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OFFICIAL
Document Title: Paediatric Intensive Care Surge, Standard Operating Procedure

Version number: 3

First published: November 2013
Updated: November 2016
Prepared by: Rachel Lundy on behalf of the Women & Children Programme of Care

The National Health Service Commissioning Board was established on 1 October 2012 as an executive non-departmental public body. Since 1 April 2013, the National Health Service Commissioning Board has used the name NHS England for operational purposes.

This is a controlled document. Whilst this document may be printed, the electronic version posted on the intranet is the controlled copy. Any printed copies of this document are not controlled.
As a controlled document, this document should not be saved onto local or network drives but should always be accessed from the intranet.

Contents

9. Monitoring 9

2. Introduction
2.1 This document provides a framework for the Paediatric Intensive Care (PIC) community response to manage escalating and unplanned peaks in demand for critical care beds.
2.2 It is intended for use by all NHS acute hospital providers with paediatric intensive care facilities on site but recognises that whole system solutions may sometimes be required to ensure timely access to intensive care for the sickest children. This document is also for use in those planning PICU services, others involved in the oversight of specialised services in NHS England and communications staff. It should be incorporated within local Trust escalation plans and should be viewed as part of the overall response to surge events.
2.3 In the context of this Standard Operating Procedure (SOP), the term surge is used to describe pressure on the whole paediatric intensive care system rather than referring to day to day peaks within individual units that can be reasonably managed locally.
3. Context
3.1 This National Standard Operating Procedure (SOP) forms part of a suite of national SOPs that cover the following services:

• 
  Adult Intensive Care Services
  

https://www.england.nhs.uk/wp-content/uploads/2013/11/sop-adult-cc.pdf

• 
  Adult and Paediatric Burn Care Services
  

https://www.england.nhs.uk/commissioning/wp-content/uploads/sites/12/2013/11/sop-burns.pdf

• 
  Adult Respiratory Extra Corporeal Membrane Oxygenation (ECMO)
  

https://www.england.nhs.uk/commissioning/wp-content/uploads/sites/12/2014/12/ecmo-adult-sop.pdf

• 
  Paediatric Respiratory Extra Corporeal Membrane Oxygenation (ECMO)
  

https://www.england.nhs.uk/commissioning/wp-content/uploads/sites/12/2014/12/ecmo-paediatric-sop.pdf
3.2 Paediatric critical care services include those delivered within dedicated critical care units.
The whole pathway of care includes paediatric intensive care transport services and limited high dependency care where this is commissioned by NHS England that is (PCC Level 2 where care is aligned to a PIC Unit, Level 3 and 4).
The table below is from the NHS England Paediatric Critical Service Specification E07/S/a and identifies the varied complexity of patients.

PCC Level	Provided in	Description
1	Level 1, 2 & 3 PCCU	Children requiring monitoring or interventions defined by the PCC HRG 07Z
2	Level 2 & 3 PCCU	Children requiring monitoring or interventions defined by PCC HRG 06Z
3	Level 3 PCCU	Children requiring ventilatory support or support of two or more organs systems. Children at level 3 are usually intubated to assist breathing. PCC HRG 05Z/04Z
		Children undergoing complex monitoring and / or therapeutic procedures including advanced respiratory support. PCC HRG 03Z/02Z.
3	Level 3 PCCU which supports cardiac surgery	Children receiving treatment by extra corporeal membrane oxygenisation (ECMO) PCC 01Z

Within the UK, services are organised such that the most acutely unwell children or, those requiring intensive care after surgery are cared for in an intensive care unit.

