Managing Surge Capacity. Mark Williams-Jones (Clinical Nurse Manager ICU, Glan Clwyd) Sue O KeeffeO (Critical Care Network Manager, North Wales)

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1 Managing Surge Capacity Mark Williams-Jones (Clinical Nurse Manager ICU, Glan Clwyd) Sue O KeeffeO (Critical Care Network Manager, North Wales)

2 North Wales Three hospitals (DGHs) 65miles apart

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4 North Wales Critical Care Beds Normal bed stock 32 Critical Care beds Two combined ICU/HDUs 1x 13 beds, 1x 8 beds One ICU x8 beds One SHDU (Surgeon led) x3 beds NW CC beds 2.78 per 100,000 population Huge additional holiday population (staying 11.5m nights) Wales CC beds 3.2 per 100,000 population England CC beds 4.0 per 100,000 population

5 Pandemic Planning 2009/10 saw a huge amount of planning for the impending impact on CC from the pandemic Fit Testing Training Recovery and ODP staff Paediatric CC skills A and B lists compiled Fit Testing Picture

6 Network Plans Network Emergency plans Major incident Unplanned closure of a unit Pandemic Flu including paediatric competencies High level; little operational detail

7 Pandemic Plans Emergence of H1N1 in Pandemic Plans developed including; Regional Escalation plan to optimise collective capacity (phased response) O.R. closure + to free up staff Triage tool (for Status 2/3 + Exec authori- sation)

8 Winter 2010/11 Reviewed plans alongside guidance from WG review organisational readiness Revisited fit testing Attempted to undertake acute staff training. BUT not a Pandemic so impetus not as noted

9 The Reality Neighbouring regions, North West England, started to be badly affected. Commenced, in earnest, two weeks before Christmas Limiting potential for Transferring out of North Wales 1 st January North West commenced stage 2 escalation Opened cardiac beds into the general bed stock Stopped all elective inpatient surgery Opened ECMO beds

10 Neighbouring Networks

11 North Wales North Wales Wk 46 21/11/2010 Wk 47 28/11/2010 Wk 48 05/12/2010 Wk 49 12/12/2010 Wk 50 19/12/2010 Wk 51 26/12/2010 Wk 52 02/01/2011 Wk 1 09/01/2011 Wk 2 16/01/2011 Wk 3 23/01/2011 Wk 4 30/01/2011 Wk 5 06/02/2011 Wk 6 13/02/2011 Date of Admission (W/E) Bangor Glan Clwyd Wrexham Number of Admissions

12 Winter 2010/11 29 patients confirmed H1N1 Evenly spread across three units 2 For ECMO 1x Glenfield, 1x Wythenshawe 3 HFOV (another pt randomised to conventional -OSCAR)

13 Reality Usual Winter demands.+ Slow creep of H1N1, impact felt in CC primarily rather than pressure on CC from wards Surgery continued until CC patients overflowing into recovery Numerous cancelled ops due to lack of a CC bed

14 Realisation-positives Exec and CPG support Managed situation BCUHB wide Overtime ban lifted Recovery and Theatre staff support Non-USC cases cancelled USC cases reviewed daily/managed within escalation Additional equipment purchased Consumables and equipment sharing

15 Realisation-positives Twice daily conference calls (+w/e) across three hospitals CC staff (Medical and nursing) Theatre & Recovery staff Managers Network staff Demands, LOC, H1N1 pts., Pharmacy, USCs, Equipment, DToCs, Staffing + Escalation potential

16 What could be improved? Earlier recognition of the problem Because not a Pandemic not picked up as quick slow creep, slow realisation Uniform approach to escalation sooner Speedier decision re cancelling surgery Had been a debate vis a vis reducing major but increasing minor ops. WG to send correct masks!

17 Lessons Learned Communication Collaboration Leadership Caution with equipment transfer!

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19 Can we do it? Requirement for non Pandemic plans i.e. Generic Escalation for Surge Operational response to unplanned increases in demand for Critical Care Where neighbouring Networks are experiencing similar demands

20 Escalation Plan Normal rules of transfer apply but pts will not be transferred to accommodate surgery Shared managerial and clinical responsibility; daily status reports (teleconferences) Staffing, demands, equipment, etc., Consideration for reducing elective/urgent surgery Proactively manage DToCs Consumables, pharmaceuticals.

21 Critical Care Phased Response Green Level 1 (Normal effect on services) Yellow Level 2 (Moderate effect on services) Normal working Critical Care beds available Elective/planned admissions requiring Critical Care continuing Transfers accepted Early signs of difficulty Normal Critical Care bed stock full (or nearing full regionally) Non-urgent surgery, requiring Critical Care, cancelled Careful consideration required for urgent planned/elective surgery No capacity for receiving transfers.

22 Critical Care Phased Response Amber Level 3 (Severe effect on services) Red Level 4 (Major disruption to services) Severe/prolonged excess pressures requiring significant additional management Normal Critical Care bed stock full and into surge capacity Decision of proceed with urgent surgery taken on a regional basis. Careful consideration required for continuing (non- ICU) routine in-patient surgery. Extreme pressures requiring immediate and significant actions All surge beds and normal beds full (at 100% surge or beyond) No ventilation capacity available All ventilated admissions will require transfer out

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25 Challenges. Implementing plans across Network No unit to work in isolation - normal rules of transfer apply Tension of RRTs and [high] demands Collaborative working with other CPGs Surgical CPG vis a vis cancelling surgery Communicating/implementing plans throughout the whole hospital DToCs

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