Agenda item: 8.1, Public Board meeting Date: 30 th November 2016 Title: 2016/17 Operational Capacity and Resilience Plan Prepared by: Phil Luke, Divisional Director for Operations Presented by: Peter Adey, Director of Operations Responsible Executive: Summary: Peter Adey, Director of Operations The 2016/17 Operational Capacity and Resilience Plan outlines the plan to support the expected increase in demand over the winter period and an escalation process and how to manage a surge response if at any time demand exceeds capacity. Actions required: Status (*): History: The Trust Board is requested to endorse the Operational Capacity and Resilience Plan 2016/17 Decision Approval Discussion Information x This paper is an update of the 2015/16 Operational Capacity & Resilience Plan Link to strategy/ Assurance framework: The issues discussed are key to the Trust achieving its strategic objectives. Monitoring Information Please specify CQC standard numbers and tick other boxes as appropriate Care Quality Commission Standards Outcomes Monitor Service Development Strategy Local Delivery Plan Assurance Framework Equality, diversity, human rights implications assessed Other (please specify) Finance Performance Management Business Planning Complaints 2016/17 Operational Capacity and Resilience Plan 30 November 2016 Page 1 of 3
1. Purpose of paper To provide assurance to the Board of Directors that robust plans are in place to manage anticipated demand for inpatient beds in support of the Trust s strategic objectives. To appraise the Board of Directors of the changes to the approach to bed capacity in the 16/17 Operational Capacity and Resilience Plan (OCRP) compared to last year. 2. Background The 2016/17 OCRP underpins year round operational resilience and is aligned to the guidance from NHS England (South) Surge Management Framework August 2015 and Operational Pressures Escalation Framework (October 2016.) The primary aims of the plan are to be able to respond to the forecasted increase in emergency admissions, while maintaining elective activity and ensuring safety of patients at all times throughout the year. The plan builds on the key lessons learned over previous years in terms of what worked well and areas requiring improvement. The RD&E OCRP will be implemented as part of the whole system Resilience Plan with other health and social care provider plans including Devon Doctors on Call, South West Ambulance Foundation Trust, Devon Partnership Trust and Devon County Council Social Services. The NEW Devon Clinical Commissioning Group (CCG) has overall responsibility for the coordination of the System Wide Plan which is led by the Eastern Devon A&E Delivery Board. 3. Analysis The Board will be aware of previous years Operational Capacity and Resilience Plans, which typically modelled demand, identified the inpatient bed shortfall and sought to bridge the gap through the provision of additional medical beds. The 16/17 approach reflects the changing local and national context, particularly with reference to the following: The greater opportunities for integrated working provided through the acquisition of community services The greater opportunities for multi-agency collaboration supported by the Devon Success Regime. The Trust s 16/17 plan is closely aligned with the plans developed through the Bed-based Care work stream of the Success Regime. The financial constraints in which the health and social care community is operating 2016/17 Operational Capacity and Resilience Plan 30 November 2016 Page 2 of 3
In response to the changing environment the 16/17 plan contains three key elements as follows: Optimising hospital care to reduce hospital occupancy. Working in partnership with (and in some cases providing) community services to keep people healthy at home. Changing the culture and behaviours with a greater focus on reducing hospitalisation and increasing care at home. In addition to this shift in approach, changes to the escalation process have been made with the aim of early mobilisation of Trust resources to streamline emergency care and discharge patients home. 4. Resource/legal/financial/reputation implications Provision of a robust operational capacity plan is important in order to support the reputation of the Trust as a high performing organisation with good quality emergency care. The OCRP is funded through a combination of winter contingency funding allocated at the beginning of the year and partial reinvestment of anticipated savings as part of the Success Regime, Bed-based Care workstream. 5. Link to BAF/Key risks The main risks to the plan are surges in demand beyond planned levels, outbreaks of infection and the risk that elements of the plan which aim to reduce dependency on hospital beds are less successful than anticipated. The potential impact on services in the event of significant pressure could include: Adverse patient impact if treatment for elective care is delayed. Cancellation of elective admissions due the number of emergency admissions or delays in patients waiting for onward care. This could add risk to the delivery of RTT and cancer waiting times with an associated loss of income linked to the Sustainability and Transformation Fund (STF.) Risk of failure of ED 4-hour target due to bed capacity problems, consequent regulatory performance failure and loss of income linked to the STF. Bed capacity is recorded and reviewed on the Corporate Risk Register. 6. Proposals The Trust Board is requested to note the content and endorse the 2016/17 OCRP. 2016/17 Operational Capacity and Resilience Plan 30 November 2016 Page 3 of 3
Royal Devon & Exeter NHS Foundation Trust Operational Capacity and Resilience Plan 2016-2017 DRAFT Operational Capacity & Resilience Plan 2016/17 v9 Page 1 of 44
Full History Status: Draft or Final Version Date Author (Title not name) 1.1 11/11/16 DD Operations Draft Status To be used in conjunction with: NHS England Operational Pressures Escalation Levels Framework. In consultation with Divisional Leads Senior Delivery Team Operational Capacity Steering Group Approval required from Royal Devon and Exeter NHS Foundation Trust Board Contact for Review: Peter Adey Director of Operations Phil Luke Divisional Director, Operations DRAFT Operational Capacity & Resilience Plan 2016/17 v9 Page 2 of 44
