a strategic vision for critical care services in wales

A Strategic vision for Critical Care Services in Wales Critical Care Networks February 2013

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A Strategic Vision for Critical Care Services in Wales


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Contents:

A Strategic Vision for Critical Care Services in Wales

1. Executive Summary

2. Introduction

3. Strategic Context

4. Putting this into context for Critical Care 4.1 Equitable access to high quality critical care for all

Welsh citizens 4.2 Appropriately trained staff available to meet the

care needs of critically ill patients

4.3 Appropriate support from and for other specialities: medicine, surgery, pathology, radiology etc

4.4 Patients and carers involvement in shaping the experience of critical care.

4.5 A change in emphasis to the use of direct and indirect outcome measures to assess critical care service

delivery and improve it where necessary 5. What do we want to achieve?

6. Delivery requirements of the NHS 6.1 The role of Local Health Boards Critical Care Delivery

Groups (CCDG) 6.2 The role of Welsh Health Specialist Services Committee

(WHSSC) 6.3 The role of Welsh Government (WG)

Appendix 1. Tiers of Critical Care Units and Medical Staffing

Appendix 2. Quality Requirements for Adult Intensive Care

Appendix 3. Direct and Indirect Outcome measure. An expanded rationale for their use


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1. Executive Summary

This strategic vision provides recommendations for action by Local Health Boards to improve critical care in Wales. It sets out

the expectations of the NHS in Wales to improve patient’s access to critical care wherever they live in Wales and whatever their

circumstances. It emphasises the use of expected outcomes measures from critical care units to improve care rather than just

an emphasis on critical care structures and processes.

The document is designed to enable the NHS to deliver on its

responsibility to meet the needs of people who require critical care and sets out:

• How critical care in Wales should be structured.

• The outcomes expected from critical care. • Key areas for action by the Health Boards and their partners.

It is expected that Health Boards in Wales will use this strategic vision as part of their planning to meet the critical care needs of

their populations. Based on good practice and sound clinical evidence, the vision sets out how a safe, effective and high

quality critical care service should look.

The expectations from this document will be summarised and

made available in Critical Care units across Wales for service users and carers to access.

Whilst some of the recommendations made are implementable

now others will take time. A slower timeframe for complete implementation is particularly applicable to allow Health Boards

to allocate the envisaged critical care unit tier structure, and staffing to their critical care units. This restructuring will need to

fit into both the Health Boards’ plans and any regional changes in health care delivery. It is expected however that within five

years these changes should have been implemented to create a

modern equitable critical care service for Wales. The Welsh Government will be updated yearly in relation to this

implementation.

Whilst this document is written by the Critical Care Networks we have widely consulted with those working in Critical Care across

Wales through the Network’s Service Improvement Groups, which includes Allied Health Professional representation, and

through our Network Board meetings. The document also has been viewed and has a broad consensus of support from the

Senior Critical Care Nurses Forum, from the Welsh Intensive


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Care Society, and from the National Specialist Advisory Group

Sub Committee for Critical Care. Whilst modern critical care is very much a team effort including amongst others ward and data

clerks, allied health professionals, and medical and nursing staff the patient must remains the focus of all our attention. A

patient’s needs dictate the necessary service for them and when that can’t be delivered the patient should move safely to

somewhere where they can receive it.

This Strategic Vision for Critical Care Services in Wales should help inform the regional planning of those services that are

dependent on critical care services.


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2. Introduction

Every year around 9000 adults (Critical Care Minimum data set 2007-2012) receive critical care in one of the current 16 critical

care units in Wales. The number of patients requiring critical care per year is rising. Preliminary mathematical modelling by

Intensive Care National Audit and Research Centre (ICNARC) currently predict a 4% per annum increase in critical care

requirement (personal communication from Professor Kathy Rowan, Director ICNARC). The increase in critical care

requirement is due to the demographics of an ageing population, increases in more complex surgery, providing critical care to

meet public expectations where in the past it would not have been offered, and in Wales at least achieving the desired

increase in organ donation targets with the introduction of presumed consent.

Trying to keep pace with this increase in critical care demand will require an increase in critical care bed capacity and an increase

in efficiency. This increase needs to be planned and executed by Health Boards’ Executive Teams. This should be guided by their

Critical Care Delivery Groups and informed by validated critical care outcome data.

This strategic vision puts the patient’s needs uppermost. The current major pressures that critical care faces in delivering best

care are:

1) equitable access to critical care 2) reconfiguration of services dependent on critical care

3) delivering value for money 4) senior and junior medical staffing

This strategic vision supports the case for change advocating the

structures, processes and outcomes envisaged to provide an equitable, high quality and sustainable critical care for Wales.

3. Strategic Context

The main NHS strategic drivers are:

The Welsh Government’s five year vision for the NHS in Wales, ‘Together for Health’ (2011), which sets out an

ambitious programme for health and healthcare in Wales so that:

1. Health will be better for everyone 2. Access and patient experience will be better

3. Better service safety and quality will improve health outcomes


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The Welsh Government’s quality plan ‘Achieving

Excellence: the quality delivery plan for the NHS in Wales 2012 – 2016’ sets out the Government’s “vision for a

quality driven NHS”.

This document calls for the health service to be provided safely, effectively, efficiently, equitably, and centred on the needs of the

patient in a timely manner.

4. The context for Critical Care 1. Equitable access to high quality critical care for all Welsh

citizens 2. Appropriately trained staff available to meet the care needs

of critically ill patients at all times 3. Appropriate support from and for other specialities

4. Patients and carers involvement in shaping the experience

of critical care 5. A change in emphasis to the use of direct and indirect

outcome measures to assess critical care service delivery and improve it where necessary

4.1 Equitable access to high quality critical care for all

Welsh citizens A joint paper with Public Health Wales in 2011 examined critical

care use across the country using the Critical Care Minimum Data set (CCMDS 2007-2011). This usage was matched to areas of

social deprivation using postcodes.

