NORTHERN DEVON HEALTHCARE NHS TRUST CAPACITY PLAN

NORTHERN DEVON HEALTHCARE NHS TRUST CAPACITY PLAN 2013-14 Northern Devon Healthcare NHS Trust Page 0

CONTENTS Section Page 1. Introduction 2 2. Demand and Capacity 4 3. Trust Wide Actions to Increase Capacity and Improve Patient Flow 4. Divisional Actions to Increase Capacity and Improve Patient Flow 9 11 5. Operational Management 20 6. Escalation Framework 23 7. Major Incident Plan 27 8. Business Continuity 27 9. Adverse Weather 27 10. Communications 28 Appendices A: NDDH Escalation Action Cards 30-38 B: Community Hospital Action Cards 39-43 C: Health and Social Care Action Cards 44-48 D: ED Escalation Framework 49-50 E: External Communication Flow Chart 51 F: Children s Services Contingency Plan 52 G: RAG Rating to aid decision making in escalation to SCU ward 53-45 closure Northern Devon Healthcare NHS Trust Page 1

NORTHERN DEVON HEALTHCARE NHS TRUST CAPACITY PLAN 2013-14 1. INTRODUCTION This plan describes the measures Northern Devon Healthcare Trust will take to manage any sudden increases in demand. It is a year round plan, which encompasses the Trust s plans for managing seasonal pressures, including winter. It describes the Trust s processes and procedures for managing increases in demand, ensuing that the organisation has plans in place to return our services to normal operating levels as quickly as possible following periods of escalation and to ensure that all performance targets are met during the winter period. 1.1 SCOPE The plan includes: An analysis of demand and capacity pressures Trust wide plans for increasing capacity and improving patient flow Divisional specific plans for increasing capacity and improving patient flow Operational Management Arrangements Trust s Escalation Framework Links to the Major Incident and Business Continuity Plans Links to the Adverse Weather Plan 1.2. LINKS TO OTHER PLANS AND DOCUMENTS The plan should be read in conjunction with the Major Incident Plan, the Pandemic Flu Plan, Business Continuity Plan and the Bed and Site Management Policy. The plan has been developed to link with the escalation plans of other key organisations, including SWAST, DDoc, Primary Care, Adult Social Care and other provider organisations. 1.3 ROLES AND RESPONSIBILITIES Executive Director of Operations The Executive Director of Operations is the Executive Lead for the Capacity Plan. DGM Emergency Services, Logistics and Resilience The DGM Emergency Services is the operational lead for the plan and responsible for the day to day operational site management at NDDH. Director of Human Resources The Director of Human Resources is responsible for the Trusts Flu Pandemic Plan Northern Devon Healthcare NHS Trust Page 2

1.4 KEY RISKS TO THE ORGANISATION The trust has identified the following key risks: 1. Unplanned absence of staff due to seasonal flu, swine flu, D&V outbreak 2. Increased demand for services due to higher levels of infection within the health care community 3. Increased demand for emergency care in all specialities 4. Issues relating to delayed discharges and community hospital capacity 5. Cancellation of elective admissions and failure of 18-week performance target 6. Failure to deliver A&E and ambulance handover targets 7. Further problems relating to adverse weather conditions 8. Potential for compromised patient safety. 9. Partner agencies unable to cope with increased demand, their specific targets 10. and patients diverting to Community Hospitals 11. Adverse weather conditions 12. Snow and Ice impairing access to premises and services 13. Schools closing causing staff to remain at home. 14. Breakdown in supply chain 15. Independent and voluntary sector problems with delivery of community care services 16. Inability to secure appropriately skilled temporary workforce via recruitment, bank or agency to meet demand. 17. Inability to recruit to the substantive acute physician and Care of the Elderly posts (3 acute physician and 2 COTE) 18. Availability of additional resources including agreement of 70% Emergency Admissions Tariff Northern Devon Healthcare NHS Trust Page 3

2 DEMAND AND CAPACITY PRESSURES 2.1 INTRODUCTION Over the last 6 months the Trust has been reviewing its emergency and elective activity and its current capacity to meet demand. This has included a review of: Emergency Department Attendances Emergency Admissions Elective Admissions Bed Occupancy Outliers Demand for Community Health and Social Care Demand for Community Hospital Beds Some of the key findings of these reviews are as follows: 2.2 EMERGENCY DEPARTMENT (ED) ATTENDANCES As shown by figure 1 there has been a 16% rise in ED attendances over the last 5 years. Figure 1: ED attendances 2008/09 2012/13 Year Total Attendances 2008/09 34693 2009/10 37639 2010/11 39277 2011/12 39580 2012/13 40,329 There has also been a steady increase in the proportion of attendances requiring admission, suggests that in addition to an increase in the number of ED attendances we have also seen an increase in both the complexity and the acuity of attendances. This is particularly marked during the winter months when over 35% of attendances require admission. Figure 2: % of ED attendances resulting in Admission 40% 38% 36% 34% 32% 30% 28% 26% 24% 22% 20% % of ED Attendances Resulting in Admission Oct 2010 - Jan 2013 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Northern Devon Healthcare NHS Trust Page 4

2.3 EMERGENCY ADMISSIONS In the last 5 years the Trust has seen a 19% increase in emergency admissions over and above the 2008/09 baseline year for funding at full tariff. This equates to approximately 2,700 additional admissions. Assuming an average LOS for emergency admissions of 3.5 (current average) this would equate to a demand for 26 additional beds over and above the baseline of 2008/09. This equates to an increase in 5 beds per year over a period of 5 years. 2.4 ELECTIVE ADMISSIONS The trust has an excellent record for delivery of the national 18 week referral to treatment pathway. The contracted activity below will be delivered to maintain 18 week performance and deliver the trust contractual obligations. Figure 3: Elective Activity 2013-14 The trust is committed to day case treatment, where this is clinically appropriate, and is a high performing organisation for day case rates. The trust over performances against a target 84%, our current day case rate is 87.3%. 2.5 BED OCCUPANCY As shown by figure 4 occupancy levels at NDDH fluctuate throughout the year and are linked to the levels of emergency admission. Best practice suggests that an occupancy level averaging 85 % provides both the most efficient nursing utilisation and best patient experience. Average occupancy for the current financial year at NDDH is 88.8%, but over the year it can reach 100% and rarely dips below 80%. Indeed at peak times when day surgery facilities are used to accommodate inpatients the occupancy can reach over 100%. Northern Devon Healthcare NHS Trust Page 5

01/04/2012 15/04/2012 29/04/2012 13/05/2012 27/05/2012 10/06/2012 24/06/2012 08/07/2012 22/07/2012 05/08/2012 19/08/2012 02/09/2012 16/09/2012 30/09/2012 14/10/2012 28/10/2012 11/11/2012 25/11/2012 09/12/2012 23/12/2012 06/01/2013 20/01/2013 03/02/2013 17/02/2013 03/03/2013 Number of Outliers Figure 4: NDDH Bed Occupancy (%) April 2012 March 2013 NDDH Occupancy (%) April 2012 - March 2013 105.0% 100.0% 95.0% 90.0% 85.0% 80.0% 75.0% 70.0% 65.0% 60.0% Occupancy 2.6 MEDICAL OUTLIERS Figure below shows the variation in the number of medical outliers across the year. We know that the practice of outlying patients is detrimental to the patient experience and extends LOS. Again periods of increased in Medical Outliers can be directly linked to periods of increased emergency admissions. Fig 5: Medical Outliers April 2012 March 2013. 40 35 30 25 20 15 10 5 0 Outliers per day 2012-2013 Date Northern Devon Healthcare NHS Trust Page 6

2.7 COMMUNITY SERVICES The figure 5 below illustrates the demand on community services. Figure 6: Demand for Community Services The initial patient demand for healthcare is first seen in peaks of admission avoidance activity as these services seek to reduce patient flows to hospitals and in a build up of patients in residential and nursing homes. The pressure then moves through acute and then community hospitals as admissions peak; while supported discharge activity seeks to reduce this pressure. As patients are discharged from hospitals, spikes in activity are seen in community teams as patients are supported at home; and social care reviews and assessments then increase as well as residential and nursing home placements. Some of these services are small but it was felt important to model the entire system as the impact on major activity such as hospital flows can be great if bottlenecks build up at any part of the system. A fully functioning system will deliver more affordable care closer to home. 2.8 CONCLUSION Our analysis of our demand and capacity has demonstrated how much activity, particularly emergency admissions varies over the course of the year. This includes increased emergency admissions and the associated increases in bed occupancy and medical outliers during winter. However it also includes increases in ED attendances during the summer months. It also demonstrates the need to understand demand across the health and social care system. Northern Devon Healthcare NHS Trust Page 7

This demonstrates the need to have a capacity plan which includes: Actions to increase capacity during know periods seasonal pressures robust Robust actions to respond to periods of escalation Actions which do not focus solely on increasing beds but also focus on improving patient flow Actions to ensure health and social care services in the community have the right capacity to respond to increases in demand. Northern Devon Healthcare NHS Trust Page 8

