Testing the ED Capacity Management Guidance document within Hairmyres Hospital

Process

In total, it took the improvement team six months to draft and test the ED Capacity Management Guidance and escalation steps. This involved building on previously implemented improvement work to improve safe and timely whole system patient flow. For example, Hairmyres Hospital uses a daily barometer to understand the pressures on the site, with associated management team actions and systematic use of surge capacity. This work was aligned closely to existing escalation steps, with a focus on understanding the early signs of crowding in ED to allow for earlier escalation.

The high level process steps the team followed throughout the six months are described below:

1. Set up short life working group

The first step in developing and testing the guidance was to set up a short life working group. This group was made up of clinical leaders, managers and directors and chaired by the Chief Executive. This provided strong leadership and support for the work and helped to maintain focus, direction and momentum.

2. Tested operational definitions

The group considered what measures should be used locally to trigger escalation steps in response to crowding. The principles required locally for measures included:

• Can the measure be easily monitored?
• Is it meaningful?
• Does it lead to focused action?

The improvement team developed a tool to assess capacity within the ED and carried out four test of change cycles to refine the tool, measuring activity in the department at different times in the day to establish their triggers for escalation (see below).

Once triggers for escalation had been identified, the next step was to agree algorithms and create Action Cards linked to each trigger point, providing a structured decision making process and steps to work through to safely reduce the risk of crowding in the Emergency Department (see below).

NHSL Emergency Department Crowding Tool

ED Crowding - IS the ED Crowded? - Step 1
A. 1. How many bays are available in resus if only one resus is crowded.
Action - Move patients who do not require resus care to other appropriate clinical area
2. How many bays in majors/resus are occupied
If 80% or more spaces occupied - review use of cubicles
Action - move patients who do not currently require cubicle into waiting area.
Patients cannot be moved to be on a trolley in corridor.
3. If unable to clear space and majors patients still in waiting room or awaiting ambulance offload = ED is crowded - escalate to Action Card 1
B. 1. Are there patients waiting > 2 hours from time clinically ready to move
2. How many? - if 5 or more patients = ED Crowded - escalate to Action card 1

ED is Crowding - IS the ED at Full capacity? - Step 2 (cannot reach step 2 without having been at Step 1 previously)
A. 1. All bays in majors occupied & only 1 space in resus available (Despite actions at Step 1)
Action - Immediately free ED cubicles by moving patients who do not currently require cubicle to other area of the ED.
Patients cannot be moved to be on a trolley in corridor.
2. If unable to clear space ED at Full capacity - escalate to Action Card 2
B. 1. Are there patients waiting > 4 hours from time clinically ready to move
2. How many? - if 5 or more patients = ED Crowded - escalate to Action Card 2
C. Are there delays in offloading ambulances > 15min - escalate to Action Card 2

NHSL Emergency Department Crowding Tool

ED is Crowded - Is the ED Overcapacity? - Step 3 (cannot reach Step 3 without having been at Step 1 & 2 previously)
A. All ED cubicles are full (and used appropriately) & patients are in non clinical areas
i.e. Patients on trolleys or chairs in corridor, patients in waiting room with conditions requiring trolley +/- monitoring)
Action - Department is over capacity - escalate to Action Card 3
B. 1. Are there patients waiting > 8 hours from time clinically ready to move
2. How many? - if 5 or more patients = ED Crowded - escalate to Action Card 3
C. Delays in offloading ambulances > 30min - escalate to Action Card 3

NHSL Emergency Department Action Card

Action Card 1
1. Site/Duty Manager informed
2. Ensure resus capacity maintained
3. Senior nurse attends ED to support ED Senior nurse
Are beds available within 1 hour?
Yes - Why not available now? - prioritise measures to move patients to these beds & de-escalate ED crowding
No - high risk of situation escalating to full capacity, ED Consultant to complete department board round with the Senior Manager on site
4. Ensure that actions from Dashboard are being carried out

• Downstream ward Senior review
• Identify and rectify blocks to flow
• Optimise ambulatory care and use of discharge lounge

5. If cannot rapidly de-escalate

• Divert GP expects to other NHS Lanarkshire sites
• Inform Director of Acute Services

6. If extra capacity not already in use make plans to open & staff

NHSL Emergency Department Action Card

Action Card 2
1. Ensure resus capacity maintained
2. Conference call

• COTE, Medical, Surgical, ED Consultants & Site Manager
• Meet in ED during day - Conference call OOH
• Within 15 mins

3. Ensure that actions from Dashboard are being carried out

• Downstream ward Senior review
• Identify and rectify blocks to flow
• Optimise ambulatory care and use of discharge lounge

4. Ensure pre-identified extra-capacity is staffed and now in use
5. Identify patients who can safely be boarded
6. Consider cancelling day case procedures to free up this area for appropriate patients if not already done so
7. If GP referrals not already diverted - must occur unless other hospitals at same level of crowding
8. Executive on-call informed of critical nature of situation

NHSL Emergency Department Action Card

Action Card 3
1. Invoke full capacity plan
Immediately contact Director of Acute Services (in hours) or the Executive on Call (out of hours)
Director of Acute Services and or Executive on Call will escalate to the Chief Executive
The Chief Executive confirms action to FCP
2. Move pre-indentified patients to be 5th patient in 4 bedded area
a. 1 patient each to the identified wards
b. All attempts must be made to find capacity and bed so this lasts for minimum amount of time
3. Ensure diverts remain in place
4. Expedite any discharges/investigations etc. that will free capacity and allow de-escalation
5. Review all elective activity for following day

These Action Cards have been printed and are available in the ED and in a duty manager box file available in the management suite. This box file also contains copies of 'business as usual' escalation including an SOP for managing every patient, every time in ED (which is displayed in the ED), the hospital barometer and associated escalation steps, and guidance on FCP.

3. Clinical decision making

Full Capacity Protocol is considered an exceptional response to untoward and unexpected circumstances. The decision to implement this step must be clinically-led, however, final authorisation should come from the Chief Executive. Therefore, it was crucial that clinicians from all specialties were involved in developing the decision matrix that included the possibility of having to enact Full Capacity Protocol and understanding risks and consequences of this decision. This was helped by senior, clinical leadership. Clinical leads from across all areas of the organisation had membership on the working group, ensuring that progress was clinically-led and understood across the whole hospital. This also helped create a sense of shared responsibility across the hospital in ensuring that all steps were taken to proactively manage patient flow, eliminate ED crowding and avoid having to enact FCP.

4. Managerial and executive decision making

To support the clinical decision making matrix, the team developed managerial and executive decision making matrixes and action cards. This includes question prompts, information metrics to monitor and system wide actions i.e consideration of cross-site ICU cover, communication with GP, Out of Hours Service & Director for Primary Care to scope out support from district nursing services etc.

5. Table top exercise

Two table top exercises, held in November 2015 and January 2016 helped the team to work through and fine tune the process, working through all escalation steps and Action Cards to ensure everyone knew what their role should be and what would be expected of them. These table top exercises included the Chief Executive, lead clinicians and teams from across the three hospital sites and allowed them to simulate the steps from recognising escalation trigger points and working through all clinical, managerial and executive decision making steps.