BED CAPACITY MANAGEMENT POLICY
Version
4
Name of responsible (ratifying) committee
Operational Board
Date ratified
31 August 2016
Document Manager (job title)
Project Manager/Emergency Planning Officer
Date issued
04 October 2016
Review date
31 July 2017
Electronic location
Management Policies
Related Procedural Documents
Operational Procedures Manual – internal
Trust Escalation Plan
Adult Outliers Policy
Transfer Policy
Infection Prevention & Control Policy
Isolation Policy
SAFER – CSC Review Meetings - SOP
Key Words (to aid with searching)
Bed, Capacity, Management
Version Tracking
Version
Date Ratified
Brief Summary of Changes
Author
4
31/08/2016
Updates to: bed declaration flow chart, all roles and
responsibilities, Site Ops meeting times and agenda,
Process/General principles. AMU Operations room removed and
updated Quick reference page.
Carla Bramhall
3
03/02/2015
Managing Directors/General Managers, Remove On Call
Manager, MAU now AMU, Estimated date of Discharge now
Predicted Date of Discharge, Bed declaration policy merged with
this policy, Gold Command meetings added, Policy in line with a
centralized model of bed management, Risk assessed additional
capacity, Extension of Review Date
Carla Bramhall
Bed Capacity Management Policy
Version: 4
Issue Date: 04 October 2016
Review Date: 31 July 2017 (unless requirements change)
Page 1 of 22
CONTENTS
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Introduction
Purpose
Scope
Definitions
Duties and Responsibilities
Process
Training
References
Equality Impact Statement
Monitoring Compliance
Bed Capacity Management Policy
Version: 4
Issue Date: 04 October 2016
Review Date: 31 July 2017 (unless requirements change)
Page 2 of 22
11.
QUICK REFERENCE GUIDE
This policy must be followed in full when developing or reviewing and amending Trust procedural
documents.
The following flow chart demonstrates the expectation of flow between beds.
This does not negate the need for the document author and others involved in the process to be
aware of and follow the detail of this policy as the policy discusses how each of the following impacts
on ensuring the above occurs:
1. Duties and Responsibilities of each individual in relation to managing Bed Capacity
2. General Principles in managing Bed Capacity
3. Patient Flow Standards
4. Emergency Department
5. Assessment Areas
6. Day Care Units
7. Ambulatory Units
8. High Care Units
9. Wards
10. Discharge Process
11. Outlying and making decisions on opening further capacity
12. Bed Declaration
Bed Capacity Management Policy
Version: 4
Issue Date: 04 October 2016
Review Date: 31 July 2017 (unless requirements change)
Page 3 of 22
1. INTRODUCTION
This policy will outline the principles and processes required for effective bed capacity management
This policy covers all areas of guidance for bed capacity management to improve the emergency and
elective flow of patients across the Trust. It is a Trust wide bed capacity management policy that
describes how decisions will be made on a day to day basis to:
This policy covers the management of admissions, transfers and discharges between the Emergency
Department, Assessment Units, High Care Units, Day Care or In Patient facilities and must be
applied in conjunction with the Adult Outliers Policy, Transfer Policy, Discharge Policy, as well as the
Infection Control Policy and Isolation Policy.
The actions required for escalation due to shortage in the Trust capacity are detailed in the Trust
Escalation Plan.
2. PURPOSE
This policy covers all areas of guidance for management of beds across the Trust
This policy applies to:
1.
Emergency and elective admission
2.
Admission to a day case facility for a surgical procedure or other treatment requiring postprocedure care (e.g. chair, trolley or bed)
3.
Admission to High Care Units and ambulatory areas
4.
Admissions to an assessment area linked to Acute Admissions Unit (e.g. Rapid assessment
clinic)
5.
All in-patient services except Maternity
6.
Patients requiring isolation facilities and specific infection control measures to be taken within
ward areas
This policy defines the individual responsibility and accountability of members of staff involved in bed
capacity management to ensure the provision of safe and high quality patient treatment and care.
3. SCOPE
The policy applies to all staff, employed by Portsmouth Hospitals NHS Trust, both clinical and non
clinical and sets out the process requirements and staff responsibilities regarding the safe and timely
management of bed capacity. PHT employees have a responsibility to inform any temporary or
contractual staff they are working with about the requirements of the policy.
‘In the event of an infection outbreak, flu pandemic or major incident, the Trust recognises that it may
not be possible to adhere to all aspects of this document. In such circumstances, staff should take
advice from their manager and all possible action must be taken to maintain ongoing patient and staff
safety’
4. DEFINITIONS
PDDs – the Predicted Date of Discharge by the clinical team that the patient will be clinically stable to
leave hospital
Out of Hours – Out of hours is identified as the time between 19:00 – 08:00 weekdays and from 1900
Friday – 0800 on Monday
Specialty teams – Clinical Service Centre (CSC) Management Team and Consultants
Bed Capacity Management Policy
Version: 4
Issue Date: 04 October 2016
Review Date: 31 July 2017 (unless requirements change)
Page 4 of 22
CCGs – Care Commissioning Groups.
AMU – Acute Medical Unit
CSC – Clinical Service Centre
5. DUTIES AND RESPONSIBILITIES
5.1 Trust Board



The Board is responsible for setting the strategic context in which Organisational policies are
developed
The Board may designate approval authority
The Chief Executive has overall responsibility for the strategic and operational management
of the Trust, including ensuring that the Trust policies comply with all legal, statutory and good
practice requirements.
5.2 Chief Operating Officer



