1 CSSD Seasonal Plan NEW 23 10 13 MC Approved (1)

East Kent Hospitals University NHS Foundation Trust

Clinical Support Services Division

SEASONAL PRESSURES PLAN 2013 / 14

Version: 1

Ratified by: Divisional Director

Date ratified:

Name of originator/author:

Director responsible for implementation: Marion Clayton, Divisional Director

Date issued: October 2013

Review date: October 2014

Target audience: Divisional Staff

This plan sets out Clinical Support Services Divisional Preparation for all seasons. The Plan provides information regarding baseline Site and Divisional Capacity and expected Demand, identifies planned and unplanned ‘surge capacity’ to be utilised during seasonal pressures, escalation triggers and processes to follow in response to surges in activity (see ACTION CARDS in Appendix) and Site / Divisional plans and responses regarding inclement weather.

Version Control ScheduleVersion Date Author Status Comment

0.1 18.10.13 Draft

EKHUFT Seasonal Pressures Plan 2013 /14– CSSD Version 1Date of issue: October 2013 Review Date: October 2014

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CONTENTS

Introduction....................................................................................................................5Aim.................................................................................................................................5Objectives......................................................................................................................6Plan Excludes................................................................................................................6Ownership and Maintenance.........................................................................................7Capacity and Demand - Overview.................................................................................7Predicted Division Activity..............................................................................................8

Deparmental Capacity Required Planned Additional Capacity Internal Contingency Surge Capacity- Internal

Radiology 13Laboratory Medicine 16Pharmacy 21Outpatients 24Therapies 28Infection Control 33Capacity Required...........................................................................................................Planned Additional Capacity Internal...............................................................................Contingency Surge Capacity - Internal............................................................................

Inter-Divisional Working...............................................................................................34Discharges...................................................................................................................36Elective Admissions.....................................................................................................39Escalation Framework.................................................................................................40


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Introduction

The Clinical Support Services Division Seasonal Pressures Plan has been developed in accordance with the NHS England South Escalation Framework and reflects the key principles incorporated within the Trust Seasonal Pressures Plan.

Site and Divisional Compliance with the Seasonal Pressures Plan will be monitored by Divisional Directors and the Clinical Quality and Patient Safety Division, reporting through the Risk Management and Governance Group and Emergency Planning and Business Continuity Steering group.

Whole systems compliance and partnership working will be monitored by Ashford, Canterbury, South Kent Coast and Thanet CCGs, reporting in to the Integrated Urgent Care Board.

The responsibility of this plan is to maintain service provisions, patients and staff safety at all times throughout the year. Timely patient flow is the responsibility of the whole system across the trust, therefore requiring a consistent and urgent approach throughout trust to ensure the impact on patients and staff are mitigated.

Aim

To provide a robust Seasonal Pressures Plan to deliver an excellent patient experience across all aspects of healthcare delivered within Clinical Support Services Division, irrespective of seasonal pressures, activity surges or inclement weather.

The NHS England South Escalation Framework states that all Service providers have a responsibility to:

Have an organisational Seasonal Pressures Plan

Provide their Seasonal Pressures Plan to the trust Seasonal Pressures lead for co-ordination

Describe within the Plan how the division will determine its status (Green to Black)

Describe how the organisation will respond to declarations on the status of the health economy and what cross organisational support the organisation can provider to other divisions

Ensure that Seasonal Pressures Plans address the criteria set out in the NHS England South Escalation Framework.


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Ensure that their staff are trained in their role in Seasonal Pressures Plans and that this is tested via exercise

Objectives

To ensure the Trust understands predicted Emergency and Elective activity during Seasonal Pressures, and provides sufficient capacity to maintain safe, efficient and effective patient care.

To ensure the division delivers:

Sufficient and effective Demand and Capacity Planning Clear Communications Clear understanding of Escalation triggers and Response Accurate SITREP Reporting Service continuity during the ‘Festive Fortnight’. Emergency Preparedness during Inclement Weather Staff knowledge and understanding of plan through regular scheduled training

Throughout the year health and social care providers face significant challenges and demands, but winter brings an increased level of pressure to the health community. Seasonal variations in illness have historically resulted in increased emergency admissions and length of stay in hospital during the winter months, predominantly December to April.

Plan Excludes

Documenting specific recovery plans and procedures for a Major Incident occurring outside the remit of the plan

Documenting specific recovery plans and procedures for any service area, or their operations outside the remit of the plan

Documenting specific Recovery Plans or procedures for external entities or suppliers upon whom all service areas rely.


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Ownership and Maintenance

The Emergency Planning and Business Continuity Committee own this plan. The plan will be reviewed, updated and issued at least once per calendar year by the Emergency Planning and Business Continuity Department. Changes to the plan may be requested at any time based on organisational changes, actual incidents or any other factors.

All major changes need to be approved by a quorum of the Emergency Planning and Business Continuity Committee. Version control and Governance of the Plan will remain the responsibility of the Emergency planning and Business Continuity Department.

This document is distributed to the individuals identified on the Executive on Call Rota, individuals identified on the General Manager on Call Rota, and to all service areas. The ‘ratified’ Plan will also be available on SharePoint.

The plan will be fully exercised and tested at least once per calendar year.

NB: Whilst this Seasonal Pressures Plan links directly to the individual Divisional Plans and Site-based Plans, responsibility for communicating and adhering to Divisional and Site Plans remains within that remit and will not be operationally managed through the Trust-wide Plan.

Capacity and Demand - Overview

Introduction

On an annual basis, EKHUFT can expect to manage a pre-determined level of activity through the A&E Department, Elective admissions, non-elective admissions and Readmissions. However, it is also expected that there will be surges in activity at varying periods throughout the year; the winter months historically, have proved challenging as winter brings an increased level of pressure to the Health Community. Seasonal variations in illness have been shown to result in increased emergency admissions and length of stay in Hospital during the winter months, with pressures peaking between November and April.

Although arguably winter peak in demand is generally no worse than in summer peaks, the increased demand often occurs alongside peaks in seasonal flu, swine flu, norovirus. During last year’s seasonal pressures, EKHUFT experienced an increase in patient acuity which also contributed to enhanced pressure on clinical staff, acute services and a greater length of stay.EKHUFT therefore need to plan for similar pressures in order to be prepared to meet expected demand on our services.


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The Seasonal Pressures Plan will work in association with the Whole Systems Plan and be implemented in line with other Health and Social Care Service Provider Plans, such as Primary Care, Kent Community Health Trust, Social Services and SECAmb Trust.

