Milton Keynes Hospital NHS Foundation Trust Maternity Escalation Operational Policy

©Milton Keynes Hospital NHS Foundation Trust Maternity Escalation Operational Policy This document is uncontrolled once printed. Please check on the Trust’s Intranet site for the most up to date version.

Maternity Escalation Operational Policy

[to be used in conjunction with the Maternity Escalation Unit Closure and Business Continuity Plans]

Document Issue Last Next Impact Author/Contact Person Version No. Date Review Review Assessed Accountable Director Jo Sturgess Lisa Beaumont OPS/GL/12 1 03/2010 09/2010 Yes Elizabeth Allen

Approved By: Obstetric and Gynaecology Divisional Healthcare Governance Board – 31/03/2010

For use in (clinical Maternity area) For use by (staff All Maternity Staff and Operations Team groups) For use for Staff (patients/staff/public) Document Owner: Maternity Document Status: Approved

Source: Maternity \ Operational Team Issue date: 03/2010 Document Status: Approved Page 1 of 19 Review date: 09/2010 Document ID: OPS\GL\12 Version No: 1 D:\Docs\2018-04-28\0d492ef8756d5435e62a7c18d2c93d9e.doc ©Milton Keynes Hospital NHS Foundation Trust Maternity Escalation Operational Policy

Document History Version Date Author Reason 1 1.4.2010 Jo Sturgess CQC Requirement Lisa Beaumont Elizabeth Allen

Consultation History Stakeholders Area of Date Date Comments Changes Made Name Expertise Sent Received All Obstetric and Consultants in March March 2010 Yes Yes Gynaecology Obstetrics 2010 Consultants Maternity March March 2010 Yes Yes Matrons 2010 Supervisors of March March 2010 Yes Yes Midwives 2010 Lead Midwives March March 2010 Yes Yes 2010 Risk Midwife March March 2010 Yes Yes 2010 Operational March March 2010 Yes Yes Team 2010 Chief Executive March March 2010 Yes Yes 2010 Lisa Beaumont General Manager March March 2010 Yes Yes 2010 Elizabeth Allen Head of Midwifery March March 2010 2010

Document History...... 2 Consultation History...... 2 1.0 Introduction...... 4 1.1 Purpose of the plan...... 4 1.2 Objectives...... 4 2.0 Scope of document...... 4 3.0 Roles and responsibilities...... 5 3.1 Routine Operational Team / DHM responsibilities...... 5 3.2 Routine Maternity Bleep Holder 1440 responsibilities...... 6 3.3 On-Call Roles and Responsibilities...... 7 3.3.1 Responsibilities of the Supervisor of Midwives (SOM)...... 7 3.3.2 Responsibilities of the Lead Midwife on Call (LMOC)...... 7 3.3.3 Manager on call responsibilities...... 8 3.3.4 Executive on Call Responsibilities...... 8 3.4 Maternity Escalation Chart...... 9 3.5 Maternity Escalation Plan Action Cards...... 10 3.5.1 Maternity Bleep Holder 1440...... 10 3.5.2 Duty Hospital Manager...... 13 4.0 Audit and monitoring Criteria...... 16 5.0 Statement of evidence/references...... 16 6.0 Equality Impact Assessment...... 16 7.0 Standards for Better Health...... 17 8.0 Implementation and dissemination of document...... 17 9.0 Overall responsibility for the document...... 17 10.0 Attachments...... 17 11.0 Other Associated Documents...... 17 Appendix A: Daily Maternity Log...... 18 Appendix B: Daily Maternity Report...... 19

1.0 Introduction

1.1 Purpose of the plan

The purpose of this document is to ensure that Milton Keynes Hospital Foundation Trust provides safe and effective care to all women being treated within its Maternity Services.

The Trust must ensure that all Level 1 women receive 1:1 care from a Registered Midwife; Level 1 is defined as:

 All women in established labour until delivery. Established labour is defined as > 4cm dilated with regular forceful contractions.

 All women with a high level of clinical need as defined by the shift co-ordinator.

All women on Labour Ward who do not fit in to the Level 1 category will be classified as Level 2 patients. These patients will receive care from a Registered Midwife appropriate to their clinical need.

