Source: Deputy Chief Nurse Issue Date: January 2017 Page 1 of 13 Status: Approved Review Date: January 2019

Trust Policy and Procedure Document Ref. No: PP(17) 342

Staffing Escalation for Nursing - Inpatient areas

For use in: All areas of the Trust

For use by: All Trust staff

For use for: To advise and inform hospital staff of the Trusts policy regarding safe staffing levels on inpatient adult wards.

Document owner: Deputy Chief Nurse

Status: Approved

Contents

Page

Section 1 Introduction

1.1 Policy Statement and Rationale 2

Section 2 Policy and Procedure

2.1 Nursing establishment and skill mix 3

2.2 Managing staffing requirements at ward level 3

2.3 Flow Chart for the daily management of nurse staffing in inpatient

areas

4

2.4 Escalation levels and trigger points 5

2.5 Mitigation cascade 6

2.6 Reporting 6

Section 3 Duties and Responsibilities

3.1 Duties and Responsibilities 7

Section 4 Nursing Red Flags

4.1 Definition 7

4.2 Nursing Red Flag escalation process 9

References 10

Source: Deputy Chief Nurse Issue Date: January 2017 Page 2 of 13 Status: Approved Review Date: January 2019

SECTION 1 INTRODUCTION

1.1 Policy Statement and Rationale

West Suffolk NHS Foundation Trust is committed to be the healthcare provider of first choice by providing excellent quality, safe, effective and caring services. The impact of nursing, midwifery and care staffing capacity and capability, on the quality of care experienced by patients and on patient outcomes has been well documented, with multiple studies linking low staffing levels to poorer patient outcomes (DH, Hard Truths 2014).

This policy provides guidance on a shift by shift, day by day approach to the management of staffing levels in inpatient areas.

The purpose of this document is to:

Provide guidance to staff in reaching decisions regarding the organisation of staffing on any inpatient area when the number of staff falls below planned levels on a shift by shift basis.

Ensure that staffing decisions are based on the acuity/ dependency of patients across the Trust.

Minimise clinical risk associated with reduced staffing levels.

Indicate possible actions available to staff, providing a clear process for mitigation of risks and determines a risk rating following mitigation.

Explain the roles and responsibilities of team members in managing staffing issues.

Improve utilisation of existing staff and reduce reliance on temporary staff.

Enable accurate and consistent reporting.

Provide assurance to the Board that in-patient staffing and other clinical risk is managed appropriately on a shift by shift basis.

Source: Deputy Chief Nurse Issue Date: January 2017 Page 3 of 13 Status: Approved Review Date: January 2019

SECTION 2 POLICY AND PROCEDURE

2.1 Nursing establishment and skill mix

The Executive Chief Nurse holds executive responsibility for skill mix and staffing levels for wards and is required to take to open Board twice yearly a review of establishments which needs to be approved by the Trust Board.

This establishment is determined by utilising an evidence based tool and leads to planned day and night time shift staffing numbers (both registered and non-registered staff).

Each clinical ward should have a level of staff with specific skills and competencies on each shift, i.e. the ability to coordinate, IV skilled etc. as agreed with the Ward Manager /Matron.

In areas where workload is known to vary according to the day of the week planned staff numbers for day and night shifts and skill mix should reflect this.

Staff will work a combination of long and short shifts or long days in order to meet the clinical requirement. Variations to these shifts may be worked but must be with the agreement of the Ward Manager/Matron and a record kept (e-rostering).

2.2 Managing staffing requirements at ward level

The Ward Manager/Ward Coordinator are responsible for ensuring staffing levels are such that all patient care needs are met on a shift by shift basis and that any risks are escalated to their divisional bleep holder immediately.

Where there is a change from the usual plan required for a shift e.g. planned staffing not fully required due to reduction in patient admissions to ward area, this should be identified to the divisional bleep holder so that staff can be redeployed if needed.

One to one close observation (special) should be requested to and recorded by the Divisional Bleep holder.

The day and night shift planned and actual staffing levels should be clearly displayed

in every area.

To maintain safe staffing levels it is expected that nursing staff will move to work on

other wards which may be outside of their Division.

