CLINICAL FUTURES PROGRAMME – SPECIALITY SERVICE MODEL SPECIFICATION

GWENT CLINICAL FUTURES PROGRAMME

SERVICE MODEL SPECIFICATION

CRITICAL CARE

APRIL 2008

Project Title

Clinical Futures Programme

(Draft)

Critical Care

Serivce Model Specification

Version No: 4

Issue Date:14 April 08

version history

Version / Date Issued / Brief Summary of Change / Owner
Draft 1 / Sept 07 / Original draft – completed following workshop 22/05/07 – incorporating additional discussions – assumptions included / HD
Draft 2 / April 08 / Updated document to reflect outcome of SCCC user groups, work of SEWCCN / HD
Draft 3 / April 08 / updated to reflect additional comments/amendments / HD
Draft 4 / April / updated to reflect additional comments/amendments from JG, AH, SE, CM and RJ.
Version shared with Clinical Model Group / HD
Draft 5
CONTENTS
SECTION / PAGE NUMBER
1. / BACKGROUND / 4
2. / CURRENT MODEL / 5
3. / PROCESS OF DEVELOPMENT / 9
4. / EVIDENCE AND GUIDANCE / 9
5. / DEFINITION AND SCOPE / 10
6. / PHILOSOPHY AND VISION / 10
7. / PRINCIPLES & AIMS / 11
8. / SERVICE MODEL IN CLINICAL FUTURES / 12
9. / CAPACITY & PROJECTED ACTIVITY / 18
10. / PERFORMANCE INDICATORS / 20
11. / STAFFING MODEL / 21
12. / TECHNOLOGY REQUIREMENTS / 23
13. / EQUIPMENT / 24
SECTION 1
BACKGROUND

1.0This document describes the service specification for critical care services in theGwent Clinical Futures programme.

1.1Critical care services are one of those specialist services as defined in the ClinicalFutures Strategic Outline Programme case (SOP v2) that demand redesign and consolidation of services to ensure the maximum use of specialist resources and increase critical mass to recommended standards for quality purposes.

1.2The Intensive Care Society defines critical care services as being intended for the most ill patients in the hospital who have potentially recoverable conditions. Development of these services has been haphazard in the UK and resulted in great variation in configuration, scale, management, efficiency, case mix and quality (Critical to Success, Audit Commission 1999).

1.3Many people who are critically ill have complex needs although some have relatively simple needs (e.g. monitoring after an uncomplicated MI).

1.4The use of defined levels has increased and is used by most organisations now. Level 1 is generally managed at ward level; Level 2 is generally equivalent to High Dependency Unit beds while Level 3 is Intensive Care Unit beds, whether general or specialised.

1.5Critical Care has historically been considered as a “support service” and therefore the impact on critical care of developments in acute service specialties have not previously been taken into consideration. These developments generally have a “creeping” effect on critical care services but when taken together, create significant pressure on a service which is already recognized as being under capacity. The impact on patient care is that:-

  • elective operations are cancelled due to lack of a critical care bed,
  • waiting/treatment time targets for other acute service specialties are compromised,
  • patient safety is compromised as patients are discharged early from critical care beds to release critical care capacity for patients with higher levels of clinical need,
  • patients are transferred to other hospitals for non clinical reasons
  • acutely ill patients remain on wards inappropriately

1.6The South East Wales Critical Care Network was established in 2007 and is therefore a relatively new regional clinical network. This Clinical Futures Service Specification will therefore have to be responsive to the emerging body of work of the network in terms of model of care and capacity indications.

SECTION 2
CURRENT MODEL

2.0Within Gwent, Level 2 and 3 Critical care services are currently provided at the Royal Gwent Hospital (RGH) and Nevill Hall Hospital (NHH). Capacity in critical care services remains limited in Gwent as compared with other areas for equivalent catchment population as demonstrated by table 1 below.

Table 1

Region / Population / Level 3 beds / Level 2 Beds / Total
Gwent
RGH
NHH / 600,000 / 12
6
6 / 10
8
2 / 22
14
8
Cardiff &Vale / 425,000 / 32 / 16 / 48
RCT, Merthyr, Bridgend / 429,400 / 22 / 7 / 29
SW Wales
(inc NS, B&P) / 723,300 / 46 / 38 / 84

The Royal Gwent

2.1On the Royal Gwent site, critical care facilities are currently split across twodistinct locations, ITU in one area of the hospital and HDU on the same floor but not co-located. This arrangement of facilities limits the opportunities for the flexible use of capacity and flexible staffing arrangements.

