Full Capacity Policy

FULL CAPACITY POLICY

Version / 2
Name of responsible (ratifying) committee / Senior Management Team
Date ratified / 17 January 2018
Document Manager (job title) / Chief Operating Officer
Date issued / 19 February 2018
Review date / 16 January 2019
Electronic location / Management Policies
Related Procedural Documents / Escalation Policy
Standard Operating Procedure for the Prevention of 12 hour trolley waits
Key Words (to aid with searching) / Escalation, Beds, ED and Critical Incident

Version Tracking

Version / Date Ratified / Brief Summary of Changes / Author
2 / 17/01/2018 / Amendments to triggers and Critical Incident actions
Staff health and wellbeing / Liz Hall
1.2 / 15/06/2016 / Chair’s action to extend review date / -
1.1 / 05/02/2016 / Amendments to Triggers for Activation. Addition of areas to use as one up / Carla Bramhall
1.0 / 07/10/2015 / New Trust Policy / Gavin MacDonald

CONTENTS

1. INTRODUCTION 4

2. PURPOSE 4

3. SCOPE 5

4. TRIGGERS FOR ACTIVATION 5

5. ACTIVATING THE POLICY 6

6. POLICY ACTIVATED 6

7. TRANSFER OF PATIENTS TO THE WARDS 7

8. CRITERIA FOR TRANSFER TO THE WARDS (WHEN NO BED IS AVAILABLE) 7

9. ADDITIONAL NURSING SUPPORT 7

10. NURSES SENT TO THE EMERGENCY DEPARTMENT/AMU 8

11. CRITICAL INTERNAL INCIDENT 8

12. STAFF HEALTH AND WELLBEING 9

13. DE-ESCALATION OF FULL CAPACITY POLICY 10

14. MONITORING OF COMPLIANCE 10

APPENDIX 1: Wards suitable for One Up and Step- Down 11

APPENDIX 2 – Safe Staffing Levels in ED (NICE Guidance) 12

Equality Impact Screening Tool 13

QUICK REFERENCE GUIDE

This policy must be followed in full when developing or reviewing and amending Trust procedural documents.

For quick reference the guide below is a summary of actions required. This does not negate the need for the document author and others involved in the process to be aware of and follow the detail of this policy.

1. Scope – detailing Level 0 – 3 patients to allow staff utilising this policy to identify who this applies to

2. Activation Triggers:

The Full Capacity Policy will be activated when 3 of the following criteria are met:

· Trust escalation status is OPEL 3 approaching OPEL 4

· Emergency Department (ED) escalation status is OPEL 3 approaching OPEL 4

· More than 15 referred patients in ED waiting for a ward bed at 8am

· 5 patients have exceeded 8 hours from attendance

· Risk of breaching 12 hour DTAs

· No care space in the ED and patients starting to queue in HALO

· More than 6 ambulances being held for more than 30 minutes

· There is no resus capacity due to 4 patients who are unable to move out due to acuity

· ED attendances are greater than 20 per hour and there is no care space

· Additional capacity areas used in OPEL 3 and /or OPEL 4 are full

· All High Care Units, Stroke and Intensive Care are full

3. Policy contains details of how to activate the policy when 3 or more of the above are met

4. This document describes the actions to take when policy activated, including ward and ED

Responsibilities

5. Highlights how to identify which patients can safely transfer and criteria

6. Additional Nursing Support plan including Nurses sent to ED to assist

7. Additional actions to cohort in AMU and ED when in Critical Internal Incident

8. De escalation process

NB ‘In the event of an infection outbreak, flu pandemic or major incident, the Trust recognises that it may not be possible to adhere to all aspects of this document. In such circumstances, staff should take advice from their manager and all possible action must be taken to maintain ongoing patient and staff safety’

1. INTRODUCTION

The maintenance of patient safety, the provision of high quality care and a good patient experience are the organisation’s strategic priorities at all times. Organisational pressures and operational workload can limit the ability of key areas to provide this along with expected patterns of care. When this pressure stops normal daily functioning, it significantly increases the risk of failure in care occurring.

In the context of the Trust operating with a deteriorating escalation status the Trust needs to operate differently. Balancing and sharing risk is part of the organisation’s action in discharging its duty of care to patients. Allocating one extra patient to suitable wards by having those wards stepping down their next most suitable patient for discharge and allocating one extra patient to suitable wards will share this risk across the Trust and reduces the risk within the Urgent Care Pathway.

Unlike many departments the Emergency Department (ED) is unable to cap demand and close its doors when all available patient care spaces are occupied. The risk of serious incidents happening not only increases with every additional patient that arrives over and above capacity but this is concentrated in one geographical area. This represents a significant risk and as such the risk needs to be shared across the whole organisation. This protocol describes the mandated actions necessary when the ED (as the main point of entry for emergency admissions) has more patients than it can potentially safely care for.

This policy is a default list of actions to be taken when the Trust is operating at full capacity. It is not necessarily exhaustive. Other measures or situations could still affect the operational safety and are not specifically described here and so should not be excluded. It should also be appreciated that some measures should be adopted early at relatively lower levels of escalation in order to prevent the risks from occurring in the first place.

2. PURPOSE

· To maintain the safety of patients and staff in ED.

· To facilitate the admission of patients held in ED, SAU or MAU into awaiting acute beds in downstream wards.

· To enable the normal functioning of ED.

The Emergency Department (ED) at Queen Alexandra Hospital sees on average more than 300 patients per day depending upon the time of week, season or weather. The Majors (adult) department has the capacity to care for patients in 37 trolley /bed spaces across and 8 chairs across Majors and Resus.

