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Canberra Hospital and Health ServicesOperational ProcedureCapacity Escalation ProcedureContents

Contents....................................................................................................................................1

Purpose.....................................................................................................................................2

Scope........................................................................................................................................ 2

Section 1 – Capacity Escalation - Business Hours (0800-1700hrs)............................................2

Section 2 – Capacity Escalation - After Hours (1700-0800hrs), weekends and public holidays.2

Section 3 – Surge Beds..............................................................................................................3

Section 4 – Department of Neonatology...................................................................................3

Implementation........................................................................................................................ 3

Related Policies, Procedures, Guidelines and Legislation.........................................................4

References................................................................................................................................ 4

Search Terms............................................................................................................................ 4

Attachments..............................................................................................................................4

Attachment 1 - Canberra Hospital Capacity Escalation Procedure During Business Hours (0800-1700hrs)......................................................................................................................6

Attachment 2 - Canberra Hospital Capacity Escalation Procedure between 1700-0800 hours weekdays, weekends and public holidays.................................................................11

Attachment 3 - Canberra Hospital Capacity Escalation Procedure Neonatology................18

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Purpose

Canberra Hospital and Health Services provides Tertiary level care and hospital services to Canberra and its surrounding region. To ensure that the most appropriate care is provided a whole of hospital approach is required to address times where capacity exceeds available access to service.

This procedure sets out the Canberra Hospital and Health Services (CHHS) overarching approach to identifying and responding to Canberra Hospital capacity during high demand situations or where capacity exceeds available service access.

The aim of this procedure is to ensure hospital capacity concerns will be managed effectively and efficiently.

Scope

This procedure applies to all inpatient areas of the Canberra Hospital campus excluding Birthing and the Birth Centre. It outlines the processes that staff are required to follow when the hospital is experiencing high demand or where capacity exceeds available access to services.

Section 1 – Capacity Escalation - Business Hours (0800-1700hrs)

This procedure is to be applied during business hours (0800-1700hrs, Monday to Friday, see Attachment 1) and requires mandatory compliance.

This procedure outlines three Alert Levels: ALERT Level 1 – beds available for new admissions and patient flow being achieved ALERT Level 2 – Limited availability of beds, patient flow is compromised ALERT Level 3 – bed availability critical despite use of surge beds, services disrupted

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Section 2 – Capacity Escalation - After Hours (1700-0800hrs), weekends and public holidays

This procedure is to be applied between 1700-0800 hours weekdays, weekends and public holidays (see Attachment 2) and requires mandatory compliance.

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This procedure outlines three Alert Levels: ALERT Level 1 – beds available for new admissions and patient flow being achieved ALERT Level 2 – Limited availability of beds, patient flow is compromised ALERT Level 3 – bed availability critical despite use of surge beds, services disrupted

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Section 3 – Surge Beds

Surge Beds are additional hospital capacity beds that are not staffed or operational. Surge beds are a way of responding to peaks in demand and can be activated at short notice, with additional staff. The Chief of Clinical Operations, Executive On call or their delegates have authority to open these beds when required.

Short term activation can occur when the hospital is at Capacity Alert Level 2 in the procedure. As soon as the hospital returns to accept capacity, the surge beds should be deactivated. Longer term activation can occur during periods of known or predicted increase in activity i.e. during winter.

Opening of surge beds will be done in consultation with the ADON Patient Flow, Patient Flow Manager, Divisional ADON’s and After Hours Hospital Manager. Staffing for these beds will be through the After Hours Hospital Manager.

Opening of surge beds will be discussed and monitored at Bed Management meetings.

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Section 4 – Department of Neonatology

Where capacity exceeds available access to service in the Department of Neonatology please see Attachment 3.

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Implementation

Implementation of this procedure will include: Chief of Clinical Operations present the procedure at Executive Directors meeting Director of Medical Services discuss procedure at Clinical Directors meeting Present procedure at senior nursing forums Present at Directors of Allied Health meeting Incorporate procedure as part of daily Bed Management meeting

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Related Policies, Procedures, Guidelines and Legislation

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Procedures Inter-hospital Transfer: Non Critical Patients Admission Discharge – Adults, Pregnant Women and Neonates Emergency Department Admission to Ward Discharge Summary Completion SOP Clinical Record Documentation SOP

Legislation Health Records (Privacy and Access) Act 1997 Health Act 1993 Human Rights Act 2004 Mental Health Act 2015

