1.0 Introduction - NHS East and North Hertfordshire … · Web viewSharing of information at all...

East & North Hertfordshire CCG

Surge, Escalation & Capacity Plan

Version 21

November 2017

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Version Number

Purpose / Change Author Date

01 First draft Phil Lumbard/Jo Burlingham

October 2015

02 Updated with comments from Alison Pirfo, ENHT

Phil Lumbard 19.10.2015

03 Updated with comments received at the WSCC table top exercise on 21st October 2015.

Phil Lumbard26.10.2015

04 Updated with changes from JB Jo Burlingham 02.11.201505 Grammatical and Format Changes Jane Wallis 30.11.201506 Updated following action & trigger

updates from providersPhil Lumbard 17.12.2015

07 Reformatted and index system updated Jo Burlingham / Jane Wallis

23.12.2015

08 EEAST triggers & action updated Phil Lumbard 11.1.201609 EEAST Reap levels updated Jane Wallis 09.05.201610 Updated triggers and actions for HCS Jane Wallis 24.05.201611 Updated triggers and actions for ENHT Jane Wallis 13.07.201612 Update:

12 hour breach reporting protocol

Ambulance divert check lists HCS triggers and actions Updated system matrix

Jane Wallis and Jo Field 10.08.2016

13 Updated Halo and Cohorting process on pages 36 and 37.

Jane Wallis 24.08.2016

14 Updated to reflect NHS England Central Midlands Escalation Framework September 2016

Jo Burlingham 10.09.2016

15 Updated with changes from ENHT Jo Burlingham/ Barbara Harrison

30.09.2016

16 Updated with changes from EEAST Jo Burlingham/ Steve Davey

30.09.2016

17 Updated with changes from HCS Heidi Hall/ Jane Wallis 04.10.201618 Updated with changes from HUC Lucy Markham/Jane

Wallis05.10.2016

19 Updated with Acute in hours visiting service from HUC

Jane Wallis 02.11.2016

20 Incorporated OPEL guidance Phil Lumbard Sept 2017Final OPEL version Phil Lumbard Nov 2017

21 Update with new EEAST Plan Phil Lumbard/Jane Wallis

09.11.2017

21 Update HCT DTC ranges and NSHE patient handover protocol

Phil Lumbard Nov 2017

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Contents

1.0 INTRODUCTION............................................................................................................................. 41.1 NHS ENGLAND INCIDENT LEVELS...................................................................................................4

2.0 ESCALATION, SURGE AND CAPACITY PLANNING...................................................................42.1 INCIDENT DECLARATION AND DEFINITIONS......................................................................................5

3.0 GUIDANCE FOR USE OF THE CCG SYSTEM ESCALATION FRAMEWORK......................74.0 THE LOCAL ESCALATION FRAMEWORK...................................................................................8

4.1 WHOLE SYSTEM ESCALATION TRIGGERS........................................................................................94.2 COMMUNICATION AND RESPONSE TIMESCALES................................................................................9

5.0 ACTIONS REQUIRED ON DECLARATION OF OPEL 2 OR 3 ESCALATION STATUS.............105.1 ACTIONS REQUIRED AT OPEL 2 SYSTEM ESCALATION STATUS.....................................................105.2 ACTIONS REQUIRED AT OPEL 3 SYSTEM ESCALATION STATUS.....................................................125.3 ACTIONS TO BE TAKEN BEFORE ESCALATING THE SYSTEM TO OPEL 4...........................................135.4 ACTIONS ON DECLARATION OF OPEL 4 STATUS...........................................................................15

6.0 EAST & NORTH HERTFORDSHIRE SYSTEM COMMUNICATIONS PLANS.............................167.0 WHOLE SYSTEM CO-ORDINATION CENTRE (WSCC/ENHT SITE OFFICE)............................17

7.1 MANDATORY REPORTING – 12 HOUR PATIENT WAITS IN A&E........................................................17

8.0 WINTER RESILIENCE.................................................................................................................. 17APPENDIX 1 - EAST & NORTH HERTFORDSHIRE NHS TRUST ESCALATION TRIGGERS AND ACTIONS............................................................................................................................................ 18APPENDIX 2 – ADULT CARE SOCIAL SERVICES (ACS) ESCALATION TRIGGERS....................27APPENDIX 3 - HERTFORDSHIRE COMMUNITY TRUST (HCT) ESCALATION TRIGGERS...........30APPENDIX 4 - HERTFORDSHIRE PARTNERSHIP FOUNDATION TRUST ESCALATION TRIGGERS.......................................................................................................................................... 38APPENDIX 5 - HERTS URGENT CARE TRIGGERS AND ACTIONS...............................................41APPENDIX 6 – EEAST SURGE MANAGEMENT...............................................................................57APPENDIX 7 - NHSE CENTRAL MIDLANDS COMMUNICATIONS FLOW CHART.........................67APPENDIX 8 - EAST AND NORTH HERTS SYSTEM COMMUNICATIONS FLOW CHART............68............................................................................................................................................................. 68APPENDIX 9 - SUPPORTING DOCUMENTS FOR ESCALATION....................................................69

MIDLANDS AND EAST 12-HOUR BREACH REPORTING PROTOCOL V1.3 (1ST JULY 2016)........................70SERIOUS INCIDENTS REQUIRING INVESTIGATION (SIRI) SUMMARY INFORMATION..................................73REPORTING PROTOCOL: AMBULANCE DIVERT REQUESTS..................................................................75PATIENT HANDOVER DELAYS.............................................................................................................80AMBULANCE NARU REAP PLAN........................................................................................................84EAST AND NORTH HERTFORDSHIRE CCG DAILY SYSTEM TELECONFERENCE STANDARD OPERATING PROCEDURE – OCTOBER 2017..........................................................................................................85

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1.0 Introduction

All systems, led by CCGs as system leaders, are expected to have a system wide surge, escalation and capacity plan in place, in line with National OPEL guidelines, which is also coherent with the East & North Hertfordshire CCG Urgent & Emergency Care Delivery Plan. This surge and escalation framework articulates how responses will be co-ordinated between organisations across the local system by outlining trigger levels for different alert states and the corresponding actions required to manage and respond as required.

This plan should be used to coordinate Level 1 and 2 Incidents at a provider and system level and Level 3 Incidents at a regional level as outlined below (see appendix 7 Central Midlands NHSE Communications Flow Chart). Triggers to request external assistance are clearly defined and should be fully understood by all relevant managers and clinicians.

1.1 NHS England Incident LevelsCentral Midlands Escalation Framework Escalation Levels

Level 1: Patient flow management - The Local Health and Social Care System capacity is such that organisations are able to maintain patient flow and are able to meet anticipated demand within available resources. Commissioned levels of service will be decided locally.

Level 2: Mitigation of escalation – The Local Health and Social Care System starting to show signs of pressure. Focused actions are required in organisations showing pressure to mitigate further escalation. Enhanced co-ordination will alert the whole system to take action to return to green status as quickly as possible.

Level 3: Whole system compromised – Actions taken in Level 2 have failed to return the system to Level 1 and pressure is worsening. The Local Health and Social Care System is experiencing major pressures compromising patient flow. Further urgent actions are required across the system by all partners

Level 4: Severe pressure and failure of actions – All actions have failed to contain service pressures and the Local Health and Social Care system is unable to deliver comprehensive emergency care. There is potential for patient care to be compromised and a serious incident is reported by the system. Decisive action must be taken to recover capacity.

2.0 Escalation, Surge and Capacity Planning

System escalation plans should include processes and arrangements to ensure the following is considered:

Proactive decision making and the ability to manage future demands. Sharing of information at all stages within the process. Demand Variables: A&E attendances and admissions, numbers of emergency

admissions, ambulance offload / turnaround delays and minor/major splits, admitted and non-admitted 4 hour breaches in A&E.

Provider Process: Reduced acute capacity, cancelled elective operations, infection control issues, critical care bed availability and staffing issues.

Discharge Variables: The number of discharges required daily to meet demand; the level of delayed transfer of care, limited planned discharges and reduced capacity within the community.

Additional Considerations: Local public events (concerts, festivals and sports events), public holidays and extreme weather conditions.

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The assessment process to be adopted by organisations when making a decision with regard to the current urgent care status.

Checklist of escalation measures, pre-agreed by all partner organisations, including utilisation of internal resources.

Strong, appropriate leadership at all levels Full understanding of roles and responsibilities

The expectation is that business as usual system principles will include:

Robust pathways – assessment stream, ambulatory emergency care stream, short stay stream, sick speciality and frailty stream.

Integration of primary care and community workforce into front door of ED. Senior review – first patients pulled from assessment to inpatient wards by 10am or no

longer than 90mins from referral. Criteria-based discharge for all medical wards. Registered GP practice actively supporting complex discharges. Registered GP is informed of all 75+ emergency admissions. No patient to be referred from primary care prior to being seen by a GP. Implementation of the UEC 8 High Impact Changes (HIC).

Additional points for consideration:

Timely and fit for purpose information is crucial to the management of the escalation and de-escalation process.

Consideration must be given to the repatriation of patients transferred, or initially taken, to a receiving organisation.

It is appropriate for an executive level director in each partner organisation to hold the responsibility for ensuring that escalation plans are actioned and reviewed.

All escalation plans relating to a given LHE should be readily available to all relevant managers and clinicians. All should have a clear, current understanding of the processes.

The impact on other ED facilities due to the closure of a Minor Injuries Unit (from a knock-on effect) must be considered.

A stringent response to all ambulance handover delays is appropriate.

During times of pressure the System should support an equitable share of risk during times of pressure; including the sharing of accurate and agreed information to enable appropriate decision making so that Organisations can support each other bilaterally. Patients arriving at hospitals will be received and treated. Receiving trusts should not refuse to accept patients and conveyances, ensuring an equitable duty of care to all patients.

2.1 Incident Declaration and Definitions

Systems are required to escalate and communicate in a timely manner to enable effective and proactive responses. It is imperative that the appropriate incident definition is adhered to as outlined in the table below. Major Incidents should not be called to support escalation, capacity or surge requirements.

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Incident Definition Further detail

Business continuity

An incident or event that disrupts an organisation’s normal service delivery, where special arrangements are required to be implemented, until services can return to an acceptable level. (This could be a surge in demand requiring resources to be temporarily redeployed)

For circumstances which organisations are able to manage within their own internal capacity.

Critical Incident

Any localised incident where the level of disruption results in the organisation temporarily or permanently losing its ability to deliver critical services, patients may have been harmed or the environment is not safe requiring special measures and support from other.

An incident that cannot be managed within routine service arrangements are planned for and as such will have trigger points in place locally to instigate escalation.

Major Incident (Emergency)

Emergencies (major incidents) are defined in the EPRR framework and the Civil Contingencies Act as; instances which present a serious threat to the health of the community or causes such numbers or types of casualties, as to require special arrangements to be implemented.

NHS organisations should be confident of the severity of any incident that may warrant such a declaration and the required response and support that is required to support the response

When planning for and responding to surge and escalation it is essential that any decisions made or actions taken are recorded and stored in a way that can be retrieved at a later date to provide evidence in accordance with the organisation’s document retention policies and procedures. Records should contain as a minimum who, at what time and for what reason, the escalation level was increased or decreased. Resulting actions and decisions should be recorded including any options considered and rejected.

CCGs have a clear role as system leaders in coordinating the response to an incident and ensuring that their providers can deliver their duties and responsibilities as category 1 responders. This document is circulated to all staff who participate in such events, to provide a practical working reference tool aiding co-ordination, communication and implementation of the appropriate actions in each organisation.

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Roles & Responsibilities Local, Regional and National Level

3.0 Guidance for use of the CCG System Escalation Framework

The ENHCCG system escalation framework is to help providers make the best use of all locally available resources as demand rises and/or limited capacity impacts on the ability to sustain safe, high quality services.

Through agreed escalation triggers there will be a co-ordination of early action so that an OPEL 4 alert status is only reached in exceptional circumstances.

Each organisation has defined and agreed triggers, actions, roles and responsibilities throughout the escalation process including those which trigger a request for external assistance.

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Only when all escalation measures have been exhausted, will consideration be given to access capacity beyond system boundaries. The trigger for request for external assistance will be the declaration from the CCG on behalf of the WHOLE SYSTEM of OPEL 4 status.

The implementation of external support must be agreed by all relevant parties, following which the CCG shall inform NHS England. Contact with NHS England will be initiated and maintained by the executive director on call for the CCG.

Following a divert the CCG to which assistance was given must raise a Serious Incident Requiring Investigation (SIRI) and undertake a full investigation, root cause analysis and lessons learnt exercise (see appendix 9).

4.0 The Local Escalation Framework

The East & North Hertfordshire CCG Surge, Escalation and Capacity Plan follows the NHS England alert levels, comprising four distinct alert levels.

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NHS England Operational Pressures Escalation Levels (OPEL)

OPEL 1: The local health and social care system capacity is such that organisations are able to maintain patient flow and are able to meet anticipated demand within available resources. The local A&E Delivery Board area will take any relevant actions and ensure appropriate levels of commissioned services are provided. Additional support is not anticipated.

OPEL 2: The local health and social care system is starting to show signs of pressure. The local A&E Delivery Board will be required to take focused actions in organisations showing pressure to mitigate the need for further escalation. Enhanced co-ordination and communication will alert the whole system to take appropriate and timely actions to reduce the level of pressure as quickly as possible. Local systems will keep NHS E and NHS I colleagues at sub-regional level informed of any pressures, with detail and frequency to be agreed locally. Any additional support requirements should also be agreed locally if needed.

OPEL 3:The local health and social care system is experiencing major pressures compromising patient flow and continues to increase. Actions taken in OPEL 2 have not succeeded in returning the system to OPEL 1. Further urgent actions are now required across the system by all A&E Delivery Board partners, and increased external support may be required. Regional teams in NHS E and NHS I will be aware of rising system pressure, providing additional support as deemed appropriate and agreed locally. National teams will also be informed by DCO/sub-regional teams through internal reporting mechanisms.

OPEL 4: Pressure in the local health and social care system continues to escalate leaving organisations unable to deliver comprehensive care. There is increased potential for patient care and safety to be compromised. Decisive action must be taken by the Local A&E Delivery Board to recover capacity and ensure patient safety. All available local escalation actions taken, external extensive support and intervention required. Regional teams in NHS E and NHS I will be aware of rising system pressure, providing additional support as deemed appropriate and agreed locally, and will be actively involved in conversations with the system. Where multiple systems in different parts of the country are declaring OPEL 4 for sustained periods of time and there is an impact across local and regional boundaries, national action may be considered.

Individual organisations are expected to manage the escalation and de-escalation processes outlined. The CCG will use a whole systems teleconference to co-ordinate a response to an escalating situation. The scheduling of these is part of business as usual systems resilience process. It must be noted however that escalation to OPEL 4 status at organisational level automatically triggers mandatory action within this framework. (See section 4). This includes the requirement to participate in frequent teleconferences depending on the escalation status.

4.1 Whole System Escalation Triggers

The whole system escalation status is underpinned by agreed triggers within individual provider organisations and their declared alert status. Individual provider organisations have been given a whole system weighting as follows:

Organisation System WeightingE&NHT 35%HCT 30%HCS 25%HPFT 10%TOTAL 100%

The whole system escalation status will be driven by the accumulative alert status (OPEL 1, 2, 3 or 4) of each organisation within the system, with the majority percentage confirming the whole system status. The following table describes the escalation status descriptors and teleconference requirements:

Escalation Status

Ambulance REAP Status

Provider Status Descriptors

Teleconference Requirements

OPEL 1 1 Steady State ENHT to chair daily teleconference.CCG attendance not required

OPEL 2 2 Moderate Pressure ENHT to chair daily teleconference.CCG attendance not required

OPEL 3 3 Severe Pressure CCG to chair daily teleconference

OPEL 4 4 Extreme Pressure CCG to chair daily teleconferenceNHSE to be invited to join call

4.2 Communication and Response timescales

All organisations have agreed to communicate changes in escalation statuses in a timely manner to enable an effective and proactive response as outlined in Appendix 7 - East and North Herts System Escalation Communications Chart.

Actions associated with the different alert levels must be completed within the timescales outlined below.

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Status Response time allowed (7 days a week)

OPEL 1 12 hours

OPEL 2 8 hours ( same day response)

OPEL 3 3 hours

OPEL 4 2 hours

Significant /Major Incident Immediate

5.0 Actions Required on Declaration of Opel 2 or 3 Escalation Status

Prior to declaration of OPEL 4 status, all appropriate actions must be taken to reduce pressure and all system partners must be fully involved in supporting the organisation at risk of OPEL 4 escalation. The expectation is that it would be extremely rare to declare OPEL 4 status whilst any of the system partner organisations were reporting pressure less than OPEL 3. It is expected that where system escalation to OPEL 4 is anticipated, NHS England would receive regular updates on status.