Executive Director responsible for the strategic management of patient flow and bed capacity
management, giving delegate responsibility to the General Managers.
Executive management of all beds in the Trust on behalf of the CEO
Liaison with Directors of Operations and General Managers on operational and strategic bed
management issues as and when required
5.3 Deputy Chief Operating Officer






Lead for the development of policies and action plans (in collaboration with Specialties and
CSCs) to ensure that elective and non elective patient pathways work effectively and in the
best interests of patients.
Lead for the development of plans to deal with one off and seasonal pressure in relation to
whole hospital management
Liaise with internal and external parties to drive a culture promoting active capacity
management
Accountable for bed management across the organisation
Accountable for making decisions on temporary bed closures
Provide leadership for the unscheduled care Operations meetings. Appendix A details CSC
attendance requirements, roles and responsibilities and focus and priorities of these
meetings.. This links to the Trust Escalation Plan
5.4 Clinical Service Centre Boards








Ensure a CSC escalation plan is in place, understood and communicated within the CSC.
Regular review of demand and bed capacity to meet performance and activity targets, linked
to business planning
Responsible for holding to account all members of their CSC to ensure adherence to this
policy
Ensure issues regarding bed management are communicated in a timely, effective and
constructive way
Provision of problem solving and decision making support to the Operations centre, through
the CSC escalation lead
Organisation of workload to reduce variations in demand, as this causes bottlenecks in the
use of capacity, leading to cancellation and delay
Ensure compliance to the Adult Outliers policy and real-time updating of PAS and Bedview.
Ensure compliance with the Safer Bundle and Professional Standards
Bed Capacity Management Policy
Version: 4
Issue Date: 04 October 2016
Review Date: 31 July 2017 (unless requirements change)
Page 5 of 22
5.5 Chief’s of Service, Clinical Directors












Provide medical support to ensure bed capacity management is effective for emergency and
elective admissions
Senior review of all patients everyday.
Ensure junior medical staff complete TTO’s in a timely manner and that every patient has a
clear management plan
Predicted Date of Discharge agreed and documented within 24 hrs. of admission
Ensure every patient has plans in place to facilitate their journey and meet their predicted
discharge date
Ensure discharges are identified, communicated to ward staff and recorded in the patients
notes identify early morning discharges and discharges for the weekend
Ensure medical staff provide routine support and interventions for patients who are outliers
Responsible for ensuring the implementation of this policy at local level and reporting any
problems to their CSC Chief of Service, who will support their resolution at local level,
ensuring shared learning takes place across the CSC at the CSC Boards and across the
Trust at the meetings with junior doctors and other medical staff.
Support Duty Hospital Manager to ensure patients have access to beds when increased
emergency admissions means that other specialty beds have to be used.
reviewing discharge thresholds at times of pressure
To ensure that all staff are communicated with regarding issues relating to effective use of
bed capacity including holding to account individuals who do not comply with this policy
To contribute to clear plans for the creation of escalation capacity and relevant actions as part
of the Trust Escalation Plan
5.6 Duty Hospital Manager











Hold an overall, up to date view of the whole hospital
A Duty Hospital Manager rota is provided throughout the 24 hour period, 7 days a week to
oversee the whole hospital position initiating actions in line with the Trust’s Operational
Procedures, this policy and the Trust Escalation Plan
Monitor and support the Emergency Department in ensuring at 2.5 hours from arrival all
patients have plans to leave the department within 4 hours.
Ensure patients are moved through the system in a timely way and that capacity is available
to receive GP expected and ED referrals
Give both support and direction to Ops team to ensure that risks are balanced across the
hospital as a whole, particularly at times of pressure
Give support and direction to Ops team to ensure the smooth running of flow through the
hospital
Ensure that appropriate decisions are made to balance the needs of Specialties and the
hospital as whole.
Take a designated role in liaising across the hospital to identify any issues or events that may
affect effective patient flow and bed capacity management. Take action to resolve where
appropriate or direct appropriate actions by other colleagues.
Adhere to advice from the Infection Control team when making patient flow and bed capacity
management decisions. Ensure that the advice of the Infection Control Team in relation to the
management of infection outbreaks is followed
Work with wards to ensure that the allocation of cubicle space is carried out in a manner that
ensures that patients with an infection can be isolated according to their condition and as
required in the Infection Control Policy
Take account of a patient’s clinical, mental health, infection and single sex status when
leading the decision making about where patients are to be placed and the opening of
escalation capacity
5.7 Individual CSCs Operations Room
Bed Capacity Management Policy
Version: 4
Issue Date: 04 October 2016
Review Date: 31 July 2017 (unless requirements change)
Page 6 of 22




Meetings held individually in CSC Operations Rooms to coordinate the efforts of the wards
within that CSC to promote flow and manage admission, transfer and discharge (see SAFER
– CSC Patient Review Meetings SOP).
Highlight any potential blockages and work with relevant parties to remove them or escalate
Maintain communication and optimum levels of transparency at all times
Prepare for feedback into the overall Trust position during Operations Meetings.
5.8 Patient Flow Managers/Co-Ordinator













