implemented effectively within individual service lines: Ensuring systems are in place to manage patient access effectively To ensure day-to-day capacity is available for the individual specialty To ensure a forward thinking and planning approach for the provision of patient care services. Making the decision to open extra beds or a ward if the trigger level of bed availability within the Trust is not achieved. Participate in Senior Manager on call rota escalating issues to the Director on Call as required. When Senior Manager on Call work with the Bed Manager / Night Site Manager and Duty Matron to ensure effective use of beds is maintained and that patients are not kept in Accident and Emergency for any longer than necessary. 4.6 Medical Staff Medical staff are responsible for ensuring that the elements of the SAFER bundle are implemented. This includes ensuring that discharge planning arrangements are robust and in line with the Trust Discharge Policy (OP13) including setting a discharge date for all patients. In addition, collaborating with the ward nursing team to identify patients who are appropriate to be boarded to other specialties if required; organising additional ward rounds during periods of Escalation at NEEP 4; fast tracking assessments in Accident and Emergency as appropriate and explore alternatives to admission (e.g. rapid access to the next available clinic). 4.7 Bed Managers Bed Managers are responsible for: Operational responsibility for the daily management of beds Ensuring that an up to date bed state and record of patients waiting for admission is maintained Co-ordination of information for presentation at bed meetings Escalation of any potential problems to the Duty Matron Completion and delivery of Flight Deck information to NEAS. Bed Management and Escalation Policy v4 6

4.8 Matrons The Matron s role is to proactively action issues identified within their area of responsibility. They are available to provide support and advice to the ward team and to support the team in the management of effective discharge. They will provide support and advice to ward staff when they experience difficulty in identifying patients suitable for boarding. The Duty Matron will facilitate and coordinate bed meetings and actively manage within this policy escalating to the Service Line Managers, Associate Directors as set out in appendix 5. 4.9 Night Site Manager The Night Site Manager is responsible for the overnight site management of the hospital and delivery of services and ensuring any issues are escalated to the Service Line Manager on call. 4.10 Ward Sister/Charge Nurse (delegated to Nurse in Charge) The Ward Sister/Charge Nurse is responsible for ensuring staff understand the Bed Management and Escalation Policy and the Discharge Policy. They will work proactively with the medical staff to ensure the elements of the SAFER bundle are implemented to identify patients who are ready for discharge, appropriate for boarding and ensuring staff understand that at times wards will be expected to: Take boarders place boarders in an appropriate part of their ward following an infection control risk assessment Move staff to another area to support the delivery of clinical care The ultimate responsibility for providing accurate bed state updates rests with the Ward Sister/Charge Nurse (or nominated deputy). This is best facilitated by keeping Medway as up to date as possible with changes in patient movement and all wards should be working to achieve this on a 24 hour basis. They must keep the appropriate Matron aware of any concerns about staffing and/or the implementation of this policy. 4.11 A&E Co-ordinator and Clinical Lead The A&E Co-ordinator and Clinical Lead are responsible for ensuring that the person in charge is identified on each shift to provide regular updates on current occupancy, and expected admissions and discharges over the next 2 to 4 hours. The A&E co-ordinator in charge of each shift is responsible for reporting to the Duty Matron any patient who has been in the department for 2.5 hours, for whom there is no imminent plan and who looks like they will be in the department over 4 hours unnecessarily, and efforts made to ensure a safe and effective plan is put in place. 4.12 All members of staff are required to support this Policy whether or not they are directly affected by bed management and escalation. 5. Definitions Escalation Escalation, for the purpose of this Policy identifies when there are increasing levels of demand in the Emergency Department/Emergency Assessment Unit and/or lack of bed capacity and specific responses are required. Boarder This term may be used when a patient is residing on a ward outside their admitting specialty. Bed Management and Escalation Policy v4 7