This operational plan outlines the process to be followed to manage and monitor the level of risk associated with peaks in demand affecting the ability to deliver 1:1 care to Level 1 women.

Definition of 1:1 care

1:1 care is defined as one Registered Midwife allocated to one woman categorised at Level 1 dependency. Registered Midwives will remain with their allocated woman unless a plan of care agreed with that woman identifies intermittent care is appropriate.

1.2 Objectives

To provide safe care to women during established labour until delivery.

2.0 Scope of document

All ante-natal women on the Maternity Ward, Wards 9 and 10 must receive midwife supervised care.

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3.1 Routine Operational Team / DHM responsibilities

 Maintain regular contact with 1440 Maternity Bleep Holder – formally update operations team white board at 08.00, 13.00, 16.30, 20.00 & midnight with:

1. Number of women in established labour or clinical need requiring 1:1 midwife care (Level 1) 2. Number of women at (Level 2) 3. Number of midwives on duty in line with the following staffing plan:

Early Shift Late Shift Night Shift 07.00-14.30 13.30-21.00 21.00-07.30 Labour Ward 6 + MW Co-ord 6 + MW Co-ord 6 + MW Co-ord

Ward 9 3 3 3 Ward 10 2 2 2 ADAU 2 1 Antenatal Clinic 2 Monday to Thursday Community 2-3 per team 2 2 On Call On Call

4. Number of births between reporting times 5. Number of available post natal & ante-natal beds 6. Number of expected admissions & discharges

 Operations team lead and 1440 Maternity Bleep Holder will formally review all breaches of 1:1 care on a daily basis at 09.30 on Labour Ward using the maternity breach analysis reporting system. This will occur daily and the outcome of the breach analysis meeting will be reported to the Head of Midwifery of Women & Children’s Services for appropriate action and learning. Action / learning will be presented at the Directorate Clinical Improvement Group (CIG) and to Healthcare Governance Committee.

 DHM will take formal handover from the 1440 bleep holder at 16.30 daily Monday to Sunday on Labour Ward.

 DHM will visit Labour Ward a minimum of 2 times per shift 24/7, this is to be recorded on the DHM report sheet

 Monday – Friday daily report to agreed distribution list from Operations Lead by 10.00am (Appendix b)

3.2 Routine Maternity Bleep Holder 1440 responsibilities

 Responsible for ensuring staffing levels are checked on a shift by shift basis for the following 48hrs and taking appropriate action to fill any identified gaps in the rota.

 Maintain regular contact with DHM / Bleep 1222 with regards to concerns relating to staffing levels on Labour Ward and / or the maternity wards and potential breaches of 1:1 care for Level 1 patients.

 Recording the successful delivery of 1:1 care for Level 1 patients on a 4hrly basis including all actions taken to avoid breaches

 Daily at 09.30 review and analyse the root cause of any breaches of 1:1 care for Level 1 patients. RCA to be reported to the Head of Midwifery for Women and Children’s Services or Maternity Matron.

 Daily at 16.30 meet the out of hours DHM on Labour Ward for a formal update on the situation for Maternity with regards:

1. Number of women in established labour or clinical need requiring 1:1 midwife care (Level 1) 2. Number of women antenatal / post natal (level 2) 3. Number of midwives on duty in line with the following staffing plan:

Early Shift Late Shift Night Shift 07.00-14.30 13.30-21.00 21.00-07.30 Labour Ward 6 + MW Co-ord 6 + MW Co-ord 6 + MW Co-ord

Ward 9 3 3 3 Ward 10 2 2 2 ADAU 2 1 Antenatal Clinic 2 Monday to Thursday Community 2-3 per team 2 2 On Call On Call

4. Number of births between reporting times 5. Number of available post natal & ante-natal beds 6. Number of expected admissions & discharges

Source: Maternity \ Operational Team Issue date: 03/2010 Document Status: Approved Page 6 of 19 Review date: 09/2010 Document ID: OPS\GL\12 Version No: 1 D:\Docs\2018-04-28\0d492ef8756d5435e62a7c18d2c93d9e.doc ©Milton Keynes Hospital NHS Foundation Trust Maternity Escalation Operational Policy 3.3 On-Call Roles and Responsibilities

3.3.1 Responsibilities of the Supervisor of Midwives (SOM)

Midwives have access to a Supervisor of Midwives 24hrs per day to support them in providing safe and appropriate midwifery care.