The whole system must ensure that the following mandatory actions have been implemented prior to escalating to a declaration of OPEL 4 status:

5.1 Actions required at OPEL 2 System Escalation Status WHOLE SYSTEM

1 Ensure whole system is undertaking business as usual, OPEL 1 actions2 Review capacity and demand to allow timely escalation when required3 Understand current blocks in flow and try to remove these prior to escalation4 Ensure whole system daily teleconferences are taking place5 Daily review of DTC/discharge position to expedite and plan for the week aheadCCG

6 Identify potential issues via regular teleconference7 Challenge required actions and required level of success within required timeframes8 Co-ordinate system to manage rising pressure9 Remove blockages to system flow early at first point of concern10 Expedite additional capacity in primary care, out of hours (OOH), independent sector

and community11 Coordinate redirection of patients towards alternative care pathways12 Conduct demand and capacity review: peaks/conveyance increase, alternative

pathways, variation and case mix and identify services to mitigate increased pressure

ACUTE TRUST

13 Ensure effective patient navigation in ED (Emergency Department) is underway14 Tackle delays in ward transfers efficiently15 Confirm all available capacity is being used prior to escalation beds being opened16 Ensure all wards have a ward round and a board round conducted by a senior

decision maker17 Board rounds to be underway by 10am18 Maximise the use of nurse-led wards and nurse-led discharges

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19 Ensure Pharmacy prioritising of TTOs (medicines to take out) in the afternoon for next morning and in the morning for afternoon discharges

20 Prioritise discharges and outliers on wards21 Facilities to prioritise cleaning and transfers to support efficient turnaround22 To ensure a patient navigator is in ED23 Alternative transport/travel arrangements to be reviewed and identified24 Identify key pressure points and pool resources to relieve pressure25 Maximise nurse-led discharge26 Review critical care step down plan27 Review repatriationsCOMMUNITY CARE PROVIDERS AND SOCIAL CARE

28 Review all capacity and identify potential capacity available29 Expedite rapid MDT assessments30 Lower admission and treatments thresholds31 Quantify spot purchases32 Community Hospital to bring forward discharges33 Expedite care packages and negotiate quick turn around with nursing homes34 In reach activity to ED is maximisedPRIMARY CARE

35 Ensure primary care are made aware of alert status verbally or via emailed status36 Identify and encourage utilisation of alternative care pathways for minors’ patients

(e.g. step up beds, OOH).37 Expedite additional staffing capacity as per local escalation policy38 Notify CCG on-call Director to ensure that appropriate operational actions are taken

to relieve the pressure39 Community matrons to support district nurses in supporting higher acuity patients in

the community40 GPs to act on any escalation and requests (as alternatives to ED referrals) where

feasibleMENTAL HEALTH

41 Ensure departments and teams are made aware of alert status verbally or via emailed status

42 Expedite rapid assessment for patients waiting within another service and ensure adequate support to patients in crises in ED

43 Where possible, increase support and/or communication to patients at home to prevent admission

44 Consider creating additional capacity within rapid response teams if locally appropriate

45 Notify CCG on-call Director to ensure that appropriate operational actions are taken to relieve the pressure

AMBULANCE SERVICE

46 Reallocate resources to meet demandPATIENT TRANSPORT SERVICES (PTS)

47 Ensure PTS teams are made aware of alert status verbally or via emailed status to ensure PTS capacity is fully utilised for patient discharge and transfer

48 Consider extension of operational times in line with whole system discharge arrangements i.e. nursing home extended admission times

49 Notify CCG on-call Director to ensure that appropriate operational actions are taken to relieve the pressure

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5.2 Actions required at OPEL 3 System Escalation Status

WHOLE SYSTEM

1 All OPEL 2 actions undertaken2 Directors of organisations to encourage whole system accountability & joint working3 Training and non-essential leave to be reviewed4 Identify clinical staff in non-clinical roles to increase workforce opportunitiesCCG

5 Co-ordinate system call6 Ensure status alerts are cascaded7 Explore private sector capacity8 Expedite and authorise additional capacity9 Review access criteria for alternative pathwaysACUTE TRUST

10 Divisional Chairs and Divisional Directors provide support to ED for 24hrs11 Review all electives and cancel non urgent cases where appropriate12 Increase staffing to ED from other areas13 Ensure there is adequate senior decision makers in ED over 24hrs and availability to

specialist advice during the day for GPs.14 Emergency admission triage from Senior Consultant (80%) ensuring emergency

patients assessed rapidly15 Escalation beds opened in a phased approach / capacity areas on specific wards16 Review bed profiling from surgical to medical beds17 Fast track diagnostics and medications18 Deploy reverse triage for discharge19 Undertake medical ward rounds daily at consultant level by 12 noon.COMMUNITY CARE PROVIDERS AND SOCIAL CARE

20 All capacity freed and deployed21 Review all patients awaiting assessment. Expand capacity through wider agencies22 Expedite discharge and discharge processes23 Review admission and treatment thresholds to create capacity24 Activate internal pressure actions – deflect, clinical reviews and transfers25 Prioritise ‘quick wins’ to achieve maximum flow including ED prevention of admission

and turnaround.PRIMARY CARE

26 GPs and OOH to reinforce alternative pathways27 Increase access/opening hours for 111, WIC, OOH and GP front end support28 Utilise access to acute consultants for specialist advice to avoid admissionsMENTAL HEALTH

29 Ensure all teams are made aware of alert status verbally or via emailed status30 Re-plan selective training and request those on leave to consider working31 To review all discharges currently referred and assist within whole systems agreed

actions to accelerate discharges from acute and non-acute facilities wherever possible

32 All patients are prioritised and managed on a risk basis.33 Increase support to service users at home in order to prevent admission34 Notify CCG on-call Director so that appropriate operational actions as above can be

taken to relieve the pressure and agree time to report back on effectiveness of mitigating actions

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AMBULANCE TRUST

35 Call in additional ops staff and resources to support36 Agree handover plan with acute sector clinicians37 Reinforce ECPs roles (Emergency care practitioners)PTS PROVIDERS

38 Extend working hours for the next 72 hoursVOLUNTARY SECTOR

39 Ensure all local commissioned voluntary sector services are made aware of alert status verbally or via emailed status

40 Consider further support from voluntary sector such as Meet and Greet service to help discharge patients or support with minors in ED and home support services

5.3 Actions to be taken before escalating the system to OPEL 4

Before requesting system escalation from OPEL 3 to OPEL 4 the following actions should have been completed:

CENTRAL MIDLANDS TEAM

Immediately following the request from the CCG, a Central Midlands Team Director will seek assurance and an account of whole system actions preceding this request.

This will include: CCG assurance that triggers and mitigating actions have been delivered by each

party at amber and red status Assurance that Executive leadership from all partners has been involved in

discussion and agree with the reported escalation status Ensuring black triggers for escalation have been met Ensuring that all parties are expediting discharge and additional capacity Proactively challenging CCG and providers on their risk based assessment of the

best use of capacity and resource across the whole system

WHOLE SYSTEM

1 All OPEL 3 escalation actions have been implementedCCG

2 Lead Director/CEO to have system-wide teleconference to agree escalation level status and proposed actions

3 Identify mutual aid requirements4 Co-ordinate system wide approach (teleconference or face-to-face)5 Feedback escalation status and actions to NHS England6 Lead Root Cause Analysis post-escalation7 Ensure stand down from OPEL 4 in a timely manner8 Consider request of mutual aid from other systemsACUTE TRUST

9 Review all urgent electives10 Cancel routine operations where appropriate11 Additional consultants supporting ED as required12 Senior decision makers to be on wards to expedite discharge in line with SAFER13 Surgical consultants in wards, theatre and ED14 To allocate a GP into ED15 Senior Manager on site / in ED for 24 hours for the next 72 hours

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16 Provide beds for patients in ED to improve comfort and safety for long waitsCOMMUNITY CARE PROVIDERS

17 All possible capacity has been freed and redeployed to ease systems pressures18 All clinically trained staff working in non-clinical roles are redeployed appropriately19 All non-essential managerial duties are cancelled20 Additional capacity continues to be source to support demand requirements21 All relevant meetings and training cancelled22 Ensure support services are providing all support to ensure discharges are not

delayedSOCIAL CARE

23 Continue to expedite discharges, increase capacity and lower access thresholds to prevent admission where possible.

24 All non-essential managerial duties are cancelled25 Additional capacity continues to be source to support demand requirements26 SMT involved in decision making27 Prioritise quick wins to achieve maximum flow including ED prevention of admission

and turnaround.28 Link with ward and board rounds and links with discharge team and therapistsPRIMARY CARE

29 All possible actions are taken to alleviate system pressures including extending practice hours, deployment of GPs into primary & secondary care where identified

30 Review GP admissions to step up provisionMENTAL HEALTH

31 Extend working hours and liaison teams. Ensure senior presence in ED to meet 4 hour target.

AMBULANCE TRUST

32 Alert neighbouring trusts/ambulance services of pressure33 Review status on a regular basis and review 111 advicePTS SERVICES

34 Ensure all capacity is being utilised to alleviate system pressures and continue to extend working hours for the next 72 hours

GP

35 Extend opening hours/staffing in OOH, WIC, UCC etcVOLUNTARY AND PRIVATE SECTOR

36 Support Local System Escalation by flexing capacity as appropriate e.g. ED front door patient meet and greet, supporting discharge schemes.

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5.4 Actions on Declaration of OPEL 4 status

Where escalation to OPEL 4 system status cannot be averted, the CCG Director on-call must inform NHS England Central Midlands. Immediately following declaration of OPEL 4 status the following actions are MANDATORY:


• Consider chairing a system-wide teleconference• Alert neighbouring trusts and ambulance service to seek appropriate support.• Midlands and the East (Regional team) notified of alert status and involved in decisions

around support from beyond local boundaries• Review the escalation status every 2 hours and communicate this across the system.WHOLE SYSTEM

1 To continue to explore all OPEL 3 level actions as above and progress black actions as detailed in local escalation plans and take additional decisive action to alleviate pressure

2 Contribute to system-wide communications to update regularly on status of organisations (as per local communications plans)

3 Set up CEO teleconference (may be delegated to executive director)4 Provide mutual aid of staff and services across the local health economy as

appropriate5 Stand-down of OPEL 4 alert once review suggests pressure is alleviating6 Post escalation: CCG to coordinate and lead to the Root Cause Analysis and

lessons learnt process through the Serious Incident Review Investigation (SIRI)7 Ensure a system approach to de-escalation and planning to enable return to

business as usual as swiftly and efficiently as possibleCCG

8 The CCG to act as the hub of communication for all parties, in conjunction with NHS England, the Ambulance Service and Whole System

9 Assist in the management of communications and media handling10 CCG report Serious Untoward Incident on the STEIS system11 Post escalation: CCG to complete Root Cause Analysis and lessons learnt process

in accordance with Serious Untoward Incident processACUTE TRUST

12 Senior Decision Maker to be present in ED department 24/7 and Senior Medical and Surgical Decision Makers to be present on wards and supporting ED department 24/7.

13 Assign appropriate qualified clinician to manage care of patients awaiting handover from ambulance service to enable ambulance crews to be released

14 GP to be present in ED department 24/715 Senior operational leads to be on site 24/7 with this provision in place for the next

72 hours.16 Continue to monitor activity in relation to cancellation of all urgent & non urgent

electives (cancelling all appropriate electives).17 Any request to divert patients from ED must be initiated by the Acute Trust who,

having exhausted all internal support options must then contact the CCG (then CCG to DCO) to request a divert. Refer to on-call pack for protocol.

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AMBULANCE TRUST

18 Alert neighbouring trusts to seek appropriate support as dictated by circumstances of OPEL 4

19 Continue to make a risk-based assessment of the best use of capacity and resource across the whole system and shift resources to best meet demand and maintain patient safety.

20 Review the escalation status every 2 hours and communicate this across the system


21 Sign-off the use of support from beyond locality and/or regional boundaries22 CCGs to liaise with NHS England to assist in the management of

communications and media handling23 Post escalation: Involvement in and sign-off of SIRI investigation process

In addition to the actions identified above, each individual organisation has identified internal actions corresponding to the escalation triggers and resulting level of alert status declared. These are outlined in appendices 1 - 6.

6.0 East & North Hertfordshire System Communications Plans

A system conference call will be held daily at 10am including weekends with all system partners. At a trust declaration of OPEL 1 or 2 this call will be chaired by ENHT with the CCG duty manager in attendance to facilitate escalation. On a trust declaration of OPEL 3 or 4 the conference call will be chaired by a member of the CCGs senior management team and it is expected that senior management representation is also present from system partners. It is the acute trusts responsibility to circulate the current alert status prior to the call taking place.

The aim of the teleconference is to establish: The current pressures faced in the system The patient flow/movement within the system The discharge of medically optimised patients as defined by ENHT “con call list”

Outcomes agreed during this call will be actioned in accordance with timeframes in line with the systems alert status (see section 4.2). If the alert status is OPEL 3 or above it is the expectation at least one further call will be undertaken if appropriate. If the status is OPEL 4 partners will be expected to support additional calls throughout the day as the situation dictates.

The teleconference is attended by representatives from:

CCG Integrated Discharge Team (IDT) WSCC ( ENHT Site Office) Bed bureau Continuing Health Care Mental Health

At times of OPEL 4 escalation representatives from the 111 Out of Hours Provider and the ambulance service may also be required to attend. Senior representation will be required for an alert status of OPEL 3 or above.

In addition, there is a weekly Systems Operation Conference call at director level to discuss and manage urgent system pressures and review performance.

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The teleconference standard operating procedure is in appendix 9.

7.0 Whole System Co-ordination Centre (WSCC/ENHT Site Office)

A Whole System Co-ordination centre has been established within the ENHT footprint to facilitate real time monitoring of patient flow within the system.

The purpose of the WSCC is:

To monitor, report and coordinate key operational and performance information. Develop strategies and systems that will assist in managing demand and where possible

decrease demand on ENHT ED. Support daily systems operations by facilitating, coordinating and communicating real

time information across the health economy. Provide a strategic overview. Monitor ED demand as a continuing critical incident.

Activity and capacity information is provided by all system partners into the WSCC at agreed times on a daily basis. This information will change in accordance with triggers agreed and information reported in the system wide urgent care dashboard. The WSCC will be responsible for the daily management and updating of the regional CAMS system (Capacity and Management System) in line with agreed updates.

7.1 Mandatory reporting – 12 Hour Patient waits in A&E

There is a mandatory requirement that patient A&E waits of 12 hours (12 hour trolley breach) are reported to NHSE. Where an 8 hour wait is expected to exceed 12 hours the CCG Director on call is required to inform NHS England. The acute trust must escalate to the CCG Director on Call where this is the case to facilitate this process. The formal reporting procedure is detailed in the supporting information (appendix 8) and the CCG Director on call pack.

8.0 Winter Resilience

A key component of managing system pressures includes the flexibility to commission additional short term health and social care capacity over the winter period. This acknowledges that despite robust escalation plans, winter places on the system additional surges in demand and pressures on capacity. Additional capacity is commissioned through the A&E Delivery Board and monitored through the ENHCCG Systems Resilience Group.