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References

Auckland District Health Board (undated) Hospital Full – Alert Cascade, Manual Auckland City Hospital

John Hunter complex: hospital bed Alert / escalation plan

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Search Terms

Escalation, Capacity management, Demand management, Patient Flow, Bed availability, Access Block, Bed Block, Patient Flow Unit, Access Unit, Surge beds, Neonatology

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Attachments

Attachment 1 - Canberra Hospital Capacity Escalation Procedure In hoursAttachment 2 - Canberra Hospital Capacity Escalation Procedure After HoursAttachment 3 – Canberra Hospital Capacity Escalation Procedure Neonatology

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Disclaimer: This document has been developed by ACT Health, Division of Medicine / Coronary Care Unit specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.

Date Amended Section Amended Approved By24 January 2018 Neonatal Information Added CHHS Policy Committee, ED Crit

Care and ED WY&C

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Attachment 1 - Canberra Hospital Capacity Escalation Procedure During Business Hours (0800-1700hrs)

Alert Trigger Response

Capa

city

Ale

rt L

EVEL

1

Two or more of the following: Hospital 90-94% occupancy across all

divisions 5 or below bed booked patients in the ED ICU at capacity (funded beds)

Patient Flow Unit Chief of Clinical Operations(CoCO) sends text message to divisional EDs re capacity issues &

number of discharges required as a priority across all divisions Patient Flow Manager (PFM)Prioritises patient discharges with divisional ADONsExecutive Directors Inform Clinical Directors of capacity issuesMedical Leaders Clinical Directors to notify specialty teams to conduct a round as soon as possible & review

EDDsICU ICU ADON to contact Calvary Hospital ICU NUM to discuss capacity issues & patients

appropriate for transfer ICU ADON to notify ADON PF & stand up meeting convened with ICU Director/Medical

Leads/Surgical DONMental Health Services Patient Flow Coordinator contacts other service providers such as Hyson Green, 2N, Brian

Hennessy and Older Persons Mental Health Unit to discuss patients appropriate for transfer Utilise Discharge Lounge to facilitate timely dischargeWard areas Discharge 1 patient within 2 hours Utilise Discharge Lounge to facilitate timely dischargesSupport services Pathology to process collections marked “Discharge Priority” without delay Pharmacy to process discharge medications marked “Discharge Priority” without delay Wardspersons supervisor notified via page of capacity issue Radiology notified of capacity issue & redistribute resources to meet hospital demand

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Capa

city

Ale

rt L

EVEL

2Two or more of the following: Hospital 95-99% occupancy across all

divisions Between 6 or 10 bed booked patients in

the ED ED Resuscitation room full ICU over capacity (funded beds) Isolation beds unavailable Ambulance offloads in ED corridor

Patient Flow Unit Chief of Clinical Operations sends text message to EDs, CDs, Directors of Allied Health (DAHs),

Operational Director of Adult Acute Mental Health Services & DONs re capacity issues & number of discharges required as a priority from those divisions

Prioritises patient discharges with divisional ADONs ADON PF escalates patient transfers to outlying hospitals where transfer delays have occurred ADON PF activates message to be sent via pager “Capacity Alert LEVEL 2” to all registrars &

RMOs for immediate review of EDDs for next 24 hours & risk stratification for early discharge ADON PF activates message to be sent via pager “Capacity Alert LEVEL 2” to Allied Health –

prioritise patients flagged for D/C, redistribute resources to meet demand D/C patients to other hospitals including private as appropriate Cohort patients as appropriate Surge beds used as approved by Director of Operations or delegate PFM/ADON PF reassess situation hourly and communicate de-escalation or escalation Decision to review the continuation of surgeryMedical Leaders Clinical Directors to notify specialty teams to review EDDs for further potential discharges and

expedite dischargesICU ICU ADON to contact Calvary Hospital ICU NUM to discuss capacity issues & patients

appropriate for transfer ICU ADON to notify ADON PF & stand up meeting convened with ICU Director/Medical Leads Notification to CRRS consultant to re-direct retrievals where clinically appropriateMental Health Services Patient Flow Coordinator contacts other service providers such as Hyson Green, 2N, Brian

Hennessy and Older Persons Mental Health Unit to discuss patients appropriate for transfer Patient Flow Coordinator informs Allied Health clinicians in Acute Mental Health Unit of

Capacity Alert Level 2 & prioritise patients flagged for D/C, redistribute resources to meet demand