Predicted Division Activity

EKHUFT provides Emergency Care services from four of its five sites

24/7 Emergency Departments at WHH and QEQM Hospitals 24/7 Emergency Care Centre at KCH Minor Injuries units at WHH / QEQM / KCH and BHD Hospitals

Patient activity through the Emergency pathway is expected to be on average 15,000 patients per month (Majors and Minors – excludes Buckland), which equates to approximately 7,000 emergency admissions each month. The profile for A&E Attendance per site, per month is as follows (see Table 1):

TABLE 1: A&E Attendance Profile

SITE Sept 13 Oct 13 Nov 13 Dec 13 Jan 14 Feb 14 Mar 14

TRUST 15626 15848 15203 14906 14685 13788 16399

WHH 6000 5890 5815 5779 5713 5171 6115

QEQM 5667 5918 5610 5410 5373 5130 6159

KCH 3958 4037 3779 3717 3600 3486 4124

The distribution of these attendances, per CCG, is demonstrated in Map 1.

MAP 1: A&E Attendances by CCG

A&E ACTIVITY MODELLING – IMPACT OF ‘ACTIVITY SURGES’ ON PATIENT FLOW:


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Whilst it is important to understand EKHUFT’s expected activity, it is essential that we plan for unexpected surges, such as those experienced during 2012/13. Activity modelling has evidenced that for every 10% increase in A&E Attendance, EKHUFT admit on average 390 additional patients per month, requiring a further 56 beds per month; ultimately impacting on patient flow and our ability to proactively manage demand and capacity

A Seasonal Pressures ‘Calculator’ has been developed to enable EKHUFT to test various ‘activity surge scenario’s’ to determine overall impact on Emergency Admissions (A&E and Non-Elective, such as direct GP referrals), Bed capacity required and Readmissions. Using this model against the baseline and planned additional bed capacity, RAG status RED will be reached once the bed requirement exceeds 995 beds (Adult and Paediatric). This would indicate that the Trust may experience significant pressures during January 2014 (see Pictures 1-4 below), therefore sufficient planning must be undertaken to manage this predicted surge.

Picture 1: Seasonal Pressures calculator: Trust-wide Activity as expected against Baseline


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Picture 2: Seasonal Pressures calculator: Trust-wide Activity adjusted to reflect Potential Surges (impact highlighted in red)

This can further be refined to reflect specific Sites and Divisions, to support capacity planning:

Picture 3: Seasonal Pressures calculator: QEQM Hospital - UCLTC Activity as expected against Baseline


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Picture 4: Seasonal Pressures calculator: QEQM Hospital - UCLTC Activity adjusted to reflect Potential Surges (impact highlighted in red)

The Bed Pressures Calculator is based on the assumption that length of stay, clinical dependency and level of reportable Delayed Transfers of Care (DTOC’s) are within normal limits. Any increase in these figures will mean that RAG status red is reached at an earlier stage, due to a greater proportion of the acute bed base effectively being ‘unavailable’ to manage emergency patient flow. Therefore it is essential, that partnership working across the Whole System, actively supports achievement of reduced avoidable A&E Attendances, through provision of robust and responsive Admission Avoidance schemes within Community-based resources, such as direct access to ‘step up beds’ or domiciliary care ‘flex’ via Social care.


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PLEASE SEE ‘WHOLE SYSTEMS WORKING’ SECTION (Page 16)

RADIOLOGY

TRUST TRIGGERS Radiology Department Action Escalation

GREEN(Level 1)

MAX TRUST Beds: 916

Capacity available to meet expected demand Good patient flow through A&E and other access points A&E 4 hour target consistently being met

Normal Service None

Normal attendance at Bed Meetings.

AMBER (Level 2)MAX TRUST

Beds: 995

Beds available, but short of beds in 1 main area * Anticipated pressure on maintaining A&E 4 hour target

Typically a normal ‘busy period’ but with potential to deteriorate. Pressure to accommodate IP and AE within normal working.

Modality Sup to advise Site Leads of demand and activity balance. Site Lead to actively monitor situation and advise GM/DGM of developing situation.


Table 10: Trust-wide Escalation

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Anticipated pressure in facilitating ambulance handovers Discharges below expected norm Slow patient flow through A&E, Assessment Units Some unexpected reduced staffing numbers (due to e.g. sickness, weather conditions) in areas where this causes increased pressure on patient flow Infection control issues

Prioritise AE and IP Identify and prioritise potential bed blockers Extend / Overbook list(s) as required. Add additional lists where practical. Review resource availability (prepare for Red). Identify where resources maybe re-allocated. E.g. Radiologist from routine CT reporting to US list and constraints Selective re-booking of cancellations to increase capacity. Review plans for scheduled maintenance work where it is likely to impact on capacity or patient flow

Local participation in Bed Meeting active liaison with Bed Manager and AE/Urgent care Teams. Divisional Director to be aware Raise awareness of staff. Radiology has a detailed business continuity plans that outline with telephone numbers who and under what circumstances extraordinary issues can be escalated. In summary staff contact the principle Radiographer (24/7) who if the issue is deemed of sufficient magnitude will contact the General Manager or Deputy Manager who will inform the Clinical Lead. They in turn will escalate to the Divisional Director.

RED(Level 3)

MAX TRUST Beds: 1030

Actions at Amber failed to deliver capacity Lack of beds across the Trust Predicted discharges < expected admissions Significant failure of A&E 4 hour target Patients awaiting handover from ambulance service within 15 minutes significantly compromised Patient flow significantly compromised A&E patients with DTAs and no plan Significant unexpected reduced staffing numbers (due to e.g. sickness, weather conditions) in areas where this causes increased pressure on patient flow

Escalating situation not addressed by ‘normal’ activity and actions. Increasing external pressure. Prioritise AE Identify and prioritise bed blockers Develop additional activity in key areas by re-deploying resources. Extend lists / ‘sweat lists’ Re-schedule meetings / study leave Review leave situation. Re-schedule patients within access targets. Stop maintenance. Retain cancellations as spare capacity Identify sources of additional capacity Implementation of Seasonal Pressures Plan 2013 Implementation of Divisional Business Continuity Plan

Site managers to monitor situation ongoing. Initiate regular telephone conference Local participation in Bed Meeting Active liaison with key teams external to radiology. Regular updates to GM/DGM Divisional Director briefed by GM Brief staff

BEFORE ESCALATING TO BLACK: Unable to meet key pressures within required Site managers to monitor situation


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PRE-BLACK


timescales. Ongoing and developing situation Initiate additional capacity

ongoing. Initiate regular telephone conference Local participation in Bed Meeting Active liaison with key teams external to

radiology. Regular updates to GM/DGM Divisional Director briefed by GM Brief staff

BLACK(Level 4)

Actions at Red failed to deliver capacity No capacity across the Trust Emergency care pathway significantly compromised Unable to offload ambulances A&E patients with DTAs >8 hrs. 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

Re-schedule patients except 2WW and Interventions. Reduction of non critical services (e.g. routine screening) Priority to AE and IP Maintain priority services. Stop planned maintenance Cancel leave as required.

Site managers to monitor situation ongoing.

Initiate regular telephone conference Local participation in Bed Meeting Active liaison with key teams external to

radiology. Regular updates to GM/DGM Divisional Director briefed frequently. Brief staff


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Capacity Required

Not possible to identify in terms of numbers of examinations.