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APPENDIX 1 - East & North Hertfordshire NHS Trust Escalation Triggers and Actions

ENHT Dashboard Metrics

OPEL 1 OPEL 2 OPEL 3 OPEL 4

Ambulance Handover >15 mins 15-59 60-119 minutes

120+

DTA Patients Waiting to be Admitted

< 60 minutes

60 - 120 minutes

121 - 239 minutes

>=240 minutes

A&E 4 Hour Target >=92% 85.0% - 91.9% 60% - 84.9% <=59.9%

Occupancy <93% 94%-96% 97%-99% 100%+

Stranded Patients <45 45 to 69 70 to 89 90+

Medical Staffing Rota No concerns

Moderate concerns

Severe concerns

Extreme concerns

Nursing Staffing Rota No concerns

Moderate concerns

Severe concerns

Extreme concerns

18

ENHT Summary

ED TRIGGERS Format Opel 1 Opel 2 Opel 3 Opel 4Ambulance handover minutes >15 mins 15-59 60-119 minutes 120+

DTA Patients waiting to be admitted minutes < 60 minutes 60 - 120 minutes 121 - 239 minutes >=240 minutes

Medical Staffing Rota BRAG No concerns Moderate concerns Severe concerns Extreme concerns

Nursing Staffing Rota BRAG No concerns Moderate concerns Severe concerns Extreme concerns

A&E 4 hour target Percentage >=92% 85.0% - 91.9% 60% - 84.9% <=59.9%

Time to be seen - first clinician minutes <120 minutes (2 hours)

120 - 179 minutes (2-3 hours)

180 - 239 minutes (3-4 hours)

>=240 minutes

Patients waiting to be seen - speciality review

minutes <30 minutes 30 - 59 minutes 60 - 89 minutes >=90 minutes

ASSESSMENT AREAS TRIGGERS Opel 1 Opel 2 Opel 3 Opel 4Assessment Spaces in AMU/SAU number 10+ 6 to 9 1 to 5 0 bedsAdmissions in Assessment Areas waiting for inpatient speciality beds

minutes <4 hours 4-8 hours 8-24 hours 24 hours+

Patients admitted and waiting for post take review - wait time

minutes <4 hours 4-8 hours 8-12 hours 12 hours +

Medical Staffing Rota BRAG No concerns Moderate concerns Severe concerns Extreme concernsNursing Staffing Rota BRAG No concerns Moderate concerns Severe concerns Extreme concernsINPATIENT AREAS TRIGGERS Opel 1 Opel 2 Opel 3 Opel 4Occupancy Percentage <93% 94%-96% 97%-99% 100%+Stranded Patients number <45 45 to 69 70 to 89 90+Empty Beds on Inpatient Wards number >=12 5 to 11 <4 0TCIs BRAG No concerns Moderate issues with

elective sSevere concerns Extreme concerns

Planned Discharges number >30 20-29 <19 0Medical Staffing Rota BRAG No concerns Moderate concerns Severe concerns Extreme concernsNursing Staffing Rota BRAG No concerns Moderate concerns Severe concerns Extreme concerns

19

ENHT Detailed Triggers

OPEL 1 Escalation – Steady State / Low Levels of Service

Trigger / MetricsEmergency Department 4 or more free spaces in Resus 6 or more free spaces in Majors Time to see first clinician under 120 minutes (2 hours) in Emergency Care ED Ambulance handover for all patients is less than 15 minutes 0 patients waiting over 30 minutes for specialty review 0 patients with a DTA waiting over 1 hour for admission No concerns with medical rota (defined by Emergency Consultant In Charge) No concerns with nursing rota (defined by Nurse Co-ordinator) 92.0% performance or greater of the 4 hour access target as measured by the ED Dashboard

Assessment Areas 10 beds available in the Assessment Areas 0 patients with a DTA waiting more than 4 hours for admission 0 patients waiting over 4 hours for senior clinical review No concerns with medical rota (defined by Acute Consultant) No concerns with nursing rota (defined by ED Matron)

Inpatient Areas 12 medical beds available No concerns with nursing levels (defined at Safety briefing) <45 medically fit patients waiting for discharge or transfer (defined as Stranded or DTOC)

OPEL 2 Escalation – Moderate Pressure

Triggers / MetricsEmergency Department 2 to 3 free spaces in Resus 2 to 5 free spaces in Majors Time to see first clinician 120 - 179 minutes (2-3 hours) in Emergency Department (ED) Ambulance handover greater than 15 – 59 minutes Patients waiting between 30 - 59 minutes for specialty review Patients with a DTA waiting 60-120 minutes for admission Moderate concerns on medical rota (defined by Emergency Consultant In Charge Moderate concerns on nursing rota (defined by ED Matron) 85.0% - 91.9% performance of the 4 hour access target as measured by the ED Dashboard

Assessment Areas 6 - 9 beds available in the Assessment Areas Patients with a DTA waiting between 4-8 hours for admission Patients waiting between 4-8 hours for senior clinical review Moderate concerns on medical rota (defined by Acute Consultant) Moderate concerns on nursing rota (defined by Matron in Surgery and Medicine or Duty

Matron.)

Inpatient Areas 5 - 11 medical beds available Moderate concerns with nursing levels (defined at Safety Brief)

45-69 medically fit patients waiting for discharge or transfer (defined as Stranded or (DTOC))

OPEL 3 Escalation – Severe Pressure20

Triggers / Metrics

Emergency Department 1 free space in Resus 1 free spaces in Majors Time to see first clinician over 180 – 239 minutes (3-4 hours) in Emergency Ambulance handover greater than 60-119 minutes and corridor full and coherting taking place. Patients waiting between 60 - 89 minutes for specialty review Patients with a DTA waiting 90-119 minutes for admission Severe concerns on medical rota (defined by Emergency Consultant in charge) Severe concerns on nursing rota (defined by EDMatron) 60 - 84.9% performance of the 4 hour access target as measured by the ED Dashboard

Assessment Areas 1 - 5 beds available in the Assessment Areas Patients with a DTA waiting between 8-24 hours for admission Patients waiting between 8 – 12 hours for senior clinical review Severe concerns on medical rota (defined by Acute Consultant) Severe concerns on nursing rota (defined by Duty Matrons for Surgery and Medicine)

Inpatient Areas Less than 4 general medical beds available

Severe concerns with nursing levels (defined at Safety Brief) 70-89 medically fit patients waiting for discharge or transfer

OPEL 4 Escalation – Extreme Pressure Serious Internal CrisisTriggers / Metrics

Emergency Department

0 free space in Resus 0 free spaces in Majors Time to see first clinician over 240 minutes (4 hours) in Emergency Department (ED) Ambulance handover greater than 120 minutes and overcrowding in dept. Patients waiting over 90 minutes for specialty review Patients with a DTA over 120 minutes waiting for admission Extreme concerns on medical rota (defined by Emergency Consultant In ED. Extreme concerns on nursing rota (defined by ED Matron) Less than 59.9% performance of the 4 hour access target as measured by the ED DashboardAssessment Areas 0 beds available in the Assessment Areas Patients with a DTA waiting more than 24 hours for admission Patients waiting over 12 hours for senior clinical review Extreme concerns on medical rota (defined by Acute Consultant) Extreme concerns on nursing rota (defined by Duty Matrons)

Inpatient Areas 0 medical beds available includes speciality beds (stroke, renal, cardiology and so on) Extreme concerns with nursing levels (defined at Safety Brief) 90 or more medically fit patients waiting for dx or transfer

21

ENHT Detailed Actions

Escalation / Actions Communication

All Areas

In ED, 2 hourly rounds to identify clinical plans for all patients including those requiring a specialty review and require a senior decision.

In ED, ensure staffing in all areas are appropriate to workload and consider streaming to other areas.

All areas to review staffing deployment and staffing shortfalls to be reported to Senior Nurse and Doctor for action.

Daily and regular ward rounds led by senior decision makers to expedite discharges.

Ensure sufficient transport is available to expedite all discharges.N.B. Actions needed from IDT

Patients identified for discharge to be taken to discharge lounge ASAP.

Elective teams to risk assess the continuity of elective activity if capacity becomes under pressure

Site Management Team to lead bed capacity meetings to ensure capacity is available in all areas throughout the next 24 hours.

Site Management Team to communicate with clinical teams regarding any anticipated pressure in the system.

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OPEL 2 Escalation – Moderate Pressure


All Areas

Senior clinicians to resolve specialty review patients lodged and rota concerns.

Undertake additional ward rounds to expedite discharges.Senior decision makers to front all services.

Extra medical support to AMU A if available or pulled from another area.

Book additional discharge transport.N.B. Actions needed from IDT.

Mobilisation of additional resources to assist with transfer of patients.Patients identified for discharge to be taken to discharge lounge ASAP.

Elective teams in conjunction with the Clinical Director to risk assess the continuity of elective activity.

All matron and senior nurses to attend to assess and actively create capacity.

Director in Charge to risk assess the need to open additional staffed bed capacity.Director in Charge to risk assess the need to open the Ambulatory Care Unit (ACU) for additional hours.

Site Management Team to communicate with clinical teams regarding pressure being experienced.

Communicate with ENH CCG on call manager/ Director Team for external partners support required.

23

OPEL 3 Escalation – Severe Pressure


All Areas

In ED, 2 hourly Huddles to identify patients requiring senior decision or intervention. All patients to have an identified and agreed clinical plan.

ED consultants to have direct admitting rights to specialties if no specialty response received within clinical escalation standards.

Trust Gold Command to appoint an escalation manager to work in ED to enable clinical staff to focus on patient care.

In ED, Review staffing deployment to stream to the most high risk areas

All areas to review and prioritise staffing deployment and request additional staffing from other departments. Study leave and non-essential training to be cancelled.

Specialties to pro-actively report to ED and expedite all specialty patients to either a based ward or discharge.

Medical Consultant on call to work in AMU2nd Reg to support AMU if availableSpecialties to pro-actively report to Assessment Areas and expedite all specialty patients to either a based ward or discharge.

Undertake additional consultant led Board/ward rounds to expedite discharges.Consultant staff to front all services.All transport to focus on discharge. Book additional transport from the private sector via CCG.N.B. Actions needed from IDT/Therapy teams.

Mobilisation of additional resources to assist with transfer of patients.Patients identified for discharge to be taken to discharge lounge ASAP.

In conjunction with the Clinical Director, elective teams to risk assess the continuity of elective activity and postpone all non-urgent cases.

Nurse Directors and Operations Directors to attend the bed capacity meeting to assess and actively create capacity which could include the opening of additional staffed beds. On call

Gold Command to lead on the management of flow involving all partners with ENH CCG

24

managers to attend bed meetings.

Medical Directors to advise on clinical areas cancelling consultant SPA’s.On call Consultants to attend bed meetings.

Director in Charge to risk assess the need to cancel all non -essential outpatients

Ambulatory Care Unit to remain open.

Senior clinician to triage all GP admissions

OPEL 4 Escalation – Extreme Pressure Serious Internal CrisisEscalation / Actions Communication

Establish Control Team to command, control and coordinate tactical response to crisis through to de-escalation.

Control Team will be based in Site management Room during the crisis.

In hours Team will comprise:

Manager (Director of Operations) Nurse (Director of Nursing) Doctor (Medical Director / CD) Head of Site management

Out of hours on call Director, Senior Manager and Duty Matron will agree Control Team roles.

Action Cards available in Site Room.

Control Team will:

Assess position Manage crisis to ensure patient safety Develop and implement response Create capacity to meet demand Coordinate staffing requirements Continually review position and record

actions Identify Team to hand over

responsibilities to in event of extended period at OPEL 4.

All clinical on-call teams to attend the hospital for instructions from the Control Team.

All inpatients to be reviewed with a view to discharge.

Director and 1st on call manager to determine whether to call a Serious Internal Crisis.

External communications to be established via the Surge and Escalation Protocol. A system call with all major partners will be established.

CCG Director on call to be contacted out of hours.

Contact the HALO at EEAST to co-ordinate.

Ensure Executive Team regularly updated

25

ENHT ED Escalation protocolDepartment time before escalation and action

Bronze Silver Gold Platinum

Delays in triage 20 minutes after arrival

escalate after 20 minutes 20 minutes to action

Escalate after 40 minutes from commencement if delays continue

20 minutes to action




informed of delays greater than 80 minutes

Delays in ambulance off load greater than 30 minutes








Delays in diagnostics greater than 60 minutes








Delays in patients seen by speciality greater than 30 minutes following referral








Delays in bed allocation greater than 30 minutes after DTA








Delays in patients being transferred to ward within 30 minutes of bed allocation


Escalate after 45 minutes if delays continue






Delays in patients seen by Mental Health greater than 60 minutes after initial referral








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APPENDIX 2 – Adult Care Social Services (ACS) Escalation Triggers

ACS Dashboard Metrics


Staffing No concerns

Moderate concerns

Severe concerns

Extreme concerns

Total Medically Optimised on Con Call

<45 46-55 56-65 66+

Total IDT Medically Optimised on Con Call

0-25 26-35 36-45 46+

Total Daily DTOC 0-19 20-25 26-30 31+

Available Resources Capacity in 24 hours

Limited capacity in 48 hours

0 capacity in 72 hours

0 capacity in 96 hours

Status triggers when at least two measures are reached.

OPEL STATUS TRIGGER AREA TRIGGER STATUS1

Patient flow is maintained

Staff Normal staffing levels are available across IDT. No concerns.

Total Medically optimised on Con Call

<45 patients


0-25 Patients

Total Daily DTOC 0-19 PatientsAvailable resources There is capacity available within 24

hours for packages of care and placements to meet expected discharge numbers, including community based settings.

2

Signs of pressure/focussed

actions required

Staff Moderate concerns regarding staffing levels across IDT.


46-55 Patients


26-35 Patients

Total Daily DTOC 20-25 PatientsAvailable resources There is limited capacity available

within 48 hours3

Major pressures/ compromised patient flow.

Staff Severe concerns regarding staffing levels across IDT.


56-65 Patients

Total IDT Medically optimised on Con Call

36-45 Patients

Total Daily DTOC 26-30 PatientsAvailable resources Unable to facilitate packages of

care/placements within 72 + hours

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4

Unable to deliver comprehensive

care

Staff Extreme concerns regarding staffing levels across IDT.

Total Medically Optimised on Con Call

66+ patients

Total IDT Medically optimised on Con Call

46 + patients

Total Daily DTOC 31+ PatientsAvailable resources Unable to facilitate care

packages/placements to facilitate discharges within 96+ hours.

Mitigating Actions

OPEL STATUS ACTIONS1 Immediate allocation of Assessment and Discharge Notifications and

consideration of community pathways for medically optimised patients.Checklists to be organised within 24 hours and consideration of community pathways.DTM/ IDT Deputy to Chair daily con call and give regular and accurate updates to site office, DX lounge and transport.IDT to attend daily board rounds and chase EDD and add names to con call.Equipment to be ordered on day of AX and delivery date TBC within 24 hours.Meet and Greet new patients on ward.IDT representative to attend weekly stranded patients walk around and wash up in site office.

2 Actions above and review and action twice daily. Management oversight of all DTOC to maintain flow out of hospital and review community pathways.Escalation of all patients on con call over 48 hours to managers. Escalation pathway to be followed.Manager to attend site office, DX lounge and Transport daily to ensure safe and timely DX.Manger to have oversight of care/placement capacity to expedite placements and POCCirculate weather/stay well planning advice and actionEquipment to be ordered on day of AX and delivery date TBC within 24 hours. If delivery not within 48 hours escalate to manager.Communication to commissioners to flag to system providers, pressure on the system

3 Above + Deputy Head/Head of service to attend minimum of 1 of the twice daily con calls. Con call to be attended by Managers and take 4 hourly actionsDaily sweep of all wards and challenge EDD by IDT staff and add to con call.Twice daily meet with site office and transport.Mangers to escalate to HOS any patients on con call over 72 hours.Extra ordinary con call to be facilitated for complex patients with system partnersTeam managers / Deputy team managers to expedite care packages and raise any immediate issues with Deputy/Head of IDT who can link in with commissioners and other partner organisations.All social care assessments to be completed within 24 hours of assessment notification.Consider full deployment of social care staff to areas of need/ escalation areas and take active moves to increase resources available (priority area

28

ED)Communication with community teams for increased support and to prevent admissionsCommunication to all out of county teams from Deputy head of IDT to expedite discharges within 48 hoursManagers to be on site and cancel all non-urgent meetings and prioritise support of discharges

Managers to review all patients on con call without a DX plan.

Equipment to be ordered on day of AX and delivery date TBC within 24 hours. If delivery not within 24 hours escalate to managerChecklists to be completed on the day/ in the community

4 Above + sweeping of all wards and ED, to focus resources and expedite quick discharges immediatelyHOS to review all patients on con call without a DX plan.

Stranded patient meeting to be brought forward

Head of service to discuss blockages with commissioners including voluntary agencies to ensure capacity is utilised appropriately to support on day dischargesTo identify immediate available market capacity to inform commissioning decisions. Including increasing FOH capacity.Prioritise all community resources for the hospital

Provider presence on site to complete assessments and give real-time availability of care 7 days a weekEnsure full deployment of IDT staff to priority/ escalation areas (ED) as agreed by senior management and as required pull from community health (homefirst) and social care teams to come into the hospitalFlex all available beds and resources and ensure D2A/DH2A process is followed fully- pulling all medically optimised patients out.Equipment to be ordered immediately and delivery date within 24 hours. If delivery not confirmed immediately escalate to manager.Head of Service to be on site and cancel all non-urgent meetings and support team with triaging and escalating discharges.All assessments to be completed in the community.

