Managing Surge CapacityManaging Surge Capacity

Mark WilliamsMark Williams--JonesJones(Clinical Nurse Manager ICU, Glan Clwyd)(Clinical Nurse Manager ICU, Glan Clwyd)

Sue OSue O’’KeeffeKeeffe(Critical Care Network Manager, North Wales)(Critical Care Network Manager, North Wales)

North WalesNorth WalesThree hospitals (DGHs) 65miles apartThree hospitals (DGHs) 65miles apart

North Wales Critical Care BedsNorth Wales Critical Care Beds

Normal bed stock Normal bed stock –– 32 Critical Care beds32 Critical Care bedsTwo combined ICU/HDUsTwo combined ICU/HDUs

1x 13 beds, 1x 8 beds1x 13 beds, 1x 8 beds

One ICU x8 bedsOne ICU x8 bedsOne SHDU (Surgeon led) x3 bedsOne SHDU (Surgeon led) x3 beds

NW CC beds 2.78 per 100,000 populationNW CC beds 2.78 per 100,000 populationHuge additional Huge additional ‘‘holidayholiday’’ population (staying 11.5m nights)population (staying 11.5m nights)

Wales CC beds 3.2 per 100,000 populationWales CC beds 3.2 per 100,000 populationEngland CC beds 4.0 per 100,000 populationEngland CC beds 4.0 per 100,000 population

Pandemic PlanningPandemic Planning

2009/10 saw a huge amount of planning 2009/10 saw a huge amount of planning for the impending impact on CC from the for the impending impact on CC from the pandemicpandemic

Fit TestingFit TestingTraining Training

Recovery and ODP staff Recovery and ODP staff Paediatric CC skillsPaediatric CC skills

A and B lists compiledA and B lists compiled

Fit Testing Picture

Network PlansNetwork PlansNetwork Emergency plans Network Emergency plans Major incidentMajor incidentUnplanned closure of a unitUnplanned closure of a unitPandemic Flu Pandemic Flu includingincludingpaediatric competenciespaediatric competencies

High level; little operational detailHigh level; little operational detail

Pandemic PlansPandemic PlansEmergence of H1N1 in 2009Emergence of H1N1 in 2009………………..Pandemic Plans developed Pandemic Plans developed including;including;Regional Escalation plan to Regional Escalation plan to optimise collective capacity optimise collective capacity (phased response)(phased response)

O.R. closure O.R. closure ++ to free up staff to free up staff Triage tool Triage tool (for Status 2/3 + Exec (for Status 2/3 + Exec authoriauthori--sationsation))

Winter 2010/11Winter 2010/11

Reviewed plans alongside guidance from Reviewed plans alongside guidance from WG WG

““review organisational readinessreview organisational readiness””Revisited fit testingRevisited fit testingAttempted to undertake acute staff Attempted to undertake acute staff training.training.BUTBUT…… not a Pandemic so impetus not as not a Pandemic so impetus not as noted noted

The RealityThe RealityNeighbouring regions, North West England, Neighbouring regions, North West England, started to be badly affected.started to be badly affected.

Commenced, in earnest, two weeks before ChristmasCommenced, in earnest, two weeks before ChristmasLimiting potential for Transferring out of North WalesLimiting potential for Transferring out of North Wales

11stst January North West commenced stage 2 January North West commenced stage 2 escalationescalation

Opened cardiac beds into the general bed stockOpened cardiac beds into the general bed stockStopped all elective inpatient surgery Stopped all elective inpatient surgery Opened ECMO bedsOpened ECMO beds

Neighbouring NetworksNeighbouring Networks

North WalesNorth Wales

0123456789

10W

k 46

21/

11/2

010

Wk

47 2

8/11

/201

0

Wk

48 0

5/12

/201

0

Wk

49 1

2/12

/201

0

Wk

50 1

9/12

/201

0

Wk

51 2

6/12

/201

0

Wk

52 0

2/01

/201

1

Wk

1 09

/01/

2011

Wk

2 16

/01/

2011

Wk

3 23

/01/

2011

Wk

4 30

/01/

2011

Wk

5 06

/02/

2011

Wk

6 13

/02/

2011

Date of Admission (W/E)

Num

ber o

f Adm

issi

ons

BangorGlan ClwydWrexham

Winter 2010/11Winter 2010/11

29 patients confirmed H1N129 patients confirmed H1N1Evenly spread across three unitsEvenly spread across three units

2 For ECMO2 For ECMO1x Glenfield, 1x Wythenshawe1x Glenfield, 1x Wythenshawe

3 HFOV 3 HFOV (another pt randomised to (another pt randomised to conventional conventional --OSCAR)OSCAR)

RealityReality

Usual Winter demandsUsual Winter demands…….+.+Slow creep of H1N1, impact felt in CC Slow creep of H1N1, impact felt in CC primarily rather than pressure on CC from primarily rather than pressure on CC from wardswardsSurgery continued untilSurgery continued until

