Settings of Care''''' Critical Care Sussex Network CRG

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Settings of Care..... Critical Care Sussex
Network CRG Dr Neil Jackson ICU Consultant
RSCH Sussex Critical Care Network Medical Lead
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• SETTINGS OF CARE Critical Care Issues
  Discussed
• Critical Care Sussex Network CRG 14/05/07
• Current numbers of critical care beds
• supply and demand?
• 2. Settings of care and "critical care without
  walls"
• 3. Defining a Critical care hospital
• Major general hospital
• Local general hospital
• 4. What resources does a critical care unit
  require
• staff, competencies, cover, support, number of
  beds, Level 2 only
• 5. Where will you put general medical patients
• Triage, risk modeling, Level 2
  on-site, Level 3 on-site

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Terminology is unclear and rapidly changing.
There is potential for misunderstanding. Suggest
establish either precise definitions or
identifying the care that a centre can provide
.....i.e. can a LGH provide Critical Care without
becoming a MGH
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• Critical Care Issues
• Current lack of critical care beds
• Fracturing the service .. rebuilding walls
• Pivotal role for ambulance service
• Placing general medical admissions

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• Critical Care Issues
• Current lack of critical care beds
• Fracturing the service .. rebuilding walls
• Pivotal role for ambulance service
• Placing general medical admissions

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To meet need 95 of time a population of 500,000
would require 30 ICU and 55 HDU beds if on 1
site and 10 more if split to 3 sites
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Probably need 2x Level 2 Beds to Level 3 beds
to meet hidden demand
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• Current Lack of Critical Care Bed
• bed occupancy
• discharge at night
• non clinical transfer
• Cancelled elective surgery (including Cancer)
• ventilation in recovery
• spot audits

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• Current Lack of Critical Care Bed
• bed occupancy
• discharge at night
• non clinical transfer
• Cancelled elective surgery
• ventilation in recovery
• spot audits

lack of level 2 critical care beds lack of Level
1 ward beds
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lack of Level 1 ward beds in all trusts will
continue to delay ICU discharge
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Discharges at night are a marker of a system
under pressure Discharges at night are associated
with an increased mortality
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• Current Lack of Critical Care Bed
• there is a large hidden pool of Level 1 and level
  2 pts on the general wards
• as ward resources decrease and at risk scoring
  improves they will be increasingly identified
• this unmet demand may overwhelm the new system
  .... not as a fault of the system
• there will be new demand as centres without
  critical resources refer early upwards

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there is no evidence that the intended reduction
in acute hospital admissions will lead to any
reduction in critical care admissions...if
anything they will increase

• Critical Care Demand will increase
• Level 2 unmet need from wards
• Decreasing ward resources
• Continued loss of Level 1 beds
• Earlier referrals of at risk pts

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• Critical Care Issues
• Current lack of critical care beds
• Fracturing the service .. rebuilding walls
• Pivotal role for ambulance service
• Placing general medical admissions

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Comprehensive Critical Care

• Audit commission 1999
• Expert group 1999
• Winter issues 2000
• Critical Care Report May 2000
• HSC 2000/017 May 2000

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• Critical Care Without Walls
• Seamless part of care pathway
• Fully integrated
• Following patients journey
• Outreach Teams
• Based on need rather than location

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• Models are unclear
• terminology changes constantly
• what sort of ICU is envisaged

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Opinion from the majority of Consultants within
Sussex Crit Care Network remains that unselected
take requires on site availability of Level 2 and
Level 3 care the concept of 'micro' ICU's of 2 or
3 beds is not supported if 'micro' ICU's were
used they would need to function to ICS
standards/competencies etc
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• pts don't always progress smoothly or
  predictably from one level to another
• any unit caring for Level 2 pts must be able to
  support Level 3 pts
• the most difficult pts to transfer are unstable
  non- intubated Level 2 pts
• hospitals without critical care will need to
  transfer early at risk pts or post
• intubation stabilisation .... there will
  need to be ?? beds to support this

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• What are the minimal requirements for a critical
  care unit?
• (as discussed by Crit Care CRG)
• not just beds but the resources that are
  required 24 hrs/day
• must run to current ICS standards
• maintaining competencies
• nursing ratios
• consultant delivered service 24hrs/day
• access to radiology/ path labs 24hrs/day
• multidisciplinary support physio, pharmacy etc
• unlikely to be possible with a unit of less than
  3- 4 beds which
• would need to be linked to a larger unit for
  training purposes
• a 3-4 bed unit ? flexibility and increased
  fixed costs

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• Critical Care Issues
• Current lack of critical care beds
• Fracturing the service .. rebuilding walls
• Pivotal role for ambulance service
• Placing general medical admissions

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YOU ASKED FOR AN AMBULANCE.... what sort?
A mobile ICU with fully trained crew
paramedics, anaesthetist, ICU
nurse standardised equipment ventilator,
monitoring, drugs, lines is required to safely
transfer large numbers of unstable critical care
patients ?? RESPONSE TIME
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Pts who spendgt 6hrs in AE have an increased
mortality and survivors have increased LOS
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• Critical Care Issues
• Current lack of critical care beds
• Fracturing the service .. rebuilding walls
• Pivotal role for ambulance service
• Placing general medical admissions

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Opinion from the majority of Consultants within
Sussex Crit Care Network remains that unselected
take requires on site availability of Level 2 and
Level 3 care the concept of 'micro' ICU's of 2 or
3 beds is not supported if 'micro' ICU's where
used they would need to function to ICS
standards/competencies etc
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• Can we triage General Medical patients to send
  the
• majority away from immediate Critical Care
  Support?
• this is a question for Acute Medicine CRG but
  Crit Care must be involved in discussions re crit
  care aspects
• very few medical pts actually require Crit Care
• there already are some risk stratification models
• CURB65
• Glasgow GI bleed
• critical care doesn't support sending unselected
  medical patients to centres without Level 2 and
  Level 3 on- site support
• NEED TO BEGIN LOCAL BENCHMARKING OF TRIAGING
  MODELS

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Settings of Care will lead to identification
of current hidden critical care need risk
adverse strategies... ? safety net early
increased transfer to ICU the system will only
work effectively if there are beds available so
that pts can rapidly access critical care if
required...6 hrs ventilated in day theatre
doesn't work .... if new models are constructed
the identification and subsequent care of the
critically ill could improve
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• It is possible to construct robust Critical Care
  models within
• Settings of Care strategy
• This would require investment in
• Level 1 beds
• Level 2 beds
• Critical Care Outreach working across
  geographical sites
• Ambulance Mobile ICU Services
• New models of working practices competencies
• New skill mixes for doctors
• Critical Care delivery within networks

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