PORTSMOUTH HOSPITALS NHS TRUST
CLINICAL POLICIES
Section 3.66
Title
Adult Outliers & Buffer Capacity Policy
Reference number
Manager /
committee
responsible
Date issued
Version
Review date
3.66
Author
Maria Purse, Emergency Pathway Manager
Equality impact
assessment has
been applied to
this guideline
Yes
Ratified by
Hospital Management Committee - 25th March 2009
Hospital Management Committee
03.09.2009v2
2
June 2010
This policy provides staff with guidance on the actions to take when hospital
capacity is limited and adult patients must be accommodated in a clinical
area outside of their expected speciality. It gives guidance on how to safely
risk assess patients as suitable to be “outlied”, and provides a risk
Summary
assessment and checklist for the opening of buffer capacity. This is a
generic policy which applies to adult patients in all PHT sites. It is recognised
that clinical specialties may also wish to develop local guidelines for outlying
with the Trust’s operational team. It is applied in conjunction with the Bed
Capacity Management Policy and the Trust Escalation Plan.
AMENDMENTS RECORD
DATE
PAGE
COMMENTS
1
Removal of Mary Sherry name’s as co-author
3
Changes to location of buffer capacity
8
Changes to reflect the fact that Mary Sherry is no
03.09.09
longer with PHT
10
Changes made to times of Operations Meetings
CONTENTS:
1.
2.
3.
4.
5.
6.
7.
8.
9.
Introduction
Status
Purpose
Scope/Audience
Definitions
Process
Supporting Evidence
Training
Associated Documentation/References
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Section 3.66
1. INTRODUCTION / BACKGROUND
Portsmouth Hospitals NHS Trust (PHT) is committed to providing a high quality care environment where
patients and staff can be confident that best practice is being followed at all times and that the safety of
everyone is of paramount importance. The Trust strives to provide care and treatment, which promotes high
standards of privacy and dignity as well as clinical care, throughout patient’s individualised care pathway.
It is the clear intention of the Trust to over time remove the need for outlying patients wherever possible. At
the present time process changes are focussed on patients having minimal moves and only those clinically
indicated (eg from an Assessment Area to an In Patient Ward). On a daily basis wards should focus on
Pursuing actions to increase discharges rather than using outlying to create capacity.
A correlation between increased mortality rates and the practice of outlying is emerging. In addition, the risks
of healthcare associated infection (HCAI) are greatly increased by extensive movement of patients within the
hospital, by very high occupancy rates and by an absence of suitable isolation facilities (DoH 2003, Winning
Ways; DoH 2005 Saving Lives). It is also a risk that outlying increases length of stay which in its turn then
blocks capacity. It is therefore imperative that all actions are focussed on reducing the need for outlying.
Therefore Portsmouth Hospitals NHS Trust seeks to make every effort to minimise the numbers of patients
who are outlied, but recognises that at times, when emergency admissions are high, decisions to outlie may
be necessary. This policy seeks to provide clear protocols and procedures in order to minimise the known
risks to the practice of outlying.
This policy should be read in conjunction with the policies and guidelines listed in section 9 of this document.
2. STATUS
Clinical Policy
3. PURPOSE
This policy is intended to ensure the safety, dignity and duty of care for both patients and staff who are
involved in the process of caring for adult patients in clinical environments outside their own speciality and/or
in unfunded or emergency capacity.
4. SCOPE/AUDIENCE
This policy applies to all staff who have contact with adult patients working within PHT, including medical staff,
nursing and midwifery staff, allied health professionals, medical students, nursing and midwifery students, and
other members of the multidisciplinary team working with individual patients in wards, and departments. It also
applies to any staff (clinical and non clinical) who are either making decisions about the most suitable clinical
areas for patients to receive care and treatment or who are caring for patients outside of the expected clinical
speciality. This is a generic policy designed to assist those responsible for the delivery of care to all adult
patients. Individual speciality guidelines may also be required and should also be followed, but are not
included in this policy.
5. DEFINITIONS
 Clinician - describes the Healthcare Professional responsible for the patients care and treatment.
 “Outlying” – Transferring a patient to a clinical area outside of their speciality.
NB: A patient under a medical consultant’s care who is cared for in a bed which is normally allocated
to another medical consultant is not normally classified as an ”outlier” in relation to the term used in
this policy.
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



