escalation policy - maternity - networks

Escalation Policy – Maternity v3 (042) Sept 2014 – Sept 2017 of 32

Escalation Policy - Maternity

Version 4

Lead Person(s): Andrew Tapp, Care Group Medical Director Cathy Smith, Head of Midwifery and Care Group Director

Care Group: Women and Children’s

First Implemented: June 2010

This Version Implemented: 1st December 2015

Planned Full Review: December 2018

Keywords: Staffing levels, midwifery; Escalation, staffing levels

Written by: Anthea Gregory-Page, Deputy Head of Midwifery Jan Latham, Senior Midwife for Consultant and In Patient Services Clinical Risk Co-ordinator (2010)

Revisions By: Maggie Kennerley, Lead Midwife Angela Hughes, Assurance lead Paula Williams, Guideline Midwife

Consultation: Andrew Tapp, Care Group Medical Director Cathy Smith, Head of Midwifery and Care Group Director, Anthea Gregory Page, Deputy Head of Midwifery

Comments: References to SaTH Guidelines in the text pertain to the latest version of the Guideline on the intranet. Printed copies may not be the most up to date version.

To be read in conjunction with: Neonatal Escalation Guideline

For Triennial Review

Version Implementation Date

History Ratified By Full Review Date

1 June 2010 New Maternity Governance March 2013

1.1 3rd October 2011 New structure/ title changes

GC Authorisation October 2014

2 15th January 2013 Escalation for MLU and Escalation forms & CNST requirements

Maternity Guidelines Group (MGG)

Maternity Governance

October 2014

2.1 20th September 2013

Addition of Appendix 2b GC Authorisation October 2014

3 30th September, 2014

Full Review / Revision due to reconfiguration

GC Authorisation Extraordinary Approval

September 2017

4 1st December 2015 Full Review in line with national guidance

MGG Maternity Governance

December 2018


Appendices

• Appendix 1: Red Flag events

• Appendix 2 Maternity Escalation flowchart

• Appendix 3 Midwife Led Units Safe Staffing levels

• Appendix 4: Maternity Escalation Form

• Appendix 5: Closure of Maternity Beds, Ward, Department or Unit

• Appendix 6: Re-opening of the Unit

• Appendix 7: Letter to parents

• Appendix 8a-e: Acuity Tools

• Appendix 9 Hospital Contact Numbers


1.0 Introduction 1.1 This escalation policy is specific to the Maternity Units within Shrewsbury and Telford

Hospital NHS Trust (SATH), which include the Consultant Units and all peripheral Units within the Trust. This must be read in conjunction with the Neonatal Escalation Policy SaTH, the Strategy for Safe Staffing- Midwifery Guideline, the SaTH On-call policy, and the Labour Ward Staffing Guideline.

1.2 Every effort will be made to accommodate the women booked within Shropshire for maternity care to be cared for within SATH.

1.3 Appropriate staffing levels and skill mix across all Midwifery, Nursing, Support Staff, Obstetricians and Anaesthetists are essential for providing a safe maternity service.

1.4 Closure of the Unit would have major implications for all patients booked for care, neighbouring hospitals and the neonatal services. The decision to close is a final resort with the decision taken by Trust / Centre Board, Head of Midwifery, , Care Group Medical Director and Consultant Obstetrician, in consultation with the Supervisor of Midwives.

1.5 Closure will only be considered when all other potential solutions are exhausted. However, in the rare event of the closure of the Maternity Unit it is paramount that we have clear safe alternative arrangements for the care of mothers and babies. This document should be read in conjunction with the West Midlands Local Supervising Authority – The Management of Maternity Beds (2008) see Appendix 1.

1.6 This guidance has been reviewed against NICE safe midwifery staffing (2015) guidance and incorporates the recommendations made.

2.0 Aim(s) The purpose and intention of this document is to provide staff within the multidisciplinary team with guidance on how to manage beds and staffing levels to ensure services are maintained during times of high activity or staffing shortfall within the Consultant Unit and all peripheral Units within Maternity.

3.0 Objectives 3.1 Provision of guidance for staff on routine bed management within the Consultant Unit

and all peripheral Units within Maternity. 3.2 Provision of guidance for staff on crisis bed management within the Consultant Unit and

all peripheral Units within Maternity. 3.3 Provision of guidance for staff on unit closure within the Consultant Unit and the relevent

peripheral Units within SaTH Maternity. 3.4 To provide guidance for staff on trigger systems (red flags) and when to escalate short

and long term staffing to Lead Midwives, Maternity Governance or Centre Board. 3.5 To identify the resources required to evaluate the effectiveness of service provision and

in order to meet these needs, if required, facilitate a service restructure

4.0 Definitions 4.1 Factors precipitating suspension of a Maternity Unit

1. Insufficient Midwives or Doctors 2. Inappropriate experience/skill mix to provide suitable care 3. No available beds 4. Infection of clinical areas – advised by microbiologist 5. Major security alert/incident, or environmental factors such as power failure or

flooding 6. NNU Escalation at Red + with no apparent resolution. 7. Red Flags identified

4.2 Green – routine bed management procedures The Maternity Unit has no anticipated concerns that will prohibit admissions.