To ensure patient safety, short notice sickness will be covered initially by the

supervisory Ward Manager when they are on duty, they will work clinically to fill

essential gaps until other arrangements can be made.

When agency nurses are required they will be allocated to a ward where WSH staff

are working. No shifts will be staffed by agency nurses alone.

Newmarket and Glastonbury have flowcharts to escalate staffing issues see

appendix 1.

Source: Deputy Chief Nurse Issue Date: January 2017 Page 4 of 13 Status: Approved Review Date: January 2019

2.3 Flow chart for the daily management of safer staffing and escalation

08:00 Divisional bleep holder collects ward staffing numbers for the late and night shift

for that day and the early shift, where appropriate, the following day and makes decisions to move staff as required within Division and contacts WSP (bank) to cover

any gaps.

ACTION POINT: Any patient safety risks identified that cannot be mitigated by bleep holder are discussed with Matron or Deputy Chief Nurse

By 09:00 Divisional bleep holder contacts WSP to update any staffing requests with

them. Ward staffing not meeting core levels are reviewed and actions taken according to escalation levels (Escalation support tool 2.4).

ACTION POINT: 12:00hrs Bed meeting is attended by all Divisional bleep holders

358 bleep holder updates electronic staffing situation report that informs the Capacity Report RAG rating.

When ward staffing is not meeting core, levels are reviewed and actions taken according to escalation levels (in 2.4) by Divisional bleep holders.

By 15.00 Trust wide RAG on Capacity Report to be updated by 358 bleepholder

Action point: 15:00 Divisional bleep holders to develop a plan for staffing over the night shift and early shift for following day & communicate with the Patient Flow Team at 20:00 who have responsibility for overnight staffing escalation.

Source: Deputy Chief Nurse Issue Date: January 2017 Page 5 of 13 Status: Approved Review Date: January 2019

2.4 Trust Nurse Staffing Escalation support tool Level One or more of following:

Decision made by Action

Level 1 GREEN

Safe staffing levels achieved across most wards to meet activity and patient acuity /dependency requirements Nursing Red Flags resolved at ward level 90% of wards (18 - 20) at planned staffing levels

Ward (supported by Divisional bleep holder)

Monitor and inform Matrons of areas not at plan.

Level 2 AMBER

Staffing levels fall below template and some shifts are not covered for next 24 hours Rising staffing pressures with gaps in the roster that cannot be mitigated for Gaps across one division area or widely spread across Trust Nursing Red Flags resolved at Divisional level 70% - 90% of wards (14 - 18) at planned staffing levels

Divisional bleep holders

Advise WSP of staff cover required.

Ward Manager & band 6s on management days to support delivery of care into ward numbers.

Staff moved within Division - risk is shared but manageable in line with patient acuity review

Regular review by Divisional bleep holder

Matrons all aware

Level 3 RED

Numerous gaps in staffing across more than one Division

High levels of activity requiring opening of escalation areas

All mitigation for Amber status taken and risk remains Nursing Red Flags not resolved at Divisional level

60% - 70% of wards (12 - 14) at planned staffing levels

Divisional bleep holders (supported by Senior Matrons)

Staff moved across Divisions

Use Health Roster to review time owing to the Trust from members of staff and utilise these where possible

Deputy Chief Nurse fully aware of the situation and advise on redeployment

Level 4 BLACK

Numerous staffing gaps. High levels of activity requiring opening of escalation areas Mitigation actions taken but risks remain high 60% or less of wards (<12) at planned staffing levels Black escalation status can only be declared by Executive Chief Nurse or deputy in the absence of.

In hours:

Executive Chief Nurse

Out of hours:

Silver on call

Patient Flow Team

Escalate to Gold if required

Notify: (In hours) Executive Chief Nurse (Out of hours) Silver on call

Matrons and Deputy Chief Nurse are deployed to ward areas

Deploy available RNs from non-ward based roles to wards

Cancel non-mandatory training sessions

Additional agency nurses will be considered at this point if the above mitigation does not reduce the level

All mitigation actions reviewed.