CONTENTS 1. INTRODUCTION... 5 1.1. OBJECTIVES... 6 1.2. OWNERSHIP AND MAINTENANCE... 6 PART ONE 2. THE 16/17 RD&E WINTER PLAN... 7 2.1. OVERVIEW... 7 2.2. CONTEXT AND STRATEGIC APPROACH... 7 2.3. MODELLING OF DEMAND... 8 2.4. THE 16/17 TRUST-WIDE PLAN... 9 2.5 ANTICIPATED IMPACT OF THE 16/17 WINTER BED CAPACITY PLAN... 10 2.6. SUMMARY OF THE TRUST-WIDE PLAN FOR COMMUNICATION TO STAFF... 12 2.7. DIVISIONAL PLANS... 15 2.8. RISKS THAT COULD IMPACT UPON THE DELIVERY OF SERVICES... 18 2.9. TRUST-WIDE ISSUES... 19 PART TWO 3. OPERATIONAL CAPACITY MANAGEMENT & ESCALATION... 21 3.1. THE DAILY PROCESS OF OPERATIONAL CAPACITY MANAGEMENT AND ESCALATION... 21 3.2. ESCALATION STATUS DEFINITIONS, TRIGGERS AND ACTIONS... 22 3.3. THE RED ESCALATION TEAM (RET)... 24 3.4. GUIDELINES FOR OPENING ADDITIONAL INPATIENT AREAS DURING ESCALATION... 25 3.5. ACTIONS REQUIRED BEFORE DECLARING OPEL 4... 25 3.6. CRITICAL INCIDENT PROCESS... 26 3.7. EXTERNAL REPORTING AND ESCALATION STATUS... 28 3.8. OTHER TRUST ISSUES... 28 3.9. INDIVIDUAL ACTION CARDS FOR SPECIFIC ROLES... 29 4. APPENIDCES... Error! Bookmark not defined. APPENDIX 1: RED ESCALATION TEAM CHECKLIST DRAFT... 30 APPENDIX 2: GUIDELINES FOR OPENING UP ADDITIONAL BED CAPACITY... 32 APPENDIX 3: OPENING EXTRA CAPACITY CHECKLIST... 34 APPENDIX 4: NHS ENGLAND (SOUTH) SURGE MANAGEMENT FRAMEWORK A EXTRACT... 36 APPENDIX 5: CANCELLING ELECTIVE PATIENT GUIDANCE... 37 DRAFT Operational Capacity & Resilience Plan 2016/17 v9 Page 3 of 44
APPENDIX 6: ACTIONS TO CONSIDER DURING A CRITICAL INCIDENT WHEN AT A OPEL 4... 39 APPENDIX 7: COMMUNITY SERVICES DIVISION ESCALATION ACTIONS AT OPEL 2, 3 F & 4... 41 DRAFT Operational Capacity & Resilience Plan 2016/17 v9 Page 4 of 44
1. INTRODUCTION This Operational Capacity and Resilience Plan (OCRP) sets out the following: Part one - An overview of the 2016/17 RD&E winter bed capacity plan. Part two - How the Trust will operationally manage bed capacity throughout the forthcoming year, including key escalation triggers and actions to be taken in times of increasing pressure on the system. Due to the changing local and national context, the strategic approach to bed capacity taken in the 2016/17 plan differs from previous years, in which additional inpatient beds have been provided in an attempt to bridge the anticipated winter capacity shortfall. This winter plan is more focused on three key elements: Streamlining hospital care to avoid unnecessary hospital occupancy. Working in partnership with (and in some cases providing) community services with the aim of keeping people healthy at home. Changing attitudes and behaviours of staff, patients and their relatives regarding hospital care. Accompanying the changes to approach to the winter bed capacity plan, is a change to the internal escalation processes described in section 2 as follows: A greater emphasis on mobilising hospital resources to discharge patients when in escalation. A higher threshold for opening up additional inpatient bed capacity. A higher threshold for cancellation of elective capacity in order to create capacity for medical outliers. The OCRP has been developed and written with reference to the NHS England Operational Pressures Escalation Levels Framework (October 2016). It should be noted that the OCRP shares common actions with the Emergency Preparedness, Resilience and Response (EPRR) framework, however, they are not interchangeable. EPRR escalation should be considered separate from the framework described in this document. The OCRP forms part of the Local Healthcare Economy (LHE) plan which is aimed at managing patient pathways across all services. It has been developed to link with other key organisations including NEW Devon Clinical Commissioning Group (CCG), South West Ambulance Service Foundation Trust (SWAST), Northern Devon Healthcare Trust (NDHT), Devon Doctors On-Call (DDOC), Primary Care, Devon Social Services (DCC) and Devon Partnership Trust (DPT). In addition to the above, this plan is closely aligned with the bed based care work stream of the Devon Success Regime. Whilst winter is a period of increased pressure to the Health Community, establishing sustainable year-round delivery requires capacity planning. It is essential that the health economy has a clear understanding of how much capacity will be required to ensure that the whole health system achieves and maintains safe and effective patient care. Extensive demand and bed capacity modelling has been undertaken to support safe effective care for emergency and elective patients. DRAFT Operational Capacity & Resilience Plan 2016/17 v9 Page 5 of 44
The effectiveness of this plan requires all partnership organisations to have robust and consistent plans in place that are responsive with sufficient capacity to support surges in demand and that deliver effective patient flow throughout the year. The Devon A&E Delivery Board will monitor whole system compliance and partnership working. 1.1. OBJECTIVES The objectives supported by the OCRP fall under the Trust s first strategic goal, the sound delivery of existing services and are as follows: Minimise hospital stay. Maximise care at home and by community services. Care for Medical patients in Medical beds. Minimise cancellations of elective procedures due to bed capacity constraints. Deliver resilience whilst maintaining financial balance. Understanding and compliance with the system-wide escalation process. Supporting our staff by providing a clear plan as well as clear guidance of what to do in times of escalation. 1.2. OWNERSHIP AND MAINTENANCE Executive Director Lead Peter Adey Director of Operations Capacity Management Lead Phil Luke Divisional Director, Operations The Hospital Operations Board overall has responsibility and oversight of the plan, which it carries out through a sub group named the Operational Capacity Steering Group. The OCRP is intended to be a live document which will be subject to amendments in the light of new guidance and operational changes. All changes of the OCRP need to be approved by a quorum of the Operational Capacity Steering Group. Version control and governance of the Plan will remain the responsibility of the Operations Support Unit. This plan will be distributed to individuals on the Director, Manager and Senior Nurse on-call rotas and the Site Management Office. The approved plan will be available on the Trust s Intranet HUB. This Plan will also be distributed to partner organisations in the local healthcare community including NEW Devon CCG and the Devon A&E Board. Divisions have the responsibility for communicating and adhering to their specific plans. DRAFT Operational Capacity & Resilience Plan 2016/17 v9 Page 6 of 44