Action cards Key staff members have action cards (within this policy) which provide them with actions that they should undertake at a particular escalation status level. North East Escalation Plan (NEEP) NEEP is a common language used by all hospital and community organisations in the North East to identify the levels of activity pressure and escalation across the area. In producing this document the Trust has aligned this Policy to the North East Surge and Escalation Framework (Appendix 2). SAFER Bundle The SAFER bundle is a set of recommended good practice actions to be taken on a daily basis to support good patient flow. S Senior review of all patients before mid-day A All patients to have an expected date of discharge F Flow of patients, wards to pull patients from assessment units to wards before 10am E Early discharge, 33% of patients from base wards to be in discharge lounge with to take out (TTO s) medications and letter before mid-day R Review of all patients with extended length of stay (10-14 days) to have a management plan Gold Command Gold Command is introduced at NEEP Level 5, or at NEEP 4 to prevent NEEP 5 status being reached. This involves a decision being made by the Director on Call in liaison with the Senior Manager on Call. Identified staff will be required to report to a designated area to oversee all actions in respect of escalation. This is part of our major incident plan. HALO The Hospital Ambulance Liaison Officer (HALO) is a member of staff from the North East Ambulance Service who works very closely with the A&E Co-ordinator to support the levelling of activity across the local area. The Flight Deck Is a series of metrics submitted by Trusts from across the Region to the North East Ambulance Service (NEAS). The metrics include: NEEP status Empty bed numbers including critical care, surgery, medicine and maternity Are there any diverts in place Are there any bed closures Length of waits to be seen in A&E The information collected is then shared across the Region. The NEAS use this information to facilitate decisions on diverts and deflections. 6. Main Body of the policy 6.1 Normal Working Normal working is how the Trust operates on a day to day basis to ensure NEEP level 1 (see appendix 1). All Trust employees are required to actively contribute to the timely and safe care of patients and implementation of the SAFER bundle. Bed Management and Escalation Policy v4 8

6.2 Bed management process Every morning there is a report and bed state email handover from the Night Site Manager to key personnel and a verbal handover to the Duty Matron and Bed manager. 6.2.1 Bed meetings Bed meetings are held at 9am, 1pm and 4.30 pm with Business unit staff. Frequency of meetings may change when the Trust is on NEEP 3 & 4 at the discretion of the Duty Matron. 6.2.2 The Bed State Throughout the day the bed state will be updated using the bed monitoring proforma. This will include: Number of empty beds by ward, specialty, male/female and side wards. Number of patients expected to be discharged that day. Number of patients boarded out or awaiting transfer to other hospital sites. Number of beds occupied by patients awaiting arrangements for discharge and the reasons for these delays. Number of patients waiting for isolation facilities. Potential patients who will be ready to come out of Critical Care the next day. Number of electives due to come in the next day. Numbers of in-patients admitted following an agreed Durham divert. It is the responsibility of ward staff to provide accurate and timely information. 6.2.3 Patients Awaiting Admission The Bed Manager will be informed of patient admissions and demand for beds by the Nurse Co-ordinator in A&E, waiting list managers, member of staff taking GP referral calls and Matrons. All patients arriving by ambulance will arrive at the ambulance entrance and will be streamed (initial assessment and directed to appropriate care setting) by the A&E co-ordinator. GP referrals will be streamed direct to EAU unless there is no capacity (in which case they will be streamed to appropriate pathway in EAU), unless they require immediate resuscitation, or can be appropriately managed in Majors. 6.2.4 The Flight Deck Information to be submitted three times a day at 11am, 4pm and 8pm by the Bed Manager. 6.3 Early Supported Discharge and Alternatives to Admission Several services have been developed to provide an alternative to hospital admission and support early discharge: All specialist nurses work to provide early supported discharges and prevent unnecessary admissions where appropriate. CROP team can facilitate a discharge and provide interim support whilst awaiting more formal care packages to start. Rapid Response Domiciliary Care Team Gateshead Immediate Care Team Bed Management and Escalation Policy v4 9

A site wide Multi-Disciplinary meeting takes place every day at 12.30pm to identify patients who are awaiting discharge and to ensure all actions are in place to help people to be discharged from hospital. 6.4 Boarding of Patients When bed pressures continue is may be necessary to board patients to another ward. In the context of this policy, a boarder is defined as a patient residing on a ward outside their admitting specialty. The boarding of patients should be avoided as far as possible. However, there are times when such activity becomes a necessary part of managing emergency admissions and maintaining a supply of appropriate beds. The decision to board patients will be co-ordinated by the Duty Matron. While there are no protected beds within the hospital all beds that are planned for elective admissions later that day or the following day should be last in line to board to. The clinical teams on the base wards remain responsible for identifying patients that are suitable to be moved elsewhere. It is acknowledged that, at times, there will be no patients that are deemed suitable. Under these circumstances the clinical teams will be expected to make decisions based on their professional judgement, to identify patients to move. In the event of patients being boarded the Named Nurse or nurse in charge will explain this to the patients and relatives, if possible, in a manner appropriate to the patient s individual needs accessing the support of the interpretation services or support worker if required. If the relatives are not present it is the responsibility of the Named Nurse or nurse in charge to notify the next of kin / person to notify of the patient s transfer and ensure that this is documented. The Bed Manager will liaise with the Matron from the Division to which patients are boarded at the regular bed meetings. The Bed Manager should inform the appropriate wards of the arrangements to transfer or board a patient. As stated above Ward Staff on the transferring ward will remain responsible for providing necessary clinical detail to facilitate arrangements. When it is necessary to board from one specialty to another it is best practice to allocate a single bay to accommodate the patients from the boarding specialty whenever possible. Advice must be sought from the Infection Prevention and Control Team for any patient/s with a known or suspected infection. The boarding of patients should take place between the hours of 09:00 and 22:00 each day wherever possible. Only in exceptional circumstances will the moving of patients occur outside these hours or during protected mealtimes. No patient should, during their stay, be boarded out more than once. This does not include any subsequent transfer to the care of another Consultant or Specialty, for a clinical need, or repatriation to original base ward in exceptional circumstances. The dignity and quality of care given to the patient will be maintained throughout the transfer or boarding process (OP29). Staff must use their professional judgment when attempting to move patients who would be clearly distressed by the move e.g. patients with learning difficulties or there is knowledge that the family have raised strong concerns. When patients are boarded out from the specialty, which would normally receive the admission, it becomes the responsibility of the receiving ward and patient s consultant team to ensure they receive the same standard of care. Junior medical teams on receiving Bed Management and Escalation Policy v4 10

