Patient Flow Internal Escalation

Trust Policy and Procedure Document Ref. No: PP(15) 304 Policy Name Internal Escalation For use in: For use by: For use for: Document owner: Status: All areas of the Trust All Trust staff Trust Wide ECOO Approved West Suffolk Hospital NHS Foundation Trust Patient Flow Internal Escalation Policy and Plan

Contents Key Principles The 10 Golden Rules 3 1.0 Introduction 4 1.1 Aim 4 1.2 Objectives 4 1.3 Scope 4 1.4 Methodology 5 2.0 Patient Flow Team 5 2.1 Specific Incidents Requiring an Immediate Response 6 2.2 Operational Meetings 7 2.2.1 Handover Meetings 7 2.2.2 Operational Capacity Meetings 7 2.2.3 Standing Agenda for Capacity Meetings 8 2.2.4 The Capacity Report 9 3.0 Escalation Status 9 3.1 Escalation Process 12 3.2 Normal Working/Out of Hours 12 3.3 Escalation Actions 13 3.4 Capacity Meeting Attendees 14 4.0 Critical Care 15 5.0 Infection Control 15 6.0 Reporting The Capacity Report 15 7.0 Communication 16 8.0 Internal Communication of Escalation Status 16 8.1 External Communication 16 9.0 Escalation & De-Escalation Actions 18 9.1 Escalation Actions & Authority 18 9.2 Actions Prior to Opening Escalation Areas 18 (Detailed in Action Cards) 18 9.3 Trust Escalation Flow Chart 19 9.4 De-Escalation 20 10.0 Plan Validation and Review 20 11.0 Black Escalation Process Appendix 1 21 Action Cards For Trust Level Roles Appendix 2 22 12.0 Trust Level Expectations Appendix 3 40 Source: COO Status: Approved Page 2

Key Principles The 10 Golden Rules The 10 Golden Rules are critical to the Trust maintaining a high performing emergency pathway and effective capacity management regime for its patients these are foundations upon which the trust builds effective and safe patient pathways and flows. 1. Patients who come into the hospital via the Emergency Department (ED) will be subject to a system of rapid initial assessment and treatment by a senior clinician 2. GP referred patients should go to assessment areas directly; from there they will be streamed to the appropriate ward or short stay area. The ED is strictly for diagnosis and routing of emergency patients only. 3. ED will have arrangements in place to assess emergency patients within an hour and, if admission is obvious, a referral to the appropriate specialties should occur within 2 hours. No breaches will be caused by disputes between specialties about where a patient is to go. In the event of a dispute the ED Consultant will adjudicate in hours, the senior doctor out of hours. 4. We will not admit a patient likely to be able to go home or discharge a patient who needs urgent assessment/treatment in order to primarily avoid a transit time breach. 5. We will not admit patients for tests who are well enough to go home and return for those tests - and we will ensure those tests are available when required. 6. Once a decision to admit is made, the patient will not be re-reviewed in the ED causing them to stay in the department for longer than 4 hours from their time of arrival. Such patients will be reviewed on the assessment units unless there is a change in their condition. 7. The creation of capacity in admission/assessment areas is a trust priority. 8. Patients will be accepted on to the assessment units prior to full clerking. Initial documentation will be carried out by ED, and be checked by the speciality registrar. 9. Discharge planning will begin at the time a decision to admit is made. Each patient will have a discharge plan with a clearly defined predicted date of discharge given within 12 hours of admission to be agreed with the medical team. Plans for the discharge of elective patients should start at the pre-assessment stage. The patient and their carers, where appropriate, must be involved in all stages of the process. 10. Clinicians are responsible for ensuring the following takes place: Daily ward/board rounds with prompt decision making, immediate prescribing of TTOs and ordering of tests. Once a decision has been made, explicit notes made to indicate suitability for nurse-led discharge. Source: COO Status: Approved Page 3

1.0 Introduction The purpose of escalation is to ensure that decisions are made at the right level and those who need to be informed are made fully aware of circumstances in a timely manner. This policy recognises the effects that variation in demand and activity has on the effective operational management of the Trust, with enhanced focus on attendance and admission areas. It sets out the actions required across the Trust at each level of escalation to minimise the need to escalate further whilst at the same time seeking to return the Trust to normal working as quickly and safely as possible. The plan seeks to ensure that patients receive the highest levels of care and experience whilst minimising risk. It also informs the wider Suffolk health economy of challenges facing the Trust due to high levels of activity and supports system wide actions to mitigate the effects of such pressures. 1.1. Aim The aim of this plan is to measure the degree of operational pressure on the Trust and set out the actions required at each level of escalation to maintain patient safety, minimise risk and return the Trust to normal working. 1.2. Objectives Compliance with an effective escalation policy and plan will enable: - the efficient use of beds and the early identification of capacity problems - a proactive rather than reactive response, with defined responsibilities and clear, concise actions - patients safety and clinical needs to be met appropriately and as effectively as possible - compliance with national targets and fulfilment of contractual agreements with commissioners 1.3. Scope This Policy and plan applies to all areas of the Trust, be they directly clinical or support services (e.g. Facilities). The daily operation of the Trust in relation to clinical capacity management is governed by the Adult Bed Capacity Management Policy, a key element of which is the 10 Golden Rules. These are key to the Trust maintaining a high performing emergency pathway for its patients and should be followed at all times The Trust has developed a series of escalation plans using a traffic light system approach. These outline the arrangements for managing pressure on bed capacity due to acute emergency demand and elective admissions to West Suffolk Hospital. The arrangements may also be invoked in response to: Severe congestion in A&E Trust capacity status Staff shortages which limit or reduce capacity, or In accordance with specific Business Continuity plans Each stage of the escalation plans outlines the roles and responsibilities of key personnel involved in facilitating patient flow. A Critical Capacity Incident Plan will be invoked when, despite the escalation procedures in this plan, the Trust has insufficient capacity to admit and/or treat emergency patients but where the designation of controlled areas for receiving injured casualties from a major incident is not required. Source: COO Status: Approved Page 4