Those in the lowest socio-economic group used twice as much emergency critical care compared with the highest socio-

economic group.


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131 140169

217

283

Least deprived Next least

deprived

Middle Next most

deprived

Most deprived

Unplanned critical care admissions* by WIMD 2008 fifth, European age-standardised

rates per 100,000 persons, 2007-2010

Produced by Public Health Wales Observatory, using CCMDS (NWIS) and MYE (ONS)

EASR with 95% confidence interval

Wales EASR = 185

* The method of data extraction limits each patient aged 16 and over to one admission

per calendar year - this answers the question "How many people (aged 16+) have had at least one unplanned admission to critical care?" for any given year

The number of Level 3 (Intensive Care) beds in Wales is 3.2 per 100,000 population. The Welsh figures exclude cardiac and burns

intensive care beds, but do include neuro-critical care beds. This figure is the lowest in Europe; notably Wales has fewer Intensive

Care beds than England which has 4 beds for every 100,000 people. That said this figure is still seven times fewer than

European leaders Germany which has 24.6.

Number of ICU Beds per 100,000 Population

0

5

10

15

20

25

30

Wale

s

Engla

nd

Spain

Nether

land

s

Sweden

Franc

e

Canada

USA

Croat

ia

Belgi

um

Ger

man

y

There is not only inequity on an international level but also at a local level which does not relate purely to socioeconomics.


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The National Confidential Enquiry into Patient Outcome and Death (NCEPOD) ‘Knowing the Risk A review of the peri-

operative care of surgical patients’ reported in 2011 that approximately 1 in 10 to 1 in 20 of all patients undergoing

surgery should be considered high risk and should therefore be considered for admission to critical care peri-operatively.

Admitting this cohort is already unachievable with the current critical care bed provision in all Health Boards.

In summary, there are large discrepancies in critical care bed

provision across Wales and therefore inequities in accessing a

critical care service. Health Boards need to revise and plan to increase critical care bed numbers. This needs to take into

account socioeconomics, ageing populations and equitable patient access and therefore needs to be cognisant of regional

plans. Wales as a whole needs to bring critical care capacity at least into line with comparable countries.

4.2 Appropriately skilled clinical staff available to meet

the care needs of critically ill patients. In order to ensure good quality care for critically ill patients, it is

vital that they are treated by appropriately trained critical care staff. A review of Health Boards against the Quality

Requirements (2006) has highlighted difficulties in providing the necessary staff, especially medical staff. The Intensive care

Society, and the European Society of Intensive care Medicine,

amongst others, state that critical care should have a consultant Intensivist available 24 hours a day and a dedicated on site

trained doctor present in the critical care unit. The persistent inability to meet the current Welsh Quality Requirements, which

2.5 2.5

3.6 3.84.5 4.8

Aneurin

Bevan

Betsi

Cadwaladr

Hywel Dda Cwm Taf Cardiff &

Vale

ABM

Number of ICU beds per 100,000 population by health board, 2010Produced by Public Health Wales Observatory and Critical Care Networks, using 2011 ward data provided by critical care units and MYE (ONS)

NB; LHB populations do not account for cross-border patient flows (secondary to tertiary unit transfers) or influxes of holiday makers and other seasonal variations.


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also set this target, demonstrates that the current system is not

working.

In future there will need to be changes in how many units are staffed so that a sustainable appropriately trained team is

available to meet the level of care required 24 hours a day. This may include:

1. Increasing utilisation of Advanced Critical Care Practitioners

(ACCPs) to provide care which in the past would have been considered to be the role of junior medical staff whose

relative numbers are falling. ACCPs’ training and working practice need to be agreed, structured and appropriately

regulated. 2. Use of Staff Grade and Associate specialists (SAS), and post

Completion of Certified Training (CCT) doctors need to be

considered in place of junior doctors in training. 3. Separation of Consultant Intensivist on-call rotas from

Anaesthesia consultant rotas will require investment and expansion of Intensivist numbers in some Health Boards.

4. Changes in how Intensivists work out of hours will need to take into account changes in retirement age, feminisation of

the workforce and changes in consultant career progression in-order to provide a flexible sustainable consultant work

force necessary to meet the patient’s needs.

The medical staffing requirements for the tiers of critical care are set out in more detail in Appendix 2.

Local Health Boards will need to determine how they can best

meet these patient requirements and workforce developments

when designating units within their organisation.

4.3 Appropriate support from and for other specialities High quality critical care requires support from a large team of

clinical and technical staff, often using specialist equipment 24 hours a day, 7 days a week (appendix 2). Conversely many

services including acute medicine, emergency medicine, surgical specialities, and obstetrics are dependent on critical care

provision to be able to provide their service.

Critical care and the planning of dependent and supportive services must be co-ordinated.


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4.4 Patients’ and carers’ involvement in shaping the

experience of critical care. In addition to high quality clinical outcomes in critical care, it is

important that patients, families and carers have as positive an experience as they can while receiving critical care. ’Achieving

Excellence’ states that the best judge of quality of service given is the recipient. It is vital that patient and carer views are

actively sought, listened to, and acted upon in order to improve experiences.

A national carers’ experience questionnaire has been developed

by the Intensive Care Society. Many units already use patient stories and patient diaries. These good practices will be

encouraged and supported by Networks for further adoption across Critical Care units.