The key indicator is ability to meet requests within access targets and ability to carry out examinations to facilitate discharge of IP within required discharge plan.

Where these are no met i.e. by delay or exams being carried over escalation is identified by the actions required to address.

Planned Additional Capacity Internal

Cancelled appointments.Allocation of protected capacity to prioritised patient groups.Selective re-schedulingSweat listsExtended listsRe-schedule meetings/study leaveRe-deployment of resources.

Contingency Surge Capacity - Internal

Re-schedule elective examinationsReduce leaveReduction of non critical services


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LABORATORY MEDICINE

TRUST TRIGGERS Laboratory Medicine Department Action Escalation

GREEN(Level 1)

MAX TRUST Beds: 916


Normal Service None



Beds: 995

Beds available, but short of beds in 1 main area * Anticipated pressure on maintaining A&E 4 hour target Anticipated pressure in facilitating ambulance handovers Discharges below expected norm Slow patient flow through A&E, Assessment Units Some unexpected reduced staffing numbers (due to e.g. sickness, weather conditions) in areas where this causes increased pressure on patient flow Infection control issues

Typically a normal ‘busy period’ but with potential to deteriorate. Pressure to accommodate IP and AE within normal working. Prioritise A&E/ECC, discharge dependant and wards Identify and prioritise potential delayed discharges relevant to Laboratory Medicine Review resource availability (prepare for Red). Identify where resources maybe re-allocated. Cancelling non essential meetings and non patient activity Consider whether to cancel Phlebotomy OPD work Consider increasing staff for CPP rotas if patient acuity demands

Be aware of hospital status Head BMS’s to actively monitor situation and advise General Manager of developing situation. Update from Bed Meeting, via CSSD representative. Divisional Director to be aware Brief staff about situation and response required. Discussion with staff from other divisions The department has detailed business continuity plans that outline with telephone numbers who and under what circumstances extraordinary issues can be escalated. In summary staff contact the Head BMS (24/7) who if the issue is deemed of sufficient magnitude will contact the General Manager. They in turn will escalate to the Divisions Clinical Lead and Director.

RED Actions at Amber failed to deliver capacity Escalating situation not addressed by ‘normal’ Head BMS’s to monitor situation ongoing.



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(Level 3)MAX TRUST Beds: 1030

Lack of beds across the Trust Predicted discharges < expected admissions Significant failure of A&E 4 hour target Patients awaiting handover from ambulance service within 15 minutes significantly compromised Patient flow significantly compromised A&E patients with DTAs and no plan Significant unexpected reduced staffing numbers (due to e.g. sickness, weather conditions) in areas where this causes increased pressure on patient flow

activity and actions. Increasing external pressure. Prioritise A&E/ECC, discharge dependant and wards Identify and prioritise potential delayed discharges relevant to Laboratory Medicine Develop additional activity in key areas by re-deploying resources. Re-schedule all meetings / study leave Review annual leave situation. Implementation of Divisional Business Continuity Plan Approve overtime Consider increasing staff covering CPP Gain approval for/consider use of agency staff to increase resources

Initiate regular telephone conference Update from Bed Meeting via CSSD representative Active liaison with other divisions Regular updates to General Manager and Director of Laboratory Medicine Divisional Director briefed by General Manager Brief staff

PRE-BLACK


BEFORE ESCALATING TO BLACK: Unable to meet key pressures within required timescales. Ongoing and developing situation Initiate additional capacity - cancel annual leave where possible/ reschedule relevant out patient clinics/approve overtime/consider full utilisation of current weekend rotas to cover pressure areas/use of agency staff

Site Leads to monitor situation ongoing. Initiate regular telephone conference Local participation in Bed Meeting Active liaison with out patient therapy

teams Active liaison with other divisions Regular updates to GM for Lab Med Divisional Director briefed by GM for

Lab med Brief staff

BLACK(Level 4)

Actions at Red failed to deliver capacity No capacity across the Trust Emergency care pathway significantly compromised Unable to offload ambulances A&E patients with DTAs >8 hrs. Unexpected reduced staffing numbers (due to e.g. sickness, weather conditions) in areas where this causes increased pressure on

Full Reduction of non critical services Priority to A&E/ECC and IP discharges Maintain priority services. Cancel leave as required. Redeploy staff, including admin, as situation demands Use of agency staff to support substantive resources

Head BMS’s to monitor situation ongoing.

Initiate regular telephone conference Update from Bed Meeting via CSSD

representative Active liaison with key teams external to

Laboratory Medicine, especially bed managers and A&E/ECC Matrons

Regular updates to General Manager


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patient flow is at a level that compromises service provision / patient safety

and Director of Laboratory Medicine Divisional Director briefed frequently. Brief staff


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Capacity Required

Laboratory Medicine - The following table shows the staff required in order to maintain the essential services within the Trust. These services are inclusive of the priority Trust services including A&E response, ward discharges and the acute essential service. It also shows the total number of staff within the departments.

Site/ speciality Essential services Minimum number of staff

required to deliver

essential service

Number of staff skilled to

deliver essential service

Total number of

staff

WHHCellular Pathology (including Mortuary)

Clinical Biochemistry

Haematology/Blood Transfusion

Microbiology

Phlebotomy

Non gynae cytology for septic knee joint aspirates

Provide analysis of blood samples for all urgent in-patients

Provide analysis and cross matches for all urgent in-patients

Provide analysis for all urgent in-patients and in-progress cultures.

Provide urgent blood tests for in-patients

2

9

9

4

5

2

15

15.8

17

10.15

2

37

30.8

62

10.15

KCHClinical Biochemistry


Haemophilia

Phlebotomy



Provide analysis for all urgent in-patients and urgent referrals


6

6

2

4

7.5

9

1

7.94

14.5

18.4

7

7.94QEQMClinical Biochemistry


Phlebotomy




6

6

5

8.5

8

10.07

16.5

18.5

10.07


Laboratory Medicine – staff would flex internally to ensure that staff were working in the areas of greatest pressure. This would usually be to ensure that A&E/ECC/CDU work discharge dependant patients were prioritised.



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Staff to be moved across sites if required. All non essential work to be stopped and all non ward Phlebotomy work to be stopped.Locum staff could also be used to support if approval was given.


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PHARMACY

TRUST TRIGGERS Pharmacy Department Action Escalation

GREEN(Level 1)

MAX TRUST Beds: 916

Capacity available to meet expected demand

Good patient flow through A&E and other access points

A&E 4 hour target consistently being met

Normal Service None


AMBER (Level 2)

MAX TRUSTBeds: 995

Beds available, but short of beds in 1 main area *

Anticipated pressure on maintaining A&E 4 hour target

Anticipated pressure in facilitating ambulance handovers

Discharges below expected norm Slow patient flow through A&E,

Assessment Units Some unexpected reduced staffing

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

Infection control issues

Typically a normal ‘busy period’ but with potential to deteriorate. Pressure to accommodate IP and AE within normal working.

