ESCALATION PLAN PAEDIATRICS AND NEONATAL UNIT 1. Aim/Purpose of this Guideline 1.1. This guidance is designed to aid staff to monitor capacity and staffing in Child Health. 2. The Guidance 2.1. The majority of admissions to child health are emergency admissions via Primary care or the emergency department and are therefore unpredictable. It is essential that capacity and staffing is monitored on an ongoing basis throughout each shift taking into account activity as far as known or epected. 2.2. To facilitate this we assess the safety of each day shift in line with safe care data and epected ward staffing. This system is reviewed by a senior member of nursing staff allocated the paediatric bleep holder role. At night the same system operates when an eperienced band 5 staff nurse takes responsibility for the bleepholder role. It is epected that the matron, ward manager or deputy makes plans and decisions with regard to staffing the unit safely during the day and night shifts. These plans should be recorded on the bed management sheets. Ideally these should be anticipated and planned in the day when senior staff are available. Planned activity, both medical and surgical also needs to be factored into these plans. Below is outlined the capacity and age ranges of all of the wards within child health. It is important that age is only one of the factors considered when allocating beds the main factor being clinical need of the child. At times of bed pressures factors such as patient dependency, workload and medical input required should be considered when allocating beds. Problems with eisting inpatients and other issues should be dealt with promptly and decisions made and documented before 5pm. Potential problems should be anticipated and dealt with in normal working hours. Plans of care including discharge arrangements should be made and documented in inpatient notes prior to out of hours and weekends. 2.3 Capacity of Wards in Child Health Fistral ( adolescent unit 11-16 years ) 10 beds ( 4 girl, 4 boy and 2 cubicles) CLIC (cubicles for children/young people with cancer and leukaemia but can be used for other patients when available) - 4 cubicles Polkerris ( 0-11 years ) 12 beds ( 8 cubicles + 4 bedded bay) Harlyn Day Beds ( elective surgery) 8 beds - open 0730-2000 Mon - Fri Paediatric HDU 3 beds (includes availability of a cubicle) Paediatric Assessment Unit Waiting area, assessment bay + 4 cubicles Page 1 of 13
All ward areas have a resuscitation/ treatment area which can be used to assess and admit if required. 2.4 Nurse Staffing Nurse Staffing Levels for Paediatrics are based on RCN standards (July 2013). Along with numbers of staff on shift patient acuity and dependency needs to be monitored. The safer care tool is now being used daily in paediatrics. If 1:1 staffing is required for enhanced care in hours please liaise with the Ward Sister/Charge Nurse/Nurse in charge/matron to coordinate. If out of hours please liaise with clinical site coordinator. The following table outlines nurse to patient ratios for paediatric wards ( RCN 2013) However acuity and dependency will be considered alongside these ratios as indicated in safer care. It is epected that staff will monitor patients in line with The Observation and Monitoring Policy for Children and escalate accordingly. There is an epectation that each floor has a co ordinator who liaise with each other. The bed management role should remain with the most senior member of staff on shift who trouble shoots and makes decisions when in escalation. Stage One (Green) 2.5 PATIENT FLOW ESCALATION PLAN Child Health STATUS ACTIONS LEAD Routine activity is carried out patients assessed and seen promptly Assessment unit have beds/spaces for admissions epected Discharges and admissions to paediatric wards occur without delays Adequate staffing for all areas including Paediatric ED Capacity to move patients from assessment unit to age appropriate wards. All elective patients can be accommodated Day Night HDU 1:2 1:2 Under 2 years 1:3 1:3 Over 2 years 1:4 1:4 Nurse in charge of each ward area liaises with bleep holder to let them know how many patients and staff they have highlighting any issues epected around patient dependency, staffing or capacity and following risk assessment of that area *(refer to escalation flowchart-appendi 2) Bleep holder records all information related to staffing and activity on bed management sheet Assessment unit keeps bleep holder up to date with admissions epected highlighting issues of capacity and activity Discharge summaries and TTOs ready for potential discharges post ward round Paediatric Bleep holder Ward Managers Ward coordinators Stage Two (Amber) Bleep holder to ensure ward Paediatric Bleep Page 2 of 13
