HASU Capacity Management Escalation Protocol
June 2012
The LAS plays an important role in balancing the flow of patients into London’s HASUs. Whilst rapid
assessment and thrombolysis of eligible patients is vital, ongoing care in a specialist bed is equally
important. The following process has been agreed by the Stroke Networks as per the London stroke
model.
As tertiary specialist sites, HASUs can not formally go on “divert” unless a Tertiary Service Divert has
been authorised by the NHS London Gold or an internal Major Incident has been declared by the
relevant Acute Trust. A divert for stroke patients will only be considered if a HASU has no capacity –
i.e. all HASU beds are occupied with patients on the stroke pathway. If an ED is on divert, Cardiac
Arrests, Major Trauma, Heart Attack, Paediatrics and Stroke are excluded.
FAST + Patient, clinically stable
and safe for longer journey 1,2
Does the nearest HASU have
capacity?
Yes
No
Is there an available bed in the
second-nearest HASU? 3
No
Yes
Is the second-nearest HASU
within a
45 minute drive time? 4
No
Yes
Convey the patient to the
nearest HASU with a
pre-alert message to the ED 5
1
Convey the patient to the
second-nearest HASU with an
appropriate pre-alert message
The default position is that a HASU should accept new onset FAST+ patients from within its
catchment area. Clinical Coordination Desk (CCD) has limited capacity and opportunity to influence
patient flow. Only those patients who have symptoms within the thrombolysis window are prealerted – other patients are taken in under normal driving conditions, with no routine
communication with CCD.
Notes:
1. This only applies to patients who are stable, and deemed safe enough to transfer to a more
distant HASU. Unstable patients should be taken to the nearest HASU; patients with critical
airway compromise or respiratory failure should be taken to the nearest Emergency
Department
2. Patients with chronic neurological signs, or where the history is unclear and the diagnosis of
acute stroke is unlikely should be taken to the nearest Emergency Department
3. The ‘next nearest’ HASU refers to geographical location, and not ‘nearest available bed’. If
there is no bed available in the next nearest HASU, the patient is conveyed to the nearest
HASU (i.e. the one where the patient would normally be taken to). Conveying patients
beyond the next nearest HASU is not appropriate, as this potentially delays thrombolysis and
could become very inconvenient for the patient and his / her relatives
4. “Reasonable Journey Time” is subjective. For example, a patient who is in Romford should
be conveyed to Queens Hospital, Romford regardless of their capacity; a patient in Newham
could be conveyed to either Queen’s Romford or the Royal London. Journey time should be
less than 30 minutes under normal circumstances, and certainly not exceed 45 minutes at
times of stress
5. Pre-alert calls should be placed for all patients within the thrombolysis window (4 ½ hours
from onset of symptoms), or where the crews have clinical concerns
Daily Procedure
1. HASU bed-state only takes into account patients on the Stroke pathway. Outliers from other
wards or units should not be counted.
2
2. EBS team will call the HASU clinical coordinators at least twice per 24 hour period, and
record the bed status in the database; this should include a prediction of available beds.
This is accessible to CCD.
3. CCD will track patient movement, and monitor HASU bed capacity, so that patient flow can
be balanced.
4. CCD must keep a record of patients who have been subject to a ‘redirection’, or where a
redirection has been considered / discussed.
5. HASUs may call CCD and advise them of capacity at any time. This should be logged and
used to guide decision-making.
6. A HASU cannot declare itself “closed” without authority from NHS London
Mimics
It is recognised that moving presumed stroke patients longer distances increases the potential issues
with repatriating stroke mimic patients back to an appropriate centre. Ambulance turn-around and
send back is NOT PERMITTED.
Escalation
The process outlined below is to be used when the whole of the London stroke system is
experiencing periods of reduced/minimal capacity. This protocol outlines different levels of
escalation, the planned responses and the communications plan.
The protocol is based on the assumption that the London HASU model can be considered as an inner
group of units (5) and an outer group of units (3) (see map below). Because of journey times
redirection to a further HASU is likely to be inappropriate for the 3 outer London units unless HASU
is formally closed through NHS London.
It should be noted that this protocol is to be seen as a temporary measure to ease short term
capacity issues and not a change to the agreed London stroke model. The period of time that this
protocol is in operation will not be included in assessment data (assuming the period does not
exceed 7 days).
