Northern Staffordshire System Escalation Plan (Health and Social Care) April 2015

Northern Staffordshire System Escalation Plan (Health and Social Care) April 2015 Review Date: July 2016 or in response to post event learning or material changes to the urgent care system Page 0

Foreword In the winter of 2015-2016 we faced one of our most challenging times with high demands on services within health and social care. There were a number of reasons including an increased number of patients needing care within the community or the acute hospital, alongside the other pressures we face during the winter period. Following winter we have looked at what we could do better; one aspect is to make sure we are all very clear on what we need to do at times of increasing demand for our services, how we need to operationally manage those demands and making sure our leaders know what is expected of them. To build on our existing partnership working we continue to strive to improve the way we jointly work; as a result we have reviewed our, System escalation Plan which is set out in this document. It is important that we provide the best care and experience possible for the local population and to make sure our staff continue to enjoy coming to work, even when we are faced with challenging circumstances. We therefore support this System Escalation Plan in a step forward to improving the experience of patients and their families and also to support the working lives of our staff. Signed: Mark Hackett, UHNM Stuart Poynor, SSoTP Caroline Donovan, NSCHT Anthony March, WMAS Dr Andy Bartlam, Stoke CCG Dr Julie Oxtoby, North Staffs CCG John van de Laarschot, Stoke City Council John Henderson, Staffordshire County Council 1

Version History Log This area should detail the version history for this document. It should detail the key elements of the changes to the versions. Version Date Description of significant changes implemented Intentionally left blank 2

Contents FOREWORD... 1 1. INTRODUCTION... 4 1.1. PURPOSE... 4 1.2. BACKGROUND... 5 1.3. LESSONS LEARNT... 6 2. TRIGGERS... 7 2.1. ESCALATION LEVELS AND TRIGGERS... 7 2.2. WHAT IS EMS?... 7 2.3. EMERGENCY AMBULANCES... 8 2.4. WEST MIDLANDS EMS TRIGGERS... 9 3. LEADERSHIP... 10 4. COMMAND AND CONTROL... 10 4.1. When would we use Command and Control principles?... 10 4.2. What do we mean by Command and Control?... 10 4.3. Command and Control roles... 10 4.4. Command and Control SILVER & GOLD MEETING AGENDA... 12 5. COMMUNICATION... 12 6. INFECTION CONTROL... 12 7. ROLES AND RESPONSIBILITIES... 12 7.1. SHARED RESPONSIBILITY... 12 7.2. CHIEF OPERATING OFFICERS / GOLD COMMANDERS (STRATEGIC LEADER):... 12 7.3. SILVER COMMANDERS:... 12 7.4. CLINICAL COMMISSIONING GROUPS:... 13 8. ASSURANCE FRAMEWORK... 13 9. ACTION CARDS LEVEL 1... 14 10. ACTION CARDS LEVEL 2... 19 11. ACTION CARDS LEVEL 3... 24 12. ACTION CARDS LEVEL 4... 30 13. NON-URGENT PATIENT TRANSPORT ACTIONS (NSL)... 35 15. REGIONAL CAPACITY MANAGEMENT TEAM (RCMT) ACTIONS... 36 14. AREA TEAM PRIMARY CARE ACTIONS... 38 15. NHS111 ACTIONS... 38 16. STAFFORDSHIRE DOCTOR URGENT CARE ACTIONS... 40 17. APPENDIX 1 EMS TRIGGER 3, 10 AND 14-SPECIFIC ACTION CARD... 41 ACTIONS TO BE CARRIED OUT IF TRIGGERS 3, 10, 14 ARE REPORTED AT LEVEL 3 OR 4 WITHIN THE EMS LEVEL... 41 18. APPENDIX 2 SILVER CONFERENCE CALL AGENDA... 43 19. APPENDIX 3 GOLD CONFERENCE CALL AGENDA... 45 20. APPENDIX 4 GOLD AND SILVER COMMAND AND CONTROL AGENDA... 47 21. APPENDIX 5 SILVER SITUATION REPORT SITREP FOR GOLD... 49 22. APPENDIX 7 CONFERENCE CALL CODE OF CONDUCT... 51 23. APPENDIX 8 AUDIT TOOL... 52 24. APPENDIX 9 UHNM FULL CAPACITY PROTOCOL... 53 25. APPENDIX 10 OTHER ORGANISATIONS - FULL CAPACITY PROTOCOLS... 62 GOLD: EXECUTIVE ON-CALL (ON-CALL) SILVER: SENIOR MANAGER (ON-CALL) BRONZE: SERVICE MANAGERS... 64 26. APPENDIX 11 CCG CHECK LIST... 70 3

1. INTRODUCTION 1.1. Purpose This is a health and social care plan which sets out the process for escalation when there is increased demand for health and/or social care services across the Local Health and Social Care Economy (LHE). This escalation plans sits in support of additional plans, such as Winter Resilience and Capacity & Demand modelling and Major Incident Response. The plan is supported by a programme of system wide education and will be subject to annual testing through exercise and audit. In support of this plan, an accountability and audit framework has been developed (appendix 8) to support the continued drive for excellent patient experience and services in North Staffordshire The Northern Staffordshire partnership within the LHE includes health and social care, voluntary services and includes primary care and out of hours services, demonstrating an integrated approach to effectively maintain quality, supporting parts of the system which may be under pressure at a point in time. The focus of the plan is to achieve level 1 consistently as a system and to de-escalate quickly should pressures arise. EMS level 4 should be seen as a never event and all actions focused on returning / maintaining EMS level 1. The standard is to have a robust escalation system to support sufficient and safe service capacity across the health and social care system, including: Providing transfers of care for the patient in the most appropriate setting. Supporting best practice in Infection Prevention and single sex accommodation Supporting staff by clearly setting out roles and expectations Delivering the A&E 4 hour wait and other emergency metrics Keeping Delayed Transfers of Care (DToC) at a minimum The number of patients assessed and waiting for services is kept to a minimum Delivering speciality compliant 18 week pathways Support effective use of ambulance services Avoid system failures that result in penalties Shared risk management across the whole system Shared responsibility across the system for effective patient flow Specifically this plan will outline the arrangements regarding: Structured system wide escalation & de-escalation Timely response Roles and responsibilities Leadership Action cards Accountability and Assurance 4