Section 3.66
Buffer Capacity – Use of beds which are either designated for flexible use or are normally closed or
used for another purpose (e.g. C5, C6, E8 for medical patients and F3 and G2 for DMOP patients)
Internal transfer – The movement of a patient from one ward or department to another within Trust
clinical areas and/or across PHT sites.
Out of Hours – Between 22.00 and 08.00 and at weekends.
Single Sex Accommodation/Facilities - men and women have separate sleeping areas (eg single-sex
bays) and have separate toilets and bathrooms that they can reach without having to pass through (or close
to) opposite sex areas. Ward layouts should minimise any risk of overlooking or overhearing from patients from
the opposite gender. (CNO 2007)

Risk – Possibility of exposure to a hazard & therefore the chance of injury, ill health, harm, damage
or loss. It may include the effects of substances, equipment, a work practice or proposed business
plan.
6. PROCESS
6.1 Risk
The central principle underlying outlying decisions is rooted in the management of risk. The Trust’s Risk
Assessment Policy explains that a risk assessment is no more than a careful examination of what might
cause harm to patients, staff, visitors and others. A risk assessment provides a systematic and methodical
tool for identifying risks, removing them where possible or otherwise adopting all the control measures and
precautions that are reasonable and practical in the circumstances.
In circumstances where it is necessary to make decisions about outlying (i.e. limited bed capacity to ensure
appropriate and timely patient flow), the degree of risk needs to be clearly identified. It is recognised that
normally, the best course of action is not to outlie, but where outlying decisions are needed these must
ensure the minimal risk to patients and staff.
6.2 Principles
The following principles govern decisions to outlie patients to areas outside of their expected speciality:

All efforts must be made to ensure patients normally receive care and treatment in the most
appropriate clinical speciality area for their current condition.

Safety, clinical efficacy and a positive patient experience are the goals of all outlier decision making.
Decisions to outlie must be based on the patient’s current clinical and mental health needs, their level
of acuity and dependency and the clinical capability of the receiving area.

Decisions to outlie should always be taken in a manner that supports the achievement and
maintenance of patients individual needs, privacy and dignity, infection control status and single sex
ward requirements. Such decisions must be taken according to current infection control policies and
practice in order to reduce the risk of exposure to infection.

Patients who are placed outside of their normal specialty areas are entitled to the same level of care
and treatment that they would receive if cared for within their specialty areas. Every effort will be
made to ensure that outlying patients are reviewed by nursing and medical teams from their specialty
on a daily basis during Monday to Friday and if possible at weekends.
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Section 3.66

It must be recognised that this may challenge some medical and nursing teams and, particularly at
times of high outlier numbers, the Divisional Management Team must work with specialty clinicians to
agree how outlier patients will be supported medically. This may require some flexibility between
clinical teams if total patient numbers for a specialty are particularly high.

Once it is deemed necessary to outlie and/or open buffer capacity, clinical teams must make the
decisions on specifically which patients are to be outlied. Patient treatment plans must be updated
including pending investigations and discharge plans carefully documented in the patient’s health
records. Where inappropriate decisions to outlie patients are made, feedback and review needs to
take place with the clinician making that decision.

Clinical teams must be informed of patients who are actually outlied, with clear information given on
where the patient has been outlied to. The Patient Administration System must be updated promptly
as this will help the clinical teams identify the patient’s outlying ward from the patient list printed by
the team each morning.

The number of bed moves during each patient’s stay must be minimised. Ideally once a patient has
been outlied from their original ward they should not be moved again. If this is necessary then careful
dialogue must take place with the patient and care taken not to move the patient again.

Regulations around single sex accommodation and facilities will not be breached and there may need
to be some cohorting of patients to achieve this.

Outlier decisions must be based on a full understanding of the current position regarding whole
hospital capacity and decisions made to balance the prevailing risk across the whole hospital and
between specialties

Relatives must be informed of all decisions to move patients and it must be the case that they given
precise details of the ward to which the patients has been moved.
6.3 Decision Making

Outlier decisions will be made according to all of the above points as well as within the context of the
achievement of the Trust’s objectives and standards.

Any decision to open unfunded capacity or move patients to areas outside their specialty must,
ideally, be preceded by a formal risk assessment (see appendices A, B and C) undertaken by the
patient’s doctor, nurse in charge of the ward, Matron or Unit Bleep holder and the documentation
reflecting this will be filed in the patients health records where appropriate.

As a minimum the decision to outlie must be documented in the patient’s notes.

