SOLUTION: Escalation Framework | My Assignment Tutor

Version 2.0 May 2013NHS EnglandSouthEscalationFrameworkVersion 2.0 May 2013Version 2.0 May 2013Escalation FrameworkNHS England SouthFirst published: April 2013: Version 1.0Updated: May 2013: Version 2.0Prepared by Gail King, Head of EPRR, Thames Valley Area Team andCatherine Hartz, EPLO, Buckinghamshire & Berkshire CCGsVersion 2.0 May 2013Contents1. INTRODUCTION…………………………………………………………………………………………………………….12. GUIDANCE FOR USE OF THE NHS ENGLAND-SOUTH ESCALATION FRAMEWORK……….13. NHS ENGLAND–SOUTH EXPECTATIONS OF LOCAL HEALTH ECONOMIES (LHES)……….24. MANDATORY PROCEDURES ON DECLARATION OF ‘BLACK’ STATUS………………………….34.1 AT SINGLE ORGANISATIONAL LEVEL …………………………………………………………………………………..3APPENDIX 1………………………………………………………………………………………………………………………….7ESCALATION COMMUNICATION FLOW CHART ……………………………………………………………………………….7APPENDIX 2………………………………………………………………………………………………………………………….8ESCALATION STATUS TRIGGERS ………………………………………………………………………………………………8APPENDIX 3A ……………………………………………………………………………………………………………………..12ACTIONS TAKEN AT AMBER (LEVEL 2) ………………………………………………………………………………………12APPENDIX 3B ……………………………………………………………………………………………………………………..14ACTIONS TAKEN AT RED (LEVEL 3) ………………………………………………………………………………………….14APPENDIX 3C ……………………………………………………………………………………………………………………..17ACTIONS TO BE TAKEN BEFORE ESCALATING TO ‘BLACK’ (LEVEL 4)………………………………………………17APPENDIX 3D ……………………………………………………………………………………………………………………..19ACTIONS TO BE TAKEN AT ‘BLACK’ (LEVEL 4)……………………………………………………………………………..19APPENDIX 4– IMPLEMENTATION OF A DIVERT ……………………………………………………………………………………..21APPENDIX 5– SIRI GUIDANCE …………………………………………………………………………………………………………….22APPENDIX 6 …………………………………………………………………………………………………………………………26KEY DEFINITIONS ………………………………………………………………………………………………………………..26APPENDIX 7………………………………………………………………………………………………………………………..28REVERSE TRIAGE ALGORITHM ……………………………………………………………………………………………….28Page 1 of 26Version 2.0 May 20131. IntroductionThis NHS England-South Escalation Framework sets out the procedures acrossNHS England-South to manage day to day variations in demand across the healthand social care system as well as the procedures for managing significant surges indemand. The purpose is to ensure that all partners, health and social care have amechanism to access additional short term capacity in the right part of the systemwhen demand peaks.This framework provides a consistent and co-ordinated approach to themanagement of pressures in NHS England-South’s acute and emergency caresystems, where local escalation triggers have already been applied and yet thepressure on capacity and the need to mitigate against the possibility ofcompromising patient care, require additional support from other service providers,including those which cross Clinical Commissioning Group (CCG) and Area Teamboundaries.This framework is designed for managers and clinicians involved in managingcapacity and patient throughput at a time of excess demand on NHS emergency andacute care services.This document is to be circulated to all staff who participate in such events, toprovide a practical working reference tool for all parties, thereby aiding co-ordination,communication and implementation of the appropriate actions in each organisation.2. Guidance for use of the NHS England-South Escalation Framework1. Use of this escalation framework is triggered where a Local Health Economy(LHE) experiences pressure such that despite all actions by the whole system toreduce that pressure external assistance is needed.2. This should only be in the most exceptional circumstances.3. Each system must define and agree triggers, actions, roles and responsibilitiesthroughout the escalation process including those which trigger a request forexternal assistance.4. The point at which a LHE deems that external assistance is required must beclearly defined and fully understood by all relevant managers and clinicians.5. Only when all de-escalation measures have been exhausted, will organisationsact from a position of last resort in response to the most unusual and exceptionalpressures to access capacity beyond LHE boundaries. In such circumstancesdecisions must be made with the overall best interests of patients and service usersas the top priority.Page 2 of 26Version 2.0 May 20136. The trigger for request for external assistance will be the declaration by the LHE ofwhole system ‘Black’ status.7. The implementation of external support must be agreed by all relevant parties,following which the LHE shall inform its own Area Team.8. Contact with the local Area Team will be initiated and maintained by the executivedirector on call for the lead commissioners of the LHE.9. Following a divert the LHE to which assistance was given must raise a SeriousIncident Requiring Investigation (SIRI) and undertake a full investigation, root causeanalysis and lessons learnt exercise.3. NHS England–South expectations of Local Health Economies(LHEs)Individual LHEs are expected to manage the escalation and de-escalation processesat local level and this framework does not seek to prescribe the detail of escalationprocesses and management. Whole systems teleconferences can be a useful way toco-ordinate a response to an escalating situation and can be managed at thediscretion of individual organisations. The scheduling of these can be part ofbusiness as usual systems resilience processes or when deemed necessary. It mustbe noted however that escalation to ‘Black’ status or the threat of such escalation atLHE or organisational level automatically triggers mandatory action within