Adult Critical Acute Care Services an international perspective

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Adult Critical (Acute) Care Services-an
international perspective

• Graham Ramsay
• Medical Director
• WHHT

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(No Transcript)
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Comparison of United Kingdom with the Netherlands
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Health Care Financing

• UK 6.5 of GNP
• Netherlands 9 of GNP
• euro 34
  billion

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UK v NL

• Western Infirmary Glasgow
• 1200 beds
• 8 non-cardiac ICU beds
• University Hospital Maastricht
• 800 beds
• 18 non-cardiac ICU beds
• 6 HDU beds

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ICU bed numbers

• Percentage of acute beds
• UK 2.9
• Netherlands 6
• USA 13

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UK v NLStaffing

• Glasgow
• 5 anaesthetists
• 1 surgeon
• 1 respiratory physician
• Maastricht
• 3 surgeons
• 4 physicians
• 3 anaesthetists
• 1 respiratory physician

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ICU staffing

• Full time, part time or combination
• Intensive Care
• Separate primary specialty?
• Supra-specialty?
• Benefits of multidisciplinary supra-specialty
  model

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HDU in Europe

• Extending or replacing inadequate ICU facilities
• Improving efficiency of use of ICU resources

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HDU

• HDU becomes cost-effective when care requires
  more than 1 nurse for 3 patients
• Many potential HDU patients are managed in
  general wards or in ICU
• Boots,
  Lipman 2002

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Effect of lack of HDU

• 28 bed surgical ward
• Mean of 1.4 patients/day judged as HDU
• More observations than non-HDU patients
• 11.3 v 4.2 in 24 hours
• Presence of HDU patient adversely affects care of
  other patients
• 
  Coggins 2000

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Comparison of units with and without HDU

• 192 patients studied
• 2 groups well matched by POSSUM
• HDU present complications OE 1.09
• No HDU complications OE 1.74
• Shorter hospital stay with HDU
• 
  Jones 1999

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Level of care requested and received (UK)

• Requested IC 9,7
• HDU 23.6
• Level not available IC 15.9
• HDU 73.8
• Mortality 1.5 overall and 3.1 if level of care
  not achieved
• 
  Turner 1999

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Specialty linked HDU

• Learning environment for trainees
• Nurses do not lose their patients
• Perhaps less efficient

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IC usage in a UK hospital

• 10 month study
• IC occupancy was 100
• 13 of admissions refused
• 26 of bed days were for HDU care of improving IC
  patients
• Morrow,
  Lavery 1996

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Effectiveness study Effect of opening a
Medium Care Unit

• G. Ramsay
• B. Janssen-Solberg

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Patient population ICU2001

• 795 admissions
• Average length of stay 6.5 days
• Bed occupancy 83 ( 92 in 2002)
• Ventilator days 68
• Mortality 18
• 16 re-admissions lt 24 hours

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Inappropriate use of IC bed (12 months)

• 117 patients inappropriate for IC
• 489 nursing days
• Average TISS 19 (sd5.3)
• Suitable for general ward 144 days
• Suitable for MC 293 days
• Medium Care neurology 42 days

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Data after opening of MC(20 weeks)

• 8 IC admissions refused (13 reduction)
• 25 inappropriate days (87 reduction)
• 106 MC patient days on general wards (42
  reduction)
• 3 re-admissions lt 24 hours (66 reduction)
• IC ventilator days 68 to 91

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Medium Care

• 6 step-down beds
• 75 of admissions surgical
• 10 inappropriate bed use on MC
• admission indication MC usually haemodynamic
  monitoring or bronchial toilet

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Summary

• MC increased IC capacity
• MC bed can not replace an IC bed
• MC admissions controlled by intensivist
• 75 of admissions surgical
• Average TISS score 19.6

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Conclusions on HDU

• Europe is diverse and facilities vary
• UK is underprovided with IC beds
• HDU can improve efficiency of IC bed usage
• Cost-effectiveness proven
• Submit your business case
• Should HDU be central or specialty based?

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HCAIs

• Netherlands
• No MRSA bacteraemia seen in 10 years
• C Diff very rare and none on ICU
• West Hertfordshire
• 43 MRSA bacteraemias in 06/07
• 683 cases of C Diff in 06/07
• 15 deaths in last 6 months

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Acute Care
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Changing Health Systems Commonalitiesthe common
challenge of the acutely ill patient

• Cost containment
• Use of for-profit services
• Mobility of workforce
• Working hours ?
• Demographic changes
• Acute hospital beds ?
• Throughput ?, LOS ?
• Emergency admissions ?
• Proportion gt 65 yrs ?
• Clinical error the new epidemic

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TRIAGE DECISION

• Triage chain
• Home / Institution / Other hospital
• Emergency Dept
• ICU
• Department / Ward
• Home

• Triage elements
• Self-triage
• Pre-ICU triage
• ICU triage
• Post-ICU triage

Flow limitations Inflow Resource
availability Outflow
( Levin PD et al. Intensive Care Med 2001 27
1441-5 )
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Post hospital
Pre-ICU
ICU
Post-ICU
Med-Surg Team
Med-Surg Team
Family MD
ER Team
ICU Team
ER
Ward
ICU
Ward
Home
TRADITIONAL MODEL
ALTERNATIVE MODEL
Med-Surg Team
Med-Surg Team
Family MD
ICU Team
ER Team
ER
ICU
Ward
Ward
Home
CC consult
CC consult
D/C consult
F/Up clinic
ICU
( McMullin Cook. In Angus Carlet (eds)
Surviving intensive care, 2002 )
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THE ER ICU CONTINUUM
Intensive Care expertise
Med-Surg Team
Family MD
Other hospital team
ER Team
ICU Team
ICU
Ward
Other ER
ER
Home
CC consult
D/C consult
F/Up clinic
CC consult
ICU
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Acute Care

• How is AE organised
• Medium Care Unit
• Recovery or PACU 24hour?
• Acute admissions unit
• Hospital management structure

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Problems we do not want

• Code Red (no beds)
• Acute admissions spread over several wards
• Acutely ill patients on poorly staffed wards in
  evening and night
• Cancelation of elective patients
• Disruption of theatre planning

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Separate patient flows

• Three separate patient flows
• - outpatient
• - acute
• - elective

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Aims

• Efficient organisation of elective care
• Increased bed occupancy (close to 100)
• Well organised acute care

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Requirements

• Realise an Acute Admissions Unit
• Increased consultant involvement
• 24 hour diagnostics

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Effect of AAU

• 66 AAU beds opened
• 145 ward beds closed
• 48 of patients discharged from AAU to home
  within 48 hours
• LOS stay acute patients reduced by 1.5 days (40)
• Reduction of 55 wte (wards and AE)
• Investment 4.6m euro !!!!!
• Saving 3.25m euro per year
• Increased efficiency for elective cases

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Develop the Concept

• 3 patient flows
• 3 value chains
• Each flow has specific strategies and performance
  indicators
• Large degree of individuality
• Recognisable in building, strategy and
  organisation

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Conclusions

• Thinks about the acute care continuum
• Business case for HDU
• Break away from silo culture
• Restructuring
• Focus strategy and goals
• Capacity management
• Trading accounts for specialties