Extra con calls to be arranged and agreed throughout the day and extra ordinary calls on all patients over 5 days on the con call with system partners without a DX plan.Managers to attend escalated board rounds and chase EDD and facilitate daily DX

29

APPENDIX 3 - Hertfordshire Community Trust (HCT) Escalation Triggers

OPEL 1 OPEL 2 OPEL 3 OPEL 4Bed Capacity (after allocation) >5% 3-5% 1-2% 0%

Patient transfer within 72 hr target (all patients)

>70% 51-70% 30-50% <30%

DToCs <10 10-15 15-20 >20

Planned Discharges >10% in 24 hours

>5% in 24 hours

>2% in 48 hours

0% in 48 hours

Staffing levels >90% 80-90% 60-79% <60%

ICT priority 1-4 1-3 1 1 (difficulties)

HCT Triggers

OPEL 1 OPEL description: Community capacity available across system. Patterns of service and acceptable levels of capacity are for local determination

Capacity available across all HCT services to meet demandNo expected reductions in capacity

Staffing = 90-100% (includes medical cover) Bed state/capacity = 9-10% of bedded capacity available or becoming

available for capacity or being transferred into today Total DTOCs are not effecting patient flow and closer to 5% 100% of patients offered a bed within 24 hours No patients waiting longer than 72 hours for transfer to a community

bed and within 90% Number of patients on the waiting list not exceeding the 72 hour target

of transfer. All priority patients being seen within ICTs No planned bed closures No operational issues – services operating as business as usual All patients that require repatriation are accepted No other pressures in the system

OPEL 2 OPEL description: Patients in community and / or acute settings waiting for community care capacity

Lack of medical cover for community beds Infection control issues emerging Lower levels of staff available, but are sufficient to maintain services Staffing = 80-90% (includes medical cover) Bed state/capacity = 5% of bedded capacity available or becoming

available for capacity or being transferred into today Total DTOCs are starting to increase further and influence patient flow

and closer to 10%-15% 100% of patients offered a bed within 24 hours 30% of patients transferred waiting longer than 72 hours for transfer to

a community bed Patients on the waiting list now highlighted as likely to wait longer than

the 72 hour target for transfer.30

Expected discharges in the next 24 hours reduced to 5% or less of bed base

All priority 1- 3 patients being seen within ICTs with priority 4 being de-prioritised

No planned bed closures No significant operational issues – services operating as business as

usual All patients that require repatriation are accepted but are now also

waiting Isolated infection control issues, ward closure due to outbreak of

infectious disease or Estates issues (e.g. flooding, disruption to utilities)

OPEL 3 OPEL description: Community capacity full

Significant unexpected reduced staffing numbers (due to e.g. sickness, weather conditions) in areas where this causes increased pressure on patient flow

Staffing = 70-80% (includes medical cover) Bed state/capacity = >2% of bedded capacity available or becoming

available for capacity or being transferred into today Total DTOCs are starting to increase further and influence patient flow

and closer to 10-20% <50% of patients offered a bed within 24 hours 50% of patients transferred waiting longer than 72 hours for transfer to

a community bed Patients on the waiting list delayed longer than the 72 hour target for

transfer. Expected discharges in the next 48 hours reduced to 2-3% or less of

bed base All priority 1 patients being seen within ICTs with priority 2-4 being de-

prioritised Significant operational issues – have arisen i.e. flooding All patients that require repatriation are waiting longer than 72 hours for

transfer Isolated infection control issues, ward closure due to outbreak of

infectious disease or Estates issues (e.g. flooding, disruption to utilities). More than 1 ward and/or teams involved.

OPEL 4 OPEL description: No capacity in community services Unexpected reduced staffing numbers (due to e.g. sickness, weather

conditions) in areas where this causes increased pressure on patient flow is at a level that compromises service provision / patient safety

Staffing = <60% (includes medical cover) Bed state/capacity = 0% of bedded capacity available or becoming

available for capacity or being transferred into today Total DTOCs are increasing further and influence patient flow and

closer to >20% <80% of patients offered a bed within 24 hours 90% of patients transferred waiting longer than 72 hours for transfer to

a community bed All patients on the waiting list delayed longer than the 72 hour target for

transfer. Expected discharges in the next 72 hours reduced to 0-1% of bed base All priority 1 patients being seen within ICTs with priority 2-4 being de-

prioritised. Priority 1 patients also being prioritised with the referrer to reduce this demand

31

More than 1 significant operational issues – have arisen i.e. flooding All patients that require repatriation are waiting longer than 72 hours for

transfer Large scale infectious disease outbreak or ongoing Isolated infection

control issues, ward closure due to outbreak of infectious disease or Estates issues (e.g. flooding, disruption to utilities). More than 1 ward and/or teams involved.

32

HCT Actions

Alert Status

Trust wide and Capacity Meeting actions

HCT Actions by service line

Bed bases and Bed Bureau

Integrated community teams

Adult Specialist services (inc Neuro)

Children’s services

Corporate services

Trust Status – OPEL 1

Business as usual conference calls including daily reporting

DGM’s monitor daily bed situation and operational issues throughout the day. IDT/discharge team have a good understanding of the predicted levels of demand and monitor community bed and ICT capacity.

Bed states available via the Business Intelligence Portal and Bed Bureau. Bed Bureau team proactively review bed and community capacity in conjunction with operational managers.

Active monitoring of infection control issues

Maintain timely updating of local information systems

Ensure all pressures are communicated regularly to all local partner organisations, and communicate all escalation actions taken

Proactive public communication strategy

Con calls – Bed bureau to represent HCT on conference calls

DToC con call – held once a week for each side of the county and chaired by Patient flow manager including a lead executive

Sit rep release (0930) Produce once a day

capacity reports / sit rep via bed bureau to include daily staffing, bed state, etc. Appropriately structured for internal and external distribution.

Business as usual management of patients at ward level including management of DTOCs

Ensure all planned discharges to community beds and teams occur.

LM’s monitor capacity and demand daily ensuring safe staffing levels met

Forward planning rosters for weekends and bank holidays

Daily declaration of capacity status

Integrated Community Team capacity communicated weekly to DGM via locality managers, with any teams reporting Amber to be escalated immediately to DGM

DToC con call – held once a week for each side of the county and chaired by Patient flow manager including a lead executive

Business as usual management of patients at ward level including management of DTOCs

33

eg. Stay Well messages, Cold Weather alerts

Maintain routine active monitoring of external risk factors including Flu, Weather.

Trust Status OPEL 2

Conference calls continue and agree on system call(s) if further required

DGM on the call(s) as required

Escalation information to be cascaded to all community providers with the intention of avoiding pressure wherever possible. Maximise use of re-enablement beds

Community providers to lower admission/treatment thresholds wherever possible through implementation of previously agreed flexible working arrangements to alleviate pressure

Redistribute staff where individual units are experiencing difficulties

Escalation of DToCs to appropriate agencies to expedite discharges

Task wards with bringing forward discharges to allow transfers in as appropriate.

Consider further flow conference calls with IDT

Additional ward rounds within community providers to expedite discharge and create capacity

Bring forward discharges as appropriate

Community hospitals to liaise with Social and Healthcare providers to expedite discharge from community hospitals.

IDT /Discharge and Bed Bureau team to proactively identify and progress patient discharges over the coming days

IDT/Discharge team to establish priority waiting list (in conjunction with Bed Bureau) to ensure forward planning of discharges

LM’s escalate reductions in capacity and/or demand to DGM

Review RAG rating and staffing levels at each shift including a plan for gaps that are at significant risk

Source temporary staffing as required

Consider deferring P4 activity

Consider deferring all non-urgent training, appraisals and non-face to face activity

Discuss and identify mutual aid and/or cross locality working including utilisation of community matrons and rapid response to deliver P1 activity Escalation of RRT DTOCs

Integrated nursing and therapy teams prioritise caseloads. Mutual Aid arrangements established to ensure minimum staffing levels are maintained in all areas

Redistribute staff where individual units are experiencing difficulties

Escalation of DToCs to appropriate agencies to expedite discharges

Task wards with bringing forward discharges to allow transfers in as appropriate.

Additional ward rounds within community providers to expedite discharge and create capacity

Bring forward discharges as appropriate

Community hospitals to liaise with Social and Healthcare providers to expedite discharge from community hospitals.

IDT /Discharge and Bed Bureau team to proactively identify and progress patient discharges over the coming days

Ensure corporate teams are aware of status

Corporate teams unlisted as necessary

34

2

IDT/Discharge team to establish priority waiting list (in conjunction with Bed Bureau) to ensure forward planning of discharges

Trust Status OPEL 3 Further internal and

external calls put in place to start the same day and to include all DGMS from Adult service portfolios

Escalation capacity discussed with the system and agreed what action to take (open/stay closed)

Patient Flow Manager informs DGM and Associate Director of Ops

Director of Operations informed

Following review, Director or Operations to notify Chief Exec and Board if necessary

Internal comms circulated to all staff re: escalation state

CCG to be notified by DOO or Chief Executive if necessary

DOO to advise partner organisations of escalation

Community providers to expand capacity wherever possible through additional staffing and services. Consider cancelling non-essential training/ supervision to release staff to manage

Additional senior clinical review of patients on bed based units including additional ward rounds

Senior manager on con call with system partners Internal HCT con call with DGMs/including neuro manager

Close working with Rapid Response / First / Integrated Community Teams to support additional discharges

Second sit rep / capacity report to go out at 1300 (internally and externally)

Further unit calls to challenge dtocs and patients within three days of edd.

Additional daily conference call with social care team to escalate barriers to discharge.

Cancel all training and all non-patient facing activity Consider re-allocating staffing resource from CQL’s, corporate services and other aligned services

Consider utilisation of additional clinical capacity

Senior clinician review of

Review RAG rating and staffing four hourly

DGM from ICTs representation at internal/external conference calls as required by the system

Daily review and RAG rating of caseload by band 6 caseload holder or deputy

Administrators to contact all deferred patients

Consider deferring P3 activity

Cancel all training and all non-patient facing activity Consider re-allocating staffing resource from CQL’s, corporate services and other aligned services

Consider utilisation of additional clinical capacity

All community care teams to review all patients awaiting assessments in order to expedite discharge or transfer – this will include in reach teams.

Prioritisation tool fully implemented and all non-urgent/lower priority care suspended by Integrated Community Teams, with

Additional senior clinical review of patients on bed based units including additional ward rounds

Senior manager on con call with system partners Internal HCT con call with DGMs/including neuro manager

Close working with Rapid Response / First / Integrated Community Teams to support additional discharges

Further unit calls to challenge dtocs and patients within three days of edd.

Additional daily conference call with social care team to escalate barriers to discharge.

Cancel all training and all non-patient facing activity Consider re-allocating staffing resource from CQL’s, corporate services and other

Staff able to help with logging and minute taking highlighted

Corporate staff with clinical skills and competencies highlighted

Quality, HR, Finance and P&I tams represented on internal conference calls

Quality team awareness of status and help required for risk assessing and ensuring safety supported by them

Finance team to be on assistance for review and costing of resources required

35

3

demand Consider deploying

clinically trained managers to assist in meeting current demand and using a wider group of agencies to increase staffing capacity.

Consider deploying staff to inpatient areas including by offering extra hours to contract.

Where possible, increase support and/or communication to patients at home to prevent admission

inpatients to clinically manage capacity / expedite discharges.

Transfer patients to different beds if ceasing to benefit from ICT, e.g. enablement etc.

.

suspension of visits for fixed period to lower priority patients. Cancel non-essential clinical activity

Community matrons to review caseloads using risk stratification tools to support the identification of additional capacity.

Patients waiting at home for admission to be referred to Community Teams (by in reach nurses)

aligned services Consider utilisation

of additional clinical capacity

Senior clinician review of inpatients to clinically manage capacity / expedite discharges.

Transfer patients to different beds if ceasing to benefit from ICT, e.g. enablement etc.

Compile a list of available staff and skill set from within specialist services

HR resourcing and HR Business partners to support with workforce demands (agency, sickness etc)

P&I team available to support an increase requests for information

Trust Status OPEL 4 Establish move to internal

twice daily conference calls chaired by Director of Operations

External conference calls with attendance by DOO and Associate Dir of Ops

Ensure all action from previous stages have been enacted and all other explored and utilised

All possible capacity has been freed and redeployed to ease systems pressures

Surge areas made available

Cancel all training and non-patient facing activity.

Consider redeploying all clinical facing staff to support areas of shortfall.

Medical director and CQL ward rounds to take place to expedite discharge

Continue daily review of and escalation of all patients

Ensure discharges to ICT and FIRST teams – prioritise this capacity for flow from HCT and WHHT units

Daily escalation call chaired by the DGM

Review RAG and staffing two hourly

LM’s to join twice daily conference call chaired by DGM

Defer all P2,3,4 activity Cancel all training and

non-patient facing activity Consider utilisation of specialist services staff

Bring in extra staff for FIRST service to help discharge

Medical director and CQL ward rounds to take place to expedite discharge

Continue daily review of and escalation of all patients

Ensure discharges to ICT and FIRST teams – prioritise this capacity for flow from HCT and WHHT units

Re-deploy staff from specialist services to bed bases and ICTs

Deputy Director/Director level representation on internal conference calls from Quality, Finance, P&I and HR

Short term re-deployment of clinically skilled corporate staff

36

4

Managers with clinical registration to be redeployed to clinical facing roles on wards or in community teams to support patient flow and patient management.

Contribute to system wide communications to update regularly on status of organization

Provide mutual aid of staff and services

Continue to expand capacity where possible - extra staffing

37

APPENDIX 4 - Hertfordshire Partnership Foundation Trust Escalation Triggers


Bed occupancy (all beds) <92% 92-95% 96-99% 100%Staffing (RAG rating from SafeCare)

No concerns

Moderate concern

Severe concerns

Extreme concern

DToCs <8 8-12 13 - 19 20+Number waiting in acute trust for MHAA

0 - 1 2-4 5-8 9+

Decision to admit made and waiting in acute

0 - 1 2 - 4 5 - 8 9+

Alert Status Triggers

OPEL 1 Demand for service within normal parameters; 2/3 older people; 1 CAMHS; 10 adult requests

Demand for MHAA/ S136 PoS within normal parameters/ ability to meet informal and formal admissions/ no ward based staffing issues identified through SafeCare system

PARIS is live/ communication systems live CAMHS & PICU/Mother & Baby services have capacity/ emergency social

care placement is available No older people or acute place in Non HPFT providers 0 -1 Mental Health waits in acute trust ED Planned discharges are taking place as predicted Usual ward activity able to continue No breach of Eliminating Mixed Sex Accommodation (EMSA) <8 DToC identified

OPEL 2 Anticipated pressure in facilitating assessment i.e. CATT/ CFT/ CCATT or AMHP requests

Insufficient discharges across all care groups Less than 8/9 discharges per day (adult)/ 1 (older people)

Emerging Infection Control (IC) issues Lower levels of staff to maintain services (SafeCare identified) Increased continuous observations CTO / 135 recall requests more than 1 per day Break down of placement x 1 per day More than 3 females in PICU Admission of 1 person or more in Non HPFT bed (adult and Older people) PARIS/ IT infrastructure is compromised 8 - 12 DToC identified <4 individual waiting for a mental health bed in the ED

OPEL 3 Patient flow significantly compromised; all 136 full & police waits / no AMHP availability/ a number of failed placements which were expected/ no community social care provision

Increased requests above 1 for non HPFT beds; male PICU/ lack of available female PICU/HDU

Increased numbers waiting for specialist treatment beds (Eating disorders/ Personality)

Breach of EMSA Admission of any Care group to alternative bed Lack of availability of specialist transport Closure to admission due to staffing levels or environmental issues Closure to admissions due to increased continuous observation (3 per ward) Increased non-Hertfordshire admissions

38

Confirmed IC outbreak leading to ward closure 5-8 Acute Trust Mental Health waits 13-19 DToC identified

OPEL 4 No available Hertfordshire beds trust wide No flow/ discharges planed or anticipated 136 PoS full/ no capacity outside Hertfordshire/ police & ambulance waits No availability of non HPFT beds Prolonged lack of available beds outside HPFT 9+ Acute Trust Mental Health waits 20+ DToC identified

.

HPFT Actions

Alert Status ACTION

OPEL 1 Predictive Date of Discharges for all Patients are reviewed and updated daily

Daily reviews of all patients by Consultant Psychiatrist and T/L/ NIC (Red2 Green)

Daily bed trackers to be updated and submitted to bed management team by 9am each working day

All wards to ensure weekly bed meetings take place with a multi agency attendance

Bed Capacity Meeting (Acute Services) will meet weekly on Monday and Thursday to plan for weekend availability

OPEL 2 Ward consultants to ensure all discharge plans are expedited. Bed Management Team to prioritise identification of a bed resource for

those in ED NIC of S136 to monitor time standards in relation to S136 detentions and

escalate SLL Bed Management Team will monitor time standards in relation to S136

detentions and PACE (Police Detention in Custody) Crisis and Community Managers are asked to ensure discharge plans are

expedited. Team leaders to update bed manager with confirmed plans and provisional

plans for discharge SLL and Medical Leads are made aware of escalated bed pressures by

direct contact from Bed Management team. If appropriate actions have not been taken, the Service Line Leader (or

deputy) for acute service line will be informed. Managing Directors and Clinical Leads for all care groups will be alerted to

OPEL Status Bed Capacity Meeting (Adult acute Services) will meet weekly on Monday

&Thursday to plan for weekend availability Bed Management Team will provide detailed strategy for use of available

beds during out of hour’s periods, particularly weekends and public/bank holidays.

39

OPEL 3 Bed Manager to confirm with modern matrons in acute services that all actions outlined in the OPEL 2 escalation have been taken.

All Acute Inpatient Consultants are asked to urgently review service users Crisis teams are asked to prioritise review of service users identified through

above action Medical Clinical leads to review service users for whom leave or discharge

with intensive support may be appropriate, if the above action is unsuccessful at providing additional capacity.

Bed Management team to provide OOH leads with strategies for use of available or potential capacity

On call consultants must be consulted about out of hours admissions during OPEL 3 alert periods

OPEL 4 Service Line Lead to confirm with all modern matrons that all actions outlined in the OPEL 3 escalation have been taken.

