WEST YORKSHIRE CRITICAL CARE NETWORK
Admission To and Discharge From Critical Care Policy
Each critical care unit in the Network should have its own admission and discharge policy. This may reflect the specialist nature of the unit and include information specific to the unit in question. This WYCCN policy reflects an overall agreed framework for use in the Network.
Patient Criteria:
Care for critically ill patients should be provided in a unit designed for this purpose. This document refers to admission and discharge criteria for such a unit.
Reasons for Admission: Dependency of care can be assessed with the help of the Intensive Care Society guideline1. Any patient requiring higher care than can be provided on a ward (mainly but not exclusively level 2 or 3) should be transferred to a critical care unit.
Reasons to Not Admit: Exceptions to the above criteria include patient choice and futility. Futility means that admission would not be in the patient’s best interests. Decisions about futility should not be made by an individual but a multidisciplinary team of senior staff. The patient and relatives should be kept informed of these discussions2.
Experienced clinicians should review individual patient circumstances before considering admission futile. It is inappropriate to refuse admission merely on the basis of a predefined diagnosis, age or physiological score. Data relating facts such as these to outcome have been validated for populations not individuals.
Patient Referral:
Patients may be referred to intensive care from wards, emergency room, theatres and via the outreach service. All hospitalised patients are under the care of a consultant (the primary consultant). Requests for admission to intensive care should come from the primary team after discussion with the primary consultant unless this would delay the process of admission and compromise care. Generally when the outreach service is highlighting the need for admission it will have been alerted to patient deterioration by the primary team; if this is not the case efforts should be made to involve the primary team if practicable.
‘If the team caring for the patient considers that admission to a critical care area is clinically indicated, then the decision to admit should involve both the consultant caring for the patient on the ward and the consultant in critical care.’ NICE clinical guideline 503
Patient Discharge:
Once patient dependency is assessed as having changed to that consistent with ward care the patient should be discharged. The critical care environment has a number of hazards for patients such as; risk of cross infection; poor rehabilitation environment and psychological effects. In addition the critical care resource is limited. Finding the most appropriate ward bed may take a short time but it is important that patient discharge should not be delayed longer than four hours from the time a bed was requested.
‘After the decision to transfer a patient from a critical care area to the general ward has been made, he or she should be transferred as early as possible during the day. Transfer from critical care areas to the general ward between 22.00 and 07.00 should be avoided whenever possible, and should be documented as an adverse incident if it occurs.’ NICE clinical guideline 503
Insufficient Beds:
Whenever a resource is limited it is possible that demand may outstrip supply. The clinical team is responsible for allocating available critical care resource in the most effective way. Under no circumstances should bed availability be an issue when considering whether an individual is suitable for receiving intensive care treatment.
When the critical care unit is full and another patient requires admission it will be necessary for the consultant and senior nurse responsible for the unit to consider the relative needs of all the patients. This will include many issues such as the dependencies of all the patients, any speciality requirements and suitability for transfer. As a general rule transferring a patient to another hospital critical care facility should only be done as a last resort unless this is consistent with the patient’s wishes or clinical needs. All local options must be explored such as flexible use of nursing staff or temporary care in a safe area such as a recovery room.
If delayed admission is necessary then the choice of which patient is to be admitted to the unit must be based on clinical need; this may involve transferring a lower dependency incumbent patient to the temporary area. If transfer is deemed essential the choice of patient to be transferred would be made on similar grounds. In both these situations it must be recognised that the Trust responsible for a patient denied access to critical care is providing substandard care and should investigate the incident.
Unique transfer groups have been set up to limit the risk of long distance transfer of level 3 patients. These are available for reference in the West Yorkshire Critical Care Networks Transfer Guidelines on www.wyccn.org.uk. If the Network is in a ‘Red Alert’ situation and a bed cannot be located in the local unique transfer group contact the WYCCN who may be able to help find a suitable bed. Transfers outside unique transfer groups for non clinical reasons (or lack of bed availability in the local tertiary centre) must be reported to the Trust Chief Executive who will inform the SHA and an investigation of the process will occur.
Repatriation:
The commonest reason that patients should require repatriation is that they have been transferred long distances to receive tertiary services or they became ill outside their normal locality. Patients and relatives wishes need to be considered when planning repatriation. Some tertiary centres with highly specialised beds have limited availability for providing an acute service, therefore such repatriations may be required in the convalescent phase of the illness to keep the service running.
If it is accepted that repatriation is in the patients best interests then bed allocation should be organised with senior staff in the receiving unit. Patients to be repatriated should take priority over elective work in the receiving Trust.
The Last Bed:
Patients may be referred from outside the Trust for repatriation, need for specialist services or capacity reasons. Generally all beds within the unit should be made available for such patients but it must be recognised that this will not always be appropriate. Decisions have to be made by senior staff in the local unit and take into account local pressures, the size of the unit, the dependency of patients on the unit and other patients potentially requiring admission, being followed up on the ward.
Elective Admissions:
Trusts have a responsibility for running a critical care service capable of dealing with normal levels of emergency and elective admissions. Local arrangements for booking elective patients should be set up to minimise last minute cancellations while recognising the need to prioritise on the basis of clinical need. Some tertiary units may need to ‘ring-fence’ beds to provide specialist services.
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1) Levels of critical care for adult patients
http://www.ics.ac.uk/icmprof/standards.asp?menuid=7
2) When dealing with incompetent patients normal Trust guidelines should be followed.
3) NICE clinical guideline 50
http://www.nice.org.uk/nicemedia/pdf/CG50QuickRefGuide.pdf
Distributed by WYCCN – Tel: 01924 512280
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Admission- WYCCN – Draft 5 – 9 Sep 08