Executive Chief Nurse to consider number of beds open

Source: Deputy Chief Nurse Issue Date: January 2017 Page 6 of 13 Status: Approved Review Date: January 2019

2.5 Mitigation Appropriate mitigation where there are individual unplanned staffing gaps should be taken in the following order:

Mitigation action Responsible person for this decision

WSP used if within staffing budget Ward Manager Matron 888 OOH

Move own staff within Division Divisional bleep holder Matron 888 OOH

Review staff not in ward numbers (supervisory shifts – not including student nurses), Ward Manager into numbers.

Divisional bleep holder Matrons 888 OOH

Move staff across the Divisions Deputy Chief Nurse 888 OOH

Consider downgrading registered nurse vacant shift to nursing assistant if safe to do so

Deputy Chief Nurse 888 OOH

Utilise Assistant Practitioners where available to fill RN gaps moving across division where appropriate

Deputy Chief Nurse 888 OOH

Deploy available non ward based registered nurses to ward areas

Deputy Chief Nurse Service Managers 888 OOH

Temporary staffing from usual/ Agency staff to be booked

General Managers Executive Chief Nurse

2.6 Reporting

Monthly data on staffing fill rates to plan for nurses, midwives and care staff has been presented on NHS Choices website from June 2014 onwards. Patients and the public will be able to see how hospitals are performing on this indicator in an easy and accessible way. The data will sit alongside a range of other safety indicators. This data will be submitted via UNIFY on the 10th of each month with the preceding month’s data. The Trust Board will receive ward level information on actual versus planned nurse staffing

and triggers of nurse red flags every month and every six months a detailed review of staffing using evidence based tools will be reported to the Trust Board. The Trust will also publish their actual versus planned staff fill rates on a ward by ward basis on the Trust website.

Source: Deputy Chief Nurse Issue Date: January 2017 Page 7 of 13 Status: Approved Review Date: January 2019

SECTION 3 DUTIES AND RESPONSIBILITIES

The following roles listed below each have a responsibility in managing staffing levels and plans on a daily basis, and escalating issues in a timely fashion

Role Responsibility

Divisional Bleep holder

A Ward Sister who holds the bleep for their Division. Responsible for collating staffing numbers and nurse sensitive issues (patients requiring 1:1, high acuity etc.) including responding to reports of Nursing Red Flags. They move staff within their Division to mitigate any risk. Any outstanding risks they are unable to manage within their Division are escalated to the Matron and Service Manager.

Ward Sister/Charge Nurse

Responsible for rostering effectively and minimising planned staffing gaps including responding to reports of Nursing Red Flags.

Clinical site practitioner 888

Responsible for holding the Divisional bleep’s OOH –following staffing plan identified by the Divisional Bleep holder/matron and uses clinical judgement to manage any further issues that arise, including responding to reports of Nursing Red Flags out of hours. To assess staffing plan for night on Friday’s for weekends.

Senior Manager on call Silver

Responsible for supporting the Clinical Site practitioner regarding Trust staffing overnight, and also when patient flow is compromised. Responsible for determining additional actions when staffing at Black and escalating risks to Exec on call. Attend 3pm bed meetings. To assess staffing plan for night on Fridays for weekends.

Deputy Chief Nurse

Review and lead on actions being taken when staffing is at Red/Black status within their Divisions. Attend 3pm bed meetings where possible. To assess staffing plan for night on Fridays for weekends.

Executive Chief Nurse

Responsible for the agreement of use of agency staff. Responsible for determining additional actions when staffing at Black (in hours) and advising others as appropriate. To authorise the continuation of the number of beds open when staffing issues cannot be rectified and where patient care and safety is compromised.

Source: Deputy Chief Nurse Issue Date: January 2017 Page 8 of 13 Status: Approved Review Date: January 2019

SECTION 4 NURSING RED FLAGS 4.1 Definition

Nursing Red Flags (NICE, 2014) are identified as:

Unplanned omission in providing patient medications.

Delay of more than 30 minutes in providing pain relief.

Patient vital signs not assessed or recorded as outlined in the care plan.

Delay or omission of regular checks on patients to ensure that their fundamental

care needs are met as outlined in the care plan, i.e. intentional rounding.

A shortfall of more than 8 hours or 25% (whichever is reached first) of registered

nurse time available compared with the actual requirement for the shift.

Less than two Registered Nurses present on a ward during any shift.