Utilise Discharge Lounge to facilitate timely discharge

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Ward areas Utilise Discharge Lounge to facilitate timely discharges Discharge 1 patient within 2 hours Ward CNCs contacted by their ADON advising of capacity issue & request that CNCs identify

further potential discharges. CNC to contact treating teams to inform them of patients potentially suitable for D/C

Identify patients appropriate for D/C to other hospitals (private and NSW)Support services Allied Health notified via page to prioritise patients flagged for D/C, redistribute resources to

meet demand Pathology to process collections marked “Discharge Priority” without delay Pharmacy to process discharge medications marked “Discharge Priority” without delay Wardspersons supervisor notified via page of capacity issue Radiology notified of capacity issue & redistribute resources to meet hospital demand Cleaners notified of capacity issue & to prioritise terminal cleans, redistribute resources to

meet hospital demand

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Capa

city

Ale

rt L

EVEL

3Two or more of the following: Hospital ≥ 100% occupancy More than 11 bed booked patients in ED All surge beds open Unable to decant resuscitation room Unable to admit patients from other

hospitals Isolation beds unavailable & cohorting

unable to be implemented ICU over capacity (funded beds) Considering cancellation of surgery

Patient Flow Unit Chief of Clinical Operations sends text message to divisional EDs, CDs, Directors of Allied

Health (DAHs), Operational Director of Adult Acute Mental Health Services & DONs re capacity issues & number of discharges required as a priority across all divisions.

Chief of Clinical Operations sends text message 2 hours later to targeted EDs, CDs and DONs re capacity issues & number of discharged required

D/C patients to other hospitals including private as appropriate ADON PF activates message sent via pager “Capacity Alert LEVEL 3” to all registrars & RMOs

for immediate review of EDDs for next 24 hours & risk stratification for early discharge ADON PF activates message to be sent via pager “Capacity Alert LEVEL 3” to Allied Health –

prioritise patients flagged for D/C, redistribute resources to meet demandExecutive Chief of Clinical Operations holds an Escalation Meeting with Executive staff (EDs, CDs, DAHs,

Manager of Medical Imaging, Operational Director of Adult Acute Mental Health Services & DONs) to develop short term strategies to reach target of <95% capacity within 4 hours

Decision to review the continuation of surgery Cancel non-urgent meetings to enable executive teams to facilitate flow and hospital demandMedical Leaders Clinical Directors to notify specialty teams to review EDDs for further potential discharges and

expedite discharges Treating teams conduct ward rounds as a priorityICU ICU ADON to contact Calvary Hospital ICU NUM to discuss capacity issues & patients

appropriate for transfer ICU ADON to notify ADON PF& stand up meeting convened with ICU Director/Medical Leads Notification to CRRS consultant to re-direct retrievals where clinically appropriate

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Mental Health Services Patient Flow Coordinator contacts other service providers such as Hyson Green, 2N, Brian

Hennessy and Older Persons Mental Health Unit to discuss patients appropriate for transfer Patient Flow Coordinator informs Allied Health clinicians in Acute Mental Health Unit of

Hospital Capacity Alert LEVEL 3 & prioritise patients flagged for D/C, redistribute resources to meet demand

Utilise Discharge Lounge to facilitate timely dischargeWard areas Discharge 2 patients within 1.5 hours Ward CNCs contacted by their ADON advising of capacity issue & request that CNCs identify

further potential discharges. CNC to contact treating teams to inform them of patients potentially suitable for D/C

Identify patients appropriate for D/C to other hospitals (private and NSW) Clinical staff in non-clinical roles redirected to assist with staffing surge beds Utilise Discharge Lounge to facilitate timely discharges Increase PTV availability to increase transfers out of hospital subject to availabilitySupport services Allied Health notified via page to prioritise patients flagged for D/C, redistribute resources to

meet demand Pathology to process collections marked “Discharge Priority” without delay Pharmacy to process discharge medications marked “Discharge Priority” without delay Wardspersons supervisor notified via page of capacity issue Radiology notified of capacity issue & redistribute resources to meet hospital demand as a

priority Cleaners notified of capacity issue & redistribute resources to meet hospital demand as a

priority Discharge Lounge operational hours extended to 7pm to facilitate more discharges

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Attachment 2 - Canberra Hospital Capacity Escalation Procedure between 1700-0800 hours weekdays, weekends and public holidaysAlert Trigger Response