PART ONE 2. THE 16/17 RD&E WINTER PLAN 2.1. OVERVIEW This section of the 2016/17 Operational Capacity and Resilience Plan (OCRP) sets out the plan to ensure sufficient bed capacity to safely care for our patients over the winter period. The following information is provided in the sections below: Context and strategic approach. How the demand for beds was modelled. The 2016/17 Trust-wide bed capacity plan including the anticipated impact. Divisional plans feeding into the Trust-wide plan. Risks that could impact upon the delivery of services. The potential impact of the stated risks. The delivery of the plan is closely interlinked with the aims, objectives and implementation of the bed-based care work stream of the Devon Success Regime, however, the two are not entirely interchangeable. The focus of the OCRP is to ensure that there is sufficient bed capacity for the Trust to provide safe, high quality inpatient care, whilst undertaking the elective activity required to fulfil its contractual commitments. It is not intended to describe measures which will be taken after the winter period to reduce bed capacity and associated costs. 2.2. CONTEXT AND STRATEGIC APPROACH The 2016/17 OCRP takes into account the changing local and national context, which includes the following key features: Year on year rising demand for emergency care. An increasingly older, more frail population. A constrained financial environment. Changes to the shape of provision which include: o RD&E providing community health services for North, East and West Devon. o Changes to the provision of local Minor Injury Units (MIUs). o 111 service being provided by Devon Doctors. A growing evidence base that unnecessary hospitalisation can cause adversely affect patients through loss of independence, muscle atrophy and the risk of hospital acquired infections. Greater opportunities through collaboration with partner organisations catalysed by the Devon Success Regime. Changes to the commissioning of acute services where finances are no longer strictly linked to individual episodes of patient care. DRAFT Operational Capacity & Resilience Plan 2016/17 v9 Page 7 of 44
2.3. MODELLING OF DEMAND 2.3.1. Methodology In order to forecast the scale of demand for bed capacity this winter, the Trust Discrete Event Simulation (DES) bed capacity model has been used. The model was developed internally and its use for winter bed planning and has been validated by the Academic Health Sciences Network (AHSN) in previous years. The bed model is based on adult inpatient admissions on the Wonford site only and uses the 2015/16 length of stay profiles. The model generates a bed demand profile for the bed-pools of Medicine, Surgery, Trauma & Orthopaedics and Gynaecology which are combined to produce an overall bed demand. The model assumes no change to existing community bed capacity or current levels of social care, intermediate or nursing home provision. The growth assumptions that have been used in the 2016/17 bed-modelling are: Bed Pool Admission 2016/17 Type growth Medical Elective -1.0% Non-Elective 2.0% Surgical Elective * Non-Elective 0.0% Gynae Elective -4.0% Non-Elective 0.0% Orthopaedics Elective ** Non-Elective Trauma Elective 0.0% Non-Elective 0.0% * & ** Elective Orthopaedic and Surgery demand based on activity in 2016/17 Demand Planner profiled by working days not using 2015/16 activity & profile. 2.3.2. Outputs of the Bed Modelling The graph below shows the output of the bed modelling for the Medical bed pool, which faces the highest pressure during the winter period if no management interventions are made. Shortfalls of medical beds are shown in red with surpluses in green, illustrating that without significant intervention the number of medical patients will be greatly in excess of those available, which would result in large numbers of medical outliers in surgical wards and inevitably lead to large scale cancellation of elective activity. The modelling of the Medical bed pool suggests that an average of 84 additional medical beds are required for Medicine during the winter period. It is important to note that because the model uses historical admission data any high variations in demand, such as that experienced in January 2015, will also be reflected in the forecast. DRAFT Operational Capacity & Resilience Plan 2016/17 v9 Page 8 of 44
The following section shows the planned interventions to mitigate against the anticipated bed capacity shortfall, as well as the expected impact that this will have on capacity. 2.4. THE 16/17 TRUST-WIDE PLAN In response to both the challenges and opportunities provided by this changing context, the 2016/17 winter bed capacity plan has three key elements: Streamlining hospital care to reduce hospital occupancy. Working in partnership with (and in some cases providing) community services to keep people healthy at home. Changing the culture and behaviours around discharge and keeping patients in hospital. The plan is summarised as an illustration on page 14 as part of the communication plan for staff, and a table showing the headline, description, lead division and anticipated medical bed gain on page 12. A summary of the key elements of the plan is provided below. 2.4.1. Streamlining Hospital Care In previous years a key element of the approach has been to increase medical bed capacity over winter, however this typically presents significant challenges relating to nursing, medical and therapy staff cover and is highly expensive. This year there is a greater emphasis on maximising the efficiency of the acute non-elective system by streamlining hospital care, avoiding unnecessary admissions and discharging patients back home as quickly as possible. The key elements of this part of the winter plan are as follows: Enhanced weekend working. Practice educators for nursing and therapy staff. Ward productivity programme. The conversion of existing capacity into a specialist Frailty Unit. The conversion of existing capacity into an Ambulatory Care Unit. DRAFT Operational Capacity & Resilience Plan 2016/17 v9 Page 9 of 44