Patients who receive care and treatment in outlier areas are entitled to care from staff according to:
o Agreed & safe staffing levels (in both speciality and outlier areas) in line with guidance set
out by the Chief Nurse and the Medical Director
o Agreed and appropriate staff knowledge skills and competencies related to their condition
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Section 3.66

Staff should not be put at risk by being asked to care for patients in environments where there are
insufficient staffing, equipment or physical resources or where they do not have the appropriate
knowledge and skills for those patients’ conditions.

Normally patients are not to be admitted to an outlying area straight from the Emergency Department
or assessment area such as the Medical Assessment Unit.

Staff involved in making decisions to outlie or open unfunded capacity will use the risk assessment
tools and be prepared to justify that all decisions were taken in a robust manner, taking into account
individual patient conditions as well as the whole hospital capacity situation.
6.4 Outlying Criteria
 FIRST OPTION: OUTLIE PATIENTS FROM ONE SPECIALITY TO ANOTHER
Into an open and funded bed
 SECOND OPTION: USE BUFFER CAPACITY WITHIN AN EXISTING STAFFED BED
FOOTPRINT
Accommodate patients in wards where flexible beds are available and can be opened but where
additional staffing is not normally required or is minimal.
 THIRD OPTION: OPEN BUFFER CAPACITY IN AN EMPTY AREA OR ONE WHICH IS NOT
NORMALLY OPEN AT PARTICULAR TIMES (eg Trafalgar Ward, Day Surgery Unit)
Open additional capacity in agreed locations which will normally require additional staffing, as set out
in the Trust Escalation Plan.
The criteria for risk assessing patients as suitable to be outlied are sub-categorised into essential and
desirable criteria:
6.5 Actions:
The following decision tree details the actions associated with outlying patients and encompasses:
1) Decisions to move an individual patient to a clinical area outside their normal speciality
2) Decisions to move an individual patient to a flexible bed space either in unfunded or emergency capacity
(normally no additional staff required)
3) Decisions to open buffer capacity in an established clinical area
4) Decisions to open and staff buffer capacity (normally additional staff required)
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Section 3.66



Essential:
These criteria MUST be met for ALL patients,
regardless of speciality




The patient has a confirmed diagnosis
and/or a treatment and discharge plan is in
place
The patient will not have experienced
symptoms of infective diarrhoea or vomiting
within the last 72 hours
The patient is clinically stable and has not
experienced deterioration in their condition
in the previous 24 hours. EWS score is
within expected limits for patient.
Resuscitation status is known/clearly
documented
The patient is not confused or disorientated
and has not attempted deliberate self harm
at this admission.
The patient will not be undergoing treatment
for an MRSA bacteraemia
The patient does not pose a risk to other
patients or staff.

