County Durham and Darlington A&E Recovery and Improvement Plan

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20 Νοε 2013 (πριν από 3 χρόνια και 8 μήνες)

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1

29/05/2013

County Durham and Darlington
A&E Recovery and Improvement Plan

Incorporating:

NHS Darlington CCG

NHS North Durham CCG


NHS Durham Dales, Easington and Sedgefield CCG

NHS
County Durham and Darlington Foundation

Trust

(CDDFT)

Darlington Borough Council

Durham County Council


1.

Local Context


The Department of Health defines urgent and emergency care as the range of healthcare services available to people who need m
edical
advice, diagnosis and/or treatment quickly and unexpectedly. This could include, for e
xample, accident and emergency (A&E), walk
-
in and
minor injury and illness services. It could also include access to GP practices in hours, community care, transport provision

and social care as
well as more specific pathways e.g. poorly child.

There are s
ix urgent care centres across County Durham and Darlington, provided by CDDFT. These are: Darlington (Dr Piper House),
Peterlee, Seaham, University Hospital of North Durham (UHND), Bishop Auckland and Shotley Bridge. They are provided as part o
f the wider
communities cont
ract that was held by the PCT and now the three CCGs.

The Seaham site is open from 8am


6pm Monday to Friday only and UHND is open from 6pm


8am Monday to Friday and 24 hours at
weekends. The other four sites are open 24 hours, 7 days per

week. Access is via a walk in or through NHS 111 booked appointment

There is also a Durham and Darlington Urgent Care Transport service (DUCT) which is provided by NEAS. The service provides tr
ansport for
patients who require urgent care services but wou
ld otherwise be unable to access these services. In addition it supports discharges from
emergency departments, transport to and from nursing and care homes, delivery of medicines and transport of notes, specimens
etc. and the
service also provides the tra
nsport for urgent care centre clinicians to conduct home visits

NHS 111 has been rolled out across the three CCG areas via a five year contract with NEAS. The service has four lead CCGs for

the region
and the contract management is provided via NECS.

Previ
ous PCT Urgent Care strategy aimed to have a single point of access via NHS 111, provide transport for urgent care work via D
UCT and
look at where Urgent Care could be more integrated e.g. with A&E.

County D
urham and Darlington Foundation
Trust have iden
tified unscheduled care as a key priority for 2013/2014.


2

29/05/2013

The brief of the Blue River report was to undertake a stocktake position of the CCGs

reviewing activity and service provision; gathering ideas
of stakeholders; examining potential options and provi
de a summary report to take forward the next stage of the urgent care agenda and a
refresh of the Urgent Care Strategy (2013
-
2018). The report was published in March 2013 and recommended the establishment of a strategic
Programme Board for Urgent Care and
supporting

work strea
ms across Durham and Darlington.

A recent report from the Kings Fund
’Urgent and Emergency Care: A review for NHS South of England’ issued in March 2013 pulls together
learning from successful organisations and systems, and suggests how this can be used to improve and sustain performance in t
he future. The
report contains a helpful emergency care system checklist that includes an outline of current approaches and process
es that are known to
improve emergency care performance and where possible supported by research evidence.
The
Area Team

are planning an event on the 13
th

June 2013 to look at emergency care which will build on the report and consider potential approaches
and improvements.


2.

Response


In response to NHS England: Improving A&E Performance Gateway Ref. 00062,
NHS Darlington CCG
,
NHS North Durham CCG
,
NHS
Durham Dales, Easington and Sedgefield CCG

and
NHS County Durham and Darlington Foundation Trust
ha
ve colla
borated with Darlington
Borough Council and Durham County Council to produce

a recovery and improvement plan developed to ensure that a rapid and sustainable
improvement in emergency
and urgent care delivery

is achieved.


This plan
,

agreed by all key part
ners in hospitals, primary care, and local authorities
,
has been considered in 3 phases and demonstrates
actions for immediate recovery of A&E performance, winter planning measures and sustainable improvements including:

i.

An urgent recovery programme with
attention given to all factors which can help recover the standards and includes clear
performance management

ii.

A medium term approach to ensure delivery over the next winter period.

iii.

A long term plan setting out how the implementation of the urgent care str
ategy will ensure safe and sustainable services.


Key Barriers to Delivery:




Getting bed capacity and staffing right before Winter starts



Maintaining patient flow and reducing the number of internal diverts between UHND and DMH



Reducing ambulance handover delays in A&E



Ensuring a timely and efficient flow of patients through the Emergency Dept based on early Speciality review



Managing increased 999 activity to UHND in particular



Reducing delayed transfers of care, especially fo
r patients likely to need Continuing health care



Engaging Primary care more effectively in the management of operational pressures


3

29/05/2013




3.

Structure and Governance


The three CCGS have agreed and formed a Clinical Programme Board, which has three sub groups,
one of which is for Urgent and Emergency
care. It is anticipated that this sub group will evolve into the Urgent Care Board. The first meeting is due in early June an
d draft Terms of
Reference
are

attached as Appendix 1.
The urgent care board will be respo
nsible for monitoring this action

plan as well as oversight of the A&E
recovery

plan and prioritising the actions required. The Board will receive the dashboard of indicators described in
A
ppendix 3 and will adjust
the action plan accordingly. The Board wi
ll also be responsible for ensuring that sufficient time and resource is allocated to the work.


The Board will also ensure that actions take account of the multiple sources of information available including ECIST repor
ts from elsewhere in
the region and
recent

reports
from the Kings Fund
(
Urgent and Emergency Care: A review for NHS South of England’

-

March 2013
) and the
locally commissioned
Blue River report

(March 2013


a
review

of

activity and service provision; gathering ideas of stakeholders; examin
ing
potential options and provide
s

a summary report to take forward the next stage of the urgent care agenda
)


Risk and issues, including surges in demand such as winter (for example see Appendix 4) will be managed initially by the Urge
nt Care Board to
ens
ure mutual support is co
-
ordinated between health economies


This plan has been drawn up giving due consideration to the CDDFT response to the Francis report .The CDDFT Quality Review Gr
oup on the
7
th

May (Item 9.1) noted an update on actions to the Franc
is report agreed by the CDFT Board. The CCDFT Board are responsible for assuring
themselves that all risks are mitigated and all safeguarding measures are in place which comply with the Francis recommendati
ons.


4

29/05/2013






As part of the
Terms of R
eference for
this Urgent Care Board it will be responsible for monitoring the short term recovery plan as well as the
more sustainable long term actions and the Winter Plan.


In addition to this CDDFT have
recently

established a Front of House Task Group which has the

following remit:


5

29/05/2013




To c
ontinue to analyse and learn lessons to improve the performance of ED



To p
roduce a robust action plan to minimise delays in the patient pathway. In particular, it will reduce the number of 4
-
hour waits and
ambulance handover delays
thus improving the patient experience and outcomes.



