critical care programme newsletter no. 3 15 … · critical care programme newsletter no. 3 ......

CRITICAL CARE PROGRAMME NEWSLETTER No. 3 15th Jan 2018

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Critical Care Programme is pleased to forward its third Newsletter.

Due to the hard work and the strong support of many, clinicians, administrators, political system alike, not

only in 2017 but also over the years, a recognition of the need for critical care capacity provision for

critically ill adult patients, according to a ‘hub-and-spoke’ provision model, is now being realised.

Critical Care Programme gratefully acknowledges the strong support of its work by Joint Faculty of

Intensive Care Medicine of Ireland (JFICMI), College of Anaesthetists of Ireland (CAI), Intensive Care

Society of Ireland (ICSI), Office of Nursing and Midwifery Services Director (ONMSD), HSE, Irish

Association of Critical Care Nurses (IACCN), Clinical Strategy and Programmes Directorate HSE, Acute

Hospitals Division HSE, National Transport Medicine Service HSE and National ICU Audit NOCA.

HSE National Service Plan 2018- Published 20th Dec 2017

On 20/12/17 HSE published its National Service Plan 2018. (The extracts relevant to critical care capacity

provision are copied below, in italics).

Of note, and for the first time in a HSE National Service Plan, following advocacy from both inside and

outside HSE, Intensive Care Society of Ireland (ICSI), Irish Association of Critical Care Nurses (IACCN)

and Irish Hospital Consultants Association (IHCA), critical care capacity provision is prioritised as a policy

direction in HSE National Service Plan 2018 by a ‘line-item’.

In real terms then, critical care capacity resource is also allocated to CUH and Mater MUH in 2018 (p53).

In 2017, a similar HSE National Service Plan 2017 allocation resulted in the commissioning and

commencement in operation of two new, extra, additional ICU beds in Cork University Hospital (CUH) in

Nov 2017 to serve sub-regional, regional and supra-regional critically ill adult patient needs across Cork,

the SSWHG and the south of Ireland.

HSE National Service Plan 2018

“Priorities 2018

Increase critical care capacity.” (p53)


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“HSE National Service Plan 2018

Building a Better Health Service

“Key reform themes Consistent with the need to improve the health of the population, and to radically reshape where and how services are provided, we shall be pursuing four key reform themes during 2018 and beyond, namely: 1. Improving population health. 2. Delivering care closer to home. 3. Developing specialist hospital care networks. 4. Improving quality, safety and value. (p5)

“3. Developing specialist hospital care networks During 2018 and beyond, we will seek to progress a range of initiatives and actions that:… Demonstrably support the delivery of safe, high quality complex, specialised and emergency care in specific locations. (p7)

“Section 3: Building a Better Health Service A number of programmes are underway, supported by evidence, that offer potential to shift the balance of care. We are prioritising the continuation and further support for initiatives under these programmes in 2018, in the knowledge that they will lay the necessary foundations for developing a more sustainable health service into the future. (p11)

“National Clinical and Integrated Care Programmes The work of the national clinical and integrated care programmes to date, when piloted and evaluated, provides strong evidence to demonstrate that significant improvements in the delivery of health and social care services can be achieved when compared to previous models and ways of working. (p14)

“Develop specialist hospital care networks Redesign acute service to meet the long term needs of the population, providing timely access to the right services, regionally and nationally, that consistently deliver best clinical outcomes… [T]here is a need to ensure that the secondary and tertiary care sectors are able to deliver the complex, specialised and emergency care that will be required by patients. (p16)

“Acute Hospital Services Services provided. Acute services include emergency care, urgent care, short term stabilisation, scheduled care, trauma, acute surgery, critical care and pre-hospital care for adults and children. (p50)

“Acute Hospital Services Issues and opportunities. The increase in funding for acute hospital services in recent years is welcome…. There are critical care capacity deficits in hospitals across the country. Following the organisation of hospitals into Hospital Groups, it is clear that critical care capacity building is required in the ‘hub’ hospitals to meet the on-going and increasing critical care requirements of complex, multi-specialty, severely critically ill patients. It is known that access delays for critically ill patients arising from capacity deficits is associated with increased mortality, increased costs and poorer outcomes. (p51)


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“Priorities 2018 Increase critical care capacity. (p53)

