NHS National Waiting Times Centre Winter Plan 2010/11 Introduction This plan outlines the proposed action that would be taken to deliver our key business objectives supported by contingency planning. This plan supports the existing NWTC Business Continuity Planning Policy, Pandemic Flu Contingency Plan and NWTC Pandemic Flu Business Continuity Plan. It is anticipated that this winter may present greater capacity and demand issues in the event of an influenza or norovirus outbreak, and these issues have been factored into local delivery and capacity plans. The challenging financial climate is also of concern as health providers and local authorities work to make necessary efficiency savings, while anticipating winter pressures. Specific services i.e. social services and transport need different consideration during the festive period. These are also considered within the corporate business continuity plan: (udrive/civilcontingency/bcp/businesscontinuitybookletboard10081). The impact of a flu or norovirus outbreak could have a significant impact on health and social services and could involve: Increased workload of patients with influenza/ norovirus and its direct complications. Particular needs for critical care and infection control facilities and equipment. Depletion of the workforce and of numbers of informal carers, due to the direct or indirect effects of flu on themselves and their families, e.g. the need to provide childcare or care for ill members of their families. Changes to our Plan for 2010/11 The NHS National Waiting Times Centre has adjusted our Winter Plan due to a number of key risks: The widespread disruption as a result of the flu pandemic predicted for the winter period 2009/10 did not materialise and the Board considers the threat to business continuity from influenza to be reduced for this winter. Nevertheless, our Pandemic Flu Business Continuity Plan is still active and describes the control measures that we have put in place. It is noted that any significant influenza or norovirus outbreak could have a significant impact on staff availability. For this reason, department business continuity arrangements are in place which describe priorities for skill sets in the event of an increasing percentage absence rate. 1
The requirement to meet a range of activity targets based on our agreed allocations with other NHS Boards and the waiting time guarantees for cardiothoracic patients. Where our Board and other NHS Boards experience winter pressures, we may, in discussion with the Scottish Government Health Directorate (SGHD), agree to adjust our activity levels to provide assistance with winter pressures. Period Affected This plan covers the winter period effective from 1 December 2010. Key Objectives To communicate business continuity planning over this period that is in line with Board continuity plans and enables the Board: to continue to provide the planned elective activity where possible ( in discussion with SGHD and other NHS Boards) and emergency/urgent services; to continue to work with partners i.e. social services and primary care services and ensure effective discharge. This is likely to be more challenging with the impact of financial pressures; to enhance the ability of staff to face the challenges of the winter period efficiently and effectively and with confidence; and to continue to work with NHS Greater Glasgow and Clyde (NHSGGC) ensure the effectiveness of the patient pathway for re-patriating medical and cardiology patients. When developing this plan a number of key factors have been taken into account. Current Board-wide and department specific business continuity plans Ongoing work in relation to bed management, discharge planning and the patient journey Initiatives to reduce staff sickness absence levels Communication The Internal Incident Escalation Procedure (attached at Appendix 1) should be used in emergency situations The Pandemic Service Escalation Form (attached at Appendix 2) may be used during major winter pressure situations The communications department will co-ordinate and respond to any press enquiries over the winter period Exception reporting of events that are likely to or will significantly reduce the hospital s ability to manage waiting lists, will be made known to Scottish Government by the Nurse Director or delegated Executive Director. The Scottish Government Winter Management report will be returned by the Board on a weekly basis throughout the 2
winter period until early April 2011.In addition, the Board already provides regular reports to SGHD on the availability of intensive care beds. We have developed a reporting template to share our critical care bed availability status with NHS GGC worked closely with NHSGGC to agree H1N1 patient pathways Health Protection Scotland issue influenza updates and norovirus ward closures to the NHS during the winter period. Staff Flu Immunisation Programme The Scottish Executive Health Department Circular SEHD/CMO (2001)13 recommended that NHS and Social Care employers should offer influenza vaccine to employees directly involved in patient care. Influenza immunisation is highly effective in preventing influenza in working age adults. In addition, influenza immunisation may reduce the transmission of influenza to vulnerable patients, some of whom may have impaired immunity and thus reduced protection from any influenza vaccine they have received themselves. Health Protection