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Protocol for managing capacity of Queensland public hospitals

Protocol number: QH-HSDPTL-025-3:2021

Effective date: 1 October 2021

Review date: 1 October 2024

Supersedes: Nil

On this page:

  1. Purpose
  2. Scope
  3. Managing hospital capacity
  4. Escalation processes for hospital and health services
  5. Supporting and related documents
  6. Approval and implementation
  7. Version control

1. Purpose

This Protocol outlines the mandatory processes for managing capacity within Hospital and Health Service (HHS) hospitals.

2. Scope

This Protocol applies to all Department of Health and other employees working in or for HHSs. This Protocol also applies to all organisations and individuals acting as an agent for HHSs (including Visiting Medical Officers and other partners, contractors, consultants, and volunteers).

3. Managing hospital capacity

Active management of total hospital capacity and demand is essential in ensuring patients have timely access to care across the healthcare continuum.

HHSs will:

  1. Provide models of care and pathways to support alternatives and minimise transfers where clinically appropriate.
  2. Have systems to ensure effective patient flow, including mechanisms to understand current demand and capacity, and triggers and actions to support the early identification and response to acute increases in demand.
  3. Have bed management/patient flow systems to proactively manage patient care on the basis of clinical need and urgency across the entire patient journey, including ambulance demand. Demand includes the need to return Queensland Ambulance Service (QAS) vehicles and crew back to the community for service delivery.
  4. Authorise the relevant Patient Access Coordination Hubs or equivalent, where established, to:
    1. Provide situational awareness of the demand and capacity of all facilities in the HHS
    2. Monitor and escalate as needed
    3. Collaborate with Queensland Ambulance Service to load-share patient demand across the HHS.
    4. Support timely inter-hospital transfers.
  5. Have processes to maximise bed availability for patient care.

4. Escalation processes for hospital and health services

HHSs will:

  1. Have a clearly defined process to ensure capacity issues are escalated to the executive level.
  2. Establish escalation plans, which include triggers and actions to respond to demand within the HHS.
  3. When communicating acute capacity levels outside the HHS, map local escalation and reporting language against the levels shown in Diagram 1.

Diagram 1: Capacity Escalation Levels

Capacity escalation levels

5. Supporting and related documents

Authorising Health Service Directive

Patient access to care health service directive

Procedures, guidelines, protocols

Clinical Services Capability Framework for Public and licensed Private Health Facilities version 3.2 retrieved from:

Acronym table

Acronyms Full title


Patient Access Coordination Hub


Queensland Patient Access Coordination Hub

6. Approval and implementation

Protocol custodian: Healthcare Improvement Unit, Clinical Excellence Queensland

Approving officer: Deputy Director-General, Clinical Excellence Queensland

Approval date: 23 September 2021

Effective from: 01 October 2021

7. Version control

VersionDate Prepared byComments



Healthcare Improvement Unit

Protocol for Managing Capacity of Queensland Public Hospitals developed in consultation with key stakeholders.

Last updated: 1 October 2021