Clinical Directors to provide assurance that all current inpatients, not classified as DTC, continue to require admission on basis of risk

Critical bed meeting (Monday & Thursday) to be chaired by Exec Director if OPEL 4 Status remains in place for 3 days or more

Consider Non NHS/ HPFT hospital bed use strategy for pending admissions

40

APPENDIX 5 - Herts Urgent Care Triggers and Actions


111 call volumes predicted range

20-30% increase

30 -40% increase

40%+ increase

111 staffing 81-100% 80% 60-79% <60%% Ambulance Triage Figures will just be entered as a percentage and not

have a rag rating at this time.% ED Triage% Closed to Self Care

41

Hertfordshire Integrated Urgent Care Business Continuity Escalation Flow Chart

42

Hertfordshire Integrated Urgent Care -Capacity Escalation Flow Chart

43

IUC National Business Continuity Arrangements (Interim Guidance)

44

Integrated Urgent Care Escalation Policy

V1.3 September 2017

Summary:

The purpose of this policy is to ensure there is a robust system in place to maintain a clinically safe service in times when demand outweighs capacity, for example when un-predicted volumes of patients contact the service, or when resource has been limited due to unforeseen circumstances.

The policy is designed to aid staff in recognising the trigger points of escalation and to help them manage shifts in appropriately, the content of the suggestions is not exhaustive.

This policy replaces previous escalation matrix documents that have been in use.

Monitoring Periods will be at 10am, 1pm, 5pm and 10pmPlease record all on shift reports

Confidential – not to be circulated without the written permission of Herts Urgent Care

45

IUC111 Call Volumes and Staffing

Level of Demand

Level 1Patient Flow is maintained

Trigger Area Level of Escalation Action to be taken

Normal staffing levels are available across the 111 Services for 24 hour period

Staffing None Monitor staffing at 11am, 1pm, 5pm, 10pm

Call volumes within predicted ranges and can be dealt with by the resources available

Call Volumes None Monitoring periods – 11am, 1pm, 5pm, 10pm in addition to constant monitoring via wall board and system control panel.

Level 2Signs of Pressure


Staffing levels drop to 80% of normal levels

Staffing Report to Service Delivery Manager in the call centre

Contact On-call manager if SD manager not available

Send out text via Rota master to obtain staffing support Message all staff within contact centre to stay on or

come in early Liaise with other contact centres to assist if call volumes

exceed demand on capacity of available resources Log in standby staff i.e. Team Leaders, Coaches, Shift

Co-ordinator Inform Senior CAS lead

Influx of calls above 20% increase Call Volumes If a member of IUC management are present in the call centre report to them to offer support

Monitor call levels Monitor breaks Liaise with C&P, L&B and WGC for additional resources Ask staff to stay on or come in early Send text out via rota master Prepare Standby staff (Shift

Co-ordinators/Coaches/Team Leaders/Navigators/Central Bookers)

Clinical Advisors to pluck calls Liaise with Senior CAS Lead Shift Manager to inform On call Manager

Level 3 Trigger Area Level of Escalation Action to be taken

46

Major PressuresMajor- Staffing level drop to between 60 – 80%

Staffing On Call manager / Service Delivery escalates to Clinical on Call and Director on Call

Director on Call escalates to CCG

Confirm all above measures have been undertaken Implement revised telephony greeting messages to aid

management of patient expectation and try and reduce the number of non-urgent cases.

Log CA’s into secondary or ensure that plucking is auctioned

Limit staff breaks where possibleCall volumes are 30% above predicted levels

Call Volumes Escalate to IUC manager on call

Confirm above measures have been taken On call manager to liaise with Director on call On call manager to run reports on the number of

breaches so far and calculate the predicted call volumes for the entire day, this information can be used to analyse whether 95% is achievable

Continue monitoring and running reports throughout the day

Implement revised telephony greeting messages to aid management of patient expectation and try and reduce the number of non-urgent cases.

CCG to be made aware that call volumes are above predicted and further escalation may be required

Level 4Critical Pressures

Delivery of Service is compromised


Critical - Below 60 % of staffing levels are available

Staffing Director on Call to Liaise with CCG

CCG may consider liaising with NHS England


CCG may consider escalating to NHS England and National 111 team

47

Call volumes are 40% above predicted levels

Call Volumes Escalate to HUC director and manager on call

HUC director/manager to discuss whether to escalate to CCG

Director to escalate to the CCG to make aware that call volumes are above predicted and further escalation may be required


CCG may consider escalating to NHS England and National 111 team

48

IUCManaging Patients awaiting Telephone Consultation

Level of Demand

Level 1Patient Flow is Maintained


4 – 7 calls per clinician on duty or call back time greater than 30 minutes, but less than one hour.

IUC Telephone Consultation

No escalation required

Monitor Queue Allocate GP’s to specific calls to avoid calls breaching Ensure there is enough clinical support to deal with the

call volumes , if there is a short fall send a text out for home working

Request support from smaller basesLevel 2

Signs of PressureTrigger Area Level of Escalation Action to be taken

10 calls per clinician on duty or over one hour call back time or queue felt not to be clinically safe


Level 3Major Pressures


Over 12 Calls per Clinician on Duty and Call back time up to 3 hours


Senior On call Manager to escalate to Director on call

Document on Datix

Senior Manager to investigate possible alternative – can more calls be passed to the clinical advisors to assess

If escalation to commissioners required escalate –senior Manager

Advise local A&E or local emergency departments of the delay

Director on call informs the CCG of the service pressures

49

Level 4Critical Pressures

Delivery of Service is compromised


20 calls per clinician on duty and call back time greater than 3 hours.


Escalation to the Director on Call

Director to escalate to CCG

Continue to implement steps in levels 3 and 4

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CAS Clinician Queue

Level of Demand Level of Escalation Action to be taken

Level 1

Normal staffing levels are available across the CAS for 24 hour period

No escalation required None – normal service operates

Call backs within 15 minutes, 4-7 calls per clinician

No escalation required Liaise with CAS lead throughout shift Monitor Queue CAS lead to allocate GP’s to specific calls to avoid calls

breaching CAS lead to ensure there is enough clinical support to deal

with the call volumes , if there is a short fall send a text out for home working

Request support from smaller bases if necessaryLevel 2

CAS Staffing levels have gaps in cover

Escalate to On Call Manager Split shifts on the rota Move Redeye or consultation GP’s around to provide cover Email sent to all GP’s to pick up

Call backs greater than 15 minutes, 12 calls per clinician

Liaise with Senior CAS lead If a member of the IUC management team are

present in the call centre report to them to offer support

Document in your shift report Inform on call IUC Manager On call manager to escalate to Clinical on Clinical on call and CAS lead to make a

judgement if it needs to be escalated to Directors on call

Directors to escalate to the CCG on call

Move clinicians from OOH’s to the CAS pool if trained Ask existing staff if they could work on. Patient deterioration should be noted and a GP should be

alerted. Send text message to all GP’s Document all events in your shift report CAS clinicians to prioritise ED and Ambulance calls CAS lead to triage calls are required

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Level 3

CAS Staffing remains unfilled Escalate to On Call Manager Identify an experienced, senior Clinical Advisor available to work outside of Pathways

Move to the CAS team Shift Manager to communicate to the call centre and inform

them that only G2’s (Green ambulances) will be validated by the Senior Clinical Advisor.

All ED’s – Emergency Department dispositions will be validated by the Clinical Advisors in the call centre

As soon as there is an CAS – Senior Clinician available – please revert back to the normal process

Call backs great than 15 minutes, 15 calls per clinician

Senior On call IUC Manager to escalate to Director on call

Document on Datix

Senior Manager and CAS lead to investigate possible alternative

Advise any local services that could be impacted by the delayLevel 4

CAS staffing gaps remain unfilled and no senior CA available or insufficient capacity to release CA

On Call Manager to escalate to Clinical On Call Please communicate to the call centre and inform them that due to sickness or shifts uncovered by the CAS Senior Clinician it is necessary to request that all ED’s and Green Ambulances (G2’s) will be validated by the Clinical Advisors until further notice.

Call backs greater than 15 minutes, 18 calls per clinician

Director to escalate to CCG Continue to implement steps in levels 3 and 4

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IUCPatients Awaiting Face to Face assessment (PCC)


Level 1

PCC patient wait within 1 hour No escalation required Monitor appointment diary to ensure base running to time.

Monitor Diary to ensure all patients arrive; non attendance of patients should be contacted.

Monitor Appointment diary, ensure Urgent appointments are within NQR time frame

Level 2

PCC patient wait over one hour PCC Receptionist to contact the shift manager

Advise patients arriving that there is a delay Block immediate appointment slots off to allow

catch up. Advise Base Clinician to allow them to prioritise

patients if necessary Advise central bookers of delays at site. Central

Bookers should in turn prepare patients for potential delays.

Monitor Appointment diary, ensure Urgent appointments are within NQR time frame

Ask clinicians to stay on to assist Document on Patients waiting over one hour form

Level 3

PCC Patient wait over 2 hours PCC Receptionist to contact SM Shift Manager to inform on call.

Advise patients arriving that there is a delay Block immediate appointment slots off to allow

catch up. Advise Base Clinician to allow them to prioritise if

necessary Escalate to Shift Manager

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Central Bookers to offer alternative base appointments

Assess Visiting service capacity- re-deploy visiting Doctor to assist in base.

Send Flexi GP Document in the Shift Report

Level 4

Level 3 Sustained for more than one hour

On Call Manager Clinical on call

Receptionist to assess appointment screen and move appointment to alternative base.

Escalation to On Call Central bookers to offer alternative base

appointments If applicable: Defer A&E Referrals

Level 5

No improvement from level 4 After 3 hours

Director on Call Receptionist to contact patients booked in to base to try and move further appointments to alternate bases

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IUCPatients Awaiting Face to Face assessment (Home Visit)


Level 1

Home Visit- Routine Calls within 4 hours.

Urgent visits within 1 hours

No escalation required Calls to be Clinically assessed upon receipt to the car to ensure Calls are visited in order of priority

‘Arrived’ to be marked when arriving at patients address ‘En-route’ to be marked when moving to next visit Use all available resource to ensure even distribution of

visits between cars Routine Calls about to breach should be comfort called

by the driver and if any deterioration discuss with the Clinician who could review and speak to patient

Urgent Visits about to breach should be comfort called by the driver

Level 2

Home Visit- Routine Calls within 6 hours

Urgent visits within 2 hours.

No escalation required Calls to be comfort called by driver to advise of situation and to check for deterioration

Continue to ensure even distribution of calls Comfort Calling should continue to take place for

Routine Calls that have breached at least two hourly, and if any deterioration is noted the Clinician should review and speak to patient.*

Urgent Visits about to breach should be comfort called by the driver *

*Comfort calling can be undertaken by alternative Operational staff e.g. Receptionist central bookers or despatcher

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Level 3

Home Visit- Routine Calls over six hours.

Urgent visits over 2 hours

Despatcher (OOH Supervisor) to inform the Shift Manager.

Ask existing staff if they could work on. Document all events in Shift Report. Despatcher (OOH Supervisor) to ensure comfort

calling continues as per level one and two escalation, ensure calls are documented, and patient deterioration is noted, consider GP second contact advice.*

Send additional visiting GP & Driver Nominate senior Clinician to re-triage Offer base appointments if available

Comfort calling can be undertaken by alternative Operational staff eg Receptionist central bookers or despatcher

Level 4

Home visit- Routine Calls over six hours up to 8 hours

Urgent Visits over 3 hours or queue felt not to be clinically safe

On call Manager to escalate to clinical on call

Clinician to assess home visits to re-prioritise. This person needs to be identified

Urgent visits may require Ambulance intervention Offer base appointments Ensure that patients are regularly comfort called to

be updated on ETA and check patient’s condition.

Level 5

Sustained level 4 for more than 3 hours

Escalation to the director on Call Continue to implement steps in levels 3 and 4

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Appendix 6 – EEAST Surge Management

This surge management plan outlines the operational arrangements undertaken by the East of England Ambulance Service NHS Trust (EEAST) to manage emergency and urgent demand within the Emergency Operations Centres (EOCs) at times of peak operational pressures or when activity levels exceed normal demand profiles. This plan should be read in conjunction with the EEAST Major Incident Plan, EOC Standard Operating Procedures (ESOPs), EOC Instructions and Trust Escalation Guidelines.

The Surge Plan contains triggers for the various levels. However, this does not preclude a Trust Strategic Commander making a decision (normally in conjunction with EOC Tactical) to implement a higher level should the situation necessitate (for example due to the level of acuity of waiting calls).

De-escalation It is important to note that the triggers are designed to be followed and indicates the level of SURGE. However it is important to note that the strategic commander may remain at a higher level of SURGE based on predicated demand or service pressures.

EEAST REAP Levels

The Resourcing Escalatory Action Plan (REAP) is a national indicator of the pressure in ambulance services across the UK, which triggers specific measures when the Trust is operating at significant and sustained levels of increased activity. The levels of REAP range from 1 (normal service) to 6 (potential service failure). The Full plan is located in appendix 9

REAP Level System Status

4 Extreme Pressure3 Severe Pressure2 Moderate Pressure1 Steady state

EEAST is a regional organisation and the REAP level will indicate the pressure on the service across all 6 counties. To monitor pressure in the local system, ambulance handover delays and surge and capacity management at the sector EOC level (Bedford) is appropriate.

HALO/Ambulance Handover Delays

The Hospital Ambulance Liaison Officer’s (HALO) daily role it is to be the escalation and co-ordination point between the acute trust and ambulance service to manage ambulance handover and ambulance clear delays. This will take the form of a liaison between the acute trust and the ambulance EOC/Regional Co-ordination Centre (RCC) as well as managing ambulance crews delayed at the acute trust to maintain patient flow and the timely turnaround of ambulances within our local system. Outside of the HALO’s operating hours, during escalation, a Duty Locality Officer (DLO) will take this role.

The HALO is expected to be informed of local pressures on the acute trust and pressure being experienced within the ambulance service. To facilitate this they will attend the acute trust’s daily bed meetings to ensure they are appropriately informed and will retain contact with EOC/RCC and ambulance senior managers throughout their shift. Outside of the HALO’s operating hours, during escalation, a Duty Locality Officer (DLO) will take this role.

Contact numbers: In-hours (10am – 10pm): Lister HALO on-site - 01438 286411Out of hours (10pm – 10am) Regional Co-ordination Centre 01245 444515

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ENHT Cohorting Protocol

During periods of pressure where ambulances are subjected to significant delays at the emergency department ENHT have a procedure in place to facilitate the cohorting of ambulances to allow ambulance vehicles to be made available to EOC at the earliest opportunity. The HALO will co-ordinate the management of ambulance cohorting which includes the deployment of the ENHT process and EEAST’s own cohorting arrangements.

The ENHT cohorting protocol is detailed below;

ENHT PROCESS FORAMBULANCE OFFLOADING / COHORTING

What is cohorting: a process whereby patients who arrive by ambulance and cannot be offloaded into an appropriate space in ED and are offloaded into an identified area until space becomes available. Handover is taken physically and clinically in order to release the ambulance crews. Staff are deployed to manage patients in the identified cohorting area.

Where will patients be cohorted in ED: The corridor leading to the sister's station (where ambulances currently handover) will be the location for the cohorting.

How many patients can be cohorted in the ED corridor at any one time: 4 patients per member of staff

Who will take handover from the ambulance crews: The assigned handover nurse / sister will take handovers from the ambulance crews. The HALO from East of England Ambulance Service will support the efficient handover and support cohorting. The band 7 nurse or sister in charge of majors is expected to know as soon as possible, the clinical condition and presentation of each patient who has been handed over. The nurse will document the priority of the patient and a plan for their care i.e. pain relief / observations / ECG / x-ray assessment etc.

Who will remain with the patients in the cohorting bay: Agreed EEEAST or ENHT member of staff will remain with the patients, taking observations, administering analgesia etc. Where ECG or other interventions are required an area where privacy and dignity can be maintained will be identified. This may involve moving a patient out of a majors cubicle once their examination / investigations have been concluded.

Where will the additional trolleys be stored: 6 trolleys are stored under the stairwell in ACU. The key for unlocking the trolleys is in the sisters office in ED (black metal box on the shelf above the pc’s).

Triggers for deploying cohorting process

Inbound screen shows 4 or more patients due to arrive in ED, and the department at that time has no space to offload

Or

3 or more ambulances are already waiting > 15 minutes to offload with no space available in the department imminently

PLEASE REMEMBER

To inform the patient and relatives regarding the process and reasons for moves. Escalate any patient who is triggering on NEWS score or whose presentation is

causing concern. Manage the patients pain. Take all possible measures to maintain privacy and dignity.