3. TRUST WIDE ACTIONS TO INCREASE CAPACITY AND IMPROVE PATIENT FLOW 3.1 INCREASED BED CAPACITY Based on our assessment on current demand and capacity the Trust is working on a plan to reconfigure beds as follows: Specialty Current Proposed Core Flex Core Flex Medicine 131 6 146 19 Surgery 91 19 90 8 Other (ICU) 6 0 6 0 Totals 228 25 242 27 This includes: Moving Lundy Roborough (Elective Orthopaedics) to Caroline Thorpe Ward with a maximum of 20 beds for the winter Moving Fortescue (male surgical) to Lundy Roborough with 26 beds Moving Alex Ward to Fortescue ward with 24 beds substantially, but option to increase to 30 for the winter Maintaining Staples at 24 beds with option to increase to 30 for winter Increasing acute stroke capacity on ASU from 10 to 14 beds Increasing cardiology capacity on Victoria ward by 4 beds Together this provides an improved balance of medical and surgical beds, increasing capacity for emergency admissions, cardiology and stroke patients and greater flexibility to increase flex capacity to manage seasonal and other short term pressures. As yet resources have not been identified to support these pressures 3.2 IMPROVED PATIENT FLOW The Trust recognises that managing demand is not just about increasing capacity, but requires a focus on improving the flow of patients through the hospital. Over the last twelve months the Trust has put in place a range of initiatives aimed at improving patient flow, increasing morning discharges, increasing weekend discharges. Moving forwards our on going actions will include the following: 3.2.1 Improving Patient Flow Interactive White Boards From August 2013 the Trust will be commencing an Interactive white board pilot on four wards. This includes MAU, Glossop, Fortescue and Lundy Roborough. The touch screen white boards will be used by wards at board rounds to support patient management on the wards. Having a more up to date view of wards particularly patient s estimated discharge dates (EDD) will also support the operational management of the hospital. Northern Devon Healthcare NHS Trust Page 9

Home Before Lunch Campaign we will be continuing our Home before Lunch campaign aimed at discharging 30% of patients by midday. This forms part of the Trust s Urgent Care Dashboard and will be monitored by the Patient Flow Group. Daily Morning Board Rounds Following a pilot in 2012-13 all wards will have in place daily Board Rounds to review all patients and identify patients who are due to be discharged over the next 24hrs. Discharge Lounge following a successful pilot in 2012-13 the Executive Team have agreed to extend the Discharge Lounge until March 2014. The Discharge Lounge will be open form 10am 7pm Monday to Friday for mobile, independent patients who are awaiting TTA s and transport home. Morning Discharge Crew the Trust will continue to ensure there is sufficient capacity in the Non Emergency Patient Transport Service to facilitate morning discharges. As part of our discussions with the CCG about the use of the 70% emergency admissions tariff and winter funding, the Trust has developed a number of specific proposals aimed at further enhancing patient flow and seven day working. Whilst the Trust remains prepared to implement these proposals as yet there has been no agreement regarding this funding and therefore we are currently unable to progress them. Additional Ward Pharmacists - Following the outcomes of a three month pilot carried out as part of the Trust s Patient Flow project the Pharmacy Department is proposing to increase the pharmacy support on the Medical Admissions Unit and Surgical Wards. This is aimed at increasing medication reconciliations and reducing in the delays in dispensing discharge medication which can lead to discharge delays. The proposal would also extend this service to seven days a week supporting our aim of increasing discharges and reducing discharge times seven days a week. Early Supported Discharge Services for Stroke Patients (ESD) - Implementation of ESD for Stroke services has resulted in substantial annual bed day savings. With the uplift in ASU beds, patients with acquired brain injuries (ABI) other than stroke will also be routinely admitted to the ASU and SRU to be managed by the neurospecialist staff. Unlike stroke patients, there is not currently a clear pathway for the management of these patients, nor can they access specialist neuro-rehab services in the community. Enhancing ESD resources to enable inclusion of this client group will not only improve the quality of care and patient experience, it would increase patient flow, reducing length of stay. Early Supported Discharge Services (ESD) following fractured neck of femur A proposed 12 month pilot to provide a 7 day rehabilitation service, facilitate earlier discharge from hospital in the acute and community settings, reduced transfers to community hospital and to provide a seamless service for up to 4 weeks for patients post discharge. This service would reduce length of stay, improve the quality of care and patient experience, increase patient flow and meet NICE quality standards for Northern Devon Healthcare NHS Trust Page 10

fracture neck of femur and British Orthopaedic Association Standards for Trauma 2012) Acute Therapy Services: The Trust is proposing to increase the Occupational Therapy and Physiotherapy provision Monday to Friday which would provide a sustainable therapy service to increase patient flow and reduce length of stay. Weekend Discharge Team Whilst weekend discharges are half the number they are during the week, admissions remain similar seven days a week. In recognition of this the Trust has introduced a weekend discharge team over Bank Holidays and during peak pressures. This has been seen to increase discharges at the weekend and improve availability on Mondays and on the first day back after Bank Holidays. Additional Therapies at the Weekend The Trust is proposing to increase the therapies support for Stroke, Orthopaedic, Surgical and Medical Wards. This would ensure that timely specialist assessments and discharge planning can be completed, enabling morning discharges throughout the whole week and avoiding a back log of patients to be seen on a Monday. This includes a proposal for an Early Supported Discharge service for fractured neck of femur patients which will reduce patient s length of stay in hospital and support patients in their own homes at the weekends. Having a weekend ESD service will facilitate Friday and weekend discharges as patients will be supported appropriately in their own homes over the weekends. All of which will increase patient flow both at weekends and earlier the following week. It also includes an increase in specialist OT and PT cover at weekends on the Acute Stroke Unit and Stroke Rehabilitation Unit which will ensure timely completion of assessments and discharge planning, as well as increased access to rehabilitation. 4. DIVISIONAL ACTIONS TO INCREASE CAPACITY AND IMPROVE PATIENT FLOW 4.1 EMERGENCY SERVICES, LOGISTICS AND RESILIENCE EMERGENCY DEPARTMENT (ED) - Work has been completed to improve the facilities with in the ED. This has included creating a separate Minors area and increasing the Majors area by 3 bays to 10 bays in total. This will create additional capacity to manage patients and improve ambulance handover times. ED MIDDLE GRADES The Trust Board has agreed a significant investment in Middle Grade Staffing. This will enable the department to employ additional Middle Grades thereby reducing the reliance on locum and agency doctors. In addition following the management of change process the department will also be introducing a new rota which will ensure that ED Middle Grades are present within the department overnight. Northern Devon Healthcare NHS Trust Page 11

NON EMERGENCY PATIENT TRANSPORT SERVICE (NEPTS) The Trust are currently working with our commissioners on the introduction of a new NEPTS from October 2013. The service which will include extended working hours and cover at weekends and bank holidays will be provided by a new private provider. Consideration will be given to additional NEPTS cover at weekends, bank holidays and during periods of escalation to facilitate timely discharge. This decision will be taken by the DGM for Emergency Services or Deputy. AMBULANCE HANDOVERS The Trust works closely with the South Western Ambulance Service Foundation Trust. We have an agreed Ambulance Handover Plan (Link) which includes actions to escalate delays. The Trust also meets monthly with SWAST and commissioners to review performance activity and trends and agree any interventions required to reduce delays. MEDICAL ASSESSMENT UNIT (MAU) The Trust has already increased the nursing resource on the MAU and is proposing to increase the medical cover for the ward over the winter period. In addition the ward is exploring the potential to pilot a new Ambulatory Care/ Assessment Area which will improve the flow of medical expected patients arriving in the ED department and reduce admissions for patients who require a period of assessment or ambulatory care rather than a full inpatient admission. 4.2 CLINICAL SUPPORT SERVICES ICU - There is a contingency plan in place between ICU and Recovery in Theatres to take patients if ICU becomes full (if there are no clinically suitable patients to move out of ICU to wards in NDDH). ICU is also part of the Peninsula Network and work together when capacity is an issue DIAGNOSTICS - Detailed escalation plans are in place, with a variety of contingencies that can be activated depending on the severity of the situation, to ensure that key Diagnostic services are maintained at all times. The Directorate will work closely with the Trust Operational Management Team in the event of increased activity issues, to ensure that the changing, day to day priorities are fully understood by the Directorate; and its services respond accordingly. 4.3 MEDICINE & PAEDIATRICS ACUTE PHYSICIANS AND INCREASED SPECIALTY SUPPORT ON MAU - Additional Acute Physician posts have been agreed in order to facilitate a speedier turnaround of patients. This will enable two acute physicians to be on the ward round in the morning, ensuring patients will be seen sooner and any treatment plans/issues identified earlier so that patients can either be discharged home or identified to go to the wards earlier. The Trust is also planning for additional specialty input on a daily basis from Care of the Northern Devon Healthcare NHS Trust Page 12