4.3 Amber – crisis bed management procedures The Maternity Unit has recognised factors and instigated contingency plans.

4.4 Red – restriction of admissions to obstetric clients/closure of unit After following amber bed management procedures a Unit or Department remains unable to resolve factors. Additional management is required and the Unit may have no choice but to suspend activity until the area can once again be fully operational.


4.5 Red + - Consultant Unit is unable to address factors 4, 5 or 6 which are present in the Unit.

4.6 Intrapartum score card a tool for monitoring and improving patient safety in maternity units.

4.7 Red Flag is a warning sign that something maybe wrong with midwifery staffing (NICE 2015) (see Appendix 2 for midwifery red flag events)

4.8 Delay in care or treatment- where there has been significant delay in provision of care, which has affected the quality of care, safety or clinical outcome

4.9 Ward acuity tool is a traffic light system used to risk assess, monitor activity levels and identify red flags.

4.10 Board round a multidisciplinary review, led by the consultant on call, of patients on the consultant labour, antenatal and postnatal wards and neonatal unit activity.

4.11 Maternity Escalation Alert Form (Appendix 4) enables an appraisal of SaTH maternity services and documents the action taken when amber or red escalation invoked

4.12 Normal working hours 9am- 5pm Monday to Friday. Excluding bank holidays. 4.13 Outsdie Normal working hours 5pm-9am Monday- Friday, weekends and bank

holidays.

5.0 Process see also Maternity Escalation Flowchart (Appendix 3) Bed management is reviewed within SaTH maternity services as a minimum daily, using the 08.30 board round (refer to section 4.10) during this process all activity is reviewed across the services and contingency plans are put in place to address high volumes of activity/acuity and concerns are escalated.

Midwives are responsible for reviewing the provision of care which includes staffing levels and service provision. Ward activity is recorded using ward acuity tools, which incorporate red flags, by either the designated lead clinical midwife or ward manager and recorded on activity log at the change of shift or time of escalation. (See appendix 9a 9b 9c 9d) If it becomes apparent that the issues are not being resolved by local ward action, the delivery suite co-ordinator or lead Midwife/Deputy Head of Midwifery (normal working hours hours) or delivery suite co-ordinator/ on call manager (outside normal working hours) will be informed. They will provide guidance and support to help address the issue/s. Once escalated, if issues can not be resolved an Maternity Escalation Alert Form (Appendix 4). will be commenced by the person leading the escalation to capture the issues, deficits identified and if in relation to staffing, areas where staff can be relocated from/to Outside of normal working hours the Maternity Escalation Alert Form will be completed by either the delivery suite co-ordinator or on call manager. The ward acuity tools will indicate either of the following statuses and actions taken accordingly

5.1 Green – routine bed management procedures (no factors)

The Maternity Unit has sufficient designated beds to fulfil the contracted elective and emergency activity.

• Day to day management of beds in hours is the responsibility of the Ward/Unit Manager. Implementation of maximum efficiency in bed usage is encouraged.

• Close involvement of the senior clinicians is key to efficient administration and discharge practice. Each area is expected to contain their activity within bed availability; therefore if beds are closed for any reason, activity should be adjusted accordingly.

• Out of hours and at weekends, routine bed management is the responsibility of the delivery suite co-ordinator and the manager on-call.

5.2 Amber –Bed management procedures � Alert ward managers/ Lead Midwife (in normal working hours) or delivery suite Co-

ordinator/ Women’s and Children’s on call Manager (outside normal working hours hours) to assist in undertaking amber bed management procedures.

� Consider use of all available Midwives onsite.


� Consider temporary redeployment of staff from other Departments or outlying areas to facilitate bed management procedures and ensure patient safety during crisis period.

� Alert On-call Consultant, ensure they or their Middle Grade undertake additional wards rounds in all areas to review status of inpatients.

� On-call Consultant or their Middle Grade will expedite clients’ discharge where possible.

� Alert relevant Midwives/Ward Managers in other Units/areas. � Explore the possibility of identifying additional bed and theatre capacity in liaison

with the Clinical Site Managers, the Consultant on-call and on-call managers. � Alert Neonatologist, including Consultant in order to review babies to expedite

discharge where possible. � Designate staff to help with discharge procedures. � Consultant on-call to review all elective admissions. � The Consultant on-call or their Middle Grade should consider deferring elective

caesarean sections and induction of labours if at all possible. � Women who are affected by the bed management procedures are kept fully

informed during crisis bed management. � Documentation should reflect any discussions with the women. � Consider transfer of women to peripheral units with capacity.(SaTH or external). � Consider transfer of patients with early pregnancy complications to gynaecology.

