Winter/Surge Capacity Plan 1 st December 2013 to 31 st March 2014 Position as at September 2013
Contents 1. Introduction and background... 3 2. Demand and capacity... 4 2.1. Anticipated bed demand... 4 2.2. Capacity plans... 5 2.3. Workforce plan... 5 2.4. ED performance trajectory... 6 2.5. Plans over the Christmas period... 6 3. Autumn preparations... 7 4. Improving emergency resilience... 8 5. Out-of-hospital services... 9 6. Daily monitoring and reporting... 10 6.1. Daily monitoring... 10 6.2. Reporting requirements... 10 7. Governance... 11 7.1. Approval of plans... 11 7.2. Monitoring... 11 7.3. Risk management... 12 Appendix 1: Effective Approaches in Urgent and Emergency Care... 13 2
1. Introduction and background This document contains an overview of 2013/14 winter preparation plans for Ipswich Hospital (IHT). This outlines the position as at 30 th September, and highlights areas where further preparations are underway before winter. It covers the period 1 st December 2013 to 31 st March 2014, with a special emphasis on the Christmas and New Year period, namely 21 st December 2013 through to 5 th January 2014. It builds on work and preparation undertaken in previous years, but recognises that every year is different. This year we see: The first winter with Clinical Commissioning Groups (CCGs) fully responsible for sector wide planning, albeit managed by a number of experienced officers from Primary Care Trusts. The second year of working with Serco, who now provide community services across Suffolk. Planned ward reconfiguration work underway at Ipswich Hospital up to the 20th December, driven by Dementia funding timescales. The new NHS 111 service, which has had a relatively smooth local implementation in contrast to the national picture. To fully understand the scale of winter preparations this document should be read in conjunction with: 2013/14 Urgent Care Escalation Plan currently being prepared by Ipswich and East Suffolk CCG ( the CCG ) Ipswich Hospital s Capacity Escalation Policy Ipswich Hospital s Infection Outbreak Management Plan Ipswich Hospital s Major Incident Policy Ipswich Hospital s Adverse Weather Response Plan 3
2. Demand and capacity 2.1. Anticipated bed demand IHT has modelled bed demand for the period using 2012 and 2013 data, based on a 92% bed occupancy rate, and taking into account case mix. The results are shown below: Forecast Bed Demand for Main Bed Holding Areas (Medicine, Surgery & T&O) Excludes Women & Childrens plus Somersham Per Bed Area Trust Emerg Total Emergency Beds Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Forecast Medical Beds 279 290 247 279 259 275 273 280 291 305 316 304 Variance on Available Medical Beds -32-43 0-32 -12-28 -26-33 -44-58 -69-57 Forecast Surgical Beds 60 75 65 69 61 71 66 72 67 65 79 70 Variance on Available Surgical Beds 4-11 -1-5 3-7 -2-8 -3-1 -15-6 Forecast T&O Beds 42 45 55 39 35 41 43 41 42 43 43 39 Variance on Available T&O Beds 13 10 0 16 20 14 12 14 13 12 12 16 Total Forecast Emerg Beds Required 382 410 367 387 355 387 382 393 400 413 438 413 Total Variance Emerg Beds Available -16-44 -1-21 11-21 -16-27 -34-47 -72-47 Per Bed Area Trust Elec Total Trust Combined Total Elective Beds Forecast Medical Elect Beds 4 6 3 4 4 2 2 4 2 3 4 4 Variance on Available Medical Beds -4-6 -3-4 -4-2 -2-4 -2-3 -4-4 Forecast Surgical Elect Beds 22 27 24 25 25 26 24 27 22 21 25 24 Variance on Available Surgical Beds 18 13 16 15 15 14 16 13 18 19 15 16 Forecast T&O Elec Beds 19 24 19 20 20 21 22 24 16 20 22 24 Variance on Available T&O Beds 9 4 9 8 8 7 6 4 12 8 6 4 Total Forecast Emerg Beds Required 45 56 46 49 49 49 48 55 40 44 50 52 Total Variance Emerg Beds Available 23 12 22 19 19 19 20 13 28 24 18 16 Total Forecast Beds Required 427 467 413 436 404 435 430 448 440 456 488 464 Total Variance Beds Available 7-33 21-2 30-1 4-14 -6-22 -54-30 N.B. Elective data does not take into account any day case patients admitted into inpatient beds therefore the number of available elective beds could be less if being used for day case recovery Single sex and isolation requirements will restrict the use of some beds 4
2.2. Capacity plans The model identifies that, against the standard bed establishment, one additional ward is required from October to March, with a second ward from December to end of March. Washbrook Ward will be used as the first escalation ward for respiratory and care of the elderly patients, with Kesgrave available from 21 st December following building works. Stringent financial penalties have been included in supplier contracts to ensure Kesgrave is available by the 21 st. The CCG is supporting the hospital by funding: 21 of the escalation beds we have identified as needing ( 524k) 25 community beds for supporting step up/step down for IHT patients ( 350k) Extended 7 day Social Care Crisis Response Service ( 90k) Extension of Flexible