“Implementing priorities 2018 in line with Corporate Plan goals Corporate Plan Goal 2: Provide fair, equitable and timely access to quality, safe health services that people need Increase critical care capacity - Enhance critical care capacity with the opening of additional capacity at Cork University Hospital and Mater Misericordiae University Hospital, Dublin. (p53)

“Capital funding 2018 Separately, a provision of €478m in capital funding will be made available to the HSE in 2018, comprising €418m for building, equipping and furnishing of health facilities, and €60m for ICT. (p76)

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Thus, HSE National Service Plan 2018 acknowledges “critical care capacity deficits in hospitals across

the country”. Furthermore, the Critical Care Programme ‘hub-and-spoke’ Model of Care aligns with HSE

National Service Plan 2018- “it is clear that critical care capacity building is required in the ‘hub’ hospitals

to meet the on-going and increasing critical care requirements of complex, multi-specialty, severely

critically ill patients” (HSE National Service Plan 2018 p51).

Critical Care Capacity Census 2017

The annual national adult Critical Care Bed Capacity Census measures capacity as at 30th September 2017.

The Census reports a capacity of 240 adult critical care (Level3 ICU and Level2 HDU) beds. Following

resource allocation in HSE NSP2017 and following approval by Minister Harris and implementation of the

Critical Care Nursing workforce plan, Career Pathway, and the concerted hard work of clinicians and

administrators alike, in 2017, there was an increase of seven ‘hub’ ICU beds across Ireland.

However, the 2017 Census also reports an additional 7.5% of adult critical care bed capacity or eighteen

(18) adult ICU beds remain ‘funding allocated, non-operational’. To solve this problem, the Critical Care

Nursing Workforce Planning Working Group of each Hospital Group and hub Hospital is now facilitating

the implementation of the national Critical Care Nursing workforce plan, Career Pathway, to recruit

nursing graduates to permanent pensionable full-time staff nurse posts, immediately on graduation, to

receive standardized and accredited critical care nursing postgraduate specialty certification education and

training.


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CRITICAL CARE BED CAPACITY CENSUS SEPTEMBER 2017

CRITICAL CARE SERVICE Unit (ICM National Standards)

Level 3s ICU Beds

Level 3 ICU Beds

Level 2 HDU Beds

Critical Care Bed Capacity 2017

ICM National Standard outlier

Commissioned Critical Care Beds (funding allocated, not operational) 2017

Bed spaces available (not commissioned 2017)

Critical Care Bed Capacity 2016

RCSI Hospital Group

Cavan ICU 2 2 4 1 4

Drogheda ICU 5 3 8 1 6 8

Beaumont General ICU

9 9 1 2 8 (+1)

Beaumont HDU

8

Beaumont Neuro ICU

8 8 2 7 (+1)

Connolly Hospital ICU

5 5

5

Dublin Midlands Hospital Group

Naas ICU 3 0

3 2 4(-1)

Portlaoise ICU 2 2 ICM National Standard outlier

2

Tullamore ICU 4 4 3 4

AMNCH ICU 9 2 11 11

AMNCH PACU 2 2 2

St James Burns ICU

2 2 2

St James ICU/HDU

18 0 18 2 4 18

St James CardioTh ICU

6 6 6

Ireland East Hospital Group

Mater ICU/HDU 17 12 29

7 27(+2)

Mullingar ICU 5 1 6 6


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Navan ICU 2

2 ICM National Standard outlier

2

St Vincents ICU/HDU

10 6 16

15(+1)

Kilkenny ICU 4 4 ICM National Standard outlier

4

Wexford ICU 5 5 5

South- South West Hospital Group

Clonmel ICU 4 4 1 4

Waterford ICU 5 4 9 1 9

Cork CUH CardioTh ICU

6 6 4 6

Cork CUH General ICU

11 11 1 7 9(+2)

Cork CUH HDU

12

Mercy ICU 5 5 1 3 5

Tralee ICU 4 1

5 1 5

Saolta Hospital Group

Letterkenny ICU 5 5 5

Ballinasloe ICU 2 3

5 1 5

Castlebar ICU 2 2 4 4

Sligo ICU 5 5 1 1 5

Galway UHG CardioTh ICU

4 4 2 4

Galway UHG Gen ICU/HDU

11 6 17 2 17

Univ Limerick Hospital Group

Limerick UHL ICU/HDU

8 8 16 ICM National Standard outlier

12 16

TOTAL 240 18 71 237


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Critical Care Activity Measure 2016 (reported in 2017 Census)

HSE Acute Hospitals Directorate requests an annual profile of critical care activity in all adult ICUs in

Ireland. Activity is estimated using the comparator- invasive ventilatory support. On collation Census 2017

reports just over 7,339 critically ill adult patients received invasive ventilatory support in Ireland in 2016.