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ENHT Cohorting Flow Chart

Inbound screen shows 3 or more patients due to arrive in ED, and department at that time has no space to offload

Or

3 or more ambulances are already waiting > 15 minutes to offload with no space available in the department imminently

EOC Surge Management Triggers and Actions

The following triggers and actions are monitored and managed by the Trust Regional Co-ordination Centre (RCC) in consultation with the Silver and Gold Mangers. Local actions are taken at the Bedford EOC which manages ambulance demand and dispatch to the ENHCCG catchment area

59

TRIGGER

Deploy 4 trolleys from secure location / or use spare AMUA trolleys if

possible

Position trolleys in ED corridor / Use screens to

provide patients with some privacy

Handover Nurse to take ambulance handovers

Ambulance Crews Released

EEAST Dashboard Metrics


Conveyances to Lister Figures will just be entered as a number and not have a rag rating at this time.

% Handed over <15 mins >90% 71-90% 50-70% <50%Handover time >15 mins 15-59 60-119 >120

No SURGE level triggered

The following actions are deemed to be business as usual and therefore can be taken dynamically by the EOC teams to proactively manage demand

Level 0 – GREENAction WhoReview resources within locality for movement across dispatch areas

DTLs in conjunction with DEOs

Proactive management of hospital delays with support of DLOs/HALOS.

Via RCC

Proactive management of out of service resources with operational management support

Via RCC

Proactive and dynamic management of the LOWCODE stack to ensure ECAT capacity meets demand.

Clinical Coordinators / Senior EOC Clinician

Maximise call handler availability through proactive management of not ready and Exit 4 in line with ESOP

CHTL/DEOs

Ensure duplicate calls are cleared in a timely manner to allow management of pending stack

DEOs

Urgent Script (alternative question on alternative transport)

Call Handlers/CHTLs

Review non ECAT Category 2, 3 and 4 non ECAT calls and move those clinically appropriate into ECAT

Clinical Coordinators / Senior EOC Clinicians

Consider non-clinical crews attending and convey on appropriate calls (after clinical Coordinator/senior clinical review)

Clinical Coordinators / Senior EOC Clinicians/EOC Silver

Call handler “hear and treat” on limited subset of C4 codes with exclusion criteria

Call Handlers/CHTLs

Consider Implementation of Exit 4 if appropriate

EOC Tactical

Trust Defined ECAT business as usual call back times:

Category 2 20 minutesCategory 3 60 minutesCategory 4 120 minutes

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Trigger - greater than 40 unassigned calls regionally (or greater than 20 unassigned in any individual EOC) OR any Category 1 call unable to be allocated within 5 minutes or a Category 2 within 40 minutes

All calls, includes overdue HCP calls (or forecast to be overdue) and backup requests. Excludes ECAT (although count ECAT calls likely to be returned for response).

SURGE LEVEL 1 – AMBERAction Who1 Escalate situation to EOC Silver DEO, Clinical Coordinators / Senior EOC

Clinicians or RCC2 Review resources regionally for cross EOC

support and consider supportive movement (current and planned resource)

Operational Tactical/RCC

3 Use of PTS resources to support A&E RCC to identify suitable cases and liaise with PTS

4 Consider support to RCC by Operational Tactical for hospital delay escalation and management

EOC Tactical

5 Review operational manager use/deployment (e.g. hospital inbound traffic/crew delays)

EOC with local Operational Tactical

6 Review of deployment of managers and staff responders in line with ESOP 25/SSP

Operational Tactical

7 Consider Blanket Exit 4 if appropriate EOC Tactical8 Ensure the BAU Review Category 2 and

non ECAT Category 3 and 4 calls and move those clinically appropriate into ECAT

Clinical Coordinator / Senior EOC Clinician

9 Consider Category 3 and 4 script for call handlers given potential delays (see Appendix 1) – agree advisory delay time for category.

EOC Tactical

10 Urgent Script (increased demand question on alternative transport) – advise if time delay

EOC Tactical

11 Record actions in Silver notes RCC12 Inform DEOs and Clinical Coordinators /

Senior EOC CliniciansRCC

13 Email action card to Strategic and Tactical Commanders

RCC

14 Record and escalate any potential patient safety incidents in line with policy

All

15 Consider removal of cold 3 back-ups EOC Tactical16 Agree review time EOC Tactical

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Trigger - greater than 80 unassigned* calls regionally (or greater than 40 unassigned in any individual EOC)


SURGE LEVEL 2 – REDAction Who1 Arrange conference call with Gold, EOC

Silver and RCC [call must be recorded via EOC line with time and extension noted].Teleconference 03303360670, Participant PIN: 706170

RCC (Strategic Commander to chair and authorise actions below)

2 Review Surge Level 1 (Amber) actions Strategic Commander3 Request clinical support to EOC (see

Appendix 2 for guidance on role)EOC Tactical

4 Consider support for hospital delay escalation management from Operational SLMs/Tactical

Strategic Commander

5 Determine any requirement support for EOC from Operational management teams

EOC with Operational Tactical

6 Consider support for Clinical Advice Line (CAL)

EOC Tactical

7 Consider additional Private Ambulance Service support

Strategic Commander

8 Consider increase ECAT ring back time of C2 to 30 minutes, C3 to 120 minutes, C4 to 180 minutes

EOC Tactical

9 Consider NO SEND with exclusion criteria for C4 calls.

Strategic Commander

10 Implement Category 2, 3 and 4 script for call handlers given potential delays (see Appendix 1) – agree advisory delay time for category.

EOC Tactical

11 Urgent Script (high demand and delay script) – agree advisory delay time

EOC Tactical

12 Advise critical care assets of potential ambulance response delay for attendance or conveyance.

RCC

13 Consider support for EOC “welfare" calls EOC Tactical14 Considering contacting managers/staff

responders for assistanceRCC

15 Removal of cold 3 back-ups EOC Tactical16 Send system wide notification of EEAST

Surge Red Status (pre agreed script/distribution list)

RCC

17 Send internal notification of escalation RCC18 Record actions in Silver notes RCC19 Inform DEOs and Clinical Coordinators /


20 Email action card to Strategic and Tactical Commanders

RCC


All

22 Agree review time Strategic Commander

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Trigger - greater than 120 unassigned* calls regionally (or greater than 50 unassigned in any individual EOC)


SURGE LEVEL 3 - BLACKAction Who1 Arrange conference call with Gold, EOC

Silver, RCC, Senior Clinician, TACAD [call must be recorded via EOC line, time and extension noted]Teleconference 03303360670, Participant PIN: 706170

RCC (Strategic Commander to chair and authorise actions below)

2 Review Surge Level 2 (Red) actions Strategic Commander3 Consider on site Gold Cell (confirm

attendees)RCC with Resilience Manager on Call

4 Call in additional staff to EOC and operations

EOC and Operational Tactical

5 Call in additional clinical support to each EOC (see Appendix 2 for guidance on role)

Strategic Commander

6 Consider increasing ECAT ring back time of C2 to 40 minutes, C3 to 180 minutes, C4 to 240 minutes

EOC Tactical

7 Consider moving all appropriate Category 2-4 calls into ECAT (see script in Appendix 1) agree advisory delay time for category.

EOC Tactical

8 Clinical review of back up requests (e.g. potential transport options)

EOC Tactical

9 All HCPs referrals to be clinician reviewed (preferably hot transfer from call handler)

EOC Tactical

10 Consider implementing “Do Not Send’ to Category 3 and 4 codes (see script in Appendix 1) with exclusion criteria (Appendix 3)

Strategic Commander

11 Consider implementing “Do Not Send’ to Category 3 and 4 codes (see script in Appendix 1) without exclusion criteria (Appendix 3)

Strategic Commander

12 Implement Category 2, 3 and 4 script for call handlers given potential delays (see Appendix 1) agree advisory delay time for category.

EOC Tactical

13 Urgent Script (high demand and delay script) – agree advisory time

EOC Tactical

14 Review welfare of unassigned events and consider a need to modify process with non-clinicians undertaken initial welfare

Strategic Commander

15 Consider removal of breakpoints to improve immediate resource availability

Strategic Commander

16 Consider suspension of end of shift process

Strategic Commander

17 Prepare to invoke EEAST Major Incident Plan

Strategic Commander

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18 Send system wide notification of EEAST Surge Black Status (pre agreed script/distribution list)

RCC

19 Record actions in appropriate log RCC20 Inform DEOs and Clinical Coordinators /


21 Email action card to Executive Team, Strategic and Tactical Commanders

RCC


All


All

24 Agree review time Strategic Commander

During times of extreme pressure where an acute trust is experiencing severe difficulty in manage the volumes of patients arriving at the A&E and patient safety is compromised, the acute trust may request for ambulances to be diverted to another hospital to alleviate the pressure for a defined period of time.

This may constitute a full divert whereby all ambulances are directed away from the acute trust (this may or may not include the severely ill) or a peripheral/border divert where patients on the border of a locality where an alternative acute trust is a viable option will be taken to the alternative A&E to alleviate some of the pressure.

A decision to implement an ambulance divert requires the approval of the CCG’s Director on Call and the decision will be made by exception only.

The process is detailed in Appendix 9.

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Appendix 1 – EOC Call Handler Scripts

SURGE Level Script AreaLevel 0 – Green Category 2,3 & 4 and ECAT referrals

Category 3 & 4 sendUrgent ScriptFrequent callerCall Handler Hear and TreatAdditional post-dispatch instruction

Level 1 – Amber Category 2,3 & 4 and ECAT referralsCategory 3 & 4 sendUrgent ScriptFrequent callerCall Handler Hear and TreatAdditional post-dispatch instruction

Level 2 – Red Category 4 ‘Do Not Send’ codes (with exclusions)Category 2, 3 & 4 and ECAT referralsCategory 2, 3 & 4 sendUrgent callsFrequent callerCall Handler Hear and TreatAdditional post-dispatch instruction

Level 3 - Black Category 3 & 4 ‘Do Not Send’ codes (with or without exclusions)Category 2, 3 & 4 and ECAT referralsCategory 2, 3 & 4 sendUrgent callsFrequent callerCall Handler Hear and TreatAdditional post-dispatch instruction

Appendix 2: Additional Clinicians in EOC – Guidance on Role

SURGE 3 (BLACK) with Strategic Commander Authorisation Only Triage Principles – Call backs or “Welfare calls” as defined within SOP (unassigned events)

Calls will be triaged by paramedic (ECAT, Clinical Coordinator, RCC and additional clinicians) looking for:

1. Upgrade calls as required based on worsening of presentation a. Upgraded calls to be implemented through CAD or if the operator is unable through appropriate person within the respective EOC (respective EOC is one where the call would be dispatched from). Relevant information to be entered in CAD incident notes as well.

2. Those who can continue to await a response with worsening advice/guidance a. Entered in CAD incident notes with the advice given either by assessing clinician or someone within the EOC

3. Those suitable for ECAT/further assessment that can be passed into LOWCODE (subject to capacity with Clinical Coordinators / Senior EOC Clinicians agreement) a. Passed through directly by assessing clinician or someone within the EOC

4. Assessment of suitability to be conveyed by PAS/ECA/SP for all grade of call a. Entered into CAD incident notes by assessing clinician or someone within the EOC

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Backup Requests/Attendance by non Paramedic/Technician Crews

1. Unqualified crews and PAS to be dispatched to clinically appropriate triaged call as listed above

2. Guidance and advice from CAL to support decision making once on scene

3. Paramedic Backup requests monitored by Clinical Coordinator / Senior EOC Clinician through declared HOT 1 back up. Clinical Coordinator / Senior EOC Clinician to make contact and decision on alternative support or immediate conveyance Appendix 3: Exclusion Criteria for Category 3 and 4 calls

SURGE 2 (RED) and SURGE 3 (BLACK) with Strategic Commander Authorisation Only The following are exclusions used by call handlers (taken from ESOP 41):

Patients 4 years old and under (previously 8 for the trial) Patients 70 years old and over (previously 65 for the trial) Patients on the floor unable to get up (where volunteered) Patients with cancer (where volunteered) Patients who are alone (where volunteered)

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Appendix 7 - NHSE Central Midlands Communications Flow Chart

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Appendix 8 - East and North Herts System Communications Flow Chart

APPENDIX 9 - SUPPORTING DOCUMENTS FOR ESCALATION

1. Midlands and East 12 Hour Patient waits in A&E formal reporting procedure.2. Serious Incidents Requiring Investigation (SIRI) Summary Information3. Ambulance divert requests and check list 4. Patient Handover delays 5. Ambulance NARU REAP Plan6. Teleconference Standard Operating Procedure

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Midlands and East 12-hour Breach Reporting Protocol v1.3 (1st July 2016)

Column A Column B Column C Column DTime Action By To Minimum Action/Comment

OPERATIONAL ESCALATION PROCEDURE FOR POTENTIAL 12HR BREACHESDTA <4hrs Normal Acute Trust internal arrangements

DTA +4 - <8hrs Internal Acute Trust alerting and intervention arrangements

DTA +8hrs Acute Trust Director On-call

CCGDirector On-call

Immediately contact and confirm the following information for each potential 12 hour wait:1. Unique Identifier (e.g. initials, age and gender but not patient identifiable information) to

prevent confusion in reporting2. Decision to Admit (DTA) time3. Summary of plan to resolve4. Expected time of resolution5. Clinical Assessment of potential harm

And:Confirmation of current demand/capability within A&E and the wider Trust (including active clinical triage process in place and documented plus any staffing issues).

As a MINIMUM updates every subsequent hour UNTIL resolution

Acute Trust Director On-call

CCGDirector On-call

Update of progress against/development plan until patient confirmed in bed/ discharged. UNLESS:

1. The decision to remain in A&E is based solely on clinical need for the patient (i.e. to move them would not be acceptable), authorised by the Senior Clinical Decision Maker, based on the clinical risk of potential harm being assessed and documented;

2. The patient is expected to die, and they or their next of kin have requested they not be moved elsewhere.

DTA +10hrs CCGDirector On-call

NHS England Director of Commissioning Operations (DCO) TeamSenior Manager On-call

If at any time the CCG Director believes:1. The overall position of the Acute Trust(s) is expected to get worse; or2. 12 hour breaches are expected to occur; or3. Support/coordination is anticipated across the wider economy area; or4. The patient dies before transfer to the appropriate setting is completed; or5. 5. Increased risk of clinical harm.

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Under extreme pressure and where there is significant risk to multiple DTA +11hrs

NHS England DCO Team DirectorOn-call

NHS England RegionalSenior Manager On-call

Where the system is under extreme pressures and where the DCO Team Director believes:1. Pressures will require a multi-area co-ordinated response; or2. To reduce risks to patients.

Trust Director On-call

Trust NHS Improvement Portfolio Director

If a 12hr breach has occurred:

In-hours (i.e. 9am -5pm Monday to Friday)

Persons outlined in column B immediately informs their respective regional bodyin Column C

CCGDirector On-call

NHS England DCO Team Senior Manager On-call who will inform the NHS England Regional Senior Manager On call

Summary of activity including:1. Location, number and length of each 12 hour breach

2. Actions and activity undertaken3. Any other relevant observations4. 12 hour breaches must be reported as a Serious Incident (SI) on STEISS and a Root Cause Analysis (RCA) should be completed within agreed timeframes. An initial RCA must be completed within 24hrs and shared with Senior Clinical staff to prevent reoccurrence

Initial RCA analysis to be completed on all 12hr breaches within <24hrs – and for this to be shared with the NHS England Regional Director of Delivery and NHS England Regional Team Senior Manager On call and NHS Improvement Portfolio DirectorTrust

Director On-call


If a 12hr breach has occurred: Out of Hours (i.e. 5pm – 9am Monday to Friday, Weekends and Public Holidays)

By 1100hrs the following working day the persons

CCGDirector On-call

NHS England DCO Team Senior Manager On-call who will inform the NHS England Regional Senior Manager On call

Summary of overnight activity including:1. Location, number and length of each breach >12 hours

2. Actions and activity undertaken3. Any other relevant observations4. >12 hour breaches must be reported as a Serious Incident (SI) on STEISS and a Root Cause

Analysis (RCA) should be completed within agreed timeframes. An initial RCA must be completed within 24hrs and shared with Senior Clinical staff to prevent reoccurrence.

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outlined in column B informs their respective regional body in Column C

Initial RCA analysis to be completed on all 12hr breaches within <24hrs – and for this to be shared with the NHS England Regional Director of Delivery and NHS England Regional Team Senior Manager On-call and NHS Improvement Portfolio Director.

Acute Trust Director On-call


FORMAL ACCOUNTABILITY PROCEDURE FOR A 12HR TROLLEY BREACHIf a 12hr breach has been confirmed:

In-hours (i.e. 9am -5pm Monday to Friday)

Persons outlined in column B informs immediately their respective regional body in Column C


NHS England Regional Directorand the Regional Director of Delivery

Inclusion of information in activity report

Summary of numbers; details for all waits >12hr plus any clinical harm impact and report on mitigations that are in place.

Acute Trust Chief Executive

NHSImprovement Director of Delivery and Development

Out of Hours (i.e. 5pm – 9am Monday to Friday, Weekends and Public Holidays)

By 1100hrs the following working day the person outlined in column B informs their respective regional director outlined in Column C


NHS England Regional Senior Manager On-call

Inclusion of information in overnight activity report

Summary of numbers; details for all waits >12hr plus any clinical harm impact and report on mitigations that were put in place.