To o
versee the implementation of changes to services evidenced by robust metrics.



To w
ork with external partners to ensure patients receive care in the right place at the right time by the right person,
first time.



To d
evelop pathways as alternative to ED


The full
draft Terms of Reference for this Group
are

attached as Appendix 2. The first meeting is
on

the 31
st

May and discussions will take
place around how this group will link into the Urgent Care Board.


A
set of metrics for this group have also been
drafted and will be discussed and agreed on 31
st

May

and are attached as Appendix 3
























6

29/05/2013

4.

Current performance




CDDFT
week
ending

Type 1
Attendance
s

Total
attendance
s

Type 1
breaches

Total
breaches

Type 1 4
hour
achievement

Total 4
hour
achieveme
nt

03/03/2013

2418

5521

383

383

84.16%

93.06%

10/03/2013

2321

5624

372

372

83.97%

93.39%

17/03/2013

2315

5379

223

223

90.37%

95.85%

24/03/2013

2204

5132

197

197

91.06%

96.16%

31/03/2013

2301

5257

115

115

95.00%

97.81%

07/04/2013

2500

5983

536

536

78.56%

91.04%

14/04/2013

2314

5350

554

554

76.06%

89.64%

21/04/2013

2410

5754

398

398

83.49%

93.08%

28/04/2013

2371

5570

372

372

84.31%

93.29%

05/05/2013

2379

5657

269

269

88.69%

95.24%

12/05/2013

2541

6135

303

303

88.08%

95.06%







7

29/05/2013









8

29/05/2013



The decrease in VB11Z No investigation with no significant treatment and corresponding increase in
VB09Z Category 1 investigation with category 1
-
2
treatment is likely to reflect improved coding by A&E providers.







9

29/05/2013



NB


there has been an issue
with

patients leaving A&E to be admitted
to

a ward
and
being mis
-
recorded with an outcome of “Discharged


did not require
any follow up treatment”
.



10

29/05/2013




Blue shading represents attendances during GP hours. That the UCC attendances peak more dramatically than A&E on Saturday, Su
nday and
Monday (when anec
dotally practices are busiest) suggests

these pronounced peaks might represent extra activity

arising

from
patients
not being
able to access GP services.







11

29/05/2013


5.
Recovery Plan for Quarter 1
approved by CDDFT



Q1 NON
-
ELECTIVE MEDICAL PATHWAY ACTION PLAN


IMMEDIATE MEASURES and ACTIONS


This
Action Plan summarises the operational and escalation actions we are taking in Q1 to achieve A&E target. It groups together r
outine,
operational and strategic actions which will have an impact in the remainder of Q1. It does not include actions which will
have an impact only in
the medium term. As such, it overlaps with and supplements the broader Action Plan

in this document

which has already been submitted and
which includes strategic and medium
-
term Actions. Unless otherwise stated all actions are alread
y in place as part of
CDDFT

escalation
planning.



Issue

Actions

Timescale

New Emergency
Department (ED) IT
system

Went live at UHND on 3rd April and at DMH on 30th April. Key
functionalities include:



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May, A&
E attendances have risen 5.5%
compared to the same period in 2012. Earlier this month the
number of daily breaches we could afford stood at 22. As at today
it has risen to 24.



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捩r捵c慴



12

29/05/2013

ED efficiency

Already in place as part of routine improvements or escalation
planning:



Altered Consultant rotas to ensure a senior presence in A&E for
longer in the day



Streaming of patients with a nurse
-
led minors stream



Co
-
location with the Urgent Ca
re Centre Out
-
of
-
hours at UHND
and overnight at DMH



Additional nurse staffing at UHND



Conversion of space to clinical rooms at UHND to increase
physical capacity of ED.



Standard Operating Procedure on clock start & stop times for
ambulance handovers in co
llaboration with NEAS resulting in
improvements in touch screen processes, batching & live
discriminator lists for capturing reasons for handover breaches



Each shift, specific individuals are responsible for ambulance
handovers



Specified areas in each ED
for ambulance handovers to take place
ensuring privacy & dignity is respected



Diagnostics commenced at initial assessment to improve treatment
times.



Senior medical review of all patients identified as requiring
admission to prevent inappropriate referrals

to specialties



Agreement for senior decision makers in high volume specialities
to be available to attend the emergency department within thirty
minutes of referral



Prompt initiation of blood and radiological tests with rapid delivery
of test result. Test
s ordered at triage.



Standard Operating Procedure developed between ED/AMU and
patient flow team



ED clinics reduced to 3 x week from daily to free up clinical time
and reduce follow
-
ups.



ED’s have adopted a PDSA continuous improvement process re all
ED av
oidable breaches



College of Emergency Medicine guidance around full capacity
Already in place




































13

29/05/2013

protocols adopted.


Other measures:



Plans to convert other rooms for clinical use at UHND now delayed
beyond Q1 to avoid disruption in the Department.



UHND 8
-
trolley Assessment Ar
ea open intermittently. We are
striving to increase the amount of time it is open using Agency
staff, until full recruitment can take place, but framework agencies
are not responding reliably.




NEAS have developed the “green man” body map for County
Durham and Darlington to signpost ambulance crews to alternative
pathways. This is being distributed across the service currently.




Second cohort of paramedics trained to deploy enhanced CARe
skills (a training programme to enable paramedics to treat minor

ailments in the home setting and therefore avoid hospital
admissions)







Interviews take
place in mid
-
June.









Already in place

Patient Flow through the
hospital



We have expanded the Physician of the Day (POD) rota to include
three physicians at busy times.



In the event of necessity, we will continue to board patients onto
non
-
medical wards. The potential impact on cancelled operations
and our RTT performance will

be carefully monitored to ensure
continued compliance with national standards and principles of
good patient care.



EDD is audited on a weekly basis on both acute sites with results
fed back in real time to the clinical teams. Benchmarked length of
stay is

below the national average in 18 of 25 top HrG’s by volume
in medicine.



Regular bed meetings are held throughout the day under the
Trust’s Site Escalation Policy (SEP):



Patient Flow continually walk the wards to identify patients for
discharge and potent
ial blockages.



When bed availability becomes tight, Head of Unscheduled
Already in place


Already in place




Already in place




Already in place








14

29/05/2013

Care escalates to Head of In
-
patient services and to the POD.



From June new arrangements will apply. These will improve
clinical engagement and accountability of Wards to Patient Flo
w
(PF). In summary:



Base Wards to contact PF by 10.00 each day and then again
by 13.30 to ensure accurate real time bed states are available
to allow more time for proactive site management.



Compliance to be audited. Non
-
compliant Wards to be
escalated t
o Director of Nursing.