Prioritise ECC, discharge lounge, medical wards and medical outliers.

Identify and prioritise potential delayed discharges relevant to Pharmacy

Review resource availability (prepare for Red).

Identify where resources maybe re-allocated.

Cancel non-essential meetings and non-patient activity

Consider increasing staff for weekend/late rotas if patient activity demands

Be aware of hospital status Clinical lead pharmacists to actively

monitor situation and advise Director/Deputy directors of developing situation.

Any delays in TTAs specifically to CDU, A &E and Discharge Lounge will be notified for action to the Patient Services Lead Pharmacists and/or Patient Services Lead Pharmacy technicians in normal hours: KCH 74448, QEQM 62451, WHH 88005, and the On-Call Pharmacists via the switchboard out-of-hours.

Local participation in Bed Meeting, active liaison with Bed Manager.

Divisional Director to be aware Brief staff about situation and response

required. Discussion with staff from other

divisions

RED Actions at Amber failed to deliver Escalating situation not addressed by Clinical lead pharmacists to monitor



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(Level 3)MAX TRUST

Beds: 1030

capacity Lack of beds across the Trust Predicted discharges < expected

admissions Significant failure of A&E 4 hour

target Patients awaiting handover from

ambulance service within 15 minutes significantly compromised

Patient flow significantly compromised

A&E patients with DTAs and no plan Significant unexpected reduced

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

‘normal’ activity and actions. Increasing external pressure.

Prioritise ECC, discharge lounge, medical wards and medical outliers

Identify and prioritise potential delayed discharges relevant to Pharmacy

Develop additional activity in key areas by re-deploying resources.

Re-schedule all meetings / study leave Review annual leave situation. Implementation of Divisional Business

Continuity Plan Approve overtime Gain approval for/consider use of

agency staff to increase resources

situation on-going. Patient Services Leads/On-call

Pharmacists to be notified of/take action to deal with any delays to TTAs on-going.

Initiate regular telephone conference Local participation in Bed Meeting

active liaison with Bed Manager Active liaison with other divisions Regular updates to Director/Deputy

Directors of pharmacy Divisional Director briefed by

Director of Pharmacy Brief staff

PRE-BLACK


BEFORE ESCALATING TO BLACK: Unable to meet key pressures within required timescales. Ongoing and developing situation

Initiate additional capacity - cancel annual leave where possible/ approve overtime/consider utilisation of weekend rotas to cover pressure areas/use of agency staff

Lead Clinical Pharmacists to monitor situation ongoing.

Patient Services Leads/On-call Pharmacists to be notified of/take action to deal with any delays to TTAs on-going.


active liaison with Bed Manager Active liaison with out patient therapy

teams Active liaison with other divisions Regular updates to Director/Deputy

Directors of pharmacy Divisional Director briefed by Director

of Pharmacy Brief staff

Actions at Red failed to deliver capacity Full Reduction of non critical services Lead Clinical Pharmacists to monitor


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BLACK(Level 4)

No capacity across the Trust Emergency care pathway significantly

compromised Unable to offload ambulances A&E patients with DTAs >8 hrs. 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

Prioritise ECC, discharge lounges, medical wards, medical outliers and all discharges

Maintain priority services. Cancel leave as required. Redeploy staff, including admin, as

situation demands Use of agency staff to support

substantive resources

situation ongoing. Patient Services Leads/On-call

Pharmacists to be notified of/take action to deal with any delays to TTAs on-going.


active liaison with Bed Manager Active liaison with key teams external to

Pharmacy, especially bed managers and Matrons

Regular updates to Director/Deputy Directors of pharmacy

Divisional Director briefed frequently. Brief staff


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Capacity Required

Pharmacy - The following table shows the staff required in order to maintain the essential services within the Trust across all 3 sites. These services are inclusive of the priority Trust services including ECC, Discharge Lounges, ward discharges and the acute essential service.


Pharmacy – staff would flex internally to ensure that they were working in the areas of greatest pressure. This would usually be to ensure that ECCs, discharge lounges, medical patient admissions and any patient requiring discharge were prioritised.


Staff to be moved across sites as required. All non-essential work to be stopped. Locum staff could also be used to support if approval was given.


Speciality Essential services Minimum number of

staff required to deliver essential service

Number of staff skilled to deliver essential service

Dispensary/Clinical Dispensing, clinical screening, medication histories, facilitating discharge

20 Technicians

21 Pharmacists

3 ATOs

26 Technicians

27 Pharmacists

6 ATOs

Clinical Trials Maintenance of clinical trial supplies

1 3 Technicians

Oncology/Haematology Screening chemotherapy prescriptions

2 5

Aseptics/QA/Radiopharmacy Preparation of chemotherapy & radiopharmaceuticals/Quality Assurance

11 16

POSD/Homecare Purchasing, over-labelling and distribution of all medication trust wide, processing of Homecare prescriptions.

18 31

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OUTPATIENTS

TRUST TRIGGERS Outpatient Department Action Escalation

GREEN(Level 1)

MAX TRUST Beds: 916


Normal Service None



Beds: 995


Normal Service None

Be aware of hospital status Local participation in Bed Meeting, active liaison with Bed Manager and A&E/Urgent care Teams. Brief staff about situation and response required. Discussion with staff from other divisions regarding any potential plans

RED(Level 3)


Actions at Amber failed to deliver capacity Lack of beds across the Trust Predicted discharges < expected admissions Significant failure of A&E 4 hour target Patients awaiting handover from ambulance service within 15 minutes significantly compromised Patient flow significantly compromised A&E patients with DTAs and no plan Significant unexpected reduced staffing numbers (due to e.g. sickness, weather conditions) in areas where this causes

Escalating situation not addressed by ‘normal’ activity and actions. Increasing external pressure. Prioritise appointments to be booked vs appointments to be cancelled – appointment centre Identify any increase in the number of inbound patient calls – appointment centre Identify any increase in Health Record requests- Health Records Encouraging weekend and evening overtime as appropriate- all outpatient departments

Local participation in Bed Meeting Active liaison with other divisions Regular updates to Head of Outpatients Divisional Director briefed by Head Therapies Brief staff



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increased pressure on patient flow Implementation of Divisional Business Continuity Plan – all outpatient departments

Work with other divisions to cancel non urgent outpatient activity as requested and required by the other divisions- appointment centre.

Redeploy any staff released by clinic cancellations as appropriate- nursing and reception

PRE-BLACK


BEFORE ESCALATING TO BLACK: Unable to meet key pressures within required timescales. Ongoing and developing situation Flex workforce to deal with rescheduled relevant out patient clinics and inpatient health record demands Flex workforce to deal with increased inbound calls from patients


Initiate regular telephone conference Local participation in Bed Meeting Active liaison with out patient reception

teams across the Trust Active liaison with other divisions Regular updates to Head of Outpatients Divisional Director briefed by Head of

Outpatients Brief staff

BLACK(Level 4)


Cancel leave as required. Redeploy staff, including admin, as situation demands Full Reduction of non critical services Consider suspending all outpatients Maintain priority services.