1.2. Background The Plan framework provides a consistent and co-ordinated approach to the management of pressures in Northern Staffordshire and is designed to ensure the system is process driven and not person dependent. Planning arrangements for the Northern Staffordshire health and social care economy and has been prepared in conjunction with the following partner organisations: Stoke-on-Trent Clinical Commissioning Group (SOTCCG) North Staffordshire Clinical Commissioning Group (NSCCG) Staffordshire and Stoke on Trent Partnership Trust (SSOTPT) University Hospitals of North Midlands (UHNM) Stoke-on-Trent City Council Staffordshire County Council North Staffordshire Combined Healthcare (NSCH) West Midlands Ambulance Service (WMAS) This escalation plan sets out the procedures across the LHE to manage day to day variations in demand across the health and social care system as well as the procedures for managing significant surges in demand by having a clear escalation and de-escalation plan where everyone knows what they should be doing and when, taking responsibility for their individual and organisational actions and contributing to a shared risk management approach across the system. This plan will not specifically detail any requirements under the Emergency Preparedness, Resilience and Response guidelines although, of course, there may be interconnection between processes depending on the nature of the incident / emergency. At the point of which a Major incident is declared please refer to the relevant organisations Major Incident Response and Recovery Plan. EMS level 4 should be seen as a never event and all actions focused on maintaining EMS Level 1. 5

1.3. Lessons Learnt As part of the Lessons learnt following winter 2014-15, 15 key points have been agreed; this plan meets recommendations 6 and 15 as set out below: KEY POINTS 1. Plan to empty capacity across the system routinely particular in advance of predicted periods of increased demand. 2. Capacity plan to be discussed at SRG with a view to developing capacity planning over a rolling period. 3. There should be a QIA on the actions taken during the Major Incident with a view to understanding how to use the QIA to assess decisions in the future. 4. Major Incident plans / actions need to be brought into alignment with escalation and de-escalation plans across the system. 5. An agreed process around assessment of patients waiting social care discharge needs to be agreed. 6. All organisations need to bring their escalation actions in line and a system wide plan with actions needs to be in place for routine service developments. 7. A system wide communications plan needs to be in place to ensure clear wide system messages, including; communication to the public and external organisations. 8. The consultant based in the Ambulance control room worked well along with clinical triage in 111 placements needs to be reviewed to provide evidence of this working well and whether something can be provided longer term. The impact on having a GP based at the Walk In Centre also needs to be reviewed to see if this is having enough of a positive impact and whether this service should be continued. 9. Ambulance Services and UHNM Emergency Department Representatives to see if there are any better ways to manage patients waiting assessment in ambulance triage and to improve ambulance turnaround times, (queues). 10. Education around the discharge process and thresholds needs to be potentially changed along with what services are available in the community to support clinical decision making during the discharge process. 11. There needs to be clear system wide structure to command and control during times of significant increase in demand not just in escalation. 12. There needs to be better integration of primary care within agreed plans for example staffing resources. 13. Timely interaction and a consistent focus required to maintain pace of decision making and acting, this should be developed within the system wide plan. 14. HR colleagues to develop a system wide workforce plan to support greater resilience across the health and social care system. 15. An economy wide Gold and Silver training programme needs to be developed to include the use of the agreed system wide actions / protocols, including structure of conference calls to ensure consistency of approach against a set of escalation and de-escalation metrics. 6

2. TRIGGERS 2.1. Escalation levels and triggers Escalation levels are determined by the regional capacity Escalation Management System (EMS) with pre-determined triggers. However, we recognise limitations in the system in that not all partners currently use or are able to use EMS; this leaves the focus of the response being driven by the acute hospital status. Nonetheless, a rise in EMS levels can be seen as a symptom of whole system pressures and we will therefore focus on strengthening escalation actions with clear leadership against the acute hospital triggers. 2.2. What is EMS? EMS is a bespoke, dynamic regional health economy escalation management system. The system is designed to work with health economies nationally. The tool is an interactive secure NHS website for all acute trusts and local health economy (LHE) partners to report escalation levels during the day. The site provides a helicopter view of pressure across health economies to all users. It is populated locally, using regionally agreed escalation triggers and is key to all managers in call when accessing regional pressure. LEVEL 1 Normal Pressure LEVEL 2 Moderate Pressure LEVEL 3 Significant Pressure LEVEL 4 Extreme Pressure There are two mandatory update periods for acute trusts, 07:30-09:30 and 14:30-16:30 to update EMS daily. However, the system should be updated as and if the position changes by the Site Mangers at RSUH and County sites. The EMS functionalities underpin the surge planning strategy for all health and social care partners. This allows transparency across the whole LHE and is led by the Regional Capacity Management Team (RCMT). Within each EMS level are a set of triggers that, depending on the inputted response, determine the EMS level. The summary of those triggers is circulated to partners. For example, it is possible to be on Level1/2/3 but still have key triggers reported at level 3 or 4. This summary should form a part of the LHE conference calls and focus on deescalating triggers at level 3 and 4 within the EMS Level. A measure of success of the actions taken will be lower reported levels. In Northern Staffordshire analysis shows that the following triggers are run at a consistently high level: Trigger 3 Trigger 10 Trigger 14 Expected Capacity deficit Planned additional bed capacity occupancy Number of patients Medically Fit for Discharge 7