5.3 Red – Restriction of Activity on consultant unit or MLU Amber bed management will continue when red has been identified on a ward(s) acquity tool, however if this does not resolve the issues the following will be undertaken:

• Ensure Ward Managers/ Lead Midwive(s) (in normal working hours) or delivery suite Co-ordinator/ Women’s and Children’s on call Manager (outside normal working hours hours)

• Desist all unnecessary activity

• Review induction of labours, with a view to postpone

• Transfer high risk women to other consultant units.

• Redeploy all midwives, including non clinical, to the areas of high activity.

• Inform the deputy head of Midwifery/Head of Midwifery.

• Escalation management meeting called

Either the lead midwife or, the manager on-call (if out of hours) with support from a Supervisor of Midwives (where appropriate) will co-ordinate the procedure for diverting some maternity activity. Diversion of clients should be carried out on an individual basis following consultation with the On Call Consultant Obstetrician and/or Consultant Neonatologist as appropriate. If amber and red bed management procedures have not resolved the bed crisis, the Lead Midwife or manager on-call (out of hours) will liaise with the Deputy Head of Midwifery/ Head of Midwifery when considering the decision to suspend the Maternity Services. Only the Deputy Head of Midwifery, Head of Midwifery or Care Group Medical Director can make the decision to close beds/wards/departments or Units. If closure is required, Individuals identified on the closure of a Maternity Unit Form (see Appendix 5) will be informed. Suspension of maternity services may involve the closure of beds, ward/s, departments/s or unit/s and may not always be in relation to staffing issues. Other possible reasons for closure will include:

• Lack of essential resources e.g. electrical/water utilities

• Equipment failure e.g. lifts,

• Infection in the clinical area, where closure has been advised by the microbiologist.


• In the event of a major security incident. If the decision is made to suspend Maternity services the person leading the closure will ensure that: � The closure of Maternity Beds, Ward, Department or Unit actions and

communication list (Appendix 5) is completed � Staff working at the time of the suspension of services will be fully informed of the

suspension status. � The contingency plans will be outlined on the delivery suite board and continually

updated until the suspension is lifted. Explore the possibility of identifying additional bed and theatre capacity in liaison with the Clinical Site Managers, the Consultant on-call and On-call Managers.

� Arrangements are made with neighbouring Maternity Units to accept women in labour always aiming to take into consideration where women live.

� The Consultant Neonatologist and Lead Nurse for the Neonatal Unit (NNU) are informed.

� Ambulance Control for both the West Midlands and Powys regions are informed. � Women who have not contacted the Maternity Unit prior to their arrival will be

assessed and arrangements made for their safe transfer via paramedic ambulance to a receiving Unit.

� Each woman requiring admission has confirmation of the arrangements for transfer and details of the hospital location. In addition, she will be reminded to take her pregnancy health record with her.

� The Trust Executive is informed by Lead Midwife or Maternity On-call Manager. � Switchboard is informed. � The Trust Communication Team is informed. Re-opening the Maternity Unit � The Lead Midwife or manager on-call will reverse the suspension of services

process when the factors that precipitated the closure are resolved. � The communication checklist (Re-opening of a Maternity Unit form – Appendix 6)

will be used to ensure that all relevant personnel are informed of the re-opening. � A letter will be sent to all women who were directed to other Units as a result of the

closure to apologise for the inconvenience caused (Appendix 7). Restriction of Activity on the Neonatal Unit

If the Neonatal Unit is on a category red plus, an escalation planning meeting will be called to identify priorities and to assist this process, refer to Neonatal Escalation Guideline.

Role of the Supervisor of Midwives (SOM) during periods of escalation The primary function of the SOM at these times is the continued protection of the public and the SOM will support midwives to ensure that midwifery practice occurs in the safest possible environment. Escalation will be co-ordinated by the Lead midwife/on call manager with support/input from the SOM.

Addressing Staffing Shortfalls Staff shortage can occur at times of unusually high workload or high dependency, at times of increased staff sickness levels, when there are unfilled vacancies or during adverse weather events. Immediate, time critical management of staffing shortage. This may be due to a period of high activity on Delivery Suite or more than one home birth attendance in one outlying area.

• Ward/Unit manager will alert the Lead Midwife for the area during business hours or manager on-call out of hours.

• Consider redeploying staff, including specialist midwives, from other wards or departments.


• Consider redeploying staff from peripheral Midwife Led Units if there are no women in labour.

• Consider redeploying staff to assist MLU’s or community.

• Consider asking staff to extend their shift hours or to come in early for their next shift.

• Consider using the staff texting system to send out an SOS message for assistance.

• Consider calling in the MLU/Community on-call staff to staff the unit, unit midwife to be redeployed for a maximum of four hours call-out.

• Unit manager, Lead Midwife or Manager on-call to liaise with Consultant on-call and delay all non-essential inductions and elective caesarean sections.

• If this does not resolve the problem, manager or manager on-call to escalate to Deputy Head of Midwifery/Head of Midwifery.