1.4. Methodology Departmental escalation plans are in place and their interaction is checked and tested (both jointly and severally) as part of the annual planning and review process. Nevertheless, there are overarching principles which are core to any Trust procedure: 1. Patients safety and clinical need will always be the overriding priority 2. Emergency admissions will be given priority in the allocation of beds 3. All patients will receive an equitable and professional service 4. All nurses have a responsibility to report accurate and timely bed availability to the Patient Flow Team 5. Patients will not be transferred between wards unnecessarily, and transfers or discharges at night will be avoided wherever possible 6. All elective surgical and medical admissions are admitted directly to the appropriate wards. The waiting list office provides the planned admission lists each week. There are three categories of elective patients awaiting an in-patient spell: Urgent (Cancer & other clinical urgent) Long Waiters Routine (clinically non - urgent) Allocation of beds for elective admissions within the Trust: Patients for admission on day of surgery or treatment will be allocated beds as available in a timely way Patients for admission for next day surgery or treatment will be allocated beds according to availability Where beds are not, or may not be available, priority will always be given to Urgent, Long Waiters then Routine Service Managers are responsible for their respective Departments during the day. However the Clinical Duty Manager is responsible for overall capacity and flow. Separate arrangements are in place for other issues of an immediate nature, such as Missing Persons or Major Incident. 2.0 Patient Flow Team The Patient Flow Team comprises of the Clinical Duty Manager (CDM) and Clinical Bed Coordinator (CBC) Teams, who are responsible for the effective day-to-day operational coordination of Trust-wide capacity management This includes monitoring and declaring the Trust Internal Escalation status and communicating it across the organisation. The Clinical Duty Manager and Clinical Bed Coordinator will be responsible for the collection and input of data which contributes to the determination of the Trust internal escalation status. This data will be entered on a four hourly basis at 08:00, 12:00, 15:00, 20:00 at which times the internal escalation status is reviewed. If workload is such that there is an increase in activity overall and multiple issues require action at the same time the CDM will notify the Senior Manager on Call (SMOC) and ask for assistance, agreeing shared actions to maintain safety and patient flow. For service specific issue the CDM will escalate directly to the relevant service manager for the area to resolve the problem. Source: COO Status: Approved Page 5

2.1 Specific Incidents Requiring an Immediate Response The Clinical Duty Manager is responsible for maximising patient flow while maintaining patient safety and supporting the delivery of Trust targets. They will be the first point of contact for all escalation issues. As well as the Executive on Call arrangements, a rota of Senior Managers is available to support the Clinical Duty Manager in the event that any of the following occurs: Trigger are met which initiate a specific plan (such as ITs Disaster Recovery, Armed Response, Site Lock Down etc.) A Major Incident or Major Incident Standby has been declared by another agency A standby warning call is received from blue light agency or local authority One or more core functions of the Trust (defined) is or could be jeopardised Any on-going SIRI ** A missing patient has a score >100 confirmed by CDM - or any missing child There is an imminent loss of any utility Any confirmed fire or other serious incident on the site A Command and Control response is mandated by NHSE or Commissioners A situation generates Media interest beyond normal status checks Any other serious situation Short notice unfilled SpR shift i.e. sickness The Clinical Duty Manager will always call for support for any of the above. If a Command and Control response is required, the Clinical Duty Manager will start a personal log. Clinical Duty Manager will arrange for the Hospital Control Centre to be set up and remain in the Control Room until relieved. Once Control staff arrive there should be a handover briefing and the Clinical Duty Manager will revert to providing proactive support for wards and departments and ensuring that all are aware of the current situation. Arrangements must be put in place for the CDM to provide regular reports on bed or staffing issues and to action as appropriate. ** Serious incidents requiring investigation are defined as incidents that occurred in relation to NHS-funded services and care resulting in one of the following: Unexpected or avoidable death of one or more patients, staff, visitors or members of the public, and up to six months from discharge from services. A scenario that prevents or threatens to prevent the Trust s ability to continue to deliver healthcare services, for example, actual or potential loss of personal/organisational information, damage to property, reputation or the environment, or IT failure; Acts or allegations of abuse (sexual, physical, psychological, theft, misuse or misappropriation of money or property and neglect or acts of omission which cause harm or place at risk of harm) of a service user; Adverse media coverage or public concern about the Trust or the wider NHS. One of the core set of Never Events as updated on an annual basis, for example, inpatient suicide using non collapsible rails; The admission of a child of 17 years, or under, to an adult psychiatric ward; significant healthcare associated infections (as defined by Health Protection Agency) i.e. an outbreak of infection, failure in decontamination or infected healthcare worker; The Anglia Health Protection Team should also be advised. Information Governance events. IG SIs are defined as Any incident involving the actual or potential loss of personal information that could lead to identity fraud or have other significant impact on individuals should be considered as serious Source: COO Status: Approved Page 6