Take the lead for overseeing Patient Flow and management of the inpatient care pathway for
designated day for the CSC
Support the wards with Bedview updates to include; predicted discharges, discharges so far,
demand, electives, medically fit status
Observe the SAFER bundles and ensure areas are following these, escalating to Silver
Command any non compliance
Liaise with senior ward staff to ensure appropriate moves to the discharge lounge are taking
place in a timely manner, taking a proactive, and problem solving approach to overcome
issues
Work with teams in achieving CSC discharge targets in a timely manner
Ensure predicted discharge lists for following day and the weekend with actions to expedite
discharges are included
Ensure overnight plans are in place
Maintain continuous contact throughout the day with the relevant CSC Silver Command and
DHM
Update the DHM at required intervals on bed flow status – formal updates required an hour
before each Ops meeting (attendance not required)
Escalate any blocks to patients pathway to relevant CSC, DHM or Silver Command
Coordinate with other Hospitals, CSCs and departments with repatriations
With ward nursing and clinical staff identify outliers, maintain lists of moves and support the
opening of additional capacity within the CSC
Work with ward teams to identify suitable patients for above
Surgery Specialties:
 Work with each specialty to ensure they have capacity for their elective surgical patients
 Escalate the possibility of cancellations to Silver
 Lead on ensuring the balance of beds given to electives and emergency patients continues
5.9 Infection Control Team




The Infection Control team will liaise with Duty Hospital Managers and ward staff to ensure
that patients with infection are allocated to appropriate beds, based on a risk assessment of
their condition which must be documented in the patient notes
The Infection Control Team will provide proactive advice to the Duty Hospital Managers and to
wards on infection control issues and in particular in relation to where patients are placed.
The Infection Control Team will provide Regular Outbreak Reports giving clear direction by
ward on infection status and specific actions in particular the opening and closing of wards and
other areas
The Infection Control Team will advise directly on the communications required at both ward
and Trust level, or externally, to provide effective containment of outbreaks.
5.10 Matrons


Ensure high standards of infection control, dignity, privacy and individualised patient care are
maintained throughout all aspects of bed management.
Ensure that all patients have a predicted date of discharge and that all actions are being
progressed to achieve this discharge date
Bed Capacity Management Policy
Version: 4
Issue Date: 04 October 2016
Review Date: 31 July 2017 (unless requirements change)
Page 7 of 22






Ensure that all patients are RAG rated as per Adult Outlier Policy
Ensure that all wards are working proactively as part of the Visual Hospital Management
system and that information is correct and proactively managed
Ensure patients have access to beds when increased emergency admissions dictate that
other specialty beds have to be used
Ensure that appropriate action is taken at times of pressure in line with decisions made at
hospital site operations meetings and the Trust Escalation Plan
Ensure issues regarding bed management are communicated in a timely, effective and
constructive way.
Ensure that all ward comply with the requirements of this policy in particular the declaration
and filling of beds in timely manner
5.12 Ward Managers/Nurse in Charge of the Ward












Responsible for ensuring the implementation of this policy at local level and reporting any
problems to their Matron, who will support their resolution at local level, ensuring shared
learning takes place across the CSC at the CSC Boards and across the Trust at the Senior
Nurse meeting, chaired by the Head of Nursing.
Ensuring that all ward staff understand and comply with this policy
Ensure all patients have a Predicted Date of Discharge agreed and documented, and that
clinical staff are working proactively to achieve this date
Ensure all patients are RAG rated for their ability to outlie – See Adult Outliers Policy
Ensure all patients have a clearly documented medical plan within 24 hours of admission
Ensure that early morning and weekend discharges are identified and enacted
Ensure that patients and relatives are kept fully informed of all patient moves and discharge
dates
Ensure that patients’ clinical progress and recovery pathways are monitored and tracked to
prevent avoidable delays in discharge, including referral and liaison to other services which
support discharge planning.
Provide accurate information to the Ops centre to inform of delays, or increased demand for
beds, affecting timely patient flow in CSCs
Ensure that appropriate action is taken at times of pressure in line with the Trust Escalation
Plan
Ensure beds are declared and real time PAS and Bedview recording occurs
Ensure patients with a LOS >14 days are closely monitored
5.13 All Clinical Staff
•
•
Are required to comply with this policy and to escalate any issues or problems to their Line
Manager.
Ensure that any temporary staff they work alongside are briefed about the requirements of
this and associated policies.
5.14 Silver Command
•
•
•
•
•
•
Act as the point of escalation for the CSC for times when discharges do not meet targets or
delays occur in patient movement
With Patient Flow, ensure plans are in place to meet discharge targets for CSC and to
accommodate the demand
Support Patient Flow in ensuring movement starts at the earliest possible time
Attend the Operations Centre meetings at the designated times throughout the day (see
Appendix A) to present issues around safety, flow and what the CSC plans are in place to
address this
Ensure plans are in place that address any shortfall in meeting discharge targets
Act as a point of escalation for Patient Flow, DHM and other CSCs if required
Bed Capacity Management Policy
Version: 4
Issue Date: 04 October 2016
Review Date: 31 July 2017 (unless requirements change)
Page 8 of 22
•
•
Support staff across the CSC in meeting the SAFER bundles acting as a point of escalation
where required and supporting the wards, medical teams and Matrons in meeting these in the
future
Take the lead in supporting the Patient Flow and Clinical Teams in invoking the Full Capacity
Policy when requested, ensuring the Matron for the relevant area has completed the risk
assessment
Liaise with other members of the multi disciplinary team when required to in order to facilitate
flow
Take responsibility, with the support of patient flow, for ensuring robust weekend and
overnight plans are produced
Receive any escalation from the DHM that may relate to the CSC
•
•
•
•
Surgery Specialties:
Supported by Patient Flow, manage the booking and planning of elective surgery spaces
Manage rebooking and communication with patient when cancellation due to capacity issues
Liaise with Clinical teams when reviewing elective admissions on the day
•
•
•
5.15 Ward Clerks
•
•
•
•
The Ward Clerk is responsible for the electronic admissions and discharges of patients and
the other administration support to ensure smooth and timely discharge and admission
processes, supporting patient flow
Ensure that transactions on the Patient Administration System are updated in a timely manner
and as soon as possible after a patient admission, transfer or discharge
Ensure that the administrative work associated with referrals to progress care or achieve
discharge are made in a timely manner and progressed proactively, referring up to the ward
manager/nurse in charge for support if delays are occurring
Ensure that Bedview is updated to reflect admissions and discharges in a timely manner.
5. 16 All Trust Employees
•
All staff are responsible for co-operating with the development and implementation of Trust
policies as part of their normal duties and responsibilities. They are responsible for ensuring
that they maintain up to date awareness of corporate and local policies.
5. 17 On-Call Director
•
The On Call Director is on call to provide advice and guidance to the On Call Manager
including to agree decisions on the opening of flexible/unfunded capacity
5.18 On Call Manager