Elderly, Cardiology, Gastroenterology and Respiratory allowing for pathway decisions to be made earlier to facilitate patient flow. MANAGEMENT OF MEDICAL OUTLIERS With the increase in beds, the plan is for all medical patients to be cared for on a medical ward. However, until the bed base increases, the surgical / orthopaedic wards are linked with the following Physicians: Fortescue Dr Moran / Dr Davis KGV Dr Dent Lundy/Roborough Dr Moody / Dr Hands Capener Dr Rasool The Physicians and Ward Managers are responsible for identifying medical patients who fit the criteria for outlying. Please refer to the Bed and Site Management Protocol. If patients are outlied from a medical inpatient ward, the aim would be to transfer them to their consultant s outlying ward. However, this is not always possible (e.g. due to single sex surgical wards). The transferring ward should clearly indicate in the notes which consultant the patient is to be under. It is the responsibility of the receiving ward to update PAS with any transfer of consultant. If a patient is outlied to a Surgical/Orthopaedic ward directly from MAU the patient will be admitted under the Physician responsible for that linked ward, e.g. if a patient is admitted to Capener directly from MAU, they will be under Dr Rasool s care. It is the receiving ward s responsibility to update PAS with the change of consultant. Particular care should be taken when the Physician of the Day (PoD) is not an Acute Physician to ensure that the patient is recorded under the link consultant rather than the PoD. The Acute Physicians (Dr Watt, Dr Peasegood) do not have inpatients. Therefore, under no circumstances, can medical outliers be under these consultants The medical outliers report is created from the Patient Management System RESPRIATORY - Glossop ward is the respiratory ward within the Acute Trust and has been identified as the Flu ward. The ward can take additional acute respiratory patients as identified in the Pandemic flu Plan. Additional equipment is available for non-invasive respiratory support. Community respiratory services will be expected to work differently to support the acute patients. ACUTE STROKE UNIT - the Medicine Division will continue to oversee the optimal Stroke service, ensuring patients presenting with a new stroke are admitted directly to the Acute Stroke Unit and spend 90% of their stay within Stroke services. An additional 4 Acute Stroke beds are being developed ahead of winter to support optimal delivery. CARDIOLOGY - Cardioversions will continue to be managed on a day case basis and close liaison will be maintained with the RD&E and Derriford to ensure minimal delays in cardiac investigations and surgery. Northern Devon Healthcare NHS Trust Page 13

COMPLEX DISCHARGE - The Complex Discharge Co-ordinators based at NDDH are responsible for: Reviewing all MAU patients transferred from MAU to an inpatient ward who have been referred by MAU as likely to have complex discharge needs to ensure that any patient with complex discharge needs is highlighted early and appropriate processes are started. Assessing all patients highlighted by the wards as being suitable for transfer to a Community Hospital. Reviewing medical outliers as appropriate. PAEDIATRICS - The Trust has in place robust escalation plans to manage an increase in paediatric activity (Appendix F&G) Mechanisms are in place between health and social services to complete a preadmission assessment to influence the health care process for children who require hospital admission. Arrangements are in place for disabled young people to receive short breaks and that staffing will be adequate in the carer s short breaks units (Barnes, Honeylands, Meadowpark, Welland House, Hillcrest) Arrangements for babies and children requiring hospital admission, urgent feeding or medication needs in place 4.4 DIVISION OF SURGERY, MIDWIFERY, OBSTETRICS & GYNAECOLOGY NURSING RECRUITMENT Work has been undertaken to insure all areas are fully established across all areas. The Acute Service Unit and the Assistant Director of Nursing (Acute) have worked in collaboration to recruit newly qualified and experienced nursing staff to deliver the organisations bed proposals. ELECTIVE ACTIVITY the division have planned to deliver the organisation planned activity throughout the winter period. Elective activity is planned to deliver the contract plan and to maintain Referral to Treatment Times (RTT) performance. Elective admissions will be reviewed and any decisions to cancel will be made in advance in line with the Escalation Plan. These actions should reduce last minute cancellation of elective surgery. All decisions to cancel will be made by the Director of Operations or the Executive on call and all actions will have been taken to avoid cancellation. Day Case Surgery rates remain consistently high, and every effort is made to maximise the number of patients treated on a day case basis. The Trust plan is to achieve an annual rate of 84% Day Case rate, and actual performance is in excess of 87%. Northern Devon Healthcare NHS Trust Page 14

FLEXIBLE BEDS The division is committed to deliver the core and flexible bed as detailed in the trust bed reconfiguration project. ENHANCED RECOVERY Enhanced Recovery Programmes are in place for patients undergoing Hip Replacement and Knee Replacements, as well as those undergoing major colorectal surgery. EMERGENCY ADMISSIONS - There is a daily Surgical Emergency Clinic between Monday Friday, with dedicated diagnostic support. MATERNITY The Trust has in place robust escalation plans to manage an increase in maternity activity and a plan if it is required to close the unit. 4.5 HEALTH AND SOCIAL CARE (NORTHERN, MID, EXETER AND EAST DEVON) INCREASING CAPACITY IN COMMUNITY SERVICES -The service developments implemented under S256 test for change are now embedded within the health and social care clusters services and will demonstrate key benefits for this winter. The key changes that will improve capacity and system flow include: Eastern and Northern Devon Provision of recuperative care providing time limited care to facilitate discharge or prevent an avoidable admission Investment in social care assessment capacity in community hospitals to reduce delayed discharges Development of discharge co-ordinators to facilitate timely discharges from community hospitals and support patient flow Development of rehabilitation support workers who work across therapy and nursing Eastern Devon The Hospital at Home in WEB provides multidisciplinary intervention led by a consultant geriatrician to prevent admissions and facilitate timely discharge. Key benefits of the service are the clinical leadership by the consultant geriatrician, access to a responsive assessment (2 hours for step up and 4 hours for 2 step down) and access to spot purchase of care and overnight care. The RAAH (Rapid assessment at home) in Exeter providing assessment within 2 hours and multidisciplinary intervention to prevent an avoidable admission or facilitate early discharge Development of the Onward Care Team at RD&E to provide therapy at the front door to prevent an avoidable admission and extension of the service to cover weekends and to 6.30pm weekdays. Northern Devon Healthcare NHS Trust Page 15

Mid Devon pathways to prevent avoidable hospital admissions and facilitate early discharges with access to rapid response team for urgent same day referrals Single point of access across the Wakley area through the Eastern Rapid Intervention Centre (RIC) in or through the Red phone Provision of rapid response service providing care 7 days a week to 11.00pm and access to overnight care Additionally following reduction of beds at a number of community hospitals, The Trust has invested additional resources at Mortonhampstead and Exeter (Whipton), including: o Mortonhampstead Additional community nursing, RRS therapy support, Community OT/Physio, Consultant Geriatrician time o Exeter (Whipton) Additional physiotherapy on remaining inpatient ward, community nursing, community therapies. Northern Devon Enhanced involvement of the voluntary sector to support discharge planning eg befriending Extension of the pathfinder service to 8.00pm Enhanced therapy provision to provide more intensive home rehabilitation and reablement and extension of the community nursing service in Torrington & Holsworthy Education and training packages by community nurses into nursing homes to reduce avoidable admissions to hospital 4.6 COMMUNITY HOSPITALS (NORTHERN, MID, EXETER AND EAST DEVON) COMPLEX DISCHARGE / ONWARD CARE TEAMS - There will be continuous validation and increased scrutiny of in-patients at hospitals with the greatest number of patients waiting for transfer as highlighted by the Onward Care Team - at direction of the Divisional Manager, Community Hospitals and Assistant Director Health and Social Care or nominated deputies. COMMUNITY FLEX BEDS The Trust has identified the potential to flex community beds during periods of peak demand. Again these proposals have been discussed with the CCG as part of the discussions regarding the 70% emergency admissions tariff and winter funding: o o o o o o o o 6 beds in South Molton 4 beds on Willow, Bideford 10 beds at Ottery St Mary 8 beds at Tiverton 6 beds at Seaton 6 beds at Axminster 6 beds at Sidmouth 10 beds at Whipton As yet funding for these additional beds has not been agreed and they are currently not available. Northern Devon Healthcare NHS Trust Page 16

ADMISSIONS AVOIDANCE Community Hospital Matrons are actively linking with local GPs to encourage direct admissions to community hospitals as opposed to direct admissions to DGH s and an ability to divert patients from GP based A&E services to Community Hospitals. 4.7 MORTUARY The mortuary at NDDH has 39 refrigeration and 5 deep freeze spaces. The capacity can increase to 8 by utilising the mobile body racking and external air temperature control can be reduced to 10 o c. The mortuary has in place a contingency plan in which it could double capacity if required and has developed plans for the prompt turnaround of death documentation. Community Hospitals do not have mortuary facilities and have SLAs with approved Undertakers. 4.8 INFECTION CONTROL The Northern Devon Healthcare Trust takes a proactive approach to managing infection control issues via the Trust s infection control team. There are existing policies that cover isolation, Gastro Intestinal disease and outbreak management which allows the outbreak control committee to be invoked and decisions taken on the need for ward closure or opening a dedicated isolation ward if that was necessary to control spread. An Infection Control (IC) team member joins in bed meetings daily if necessary to help inform operational management decisions and the team also have a high profile in all clinical areas. The IC team report outbreaks of D&V via the norovirus reporting system of the HPA. Any outbreaks of potentially infectious diarrhoea and/or vomiting are managed via the Infection Control Team and with patient transfers co-ordinated via the daily operational meeting. The Trust have a designated bed washing service that helps with patient flow. This supplements bed washing by nurses ensuring that beds are ready for new admissions more quickly, especially where post infection cleans are needed. This service is further supported during the winter months with an enhanced cleaning service which focusses on wards which have an outbreak ensuring that these areas reopen more quickly. See the following policies for further information: Gastro Intestinal Disease Policy http://ndht.ndevon.swest.nhs.uk/policies/departments/nursing/infection_control/g astro%20intestinal%20disease%20policy.pdf Northern Devon Healthcare NHS Trust Page 17