1700-0800

Capa

city

Ale

rt L

EVEL

1Two or more of the following: Hospital 90-94%

occupancy across all divisions

5 or below bed booked patients in the ED

ICU at capacity (funded beds)

EMU backing up – EMU full & 2 or more EMU bed booked patients awaiting admission

Patient Flow Manager/ After Hours CNC / After Hours Clinical Manager & After Hours Hospital Manager PFM & AH CNC/AHCM prioritise patient discharges with ward Team Leaders and After Hours Hospital Manager After Hours Hospital Manager informs Surgical Registrar, Admitting Registrar for Medicine (ARM) & Paediatric Reg of

capacity issues AH CNC works with the ARM and Surgical Reg and AH CM works with the Paediatric Reg to assist patient flow.Medical Leaders ARM, Surgical, Psych & Paediatric Reg’s in conjunction with JMO’s review EDDs for further potential discharges before 8pmCritical Care ICU Consultant to contact Calvary Hospital ICU Consultant to discuss capacity issues & patients appropriate for transferWard areas Ward Team Leaders review EDDs and prepare at least one patient with an EDD for the following day for discharge by 9amSupport services Pathology to process collections marked “Discharge Priority” without delay Pharmacy to process discharge medications marked “Discharge Priority” without delay Radiology notified of capacity issue & redistribute resources to meet hospital demand Wardspersons supervisor notified via page of capacity issue

Weekends & Public Holidays 0800-1700Patient Flow Manager/ After Hours Hospital Manager PFM prioritises patient discharges with ward Team Leaders and After Hours Hospital Manager After Hours Hospital Manager informs Surgical Registrar, ARM and Paediatric Reg of capacity issuesMedical Leaders Medical staff to conduct a round as soon as possible & review EDDs for further potential discharges and expedite dischargesCritical Care ICU Consultant to contact Calvary Hospital ICU Consultant to discuss capacity issues & patients appropriate for transfer

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Ward areas Discharge 1 patient within 2 hoursSupport services Pathology to process collections marked “Discharge Priority” without delay Pharmacy to process discharge medications marked “Discharge Priority” without delayRadiology notified of capacity issue & redistribute resources to meet hospital demand

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Alert Trigger 1700-0800Ca

paci

ty A

lert

LEV

EL 2

Two or more of the following: Hospital 95-99%

occupancy across all divisions

Between 6 or 10 bed booked patients in the ED

ED Resuscitation room full ICU over capacity (funded

beds) Isolation beds unavailable Ambulance offloads in ED

corridor

Patient Flow Manager/ After Hours CNC / After Hours Clinical Manager & After Hours Hospital Manager PFM & AHCNC/AHCM prioritise patient discharges with ward Team Leaders and After Hours Hospital Manager AH CNC works with the ARM and Surgical Reg and AH CM works with the Paediatric Reg to assist patient flow After Hours Hospital Manager informs Surgical, ARM and Paediatric Reg’s of capacity issues & need to expedite discharges After Hours Hospital Manager contacts Exec-Oncall +/- MH Exec On-Call to notify them of hospital status D/C patients to other hospitals including private as appropriate Cohort patients as appropriate Surge beds used as approved by Exec On-call or delegate AH CNC/CMC reassess situation hourly and communicate de-escalation or escalation to After Hours Hospital ManagerMedical Leaders ARM, Surgical, Psych and Paediatric Reg’s inform JMOs of capacity issues & request review of EDDs for further potential

discharges before 8pm ARM, Surgical, Psych and Paediatric Reg’s consider risk stratification for patients identified for early discharge (before EDD)Critical Care ICU Consultant to contact Calvary Hospital ICU Consultant to discuss capacity issues & patients appropriate for transferWard areas Ward Team Leaders review EDDs and prepare at least one patient with an EDD for the following day for discharge by 9amSupport services Pathology to process collections marked “Discharge Priority” without delay Pharmacy to process discharge medications marked “Discharge Priority” without delay Radiology notified of capacity issue & redistribute resources to meet hospital demand Cleaners notified of capacity issue & to prioritise terminal cleans, redistribute resources to meet hospital demand Wardspersons supervisor notified via page of capacity issue