Example, of trigger levels reported at EMS level 2: FOR ACTION CARDS SEE SECTION 9 PAGE 14 It is this summary that will now help to focus the actions within each level, as well as the overarching action cards. There are specific LHE action cards for these triggers 3, 10 and 14 are reported at level 3 or 4. (Appendix 1) 2.3. Emergency Ambulances The Northern Staffordshire LHE works in partnership with West Midlands Ambulance Service NHS Foundation Trust (WMAS) but it worthy to note that WMAS is a regional ambulance service and has its own escalation system actions; WMAS Resource Escalation Action Plan (REAP). There is a need to be mindful that WMAS as a regional service may escalate even though the pressures are outside of Staffordshire. Furthermore, WMAS has developed its Strategic Surge Management Plan to ensure that the expected high standards and safe delivery of services are maintained throughout the whole of the winter period of 1 November 31 March. This period represents the winter period when demand for ambulance services is traditionally at its highest. However, the response actions in this plan can be used at any time when a demand spike is expected or experienced. WMAS has developed this plan to outline the actions that will specifically be undertaken by the Trust to maintain business continuity, provide support to local Health Economies and support the national Department of Health strategy. Where events are foreseeable the Trust will put in place necessary arrangements; however some events and changes in demand are unexpected and require appropriate management and coordination arrangements.) 8