3
All acute stroke patients should be assessed and treated in a HASU. If the HASU does not have a
bed, it is incumbent on the HASU provider trust to have a contingency plan to accommodate these
stroke patients.
It is not appropriate to operate a reduced 'thrombolysis only' service or to transfer a stroke patient
from one HASU to another for HASU care. The only occasion it may be appropriate to transfer a
HASU patient is if they require other specialist intervention.
Network HASU capacity
Network
HASU
Total number of HASU beds
North Central London
University College Hospital
18
The Royal London Hospital
12
Queen’s Hospital
12
Charing Cross Hospital
20
Northwick Park Hospital
16
King’s College Hospital
12
Princess Royal Hospital
14
St. George’s Hospital
20
North East London
North West London
South East London
South West London
Escalation level one
Information is received that 3 or more HASUs are reporting capacity of one or zero beds for more
than 12 hours.
In this instance the following steps will be taken;
1. HASU services reporting low capacity will initiate their provider trust contingency plans to
accommodate any stroke patients that require HASU services after low capacity is reported.
This is so that patients arriving at the affected HASUs by a route other than through LAS are
managed appropriately.
2. Any delay in the transferring of non-stroke patients to the appropriate setting is escalated by
the HASU teams in line with cluster mimic repatriation policies where they exist. In the
absence of local mimic repatriation protocols, refer to section 3 of the Pan London HASU SU
Repatriation Protocol V4 July 2010 (electronic link to be added). If these delays are cross
sector they are escalated to the HASU Site Manager1 on call.
3. The relevant network team will contact stroke units in the network to ascertain whether
HASU capacity is under pressure due to stroke patient repatriation issues. If this is a factor
the Network will request that the appropriate steps are taken to enable repatriation in line
1
See; Appendix two – HASU manager on call communications list
4
with section 5 of the Pan London HASU SU Repatriation Protocol V4 July 2010. This could
include, but is not limited to, requesting that stroke units with capacity take patients from
outside of their defined SU catchment areas as quickly as possible. These spells will attract
the London SU tariff.
Escalation level two
Information is received that there is a total of 3 or less beds in the inner group of units for at least 12
hours, or if a HASU has to close due to infection (complete steps 1-3 as above).
4. Notification that the London stroke system has moved to escalation level two is sent out
from the London Stroke Clinical Director to both the HASU leads and the HASU site
managers on call.
5. The HASU consultant on call will cascade this message to the clinical leads at the stroke units
in their sectors.
6. During the week (Mon to Friday 9 to 5) the relevant network teams contact the affected
HASUs to confirm that their provider trust contingency plans to accommodate any stroke
patients that require HASU services have been activated and to receive confirmation of
capacity that includes beds provided in these contingency plans. Out of hours and at the
week end this is done by the London Stroke Clinical Director or their designated deputy.
7. If capacity pressures are due to stroke patient repatriation issues; all network teams to
contact SUs within their sectors that are able to operate timely repatriation in order to
arrange for the opening of additional SU capacity and to take patients from outside their
normal catchment areas (this could mean taking patients from other sectors). These spells
will attract the London SU tariff. Arrangements for additional capacity can be flexible, and
agreed on at unit by unit basis with the relevant Network Director.
8. Network teams to collate information with regard to any available additional SU capacity
and share with the other network directors and the London Stroke Clinical Director so that
additional capacity can be utilised effectively. This additional capacity information is then
communicated to the relevant HASU leads.
9. If delays in the transferring of non-stroke patients remain, the network team will escalate to
the appropriate Operational Director at both the HASU trust and the receiving trust (if
different) in order to facilitate timely repatriation in line with local mimic repatriation
protocols, where they exist. In the absence of local mimic repatriation protocols, refer to
section 3 of the Pan London HASU SU Repatriation Protocol V4 July 2010.
5
10. If capacity pressures are due to a lack of HASU beds (increased demand) network teams will
contact the nominated operational lead at the HASUs affected in their sectors to arrange for
further additional capacity beyond the trust’s standard internal contingency plans.
Escalation level three
Information is received that there is 1 bed or less across the inner group of London HASUs and less
than 3 beds are predicted to become vacant. (complete steps 1-10 as above).
11. Notification that the London stroke system has moved to escalation level three is sent out
from the London Stroke Clinical Director to both the HASU leads and the HASU site
managers on call.2
12. Network teams cascade this message to the clinical leads at the stroke units in their sectors.
At the weekend this is done by the London Stroke Clinical Director.