Maternity, infant and child incidents as described in the NPSA National Framework for Reporting and Learning from Serious Incidents Requiring Investigation 2.2 Operational Meetings At regular points throughout the day, meetings are held to receive handover between teams and to review current status and invoke relevant action cards. 2.2.1 Handover Meetings At 08:00 and 20:00 the outgoing Clinical Duty Manager (CDM) will conduct a brief handover meeting in the Hospital Control Centre. This will be attended by the incoming CDM (bleep 888), the Surgical and Medical Bleep Holders 390 and 933 and Clinical Bed Coordinator (bleep 358). The Medical & Surgical Managers of the day will attend the 08.00 handover meeting only. The Senior Manager on Call (Silver) will attend the 08.00 meeting when on site or make arrangements to receive an update from the CDM as soon as possible after the meeting. The CDM will brief the Doctor s Handover meeting at 08:30-09:00 about the Trust s position and any specific input required of the Medical staff 2.2.2 Operational Capacity Meetings Operational Capacity Meetings will normally be held at 12:00, 15:00 and 17.30hrs in the Hospital Control Centre. These will be chaired by the CDM and attendance is dictated by Trust Capacity Status. The Senior Manager on call will attend all operational capacity meetings to gain an oversight of the organisation and provide support to the CDM. At Black escalation, the ECOO (or nominated deputy) will take over and Chair the meetings. Additional bed meetings may be convened when the Trust escalation status is at red or black. At the 15:00 meeting the initial Trust plan for the out of hours period is to be agreed. The plan will also be confirmed at the 17.30 meeting if required. The Surgical Service Manager or nominated deputy for the surgical wards will attend the 15:00 meeting to review planned TCI activity for the following day and identify the potential for cancelling electives in the event capacity is required to meet anticipated or actual emergency demand overnight. Meetings should last no more than 15 minutes and will follow a fixed agenda (see below). The primary focus of the meeting will be to review and confirm plans for the next period, identify issues impacting the safe and efficient patient flow through the Trust and agree and log actions, owners and timescales to address. The development of plans and resolution of the issues must take place outside the meeting. All numerical data regarding capacity and current position MUST be reported to the Patient Flow team no later than 15 minutes prior to the meeting start. The ED Coordinator should arrive five minutes before the meeting time to input data to the Capacity Report Source: COO Status: Approved Page 7

2.2.3 Standing Agenda for Capacity Meetings 1 2 Allocate an individual to log and allocate all actions on white board for review next capacity meeting Review of outstanding actions from previous meeting 3 Patient safety issues requiring immediate action 4 Situation report (exception / issue reporting only) ED Review Numbers in Department Triage Delays Any delays in waiting to be seen by a Doctor Unvalidated Breaches CDU status Ambulance situation Patients awaiting beds Medical staffing issues Other Capacity Review AMU & Ambulatory Emergency Care capacity / issues F7 Capacity/ Issues SAU Capacity/ Issues CCS capacity and step down Stroke capacity CCU capacity Community bed availability Overall Trust bed capacity including escalation Other Areas for Review Staffing Discharge planning / Medically Fit Support Services / Pharmacy/ Imaging/ EIT/ Therapies Infection Prevention 5 Activity Forecast Predicted emergency admissions & discharges Planned elective activity MTU planned activity and potential capacity 6 Agree plans and required actions for next meeting / overnight 7 8 Confirm internal escalation status and invoke action cards as appropriate Agree time of next capacity meeting Source: COO Status: Approved Page 8

2.2.4 The Capacity Report 08:00 Bed Capacity Position Day Month Year 11 October 2013 Status None Physician 0 Elderly 0 Exec 0 Surgeon 0 Gynae 0 Manager 0 08:00 ED Green Beds Black Emergency Department Today Attendances Number of 4 hr breaches Outliers 68 1 Med in Surg 4 Closed beds empty 32 Surg in Med 1 ED Cubicles in use/currently in department Total 5 TOTAL Not Triaged See & Treat Minor Major Resus TCI Today Cancelled 1 29 1 12 9 5 2 Clinically stable 0 Medically Fit 0 Med 1 Community Beds Decision to admit 2 Available Referrals Surg 15 Nursing 0 0 Paeds Speciality redirections Residential 0 0 Ambulance's held No / max time 0 0 Nursing Shifts Not Covered Registered Unregistered Bed State Empty Def / Lat Poss Early 0 0 Med 2 0 Late 0 0 Surgery/Trauma 4 0 0 Night 0 0 Bed Capacity 6 0 0 Alerts & Messages ITU 4 CCU 3 Paediatrics 15 Theatres All theatres closed due to generator failure Forecast Position Infection Control G9 Closed due to Norovirus and Swine Flu. Forecast admits Admits to date Current bed state Forecast Med 52 17 2-37 Surgery/Trauma 63 5 4-62 Same Sex Breaches All wards - to accommodate emergency patients from ED Gynae 0 0 Discharge Indicators TOTAL 115 22 6-87 Figure4: Bed Capacity Report (under development) The completed Trust Capacity Report is issued at 0800, 1200, 1600 and 2000. 3.0 Escalation Status The Trust Escalation status is an indicator of the operational pressure that the Trust is under and will rise and fall in a controlled manner based on prevailing and anticipated pressures. Responsibility for the declaration of escalation status varies according to the level The internal escalation status is a component part of the county and region wide Escalation status. Where requested, organisations within the health economy will take supportive actions commensurate with the escalation level of the Trust declaring the highest status. The escalation status is based on a scale that reflects the level of risk to the Trust s ability to provide services, and the extent to which patient safety and experience may be compromised see figure 1. Source: COO Status: Approved Page 9