Dementia Service ( 100k) Weekend therapy service to Woodbridge (short-stay elderly) Ward ( 53k) GP support to ED (streaming from ED to on-site out-of-hours GP service) ( 195k) 2.3. Workforce plan ED co-ordinator roles are currently under review with a view to extending shift times to utilise prediction model in ED. Further work is currently underway to match workforce profile to demand peaks. Active recruitment of middle grade and consultant posts in ED is underway, with a 5th ED consultant confirmed to start in October. Additional resource is also being put in place to support ambulance off-load and cohorting in ED. Twenty-eight nursing posts have been advertised for fixed term three and six month contracts. The senior nursing team are considering alternative options such as block agency contracts, and turnover rates to appoint permanent staff, as it is unlikely that we will recruit to all 28 posts. Specialist nurses will be asked to support a shift per week. HCA recruitment is following same path as RN. Consultant cover for beds has been agreed and locum cover for junior medical posts is being sought. Therapy posts are out to advert and negotiations are underway with agencies for difficult-to-fill posts. Pharmacy have appointed to their additional posts. 5
2.4. ED performance trajectory The Trust is aiming to deliver the following trajectory on the 4 hours target. This will be continuously reviewed to ensure the 95% target is met for each quarter and the full year. Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 93.78% 97.10% 96.35% 95.14% 93.59% 95.00% 97.00% 96.00% 95.00% 95.00% 96.00% 95.00% 2.5. Plans over the Christmas period Fri Sat Sun Mon Tue Wed Thu Fri Sat Sun Mon Tue Wed Thu Fri Sat Sun Mon Action Lead By 21/12 21/12 22/12 23/12 24/12 25/12 26/12 27/12 28/12 29/12 30/12 31/12 01/01 02/01 03/01 04/01 05/01 After 5 Jan 80 vacant beds LN/NO X Equipment store fully stocked GC X Planned readmits and clinics 1 NO X X X X X IP pacing lists AW X X X Additional ward rounds RM X X X X X X X X X Additional TTA pharmacist KP X X X X X Additional therapists GC X X X X Extra imaging lists JM X X X X Additional portering 2 ISS X X X X X X Additional pathology 2 BK X X X X X X Senior Manager cover LN/NO X X X X Elective activity 3 JT X X X X X X X X X 1 2WW/hot clinics/urgents to free consultant time to undertake ward rounds 2 Still in discussion 3 Elective plans are under review to free bed capacity, especially from 1st Jan, whilst maintaining 18 week access commitments. 6
3. Autumn preparations NHS Interim Management and Support (NHS IMAS, incorporating the Intensive Support Teams) are undertaking a visit on 24 th September in preparation for an Acute walk through of our emergency care clinical pathways on 29 th October to review our existing plans and consider other options for our emergency care plan. Their report will assist us in maintaining the relevant focus on our Improving Emergency Care project already underway and on any other suggested system wide improvements (see Improving Emergency Resilience below). A review of the Capacity Escalation Policy is underway, linked to revised roles for on call managers that were implemented at the beginning of September. The Infection Outbreak Management Plan, the Major Incident Policy, and the Adverse Weather Response Plan will also be reviewed. The main changes relate to updating the policy for the new management structure. A new daily status reporting and escalation process is also being implemented during September to support early identification of issues and a sector wide telecom to ensure continuity of patient flow. Workflow support cards are also being developed to ensure escalation and reaction processes are consistent and robust. A desk-top exercise of escalation plans is scheduled for early October to test their robustness. The results of this exercise will be fed into the capacity escalation review, and discussion with the CCG and other external agencies. Final arrangements for out-of-hospital support services are being agreed as a number of areas are still in negotiation. Proposals are being developed for presentation to commissioners The Trust has ordered 2,500 flu vaccines and will be made available from the first week of October to targeted high risk areas first i.e. ED, respiratory, critical care, midwifery, children and neonates. Drop in clinics are booked from the 2 nd week for two weeks, and will include night clinics. Staff vaccinations are available up until mid-december and nurses have signed up to give the flu jab locally. Last year the Trust achieved a 42% uptake, with a target of 75% this year to secure additional national ED funding next year. This programme will be supported by the flu campaign being led across the county by the CCG. We are also in discussion with the CCG to update community physiotherapists skills to support respiratory care. 7