Midwives should consider calling a Supervisor if he / she:-

 Has difficulty supporting women in their choices at home or in hospital  Requires support or advice when attending a woman in labour at home  Requires support or advice when a woman refuses to follow professional advice  Needs professional advice in any circumstances  Has been involved in a critical incident  Feels that the practice environment is unsafe  Has a personal problem / issues that may affect their practice

Incidents to be reported to a Supervisor of Midwives immediately:-  Maternal death  Intrapartum stillbirth  Possible professional midwifery misconduct The SOM will also support the DHM and Lead Midwife on call when the ability to provide 1:1 care is compromised and will initiate and facilitate escalation and closure of the unit if required.

Contact the Supervisor of Midwives via hospital switchboard who hold a copy of the rota

3.3.2 Responsibilities of the Lead Midwife on Call (LMOC)

The role of the Lead Midwife on call will be to provide additional advice support and guidance to Duty Hospital Manager and Supervisor of Midwives working in collaboration with Maternity Bleep Holder out of hours when first line capacity demand and resource issues in the unit have been exhausted.

Remit of Lead Midwife on Call  Attend daily (Mon-Fri) operations meeting at 16.30 on Labour Ward  Help support and guide decision making  Initiate and facilitate unit escalation and closure if required  Facilitate deployment of staff to meet urgent clinical needs prioritising one to one care in labour  Allow flexibility to keep overview of service requirements and address the non clinical needs of the situations.  Undertake In/Ex utero transfers  Only in extremis to take a labouring woman Source: Maternity \ Operational Team Issue date: 03/2010 Document Status: Approved Page 7 of 19 Review date: 09/2010 Document ID: OPS\GL\12 Version No: 1 D:\Docs\2018-04-28\0d492ef8756d5435e62a7c18d2c93d9e.doc ©Milton Keynes Hospital NHS Foundation Trust Maternity Escalation Operational Policy

Lead Midwife on call until 08.00 From 08.00 Maternity Bleep Holder and Maternity Matrons take over.

Contacting Lead Midwife on Call

Maternity bleepholder 1440 will inform the DHM and the LMOC can be contacted via Switchboard

3.3.3 Manager on call responsibilities

The responsibility of the Manager on Call is to support and advise the DHM with the implementation of actions to manage the identified areas of concern within Maternity Services.

Issues: Capacity, Staffing and SIs

To ensure that all of the actions described in the DHM / 1440 Maternity Bleep Holder responsibilities have be completed, offering support and assistance where necessary to alleviate the burden of administrative work enabling the DHM to continue to manage the hospital site.

In addition to this the MOC should:

 Maintain regular contact with the DHM to ensure the situation is being managed effectively & to offer support  Notify the Executive on call in the event of a potential SI or breach of 1:1 care – EOC can be contacted via bleep 1610 in hours (or via switch if off site) & via switch out of hours.

3.3.4 Executive on Call Responsibilities

The role of the Executive on Call is to take overall responsibility for any given situation escalated up to them; deciding on any actions to be taken as appropriate.

Specifically the EOC will:

 Determine whether any situation is to be treated as an SI  Be notified of the decision to close the maternity unit

This operational plan is underpinned by action cards (on pages 6-11) for the maternity bleep holder’s role and the DHM role both in and out of hours.

Source: Maternity \ Operational Team Issue date: 03/2010 Document Status: Approved Page 8 of 19 Review date: 09/2010 Document ID: OPS\GL\12 Version No: 1 D:\Docs\2018-04-28\0d492ef8756d5435e62a7c18d2c93d9e.doc ©Milton Keynes Hospital NHS Foundation Trust Maternity Escalation Operational Policy 3.4 Maternity Escalation Chart

