NHS Borders
Development of Escalation Policy
Dr. Simon Watkin
Consultant Respiratory Physician
Borders General Hospital
simon.watkin@borders.scot.nhs.uk
Setting
• NHS Borders
Borders General Hospital
Primary and Community Services
Mental Health
Social Services
Scottish Ambulance Service
Partnership forum
• Population 106,500
• 280 beds total
• 102 GIM beds including 30 MAU and 12 HD
• 30 DME, 30 stroke/palliative/community
Numbers
General Surgery Admissions and Discharges over a 15 month period
General Medicine Admissions and Discharges over a 15 month period
300
800
750
250
Number of Episodes
Number of Episodes
700
650
600
550
200
150
100
500
50
450
400
0
Jun-09
Jul-09
Aug-09 Sep-09
Oct-09
Nov-09 Dec-09
Jan-10
Feb-10 Mar-10
Period
ADMISSIONS
Apr-10
May-10 Jun-10
Jul-10
Aug-10
Jun-09
Jul-09 Aug-09 Sep-09 Oct-09 Nov-09 Dec-09 Jan-10 Feb-10 Mar-10 Apr-10 May-10 Jun-10 Jul-10 Aug-10
Period
DISCHARGES
ADMISSIONS
DISCHARGES
Length of stay
NHS Borders
X Chart showing average length of stay in General Medicine
15 MONTHS
7
5
4
3
Period
Trajectory Scottish Average Performance 2008 - 09
Dec-10
Nov-10
Oct-10
Sep-10
Aug-10
Jul-10
Jun-10
May-10
Apr-10
Mar-10
Feb-10
Jan-10
Dec-09
Nov-09
Oct-09
Sep-09
Aug-09
Jul-09
2
Jun-09
Average Lengths of Stay
6
Why might you need an escalation plan?
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95+% bed occupancy
Delayed and cancelled surgery
4 hour waiting breached
Medical boarders
Norovirus
Severe weather
Influenza
Development of Escalation Policy
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Executive support
Large scale 1 day event
Small working group weekly
Agreed policy
Executive mandate
Implementation group
“Thin” policy document
Clear operational arrangements
Who was involved?
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AHPs
Bed Management
BGH Clinical Board
Borders Emergency Care Services
Borders Improvement Support
Team
Communications Team
Community Hospital
Superintendents
Discharge Liaison
Domestic and Portering Services
Infection Control
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IM&T
Mental Health Clinical Board
PACS Clinical Board
Pharmacy
Planning and Performance
Public and Patient
Representatives
Scottish Ambulance Service
Scottish Health Council
Social Work
Voluntary
Timescale
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Concept
Workshop
Executive approval
Implementation
April
June
August
October
Positives
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Creative and innovative
Multi professional
Alignment of objectives
Better, safer treatment
Efficient
Cost effective
Now what?
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Implementation group
Data quality
Action cards
Patient flow action team
Monitoring
Trial period
Re-assess
Re-calibrate
Colour
Capacity
Level of Concern
for Service
Delivery
Black
No capacity to meet
actual unscheduled
demand
Critical
Red
Insufficient capacity
to meet predicted
planned and
unscheduled demand
Severe
Amber
Limited capacity but
discharges are
predicted
Green
Sufficient capacity to
meet predicted
planned and
unscheduled demand
Moderate
Nil / Minor
Status at Midnight
Treatment Capacity
Staffing Levels
Support Services
Risk Levels
Repatriation / Boarders
Board Status
Colour Action
staff are required to contribute to
Black All
managing this through direction from
Red
Amber
Green
Patient Flow Action Team.
All those with roles and responsibilities
outlined in Action Cards must prioritise
these over normal duties.
Limited number of staff involved in actions
as directed through the Clinical Boards.
No requirement for actions in additional to
normal procedures.
How do we set the whole system status?
Red
Amber
Red
Red
Red
Red
Amber
Green
Green
Green
Green
Amber
Red
Amber
Amber
Green
Red
Red
Red
Amber
Red
Green
Green
Green
Green
Amber
Green
What’s next?
• Have we got the thresholds correct
• Can all groups react in real time
• Will we learn anything we do not already
know
• Equitable spread of risk
• Common understanding
"If you are too good at adjusting to the
current system, you may never realise
that the system needs changing“
Edward de Bono