When sites are at SEP level Amber the bed meeting will
involve conference call and Heads of Service, Clinical
Directors, Clinical Leads and Associate Chief Operating
officers will be informed by text message. They will ensure
clinica
l colleagues and Ward staff take all available measures
set out in the SEP to identify patients suitable for discharge or
boarding. Key actions will include:



Ensuring all the good practice patient flow initiatives are
being followed systematically



Medical
boarding, including diverts between sites



Consultants on SPA time to switch to clinical duties



Additional Ward Rounds



Working
with RIACT

to identify all patients who could be
transferred into the community with support



Open up additional beds where feasibl
e



Temporary funding for the 7
-
day discharge management service
has been extended to the end of June in the light of continuing
non
-
elective pressures



Daily potential discharge list produced for DMH, UHND, BAH sites.
Discharge Management Team work with part
ner agencies to
minimise delays.



Discharge management team extend their remit to support less
complex discharges when sites under pressure


Commence 3
rd

June























Funded through
Winter pressures
continuing to end of
Q1





Community support for
admission avoidance and
Pending full evaluation of the non
-
recurrently funded admission
avoidance schemes, funding has been extended to the end of Q1 in
Alread
y in place



15

29/05/2013

early discharge

the light of the continuing non
-
elective pressures. This provides:



A guaranteed 2
-
hour response time from the Community Support

Team (RIACT) to referrals from ED at UHND and DMH.



A service is available to all patients presenting in ED, 7 days per
week until 17.00 irrespective of their home address providing
assessment, equipment, monitoring of base line observations (e.g.
followin
g an exacerbation of COPD) and care support.



The service also



have a concerns file in which ED staff can identify a patient
they are discharging whom they think will benefit from
community follow
-
up



follow
-
up ( telephone and face to face) all patients
over 65
years presenting with a fall or fracture to prevent risk of re
-
admission



At UHND, our most pressurised site, the RIACT team provide in
reach support to identify patients who may require additional
support to ensure a safe and effective discharge



fi
rst thing every morning they assess patients presenting
overnight who are identified as medically fit for discharge but
whom the staff feel cannot return home



all patients presenting throughout the day ( either pro
-
actively
whilst in department)



This may

also include those patients referred to fracture clinic
for orthopaedic review of the fracture
.



Non
-
recurring monies have also been extended to:



provide social work input 08.00


20.00 7 days per week in
DMH to facilitate earlier discharges, enabling fam
ilies visiting
in the evening visiting and ward nurses to see social workers
at those times



pro
-
actively identify patients in need of community support to
prevent a re
-
admission rather than wait for referral at the point
they are medically stable.
















Already in place










Already in place


Monthly Front
-
of
-
house
First meeting on 31
st

May. Will agree any further immediate actions by


16

29/05/2013


This plan has
been developed in close partnership with key stakeholders and will be driven forward and monitored on a weekly basis. There i
s a willingness
and commitment from all involved to improve the position and maintain performance to achieve the 95%
target in the short and long term.



6.

Longer

term plan



Prior to A&E

Issue

Actions

Timescale

Lead

Strengthening primary and
community care for frail
and elderly patients.

To be considered as part of the Urgent Care
Board



Review of non
-
recurrently funded admission
avoidance schemes is taking place:
RIACT
(
Rapid Integrated Assessment and Care
Team
),
RAICT
, CREST, discharge
management and facilitator teams, ERALS.



Multi
-
agency Intermediate Care Business
Case being developed.



Work is ongoing with RIACT to ensure
the
service is used to prevent admissions




June 2013




August / Sept
2013

Chair of Urgent Care Board

Alternative pathways to
A&E



Develop and roll out
,

the poorly child
pathway
,

following review and validation
(
Source: DDES Clear and Credible plans

and
Darlington CCG Clear and Credible
Plan
)



Progress A&E outpatient clinics through
implementing a new service specification
(Source: North Durham Clear and
Credible Plan)



Head of Unscheduled care has developed a
new model for stand
-
alone and integrated
ED/UCC’s. Discussion about potential for
To be agreed
via Urgent Care
Board





a
sap





Chair of
Urgent Care Board



Chair of Urgent Care Board





Chair of Urgent Care Board




Task Group

all partners to reduce breaches.


17

29/05/2013

new model for ED/UCC to be facilitated by
the Urgent Care Board.



Business Case to extend current ambulatory
care service to 0800
-
2200

7 days per week
in final approval stage. Business Case
includes additional Consultants and 7
-
day
diagnostics.



New medical assessment unit opened at
UHND. Staff recruitment is still fragile
.



Each stakeholder to develop an Action
Plan covering their contrib
ution to a
reduction in A&E pressures. To be
monitored through the Task Group.



RIACT service provided by social services
offers alternatives to ED admission



NEAS have developed the “green man”
body map for County Durham and
Darlington to signpost ambulance

crews
to alternative pathways. This is being
distributed across the service currently



Second cohort of paramedics trained to
deploy enhanced CARe skills (Enhances
CARe is a training programme to enable
paramedics to treat minor ailments in the
home settin
g and therefore avoid hospital
admissions)







Extend
pilot Palliative Care Rapid
Response Service run by Marie Curie
Cancer Care and St Teresa’s Hospice to
end August 2013



Development of a COPD Rapid Response

June 2013





Feb 2013



July 2013


Head of Unscheduled Care,
CDDFT




Head of Unscheduled Care,
CDDFT























Darlington CCG Clinical Leads




Darlington CCG Clinical Leads


18

29/05/2013

Service



Improve access to Primary Care



Reconfiguration of Urgent Care and A&E
services in Darlington



Intermediate Care


provision of step
up/step down care in patients own home
or in care homes



Darlington CCG
Clinical Leads


Darlington CCG Clinical Leads



Darlington CCG Cl
inical Leads

Strengthening GP out
-
of
-
hours services.

DDES and Darlington
CCGs
are keen to more
closely integrate services with County Durham
and Darlington FT e.g. commission more in
-
hours
urgent care services at University of Durham
Hospital and the
integration and
co
-
location of

the

urgent care centre with A&E
at

Darlington

Memori
al Hospital
. North Durham CCG are keen
to develop a proposed model and approach for
commissioning urgent care with a greater
integration within primary care.




Head of Unscheduled
Care
has
developed a proposal for a centralised GP
OOH’s service which will b
e based in EDs
at both acute sites.
proposals for
centralisation will be discussed at the
Urgent Care Board and any changes to
service provision will be subject to public
consultation
.
.



