Cohorting and configuration plan September 2020

Covid has created many challenges for CUH and our teams over the last 6 months and will continue to do so for some time yet. Our collective response and earlier reconfigurations have kept our patients safe and our teams calm during this period. This is thanks to the collective efforts of the whole CUH team, which we are grateful for.

Background

We began 2020 with a hospital that was regularly full with insufficient beds available for the number of patients we were trying to treat.  Before Covid we had c.1,000 beds available which was reduced to c.800 at the peak of the first wave of Covid. Currently we have c.950 available. It is likely that as Covid activity increases we will see a swing back to fewer available beds. Beds have been lost predominantly:

  • to create assessment units for Medicine and Surgery to reduce crowding in the Emergency Department; and
  • for social distancing on amber wards.

Over the last 6 months, dealing with Covid and then restarting non-Covid services has led to significant disruption for staff.  As it became clear that we would be living with Covid for a considerable time, we agreed to try to design a configuration that would be suitable for both low and high levels of Covid activity. This will allow our staff to have a degree of certainty over what functions their wards would be likely to play over the next 12-18 months.

Development of a flexible configuration plan

As we have worked through the approach to designing a configuration of the hospital, we have taken a significant range of views into consideration. We:

  • benchmarked our infection control approach with other Shelford Hospitals to ensure we were not taking out more beds than necessary;
  • carried out a series of After Action Reviews to hear about our staff experience of the previous two reconfigurations and what we could learn from that;
  • met with representatives of medical, surgical and specialty services with significant inpatient activity to understand their needs and those of their patients;
  • were given a number of principles by Management Executive to guide planning including that surgical activity should be ringfenced in the ATC and the A block to protect from the effects of perioperative Covid infection whilst maintaining the specialist multi-disciplinary teams needed to care for patients; and
  • took the approach of only moving wards where there was a clear problem to be solved given the significant disruption that had been experienced over the previous 6 months. As a result, many wards will be unaffected by this plan in a low Covid state.

As we worked on the configuration, we met again with specialties to get deeper insight into issues and to work on compromises.

We also worked to describe the order in which wards would convert from green to amber or red as numbers of Covid cases increased and how we would cohort cases of Influenza in winter given the reduced availability of side rooms with the ATC ringfenced for surgery.

Outcomes

This configuration does not meet the needs of all services because of the major constraints (there are fewer available beds than before) but we do believe this is the best compromise that can be achieved and describes how we would manage Covid over this period whilst maximising the amount of elective activity we can do. Thank you to the individuals and teams who have contributed to this work, your open mindedness and understanding have helped us to work through a difficult task to reach an acceptable outcome.

Next steps

The configuration has been signed off by Management Executive and will now be implemented over the coming weeks. The below tables show two things:

  • In table 1 you will see the order of ward changes from green to amber and red.  The exact order of these changes will depend on the relative need for each type of bed so it is possible that conversions to either red or amber will occur more rapidly than the other. For the bottom of each table to be reached would require a larger number of cases of Covid than experienced in the first wave. We think this is unlikely to occur but also think it is sensible to plan for this level.
  • In table 2, the function of each adult ward is shown along with whether it is green, amber or red. The first column is a low Covid state like the state in mid-September 2020. The middle column is a state similar to the first wave and the third column is the state in a wave worse than the first. One further principle that we have worked on is of ward based care where possible such that junior doctors will be expected to look after all patients on their home ward to minimise movement between wards.

As one of the aims of this plan is to provide wards with a degree of certainty, we will only plan to review it in the event that something significant changes such as additional inpatient capacity on site (regional surge capacity is expected to become available on the site in two phases, January 2021 and September 2021) or the development of a vaccine although there does remain a piece of work that may lead to slight adjustments to exactly where certain groups of patients are treated in the height of winter. We are also acutely aware that there are some services and groups of patients for whom we have not yet been able to identify the right solution for and work continues on this as part of phase 2 of this plan. It is also worth noting that this configuration plan will sit alongside a detailed winter plan with clear trigger points for escalation.

We need your help to support delivery of this plan.

In order to maximise the effectiveness of this plan we need everyone to focus on efficient patient flow. To make best use of our limited bed capacity, a daily focus on timely discharge, moving patients to the safest setting and focusing on those medically fit for discharge will make a significant difference to the pressures we face this winter.

We are really grateful for the input and collaboration of everyone who has been involved throughout the process, thank you.

Table 1

Order of conversion of wards to amber and red if Covid activity increases

Table 2

Function and RAG status of wards in Low, Intermediate/ High and High Covid states

* C6 will transition to a red end and amber bays before turning fully red
** D10 manages Covid patients in side rooms in low-state
*** Critical care expands into J3 in higher Covid states