This status setting applies to the Trust s overall capacity, and excludes paediatrics and maternity services. There are three triggers to help determine the escalation status and appropriate response: (1) bed capacity; (2) pressure in the emergency department and (3) staffing levels. The Trust s escalation status will be reviewed at periodic intervals throughout the day at the planned capacity review meetings. The Trust escalation status is determined by assessing a number of key performance metrics on an on-going basis. These metrics assess both current and anticipated operational pressures. Appendix 2 describes the nature of likely pressure as Capacity pressure increases. Data will be input to the Trusts Capacity Report against a series of indicators. These will be weighted according to a matrix and a Trust score generated which will suggest an overall status. SUMMARY ESCALATION LEVELS / ALERT STATUS ESCALATION ESCALATION MEASURE / STATUS TRIGGERS GREEN Bed capacity within the Trust is able to maintain both emergency and elective capacity. RESPONSIBILITY Managed by the Patient Flow Team at all times AMBER Deliver emergency care services across the system. Good patient flow through ED and other access points with ED four-hour target consistently being met. Pressures are increasing and the predicted or actual bed capacity may not meet demand in one main area. Discharges are below those expected. Anticipated pressure on maintaining ED four-hour target and in facilitating ambulance handovers with delays breaching 30-minute turnaround times. Constituent parts of the health economy are experiencing similar pressures; this is reported by WSCCG and via EEAST CAMS in the daily capacity meetings and corrective action identified. 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. The actions to be taken aim to bring trusts and the system back to a Green position. Managed by the Patient Flow Team with support from the Clinical Divisions. OOH support from Senior Manager on Call and Executive Director On-call Source: COO Status: Approved Page 10

RED Despite measures undertaken, pressures are continuing to increase. There is a lack of beds across the Trust with discharges predicted to be lower than forecast and admissions. 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. Community services may not be able to transfer medically fit patients to community care. Social services may be unable to facilitate care packages for discharges. Significant unexpected reduced staff numbers due to sickness or weather conditions are experienced. There may be infection control issues resulting in significant pressures on the system. The actions taken aim to bring the Trusts and the system back at least to an Amber position. Managed by the Patient Flow Team, supported by the Senior Manager on Call and Executive Director Oncall. Attendance as per action cards External communication ECOO /Deputy OOH support from Senior Manager on Call and Executive Director On-call Black Actions at Red failed to deliver capacity and there is system gridlock with no capacity across the acute trusts or within the community. The Trust is unable to admit GP referrals. The Emergency Department is unable to safely provide emergency care service. Ambulances are unable to offload patients affecting their response to 999 calls. Elective work is cancelled. Unexpected reduced staffing numbers are such that this causes increased pressure on patient flow to such a level that it compromises service provision/patient safety. The Trust is experiencing severe operational challenges despite implementation of agreed actions with little or no likelihood of improvement within the next 4 hours. The Executive Medical Director and Executive Chief Nurse and/or ECOO are likely to believe that the clinical safety of patients has become compromised, and/or staffing levels and skill-mix is unsafe to care for patients. TRUST BLACK escalation status can only be declared by the Executive Chief Operating Officer/ Deputy (in hours) or the Executive on-call (out of hours) following consultation with the Clinical Duty Manager Managed by the ECOO/Deputy or Executive on Call at all times Source: COO Status: Approved Page 11

At TRUST BLACK status, the ECOO/Deputy will constantly review the situation and determine if an internal critical capacity incident should be declared. When the critical internal capacity incident is stood down, the ECOO/Deputy will determine which level of escalation the Trust should revert to. It is anticipated that at TRUST BLACK escalation status, significant input will be required from the wider health economy to return the Trust to operational normality. Routinely there should be: At least daily teleconference calls involving NHSE Area Team, CCG Exec on Call, East of England Ambulance Service Trust, Adult Social Care and Community 3.1 Escalation Process 3.2 Normal Working All Trust members of staff are required to actively and continuously contribute to the timely and safe discharge of patients from hospital. Medical staff should ensure that board or ward rounds for discharge decision/planning have been completed during the morning; Medically fit and Clinically Stable patients should be identified within this process. Confirmed and Potential Discharges should be declared to the bed coordinators at the earliest opportunity. Ward staff should make appropriate use of any identified discharge waiting areas to ensure that beds are freed up to accept acute admissions as soon as possible. Providing timely bed availability information to the Clinical Bed Coordinator is key to the Trust s ability to manage beds successfully and to cope with increased demand. Currently this information is obtained direct from ward staff, including the following: beds available now to be used definite discharges - beds later potential discharges - beds later Ward staff will ensure that the ward whiteboards are constantly updated and will also provide information for the Trust s electronic systems, including each patient s anticipated discharge arrangements. Beyond Green Level 1, ward staff or the shift co-ordinator will, without delay, bleep to inform the Clinical Bed Coordinator of: 1. Any additional definite or potential beds becoming available in between Clinical Bed Coordinator rounds 2. Any unexpected discharges (for example deaths) Trust medical and surgical staff will respond to requests from Patient Flow or Trust managers to review patients and, wherever possible, expedite their discharge. As pressures increase, clinicians may have to prioritise both admissions and those already admitted. Out of Hours During out of hours periods the Trusts ability to escalate to the wider team is limited, i.e. those staff groups listed in section 3.3. However, if BLACK Trust status is declared by the Exectuve on-call (Gold), the following staff groups will be called to attend a BLACK capacity meeting in the HCC. Source: COO Status: Approved Page 12