Head of Unscheduled care has developed an
integrated governance and ma
nagement
structure across unscheduled care which
includes urgent care centres



Discussions with CCG’s being held to agree
Urgent Care model across the county
following completion of Blue Rivers report

To be agreed
via Urgent Care
Board















a
sap


Completed




asap

Chair of Urgent Care Board























Chair of Urgent Care Board

Use of virtual wards in the
Pilot ongoing in DDES locality, outcome will be
To be evaluated
DDES CCG Urgent Care Lead


19

29/05/2013

community.

shared with other CCGs via Urgent Care Board

June 2013

Support to care homes to
avoid emergency referrals

The North Durham GP beds pilot enables
patients aged 65 and over who require nursing
care to receive care from their GP and nursing
home staff in a nursing care of their choice
within
their GP practice’s catchment area.

The North Durham GP beds pilot is intended to:



Increase short stay admissions to local
nursing homes rather than being admitted
to a secondary care hospital (for patients
aged 65 or over registered to a GP
practi
ce which is part of North Durham
Clinical Commissioning Group).



Reduce the number of admissions to
secondary care hospitals.



Improve the experience of patients by
providing care closer to home in a homely
community setting, with medical care
provided by
the patient’s GP to ensure
continuity of care.




Evaluate Dales Care Home pilot



Review Primary Care support to Care Homes
against the Kings Fund checklist and develop
action plan


Alignment of GP’s to care homes in Darlington
with regular reviews of
patients to be undertaken
























Mar/Apr 2014

asap
























Dales Commissioning Manager


CCG Urgent Care Leads



Darlington

CCG

Clinical

Leads

Peer review of GP
emergency referrals

To be considered
by

the Urgent Care Board. GP
variation work will contribute towards this but
discussions still ongoing with CCGS to agree how
this will be taken forward



Review Primary Care actions and




asap





Chair of Urgent Care Board


20

29/05/2013

opportunities against the Kings Fund
checklist and develop action plan


Reducing ambulance
conveyance rates

To be considered as part of the Urgent Care
Board



Review appropriateness of ambulance
conveyances and develop action plan



Support NEAS work on alternative
pathways such as the
“green man”
prompt card and the Enhanced CARe
programme



Support for city centre treatment centres
(booze buses) on identified nights of the
year



Enhanced hear and treat programme
within NEAS




asap



Chair of Urgent Care Board

Patient education on
appro
priate use of
emergency services

To be considered as part of the Urgent Care
Board



Review reasons for patients choosing to
come to A&E and Urgent Care Centres and
develop action plan



asap



Chair of Urgent Care Board

Roll
-
out arrangements for
NHS 111

NHS 111 has been rolled out across the North
East CCGS and has been live in DDES,
Darlington and North Durham since 27
th

November 2012. There are ongoing contractual
performance meetings on a monthly basis and
NHS 111 reps via NEAS will be invited to the
Urgent Care Board as required



Review required to audit impact of 111 on
Urgent Care and A&E attendances.

N/A







asap








Chair of Urgent Care Board



21

29/05/2013


Flow within the hospital

Issue

Actions

Timescale

Lead

Prompt booking of patients to

reduce ambulance turnaround
delays.

Implemented a Standard Operating
Procedure on clock start & stop times for
ambulance handovers in collaboration with
NEAS resulting in improvements in touch
screen processes, batching & live
discriminator lists for cap
turing reasons for
handover breaches


Each shift, specific individuals to be
responsible for ambulance handovers


Specified areas in each ED for ambulance
handovers to take place ensuring privacy &
dignity is respected


Increased medical juniors & nurse st
affing


Increased capacity on UHND site by
converting existing rooms into clinical areas.


Source


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A Capacity management plan with
redesign of both emergency
departments has commenced (on

hold whilst CCG’s agreed integrated
model)



New reporting system in place by
October to improve ability to identify
reasons for ambulance handover
breaches live from the NEAS system
























a
sap




October
2013

Head of Unscheduled Care, CDDFT








Head of Unscheduled Care, CDDFT



Head of Unscheduled Care, CDDFT




Head
of Unscheduled Care, CDDFT



Head of Unscheduled Care, CDDFT





ALTC Business Manager, CDDFT




NEAS rep on Urgent Care Board






22

29/05/2013



NEAS are implementing a programme
of work to reduce turnaround delays
incl
uding: review of escalation
triggers, active management of crews
taking excessive times to clear,
management presence on sites with
delays to take handover from multiple
crews waiting, rapid handover
protocols for low risk patients



NEAS follow up summit to

be held in
July



Discussions ongoing about NEAS
“managing” delays and diverts at a
regional level


NEAS rep on Urgent Care Board








NEAS rep on Urgent Care Board



Provider Management Lead for NEAS
999 at NECS

Full
see
-
and
-
treat in place for
minors



Implemented streaming of patients into
minors/majors streams.



Introduced Practitioner Roles to triage and
treat minors



Appropriate patients diverted to the
Urgent Care Centre during co
-
located
opening hours.



Full integrat
ion of Urgent Care and A&E
(in Darlington)
required to achieve full
benefits of a true Multi
-
disciplinary
Emergency Care Centre

Complete


Complete


Complete



asap








Urgent Care Lead Darlington
CCG/
Chair of Urgent Care Board

Prompt initial senior
clinical
assessment within A&E and
rapid

referral if admission is needed

Diagnostics commenced at initial assessment
to improve treatment times.


Senior medical review of all patients
identified as requiring admission to prevent
inappropriate referrals to
specialties


Changed Consultant rotas to provide more
senior cover into evenings & weekends.










Head of Unscheduled Care, CDDFT



Head of Unscheduled Care, CDDFT




Head of Unscheduled Care, CDDFT



23

29/05/2013


Source


CDDFT Emergency Department
4 Hour Breach Analysis Report March
2013




Consultant’s to be available 7 days a
week until 8pm following further
recruitment.

Recruitment of two additional
ED Consultants and three ACPs has
begun



Agreement for senior decision makers in
high volume specialities to be available to
attend the emergency department within
thirty minutes of referral



Two additional rooms to be converte
d to
clinical use at UHND



Doubling up Consultant offices to create
extra capacity at DMH






a
sap





Complete




tbc


tbc






Head of
Unscheduled Care, CDDFT









Head of Unscheduled Care, CDDFT


Head of Unscheduled Care, CDDFT


Prompt initiation of blood and
radiological tests with rapid
delivery of test result.



Tests are ordered at initial triage



Task Group will develop Performance
Measure

C
omplete


June 2013



Head of Unscheduled Care, CDDFT

Prompt access to specialist
medical opinion



Work with Consultants to improve:

use of estimated date of discharge
(EDD) or transfer (EDT) within 24
hours of admission with criteria
-
led
discharges.