Isolation Policy http://ndht.ndevon.swest.nhs.uk/policies/departments/nursing/infection_control/o utbreak%20of%20infection%20policy.pdf Outbreak Policy http://ndht.ndevon.swest.nhs.uk/policies/departments/nursing/infection_control/o utbreak%20of%20infection%20policy.pdf 4.9 STAFFING Business as Usual The following actions will be taken to minimise the impact of any staff shortages: Escalation The Trust has an agreed Nurse Staffing Policy (http://ndht.ndevon.swest.nhs.uk/policies/?p=1457) Staff also use the Enhanced Observation policy (http://ndht.ndevon.swest.nhs.uk/policies/?p=7085) to assess patient at risk and to prioritise their staffing when a patient is needed enhanced observation. NHSP are being contacted to advise what actions they are taking to increase NHSP and agency staff availability. NDHCT has a nurse pool which is used to cover short-term, last-minute absence. When fully established, there is one trained and one HCA available for the day, and two trained and one HCA available for the night. The nurse pool provides cover 24/7 across both the acute and community hospitals. Trust recruitment is currently on track with limited vacancies. Services are rostering staff, managing annual and study leave to ensure maximum coverage of staff over the peak winter months, including Christmas and New Year. There is a Ward Workload Assessment Tool that allows wards to determine the workload and the staffing to identify what additional resources they need or can spare to manage the workload safely. This has a green, amber, red scoring system. In escalation deferral of non-mandatory study leave for all staff will be implemented. All departments/clinical areas maintain staff availability/contact lists so that in the event of unprecedented activity, staff will be called in. Medical students will be offered the opportunity to work as healthcare assistants if additional staff are required and as per the Pandemic flu plan, some non-clinical staff are being prepared to work in a clinical environment. Senior Nursing staff (including specialist nurses and managers with nursing backgrounds) may be pulled into rostered practice if required. While it is a last resort to cancel operations, any cancellation of elective surgery may free up recovery staff who can then support critical care, after a period of training which is underway. Any other elective activity, including Outpatients, may be curtailed as required, thereby releasing staff. The management of significant staffing shortages is addressed in the Pandemic Flu Plan. Northern Devon Healthcare NHS Trust Page 18

4.10 FLU VACCINATON PROGRAMME A flu vaccination programme for staff will be provided which will be advertised during September, commencing October/November. As in previous years, all staff will be encouraged to take up the vaccine and clinics will be scheduled both in and out of clinical areas at various times to make access easy for staff. In addition, clinical operational staff will be involved in administering the vaccine to encourage uptake. Northern Devon Healthcare NHS Trust Page 19

5 OPERATIONAL MANAGEMENT ARRANGEMENTS 5.1 INTRODUCTION The Trust has well established bed and site management processes. These are detailed in the Trust s Bed and Site Management Protocol (link) and are summarised below: 5.2 WEEKLY PLANNING There will be a weekly planning meeting held every Friday at 11.00hrs at NDDH. This meeting will be attended by Divisional General Managers and Duty Manager for the weekend The purpose of this meeting is to take a forward view of the week ahead to determine a framework for the clinical site managers to work within. This framework will be based on 4 key areas: a review of the past week, its management, issues, decisions and actions and identify any problems which require action what has happened in the previous week emergency/elective activity, staffing issues, ED to take a view of pressures and trends what is the position on the day going into the weekend what is forecast for the week ahead known TCIs, predicted emergency admissions planned discharges staffing etc The key information, decisions and actions from this meeting will documented and circulated to CSMs, all duty managers (in hours and on-call) and the Executive on-call. 5.3 DAILY PLANNING 5.3.1 NDDH AND NORTHERN DEVON There will be site meetings at 08.30hrs, 13.30hrs and 16.30hrs. During periods of escalation (Red or Black) there will be additional meetings at 10.30hrs and 15:00hrs. There will be an additional meeting/ phone conversation between 21:00hrs and 22:00hrs between the Clinical Site Manager and On-Call Duty Manager. Out of hours these meetings will normally be done via telephone unless the escalation plan or situation within the hospital requires the On-Call Duty Manager to be on site. 5.3.2 MID, EXETER AND EASTERN DEVON Each weekday morning at 9.30am, a virtual bed meeting (VBM) takes place via telephone conference call with each community hospital matron (or nominated deputy) and the RDE bed discharge coordination team. Northern Devon Healthcare NHS Trust Page 20

5.4 ATTENDANCE AT BED MEETINGS 5.4.1 NDDH AND NORTHERN DEVON The attendance at bed meetings will normally be as follows: RAG Status Attendees Green / Amber Clinical Site Manager who will co-ordinate the meeting Duty Manager for the day ahead Red/Black As per Green /Amber Representative from Each Division Infection Control representative(if required) Complex Discharge Co-ordinator / Pathfinder representative (if required) Clinical Directors The Senior Nurse for Medicine, Surgery and Emergency Services will normally liaise with the CSM before 9am in the morning to review staffing for the day and to agree any plans to redeploy staff is this is required. Additional representatives can be called to attend bed meetings at the discretion of the Clinical Site Manager and Duty Manager based on their assessment of the position. A list of attendees at bed meetings will be documented by the Duty Manager in the Day Duty Log Book. 5.4.2 MID, EXETER AND EASTERN DEVON The attendance at bed meetings will normally be as follows: RAG Status Attendees Green / Amber Divisional Manger Community Hospital Matrons Red/Black Divisional General Manager (chair) Cluster Manager Infection Control Manager Professional Practice rep RDE Access team Northern Devon Healthcare NHS Trust Page 21

5.5 AGENDA BED MEETINGS The agenda for the bed meetings across the Trust cover the following issues: Current bed position ED any capacity constraints Planned TCIs Planned Discharges Outlier position Staffing position. Any infection control issues. Patients waiting for a bed at a community hospital Patients whose length of stay exceeds 28 days and reason why Other relevant information Whether the hospital is in escalation and if a further meeting is required During escalation the agenda will include an increased emphasis on identifying areas of concern and identifying and implementing action plans in conjunction with all hospital and community based care services. 5.6 DAILY BEDSTATE REPORTING The Trust has a daily bed state report which shows the current bed state, predicted emergency admissions, elective TCI s and predicted discharges at NDDH. This is circulated across the organisation by 9am each morning. A similar report is in place for community hospitals which is circulated following the VBM. 5.7 DOCUMENTING ACTIONS In hours any key discussions and actions will be documented by the Day Duty Manager / CSM. Out of Hours a record of any key discussions and actions will be recorded by the On-Call Duty Manager. At NDDH the CSMs will keep a record of any 4hr Breaches and their reasons in the CSM log book. Northern Devon Healthcare NHS Trust Page 22

6 TRUST ESCALATION FRAMEWORK 6.1 INTRODUCTION The Trust has a well developed Escalation Framework. This encompasses NDDH, Community Hospitals and Health and Social Care. The Escalation Framework has also been aligned with the South of England Escalation Framework. 6.2 DETERMINING THE ESCALATION LEVEL 6.2.1 NDDH The overall RAG rating for NDDH is determined by the Duty Manger in discussion with the CSM based on the Escalation Framework (appendix D) which includes an assessment of: Bed Availability Predicted TCI, Emergency Admissions and Discharges ED attendances, 4 hr. Breaches and Ambulance Handover Times Staffing Ward Acuity Infection Control The agreed RAG will be written on the Site Management White Board at 8.30am and updated during the day as necessary. A Black RAG rating can only be declared following discussion with the Director of Operations or On Call Executive. 6.2.2 COMMUNITY HOSPITALS AND COMMUNITY SERVICES The overall RAG rating for Community Hospitals is determined by the Divisional Manger in based on the Escalation Framework (appendix D) which includes an assessment of: Bed Availability Predicted Transfers and Discharges MIU waiting times Staffing Ward Acuity Infection Control Packages of Care Referrals to Community Services The RAG is reported via the daily sitrep. Again a Black RAG rating can only be declared following discussion with the Director of Operations or On Call Executive. Northern Devon Healthcare NHS Trust Page 23

