ED Validation reassessment in BrisDoc IUC CAS

Introduction

The purpose of this SOP is to explain the process in which SevernSide will deliver ED/999 Validation.  SevernSide’s ED/999 validation work will supplement that carried out by Practice Plus Group for SevernSide IUC.

Objectives of the procedure

Background:

In Summer 2020 as part of the country’s response to the Covid19 pandemic, the Government launched the 111 First programme.  One of the key aims of the programme is to encourage patients to call NHS 111 First before attending local emergency departments.

To support our local healthcare system response SevernSide IUC’s target for Cat 3/4 999 Validation and ED Validation is 80%.

PPG validation process:

After a patient calls NHS111 a non-clinical Health Advisor (HA) from Practice Plus Group (PPG) assesses the patient using NHS Pathways. Where the recommended pathway is either a ‘Cat 3/4 ambulance’ or attend an ‘Emergency Treatment Centre’ the case, where capacity allows, is passed to a Clinical Advisor (CA) for ‘validation’.  Up to 80% of these are being “validated” within PPG at Nicholson house to seek alternative outcomes, by paramedics and ANP’s using NHS pathways assessment.

SevernSide clinicians will be supporting the current PPG process (described above) with validation.

Aims:

1. To achieve the SevernSide contractual obligation to deliver “non pathways” validation
2. To assist SevernSide’s aim to reliably achieve and sustain the 80% ED validation target
3. To deliver the right care, in the right place, the first time, for this cohort
4. Increase SevernSide’s capacity for complex clinical risk management
5. To provide a responsive and flexible assessment platform to respond at periods of system escalation
6. To deliver good patient experience and safe care
7. Provide an alternative type of consultation for colleagues interested in hospital avoidance.

The Standard Operating Procedure

Validation process

The SevernSide CAS will provide an additional layer of “non-pathways validation”, by clinicians within the CAS, with access to video consulting/ EPS/ EMIS, DOS for onward referrals.

The operational management of this will be led by the Shift Manager, with the support of the call handlers and W&CC team.

Validation of 999 cases should take priority over ED cases. The priority order of validation is:

1. 999 cases (streamed to Adastra via PPG)
2. 999 online cases (streamed to Adastra via PPG)
3. ETC (ED) cases (managed via the DoS)
4. ETC (ED) online cases (streamed to Adastra via PPG)

• Requesting 999 cases, and 999 online cases, is done manually. At the start of each shift the operational lead will phone the PPG lead to agree that we are “open” to receive cases. The number for the Real Time Team is – 0300 130 3007, select option one. When the evening Shift Manager takes over leadership, they should also make contact to introduce themselves. Alternatively, this can be done via email from the brisdoc.oneoneone email account
• ED cases are received automatically, through us being “open” on the DoS. The Shift Manager should check the DoS to ensure it is set correctly for the times we can receive ED validation cases
• If with both 999 and ED flow open, we have additional capacity we can discuss requesting online ETC cases. These cases will be streamed over in the same way as the 999 cases
• We should communicate with PPG as appropriate, either by phone (info above) or email (RealTimeEscalations@practiceplusgroup.com) throughout the shift. Please email from the brisdoc.oneoneone email account. This includes if we need pause 999 cases
• Operational and clinical colleagues should keep in close contact when making decisions around capacity and if we need to pause accepting new cases at any time. The flow of cases must be monitored and queried with PPG if we are not receiving the expected cases. If needing to pause cases this should be done in the reverse order to the way they were switched on, e.g.
  • ETC online cases switched off first
  • ED cases via the DoS switched off second
  • 999 online cases
  • 999 the last group to be switched off

 

• At the close of the shift, a call should be made to PPG to confirm that no more cases can be accepted.

 

Mental Health 999/ED case streaming

At times when the AWP mental health team are active and have capacity, we may agree with them to accept mental health ED/999 streaming cases.

When System CAS validation is active, we can identify 999/ED cases appropriate for the mental health team on Adastra and then add the mental health tag to make them visible in the mental health queue. This role sits with the shift manager.

At times where System CAS validation is closed but AWP have capacity, we need to contact PPG Realtime team and request mental health 999 cases, and mental health ED cases if still capacity, are streamed across. This is a manual PPG process and not managed through the DoS. This is the only time we should be putting restrictions on cases we are asking for.

These cases will fit the following criteria:

• ED/999 cases
• Patients with a primary mental health need (this can include physical health comorbidities)

 

Cases will land in the advice queue as a ‘clinician advice’ case type and mental health case tag so will also be visible in the Mental Health queue. Cases will need to be edited so the case type matches either 999 or ED as relevant. The Shift Manager should do this when they land.

At times a streamed case may have a mental health tag but not appear to be related to a mental health need. In cases such as this it should be queried with PPG as it may have the Mental Health tag attached incorrectly. If that is the case, please remove the tag.

Should you need to turn off this streaming, you will need to contact the real-time team.

Case Types

Cases will be ‘streamed’ into the SevernSide CAS when there is capacity to ensure we are able to meet the required call back timeframe for these patients. Once cases have been ‘pushed’ to the CAS from PPG or DoS they will land in the IUC Advice queue with a case type of ‘ED/999 Validation’ and the appropriate call back timeframe.

 

There are three types of ED DX codes:

• DX334 – 1 hour timeframe
• DX337 – 4-hour timeframe
• DX338 – 12-hour timeframe

 

Streaming DX334 – 1 hour

For cases that have a DX code of DX334 we should aim to contact the patient within 30 minutes of the end of the HA assessment. PPG should only stream these cases where they have been waiting less than 15 minutes in their CA queue.  The cases will then land in our IUC Advice queue with a 15 min priority.