The On Call Manager is on call to provide advice and guidance to the Duty Hospital Manager
and Duty Matron including to agree decisions on the opening of flexible/unfunded capacity
6. PROCESS
6.1 General Principles
Each Specialty team is responsible for proactively managing their admissions and discharges to
ensure all anticipated elective and emergency patients can be accommodated.
Specialty teams will work collaboratively the Duty Hospital Manager and Matron/s who will provide
the overview, co ordination and support for effective bed use across the Trust. This will be done in a
way that balances the risks as whole to accommodate patients’ clinical, social, mental health, single
Bed Capacity Management Policy
Version: 4
Issue Date: 04 October 2016
Review Date: 31 July 2017 (unless requirements change)
Page 9 of 22
sex and infection control requirements. Out of hours support in which to do this can be given by the
On Call Director and the Hospital at Night team.
To reduce the Length of Stay (LOS) in an inpatient bed, effective discharge planning is crucial.
Discharges should be managed within specialties and the CSC, in line with the Trusts’ discharge
policy, supported by the Discharge Planning Team and overseen by the Matron of the relevant
specialty
All patients will have a predicted date of discharge set by medical staff (or nurses in nurse led
services) which will be proactively tracked utilizing ward visual boards and vitalpac and implemented
by medical and ward nursing staff. This should start at pre assessment for elective admissions and
within 12 hours of admission for emergency patients.
All patients will have their discharge process commenced within 24 hours of admission to hospital.
CSCs are expected to adopt a flexible approach to the needs of the Trust as a whole, reallocating
resources, including beds and theatre time, between and within CSCs, as required to accommodate
the interests of the whole hospital patient population. This includes the flexible use of staff when
required to ensure safe and effective staffing levels and bed capacity across the hospital as a whole.
The planned number of Elective admission per day must take into account that bed provision must be
made for both elective and emergency admissions. The allocating of patients to emergency and
elective beds will be balanced to equally meet the demands of both pathways mindful of the national
targets that are associated with each. Decisions relating to the timing of bed allocation for Elective
admissions must be with the Duty Hospital Manager to allow for capacity planning throughout the
day.
At times priority will have to be given to emergency admissions, but every effort will be made to avoid
the cancellation of elective admissions. The cancellation of elective admissions must only occur
once all other avenues for creating capacity have been explored and must be agreed with CSC
Escalation Lead.
The patient’s safety and clinical need are paramount and must be given priority. Patients will normally
be cared for by members of staff who have demonstrated the relevant knowledge, skills and
competencies.
All efforts will be made to preserve Specialty beds, but it may be necessary to use these flexibly at
times of peak demand. It is the responsibility of each CSC to define clinical limitations on such
flexibility as set out in the Adult Outlier Policy and Trust Escalation Policy.
Every effort will be made to ensure that patients are allocated to beds in a manner that respects their
privacy and dignity, single sex requirements and ensures access to their specialty consultant.
All discharge timings must be within timescales set out in this policy
Beds that become available MUST be notified to Ops centre immediately.
discharged this must also be updated on PAS, Bedview and Vitalpac.
When a patient is
Once vacated, beds must be made ready and available within 30 minutes and admissions to empty
beds must be facilitated in a manner that ensures beds are not left empty and are filled within the
timescales set out in this policy, so that patients can be transferred into them in line with patient flow
standards and the prevailing demand requirements.
Principles of safer start must be adhered to.
Bed Capacity Management Policy
Version: 4
Issue Date: 04 October 2016
Review Date: 31 July 2017 (unless requirements change)
Page 10 of 22
6.2 Patient flow standards
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Predicted Date of Discharge to be identified within 24 hours of admission with initial treatment
plan set out clearly in patient’s notes, Bed view and on ward Visual Boards.
Bedview sheets must be maintained and updated, demonstrating discharge plans
Patients to be informed of this date and the date to be continuously reviewed as part of the
patient’s progression of care by both medical and nursing teams
Discharge planning for the patient must commence within 24 hours of admission to hospital.
As care is progressed, action to be focused on achieving the predicted date of discharge
including all appropriate referrals (e.g. to other clinical specialties, social services,
Occupational Therapy) being made in a timely manner to achieve the estimated date of
discharge
All care progression to be tracked in both the medical notes and visual boards
Appropriate adjustment to be made to the Predicted date of discharge to take account of
progression of a patient’s condition and the actions necessary to achieve a safe discharge