Acute Trust Chief Executive

NHSImprovement Director of Delivery and Development

Trust CEO is requested to personally telephone NHS Improvement Director of Delivery and Development in order to explain the reason for the breach, on the day it happens (or if a breach occurs out of hours an update is required the following morning by 11.00am).Summary of the numbers and details regarding any 12hr breaches plus any clinical harm impact and report on mitigations that were put in place.

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Serious Incidents Requiring Investigation (SIRI) Summary Information

Background: Serious incidents must be reported by any provider organisation within 1 working day of them

becoming aware of the incident. Only high profile incidents should be received by on-call staff

Adverse media coverage or public concern about the organisation or the wider NHS One of the core set of ‘Never Events’ as updated on an annual basis and currently including:

Wrong-site surgery; Retained instrument post-operation; Misplaced nasogastric or orogastric tube not detected prior to use; Inpatient suicide using non-collapsible rails; Escape from within the secure perimeter of medium or high security mental health services by

patients who are transferred prisoners; In-hospital maternal death from post-partum haemorrhage after elective caesarean section; Intravenous administration of mis-selected concentrated potassium chloride.

Supplementary Term1. Incident – an event or circumstance that could have resulted, or did result, in unnecessary

damage, loss or harm such as physical or mental injury to a patient, staff, visitors or members of the public.

2. NHS-funded services and care – healthcare that is partially or fully funded by the NHS, regardless of the location.

3. Unexpected death – where natural causes are not suspected. Local organisations should investigate these to determine if the incident contributed to the unexpected death.

4. Permanent harm – directly related to the incident and not to the natural course of the patient’s illness or underlying conditions, defined as permanent lessening of bodily functions, including sensory, motor, physiological or intellectual.

5. Prolonged pain and/or prolonged psychological harm – pain or harm that a service user has experienced, or is likely to experience, for a continuous period of 28 days.

6. Severe harm – a patient safety incident that appears to have resulted in permanent harm to one or more persons receiving NHS-funded care.

7. Major surgery – a surgical operation within or upon the contents of the abdominal or pelvic, cranial or thoracic cavities or a procedure which, given the locality, condition of patient, level of difficulty, or length of time to perform, constitutes a hazard to life or function of an organ, or tissue (if an extensive orthopaedic procedure is involved, the surgery is considered ‘major’).

8. Abuse – a violation of an individual’s human and civil rights by any other person or persons. Abuse may consist of single or repeated acts. It may be physical, verbal or psychological, it may be an act of neglect or an omission to act, or it may occur when a vulnerable person is persuaded to enter into a financial or sexual transaction to which he or she has not consented, or cannot consent. Abuse can occur in any relationship and may result in significant harm or exploitation of the person subjected to it. This is defined in No Secrets for adults and in Care Quality Commission (CQC) guidance about compliance. Working together to safeguard children states that ‘abuse and neglect are forms of maltreatment of a child. Somebody may abuse or neglect a child by ‘inflicting harm’ or by failing to act to prevent harm

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User: CCG Senior Manager On Call

No. Action

1. Determine whether this is a high profile Serious Incident using the definition above. If it is, contact the Area Team On-Call Manager;

2.Ensure details of the incident are reported to the Director of Safeguarding and Deputy Director of Quality & Nursing and that the Serious Incident module of STEIS is completed as soon as possible on the first working day following the reporting of the incident.

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Reporting Protocol: Ambulance Divert RequestsVersion 3.1, issued 1st July 2016

BackgroundThis document sets out the process for requesting ambulance diverts within the NHS England (Midlands & East) region. The management of a declared major incident will supersede the requirements of this protocol.

Definitions

Full DivertA Full Divert is defined as movement of ambulance borne activity away from a site under pressure to the next nearest/appropriate A&E - with their agreement (not hospitals that are part of the same Trust)

There are occasions when due to service failure certain groups of patients require diverting (i.e. failure of a CT scanner etc.) – the process for requesting a Full Divert should followed.

Peripheral / Border DivertA peripheral divert is a request for patients in border areas i.e. those equidistant between acute trusts, to be taken to the acute trust under less pressure. These are often used to ease acute peaks and are usually short term with a defined number of ambulances over an hour period rather than a full divert of ambulances.

In certain areas, local agreements are in place to enable peripheral diverts to happen. In these circumstances there is no requirement for additional approval, only notification.

DeflectA Deflect is the movement of ambulance borne activity to another site within the same acute hospital group.

Expectations

1. The Protocol will only be used when Trusts have exhausted both internal systems and escalation plans as well as local health and social care plans to meet demand.

2. The Protocol will not apply for the purposes of protecting elective beds.

3. Peripheral Diverts or Deflects should only require authorisation by the CCG Director On-Call where Ambulance and Acute Trust Directors On-Call cannot reach agreement locally.

4. A&E departments will not close other than in extremis (e.g. fire) and therefore requests for Full Divert will be by exception only and require approval by the CCG Director On-Call prior to implementation. The NHS England Director of Commissioning (DCO) Team Senior Manager On-call should be contacted to either:

i. Notify of the decision/outcomeii. Request direction of Provider(s) where no agreement can be reached

5. The DCO Team Director On-Call retains authority to stop any local divert agreement where they consider not to do so would put patients at unacceptable clinical risk

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6. Trusts requesting a Full Divert are expected to have implemented internal major incident protocols to manage the situation with clear command and control structures (Gold-Silver-Bronze commands).

7. The decision to implement any type of divert will have been taken following completion of a full (documented) risk assessment.

8. Locally agreed escalation process and triggers are in place and all actions associated with managing capacity pressures have been put into place prior to any requests for divert(s). Acute Trusts must implement actions as early as possible when pressure starts to build in order to try to minimise the need for diverts.

9. All actions on the Escalation Actions Checklist (Annex A) must have been taken, as far as reasonably practicable, before contacting the Ambulance Trust to request a Full/Peripheral Divert or Deflect.

Procedure for requesting a FULL DIVERT

1. The Requesting Acute Trust Director On-Call must contact the Ambulance Gold Commander to investigate receiving hospital options and the most appropriate type of divert to support relief of their situation.

2. The Requesting Acute Director On-Call must confirm the actions in Escalation Checklist (Annex A) are in place; the Ambulance Gold Commander should complete the Checklist at Annex B

3. The Requesting Acute Trust Director On-Call must confirm situation and divert requirements (e.g. by teleconference) from:

Receiving Hospital Director(s) On-Call Ambulance Gold Commander CCG Director On-Call

4. The CCG Director On-Call will record the decision and notify the DCO Team Senior Manager On-Call with the following information:

Requesting Trust(s) Time of decision Divert outcome (Full / Peripheral / Deflect) Reason for divert, duration & review times

Note: Where no agreement can be reached and concerns remain regarding patient safety, the CCG Director On-Call must request the DCO Team Director On-Call join the teleconference to bring guidance/resolution/agreement.

Organisational actions for any divert request:

Ambulance Trust Gold Commander:1. Communicate Ambulance Trust actions in line with local policy.2. Inform neighbouring Ambulance Trusts of Divert details.3. Inform neighbouring Ambulance Trusts if the Divert is changed/lifted.

Requesting Acute Trust Director On-Call:

1. Ensure that contact has been made with the Director On-Call of neighbouring hospitals and confirm their acceptance to receive diverted patients. This includes confirmation that all relevant departments are aware of the Divert e.g. Emergency Departments, Critical Care Units, Medical Admissions Units etc.

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2. Inform the CCG Director On-Call where a Peripheral/Deflect Divert has been agreed including reasons, duration etc

3. Demonstrate a clear and actionable de-escalation plan to return to a situation whereby inbound patients can be taken to the hospital.

4. Regularly review the need for the Divert and inform the Ambulance Gold Commander, receiving Trust Director(s) On-Call and CCG Director On-Call if the Divert needs to be changed/lifted.

Receiving Acute Trust(s) Director On-Call:1. Ensure staff are briefed of the Divert arrangement.2. Ensure sufficient additional resources are provided to support additional patients.3. Maintain close liaison with the Requesting Acute Trust Director On-Call to review impact of the Divert.

CCG Director On-Call:1. Ensure affected CCGs are informed at an appropriate time.2. Facilitate support to affected Trust(s)3. Ensure the DCO Team Senior Manager On-Call is notified of the divert decision including rationale and anticipated duration.4. Ensure the need for the Divert is periodically reviewed5. Ensure the DCO Team Senior Manager On-call is notified when the Divert is lifted6. Ensure the process and impact is reviewed at the end of the Divert

DCO Team Senior Manager On-Call1. Notify the DCO Team Director On-Call of the divert.2. Notify the Regional Senior Manager On-call (for information only)3. Contact neighbouring DCO Team Senior Manager(s) On-Call if the diverts will affect

them.4. Notify the Regional Senior Manager On-Call when the Divert has ended.

CommunicationsIn the event of a Full Divert, a clear communications process is necessary so that the affected health community is aware of the situation, the likely impact and the potential duration of any Emergency Department closures. This will need to be aligned to public information messages to ensure that the patients and the public are aware of the situation. All Requesting & Receiving Acute Trusts and the Ambulance Trust should be involved in communications to the public; the lead Trust will be the Requesting Acute Trust.

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Escalation Checklist

It is recommended that these actions be implemented as early as possible as pressure starts to build, in order to try to minimise the need for a diversion of inbound patients. Actions should be taken, as far as reasonably practicable, before the Requesting Acute Trust contacts the Ambulance Trust to request a divert.

Escalation Activity

Health system actionsThe health system supports triage of GP patients for admission and all alternative pathways are reviewed.Emergency Department bed meetings to include Health & Social Care partners to ensure all actions are understood by the whole health-care system.Acute Trust – managing and reducing demandBefore requesting a full divert – internal business continuity/ critical incident actions should be in placeThere should be senior clinical leadership (i.e., consultant level) immediately available within the Emergency Department (ED)Patients to have initial assessment by registrar or consultant grade, to determine appropriateness of attendance or need for admission/re-direction wherever possible and not life threatening, all admissions to be reviewed and agreed by a consultant.Maximisation of alternative care pathways, prior to arrival of patient at Emergency Department, through telephone triage of all GP referrals for admission, led by consultants (e.g., acute physicians, not necessarily ED consultants – see above) to ensure that admission levels are kept to a minimum, including: Advising on more appropriate care pathways (e.g., community based) for specific

patients or conditions. Enabling access to diagnostics not normally directly available to primary care. Support to GPs who have patients on “care of the dying”, pathways to prevent

unnecessary admissions. Brokering urgent Out Patient Department appointments to avoid unnecessary admissions

to hospital etc.Acute Trust – improving supplyBefore requesting a Full Divert – internal business continuity/ critical incident actions should be in placeAll routine escalation actions should be completed including Inpatients reviewed early in the morning for discharge by consultants before 10am.

“Case conferences” between specialists such as consultants, medical directors, managerial staff etc. to review inpatients and agree appropriateness of continued stay.

Opening of all possible extra escalation capacity, private wards etc.

Cancellation of all clinically non urgent electives (including private work)

Cancellation / redirection of urgent electives / move of work to other NHS trusts / transfer of work to private sector.

Social Services on call managers have been notified of the situation and requested to expedite care packages. Social Services to be in contact several times a day.

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Ambulance full divert checklist

Date/TimeName of Hospital Trust requesting Divert(The “Requesting Hospital”)Name and contact information of person requesting the divert/closure & confirmation that they are a Director from the Requesting Hospital

Escalation Actions Checklistreceived & completed (Y/N)Reason(s) for the requested divert

Estimated duration of the divert (confirm the time up to which the divert will operate)

Detail what departments are effected (e.g. A&E or Maternity)This may include the types of patient/s to be diverted i.e. GP diverts, minor injury/illness, trauma, maternity etc.

Teleconference details Dial-in:Participant Code:

Confirmation that following have been contacted:

Receiving Hospital(s) Director On-Call CCG Director On-Call

For Ambulance Service

Agreement reached with CCG / Area Team Director On-Call Duration of diversion (time up to which the divert will operate) Confirmed communication system with requesting trust & schedule of updates

Neighbouring Ambulance Services notified (if applicable)

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Patient Handover Delays Version 4.12 Issued 29th November 2017

Background

Patients arriving via ambulance to an Acute Trust A&E are required to be handed over into the care of Acute Trust Clinicians within 15 minutes of arrival. This is a maximum handover time placed on Ambulance and Acute Trusts to ensure patient safety and quality of care, and is expected to be achieved on all occasions.

It is the responsibility of the Acute Trust to ensure clinical handover takes place within 15 minutes of each patient arriving.

Additionally, the Ambulance Trust must ensure their crews are ready to respond to their next call within a further 15 minutes (i.e. a total maximum turnaround time of 30 minutes). Again, this is a maximum expected time to help ensure all patients receive clinically safe and appropriate care.

It is the responsibility of the Ambulance Trust to ensure crews and resources are available to respond to calls within the overall turnaround time.

It is recognised that there will be occasions when clinical handover and turnaround cannot be completed within the contracted times, however, all Trusts must work together to minimise delays and prevent them reaching clinically unsafe levels.

Four Key Principles of Handover

The patients in the urgent care pathway who are at highest risk of preventable harm are those for whom a high priority 999 emergency call has been received, but no ambulance resource is available for dispatch.

Acute Trusts must always accept handover of patients within 15 minutes of an ambulance arriving at the ED or other urgent admission facility (e.g. medical/surgical assessment units, ambulatory care etc.).

Leaving patients waiting in ambulances or in a corridor supervised by ambulance personnel is inappropriate.

The patient is the responsibility of the ED from the moment that the ambulance arrives outside the ED department, regardless of the exact location of the patient.

A. Actions to be taken now, and embedded as part of normal working practice to reduce the likelihood of delays

To reduce the likelihood and impact of ambulance handover delays, Local A&E Delivery Boards should ensure that:

1. Acute trusts and ambulance trusts must appoint a senior lead accountable to the A&E Delivery Board to oversee the development and implementation of clinical handover protocols for acute departments.

2. Must avoid the use of ambulance trolleys and ambulance staff to queue patients in a corridor or other areas of the ED or Admissions Unit, including Ambulance Triage areas where these are used. Patients should be transferred to a hospital trolley on arrival and hospital staff allocated to provide safe care to these patients.

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3. Must avoid the use of ambulance trolleys for patients who are ‘fit to sit’, and should move them to a chair if appropriate. This can expedite investigations and facilitates discharge assessments. Such an approach assists greatly the use of ambulatory care pathways and reduces the demand on trolley/cubicle spaces. Hospital staff including handover staff, and ambulance staff should be made aware of the fit to sit guidance and a clinical champion appointed to see that this is being implemented. 4. Must book patients onto the Hospital PAS or ED PAS system when the patient first arrives in the department. 5. Must ensure that handover standards are applied consistently where patients are transferred directly to admissions units and other clinical departments. 6. Must have an agreed protocol for the timely escalation of handover delays with established warning and trigger responses. This should include a clear policy to manage waiting ambulances safely with regular risk assessments and required actions in order to deliver a safe waiting environment for patients. 7. At no time should a patient be kept in an Ambulance outside a hospital.

Commissioners 8. Must facilitate ambulance services and acute hospitals working together and with partner organisations at STP level to agree effective escalation procedures and interventions for periods of high demand, and agree trigger and response mechanisms. HAS screen information may be a useful source for local monitoring and escalation. 9. Should ensure that they fully understand where high demand increases are being generated from, and take appropriate action to assist in reducing demand growth, for example high 111 referral rates to 999, high volume frequent users and other sources of demand resulting from alternative access to services. 10. Must ensure ambulance services have in place regional capacity management systems to be enacted when queues develop. These should provide information to hospitals and ambulances services to know capacity in real-time and include processes for diverting patients at times of significant pressure. This allows clinicians and managers to make better informed decisions about patient care and use of alternative care pathways. 11. Should improve general practice input to care homes to reduce unnecessary conveyance and implement care home navigators as a matter of urgency. These should be provided 24/7 or over extended hours wherever possible. 12. Must ensure that there are a wide range of referral options within the community that 999 and the Clinical Assessment Service (CAS) supporting NHS 111 can use as an alternative to the ED. This could include frailty services, ambulatory emergency care services, falls services and urgent treatment services. These should be provided 24/7 or over extended hours wherever possible.

GP Practices 13. Must ensure prompt telephone access for ambulance crews to make contact with a patient’s own GP surgery before deciding whether to convey, as access to advance care and end-of-life plans, advice or urgent GP review may avoid the need for conveyance and hospital attendance/admission or enable direct referral to the medical or surgical take teams. 14. Should take measures to avoid referred patients arriving in surges as a result of all domiciliary visits, and thus conveyance requests, taking place after morning surgeries. This severely inhibits the ability of ambulance services to convey these patients in a timely manner and practices should have plans in place to run visits throughout the morning, as opposed to batching them. 15. CCGs and GPs should work together with the CCG being responsible for overseeing the daily schedule of GP visits from all surgeries to ensure that large numbers of Ambulances do not arrive together.