wards are expected to support the care of patients who have been moved from their base ward. If needed, advice can be sought from the specialty Matron. Circumstances such as skill mix, infection status on the receiving ward should be taken into consideration. The numbers of patients boarded into different specialties will be reported on a daily basis through the SITREP report in line with DH guidance. When transferring (either within Gateshead Health NHS Foundation Trust or to another hospital / organisation) boarding or receiving a patient all nursing documentation must be updated. It is the responsibility of the Named Nurse to make an assessment of the patient s needs to determine if an escort is required to accompany / stay with the patient when they are being transferred to another ward, department or site within Gateshead Health NHS Foundation Trust in line with the Internal Transfer/Escort Policy (OP84) 6.4 Trigger levels and Escalation 6.5.1 Alert Levels (NEEP) The following alert levels will be used to help communicate the escalation status and guide people to the correct actions. This is based on a number scale that reflects the level of risk to patient safety and the extent to which patient experience may be compromised (as outlined below). 1 2 3 4 5 6 Low Risk Low Risk Moderate Risk High Risk Critical Service Failure To 6.5.2 Triggers for escalation Appendix 1 Trigger/alert levels are identified in (quick reference guide). Appendix 2 outlines the Trust NEEP levels and escalation framework agreed by Trust Board in line with North East Surge and Escalation Framework Appendix 3 local triggers for Accident & Emergency Appendix 4 local triggers Emergency Assessment Unit Please refer to guidance, when appropriate, for actions specific to other departments Maternity, Critical Care Escalation Plans. 6.5.3 Action cards The Action cards highlight actions to be taken by key individuals in the event of increasing pressure and when triggers are causing any concern. Bed Management and Escalation Policy v4 11

Following the identification in a rise in the Escalation/NEEP Alert levels within the NEEP escalation framework and local triggers for Accident & Emergency (Appendix 3) and Emergency Assessment Unit (Appendix 4), actions identified in the suite of Action Cards (set out in appendix 5) will be followed by all key personnel. 6.6 Requesting and Receiving Diverts from other Trusts 6.6.1 Requesting a Divert When the Trust is at NEEP 4 the Trust may need to request a divert to another hospital. The requirement to consider this should be escalated by the Duty Matron or Service Line Manager to Associate Director during office hours or Senior Manager on Call to Director on Call out of hours. The regional divert policy should be consulted in relation to this. 6.6.2 Receiving a Divert Any request to receive a divert should be made to a Service Line Manager in Medicine (in hours) or Senior Manager on Call out of hours. Discussion should then take place with the on site team which may include Bed Manager, Duty Matron, SLM, Consultant in charge of A&E, A&E nurse co-ordinator before making a decision to accept patients. It is advised a fixed number of patients to accept should be agreed with a built in review rather than a time period. Close monitoring is required to assess the impact on our internal patient flow. Refer to North East Divert Policy (NEAS- May 2015) Escalate or further discuss with Associate Director (in hours) or Director on Call (out of hours). 6.6.3 Durham We currently have an agreement with Durham CCG with regards to diverts refer to NDCCG Local Divert Policy (June 2015). This will be a NEAS direct contact to the Service Line Manager in medicine (in hours) or Senior Manager on Call (out of hours). Discussion with Associate Director (in hours) or Director on Call (out of hours) can take place if required. When making decisions to request or accept a divert the Flight Deck information may be of some help. Patient level details are required for Durham diverted patients in order to ensure they are correctly logged on Medway. 6.7 Ambulance Handover Delays Queuing of ambulances at A&E should be avoided whenever possible and proactive management is required to ensure kept to a minimum. Appendix 6 outlines key actions to be taken and how ambulance handover delays should be monitored. 6.8 Winter Resilience Plan Every year additional measures are put in place for the winter months. Appendix 7 outlines the current Winter Resilience Plan. 7. Training Training with regards to this policy will take place at Site Training days, at Matron and Ward Manager days, the Service Line Manager forum and the Central Management team time out. Bed Management and Escalation Policy v4 12