3.3 The list of interventions that define paediatric intensive care is available by viewing the Paediatric Critical Care Minimum Data Set (PCCMDS).
Data Set: Paediatric Critical Care Minimum Data Set
3.4 There are 29 units across the country and the list of these is attached for reference at Appendix 1.
3.5 The contact details for the four regional commissioning hubs who will be monitoring PIC surge in hours and NHS England on call teams (including EPRR teams where relevant) are attached who will oversee PIC surge out of hours is attached at Appendix 2.
3.6 This document should be read with reference to individual Provider organisation’s Incident Response Plan (IRP) e.g. NHS England Incident Response Plan or Local Service Providers Incident and Escalation Plan. It should be noted however that the steps applied in this document aim to mitigate the risk of escalation to this point.
4. Surge and Escalation Management Arrangements
4.1 Surge capacity requirements are usually agreed at a regional level. Only when referrals increase above NORMAL* levels and capability within the service is exhausted will escalation be required.
4.2 The levels of surge and escalation are described using the Critcon definitions as shown in Table 1 below.
4.3 The Critical Care Condition (Critcon) definitions used in this procedure have been adapted from those applied to adult critical care (within London). They are used to ensure a common level of understanding regarding service pressure and associated actions.
Paediatric Critical Care Critcon (PCC Critcon) levels and associated unit information on CMS2 will be monitored by NHS England regional commissioning hubs or nominated representative (ie local critical care networks). This information will form the basis of the regional and national discussions (including with clinical leads) described in this document.

5. Description of Critcon Levels

Table 1
Definition	Status
NORMAL - ‘Business as usual’ Normal, able to meet all paediatric critical care needs, without impact on other services. Normal activity levels of non-clinical transfer and other ‘overflow’ activity.	PCC CRITCON 0
LOW SURGE - ‘Bad Pressure’ The service’s bed capacity and or skill mix within a region is becoming limited but is able to receive patients and maintain optimal care. A region is defined by the hospitals shown in Appendix 1.	PCC CRITCON 1
MEDIUM SURGE - ‘Full stretch’ All services within a single region are operating at maximum capacity and are unable to accept new referrals within 12 hours, and, when the number of children awaiting admission exceeds the number of beds that will be released.	PCC CRITCON 2
HIGH SURGE - ‘Unprecedented’ 3 of the 4 Regions are declaring Critcon 2. There is very limited capacity or capability available. The initiation of alternative capacity must be considered.	PCC CRITCON 3
TRIAGE - ‘Last resort’ All 4 of the regions are declaring that there is no capacity or capability available and alternative capacity is required.	PCC CRITCON 4

6. Data Sources

6.1 The Emergency Bed Service (EBS) currently manages the data held on the (CMS2) bed management system updated by individual services twice daily. The system provides information for service managers, commissioners and clinicians but it does not provide an unequivocal view of available capacity due to real time changes that may not be immediately reflected on the system.

6.2 The EBS monitors the completeness of data nationally and will follow up any delayed or unusual entries to the system.
6.3 Trusts and regional hub teams will be responsible for collecting additional data to inform more regular situation reports as and when required. These will be identified and agreed as part of the surge calls described in the Critcon levels and units may be asked to provide information more frequently.
7. Roles and Responsibilities
7.1 It is the role of the regional commissioning hubs to determine the capacity required for their local populations reflecting any seasonal variation in demand. .
7.2 The Action Cards at Appendix 3 set out the headline roles and responsibilities to be undertaken during surge periods.
8. Engagement
8.1 This document will be reviewed annually and has been agreed with the Paediatric Critical Care Clinical Reference Group.

9. Monitoring

9.1 Implementation and amendments to this policy will be led via the NHS England Women & Children Programme of Care Board and Paediatric Critical Care Clinical Reference Group.

10. Equality and Health Inequalities Analysis
10.1 This procedural document forms part of NHS England’s commitment to create a positive culture of respect for all individuals including staff, patients, their families and carers as well as community partners. The intention is to identify, remove or minimise discriminatory practice in the areas of race, disability, gender, sexual orientation, age and ‘religion, belief, faith and spirituality’ as well as to promote positive practice and value the diversity of all individuals and communities.
Every corporate procedural document must include an assessment of the impact it will have on inequalities and on addressing health inequalities and the following template must be completed.
Further advice can be obtained from the Equality & Health Inequalities Team.