thisframework. Please refer to section 4 below. The following points should beaddressed as part of the process of system resilience and escalation frameworkplanning:1. Each LHE partner organisation within a LHE must have a robust, up-to-date localescalation plan signed off at Board level which dovetails into up-to-date overarchingLHE wide plans.2. Each acute trust is also required to have an ambulance services handover planand to comply with its obligations under the plan.3. Escalation planning must also form an integral part of system resilience and winterplanning of all partner organisations in the LHE, throughout all community andhospital care settings, with due regard for emergency, elective and on-going patient /service user care.4. It is expected that all local escalation plans will have clearly defined escalationtriggers, with actions to be taken to avoid the need for escalation and to enable deescalation as quickly as possible. Example triggers (including to ‘Black’ status),actions and further information for escalation in the Green-Amber-Red range areavailable in the appendices of this document. It should be noted that these are notexhaustive and are for information only; they are not prescriptive. Please note thatPage 3 of 26Version 2.0 May 2013the decision to escalate to ‘Black’ status or the threat of such decision automaticallyinvokes mandatory action within this framework. Please refer to Section 4 below.5. Special action will be required where an A&E department has to close (asopposed to not being able to receive new attenders) as it will not be able to offerresuscitation facilities.6. There must be clear identification of the system leaders (including identification oforganisation, role/s and responsibilities) who will oversee all levels of escalation,especially those where whole LHE action is needed to avoid or mitigate pressure,and where external support might be required.7. Where an organisation and / or a LHE has undergone escalation of status it isexpected that the executive directors of the lead commissioners shall lead the deescalation process once review shows suitably reduced pressure.Additional points for consideration:Timely and fit for purpose information is crucial to the management of theescalation and de-escalation process.Consideration must be given to the repatriation of patients transferred or initiallytaken to a receiving organisation.It is appropriate for an executive level director in each partner organisation tohold the responsibility for ensuring that escalation plans are actioned andreviewed.All escalation plans relating to a given LHE should be readily available to allrelevant managers and clinicians. All should have a clear, currentunderstanding of the processes.The impact on other A&E facilities due to the closure of a Minor Injuries Unit(from a knock on effect) must be considered.A stringent response to all ambulance handover delays is appropriate.4. Mandatory procedures on declaration of ‘Black’ status4.1 At single organisational level1. Prior to declaration of ‘Black’ status, all actions must be taken to reduce pressureand all system partners must be fully involved in supporting the organisation at riskof this escalation. The expectation is that it would be extremely rare and the reasonsexceptional for an organisation to declare ‘Black’ status whilst any of the LHE partnerorganisations were reporting pressure less than Red level.2. Prior to the declaration of ‘Black’ status by an organisation the whole system mustensure that the following mandatory actions are implemented alongside all otherlocally defined actions:Page 4 of 26Version 2.0 May 2013a. Whole LHEAll local Green-Amber-Red escalation actions in placeExecutive directors from all partners have been involved in discussion andagree with escalation statusb. CommissionersContinue to co-ordinate communication and escalation response across thewhole systemExpedite additional capacity and increased support wherever possible(including voluntary and independent sector capacity)Make a risk based assessment of the best use of capacity and resourceacross the whole system and shift resources to best meet demand andmaintain patient safetyc. Acute TrustRoutine elective admissions have been cancelledUrgent elective admissions have been reviewed and, where possible,rescheduled or cancelledd. Community care providersAll possible capacity has been freed and redeployed to ease systemspressurese. Social CareContinue to expedite discharges, increase capacity and lower accessthresholds to prevent admission where possiblef. Primary CareAll possible actions are being taken ongoing to alleviate system pressuresg. Mental health trustContinue to expedite discharges, increase capacity and lower accessthresholds to prevent admission where possibleh. Ambulance trustReview current GP Admissions with GPs to ensure safe standards of care topatientsReview on going 111 advice strategyCall in additional operational & communications centre staff and additionalresources such as the voluntary aid societies, private ambulance servicesReview all long-distance inter-hospital transfersEnsure all Ambulance Trust PTS and private providers resources are directedto maintaining patient flow across the whole system. Ensure appropriate coordination with other PTS providers where other provision is commissionedEnsure direct communication between ambulance trust executive on calldirector and wider health system executives is under wayPage 5 of 26Version 2.0 May 2013If emergency response is severely compromised consider use of MajorIncident