8. Equality and diversity The Trust is committed to ensuring that, as far as is reasonably practicable, the way we provide services to the public and the way we treat our staff reflects their individual needs and does not discriminate against individuals or groups on any grounds. This policy has been appropriately assessed. 9. Monitoring Effectiveness of this Policy To ensure the effectiveness of this policy the following indicators will be monitored: Number of 4 hour A&E waits Number of 12 hour A and E breaches Number of black (over 1 hour) Ambulance handover delays. Number of Ambulance handover delays above 30 minutes Number of diverts to other hospitals requested Number of cancelled operations as a result of bed pressures 10 Consultation and review A Kaizen event was held with a number of stakeholders including Medical Staff, in order to engage a broad spectrum of staff in the development of this policy. This was followed up with a series of discussions to finalise actions. The implementation and effectiveness of the policy will be reviewed through Performance Board Reports and annually at the Annual Winter Review event. 11 Implementation of policy (including raising awareness) The policy will be implemented immediately and awareness will be raised at Matron /Ward Manager Away Days, SLM forum, CMT time out, and Consultants meetings. 12. Associated Policies This policy must be read in conjunction with the following Gateshead Health NHS Foundation Trust Policies: Privacy and Dignity: Infection Prevention and Control Policies (IC1 26) Safeguarding Patients Privacy & Dignity (OP29) Patients Access Policy (OP12) Discharge Policy (OP13) Resuscitation Policy (RM27a and RM27b) Records Management Policy (OP10) Critical Care Escalation Policy Maternity and Special Care Baby Unit Escalation Policy 13 Appendices Bed Management and Escalation Policy v4 13

QE TRIGGERS FOR ALERT LEVELS (Quick Reference Guide) Appendix 1 Level A&E (see Appendix 3) EAU (see Appendix 4) Back of House 1 Business as Usual Business as Usual Business as Usual 2 3 4 5 1 patient spending more than 4 hours in the ED (avoidable) 1 resus space and 1 majors space Time from DTA to admission 1-2 hours 1-2 ambulance handovers > 15 minutes Multiple patients spending more than 4 hours in the ED (avoidable) 0 resus spaces and 0 majors spaces Time from DTA to admission 2-4 hours 4-8 patients stacking in the ED awaiting admission 2 ambulance handovers > 15 minutes Multiple patients spending significantly longer than 4 hours in the ED No capacity to receive patients Time from DTA to admission >4 hours >8 patients stacking in the ED awaiting admission Ambulances queuing to handover Pts on trolley >8hrs 0 cubicle availability 0-1hrs Pts on trolley >12hrs 0 cubicle availability between 1-4hrs Pts on trolley >24hrs 0 cubicle availability >4hrs Pts on trolley >36hrs 0 cubicle availability >8hrs Beds not available to receive non elective patients (ie less than one male and one female bed available for each non elective receiving areas) Insufficient capacity identified in bed meeting for TCIs either medicine or surgery Between 1 5 outliers in other specialties No critical care bed immediately available Ward staffing below agreed levels by 1 3 nursing staff across the site and is judged to present a low risk to patient safety Insufficient capacity to accommodate non clinically urgent TCIs in either medicine or surgery 5 14 outliers No critical care bed available and no plan in place for one to become available in the next four hours Ward staffing is below agreed levels by 4 6 nursing staff across site and is judged to present a moderate risk to patient safety Insufficient capacity to accommodate TCIs in either medicine or surgery who are clinically urgent >15 outliers in other specialties Ward staffing is below agreed levels by 7+ nursing staff across site No critical care bed available, no place in place for one to become available in the next four hours and no scope for escalation of critical care capacity Negative bed state in either medicine or surgery with escalation areas open & continued A&E/EAU triggers Ward staffing is below agreed levels by 7+ nursing staff across the site and is judged to present a high risk to patient safety 6 Bed Management and Escalation Policy v4 14