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Alert Trigger Weekends & Public Holidays 0800-1700Patient Flow Manager/ After Hours CNC / After Hours Clinical Manager & After Hours Hospital Manager PFM prioritises patient discharges with ward Team Leaders and After Hours Hospital Manager After Hours Hospital manager informs Surgical, ARM and Paediatric Reg’s of capacity issues & need to expedite discharges After Hours Hospital Manager considers opening the Discharge Lounge to assist with patient flow Patient Flow Manager escalates patient transfers to outlying hospitals where transfer delays have occurred D/C patients to other hospitals including private as appropriate Cohort patients as appropriate Surge beds used as approved by Exec On-call or delegate AH CNC/PFM reassess situation hourly and communicate de-escalation or escalation with ARM and Surgical Registrar Decision to review the continuation of surgeryMedical Leaders ARM, Surgical, Psych and Paediatric Reg’s inform JMOs of capacity issues & request review of EDDs for further potential

discharges and expedite discharges ARM, Surgical, Psych and Paediatric Reg consider risk stratification for patients identified for early discharge (before EDD)Critical Care ICU Consultant to contact Calvary Hospital ICU Consultant to discuss capacity issues & patients appropriate for transferWard areas Discharge 2 patients within 2 hours Ward Team Leaders contacted by Patient Flow Manager advising of capacity issue & request that they review patients and

identify patients suitable for D/C, including to other hospitals if appropriate (private & NSW)Support services Pathology to process collections marked “Discharge Priority” without delay Pharmacy to process discharge medications marked “Discharge Priority” without delay Radiology notified of capacity issue & redistribute resources to meet hospital demand Cleaners notified of capacity issue & to prioritise terminal cleans, redistribute resources to meet hospital demand Wardspersons supervisor notified via page of capacity issue

Alert Trigger 1700-0800

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Two or more of the following: Hospital ≥ 100% occupancy More than 10 bed booked

patients in ED All surge beds open Unable to decant

resuscitation room Unable to admit patients

from other hospitals Isolation beds unavailable

& cohorting unable to be implemented

Patient Flow Manager/ After Hours CNC / After Hours Clinical Manager & After Hours Hospital Manager PFM & AHCNC/AHCM prioritises patient discharges with ward Team Leaders and After Hours Hospital Manager After Hours Hospital Manager informs Surgical Registrar, ARM and Paediatric Reg of capacity issues & need to expedite

discharges D/C patients to other hospitals including private as appropriate After Hours Hospital Manager contacts Exec-Oncall+/- MH Exec On-Call & conducts teleconference including Patient Flow

Manager/ AHCNC/AHCM to develop short term strategies to reach target of <95% capacity within 4 hoursExecutive On-call Decision whether to request beds at private hospitals Decision to review the continuation of surgeryMedical Leaders ARM, Surgical, Psych and Paediatric Reg’s in conjunction with JMOs review EDDs for further potential discharges before

8pm ARM, Surgical, Psych and Paediatric Reg’s consider risk stratification for patients identified for early discharge (before EDD)Critical Care ICU Consultant to contact Calvary Hospital ICU Consultant to discuss capacity issues & patients appropriate for transferWard areas Ward Team Leaders review EDDs and prepare at least two patient with an EDD for the following day for discharge by 9am AH CNC/CMC notify ward Team Leaders of capacity issue & request that they review patients and identify patients suitable

for D/C, including to other hospitals (private & NSW) Non-clinical staff redirected to assist with staffing surge beds

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Alert Trigger Weekends & Public Holidays 0800-1700Support services Pathology to process collections marked “Discharge Priority” without delay Pharmacy to process discharge medications marked “Discharge Priority” without delay Radiology notified of capacity issue & redistribute resources to meet hospital demand as a priority Wardspersons supervisor notified via page of capacity issue Cleaners notified of capacity issue & redistribute resources to meet hospital demand as a priority Discharge Lounge operational hours extended to 7pm to facilitate more dischargesIncrease PTV availability to increase transfers out of hospital subject to availabilityPatient Flow Manager/ After Hours CNC / After Hours Clinical Manager & After Hours Hospital Manager PFM prioritises patient discharges with ward Team Leaders and After Hours Hospital Manager AH Hospital Manager consider opening D/C Lounge to facilitate patient flow After Hours Hospital Manager informs Surgical Registrar and ARM of capacity issues & need to expedite discharges AH Hospital Manager activates message sent via pager “Capacity Alert Level 3” to all registrars & RMOs for immediate

review of EDDs for next 24 hours & risk stratification for early discharge D/C patients to other hospitals including private as appropriate After Hours Hospital Manager contacts Exec-Oncall & conducts teleconference including PFM/ AHCNC/AHCMC to develop

short term strategies to reach target of <95% capacity within 4 hours AH CNC/CMC/PFM reassess situation hourly and communicate de-escalation or escalation with ARM, Surgical & Paediatric