2.4. West Midlands EMS Triggers Level 1 - Planned Operational Working Level 2 - Moderate Pressure Level 3 - Severe Pressure Level 4 - Extreme Pressure Acute Acute Acute Acute current risk of a patient waiting more than 4 hours to be seen more patients waiting more than 4 hours patients waiting more than 4 hours a decision patients waiting more than 4 hours and a 1 No in ED 1 Risk of one or in ED within the 1 One or more is unlikely to 1 One or more decision is unlikely next hour. be made for the next hour. to be made for the next 4 hours. 2 Transfer of Ambulance patient care is shorter than 15 minutes. 2 Transfer of Ambulance patient care is between 15 and 30 minutes. 2 Transfer of Ambulance patient care is between 31 and 60 minutes. 2 Transfer of Ambulance patient care is longer than 60 minutes. 3 Expected admission capacity greater than or equal to expected admission 3 There is an expected admission capacity deficit of less than 10% of 3 There is an expected capacity deficit of between 10% and 20% of expected 3 There is an expected capacity deficit of more than 20% of expected demand for the next 24 hours. expected demand for the next 24 hours. demand for the next 24 hours. demand for the next 24 hours. 4 Elective work proceeding as planned. 4 Up to 10% of elective and urgent inpatient work cancelled on the day. 4 10% to 90% elective and urgent inpatient work cancelled for the next 24 4 More than 90% elective work including oncology patients cancelled for the hours. next 24 hours. 5 Patients subject to a decision to admit not at risk of 8 hour trolley waits. 5 Risk of one or more patients subject to a decision to admit at risk of 5 One or more patients subject to a decision to admit now waiting longer 5 One or more patients subject to a decision to admit now waiting longer waiting 8 hours on a trolley in the next 2 hours. than 8 hours on a trolley. than 8 hours on a trolley and at risk of waiting longer than 12 hours. 6 Medical outliers form less than 0.5% of total inpatient population. 6 Medical outliers form between 0.5% and 1% of total inpatient population. 6 Medical outliers form between 1% and 3% of total inpatient population. 6 Medical outliers form more than 3% of total inpatient population. 7 Cubicles in A&E are less than 80% occupied. 7 Cubicles in A&E are 80% -100% occupied. 7 All Cubicles in A&E are full and patients are waiting in planned overflow 7 All Cubicles in A&E are full and patients are expected to wait in unplanned areas. overflow areas. 8 More than 1 resuscitation bay available for immediate use. 8 Only 1 resuscitation bay available for immediate use. 8 No formal resuscitation bay available in A&E for the next 30 minutes. 8 No formal resuscitation bay available in A&E for next hour. 9 Beds in Assessment Areas are less than 90% occupied. 9 Beds in Assessment Areas are 90%-99% occupied. 9 No Assessment area beds for up to 3 hours minimum. 9 No Assessment area beds for more than 3 hours. 10 Planned additional bed capacity on standby. 10 Planned additional bed capacity open and less than 80% occupied. 10 Planned additional bed capacity open and more than 80% occupied. 10 All planned additional bed capacity open and full; unplanned capacity in use. 11 No loss of admission bed capacity due to infection control measures. 11 Partial or whole ward closed to admission or discharge due to infection 11 More than one ward closed to admissions or discharge due to infection 11 More than one ward closed to admissions or discharge and whole control measures. control measures with local restrictions on visiting. Hospital closed to visitors due to infection control measures. 12 Critical care capacity less than 80% occupied. 12 Critical care capacity is 80%-100% occupied. 12 All formal critical care capacity occupied and planned overflow areas in 12 All formal critical care capacity occupied and planned overflow areas in use. use. Potential transfers identified but unresolved. 13 Gender specific beds available as planned. 13 Patient moves required, expected within 1hr. 13 Patient moves required, expected within 4hrs. 13 Patients waiting for appropriate gender beds; non-planned or available. 14 Medically Fit for Discharge cases form less than 9% of the inpatient total. 14 Medically Fit for Discharge cases form between 9% and less than 11% of 14 Medically Fit for Discharge cases form between 11% and 13% of the 14 Medically Fit for Discharge cases form more than 13% of the inpatient the inpatient total. inpatient total. total. Community Providers Community Providers Community Providers Community Providers Community Beds Community Beds Community Beds Community Beds (Minimum of two triggers applicable) (Minimum of two triggers applicable) (Triggers 1 to 3 are mandatory) (Triggers 1,2 & 3 are mandatory) 1 Community bed availability is > 5% 1 Community bed availability is < 5% 1 No community bed capacity 1 No community bed capacity 2 No operational issues 2 Discharges are planned for today 2 Anticipated discharges by next day 2 All additional capacity is open 3 Planned admissions > 5% 3 Planned admissions < 5% 3 Planned admissions by next day 3 No anticipated discharges within 48 hours 4 Emergency direct admission being refused (Optional trigger) Urgent Care Centres/Minor Injury Unit/ Walk In Centre Urgent Care Centres/Minor Injury Unit/ Walk In Centre Urgent Care Centres/Minor Injury Unit/ Walk In Centre Urgent Care Centres/Minor Injury Unit/ Walk In Centre 1 100% of patients are treated and discharged with in 2 hrs 1 98% of patients are treated and discharged between 2 to 3 hrs 1 95% of patients are treated and discharged between 3 to 4 hrs 1 Time taken to treat and discharge any patients is > 4 hrs Community Services Community Services Community Services Community Services 1 All rostered staff working 1 Staffing levels at > 90% of rostered availability. Skill Mix appropriate 1 Staffing levels at 80-90 % of rostered availability. Skill Mix tolerable 1 Staffing levels at < 80% of rostered availability. Skill Mix inappropriate 2 New referrals accepted 2 New referrals accepted through prioritising care 2 Prioritising routine care and only responding to urgent new referrals 2 Only urgent complex and high priority care can be delivered 3 Can respond to normal request in 2 working days 3 Unable to respond to routine referrals in 2 working days 3 Urgent response will be within 4 hours. Routine Responses will be 3 Emergency visits only. Business continuity plan enacted rescheduled 4 Updating of administration within the day. Staff breaks possible, 4 Reduced time for office work and documentation, review all meeting representation at meetings, and working to normal hours. Patient records requests. Normal working hours need to be extended. Back log of activity and activity are recorded. being recorded 4 Staff breaks not accommodated and working over contracted hours in excess of 2 hours Study leave, training and courses cancelled. Only patient records completed 4 Agreed overtime to complete patient related tasks 5 Able to deliver routine, essential and critical services. 5 Complex & Palliative care prioritised over routine services. 5 No routine visits or assessments undertaken. 5 Complex patient care only undertaken - potential risk to patient safety 6 No adverse weather conditions or planned major disruptions 6 Short term disruption expected <24hrs 6 Medium term disruption expected. > 24 hours < 48hrs 6 Long term disruption expected. > 48 hours WMAS WMAS WMAS WMAS (Normal working - all triggers apply) (3 out of 4 triggers apply) (4 out of 5 triggers apply) (2 out of 3 triggers apply) 1 Red response for cluster is > 75% 1 Red response for cluster is < 75% for the cluster 1 Red response < 65% for the cluster 1 Red response is < 60% for the cluster 2 No out of time referrals for the cluster 2 RRV's are waiting > 15 minutes for back up in the cluster 2 RRV's waiting >30 minutes for back up on the cluster 2 Empty status plan for the cluster 3 WMAS reporting REAP level 1 or 2 WMAS reporting REAP level 1 or 2 3 5 or less out of time referrals in the cluster 3 6 or more out of time referrals in the cluster 3 WMAS reporting REAP level 4 or 5 4 Hospital Turn round issues have been escalated to Senior 4 Hospital Turn round times escalated to Director/SHA level within the Management level within the Cluster 5 WMAS reporting REAP level 2 or 3 5 WMAS reporting REAP level 3 or 4 OOH OOH OOH OOH forecast forecast 1 Call volume within forecast 1 Call volume 20% above forecast 1. Call volume 20-50% above 1 Call volume > 50% above 2 Staff redeployed to meet demand 2. Extra resource deployed to meet demand 2 Able to only deliver urgent care Hospital Social Care Services Hospital Social Care Services Hospital Social Care Services Hospital Social Care Services (Minimum of two triggers applicable) (Minimum of two triggers applicable) (Minimum of two triggers applicable) (Minimum of two triggers applicable) 1 Normal staffing levels available 1 <70% of normal staffing levels available 1 <60% of normal staffing levels available 1 <50% of normal staffing levels available 2 Normal amount of referrals received eg. Section 2 referrals 2 >10% increase of the normal amount or referrals eg. Section 2 referrals 2 >20% increase of the normal amount of referrals eg. Section 2 referrals 2 >40% increase of the normal amount of referrals eg. Section 2 referrals 3 <10% above the normal amount are unable to progress 3 >10% above the normal amount are unable to progress 3 >20% above the normal amount are unable to progress 3 >40% above the normal amount are unable to progress 4 Normal team caseload levels 4 10% above normal team caseload levels 4 20% above normal team caseload levels 4 40% above normal team caseload levels 5 All cases have been assessed within 24hrs of an active 5 >5% of cases which have not been assessed within 24 hrs of the active 5 >10% of cases which have not been assessed within 24 hrs of the 5 >15% of cases which have not been assessed within 24 hrs Section 5 referral Section 5 referral (not due to external factors) active Section 5 referral (not due to external factors) of the active Section 5 referral (not due to external factors) Cluster 9