The CDM (888) will be responsible for co-ordinating the aforementioned, and will call the following staff members: 1. Portering Supervisor 2. POD on-call 3. GOD on-call 4. AMU on site Consultant 5. General Surgery/Urology/Orthoapedics on-call 6. Medical SpR 7. Gold/Silver on-call 3.3 Escalation Actions The following key members of staff have Action Cards which provide them with tasks that they should undertake at a particular escalation status level. 1. Switchboard 2. Clinical Duty Manager Bleep 888 3. Senior Manager on Call 4. Executive Chief Operating Officer/ Deputy/ Executive Director on Call 5. Senior Nursing Staff 6. Director of Nursing/ Deputy 7. Ward Consultants / On Call Consultants 8. Clinical Director 9. Medical Director 10. Discharge Planning Lead 11. Divisional Management Representatives 12. Chief Pharmacist/ Deputy 13. Head of Therapies/ Deputy 14. Radiology Service Manager/Deputy 15. Facilities Representative The role of nominated key members of staff in relation to Internal Escalation is to ensure that all actions documented within the relevant Escalation Action Cards are completed in a timely manner with any issues being reported back to the Patient Flow Team. Source: COO Status: Approved Page 13

3.4 Capacity Meeting Attendees Attendance at the capacity meetings is determined by the Trust escalation status according to the table below. * In hours ONLY Job Title / Role Green Amber Red Black Clinical Duty Manager X X X X Clinical Bed Coordinator X X X X Contracted Pool Co-ordinator / Nurse Staffing Bleep X X X X Holders Senior Manager on Call (Silver) X X X ED Shift Coordinator (at black Senior representative X X X X from ED) AMU Shift Coordinator(at black Senior representative X X X X from ED) Discharge Planning Team representative X X Critical Care Nurse representative plus intensivist X X when on black Infection Prevention* (If any IPT issues) X X X X ECOO (or Deputy)* Executive Director On Call (Gold) X X Head of Pharmacy/ Deputy * On call Pharmacist out of hours X X X Medical & Surgical Service Managers, Deputy X X General Managers Medical Manager of the day* X X X X Surgical Manager of the day* X X X X Nominated Senior Nurse for each Division * X X Director of Nursing/ Deputy* Facilities Representative On call Consultants (PoD, GoD, AMU & ED) X X X Nominated Clinical Support Services Representative* X X Portering Supervisor OOH only X X Source: COO Status: Approved Page 14

4.0 Critical Care Intensive Care capacity within the Trust and in the health system generally is both limited and volatile. The service has its own capacity and escalation arrangements drawn up with input from the Critical Care Network. However Critical Care is a key element of the Trust s ability to function under pressure; therefore the Service Manager or Nurse in Charge should attend RED and BLACK Bed Meetings. The intensivist should attend Black capacity meetings 5.0 Infection Control The need to maintain the integrity of isolation areas and infection control and prevention measures can impinge heavily on the availability of beds. The Trust has a number of plans in place to deal with specific diseases including Infectious Gastroenteritis (Norovirus) and viral respiratory illness. Infection Prevention Nurses will attend bed meetings in accordance with 3.3, unless beds are closed in which case they will attend every bed meeting. Their role at these meetings is to advise those responsible for flow and capacity. 6.0 Reporting The Capacity Report A Capacity Report is circulated to key staff 4 times per day by the Patient Flow Team. This report shows key information including escalation status, available capacity, bed status and operational issues as well as agreed actions. External status reporting during the winter period is done via use of the National UNIFY system and daily SITREPS. SITREP This is reported on a daily basis in winter for the previous 24 hour period, giving a range of pre validated statistics; the Patient Flow Team will complete a template and submit to the information team for sign-off. The information required is specified by the DoH and NHSE and routinely includes: cancellations, 12 hour waits in A&E, clinical and non-clinical critical care transfers, ambulance hand over delays, beds available and used, critical care capacity, beds closed due to D&V and / or Flu, number of delayed transfers of care and the operational status of hospital Any serious operational issues reported on the form must be signed off before publication by the ECOO or nominated Deputy before publication. This information is visible to all NHS organisations including CCG and NHS Area Team. Source: COO Status: Approved Page 15