 

You may request a case waiting longer than 15mins in the PPG queue where you have a clinician available and waiting to pick a case up.

Streaming DX337 (4 hours) and DX338 (12 hour)

DX337 and DX338 have longer timeframes of 4 and 12 hours, respectively.  This means they could have waited longer in the PPG queue before they are streamed.

 

DX337 (4 hours) should be streamed within 30 minutes of the HA assessment.  These cases will land in the IUC Advice queue with a 30-minute priority.

 

DX338 (12 hours) should be streamed within 60 minutes of the HA assessment.  These cases will land in the IUC Advice queue with a 30-minute priority.

 

Please note, at times of escalation for the system, we may accept cases which have been held at PPG for longer. Please discuss this with one of the Team Managers, or on call manager as appropriate.

 

 

Role responsibilities

Operational Lead: The operational lead will be responsible for liaising with the PPG Real Time Team and managing resource/capacity. This should be monitored closely to ensure capacity will allow us to respond to patients within the agreed timeframe (see above). Remember the timeframe includes any wait time in the PPG queue. It is also the responsibility of the operational lead to; monitor the queue for breaches; and monitor the queue for incorrect cases received, i.e. out of area patients. They should manage safety calling of appropriate patients too.  More details on these are below.

 

GP, ANP and ECP: Validation/assessment will be carried out by a senior clinician (GP/ ANP/ ECP), who has received appropriate training in PACCs, and who is experienced and has access to:

• Adastra
• Emis clinical records
• Connecting care
• Accurx for video
• EPS for prescribing
• SCM

PACCs

Paccs is the referral system to aid clinicians to refer patients onward to appropriate services depending upon the clinical scenario. All clinicians will have done training on PACCs via DLS training website before the pilot commences

 

PACCs will be used for onward referral to:

• UTC or MIU services across BNSSG
• Pharmacy

 

All other external referrals will be via SevernSide’s usual process including;

• Ambulances (via 999 or ambulance transfer 0300 369 0097)
• ED’s within BNSSG. Advise patient to attend
• Usual GP, informing the patient to call their own GP. (Adastra record will be sent via PEM as per usual)
• Referral into SevernSide F2F, via “admin function” and senior clinical review

Breaching the wait time

If for any reason a case breaches the call back time described above, or is likely to ie. turns red, we will need to contact the patient immediately. The operational lead or call handler should call the patient/representative and introduce yourself as a non-clinical member of the team. Check if anything has changed or worsened using our standard safety calling script. If anything has changed or worsened you should highlight this to a clinician using the priority tagging process via the Shift Manager. The full safety calling process can be found in the call handler handbook.

 

Failed contacts

If we are unable to contact a patient we must:

• Make another three attempts operationally immediately, and then five minutes apart
• If at that point there is still no contact we should follow the actions in our Failed Contact SoP
  • Check numbers with NHS111
  • Contact the ambulance service and EDs
  • Detail all attempts as comfort notes on the case
  • Ask for clinical review if unable to contact or locate the patient.

999 referrals

During a consultation, the clinician may find they need to refer the patient to 999 because an emergency response is required, either police or ambulance.  Ambulance can be done through PACCS, or by dialing 999 if that does not work.

Closure of validation lines at PPG

In times of escalation, PPG may close the 999 and/or ED validation lines to manage risk. If you are advised this is the case, we should ask for the BNSSG ED validation line to be opened whilst our 999-validation service is active. ED validation should not be affected as long as we remain open on the DoS.

Supporting information

Ambulance response

If an ambulance response is required, the clinician should tell the patient that they are arranging for an ambulance transfer. The clinician must advise the patient that if their medical condition worsens or deteriorates, they must call 999.

For full details on arranging an ambulance please refer to relevant the Clinical Toolkit ‘Arranging an ambulance for your patient’ page.

The following gives some guidance on deciding the required category of ambulance response to most safely respond to the patients needs:

 

 

 

Failed contacts

If you have a failed contact, the operational lead should follow the usual process (refer to the Call Handler Handbook) and, in every case, alert a clinician.

Failed call backs for ED validation cases are more of a concern than for normal cases so a clinician should be advised every time to assess the risk.

If a case needs to be closed following multiple failed call backs, a clinician will perform this task is they deem it safe to do so.

Clinicians should refer to the failed contact SOP on the Clinical Toolkit if further information is required.

Incidents/learning

All incidents should be reported via the incident reporting portal and investigated in line with BrisDoc’s incident process.

IT issues

All technical issues should be reported via the IT reporting portal.

Monitoring

Volumes will be reported through the daily SitRep and performance dashboards.

Related Documents

SOPS:

Standard Operating Procedure for failed contact with cases within the clinical advice queue

Call Handler Handbook

Arranging ambulance transfer for your patient

 

 

Change Register

Date	Version	Author	Comments
27/09/2021	1.9		Post pilot update
16/09/2021	1.10
19/01/2022	1.11	N Ryan	Removal of recording dashboard
17/05/2022	1.12	N Ryan	Reprioritising 999/ED cases
20/12/2022	1.13	N. Ryan	ETC online cases
27/02/2023	1.14	N.Ryan	Addition of Mental Health validation
08/09/2023	1.15	N.Ryan	Update to safety calling process
19/09/2023	2.0	N.Ryan	Full review