The patient is pain free or on a stable
analgesia regime
 The predicted date of discharge will
Desirable:
normally be at 48 hours or less
Patients who meet all of the essential criteria but
 The patient is not expected to die
fail some of the desirable criteria may be
 The patient is safe to be cared for by
suitable to be outlied where this has been
nursing staff who do not necessarily have
approved by the doctor and nurse in charge of
speciality knowledge or experience
the patient’s care.
The patient may require a “social stay” i.e. with no
active treatment, following medical interventions or
elective surgery
 The patient has been stabilised post
operatively within their own specialty
Speciality:
Agreed speciality plans/criteria must be followed.
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Section 3.66
Actions required to move an individual patient to a clinical area outside their normal speciality
Transfer Team
Site or Duty
Hospital Manager
Need for additional Bed Capacity to
maintain patient flow is identified and
agreed at capacity meeting or via
Duty Hospital Manager
Ward RN
Duty Hospital
Manager or Matron
Are suitable patients
identified to be outlied?
(Normally by ongoing
medical review)
Are there beds in funded
areas suitable to use for
outliers?
NO?
YES?
a) Risk Assess
suitability to use
for outlier
patients
(Appendix B)
(including
decisions about
staffing)
YES?
a) Identify and agree
area to be opened
b) Prepare area using
Checklist (appendix C)
NO?
a) Has risk
assessment
been
completed?
(Appendix A)
a) Request to
ward to
complete risk
assessment by
Duty Hospital
Manager
c) Risk Assess Area
(Appendix B)
b) Ward/Dept.
staff risk assess
suitable patients
to outlie
(Appendix A)
d) Ensure safe staffing
level and skill mix
available
Patients ready to be
outlied.
Beds suitable to use for
outliers.
Ensure patients, relatives and other healthcare
staff are notified of impending move, and
medical/surgical team are informed.
Adhering to the Trust’s
“Transfer of Patients”
Policy, move outlier patients
to new clinical area.
Ward Staff
Arrange Move and
escort/handover
Adult Outlier & Buffer Capacity Policy. Issue 2. 03.09.2009v2 (Review Date: June 2010)
Transfer Team
Arrange Move and
escort/handover
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Section 3.66
6.6 BUFFER CAPACITY
At times of pressure, both predicted and exceptional, it will be necessary to open additional bed capacity,
termed buffer capacity. This may be for short period of time to ease what is anticipated to be short term
pressure or in anticipation of predicted pressure such as Bank Holidays and seasonal variation in demand.
This buffer capacity may be provided in known flexible beds or in beds that are normally closed or used for
another purpose.
For short term pressure the preference is always to make sure that all actions for current patients are up to
date and being progressed so that discharges can be maximised and beds freed up for new admissions.
Where that is not possible, specialties will have agreed bed spaces that they will flex into to deal with this
short term pressure and these bed spaces will be closed again once that pressure has eased.
For predicted seasonal variation in demand a formal plan will be put in place to set out where the buffer
capacity is to be located and the criteria upon which it will be used including patient type.
The location and number of bed spaces in such buffer capacity will vary and the current configuration and
criteria for opening buffer capacity will be set out and updated in the Trust Escalation Plan.
The planning and utilisation of this buffer capacity will be overseen by the Emergency Pathway Manager, who
will work with Specialties and Divisions to ensure that the deployment of this buffer capacity achieves an
appropriate accommodation of pressure across the hospital as a whole.
7. DUTIES AND RESPONSIBILITIES
Clinician teams, ward staff and operational managers are all responsible for ensuring that patient focussed
and safe decisions are made prior to moving patients to wards/departments outside of their expected
speciality area. Wherever possible, as a priority additional actions should be pursued to avoid the need to
outlie patients by increasing discharges to increase capacity.
Emergency Pathway Manager
 Day to day operational management of patient flow and utilisation of bed capacity
 Leadership of Duty Hospital Manager team
 Overall leadership and management of Trust bed stock, as delegated by Chief Operating Officer
 Develop with Divisional Management Teams plans and processes for the management of bed
capacity that will reduce over time the need for outlying.
 Hold delegated executive authority to place patients in the most appropriate beds and to access beds
at times of increased demand
Duty Hospital Manager:
 Keep continually appraised of the whole hospital position in relation to capacity and demand and on
any internal/external issues which might affect patient flow
 Lead hospital capacity meetings during their shift in order to assess the need for identifying outliers
and opening unfunded capacity
 Receive reports from speciality and duty matrons in relation to current staffing issues
 Keep the on call manager and on call director fully briefed of the hospital position and request
authorisation to open unfunded capacity and outlie when required
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Patient Flow Managers
 To ensure risk assessment for opening unfunded capacity is completed (and copies to Emergency
Pathway Manager and Divisional Senior Nurse of the division) where unfunded capacity has been
opened
 To ensure checklist for opening unfunded capacity has been completed with copy to Patient Access
and Emergency Pathway Manager and DSN as above
 Ensure sufficient potential patients to be outlied from suitable wards and departments are noted at
each bed meeting
 Liaise closely with the Infection Prevention and Control Team
On Call Manager