Appendix 1 – Paediatric Critical Care Units

LONDON
	PICU: Barts Health (Royal London)
	PICU: Evelina Children’s Hospital
	PICU: Great Ormond Street Hospital
	PICU: Imperial (St Marys Hospital )
	PICU: King's College NHS Foundation Trust
	PICU: Royal Brompton Hospital
	PICU: St Georges Hospital
	Retrieval Team: Children's Acute Transport Service (CATS)
	Retrieval Team: STRS
	Retrieval Team: Neonatal Transfer Service (NTS) London
MIDLAND AND EAST
	PICU:  Addenbrookes (Cambridge)
	PICU:  Birmingham Children’s Hospital
	PICU:  Glenfield Hospital (Leicester)
	PICU:  Leicester Royal Infirmary
	PICU:  University Hospital of North Staffordshire PICU
	PICU:  Nottingham Children's Hospital
	Retrieval Team: ANTS Addenbrookes (Cambridge)
	Retrieval Team: KIDS Birmingham retrieval team
NORTH
	PICU: Alder Hey Children’s Hospital (Liverpool)
	PICU: James Cook University Hospital (Middlesborough)
	PICU: Leeds Teaching Hospitals
	PICU: Sheffield Children’s Hospital
	PICU: The Freeman Hospital (Newcastle)
	PICU: The Royal Victoria Infirmary PICU (Newcastle)
	PICU: Royal Manchester Children’s Hospital
	Retrieval Team: Embrace – North Trent and Yorkshire retrieval team (based in Sheffield childrens)
	Retrieval Team: NEWTS – North West and North Wales Team – (Manchester and Alderhey)
SOUTH
	PICU: Bristol Children’s Hospital
	PICU: John Radcliffe Hospital (Oxford)
	PICU: Southampton University Hospitals NHS Trust
	Retrieval Team: Bristol PIC retrieval service.
	Retrieval Team : SORT – Southampton and Oxford
OTHERS
	PICU: Cardiff Children’s Hospital for Wales
	PICU: Edinburgh Hospital for Sick Children
	PICU: Glasgow Royal Hospital for Sick Children
	PICU: Royal Belfast Hospital for Sick Children

Appendix 2 – Regional Contact Details In and Out of Hours

1. 
   North Region
   

Area Team	Contacts (In Hours)	Telephone	Out of Hours Contacts
North East and Cumbria	Assistant Director, Liz Rogerson Service specialist, Peter Dixon	07795684982 0113 8253030 07900715346 0113 825 1602 (Business Support)	0191 4302453 or (back-up 0191 4302498) Please ask for the regional specialised commissioning manager
North West including South Cumbria	Assistant Director, Andrew Bibby Service Specialist, Roz Jones	07909000281 01138252600 01138252815 07824639601 0113 825 2736 (Business Support)
Yorkshire & Humber	Assistant Director, Matthew Groom Service Specialist, Sarah Halstead	07860177983 07900 715105 0113 825 3391 (Business Support)
Programme of Care Manager: Penny Gray – [e-mail] - 07876 851 860

2. South Region

Area Team	Contacts (In Hours)	Email	Telephone	Contacts (Out of Hours) Ask for Commissioning Hub Manager On Call
Wessex	Caroline Cairns Paediatric Critical Care Network Manager Una Vujakovic ODNs Director Thames Valley & Wessex	[e-mail]	07585 998497 07721 231759	Wessex – 07623 503 888 ( Pager )
BNSSG	Rod Walsh	[e-mail]	01138253631/07733327613	South West – 0303 0338833
Programme of Care Manager: Linda Doherty – [e-mail] - Mobile: [phone]

3. Midlands & East

HUB	Commissioning Lead	Email	Telephone
EAST MIDLANDS (Link for Nottingham and Leicester PICs) When absent:	Paul Webb Jude Bowler	[e-mail] [e-mail]	01138249646 07710152746 0773 0371 063
WEST MIDLANDS (Link for Birmingham Children’s and University Hospitals of North Staffordshire) When absent:	Vandna Najran Hannah Williams Leigh	[e-mail] [e-mail]	01138251688 07748780562 07568 431 790
EAST OF ENGLAND (link for Addenbrookes Hospital) When absent:	Daniel Eve Joanne Pope	[e-mail] [e-mail]	Mobile: [phone] 07900715454 Admin no: 01138253659
Midland and East (Region) During Office Hours Natalie Hariram, Programme of Care Manager W&C, [e-mail]/ 07909099203
Midland and East (Region) Out of Hours Pager 07623503831 - ask for regional on call manager.