Surge and Escalation Framework for : GATESHEAD HEALTH NHS FOUNDATION TRUST Appendix 2 Version number: 3.0 Date created: July 2015 Author: Pam Naylor Glossary of Terms/Abbreviations: NEEP North East Escalation Plan NEAS: North East Ambulance Service NECS: North East Commissioning Service DEP Department Escalation Plan REAP: Regional Escalation Action Plan DM: Duty Matron NECS: Clinical Commissioning Group AD: Associate Director ED: Emergency Department OOH: Out of Hours DOC: Director on Call CD: Clinical Director SMOC: Senior Manager on Call ART: Acute Response Team Trigger Level Action Communication Command and control Impact Implications? What needs to have happened (actual), or be about to happen (prospective trigger)? Are these internal organisational triggers, or external ones i.e. across the NECS? NHS North East Escalation Plan (NEEP) level Description of what is happening in the organisation or service at this level What will be done to mitigate the raised level of pressure as a result of moving to this level? Who by? When? Where? What will be communicated intra and/ or inter organisationally? Who by? When? What command and control arrangements will be in place? Who has the authority and responsibility to trigger? When and where will it be triggered? Are these different in hours and out of hours? Expected impact of these actions Any implications of these actions on other organisations *ED consultant when present in the ED. ED middle grade at other times. 15

Surge and Escalation Framework for : Gateshead Health NHS Foundation Trust Version number: 3.0 Date created: July 2015 Author: Pam Naylor Glossary of Terms/Abbreviations: NEEP North East Escalation Plan NEAS: North East Ambulance Service NECS: North East Commissioning Service ED: Emergency Department DEP Department Escalation Plan REAP: Regional Escalation Action Plan CD: Clinical Director DM: Duty Matron NECS: Clinical Commissioning Group AD: Associate Director ART: Acute Response Team SMOC: Senior Manager on Call OOH: Out of Hours DOC: Director on Call Trigger Level Action Communication Command and control Impact Implications? What needs to have happened (actual), or be about to happen (prospective trigger)? Are these internal organisational triggers, or external ones i.e. across the NECS? The Trust is operating at normal service 16 beds funded for winter contingency are available at NEEP level 1 Influencing factors (changes to the following): Premises Workforce IT Resources, assets, utilities and supplies Surge in demand Queuing ambulance NHS North East Escalation Plan (NEEP) level Description of what is happening in the organisation or service at this level NEEP 1 Normal(white) NOTE PROVISIONAL DATA- STILL MODELLING G& Acute Baseline: Total beds available - 603 Of which is core bed stock 442 ( in Winter) Acute - 442 Maternity 16 Paediatrics - 8 Of which are What will be done to mitigate the raised level of pressure as a result of moving to this level? Who by? When? Where? The organisations plans are in place for winter, escalation and surge. Daily operational meeting with clinical team within surgical business unit to assess elective for the day and capacity for emergency admissions. The Patient Flow Coordinator, DM and ARTOOH must monitor and report any surges in activity and report to DM s and SLM s if their Directorate is under pressure prior to or at the daily patient flow meetings. Patient flow meetings to be attended by the on call manager and What will be communicated intra and/ or inter organisationally? Who by? When? A copy of the organisation winter plan communicated to NECS. Trust winter plan and escalation plan available on intranet site. Participate in the daily situation reporting (11am) during the winter monitoring months published on the winter planning and surge management website. Participate in daily teleconferencing during the winter reporting period chaired by North of 16 What command and control arrangements will be in place? Who has the authority and responsibility to trigger? When and where will it be triggered? Are these different in hours and out of hours? Operational Patient Flow meetings x 3 daily - See bed meeting standard operating procedure. The patient flow co-ordinator with the Duty M has overall responsibility for managing the surge and capacity within the organisation Overnight this responsibility lies with ARTOOH and Senior Manager on Call Communication with AD/DOC as required. Expected impact of these actions Any implications of these actions on other organisations May be able to offer mutual aid to other organisations.