proceduresUtilise actions from REAP plan to create capacity where possiblei. PTS serviceEnsure all capacity is being utilised to alleviate system pressures3. Where escalation to organisational ‘Black’ status cannot be averted, the executivedirector on call for the organisation declaring ‘Black’ status must immediatelyinform the executive director on call for the CCG.4. The executive director on call for the CCG must then immediately inform theappropriate Area Team.5. Immediately following declaration of ‘Black’ status the following actions aremandatory, alongside other locally defined actions:a. Whole system:Continue to explore all local Green-Amber-Red escalation actions as well asthose taken to avert further escalation to ‘Black’ status and take decisiveaction to alleviate pressureContribute to system-wide communications to update regularly on status oforganisations (see flow chart)Provide mutual aid of staff and services across the local health economy asappropriatePost escalation: Contribute to the Root Cause Analysis and lessons learntprocess through the SIRI investigationb. CommissionersNotify Area Team of alert statusIn conjunction with Ambulance Service and Acute Trust the commissionersact as the Hub of communication for all partiesEnsure all system partners are informed of stand-down of ‘Black’ status oncethis information is received from the organisation previously at ‘Black’ statusand oversee further de-escalation processesPost escalation: Lead and complete Root Cause Analysis and Lessons Learntprocess in accordance with SIRI processc. Acute trustA&E consultant to be present in A&E department 24/7Consultant Physician to be present on wards or in A&E department 24/7Surgical consultant to be present on wards, in theatre or in A&E department24/7Assign appropriate qualified clinician to manage care of patients awaitinghandover from ambulance service to enable ambulance crews to be releasedExecutive director to be on site 24/7Page 6 of 26Version 2.0 May 2013Any request to divert patients from A&E must be initiated by the Acute Trustwho having exhausted all internal divert options must contact the CCG torequest a divert to neighbouring trusts whether these are in or out of region.Refer to divert flow chart – Appendix 4d. Ambulance trustAlert neighbouring trusts to seek appropriate support as dictated bycircumstances of ‘Black’ AlertContinue to make a risk based assessment of the best use of capacity andresource across the whole system and shift resources to best meet demandand maintain patient safetyReview the escalation status every 2 hours and communicate this across thesystem6. The organisation which has declared ‘Black’ status must report a SIRI on theSTEIS system.Page 7 of 26Version 2.0 May 2013Appendix 1Escalation communication flow chartPage 8 of 26Version 2.0 May 2013Appendix 2Escalation Status Triggers Acute TrustAmbulanceServiceCommunity CarePrimary CareSocial ServicesOtherActionGreen(Level 1)Capacity availableto meet expecteddemandGood patient flowthrough A&E andother access pointsA&E 4 hour targetconsistently beingmetOffloadingambulanceswithin 15 minutes.Ambulance callvolumes withinexpected levelsResourcingEscalatory ActionPlan (REAP) level1Communitycapacity availableacross system.Patterns ofservice andacceptable levelsof capacity arefor localdeterminationOut of Hours(OOH) servicedemand withinexpected levelsGP attendanceswithin expectedlevels withappointmentavailabilitysufficient to meetdemandSocial servicesable to facilitateplacements, carepackages anddischarges fromacute care andother hospital andcommunity basedsettingsNHS Direct and /or 111 callvolume withinexpected levelsMonitor capacityacross wholesystem and takeroutine action tomanage demandand preventescalation to AmberAt least 5 of the following across the local Health system in more than one organisationAmber(Level 2)Beds available,but short of bedsin 1 main area *Anticipatedpressure onmaintaining A&E 4hour targetAnticipatedpressure infacilitatingambulancehandoversDischarges belowexpected normSlow patient flowthrough A&E,Delaysbreaching 30minuteturnaround timeAmbulancedemandbreachingpredicted peaksREAP level 2and 3Someunexpectedreduced staffingnumbers (due toe.g. sickness,weatherPatients incommunity and /or acute settingswaiting forcommunity carecapacityLack of medicalcover forcommunity bedsInfection controlissuesSome unexpectedreduced staffingnumbers (due toe.g. sickness,weatherGP attendanceshigher thanexpected levelsOOH servicedemand is aboveexpected levelsSomeunexpectedreduced staffingnumbers (due toe.g. sickness,weatherconditions)Patients incommunity and /or acute settingswaiting for socialservices capacitySomeunexpectedreduced staffingnumbers (due toe.g. sickness,weatherconditions)Rising NHSDirect and / or111 call volumeabove normallevelsSurveillanceinformationsuggests anincrease indemandWeatherwarnings suggesta significantincrease indemandThe systemimplements allnecessary actionswithin organisationsto increase capacityand improve flow Page 9 of 26Version 2.0 May 2013 Assessment UnitsSome unexpectedreduced staffingnumbers (due toe.g. sickness,weatherconditions) inareas where thiscauses increasedpressure onpatient flowInfection controlissuesconditions)conditions)At least 5 of the following across the local Health system in more than one organisationRed(Level 3)Actions at Amberfailed to delivercapacityLack of bedsacross the TrustPredicteddischarges 8 hrs.Unexpected reducedstaffing numbers(due to e.g. sickness,weather conditions)in areas where thiscauses increasedpressure on patientCat A responsetarget