 To support the Duty Hospital Manager in making decisions to outlie patients and particularly
when this requires the opening of buffer capacity
 Give advice and guidance to site and speciality teams in relation to patient flow and outlying
decisions
On Call Director:
 Give authorisation for the use of buffer capacity for outlier patients
 Ensure all policies and procedures have been adhered to in the process of outlying
Divisional & Operational Management Teams
 Ensure robust systems and processes are in place for capacity management within the division
 Monitor and ensure action is taken on areas of identified risk
 Provide timely and accurate information to appraise Patient Flow Managers and Duty Hospital
Manager of current demand and capacity issues and work to prevent the need to move patients
outside their speciality by maintaining effective flow
Divisional Clinical Directors, Clinical Directors & Consultants:
 Ensure capacity management is effective within own divisions
 Ensure patients under their care have agreed treatment plans and PDDs in place
 Adjust discharge thresholds where possible in order to ensure that maximum bed capacity is created
and to avoid the need to outlie and in particular avoid the need to open buffer capacity
 Ensure patients who have been outlied get prompt and appropriate medical assessment and
interventions, and receive a medical review at least once in every 24 hour period over Monday to
Friday period and preferable at weekends
 As part of patient medical review, ensure decisions about outlying suitability are made and
communicated to Junior Medical Staff and the Ward Nursing team.
 Ensure specialties have identified appropriate criteria for assisting with outlying decisions and that
this is widely understood/communicated to all members of the healthcare team
 Ensure that junior medical staff respond appropriate to calls concerning an outlier patient’s condition
and that that appropriate cover arrangements are in place in the case of a patient’s condition
deteriorating or in a medical emergency
Junior Doctors
 Ensure daily medical review of patients who are being cared for in outlying areas
 Respond promptly to ward requests to review outlying patients e.g. if MEWS scores deteriorating.
 Ensure patients who are outlied have appropriate treatment and medication regimes prescribed
Matron for Division/Speciality:
 Understand the daily position with regard to capacity, patient moves and outliers either at the morning
divisional capacity meeting or by contacting clinical areas
 Ensure that all wards/department shift leaders have complied with requirements to identify outliers
and have escalated these to Patient Flow Manager.
 Ensure risk assessments are completed for all patients identified as suitable to outlie
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
Ensure that a review of all speciality outliers takes place at least every 24 hours Monday to Friday
and at weekends if possible i.e. how many, where are they, are treatment plans being followed
 Identify staffing situation and requirements for any buffer capacity within the division
Duty Matron
 Review nurse staffing situation for the evening, night and if possible early shift of the next day
 Make decisions to move nursing staff to cover gaps which have arisen either through unplanned
absence or from the opening of buffer capacity
Ward Sister/Charge Nurse/Senior/Staff Nurse in charge of clinical area:
 Identify suitable outliers (normally 1 per ward/department at morning handover and a further 1 by
15.00) and communicate this to the Patient Flow Manager.
 Supply name of potential outlier(s) to Patient Flow Manager at their first round of the day for 11.30
Operations Meeting and again provide name of second outlier to Patient Flow Manager for 15.30
Operations Meeting
 Confirm outliers list with medical teams during ward rounds
 Complete risk assessment documentation and record in patient’s notes
 Ensure patients and their families/carers are kept fully informed of potential/actual decisions to outlie
 Ensure nurse in charge of receiving ward is given comprehensive handover of patients condition,
care and treatment plans
Unit/Floor Nursing Bleep Holders (OOH)
 Ensure continuous and effective flow of patients is maintained within the unit/across floor during the
shift
 Support Ward Nurses in Charge to make decisions about patients suitable to outlie according to
appendix A of this policy
 With Patient Flow Manager and Duty Matron (where available) undertake risk assessments prior to
opening buffer capacity, securing appropriate equipment and ensuring the area is safe, appropriately
staffed and well prepared to receive patients.
Outlier Nurse (QAH Only) from each specialty
 Review every outlier patient under their speciality at minimum of once in every 24 hour period over
the Monday to Friday period.
 Ensure patient’s progress towards safe and effective discharge is maintained
 Make recommendations/arrangements to repatriate patients to their original speciality if their
condition deteriorates or progress is not as per expected pathway
Specialist Nurses
 Provide advice and guidance about speciality aspects of patient’s conditions to ward teams caring for
the patient.
Infection Prevention and Control Team member (Daily Duty Rota)
 Attend 11.30 capacity meeting to advise of any specific outbreak notifications
 Contribute to decisions about outliers and ensure any proposed outlier moves are appropriate,
particularly for patients who are identified as having a high risk of infection
 Make every effort to avoid transferring patients who are more likely to carry HCAI organisms
Therapists
 Continue to provide therapy for patients under own speciality who have been outlied to another
speciality or hand patients over to the appropriate team for the outlying ward.
8. TRAINING
Duty Manager Briefing
Duty Matron Briefings
Departmental Induction
On Call Director Briefings
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Section 3.66
9. ASSOCIATED DOCUMENTATION