escalation beds - Critical care capacity - 12 Level 1 - Level 2-6 Level 3-6 High dependency unit 6 (Level 2) Average daily A&E attendances Monday - 332 Tuesday - 298 Wednesday - 280 Thursday - 281 Friday - 271 Saturday - 310 Sunday - 325 Ambulatory care capacity 10 patients Average daily Acute admissions Monday - 83 Tuesday - 79 alert any issues to the Director on Call via the telephone or E mail. Bed Predictions to be used at Bed Meetings.. Action planning must follow the patient flow meetings and an action plan developed for evening/overnight. The Ward Manager/ senior nurse is responsible for 24/7 staffing cover for their area concerns must be raised through the Matron and the SLM if necessary. Late staffing issues to be highlighted at Patient Flow Meetings and resolution facilitated by Duty Clinical Matron. Patients identified for discharge to be taken to the discharge lounge as early as possible in the day even if the relatives are attending to take home. Test escalation areas are fit for purpose i.e. alarms and equipment are in good working order ED Co-ordinator to front all majors/resus triage. Board rounds on all wards. SAFER bundle principles in place S Senior review of all England Commissioning Support Unit on behalf of the CCG. Flight deck information complete at 11am, 4.30pm and 8pm. Any escalation of NEEP levels to be communicated to the on call NECS Manager via the teleconference or directly. The organisations internal infrastructure Director/Senior Manager on Call system in place. Patient Flow Team presence on site 8am 8pm 7 days a week. Duty Matron on site 8am-8pm 7 days a week SMOC Daily analysis of ED 4 hour breaches with issues communicated to relevant specialties, Daily Discharge facilitation meetings. The organisations internal on call 17

Wednesday - 74 Thursday - 74 Friday - 78 Saturday - 62 Sunday - 60 Average daily discharges required (Acute) Monday - 80 Tuesday - 88 Wednesday - 83 Thursday - 78 Friday - 90 Saturday - 52 Sunday - 40 Average length of stay Elective (minus Daycase) 3.5 Non-Elective 5.0 patients before mid-day A All patients to have an expected day of discharge F Flow of patients, wards to pull patients from assessment unit to wards before 10am E Early discharge 33% of patients from base wards to be in discharge lounge until TTO s and letter before mid-day R Review all patients until extended length of stay (10-14 days) to have a management plan. infrastructure is in place Weekly operational delivery group meetings Regular winter / surge planning meetings During NEEP level 1, the organisation will be providing a full elective 18

programme: Average daily electives required Monday - 111 Tuesday - 127 Wednesday - 123 Thursday - 126 Friday - 112 Saturday - 25 Sunday - 7 Consideration to be given to the following Triggers to activate NEEP level 2 Three or more of the following indicators are hit. ALL ACTIONS AT NEEP 1 IN PLACE Command and control - communications All communication within NEEP 1 will have been activated All command and control actions in NEEP 1 will have been activated. INDICATORS A&E 1 patient spending more than 4 hours in the ED (avoidable) 1 resus space and 1 majors space Time from DTA to admission 1-2 hours 1-2 ambulance handovers > 15 minutes NEEP 2 Concern (green) At the teleconferences NEAS/OOH via NECS to be informed of growing pressures within the Acute Trust Duty Matron to request additional matron, SLM support and support services representation at bed meetings. Team briefed of capacity issues all matrons/senior nurses to attend their respective areas to assess and to actively create capacity; Inform Communications Impact on May not be able to offer mutual aid. May not be able to attend external meetings May impact on NEAS Risks to KPI s 19

EAU Pts on trolley >8hrs 0 cubicle availability 0-1hrs Back of House Beds not available to receive non elective patients (ie less than one male and one female bed available for each non elective receiving areas) Insufficient capacity identified in bed meeting for TCIs either medicine or surgery Between 1 5 outliers in other specialties No critical care bed immediately available Ward staffing below agreed levels by 1 3 nursing staff across the site and is judged to present a low risk to patient safety No critical care beds available at present and no movement identified in the next few hours. Team of Escalation and ask for appropriate screen saver launch. Critical Care network to be informed if no beds and none imminent. Ambulance queuing/ demand on A&E department ED Co-ordinator or ED Senior Dr fronting triage Senior decision makers to front all services (minors and majors category) e.g. Consultant in Ambulatory care Ensure ED is adequately staffed with a transfer nurse and porters. Mobilisation of additional resources to assist with transfer of patients. Duty matron to liaise with A&E co-ordinator and consultant to activate A&E escalation plan. Early comms out to clinical teams re pressure being experienced.. Enhanced liaison with co-ordinator on A&E & EAU. Communication to NECS & other organisations on teleconference call.. Flight deck information complete at 11am, 4.30pm and 8pm. Matron/SLM other commitments May impact on staff being able to attend meetings. Bed availability Identify patients to be moved to different speciality wards. Discuss with Bed Manager opening and staffing additional escalation beds Test escalation areas are fit for purpose i.e. alarms 20