Scotland has stated that an uptake target of 20% is expected from NHS Boards. Our Board flu vaccination programme commences in October 2010. Last year, 52% of frontline staff received the H1N1 vaccine and 20% received the influenza vaccine. Flexible approaches to facilitate staff vaccination will be provided to encourage wider uptake. Contingency Plan Demand Management and Communications NHS National Waiting Times Centre has: a Board Pandemic Influenza and Contingency Plan Board-wide and department specific Business Continuity plans a Senior Duty Manager rota to deal with out of hours operational issues 24-hour Senior Nurse cover including a Hospital at Night Service Bed Management and Discharge Coordination an external communications plan which is managed by our Head of Corporate Affairs with appropriate out of hours arrangements Elective Demand, Capacity and Activity for the Winter Period A multidisciplinary planning group meets fortnightly to review elective admissions. These admissions are planned approximately six weeks in advance and are adjusted, if necessary, to accommodate last minute changes. Admissions around the festive period are largely dictated by the patients willingness to accept an admission date close to Christmas or New Year. Our experience to date has been that patients are more receptive to accepting festive dates for major joint replacements than for minor orthopaedic procedures, we therefore plan to maximise the opportunity to continue with joint replacements at this time. Elective cardiac surgery will not continue over the festive period due to the availability of blood products. 3
Elective cardiac activity will recommence with careful case selection by Friday 7 January 2011. All other elective surgery will continue on all days with the exception of the public holidays again this will be dictated by the patients willingness to accept the dates offered. It is anticipated that elective orthopaedic activity will return to normal levels on Wednesday 5 January 2011. The plan also takes into account the general guidance for NHS Boards on triggering mutual aid and the notification of abnormal service pressures. Detailed plans were developed during the winter period 2009/10 as part of pandemic flu preparations. These plans align to the escalation process outlined in Appendix 3. Escalation Plans Escalation arrangements are in place to ensure that the Scottish Government Health Directorates receives appropriate and timely notification of winter pressures. Plans have also been developed which describe the impact on elective activity in the event of increasing emergency admission rates for flu patients. Escalation plans are in place within Clinical Directorates which describe the processes for managing clinical activity during periods of winter pressure. While it is intended that boarding of patients outwith the specialty area will be avoided as far as possible, cross- directorate arrangements are in place to manage any boarding through joint working with General Managers, Nurse Managers and Bed Management support. Patients to be boarded would be those patients who are close to discharge, who require less medical and nursing input and have no infection control issues. Ward nurses will ensure clinical handover of the boarding patient and provide advice on care as required. The patient will remain under the care of the original consultant and team and will be included in ward rounds and reviews. Management Meetings Twice daily operational meetings will be held to ascertain: levels of staff sickness; bed availability; theatre requirement and availability; and cardiac catheterisation lab requirement and availability. The operational meetings will also consider any threats to the provision of clinical support services, coordinated through the senior nurse on duty. Similarly twice daily multidisciplinary clinical briefings will be held to monitor bed status and handover unstable or problem patients. 4
Discharge lounge The efficient and effective flow of patients out of the NWTC on a daily basis remains an issue of service quality and patient safety. The purpose of the discharge lounge, which is co-located with an inpatient nursing unit, is to provide and appropriate supervised environment for patients to wait discharge thereby freeing beds for new patient throughput. Transport We operate a range of vehicles to deal with transport requirements of our patients. All patient transport drivers have undergone basic first aid courses. Two dedicated ambulances, operated by the Scottish Ambulance Service (SAS), are based at GJNH to facilitate the transfer of cardiothoracic and cardiology patients to GJNH and back to their base hospital. This will continue to be available over the winter and festive period. In the event of extreme pressures, we will review options for the use of our vehicles to assist with the re-patriation of medical patients back to NHSGG&C. Social Services Links Early notification of requirements is essential to allow social services to source the care package required. We have named contacts within most local authorities and have also requested that the territorial boards who refer their patients to us ensure that their local authorities ensure adequate resources are available during the winter period. Where available or appropriate for individual patients, discussions with local authority partners, referring NHS Boards, and/or primary care services around