Appendix 3 Swine Flu Management plan: September 2009

Contents:

1. Executive summary

2. Aims of the plan

3. Command and control

4. Pandemic Flu Management Group

5. Patient Flow

6. Critical care expansion

7. Suspension of elective activity and resource redeployment

8. Training

9. Procurement and business continuity

10. Stress-testing

11. Vaccination

12. Plan risks

Appendix 1: ‘Ian Dalton’ Programme of work. Appendix 2: Pandemic influenza organisational chart, RUH, 2009.

Appendix 3: Patient Flow in pre-surge and surge phases of SF outbreak Appendix 4: Process map and patient pathways for cluster presentation Appendix 5: Operational policy for ITU expansion. Appendix 6: Priority for cancellation of elective activity

Appendix 7: Summary of operational arrangements for a pandemic. 1. Executive summary This plan is intended to manage a specific threat: the global outbreak of novel H1N1 influenza virus in 2009, also known as Swine Flu. This plan draws from the generic RUH Pandemic Influenza Contingency Plan, which itself was reviewed and update in August 2009. References to Global and National guidance, and planning assumptions for the management of infectious disease outbreaks, are contained in that document, which is held on the Trust

1

intranet system. This plan contains less detail, and should be seen as an implementation plan only. It is summarised in table form at Appendix 7. In the UK, the Swine Flu outbreak is considered in three phases:

• Pre-surge phase: the illness is present in the population and requiring special measures, but normal business is not threatened.

• Surge phase: presentations are high in number, and significant service redesign is required to manage the threat.

• Post-surge phase: presentations diminish, but resources may have been exhausted and normal service continuity may have been eroded.

Individual Trusts, and even individual departments within Trusts, may find themselves experiencing different levels or phases of activity at any one time. This plan allows a proportionate response to a threat in any area. 2. Aims of the plan This plan aims to ensure:

• The safe and timely care of hospitalised patients suffering from Swine Flu.

• Protection of non-infected patients from the effects of the disease. • Maintenance of essential services in the face of threats to staffing,

supplies and utilities. • Maintenance of staff welfare and Trust reputation. • Maintenance of normal services as far as is possible.

3. Command and control This plan is set in the context of contingency plans for the Bath and North East Somerset PCT, Avon Area Resilience Group and the South West Strategic Health Authority. The Director of Operations or his nominated deputy will represent RUH at meetings and teleconferences organised at local and regional level, complete periodical situation reports as required and participate in tests and exercises to evaluate the broad response. All provisions of this plan will be communicated with BaNES PCT and the BaNES Director of Public Health. This plan will link with the Winter Plan for the likely period of the threat. At an internal level the Pandemic Flu Management Group, supported by its sub-groups, has operational management of the Flu Plan under the Direction of the Director of Operations (Flu Director). The Pandemic Flu Management Group reports into Silver Tactical Control which in turn links (externally) with Strategic Co-ordinating Group (SCG) – Gold. In order to ensure a consistent approach to the threat Ian Dalton, National Director for Pandemic Influenza, has issued a six-part work plan with which all NHS Trusts must comply. RUH aims to be compliant with the milestones set

2

out in this document (See appendix 1: RUH SF Work Programme re: Ian Dalton letter of 2nd July). 4. Pandemic Flu Management Group (PFMG) PFMG will be convened and constituted by the Director of Operations and will meet weekly in the pre-surge phase, daily (or more frequently) during the surge phase, and less frequently as the threat diminishes. PFMG terms of reference and constitution are described in the Pandemic Influenza Contingency Plan. PFMG will create subgroups to manage the threat. These subgroups will report back to the main group at its regular meetings, and each will be chaired by a full member of the PFMG. Subgroups will meet as frequently as is necessary to ensure timely completion of work and effective reporting. Subgroups will have no authority except that devolved by the Director of Operations through PFMG. (See Appendix 2: Pandemic influenza organisational chart, RUH, 2009). 5. Patient Flow In the pre-surge phase of a local outbreak it is anticipated that emergency admissions, referrals and self-referrals of suspected Swine Flu victims, will be managed according to Trust’s existing Infection Control procedures, and via the normal emergency access route to the hospital, utilising isolation areas on one ward to contain these cases if possible. However, in the surge phase, a novel patient flow will be required, by-passing the Emergency Department and attempting to cohort Swine Flu activity into designated areas in the hospital, isolating these patients from others as far as possible. This model involves removing ED from the process in all but the most critically ill cases, by converting the Medical Assessment Unit into an adult Swine Flu Assessment Unit, with a separate external entrance, and a new triage facility in Ambulatory Care. The three clinical areas of MAU will be given over in sequence to the Swine Flu pathway as numbers build, and further expansion will be into wards in the South building. The normal MAU facility will be replicated in MSSU. Children presenting in the surge phase will go direct to the children’s ward, where sequential expansion is also possible. (See appendix 3: Patient Flow in pre-surge and surge phases of SF outbreak) In addition, provision is made for moderate clusters of ‘well’ but symptomatic patients presenting to the Emergency Department in the pre-surge phase. This enables the normal non-elective pathways to be adapted for safe management of a temporary peak in activity, without disruptive effects on emergency patient flow in general. (See appendix 4: Process map and patient pathways for cluster presentation.) Where co-morbidity exists, and the patient’s underlying condition is of greater clinical significance than the influenza symptoms, the patient will be managed