4.5 Use of outcome measures to assess and improve quality of critical care.

The publication in 2006 of ’Designed for Life: Quality Requirements for Adult Critical Care in Wales’ [Quality

Requirements] was a milestone in the development of critical care services in Wales. Whilst improvements have resulted from

the ability to measure facilities against these requirements, the major emphasis was on ensuring structures were in place.

This document builds on the previous Quality Requirements by

emphasising the use of direct and indirect outcome measures to uniformly improve the delivery of critical care and its quality.

These outcome measures must be reviewed by the Health

Board’s Critical Care Delivery Group who are tasked, with the

help of the Critical Care Networks, to also provide annual reports to the Welsh Government.

A summary of the expected outcome measures are shown below

with a more detailed explanation in appendix 3.


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Summary of Processes of Reporting Outcomes Measures

Processes of Reporting

When

1 Regular reporting at Local Health

Board executive level on Delayed Transfers of Care and the effects on

patients.

3 monthly at CCDG and

Network 6 monthly

2 Survey of carers of critical care patients using the ICS Carer

Survey.

Annually to CCDG and Networks

3 Root cause analysis of circumstances

surrounding “never events” with action plans to prevent

recurrence. Reporting of critical incidents and

serious adverse events

3 monthly to CCDG,

Health Board and Network

4 Regular reporting of critical care audit results and progress against

agreed local action plans

Annually to CCDG

5 Compliance with reporting to Welsh

Hospitals Acquired Infections Programme

Annually to WHAIP. Unit

acquired infections to CCDG and Network 6

monthly 6 Undertaking an audit of compliance

with any relevant NICE guidance

within 6 months of its launch, for example NICE 83 critical care follow

up

6 monthly to Networks and CCDG with

implementation of guidance planning

7 Completion of action plans to implement improvements in key areas

identified through RRAILS and 1000 Lives Plus.

To critical care networks

8 Regular reporting and discussion of cancelled operations due to lack of a

critical care beds

3 monthly to CCDG

9 Reporting all non-clinical transfers through the Local Health Boards’

clinical incident mechanisms for investigation

As need arises

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Regular discussion of critical care re-admissions within 48 hours.

3-6 monthly to CCDG

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Regular discussion of premature

discharges

3-6 monthly to CCDG


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5. The Vision for Critical Care

Critically ill patients must receive: the right care,

in the right place in an appropriate timeframe

delivered by a trained and competency assessed team.

In order to provide such a vision of equitable care it is no longer reasonable or indeed possible to expect Health Boards to be able

to meet every patient’s need in every critical care unit. In future

this may require patients being transferred safely to a unit that can meet their needs.

Health Boards will be required to

determine the tier of care it’s critical care units can meet to care for the severity of a patient’s illness

ensure it continues to meet the necessary requirements for high quality care at that level (table 1 and appendix 2).

Local Health Boards are required to agree robust mechanisms

for promptly transferring patients to a unit that is equipped to manage the severity of their illness when it becomes clear that

transfer is necessary.

The requirements for provision of critical care to patients in the

tiers set out in Appendix 1 apply to all adult patients. This is irrespective of their clinical specialty. Additional requirements

should be added as necessary by the clinical specialty.

6. Delivery Requirements of the NHS

6.1 The role of Local Health Boards Critical Care Delivery Groups (CCDG)

The CCDG must plan and provide critical care services that are appropriate for their population. In order to work

effectively, critical care units within each Health Board will need to interact with units in other hospitals, via the Critical

Care Networks to ensure that patients are able to access the most appropriate level of care when they need it.

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Regular review of unit’s Morbidity and

Mortality data including SMR utilising the ICNARC case mix programme

6 monthly to CCDG, and

annually to WG

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Regular reporting of out of hours critical care discharges.

3-6 monthly to CCDG


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To deliver the expectations set out in this document, Health

Boards will need to review current services, based against the outcomes measures (appendix 3), to inform local delivery

plans.

Short-term critical care must be available on all acute hospital sites with unselected medical and surgical on-call (“take”). If

a patient’s critical care needs cannot be met by their local hospital’s critical care service, the patient should be

transferred safely within a specified time frame to a critical care unit that has that capability.

6.2 The role of Welsh Health Specialised Services

Committee (WHSSC) WHSSC has a role in ensuring that there is fair equitable

access to specialist services. The areas of current concern to

critical care relate to Extra Corporeal Membrane Oxygenation (ECMO) for severe refractory respiratory failure and Long

term invasive ventilation (LTIV).

ECMO is rarely required and the population of Wales cannot probably currently economically support such a service.

Commissioning of services may therefore be required in England. Recommendations have been made by the Networks

to the WG following the impact of influenza in 2010/2011.

LTIV is an area where there will be a growing requirement for home ventilation. These patients should be cared for in

designated LTIV beds which are appropriate for their specialist needs and not in acute critical care beds where their needs

are not appropriately met.

6.3 The Role of Welsh Government

It is envisaged that rationalisation of acute hospital services

onto fewer sites will increase the number of transfers of sick patients over increased distances.

At present transfers of the critically ill between critical care

units for clinical and non-clinical reasons have been conducted by the Welsh Ambulance Service Trust (WAST) and critical

care staff. This “Strategic Vision for Critical Care services” will by design require an increase in transfers of critically ill

patients to ensure best care. Whilst great improvements in the safety and accountability of transfers of the critically ill

have already been made there may be further advantage in having a dedicated transfer and retrieval service for critically

ill patients. The development of a new service crossing Health


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Board boundaries will require clinical leadership allied with

new investment to make it work. In practice such investment in a new service will most likely require the direct involvement

of the Welsh Government. The additional advantage of the service might be to allay and reassure the public and NHS

staff that whilst all local general hospitals may not be able to provide every acute service on-site there is the availability of

a transfer and retrieval service to move very sick patients quickly and safely to a hospital that can.