Nursing Red Flags will be recorded on e-rostering by nurse in charge or Divisional bleep holder. If unable to record on e-rostering at the time a message must be left for the Ward Manger to enter this retrospectively. Actions to be taken regarding Red Flags are listed in section 4.2 Nursing Red Flag Escalation Process.

Source: Deputy Chief Nurse Issue Date: January 2017 Page 9 of 13 Status: Approved Review Date: January 2019

4.2 Nursing Red Flag Escalation Process

Yes No

Yes No

Red Flag resolved

Review Ward Based Resolution

Red Flag identified

Record Red flag on HealthRoster and inform Divisional Bleep

holder

Bleep holder to liaise with ward to provide support

Red Flag resolved

Ward senior nurse and bleep holder escalate in line with escalation support tool

Source: Deputy Chief Nurse Issue Date: January 2017 Page 10 of 13 Status: Approved Review Date: January 2019

Source: Deputy Chief Nurse Issue Date: January 2017 Page 11 of 13 Status: Approved Review Date: January 2019

References

NICE 2015 Safe Staffing and effiency – http://pathways.nice.org.uk/pathways/safe-staffing-for-nursing-in-adult-inpatient-wards-in-acute-hospitals Spilsbury et al 2011 Evaluation of the Development and Impact of Assistant Practitioners Supporting the Work of Ward-Based Registered Nurses n Acute NHS (Hospital) Trusts in England http://www.netscc.ac.uk/hsdr/files/project/SDO_FR_08-1619-159_V01.pdf p142

Version and Status Approved

Date Ratified 15 August 2016

Ratified by Trust Executive Group

Name of Originator / author, job title and Department

Tracey Oats, Deputy Chief Nurse, Nursing & Governance Directorate

Name of Responsible Committee Trust Executive Group

Issue Date January 2017

Review Date January 2019

Notes To be reviewed by TEG in December 2016

Source: Deputy Chief Nurse Issue Date: January 2017 Page 12 of 13 Status: Approved Review Date: January 2019

Appendix 1

Rosemary Ward, Newmarket Hospital Staffing – Guidance for 933 Bleep

Holder.

Rosemary Ward staffing at core

staffing levels: Early: 2:3, Late:

2:2, Night: 2:1 Yes

Update 933 template. No

further action required.

No.

Confirm level of staffing

deficit. Update staffing board

in Hospital Control Centre.

With support of Medical

Manager of the Day and Senior

Matron, identify WSFT staff

available to provide Rosemary

Ward with support.

(Liaise with Bleep Holder 888

during Out of Hour periods).

Update Rosemary Ward. Book

taxi, if required, to transport

member of WSFT to and from

Rosemary Ward.

Inform WSFT member of

staff of need to transfer to

Rosemary Ward.

Ask Nurse in Charge of WSFT

ward to ensure blue flag entered

on Healthroster, to reflect move

of team member to Rosemary

Ward.

07:00 – 08:00. 933 Bleepholder

to contact Nurse-in-Charge on

Rosemary Ward to confirm staffing

numbers (#6381).

Source: Deputy Chief Nurse Issue Date: January 2017 Page 13 of 13 Status: Approved Review Date: January 2019

King Suite, Glastonbury Court Staffing – Guidance for 933 Bleep

Holder.

Yes

King Suite, Glastonbury Court

staffing at core staffing levels:

Day: 3:3, Night: 2:2.

Update 933 template. No

further action required. No.

Confirm level of staffing

deficit. Update staffing board

in Hospital Control Centre.

With support of Medical

Manager of the Day and Senior

Matron, identify WSFT staff

available to provide King Suite,

Glastonbury Court with support.

(Liaise with Bleep Holder 888

during Out of Hour periods).

Update King Suite, Glastonbury

Court. Book taxi, if required, to

transport member of WSFT to and

from Glastonbury Court.

Inform WSFT member of

staff of need to transfer to

King Suite, Glastonbury

Court.

Ask Nurse in Charge of WSFT

ward to ensure blue flag entered

on Healthroster, to reflect move

of team member to Glastonbury

Court.

07:00 – 08:00. 933 Bleep Holder to

contact Nurse-in-Charge on King

Suite, Glastonbury Court, to confirm

staffing numbers (01284 706850).