Outpatients, especially bed managers and A&E/ECC Matrons

Regular updates to Head of Outpatients Divisional Director briefed frequently. Brief staff


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Capacity Required

Outpatient Appointments - The following table shows the staff required in order to maintain the essential services within the Trust. These services are inclusive of the priority Trust services including A&E response, ward discharges and the acute essential service. It also shows the total number of staff within the departments.

Site/ speciality Essential services Minimum number of staff

required to deliver

essential service

Number of staff skilled to

deliver essential service

Total number of

staff

Appointment Booking Office

Priority given to 2 week wait registration, and booking. All inbound callsPre-registration of 18week outpatients

Clinic maintenance to be actioned >6weeks to be parked

16 WTE band 2, 2 WTE band 4, 1 WTE band 6

32 WTE band 2, 4 WTE band 4, 1 WTE band 52 WTE band 6

32 WTE band 2, 4 WTE band 4, 0.57 WTE band 31 WTE band 52 WTE band 6

Health RecordsRetrieval of Heath Records for admissions.

Clinic prep for 2WW and other outpatient clinics that are running.

Transport of Health Records between sites.

For 2WW and admission retrieval only:-22 WTE staff required

92.8 WTE band 27 band 3 WTE3 band 5 WTE

92.8 WTE band 27 band 3 WTE3 band 5 WTE

Nursing Support for clinics that are running Depending on the clinics running

25 WTE RGN from 5 sites.7 WTE Associate Practitioners total from 5 sites.48.36 WTE HCA’s total from across the 5 sites.

25 WTE Band 5,6,7

7 WTEBand 4

48.36Band 2

Reception Support for clinics that are running Depending on the clinics running

23.64 WTE staff total from 5 sites.

23.64Band 2


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OPA colleagues would support those areas they are able as requested.


OPA colleagues would support those areas they are able as requested.


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THERAPIES

TRUST TRIGGERS Therapy Department Action Escalation

GREEN(Level 1)

MAX TRUST Beds: 916


Normal Service None



Beds: 995


Typically a normal ‘busy period’ but with potential to deteriorate. Pressure to accommodate IP and AE within normal working. Prioritise A&E/ECC/CDU admission avoidance and discharges, ward discharges and acutely unwell patients Identify and prioritise potential delayed discharges relevant to Therapies Review resource availability (prepare for Red) and move in patient staff to pressure areas Identify where resources maybe re-allocated to support A&E/CDU/Wards to support discharge process. Cancelling non essential meetings and non patient activity Consider whether to cancel out patient work undertaken by in patient staff Consider increasing staff for emergency on call rotas if patient acuity demands Encouraging weekend and evening overtime especially for A&E/ECC

Be aware of hospital status In Patient Team Leaders to be available for communication with ward areas/Divisional Leads so that they can ensure resources are where requiredLiz Woods WHH ext 88788Kelly Park QEQM ext 62697Andrea Reid/Jane Pollok KCH ext 73030 Site Leads to actively monitor situation and advise Head of Therapies of developing situation. Local participation in Bed Meeting, active liaison with Bed Manager and A&E/Urgent care Teams. Divisional Director to be aware Brief staff about situation and response required. Discussion with staff from other divisions

RED Actions at Amber failed to deliver capacity Escalating situation not addressed by ‘normal’ Site managers to monitor situation ongoing.



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(Level 3)MAX TRUST Beds: 1030

Lack of beds across the Trust Predicted discharges < expected admissions Significant failure of A&E 4 hour target Patients awaiting handover from ambulance service within 15 minutes significantly compromised Patient flow significantly compromised A&E patients with DTAs and no plan Significant unexpected reduced staffing numbers (due to e.g. sickness, weather conditions) in areas where this causes increased pressure on patient flow

activity and actions. Increasing external pressure. Prioritise A&E/ECC and ward discharges Identify and prioritise potential delayed discharges relevant to Therapies Develop additional activity in key areas by re-deploying resources. Re-schedule all meetings / study leave Review annual leave situation. Identify sources of additional capacity – consider cancellation of Day Hospitals and possibly some out patients to release staff Implementation of Divisional Business Continuity Plan Approve overtime Encouraging weekend and evening overtime especially for A&E/ECC Gain approval for/consider use of agency staff to increase resources especially for the weekends

Initiate regular telephone conference Local participation in Bed Meeting In Patient Team Leaders to be available for communication with ward areas/Divisional Leads so that they can ensure resources are where requiredLiz Woods WHH ext 88788Kelly Park QEQM ext 62697Andrea Reid/Jane Pollok KCH ext 73030 Active liaison with other divisions Regular updates to Head of Therapies Divisional Director briefed by Head Therapies Brief staff To contact on call physiotherapy teams out of hours via switchboard or as follows –

WHH bleep 8904QEQM ext 65090KCH bleep 7249

PRE-BLACK


BEFORE ESCALATING TO BLACK: Unable to meet key pressures within required timescales. Ongoing and developing situation Initiate additional capacity - cancel annual leave where possible/ reschedule relevant out patient clinics/approve overtime/consider full utilisation of current weekend rotas to cover pressure areas/use of agency staff

Site Leads to monitor situation ongoing. Initiate regular telephone conference Local participation in Bed Meeting Active liaison with out patient therapy

teams Active liaison with other divisions Out of hours contact on call

physiotherapy teams who will escalate as required via switchboard or as follows –

WHH bleep 8904QEQM ext 65090KCH bleep 7249


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Regular updates to Head of Therapies Divisional Director briefed by Head of

Therapies Brief staff

BLACK(Level 4)


Full Reduction of non critical services Priority to AE/ECC and IP discharges Maintain priority services. Cancel leave as required. Redeploy staff, including admin, as situation demands Use of agency staff to support substantive resources, especially for increasing weekend cover to support the emergency floor and ward discharges



Therapy, especially bed managers and A&E/ECC Matrons

Regular updates to Head of Therapies Divisional Director briefed frequently. Brief staff


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Capacity Required

Therapy - The following table shows the staff required in order to maintain the essential services within the Trust. These services are inclusive of the priority Trust services including A&E response, ward discharges and the acute essential service. It also shows the total number of staff within the departments.