4. London Region

Contacts (In Hours)	Email	Telephone	Contacts (Out of Hours)
1^st contact – Rod Booth	[e-mail]	0113 807 0105	08448222888 Leave a message for NHS01
2^nd Contact – Ian Murdock	[e-mail]	0113 807 0173
Programme of Care Manager, Rachel Lundy [e-mail] & Mobile [phone]

In the event that a national call is required out of hours this can be organised by escalating to NHS England National On Call and will usually be instructed by the regional contacts listed here – 0844 822 2888 requesting NHS 05

Appendix 3 – Surge Action Cards

PCC CRITCON 0 – Normal “Business as Usual” THE SERVICE IS ABLE TO MEET ALL CAPACITY REQUIREMENTS WITHOUT IMPACTING ON OTHER SERVICES OR ORGANISATIONS
Critical Care Service
1. 2.	Will update the CMS2 system as and when patients are admitted or discharged at least twice daily at 10am and 8pm during normal service delivery. Each service will signify the Critcon Level in the “Service Notes” section of the system.
1. 2.	The PIC service and Trust bed managers will meet routinely (frequency as per organisation’s policy) to discuss the management of bed capacity, capability (skill mix of staff). Trusts should review the CMS2 system to consider regional bed availability to inform decision making locally.
EBS
1. 2.	The emergency bed service will routinely monitor CMS2 nationally and ensure all critical care services are updating the system in line with the requirements above. In the event that a service has not updated the system in the previous 12 hour period, the EBS will contact, by telephone, the service and request the system be updated with immediate effect.
NHS England Regional Team
1.	Will regularly monitor bed capacity for the PIC units within their region using CMS2.
1. 2.	Will maintain a log of the capacity figures and status of all critical care services, with a daily record of the figures and status for each service within their usual boundaries. The daily log should be indicative of the highest Critcon status declared by the service on the day (including weekends.
NHS England On Call
1.	No action required – routine monitoring out of hours.

PCC CRITCON 1 – Low Surge “Bad Pressure” EXPECTED WINTER PRESSURE OR OUT OF SEASON DEMAND SURGE THE PIC UNIT BED CAPACITY AND/OR SKILL WITHIN ONE REGION IS BECOMING LIMITED BUT THE SERVICE IS ABLE TO RECEIVE PATIENTS AND TO MAINTAIN OPTIMAL CARE
Critical Care Service
1.	Will immediately amend the CMS2 system to signify CRITCON 1.
2.	Inform the Emergency Patient Transport Service (PTS) and regional contacts by telephone that the service is operating at CRITCON 1 and include the rationale for declaring CRITCON 1 status.
3.	The service will continue to update on any change in the situation and amend the status on the CMS2 system as soon as admitting capacity changes.
4.	Maximise repatriations and ward discharges to general paediatric or neonatal care.
EBS
1. 2.	Will routinely and regularly monitor CMS2 and ensure PIC units are updating the system as required. In the event that a service has not updated the system in the previous 12-hour period, the EBS will contact, by telephone, the service and request the system be updated with immediate effect.
NHS England Regional Team
1. 2.	Will regularly monitor bed capacity for the PIC units within their region using CMS2. On being notified of CRITCON 1, regions should consider the position of neighbouring services and consider whether any further escalation is required to contain the situation.
NHS England On Call
1.	No action required – routine monitoring out of hours.