All workstreams regarding critical care at an all Wales

strategic level must be referred to the National Strategic Advisory Group (NSAG) Anaesthetics, Sub-Group Critical

Care, or its equivalent.

The Welsh Government will hold NHS Wales to account for

delivery of their local services.

7. Reporting and Monitoring Compliance with these standards and plans for addressing any

shortfalls, should be timetabled and costed. These must be reported to LHB Clinical Governance Committees (or their

equivalent) and to the Critical Care Network Board every six months.

The Critical Care Networks in conjunction with the Health

Board’s CCDG will provide Health Board Chief Executives and

the Welsh Government with an annual report on action plans against compliance shortfalls.


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Appendix 1. Tiers of Critical Care Units

This service model recognises that all critical care facilities cannot be provided on all hospital sites. Sicker patients will

sometimes have to be moved to larger units for specialist care. Each Critical Care Unit should be designated as one of

the following Tiers; this will determine how it functions within the Health Board and regional Network.

Tier 1 Unit

District General Hospitals providing Level 2 care only.

There need to be clear pathways regarding ability to escalate care

and the skills to resuscitate, package and transfer all Level 3 patients safely to a higher tier unit.

Medical staffing

Consultants: it is recommended that there is a minimum of 7 sessions/week from a Critical Care Trained Consultant1 for a unit of

up to ten beds. The number would need to be increased with higher bed numbers.

The remaining cover may be provided by Medical and Surgical Care

with Anaesthetic cover. Staffing need not be dedicated and can attend to other duties in the hospital i.e. cardiac arrest, anaesthesia

(e.g. obstetric anaesthesia) or surgery. There does however need to be immediate access to staff with advanced airway training.

If an ACCP tier is put in to replace a junior medical team arrangements would need to be made for advanced airway cover.

Arrangements must be in place for advice to be available from a

Critical Care Consultant 24hrs/day, 7 days a week but this need not be on-site.

These may be “open” units but they must supply data through

ICNARC case mix programme and other outlined outcome measures.

1"Critical Care Consultant" = Consultant with a Certified Completion of Training in Critical Care,

equivalent training, or current working daytime sessional commitment e.g. existing Critical Care Consultants with day time sessional commitment to Critical Care in their job plan, or recognised critical care training (approved by the Faculty of Intensive Care Medicine) from abroad. Consultants must demonstrate continuing professional development to Critical Care in their annual appraisal.


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Tier 2 Unit

District General Hospitals looking to provide Level 2 care and short term (<48hrs) Level 3 Care.

This would include all hospitals with acute unselected medical and

surgical on-call (“take”).

Medical Staffing Consultants: it is recommended that there are 14 sessions/week

for up to an eight to ten bedded unit. These Tier 2 Units need 24 hour cover by Anaesthetists with the necessary skills and training to

intubate and ventilate patients. Level 2 patients should be reviewed daily by a trained Critical Care Consultant and Level 3 patients twice

daily. Arrangements must be in place for advice to be available from a Critical Care Consultant 24hrs/day, 7 days a week if out of hours

cover is provided by Anaesthesia.

The middle grade/trainees: There should be a dedicated junior tier

of medical staff 24 hours a day for the unit seven days a week without commitments outside of the unit except to acutely critically

ill patients. This applies to a unit of up to 8-10 beds; additional staffing is required for larger units.

If an ACCP tier is put in to replace a junior medical team

arrangements would need to be made for advanced airway cover.

On call commitments: these units may be covered by anaesthetics out of hours.

Tier 2 units should function as closed units2.

Tier 3 and Tier 3T Hospitals providing long term Level 3 Care and specialist level 3

Care.

Some District General Hospitals, and Teaching Hospitals. Tier 3 Units must be able to provide long term Level 3 care to patients

with multiple organ failure.

Medical Staffing Consultants: As with Tier 2 units, all Level 3 patients need review

within at least 12 hours of admission by a Critical Care Consultant. In addition Tier 3 units should have a dedicated Critical Care

Consultant on-call rota.

2 "Closed units" = units where admissions, discharges and care are under the direction of the Critical

Care consultant. An open unit may admit patients without critical care involvement.


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The middle grade/trainees: There should be a 24 hour dedicated

junior tier of medical staff for the unit without commitments outside of critical care and large units should have a medical team per 8-10

Level 3 patients.

If an ACCP tier is put in to replace a junior medical team arrangements would need to be made for advanced airway cover.

Tier 3T Units

These units are those as above but also with specialist services including Neurocritical Care, Cardiothoracics, Respiratory Centre

recognition and Burns. In view of the complexity of patient care these units may wish to extend to resident consultant Intensivist

cover.

Tier 3 and Tier 3T should function as closed units3.

Medical Staffing

“No amount of equipment can compensate for the lack of appropriately trained staff’. Department of Health ‘Comprehensive

Critical Care ‘A review of Adult Critical Care Services.’ 2000

Medical staffing has been a challenge and is set to become more of a challenge in terms of numbers of trainees and meeting consultant

staff requirements.

Specialist and multi-organ support for Level 3 patients needs specialist critical care input from those with the appropriate

recognised training. Cross cover by Anaesthetists is entirely appropriate for the initiation of short term critical care where there

is an emphasis on resuscitation and stabilisation; however it is not

appropriate for those with prolonged critical care needs. This emphasis on the patient’s requirements needs to be accepted and

units need to be staffed by appropriately trained clinicians according to the tier of the unit.

The Strategic Vision acknowledges that those units seeking to

resuscitate, stabilise and transfer all Level 2 patients (Tier 1) cannot and need not meet the same staffing requirements of those units

seeking to provide prolonged Level 3 care with complex critical care needs (Tier 3).