All patients to have a senior clinical
review within 24 hours of admission
when a care plan will be put in place



All patients to have a d
ischarge letter
/ medication / transport in place the
day before discharge



Standard Operating Procedure developed
between ED/AMU and patient flow team

Continuing












Complete


Head of Unscheduled Care, CDDFT






Head
of Unscheduled Care, CDDFT



Head of Unscheduled Care, CDDFT






24

29/05/2013



ED clinics reduced to 3 x week from daily
to free up clinical time and reduce follow
-
ups.



agree new Serv
ice Spec for ED clinics
across the county



emergency department developing direct
admission rights using agreed protocols.



Business case approval to be agreed to
achieve Kings Fund standards:



During the period of consultant
presence on AMU, all newly admitt
ed
patients should be seen within six to
eight hours, with the provision for
immediate review as required.



A newly admitted patient must be
seen by a consultant within 14 hours
after arrival on AMU.



All patients in the AMU should be
reviewed twice each d
ay by senior
staff



Consultant presence on the AMU
should start no later than 8am

C
omplete



August
2013

Aug 2013


Continuing



Complete
in hours




Complete



Complete



C
omplete






Head of Unscheduled Care, CDDFT


Head of Unscheduled Care, CDDFT






Full use of computer
-
aided
patient tracking and system
for progress
-
chasing

New ED IT System implemented from 3
rd

April 2013 at UHND & 30
th

April 2013 at
DMH. Expected improvements in data
collection & live patient data, thus improving
patient pathway.




Further investigation of technical reasons
for the low number of ambulance
handovers recorded.



Procurement priority

for 2013
-
14 is a new
patient flow/bed management software
system. Process commenced.







May/June
2013



Winter
2013








Head of Unscheduled Care, CDDFT





Head of Unscheduled Care, CDDFT



25

29/05/2013



Weekly report demonstrating causes of
ED breaches

C
omplete

ALTC Business Manager

Regular seven
-
day analysis
should be in place for rapid

identification and release of
bottlenecks



Daily and weekly activity and breach
spread
-
sheet circulated



Patient Flow to “man mark “all potential
breaches. Additional staffing for

Patient
Flow to be authorised if required.



ALTC Business Manager to focus on ED
performance for remainder of Q1.



ED’s have adopted a PDSA continuous
improvement process re all ED avoidable
breaches



College of Emergency Medicine guidance
around full capaci
ty protocols adopted.
New process to be implemented by
Patient Flow/bed management team.



Emergency department workforce plan is
in the process of development

Complete





Bed base management

If we find the bed base under pressure or ED
breaches
increasing, we will respond within
the framework provided by the SEP
-
NEEP
levels and our Business Continuity plans.
Key actions will include:



Ensuring that all the good practice
patient flow initiatives are being followed
systematically



Medical boarding



Us
ing internal or external diverts



Additional shift working



Calling on staff who are able to move
from their current location to work on the
Wards



Putting in place additional Ward Rounds,
7 days per week























Head of Unscheduled Care,
CDDFT
/Head of In
-
Patient Services,
CDDFT











26

29/05/2013



Working with
RAICT

to identify all
patients who coul
d be transferred into
the community with their support



Re
-
direct resources into beds from
elsewhere if this is the only way to
manage bed pressures.



Consider community hospitals accepting
a wider range of direct admissions (eg:
from nursing homes)



Consider
ation to purchase beds in
nursing homes for non
-
weight bearing
patients who otherwise don’t need to be
in hospital

Source


CDDFT Winter Plan 2012/13




Increase accountability of Wards to
Patient Flow. Base Wards to contact PF
by 10am each day and then aga
in by
1.30pm to ensure accurate real time bed
states are available to allow more time
for proactive site management.
Compliance to be audited. Non
-
compliant Wards to be escalated to
Director of Nursing



If Sites are at SEP level Amber the bed
meeting will i
nvolve conference call and
senior HOS CD, CL’s ACOOs and will
be informed by text message



Audit against London Standards



Review Emergency Pressures and Bed
Management Policy



Develop Winter Plan for 2013
-
14



Early recruitment of staff for Winter



CDDFT work actively with RIACT to



























tbc

July 2013


July 2013

Continuing
















Head of Unscheduled Care,
CDDFT/Head of In
-
Patient Services,
CDDFT











Medical Director/Clinical
Director/Clinical Leads, CDDFT


Head of Unscheduled Care,
CDDFT/Head of In
-
Patient Services,
CDDFT


27

29/05/2013

ensure patients who can access the
scheme are enabled to do so


Daily consultant ward rounds

Work
with Consultants through Job Planning
to improve the number of morning ward
rounds and discharges.

Ongoing

Head of Unscheduled Care, CDDFT

Provision of specific services
for patients groups such as
those with

mental health problems

Mental health providers

to be part of Task
Group and to be asked to develop an Action
Plan to reduce breaches attributable to them.

Source


CDDFT Emergency Department
4 Hour Breach Analysis Report March
2013


Review delays caused by waits for CHC
assessment.


Head of Unschedu
led Care, CDDFT







Chair of Urgent Care Board



28

29/05/2013

Discharge

transfer, re
-
ablement

and out of hospital care

Issue

Actions

Timescale

Lead

Designation of expected
date of discharge (EDD)
on admission

EDD is audited on a weekly basis on
both acute
sites with results fed back in real time to the
clinical teams involved. Results are variable

NEAS to maximise same day discharge facility
where possible by using spare capacity and by
introduction of better planning tools

Continuing

Head of Uns
cheduled Care, CDDFT

Maximisation of morning
and weekend discharges

Work with Consultants in job planning to move
Ward round activity to morning.

Continuing

Head of Unscheduled Care, CDDFT

Full use of discharge
lounges



Work with Consultants in job plann
ing to
move Ward round activity to morning



Additional pharmacy support built into the
AMEC Business Case

Continuing

Head of Unscheduled Care, CDDFT


Head of Unscheduled Care, CDDFT

Minimisation of outliers



Business Case for an additional Ward at DMH
to cope with Winter pressures 2013
-
14.



Exploring options for additional acute bed
capacity at UHND.

Winter
2013

Head of Unscheduled Care, CDDFT


Head of Unscheduled Care, CDDFT


Delayed transfers of care
reduc
ed



Move community bed availability to
SharePoint



Introduce a 3rd Physician of the day at busy
periods

June 2013


Continuing

Head of Unscheduled Care, CDDFT


Head of Unscheduled Care, CDDFT


Flexing of community
service capacity to accept
discharges



Multi
-
agency Intermediate Care Business
Case



Review of non
-
recurrent admission avoidance
schemes

Aug/Sept
2013


June 2013

Chair of Urgent Care Board


Chair of Urgent Care Board

Review of continuing care
processes

Review delays caused by waits for CHC
assessment.