Escalation Situation Reporting Maternity Bleep 1440 Responsibility Ops Team / DHM Responsibility Level GREEN  Midwives available for all  Monitor and Report any changes to Operational  Monitor- Usual operational Level 1 and Level 2 Management Team bleep 1222 procedures with updates at patients 08.00, 13.00, 16.30, 20.00,  Available bed capacity midnight & 04.00. >3 beds on Labour Ward and on Ward 9 AMBER  Midwives operating at  Escalate to Ops team / DHM  Support maternity in terms of upper limits of 1:1  Place community midwives on standby patient transfers and calling E.g.: 4 patients at  Notify Supervisor of Midwives & Lead midwife on call team as directed by level 1 & 3 patients at on call to support the unit and advise on the Labour Ward shift level 2 situation/options coordinator  <3 beds on Labour Ward  Review staffing across maternity & redeploy  Contact TVEA (Thames and /or <3 beds on midwives from other areas (Ward 9/10, ADAU, Valley Emergency Access) to Maternity ward ante-natal clinic) as appropriate advise that patients need to  Enough bed capacity for  Consultant/Registrar to review patients on be considered for diversion pending admissions, but Labour ward and Ward 9 as appropriate “at the borders” <2 beds after all patients  Instigate the agreed process to open Ward 10  Inform MOC that situation admitted. if capacity the problem and staffing available has escalated  Consider rescheduling elective caesarean sections, planned inductions and augmentations of labour. RED  Unit full – either no bed  Notify Head of Midwifery in hours capacity and/or 6  Suspend home births & call in community  Assist maternity staff with midwives committed to midwives if able transfers out of labour ward delivering care  Call in Lead Midwife to coordinate unit and  Update MOC e.g:6 patients at implement escalation plan  Notify TVEA of Unit closure level 1  Open ward 10 if not already open  No capacity on Maternity  Consultant/Reg to review all patients & Ward 9 or 10 discharge from where appropriate  Expedite transfers out of labour ward  Call in Supervisor of Midwives to coordinate closure of unit

Source: Maternity \ Operational Team Issue date: 03/2010 Document Status: Approved Page 9 of 19 Review date: 09/2010 Document ID: OPS\GL\12 Version No: 1 D:\Docs\2018-04-28\0d492ef8756d5435e62a7c18d2c93d9e.doc ©Milton Keynes Hospital NHS Foundation Trust Maternity Escalation Operational Policy 3.5 Maternity Escalation Plan Action Cards

3.5.1 Maternity Bleep Holder 1440

Maternity Escalation Plan Maternity Bleepholder 1440 GREEN CARD Midwives available for all Level 1 and Level 2 patients Available bed capacity >3 beds on Labour Ward and on Ward 9  Monitor and report any changes to Operational Management Team bleep 1222  Responsible for ensuring staffing levels are checked on a shift by shift basis for the following 48hrs and taking appropriate action to fill any identified gaps in the rota.  Maintain regular contact with DHM / Bleep 1222 with regards to concerns relating to staffing levels on Labour Ward and / or the maternity wards and potential breaches of 1:1 care for Level 1 patients.  Recording the successful delivery of 1:1 care for Level 1 patients on a 4hrly basis including all actions taken to avoid breaches  Daily at 09.30 review and analyse the root cause of any breaches of 1:1 care for Level 1 patients. RCA to be reported to the Head of Midwifery, General Manager for Women and Children’s Services or Maternity Matron.  Daily at 16.30 meet the out of hours DHM on Labour Ward for a formal update on the situation for Maternity with regards: 1) Number of women in established labour or clinical need requiring 1:1 midwife care (Level 1) 2) Number of women antenatal/post natal women requiring Level 2 care 3) Number of midwives on duty Early Shift Late Shift Night Shift 07.00-14.30 13.30-21.00 21.00-07.30 Labour Ward 6 + MW Co-ord 6 + MW Co-ord 6 + MW Co-ord Ward 9 3 3 3 Ward 10 2 2 2 ADAU 2 1 Antenatal Clinic 2 Mon - Thurs

Community 2-3 per team 2 on call 2 on call

4) Number of births between report times 5) Number of available post natal & ante natal beds 6) Number of expected admissions and discharges Source: Maternity \ Operational Team Issue date: 03/2010 Document Status: Approved Page 10 of 19 Review date: 09/2010 Document ID: OPS\GL\12 Version No: 1 D:\Docs\2018-04-28\0d492ef8756d5435e62a7c18d2c93d9e.doc ©Milton Keynes Hospital NHS Foundation Trust Maternity Escalation Operational Policy