Portsmouth Hospitals NHS Trust Bed Capacity Management Policy
Portsmouth Hospitals NHS Trust. Transfer Policy
Portsmouth Hospitals Escalation Plan - internal
Portsmouth Hospitals NHS Trust Risk Assessment Policy and Protocol
Portsmouth Hospitals NHS Trust Mixed Sex Accommodation Policy
Portsmouth Hospitals NHS Trust Accommodation of Babies with their Mothers
FURTHER INFORMATION
 Mental Capacity Act Mental Capacity Act 2005 : Department of Health - Policy and guidance
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Appendix A – Risk Assessment for Individual Patient Outlier Decisions
Any recorded NO response in the essential criteria indicates the patient should not be outlied. If hospital capacity is
such that patients are being put at clinical risk in other areas (e.g. by being held in en Emergency Department queue)
there may be pressure to outlie patients who meet essential but not all desirable criteria. The decision to outlie must
then be taken by the following staff:
 In Charge Medical Consultant or their nominated Deputy
 Nurse in Charge of Ward/Department
Other staff who should be included in this decision making include:
 Matron/Unit/Floor Nursing Bleep holder
 Patient Flow Manager
 Duty Matron
 Duty Hospital Manager
 Other members of the healthcare team e.g. therapists and discharge planners
NAME OF PATIENT……………………………………………………………DATE OF BIRTH………………………………..
HOSPITAL NUMBER………………………………………DATE/TIME OF ASSESSMENT…………………………………..
SPECIALITY WARD/DEPARTMENT NAME……………………………………………………………………………………
NAMES OF HEALTHCARE TEAM CONTRIBUTING TO THE OUTLIER DECISION (please print)
1) ……………………………………………………… ……… 2) ………………………………………………………………….
3) ……………………………………………………………….. 4) ………………………………………………………………….
Prioritisation
Criteria
Yes
Essential:
These criteria MUST be
met for ALL patients,
regardless of speciality
The patient has a confirmed diagnosis and/or a treatment and discharge plan is
in place
The patient will not have experienced symptoms of diarrhoea or vomiting within
the last 72 hours
The patient is clinically stable and has not experienced deterioration in their
condition in the previous 24 hours. EWS score is within expected limits for
patient.
Resuscitation status is known/clearly documented
The patient is not overly confused or disorientated and has not attempted
deliberate self harm at this admission.
The patient will not be undergoing treatment for an MRSA bacteraemia
The patient does not pose a risk to other patients, staff or themselves e.g.
severe dementia.
Desirable:
The patient is pain free or on a stable analgesia regime
Patients who meet all of
The predicted date of discharge will normally be at 48 hours or less
the essential criteria but
fail some of the desirable The patient is safe to be cared for by nursing staff who do not necessarily have
speciality knowledge or experience
criteria may be suitable
to be outlied where this
The patient may require a “social stay” i.e. with no active treatment, following
has been approved by
medical interventions or elective surgery
the doctor and nurse in
The patient has no known mental health condition or learning disability
charge of the patient’s
The patient is not expected to die
care
Speciality:
The patient has been stabilised post operatively within their own specialty
Agreed speciality plans/criteria must be followed.
Special equipment is available or can be transferred with the patient.
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2
3
4
5
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Section 3.66
ADDITIONAL MEDICAL ASSESSMENT UNIT CRITERIA incl outlying to SAU
The patient has normally been seen on a post take ward round by a medical consultant or their
deputy and allocated a specialty. On occasions, some patients may be transferred to SAU prior to
this process being completed.
The patient has had full medical clerking completed, as well as nursing admission and treatment
and investigation plan documented in notes.
The patient has a consistently recorded MEWS score below 3 on 3 consecutive occasions
The patient has had medications and Intravenous fluids prescribed
The patient does not require vital signs monitoring more frequently than 4 hourly
The patient does not require specialist interventions or treatments requiring close observation
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Section 3.66
Appendix B –Risk Assessment /Check List for Use of Buffer Capacity
On some occasions, pressure for capacity may be great. The decision to open additional buffer capacity must be taken
with:
 The Duty Manager
 The Patient Flow Manager / Duty Hospital Manager
 The Duty Executive
 The most senior and appropriate clinician and/or nurse available (e.g. Matron in hours/Duty Matron or bleep
holder OOH)
NB: If a ward regularly opens and closes buffer capacity and has undergone an initial risk assessment according to this
process, it is not necessary to repeat the risk assessment every time a bed is used flexibly. If staff are in doubt, advice