5.6.1 Short term staffing shortage – midwifery, nursing or support staff

In the event of short term staffing shortages the Ward Manager/delivery suite co-ordinator or the Lead Midwife for that area or Unit during day time hours or the delivery suite co-ordinator or manager on-call out of hours will take into consideration the following: � Review off duty rota’s for all areas and consider redeploying staff from other

wards, departments or peripheral Midwife Led Units. � Review planned study leave/annual leave and re-schedule. � Review of elective work – inductions, caesarean sections with the Consultant

on-call. � Review ward areas and peripheral units and expedite discharges where

possible. � Review all non urgent work, community and parent education. � Liaise with Consultant on-call and consider cancellation of any non-urgent

activities. � Assess overall skill mix of midwifery, nursing and support staff and utilise

appropriately.

The delivery suite co-ordinator or Lead Midwife will contact: � Antenatal Clinics and peripheral Midwife Led Units to ascertain if staff are

available to cover on a short term basis. � Part time staff who have indicated that they would be willing to work

additional hours. � Bank staff. � During exceptional times, full time staff may be requested to work overtime

hours (including those on annual leave).

To ensure patient safety and safe staffing levels, staff must be prepared to move to another area or Unit when requested to do so by the Lead Midwife, the delivery suite co-ordinator or the manager on-call. (This could be from MLU to the consultant unit or the consultant unit to an MLU)

Short term staffing shortage – medical staffing If medical staff are unwell relevant personnel will be contacted, refer to staffing guideline for obstetricians for contact details. Process

� On receipt of notification in hours, the rota co-ordinator reallocates medical staff to ensure continuous emergency cover to the Labour Ward.

� If the rota can be adequately filled with in-house “locums” and cross cover of clinical activity, no external aid is sought.

� If the rota cannot be filled then agency locums are appointed to ensure smooth running of all aspects of the department, but primarily 24/7 cover of the Labour Ward.

� Out of hours the onsite manager and the Consultant on-call identifies the impact of the deficit on the department.

� If there is going to be or is an immediate absence on the 24/7 Labour Ward cover rota, all permanent members of staff are contacted to see if they are able to


supply short term locum cover. If they are unable to supply short term locum cover, then agency assistance is sought.

� The Consultant on-call and the Ward Manager/Lead Midwife work together to understand the safety of continuing acute obstetric practice in such circumstances and assistance is sought from surrounding Obstetric Units. Other resident medical rotas are also contacted to see if some of the emergency activity of the medical staff can be undertaken by alternative medical practitioners in a safe manner.

5.6.2 Ongoing staffing shortfalls When the above measures have not resolved staffing issues for Midwives, nursing, support staff or medical staff, the following should be made aware of the situation:

• Lead Midwife for that area/Midwife Led Unit

• Deputy Head of Midwifery/Head of Midwifery

• Care Group Medical Director

The Ward Manager/Lead Midwife in hours or the manager on-call out of hours will ensure the following:

• Review of all areas to judge workload and dependency

• Contact part-time staff who may work extra hours

• Contact specialist and Lead Midwives to work clinically

• Contact full time staff to work overtime hours

• Consider redeploying staff from peripheral units

• Consider redeploying staff to assist community or peripheral units

• Consider closure of peripheral units on a temporary basis

• Review of all planned study leave/annual leave and reschedule

• Cancellation of all non-urgent activities

If any of the Maternity Units continues to be unable to address staffing shortfalls the Unit has no choice but to suspend activity until the unit can once again be fully operational.

5.6.3 Long term staffing shortfalls – midwifery, nursing and support staff When short term or ongoing staff shortfalls have not been resolved it is imperative that the Lead Midwives, the Head of Midwifery and the Centre Chief are made aware of the situation and will risk assess and if necessary place onto risk Register. Please refer to Safe Staffing Levels for Midwifery, Nursing and Support Staff for details of contingency and business planning for medium and long term staffing shortfalls and Safe Staffing Levels for Obstetricians. The co-ordination of ward acuity forms rests with the ward manager who will report this activity to the maternity management meetings. Any other concerns will be escalated to maternity Governance.

6.0 Training 6.1 New Midwives and medical staff will be informed about the process for accessing

guidelines during their induction. 6.2 New or updated guidelines will be disseminated as per the Guideline, Protocol and

Policy Development Framework – Maternity (060)

7.0 Monitoring/Audit Acuity forms will be monitored through maternity management meetings. If escalation tracker forms are required in an area 3 times or more in one month for 3 consecutive months then these trends will be escalated to Maternity Governance. Decision for Audit/Monitoring The requirement to undertake audit/monitoring will be identified via legal cases, high risk case review, serious incidents, and where there is trends in incident reporting.