Maternity Escalation Plan Maternity Bleepholder 1440 AMBER CARD Midwives operating at upper limits of 1:1 E.g.: 4 patients at level 1 & 3 patients at level 2 <3 beds on Labour Ward and /or <3 beds on Maternity ward Enough bed capacity for pending admissions, but <2 beds after all patients admitted.  Escalate to Ops team / DHM  Place community midwives on standby  Notify Supervisor of Midwives & Lead Midwife on call to support and advise  Review staffing across maternity & redeploy midwives from other areas as appropriate (Wards 9/10, ADAU, Ante-natal clinic)  Consultant/Registrar to review patients on Labour ward and Ward 9  Instigate the agreed process to open Ward 10 if capacity the problem where staff available  Consider rescheduling of elective caesarean sections, planned inductions and augmentations of labour.

Maternity Escalation Plan Maternity Bleepholder 1440 RED CARD Unit full – either no bed capacity and/or 6 midwives committed to delivering care e.g: 6 patients at level 1, No capacity on Maternity Ward 9 or 10  Notify Head of Midwifery in hours  Suspend home births & call in community midwives if not already at home birth  Call in Lead Midwife to coordinate unit  Call Supervisor of Midwives for advice and assist in closing unit  Open Ward 10 if not already open and staffing allows  Consultant/Registrar to review all patients & discharge from Labour Ward and Ward 9 where appropriate  Expedite transfers from labour ward and offer assistance with discharges home from Ward 9  Close maternity unit by following maternity unit closure procedure

Source: Maternity \ Operational Team Issue date: 03/2010 Document Status: Approved Page 12 of 19 Review date: 09/2010 Document ID: OPS\GL\12 Version No: 1 D:\Docs\2018-04-28\0d492ef8756d5435e62a7c18d2c93d9e.doc ©Milton Keynes Hospital NHS Foundation Trust Maternity Escalation Operational Policy 3.5.2 Duty Hospital Manager

Maternity Escalation Plan

Duty Hospital Manager

GREEN CARD Midwives available for all Level 1 and Level 2 patients Available bed capacity >3 beds on Labour Ward and on Ward 9

 Maintain regular contact with 1440 Maternity Bleep Holder – formally update operations white board at 08.00, 13.00, 16.30, 20.00, midnight and 04:00 with: a. Number of women in established labour or clinical need requiring 1:1 midwife care (Level 1) b. Number of antenatal and postnatal women (Level 2) c. Number of midwives on duty Early Shift Late Shift Night Shift 07.00-14.30 13.30-21.00 21.00-07.30 Labour Ward 6 + MW Co-ord 6 + MW Co-ord 6 + MW Co-ord Ward 9 3 3 3 Ward 10 2 2 2 ADAU 2 1 Antenatal Clinic 2 Mon - Thurs Community 2-3 per team 2 on call 2 on call

d. Number of births in between reporting times e. Number of available post natal & ante-natal beds f. Number of expected admissions & discharges

 Operations Team Lead and 1440 Maternity Bleep Holder will formally review all breaches of 1:1 care on a daily basis at 09.30 on Labour Ward using the maternity breach analysis reporting system. This will occur daily and the outcome of the breach analysis meeting will be reported to the Head of Midwifery and General Manager for Women & Children’s Services for appropriate action and learning. Action. Learning will be presented at the Directorate Clinical Improvement Group (CIG) and to Healthcare Governance Committee.

 DHM will take formal handover from the 1440 bleep holder at 16.30 daily Monday to Sunday on Labour Ward.