The conversion of existing capacity into an Orthopaedic Short Stay Unit. An escalation process to reduce waiting times for non-elective cardiology patients requiring investigation and treatment. Additional trauma lists to ensure patients with fractured femurs are operated on more quickly. 2.4.2. Keeping People Healthy at Home This element of the winter plan builds upon opportunities created through the recent transfer of local community services to the RD&E and the increased multiagency collaboration facilitated through the Devon Success Regime. The key elements of this part of the winter plan are as follows: RD&E led community response providing support to people in their own homes. Supporting initiatives to promote better use of health and social care resources such as the Choose Wisely campaign. Maximising the gains through integration with community health services. Working with partner agencies in the provision of emergency care, such as utilising urgent GP appointment slots provided by Devon Doctors Ltd as part of their provision of the 111 service. 2.4.3. Changing Culture Broadly, the approach in the 2016/17 plan seeks to shift the emphasis of care from the acute sector to community services, with the ideal location of care being patients homes. This represents a shift in culture and mind-set, not only on the part of healthcare professionals in the Trust and the wider healthcare community but also of patients and their relatives. A growing body of evidence shows that once the acute element of a patient s care is safely managed, hospitalisation presents a number of risks to patients including loss of independence, muscle deterioration and hospital acquired infections. Changing the culture, attitudes and behaviours relating to hospitalisation is complex and will require a concerted programme of education over a considerable period of time. The key elements of this part of the winter plan are as follows: A staff training programme covering nurses, therapists and medical staff is being implemented making the case for a change in approach and informing staff of what they need to do. A patient video acknowledging the benefits of NHS hospital care whilst crucially explaining the risks of unnecessary hospital stays. This will inform and empower patients to enable them to play a role in reducing length of stay. This short video will be shown to approximately 60,000 people per year and should therefore contribute significantly over time to shifting attitudes towards being in a hospital bed. 2.5 ANTICIPATED IMPACT OF THE 16/17 WINTER BED CAPACITY PLAN Using the same methodology applied to establish the demand for medical beds over the winter period, modelling of the anticipated impacts of the Trust wide plan. Each element has been quantified using existing baseline data whilst building in assumptions of the impact of any change based on experience from other organisations and the judgement of the clinical teams. The graph below illustrates the impacts, with green showing surpluses of bed capacity and red showing deficits. DRAFT Operational Capacity & Resilience Plan 2016/17 v9 Page 10 of 44
Surplus / Deficit of Beds Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 100 Surplus / deficit of medical beds based on implementation of 16/17 winter bed capacity plan. 80 60 40 20 0-20 -40-60 -80-100 Modelled based on 2% growth in EM medical admissions & a -1% growth in EL medical admissions in 2016/17. Baseline bed capacity of 390 beds. Date The impact of the planned interventions is significant and represents a marked improvement from the position without interventions shown on page 9, in which a deficit of up to 84 beds could be seen throughout Q4. One further element of the winter plan that is not specifically shown as an intervention but which is built into the plan, is that the surgical wards are able to accommodate approximately 20 medical outliers without cancellation of elective activity. Taking this into account, the winter plan is expected to be sufficient to effectively manage medical patients during Q3 and much of Q4 but with a deficit of up 20 beds on some days during January and February. One potential significant benefit, which has not been quantified is the increased efficiency generated through the integration of acute and community care brought about by the recent transfer of community services. DRAFT Operational Capacity & Resilience Plan 2016/17 v9 Page 11 of 44
2.6. SUMMARY OF THE TRUST-WIDE PLAN FOR COMMUNICATION TO STAFF The key elements comprising the 2016/17 winter plan are summarised in the table below. In addition to this, an illustration showing the key elements of the 2016/17 plan has been provided on page xx. These two resources combined should provide an accessible quick reference guide to support managers and clinical leaders across the Trust in briefing their teams regarding the 2016/17 plan. Intervention Description Lead division Streamlined hospital Enhanced weekend working Practice educators Ward productivity programme Additional therapy staff. Additional pharmacy staff. Experienced nursing and therapy staff to support education of more junior staff, particularly around risk management and safe discharge. An improvement programme in ward processes and behaviours relating to effective discharge. Frailty Unit The conversion of existing capacity into a specialist, multidisciplinary area to support rapid assessment and discharge of frail, elderly patients. Ambulatory Care Unit Orthopaedic Short stay Unit Cardiology nonelective escalation Additional trauma lists Healthy at home RD&E community response Reducing LOS for frail elderly patients. The conversion of existing capacity into an Ambulatory Care Unit. Avoiding admissions. Expediting discharge of existing inpatients i.e. patients receiving IV antibiotic therapy as inpatients. The conversion of existing capacity into an Orthopaedic Short stay Unit. Enables Trauma beds to be increased from 35 to 60, which will end trauma outlying and provide some capacity for approximately 6 medical