PCC CRITCON 2 – Medium “Full Stretch” ALL PIC UNITS WITHIN ONE OF FOUR REGIONS ARE OPERATING AT MAXIMUM CAPACITY AND ARE UNABLE TO ACCEPT NEW REFERRALS WITHIN 12 HOURS AND THE NUMBER OF CHILDREN AWAITING ADMISSION EXCEEDS THE NUMBER OF BEDS TO BE RELEASED THAT DAY
Critical Care Service
1.	Immediately amend the CMS2 system to signify CRITCON 2.
2.	Continue to notify PTS and the region and amend the status on the CMS2 system as soon as admitting capacity changes.
3.	Maximise repatriations and ward discharges to general paediatric or neonatal care.
4.	Trust Chief Operating Officer (COO) & Clinical Director to review paediatric elective surgery requiring PIC
5.	Consider cancellation of study leave for PIC trained medical, nursing and key support staff.
6.	Consider skill mix and resource allocation.
7.	Review utilisation of adult intensive care for any age / clinically appropriate young people.
8.	On Call Consultant and COO to participate in all agreed teleconferences when requested.
NHS England Regional Team
1.	During the Winter November to January, regional teams (or critical care networks where these are established) are encouraged to monitor escalating demand for Paediatric Intensive Care Beds. In the event that Critcon 2 has been confirmed, the Regions will ensure a) that they coordinate the collection of the information at Appendix 4 and assure that it accurately reflects actions taken by Providers in their regions and b) that they confirm the likely duration of the CRITCON 2 position.
2.	Will ensure that units correctly reflect their status on the CMS2 system.
3.	Having collated information in Appendix 4, the regional lead in the affected area will arrange a teleconference with the other regions (and London as the lead) to discuss the situation, to confirm the position and to agree any on-going actions for escalation if appropriate. Contacts for London to initiate calls at Critcon 2 and above are: Rachel Lundy – Regional Programme of Care Manager (London) – 07900712998
4.	Will work with general paediatric services to ensure that all reasonable steps are taken to discharge children suitable for acute care in order to release PIC beds.
5.	Where a prolonged delayed discharge occurs which requires external facilitation the regional lead will issue the communication attached at Appendix 4 to the receiving unit and agree an indicative timescale for admission.
6.	The nominated regional lead will provide the local NHS England regional On Call lead with any information or situation reports, as required.
NHS England On Call
1.	NHS England regional on-call will be aware of the status from regional handovers. The teams will oversee and manage the process out of hours and consider any national escalation required.
PCC CRITCON 3 – High “Unprecedented” 3 OF THE 4 REGIONS ARE DECLARING CRITCON 2 RESULTING IN VERY LIMITED CAPACITY OR CAPABILITY AVAILABLE SOURCES OF ADDITIONAL CAPACITY MUST BE CONSIDERED Actions as above for CRITCON 1 and 2 must be completed prior to the following actions
Critical Care Service
1.	Ensure that CMS2 system accurately represents the CRITCON level.
2.	Continue to notify PTS and the regional team and amend the status on the CMS2 system as soon as admitting capacity changes.
3.	Maximise repatriations and ward discharges to general paediatric or neonatal care
4.	Trust COO & Clinical Director to review paediatric elective surgery requiring PIC.
5.	Ensure cancellation of study leave for PIC trained medical, nursing and key support staff wherever possible.
6.	Consider skill mix and resource allocation
7.	Review utilisation of adult ICU for any age / clinically appropriate young people.
8.	On Call Consultant and COO to participate in all agreed teleconferences.
Regional
1.	Provide the local NHS England Regional On Call team with any information or situation reports as required.
2.	Will participate in any teleconference co-ordinated by London Region as the national PIC Surge lead, implement and oversee any actions arising from the TC.
National
	London Region (in hours) or the respective On Call team (out of hours) will convene a teleconference comprising: The On Call PIC Consultant in each unit and transport teams All nominated regional /EPRR leads 4 Regional Medical Directors for Specialised Services (in hours) Where it is necessary to raise a surge alert out of hours, units or local transport services should do so through their regional contacts at Appendix 2. They will lead the coordination of a national call as necessary. The aim of the TC is to review and confirm the current situation, agree the next steps and who will be responsible for implementing these. This should include: What is causing the current source of pressure, actions already taken and additional steps that could be taken to reduce pressure (step-down, repatriation etc) Impact on the critical care system Potential recourse to whole system responses required in light of respective major incident plans The telephone conference details used will be: 08009171950 Participant: 44744236 then #
NHS England On Call
1.	NHS England regional on-call will be aware of the status from regional handovers. The teams will oversee and manage the process out of hours and consider any ongoing national coordination required.
PCC CRITCON 4 – TRIAGE SERVICE FAILURE & LAST RESORT ALL 4 CRITICAL CARE REGIONS ARE DECLARING NO NHS CAPACITY OR CAPABILITY AVAILABLE ADDITIONAL CAPACITY FROM OTHER PIC PROVIDERS OR MUTUAL AID IS REQUIRED Actions as above for Level 1, 2 and 3 must be completed prior to the following actions.
Critical Care Service
1.	Ensure that CMS2 system accurately represents the CRITCON level.
2.	Continue to notify PRS and amend the status on the CMS2 system as soon as admitting capacity changes.
NHS England Regional Team
1.	The nominated regional lead will provide the local NHS England regional On Call with any information or situation reports (SitReps) as required.
2.	Will participate in any teleconference co-ordinated by London Region as the national PIC Surge lead and facilitate any agreement stemming from the TC.
National
1.	In the event of Critcon 4, London Region will: In discussion with the NHS England nominated regional lead (in hours) or On Call team (out of hours) will convene a teleconference comprising: The On Call Consultant for each unit and transport service 4 Regional Medical Directors for Specialised Services NHS England regional On Call leads (for continuity out of hours) The aim of the TC is to review and confirm the current situation and agree the next steps and who will be responsible for implementing these and should include. What is causing the current source of pressure, actions already taken and additional steps that could be taken to reduce pressure (step-down, repatriation etc) Impact on the critical cares care system Potential recourse to whole system responses required in light of respective major incident plans Where it is necessary to raise a surge alert out of hours, units or local transport services should do so through their regional contacts at Appendix 2 who will lead the coordination of a national call as necessary. The telephone details used will be: 08009171950 Participant: 44744236 then #
Paediatric Transport Service
1.	In the event that a new referral is made, the regional paediatric transport team will determine (as routine) the requirement for a PIC bed and advise the referring clinician that an alternative is being sought. The PTS will continue to manage referrals for beds and ensure that details of cases are relayed accurately for consideration in the national calls as outlined above.
NHS England On Call
1.	NHS England regional on-call will be aware of the status from regional handovers. The teams will oversee and manage the process out of hours and consider any ongoing national coordination required.