options for utilisation of community hospital capacity will be pursued. Most social work services have cut- off points for referrals over the festive period. This is likely to mean that all referrals would require to be made before 24 December 2010. Governance Arrangements Staff Governance Plans are in place to provide information for staff on how to access services during the period and to ensure that they are offered flu vaccinations in a timely manner. A Pandemic Flu Human Resources policy has been agreed which describes the staff governance arrangements during a pandemic. Clinical Governance There is a need to ensure that patients are cared for in the most appropriate environment and that the quality and safety of clinical care is maintained throughout the winter period. There is heightened awareness of infection control arrangements and support as well as risk management arrangements. The purpose of the plan is to ensure that as far as is possible an acceptable level of service is maintained during the winter and festive period. The Head of Clinical Governance is involved in the development and implementation of 5
Business Continuity Plans. A detailed and robust Governance structure for Pandemic Flu is in place. Financial Governance It is anticipated that the plan will be achieved within existing resources, although, any exceptional demands on beds may require the use of external agencies to provide additional capacity on a short term basis. Should there be any resource implications, proposals will be discussed at Senior Management level. It is anticipated that additional financial pressures would result in the event of a flu pandemic. Equality and Diversity Every effort will be made to ensure that as far as possible the needs of all patients are met and that there is equality of access during the winter period. This plan has been assessed for relevance and screened for equality impact. The relevant assessment documentation is available on request from the Performance and Planning Department Performance and Planning Department September 2010 6
Appendix 1 - Internal Incident Escalation Procedure Definition of Incident: An Internal incident is defined as a situation either arising or threatened which requires the special mobilisation and/or redeployment of staff or other resources with consequent interruption to routine activities. An emergency is something, which arises unexpectedly and requires urgent action to resolve. Switchboard to contact/connect Senior Nurse to Duty Manager Senior Nurse will tell switchboard who to call from the ongoing list and what essential information to provide Duty Manager will discuss with Senior Nurse who requires to be called from the Incident oncall list Switchboard will immediately alert security to collect the Contingency Box containing emergency cards. Duty Manager will contact Head of Communications directly Normal Working Hours Duty Manager goes to control room and assumes duties as per card Out with normal working hours Senior Nurse will assume the role of Duty Manager until the on call manager arrives and assumes role. Duty Manager will make contact with Senior Nurse via mobile radio Senior Nurse will discuss with Medical Officer if patient need to be transferred- if urgent dial 999 and update Duty Manager 7
Appendix 2: SERVICE ESCALATION CARD This card gives guidance on the daily actions required to support the management of services during major flu pandemic and winter planning. It is important that senior management are fully aware of staff and resource issues which may impact on delivery of services. This card applies to: Directorate general managers and designated deputies. Booking office and business service managers Executive directors leading corporate services and their designated deputies. Chief executive AT LEVELS 4-6 OF THE WHO PANDEMIC ALERT SCORE, THE BOARD RESPONSE TEAM WILL BE CONVENED TO OVERSEE MANAGEMENT OF THE PANDEMIC. SUPPORT AND ADVICE CAN BE OBTAINED FROM ANY MEMBER OF THIS TEAM AND CONTACT NUMBERS FOR ALL MEMBERS ARE HELD IN THE HOSPITAL RECEPTION. Escalation and reporting procedures. Stage 1 and 2 are managed in normal operational working. Stage 3* Higher levels of emergency admissions escalation procedures triggered within NHS Boards. there is increased emergency activity arising from pandemic flu and elective activity will be under pressure and with much higher levels of reschedulings. Whilst no breaches of waiting time targets have yet occurred, there is a potential for future serious disruption if higher levels of emergency activity still maintain. At this point (1 st Flag), NHS Boards should provide detail to the SGHD Performance and Business Management Team and NHS Special Board sponsor through the normal Winter Weekly Management Information report, to be submitted to SGHD each Tuesday by 12.00 Noon. Stage 4 Increased emergency activity, regional mutual aid arrangements triggered. NHS Board should immediately notify performance management of the situation (2 nd Flag). NHS Boards can accommodate some (but not all) elective activity within National Waiting Time Targets. Regional mutual aid arrangements require to be formally triggered, where NHS Boards seek additional capacity in neighbouring NHS Board areas (including, where appropriate, private sector capacity) to ensure that waiting time guarantees are maintained. The Board Chief Executive or named Deputy should make telephone contact with the NHS