3

in an appropriate specialist area, with infection control precautions applied as per policy. 6. Critical Care expansion Reported experiences in other acute hospitals both in the UK and abroad are of a modest number of hospital admissions, but a significant increase in admission to critical care facilities for children and adults. This plan appends an operational policy (see Appendix 5) for doubling and, if necessary, tripling intensive care capacity to increase the number of patients who can be ventilated at RUH. Intensive care expansion is primarily into general theatres and the Post Anaesthetic Care Unit, with further expansion into Day Surgery theatres if needed. The model of care has been modified for this scenario, with experienced critical care nurses overseeing small groups of less experienced nurses, each maintaining 1-1 care to SF (and other) patients. This model is founded on a programme of basic training for ward staff to enable them to care for ventilated patients, which has been designed by senior critical care staff. The hospital has no paediatric critical care, so provision such services for children, if required, will be alongside (but separated from) adult intensive care services, using existing staff. The plan for reserve staff training is in preparation. It is immediately available for reserve staff caring for adult ventilated patients, and for developing supervisory skills. Reserve staff training for the care of ventilated children is in preparation. Some trainers are identified and training for reserve staff training for adults could begin immediately if required, with supervisory skills training possible in a short time frame. 7. Suspension of elective activity and resource redeployment The likely increased demands for emergency care, and the possibility that up to 50% of our own staff may be affected by the illness, mean that some non-urgent activities may have to be suspended or retarded in order to release capacity to deliver essential services. A subgroup of PFMG will plan and implement a prioritised programme of elective activity suspension, based on how essential the activity is, and the overall effect on resources if cancelled. Resources may include space and equipment but are defined here as staff. Implementation may have to be on a weekly or even daily basis, working within the framework illustrated. (See appendix 6: Priority schedule for the cancellation of elective activity). It is intended that the Trust managers involved in implementing this schedule will also be engaged in the staff redeployment process that follows, in order to ensure a seamless connection between the two complementary work streams. In surge phase, staff deployment will be managed by the staff redeployment centre, reporting and managing staff absence, as well as prioritising and filling resource gaps as and when they emerge. Occupational Health will advise on the redeployment of high-risk staff and the return to work of staff who have been absent through Swine Flu.

4

8. Training The staff redeployment schedule described above necessitates a training programme to enable the redeployed staff to undertake new duties effectively. Two specific areas are identified:

• Delivering care in ITU. Two-hour (adult) and four-hour (paediatric) sessions are being designed and will be ready to implement shortly. Work is in hand to secure release from duties in order that this may happen. Neil Boyland and Julian Hunt lead this training programme. Timeliness of release for training in this group remains a challenge (see Plan Risks below).

• Use of personal protective equipment (PPE). Cascade training is at an

advanced stage, with key staff trained in all areas likely to receive SF patients, a 24/7 back-up training provision and a majority of junior and middle-grade doctors already trained. Julie Blackman leads this training and chairs the training subgroup.

9. Procurement and business continuity. Procurement of SF-related supplies, notably PPE, will be managed by the procurement subgroup, and will be largely dependent on contingency supply chains controlled by SHA and the Avon Local Resilience Forum. Trust will maintain a buffer stock of 5,000 FFP3 masks on site at any one time. Business continuity measures are aimed at maintaining normal services during threats to and erosion of:

• staffing (non-SF as well as SF areas) • facilities, including water, gas, electricity, fuel, oil, food, medical and

non-medical supplies, waste management and essential maintenance • support services, internal and external

The Head of Estates will plan for service discontinuities in relation to utilities, food and universal supplies. All department heads and service leads are required to provide detailed plans for substitution of themselves and their team members in case of absence, and for continuing essential activities in the event of a 50% reduction in staffing levels. Detailed plans will be appended to the Pandemic Influenza Contingency Plan as they are completed, for which the final deadline is 20th September 2009. 10. Stress-testing. The provisions described above will be tested against likely numbers of SF cases in walk-through and table-top exercises. Stress-test patient flow exercises have been completed for MAU, Children’s ward and ITU, Supply Chain and Antiviral drugs, and are scheduled for Marlborough ward (21st

5

September 2009) and ED (22nd September 2009). A BaNES multi-agency version of Exercise Coldplay took place on 14th September 2009, and a similar exercise with Wiltshire colleagues will take place on 2nd October 2009. A wider base multi-agency exercise will follow on 28th September, with a further region-wide exercise (Peak Practice) on 29th September. 11. Vaccination. Occupational Health, Human Resources and Staff Side have worked together to produce a vaccination plan for staff based on the assumption that stocks of vaccine may arrive sporadically, and prioritising agreed high-exposure and high-risk groups. Vaccinations will be recorded using the Trust’s Electronic Staff Record and will include staff refusals. Refusal will not affect redeployment. 12. Plan Risks. A number of elements of the plan are not yet resolved and represent significant risk for Trust:

• Equipment levels for expansion of ITU are only suitable for managing (extra) straightforward cases of single-organ support. If significant additional numbers of patients present requiring multi-organ support, or those requiring high-level respiratory support, are to be admitted, then further investment in equipment will be required. The Trust has submitted to the SHA an estimate of the extra equipment required.

• Training time for ‘up-skilling’ staff to work in critical care has not yet been fully identified. This may require interruption of elective activity ahead of any escalation to surge phase, or conversion of Trust mandatory training sessions.

• Exhaustion of supplies: especially Personal Protective Equipment, in the latter stages of the Pandemic.

• Exhaustion of staff, and increased rates of general sickness/absence. • Likely reduction in security personnel at a time when site control may

require closer management. • Staff/resource shortage in infection control team • Mandatory training may be affected both by sickness absence amongst

training staff and the need to divert training resources to SF training • Swine flu infections in the nursery in either staff or children may impact

on the Nursery’s ability to provide a service. This in turn will affect staff absence rates due to extra carer responsibility for our staff.

• Potential loss of income due to cancellation of elective capacity in surge approximately £0.6m

• Cancellation of elective surgery would also impact on Trust’s ability to maintain its performance against the 18 week RTT and other targets.

6

Appendix 1: RUH swine flu work programme relating to key issues detailed in Ian Dalton’s letter of 2nd July

Task Progress to date Actions taken / required Leads and links with existing workstreams.

1. Appoint a fulltime director level lead dedicated to flu preparedness and resilience with immediate effect. This can be a single individual or shared between directors but must provide visible fulltime senior leadership and ensure well resourced team on this issue through the months ahead.