Reg’sExecutive On-call Decision whether to request beds at private hospitals Decision to review the continuation of surgeryMedical Leaders ARM, Surgical & Paediatric Reg’s review EDDs for further potential discharges and expedite discharges ARM and Surgical Reg consider risk stratification for patients identified for early discharge (before EDD) Conducts ward rounds as a priority

Alert Trigger Weekends & Public Holidays 0800-1700

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Critical Care ICU Consultant to contact Calvary Hospital ICU Consultant to discuss capacity issues & patients appropriate for transferWard areas Discharge 2 patients within 1.5 hours PFM/AH CNC/CMC informs ward Team Leaders of capacity issue & request that they review patients and identify patients

suitable for D/C, including to other hospitals (private & NSW) Non-clinical staff redirected to assist with staffing surge bedsSupport services Pathology to process collections marked “Discharge Priority” without delay Pharmacy to process discharge medications marked “Discharge Priority” without delay Radiology notified of capacity issue & redistribute resources to meet hospital demand as a priority Wardspersons supervisor notified via page of capacity issue Cleaners notified of capacity issue & redistribute resources to meet hospital demand as a priority Discharge Lounge operational hours extended to 7pm to facilitate more discharges Increase PTV availability to increase transfers out of hospital subject to availability

Attachment 3 – Centenary Hospital for Women & Children Department of Neonatology [Neonatal Intensive care Unit (NICU) and Special Care Unit (SCN)] Capacity Escalation Procedure

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Level Triggers Response Responsibility

Normal Activity/No Access Block

Ability to admit to NICU due to funded bed availability/full staffing/skill mix

No access block from NICU to SCN Ability to admit babies from within local

NSW/ACT network area. (ACT: Calvary Bruce, Calvary John James, NSW: Queanbeyan, Batemans Bay, Bega, Bombala, Cooma, Cootamundra, Goulburn, Moruya, Pambula, Temora, Tumut, Wagga Wagga, Young, Yass) and other areas

If unit is over capacity ability to delay transfers when necessary. Transfers should continue to be planned according to usual flow pathways within business hours if beds available.

NETS Bed state GREEN

Attendance at Flow Huddle 3x per day and multidisciplinary handover meeting daily by nursing and medical staff to identify all imminent or potential NICU admissions (from Birthing, Antenatal or external)

Post Huddle ‘Huddle’ in NICU at 0830 with Consultant +/- Fellow, Assistant Director of Nursing (ADON), NICU and SCN Clinical Nurse Consultants (CNC), SCN Career Medical Officer/Fellow, Registrars.

Ongoing discharge planning/preparation to facilitate timely discharge of chronic patients (by 10am where appropriate).

Regular NICU CNC and Birthing Clinical Midwife Consultant (CMC) liaison Identify patients suitable for internal transfer (NICU, SCN, Postnatal ward

(PNW), Paediatrics) Identification of patient health insurance status on daily list. Daily phone contact with Calvary Bruce SCN and Calvary John James SCN

(when appropriate) and transfer of any local area patients when beds available.

NICU and SCN CNC’s to update ADON re activity and admission requiring changes to staffing/skill mix.

Fortnightly meetings with Paediatrics for planned patient transfers.

After Hours Post Huddle ‘Huddle’ in NICU at 1600 hrs with Consultant +/- Fellow,

ADON, NICU and SCN CNC’s. SCN CMO/Fellow, Registrars. Continue back-transfers to local area hospitals on weekends/public

holidays, utilising rostered staff with Retrieval experience

All staff

Level 1

Increasing Activity

One to two funded beds available in NICU/SCN

And/or patient acuity high with staffing availability/skills for only 1 NICU admission within rostered allocation

Ability to accept patients from local NSW/ACT network area; but limited capacity to accept outside the network

Limited ability to transfer patients to local SCN’s in next 24 hours due to their capacity

NETS Bed state AMBER

Extra Actions (within Hours) Identify and prioritise planned and potential early discharges/transfers at

the 0830am Neonatal Huddle ADON to facilitate transfers to PNW/antenatal ward (ANW)/Paediatrics if

bed block. ADON to escalate to Calvary Bruce and Calvary John James Bed

Management if receiving SCN unable to accept. All phone calls from external hospitals requesting transfer of a potential

NICU admission to be discussed between Obstetric and Neonatal Consultant. Refer potential admissions (including from Calvary hospital or private obstetricians) to on-service obstetric consultant for prioritisation.