4. Improving emergency resilience Ipswich Hospital, in partnership with the CCG, has initiated a transformation programme for emergency care. This incorporates 9 work streams, within an overall programme management structure: The key areas which are relevant to winter planning include the following: Improving patient flow through ED. This includes implementing GP streaming; Rapid Assessment and Treatment (RAT); See and Treat; improving ambulance turnaround; and revising predictor and escalation protocols. Professional standards and clinical guidelines. Clearing defining emergency service standards across all specialties; reviewing real time data collection and reporting; and linking this to improved bed management and escalation plans. Improving Ambulatory Emergency Care (AEC). Creating alternatives to hospital admission (e.g. hot clinics); community based assessments (e.g. interface geriatrician). Care planning and discharge. Maximising early and weekend discharges; full implementation of EDDs; and reviewing LoS performance to develop opportunities for improvement. Workforce. Review of ED establishment capacity; productivity and profiling; role redesign; and 7 day working Technology. Real-time information tools to support escalation of pressures and clinical need; Lorenzo Regional Care Emergency Care Module; review of mobile technology for use in emergency care; review of Evolve/Lorenzo Regional Care clinical noting and discharge functionality; new Bed Management System Admission processes and bed modelling. Pathway reviews; use of assessment units in other specialties; hot clinics; and optimum bed capacity and location. Winter planning and emergency resilience plans. Improving capacity and capability of organisation to respond; review of impact of 7 day working arrangements over winter to consider areas to permanently establish as 7 day services Engagement. Building in system wide processes to drive continuous learning and improvement in emergency care. A detailed assessment of our current position against the IMAS standards is presented at Appendix 1. The Trust, with the support of IMAS and the CCG, expects to make significant progress against the majority of standards in time for winter, with the work streams picking up the shortfall against these standards. 8
5. Out-of-hospital services The following table presents the current status on the main out of hospital services that will be available over the winter period: Social services Service Normal operation Winter operation Christmas operation M-F 9-5 plus emergency on call service Harmoni / out of hours GP 6pm to 8am and weekends GP booked referrals only Normal operation plus 7 day Social Care Crisis Response Service ED triage then stream to Harmoni out of hours service Service closing 23 rd December until 2 January, except for emergency on call service. No closures over Christmas period Admission prevention service EAU and ED in-reach service not currently operating discussions underway to restart Community beds Currently 7/7 access but Christmas arrangement not yet confirmed Psychiatric liaison (N&S NHSFT) Patient Transport Service (EEAST) PTS out of hours New service being initiated Christmas cover still under negotiation M-F 8-5 M-F 8-5 No service Christmas Day or Boxing Day M-F 5pm to 11pm S&S 10am to 11pm Normal operations No service Christmas Day A priority action for the Trust is to confirm and improve service provision, with the support of the CCG. 9
6. Daily monitoring and reporting 6.1. Daily monitoring The Trust has initiated a four stage daily monitoring cycle: 09:00 Situation Update. Led by the Hospital Co-ordinator the focus is on a review of overnight activity and the previous evening s plan, current bed status, operational issues affecting delivery (e.g. staffing, backlogs, infection and weather), and agreeing corrective action. 10:30 System-wide Telecon. Led by a Head of Operations the focus is on discussing system wide capacity issues and maintaining patient flow. This typically results in an internal focus on progressing long staying and delayed patients. 11:00 Beds and Staffing Meeting. Led by the Hospital Co-ordinator, the focus is on admissions, discharges, beds and staffing, and agreeing actions with matrons from each area. 16:00 Planning Meeting. Led by the Hospital Co-ordinator, and attended by the On-Call Manager, the meeting reviews the current and overnight bed status alongside staffing and operational issues. It agrees overnight escalation actions, but always with a view to minimising disruption to elective activity. The Hospital has a 4 stage alert level which is reviewed at every meeting 1 steady state; 2 early warnings; 3 red alert; 4 black alert. The levels are defined in detail in the Capacity Escalation Policy, and will be reviewed as part of the planned policy review. At stage 3 the Hospital will initiate external escalation across the Suffolk health system to agree corrective action and system wide responses. Level 4 escalation requires Director level meetings to agree action. 6.2. Reporting requirements SITREP reporting requirements are not yet confirmed, but the Trust should plan for daily updates over the winter period except on the additional bank holidays of Christmas Day, Boxing Day and New Year s Day. 10