Director of Operations nominated, with support from Medical Director and Director of Nursing. Nomination reported to Avon Health Emergency Resilience Group (AHERG)

James Rimmer supported by Pandemic Flu Management Group (PFMG)

2. Stress test your pandemic preparedness plans to ensure that the provision of high quality care to flu and non flu patients now and during a second, sustained wave of up to five months can be sustained. Themes: • direct response to the threat • safe treatment for SF victims: • protection of our other patients • protection of our staff

Pathways identified for all areas. Walk-though and table-top stress- test programmes detailed below: Work programme: • ST for ITU complete • Test supply chain and

storage for antiviral drugs and PPE (complete)

• ST for ED 27/8/09 complete but further stress test on 22/9/09

• ST for Marlborough 25/9/09

• Test supply chain PPE

• Test for unexpected presentation/ discovery of cases in non-flu areas.

• Use logs from TTSTs to inform action plans for staff redeployment, supply chain and training.

• Test training plan (29/09/09) • Coldplay Avon LRF 28/9/09 • Peak Practice 29/9/09 • Coldplay Wiltshire 2/10/09 When all actions above complete, revisit each workstream to test for sustained resilience over 5 months.

Alex Massey, Avril Webb, Mark Mallet, Terry Farrant, Lucy Hobbs, Lesley Dyer, Alexandra Ward, Decklan Howard. Jane Davies, Gerrit Van Renserg (adult surge) Natasha Zurick, Bev Boyd (Children’s surge) Kim Gupta, Julian Hunt, Neil Boyland, (ITU) Regina Brophy, Martyn Howard-Evans, Jenny Belcher (supply chain) Julie Blackman (training)

7

complete • Test supply chain AV

complete • Coldplay BaNES complete• Test supply chain and

storage for antiviral drugs and PPE (complete)

3. Understand and test capacity constraints that may be caused through increased demand and workforce sickness absence. This includes but is not limited to those clinical areas that are likely to face most flu-related pressures. Themes: • managing staff redeployment • managing staff sickness • service/business continuity

Workgroups set up under the leadership of Sharon Bonson/Peter Eley and Stephen Roberts. Fit-testing programme well advanced, including mass training for new junior doctors (complete) Staff redeployment centre will be located in the Staffing Solutions office. Business Continuity group set

To establish which elements of non-clinical work are essential to the core activities of trust (e.g. payroll) and ensure their continued function complete. To ensure processes in place for reducing non-essential services and redeployment of staff. To include fit-test training, up-skilling and refresher training for staff in key clinical areas (on going) To ensure the Trust has robust processes and recording mechanisms for staff absence, including a resilient process for backfilling essential clinical posts (due to staff sickness) (complete). To establish processes for considering elective work which needs capacity in ITU, to be

To be led by Staff Deployment Group, Chair Peter Eley supported by Divisions, Facilities staff, Site Team, Julie Blackman, Alex Massey and Avril Webb. Strategic decisions around elective cancellations to be supported by executive team Alex Massey, Martyn Howard-Evans,

8

up, first meeting of group to take place in October 09.

completed by 30/9/09. To establish sound materials management processes and protect critical supply chains (complete). To ensure plans are in place for continuation of service from supplies, utilities and staffing (complete).

Avril Webb and department leads

4. Engage in discussion with trade unions about a staff vaccination programme and wider communications to and support for staff. Encourage as many staff as possible to: a) participate in the programme to protect themselves, their families and their patients b) ensure clarity for all for the support that we are putting in place for staff

Meetings programmed with staff side already under way. Internal and external web access to updated advice for staff and FAQs.

To establish processes for managing and promoting staff vaccination programmes for both swine flu and seasonal flu (complete). Ensure there are enough staff trained to deliver a high throughput for staff vaccinations, in line with awaited national guidance (ongoing). To ensure process for widespread, updated and accurate dissemination of information using a variety of media, including August pay-slip letters (complete).

Stephen Roberts and Peter Eley supported by Julie Blackman for training in vaccination capability. Members of Staff-side and Helen Robinson-Gordon for Communications (plus comms team)

5. Build on existing relationships with local partner agencies to ensure that their role, channels of

RUH central to delivery of Avon PF patient pathways. Full presence at AHERG and

To ensure the Trust participates in joint exercises, attend regular meetings with local NHS partners

James Rimmer, Alex Massey and Avril Webb

9

communications and ways of working during any second, sustained wave are clear.

HICC meetings. Full RUH attendance at PF exercises in Avon and Wiltshire (Coldplay 1+2) Full RUH contribution to staffing Flu centre in Bristol (stood down).

and takes part in telephone conference calls (ongoing). To produce local reports and to communicate these widely on a daily/weekly basis (ongoing).

6. Support the Sentinel surveillance system on patients hospitalised with swine flu which will be used to provide advice on clinical management.

Dual reporting systems set up,; via BIU to SHA and via RUH SF team to AHERG

To ensure that the daily situation reports are communicated to the SHA inline with the specified requirements (ongoing).

Annika Atkins and Stuart Godfrey, supported by Alex Massey, Avril Webb, Paula Adley and Simon Chittendon

10

Appendix 2 Pandemic Influenza Organisational Chart, RUH, 2009.

Management Board

Clinical subgroup Staff redeployment and elective cancellation subgroup

Pandemic Flu Management Group

Patient Flow Subgroup

BIU

Training subgroup

SHA

Avon Health Executive Resilience Group / Health Incident Co-ordination Centre / Local Resilience Forum / Health Protection Agency

Secure delivery and storage of consumables, including PPE, AV drugs and vaccination supplies in volumes required to maintain services for up to five months.

Allow clinician input; establish best practice principles and brief senior clinicians on management plan.

Train staff in use of PPE and ITU/HDU upskilling/refresher when necessary.

Avril Webb, Martin Howard-Evans, Jenny Belcher, Regina Brophy, Stephen Roberts.

Procurement subgroup

James Rimmer (chair), Avril Webb, Sarah Meisner, Alex Massey, Clare Taylor, Heather Cooper, Nicky Ashton, Julie Blackman, Neil Boyland, Regina Brophy, Lesley Dyer, Peter Eley, Martyn Howard-Evans, Jenny Belcher, Gareth Howells, Jan Lynn, Yvonne Pritchard, Stephen Roberts (OH), Helen Robinson-Gordon, Mandy Rumble, John Travers, Clare O’Farrell, Steve Hart, Natasha Zurick, Kim Gupta, Craig Forster, Jo Miller, John Sexton, Sharon Bonson, Paula Adley

Prioritise elective activity and authorise cancellations where required. Oversee redeployment of staff to flu and non-flu areas.