In summary, the 8 central hospitals deliver 72% of critical care activity in Ireland with the remaining 18

hospitals delivering 28% of critical care activity, using this measure.

(Limitation- It should be noted the measure is a crude comparator as noninvasive ventilatory support and other

invasive organ supports (e.g. continuous renal replacement therapy, pharmacologic and mechanical circulatory

supports, nutritional supports etc.) are also delivered to critically ill patients and for long durations in ICUs in

Ireland.)

Census Table Legend

ICM National Standard- in scope

ICM National Standard- outlier


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Graph. A profile of 2016 adult critical care activity in Ireland

Volume-outcome evidence in critical care.

There is a body of evidence in the intensive care medicine literature- and in other acute care literatures- to

support a volume-outcome relationship (Nguyen, Chest 2015). The ICM National Standard 2.4 references

this evidence- “For maintenance of skills and professional competencies, a Critical Care Service Unit will

likely be treating at least 200 Level 3 patients per annum and therefore likely to entail Critical Care Units

of 6 beds or more” (JFICMI National Standards 2011, p5).

In line with specialty service policy direction and in line with the evidence base, critical care capacity

provision and expansion at centres is required. HSE National Service Plan 2018 is clear on this- “Following

the organisation of hospitals into Hospital Groups, it is clear that critical care capacity building is required

in the ‘hub’ hospitals to meet the on-going and increasing critical care requirements of complex, multi-

specialty, severely critically ill patients” (p51).


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Critically Ill Adult Patients with Confirmed Influenza 2016-2017 Season

Fortunately, due to the decreased virulence of the predominant seasonal Influenza A(H3N2) strain as well

as increased vaccine uptake, the volume of adults with NVRL-confirmed influenza diagnosis admitted to

ICU decreased by 110 (or 68% decrease) in comparison with prior 2015-2016 influenza season. For the

prior 2015-2016 season HSE/HPSC ICU Influenza Surveillance recorded 127 critically ill adults were

admitted with influenza, a "133% rise", over the 2014-2015 season. In the 2015-2016 season predominant

influenza was Influenza A(H1N1).


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Critical Care Nursing Workforce Planning- Career Pathway

Launch by Mr. Simon Harris TD Minister for Health

On Sept 20th 2017 Mr. Simon Harris TD Minister for Health launched Career Pathway the national

standardised Critical Care Nursing postgraduate specialist education and training Programme in College of

Anaesthetists of Ireland, 22 Merrion Square, Dublin 2.

Pictured at the Launch of Career Pathway, the National Intensive Care Nursing Workforce Plan, by Mr. Simon Harris

TD Minister for Health 20th Sept 2017 at College of Anaesthetists of Ireland 22 Merrion Square Dublin were Mr.

Simon Harris TD, Minister for Health, Dr Michael Power National Clinical Lead Critical Care Programme, Ms. Mary

Wynne Director Office of Nursing and Midwifery Services Director, Mr. Derek Cribbin Nurse Lead Critical Care

Programme, Ms. Ger Shaw, Area Director of Nursing and Midwifery, Office of Nursing and Midwifery Services

Director, Ms. Una Quill, Programme Manager Critical Care Programme, Dr Jeanne Moriarty, Dean Joint Faculty of

Intensive Care Medicine of Ireland JFICMI, Dr Catherine Motherway President Intensive Care Society of Ireland


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ICSI, Dr Colm Henry National Clinical Advisor and Group Lead NCAGL Acute Hospitals Division HSE, Mr. Martin

McCormack CEO Ms. Margaret Jenkinson COO College of Anaesthetists of Ireland, Dr David Honan CAI.

Through Career Pathway Ireland’s graduate nurses now gain immediate access to postgraduate critical

care nursing education, training and certification on graduation in full-time staff nurse employment.