patients. Will provide 39 elective orthopaedic beds, in order to give reliability to surgeons and end cancellations of inpatient activity. An escalation process to ensure that patients waiting times for inpatient, non-elective interventions in the cardiac catheterisation lab are prioritised. Reducing LOS for Cardiology patients. Freeing up capacity on AMU through Cardiology patients awaiting cardiology beds. Reducing the risk of cancellation of elective cardiology due to compromise of ring-fenced elective beds. Saturday AM operating lists to ensure patients with fractured femurs are operated on more quickly. Providing support to people in their own homes. Implementation of the Discharge to Assess model across all elements of the community. Review of the existing onward care practice. Improved communication system. Specialist Services Specialist Services Planned start date Dec 2016 Dec 2016 Medicine Oct 2016 19 Medicine Dec 2016 14 Specialist Services Nov 2016 10 Surgery Dec 2016 6 Medicine Oct 2016 6 Anticipated medical bed gain Supporting other measures Supporting other measures Surgery Dec 2016 Supporting other measures Medicine Jan 2017 33 DRAFT Operational Capacity & Resilience Plan 2016/17 v9 Page 12 of 44
Intervention Description Lead division Choose Wisely campaign Maximising the gains through integration with community health services Devon Doctors urgent GP slots Changing Culture Staff training programme Patient education video Swift and appropriate discharge home with the wrap around support and re-ablement provision that will enable the person to return to their normal activities of daily living at the earliest possible time. A national and local information campaign to inform and empower patients through explaining what local services are available as alternatives to emergency service and acute hospital admission. Expedited pull of patients from community hospitals. RD&E discharge approach augmented by increased understanding of local services. Devon Doctors Ltd now provides the 111 service. This includes 14 urgent GP slots per week day and 40 per weekend day to be accessed by ED & MIUs. Avoiding admissions. Reducing pressure on ED. Linked with ward productivity programme. Covering nurses, therapists and medical staff. Making the case for a change in approach. Informing staff of what they need to do differently. Educating patients on why being at home as soon as possible is in their best interests. Will be shown to approximately 60,000 people per year. Planned start date Anticipated medical bed gain Medicine Oct 2016 Supporting other measures Community Services Medicine Operations & Medicine Jan 2017 Supporting other measures Supporting other measures Supporting other measures Operations Jan 2017 Supporting other measures DRAFT Operational Capacity & Resilience Plan 2016/17 v9 Page 13 of 44
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2.7. DIVISIONAL PLANS 2.7.1. Medical Services Division Bed Capacity and Cohort Ward Arrangements The modelling work demonstrates that the Medicine bed-base needs to increase by approximately 84 medical beds over the winter period to manage the demand. The Trust-wide work on reducing the reliance on bed based care is being led through the Medicine Division and there is a significant programme of work being undertaken to deliver appropriate levels of efficiency and capacity for the winter surge. Ward Productivity Programme An improvement programme in ward processes and behaviours has been running since August 2016. There is a ward-by-ward roll out of service of improvement tools and techniques to support the ward teams to drive out waste and maintain the independence of people that we are caring for on our wards. It is expected that this will generate small productivity gains for all patients in the hospital thereby improving patient flow. Ambulatory Care Unit A new ambulatory care unit has been set up and is extending the current practice of offering ambulatory care pathways to patients who otherwise would have been admitted or for whom their discharge can be expedited by delivering their on-going care needs through an ambulatory facility. Frailty Unit A frailty unit will be implemented in December 2016 to ensure that people who are frail, and may have complex needs but do not need a long stay in hospital, have a dedicated facility for diagnostics, treatment and early supported discharge. This will reduce the number of people who are admitted to the base wards and overall reduce length of stay. Community Response A significant investment is being made into community services, with the extended roll out of the Discharge to Assess model across all elements of the community. In order to complement this redesign, a review of the existing onward care practice and an improved communication system will enable professionals in the acute trust to speak to community colleagues and develop a shared plan to meet the on-going care needs for the person. The outcome of this will be a swift and appropriate discharge home with the wrap around support and re-ablement provision that will enable the person to return to their normal activities of daily living at the earliest possible time. In conjunction with the roll out of the Discharge to Assess model, the current care provision for patients who had short stay rehabilitation needs will be reviewed. Emergency Department The Emergency Department continues to review emergency care pathways for our patients to reduce delays and maximise the opportunity for admission avoidance. The Emergency Department team have undertaken a significant amount of work to ensure that the service is adequately resourced and that workforce capacity matches required demand. The additional resource for Nurse Practitioners has been continued and the team have implemented a Rapid Assessment at Triage process, which will put Consultants at the DRAFT Operational Capacity & Resilience Plan 2016/17 v9 Page 15 of 44