Sarah Meisner, Yvonne Pritchard, Consultant Physicians, Surgeons, Nurses and Anaesthetists. Clare Taylor, Alex Massey, Avril Webb.

Julie Blackman Yvonne Pritchard, Julian Hunt Neil Boyland, Gerrit van Rensburg.

Sharon Bonson, Heather Cooper, Nicky Ashton, Steve Hart, Clare O’Farrell, Gareth Howells, Jan Lynn, Andy House, Peter Eley Stephen Roberts, Liz Cowdrey, Craig Forster, Avril Webb, Julian Hunt, Sarah Wexler or Helen Maria.

Business continuity subgroup

Ensure continuation of service for pandemic and non-pandemic patients, in the face of threats to supplies, utilities and staffing.

Martin Howard-Evans, Alex Massey

Trust Board Silver tactical control

Alex Massey, Avril Webb, Lesley Dyer, Mandy Rumble, Clare Taylor, Mark Mallett, Tim Evans, Andy House, Regina Brophy, Sarah Meisner, Andy House Julian Hunt, Alexandra Ward, Decklan Howard.

Devise and test pandemic patient pathways for pre-surge, cluster, surge, and post-surge phases. Leads identified for each workstream.

11

12

Appendix 3 Patient flow in pre-surge and surge phases of a swine flu (SF) outbreak.

SF patient presents in ED and are isolated

Triage in ED

Marlborough

• Clusters of low morbidity SF patients presenting at ED in pre-surge phase to be managed by flow acceleration to Marlborough ward. Patients should still transfer in order of arrival (with local variation where sensible) but may arrive on Marlborough ward with assessment incomplete.

1.MarlboroughSurge flow

• Transition from pre-surge to surge will be decided by the Director of Operations in discussion with the Pandemic Flu Management Group (PFMG). This may be triggered by increased SF activity in a number of areas and so may be modified to fit the circumstances at the time. PFMG will advise the Director of Operations on the need for any suspension of elective activity, and the Business Continuity/Redeployment subgroup will implement agreed cancellations and subsequent redeployment of staff. For trigger details see ‘RUH suspension of elective activity plan’.

ITU/HD

Direct to Paeds where appropriatePaediatrics

Home

ITU expansion: general theatres

Home

SF adult presents to SFAU (MAU-Ambulatory care)

Home

Triage in AC/SFAU

Home

SF child presents to children’s ward

Triage in children’s ward

Critically ill (peri-arrest) patients to resus bay in ED

2. Victoria

3. Helena

4. TBC*

Children’s ward expansion TBC*

*Areas to be confirmed, depending on presentation and morbidity patterns.

• In-patient SF capacity is based on experience in Birmingham where 5-10 admissions per day resulted from 100+ attendances per day at ED in a similar-sized hospital. In-patient LOS of 8 days per patient would suggest 60 beds at peak, although Birmingham hospitals managed with far fewer.

• Data awaited on paediatric and ITU activity.

• SF patients diagnosed after admission to be managed according to ‘main’ problem. E.g. myocardial infarct with mild SF to be managed in CCU rather than transferred to SF area.

Childrens HDU in DSU theatres

Pre-surge flow Pre-surge flow

Appendix 4: Guidelines for management of short term peaks in attendance of suspected swine flu patients (adult) Context: RUH has developed pre-surge and surge PF patient flow pathways, the latter involving a major re-alignment of patient flow, with significant impact on in-patient services. It has become apparent that, whilst still in the pre-surge phase, the hospital may experience clusters of activity which stretch our capacity for a brief period, but do not warrant escalation to surge phase. This document aims to help manage this scenario by defining the characteristics of each level of escalation and advising on the required response. No numerical triggers are included, except as guidelines, as the clinical conditions and likely outcomes for the patients involved may influence the decision-making process. Instead, scenario characteristics are listed to assist operational managers in reaching a decision.

Characteristics of pre-surge phase • Fewer than four SF patients presenting in ED at

any one time • Few, or no, SF in-patients in the hospital • Patients stable, with some potential for discharge • Management possible by clinical staff on duty in

ED • National picture: few admissions, few or no deaths • Local picture: few admissions, no deaths

Characteristics of attendance cluster during pre-surge phase • Larger numbers of SF patients presenting at the

same time than can be accommodated in ED designated isolation areas

• Up to 9 SF in-patients in the hospital • Presenting patients likely to require admission • Management temporarily not possible by clinical

staff • This scenario may occur ‘out of hours’ and require

a holding strategy, until the full PFMG can meet.

Response during cluster • Expansion of pre-surge algorithm • Patients present in ED • Patients assessed in designated

isolation areas in ED and ongoing assessment in Marlborough side rooms

• Confirmed cases may be cohorted in Marlborough bays

• Response initiated by ED consultant and on-call manager, with on-call director informed.

Characteristics of surge phase • Large numbers of SF patients presenting to the

hospital continuously • More than 10 SF in-patients in the hospital • Patients ill, with high likelihood of further

admissions • Management only possible by separate streaming

of SF patients. • Unlikely to arise unexpectedly ‘out of hours’.

Response in surge phase • Follow surge algorithm • Patients present at Ambulatory Care

entrance • Patients assessed in AC • In-patients to MAU and thence to

neighbouring wards • (normal MAU moves to MSSU) • Response initiated by Operations

Director in consultation with PFMG

Response in pre-surge phase• Follow pre-surge algorithm • Patients present in ED • Patients assessed in designated

isolation areas in ED • In-patients to Marlborough side

rooms • Response initiated by normal clinical

teams

13

Appendix 5: Critical care services operational policy for escalation to manage pandemic flu Planning assumptions

• Early escalation should follow existing contingency plans until a decision is made in stage 1 to invoke pandemic flu plan.