7. Governance 7.1. Approval of plans Detailed plans have been agreed at divisional boards, and this plan is presented to the Combined Board (23 rd September) and Trust Board (26 th September) for approval. An update will be presented to November s Combined Board. 7.2. Monitoring The Emergency Care Programme Board will monitor progress against the 9 work streams which incorporate winter preparations (see section 4). The Board links into the CCG s Urgent Care Board (also known as the Integrated Care Network meeting) and a number of the projects will require the full involvement and participation of the CCG. Monthly performance meetings, as part of the Trust s Accountability Framework, will continue with a review of milestones and KPIs to ensure all aspects of patient experience, clinical quality, staff satisfaction and value for money are maintained across the winter period. These domains include the key winter issues of access targets, infection rates, falls and pressure ulcers, staff absence, nonclinical bed moves and short-notice cancelled elective activity. Escalation processes are clearly defined within the Accountability Framework, as is a framework for developing, agreeing and monitoring recovery plans. The Healthcare Governance Committee also reviews quality and safety indicators on a monthly basis on behalf of the Trust Board. The Trust Executive formally reviews performance on a weekly basis, noting lessons learnt from the previous week and improvements to be made. This process is supported by divisional quality and safety groups which reviews the position on a ward by ward basis. 11
7.3. Risk management The key risk to delivering the winter plan will be the ability to successfully recruit the additional staff needed. The appointment of a 5 th consultant starting in October reduces the immediate risk in ED, as current locums will be retained over the winter period. Recruitment of sufficient nursing staff for escalation wards will also present a risk. However the Trust has agreed the permanent establishment and timescales now, rather than managing escalation on a reactionary basis, and this will reduce this risk compared to previous years. Recruitment has already started, with a formal review planned for October to assess progress and to initiate and inform discussions with agencies and our internal staff bank. Annual leave policies have been agreed: No nursing staff have been offered leave over the Christmas period, consultant and junior doctor rotas have been agreed and filled, senior managers and nurses are available throughout the period, and additional diagnostic sessions have been agreed and staffed. Consistent access to community beds, and the impact on patient flow, is a risk which will be raised as an issue for sector-wide discussion, including actions IHT can take to support and improve local access (e.g. running an IV service). Each ward will have a full time Matron in charge who will be responsible for staffing and clinical standards on the ward. This will ensure the focus on quality of care is maintained through a single accountable Matron for each area. New ED and bed state predictor tools have been introduced this year to provide advance warning of potential problems and to allow mitigation plans to be developed. ED has an additional co-ordinator to support the use of the predictor tool. A number of managers at both the CCG and hospital are new in post. However most are operationally experienced, and additional training and workflow cards are in development to assist with familiarisation with local protocols. 12
Appendix 1: Effective Approaches in Urgent and Emergency Care Each element of the table has been rated: - in place; - progress by winter; red - will not be in place by winter or status unknown Priorities within Acute Hospitals Self Assessment RAG Rating 1. There should be early senior review of all patients along all parts of the pathway The Emergency Department - Implement RAT 1 for majors patients Plan to trial. See action in Improving Emergency Care Project (IEC) Improving patient flow through ED - Implement See and Treat 2 for patients with minor injuries and Reviewing options. See actions in IEC Improving patient flow illnesses. through ED - Reduce or eliminate triage 3 No plans other than changes through RAT and See and Treat. - Ensure that there is effective departmental co-ordination of activity Assessment Units / Acute Medical Units - Implement consultant-led