Chair of Urgent Care Board

Assessment of use of
reablement funding by
local authorities

CDDFT work actively with RIACT to ensure
patients who can access the scheme are
enabled to do so

Ongoing

Chair of
Urgent Care Board






Appendix One



Terms of Reference for Urgent Care
Board
for DDES, North Durham and
Darlington CCGs

May 2013


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Audience

Urgent Care Board for DDES, North Durham and Darlington CCGs members

Document
Title

Urgent Care Board for DDES, North Durham and Darlington CCGs

Terms of
Reference

Document Status

Draft for sign off.

Document Version

1.1

Issue Date

May 2013

Prepared By

Kathleen Berry, Commissioning Manager, NECS on behalf of Dr Stewart
Findlay,

Chair of the Urgent Care Board

for DDES, North Durham and
Darlington CCGs


Version

Date

Name

Comment

1.0

17/5/13

Kathleen Berry

First draft for comments

1.1

30/5/13

Kathleen Berry

Updated with LAT comments on diagram to add TDA and
Monitor











Document control


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Document control

2

Contents

3

1

Introduction

4


Purpose

4


Audience

4


Status

4


Related documents

4

2

Purpose

5


Context

5


Functions

5

3

Meeting Details

6


Membership

6


Agenda

6


Frequency & location

7


Overarching principles


Governance

7



7


Contents


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Purpose

This document sets out the terms of reference for the

Urgent Care Board for DDES,
North Durham and Darlington CCGs
. It includes details of the membership of the
group and how it fits into the governance structure of the
Clinical Programme
Board.

Audience

The primary audience for this document is the

Urgent Care Board
for DDES, North
Durham and Darlington CCGs.

Status

This version of the document is a draft for consultation and initial approval with
members of the group.

Related documents

This document should be read in conjunction with




NHS England: Improving A&E Performance Gateway ref: 00062.

http://www.england.nhs.uk/wp
-
content/uploads/2013/05/ae
-
imp
-
plan.pdf


Introduction


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C
ontext

The

Urgent Care Board for DDES, No
rth Durham and Darlington CCGs

will act as
sub group of the

Clinical Programme Board

addressing issues

concerned with
ensuring a sustained improvement in A&E performance in the area covered by the
CCGS as well as leading on Urgent Care more generally and co
-
ordination and
production of

winter plans. The mandate for the group has come from NHS England
via the document
NHS Eng
land: Improving A&E Performance
Gateway ref: 00062
.

The Department of Health defines urgent and emergency care as the range of
healthcare services available to peopl
e who need medical advice, diagnosis and/or
treatment quickly and unexpectedly. This could include, for example, accident and
emergency (A&E), walk
-
in and minor injury and illness services. It could also
include access to GP practices in hours, community c
are, transport provision and
social care as well as more specific pathways e.g. poorly child.

There are six urgent care centres across County Durham and Darlington, provided
by CDDFT. These are: Darlington (Dr Piper House), Peterlee, Seaham, University
Hos
pital of North Durham (UHND), Bishop Auckland and Shotley Bridge. They are
provided as part of the wider communities contract that was held by the PCT.

The Seaham site is open from 8am


6pm Monday to Friday only and UHND is
open from 6pm


8am Monday to

Friday and 24 hours at weekends. The other four
sites are open 24 hours, 7 days per week. Access is via a walk in or through NHS
111 booked appointment


There is also a Durham and Darlington Urgent Care Transport service (DUCT)
which is provided by NEAS.

The service provides transport for patients who require
urgent care services but would otherwise be unable to access these services. In
addition it supports discharges from emergency departments, transport to and from
nursing and care homes, delivery of m
edicines and transport of notes, specimens
etc. and the service also provides the transport for urgent care centre clinicians to
conduct home visits

NHS 111 has been rolled out across the three CCG areas via a five year contract
with NEAS. The service has
four lead CCGs for the region and the contract
management is provided via NECS.


Functions

The
Urgent Care Board for DDES, North Durham and Darlington CCGs
will be
accountable to the
Clinical Advisory Group

and will:



R
eview the full range of appropriate
data.



Ensure that b
est practice is
identified and
adopted by all concerned.



Ensure that a review of t
he effectiveness of primary care services

is carried
out

including

out of hours and admission avoidance schemes.



Ensure that t
he effectiveness of community

services is reviewed, including
any

walk in centres, minor injury units and how they integrate with

Purpos
e


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secondary care.



Ensure that t
he effectiveness of ambulance services is reviewed.



Ensure that t
he effectiveness of NHS 111 is reviewed.



Ensure that t
here ar
e local plans in place to support the care of the key

categories of patient who attend or are admitted frequently:

Patients with multiple comorbidities especially those with poorly

controlled chronic disease:

Frail elderly, especially those with mental hea
lth problems;

Sick children; and,

h
igh dependency individuals, especially vulnerable adults

(homeless, drug and alcohol related problems, mental health

problems).



Be assured that a

full range of services is available to acute trusts for those
patients

in A
&E who need services not provided by acute hospitals are in

place.



W
orking with local authorities ensure that a

review to ensure early discharge
is

feasible is undertaken.



O
versee the use of the 70% funding

retained from excess care urgent tariff.

The use
of the money must be

clearly linked to specific delivery of outcomes
and improvements in

standards.

T
he use of this money to be signed
-
off
jointly by CCG

leaders, NHS England Area Directors, provider Chief
Executives, and

local authority Chief Executives

b
y end of June 2013.



R
esponsible for the coordination and production of winter capacity and
escalation plans for their local health economy.



Responsible for oversight of the A&E recovery plans agreed with CDDFT


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Membership

Membership of the
Urgent Care Board for DDES, North Durham and Darlington
CCGs
is outlined below.

Further members may be included on invitation by the Chair.

The meeting will be
held as a face to face
meeting unless the Chair decides
otherwise


Name

Representing


Dr Stewart Findlay

DDES CCG (chair)

Gillian Findley

DDES CCG


North Durham CCG


North Durham CCG

Dr Chris Mathison

Darlington CCG (Vice Chair)

Jackie Kay

Darlington CCG

Caroline
Thurlbeck

Area Team

Lesley Jeavons

Durham council


Darlington council


Healthwatch Durham


Healthwatch Darlington


NEAS A&E


NEAS 111


CDDFT A&E


Patient rep


Patient rep

Richard Harrety

NECS

Kathleen Berry/Sara Wooley/Tony Byrne

NECS


TEWV


?Clinical expertise


Social care?


Others? E.g. other CCGs

Meeting Details


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Agenda and Minutes

The meeting will be formatted around the
key functions of the group but the
standing agenda items will include A&
E performance data, recovery and
improvement action plan, Winter Plan 2013/14 and
excess care urgent tariff.

Meeting support will be provided by the
Admin team at DDES CCG
with minutes
and action notes being issues no later than one week after the meeting and then
agreed at the following meeting.

Frequency & location

The
Urgent Care Board for DDES, North Durham and Darlington CCGs
will meet
monthly.