• Effective implementation of the escalation policy requires increased

availability of suitably trained nursing and medical staff. The provision of these is dependent on a program of training and preparation that must have been largely completed before the escalation policy is implemented. Training is of two types:

1. Implementation of training plan for teaching novice staff from

surgical wards, operating theatres in fundamental care of ventilated patients, supervision skills for intensive care nurses and in fundamental care of the ventilated child. i

2. Accelerate programme of fit test training for PPE alongside 1

This protocol should be read in conjunction with the Critical Care Admission and Discharge Policy, the escalation process of which is the starting point for pandemic flu escalation

1. The site manager should be involved in much of the following process. In any escalation the Modern Matron for critical care (and in his absence, the consultant nurse for critical care should be informed).

2. Any patient assessed as ready for ward discharge by the critical care

team should be immediately discharged from the Critical Care Unit, according to the critical care unit discharge protocol.

3. Send to the normal ward any patient who can reasonably be

prematurely discharged from critical care. In this circumstance: a. The receiving ward team must be fully informed of all on-going

clinical needs of the patient b. The Outreach Service should be informed (if available).

4. Mobilise critical care nurses from other duties (e.g. administration, bleep holding).

5. Review and where possible reduce nurse to patient ratios for all level 1

or 2 patients in the Critical Care Unit. This may require temporary simplification of treatment plans, such as cessation of invasive monitoring.

6. Review and where possible reduce nurse to patient ratios for Level 3

patients. This may require temporary simplification of treatment plans if

14

clinically feasible and appropriate (e.g. avoidance of sedation holds, discontinuation of haemofiltration or increasing sedation).

7. Non-registered practitioner support (Level 2 / 3 NVQ) should be

mobilized from wards if available (site manager).

8. The nurse in charge should be allocated a patient. Note that the nurse in charge is essential for mobilizing more nurses for subsequent shifts, for providing assistance with more complex patients and providing support for more junior nurses. It is important, therefore, that the nurse in charge is allocated a patient only as a temporary measure, for example to allow urgent admission and stabilisation of a patient.

9. Critical care matron to help to support clinical staff.

10. Critical care trained nurses working elsewhere in the trust should be

mobilised to the unit if available. (Central list available via Staffing Solutions)

11. Consultant nurse / Outreach nurse should help to support the staff on

the critical care unit, where outreach duties allow. (At night a night nurse practitioner may be able to support staff on the unit).

12. If the above measures do not create sufficient capacity on the critical

care unit, contingency arrangements will involve Main Theatre PACU. The options should include:

a. Admit critical care patient(s) to PACU with theatre or PACU nurses, ODPs and 1st on-call anaesthetist in attendance (with support of 3rd on-call & Critical Care team)

b. Mobilise PACU nurse(s) to the Critical Care Unit to allow

admission of new critical care patient to unit.

Choice of options is to be decided by the critical care and general anaesthetic consultants (who should both be informed), and the staff in charge of theatres, PACU and the Critical Care Unit. Factors to be considered include (but are not restricted to):

a. Complexity of patient for transfer (as a general principle, only the most stable / least complex patient(s) should be managed on PACU).

b. The need for advanced techniques of lung ventilation, which cannot be provided using the equipment available in theatres.

c. Ease of nursing d. Skills of PACU nurse e. Impact on theatre work – it is likely that emergency and some

elective surgery will be compromised or delayed.

In the event of a high dependency patient being managed on the PACU out of hours, the on call manager is to be informed.

15

13. Duty intensivist and nurse in charge of critical care unit (in consultation

with Modern Matron / Consultant nurse if available) to review all patients and identify patients who may be suitable for non-clinical transfer. Liaison with Emergency Bed Service to discuss possible bed availability.

14. The transfer of critically ill patients between critical care units (for non-clinical reasons) is an inevitable consequence of a limitation on the number of beds, and peaks in workload at a local level. All efforts will be made to avoid a transfer through contingency planning (See section 8). Where this is unavoidable, the duty critical care consultant will take the decision to transfer in conjunction with the nurse in charge of the critical care unit and the on call executive director. If required the executive director will be involved in discussions with patients / relatives as appropriate.

15. Transfers at night should be avoided if at all possible.

16. If we expect to export, we must be prepared to import patients. A patient should be imported into the last available bed only if other local hospitals are also down to their last bed. (This is important to avoid importing a patient only to have to immediately export another because of an in-house emergency).

17. Enquiries about bed availability in other trusts will be made only on the decision of the duty critical care consultant and discussion with the duty general manager (and if appropriate, on call trust executive).

18. All transfers will be within the Critical Care Network if at all possible. If a transfer is made out of network because of family request then the transfer will be logged on the Strategic Executive Information System (STEIS) by an appropriate Executive and reported through the Trust risk reporting system

19. If escalation in activity is associated with ventilated swine flu patients, consideration should be given to out of area transfers if regional and national advice reports variations in workload across the UK.

20. The site manager must ensure that any non-clinical transfer is recorded in any required daily situation reports

21. It is an Executive Decision to Trigger Phased Responses and staged triage for Increasing Critical Care Bed Capacity.

22. Duty intensivist / nurse in charge of the unit to contact site manager, on call duty manager, executive director on call. The Executive director on call will directly contact the duty intensivist.

23. Continuous clinical review and identification of patients who are fit for non-clinical transfer. Information to be collected by nurse in charge of unit and entered in unit diary each day.

24. Pandemic flu phase 1 escalation process will start. The decision to start this phase of escalation rests with the on-call executive in consultation

16

with the duty intensivist. Lead clinician and Modern Matron / Consultant Nurse must be informed when this decision is made.

25. Cancellation of all elective surgical procedures requiring post-operative critical care admission. Every effort will be made to assure business continuity for other cases.

26. Critical care senior team to assess staffing needs for the provision of critical care to ITU patients in the theatre complex, and for expansion in to all critical care available bed-spaces on the ITU (currently 14 bed spaces).

27. Reserve staff to be rostered and preparations for introducing them to look after patients with supervision of several patients / nurses by upskilled Intensive Care and Theatre Nurses.

28. Staffing rosters to provide a senior critical care nurse in theatres and one in the critical care unit will be established for 48 hours pending refinement and extension if required. Staffing rosters for critical care nurses to

29. Critical care and main theatre senior team to identify and mobilise all available ventilators, anaesthetic machines, infusion pumps, PPE and other resources required to expand critical care services into main theatres .