Wards to ensure that accurate data is fed into Bedview system and updated on an hourly
cycle
Ops centre to make sure that wards are aware of patients requiring admission from
Assessment Units by specialty, single sex and infection control requirements;
Ward staff to create capacity in readiness for the demand of patients requiring admission to
their ward
Communication between wards, and Assessment Units to ensure that information is current
and beds are declared and filled promptly
Wherever possible elective patients to be admitted as a day case; if required in patient beds
will be found for patients subsequently requiring in patient admission
Wherever possible elective patients to be admitted on the day of surgery with admission the
day before the day of surgery being the exception and appropriate only to clinical need,
unless significant social needs prevail
Decisions to open or close bed capacity will be made by the DHM in consultation with the
Head of Site Ops, Director of Operations (Unscheduled) or On Call Director, in line with the
Trust Escalation Policy.
6.3 Emergency Department
The Emergency Department will continue to ensure that all admissions are transferred within the four
hour standard or earlier if a bed becomes available.
All patients will be assessed within the first 15 minutes of arrival and will be assessed by a clinician
within 60 minutes.
Patients requiring specialty opinions within the Emergency Department must be seen within 30
minutes of the referral. The Nurse in Charge of this area in the ED will is expected to escalate to the
CSC Escalation Lead in hours and Duty Hospital Manager out of hours if this does not take place.
The Duty Hospital Manager can then assist in escalation.
Other than in exceptional circumstances this must occur no later than 2.5 hours. Communication
must be maintained with the relevant unit to ensure that the transfer takes place within the 4 hour
standard.
All patients requiring Medical or Surgical admission must transfer to the relevant assessment unit
unless clinical indication dictates otherwise. When a patient is accepted by a Specialty, the patient is
transferred to the ward in 30 mins. It is the specialty areas responsibility to create a bed within this
time frame.
The Emergency Department will admit appropriate patients to the Observation Ward where they
require observation and monitoring, await blood results and other assessments. In addition
appropriate patients may be admitted there who require an in patient bed which is not yet available,
Bed Capacity Management Policy
Version: 4
Issue Date: 04 October 2016
Review Date: 31 July 2017 (unless requirements change)
Page 11 of 22
but for whom admission to an observation bed would make them more comfortable. Patients must
not stay in the Observation Ward for longer than 24 hours and the criteria must be adhered to.
In the event of the Resuscitation Room reaching four patients, Majors must maintain a space for
Resus in the event of another admission presenting.
All patients should have a plan by 2.5 hours to leave ED within 4 hours. Patients who reach 2.5
hours without a plan should be escalated by the ED Co-ordinator to the CSC Escalation Lead for
Emergency Medicine or DHM out of hours (see Appendix B).
Patients must be discharged from the system as soon as they have left the department.
6.4 Assessment Units
Other than in exceptional circumstances, GP expected patients will be received directly into the
designated assessment and admission units and not diverted to the Emergency Department. These
units will work to create capacity to receive both GP expected patients and those from the
Emergency Department requiring admission for assessment.
The AMU and the Surgical Assessment Unit (SAU) will ensure that capacity is maintained to receive
GP expected patients. The default should be that ambulatory areas are used to receive referred
patients provided that it is clinically safe to do so and the relevant criteria are met. To facilitate this
AMU and SAU should ensure at least 1 male and 1 female bed is empty and available for
unscheduled demand before 10am each morning.
Orthopaedic expected admissions will go to Fracture Clinic within hours if deemed appropriate by the
On Call Orthopaedic Registrar.
All patients must be seen by a senior clinical decision maker within 12 hours of admission. This
should be a Specialty Consultant or Registrar pertinent to the patients admitting diagnosis.
All units must work to make sure that patients requiring onward transfer to inpatient or other facilities
are transferred in a timely manner so that space is kept available on the unit for GP expected
patients and those from the Emergency Department.
Beds declared to these units must be filled within 30 minutes of declaration.Failure to achieve this
standard should be escalated to the CSC escalation lead. Communication must be maintained
between AMU, the Site Operations Centre and the relevant CSC to prevent any unnecessary delays
in bed utilization.
For patients requiring ambulatory or very short stay assessment, trolley and chair spaces should be
used in preference to bed spaces. Both AMU and SAU will provide dedicated space for these
patients.
Patients must not remain on a trolley longer than 4 hours and the same escalation actions should be
carried out as for the 4 hour standard that are applied in the emergency department (Appendix B).