Extra Actions (After Hours)

CNC - NICU, SCNConsultants on Service – NeonatologyFellow / RegistrarsADON

After Hours include:Team LeadersAfter Hours Hospital Manager (CHHS)

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Level Triggers Response Responsibility Attend after hours Women Youth & Children (WY&C) Huddles to discuss

potential transfers/ admissions within WY&C if bed block. All phone calls from external hospitals requesting transfer of a potential

NICU admission to be discussed between Obstetric and Neonatal Consultant.

Level 2

At Capacity

No funded beds available in NICU/SCN Or high patient acuity with no staffing

availability/skills Intensive Care / High Dependency funded

beds occupied with no ability to transfer patients to SCN

Minimal planned discharges within the next 24 hours

Calvary Bruce SCN (any patient) and Calvary John James SCN not accepting admissions in the next 24 hours

No ability to transfer patients to regional Level 2 SCN using conventional transport in the next 24 hours

NETS Bed state RED

Extra Actions (Within Hours) Alert on service obstetric team to identify patients at risk of delivery on

ANW and Birthing for additional review and possible transfer out. When considered safe request obstetric patients requiring a NICU bed to

be transferred to another facility. All phone calls requesting in-utero admission or transfer out to be

discussed between Neonatal and Obstetric Consultants, with Perinatal Advice Line (PAL) involvement when necessary.

In conjunction with CD and ADON consider back transfer of patients to regional Level 2 SCN’s utilising ACT NETS (if a backup team can be arranged).

If a patient is identified for transfer to any level 2 and transfer refused by parents for social or financial reasons and can’t be resolved at a clinical level, to be escalated to ADON, Clinical Director.

Extra Actions (After Hours) As above

Consultants on Service – Neonatology and ObstetricsFellow / RegistrarsCNC - NICU, SCN, PaediatricsCMC - Birthing, PNW, ANWADON, ADON/MClinical Director

After Hours include:Team LeadersAfter Hours Hospital Manager (CHHS)

Level 3

Over Capacity

Maximum bed capacity 34

Over funded beds in NICU/SCN If lower patient acuity; > 3 over funded

beds with limited/no ability for extra staff Or high patient acuity with limited/no

extra staffing available/skills for current patients for > 8 hours or admissions

Intensive Care / High Dependency funded beds occupied with no ability to transfer patients to SCN

No forecast discharges within the next 24 hours

No ability to transfer patients to local or regional Level 2 SCN using conventional

Extra ActionsActively work to get back to Level 2 ASAP Written /text notification of overcapacity status to WYC Executive Director,

WYC Director of Nursing and Midwifery (DONM), Departmental Leads, and Access Unit by ADON

Over capacity alert via wifi phones Discuss every patient for possible early discharges / transfers at Neonatal

‘Huddle’ including ADON and Consultant. Further Huddles 1200 and 1600hrs until de-escalation Utilise non-clinical neonatal staff to provide patient care where

appropriate ADON and Clinical Director in conjunction with Executive Director will

consider other options to facilitate transfers/discharges i.e purchasing

Executive Director WYCClinical Directors – all DepartmentsConsultants on Service – Neonatology and ObstetricsWYC DONMADON, ADON/MCNC - NICU, SCN,PaediatricsCMC - Birthing, PNW, ANW

After Hours include:Team LeadersAfter Hours Hospital Manager (CHHS)Access Unit

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Level Triggers Response Responsibilitytransport in the next 24 hours

NETS Bedstate REDbeds for public patients to be transferred to Calvary John James Hospital.

Notify Perinatal Services Network of no capacityExtra Actions (After Hours) Transfer patients to local and regional hosptials out of hours. (ADON

required to approve if retrieval nurse called in) Consider ex-utero transfer of NICU patients Decison to review and cancel elective procedures and admissions

Execuitve Director On call (after hours)

AlertAs per NSW Critical Care Tertiary Referral Network (perinatal) advice and emergency treatment needs to be given by the referral hospital (Centenary Hospital for Women and Children) to all the local NSW/ACT network area irrespective of bed state.

Doc Number Version Issued Review Date Area Responsible PageCHHS16/235 1 05/12/2016 01/12/2018 Operations 20 of 20

Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register