30. Consideration should be given to a second consultant intensivist to oversee the care of ITU patients in theatres, and to be available day and night for triage decision support. At this stage it may still be appropriate to continue providing level 2 care (subject to case mix and clinical demand)

31. Organisation of all anaesthetic and critical care medical staff into a rota to provide team-based 24 hour medical cover to critically ill patients on ITU and in theatres, whilst maintaining anaesthetic support for emergency and trauma surgery provision.

32. Nurse in charge to organise an HCA through staffing solutions to assist unit staff in setting up bed spaces and obtaining equipment from identified checklist.

33. Nurse in charge in consultation with duty intensivist to set up equipment for all available bedspaces in Critical care and Main Operating theatre.

34. Urgent meeting of pandemic flu management group to invoke surge plans. Staffing group to identify medical staff who can be seconded from other areas where elective duties were being done.

35. Critical care outreach service will withdraw from follow-up and rehabilitation services. It will (if available) work to assist in transfer of suitable patients to the ward who may have ongoing level 2 needs

36. Outreach (if available) will work flexibly to provide outreach and “inreach” where appropriate to support critical care unit staff directly.

17

37. All referrals to critical care will be required to be made after a pro-forma of clinical information has been collected. No referral will be accepted without senior medical review by patient’s parent team.

38. Critical Care Outreach (if available) will support ward teams in optimising care and collecting appropriate clinical information to support appropriate referrals. Outreach will not be part of the formal referral process unless asked specifically to do so by duty intensivist on a case by case basis.

39. The escalation of critical care facilities at this stage is focussed on providing limited organ support (essentially advanced respiratory support and some cardiovascular support). With expansion there will be no increase in provision of multi-organ support.ii

40. Clinical triage and withdrawal of life-support decisions are likely to require two consultant intensivists to review patients and their prognosis.iii

41. Cancellation of all non-urgent surgery.

42. Theatre service to move entirely to Princess Anne Wing Theatres. Day surgery theatres to close.

43. Anaesthetic machines and medical / nursing staff to move from Day surgery theatres to Main theatres. Day surgery to either close or become Childrens’ Ward overspill (if the case-mix of presentations requires it).

44. Day surgery to be prepared for sick children (or deployed to main theatres) depending on presenting case-mix of patients.

45. Cancellation of all annual leave for medical, nursing and some A&C staff.

46. Contingency outreach service to be identified and briefed. Night Nurse Practitioners plus anaesthetic staff plus medical staff displaced from cancellation of elective work.

47. Flu patients (patients presenting with flu like illness) will be cohorted where possible, depending on case-mix and complexity and availability of staff resources. Decision about placement of patients will be made by duty intensivist / lead clinician and senior critical care nursing team members, in conjunction where necessary with infection control. Site manager and on-call executive will need to be involved.

48. Deployment of reserve-trained critical care nursing and medical staff.

49. Further escalation of reserve-trained staff

50. No specific planning is possible for phase 4 (deterioration of infrastructure)

51. De-escalation. The winding down of escalation needs to be as planned as escalation, but it is difficult to describe the process in detail. There are a number of principles which should apply

18

52. As soon as the number of patients requiring ventilation starts to recede, staffing will be moved to rebuild more appropriate staffing levels

53. Decision to withdraw service from escalation area will be made by lead clinician in consultation with theatre manager, critical care Modern Matron, Infection control team and Director of Operations.

54. Up until a decision is made services will be maintained and logistics will be replenished to continue high levels of service if needed.

55. Consideration may need to be given to offering any spare capacity for level 2 (High Dependency Care) which may be required.

56. Urgent surgery will be re-started as soon as it is safe and effective to do so.

57. Routine elective work will not be started until critical care is able to operate at phase 0 (i.e. with service for eleven critical care – seven level three and four level 2 beds)

58. Stepping down of reserve staff to prepare for normal duties will be managed in a controlled way with elective in patient work starting before the restarting of outpatient services.

59. All staff involved in critical care during escalation beyond phase 0 will require de-briefing through existing line management, occupational health, and Employee Assistance Programme staff. Although the primary aim of debriefing will be to provide support to staff who have worked in difficult circumstances it will also enhance future emergency planning.

60. Attempts to remove critical care patients from PACU and to return non-Critical Care Unit staff to their usual clinical areas should commence as soon as possible, and the situation reviewed frequently. This should involve consideration of the following:

a. Increasing the number of critical care trained nurses on the Critical Care Unit.

b. Transferring critically ill patients to other units (non-clinical transfers – see section 8 above). This will rarely be feasible or safe out of hours, but should be considered during normal working hours when additional staff capable of transferring patients can be found. The on-call executive director must be involved in all decisions regarding non-clinical transfers of critically ill patients.

c. Cancellation of elective surgery in any patients who may require prolonged recovery or the provision of level 2 or 3 care post operatively.

d. Consideration of diversion of major medical or surgical emergencies to other Emergency Departments.

(CC operational policy appendices removed from SF plan version to avoid duplication, but available in original)

19

Appendix 6: Priority for cancellation of elective activity Swine Flu 2009. Surge Phases. Priority Schedule and Guidelines. Note: It is accepted that emergency and clinically urgent work will continue and therefore provision will remain for this, albeit in a different location. Elective and Emergency Activity / Department

Impact in Relation to Trust Objectives

Clinical Impact on patients: High, Medium Low

Staff/Capacity/Resources released by suspension

Suggested order of suspension Phase 1 = First to go Phase 2 = Second Phase 3 = Last to go

Possible alternative setting / provider. To be decided following exercises in Sept/Oct 09.

Orthopaedic elective activity

WL targets

Low

Philip Yeoman Ward – 30 beds Nurses Doctors AHPs Ward Receptionist Domestic staff

Phase 1

ISTC

General surgery in-patient activity

WL targets

Low

Ward - 28 beds Treatment Centre - 12 beds Pre-operative Assessment (all specialities)

Phase 1

ISTC

20

High Cancer and other urgent cases would still require treatment.