 DHM will visit Labour Ward a minimum of 2 times per shift 24/7, this is to be recorded on the DHM report sheet

 Monday – Friday daily report to agreed distribution list from Operations Lead by 10.00am (Appendix B

AMBER CARD Midwives operating at upper limits of 1:1 E.g.: 4 patients at level 1 3 patients at level 2 <3 beds on Labour Ward and /or <3 beds on Ward 9 Enough bed capacity for pending admissions, but <2 beds after all patients admitted.  Inform Manager on Call that situation has escalated to Amber  Support maternity in terms of patient transfers and calling on call team as directed by the Labour Ward shift coordinator  Contact TVEA to advise that patients need to be considered for diversion at “the borders”

RED CARD Unit full – either no bed capacity and/or 6 midwives committed to delivering care e.g: 6 patients at level 1, No capacity on Maternity Ward 9 or 10  Update Manager on Call.  Notify TVEA of unit closure.  Assist maternity staff with transfers out of Labour Ward and Ward 9  Support the Supervisor of Midwives with closure of unit within the Maternity Escalation, Unit Closure and Business Continuity Plans

Source: Maternity \ Operational Team Issue date: 03/2010 Document Status: Approved Page 15 of 19 Review date: 09/2010 Document ID: OPS\GL\12 Version No: 1 D:\Docs\2018-04-28\0d492ef8756d5435e62a7c18d2c93d9e.doc ©Milton Keynes Hospital NHS Foundation Trust Maternity Escalation Operational Policy 4.0 Audit and monitoring Criteria

Document Audit and Monitoring Table Monitoring a ) Mon-Friday daily monitoring of breaches requirements: b) Quarterly report to CIG and Divisional Governance Board

Monitoring Method: a) Daily ongoing audit

Monitoring prepared by: a) Risk Midwife and Labour Ward Matron

Monitoring a) Risk Meeting presented to: b) CIG c) Divisional Governance Board d) Trust Board Frequency of a) Quarterly presentation:

5.0 Statement of evidence/references

6.0 Equality Impact Assessment

This document has undergone an Equality Impact Assessment. No detailed action plan is required. Any specific issues raised relating to equality will be appropriately addressed through the monitoring processes which oversee the implementation and effectiveness of this document in practice.

Source: Maternity \ Operational Team Issue date: 03/2010 Document Status: Approved Page 16 of 19 Review date: 09/2010 Document ID: OPS\GL\12 Version No: 1 D:\Docs\2018-04-28\0d492ef8756d5435e62a7c18d2c93d9e.doc ©Milton Keynes Hospital NHS Foundation Trust Maternity Escalation Operational Policy 7.0 Standards for Better Health

Domain Definition/Evidence Safety This guideline has been designed to promote health care processes, working practices and systematic activities prevent or reduce the risk of harm to pregnant women. Clinical and Cost Healthcare decisions and services are based on what appropriately assessed Effectiveness research evidence has shown provides an effective outcome for women’s individual needs. Governance All providers of maternity services have in place the managerial and clinical leadership and accountability, the organisational culture, and the systems and working practices to enable probity, quality assurance, quality improvement and patient safety to be the central components of all routines, processes and activities. Patient Focus Maternity care is provided in partnership with women, their carers and relatives. Accessible and Women receive services as promptly as possible. Responsive Care Care Environment and Maternity care is provided in environments that promote women’s well-being Amenities and respect for women’s needs and preferences, accord an appropriate degree of privacy, are well maintained and are cleaned and optimise health outcomes. Public Health Maternity care provides leadership and collaborate with relevant local organisations and communities to ensure the design and delivery of programmes and services, which promote, protect and improve the health of the pregnant population.

8.0 Implementation and dissemination of document

Available on Intranet Maternity Escalation Action Cards available on Labour Ward and with Hospital Duty Manager

9.0 Overall responsibility for the document

General Manager Women and Children’s Division

10.0 Attachments

Appendix A – Daily Maternity Log Appendix B – Daily Maternity Report

11.0 Other Associated Documents Maternity Escalation, Unit Closure and Business Continuity Plan

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DATE: Daily Maternity Log

Incidences No of Time Capacity Dependency Levels of non- Actions Taken hospital compliance births with 1:1 care

LW W9 W10 LEVEL 1 LEVEL 2

8.00AM

1.00PM

4.30PM

8.00PM

12.00AM

4.00AM

STAFFING LEVELS:- EARLY LATE NIGHT

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DATE: Daily Maternity Report

Incidences No of Time Capacity Dependency Levels of non- Actions Taken / hospital compliance Comments births with 1:1 care