8.0 References Department of Health. (2007). Maternity Matters: Choice, access and continuity of care in a safe service. London: COI. Available at: www.dh.gov.uk

NHS Litigation Authority Clinical Negligence Scheme for Trusts (2009). Maternity Clinical Risk Management Standards (Version 2 2009/10). Available at: www.nhsla.com NICE (2015) NICE Safe Midwifery Staffing, NICE

Royal College of Anaesthetists, Royal College of Midwives, Royal College of Obstetricians and Gynaecologists, Royal College of Paediatrics and Child Health. (2007). Safer Childbirth: Minimum Standards for the Organisation and Delivery of Care in Labour. London: RCOG Press. Available at: www.rcog.org.uk

Royal College of Obstetricians and Gynaecologists, Royal College of Anaesthetists, Royal College of Midwives, Royal College of Paediatrics and Child Health. (2008). Standards for Maternity Care: Report of a Working Party. London: RCOG Press. Available at: www.rcog.org.uk


Appendix 1 Midwifery Red Flag events Agreed locally by the West Midlands Heads of Midwifery

• Delay in suturing of more than 60 minutes

• Delay in Triage of more than 30 minutes

• Delay in commencing Induction of Labour of more than 2 hours

• Delay in category 1 caesarean section of more than 30 minutes

• Unable to achieve one to one care in labour


Appendix 2- Maternity Escalation Flowchart

Person responsible- In normal working hours Out side normal working hours

Ward or Unit acuity tool Completed by ward manager or designated midwife in charge of shift at change of shift. Indicating GREEN, AMBER or RED status or red flag identified

Unable to resolve issue

Inform lead Midwife or Delivery Suite Co-ordinator Datix completed (followed up at governance)

Escalation meeting called (Daytime hours) by lead midwife or Deputy HOM On call manager informed and may need to attend and co-ordinate escalation process.

Local action taken

Issue resolved following involvement of ward manager or delivery

suite co-ordinator Issues resolved e.g. by redeployment of staff returning area to AMBER/GREEN status

Escalation Alert form completed by person leading escalation or labour suite co-coordinator/on call

manager

In discussion with the Deputy HOM or HOM, evaluate if closure of the unit is required. (See section of guideline)

Decision made to close beds/ward/ department/unit

Local action taken to address shortfalls. Area/ward status returning to AMBER/GREEN

Complete closure of maternity beds/ward/ department/unit form and relevant personnel informed

Unable to resolve issue

Re-evaluate using ward acuity tool and escalation Alert form


Appendix 3 Midwife Led Units Safe Staffing Levels

RSH MLU Midwives WSA Other

Day Shift 12 ½ hours 2 1 Includes 30 min handover

Night Shift 12 ½ hours 1 1 Includes 30 min handover

Oswesrty MLU Midwives WSA Other

Day shift 12 ½ hours 1 1 Includes 30 min handover

Night Shift12 ½hours 1 1 Includes 30 min handover

Ludlow MLU Midwives WSA Other

Day shift 12 ½ hours 1 1 Includes 30 min handover. Early and late shifts at weekends

Night Shift12 ½hours 1 1 Includes 30 min handover

Bridgnorth MLU Midwives WSA Other


Night shift 12 ½ hours 1 1 Includes 30 min handover

Wrekin MLU Midwives WSA Other


Night shift 12 ½ hours 2 1 Includes 30 min handover

Consultant Unit Safe Staffing Levels

Delivery Suite Coordinator Midwives WSA

Early 1 6 3

Theatre List Days Tues, Weds & Thurs

2

Late 1 6 3

Night 1 6 3

Antenatal Ward Midwives WSA Other

Day Shift 12 ½ hour 3 2 Includes 30 min handover Night shift 12 ½ hour 3 2 Includes 30 min handover

Postnatal Ward Midwives WSA Other


Night Shift 12 ½ hours 3 2 Includes 30 min handover


Day Assessment Safe Staffing Levels

RSH - MLU Covered by Midwives working on the MLU

PRH - WANDA Midwives WSA Other

09.00-21.30 daily 2 1 Ward Clerk 4 days per week.

Antenatal Clinic Safe Staffing Levels

RSH Midwives WSA Other

Weekday 1 3 Triage Midwife 5/7

Wrekin Midwives WSA Other

Early – weekday 2 2 Triage Midwife 5/7

9-5 weekday 1 or 2 depending on clinic

2 or 3 depending

on number of midwives

Oswestry MLU Midwives WSA Other

Monday & Thursdays 1 0 USS clinic on Fridays (WSA -1)

Scanning Safe Staffing Levels

RSH Midwives WSA Other

Weekday 4 0 WSA 3/7

Weekend 1 0

PRH Midwives WSA Other

Weekday 2 0 WSA 3/7

Weekend 1 0


Midwifery Community Teams Safe Staffing Levels

Community Team

Weekday Cover

Weekend Cover

Night Cover

Additional for clinic cover

RSH 5/7 +/- TIM Midwives

3/4

Oswestry 1 1

Ludlow 1 0.27 Returns to unit

following community visits

Extra Midwife on Monday

Bridgnorth 1 1 Extra Midwife on Tuesday Wednesday and Thursday

Wrekin 8/9 4 Depends on number of antenatal clinics on the day (some days have 9 community antenatal clinics)