Nurses Doctors AHPs Ward Receptionist Domestic staff Administrative staff (Surgical Admissions Unit and Waterhouse Ward and 28 bedded ward would be used for emergency and urgent cases)

Phase 3

Gynaecology surgery

WL targets

Low High Cancer, terminations and miscarriages would still require timely treatment

Charlotte Ward - 12 beds Nurses Doctors Ward Receptionist Domestic staff Charlotte ward - 10 beds for emergency/urgent work. This could include Day case and short stay.

Phase 1 Phase 3

ISTCs ? UHB St Michaels Hospital may accept Gynes referrals as a non-flu Hospital

21

Urology surgery

WL targets

Low High Cancer and other urgent cases would still require treatment.

Cheselden Ward - 12 beds (from 22 beds) Nurses Doctors Ward Receptionist Domestic staff Cheselden ward - 10 beds for emergency/urgent work. This could include Day case and short stay.

Phase 1 Phase 3

ISTCs ? NBT Southmead would accept urology referrals as a non-flu Hospital

Paediatric in-patient activity

WL targets

Low High Cancer and other urgent cases would still require treatment.

Children’s ward - 6 beds Children’s ward - 32 beds

Phase 1 Phase 3

? could UHB Children Hospital co-ordinate and receive non-flu children

22

Ophthalmology Unit

WL targets Low High Emergencies and urgent cases would still require treatment.

Ward - 5 beds Clinic space and waiting area Nurses Doctors Administrative staff Emergency and urgent clinics would need to continue

Phase 1 Phase 3

?ISTCs ? UHB Eye Hospital would accept referrals as a non-flu Hospital

Day surgery; dental

WL targets

Low High Emergencies and urgent cases

Operating Theatre / Day Surgery Unit Nurses ODP / ODAs Doctors Anaesthetists Administrative staff Clinic capacity may need to allocated for this

Phase 1 Phase 3

ISTC ? UHB Dental Hospital

23

Day surgery; general

WL targets

Low High Cancer (diagnostic) and emergency patients will still need treating

Operating Theatre / Day Surgery Unit Nurses ODP / ODAs Doctors Ward Receptionist Domestic staff This can be provided in Princess Anne Theatres on emergency general lists

Phase 1 Phase 3

ISTCs

Bath Fertility Clinic

W/L targets Income (Private patients)

Low

Clinic space and waiting areas Doctors Nurses Administrative staff Domestic staff

Phase 1

?None

Day surgery; orthopaedics

WL targets

Low

Operating Theatre / Day Surgery Unit Nurses

Phase 1

ISTCs

24

High Emergency and urgent Trauma

ODP / ODAs Doctors Administrative staff Trauma wards would still be open and day case patients would be sent there.

Phase 3

OP activity Urology Clinic Gynaecology Clinic ENT clinic Pain clinic Vascular Clinic Audiology

WL targets

Low High Cancer, emergencies and urgent cases would need treatment. Urgent diagnostic work would still need to be undertaken

Clinic Spaces and waiting areas Nurses Technicians Doctors Administrative staff Domestic staff Radiology and other routine investigations Limited clinics would operate to accommodate emergency and urgent work

Phase 1 Phase 3

ISTCs

25

Elective activity requiring post-op care in ITU/HDU Vascular surgery Head and neck surgery Gynaecology Bowel procedures

WL targets High Usually cancer and urgent cases

ITU bed Anaesthetist 0.5-1 session Nurses (all above would be used for Flu critical care pts) Surgeon 0.5-1 session

Phase 2 / 3 Some patient’s surgery may be able to be delayed or 4 weeks but not 5 months

Oncology inpatients, day case and outpatients

W/L targets Patient outcomes

High Delayed Chemotherapy and Radiotherapy treatments Risk of oncology patients coming to the Hospital and getting swine flu as immunocompromised.

Ward beds, Day case and Clinics and waiting areas Nurses Doctors Pharmacists Administrative staff Domestic staff

Phase 3

? UHB Oncology Centre co-ordinate and accept referrals as a non-flu hospital ? could any capacity be relocated in Primary Care to reduce the risk to patients getting swine flu

26

Cardiology Cath Lab Assumption: all PPCI will be cared for in specialist centre ?UHB Outpatients Echos Tapes and Exercise RACPC

W/L targets

Medium Low High

Cardiac Day Case - 6 beds Nurses Clinics spaces Nurses Nurses

Phase 2 Phase 1 Phase 2 / 3

? UHB Cardiac centre non-flu PCT Provider PCT Provider

Respiratory Outpatients Laboratory

W/L targets

Low High Cancer and urgent cases Low

Clinics Nurses Administrative staff Few clinics will need to be provided Technical staff

Phase 1 Phase 2 / 3 Phase 1

Dermatology

W/L targets

Low

Clinic space

Phase 1

ISTCs

27

outpatients High Cancer

Nurses Doctors Administrative staff

Phase 2 /3

? UHB Dermatology centre as non-flu building

Diabetes and Endocrine Outpatient

W/L targets

Low

Clinic space Nurses Doctors Administrative staff

Phase 1

PCT Provider

Neurology and OPU Outpatients

W/L targets

Low

Clinic space Nurses AHPs Doctors Administrative staff Technical staff

Phase 1

PCT Provider

Gastro-enterology Endoscopy Suite

W/L targets

Low (screening) Medium (diagnostic ?

Trolley areas 10 Nurses Doctors Admin staff

Phase 1 Phase 2

ISTCs ? NBT Southmead

28

Outpatients

cancer) High (emergencies) Low High

Phase 3 Phase 1 Phase 3

elective non-flu Hospital PCT Provider ISTCs or NBT

29

Appendix 7: Summary of RUH’s operational response arrangements for a pandemic At WHO Pandemic Alert Phase 6, the PFMG will convene to develop the Trust’s arrangements for a pandemic. RUH PF Escalation State Pre-surge

Department/Service etc.