Special Board sponsor to discuss the extent of the pressures and recovery measures. It would be responsibility of both the regional coordinating manager and the Board Chief Executive or named deputy to provide subsequent situation updates to the NHS Special Board sponsor. The normal Winter Weekly Management Information report (including details of the stage 4 rescheduled activity) will continue to be provided by NHS Boards. Stage 5 Very high emergency activity and / or with significantly reduced elective capacity. NHS Boards cannot accommodate elective activity either within NHS Board areas or via regional mutual aid arrangements. Numbers of potential breachers and expected duration of the cessation of elective activity (by specialty) must be notified as soon as possible (3 rd Flag). Initially the Board Chief Executive or named Deputy should make telephone contact the NHS Special Board sponsor, to discuss the extent of the pressures and recovery measures, including continually retrying mutual aid. This should be followed up with immediate written email notification to the Director of Health Delivery. The normal Winter Weekly Management Information report (including details of the stage 4 rescheduled activity) will continue to be provided by NHS Boards. - *(modified from Health Delivery Directorate Letter 5.11.09) 8
YOU OR YOUR DESIGNATED DEPUTY SHOULD: Daily: complete Proforma A (below) electronically and place in the relevant folder on the U drive (see below for location). this will ensure sufficient information is available to populate the daily board situation reports which feed report sent daily/weekly to the Scottish Government. Complete Proforma B. this provides important information to the boards response team regarding the operational activity within your area and key staff. This need only be completed on an exception basis where more detail on essential working is required. If board priorities change which impact on your local priorities, you will be informed of this. Refer to pandemic flu policy and pandemic flu business continuity plan for advice and guidance. Regular staff bulletins will be issued updating key issues. Folders are found at: U:\PANDEMIC FLU\Level 6 resource updates. Place complete Resource Proforma here Folders are arranged by area / by week / by day. Open appropriate folder to place template as appropriate 9
STATUS REPORT FORM COMPETED BY: DATE: DIRECTORATE a Are all departments are fully staffed? Document areas of concern below: b If no, are there implications for service delivery? (e.g. potential for breaching patients or requests for additional work mutual aid) Describe: Describe levels of sickness/absence (e.g. influenza/norovirus) (i) Number of probable cases c (ii) Number of possible cases (iii) Number of staff off caring for family members (iv) Number of staff off sick (v) Approx total % of absence for this directorate (vi) Staff returning to work- Are there any concerns for specific departments? This form will be completed by all ward/department managers and submitted to their General Manager on a daily basis to inform Management meetings during any period of significant staff illness. 10
DIRECTORATE SERVICE PRIORITY FORM PROFORMA B Corporate services Name of person completing form Specific Service and description of service. Date complete Review Service Leader(s) (Include key leaders) Name Contact number Internal: External: Internal: External: Internal: External: Internal: External: Service priorities Corporate service priorities will be agreed by Board Response Team following declaration of level 6. You should check status thereafter.. If there is no change to status mark clearly in red NO CHANGE. Priority A: Essential Area s within service priority applies to. Status Priority B: Important Area s within service priority applies to. Status Priority C: Support Function Area s within service priority applies to. Status 11
Appendix 3- Maintaining Patient Safety Ceasing Elective Treatment Algorithm Stage 1: Normal / Steady State Emergency Activity Elective Activity Access Targets Maintained Stage 2: Minor Rescheduling of Appointments/Elective Procedures, but no Elective Breachers Increased Emergency Activity Access Targets Maintained Reduced Elective Activity Cancellations rescheduled within target times Stage 3: Higher Levels of Emergency Admissions, Trigger Escalation Procedures within NHS Boards Further Increased Emergency Activity Access Targets Maintained Further Reduced Elective Activity Stage 4: Increased Emergency Activity, Trigger Regional Mutual Aid Arrangements 1 st FLAG notify SGHD Higher levels of cancellations - escalate within Board e.g. increase daycases; rigorous discharge; etc 2 nd FLAG notify SGHD Further Increased Emergency Activity Further Reduced Elective Activity Some rescheduling can be done within Board Boundaries Some rescheduling CANNOT be done within Board Boundaries Some Patients may miss Access Targets: Re-book with Minimum Delay Trigger Regional Mutual Aid Stage 5: Very High Emergency Activity and with Significantly Reduced Elective Capacity Heightened Emergency Activity Reduced Elective Activity Some Patients may miss Access Targets: Re-schedule with Minimum Delay In extreme situations suspend targets for limited period Some rescheduling can be done in Board Rescheduling cannot be done in Board - retry Mutual Aid Rescheduling cannot be done - - classified as breaches 3 rd FLAG - written notification to SGHD 12