3 "Closed units" = units where admissions, discharges and care are under the direction of the Critical

Care consultant. An open unit may admit patients without critical care involvement.


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There are significant factors impinging on how a critical care service

is going to be delivered over the short, medium and long term across Wales. These include:

1. A reduction in training hours brought about by the European

Working Time Directive (EWTD). 2. A call by the Royal College of Anaesthetists for a reduction in

service delivery to critical care. A training commitment in critical care for Anaesthetists remains due to competencies

being best met by some competency assessed training in critical care medicine.

3. A deanery recommended increase in the number of trainees per rota from 1:8 to 1:10 (11).

4. The Faculty of Intensive Care Medicine (FICM) has from 2012 dedicated critical care medicine trainees but the numbers are

very small (4 posts in Wales 2012).

In view of the above, alternative staffing utilising Advanced Critical

Care Practitioners (ACCPs), Staff Grade and Associate specialists (SAS), and post Completion of Certified Training (CCT) doctors need

to be further explored and initial investment made in the medium to long term to create a team to provide the necessary service. An

ACCP course exists in Cardiff from 2012. The costs of a 2 to 3 year training course, back-filling the nursing posts need addressing.

Medical staffing as a whole needs to be jointly addressed by Health Boards, the Welsh Deanery, and the Critical Care professional

bodies – Welsh Intensive Care Society (WICS), the Critical Care Networks and the NSAG for anaesthesia and critical care.

It is generally accepted that a critical care team, led by a

consultant, would be able to care for up to 10 critically ill patients. A

unit with more than 10 patients would therefore require more than 1 team. A team would traditionally comprise a nurse at the bedside,

a junior doctor and a consultant. It is likely in future that ACCPs who have undergone competency-based and assessed training will

replace scarce junior doctors provided there is still 24 hour resident advanced airway skills on-site to call on. This advanced airway

service would usually be provided by anaesthesia except in large Tier 3 and 3T units which may find it advantageous to have resident

intensivists. These may be senior critical care trainees or consultant intensivists. A critical care consultant working without a team would

be able to safely look after less than 10 patients.

In addition consultant staffing models will need to be flexible taking into account feminisation of the workforce, retirement age, and

movement of intensive care consultants out of critical care into


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other specialities with less onerous out-of-hours commitments

during their later working life.

Table 1. Critical Care Tiers.

The Medical staffing requirements reflect the minimal level of recommended input.

Unit

Tier

Level 3 Care Critical Care

Consultant

Staffing

Anaesthesia

Consultant

Dedicated

Critical Care

tier

Level of patient care

provided

Tier 1 Ability to intubate

/ventilate/transfer

Level 3 patients

7 session/week Yes, in

emergencies

0 Level 2 only

Tier 2 Level 3 care

<48hrs

14 session weekly

commitment by a

Critical Care

Consultant rota

Overnight out of

hours cover

acceptable

within the 12

hourly review by

a Critical Care

Consultant

Dedicated Level 2 and short

term level 3

Tier 3 Prolonged level 3

care

Dedicated Critical

Care Consultant

rota, > 14

sessions/week.

Emergency

unpredictable

only

Dedicated Level 2 and

prolonged level 3

care

Tier 3T Prolonged level 3

care and specialist

care

Dedicated Critical

Care Consultant

rota

Emergency

unpredictable

only

Dedicated Level 2, 3 and

specialist care.


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Appendix 2 - Quality Requirements, infrastructure and staffing requirements for Adult Intensive Care Quality Requirement Tier 1 Tier 2 Tier 3

Structures

Monitoring

Access to non-invasive blood pressure

monitors, cardiopulmonary resuscitation

equipment, pulse oximeters and patient

controlled analgesia devices

At every bed there must be monitors

displaying continuous ECG, respiratory

rate, pulse oximetry, invasive venous

pressure, invasive arterial pressure,

capnography

Facilities for advanced cardiovascular

system monitoring

Respiratory Support

Access to oxygen and suction

equipment

Availability of humidification for the

upper airway

At every bed there must be

humidification equipment available, 2

oxygen outlets, 2 air outlets, 2 suction

outlets, multiple power sockets

Access to non invasive ventilation

equipment

Facilities for difficult intubation

Facilities for short-term invasive

respiratory support

Facilities for long-term invasive

respiratory support

Quality Requirement Tier 1 Tier 2 Tier 3

Other Organ Support

Access to additional organ support,

diagnostic and monitoring equipment

appropriate to the unit’s case mix

Facilities for active re-warming of

hypothermic patients

Access to appropriate communication

aids

At every bed there must be drug

infusion devices and volumetric infusion

pumps

Access to a chair or specialist bed to

facilitate early rehabilitation

Specialist manual handling equipment

Bedside services must be as per HBN 57


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Access to Diagnostics

Access to plain film radiology,

ultrasonography and computerised

tomography

Rapid access to plain film radiology,

ultrasonography and computerised

tomography

Access to blood transfusion services 24

hours per day everyday

Access to biochemistry, haematology,

microbiology laboratory services 24

hours every day

Rapid access to blood gas analysis

Immediate access to blood gas analysis

24 hour immediate access to blood

transfusion services

24 hour immediate access to

biochemistry, haematology,

microbiology and toxicology

There must be on site 24hr emergency

access to magnetic resonance imaging

Patient Transport

Availability of full transfer equipment as

per guidelines

Medical Staff

All medical staff must be familiar with

protocols for communicating information

about sick patients to senior staff and

critical care outreach teams

Medical staff should be supported by the

multidisciplinary critical care team

There must be a designated lead

consultant with critical care training and

a sessional commitment

On the hospital site there must be 24

hour availability of medical staff from

the referring speciality.