Necessary Actions Notes (ALL REFERENCES ARE TO RUH GENERIC PANDEMIC FLU CONTINGENCY PLAN). Bed Meeting • Daily assessment of PF position, with information from HPA reported by Infection

Control. Information from national resources, SHA, CMS and RUH also fed in PFMG and sub-groups

• Convene, in order to review PF arrangements • Alert relevant personnel to ensure PF arrangements are finalised and ready for

implementation • Consider Directorates/Departments preparations and state of readiness, including

arrangements for staff-rostering and for working with minimum staffing levels • Review escalation management arrangements (from the accommodation of initial

PF patients, to proposals for designating PF cohort wards as the numbers of cases increases)

• Review arrangements for maintaining regional specialist services, liaising with SW SHA / DH as necessary

• Check on state of supplies of appropriate PPE and arrangements are in place to ensure Directorates / Departments have adequate supplies

• Review number of ventilators in Trusts • Review state-of-play in respect of fit-testing of respirators for staff • Review staff welfare arrangements • Review arrangements for assessing staff attendance / absence levels (and for

identifying available staff skills/ training) during a pandemic • Review Directorates / Departments arrangements for allowing non-essential staff to

• Seek guidance from SW

SHA/ DH • Confirm funding • HR/OH to devise

30

work from home • Consult, through the LRF Avon Health Executive Resilience Group, with PCTs and

GWAS in order to finalise PF admissions criteria/strategy • Liaise with other local NHS/LRF organisations as necessary

Directorates / Departments

• Report to PFMG state of readiness of PF arrangements, together with outstanding issues

• Check on state of supplies / storage of appropriate PPE • Confirm which staff still required fit-testing of respirators

RUH PF escalation state pre-surge continued….

Emergency Department / MAU

• Review arrangements for separation of GP PF referrals for separate initial triage / assessment area

• ED and MAU to constantly monitor admissions and attendances. If PF case admitted, inform Senior Nurse (on call if OOH), Site Manager and Infection Control immediately. Senior Nurse to log PF cases and notify On-Call Executive Director, Director of Operations and Assistant Directors of Nursing accordingly

• See appendix 3, patient process map

Infection Control Team

• Instigate Infection Control training programme for staff • Underway

Hotel / Support Services

• Review arrangement for increasing cleaning requirements, in accordance with Infection Control procedures

• Review arrangement for maintaining adequate portering capability • Review arrangements for maintaining adequate catering services, including provision

of catering for staff working in PF cohort areas

• Additional cleaning materials / equipment

• Temporary staff?

Communications Team

• Instigate communications and public information arrangements, as appropriate to this stage of the pandemic

• See intranet flu pages

Head of Pharmacy

• Review pharmaceutical supply arrangements (including liaising with PCTs / AAH)

31

Mortuary Manager

• Implement arrangements for emptying mortuaries as quickly as feasible • Review arrangements for increasing body-storage capacity

• As required • Refrigerated containers,

under review Security

Manager • Review arrangement plans for enhancing security measures as necessary

32

RUH PF escalation state surge Department/Service Necessary Actions Notes

Bed Meeting • Twice daily assessment of PF position at morning and afternoon bed meetings, with information from HPA reported by Infection Control. Information from national resources, SHA, CMS and RUH also fed in

PFMG • Convene once a day if required • Consider reports from Divisions on the effectiveness of their arrangements /

stocks of PPE • Monitor overall effectiveness of Trust’s PF arrangements (particularly in

respect of PF segregation), address matters arising and adjust response as necessary (e.g. consider and prepare for using cohort wards)

• In conjunction with other local NHS Trusts, consider using other health facilities as overspill

• Review medical equipment issues (particularly in respect of numbers of ventilators available)

• Assess reports from Directorates / Departments / Wards on staff absence levels / skills available and consider re-deploying staff as necessary. Lists of non-ward clinical staff to be prepared if redeployment to cover wards is required

• Commence re-configuring the Trust to accommodate an anticipated increase in PF cases

• Consider cancelling all non-urgent out-patient appointments • Consider reducing / cancelling all non-essential elective surgery in

accordance with table in appendix 6 • Consider cessation of non-essential services enhanced security measures

as necessary • Consider any staff welfare issues arising • Direct Directorates / Departments to minimise frequency of face-to-face

meetings

• Investigate loan of ventilators

from GWAS

33

• Direct the closure of communal areas (e.g. restaurants etc) as necessary • Take report(s) from Trust representative(s) at HICC/SC • Liaise with local NHS / LRF organisations

Directorates / Departments

• All patients fit for discharge to be discharged home / to community care • Maintain regional specialists services, liaising with SW SHA / DH as

required • Instigate arrangements for the segregation of PF patients in pre-arranged

cohort wards and in specialist areas • Implement arrangements for ceasing non-essential services as necessary

RUH PF escalation state surge continued…. Department/Service Necessary Actions Notes • Implement arrangements for operating with minimum staffing levels as

necessary • Maintain adequate supplies of PPE and other essential supplies • Monitor staff welfare issues • Report to PFMG state of readiness of PF arrangements, together with

outstanding issues • Maintain programme of respirator for fit-testing for staff as necessary

ED / MAU • Instigate arrangements for separation of GP PF referrals for separate initial triage / assessment area

• ED and MAU to constantly monitor admissions and attendances. If PF cases admitted, inform Senior Nurse and Infection Control immediately. Senior Nurse to log PF cases and notify the On-Call Executive Director, Director of Operations and Assistant Directors of Nursing accordingly.

• See appendix 4

Critical Care Areas • Instigate capacity management arrangements for Critical Care clinical areas, as the situation demands, increasing capacity as required and as staff and

34

resources allow Infection Control Team

• Maintain Infection Control training programme for staff • Undertake inspections of clinical areas as necessary

Hotel / Support Services

• Implement arrangements for enhancing cleaning requirements, in accordance with Infection Control procedures

• Implement arrangements for maintaining adequate portering capability • Implement arrangements for maintaining adequate catering services,

including provision for staff working in PF cohort areas Communications

Team • Maintain communications and public information output as appropriate to

this stage of the pandemic Head of Pharmacy • Issue Tamiflu to patients and staff as required, and maintain necessary

supplies Mortuary Manager • Implement arrangements for increasing body storage capacity

Security Manager • Implement enhanced security measures as necessary

35

36