Involving all clinicians:
Having clinical leads from across all areas of the organisation on the working group helped the team to ensure that progress was clinically led and understood across the whole hospital, including nursing staff. It helped to evoke a sense of shared responsibility and ensure there was a whole system response to avoid crowding in the ED. It was also crucial in developing contingency plans in the event that steps to avoid crowding are not successful, to ensure that patients are kept as safe as possible at all times. It is vital that clinicians from across the hospital were involved in those conversations to ensure in the event that the site did have to go to FCP, there is a clear understanding of where the clinical responsibility for individual patients lies. It therefore proved crucial to have strong clinical leadership and engagement from clinical leads across the whole organisation when developing escalation plans.
Testing local definitions of crowding:
Measures for crowding need to be agreed and tested at a local level. Having a Quality Improvement lead working alongside a clinical lead helped the team at Hairmyres to ensure there was a robust process to track and measure cycles of change whilst testing these measures, local definitions and trigger points. It helped us to refine our SOP for managing every patient every time and review how ED escalation steps fit into wider hospital escalation within the Barometer. Testing local definitions also helped challenge myths around crowding and put some robust triggers and definitions in place.
Who declares overcapacity?
The ED Capacity Management Guidance document advises that the decision to enact Full Capacity Protocol should only be made by the Chief Executive, Medical Director or formal deputy. In testing the guidance, NHS Lanarkshire are in agreement and believe this decision should be clinically led, however final authorisation should come from the Chief Executive.