3. LEADERSHIP LEVEL 1 Normal Pressure Management: Operational Managers/Site Manager Assurance to: Heads of service Assistant/deputy LEVEL 2 Moderate Pressure Management: Heads of Service/ Assistant Director/Deputy Assurance to: Assistant/Associate Director level LEVEL 3 Significant Pressure Management: Assistant/Associate Director level/silver Assurance to: COO/Director LEVEL 4 Extreme Pressure Management: Director/COO/Gold Assurance to: Chief Executive/CCGs GOLD may give instruction to enact UHNM and Full Hospital Protocol RSUH site only) 4. COMMAND AND CONTROL 4.1. When would we use Command and Control principles? In the event that emerging pressures show either no sign of de-escalation after 4 hours nr EMS level 4, the system will run on, Command and Control principles this will be approved agreed by the Gold commander only. 4.2. What do we mean by Command and Control? Command and control is the means by which a commander recognises what needs to be done and sees to it that appropriate actions are taken. This means that the Silver commander/s will take operational control and responsibility reporting to Gold. No component part within organisations should then make unilateral decisions on matters relating to capacity but can seek authorisation by Silver. RSUH control room function will change and each day run from 08:00 to 20:00 hours (extended on instruction of the Gold Commander). NSCHT will run on Command and Control as instructed through Strategic Commander [On Call Executive]. The hours of Operation will vary depending on the issues and actions required. Detail will be agreed through the Strategic LHE structure 4.3. Command and Control roles To Note Silver / Gold/ Bronze roles do not reflect any hierarchical existing job titles or roles and cannot be overruled during the incident management process without the commanders approval. Day to day job titles stay outside of the incident management command and control structure. 4.3.1 GOLD Commander - STRATEGIC. Oversee the strategic provision of healthcare services across the organisation, coordinate communication with other organisations Directs and monitor delivery of agreed actions and give overall strategic direction. Do not take on the role of Silver who is operationally in charge. At UHNM supported with on-site presence from: Gold level senior nurse and Gold level senior medic. Communications lead. 10

At SSoTP supported with on-site presence from: Strategic Lead for Unplanned Care Chief Operating Officer for the North At WMAS supported by; Silver SOC Commander Silver on call on-site 4.3.2 SILVER Commander TACTICAL. At UHNM Silver will: Co-ordinate the Incident Control room function via the Incident coordination centre, Springfield building. Chair tactical meetings (Silver Update meetings, conference calls) ensuring setting and delivery of agreed actions Report to Gold and keep Gold briefed at agreed timelines. Take whole organisational responsibility for tactical (operational) management. Out of hours the role of Silver role is fulfilled by the Site Manager until the on-call manager (Silver) arrives on-site. At SSoTP supported with on-site presence from: Strategic Lead for Unplanned Care Chief Operating Officer for the North At WMAS Silver will; Liaise with On-site Bronze officer (HALO or ASO) Liaise with EOC Duty Officer Communicate to Gold when required. 4.3.3 BRONZE Commander/s OPERATIONAL At UHNM: Associate Directors are responsible for ensuring UHNM Bronze command posts are set up and function from 08:00-20:00 with a named Bronze commander (unless instructed by Silver) to extend hours, in: Emergency department Medicine Division Surgery Division Specialised Division Women s & Children s and Clinical Support Services The Director of Operations or Deputy is responsible for setting up Bronze: Capacity Team control room Each the control room must be manned for the period set out unless formally stood down by Gold. Others may be required to support as requested by Silver/Gold Commander, for example, Infection Prevention, Corporate Services. This request will be determined by emerging pressures. At level 3 additional meetings may be called by the COO or Director of Operations (Gold). At SSoTP supported with on-site presence from: Strategic Lead for Unplanned Care Chief Operating Officer for the North 11

At WMAS: HALO will be on site within the department Area Support Officer will communicate with HALO and on call Silver as required. City Social Care, North Staffordshire combined Healthcare Trust will take instruction from their Gold commanders on setting up and running a command and control structure. 4.4. Command and Control SILVER & GOLD MEETING AGENDA To support Silver and Gold commanders during command and control template agenda are set out in appendix 4. 5. COMMUNICATION The LHE Communication Team will issue press statements but only when these have been agreed by all organisations. If, however, escalation procedures have been invoked to the point of declaring a major incident, the issue of press statements will be a decision taken by the Gold Commanders. 6. INFECTION CONTROL Specialist infection prevention and control advice should be sought as part of the day to day capacity and demand management decision making processes within each organisation; Infection Prevention teams discussing directly with each other on cross-organisational issues and advising their respective Capacity management teams. 7. ROLES AND RESPONSIBILITIES 7.1. Shared responsibility Each organisation has a responsibility to maintain patient safety across the local health and social care system; this includes supporting the maintenance of a fully functioning Emergency Department and other Emergency Portals and timely response to surge. Health and social care partners in North Staffordshire will take a shared risk approach by not letting all the clinical and organisational risk sit within one point within the health and social care system, taking timely actions. 7.2. Chief Operating Officers / Gold commanders (Strategic leader): Provide strategic leadership for effective patient flow. Ensure internal escalation plans are in place and followed. Ensure system wide actions are in place and followed. Do not run the incident response 7.3. Silver Commanders: Responsible for running the incident response Briefing up Ensuring actions are being taken Provide assurance to Gold that all actions at the respective level have been done. 12