start of the patient journey in the Majors area ensuring swifter decision making. Ambulance Handovers Medical Services has a comprehensive plan that has been developed with South West Ambulance Service to manage the handover of patients. Front Door Services The Medical Services Division continues to work closely with health and social care community partners to maximise the opportunity to improve the opportunity to reduce overnight admissions through the Front Door Service The full multi-disciplinary team is in place with GPs having direct access to Consultant Geriatricians and Physicians to maximise the opportunity for advice and guidance. The team is fully functioning, working across traditional boundaries with the aim to return patients to their usual place of residence as soon as possible. The team includes: Consultant geriatrician Consultant physician Older peoples mental health worker Onward care team Age UK Specialist nurses 7/7 Consultant Provided Care Last year the majority of specialties within the Medical Division implemented seven day working, which was successful in reducing variation in healthcare provision and improving patient flow. This service will continue this year. Service Improvement The Medicine Division is committed to implementing best practice in patient flow and will implement fully the SAFER care bundle in appropriate clinical areas. The implementation of the SAFER care bundle and in particular a project called Specialty Pull, aims to improve the time of day of discharge and improve the flow of patients between AMU and base wards. 2.7.2. Surgical Services Division The Surgical Services Division has developed the plans to ensure good patient flow is maintained throughout the winter period 2016-17. The actions listed below are designed to release pressure following the festive periods and create medical capacity during the key pressure months of winter. Surgery All day general surgical emergency lists will be in place from 31 October 2016. Additional hand plastic surgery trauma capacity will be provided at Heavitree. Continue to develop bed based care in relation to emergency pathways on Surgical Triage and Assessment Unit. Provision of a 13 bedded facility for elective Orthopaedic patients over the winter from December 2016. This will enable Tavy ward to be converted to a trauma ward, which will increase the provision of trauma beds from 35 to 60. There are on average 50 trauma patients in the hospital at any one time so this intervention should end the practice of outlying trauma patients into orthopaedic elective beds. At the same time, the provision of the 13-bedded facility for elective patients will DRAFT Operational Capacity & Resilience Plan 2016/17 v9 Page 16 of 44
provide 39 elective beds, which will enable Orthopaedics to achieve its contracted level of activity without interruption. Inpatient activity will be carefully managed over the Christmas period to support patient flow, for example by increasing day case work post-christmas to reduce the impact on bed pressures. The Division can accommodate approximately 20 medical outliers in surgical beds without cancellation of elective activity. Medical outliers are planned to be cared for in dedicated bays within 2 surgical wards. Trauma & Orthopaedics 28-30 December: Short stay only through Orthopaedic elective beds. Tavy Ward will now be available for trauma and medical outliers as required during the festive period. Additional fracture clinics and trauma lists will take place following the Christmas and New Year bank holidays to clear any trauma backlog. Additional trauma (fractured neck of femur) lists will be in place on a number of Saturday mornings throughout the winter period. 2.7.3. Specialist Services Division Paediatrics Paediatrics has a well-developed plan when capacity pressure affects the flow of patients. In the event of bed capacity problems within Paediatrics the Assistant Director of Nursing for specialist services will coordinate the response. Medical Imaging 7 day services are in place for Plain Film, CT, MRI, with US 7 day services being introduced in 2016. For extended MRI capacity, a contract with Alliance Medical is in place for the provision of a mobile MRI scanner. With this mobile option, the number of days can be booked flexibly so as to respond to increased demand. The team continue to monitor demand and capacity, flexing lists as required. 7/7 Pathology Service Blood Sciences and Microbiology both provide a 7/7 service as necessary to meet existing demand. The Microbiology service cover increases to meet the need depending on infection control rates within the hospital e.g. Norovirus outbreak. Histology continues to provide a 5 day service with biomedical scientist cover on a Saturday morning to prepare specimens so as not to delay consultant review early into the next week. The Mortuary provides a 7 day service, with on call technician provision out of hours. During bank holiday periods, where there can be delays with patient transfers, extended mortuary capacity can be employed by using a portable, modular system. Along with CCG representatives and pathology leads from North Devon, a pathology optimisation group reviews best practice and clinical guidance for pathology testing. Looking to ensure tests requested are the most appropriate and that demand management methodologies are employed to help ensure in appropriate testing is reduced. Therapies Physiotherapy and Occupational Therapy will provide enhanced cover across in-patient services over the weekend. An enhanced Physiotherapy service will deliver early assessment of mobility, on-going rehabilitation to prevent patients from deteriorating, or to accelerate the progression DRAFT Operational Capacity & Resilience Plan 2016/17 v9 Page 17 of 44