Site/ speciality Essential services Minimum number of

staff required to deliver essential service

Number of staff skilled to deliver essential service

Total number of

staff

WHH/ BHD/ RVHPhysiotherapy

Occupational TherapyDieteticsSpeech and Language Therapy

OrthoticsPodiatry

A&E assessment and dischargeWard dischargeRespiratory treatmentsAdmission avoidance and ward dischargeUrgent stroke. NbM patients. In-patient dysphagia & urgent out-patient dysphagiaInpatientsDiabetes high risk foot clinics

13

103211

39

1733.4210(for all 3 sites)

61

2936218(for all 3 sites)

KCHPhysiotherapy

Occupational Therapy

DieteticsSpeech and Language Therapy

OrthoticsPodiatry

A&E assessment and dischargeWard dischargeRespiratory treatmentsECC and CDU assessment and discharge.Ward dischargeUrgent stroke. NbM patients. Inpatient Dysphagia service and some head and neck workInpatientsDiabetes high risk foot clinics

9

4

21.610.4

30

10

23.92

41

15

26.62

QEQMPhysiotherapy

Occupational TherapyDieteticsSpeech and Language Therapy

OrthoticsPodiatry

A&E assessment and dischargeWard dischargeRespiratory treatmentsAdmission avoidance and ward dischargeUrgent stroke. NbM patients. Inpatient Dysphagia service and some head and neck workInpatientsDiabetes high risk foot clinics

10

631.610.2

30

1733.92

36

2736.62


Therapy – staff would flex internally to ensure that staff were working in the areas of greatest pressure. This would usually be to ensure that A&E/ECC/CDU was well supported and that ward patient discharges were prioritised. Physiotherapy would also need to have staff to treat the acutely ill patients/those patients likely to become respiratory compromised without treatment and Speech and Language Therapy would need to be able to provide swallow assessments and dysphagia treatments. Staff would be moved to support the prioritised areas


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from other in patient areas initially. If/when required staff would be moved from out patient services which would necessitate cancelling patient lists. Initially junior staff from out patients would be moved as these staff would have the most up to date skills required for patient discharges/admission avoidance.

The Therapy teams would respond to calls for assistance as required. During normal working hours the In Patient Team Leaders should be contacted –Liz Woods WHH ext 88788Kelly Park QEQM ext 62697Andrea Reid/Jane Pollok KCH ext 73030For out of hours the on call physiotherapist should be contacted initially who will escalate as required. The on call teams can be contacted via switchboard but if the staff are in the hospital they can be contacted on –WHH bleep 8904QEQM ext 65090KCH bleep 7249

Therapies are currently working on a business case which is proposing a 7 day a week service to the emergency unit at all 3 sites. Presently staff are covering a voluntary rota for evenings until 19:30 and Sat/Sun mornings at QEQM and WHH. This is an ad hoc arrangement and not every weekend is covered. If this service was funded Therapies could put in a regular service.

Physiotherapy and Occupational Therapy staff are currently being recruited to work within the 80 community step down beds being purchased by EKHUFT across the locality. These staff will actively support the management of the patients in these beds.


If out patient areas were reduced or stopped to support in patient beds then staff could be used to increase the ward staffing. Some of the out patient staff are highly specialised within their field, so may have to work at a lower level in a different setting. Day Hospital services could be reduced/suspended initially as these staff have skills more aligned to patient discharges. If additional staff required then the MSK services would need to be reduced/suspended, initially to release the rotational staff who would have the ward experience and knowledge. But if the demand required then all staff from out patient teams could be pulled in to support the in patient services.Locum staff could also be used to support the in patient teams if approval was given, especially to support the weekend services.


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INFECTION CONTROL

GREEN(Level 1)

MAX TRUST

Beds: 916


Normal Service None

None

AMBER (Level 2)

MAX TRUSTBeds: 995

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

Deputy Director Infection Prevention and Control (DDIPC) / Deputy Lead Nurse to prioritise placement of IC Specialist Nurses (may involve change of site) to maximise IC management of patients due to pressure on patient placement (i.e. side room availability / need to cohort nurse).

Band 6 IC Sisters x2 (QEQMH and K&C) to support ward staff by working clinically - liaison with Senior Divisional Matrons to determine priority areas.

Attendance at site-based bed meetings by IC Specialist Nurses; DDIPC / Deputy Lead Nurse / on-call IC Clinical Nurse Specialist to attend Trust-wide video-conference bed meetings and out of hours dial into bed management teleconferences.

DDIPC / Deputy Lead Nurse / Team to review pending meetings, study leave and annual leave arrangements with a view to cancelling them should service provision dictate.

Liaison with Executive on-call / Site Managers out of hours regarding IC issues / patient flow / advice

RED(Level 3)

MAX TRUST

Actions at Amber failed to deliver capacity Lack of beds across the Trust

Significant unexpected reduced staff - IPC result service to be managed remotely as on-

DDIPC / Deputy Lead Nurse / Team to cancel meetings, study leave and annual leave


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Beds: 1030

Predicted discharges < expected admissions Significant failure of A&E 4 hour target Patients awaiting handover from ambulance service within 15 minutes significantly compromised Patient flow significantly compromised A&E patients with DTAs and no plan Significant unexpected reduced staffing numbers (due to e.g. sickness, weather conditions) in areas where this causes increased pressure on patient flow

call system for each site; Re-schedule all meetings / study leave; Review annual leave situation; Active liaison with other divisions; Brief staff.

DDIPC / Deputy Lead Nurse to determine / arrange remote working (as per on call system) in order to process laboratory results and liaise with ward staff re patient management.

Ongoing assessment of priority patients (e.g. patients with diarrhoea) to minimise cross-infection risks.

Band 6 IC Sisters (QEQMH / WHH) to work on the wards clinically to support nursing staff (liaison with Senior Divisional Matrons to determine priority areas).

IC Specialist Nurses that are on site to attend the site-based bed meeting

DDIPC / Deputy Lead Nurse and the IC Clinical Nurse Specialist on call to dial in to bed meeting teleconference (IC Clinical Nurse Specialist on-call also to do this out of hours).

Liaison with the Executive on-call / Site Managers out of hours to ensure access to IC advice / support to ensure patient flow / effective IC management of patients

In summary the IPC Service could be controlled remotely in an emergency. Staff that can get into hospital can provide support to manage patients.


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Inter-Divisional Working

Whilst each Organisation is responsible for providing a Seasonal Pressures Plan, EKHUFT have liaised with other service providers, with a view to aligning Plans and enhancing communication. Across the ‘whole system’ a number of additional arrangements have been established this year to ensure safe, efficient and effective patient flow is maintained and activity surges are managed in a more cohesive manner.

Through Reablement, the CCGs have funded additional support to the community Rapid Response teams to ensure they can achieve a 2 hour response time to patients within the A&E Departments and Clinical Decision Units, where admission avoidance will be facilitated. This service will predominantly be available between the hours of 08:00 – 20:00, 7 days a week. Whilst the service is provided 24 / 7, it is acknowledged that response times could be slightly longer outside core hours. Contact details for the Rapid Response Service will be circulated throughout the Emergency Floors (once confirmed).

NB: Anticipated start date for A&E 2hr Rapid Response is 1st November 2013.

A Summary of key interventions for each Organisation is provided below:

SOCIAL SERVICES

Social Services have:

Confirmed that arrangements will be in place to support 7 day working for their staff. Winter Rota’s to be provided.

Enabled EKHUFT staff to ‘Re-start’ existing Care Packages, without the need to refer to the Discharge Referral Service. This will be implemented across the Trust during October.