2.2The size of bed spaces on the RGH units do not confirm to HBN57 size requirements. In RGH there are 2 isolationcubicles (1 x negative pressure).

2.3The level 3 unit at RGH is located adjacent to the main theatres, on the same floor as radiology services but at a distance from the A&E department.

NevillHallHospital

2.4The 6 level3 and 3 level 2 beds at NHH are co-located in a single unit. Although this affords the service a degree of flexibility, the layout and size of the unit does not confirm the HBN57 size requirements. In NHH there are 2 isolation cubicles.

2.5The critical care unit at NHH is distant from A&E (but on the same floor) and on a different floor to CT.

Outreach

2.6The Comprehensive Critical Care (2000) report recommended that Outreach services should be developed as an integral part of each NHS Trust’s critical care service.

2.7The aim of critical care outreach is to share critical care skills across the hospital and help ensure that all patients who are critically ill receive the required level of care irrespective of whether they make it into a designated critical care bed.

2.8Comprehensive Critical Care (2000) identified that the purpose of an outreach service waisto:

  • Avert admissions to intensive care
  • Facilitate discharges from ICU
  • Share critical care skills across acute care areas

2.9The existing Pan Gwent outreach service was established in 2004 and has succeeded in implementing early detection and intervention systems to some clinical areas.

2.10The outreach service at the RoyalGwentHospital covers 13 of a potential 32 clinical areas. In Nevill Hall hospital the outreach service covers all 11 wards. In addition, the team has also implemented the following:

2.11Furthermore, the Outreach service currently operates Monday to Friday 9am to 5pm. The directorate are developing a business case to expand the coverage of the service to all clinical areas and to provide cover for 12 hours a day, 7 days a week.

Safer Patient Initiative and 1000 Lives Campaign

2.12The RGHwas successfully designated in 2006 a couplet organisation (along with UHW in Cardiff)in the Safer PatientInitiative (SPI). The initiative is aimed at making hospitals safer for patients. The Ciritical care element of the initiative is aimed at areas of particularrisk such as complication form mechanical ventilation, central lines and infection.

2.13The focussed work of this initiative adopts an action learning and continuous improvement approach with a focus on the measurement of improvements.

2.14In April 2008 the Critical Care Unit at NHH become involved with the 1000 Lives Campaign for Improving Critical Care. The work of this campaign echos that of the SPI initiative

Problems with current model

2.15The poor critical care capacity across the Trust has an impact on access to elective services and the management of emergencies. It also has implications on the clinical outcome measures that are currently being achieved. In Gwent the requirement to meet the All Wales Critical Care standards for adults is not achievable on a consistent basis due to the lack of capacity and the shortage in specialist skills. There is a clear need to pool the specialist resources to ensure they are used most efficiently and that quality of critical care services can be improved.

2.16There is recognition by the Trust that adult Level 2/3 beds are sometimes occupied by patients who do not meet criteria for admission, such as those who are too ill and cannot recover. However there is also acknowledgement that a number of patients receiving high dependency care are in fact managed on general wards and the demand for HDU is significantly higher than the number of beds that currently are available.

2.17There is also evidence that patients are often identified as requiring interventions too late in their illness and consequently end up in critical care bed. ICU admission was thought to be avoidable in 21% of cases by the National Confidential Enquiry for Peri Operative Deaths (NCEPOD) and there is evidence that better general ward care could also reduce admissions to level 2/3 beds.

2.18The recently published document Designed for Life “Quality Requirements for Adult Critical Care in Wales” Welsh Assembly Government March 2006 states that units providing level 3 services must have a minimum of 200 cases per year, providing organ support for most body systems. The expectation is that the core components will be met by 2008 and all be met by 2015.

2.19These requirements are difficult to sustain on multiple sites and specialist skill and resources must be used to maximise patient quality and use of resources.

2.20Congestion in critical care facilities due to high bed occupancy in acute beds and limited critical care capacity leading to difficulties in providing appropriate level of care for patients and cancellations of operations. Difficulties will be experienced in providing appropriate cover for two separate intensive care service in the longer term.

2.21The Outreach service in Gwent operates a 09.00 – 17.00hrs Monday – Friday service that although very successful, is far from ideal. In 2007 38% of admissions to Critical Care occurred outside Outreach operating hours. This highlights the importance of expanding the service beyond the present 09.00-17.00hrs Monday – Friday to a 08.00-20.00hrs 7 days per week service.

South East Wales Critical Care Network

2.22Reshaping your local Health Services– Developing a plan for South East Wales identified the need for the Critical Care Network to “define the adult critical care capacity needed across the South East Wales region in terms of the number of beds needed at levels 2, 3 and 3(T) and where these need to be sited”.