7.0 Communication 8.0 Internal Communication of Escalation Status The current internal escalation status will be shown permanently on the homepage of the intranet. The status box will include a link to the relevant escalation action cards and the Internal Escalation page which includes relevant documents and procedures. Changes to internal escalation status will be communicated though the Capacity Report by the Patient Flow team via email. It is circulated both within the Trust and to external organisations The Trust Capacity dashboard should be automatically updated at the same time on a 4 hourly basis. This will ensure all relevant stakeholders are aware of the status and the actions required of them as set out in their functional Escalation Action cards. 8.1 External Communication At all levels of escalation the Trust is required to maintain effective information flows across the wider health system. This is achieved through the use of Capacity Reports, SITREPS, and participation in daily operational teleconferences and at higher levels of escalation, strategic level teleconferences. Responsibilities for external communication are documented in the relevant Escalation Action Cards. These include informing the CCG and other external stakeholders of escalation to Red status and beyond. The Clinical Commissioning Group (CCG) holds responsibility for overseeing provider escalation plans and for ensuing that organisations respond appropriately to increased pressures in demand and capacity management. This includes participating in the provider led system wide strategic escalation conference calls, to improve flow and resilience across the urgent care system. The system providers will organise and hold strategic executive level conference calls as part of system resilience planning. A CCG led exceptions only conference call involving the whole health and care system will be held on Monday s and Thursday s throughout the year. These calls will cover highlighted barriers to service delivery that require system wide escalation. During the winter period (November March) the CCG will facilitate additional calls to ensure that capacity and demand is managed collectively. The CCG will complete and distribute the system SitRep after these calls A copy of the sitrep is included below to indicate the information which will be required for the teleconference Source: COO Status: Approved Page 16

During periods of sustained escalation additional operational teleconference calls can be initiated by any provider by paging the CCG Director on Call. The escalating provider will be expected to lead this call. To access the conference, each party dials the following details: Primary dial in number: 0844 800 3227or via mobile: 02034 639 740 At the prompt, enter Participant PIN code followed by the # key. Participant PIN code: 39 82 35 63 # Chair PIN code (CCG use only) Source: COO Status: Approved Page 17

A teleconference agenda will be used to gather a full situation report from each provider during sustained escalation or when moving to Black Trust status. 9.0 Escalation & De-escalation Actions Full details of the actions to be taken across the Trust at each level of escalation can be found in the Internal Escalation Action Cards as per appendix 2. Each action card is written for a specific role within the organisation and details the actions to be taken at Amber, Red and Black status. 9.1 Escalation Actions and Authority The ECOO/deputy or Executive Director on Call will decide to open escalation beds. Once authorised the Patient Flow Team will be responsible for ensuring the clinical mix and sex of patients is appropriate within each newly opened area. The Patient Flow Team will liaise with base ward staff to identify suitable patients with an estimated length of stay of less than 48 hours who can be transferred to escalation areas. Patients transferred to outlying or escalation beds other than F8 should ideally be medically fit or at least very stable without requiring oxygen with MEWs at zero or with a definite discharge date for tomorrow. 9.2 Actions Prior to Opening Escalation Areas (as detailed in action cards) Additional ward / board rounds and consultant review of patients under their care, to assist with earlier discharge and proper use of any discharge lounge facilities that are put in place. Liaise with other local providers and commissioners to reduce pressure on the hospital. All other demand reduction (such as cancellation of non-urgent elective activity) and capacity increase options around discharge have to be considered Source: COO Status: Approved Page 18

9.3 TRUST BED ESCALATION FLOW CHART Follow the sequence unless authorised by the Chief Operating Officer CAPACITY ISSUE OUTLYING. The use of empty beds for outlying should be considered initially, and be based on actual bed capacity at 15.00hrs. Once outlying has occurred, capacity issues within either Surgery or Medicine should be managed as follows: 1. Fill ALL Medical & Surgical beds 2. Fill Escalation beds on: F3 TAU x1, G1 Oncology assessment x1, G8 Stroke x2 3. Fill CDU beds 4. Contact the Executive on-call to discuss & agree next steps i.e: o Fill F8 incrementally to a maximum of 26 beds o Use 6 beds on MTU During escalation the following must be considered: MEDICINE SURGERY Establish todays & tomorrow MTU procedures And consider deploying patients to DSU Review tomorrow s electives Source: COO Status: Approved Page 19

9.4 De-Escalation In a de-escalation situation, the principle of completing all actions detailed on the action cards remains. This is essential in ensuring the Trust returns to normal working as swiftly and safely as possible. 10.0 Plan Validation and Review a. Plan consultation & approval Prior to ratification, this plan has been circulated to key internal stakeholders for their input. b. Training All staff with a role or potential role related to the Trusts internal escalation status will receive appropriate training and communication to enable them to effectively discharge their duties as set out in the plan. c. Monitoring & review of plan The Internal Escalation Plan will be formally reviewed on an annual basis by the Emergency Preparedness Steering Group. In the event major amendments are required to the plan to incorporate relevant internal or external organisational and / or operational changes, the approval of the revised plan will replace the annual review. Source: COO Status: Approved Page 20

11.0 Appendix 1 Black Escalation Process Triggers for BLACK escalation Clinical Duty Manager notifies IN HOURS General Divisional Managers & ECOO or Deputy contacted OUT OF HOURS Director On Call contacted Who reviews status, capacity, issues, actions taken & in progress undertaken Who reviews status, capacity, issues, and actions taken & in progress undertaken Agree immediate actions No Declare BLACK? No Declare BLACK? Yes Yes Switchboard alert Black status follow Action Card BLACK escalation status declared BLACK escalation status declared Intranet homepage updated to reflect BLACK escalation status CEO informed by ECOO Director On Call contacts NHSE Area Team and CCG to confirm escalation to BLACK ECOO convenes Critical Capacity Command CEO contacts NHSE Area Team and CCG to confirm escalation to BLACK Director On Call informs COO and agrees immediate actions Key CDM ECOO CEO Dir On Call ED on call, ECOO & CDM Source: COO Status: Approved Page 21