6.3 ESCALATION LEVELS The Trusts escalation levels are aligned with the NHS South of England Escalation Framework: Escalation Level NDDH Community Hospitals (Northern and Mid, Exeter and East Devon) Green Health and Social Care (Northern and Mid, Exeter and East Devon) Capacity available to meet expected demand Good patient flow through A&E and other access points A&E 4 hour target consistently being met Capacity available to meet expected demand MIU 4 hour target consistently being met Packages of Care (POC): All areas able to set up PoC: demand matches capacity Community Demand (CD): >80% of teams are at normal levels of activity Amber (at least 5 of the following) (at least 3 of the following) (at least 3 of the following) Beds available, but short of beds in 1 main area * Available beds & predicted discharges TCIs & predicted admissions = between 5 & -5 Anticipated pressure on maintaining A&E 4 hour target ( 5 10 actual or predicted breaches) Anticipated pressure in facilitating ambulance handovers (delays greater than 30mins) Discharges below expected norm Slow patient flow through A&E, MAU, etc Some unexpected reduced staffing numbers (due to e.g. sickness, weather conditions) in areas where this causes increased pressure on patient flow Infection control status of Amber (see IC escalation plan) Beds available, but patients on onward care list higher than normal for any 2 sites (east) 1 site (north) Fewer than 6 admissions across all sites Anticipated pressure on maintaining MIU 4 hour target (1-2 due to capacity Discharges below expected norm Some unexpected reduced staffing numbers (due to e.g. sickness, weather conditions) in areas where this causes increased pressure on patient flow Infection control status - 2 or more areas closed due to infection POC: One (Cluster or town/locality) area unable to set up any PoC within 48 hours CD: 20-35% of teams are above normal levels of activity, and this is confirmed by reports via Cluster Managers that teams are struggling to match demand with supply. Some unexpected reduced staffing numbers in health and social care (due to e.g. sickness, weather conditions) in areas where this causes increased pressure on patient flow Northern Devon Healthcare NHS Trust Page 24

Escalation Level NDDH Community Hospitals (Northern and Health and Social Care (Northern Mid, Exeter and East Devon) and Mid, Exeter and East Devon) Red (at least 5 of the following) (at least 3 of the following) (at least 3 of the following) Actions at Amber failed to deliver capacity Lack of beds across the Trust Available beds & predicted discharges TCIs & predicted admissions = -5 or more Significant failure of A&E 4 hour target (10-15 actual or predicted breaches) Patients awaiting handover from ambulance service (delays greater than 1hr or several over 30mins) Patient flow significantly compromised A&E patients with DTAs and no plan Significant unexpected reduced staffing numbers (due to e.g. sickness, weather conditions) in areas where this causes increased pressure on patient flow Actions at Amber failed to deliver capacity Beds available more than 3 sites (east) 2 sites (north) Significant failure of MIU 4 hour target (3 plus due to capacity) Fewer than 6 admissions across all sites Significant unexpected reduced staffing numbers (due to e.g. sickness, weather conditions) in areas where this causes increased pressure on patient flow Infection control status more than 3 wards closed Significant number of out of area patients POC: Significant localities within up to 3 cluster areas are unable to set up PoCs within 48 hours CD: 35-50% of teams are above normal levels of activity, and this is confirmed by reports via Cluster Managers that teams are struggling to match demand with supply Significant unexpected reduced staffing numbers in health and social care (due to e.g. sickness, weather conditions) in areas where this causes increased pressure on patient flow Black (at least 5 of the following) (at least 3 of the following) (at least 3 of the following) Actions at Red failed to deliver capacity Requires wider Devon Community Response No capacity across the Trust Position Trust considering diversion of patients Emergency care pathway significantly compromised (greater than 15 actual or predicted breaches) Unable to offload ambulances A&E patients who have been waiting >8 hrs Unexpected reduced staffing numbers (due to eg sickness, weather conditions) in areas where this causes increased pressure on patient flow is at a level that compromises service provision / patient safety Actions at Red failed to deliver capacity Requires wider Devon Community Response No capacity across the Trust Position MIU patients who have been waiting >6 hrs Unexpected reduced staffing numbers (due to eg sickness, weather conditions) in areas where this causes increased pressure on patient flow is at a level that compromises service provision / patient safety Infection Control > 4 sites closed POC: Significant localities within over 3 cluster areas are unable to set up PoCs within 48 hours CD: Over 50% of teams are above normal levels of activity, and this is confirmed by reports via Cluster Managers that teams are struggling to match demand with supply. Unexpected reduced staffing numbers in health and social care (due to eg sickness, weather conditions) in areas where this causes increased pressure on patient flow is at a level that compromises service provision / patient safety Northern Devon Healthcare NHS Trust Page 25

6.4 ESCALATION ACTION CARDS The actions to be taken at each Escalation level are detailed in appendices A - D The Trust s escalation levels are aligned with the NHS South of England Escalation Framework and New Devon CCG Escalation Framework. 6.5 ESCALATION STATUS REPORTING AND COMMUNICATION 6.5.1 Internal When it is determined that the hospital s RAG status is Red or Black, an escalation email (Appendix C) will be sent by the Duty Manager using the BEDSTATE ESCALATION CASCADE address list contained in the NDDH address book on NHS Mail. Divisional Leads will also contact key clinicians and departments to ensure that the appropriate actions are being taken in each area. 6.5.2 External The external communication process is described in Appendix E. This is aligned with the South of England Escalation Framework A daily Capacity Pressures report has been agreed with the CCG and will be implemented from the 1 st November. Daily Hospital Sitreps will also be reported to NHS England via the UNIFY process (Monday Friday) When the Trust is at RED on the Escalation Framework, the Duty Manager will also inform SWAST Ambulance Control and the Northern Devon Locality by telephone. In line with the CCG and Locality Escalation Plan, the Locality will be required to instigate a Locality Conference Call to ascertain the whole locality s escalation level and agree what actions are required to return the community to Amber or Green as quickly as possible When the Director of Operations or On Call Executive for the Trust determines that it is at BLACK on the Escalation Framework, this must be immediately communicated to the CCG Director on Call, who is required to instigate a Strategic conference call to ascertain the whole Community s escalation level and agree what actions are required to return the community to reduce the level immediately. For further details regarding the CCG s responsibilities please refer to the CCG s Capacity Plan 2013-14 (link) Northern Devon Healthcare NHS Trust Page 26

7 MAJOR INCIDENT PLAN The process for declaring and responding to Major Incidents is detailed in the Trusts Emergency Plan and Action Cards. In the event of a Major Incident being declared staff should follow the actions set out in the relevant Action Card. These are available on BOB at: http://ndht.ndevon.swest.nhs.uk/policies/?p=4434 8 BUSINESS CONTINUITY The Trusts Business Continuity Plan has been approved by the Trust Board. This is available on BOB at: http://ndht.ndevon.swest.nhs.uk/policies/?p=8759 9 ADVERSE WEATHER PLANS The Trust has well established adverse weather plans (Heatwave and Cold Weather Plans). The full details of these plans can be found here: http://ndht.ndevon.swest.nhs.uk/policies/?p=5255 An automated email cascade is in place to ensure that any Adverse Weather Warning is immediately cascaded to Heads of Department across the organisation. In the event of a level 3 alert the Deputy General Manager for Emergency Services will call a planning meeting to ensure that all areas are prepared and contingency plans are in place. In the event of a warning of adverse weather conditions, such as snow leading to closed roads and limited transport facilities the following actions will be taken: The Trust would participate in any multi-agency strategic coordination group that was convened. Rotas will be managed by the Ward managers in the event of adverse weather conditions to ensure wards and clinical areas are staffed appropriately. Staff who live locally and are able to get to work would be requested to change shifts. Further details are incorporated in the Pandemic Flu plan. Staff will be offered the opportunity to stay on site in hospital accommodation and given a voucher for hot meals. Staff who are able to work at home will be encouraged to do so. Staff who are unable to get to work will be expected to make contact with health services close to their home to offer their services. Elective services will be cancelled as appropriate and as detailed in the plan and staff moved to critical areas. The daily Sit. Rep. from all services will be adjusted to include information about availability of staff. The Daily Operational Meeting will coordinate actions required and will meet more regularly according to the severity of the situation. Northern Devon Healthcare NHS Trust Page 27

10 COMMUNICATION Communication services are provided 5-days a week. The contact telephone number is 01271 311575. Out of hours communications services are provided by the on call executive, who can be contacted through Duty Manager and switchboard. Members of the team, and a brief description of duties follows: Jim Bray, Communications and Press Officer 01271 311 575 / 01392 356 962 jim.bray@nhs.net James Rowles, Website Manager 01271 349763 / jamesrowles@nhs.net Katherine Allen, Head of Communications 01271 349 169 / 07972 772 187 Katherine.allen@nhs.net There is a more detailed communications plan in the Pandemic Flu plan 2009. 10.1 Staff Communication The following arrangements are in place for staff communication: This plan will be cascaded throughout the organisation and will be available on the Trust intranet site. Information is cascaded through Heads of Department (HODS) briefings (monthly or as required), Chief Execs Bulletin (weekly) and Staff Express (as required) Bob (internal intranet) is updated daily or as required * http://ndht.ndevon.swest.nhs.uk/) In the event of escalation, messages to staff will be published on the public website. This would be set up and managed by the communications team and can be managed remotely. Consideration will be given to other forms of communication to all staff such as payslip inclusions, posters and flyers. Established links between primary and secondary care and Clinical Commissioning Group s communications departments are in place and consistent messages to members of staff and the general public are received and given to share with staff, particularly frontline staff. Key services have been consulted in the development of the plan. 10.2 Public Communication The following arrangements are in place for public communication: Dedicated space on the front page of the public website www.northdevonhealth.nhs.uk for service updates. These can be posted and published instantly and remotely, via an internet connection. The Trust has always received strong co-operation from local media outlets including radio and newspapers to ensure important service updates were broadcast in a timely manner. This includes the cancellation of operations or outpatients due to inclement weather conditions. National campaign materials are used to ensure consistency of message across the NHS. Northern Devon Healthcare NHS Trust Page 28