Whitchurch 1 1 1 extra midwife 3 days a week

Market Drayton 1 1 1 extra midwife 3 days a week

WSA Community Teams Safe Staffing Levels

Community Team

Weekday Cover Weekend Cover

Night Cover

RSH 1 0 0

Oswestry 0 0 0

Ludlow 1 on a Monday 0 0

Bridgnorth 0 0 0

Wrekin 1/2 0 0

Whitchurch 1 (3 days a

week)

0 0

Market Drayton 1 (3 days a

week)

0 0


Appendix 4

Maternity Escalation Alert Form Date: Time: (to be completed by lead midwife/ward manager/labour ward co-ordinator/on call manager)

Area Initiating Escalation: Reason: Name of Staff Member:

Ward/Area No of Beds

No of women

No of beds

available

Normal staffing

levels met (please circle)

Number of

Midwives on call

Identified deficit & reason

Current issues /red flags

RED

AMBER

GREEN

Antenatal Ward (Bereavement Suite)

18 (1)

Y / N

Consultant Delivery Suite (Theatres)

13 (2)

Y / N

Consultant Postnatal Ward 23 Y / N

RSH MLU/Community/ DAU (labour rooms) (overflow PN beds)

10 (3) (4)

Y / N

Wrekin MLU/Community /DAU (labour rooms)

13 (4)

Y / N

Oswestry MLU/Community (labour room)

6 (2)

Y / N

Bridgnorth MLU/ Community (birth rooms)

4 (2)

Y / N

Ludlow MLU/ Community (labour room)

7 (1)

Y / N

NNU 22 Y / N

Day Assessment Unit

Y / N

Market Drayton Y / N

Whitchurch Y / N


Pending Pressures based on risk assessment (including anticipated premature deliveries):

Actions Required:

Communication Name of person informed Time informed

1. Lead Midwife on duty informed yes / no

2. On Call Manager informed yes / no

3. Deputy Head of midwifery informed yes / no 4. Head of Midwifery Informed yes / no

Closure of beds/ward/department/ unit required: Yes / No (If yes complete closure form)

Print name and designation: Signature:


Appendix 5 Closure of Maternity Beds, Ward, Department or Unit

Actions taken prior to closure YES NO NA

Review off duty rotas for all areas

Contact available staff (clinical and non clinical)

Text alerts sent to staff

Review of elective work and further ward rounds

Liaise with consultant on call and cancellation of any non urgent activities

Assess overall skill mix of midwifery, nursing and support staff/obstetric cover

Contact antenatal clinic and peripheral units to ascertain staff available for cover

Consider cancellation of study leave/ Annual Leave/non-essential leave (Supervision, Unison)

Communication List

Facility affected: Name of Manager authorising closure:

Date of closure: Time of closure:

Reason(s) for closure:

Informed? (yes/no) How?

Person informed By whom Action/comments

Unit staff informed

Other areas

W&C Management (daytime)

W&C On-call Manager (out of hours)

Deputy Head of Midwifery

Head of Midwifery/Care Group Director

Care Group Medical Director

Trust Executive

Other neighbouring units.

Clinical Site Manager (bleep 886)

Consultants on-call

West Midlands Ambulance Control(01384 215511) (01743 356331)

Powys Ambulance Control Centre (01633 626096)


Hospital Switchboard. PRH, RSH & unit affected.

Trust Communication Team

Supervisor Of Midwives on call.

CEO (Information only via Deputy HOM or HOM)

CCG (Information only via Deputy HOM or HOM)

Other People informed

Signature:

Designation

Date:

Datix Number

Patients affected during unit closure

Name and Unit number

Date and time of transfer

Site transferred to

Clinical over view Information to Patient/Family.


Actions Taken During closure

Date /Time What was done

By who

Include details of any complaints expressed or media coverage at the time of closure:


Appendix 6- Re-opening of a Maternity Unit - Communication List Name of Unit for re-opening:

Date of Re-opening: Time of re-opening:

Name of Manager authorising re-opening:

Reasons for closure:

Informed Yes / No

Person Informed

By whom?

Unit Staff Informed

Other Areas

W&C Management (Day time)

W&C On-call Manager (Out of Hours)

Deputy Head of Midwifery

Head of Midwifery

Care Group Medical Director

Supervisor of Midwives on call

Other Neighbouring / Regional Units

Clinical Site Manager (Bleep 886)

Consultants on call

West Midlands Ambulance Control (01384 215511) (01743 356331)

Powys Ambulance Control (01633 626096)

Switchboard RSH, PRH & affected Unit

Trust Communication Team

CEO (Information only via Deputy HOM or HOM)

CCG (Information only via Deputy HOM or HOM)

Other People Informed

Confirmed length of closure:

Signature:


Appendix 7

Princess Royal Hospital Grainger Drive TF1 6TF 01952 641222 ext 5995 Date Dear

I would like to apologise that you had to be referred to another Maternity Unit on (insert date) owing to the temporary closure of the Maternity Unit at (insert which hospital). As I believed you were informed at the time, this was due to (insert reason/s here)

Please be assured that the health and safety of both your baby and yourself was our prime concern when the decision to refer you to another hospital was made. A decision to close the Maternity Unit is always made as a last resort, but we understand how stressful this late change must have been for you.