Providing timely briefing to Gold prior to conference calls. Carrying out Gold instruction Appropriate and timely escalation to Gold or external colleagues 7.4. Clinical Commissioning Groups: Receive assurance that the agreed actions have been taken Respond to requests for commissioning needs Contribute to the strategic and tactical leadership of the incident at Silver and Gold level 8. ASSURANCE FRAMEWORK Standard Assurance Evidence A system wide escalation Ratified plan in place plan is jointly developed All relevant staff receive Training records training on the system wide escalation plan The health and social system in Northern Staffordshire will provide a joint response to increases in patient demand to ensure that no single part of the system experiences severe disruption. Operational implementation The plan is tested annually The plan is reviewed annually or in response to lessons learnt Quarterly audit will be conducted using the audit form in appendix 8 Exercise date is set and SRG receive post exercise report Updates are received by SRG Audit feedback: 1 st level - individuals 2 nd level - line managers 3 rd level - System issues to SRG 13

9. ACTION CARDS LEVEL 1 LEVEL 1 NORMAL WORKING Action Cards 14

EMS Level 1 UHNM Ensure all internal escalation plan actions have been completed All wards are to identify their target number of discharges (as minimum) and contact there Divisional Patient Flow lead NO LATER than 8.15 am with patient details Bed Meeting Attendance as set out by each Division Clinical Site Manger to ensure all wards aware of the EMS Level by sending IT notification. Real time bed state using WIS within the wards to be updated Bed meetings to be held three times a day, see section see section 6. CSM to proactively manage the bed stock, placing patients in appropriate bed in a timely manner. Ward Manager to make sure that each patient has a predicted date of discharge. Escalate any delays in diagnostic tests & inform of potential suitable outliers etc. Ward Manager to ensure that patients are being moved in a timely manner and expediting discharges. Ensure that the discharge lounge is utilised for appropriate patients. Ensure compliance with discharge bundles. Make sure that patients are referred to other members of the MDT in a timely fashion Support maintaining A&E 4 hour standard. Complex Discharge Co-Ordinator to update plan for every delayed transfer of care. CSM to produce over-arching plan after 3.30pm bed meeting for out of hours. Ward Managers and Matrons to identify patients who when medically stable/suitable could be transferred to UHNM at home. Matron to follow up staffing shortfalls and to produce a plan for any staffing issues OOH All areas to plan and prepare for sudden increase in demand by maintaining patient flow and ensuring timely discharge & transfers Responsible ADs/Director of Ops Ward Managers Patient Flow leads CSM Nurse in charge Capacity Team CSM Matrons/ Ward Manager Ward Manager All Complex Discharge Co-ordinator CSM Ward Leads/Matrons Matrons/Associate Chief Nurses ED, Ward Mangers EMS LEVEL 1 SSOTP Patient Flow All wards are to identify their number of discharges and contact the Patient Flow lead NO LATER than 8.15 am with patient details, this is then to be forwarded to the hub co-ordinator All step up/step down services to confirm their discharges no later than 8.30am to the Hub Co-ordinator The hub co-ordinator to ensure all service managers are aware of the EMS Level by sending IT notification. Internal Conference call - participants: Chair: Silver Commander/Co-ordinator/Area Manager/Community Hospital Manager Participants: Community Hospitals Rep, IC Capacity/LIS capacity rep, UHNM interface rep, hub co-ordinator Template to be completed and circulated with actions Community Hospitals Patient Flow Coordination Team Manager to proactively manage the bed stock, placing patients in appropriate beds in a timely manner. 15 Responsible Ward Managers Team Leaders/Silver Co-ordinator Hub-Co-ordinator Silver commander/coordinator Patient Flow Coordination Team Manager

EMS LEVEL 1 SSOTP All side room usage to be reviewed Community Services Team leaders to proactively manage capacity in accepting patients in a timely manner liaising with the hub co-ordinator All Ward Managers/Clinical Leaders to make sure that each patient has a predicted date of discharge. Escalate any delays & inform of potential suitable exit strategies etc. Ward Manager to ensure that patients are discharged before lunch and provide exception reports where this does not happen. Make sure that patients are referred to other members of the MDT in a timely fashion and escalate any delays Community Hospitals Patient flow co-ordinator to update plan for every delayed transfer of care for escalation to Patient Flow Coordination Team Manager Community Hospitals Ward Managers to identify patients who could be transferred to Intermediate Care at home. Intermediate Care Team leaders to identify patients who could transfer to domiciliary care services Ward Managers/Team Leaders to follow up staffing shortfalls and to produce a plan for any staffing issues OOH All areas to plan and prepare for sudden increase in demand by maintaining patient flow and reviewing all IC restrictions and ensuring timely discharge & transfers Responsible Managers/Clinical Leaders Ward Managers Patient Flow Coordination Team Manager Ward Leads/Matrons Ward Managers/Team Leaders Ward Mangers 16