Lack of available beds in age appropriate wards for admissions epected Delay in transferring patients to wards from assessment unit due to delay in discharges or delay in patients being assessed by medical staff Only one member of Nursing Staff available to assess and admit patients in assessment unit Stage Three (RED) Unit has a greater number of epected admissions than there are sufficient trolley /bed spaces Nursing staff insufficient to safely care for number of potential admissions in paediatric areas coordinators are getting patients discharged promptly and highlighting issues causing delay to the appropriate people. Ward coordinators to ensure cubicles are available for isolation discuss with bleepholder and consider use of CLIC cubicles if free. Wards to assess staffing and send nursing staff to assessment unit Nursing staff asks registrars to assess patients for potential discharges from wards week on service Consultant to be informed if there are issues with medical staffing, on-going care and potential discharges. Contact Pharmacy to epedite any TTO requirement on wards. Maintain information with regard to capacity, staffing and activity in all areas by keeping bleepholder up to date who will record on bed management sheet. Consider activity and staffing in in all paediatric areas ( including Gwithian, NNU, Paediatric ED) Bleepholder /coordinator on assessment unit (depending on eperience) to triage patients and divert as appropriate to age appropriate wards informing medical staff of location and condition of patient if staff not available to go there. At this point consider staffing and activity for the net few hours. Bleepholder/ward managers to inform matron as earliest opportunity. Ensure actions from previous status are ehausted Inform week on service Consultant Paediatrician Nurse coordinator of each area to review situation with Paediatric Bleep holder /senior nurse and formulate action plan which is recorded on bed management sheet. Patient numbers and dependency should be taken into account along with staff numbers and skills. Paediatric bleep holder/senior nurse and consultant and/or registrar reviews all patients Page 3 of 13 holder All ward coordinators Ward Managers Matron Senior medical staff on call (Consultant, middle grade) Pharmacy Paediatric Consultant on call Paediatric Middle grade on call Matron Divisional Management team Ward Managers Ward coordinators Site co ordinators Senior manager on call
briefly. Consider all admissions with regard to potential workload and dependency to plan to accommodate admissions in one area for ease of nursing and medical management plan of where to accommodate admissions documented in bed management file. Inform Associate Director of Nursing, WCSH (site co ordinators out of hours) and refer to guidance for diverting patients Inform On call Manager who will brief Eecutive Director On call Document if unsafe conditions are eperienced and complete incident report, log time of arrival and departure Judgments will be made with relevant managers and professionals regarding the dependency of patients, time anticipated in the unit, bed availability, and staffing and epected admissions as to what steps from this escalation procedure to implement net.. 2.6 Bullet points for all disciplines to aid planning during times of bed and/ or staffing difficulties: Ward Managers/ ward coordinators Ensure all wards communicate beds available to bed manager Bed manager to document plans and bed availability on allocation sheet ( appendi 1) Ensure discharge plans are up to date, documented and ensure all wards communicate beds available to bed manager Bed manager to document plans and bed availability on allocation sheet ( appendi 1) Ensure discharge plans are up to date, documented and medication ordered promptly Assessment unit to keep bed manager up to date with epected admissions Liaise with senior nurse/service lead for further advice and help Ensure medication ordered promptly Assessment unit to keep bleepholder up to date with epected admissions SHOs/Registrars/ MiddleGrades Promptly review patients and discuss any difficulties with the named consultant early in the day Appropriate handover to colleagues to occur at shift changeover times Recognise areas and times of pressure and support each other SHOs Clerk patients on Paed Obs promptly and discuss difficulties with registrar promptly Facilitate rapid assessment and planning of patient care Consultants Ensure written plan in place for patients when gong off duty Ensure discharge plans are documented particularly for weekends and bank holidays Regular review and discussion with colleagues / registrars for comple patients Identify a consultant colleague who will provide continuity for leave Appropriate handover of comple patients should take place to a named colleague Page 4 of 13
3. Monitoring compliance and effectiveness Element to be monitored Lead Tool Frequency Reporting arrangements Acting on recommendations and Lead(s) Change in practice and lessons to be shared Compliance with escalation in red green and amber situations Ward mangers Analysis of bleep holder sheets and DATIX At each point of escalation retrospectively following event Ward managers to matron- fed back via senior meeting and directorate meeting. Child heath senior team meeting Matron and ward mangers Required changes to practice will be identified and actioned within 3 months. A lead member of the team will be identified to take each change forward where appropriate. Lessons will be shared with all the relevant stakeholders 4. Equality and Diversity 4.1. This document complies with the Royal Cornwall Hospitals NHS Trust service Equality and Diversity statement which can be found in the 'Equality, Diversity & Human Rights Policy' or the Equality and Diversity website. 4.2. Equality Impact Assessment The Initial Equality Impact Assessment Screening Form is at Appendi 3. Page 5 of 13
Appendi 1. Eample of Bleep Holders sheet. Page 6 of 13