APPENDIX 4 – REGIONAL STATUS REPORT

How many beds are typically available within each unit?

How many beds are currently occupied? Please account for any variation between available and occupied beds.

Have Providers updated the CMS2 system to accurately reflect the CRITCON level based on available bed capacity

Do you know how many children children are awaiting admission via retrieval services and their current duration of wait?

Have Providers identified the numbers of children eligible for ward discharge, general paediatric care?

Have Providers considered whether is additional capacity that can be established by: managing suitable babies with neonatal service support considering the use of adult ICU for any age / clinically appropriate young people

Does repatriation of children enable the timely admission of children currently requiring PICU?

Can Providers identify any additional capacity through review of skill mix and acuity of patients?

Are the Tertiary hospitals currently admitting patients for paediatric elective surgery requiring PIC?

Are acute hospitals still undertaking paediatric elective surgery potentially impacting demand for general paediatric beds and repatriation from PICU

Information Collated by:

Name

Title:

Region:


Date and Time:

Appendix 5 – Delayed Discharge Letter Template

Address 1 Address 2 Address 3 Address 4 Address 5 Date	NHS England

Dear COO Name

Paediatric Intensive Care Delayed Discharge
NHS England has been notified today that the child detailed in Appendix A who is medically fit for discharge has been delayed for discharge from the Paediatric Intensive Care Unit at (PIC unit).

I note that their discharge to (insert referring unit name) has been delayed due to (insert reason) and as a consequence capacity to admit a critically unwell or unstable child is now compromised. The intensive care network is currently operating at CRITCON Level X (insert level) as described in the attached surge standard operating procedure.

Whilst acknowledging that there will of course be periods of unprecedented demand on acute and critical care beds, we would ask you to liaise with the paediatric clinical team to expedite the discharge of this child in line with the inter hospital transfer guidelines referenced in the NHS England contract. Standard 15 requires a repatriation to occur within 24 hours of the notification to the receiving hospital’s bed management team.

Please can you contact (enter name of regional lead) to notify them of the action taken in response to this letter and confirm the date that the Trust is able to accept the transfer.

Thank you for your assistance in this matter.

Yours sincerely

Name
Associate Director

X Regional Hub