Introduced ‘Domiciliary Flex’ which empowers contracted care providers to increase support for a period of up to 7 days, to support admission avoidance / facilitated discharge.

Reviewed Eligibility Criteria for Westbrook House & Westview to enhance clarity and consistency regarding referrals and acceptance. NB: Criteria will be circulated appropriately once received.

Established a process which ensures the Health Interface Manager will receive reports of Short Term Bed placements exceeding the 3 week period and will inform operational manager(s) to generate expedited discharge.

Where short term bed placements exceed the 3 week period, Service Managers will ensure that Case Managers expedite care packages to create capacity.

Agreed to provide information via SHREWD regarding forthcoming discharges (up to 48hrs in advance).

KENT COMMUNITY HEALTH TRUST

KCHT have:

Committed to achieving a 2hr response time for patients referred to Rapid Response via A&E / Emergency Floor (Reablement scheme as above)


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Have provided RAG rated Action Cards, clarifying the response to be taken with regards whole systems pressures. These actions include:

o Additional ward rounds within Community providers to expedite discharges and create capacity.

o Community Hospitals to provide ‘lower thresholds’ for admission / treatment where possible, through flexible working arrangements.

o Expedite rapid assessment by MDT (including Social Services)

Established centralised ‘Local Referral Units’ within South Kent Coast and Thanet to ensure all referrals (step up and step down) are managed and co-ordinated proactively.

Agreed to provide information via SHREWD regarding forthcoming discharges (up to 72hrs in advance).

PRIMARY CARE

Through working with CCG’s, Primary Care have agreed:

To provide a GP in A&E’s across East Kent (commencing October), to support Admission Avoidance (8am – 6pm).

‘GP in A&E’ will take phone calls from Ambulance crews prior to conveyance to Hospital to determine if:

o Patient can be treated at home with follow-up / community services

o Patient can be brought to A&E to see GP directly

o Patient needs to be brought to A&E Majors for acute assessment.

‘GP in A&E’ will be supported by a band 7 Nurse Practitioner, who will link with A&E Nurse in Charge to identify appropriate patients to ‘pull’ to Primary Care – key focus will be patients with a Long Term Condition.

Active Re-direction process will be implemented to enable patients attending A&E to be referred back to their own GP with a confirmed ‘same day / next day’ appointment.

NB: Two members of Trust staff (Ian Setchfield and Gemma Oliver) will work as Nurse Consultants, supporting the Acute Physician role and Emergency Floor. These posts will link with the GP in A&E and Nurse Practitioner where appropriate.

PILGRIMS HOSPICE

Pilgrims Hospice have:

Uploaded their ‘active caseload’ onto EKHUFT’s Electronic Patient Records system which:

o Raises an automatic flag within the Hospice system, informing them that a patient known to them has been admitted.

o Enables the Hospice to support facilitated discharge through ‘pulling’ patients

o Enables EKHUFT to know which patients are known to the Hospice, to support appropriate referral to the Navigation Centre

o Supports Admission Avoidance for patients presenting in A&E at End of Life, who would benefit from Hospice Services


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Provided the Contact details of their Navigation Centre (24/7) to ensure timely access to Hospice Services

o Tel No: 01233 504109

o Navigation Centre is manned 24 hours a day

o Has direct access to Senior Clinician / Manager on Call / Hospice Bed capacity / Hospice at Home (Carer service – up to 72hrs cover)

Provided ‘Crisis Capacity’ within Ashford Hospice (2 beds) which may be accessed by EKHUFT in extreme cases, following discussion with Manager / Clinician on Call.

Pilgrims Hospice is keen to maintain two-way dialogue with EKHUFT to enable and enhance collaborative working and support during Seasonal Pressures.

Should demand exceed capacity, EKHUFT will work with its health and social care partners under direction from the CCG’s to identify any further potential for additional capacity. The expectation is that Social Services and Kent Community Health Trust will maintain an average length of stay of 4 weeks / maximum length of stay of 6 weeks and will regularly review patients within their bed base to ensure discharge planning is robust and timely.

Discharges

The volume of daily Discharges required per Division per Site, will escalate according to the overall pressures generated by increased activity through A&E, increased admissions, extended length of stay, increased patient acuity and pressures external to the Trust.

If the minimum required Daily Discharges do not occur at Status Green (see table 7 below), the Division / Site will rapidly escalate to Status Amber and so on, therefore it is essential that the level of daily discharges are accurately recorded and reported at the Daily Trust-wide Video-conference.

NB: The difference between the number of Daily Discharges required to maintain Status Green as opposed to returning to Green once EKHUFT have reached status Black, equates to approximately 57% increase in workload with regards patient discharge.

Table 7: Daily Discharges required BY Division, to enable the Site to return to Status GREEN

DIVISION WHH QEQM KCH

UCLTC40 Discharges

TO MAINTAIN GREEN STATUS

35 DischargesTO MAINTAIN GREEN

STATUS

35 Discharges TO MAINTAIN GREEN

STATUS

SURGERY20 Discharges



STATUS


STATUS

SPECIALISTX Discharges


X Discharges TO MAINTAIN GREEN

STATUS

X Discharges TO MAINTAIN GREEN

STATUS

UCLTC50 Discharges

TO RETURN TO GREEN (10 ADDITONAL PER DAY)

43 Discharges TO RETURN TO GREEN

(8 ADDITONAL PER DAY)



SURGERY 25 Discharges 25 Discharges 25 Discharges


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TO RETURN TO GREEN (X ADDITONAL PER DAY)

X Discharges TO RETURN TO GREEN

(X ADDITONAL PER DAY)



UCLTC60 Discharges






SURGERY30 Discharges







TO RETURN TO GREEN (X ADDITONAL PER DAY)



X Discharges TO RETURN TO GREEN (x ADDITONAL PER DAY)

UCLTC

70 Discharges(APPROX 57%

ADDITIONAL DISCHARGES (30 PER DAY) TO RETURN

TO GREEN

60 Discharges (APPROX 57% ADDITIONAL DISCHARGES (25 PER DAY)

TO RETURN TO GREEN

60 Discharges(APPROX 57%


TO GREEN

SURGERY

35+ Discharges (APPROX 57%


TO GREEN

35+ Discharges (APPROX 57% ADDITIONAL DISCHARGES (15 PER DAY)

TO RETURN TO GREEN

35+ Discharges (APPROX 57%


TO GREEN

SPECIALIST

X Discharges (APPROX 57%

ADDITIONAL DISCHARGES (X PER DAY) TO RETURN

TO GREEN

X Discharges (APPROX 57% ADDITIONAL DISCHARGES (X PER DAY)

TO RETURN TO GREEN

X Discharges (APPROX 57%

ADDITIONAL DISCHARGES (X PER DAY) TO RETURN

TO GREEN

To facilitate timely patient flow, clear Roles and Responsibilities have been developed to ensure a proactive focus is maintained on both Internal and External process delays. The Capacity & Flow Managers will assume responsibility for monitoring and supporting staff with ‘Internal Waits’ whilst the Discharge Manager will lead on ‘DTOC’s’ and the active Discharge Referral Service caseload.