6.5 Ambulatory Units
Ambulatory areas are available within the AMU and the Surgical Assessment Unit (SAU). Both come
with criteria for use and patients must be referred through the Reg or Consultant on call for that area.
The aim of these units is to provide assessment and treatment which can be administered in a day
care/ambulatory setting and therefore avoid admission into an overnight facility.
Bed Capacity Management Policy
Version: 4
Issue Date: 04 October 2016
Review Date: 31 July 2017 (unless requirements change)
Page 12 of 22
Referrals to the service will be made by GPs and Emergency areas.
These areas should not be used as an overnight facility as this will prevent them to deliver the
service the following day and could result in an increase in admissions to emergency areas.
6.6 Day Care Units
Patients will be admitted to these units as set out in the relevant operational policy. The Nurse in
Charge of the unit must notify the Ops Centre if a patient requires in patient admission subsequent to
their day care treatment.
At times of pressure these beds may be used to admit patients requiring in patient care as a way to
commence their admission when an in patient bed is not yet available. Any such decisions will be
made in collaboration with the appropriate clinicians.
At times of pressure it may be necessary to use day care facilities overnight to balance pressure
either within the CSC or across the hospital as a whole. This will be directed by the Duty Hospital
Manager in a manner that aims to protect the next day’s day care admissions. This action will only
be taken in collaboration with the relevant CSC management team.
6.7 High Care Units
Patients will be admitted to these units as set out in the relevant operational policy. Admission to
these units must take place in collaboration with the Duty Hospital Manager.
The Nurse in Charge must notify the Ops centre when a patient requires transfer from the unit, giving
appropriate advance notice, so that an appropriate bed can be identified. This must be done
proactively to ensure that both the high care unit and in patient wards can effectively manage their
anticipated demand and single sex standards are not compromised.
6.8 Wards
Bed capacity must be created to provide beds for both emergency and elective admissions in a way
that enables all Trust access targets to be achieved including first assessment in ED, 4hr target, 18
week RTT target, thrombolysis, Stroke & PCI targets.
All wards will identify patients for early morning discharge the evening before and ensure TTOs are
obtained.
All wards are to aim to have discharged2 patients before 10 am every day and maximize the use of
the discharge lounge ensuring any transport requests are booked.
All wards are to aim to have achieved discharges as per the Safer discharge Bundle for their
specialty.
All wards are to complete a review of all clinically stable patients on the Integrated Discharge Bureau
List (IDB) daily and report actions to the IDB.
Wards beds to be shown to be empty on Bedview immediately when they are vacant.Ward staff will
work to make vacated beds ready within the required time of 30 minutes.
6.9 Discharge Process on the Day
•
Date of Discharge to be confirmed the day before discharge, with patients made ready for
discharge prior to 1.00 pm on day of discharge
Bed Capacity Management Policy
Version: 4
Issue Date: 04 October 2016
Review Date: 31 July 2017 (unless requirements change)
Page 13 of 22
•
•
•
•
•
•
•
•
•
Each ward to identify named patients for definite discharge prior to 10 am with TTO and
Spell Summary done the day before. Every ward will have their own target to meet which
will ensure flow is maintained within that specialty from early in the morning onwards.
Nurse in Charge of each ward to work with medical teams to ensure that these named
discharges are identified and associated action is taken to ensure they are proactively
managed.
Drug charts and spell summaries to be written up the day before confirmed estimated date
of discharge. For these named patients instructions to be given to Pharmacy for TTOs to
be available 6 pm the previous day
If further discharges are confirmed on the day, drug charts and spell summaries to be
written up promptly and drug chart sent to Pharmacy urgently, designating required time
for TTOs to be available
Transport requests to be made through the agreed process
All patients meeting the Discharge Lounge criteria must be transferred to the Discharge
Lounge at the earliest opportunity on the day of discharge to free up beds on the wards
and patients must be informed of this by ward staff
Drug packages to be handed over to the Discharge Lounge staff who will hand over these
instructions to patients and/or their carers in the Discharge Lounge
Relatives must be kept informed of discharge arrangements and the potential time of the
discharge, together with associated support services being put in place to support the
discharge where relevant.
Bed spaces requiring cleaning (scrubs) can be escalated to the Duty Hospital Manager if
the request has taken longer than 30 minutes.
6.10 Declaration and filling of Beds
Once vacated beds must be shown to be empty on Bed View as soon as possible and PAS/
updated.
Beds must be cleaned to the standard required by the Infection Control Policy.
Wards must contact the Patient Flow Manager/Duty Hospital Manager if the bed remains vacant