The CCG take a prominent role in co-ordinating the message and will liaise with Public Health and regional organisations. Our role is to support their message by supplying local case studies and spokespeople if appropriate. Signposting to appropriate services via public website. The front page of our website already carries an 'e-flyer', 'Getting the right treatment in Devon', which explains when and how members of the public should apply Self-Care, contact a pharmacist, NHS Direct, an MIU or their GP Surgery, together with opening hours for these. This will continue to be available on the front page and updates specifically relating to swine flu will continue to be added as appropriate. Northern Devon Healthcare NHS Trust Page 29

Appendix A NDDH ESCALATION ACTION CARDS Northern Devon Healthcare NHS Trust Page 30

North Devon District Hospital Actions to be taken at Green (Level 1) Action Clinical Site Management 1. Continue operation site management in line with Bed and Site Management Protocol Duty Manager 1. Continue operation site management in line with Bed and Site Management Protocol 2. Ensure Daily Sitrep has been completed and sent Ward Managers 1. Continue on-going management of inpatients. Maintain lines of communication with Clinical Site Management. 2. Pull patients from ED, MAU and theatres as soon as beds are available 3. Review potential discharges for the following day and identify those which may be discharged before midday. 4. Liaise with Medical and Surgical teams regarding TTA s and Discharge Summaries, 5. Contact PTS co-ordinators to book transport if patients meet medical criteria. Medicine Divisional Management Team 1. Review admissions and discharges for previous three days, medical outliers and planned discharges for the following day. 2. Liaise with wards and medical teams about any potential mismatch between expected admissions, available beds and planned discharges. 3. Implement actions on medicine escalation plan as appropriate. Surgical Divisional Management Team 1. Review the TCI list, bed state and planned discharges for the following day 2. Liaise with wards and surgical teams about any potential mismatch between admissions, available beds and planned discharges. 3. Implement actions on surgery escalation plan as appropriate. Northern Devon Healthcare NHS Trust Page 31

North Devon District Hospital Actions to be taken at Amber (Level 2) Action Clinical Site Management 1. Continue Green (Level 1) Actions 2. Consider use of Flex Beds Duty Manager 1. Continue Green (Level 1) Actions 2. Consider use of Flex Beds 3. Contact Northern Locality to advise of hospital status 4. Contact SWAST to advise of potential delays Ward Managers 1. Continue Green (Level 1) Actions Divisional Management Teams 1. Continue Green (Level 1) Actions 2. Ensure On Call teams are aware of increased pressures 3. Liaise with Clinical Directors regarding any gaps in doctor cover Senior Nurses 1. Liaise with CSM to identify any staffing issues or wards under pressure. 2. Review staffing levels across all wards/departments in NDDH and reallocate staff as necessary to ensure safety 3. Other actions as detailed on the WWAT Clinicians 1. Senior Clinician (the Physician) must visit their medical wards daily first thing in the morning and undertake a virtual ward round with their teams in order that early senior decisions can be made around transfer / discharge 2. Clinicians to ensure patients awaiting specialty assessment / review in ED are assessed within 1hr of referral or sooner depending on clinical need. Complex Discharge Co-ordinators 1. Complex discharge co-ordinators review all outliers and escalate to consultant responsible and Service Manager. (Phone numbers available from Annie Florey) 2. Review medical outliers and ensure they have been seen by the medical teams and have robust medical management plans that have been initiated. 3. Utilise all available community beds. Northern Devon Healthcare NHS Trust Page 32

4. Consider bringing in the second Complex Discharge Coordinator on site to help review patients who have been identified as having complex discharge needs. 5. Request Complex Discharge Co-ordinators to escalate delay issues. 6. Call in Pathfinder Operational Manager and CCT Managers to highlight options to release pressure in the system. 7. Consider spot purchase of respite/intermediate care beds. 8. Ensure all patients looking at placement have deadlines by when they must have chosen their preferred placement and ensure interim placements are discussed Theatres 1. Recovery staff to contact CSM if recovery is blocking up 2. General Manager for Surgery or the Service Managers to be consulted before surgery is cancelled. The decision to cancel surgery must be cleared by the Exec on Call and may only happen once the Physician and Surgeon on call have been contacted to give the Executive Director on call some direct assurance that all avenues have been explored. MAU Clinic 1. Speak to SWAST to see if there are options to influence the admissions times. 2. Actively try to bring the patients in the following morning if patients are unlikely to arrive prior to 4pm. 3. Review need to pull in extra medical staff to see patients (likely to require diagnostics as well). Infection Control 1. See Outbreak Escalation plan Patient Transport Co-ordinators 1. Proactively contact all wards to identify any discharges requiring PTS 2. Liaise with wards to see if patients can go in wheelchair taxi s or normal taxis 3. Liaise with Deputy GM Emergency Services if additional transport may be required Pharmacy 1. Ensure all Pharmacy Staff are aware of increased pressures 2. Liaise with CSM and Wards regarding discharges on a daily basis 3. Remind ward staff the need to prescribe discharge in advance of anticipated discharge date 4. Review patients to be discharge to resolve any continuity of care issues e.g. MDS requirements 5. Prioritise Discharge medication prescriptions Northern Devon Healthcare NHS Trust Page 33

Diagnostics 1. Radiology Services Manager to review the daily bed status and highlight to Modality Superintendents any areas of concern 2. Staff to be reallocated with the department to support service, if necessary decision by Service Manager / Modality Superintendents Northern Devon Healthcare NHS Trust Page 34

North Devon District Hospital Actions to be taken at Red (Level 3) Action Clinical Site Management 1. Continue Amber (Level 2) Actions 2. Alert pharmacy to prioritise specific TTAs Duty Manager 1. Continue Amber (Level 2) Actions 2. Send Internal Escalation Email 3. Contact SWAST to advise of potential delays 4. Contact Northern Locality to advise of hospital status 5. Discuss potential of opening escalation beds on Capener with CSM and Exec on Call / Director of Operations Ward Managers 1. Continue Amber (Level 2) Actions Surgery Divisional Management Team 1. Continue Amber (Level 2) Actions 2. In hours clinicians to ensure all patients have a clearly documented management plan and EDD 3. Clinicians to review patients to establish if EDD can be brought forward. 4. Clinicians to ensure patients awaiting specialty assessment / review in ED are assessed within 1hr of referral or sooner depending on clinical need. 5. Review all surgery next day and agree with the clinicians which patients can safely be cancelled if absolutely necessary. Patients may only be cancelled by agreement with the Director of Operations (in hours) and Duty Exec (out of hours) once all other actions have been taken. Medicine Divisional Management Team 1. Continue Amber (Level 2) Actions 2. In hours- request physician teams to review any outliers who are considered as suitable for discharge 3. In hours Clinicians to ensure all patients have a clearly documented management plan and EDD 4. Clinicians to review patients to establish if EDD can be brought forward. 5. Clinicians to ensure patients awaiting specialty assessment / review in ED are assessed within 1hr of referral or sooner depending on clinical need. 6. Consider potential for additional consultant/senior medical ward rounds Northern Devon Healthcare NHS Trust Page 35

7. Out of hours request physician of the day to review any outlier who the CSM and ward staff consider suitable for discharge Senior Nurses 1. Continue Amber (Level 2) Actions 2. Visit all clinical areas to identify any staffing issues over the next 24hrs and facilitate actions to rectify 3. Review Staffing Escalation Plan 4. Escalate to Director of Operations/Director of Nursing Clinicians 1. Continue Amber (Level 2) Actions 2. Lead Clinicians to attend capacity pressure meetings. 3. Liaise with service managers regarding prioritising possible elective cancellations although no cancellations due to bed capacity can be completed following agreement of the Director of Operations or Exec on Call. 4. In hours - physician teams to review any outliers who are considered as suitable for discharge 5. Out of hours - physician of the day to review any outlier who the CSM and ward staff consider suitable for discharge Complex Discharge Co-ordinators 1. Continue Amber (Level 2) Actions 2. Liaise with Community Hospitals Division regarding potential for community hospitals to open flex beds Theatres 1. Recovery staff to contact CSM if recovery is blocking up 2. General Manager for Surgery or the Service Managers to be consulted before surgery is cancelled. The decision to cancel surgery must be cleared by the Exec on Call and may only happen once the Physician and Surgeon on call have been contacted to give the Executive Director on call some direct assurance that all avenues have been explored. Ambulatory Care Clinic 1. Continue Amber (Level 2) Actions Infection Control 1. See Outbreak Escalation plan Patient Transport Co-ordinators 1. Continue Amber (Level 2) Actions 2. DGM for Emergency Services to Liaise with SWAST regarding prioritising discharges Pharmacy 1. Continue Amber (Level 2) Actions 2. Ensure all Pharmacy Staff are aware of increased pressures Northern Devon Healthcare NHS Trust Page 36