CC patients overflowing into recovery CC patients overflowing into recovery Numerous cancelled ops due to lack of a CC Numerous cancelled ops due to lack of a CC bed bed

RealisationRealisation--positivespositives………………Exec and CPG supportExec and CPG supportManaged situation BCUHB wideManaged situation BCUHB wideOvertime ban liftedOvertime ban liftedRecovery and Theatre staff supportRecovery and Theatre staff supportNonNon--USC cases cancelledUSC cases cancelled

USC cases reviewed daily/managed within USC cases reviewed daily/managed within escalation escalation

Additional equipment purchasedAdditional equipment purchasedConsumables and equipment sharingConsumables and equipment sharing

RealisationRealisation--positivespositives

Twice daily conference calls (+w/e) across Twice daily conference calls (+w/e) across three hospitalsthree hospitals

CC staff (Medical and nursing)CC staff (Medical and nursing)Theatre & Recovery staffTheatre & Recovery staffManagersManagersNetwork staffNetwork staff

Demands, LOC, H1N1 pts., Pharmacy, Demands, LOC, H1N1 pts., Pharmacy, USCs, Equipment, DToCs, Staffing + USCs, Equipment, DToCs, Staffing + Escalation potentialEscalation potential

What could be improved?What could be improved?

Earlier recognition of the problem Earlier recognition of the problem Because not a Pandemic not picked up as Because not a Pandemic not picked up as quick quick –– slow creep, slow realisationslow creep, slow realisation

Uniform approach to escalation soonerUniform approach to escalation soonerSpeedier decision re cancelling surgerySpeedier decision re cancelling surgery

Had been a debate vis a vis reducing major Had been a debate vis a vis reducing major but increasing minor ops.but increasing minor ops.

WG to send correct masks!WG to send correct masks!

Lessons LearnedLessons Learned

CommunicationCommunicationCollaborationCollaborationLeadershipLeadershipCaution with equipment transfer!Caution with equipment transfer!

Can we do it?Can we do it?Requirement for Requirement for ““nonnon””Pandemic plans i.e. Generic Pandemic plans i.e. Generic Escalation for Escalation for ‘‘SurgeSurge’’Operational response to Operational response to unplanned increases in unplanned increases in demand for Critical Caredemand for Critical Care

Where neighbouring Where neighbouring Networks are experiencing Networks are experiencing similar demandssimilar demands

Escalation PlanEscalation PlanNormal rules of transfer apply Normal rules of transfer apply butbut pts will pts will not be transferred to accommodate surgerynot be transferred to accommodate surgeryShared managerial and clinical responsibility; Shared managerial and clinical responsibility; daily status reports (teleconferences)daily status reports (teleconferences)

Staffing, demands, equipment, etc.,Staffing, demands, equipment, etc.,Consideration for reducing elective/urgent Consideration for reducing elective/urgent surgerysurgeryProactively manage DToCsProactively manage DToCsConsumables, pharmaceuticalsConsumables, pharmaceuticals…………..

Critical Care Phased ResponseCritical Care Phased Response

• ‘Normal’ working• Critical Care beds available• Elective/planned admissions requiring Critical Care

continuing• Transfers accepted

GreenLevel 1

(Normal effect on services)

• Early signs of difficulty• ‘Normal’ Critical Care bed stock full (or nearing full

regionally)• Non-urgent surgery, requiring Critical Care,

cancelled• Careful consideration required for urgent

planned/elective surgery• No capacity for receiving transfers.

YellowLevel 2

(Moderate effect on services)

Critical Care Phased ResponseCritical Care Phased Response

• Severe/prolonged excess pressures requiring significant additional management

• ‘Normal’ Critical Care bed stock full and into ‘surge capacity’

• Decision of proceed with urgent surgery taken on a regional basis.

• Careful consideration required for continuing (non-ICU) routine in-patient surgery.

AmberLevel 3

(Severe effect on services)

• Extreme pressures requiring immediate and significant actions

• All surge beds and normal beds full (at 100% surge or beyond)

• No ventilation capacity available• All ventilated admissions will require transfer out

RedLevel 4

(Major disruption to services)

ChallengesChallenges……. . Implementing plans across NetworkImplementing plans across Network

No unit to work in isolation No unit to work in isolation -- normal rules of normal rules of transfer applytransfer apply

Tension of Tension of RRTsRRTs and [high] demandsand [high] demandsCollaborative working with other CPGsCollaborative working with other CPGs

Surgical CPG vis a vis cancelling surgerySurgical CPG vis a vis cancelling surgeryCommunicating/implementing plans Communicating/implementing plans throughout the whole hospital throughout the whole hospital

DToCsDToCs