On the hospital site there must be 24

hour availability of anaesthetic staff

A minimum of 14 sessions from critical

care consultants per week

There must be 24 hour availability of a

consultant with recognised training in

ICM and no other commitments

Resident trainees should include doctors

from Intensive Care Medicine, Surgery,

Medicine, Emergency Medicine and/ or

Anaesthesia

Full time resident medical cover must be

available. This should be at above

Foundation Programme level

Each resident doctor must care for no

more than 10 critically ill patients


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Nursing Staff

Skill mix must be based on Audit

Commission data or benchmarking

within the Network

A staffing ratio of 0.5 nurses per Level 2

patient

A staffing ratio of one nurse per Level 3

patient should be achieved

Flexible strategies should be employed

to allow for fluctuating dependency of

the patients

At least 70% of nurses should have a

specialist qualification in critical care

nursing

At least 40% of nurses should have a

specialist qualification in critical care

nursing

Senior Registered Practitioners with a

minimum of 4 years experience in the

specialist field should hold senior

positions including sister/charge nurse,

practice educators and practice

development facilitators

Provision for education and training to

support early management of critical

illness and referral to outreach/critical

care

A registered practitioner on each shift

with training in acute care competencies

There must be access to an ongoing

education programme, to ensure the

appropriate level of knowledge and skills

Tier 1 units serve a specialist nurse

training function

Availability of in house competency

based training and NVQ training for all

Health Care Support Workers

A minimum of one senior registered

practitioner per shift should be in a co-

ordinating role

There must be prompt access to

practitioners suitably skilled in transfer

of the critically ill patient

Unit staffing levels must reflect

flexibility for provision of a retrieval

team

Allied Health Professionals

Access to physiotherapy service Monday

to Friday

Access to 24/7 on-call emergency

respiratory care physiotherapy service

Training programme to support the

development and maintenance of

specialist respiratory skills

Provision of specialist respiratory service

by highly specialised Physiotherapists


23

Chartered Society of physiotherapy

standards and local protocols of care

must be followed

Appropriate Physiotherapy staffing

levels Physiotherapy staff/patient ratio

1:5

Access to dietetics service Monday to

Friday

Provision of highly specialised dietetic

service by Specialist Dieticians

Access to Occupational Therapy service

Monday to Friday

Access to speech and language therapy

service which has appropriately skilled

staff within the fields of complex

communication and dysphagia to

provide input to all levels Monday to

Friday

Ward visited by pharmacist Monday to

Friday

Access to on-call pharmacy services

overnight and weekends

There should be 0.05-0.1 WTE

specialist/advanced pharmacist per bed

Access to social work service every day

There must be access to a bereavement

counselling service

On-call dietetics service at weekends

and public holidays

Dietetic staffing levels must be

appropriate to ward speciality and

casemix - 1.0 WTE per 80 general

inpatient beds minimum

There should be 0.05-0.1 WTE dieticians

per bed

SLT service delivered by a Specialist

SLT

Speech and language therapist to be an

integral member of tracheostomy team

Pharmacy service provided 7 days a

week by a specialist/advanced

pharmacist with a minimum of 2 years

hospital experience with ICU training

Occupational therapy service delivered

by Senior Occupational Therapist - 0.5

WTE per ward

All speech and language therapy

referrals to be seen within two working

days

Access to psychology service within 24

hours


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Policies and Governance

All equipment must be maintained and

in working order

All staff must receive training in the use

of bedside equipment with which they

are expected to work and this must be

recorded

Every Health Board must form a multi

disciplinary (including patient

representation) “Critical Care Delivery

Group” with a clear reporting

mechanism

A system must be in place for reporting,

investigating and learning from adverse

incidents and near misses

A system must be in place for

monitoring patient/relative satisfaction.

There must be a designated individual

who is responsible for co-ordinating

audit activities

There must be clearly defined links to

Tier 3 units in the Network

Every unit must provide staffing to

advise and assist with the care of

critically ill patients outside the

intensive care unit at all times

Well developed and clearly defined links

between all Tiers in the hospital and the

Network

A protocol must be in place for

identification of critically ill patients on

general wards

Written protocols must give details of

how to contact the service

Protocols must be in place for admission

and discharge

Protocols must be in place to allow the

patient to be moved between

dependency levels with minimal

disruption and no delay

Protocols must be in place for

assessment of dysphagic patients


assessment and management of

patients with tracheostomy


assessment and management of

communication problems


communication with a critical care

consultant

A system must be in place to ensure

appropriate information is available to

patients/relatives


25

Information on the functioning of the

unit must be available for patients and

relatives and new staff and referring

clinicians

Protocols must be in place for use of

invasive monitoring

Protocols must be in place for all

invasive procedures

There must be a range of clinical

guidelines agreed by the Critical Care

Network

There must be access to overnight

accommodation for relatives

A recognised audit /data clerk who must

be appropriately trained for Intensive

Care National Audit and Research

Centre (ICNARC) and other unit data

collection must be on duty every day

A ward receptionist must be on duty

every day


Processes

All LHBs must participate in RRAILS

Critical care units to comply with NICE

50


83


56

Critical care units to comply with the

following care bundles:

Skin

Ventilator

ARDS

CVP maintenance

All units to undertake hand hygiene

audit every 6 months

All premature discharges to be reported

as a clinical incident through IR1

process

All out of hours discharges to be

reported as a clinical incident through

IR1 process

All non-clinical transfers to be reported

as a clinical incident through IR1

process

Organ donation referral considered for

all patients on end of life pathway

An audit of all these quality

requirements must be reported to the

Health board Clinical

Governance Committee every six

months


26

Exception reporting to the Health Board

must occur when patient safety is

compromised

Each unit must undertake the National

Carers Questionnaire annually

There must be regular multidisciplinary

meetings

There must be regular reviews of

patient outcomes by morbidity and

mortality meetings

All Level 3 patients must be reviewed by

a critical care consultant within 12 hours

of admission and 12 hourly thereafter

All Level 2 patients must be reviewed by

a consultant within 12 hours of

admission and thereafter 24 hourly

The unit must participate in the

Intensive Care National Audit and

Research Centre Casemix Programme


27

Appendix 3.