Community Services 16. Should have rapid response teams to see patients in their own homes. Best practice is for teams to reach patients within 60 minutes of a request, and never longer than two hours.

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Ambulance Services 17. Should implement electronic patient handovers. These must be available to ED staff within 15 minutes of arrival. 18. Must share predicted activity levels with Acute Trusts on an hourly and daily basis to trigger effective escalation when demand increases. 19. Must put in place measures to enable safe reduction of conveyance to the ED, as set out in the 2017-19 CQUIN.

B. Actions to be taken when ambulances are predicted to queue or are queuing

Ambulance Trusts 1. Should escalate all handovers exceeding one hour to the on-call executive director of the responsible acute hospital trust and CCG director on-call. 2. Should consider the range of vehicles in their fleet to convey patients to the emergency department, but only where it is safe and appropriate to do so. 3. Reassess clinically appropriate alternative options to emergency department transfer.

Acute Trusts 4. Must enact a handover escalation protocol where time to handover is exceeding 30 mins. This should include contacting the on-call Hospital Director so that immediate action can be taken to release ambulance resources. Where time to handover is exceeding 60 minutes, the on-call CCG Director and on-call NHSE Director must be contacted and those individuals should put in place whole system local escalation processes to release ambulance resources. Over winter the regional winter on-call Director should also be informed 24/7. 5. Must not place restrictions on ambulances in order to limit or regulate access to the emergency department or the handover of patients arriving by ambulance. 6. Should report ambulance handover delays at site-wide bed meetings in order to ensure that there is a whole system response when required. 7. Must ensure that all patients handed over from the ambulance service are managed in a clinical setting that reflects their acuity as assessed by prompt triage. This action is often referred to as ‘cohorting’. Cohorting should occur after assessment to ensure departments are fully aware of the acuity and needs of each patient and any attendant risks.

a. Areas used for cohorting must have appropriate equipment and facilities to maintain patients’ privacy, dignity and safety at all times. b. All cohorted patients must receive regular review and be subject to an ED safety checklist. c. Escalation plans should include how the extra nursing staff required for any cohort area will be met. Ambulance staff (or managers) must not be used to look after cohorted patients.

8. Must put in place a clear process for reporting significant clinical concerns by staff and carers. 9. Must ensure that where normal processes are delayed the effects of such delays are mitigated by pre-emptive interventions (where appropriate) and investigations such as blood tests, ECGs, X-rays and CT scanning. 10. Must raise an SI for all incidents where a handover greater than 60 minutes has occurred.

Emergency Department staff11. Should assess the ‘pre-alert’ information provided by paramedics regarding acute severe injury or illness patients so they can anticipate resource utilisation. 12. Should undertake regular reviews whenever at or near full capacity. A serious handover problem is sufficient reason for escalation of the issue to senior managers and executive officers.

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13. Ensure prompt referral for in-patient care as soon as it becomes clear that admission will be necessary.

Reporting Flow Chart

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Ambulance NARU REAP plan

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East and North Hertfordshire CCG Daily System Teleconference Standard Operating Procedure – October 2017

Introduction

The East & North Hertfordshire system will hold a teleconference call on a daily basis at 10am including weekends with health and social care partners. It is the expectation that system partners will escalate during weekends if a CCG presence is required when the acute trust is OPEL 3 or 4.

The principles of the teleconference are;

To identify the current pressures faced in the system. Facilitate patient flow/movement through the system. Facilitate the discharge of medically optimised patients as defined by ENHT “con call

list”. Facilitate provider to provider resolution of issues. Patient identifiable information should not be used during the teleconference.

Outcomes agreed during this call will be actioned in accordance with timeframes in line with the systems alert status (as below). If the system alert status is OPEL 3 or above, it is the expectation that at least one further call will be undertaken that day if appropriate. If the system status is at OPEL 4, partners will be expected to support additional calls throughout the day, as the situation dictates. Additionally if OPEL 4, it will be the expectation that a second daily dashboard is completed.

Status Response time allowed (7 days a week)OPEL 1 12 hoursOPEL 2 8 hours ( same day response)OPEL 3 3 hoursOPEL 4 2 hours

Significant /Major Incident

Immediate

Membership

The teleconference is attended by representatives from (seniority will depend on organisational escalation status):-

ENHCCG Integrated Discharge Team (IDT) WSCC or Trust Senior Manager (Operations Site Manager) HCT representatives Continuing Health Care HPFT representatives

At times of OPEL 4 escalation representatives from the 111 Out of Hours Provider and the ambulance service may also be required to attend. Senior representation will be required for an alert status of OPEL 3 or above.

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Status OPEL 1/2

When the acute trust is reporting an OPEL 1 or 2 organisational status, it has been agreed that senior members of the CCG management team are not expected to attend the conference call. In this instance the IDT will assume the responsibilities of the chair. However the duty manager from the CCG will attend for escalation purposes (weekdays).

Status OPEL 3/4

When the acute trust is reporting an OPEL 3 or 4 status a member of the CCG senior management team will attend the conference call and assume the role of chair. It is also expected that upon a declaration of an OPEL 3 or 4 organisational status following the 10am call, senior management of all system partners will be required to be represented on all subsequent calls that day. At weekends the ENHCCG director on-call will chair the conference calls.

Whole System Co-ordination Centre (WSCC)

The WSCC has been established within the ENHT footprint to retain oversight of patient flow through the system. Providers are required to submit demand and capacity information and their organisational status into the WSCC (via SharePoint) at regular intervals throughout each day. This information is available for system partners to utilise via the WSCC email account:

Website: www.nhs.net User name: [email protected] Password: Operation6 (subject to change)

Representatives can retrieve the required information for the conference call from the above email address.

East & North Herts System Call information

The call will take place daily at 10am.

The dial in details to join the call are:

Telephone No: 0808 109 0617 Chair PIN: 6721539# Participant PIN: 3303080#

(Details of the PAH teleconferences can be found in appendix A)

The Conference Call (see glossary for definitions)

Pre Call

• ENHT IDT will circulate the days “con call list” for discussion before 9.15 am 7 days a week. This list will include patients who are expected to be MDT fit within 72 hours or their EDD is within 5 days.

• The conference call list will also incorporate stranded patients over 6 days who are medically optimised and actions needed for discharge.

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Criteria of patients for the T/Con

In order to record submitted assessment notifications from wards, the IDT will review the daily spreadsheet in advance of the call. All patients with an assessment and discharge notification and those on the stranded patient list with an EDD of 5 days should be added to the list for discussion on the t/con. These patients will be classified as medically optimised for discharge.

The Call

• Daily at 10am including weekends.• When the acute trust is at OPEL 3 or above an additional call will happen at 1pm. • ENHT IDT will Chair this call when acute trust status is OPEL 1 or 2.• ENHCCG will Chair this call when acute trust status is OPEL 3 or 4.• Senior management representation is required on the conference call for an

organisational status declaration of OPEL 3 or above.• It is recognised that a declaration of OPEL 3 or above may be declared following the

10am conference call. In this circumstance senior management representation from all partners is required on any subsequent calls

• Executive level representation is required following a declaration of OPEL 4.

Call Process

• ENHT WSCC will provide an update on their position since midnight by 9.45am daily into the WSCC generic email account. If the trust is OPEL 3 or above a representative from the WSCC will attend the call and give updates or update the Senior Manager /Executive appropriately who will attend the call.

• System partners will confirm their current organisations status level.• System status level will be agreed after the call and circulated on the daily dashboard.• HCT Bed Bureau will provide an update on current community capacity available.• Partners will then discuss and agree plans/EDDs for patients included on the IDT’s “con

call list” and next actions• It has been agreed that patients on the mental health (RAID) list will usually be

discussed first, followed by Continuing Health Care (CHC), Intermediate Care (ICT ) and then IDT.

• Patients discussed will include patients currently in the emergency department, assessment areas and CDU who may or may not be admitted.

• Any requirement for further calls throughout the day will be agreed on the call.

Next Action for Discharge

The T/con list will have a next action for discharge section. This section should be updated with information highlighting agreed actions and the responsible person. All agreed next actions for discharge must be given priority, for any subsequent calls that day. Any action that has not been progressed after 24 hours should be escalated.

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Post Call

• An updated “con call list” will be circulated following the call by the IDT within 1 hour of the call. Unless there is a 1pm call in which case an updated list will be circulated by midday.

• Following the call a list of confirmed and potential discharges will be circulated within 30 minutes to the WSCC, discharge lounge and transport office. This will facilitate the site team with real time information that will influence capacity and demand, and the discharge lounge team to support with flow by “pulling” the agreed patients to the discharge lounge.

• IDT specialist roles will be responsible for linking in with partners to ensure outstanding actions are completed and discharges facilitated. Outstanding actions should be escalated by 3.30pm if any discharges are likely to fail.

• The daily system dashboard will circulated by the CCG following the call. • Providers to liaise with IDT throughout the day to update as necessary and request

support where needed.• IDT will ensure all new referrals are added to the list throughout the day and circulated.• WSCC will collate actual discharges achieved that day alongside IDT.

Example agenda for the call

1. Introduction – ensure all representatives present 2. Acute trust update since midnight3. Provider update – status, capacity available and any exceptions to report4. Agreement of system escalation level (in line with the system escalation, surge and

capacity plan).5. Discussion of anonymised patient list (con call list). 6. Agreement of further call if needed.

ENHCCG Duty Manager Role

To be first point of contact Monday to Friday between 9am and 5pm for senior management support or advice.

To manage system capacity and escalation issues with support from the operations team.

To participate in the System Resilience Teleconferences throughout the day. The Duty Manager should escalate to the Operations team or Director on call as

appropriate The Director on call should be notified if the Acute Trust alert status is OPEL 3 and

invited to join the call if the alert status is OPEL 4. The expectation is for stakeholders to respond to actions in accordance with the current

ENHCCG Surge, Escalation and Capacity Framework version 21. The Duty Manager should brief the oncoming Director on Call of the day’s activity and

events.

Out of Area Medically Optimised Patients

Although it is recognised that these patients will not be discussed on the daily T/con, it is important to ensure all these patients are captured to provide an accurate reporting system for the number of medically optimised patients ready for discharge.

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ENHCCG Out of Area Delay process

At ENHCCG we have individuals identified to manage day to day escalation issues for our neighbouring hospitals across the region; this includes delayed transfers of care.

Nominated representatives are as follows:

Commissioner ENHCCG

Addenbrookes Hospital [email protected] 07552 289508

Bedford Hospital [email protected] 07881 620508

Luton & Dunstable Hospital Joanne.O'[email protected] 07919 304763

Princess Alexandra Hospital [email protected] 07765 576571

Royal Free (Barnet & Chase) [email protected] 07552 289430

Watford Hospital [email protected] 07552 289508

The following principles should be followed when seeking support to manage a delay:

CCG’s are not in a position to handle or respond to patient identifiable information. Initial escalation should be handled provider to provider via first line operational

colleagues. Should there be no response or reasonable update, escalation to senior managers may

be appropriate s outlined below:

Local Authority/IDT

Addenbrookes Hospital [email protected]@hertfordshire.gov.uk

07812 32455607812 324459

Bedford Hospital [email protected] 07812 322929

Luton & Dunstable Hospital [email protected] 07812 322929

Princess Alexandra Hospital

[email protected]@hertfordshire.gov.uk

07812 32421207812 324459

Royal Free (Barnet & Chase)

[email protected]@hertfordshire.gov.uk

07812 32294207812 322718

Watford Hospital [email protected]@whht.nhs.uk

07580 74358407880 053416

As a last resort, escalation should be made to the CCG. Escalation to the duty director on 0330 1241725 should only be action in exceptional

circumstances.

ENHCCG expects (as a minimum) that monthly reports of delays will be shared from neighbouring trusts.

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mailto:[email protected]















Appendix A

West Essex System Call Information

The West Essex teleconference is at 2pm daily. PAH will circulate a list of delayed patients for discussion prior to the call. Additional conference calls will be convened as required, particularly over the winter period.

The details to join the call are:-

Telephone No: 0800 032 8069 Participant PIN: 90701847 #

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Appendix B

Patient focussed conference calls

On occasions where a patient has complex needs which may require focussed planning, a separate conference call will be convened with relevant partners to discuss particular individual patient’s needs. These will be coordinated and hosted via the IDT and any further follow up calls will be agreed at this time. Attendance will be expected from all partners involved in discharge planning.

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Appendix C

Stranded Patient reviews/LOS (patients in an acute setting over 6 days)

There are twice weekly reviews of all patients over 6 days across all medical wards. Every Tuesday afternoon at 1.30 there is a walk round of all medical wards, starting on Barley reviewing all patients whose length of stay is over 6 days. The walk round will be attended by a consultant, therapy lead and a representative from IDT. A list of all medically optimised patients is collated following the walk round and circulated Tuesday afternoon, ready to be added to conference call list on a Wednesday morning.

On a Thursday at 2pm at the WSCC site office a review meeting is held to discuss all patients who are medically optimised from the stranded patient list, monitor progression and facilitate discharge.

Surgery wards will be following similar processes in the near future.

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Appendix D

Conference call colour codes

The IDT will advise which colour coded patients require discussion on the daily t/con.

DTOC for A&E

reporting

on more than one

list EoLAwait Referral MEDICAL LoS

HVCCG

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Appendix E

DTOC sign off

The final DTOC position is signed off via the IDT nursing and social care team every Friday. Sign off is submitted by Monday lunchtime for Head of IDT sign off before being sent to information for submission onto Unify.

The monthly DTOC submission is agreed within 10 days of the end of the month and sent to Head of IDT to sign off and return to information within 14 days of the end of the month so that reports can be submitted to unify by week 3.

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T/con Glossary

1:1 One to one careA&E Accident & Emergency (see also ED)AAU Acute Admissions UnitAMU Acute Medical UnitAssessment notification Advanced notification of social care needAx Assessment/AssessBB Bed BureauBDS POC 2 times a day package of careBrokerage Negotiating a bed for the right priceCapacity (patient) Ability of patient to make an informed decisionCCU Critical Care UnitCDU Clinical Decision UnitCHC Continuing Health CareCHC checklist A list of questions to determine if the patient is eligible for CHC

assessmentClinical Navigator Community role in ED to facilitate discharge (sometimes known

as CARS)D&V Diarrhoea and Vomiting (see also Norovirus)D2A Discharge to AssessDirect Payments Patients manage their own budget independentlyDischarge notification Formal notification of social care need (ready to be discharged)DNM Did not meetDomains Assessment against the national requirements for CHC

framework (see CHC checklist)DST Decision Support ToolDTA Decision To AdmitDTOC Delayed Transfer of CareDx DischargeED Emergency Department (see also A&E)EDD Estimated date of dischargeEnablement bed Lowest level of need - typically assistance of 1 carer to transferEscalation beds Additional capacity in times of surgeFast Track Urgent request for CHC funding for palliative/end of life patientsFlex bed Providers can flex the criteria required to access these beds on a

case by case basisFNC Funding Nursing CareHALO Hospital Ambulance Liaison OfficerHCS Hertfordshire Community Services (Social care)Home finder HCS function to source nursing and residential placements

Home First HomeFirst is a new rapid response service which helps people stay well and independent

ICT Integrated/Intermediate Care TeamIDT Integrated Discharge TeamIMCA Independent Mental Capacity ActLD Learning DisabilitiesMDT Fit A patient who having been declared medically optimised no

longer requires input from support services to facilitate discharge ie. therapy

Medical Not fit for discharge

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Medically Optimised A patient in the acute hospital who no longer requires medical input

MFFD Medically fit for DischargeMicro Living Adjustment to home environment to support downstairs/one room

living

Neuro Requires specialist neurological rehab following brain or spinal injury

NH Nursing Home#NOF Fractured Neck of Femur (fractured hip)NOK Next of Kin

Norovirus Winter Vomiting Bug, most common stomach infection in the UK (see also D&V)

NWBNon-weight bearing bed. Patients are unable to bear weight and would need a higher level of input to perform basic tasks such as transfer from bed to chair. Typically 2 carer’s to 1 patient

PCP Preferred Choice PolicyPOA Prevention of Admission bedPOC Package of carePrivate Placement Privately funded and sourcedQDS double up POC 4 times a day package of care with 2 carers requiredQDS POC 4 times a day package of careRAID Rapid Assessment Investigation and Discharge (Mental Health)RH Residential HomeSAU Surgical Assessment UnitSC@H Specialist Care at HomeSection 2 Advanced notification of social care needSection 5 Formal notification of social care need (ready to be discharged)Self-funder Patient funding own careSST Service Solution TeamSSU Short Stay UnitStep-down bed Reducing input into patient care, discharged from acute careStranded Patient In this instance it is any patient whose stay is over 6 days in the

acute hospital once they have been declared medically optimised.

TCI To come inTDS POC 3 times a day package of careTrusted Assessor Single assessment process on behalf of nursing or residential

homesTTOs To Take Out (medication)TWOC Trial without catheterWLO Ward Liaison OfficerWSCC Whole System Co-ordination Centre

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