We would like to take his opportunity to offer you further explanation if you feel you should need it. This can be done in a number of ways, i.e. in a meeting or by telephone. If you would like to take up this opportunity, please do not hesitate to contact my PA, Rachel Hanmer, on the above telephone number.

Yours sincerely

Mrs Cathy Smith Head of Midwifery


Appendix 8a Acuity Tool- All Maternity Areas

GREEN AMBER RED RED +

Level 1 Maternity Units Fully Operational No major issues

Level 2 Maternity Units Operational However experiencing some

pressures

Level 3 Maternity Services under extreme

pressure Business continuity threatened

Suspension of Consultant Unit Services

Staffing levels normal Short to medium term staff shortages affecting the Units ability to provide

specific services

Instigation of contingency plans for yellow alert has failed to resolve capacity

issues

Instigation of contingency plans for red alert has failed to resolve

capacity issues within the Consultant Unit

Medical staffing levels normal

Staffing shortfall identified

All beds in Maternity Unit are full including those utilised for low risk women on Bay C on AN ward and

following further Consultant Ward rounds

Service wide infection

Elective surgery lists proceeding as scheduled.

No significant delays.

The level of bed occupancy has reached crisis point within one or

more Units

Unresolved several short, medium and long term staff shortages impacting on safe service of either midwifery, nursing,

support or medical staff

Consultant Unit service wide equipment failure or major incident

Sufficient capacity to carry out emergency caesarean sections

Level of activity actual and anticipated is beyond the bed capacity available

Suspension/diversion of elective caesarean section service

Delivery beds available Limited capacity in antenatal and postnatal wards.

Additional capacity created in Bay E – MLU for low risk women

Suspension/diversion of induction of labour service

Postnatal ward activity normal levels

Potential closure of peripheral Units to address staffing issues

Suspension of one MLU

Capacity available on antenatal and or postnatal wards

Potential postponement of elective caesarean sections and induction of

labour

Major incident within Maternity Services or within the Trust affecting business

continuity

Potential diversion of clients to peripheral units

Neonatal Unit Escalation Level RED + with options for resolution

Neonatal Unit Escalation Level RED+ with no resolution

Neonatal Unit Escalation Level RED resulting in transfer of neonates <34

weeks gestation

Infection or equipment failure Isolate to one area/Unit


Appendix 8b Acuity Tool- Delivery Suite

5 Green = Normal Care on Delivery Suite 3 Amber = Need to consider escalation and potential staff who could be brought in 1 Red = Escalate to ward manager/Lead Midwife or Manager on call.

Ward Acuity/Activity Log- Delivery Suite

GREEN AMBER RED

Level 1 Delivery Suite

Fully Operational No major issues

Level 2 Delivery Suite Operational

However experiencing some pressures

Level 3 Delivery suite under extreme pressure

Business continuity threatened

NNU has capacity for admissions, no requirement for in-utero transfers out.

NNU limited capacity. There maybe the requirement for in-utero transfer out to

regional units

NNU has no capacity. In-utero transfer pending

All women in labour receiving one to one care.

Midwives case load more than one women in labour but no safety issues

More women than midwives can care for safely

The co-ordinator is super numerary Co-ordinator taking admissions of non- labouring/ early labouring women but still

able to safely manage the ward

Co-ordinator is caring for a woman and unable to co-ordinate delivery suite safely.

Day assessment able to take all admissions

Day assessment capacity limited for next 4 hours, so emergency cases will attend delivery suite.

No day assessment appointments available for the rest of the shift.

Admissions likely.

Women awaiting induction of labour likely to be transferred within 4-6 hours

Women awaiting IOL unlikely to be transferred in the next 4-6 hours

Women waiting more than 8 hours to be transferred to the delivery suite to continue

IOL process

Rooms available for admissions Only 1 room available on delivery suite No available delivery rooms

Delivery suite fully staffed to template Delivery suite midwifery staff reduced by 1. i.e. sickness

Midwifery staffing reduced by 2 members of staff

No LSCS outside of elective list Cat 3 LSCS, delivery staff providing some support.

Emergency LSCS requires more staff than available.