Direct and Indirect Outcomes Measures An expanded rationale for their use

1. Delayed Transfers of Care (DToC)

Rationale: In spite of targets issued by Welsh Government to reduce delays in

patient transfer from critical care, patients’ discharges are still delayed in more than 50% of cases across Wales; this is a long way

from the target of less than 5% (The Annual Operating Framework 2010 -2011 Target 8.) and equates to significant ‘bed hours’ lost.

DToCs not only prevent patients who are critically ill from accessing the treatment they need, but also have a detrimental effect on the

recovery and rehabilitation of patients whose transfers are delayed. DToCs also have a detrimental effect on patient safety as they

result in cancelled operations and non-clinical transfers, both known

to increase morbidity and mortality. DToCs also have a financial implication since a critical care bed is the most costly in the

hospital.

Reducing DToCs will result in improved flow through units which will improve utilisation of critical care beds.

Outcome:

• Reduced harm (morbidity); • Fewer instances of delayed access to critical care.

• Reduced waste. • Improved equity.

Actions to include:

Escalation of delayed transfers of critical care;

Regular reporting at Local Health Board executive level on Delayed Transfers of Care and its effects on patients.

Indicative performance measures:

Hours lost due to Delayed Transfers of Care; Numbers of patients with a delayed transfer from critical care;

Impact of Delayed Transfers of Care e.g. cancelled operations, non-clinical transfers.

Organisations accountable:

Health Boards


28

2. Out of Hours discharges

Rationale:

Discharges outside normal hours [between 10pm and 7am] have been shown to put patients at risk (Goldfrad C, Rowan K: Consequences of

discharges from intensive care at night. Lancet 2000; 355:1138-1142. Tobin AE, Santamaria JD: After-hours discharges from intensive care are associated with increased mortality. Med J Aust 2006;

184:334-337)

These patients may be premature or delayed discharges.

Outcome: • Improved patient safety;

• Reduced morbidity.

Actions to include:

Reporting of all out of hours discharges through the Local Health Boards’;

Regular reporting of out of hours discharges at Local Health Boards’ Critical Care Delivery Groups (CCDG) and Clinical Governance

Committees.

Indicative performance measures: Number of out of hours discharges from critical care.

Number of out of hours discharges from critical care cross referenced with DToCs;

Out of hours discharges as percentage of all critical care discharges.

Organisations accountable: Health Boards

3. Premature discharges

Rationale: Clinicians, in light of scarce critical care resources, sometimes have

to make difficult decisions as to which patients would better benefit from a critical care bed. In cases where patients are discharged

prematurely, there is a greater risk of mortality and later readmission to critical care.

Outcome:

• Fewer instances of premature discharges. • Reduced mortality.

Actions to include:

Reporting of premature discharges through the Local Health Boards’

clinical incident mechanisms for investigation;


29

Regular discussion of premature discharges at Local Health Boards’

CCDG and Clinical Governance Committees.

Indicative performance measures: Number of premature discharges from critical care;

Premature discharges as percentage of all critical care discharges.


4. Readmissions within 48 hours

Rationale:

Readmission within 48 hours of discharge from critical care can indicate that the patient was discharged from critical care too soon.

Readmission within 48 hours is ranked as a top quality indicator by

the American Society of Critical Care Medicine and by the European Society of Intensive Care Medicine task force on quality and safety

of critical care.

Outcome: • Fewer instances of readmissions within 48 hours.

• Reduced mortality and morbidity.

Actions to include: Regular discussion of critical care re-admissions within 48 hours at

Local Health Boards’ CCDG and clinical governance committees.

Indicative performance measures: Number of readmissions within 48 hours to critical care;

Readmissions within 48 hours as percentage of all critical care

discharges.


5. Non-clinical transfers

Rationale:

Transferring a critically ill patient represents a risk to patient safety. Where a clinical transfer is necessary in order to access specialist

services the risk is acceptable provided the transfer is done to acceptable set standards. If the transfer is needed just because a

bed is not available then this risk is unacceptable. However, sometimes it is necessary to transfer patients where there are no

beds available.


30

Outcome:

• Fewer instances of non-clinical transfers • Reduced morbidity.

Actions to include:

Cross reference non clinical transfers with delayed transfers of care in critical care.

Reporting all non-clinical transfers through the Local Health Boards’ clinical incident mechanisms for investigation;

Regular discussion of non-clinical transfers at Local Health Boards’ CCDG and Clinical Governance Committees.


Number of non-clinical critical care transfers from hospital cross referenced with DToCs;

Number of days since last non-clinical transfer.

6. Cancelled operations

Rationale:

Elective, high risk surgery is sometimes cancelled due to lack of critical care beds.

Cancellation of elective surgery due to lack of a critical care bed

may be an indicator of inefficiency, lack of flexibility and/or under-capacity within the whole hospital system and can lead to poorer

patient outcomes. It also impacts on RTTs.

Outcome: • Fewer instances of cancelled operations due to lack of critical

care beds.

• Reduced morbidity and mortality. • Decreased financial loss.