Figure. Career Pathway- national standardised postgraduate Critical Care Nursing education, training and certification

With the strong support of Ms Mary Wynne Director Office of Nursing and Midwifery Services Director

and Ms. Ger Shaw ONMSD, Career Pathway has been immediately successful in its first year with the

increase of ICU capacity by seven adult ICU beds in centres across Ireland with forty additional critical

care staff nurses.

In 2017, with university components based at UCD and UCC, thirty eight graduate nurses commenced

national standardised postgraduate Critical Care Nursing education, training and certification (see photos

below).


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In 2018 similarly, it is planned a second cohort of graduate nurses in full staff nurse employment at hospital

providers will commence postgraduate critical care nursing specialty education, training and certification.


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National ICU Audit NOCA update

Nine general hospitals are now participating in National ICU Audit; Beaumont, Mater, Tallaght, St James,

Drogheda, Limerick, Galway, Waterford and Mullingar.

We hope Cork University Hospital, St Vincents Hospital, Kilkenny and Wexford Hospitals will be

participating by mid-2018. It is hoped to extend the Audit to the remaining regional hospitals during 2018-

19, subject to support from the Hospital Groups.

Quality Indicator data from the Audit to date are reassuring; clinical outcomes are within acceptable limits

and broadly comparable to outcomes in UK Units (Fig 1).

We plan to publish an Annual Report of ICNARC reports for 2017 from Units where the Audit is well

established when the Reports are available.

Figure. Standardised Mortality Ratios (SMRs) from most recent data for the 7 Units with Reports available.

All SMRs are within acceptable limits for this metric.

Dr Rory Dwyer, Clinical Lead, National ICU Audit, NOCA, Jan 2018

A

B

C

D E

F G

0

0.2

0.4

0.6

0.8

1

1.2

1.4

SMR


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ICU Bed Information System

A system to identify vacant ICU beds would be very useful for clinicians who need to refer patients to

another Unit. A system to track the availability of ICU beds nationally has been a longstanding requirement

for the HSE.

The IT system for ICU Audit has the potential to populate a “Bed Information System” website with the

bed status in ICU’s participating in the ICU Audit. This would fill a significant deficit in information

required by clinicians who wish to transfer patients to another ICU and by the HSE in terms of live

information on the National ICU bed status (especially during surges in demand and in the event of an

Emergency e.g. terror attack).

This project has been funded by the HSE and substantial work has been done to develop the website. St

James Hospital has agreed to act as a pilot site for the project; we hope this will can be extended from there

into a national system.


‘Time to access an ICU bed’ as a Key Performance Indicator

The national shortage of ICU beds commonly leads to significant delays in accessing an ICU bed. This is

compounded by delays in discharging ICU patients because patients from ED are usually prioritised when

a ward bed is vacated. Thus patients only leave ICU when there is an admission coming.

Delays in admission to ICU worsen patient outcome and also put huge pressure on the area they are cared

for while awaiting ICU admission. We have proposed a target for time to ICU access i.e. 50% of patients

should be admitted within 1 hour of a decision to admit and 80% within 4 hours. This KPI would apply

only to admissions from ED and a ward in the same hospital (because of the multiple factors involved in

time to admissions for patients coming from Theatre or another hospital).

This target has been taken agreed by the Critical Care Programme of the HSE (with the support of the

Intensive Care Society, Joint Faculty of Intensive Care Medicine and College of Anaesthetists). This

initiative has the support of the Acute Hospital Division of the HSE and has been adopted as part of the

Service Plan for 2018.

The Report from the ICU Audit Database to provide this metric is being finalised. We now need an

education programme to ensure documentation of the decision to admit to ICU in order to make this a valid


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metric.

We believe that if this metric is documented it will increase the priority given to ICU discharges, leading

to faster access to ICU. It will also highlight hospitals which have a particular difficulty with availability

of ICU beds.


Mater Extracorporeal Life Support Service (ECLS)

The Mater Extracorporeal Life Support Service (ECLS), established in the Mater Intensive Care Unit (ICU)

in 2009, provides advanced physiologic support for adult patients with acute severe potentially reversible

heart or lung failure that have continued to deteriorate despite optimal conventional therapy. Specific

equipment is required for ECLS but more importantly, continued high quality training is essential to ensure

that our Mater ICU nursing and physician staff acquire and maintain the necessary management skills to

care for these very dependent patients. Approximately 15 – 25 patients are supported by ECLS in the Mater

ICU each year.