Appendix 2 ACTION CARDS FOR TRUST LEVEL ROLES The following section contains all of the action cards for key individuals. 1. Switchboard 2. Clinical Duty Manager Bleep 888 (Bronze) 3. Senior Manager on Call (Silver) 4. Executive Chief Operating Officer/ Deputy/ Executive Director on Call 5. Senior Nursing Staff 6. Director of Nursing/ Deputy 7. Ward Consultants/ On call consultants 8. Clinical Director 9. Medical Director 10. Discharge Planning Lead 11. Divisional Management Representatives 12. Chief Pharmacist/ Deputy 13. Head of Therapies/ Deputy 14. Radiology Service Manager/Deputy 15. Facilities Representative Source: COO Status: Approved Page 22

ACTION CARD 1: SWITCHBOARD Group Call # Message Authorised by: 173 Trust Status AMBER Activate group call out to notify status in hours only 173 Trust Status RED Activate group call out to request bed meeting, stating time of meeting in hours only 172 Trust Status BLACK/ INTERNAL CRITICAL CAPACITY In hours - Activate group call out to request bed meeting and notifying time of meeting. Plus: ECOO/ Deputy SMOC On call director at any time Director of Nursing/ Deputy Medical Director AMU Consultants On call Intensivist On call Consultants PoD, GoD, T&O, General Surgery Facilities Representative 888 888, SMOC ECOO or deputy ECOO or Deputy, Exec oncall Black Call out as red list plus Deputy General Managers and General Managers Out of hours the following ONLY Executive Director on call Senior Manager on call On call Intensivist On call consultants PoD, GoD, T&O, General Surgery Facilities Representative at any time On call Pharmacist Source: COO Status: Approved Page 23

ACTION CARD 2: CLINICAL DUTY MANAGER (CDM) Bleep 888 TRUST LEVEL GREEN Take handover at start and end of shift and obtain a baseline of Trust capacity and activity in ED from the shift co-ordinator patients waiting for admission, status, and level of activity in each area Check with ED shift co-ordinator for any issues relating to patients, staffing or support required Validate capacity report to enable the CBC to distribute at 08.00, 12.00, 15.00 & 20.00hrs Chair all capacity bed meetings following the standard agenda in section 2.2.3 Escalate to relevant Divisional Manager any potential problems to patient flow: key contacts AMU and ED shift co-ordinators Escalate to SMOC where multiple issues require action simultaneously Monitor ED position in terms of the 4 hour wait Support timely transfers out of ED With support from appropriate bleep holders ensure safe staffing across the site. AMBER All actions as per Green Activate Trust Level staff to initiate action Amber cards via switchboard Escalate issues to Divisional representatives Initiate additional resources as required such as Portering Inform Discharge Planning Team of position to expedite discharges and identify and manage delays Support the area s most under pressure with a physical presence Escalate potential breach situation to Divisional Teams/Senior Manager On-Call if it cannot be resolved in a timely way Formulate clear decisions and agree actions aimed at reducing escalation level & document those actions in action log for follow up at next capacity meeting Source: COO Status: Approved Page 24

RED All actions as per Green & Amber Activate Trust Level staff to initiate Red action cards via switchboard indicating time to attend capacity meeting Liaise directly with the Senior Manager on-call if issues unresolved at ward / department level OOH liaise directly with Executive Director On Call Initiate & chair additional capacity pressure meetings as required Allocate a member of staff in attendance at capacity meetings to capture actions Agree actions aimed at reducing escalation level & document those actions in action log for follow up at next capacity meeting Be clear where the blocks to flow are so that senior managers can support with additional resource or escalation BLACK Black status can only be declared by CEO/ ECOO/Deputy COO /Executive Director on Call All actions as per Green, Amber and Red OOH liaise directly with Executive Director On Call and SMOC Activate Trust Level staff to initiate Black action cards via switchboard indicating time of initial critical capacity meeting Initiate action log and establish command structure in HCC, taking control until SMOC or nominated senior manager arrives Provide data and attend escalated capacity meetings Implement agreed actions aimed at reducing escalation level Ensure areas most under pressure are supported personally or through delegation to others. Source: COO Status: Approved Page 25

ACTION CARD 3: SENIOR MANAGER ON CALL (SILVER) TRUST LEVEL GREEN AMBER Receive exception report handover from previous SMOC at 08:00 handover meeting or via telephone Attend if on site or call extension 3365 at 08:00 handover to gain an oversight of the organisation and decisions being made Support and be available to the CDM to resolve issues they may have Attend all in hours capacity meetings All actions as per Green Support the Patient Flow Team with any escalation issues to Medical or Nursing teams Resolve issues which have not been dealt with by the respective divisional managers RED All actions as per Green and Amber Support the Patient Flow Team to maintain patient pathways by escalating/addressing any potential/actual blocks for example; transport, portering, business continuity issues as requested by the CDM Attend capacity meetings as requested via CDM /ECOO/ Deputy COO/ Executive on Call Review elective surgical & MTU next days planned activity BLACK All Actions as per Green, Amber, Red Attend and remain on site until the situation can be stabilised Take over control of HCC and consider the following: o Remain in HCC and delegate actions as appropriate o Requirement for additional phone lines and computers o Appoint scribe to capture events and actions o Gather Sitrep to support team briefing Make arrangements for alternative support/ SMOC cover if situation is ongoing Work closely to support the Executive Chief Operating Officer/ Deputy/Executive on Call Action requests made from ECOO/ Deputy/Executive on call Source: COO Status: Approved Page 26