2.23The priority for the South East Wales Critical Care Network (SEWCCN) is to take a whole system approach to ensuring the delivery of safe and effective critical care services for the region and to act as the specific and expert resource for commissioners to provide an expert source of knowledge and service intelligence to identify service models and promote effective commissioning.

2.24The future work of the SEWCCN will be to propose a strategic framework for the development of a regional model of critical care services which distributes the resources across the region in order to maximize the current resource, minimize the investment required to bring all six critical care units to a standard in line with the Quality Requirements for Adult Critical Care. The service model specification described in Clinical Futures will need to respond to emerging work of the SEWCCN. (This draft document is included as Appendix A.)

Activity

2.25The table below provides comparative activity data for the RGH and NHH critical care units as compared to other units within the SEWCCN.

2.26There are some concerns as to the quality of data collection which is largely due to different collection and reportingarrangements across units in South East Wales. Work with SEWCCN will be ongoing to address any anomalies and ensure that the planning of critical care services is based on robust data.

Table 2: SEWCCN Activty

CRITICAL CARE ACTIVITY 1 AUGUST 2006 TO 31 JULY 2007
Llandough / UHW ITU/HDU + cardio / Nevill Hall / Royal Gwent ITU/HDU / Royal Glamorgan / Prince Charles
Type of Unit / Combined ICU/HDU / Combined ICU/HDU / combined ICU/HDU / Combined ICU/HDU / Combined ICU/HDU / Combined ICU/HDU
ADMISSIONS BY SPECIALTY
Gen surgical / 222 / 573 / 231 / 450 / 492 / 106
General medical / 200 / 388 / 244 / 545 / 513 / 144
Cardiac surgery / 0 / 36 / 0 / 0 / 0
Thoracic surgery / 0 / 0 / 0 / 0 / 0
Liver / 0 / 0 / 0 / 0 / 0
Neurological/neurosurgical / 0 / 116 / 0 / 18 / 0
Spinal / 0 / 0 / 0 / 5 / 0
Burns/plastic / 0 / 0 / 0 / 0 / 0
Trauma / 129 / 48 / 97 / 50 / 15 / 25
Primary Renal / 0 / 42 / 2 / 11 / 80 / 0
Total Admissions / 551 / 1203 / 613 / 1152 / 967 / 308
total bed days / 2826 / 33306 / 2064 / 3364 / 3573 / 1896
No of patients staying 1-2 days / 306 / 484 / 117 / 290 / 582 / 141
No of patients staying 3-4 days / 98 / 271 / 33 / 81 / 88 / 69
No of patients staying 5-6 days / 44 / 137 / 10 / 47 / 31 / 35
No of bed days occupied by pts >6 days / 1683 / 5173 / 105 / 142 / 121 / 1231
Total no of discharges 22.00 - 0700hrs / 31 / 123 / 83 / 0 / 185 / 17
Total No of premature discharges / 2 / 0 / 16 / 1 / Not available / 17
No of premature discharges 2200 to 0700 hrs / 0 / 0 / 4 / 0 / Not available / 4
Total no of delayed discharges / not recorded / 397 / 121 / 213 / Not available / 31
No of delayed discharges 2200-0700 hrs / not recorded / 24 / 11 / 0 / Not available / 3
No of transfers out (non clinical) / 1 / 0 / 6 / 8 / 0 / 1
No of transfers out (clinical) / 6 / 79 / 24 / 205 / 11
No of transfers in (non clinical) / 0 / 0 / 25 / 3 / 0 / 2
No of transfers in (clinical) / 6 / 79 / 0 / 9 / 1
Proportion of admits > or = 16 yrs of age / 100% / 100% / 96% / 90% / 99% / 95.80%
Proportion of admits less than 16 yrs of age / 0 / 0 / 4% / 10% / 0.90% / 4.20%
If Estimated or Actual / A / A / A / A / E / A
SECTION 3
PROCESS OF DEVELOPMENT

3.0This Critical Care service model specification has been developed with clinical teams from both Royal Gwent (RGH) and Nevill Hall (NHH) hospitals through a series of workshops, meetings and literature reviews.

3.1This work was further developed through the 1:500 design process for the Specialist and Critical Care Centre (SCCC) which took place between November 2007 and January 2008 over 4 meetings.

3.2The service specification has also been informed by the work of the South East Wales Critical Care Network and the draft documents, ‘Capacity Assessment and Regional Model of Care for Adult Critical Care in South East Wales (Draft - April 2008), Admission and Discharge policy for Adult Critical Care in South East Wales (Draft – April 2008)

3.3The service specification will also be reviewed on a periodic basis to ensure it reflects current best practice.