The ‘Tick it Home’ will be fully implemented across the Trust by mid-October, therefore patients Estimated Discharge Dates will be visually displayed and communicated with patients and their relatives.

EDN’s / TTO’s

Wherever possible, a patients’ EDN should be completed the day before Discharge, to enable Pharmacy to prepare TTO’s ready for discharge. Where this is not achievable, clinical teams should ensure that EDN’s are completed within 2 hours of the decision to discharge being confirmed. Any delay with this process will constitute an ‘Internal Wait’ and should therefore be reported to the Capacity & Flow Manager to resolve / escalate.

PATIENT TRANSPORT (NSL)

Wherever possible, Patient Transport (against the Criteria) to support discharge or transfer to a community resource, should be booked the day before discharge, to support planning of journeys & resources. Where this cannot be achieved, Patient Transport for discharges may


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be booked on the day, but clear instructions must be provided regarding the patients ‘Ready to Collect’ time; NSL’s standard waiting time is a maximum of 15 minutes.

DISCHARGE LOUNGE’s

Discharge Lounges are established on the QEQMH and WHH site. At KCH there will be a seasonal discharge lounge established in Harbledown Ward Day Room for February and March 2014. To ensure beds are available earlier in the day to maintain patient flow through A&E, every planned discharge must be assessed with a view to utilising the Discharge Lounge, therefore discharges directly from inpatient wards should be by exception (as per patient safety).

REPORTABLE DELAYED TRANSFERS OF CARE

The impact of reportable DTOC’s on the overall adult bed base varies dependant on the level of patients experiencing delay for whatever reason. Based on an average of 45 reportable DTOC’s per week Trust-wide, the impact equates to 6% of the total acute adult bed base.

NB: ITU and Maternity beds are excluded, as patients cannot be out-lied into these areas; however Coronary Care and other specialist beds such as Renal, are used and therefore have been included within this bed base.

During the Winter months (2012/13), the average reportable DTOC’s were reaching 70 per week, Trust-wide, meaning that over 9% of the acute adult bed base was ‘unavailable’ to manage emergency and elective patient flow. EKHUFT know therefore, that once any of the acute sites reach a level of 20 reportable DTOC’s, the adult bed base is under pressure and contingency beds are likely to be required to maintain flow.

NB: If this internal pressure occurs simultaneously with an unexpected surge in Emergency activity, EKHUFT are likely to escalate into a Business Continuity Event.

These pressures are further exacerbated when factoring in the ‘active DRS caseload’ of patients. These patients are either medically stable for transfer / discharge but are within established response timelines, are patients that are within a three day period prior to their estimated discharge date (EDD), or are patients awaiting transfer to a tertiary hospital (London). Once the active caseload Trust-wide reaches 175 patients, this reflects 20% of the acute adult bed base, placing significant pressures on patient flow which can ultimately impact on achievement of the A&E Clinical Quality Indicators and 18 week Elective pathways of care. This pressure will almost certainly place the Trust at status red or above.

Increases in Reportable DTOC’s are reasonably predictable with spikes usually occurring within 1-2 weeks of extended school holidays (see graph 5 below)

Graph 5: Weekly Trust-wide Reportable DTOC’s (Jan 12 – Aug 13)


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It is anticipated that the additional Step Down capacity (80 beds), improved efficiency through existing bed base and increased focus on Admission Avoidance and Facilitated Discharge will ensure that the number of Reportable DTOC’s reduce, in addition to the significant impact they have on efficient patient flow.

Elective Admissions

Wherever possible, Elective activity should be maintained across the Trust to ensure patient treatment and safety is maintained. The Surgical Division according to the seasonal plan may be required to provide a 10 bedded area to support the flow of 23hrs cases for Surgical activity to enable conversion from 1-2 day LOS to 23hr LOS, thereby releasing inpatient beds without the need to cancel surgery. These are included as pathway change within our efficiency group.

Escalation Framework

Escalation Process

Through monitoring the key indicators on SHREWD and /or via a notification from a provider, the Urgent Care Programme Manager on behalf of the 4 CCGs in East Kent shall trigger and chair a Teleconference call. Dependent on immediate and proposed impact on the local health economy, the Chair of the Daily Teleconference shall decide whether to monitor the situation or trigger Daily Teleconference calls (if not already initiated for the winter period). The Chair shall ascertain whether or not the triggers (in 7.2 below and in the NHS South of England Escalation Framework) identified have been met, if so, Amber escalation shall be declared and appropriate actions taken. The Chair shall brief the on-call director who shall then decide whether to either be kept informed of the situation or participate in the Daily Operational teleconference.

Escalation to Red will occur if all actions outlined in Amber have been taken and the system is still continuing to experience an increasing or unacceptable level of pressure. The Chair of the Teleconference shall manage all activities at Trigger level Amber; the on-call-director shall take the lead at Trigger level Red.

The same process shall be followed to move from Red Escalation to Black. If all escalation levels have been triggered and all actions taken and the local health economy is still experiencing increasing or unacceptable system pressure, a provider should implement their Business Continuity Plans to alleviate some of the pressure. This should be reported through the daily teleconference call and a decision should then be made by all CCGs within East Kent on if a system wide Major Incident should be declared which would result in all providers to invoked and implement their respective Major Incident Plans.

Table 9 below sets out the whole systems governance and accountability for Level 1 & 2 incidents between the NHS England South Escalation Framework, different Surge Capacity Plans and how these relate to Urgent Care Boards, CCGs and providers

Table 9: NHS England South Escalation Framework


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NHS England South - Escalation Framework (May 2013)

To ensure consistency in reporting of RAG Status, NHS England South has provided Escalation Trigger levels for all Organisations and recommended actions for acute Trusts (see Matrix below).

These actions have been endorsed by the Local Area Team and the East Kent Seasonal Pressures Group, however EKHUFT have reiterated that Surgery will only be cancelled if it will release acute inpatients beds or enable required levels of Consultant presence on site (up to 24/7). Wherever possible, Elective Surgery will be maintained through Day Surgery and 23hr Surgical units. Cancer and clinically Urgent Surgery will not be cancelled, in order to maintain patient safety. The Trust will also maintain vigilance with regards achievement of 18 weeks, wherever possible, without compromising patient care


Responsible Organisation

Framework or Plan NHS England EPRR Framework Incident Level

NHS England NHS England South Escalation Framework

Level 2: An incident across local boundary requiring Area Team co-ordination

CCG Urgent Care Board Surge Capacity Plan

Level 1: An incident that can be managed by local organisations co-ordinated by local CCG

Providers Provider Surge Capacity Plans

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1 CSSD Seasonal Plan NEW 23 10 13 MC Approved (1)

Documents

Transcript of 1 CSSD Seasonal Plan NEW 23 10 13 MC Approved (1)