CAT Escalation Policy (CREAP)

Publication: 29/01/2014

Next review: 17/10/2025

Standard Operating Procedure

CURRENT

ID: 3660

Approved By:

This Standard Operating Procedure is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Leeds General Infirmary (LGI) Children’s Assessment and treatment unit (CAT) Social Distancing Escalation Plan

GREEN - business as usual
AMBER - early escalation
RED - safety concerns

More than 2 metres social distancing
GREEN - business as usual
Area
Trolley Spaces	>5
Hot Patients	<7
Cold Patients	<5
PUMA	<1
Total	<13
No escalation required
Nurse in Charge (NiC) Consultant in Charge (CiC) Senior Nurse
Consider the following actions
Action Card Actions Regular safety huddles with NiC, CiC and Patient Flow Request any admission delays are escalated to Matron of the day to maintain flow IPC Actions All patients wearing surgical face masks All staff are wearing the appropriate PPE Department clean Bins empty Equipment clean Lavatories clean Pharmacy room tidy Storage areas tidy Cubicle spaces clean Waiting areas clean Run hot and cold waiting areas according to patient need Call bells in reach

More than 2 metres social distancing
AMBER - early escalation
Area
Free Trolley spaces	2-4
Hot Patients	7-10
Cold Patients	5-7
Puma	1
Total	20
NiC escalate to see below
PFC/Matron Bronze Command Business Support Team Clinical Site Matron (CSM) OOH Consultant in charge
Consider the following actions
Action Card Actions Ensure patients are maintaining social distancing in waiting areas Complete review of patients with board round discharge suitable patients where possible Delays to referred patients escalated to Matron/CSM OOH Identify suitable patients to be admitted to wards Ensure all patients transfers have been carried out Contact ED to inform capacity at amber Co ordinator to review Red Flag risks and escalate via safe care. Ensure chairs and screens are in place in corridor 2 m apart to maintain social distancing in case pts are needed to wait outside Inform PFC staffing may need to increase if VET nurse to be placed off the unit IPC Actions All patients wearing surgical face masks All staff are wearing the appropriate PPE Department clean Bins empty Equipment clean Lavatories clean Pharmacy room tidy Storage areas tidy Cubicle spaces clean Call bells in reach For any patient unable to wear a mask maintain 2m social distancing There is an allocated individual member of staff to support mask wearing by patients, ensuring that any person not needed to be on site is supported to leave Alcohol gel hand hygiene is been offered through implementation of intentional rounding Touch point cleaning is being undertaken Enhanced surface cleaning is being undertaken

1 metre plus social distancing
RED - safety concerns
Area
Free Trolley Spaces	0
Hot Patients	>10
Cold Patients	>7
Puma	2
Total	21-30
Matron or NiC/CiC escalate to?
CSU Tri Team Plus (In Hours) / Associate Director of Performance (ADOP) (In Hours) GM on call (Out of Hours) / Director on call (Out of Hours)
Consider the following actions
Action Card Actions Review available space in the footprint for surge capacity Contact Ed re capacity at red Consultant on duty to discuss possibility of reducing Social distancing on CAT to 1 metre plus which will create 10 extra spaces Consider appropriate queuing system in the corridor and look at reducing social distancing to 1 m using chairs and screens outside Inform PFC Vet nurse to be based outside so more staff may be needed in the unit Ask facilities if extra help available for chair and screen cleaning outside of the unit Further announcement made of extending waiting time and patients advised of alternative health care provisions IPC Actions All patients wearing surgical face masks All staff are wearing the appropriate PPE Department clean Bins empty Equipment clean Lavatories clean Pharmacy room tidy Storage areas tidy Cubicle spaces clean Call bells in reach There is an allocated individual member of staff to support mask wearing by patients, ensuring that any person not needed to be on site is supported to leave For any patient unable to wear a mask are they maintaining 2m social distancing Alcohol gel hand hygiene is been offered through implementation of intentional rounding Touch point cleaning is being undertaken Enhanced surface cleaning is being undertaken

Provenance

Record:	3660
Objective:
Clinical condition:
Target patient group:	Children
Target professional group(s):	Secondary Care Doctors Secondary Care Nurses
Adapted from:

Evidence base

Not supplied

Document history

LHP version 1.0

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