RED FLAGS 1) Delay in suturing more than 30 minutes 2) Delay in category 1 caesarean section


TO BE COMPLETED AT EACH HAND OVER OR AT TIMES OF HIGH ACTIVITY

Date Time Escalation Level Red Flags

Comments

Appendix 8c Acuity Tool- Midwife Led Unit

GREEN AMBER RED

Level 1 Maternity Units

Level 2 Maternity Units Operational

Level 3 Maternity Services under extreme pressure


Fully Operational No major issues

However experiencing some pressures Business continuity threatened

Staffing levels normal Short to medium staff shortages affecting the Units ability to provide specific services (e.g. antenatal appointments and home births)

Infection resulting in advice to close

Delivery bed available On-call midwife required to assist on MLU or another unit (excluding 2nd MW for delivery, Pethidine administration or home birth)

Major security/incident or equipment failure

Level of bed occupancy has reached capacity Postnatal ward activity normal

Midwife not able to provide continuous one-to-one care in labour but no safety issues

Instigation of contingency plans has failed to avert temporary suspension of intrapartum

services

Capacity to undertake normal community and unit activity

Antenatal and postnatal activity diverted or delayed/unable to receive transfers from the

consultant unit.

All beds in the Unit are full including labour beds

On-call cover available Women requiring early discharge due to high activity on the unit.

Diversion of all admissions including labour ward admissions to alternative MLU/ CU

Delayed acceptance of postnatal transfers from consultant unit

Unable to offer home birth service

Additional staffing requested (from ‘off duty’ or other units) or Ward manger required to work

clinically due to high activity.

More women in labour than midwives can care for safely

RED FLAGS 1)Delay in suturing more than 60 minutes 2) Delay in Triage more than 30 minutes

5 Green = Normal Care on MLU 2 Amber = Need to consider escalation and potential staff who could be brought in 1 Red = Escalate to ward manager/Lead Midwife or Manager on call.

Ward Acuity/Activity Log- MLU



Date Time Escalation Level Red Flags

Comments


Appendix 8d

Acuity Tool- Antenatal Ward

Green Amber Red

Level 1 Antenatal Ward Fully Operational

No issues

Level 2 Antenatal Ward Operational Experiencing some pressures

Level 3 Antenatal ward under extreme pressure


Staffing levels normal Staffing levels reduced, no safety issues identified

Staffing levels reduced, safety issues identified

Beds available for admissions In sufficient beds available to facilitate flow through the consultant unit.

No beds available for emergency admissions.

Acuity: No concerns , no one-one care required

Acuity: Bereavement or high risk woman requiring one-one care/ monitoring/elevated

MEWS

Acuity: More than one High risk woman/ bereavement requiring one-one care.

Open for out of county in-utero transfers in Case by case discussion with delivery suite coordinator and consultant obstetrician.

Closed to transfers in.

RED FLAG- 1) Delay of 2 hours or more between admission for induction and beginning of process

Green = Normal service on Antenatal Ward 2 Amber = Need to inform Ward Manager/Delivery Suite Co-ordinator 1 Red = Activate Escalation Policy


Ward Acuity/Activity Log- Antenatal Ward


Date Time Escalation Level

Red Flags

No of IOL in progress

No of admissions today

Comments


Appendix 8e Acuity Tool- Postnatal Ward

Green Amber Red

Level 1 Postnatal Ward Fully Operational

No issues

Level 2 Postnatal Ward Operational Experiencing some pressures

Level 3 Postnatal ward under extreme pressure


Staffing levels normal Staffing levels reduced due to redeployment to other areas/ transfers out of area or sickness

Staffing levels reduced due to redeployment to other areas or sickness.

Beds available for admissions In sufficient beds available to facilitate flow through the consultant unit.

No beds available.

Acuity: No concerns , no one-one care required

Acuity: High risk woman requiring one-one care/ monitoring. Unable to perform required frequency of observations required for

Mother/baby or both. Potential Patient safety compromise.

Acuity: More than one High risk woman requiring one-one care/monitoring. Unable to perform required frequency of observations required for

Mother and baby or both. Patient safety compromised.

Green = Normal service on Postnatal Ward 2 Amber = Need to inform Ward Manager/Delivery Suite Co-ordinator 1 Red = Activate Escalation Policy

Ward Acuity/Activity Log- Postnatal ward


TO BE COMPLETED AT EACH HAND OVER OR AT TIMES OF HIGH ACTIVITY Date Time Escalation

Level No of

patients on IV ABX

No of babies having

NEWS/TC observation

s

No of readmissions today

Comments


Appendix 9 Hospital Contact Numbers

hospitals to inform in the event of a unit closure

Alder Hey Hospital 8092

Birmingham Children’s Hospital 8174

Birmingham Women’s Hospital 8172

Birmingham Heartlands Hospital

8178

City Hospital (Birmingham) 8177

Sandwell and West Birmingham Hospital

0121 507 4703

Wolverhampton New Cross Hospital

8123 �

County Hospital Stoke 8307 �

Stafford General Hospital 8307 �

University Hospital North Staffordshire

8133

Wrexham Maelor Hospital 01978 725020

�

The County Hospital, Wye Valley NHS Trust (Hereford)

01432 355 444

�

Powys Midwives �

escalation policy - maternity - networks

Documents