Appendi 2. Flowchart Escalation process for raising staffing Concerns. Page 7 of 13
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Appendi 3. Governance Information Document Title Escalation plan- Paediatrics and Neonatal Unit Date Issued/Approved: September 2017 Date Valid From: September 2017 Date Valid To: September 2020 Directorate / Department responsible (author/owner): Melanie Gilbert- Matron Child Health Contact details: 01872 252411 Brief summary of contents Escalation plan for child health to aid staff to monitor capacity and staffing in Child Health. Suggested Keywords: Target Audience Eecutive Director responsible for Policy: Capacity Staffing Escalation Child Paediatrics RCHT PCH CFT KCCG Eecutive Director Date revised: September 2017 This document replaces (eact title of previous version): Approval route (names of committees)/consultation: Divisional Manager confirming approval processes Escalation Policy Child Health V1.0 Ward mangers Audit and guidelines Divisional board David Smith Name and Post Title of additional signatories Name and Signature of Divisional/Directorate Governance Lead confirming approval by specialty and divisional management meetings Signature of Eecutive Director giving approval Not Required {Original Copy Signed} Name: {Original Copy Signed} Page 9 of 13
Publication Location (refer to Policy on Policies Approvals and Ratification): Document Library Folder/Sub Folder Internet & Intranet Paediatrics Intranet Only Links to key eternal standards Related Documents: Training Need Identified? none Safer care policy ED escalation /SOP Observation and monitoring policy for Paediatrics and Neonatal Unit RCHT Enhanced Care and Meaningful Activities Policy No Version Control Table Date Versio n No Summary of Changes Changes Made by (Name and Job Title) Nov 2014 V1.0 Initial Issue Mary Baulch Matron child health Aug 2017 V2.0 Changes made to include safer care and paed ED Melanie Gilbert Matron Child Health All or part of this document can be released under the Freedom of Information Act 2000 This document is to be retained for 10 years from the date of epiry. This document is only valid on the day of printing Controlled Document This document has been created following the Royal Cornwall Hospitals NHS Trust Policy on Document Production. It should not be altered in any way without the epress permission of the author or their Line Manager. Page 10 of 13
Appendi 4. Initial Equality Impact Assessment Form Name of the strategy / policy /proposal / service function to be assessed Escalation plan paediatrics and Neonatal Unit Directorate and service area: Women, children and seual health. Is this a new or eisting Policy? eisting Name of individual completing assessment: T.Fergus 1. Policy Aim* Who is the strategy / policy / proposal / service function aimed at? Telephone: 01872252596 The guidance is designed to aid staff to monitor capacity and staffing in Child Health. 2. Policy Objectives* Safe care and clear instruction for staff. 3. Policy intended Outcomes* Safe care and clear instruction for staff. 4. *How will you measure the outcome? Review of incidents and regular safer care checks, review of coordinators sheet. 5. Who is intended to benefit from the policy? 6a Who did you consult with b). Please identify the groups who have been consulted about this procedure. What was the outcome of the consultation? Children, families and staff. Workforce Patients Local groups Please record specific names of groups Ward managers Matron child health Paediatric consultants Policy agreed Eternal organisations Other Page 11 of 13
7. The Impact Please complete the following table. If you are unsure/don t know if there is a negative impact you need to repeat the consultation step. Are there concerns that the policy could have differential impact on: Equality Strands: Yes No Unsure Rationale for Assessment / Eisting Evidence Age Se (male, female, trans-gender / gender reassignment) Race / Ethnic communities /groups Disability - Learning disability, physical impairment, sensory impairment, mental health conditions and some long term health conditions. Religion / other beliefs Marriage and Civil partnership Pregnancy and maternity Seual Orientation, Biseual, Gay, heteroseual, Lesbian You will need to continue to a full Equality Impact Assessment if the following have been highlighted: You have ticked Yes in any column above and No consultation or evidence of there being consultation- this ecludes any policies which have been identified as not requiring consultation. or Major this relates to service redesign or development 8. Please indicate if a full equality analysis is recommended. Yes No 9. If you are not recommending a Full Impact assessment please eplain why. No areas indicated. Page 12 of 13
Signature of policy developer / lead manager / director M.Gilbert Names and signatures of members carrying out the Screening Assessment 1. 2. Human Rights, Equality & Inclusion Lead Date of completion and submission sep 2017 Keep one copy and send a copy to the Human Rights, Equality and Inclusion Lead c/o Royal Cornwall Hospitals NHS Trust, Human Resources Department, Knowledge Spa, Truro, Cornwall, TR1 3HD This EIA will not be uploaded to the Trust website without the signature of the Human Rights, Equality & Inclusion Lead. A summary of the results will be published on the Trust s web site. Signed M.Gilbert Date _Sep 2017_ Page 13 of 13