should be sought form the Divisional Senior Nurse.
No
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
NAME OF WARD/DEPARTMENT…………………………………… BAY/ROOM/BED Numbers…………………………..
DATE & TIME OF ASSESSMENT………………………………………………………………………………………………….
NAME OF STAFF MEMBER COMPLETING ASSESSMENT (Capitals)………………………………………………………
Criteria
Risk
Assessor
Assessment Signature (when
checked & completed)
YES/NO
Suitable bed space identified and approved for use with:
 Nurse in Charge of Ward
 Unit or floor bleep holder (nursing)
 Medical Team
 Matron for Speciality or Duty Matron
 Duty Hospital Manager
Bed with suitable mattress requested from porters and in situ
Fully functioning oxygen delivery system in place (portable oxygen cylinder
requested via porters if wall O2 not available)
Fully functioning suction unit in place (portable suction collected from Medical
Equipment library if no wall suction available).
Bed has been fully cleaned and made with fresh linen
Hand Gel in place on end of bed
The following are in place
 Bedside locker
 Bed table
 Chair
Call bell/emergency buzzer in place and tested
Electrical outlet available or extension lead in place and secured safely if
necessary
Curtains in place or screens requested and in place if not available
Window curtains or blinds in place
Staffing for opening of additional capacity has been assessed and requests for
additional staffing made if necessary
Clipboard and end of bed holder for drug and fluid charts and other patient
documents is in place
Cardiac arrest trolley available at suitable distance, and has been checked and
signed recently
Toilet and bathroom facilities are appropriate in relation to the additional capacity
All patient privacy and dignity needs have been considered and are being met
Other facilities in bay not obscured by use of additional bed (e.g. hand washing
facilities or storage cupboards)
NB: No patient(s) should be moved into buffer capacity until this risk assessment and checklist has been fully
completed or that the patient has undergone the risk assessment detailed in appendix 1.
Adult Outlier & Buffer Capacity Policy. Issue 2. 03.09.2009v2 (Review Date: June 2010)
Page 14 of 15
PORTSMOUTH HOSPITALS NHS TRUST
CLINICAL POLICIES
Section 3.66
Appendix C – Risk Assessment/Checklist for Opening Buffer or Unused capacity (e.g. ward)
Name of Ward/Unit ……………………………………. Room Number (if applicable) ……………
Name of Person Completing Risk Assessment …………………………….Date .………………..
No
Criteria
Yes/No
Signature
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
32
Check each bed space using criteria in Appendix B of the Outliers Policy (Risk Assessment
/Check List for Use of Buffer Capacity
Contact pharmacy and book full pharmacy stock
All oxygen and suction equipment in place by each bed space and check portable oxygen
and suction functioning
Arrange for delivery of a drugs fridge
Obtain drugs trolley and stock
Stock clean utility room and ensure dressing trolley in place
Stock Sluice including commodes and slipper pans; linen skips; bins; wash bowls (?
Disposable) etc.
Check bed pan macerator working
Check door signage and patient information available
Stock Ward Kitchen with crockery/cutlery and drinks trolley. Test dishwasher. Request
domestic stocking of disposables and kitchen equipment via Carillion
Equip and stock ward office and nurses station
Request an urgent fire test/check
Check all appropriate waste disposal bins in place
Request Manual Handling Team to come and do urgent check of hoists and supply glide
sheets and manual handling aids.
Resus trolley in place and accessible.
Request resus. team to check all resus. equipment and ensure arrangements for use of
resus. trolley are clear.
Acquire vital signs recording equipment form medical devices
 Sphyg/Dinamapp
 Thermometers etc
Acquire sharps bins and Griff Bins (yellow) and acquire new waste bins – big and small.
Contact Carillion to arrange domestic cover
Folders and holders for end of beds in place
Notify Porters and phlebotomy dept (bleep 1093)re: specimen collection (ensure specimen
collection and return point is clear on request forms)
Make appropriate staffing arrangements e.g.:
 Medical
 Nursing
 Physio/OT
 Social Work
 A&C
Set up finance transfer points if ward will be opened longer term
Update Patient Administration System to reflect ward move on patient’s record
Check toilet and washing facilities appropriate
Book full ward clean via Carillion Helpdesk x 6321
Stock with fresh linen
Stock hand gel dispensers (wall and bed end)
Stock with IV fluids
All emergency equipment and arrangements in place
Kitchen informed for patient meal arrangements via Help Desk on X 6321
Notify Switchboard
Arrange for reports and documentation which will arrive at previous ward/department to be
forwarded on.
Adult Outlier & Buffer Capacity Policy. Issue 2. 03.09.2009v2 (Review Date: June 2010)
Page 15 of 15