patients have achieved during the week, in order to facilitate timely discharge, and will participate in Board Rounds where appropriate (AMU), following up requests identified from wards. Occupational Therapy will support discharges over the weekend and prevent delays in determining discharge destinations, ensuring functional assessments are completed promptly. Infection Control The Trust takes a proactive approach to managing infection control issues via the Trust s Infection Control Team. The Trust has a dedicated infection control ward, Torridge, where the care of all patients diagnosed with symptomatic Clostridium Difficile Infection is managed. However, the negative pressure isolation rooms are also used for the admission of adult patients suspected or confirmed on admission as having easily transmissible infections e.g. viral gastroenteritis. Education and training of staff continues to be provided to raise awareness of the importance of recognising potentially infectious patient on admission, management of patients who have to be admitted and outbreak control measures. Please refer to the following policies for further information: Infection Control policy Patient Placement Policy Major Outbreak Plan Ward Closure Due to Suspected or Confirmed Outbreak of Infection Viral Gastroenteritis Guidance Source Isolation Policy Seasonal Flu Plan Pandemic Flu Plan Pharmacy Weekend working is well established. FP10S are available out of hours from Site Team. 2.8. RISKS THAT COULD IMPACT UPON THE DELIVERY OF SERVICES The 2016/17 winter bed capacity plan has elements not contained in previous years and, whilst there is an evidence base behind each element of the plan, there is always a risk that they will not deliver the forecasted benefits. The figures used in the bed capacity modelling show benefits which are expected by the clinical and managerial teams to be the most likely case. Inevitably some elements may not deliver the full anticipated benefits, whilst others may over deliver. With regards to assessing the level of risk The Operational Capacity Steering Group will monitor the implementation and impact of the different elements of the programme such that changes can be made to address any shortcomings as they arise. 2.8.1. Other risks In addition to the risks around the delivery of the plan itself, the following risks have been identified which, if materialised, could impact on service delivery more generally: Sustained increase in non-elective admissions above predicted numbers. DRAFT Operational Capacity & Resilience Plan 2016/17 v9 Page 18 of 44
Continued increase in Emergency Department attendances causing difficulty in meeting Emergency Department targets. Unplanned absence of staff from issues, such as an increase in infections or industrial action. Increased demand for services due to higher level of infection within the Healthcare community. Adverse weather conditions. Partner agencies unable to cope with increased demand and patients diverting to RDE. A change in the baseline provision of community health and social care services from previous years levels. Outbreaks of Norovirus or any other infection control issues impacting on bed availability. Patient transport resilience is compromised. The Plan has a risk assessment which is recorded and reviewed on the Corporate Risk Register. 2.8.2. Potential Impact of Risks on Services The list below outlines the potential impact on services in the event of significant pressure affecting patient flow as described above. Potential adverse patient safety and quality impact on cancelling elective work. Cancellation of elective admissions due to the number of emergency admissions and/or delays in patients waiting for onward care, therefore, unable to meet RTT and cancer waiting times and associated loss of STF income. Risk of failure of the 4-hr A&E target, consequent regulatory performance failure and associated loss of STF income. Failure to meet ambulance handover times. This will affect both quality and safety for patients. Declaration of black escalation status which could result in divert of non-elective admissions. Additional financial expenditure risk. 2.9. TRUST-WIDE ISSUES 2.9.1. Flu Vaccination Plan Seasonal flu is a highly infectious respiratory illness caused by a variety of different flu viruses. All frontline health care workers are offered flu vaccination, to protect staff and their families and to prevent the transmission of flu to patients and visitors who may be very vulnerable to flu. The vaccination programme at the RD&E is managed by the Infection Control Team and Occupational Health Service. This year, an extensive peer vaccination programme has been established in all wards and many clinical departments e.g. ITU, Emergency Department, Operating Theatres. The aim of the peer vaccination programme is to increase uptake of vaccine by frontline staff through local promotion of the benefits and making vaccination easily accessible in the clinical area thus negating the need for frontline staff to attend vaccination clinics provided by the Occupational Health Service. 2.9.2. Seasonal Flu Plan The Trust s Guidance for the Management of Seasonal Influenza is reviewed annually against national guidance and to incorporate any learning from the previous year s flu season. The plan is activated when Public Health England s national surveillance DRAFT Operational Capacity & Resilience Plan 2016/17 v9 Page 19 of 44
scheme indicates that influenza virus A or B is circulating and there is a substantial likelihood that people presenting with an influenza-like illness are infected with influenza virus, or once Flu is circulating in the community or initial cases are identified in hospital. 2.9.3. Influenza Pandemic Plan Whilst influenza pandemics have been relatively infrequent a new pandemic could emerge at any time. The Trust s response to an influenza pandemic will be based on this Framework and the Trust s Guidance for the Management of Seasonal Influenza and Influenza Pandemic Contingency Plan. Reference should also be made to the RD&E Business Continuity Strategic Response and Recovery Plan and individual Service Continuity Plans. 2.9.4. Domestic Services Specialist Cleaning Domestic Services have two additional Specialist Cleaners to be available during the busy winter period. These additional staff will be available seven days per week and will occupy the 14:00-22:00 and 22:00-06:00 shifts to provide further support. A member of the Domestic Services Operational Team will attend bed meetings as required, in addition to a manager attending Outbreak meetings as these occur. This will ensure that the department maintains its close working links with the Site Practitioner and Infection Control teams and that up to date information on ward closures and cleaning requirements can be prepared and actioned. 2.9.5. Non-Emergency Patient Transport Services At times of escalation, information should be provided to First Care Ambulance and Devon County Council Patient Transport Advice Service about any likely increase in demand on Patient Transport Services (e.g. potential for increased discharges). 2.9.6. Emergency Preparedness and Business Continuity The Trust s Emergency Preparedness Plan sets out the arrangements for responding to any major incident. The Trust has a Strategic Business Continuity and Recovery Plan. The plan is on the Trust s intranet site. 2.9.7. Adverse Weather Conditions The Trust receives warnings of severe weather from the Met Office. The Trust also receives additional information from a Met Office Adviser via the Local Resilience Forum if forecast weather has the potential to cause disruption. The Trust has plans for severe winter weather and heat waves which can be found on the Emergency Preparedness page of HUB. The plans are reviewed each year against national guidance which corresponds to Met Office Cold Weather Alert and Heat Health Watch periods. DRAFT Operational Capacity & Resilience Plan 2016/17 v9 Page 20 of 44