rolling ward rounds 4, or RAT. Avoid batching patients to be seen on set piece ward rounds - Ensure consultant presence is available seven days a week and into the evenings - Establish clear pathways for patients requiring specialist care, so they can be cared for in the most appropriate setting as quickly as possible 6 - Set up dedicated, multidisciplinary health, therapy and social care teams based in the unit Specialty Wards - Ensure that a consultant sees all patients, and their care plans are confirmed, within 2-3 hours of admission to the ward 7 (or a maximum of 12 hours if admitted out of hours ), and sooner if the patient s clinical need requires it. - Each patient should be discussed daily (including at weekends) with the responsible consultant 8 - Ward managers need to be supernumerary to coordinate and drive care ED workforce & capacity review underway. Trigger tool developed to anticipate activity surges with agreed escalation actions. Piloting additional senior & twilight co-ordinator See action in IEC Improving patient flow through ED In place There is consultant cover up until 19.45 7 days per week There are clear pathways for certain conditions i.e. cardiology, gastro, ARCU, general medicine. Plans for direct referral to others - see IEC Setting Professional Standards and Admission Assessment Processes Therapy team established in EAU but no social worker In place for some specialties i.e. medicine. See IEC Care Planning & Discharge In place on some wards i.e. CMU. Action in IEC Care Planning & Discharge They are established to be supernumerary on rota but go into the numbers if clinically required
Priorities within Acute Hospitals Self Assessment RAG Rating 2. Maintain the momentum of care there should be a senior review of every inpatient s care plan every day - Every patient must have a consultant approved care plan in place In place 90% of the time. See action IEC - Care Planning & Discharge within 12 hours of admission at the latest - Care plans must include an expected date of discharge (EDD) 9 In place but need ongoing audit to improve - EDDs should be set by the consultant in charge and only changed with her/his permission Yes - Care plans must include criteria for discharge 10 Empower the In place in some specialities. Action in IEC Care Planning & multi-disciplinary team to discharge when criteria are met (particularly at weekends), rather than waiting for senior medical confirmation Discharge - There should be daily, early morning board rounds 11 by a senior In place on some wards. Action in IEC Care Planning & Discharge clinical decision maker (normally a consultant) to ensure that the care plan is on track - Schedule main ward rounds for the mornings, and see potential Unwell patients will always be seen first, then potential discharges discharges first, so that beds are freed as early as possible. - Develop one stop ward rounds 12, where tasks such as writing TTOs and filling request forms are completed before the round moves into the next patient (avoid batching work to the end of the round) Not in place, but will be included in review of use of mobile technology red 14
Priorities within Acute Hospitals Self Assessment RAG 3. Get patients on the right pathways manage patients in flow streams Emergency Department - Establish protected streaming create separate streams for In place minors and majors, with dedicated staff, processes and coordination - Create processes to ensure that the majors stream is not Increased staffing numbers to cover resus. Linked with workforce plan. halted by a full resuscitation room - Avoid acting as the default arrival point for referrals that do not require resuscitation or stabilisation (e.g. most GP or clinic referred patients) these patients should by-pass ED and go directly to assessment / acute medical units or specialist beds See IEC Improving Patient Flow through ED & Workforce There is a triage telephone service in place run by EAU. Some patients go directly to EAU. Plans underway for hot clinics for frail elderly and surgical patients which will avoid ED attendance - Ensure senior decision makers 13 in high volume specialties are Aim to standardise this response time. See actions IEC Setting available to attend the ED within 30 minutes of referral Professional Standards - ED should have direct admission rights using agreed protocols See actions in IEC Setting Professional Standards - Establish ambulatory emergency care 14 streams to avoid Reviewing ambulatory streams, identified 14 clinical scenarios suitable unnecessary overnight stays for ambulatory emergency care. IHT part of national AEC Network. See - Consider establishing Clinical Decision Units offering observation medicine (with LOS <12 hours) and ambulatory emergency care Admissions o Stream by length of stay and care needs: - Assessment capacity should be sized for patient