ACTION CARD 4: EXECUTIVE CHIEF OPERATING OFFICER (ECOO)/ DEPUTY ( IN HOURS) EXECUTIVE DIRECTOR ON CALL ( OUT OF HOURS) TRUST LEVEL GREEN Normal working ensure you are aware of trust escalation status Ensure you are awareness of any capacity issues in the last 24 hours AMBER All actions as per Green RED All actions as per Green and Amber Consider escalation to CCG. Executives on call/escalation lead Respond to requests from operational staff Attend capacity meetings in hours and support operational teams to resolve issues affecting patient flow. Authorise opening of escalation capacity if required Authorise cancellation of routine elective activity if required Consider/request local ambulance diverts BLACK All actions as per Green and Amber, Red Attend and chair all capacity meetings Work closely with SMOC and CDM to allocate actions as appropriate Consider o Do you need to call in additional staff/ resources particularly out of hours o Available additional nursing/medical staff options( cancelled theatre lists/ clinics) o Redeploy medical and nursing staff on non-clinical activities o Consider the potential to cancel elective admissions in consultation with SMOC and 888 o Use facilities representative to support logistics and supplies issues o Advise AMU and ED consultants of situation and promote alternative pathways and APS Source: COO Status: Approved Page 27

Inform CCG Executive on call / Escalation Lead of status and request system wide teleconference issue invitation to attend site and support capacity meetings o Consider external communications to GPs and out of hours services o DTOC and medically fit numbers o Community bed capacity spot purchases o HALO support from ambulance service Request Ambulance divert from Neighbouring Trusts Inform ambulance control of black escalation status Maintain regular communications with all external agencies Aim to reduce Trust escalation status Source: COO Status: Approved Page 28

ACTION CARD 5: SENIOR NURSING STAFF TRUST LEVEL GREEN Normal working ensure you are aware of Trust Status Respond to escalation requests from the CDM as required. Ensure good working practices are being followed in all wards in relation to patient flow/ safety AMBER Actions as per Green Provide senior support to nursing teams across the divisions as requested. Escalate any clinical/staffing issues that pose a risk to patient safety to Deputy Director of Nursing if unresolved RED Actions as per Green and Amber Attend Capacity Bed Meetings in hours as detailed in point 3.3 Support ward teams to ensure safe moves are being planned and facilitated Escalate any clinical/staffing issues that pose a risk to patient safety Should the Trust need to plan to open extra beds review staffing with divisional staff bleep holders to plan to cover this extra capacity through the next 24-48 hours If staffing levels are insufficient follow normal protocols for arranging extra staff Consider cancellation of non-effective shifts across the divisions BLACK All Local Green-Amber-Red escalation actions are in place Support patient safety/capacity as required Support the teams and Divisions to open up additional beds across the Trust. Risk assess patient moves with medical and nursing staff as requested Complete any actions from the Capacity Bed Meetings Cancel non- effective shifts if not already done. Provide physical presence on wards to support staff and patients Source: COO Status: Approved Page 29

ACTION CARD 6: DIRECTOR OF NURSING/DEPUTY TRUST LEVEL GREEN Normal working ensure you are aware of Trust Status AMBER Actions as per Green Respond to actions as requested by ECOO or Deputy to reduce level of escalation Notify the appropriate support services of any pharmacy or diagnostics issues resulting in delaying the discharge of patients RED Actions as per Green and Amber Respond to escalated requests from the Head of Nursing on any clinical/staffing issues that pose a risk to patient safety Support any actions requiring liaison with WSCCG in liaison with the ECOO With the Medical Director, ensure that clinical risk across the Trust is kept to a minimum BLACK All Local Green-Amber-Red escalation actions are in place Attend capacity meetings in hours Respond to escalated requests from ECOO Source: COO Status: Approved Page 30

ACTION CARD 7: WARD CONSULTANTS / ON CALL CONSULTANTS GREEN Normal working ensure you are aware of Trust Status Undertake ward & board rounds with a focus on discharge planning 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 fashion Escalate concerns about delayed discharges or blockages in the system to the Senior Matron RED All actions as per Green and Amber There is an urgent requirement to expedite discharges and engage in reducing capacity pressures Implement arrangements for daily review to include twice daily board rounds/additional ward rounds where possible BLACK All Local Green-Amber-Red escalation actions are in place Capacity issues causing major operational difficulties presenting risks to patients safety There is a need for emergency measures to be put into place to manage the situation and to ensure patient safety Work with the Clinical Director and management team to proactively undertake actions to expedite safe discharges and improve capacity Report to the capacity / on call team any delays in the system which are hampering ability to undertake assessments for admissions/discharges Note: At Black the AMU consultant should be responsible for actions at the front door i.e. in ED or AMU. PoD should be responsible for any actions involving the wards such as improving the discharges. PoD / GoD would not be called to ED unless the AMU consultant feels they need additional consultant help in which case the AMU consultant should call PoD themselves Source: COO Status: Approved Page 31