PART TWO 3. OPERATIONAL CAPACITY MANAGEMENT & ESCALATION This section outlines the day to day operational management processes in place to effectively manage bed capacity across the Trust. It is designed to be a useful source of reference for the operational teams responsible for ensuring that there is good patient flow throughout the hospital, as well as setting out the correct processes of escalation to follow in times of increasing pressure on bed capacity. The Trust approach to operational capacity management and escalation incorporates guidance from NHS England, detailed in their recent publication, Operational Pressures and Escalation Framework (October 2016.) This section sets out the following: The daily process of operational capacity management. Escalation triggers and actions. Red Escalation Team response. Guidelines for opening additional inpatient areas during escalation. Actions required before declaring OPEL 4. External reporting and escalation status. Other Trust issues. Individual action cards for operational capacity management and escalation. 3.1. THE DAILY PROCESS OF OPERATIONAL CAPACITY MANAGEMENT AND ESCALATION Daily operational management is delegated to the Trust Lead Patient Flow and Site Management Team, who take an active role in co-ordinating bed management and supporting the Divisions to maximise available beds. It is the responsibility of the Site Management Team to ensure that patients are allocated beds once the decision to admit is made and wherever possible in the correct ward for their clinical needs. It is their responsibility to maintain an overview of the Trust position at all times and to escalate issues to the Divisional Management Teams in hours and to the Senior Manager On-Call, as required, in accordance with this plan, out of hours. Routine bed meetings are held 7 days a week at 12:00 and 16:00 and at other times as the need dictates. This is led by the Trust Lead Patient Flow or Deputy and focuses on the development of a robust plan to deal with any predicted shortfall between admissions and discharges. The meeting also reviews Emergency Department activity and performance to ensure compliance of the ED 4-hour wait quality indicator, any infection control issues and Trust wide staffing issues. Bed meetings are attended by Trust-wide representatives and are to review the outcome and escalate actions as necessary. The Trust has a daily bed forecast which indicates the current position using a barometer based on the previous 24 hours performance and the current pressure indicators for patient flow. The forecast is circulated across the organisation by 10:00. DRAFT Operational Capacity & Resilience Plan 2016/17 v9 Page 21 of 44
Alongside the barometer, details of current capacity, the previous 24 hours performance, and the current pressure indicators are outlined. The bed forecast is updated at the midday bed meeting. Out of hours (17:00 to 09:00 Monday to Friday / 24 hours at weekends / bank holidays) the Site Practitioner will ensure that the Senior Manager On-Call is kept up to date with the Trust s status. 3.2. ESCALATION STATUS DEFINITIONS, TRIGGERS AND ACTIONS NHS England has produced a framework for the classification of escalation levels, setting out the definition of Operational Pressure Escalation Levels (OPEL) 1-4. The definitions have been incorporated into the Trusts approach and are described in the table below. Definition of Escalation Statuses OPEL ONE OPEL TWO OPEL THREE OPEL FOUR Business as usual. Capacity is such that organisations are able to maintain patient flow and are able to meet anticipated demand within available resources. Commissioned levels of services will be decided locally. The local health system is starting to show signs of pressure. Focused actions are required in organisations showing pressure to mitigate further escalation. Enhanced coordination will alert the whole system to take action to return to green status as quickly as possible. Actions taken in Level 2 have not succeeded in returning the local health system to Level 1 and pressure is increasing. The Trust /system is experiencing major pressures compromising patient flow. Urgent actions are required across the local health system by all partners. Pressure continues to escalate leaving the local health system unable to deliver comprehensive emergency care. There is potential for patient care and safety to be compromised. A Serious Incident is reported by the affected organisation. Decisive action must be taken to recover capacity and ensure patient safety. A number of factors contribute to the overall escalation status of the organisation. These indicators have a high degree of interdependency and a degree of judgement is required as well as an understanding of the key escalation triggers. The escalation status of the organisation is decided by the divisional representatives at the 08:45 daily meeting using the triggers described in the table below as a guide. If an escalation level of OPEL 3 is required the Director of Operations or Chief Executive must be informed. OPEL 4 can not be declared without agreement from the Director of Operations or Chief Executive and the on-call director from the CCG. The table overleaf describes the key actions which should be implemented according to the different escalation levels. DRAFT Operational Capacity & Resilience Plan 2016/17 v9 Page 22 of 44