· 6 Bays and 4 chairs PITSTOP

· 6 Bays and 4 Chairs Majors 2

· 18 in Majors

· 3 isolation cubicles on Majors 1

· 4 in Resuscitation

When ED has reached its’ maximum number of patients (or is rapidly approaching this maximum) the safety of the patients and staff is at risk. When ED is on OPEL 4 escalation status, normal functioning of the department is not possible.

3. SCOPE

· Adult patients only who are level 0/1 care (see table 1 for classification as per the NQB Safer Nursing Care Tool recommendations).

· Level 2/3 patients and paediatrics, incluidng 16-18 year olds are excluded under this policy

· Any patients requiring isolation will not be transferred under this Policy.

Table 1 Definitions of NQB Safer Nursing Care Tool Four Levels of Care.

Level 0 / Patients whose needs can be met through normal ward care
Level 1 / Patients at risk of their condition deteriorating, or higher levels of care whose needs can be met on advice and support from the critical care team.
Level 2 / Patients requiring more detailed observation or intervention, single failing organ system or postoperative care, and higher levels of care.
Level 3 / Patients requiring advanced respiratory support alone or basic respiratory support together with support of at least two organ systems. This level includes all complex patients requiring support for multi-organ failure.

4. TRIGGERS FOR ACTIVATION

The Full Capacity Policy will be activated when 3 of the following criteria are met:

· Trust escalation status is OPEL 3 approaching OPEL 4

· Emergency Department (ED) escalation status is OPEL 3 approaching OPEL 4

· More than 15 referred patients in ED waiting for a ward bed at 8am

· 5 patients have exceeded 8 hours from attendance

· Risk of breaching 12 hour DTAs

· No care space in the ED and patients starting to queue in HALO

· More than 6 ambulances being held for more than 30 minutes

· There is no resus capacity due to 4 patients who are unable to move out due to acuity

· ED attendances are greater than 20 per hour and there is no care space

· Additional capacity areas used in OPEL 3 and /or OPEL 4 are full

· All High Care Units, Stroke and Intensive Care are full

This full capacity policy will be instigated if 3 of the above criteria are met if this is deemed clinically necessary for safety reasons in conjunction with the Consultant In charge of ED, the Chief Operating Officer, Director of Operations for Unscheduled Care or Director On-Call out of hours. Examples of such situations include considerations of overall levels of acuity of illness in the Emergency Department regardless of absolute numbers or where there are reduced staffing levels.

5. ACTIVATING THE POLICY

The decision to activate the ‘Full Capacity’ policy is not made by one individual alone but made together with the clinical team and the Chief Operating Officer or Director of Operations for Urgent Care with the Chief Nurse and Medical Director or Director on Call out of hours.

The policy has four key elements, any or all of which can be activated independently depending on the circumstances In the Trust. These elements are:

1. Transfer of triaged patients from AMU to the wards into an empty bed created by going one up and/or stepping down a patient who is being discharged within 4 hours

2. Transfer of patients from ED directly to admitting wards at 8am once post-taked by the admitting team or having had senior review by the medical SpR On Call for medical patients, again into an empty bed created by going one up and/or stepping down a patient who is being discharged

3. Transfer of patients from ED to AMU once capacity created by element 1

4. Provision of additional transfer teams to facilitate the urgent movement from the Full Capacity rota and /or research nurses/theatre staff/non-patient facing nurses/corporate nurses (available Monday to Friday in core hours).

This decision should be considered seven days a week and should be taken as early in the day as possible, ideally at the 08:30 or 1045 operations meeting. This decision will be taken whilst balancing the clinical risk, staffing levels and the time of day.

The policy should not be implemented after 6 pm without full planning taking place during the day. However, only two wards have the ability to go ‘one up’ overnight (E2 and E3) as detailed in Appendix 1. Any deviation from this must be authorized by the Chief Nurse or the Chief Operating Officer.

6. POLICY ACTIVATED

Appropriate ED/AMU patients who have been post-taked with a clear decision to admit and triaged to a Speciality without a bed being immediately available must be identified by ED/ AMU Coordinators in conjunction with the Consultants. There will be a clear expectation that a bed will become available within the next 4 hours.

The following conditions must be met:

· The areas for one up and step down decisions , as outlined in Appendix 1, must be based on a risk assessment by the Head of Nursing/Chief of Service in hours and Duty Matron/ On Call Manager out of Hours

· The SAFER ward board rounds/huddles are started at 0800 and attended by the nurse-in-charge, Consultant +/- therapist (when available) who will identify the definite discharges for the day. It is from these definite discharges that the patients will be identified to vacate their beds if needed. Not all areas start ward rounds at 8am so there will be variation.

· There is an expectation that the identified bed on that ward should become available within a 4 hour time window.

· This does not include high care beds.

· The bed is likely to become available through the discharge of a patient who is able to sit out in an arm-chair whilst they wait. Ideally the Discharge Lounge should be used but it is acknowledged that sometimes there are clinical reasons why this is not the case. The nurse-in-charge of the ward, supported by the Matron/Head of Nursing, makes the final decision as to who is nursed where and how, and which patient (“incoming” or “outgoing”) sits out. Wards who are ‘red’ for staffing should be excluded unless additional support can be provided

· Only one patient at a time per ward will be allocated.

· The patient will be assisted in vacating their bed within 15 minutes of the request to transfer a patient from ED/AMU

· Each ward will nominate in advance where and how such patients will be nursed and this arrangement will be approved, having first considered and mitigated any significant risks for each ward, by the Head of Nursing.

· A Registered Nurse or Support Worker dependent on the patient’s acuity/dependency must be clearly identified to look after the patient in a suitable area whilst awaiting discharge.