stays of no more than 12 hours, after which patients should enter appropriate flow streams. - Provide short stay capacity for patients with an anticipated length of stay of up to two midnights (assessment and short stay capacity is usually co-located in acute medical units) 15. - Further streams should be to specialist beds (for complex speciality patients requiring >72 hour stays), beds for patients with complex discharge needs (e.g. the frail elderly) and catastrophic illness (e.g. critical care and stroke patients). - Ambulatory emergency care should be provided where appropriate. o Minimise handovers between consultant teams and maximise continuity of care a ratio of more than one handover per admission beyond ED suggests poor practice actions IEC Extending Ambulatory Care Under discussion See actions IEC Extending Ambulatory Care In place In place Work in progress bed model under review. See IEC Admission/Assessment & Bed Modelling In place. Improvements planned, see IEC Improving Ambulatory Care Approximately 80% compliant. Plans for direct referral see actions IEC Setting Professional Standards and Admission & Assessment Processes 15
Priorities within Acute Hospitals Self Assessment RAG Rating 4. Work together systematically and predictably implement internal professional standards o Response standards should be agreed for the whole pathway See actions IEC Setting Professional Standards and cover time to: - Assessment, including investigations - Treatment - Review - Referral - Discharge o Agree and implement single assessment processes to reduce duplication o o Simplify referral processes, rather than using them as mechanisms to hold back work Use metrics to measure performance and the impact of improvement initiatives. 5. Plan and manage capacity to meet demand - Develop an agreed escalation protocol that has input from all relevant stakeholders - Use a tool to predict the expected number of admissions if anticipated admissions exceed expected bed availability, escalate early! - Each specialty and supporting department should plan to match capacity to demand - Implement effective bed management, equipped with real-time information, and rigorous processes Escalation plan in place. Currently under review Predictor tool developed, currently being trialled Work undertaken across the Trust, but needs central consolidation and assessment. Bed management under review see IEC Setting Professional Standards and Technology - Staffing rotas should be designed to match demand profiles ED currently under review. Wards have been recently assessed. 16
Priorities within Acute Hospitals Self Assessment RAG Rating 6 Manage variation in discharge planning 16 - Minimise in-day bed swing 17 by maximising morning discharges set targets to maximise discharges by a locally agreed check-out time See actions in IEC Care Planning and Discharge - Consistently prioritise activities associated with discharge (except where there is urgent clinical need) in order to reduce length of stay 18 - Manage frail elderly people assertively to avoid in-hospital decompensation with associated prolonged stays 19 - Ensure services required for discharge are accessible at weekends Some areas of good practice See actions in IEC Care Planning and Discharge Therapy review at front door with plans, identify appropriate bed. Plans in place for interface geriatrician Following services available at weekends: transport, TTA s and therapists at front door. No social worker on wards - Avoid batching in diagnostics and support services (see note 5 below) Diagnostics are not batched 7 Avoid unnecessary overnight stays implement ambulatory emergency care - Download and study copies of the Directory of Ambulatory IHT is part of national AEC Network. Have reviewed Directory and Emergency Care for Adults and the how to guide from the identified 14 clinical scenarios as additional opportunities for AEC NHS Institute website. - Ensure senior clinical decision makers are available to decide on the need for admission - Ensure ambulatory emergency care is available for all patients who meet the criteria - Ensure access to timely investigations to support clinical decision making In place Under review see actions IEC Extending Ambulatory Care Generally good access. In process of setting professional standards for response times see actions IEC Setting Professional Standards - Create responsive alternatives to admission: Implementing hot clinics for elderly patients & surgical, direct referral to specialties, SAU, OAU see actions IEC Admission/Assessment Processes o Urgent clinics Implementing surgical, frail elderly and orthopaedics o Community based assessments Interface geriatrician in place. Under review see actions IEC Extending Ambulatory Care o Community support for urgent treatment at home and in Unknown at this stage residential and nursing homes red 17