once declared for longer than 1 hour.
Once a clinical/social or operational decision has been made for a patient to be transferred or
discharged all action should be taken to ensure this happens in the shortest possible time and the
Discharge Lounge used whenever possible.
Full Capacity Protocol to be invoked if in Red or Black status
Bed Declaration Flow Chart
Bed becomes vacant
Bed shown to be vacant immediately on Bedview and
made ready within 30 minutes to receive patients
Bed Capacity Management Policy
Version: 4
Issue Date: 04 October 2016
Review Date: 31 July 2017 (unless requirements change)
Page 14 of 22
Patient admitted into bed within a
further 30 minutes
If bed not filled within 1 hour
re- escalated to Operations Centre
6.11 Patient Moves
Other than from Assessment Units to appropriate wards, patient moves must be minimized unless
pertinent to the patients clinical condition (e.g. to High/Critical Care Unit) or infection control
circumstances.
Wherever possible, other than new admissions, patient moves should be organized to take place
prior to 22.30, unless exceptional circumstances prevail.
All patient moves must take place in line with the Transfer Policy.
6.12 Making Decisions on the Management of Bed Capacity over the 24 hour period
The Operations Centre will receive, monitor and manage information pertinent to the overall
management of the hospital on a 24 hour / 7 day basis, under the direction of the Duty Hospital
Manager.
Decisions will be made at the Operations Meetings (0830, 1300, 1630 and 1900) and at these times
an assessment will be made of the predicted balances based on available and predicted bed
capacity relative to the predicted demand.
The intention must be to make provision for patients to be allocated to appropriate beds and balance
bed capacity without the need for outlying. At times where this is unavoidable (aiming for this to be
exceptional) the Adult Outlier Policy must be applied.
Decisions to open additional beds will be enacted in line with the Trust Escalation Policy.
6.13 Outlying
See Adult Outliers Policy for the detailed process for outlying
6.14 Escalation Actions
See Trust Escalation Policy
6.15 Integrated Discharge Services
The Integrated Discharge Team will ensure they acquire the daily community bed status and
communicate this to the CSCs.
Bed Capacity Management Policy
Version: 4
Issue Date: 04 October 2016
Review Date: 31 July 2017 (unless requirements change)
Page 15 of 22
The Integrated Discharge Team will ensure the daily Integrated Discharge List is distributed which
will list all Medically Fit, Medically Fit Ready for Discharge and Clinically Stable patients All patients
with a Length of Stay greater than 14 days will also be reviewed daily, CSCs will be required to
monitor and manage these patients.
6.16 Accepting patients from other Trusts
This will be facilitated through the Operations Centre. All efforts must be made to maintain
cooperation and mutual support arrangements with other Trusts. Patients should be repatriated as
soon as available capacity can be identified.
Before accepting patients back into the Trust a Consultant or Registrar for the correct Specialty must
have accepted them.
The Duty Hospital Manager may review the acceptance back of patients depending on the Trust
Hospital Escalation Status.
7. TRAINING REQUIREMENTS
•
Ward Managers are responsible for ensuring their staff are aware of and comply with this
policy. They also need to ensure that staff are trained in systems to manage this process.
•
The Head of Site Operations is responsible for the Operations Centre Team, ensuring that
staff are aware of and comply with this policy and are trained in relevant systems.
8. REFERENCES AND ASSOCIATED DOCUMENTATION
Trust Escalation Policy
Adult Outliers Policy
Transfer Policy
Infection Prevention & Control Policy
Isolation Policy
Discharge Policy
Full Capacity Protocol
9. EQUALITY IMPACT STATEMENT
Portsmouth Hospitals NHS Trust is committed to ensuring that, as far as is reasonably practicable,
the way we provide services to the public and the way we treat our staff reflects their individual needs
and does not discriminate against individuals or groups on any grounds.
This policy has been assessed accordingly
Our values are the core of what Portsmouth Hospitals NHS Trust is and what we cherish. They are
beliefs that manifest in the behaviours our employees display in the workplace.
Our Values were developed after listening to our staff. They bring the Trust closer to its vision to be
the best hospital, providing the best care by the best people and ensure that our patients are at the
centre of all we do.
We are committed to promoting a culture founded on these values which form the ‘heart’ of our Trust:
Respect and dignity
Quality of care
Working together
Efficiency
This policy should be read and implemented with the Trust Values in mind at all times.
Bed Capacity Management Policy
Version: 4
Issue Date: 04 October 2016
Review Date: 31 July 2017 (unless requirements change)
Page 16 of 22
10. MONITORING COMPLIANCE WITH PROCEDURAL DOCUMENTS
Minimum
requirement to be
monitored
Lead
Tool
Frequency of Report
of Compliance
When
site
ops
issue changes to
patient flow these
must be reflected
Site
Ops
General
Manager
Urgent Care
Workbooks
Annual
Incidents occurring
due to patient flow
and bed capacity
Site
Ops
General
Manager
Datix
Annual
Reporting arrangements
Policy audit report to:

Lead(s) for acting on
Recommendations
Deputy COO
Ops Board
Policy audit report to:

Deputy COO
Ops Board
Policy audit report to:

This document will be monitored to ensure it is effective and to assurance
compliance.
Bed Capacity Management Policy
Version: 4
Issue Date: 04 October 2016
Review Date: 31 July 2017 (unless requirements change)
Page 17 of 22
Appendix A
Site Operations Meetings Times
Meeting
Times
Trust Escalation Status
Green
Amber
0830
All CSCs Silver Escalation Leads
1300
ED/AMU Co-ordinators,
DHM and Patient Flow Co-ordinators/
Managers.
Discharge Planning Lead.
Any other representative – by
invitation only.
ED/AMU Co-ordinators,
DHM and Patient Flow Co-ordinators/
Mangers,
Discharge Planning Lead.
Any other representative – by
invitation only.
Duty Matron
ED/AMU Co-ordinators,
DHM and Patient Flow Co-ordinators/
Managers,
Any other representative – by
invitation only.
Duty Matron
1630
1900
Red
All
Silver
All CSCs
plus
GM/Chief
Service
Meeting Chair
COO/DO (Unscheduled)/Head of Site
Ops
DHM
DO (Unscheduled) or Head of Site Ops
if Status: Black
Silver
either
of
Any CSCs
Red/Black
against their own
status should
send CSC Silver
All
CSCs
Silver
Duty Matron
All CSCs Silver
plus
either
GM/Chief
of
Service
Duty Matron
Any CSCs
Red/Black
against their own
status should
send CSC Silver
DHM
On Call Director if Status: Black
Attendance
based upon
agreement at
1630hrs
Attendance based
upon agreement at
1630hrs
Attendance
based upon
agreement at
1630hrs
DHM
On Call Director if Status: Black
Bed Capacity Management Policy
Version: 4
Issue Date: 04 October 2016
Review Date: 31 July 2017 (unless requirements change)
CSCs
CSC Status
Black
Page 18 of 22
Site Operations Meetings Roles and Responsibilities
Role
Chair
Responsibilities
Patient
Flow
Representative
or
CSC Silvers
1. To provide feedback/update from Operational Management Meetings.
2. To proactively present any actions being taken to tackle shortfalls in
discharge or other targets and respond to challenge on key
targets/indicators and outline actions to be taken to resolve any concerns.
3. Escalate any issues that need support or co-operation outside the CSC.
1. To ensure the meeting commences on time and is kept brief and action
focused
2. To provide the Trust Escalation Status and a brief situation report.
3. To facilitate the identification and management of any safety concerns.
4. To identify the key areas of challenge and request the appropriate
support to meet these challenges
5. To provide challenge to the CSCs on performance against key
targets/indicators.
6. To generate a list of actions that must be completed and feedback
provided at the next meeting.
7. To check that actions necessary to maintain safety and flow are being
taken.
1. To present the Community Capacity position.
Discharge
Planning Lead 2. To highlight any actions needed to support the discharge process.
3. To receive any escalations following the meeting relating to discharge
Nurse
Staffing
Matron
Ops
Centre
Administrator
planning.
1. Provide a summary of the staffing position for the Trust.
2. Detail any actions being taken to resolve staffing shortfalls.
3. Provide an update on staffing for escalation areas and plans to ensure
these are safely staffed.
1. Ensure the meeting room is prepared for the Site Ops Meeting with all
information required displayed.
2. Record any actions on the flip-chart and disseminate via the Ops
Report.
Bed Capacity Management Policy
Version: 4
Issue Date: 04 October 2016
Review Date: 31 July 2017 (unless requirements change)
Page 19 of 22
Site Operations Meetings Agenda
1.
Presentation by the Chair of the Trust Situation Report and Key Metrics
 Escalation Status
 Performance against 4 hour standard
 Number of patients remaining in ED over 3 hours and 4 hours
 Number of patients discharged
 (0830 only) Examination SAFER dashboard (Appendix C) and in
particular discharge targets. Discussion of other Key metrics such as:
AMU and ED transfer times.
2.
Safety Concerns and any actions resulting
3.
Discussion of capacity and demand
 Presentation by the Chair of the capacity position
 Identification of blockages to flow and risk to discharge target.
 Identification of actions to achieve discharge targets and resolve flow
issues.
 Decisions to be made regarding escalation capacity and planned
increase/decrease to outlier numbers.
4.
Elective admissions
 (0830 only) update from Surgical CSCs on Elective plans for the day.
 Identification of any risks to the elective programme and any action
needed to mitigate.
Community Capacity
 Presentation by Discharge Planning Lead Nurse of community
capacity and plans to fill this.
 Presentation of escalation pathways/actions to deal with any specific
delays to discharge.
5.
6.
Critical care capacity
 Identify plans and timescales for stepping patients down.
7.
Infection Control Briefing (Invitation only)
8.
Staffing
 Identify plans/actions needed to resolve any staffing issues
10.
Agree appropriate actions depending on escalation status
11.
A.O.B e.g. adverse weather warnings, estates emergencies, operational
issues
Bed Capacity Management Policy
Version: 4
Issue Date: 04 October 2016
Review Date: 31 July 2017 (unless requirements change)
Page 20 of 22
Equality Impact Screening Tool
To be completed and attached to any procedural document when submitted to
the appropriate committee for consideration and approval for service and
policy changes/amendments.
Stage 1 - Screening
Title of Procedural Document: Bed Capacity Management Policy
Date of assessment
31st July 2016
Responsible
Department
Operations Centre
Name of person
completing
assessment
Carla Bramhall
Job Title
Emergency Planning Officer
Does the policy/function affect one group less or more favourably than another on the basis
of :
Yes/No
 Age
Comments
No
 Disability
Learning disability; physical disability; sensory
impairment and/or mental health problems e.g.
dementia
No
 Ethnic Origin (including gypsies and travellers)
No
 Gender reassignment
No
 Pregnancy or Maternity
No
 Race
No
 Sex
No
 Religion and Belief
No
 Sexual Orientation
No
If the answer to all of the above questions is NO,
the EIA is complete. If YES, a full impact
assessment is required: go on to stage 2, page 2
More Information can be found be following the link
below
www.legislation.gov.uk/ukpga/2010/15/contents
Bed Capacity Management Policy
Version: 4
Issue Date: 04 October 2016
Review Date: 31 July 2017 (unless requirements change)
Page 21 of 22
Stage 2 – Full Impact Assessment
What is the impact
Level of
Impact
Mitigating Actions
(what needs to be done to minimise /
remove the impact)
Responsible
Officer
Monitoring of Actions
The monitoring of actions to mitigate any impact will be undertaken at the appropriate level
Specialty Procedural Document:
Specialty Governance Committee
Clinical Service Centre Procedural Document:
Clinical Service Centre Governance Committee
Corporate Procedural Document:
Relevant Corporate Committee
All actions will be further monitored as part of reporting schedule to the Equality and Diversity
Committee
Bed Capacity Management Policy
Version: 4
Issue Date: 04 October 2016
Review Date: 31 July 2017 (unless requirements change)
Page 22 of 22