and equipment are in good working order Request additional consultant led patient reviews on all wards to identify patients suitable for discharge. Patients identified for discharge to be taken to the discharge lounge as soon as possible even if the relatives are attending to take home. Delays with discharge letter and pharmacy to be identified and to be given priority following discussion with medical teams to be coordinated by Ward Teams / Duty Matron. Community on call manager to liaise with Trust on call manager to ensure appropriate discharge and continuing to support patients within their own home to avoid unnecessary admissions. Elective teams to risk assess the continuity of the elective activity. Matron / SLM for elective care, Women s and Children s services and perioperative service manager to liaise with booking team to review lists of TCIs for the following day. Consideration of elective work in relation to back up for Critical Care Command and control will be as at NEEP 1. Consider SLM/SMOC presence at patient flow meetings if potential to escalate to NEEP 3. 21

Identify 2 potential boarders on each ward by 1pm Patient Flow meeting. Workforce At the discretion of Duty Matron the following to be in attendance at Patient Flow Meetings or contact made with: Clinical Support Services Domestic Monitoring IPC Nursing Team Discharge Nurses Ensure Staff Breaks are coordinated to allow sufficient flexible rest periods. Consideration to be given to the following Triggers to activate NEEP level 3 Three or more of the following indicators are hit. TRIGGERS A&E Multiple patients spending more than 4 hours in the ED (avoidable) 0 resus spaces and 0 NEEP 3 Pressure (amber) Expectation that all actions from NEEP 2 have been considered and implemented. All available capacity opened and patients boarded Command and control - communications At teleconference and through the SITREP report escalation of NEEP level to the NECS manager/ CCG on-call manager out of hours Inform Communications All communication within NEEP 1 and 2 will have been activated. All command and control actions in NEEP 1 and 2 will have been activated. Impact on Matron/SLM/ AD other commitments Impact on study leave attendance Impact on meeting attendance Risks to: Elective activity KPI s Normal service delivery May impact on: NEAS Ability to repatriate from other hospitals Will have great difficulty in offering mutual aid 22

EAU majors spaces Time from DTA to admission 2-4 hours 4-8 patients stacking in the ED awaiting admission 2 ambulance handovers > 15 minutes Pts on trolley >12hrs 0 cubicle availability between 1-4hrs Back of House Insufficient capacity to accommodate non clinically urgent TCIs in either medicine or surgery 5 14 outliers No critical care bed available and no plan in place for one to become available in the next four hours Ward staffing is below agreed levels by 4 6 nursing staff across site and is judged to present a moderate risk to patient safety No critical care beds available and no potential movement identified over the next few hours with difficulty Team of Escalation for a bulletin to go to all staff re NEEP levels Director on call and Associate Director be informed of escalation to NEEP level 3 Team briefed of capacity issues all matrons/senior nurses and SLM s to attend their respective areas to assess and to actively create capacity; Request from NEAS prealert of all ambulances attendance to EAU if A&E under pressure Consider requesting HALO Critical Care network to be informed if no beds and none imminent by Critical Care Identify hot spots/process/patient flow pressure points for individual Directorates to be reported to the Patient Flow Team. Elective Ambulance queuing/ busy A&E department Senior decision makers to front all services - minors and majors category Physician of the day/week to assist with assessment of patients in A&E for suitability of referral or discharge Patient flow co-ordinator DM to trigger NEEP 3. 23 May need to request mutual aid from elsewhere.

transferring level 3 patients out because regional position has worsenend. Physician of the day/week to contact all medical consultants via voice bleep to advise of increased escalation Physician of the day/week to attend Bed Meetings to gain full briefing Physician of the day/week to consider moving junior staff to support pressure areas Physician of the day/week to ensure all sub specialty referrals are seen early in the day Physician of the day/week to consider cancelling elective activity for the afternoon and following day Refer to A&E escalation plan to inform ward teams of increasing pressure. Patient flow co-ordinator to inform DM of increasing pressure. DM/ART OOH to inform SLM/SMOC of increasing pressure Voice over - bleep voice alert to all medical consultants to inform of escalation to NEEP 3. (See medical team action card in Escalation Policy.) Flight deck information complete at 11am, 4.30pm and 8pm DM to co-ordinate additional patient flow meetings when required. SLM/SMOC to attend 9am patient flow meetings. SMOC to attend additional patient flow meetings where required. SLM/SMOC to keep AD/DOC informed of situation. Bed availability Additional escalation beds to be opened as documented in the winter plan. Additional consultant led patient reviews on all wards to identify patients suitable for discharge. Review of delayed discharges and accelerate discharge plans where possible involving Social Services and other relevant organisations. 24