A list of agreed meetin
gs is attached as Appendix 1

Location will generally be
XXXX


Overarching principles


Clear Purpose



Clear, shared objectives, with a realistic plan and timetable for reaching those
objectives



Regular assessment of whether the things the group is focusing
on are the right
ones



A clear framework of responsibilities and accountability/terms of reference


Supportive Relationships



A high level of trust between partners based on agreed and shared principles of co
-
operation and confidentiality



A willingness to
work together and consult with the widest possible network of
communities and service users



A commitment to share information to avoid suspicion and

organisational

/
sectoral

agendas



"Equality around the table" to avoid people pulling rank except where it i
s in the
interests of decision
-
making



A flexible approach and an openness to new ways of thinking



Effective and Productive Meetings




Allow time for discussion



Concentrate on relevant issues through clarity in agenda setting and sticking to that
agenda
at meetings



Meetings are well organized, timely, have good structured chairing and information
is presented well and in an easy to read format



Dates of meetings should be agreed in advance and circulated to partners



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Appropriate Behavio
u
r:



Open and hones
t discussions of differences with constructive management of any
conflict



Exhibit an understanding of other’s priorities and constraints



Listen to the views of others



Declare any conflict of interest

Governance

The
Urgent Care Board for DDES, North Durham and Darlington CCGs
will report
via the Chair or appropriate deputy directly to the
Clinical Programme Board on a
monthly basis.
There will be clear lines of communication, escalation and reporting
between Urgent ca
re boards, constituent organisations, NTDA and Monitor


these
will be agreed and discussed at the Urgent Care Board first meeting on XXX





Appendix 1

List of meeting dates and v
enues to be provided by DDES CCG

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Appendix 2










TERMS of REFERENCE
-

To be agreed and confirmed on 31/5/13


FRONT
-
OF
-
HOUSE TASK GROUP


Introduction


Non
-
elective pressures continue to be one of the key risks facing CDDFT and the wider
NHS as a whole. In May 2012 CDDFT held a two day summit with partner

organisations
and commissioners out of which developed an Unscheduled Care Strategy. The strategy
sets out our plans to redesign the delivery of unscheduled care. It is a key feature of
Operational Planning for 2013
-
14, led by our Director of Service Tran
sformation.


A weekly meeting was established in November 2012 with CDDFT and partner agencies
to examine the root causes of ED waiting times and ambulance handover delays. This
involved an in depth thematic analysis of patient timelines as well as a deep

dive into ED
data, examining the influence of various factors including time of day, activity per hour,
number of ambulances per hour, and bed availability. A report was produced
summarising the work of the group, a key feature of which was the recognitio
n that ED
performance is a symptom of problems in the wider non
-
elective pathway; hence a
whole system approach is needed to bring about lasting improvement.


This ‘Front of House’ work stream is led by the Head of Unscheduled Care and aims to
bring about
sustained improvement in ED performance by tackling the determinants of
that performance which lie within the responsibility of the Head of Unscheduled Care, but
also linking to actions plans for areas which are the responsibility of others.


Purpose and

Outcomes


The Group aims to:

1.

Continue to analyse and learn lessons to improve the performance of ED

2.

Produce a robust action plan to minimise delays in the patient pathway. In
particular, it will reduce the number of 4
-
hour waits and ambulance handover d
elays
thus improving the patient experience and outcomes.

3.

Oversee the implementation of changes to services evidenced by robust metrics.

4.

Work with external partners to ensure patients receive care in the right place at the
right time by the right person,
first time.

5.

Develop pathways as alternative to ED


The Group will constitute part of the front
-
of
-
house work
-
stream within the Unscheduled
Care Strategy.


Scope of the Group



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In order to achieve its aims, the Group will:




Agree a Performance Scorecard
through which the performance of front
-
of
-
house
services and the impact of other services on front
-
of
-
house can be understood and
managed



Commission audits, including direct patient feedback



Where possible, obtain and use benchmarking information



Receive r
eports on, and analyse, initiatives designed to improve non
-
elective
performance



Consider good practice lessons from within or outside the Trust.



Provide reports to CDDFT ECL and to CCGs as required



Consider and make recommendations on the interface betwe
en front
-
of
-
house and
other services (eg: back
-
of
-
house, mental health, NEAS, Primary, community and
social care)


Links and Accountabilities


The Group will be responsible to the CDDFT Board via ECL and the Associate Director of
Operations. Responsibility

to the CCGs and other agencies will be via the relevant reps
on the Group.
















Meetings, Reporting Mechanisms and Time
-
scales


The Group will meet monthly or at intervals determined by the members.



The Chair of the meeting is responsible for setting the Agenda



Members wishing to place an item on the Agenda should notify the Secretary to the
Head of Unscheduled Care at UHND and forward to her any supporting papers.



Action Notes will be circulated as soon as possible after the end of each meeting.


Group
Membership


The Group will consist of the following persons, plus their nominees:


Acute and Long
-
Term Conditions

J Baxter (Chair), G Hunt, K Bentham, S Dyson, B Potter,
Carol Bean, Diane Clark, Helen Godfrey, Derek Murphy, Roy
CDDFT BOARD

ECL

ALTC CARE GROUP
MANAGEMENT

ASSOCIATE DIRECTOR
of OPERATIONS

FRONT of HOUSE GROUP

CCGs

TEWV, NEAS and Social Care

UNSCHEDULED
CARE PROJECT


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Westhead

Corporate
members

S Clegg, J Shutt

Surgery &
Diagnostics

Jason Cram, Harry Greenwood, Chris Shaw

Care Closer to
Home

TBC

External

CCGs: G Findley (DDES)

TEWV: Chris Binns

Social Care reps (County Durham and Darlington)


TBC

CCG: Michael Houghton/Jan Panke (North
Durham)

CCD: Chris Mathieson (Darlington)

NEAS


Sharon Tiffen/Paul Liversidge


Review of the Terms of Reference


These Terms of Reference will be reviewed at intervals to be determined by the Group
but in any case no later than 12 months after the da
te of implementation.