EMS Level 1 WMAS WMAS operational resources to pass details patients on to hospital system. Handover and offload within 15 mins of arrival and promptly return to vehicle to make ready for availability to EOC. Maintain contact with resources at Acutes, ensuring timely handovers and bed availability Consider utilising spare stretchers to clear resources within 30 minutes and liaise with hospital desk regarding recording of this. Utilise Patient Release button functionality in CAD Online achieving at least 95% completion compliance Liaise with Hospital Desk to maintain resource overview Monitor performance and activity identifying early pressure points Update escalation management system website regarding outstanding workload Monitor turnaround times; consider level 2 if trigger point reached 4 hourly Send estimated time to clear message to resources at 20 Minutes Contact HALO s for appraisal of situation on-site at Acutes, identifying early pressure points If no HALO on site liaise directly with hospital and EOC Duty Manager to ensure ASO/BRONZE Officer responded if required Maintain Control Log and EMS entries Offer advice regarding activity across other Acute Trust sites to manage flow of patients. Liaise with On-site HALO or BRONZE Officer (if present) Provide Gold functions [Strategic] if required Provide Silver functions [Tactical] if required Review and monitor weekly delays Responsible Operational crews Operational crews HALO/BRONZE Hospital Officer HALO/BRONZE Hospital Officer HALO/BRONZE Hospital Officer EOC Duty Manager EOC Duty Manager EOC Duty Manager EOC Duty Manager Hospital desk Hospital desk Hospital desk Hospital desk Hospital desk Supervisor Hospital desk Supervisor on Call Assistant Chief Officer Manager on call Heads of Directorate or designated other Ensure all admissions to adult acute wards are gate kept Head of Directorate - Adult Inpatients or designated other EMS LEVEL 1 CITY SOCIAL CARE Normal working North Staffordshire Discharge Policy utilised Social care to arrange discharges within agreed timescales Responsible Team Manager Team Manager Team Manager Report any problems / issues with delays/access UHNM Update CDS to reflect current patient status. Attend MDT / MFFD meetings. Ensure all teams are aware of the EMS level. to services to Team Manager Team Manager Team Manager Team Manager Track bed availability across the independent sector/local authority Team Manager 17

EMS LEVEL 1 CITY SOCIAL CARE Track in house/independent sector domiciliary care Responsible Team Manager EMS LEVEL 1 CCG City/North/South Provide First Responder and Gold functions Monitor system information Ensure admission/attendance avoidance schemes are operating fully Responsible First Responder and Gold Urgent Care Team and First Responder Urgent Care Team and First Responder 18

10. ACTION CARDS LEVEL 2 LEVEL 2 Moderate Pressure Action Cards 19

EMS LEVEL 2 UHNM Actions as in Level 1 and 2 Confirm all internal level 1 & 2 actions have been completed Designated Patient Flow Manager from each Division with information of all patient delays in ED and knowledge of bed allocation / pharmacy / diagnostic delays. Clinical area reps to collect information of all patient that every action has been taken previously to escalate delay direct to the service involved, & update plan for every patient- info to be brought to Patient Flow Meetings and plans agreed to fast-track patients. To consider any clinical staff on office days, meetings, study days/ sessions etc., are to return to shop floor to assist in patient flow issues, review board rounds and facilitate discharges where ever practical. Where unable cover is to be arranged to ensure board / ward round activity is carried out in a timely manner. Consider review of patients brought in the day before surgery Directorate Mangers to inform teams of increasing pressure, requesting support in assessment reviews Review all capacity and activity with a view to using staff in areas of pressure Utilisation of Discharge Lounge use for patients waiting discharge to make capacity and ensure is used safely by default. Review any patient waiting solely for diagnostics or investigations and consider discharge with appropriate follow up with Clinicians Consider alternative f l e x i b l e transport solutions. Discuss with ambulance transport to prioritise discharges if needed. Discuss with theatres/surgical teams to ensure patients are taken to theatre in priority order as per Theatres operation procedures Delayed discharges to be escalated to Patient Flow Manager & addressed with relevant MDT Where Wards target possible discharges are not met, Directorate Manager and Matron of area to review with Wards and implement action plan to ensure discharge targets are achieved within Division. Information and update to be provided to Bed Manager / Patient Flow Coordinator continually both prior to and after Capacity Meeting. Deputy /Divisional AD to update at Capacity Meeting Responsible ALL Ads/Director of Ops Clinical Site Team Ward Managers & Discharge team Directorate Managers / Clinical Lead DMs Patient Flow Manager and Matron Patient Flow Manager / Ward Manager Ward Manager/Matron Head of Patient Transport CSM Theatres DM Discharge team Matrons / DMs Matrons/ DMs ADs / Deputies 10 Golden patients identified Matrons / DMs EMS LEVEL 2 SSOTP Actions as in Level 1, with items detailed in addition Patient Flow As in level 1 with the addition of escalation to COO with any areas where there is an issue with patient flow including information of all patient delays in all critical services. Internal Conference call participants as in level 1 but escalation to COO any 20 Responsible ALL Service Managers Silver

EMS LEVEL 2 SSOTP capacity issues. All actions to be fed through to LHE Silver conference call Health Economy Conference Call Participants: Silver commander, hub coordinator Ward managers to ensure board / ward round activity is carried out in a timely manner and all actions to be recorded. Review all capacity and activity Discuss with UHNM Silver ambulance transport arrangements to prioritise discharges if needed. Delayed discharges to be escalated to Patient Flow Manager Information and update to be provided to Bed Manager / Patient Flow Coordinator continually both prior to and after Capacity Meeting. Intermediate Care Coordinators to be based at RSUH during the weekends Attendance at all board rounds required by : As in level 2 with the addition of a Service Manager/Matron for all community hospitals with knowledge of bed allocation and delays. Ensure real time bed state through utilisation of CDS, & adjust frequency of conference calls as required, all capacity to be held by the hub coordinator. Internal Conference call participants: Chair: COO Participants: Silver Commander/Coordinator/Area Manager/Community Hospital Manager, Community Hospitals Rep, IC Capacity/LIS capacity rep, Unmet demand/ems level rep, hub coordinator, Urgent Care Lead Template to be completed and circulated with actions LHE Conference Call Participants: Urgent Care Lead, Silver Commander, hub-coordinator. Actions to feed internal communication plan for SSOTP Gold Commander to review the LHE situation with the Urgent Care Lead to determine if further escalation is likely. If so, command and control to be commenced to try and prevent further escalation Service Manager with appropriate knowledge of any operational issues for their area and action plans for any identified delays / issues to join conference call Review all level 2 actions Service Managers and Matrons are to work together to review all actions taken in level 2 and agree plan for targets not achieved. Actions to be fed to silver commander Community Services Managers are to ensure regular communication is provided to the Silver On-Call Manager and the Bed Manager / Patient Flow Manager to feedback and update throughout the day Lead Nurses to provide information on elective and day case admissions Consider use of escalation beds Prepare for use of escalation capacity Responsible Commander/Coordinator Silver Commander/Coordinator Ward Managers Patient Flow Manager and Matron Patient Flow Coordination Team Manager Discharge team Matrons/ DMs Silver Commander All those with action cards Patient Flow Manager/ward nurse in charge COO Urgent Care Lead Gold Commander Service managers/team Leaders Patient Flow Manager / Service manager / Intermediate Care Managers/LIS Managers/ Acute Social Care Manager Lead Nurse On Call Silver/On Call Gold Gold Commander 21