Request acceleration of patients waiting repatriation to other hospitals. Wards to prioritise the patients for radiology / scanning and pharmacy if this is all they are waiting for before they are discharged and to ensure Patient Flow Team informed. Ask Estates if there are any works that can be expedited should that free up bed capacity Consider a porter being assigned to patient flow Manager at a weekend Acute Care physician to be aware of potential (additional Consultant or Junior Medical support to be co-ordinated through the Medical Business Unit. Clinical Matrons and SLM s to assist discharge cocoordinator/matrons/patien t flow co-ordinator to influence all wards to encourage movement of discharged patients to the discharge lounge ACCEEP Critical Care plan will be triggered as per the regional ACEEP network agreement Daily Critical care command and control meetings will take place and plan for daily management of the 25

situation/pressures. Community On Call Manager will continue to liaise with Trust On Call Manager to ensure appropriate support for discharge and continuing to support patients within their own home to avoid unnecessary admissions. Consider additional weekend sessions for ultrasound and or CT as required Workforce Review rotas with a view of cancellation of study leave based on individual assessment of both course and staff. Assess study leave Business Units to identify case by case leave which can be cancelled and benefits provided to own or other areas. Close liaison with Nurse Bank requesting additional bank staff where appropriate. Consider use of Practice Development Team Nurses / Specialist Nurses/ART to support ward areas. Consider the appropriateness of staff that are sent to help out on the ward. Ensure Staff Breaks are 26

coordinated to allow sufficient flexible rest periods. Consideration to be given to the following Triggers to activate NEEP level 4 Three or more of the following indicators are hit. All actions from NEEP level 3 implemented with no significant improvement with capacity Critical Care patients exceed the physical bed spaces available of 17. TRIGGERS A&E Multiple patients spending significantly longer than 4 hours in the ED No capacity to receive patients Time from DTA to admission >4 hours >8 patients stacking in the ED awaiting admission Ambulances queuing to 4 NEEP Severe Pressure (red) Expectation that all actions from NEEP 3 have been considered and implemented. All available capacity opened and patients boarded Cancellation of all electives with the exception of priority 1. Command and control - communications Continue managing situation as a surge and escalation incident. Through the daily teleconference and SITREP report escalation of NEEP level to the NECS manager/ CCG oncall manager out of hours Inform Communications Team of escalation Director on call to be informed of escalation to NEEP level 4 Consider calling additional local teleconference with CCG, Local Authority, Community Services and NEAS At NEEP level 4 designated Director on Call, AD s, and SLM s to All communication within NEEP 1,2 and 3 will have been activated. AD/DOC is to be kept informed of situation by SLM/SMOC DM/ART OOH to 27 All command and control actions in NEEP 1,2 and 3 will have been activated. Impact on Matron/SLM/ AD other commitment s Impact on study leave attendance Impact on meeting attendance The need to cancel routine work will impact on KPI s and reputation. Financial cost of additional resource brought in. Risks to: Elective activity KPI s Normal service delivery May impact on: NEAS Neighbouring Trusts Ability to repatriate from other hospitals Will not be able to offer mutual aid to other organisations. Will need to request mutual aid from other organisations.

EAU handover Pts on trolley >24hrs 0 cubicle availability >4hrs Back of House Insufficient capacity to accommodate TCIs in either medicine or surgery who are clinically urgent >15 outliers in other specialties Ward staffing is below agreed levels by 7+ nursing staff across site No critical care bed available, no place in place for one to become available in the next four hours and no scope for escalation of critical care capacity report to Gold Command. Activation of their Business Continuity Plans with regard to cancellation of elective procedures and continuity of core services. NEAS/OOH via NECS to be informed of growing pressures within the Acute Trust by the daily teleconference and SITREP Team briefed of capacity issues all matrons/senior nurses and SLM s to attend their respective areas to assess and to actively create capacity Continued communication with NEAS re: pre-alert of all ambulances attendance to EAU Continued communication with Critical care network if no beds and none imminent ensure SLM/SMOC aware of situation and to request onsite presence when necessary. SLM/SMOC to request DOC to seek mutual aid. Flight deck information complete at 11am, 4.30pm and 8pm. Ambulance queuing/ busy A&E department Senior decision makers to front all services - minors and majors category Physician of the day/week to assist with assessment of patients in A&E for suitability of referral or discharge Additional consultant to be commandeered to support the on call Consultant to be co-ordinated by the SLM/SMOC to escalate to AD/DOC the need for setting up Gold Command. DOC to assess situation with SMOC and determine if on-site presence is required. 28