3. Clinical pharmacy staff attend wards to expedite timely discharge 4. Identify those patients requiring any additional medications for discharge 5. Identify those patients going to the discharge lounge prior to leaving ward 6. Support discharge to community hospitals by liaising with dispensary for any medications supply Diagnostics 1. Continue Amber (Level 2) Actions 2. All Modality Superintendents to be aware of hospital status and patients needing to be imaged and discharged and arrange lists and staff accordingly 3. Prioritise in patient examinations and patients waiting for discharge Northern Devon Healthcare NHS Trust Page 37

Actions to be taken at Black (Level 4) Action Prior to declaring Organisational Black status 1. All actions at Amber (Level 2) and Red (Level 3 have been implemented) 2. All routine elective admissions have been cancelled 3. Urgent elective admissions have been reviewed and, where possible, rescheduled or cancelled. Director of Operations / On Call Exec 1. Where escalation to organisational Black status cannot be averted, the Director of Operations or On Call Executive Director must immediately inform the executive on call for the commissioners in line with the NHS Devon Capacity Plan. 2. Any request to divert patients from ED must only be initiated after all internal divert options have been exhausted. The Director of Operations or On Call Executive Director must immediately inform the executive on call for the commissioner to request a divert to neighbouring trusts. Northern Devon Healthcare NHS Trust Page 38

Appendix B COMMUNITY HOSPITALS (NORTHERN, MID, EXETER and EAST DEVON) ESCALATION ACTION CARDS Northern Devon Healthcare NHS Trust Page 39

COMMUNITY HOSPITALS Actions to be taken at Green (Level 1) Action Matron 1. Business as usual 2. Continue operation site management in line with normal bed and site management processes. Divisional Manager 1. Liaise with matron in line with normal bed and site management processes Ward Managers 1. Continue on-going management of inpatients. Maintain lines of communication with matron. 2. Liaise with Onward Care Team re pulling patients from Onward Care list as beds become available. 3. Respond to requests from GPs for direct admissions as appropriate 4. Work with Complex Care Teams and discharge coordinators to review potential discharges for the following day and identify those which may be discharged before midday. Northern Devon Healthcare NHS Trust Page 40

COMMUNITY HOSPITALS Actions to be taken at Amber (Level 2) Action Matron 1. Continue Green level actions 2. For areas with higher than normal patients on onward care list review patients on ward and ensure appropriate discharge plans in place. 3. Engage with GPs to help facilitate above action 4. Liaise with MIU managers re potential breaches 5. Liaise with ward manager to identify staff gaps 6. Liaise with Divisional manager to consider flexing beds 7. (inc step down RD&E Theatre services) in agreement with commissioning 8. Liaise with cluster managers /Complex Care Team / discharge coordinators to identify any delayed discharges / blocks. Divisional Manager 1. Liaise with matrons re above actions 2. Liaise with partner organisations as required and take part in multi agency conference calls as required Cluster Manager 1. Work with matrons as above -may need to facilitate early discharge 2. Liaise with matrons and ward managers to review patients discharge plans Ward Manager 1. Link in with Matron to ensure above plan implemented Hospital business manager (HBM) 1. Ensure adequate ward clerk cover to facilitate patient transport e.g. transport, TTOs e-discharge Northern Devon Healthcare NHS Trust Page 41

COMMUNITY HOSPITALS Actions to be taken at Red (Level 3) Action Matron & Cluster Manager 1. Continue amber level actions 2. Work proactively to move patients safely into community to provide capacity 3. Contact GPs to discharge patients and inform of red status Divisional Manager 1. Decision made to stand down RD&E Theatre Service as detailed in SOP 2. Consider reducing opening hours of some MIUs to use staff across sites if significant reduction in staff 3. Liaise with NHS Devon re flexing beds HBM 1. Liaise with HOD to assist with bed moves, increased catering demand, cleaning Ward Manager 1. Call staff on leave extra duties 2. Contact NHSP/Agencies Northern Devon Healthcare NHS Trust Page 42

COMMUNITY HOSPITALS Actions to be taken at Black (Level 4) Action Matron & Cluster managers Continue red level actions Divisional Manager 1. Continue red level actions 2. Consider closing MIUs to use staff across sites if significant reduction in staff 3. Cancel elective outpatients to release nursing and administrative staff 4. Liaise with Specialist Services DGM to cancel elective AHP clinics to release nursing and therapy staff HBM 1. Continue red level actions 2. Call admin staff on leave / days off to help support clinical staff and coordinate cancellation of elective service Ward Manager 1. Continue red level actions Northern Devon Healthcare NHS Trust Page 43

APPENDIX C HEALTH AND SOCIAL CARE (NORTHERN, MID, EXETER and EAST DEVON) ESCALATION ACTION CARDS - HEALTH AND SOCIAL CARE Northern Devon Healthcare NHS Trust Page 44

HEALTH AND SOCIAL CARE (NORTHERN, MID, EXETER and EAST DEVON) ESCALATION ACTION CARDS - HEALTH AND SOCIAL CARE Actions to be taken at Green (Level 1) Action Health & Social Care Team Leaders Business as usual to maintain system flow addressing problems to prevent avoidable delays Normal multidisciplinary communication processes to provide effective seamless care Close work with GPs and urgent Rapid Response service to prevent avoidable admissions Normal systems and processes for caseload management, case management and prioritisation of urgent referrals Weekly multidisciplinary core group meetings to review people with complex high needs Joint work with Brokerage to arrange timely packages of care Spot purchase or care homes for recuperative care or admission avoidance Agreement of 4 week health funding for placement or package of care to facilitate discharge for patients with a positive checklist Monitoring of predicted health & social care capacity Discharge Facilitators & Complex Care Team Coordinators Joint work with community hospitals to review potential discharges for the following day and identification of patients who may be discharged before midday Joint work with acute hospital to pull patients through system Review of discharge expected discharge dates and delayed discharges Monitoring patient white boards Onward Care Team & Pathfinder Daily response to new referrals to facilitate discharge to the most appropriate community service Daily actions to address delayed discharges Monitoring patient white Boards and expected discharge dates Joint work with wards to facilitate timely discharge Cluster Manager Weekly monitoring of system flow through normal managerial systems i.e. supervision, performance, core group, etc Specific individuals and issues escalated to Cluster Manager for action Northern Devon Healthcare NHS Trust Page 45

HEALTH AND SOCIAL CARE Actions to be taken at Amber (Level 2) Action Health & Social care Team Leaders Continuation of health and social care actions for green status Review of caseloads to bring forward discharge from caseload where possible and appropriate Liaison with primary care to ensure GPs aware of capacity within rapid response Work with brokerage and independent providers to expedite discharge dates Escalation of individuals with complex needs who do not have an immediate plan of action Increased flexibility to maximise use of community capacity to accept referrals in a timely manner Increased spot purchase of recuperative beds Discharge Facilitators & Complex Care Team Coordinators Review of patients to ensure appropriate discharge plans in place Increased pulling to facilitate discharge Enhanced coordination and communication to improve system flow Onward Care Team & Pathfinder Daily tracking and review of patients waiting for discharge and review of alternative solutions in the community Increased communication to pull patients to facilitate discharge Cluster Manager Agree straightforward placements outside of panel Identification of blockages and actions required to improve system flow Divisional Manager Participation in weekly whole system tactical capacity teleconference /meeting Northern Devon Healthcare NHS Trust Page 46

HEALTH AND SOCIAL CARE Actions to be taken at Red (Level 3) Action Health & Social care Team Leaders Increased frequency of health and social care actions for amber status Additional multidisciplinary meeting to review patients - daily if appropriate Flexible working across clusters to maximise capacity Communication with GPs about operational capacity Review non-essential activities to maximise staffing capacity Review of outstanding assessments to expedite discharge Discharge Facilitators & Complex Care Team Coordinators Daily review of patients to ensure appropriate discharge plans in place Increased pulling to facilitate discharge Enhanced coordination and communication to improve system flow Onward Care Team & Pathfinder Twice daily tracking and review of patients waiting for discharge and review of alternative solutions in the community Cluster Manager Agree straightforward placements outside of panel Identification of blockages and actions required to improve system flow Increased spot purchase of care homes for recuperative care or admissions avoidance Increased involvement and communication in operational issues to identify areas where further actions can be taken to expedite discharges or prevent avoidable admissions Escalation to Divisional Manager where senior manager involvement is required Divisional Manager Participation in whole system tactical capacity teleconference /meeting frequency as required Increased communication to enable good operational knowledge and understanding of further actions planned and required Northern Devon Healthcare NHS Trust Page 47