13. The London Stroke Clinical Director or nominated deputy will call a crisis meeting with the
Network Directors or their nominated deputies within 3 hours of the decision to escalate to
level 3. If this happens over the weekend this meeting will be held as soon as possible on the
next working day.
14. Any remaining non-stroke patients in HASUs are transferred to a SU if safe to transfer the
patient. This activity should be distributed evenly across the stroke units and based on the
postcode look up table as much as possible.
6
Area where redirection to a further HASU is likely to be inappropriate unless
HASU formally closed through NHS London
Appendix one – HASU lead communications
LAS will communicate HASU capacity on a twice daily basis to this group. The London Stroke Clinical
Director has the responsibility for reviewing HASU capacity on a daily basis and action this protocol
when appropriate.
London Stroke Clinical Director
Tony Rudd, anthony.rudd@kcl.ac.uk
7
HASU
Consultant
on call
telephone
number
Charing
Cross
Hospital
King’s
College
Hospital
Northwick
Park
07774900504
Hospital
Princess
Royal
Hospital
Queen’s
Hospital
The Royal
London
Hospital
Via
Switchboard
on
01708
435000
Vis
Switchboard
0207 377
7000
St.
George’s
Hospital
University
College
Hospital
Clinical Lead
Nurse Lead
Diane Ames
Julia Slark
diane.ames@imperial.nhs.uk;
julia.slark@imperial.nhs.uk;
Dulka Manawadu
Maria Fitzpatrick
dulka.manawadu@nhs.net;
maria.fitzpatrick@nhs.net;
Memory Dzvene
David Cohen
mdzvene@nhs.net
David.Cohen@nwlh.nhs.uk;
Sue Fenwick Elliott
Sue.fenwickelliott@nhs.net
Bart Piechowski
Chris Terrahe
b.piechowski-jozwiak@nhs.net
cterrahe@nhs.net;
Sreeman Andole
sreeman.andole@bhrhospitals.nhs.uk
Ann Russell
Ann.RUSSELL@bhrhospitals.nhs.uk;
Ann Rush
Patrick Gompertz
ann.rush@bartsandthelondon.nhs.uk;
patrick.gompertz@nhs.net;
Jo Baylon
josefa.baylon@nhs.net
Hugh Marcus
Alison Loosemore
hmarkus@sgul.ac.uk;
alison.loosemore@stgeorges.nhs.uk;
Rob Simister
Simone Browning
robert.simister@uclh.nhs.uk;
simone.browning@uclh.nhs.uk;
Network Director
Network Clinical Lead
Hilary Walker
hwalker3@nhs.net;
Janet Lailey
janet.lailey@nhs.net
Charlie Davie
c.davie@ucl.ac.uk;
North West London
Hilary Walker, as above
Diane Ames, as above
South East London
Lucy Grothier
lucy.grothier@slcsn.nhs.uk;
South West London
Lucy Grothier, as above
Gill Cluckie
gill.cluckie@gstt.nhs.uk;
Geoff Cloud
gcloud@sgul.ac.uk;
Network
North Central London
North East London
Patrick Gompertz, as above
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Appendix two – HASU manager on call communications list
HASU
HASU manager on call contact
number/email
Charing Cross
Hospital
King’s College
Hospital
Northwick Park
Hospital
Sue Fenwick Elliott
Copy communication to HASU Clinical
Lead
Diane Ames
diane.ames@imperial.nhs.uk;
Dulka Manawadu
dulka.manawadu@nhs.net;
David Cohen
Sue.fenwickelliott@nhs.net
David.Cohen@nwlh.nhs.uk;
07787005902
Princess Royal
Hospital
Bart Piechowski
b.piechowski-jozwiak@nhs.net
Cass O’Reilly
Cass.O'Reilly@bhrhospitals.nhs.uk
Queen’s Hospital
The Royal London
Hospital
St. George’s
Hospital
University College
Hospital
01708 435000 Extn 2968 & Dect
Phone 6129
Out of Hours through Site Manager
via Switchboard on: 01708 435000
Out of hours through Site Manager
via switchboard on: 0207 377 7000
Sreeman Andole
sreeman.andole@bhrhospitals.nhs.uk
Patrick Gompertz
patrick.gompertz@nhs.net;
Hugh Markus
hmarkus@sgul.ac.uk;
Rob Simister
robert.simister@uclh.nhs.uk;
9