The Mater ECLS service is guided and supported by the international Extracorporeal Life Support

Organisation (based in Ann Arbor, Michigan, USA) which compares outcome in our patients to patients

from similar units around the world.

ECLS is indicated for acute severe hypercarbic or hypoxic respiratory failure. In patients who are too

unstable to transfer to the Mater with conventional mechanical ventilation, a Mater ECLS Retrieval service

can be dispatched to a referring hospital. Extracorporeal support can be deployed in the referring ICU and

the patient can be safely transferred back to the Mater ICU.

Extracorporeal support can also be used in patients with cardiogenic shock when recovery of native heart

function is possible or there are no contra-indications to long-term mechanical circulatory support (LVAD)

or heart transplantation.

We recommend that clinicians referring patients for consideration of ECLS review the ECLS information

available on the Mater website (www.mater.ie) under Clinical Services.

Dr Ed Carton, Medical Director, ECLS Service, Mater Hospital

http://www.mater.ie/


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Inter-hospital Transfer and Transport of the Critically Ill Adult Patient

The National Transport Medicine Programme, Adult Retrieval, in conjunction with intensive care,

anaesthesia and the National Ambulance Service is working to increase both the volume of critical care

retrievals undertaken by a specialist retrieval team and the quality of care delivered in the transfer of all

critically ill patients.

An audit of inter-hospital transports of critically ill adult patients in Ireland completed by NTMP in 2016

estimates an annual volume of over 800 episodes of transport of critically ill adult patients in Ireland. This

number under estimates the total volume of critically ill patients moved between hospitals as it did not

capture, for example, many time critical patient or those originating in Emergency Departments.

The evidence base of the volume-outcome literature across acute care disciplines shows that access to

timely specialist inter-hospital transport for the critically ill patient is linked with improved morbidity and

mortality outcomes.

To this end, as patient care becomes more centralised and with the advent of new developments such as a

National Trauma Network, the need for a robust, responsive and high-quality retrieval system is clear.

The typical cohorts of critically ill adult patients transported across the acute hospital system include:

1. Time-critical transports, e.g. critically ill adults with acute severe traumatic brain injury and acute

vascular injury.

2. Urgent transfers due to escalation of complex specialty care of a critically ill patient in the absence of a

time critical element, e.g. sepsis, trauma.

3. Reverse-flow transport, “repatriation”, of a critically ill adult patient following acute specialty

interventions to the referring hospital for continuity of intensive care.

4. Retrieval of patients from hospitals with no critical care service, e.g. Model 2 or specialist hospitals.

In 2013, a “new money” allocation of 19.5 WTEs, medical, nursing and paramedic resources, was delivered

in the HSE National Service Plan to commence three Adult Retrieval hub Services, operationally known as

the Mobile Intensive Care Ambulance Service (MICAS). The Model of Care supports a service with three

hubs: east, south and west, operating a 12/7 service delivering connectivity across the acute hospital

system. MICAS is currently resourced to undertake urgent transports and some repatriations, i.e. Cohorts 2

3 above.

Currently MICAS provides a service as follows:

• Dublin hub: 7 days / week (12-hour days weekends Mater/Beaumont)

• Cork hub: 4 day/week (12-hour days).

• Galway hub: commencing service Q1 2018.


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To facilitate referrals to MICAS, there is now a single phone point of contact for all MICAS referrals,

nationally: 1800 222 378. NTMP coordinates the referral with the on-call retrieval consultant and the

National Ambulance Service.

In 2018 NTMP is scheduled to transition to a Service, hosted within the National Ambulance Service

(NAS). This will bring together the critical care expertise of critical care clinicians with the operational

synergies of the NAS.

We look forward to continuing to increase service provision across the three hubs with appropriate

ambulance and clinical governance arrangements in 2018

Dr David Menzies, National Clinical Lead, Adult Retrieval;

Ms. Anna Marie Murphy, National Adult Retrieval Coordinator

Care Pathway for the Critically Ill Adult Patient with Severe Brain Injury

The National Clinical Programme for Neurology Model of Care was published 2016. It contains

the recommended clinical pathway for the critically ill adult patient with severe brain injury.