EMS LEVEL 2 SSOTP Review all activity in community Services / Bed Provision in Community Hospitals/Brighton House Communication pressures to the public Matrons/Team Leaders/Neighbourhood managers to review staffing levels and produce a plan for any shortfalls to cover gaps Contact Gold commander for decisions of flexing service criteria, focus to be on moving patients safely through the system. Internal Communications to be cascaded in preparation for further escalation Area Managers to meet with domiciliary care providers to discuss step down plan Trusted assessors deployment for critical services to attend UHNM (ICT triage) All capacity for SSOTP to be centrally held by the hub Responsible Community Teams Communications Urgent Care Lead Urgent Care Lead Gold commander Area Managers Silver Commander Urgent Care Lead EMS LEVEL 2 WMAS If unable to offload within 15 minutes notify HALO/BRONZE Officer (if on site if not liaise directly with EOC) and prepare for cohorting onto spare stretcher(s) where appropriate. Maintain regular contact with EOC and BRONZE Officer on arrival to ensure robust communication. Make contact with lead nurse (or site specific/relevant contact) and Manager identifying any issues and determine plan for onward flow. Utilise spare stretchers to release resources Liaise with Acute Site Capacity Manager regarding any potential issues which will require further escalation. Maintain regular communication with Hospital Desk Team providing on site intelligence of current and forthcoming expected events Ensure appropriate patients are sent via triage/main Waiting room (where appropriate) and walk-in centres to release resources Contact Acute on call Manager to ascertain action plan for >30 min delays If no resolution contact Acute AND CCG on call Directors stating there are now PATIENT SAFETY issues in the department and through our reduced ability to respond due to delays Monitor turnaround times; consider level 3 if trigger points reached 4 hourly Liaise and agree action plans with SOC Silver Commander if between 0000-0800hrs liaise with Area Silver on call and EOC Silver Commander on call. Contact crews after 20 minutes where there is no HALO on site, if HALO on site contact them directly and confirm update of situation, if no HALO or crew response, contact via hospital department making contact with crew. Ensure that any resources not handed over or unable to do so are identified and escalated appropriately either to HALO to deal on site or capacity manager. Liaise with EOC Duty Manager to respond Bronze Manager to potential problem site where there is no HALO present. Maintain Control Log and EMS entries for WMAS Responsible Operational Resources Operational Resources HALO/BRONZE Hospital Officer HALO/BRONZE Hospital Officer HALO/BRONZE Hospital Officer HALO/BRONZE Hospital Officer HALO/BRONZE Hospital Officer SOC Commander (if on duty) Silver Commander SOC Commander (if on duty) Silver Commander EOC Duty Manager EOC Duty Manager Hospital Desk Hospital Desk Hospital Desk Hospital Desk 22

EMS LEVEL 2 WMAS Inform SILVER; SOC Commander if on duty or On Call Silver if not. Liaise with EOC duty Manager and monitor overall situation across locality including outstanding workload and consider benefit of deflecting 999 resources inbound to lower activity Trust following discussion and agreement with WMAS SILVER PROVIDING THIS WILL NOT NEGATIVELY IMPACT ON OPERATIONAL SERVICE DELIVERY as required Contact on site / on call managers at Acutes and negotiate resolution. EMS LEVEL 2 NSCHT As Level 1 Requests for beds for out of area patients to be escalated for a decision on every occasion On Call Managers to be aware of current bed state and staffing EMS LEVEL 2 MODERATE PRESSURE City Social Care As level one plus Monitor system for early signs of blockage & address any blockages in the system Review and ensure proactive functioning of hospital discharge systems and individuals Assessment staff to operate discharge to assess model on identified wards Arrangement of appropriate discharges / return home Update CDS to reflect current patient status. Social care representative to participate in daily conference call EMS LEVEL 2 CCG City/North/South As Level 1 Expedite additional available capacity in NHS 111, out of hours and other relevant commissioned services Co-ordinate communication of escalation across the local health economy Support partners to identify risks and address issues in the system Responsible Hospital Desk Supervisor Hospital Desk Supervisor Hospital Desk Supervisor Responsible Clinical Coordinators/ Directorate Heads or designated other Clinical Co-ordinator through agreed e- mail alerts Responsible Team Manager Team Manager Team Manager Team Manager Team Manager Team Manager Responsible Urgent Care Team and First Responder Urgent Care Team and First Responder Urgent Care Team and First Responder 23