HEALTH AND SOCIAL CARE Actions to be taken at Black (Level 4) Action Health & Social care Team Leaders Increased frequency of health and social care actions for red status Daily multidisciplinary meeting to review patients - daily if appropriate Flexible working across clusters to maximise capacity Communication with GPs about operational capacity Cancellation of non-essential activities to maximise staffing capacity - eg training and meetings Review of outstanding assessments to expedite discharge Discharge Facilitators & Complex Care Team Coordinators Daily review of patients to ensure appropriate discharge plans in place Increased pulling to facilitate discharge Enhanced coordination and communication to improve system flow Onward Care Team & Pathfinder Twice daily tracking and review of patients waiting for discharge and review of alternative solutions in the community Cluster Manager Agree straightforward placements outside of panel Review of clinical thresholds with senior clinicians to expedite earlier safe discharges Joint working across clusters to enable maximum use of staffing capacity Identification of blockages and actions required to improve system flow Increased spot purchase of care homes for recuperative care or admissions avoidance Daily involvement and communication in operational issues to identify areas where further actions can be taken to expedite discharges or prevent avoidable admissions Escalation to Divisional Manager where senior manager involvement is required Divisional Manager Participation in whole system tactical capacity teleconference /meeting frequency as required Daily communication to enable good operational knowledge and understanding of further actions planned and required Discussion with commissioners for additional funding to increase capacity e.g. additional care home beds Consider redeployment of staff supporting non urgent services Northern Devon Healthcare NHS Trust Page 48

Minors Resus Reception and Triage Appendix D EMERGENCY DEPARTMENT ESCALATION FRAMEWORK Escalation Level Routine Operational Status Status Action By whom A minimum of 65% of patients are being seen and treated within two hours. Continue on-going management of department. Maintain lines of communication with Clinical Site Manager (CSM) As a minimum Board Rounds to be held at 9am, 12 midday, 3pm, 7pm and 10pm ED Consultant / Senior Doctor/ ED Co-ordinator/ ED Board Co-ordinator Routine Operational Status 98% of patients are being seen, treated and discharged within four hours. As above As above Trigger In Hours Action Out of Hours Actions The Department has an influx of patients of greater than 9 in an hour The Department has experienced attendance of greater than 12 patients in an hour Resus has more than 2 patients being actively resuscitated and are expecting more. Resus has more than three patients and have been advised to expect additional patients. ED Consultant and nurse practitioner consider additional triage nurse/ see and treat in minors / clear the minors queue ED Co-ordinator alerts CSM for information only ED Co-ordinator closely monitors timings for each patient The CSM, duty manager will be on-site in the department CSM to alert SWAST and DDoc ED Consultant to liaise with ED Co-ordinator to assess clinical risk If required ED Co-ordinator to alert CSM CSM to alert the duty manager CSM to alert POD/SpR and request help in Resus ED Consultant to be directing and leading the medical team in ED. Fully utilise all the on-call speciality teams ED Co-ordinator to review activity across the dept ED Co-ordinator to delegate ambulance arrivals to Senior Nurse In hours the CSM, Duty Manager and ED Consultant will be on-site in the department. CSM alerts SWAST and DDoc CSM to Alert Orthopaedic team and request help with minors Minors waiting longer than 2 hours to be seen. ED Consultant to consider establishing Minors Clinic ED Co-ordinator to alert CSM and request attendance in the department. CSM and ED Co-ordinator review all patients in the department and identify speciality help that could be utilised CSM alerts Duty Manager Minors waiting longer than 3 hours to be seen. The CSM, Duty Manager and ED Consultant will be on-site in the department. CSM to alert SWAST and DDoc The ED Co-ordinator, Consultant and CSM will go through all the patients in the department and identify majors and minors o The individual specialities will be contacted to see majors patients, including those who were a 999/self-presentation to free up ED staff to see minors The CSM will have already planned with the Duty Manager bed availability Senior Dr and nurse practitioner consider additional triage nurse/ see and treat in minors / clear the minors queue ED Co-ordinator alerts CSM for information only ED Co-ordinator closely monitors timings for each patient Out of Hours there will be a phone call between CSM, A&E and Duty Manager to agree a plan and if required, the Duty Manager will attend A&E Senior Dr to liaise with ED Co-ordinator to assess clinical risk If required ED Co-ordinator to alert CSM CSM to alert the duty manager CSM to alert POD/SpR and request help in Resus Senior Dr to be directing and leading the medical team in ED. Fully utilise all the on-call speciality teams ED Co-ordinator to review activity across the dept ED Co-ordinator to delegate ambulance arrivals to Senior Nurse Out of hours there will be a phone call between CSM, ED Co-ordinator and Duty Manager to agree a plan and if required, the Duty Manager will attend A&E CSM alerts SWAST and DDoc CSM to alert Orthopaedic team and request help with minors Senior Dr to consider establishing Minors Clinic ED Co-ordinator to alert CSM and request attendance in the department. CSM and ED Co-ordinator review all patients in the department and identify speciality help that could be utilised CSM alerts Duty Manager Out of hours there will be a phone call between CSM, ED Co-ordinator and Duty Manager to agree a plan and if required, the Duty Manager will attend A&E CSM to alert SWAST and DDoc The ED Co-ordinator, Senior Dr and CSM will go through all the patients in the department and identify majors and minors o The individual specialities will be contacted to see majors patients, including those who were a 999/self-presentation to free up ED staff to see minors The CSM will have already planned with the Duty Manager bed availability Northern Devon Healthcare NHS Trust Page 49

Patients Awaiting Admission Majors There are 2 or less empty bays in Majors and more ambulances are expected. Trigger In Hours Actions Out of Hours Actions ED co-ordinator checks trolley capacity in Minors and Resus ED co-ordinator to assess if patients can be moved to other areas If there is no other capacity ED Co-ordinator to alert CSM and request attendance in the department. CSM and ED Co-ordinator review all patients in the department and identify speciality help that could be utilised CSM alerts Duty Manager CSM identifies patients for admission and works to move the patients out of the department All majors trolleys full and ambulance on its way in ED Consultant will be on-site in the department CSM to alert SWAST and DDoc The ED Co-ordinator, Consultant and CSM will go through all the patients in the department and identify majors and minors o The individual specialities will be contacted to see majors patients, including those who were a 999/selfpresentation to free up ED staff to see minors The CSM will have already planned with the Duty Manager bed availability Probable admission who have been waiting to be seen for longer than 2hrs The Department has four or more patients waiting admission to a bed. ED Consultant & ED Co-ordinator to liaise and agree plan ED Co-ordinator to bleep specialty teams regarding any GP expected patients needing to be seen ED Consultant to review Ambulance arrivals ED Co-ordinator to Alert CSM CSM to alert the duty manager CSM to liaise with Specialty teams if required The CSM will have already planned with the Duty Manager bed availability ED Co-ordinator will have informed CSM of patients awaiting admission CSM to alert the duty manager and agree plan to move patients out of the department CSM to liaise with Specialty teams if required The CSM will have already planned with the Duty Manager bed availability As for In Hours Actions Out of hours there will be a phone call between CSM, ED Co-ordinator and Duty Manager to agree a plan and if required, the Duty Manager will attend A&E CSM to alert SWAST and DDoc The ED Co-ordinator, Senior Dr and CSM will go through all the patients in the department and identify majors and minors o The individual specialities will be contacted to see majors patients, including those who were a 999/self-presentation to free up ED staff to see minors The CSM will have already planned with the Duty Manager bed availability Senior Doctor & ED Co-ordinator to liaise and agree plan ED Co-ordinator to bleep specialty teams regarding any GP expected patients needing to be seen Senior Doctor to review Ambulance arrivals ED Co-ordinator to Alert CSM CSM to alert the duty manager CSM to liaise with Specialty teams if required The CSM will have already planned with the Duty Manager bed availability As for In Hours Northern Devon Healthcare NHS Trust Page 50

Number of Patients in the Department The total number of patients in the department including waiting to be seen is 25. ED Consultant and ED Co-ordinator to review activity across dept. ED Consultant and ED Co-ordinator consider additional triage nurse and /or Minors Cinic ED Co-ordinator to alert CSM and request attendance in the department. CSM and ED Co-ordinator review all patients in the department and identify speciality help that could be utilised CSM alerts duty manager CSM identifies patients for admission and works to move the patients out of the department Senior Dr and ED Co-ordinator to review activity across dept. Senior Dr and ED Co-ordinator consider additional triage nurse and /or Minors Clinic ED Co-ordinator to alert CSM and request attendance in the department. CSM and ED Co-ordinator review all patients in the department and identify speciality help that could be utilised CSM alerts duty manager CSM identifies patients for admission and works to move the patients out of the department The total number of patients in the department including waiting to be seen is 30. This triggers calling an internal incident As for In Hours Actions Northern Devon Healthcare NHS Trust Page 51

APPENDIX E: ESCALATION EXTERNAL COMMUNICATION FLOW CHART Northern Devon Healthcare NHS Trust Page 52