Actions to include:

Cross reference cancelled operations due to lack of a critical care bed with delayed transfers of care in critical care.

Regular discussion of cancelled operations due to lack of a critical care bed Local Health Boards’ CCDG and Clinical Governance

Committees.

Examples of indicative performance measures: Number of cancelled operations due to lack of a critical care bed.

Number of cancelled operations due to lack of a critical care bed cross referenced with delayed transfers of care;

Days since last cancelled operation.


31


Health Boards

7. Standardised Mortality Rates (SMR)

Rationale: A units’ SMR is derived from data supplied by all units in Wales to

the Intensive Care National Audit and Research Centre (ICNARC) database. The data is case mix adjusted for patients’ co-morbidities

and admission diagnosis. Units are also compared against other units with similar admission numbers and case mix (e.g numbers of

elective surgical admissions). A score outside 2 standard deviations may indicate a problem and requires a review especially if part of a

trend.

Outcome:

• Learn from best practice from other units with a low SMR • Reducing mortality by review of practice

8. Participation in national clinical quality initiatives, such as 1000 Lives Plus & Rapid Response to Acute Illness Learning

Session [RRAILS]

Rationale: Providing a rapid response to patients who become acutely ill in

hospital can prevent deterioration and reduce morbidity and mortality.

Outcome:

• Reduced morbidity and mortality.

Actions to include:

Completion of action plans to implement improvements in key areas identified through RRAILS and 1000 Lives Plus.


Cardiac arrest rates Severe sepsis care bundle compliance


Health Boards Networks


32

9. Implementation of relevant guidance from the National

Institute of Quality and Clinical Excellence [NICE]

Rationale: Researched and peer-reviewed guidance issued by NICE is the

standard by which care should be delivered when guidance is available. Implementation of good practice guidance will improve

quality of care, reduce morbidity and mortality and improve patient experience.

Outcome:

• Improved patient safety. • Reduced morbidity and mortality.

Actions to include:

Undertaking an audit of compliance with any relevant NICE

guidance within 6 months of its launch. Development of costed, time-specific action plans for

implementation of published clinical guidelines. Re-audit by Local Health Boards against Clinical Guideline

recommendations using available tools every 6 months. Reporting audit results and progress against action plans to LHB

CCDG and Clinical Governance Committee and Network Board six monthly.


Completion of NICE self-assessment questionnaires to be mandated with results and progress with action plans to be fed back through

the Critical Care Network Board every six months.


Health Boards

10. Reduction in healthcare acquired infections and harm within Critical Care

Rationale:

Healthcare acquired infections cause harm to patients and lead to poorer outcomes, prolonged hospital stay and poor patient

experience.

Outcome: • Reduced infection rates.

• Reduced morbidity and mortality.

Actions to include:

Compliance with relevant bundles of care.


33

Compliance with reporting to Welsh Hospitals Acquired Infections

Programme (WHAIP) Monthly hand hygiene audit at all critical care units.


Ventilator-associated pneumonia rates Central venous catheter infection prevalence and days between

“never events”; Catheter-associated urinary tract infection rates and days between

“never events”; Hand hygiene audit;

Action plan for continuous quality improvement in reduction of healthcare associated infections.


Health Boards

11. Implementation and compliance with relevant care

bundles and best practice audits

Rationale: The development and implementation of care bundles has been

proven to improve the quality of care in those hospitals that adhere to them. The implementation of central venous catheter, ventilator,

sepsis, skin and peripheral catheter bundles have helped to standardise and improve care offered to patients.

Outcome:

• Reduced lengths of stay. • Reduced morbidity and mortality.

Actions to include: Regular audit and production of action plans for continuous quality

improvement; Root cause analysis of circumstances surrounding “never events”

with action plans to prevent recurrence; Regular reporting of audit results and progress against action plans

to CCDGs and Health Board clinical governance committees.

Indicative performance measures: WHAIP reports;

Reporting and investigation of all ventilator-associated pneumonia, central venous catheter and urinary catheter-associated infections;

Hand hygiene audit and development of continuous quality improvement action plan;


34

Number of days between pressure damage “never events” including

damage from medical devices, and action plan to address root causes.


Health Boards

12. Patient and public involvement

Rationale: In addition to the provision of high quality clinical care, it is vital

that patients, families and carers are involved in making sure the care they receive is appropriate to them and takes account of their

needs.

Outcome:

• Fewer complaints • Well-supported patients and families.

Actions to include:

Completion of patient and carer involvement plans to be submitted to Critical Care Networks annually;

Survey of carers of critical care patients using the ICS Carer Survey with results reported to the Critical Care Network;

Report on involvement activities undertaken, results, and subsequent actions, to LHB CCDG, Clinical Governance Committee

and Network Board six monthly.

Indicative performance measures: Results from questionnaires

Evidence of involvement of patient representatives in CCDGs

Qualitative and quantitative data from follow-up clinics Actions undertaken in response to feedback received.


Health Boards

13. Delayed admissions

Rationale: Delayed admission to critical care causes harm to patients if

escalation of care is delayed.

Outcome: Reduce morbidity and mortality

Shorter lengths of stay


35

Actions:

Any patient who has been identified by a critical care consultant or a senior member of the team as critically ill and requiring critical

care admission must be admitted within one hour of the time of acceptance. If the patient is in theatre, this time starts from the end

of the operation. Deviations from this must be submitted to Local Health Boards’

CCDG and clinical governance committees on a regular basis.

Indicative performance measures: Patients must be admitted to critical care within one hour after

acceptance by the critical care team. The numbers of patients who breach this target as a percentage of

total admissions

Organisation accountable:

Health Boards

a strategic vision for critical care services in wales

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