Recommendation. In line with current evidence, the National Clinical Programme for Critical

Care recommends all critically ill patients with acute severe brain injury are immediately

referred for Level 3(s) Neuro-Critical Care, as appropriate, with Neurosurgery and Neuro-

specialty interventions, as appropriate, to a supra-regional or national Neuro-specialty centre.

Currently, in Ireland, Beaumont Hospital and Cork University Hospital both provide Level 3(s)

Neuro-Critical Care in their ICUs. Adequate Level 3(s) Neuro-Critical Care capacity and

transport resource is required to meet the needs of neuro-critical care patients.

National Clinical Programme for Neurology Model of Care p90

tel:1800%20222%20378


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Terror Attack / Mass Casualty Incident MCI Response Planning by

Government/Department Health/HSE/Emergency Management

In 2017, CCP participated in the HSE/Emergency Management terror-attack/MCI response planning

structures and initiatives underway by HSE/EM and across Government, Dept. Health, HSE, Hospital

Groups, Social Care CHOs, National Ambulance Service (NAS) and Hospital providers.

In Sept 2017, CCP was invited by HSE to participate (with Emergency Medicine Programme) in a

delegation including HSE Emergency Management National Director that visited King’s College Hospital

(KCH) London (5th Sept) and Manchester Royal Infirmary (MRI) Manchester (6th Sept) to learn of the scale

and the response structure and function to the terror atrocities in London and Manchester in which thirty

people lost their lives and one hundred and thirty-one people were seriously injured.

The delegation learned of the integrated three-tier EM response approach used in KCH/London and in

MRI/Manchester. The three-tier structure is a ‘gold/silver/bronze’ or strategy/tactical/delivery EM response

structure. The intent is to map this three-tier structure to Ireland’s EM structures (ACMT, HECT) and

hospitals’ Major Emergency Plans MEPs.

CCP participated at HSE National Emergency Management Planning Group (NEPG) meetings 16th Jun

2017 and 28th Sept 2017 both at Dr. Steevens Hospital also attended by a HSE Acute Hospitals Division

representative. NEPG has set up a NEPG MCI EM planning Sub Group- yet to convene.

NEPG has engaged with CHG/NPH and PICM Consultant community for PICU response requirements in

the event of critically ill children presenting in a terror-attack/MCI.

Separately, the Dublin Intensive Care Network (DICN) group, with representatives from the six Dublin

adult ICUs, was formed and convened 13th Jun 2017 and 19th Sept 2017. DICN forwarded Dublin terror-

attack/MCI response planning Recommendations to HSE/EM/NEPG. The DICN Recommendations are

supported in full by CCP. The key components of the Recommendations are a. simultaneous all-or-none

activation of all Dublin ICUs MEPs; b. effective Dispersal method with the seriously injured patient going

to the ‘right hospital, first time’; c. need for NAS provision of ‘horizontal’ inter-hospital transports of

critically ill patients e.g. craniotomy at Beaumont etc.

https://www.google.ie/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwiZ_tyHzcDYAhWjKMAKHSGACxEQjRwIBw&url=https://www.erepublik.com/en/article/-eire-doi-ireland-department-of-information-the-first-24hrs-2637028/1/20&psig=AOvVaw2rHAvMLkAYuELDzoQzSsdj&ust=1515234107335257


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To facilitate HSE/EM and to build a ‘silver’ or tactical Dublin EM terror-attack/MCI response structure,

DICN, supported by CCP, has collaborated with NAS/NEOC to develop an information communication

platform, enabled by a ready-to-go teleconference number.

Model of Care- Home / Domiciliary Ventilation for the Long-Term

Ventilation-Dependent Neuro-Rehabilitation Patient

A Social Care community provision initiative with a Social Care fund is being implemented now for long-

term ventilation patients e.g. high spinal cord injury patients and other LTV patients. Critical Care

Programme has been invited to input to the Social Care Steering Group and Social Care Working Group

components according to the LTV Model of Care published earlier.

Separately, a joint Mater MUH-NRH ICM Consultant post will go to recruitment soon to facilitate the

transition of LTV patients from Mater to NRH for LTV care by NRH at NRH.

Michael Power, Una Quill, Derek Cribbin, Critical Care Programme 17/1/18.

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Ends

DICN MCI Group Teleconference

facility number

Telephone No. 01 6648888

Host Passcode: 7492582

Participant Passcode: 527080

critical care programme newsletter no. 3 15 … · critical care programme newsletter no. 3 ......

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