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Appendix 3










“FRONT
-
of
-
HOUSE” TASK and FINISH GROUP

PROPOSED METRICS


Metric

Information Source

Emergency Department


ED activity

broken down by:



tariff type



short
-
stay Ward



time of day and day of week



number of patients seen in ED and referred to UCC


Information Dept

Information Dept

Information Dept

Information Dept

ED 4
-
hour breaches
:



numbers



reasons including ED
-
attributable and other factors


Information Dept

ED Symphony

ED Ambulance activity:



number and proportion of ambulance attends
compared to total attends



time of day and day of week



eventual tariff type of ambulance patients



number of ambulance patients not conveyed, or
conveyed elsewhere than to A&E


NEAS/Information Dept


NEAS/Informatio
n Dept

Information Dept

NEAS

ED
-
NEAS handovers:



Handovers by time
-
band



Handover recording completion rates


NEAS/Information Dept

NEAS/Information Dept

Urgent Care


UCC:



Activity by time of day and day of week



number of patients referred to ED



performance against National Quality Requirements


Information Dept

Information Dept

Information Dept

AMEC, UHND A&E Short
-
stay Unit and Assessment
unit


AMEC activity

broken down by:



Number of admissions by day of week



Length of stay



Numbers of
patients discharged directly from AMEC



Times of admission and discharge



patients using AMEC seen and assessed by a relevant
consultant within 4 hours in hours and 12 hours out
of hours


Information Dept

Information Dept

Information Dept

Information Dept

L
ocal Audit

UHND Assessment Unit activity
broken down by:



Number of admissions by day of week



Length of stay



Numbers of patients discharged directly from
Assessment Unit



Times of admission and discharge



patients using the Assessment trolleys seen and
asses
sed by a relevant consultant within 4 hours in

Information Dept

Information Dept

Information Dept


Information Dept

Local Audit


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hours and 12 hours out of hours

Other


Diagnostics (for patients in ED, UC, AMEC and
Assessment Unit)



Time taken for blood results to be returned



Time taken for imaging and reporting



Ed breaches attributable to diagnostics and blood
results

Mental Health



Breaches attributable to mental health



Pathology

Radiology

Patient Experience



Exit Survey for patients




Complaints (reduction in complaints relating to length
of wait in ED)



Compliments received



Patients seen in the right place first time


Survey by Head of
Unscheduled Care

Complaints report


Compliments report

Quarterly Audit


Head of
Unscheduled Care

Staff Survey



Quarterly survey

Survey by Head of
Unscheduled Care

Back
-
of
-
House




Discharges by day of week and time of day



Number of patients sent to Discharge Lounge before
12 noon



Number of admissions re
-
directed to ED



Number
of 0
-
day Lengths of stay on Wards

Information Dept

Information Dept


Information Dept

Information Dept



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Appendix 4


Appendix 4


Source


County Durham and Darlington FT Winter Plan 2012/13


Escalation

If we find the bed base under
pressure or ED breaches increasing, we will respond within the
framework provided by the SEP
-
NEEP levels and our Business Continuity plans. Key
actions will include:



Ensuring that all the good practice patient flow initiatives are being followed
systematic
ally



Medical boarding



Using internal or external diverts



Additional shift working



Calling on staff who are able to move from their current location to work on the
Wards



Putting in place additional Ward Rounds, 7 days per week



Working with RAS to identify

all patients who could be transferred into the community
with their support



Re
-
direct resources into beds from elsewhere if this is the only way to manage bed
pressures.



Consider community hospitals accepting a wider range of direct admissions (eg: from
n
ursing homes)



Consideration to purchase beds in nursing homes for non
-
weight bearing patients
who otherwise don’t need to be in hospital


Where there is a danger of a delayed discharge due to medication delays, contingency plans
involving alternative opti
ons for obtaining a prescription will be put in place. Options include:



If there is no urgent need to commence a new medication, and it is
acceptable to the patient/carers, we will arrange for them to return for the
medication at a later time, e.g. next no
rmal working day.



The initial medication will be administered on the Ward prior to discharge and
the patient asked to return to the ward the following day to collect the
medication (Sunday to Friday discharges)



Checking whether the patient will be willing
to take an FP10 for the required
items to a local pharmacy for dispensing.


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Additional escalation actions to be taken within Acute Care are:


Risk

Action

Bed/Ward Closures due
to Outbreak



O畴ur敡k M敥ti湧s will b攠桥e搠摡dly i渠汩湥 wit栠
數i獴i湧
Inf散瑩en C潮tr潬 灯li捹.



T桥 H敡lt栠偲ht散ti潮 U湩t will 扥 i湶it敤 t漠
慴a敮d 慮搠t漠or潶i摥 f敥摢慣欠潮at桥 灯獩ti潮
慣牯獳 t桥 桥慬t栠h捯comy.



N漠灬慣am敮t猠摵ri湧 慮 潵tbr敡k will 扥 m慤攠
from a 捬潳o搠d慲搠t漠乵r獩湧, R敳e摥nti慬,
St数
-
摯w渠潲 Prim慲a

C慲攠f慣aliti敳e



I湳瑩g慴楯n of 愠捯桯rt w慲搠f潲 湥w 慤mi獳s潮猠
摵攠eo 愠捯mm畮ity wi摥 潵tbr敡k or l慣欠of
i獯s慴楯渠f慣aliti敳e

E捥獳cv攠湵e扥rs of
摥l慹敤 摩獣桡rg敳



D慩ly m潮it潲楮g of 慬l 摥l慹敤 摩獣桡rg敳 vi愠
Di獣桡rge Si獴敲s



E獣慬慴楯渠no Divi
獩潮al S敮i潲oN畲獥

Tra湳n潲t 摥l慹s



Am扵l慮捥⁴r慮獰srtati潮 i猠re獴ri捴敤 t漠
灡ti敮t猠f潲 w桯m it i猠th攠潮ey r敡li獴i挠潰ti潮.



C潭o畮i捡瑩c湳 regar摩湧 t桥 limit敤
慶慩l慢ility 潦oP慴楥湴 Tra湳n潲o S敲ei捥
PTS)

I湡扩lity t漠o数atri慴a
灡ti敮t猠from
捲iti捡c 捡牥
慲敡a



P慴楥湴n䙬潷 T敡m (PF吩Tt漠r散eiv攠灲i潲o湯ti捥c
of i湴敮ti潮 t漠tr慮sf敲 灡ti敮ts



Agr敥d 敳捡l慴楯n

灲潣p摵r敳et漠or敶敮t
畮湥捥獳cry 摥l慹s

I湡扩lity t漠o数atri慴a
灡ti敮t猠from regi潮慬
桯獰st慬s



D慩ly m潮it潲楮g of t潴慬 湵m扥rs of
潵t獴慮摩ng
r数慴ri慴楯湳⁢n PFT



Agr敥d 敳捡l慴楯n 灬慮

D敬iv敲楮g S慭a S數
A捣潭c潤慴楯n



E獣慬慴楯渠灲潣o摵r敳eco
-
潲摩湡t敤 批 P䙔 to
灲敶敮t 畮湥捥獳cry 扲b慣a敳e

I湳nffi捩敮t Staffin朠
Av慩l慢le



C慬l 潮 捯cting敮捹 獴affi湧 li獴, 桥l搠批
Di癩獩潮慬 S敮
i潲oN畲獥u M慴a潮猠& PFT.


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Annual leave prohibited over the festive period



Study leave only authorised in exceptional
circumstances



Mandatory training for nursing staff suspended