3.4Benchmarking visits to newly developed critical care units will be explored and lesson learned incorporated into this serivce model specification.

SECTION 4

EVIDENCE AND GUIDANCE

4.0The following publications and guidance was used in the development of this service model:

  • WHC (2006)009 – Designed for Life: Quality Requirement for Adult Critical Care in Wales
  • HospitalBuilding Note 57
  • The Lancet (2000) 355:595-598 (Lyons article 2000)
  • Modernising Care for Patients Undergoing Major Surgery, Implementation Guide – A report by the Improving Surgical Outcomes Group
  • A comprehensive Report into Adult Critical Care, Department of Health 2000
  • Critical to Success, Audit Commission 1999
  • Chapter 38 “Closed” intensive care units and other models of care for critically ill patients, Rothschild, J.M M.D. M.P.H, HarvardMedicalSchool
  • Impact of outreach team on re-admissions to a critical care unit, Leary & Ridley, Anaesthesia, 2003
  • Organisation, staffing and admission criteria for critical care in the UK, Leary & Ridley,
  • South East Wales Critical Care Network Capacity Assessment and Regional Model of Care (DRAFT – April 2008)
  • South East Wales Critical Care Network, Admission and Discharge Policy (DRAFT – April 2008)
  • The Tanner Report – The acutely sick or injured child in the DistrictGeneralHospital

SECTION 5
DEFINITION AND SCOPE

5.0For the purposes of this critical care service specification, this service modelcovers the workforce,equipment and operational organisation of:

-intensive care (level 3)

-high dependency care and (level 2)

-outreach teams

-Peri operative anaesthetic care unit (PACU)

-Retrieval arrangements

5.1To reflect current approaches to these servces, these will be described with reference to Level 3 and Level 2 services.

5.2The table below provides definitions for levels of critical care dependency.

Level 0 / Patients whose needs can be met through normal ward care in an acute hospital
Level 1 / Patients at risk of their condition deteriorating, or those recently relocated from higher levels of care, whose needs can be met on an acute ward with additional advice and support from the critical care team
Level 2 / Patients requiring more detailed observation or intervention including support for a single failing organ system or post-operative care and those ‘stepping down’ from higher levels of care
Level 3 / Patients requiring advanced respiratory support alone or basic respiratory support together with support of at least two organ systems. This level includes all complex patients requiring support for multi-organ failure.

Source: DoH, comprehensive critical care: a review of adult services, 2000

5.3The scope of the critical care service includes outreach to general wards at SCCC and eLGHs and retrieval if necessary

5.4This service specificationrefers to but does not provide detail on the relationship between a level 2 Ischemic unit (Coronary care and acute stroke care). This will be developedseparately in the context of cardiology and stroke service specifications. There is however acceptance across services of certain commonalities.

5.5Paediatric HDU and stabilisationis excluded from this service specification. However, it is recognised that if it is felt clinically appropriate for paediatric patients to be managed in adult critical care pending retrieval then a joint decision will be made between intensivist and paediatrician within Tanner guidelines.

SECTION 6
PHILOSOPHY AND VISION

6.0The philosophy of critical care services within Clinical Futures is to ensure that there is equitable and timely access for the Gwent catchment population to high quality and sustainable critical care services.

6.1The SCCC will be the central location for critical care facilities in the Gwent health community. The concept of flexibility in the management of critical care and the ability to step up and down between levels 3 and levels 2 is central.

6.2In addition, the enhancement of skills and critical care support on the general wards on the SCCC and eLGHs will future increase the opportunities to operate flexibly between levels 1 and levels 2.

SECTION 7
PRINCIPLES & AIMS

7.0The key principles underpinning the critical care serivce model are:

  • Delivering a safe and quality critical care service according to the recognised quality standards (Quality standards for adult critical care)
  • Integration and consolidation of critical care services that incorporates all specialties and diagnostics
  • The critical care unit is an essential service for the hospital network especially for the support of complex elective surgery and the management of emergency care
  • The role of the critical care unit must be consistent with the needs of the patient population as reflected in volume and complexity of demand
  • The critical care unit must have effective operational and functional relationships with theatres, recovery, wards, Emergency Assessment Unit
  • The Level 3 and level 2 critical care should be managed as a combined “unit” with flexible functionality between level 2 & 3 dates
  • Critical care skills and expertise will extend outside the physical critical care unit through developed and skilled outreach teams
  • That the critical care unit works within the South East Wales critical care network.
  • The provision of high quality multidisciplinary teaching, training and education in critical care

7.1The key aims of a critical care unit are: