Critical care in the UK

A session blog from Day 2 of State of the Art, London December 2015. See the full list

Blogger PHW (@docph_w)

A full room again for these practical interesting talks.

 

What makes a successful ICU?

John Knighton

What does success mean?

Good outcome data, ICNARC, HCAIs, staff perceptions etc.

A personal take on what Portsmouth do.

  • 1000 bed hospital with 670000 population, in financial deficit.
  • NO Cardiothoracics, neuor or PICU
  • 1500 ICU admissions per year
  • 24 beds mixed level 2 and 3
  • 75% emergency 25% elective 60%medical vs 40% surgical
  • Occupancy 90%
  • Outstanding by CQC
  • 13 WTE consultants 7day ICU cover
  • Continuity and consistency
  • STR and CT tier
  • Advanced Critical Care Practitioners
  • Post CCT fellow in Echo

A great talk with some excellent hints and tips on how they run a clearly very successful unit. Sounds a great place to work.

 

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Summary/Key messages

  • CQC markers of success
  • Outcome data put on hospital internet
  • Measured CVC blood stream infections prospectively
  • Unit is well designed with plenty of natural light aided by it being a PFI new build
  • Safety Culture
    • Have a daily safety brief at 10.55
    • All med staff, AHPs, med students, nurses etc.
    • Introductions
    • ID patient specific risks and make relevant contingency plans
    • Capacity logistics, politics
    • Critical incidents and near misses
  • Watch out notices/posters around the ICU to warn of near misses and lessons learned
  • IT screens on unit scrolling through safety headlines, national warnings and watch out notices
  • No use of agency staff
  • Ward round participation amongst nurses
  • Multiple MDT training sessions per week
  • A number of Standard Operating Procedures available at the link below
  • ITU questionnaire for patients and relatives on discharge
  • Staff perceptions are high and measured by a specific questionnaire

References/Further reading

What the CQC has learned about hospitals and about ICUs

Ted Baker

Deputy chief inspector for the CQC

Encouraging to learn that Ted is largely impressed by the quality of critical care in England.

67% of critical care units are good or outstanding and come out top of the 8 KLOEs. 100% of Critical care is caring. CQC have seen many examples of exemplary care.

Aim of CQC is to change culture and challenge NHS leadership to do better thus avoiding future disasters.

Summary/Key messages

    • Critical care is one of the core services inspected
    • Level 2 and level 3 units are reviewed under critical care irrelevant of who looks after each unit
    • Key lines of enquiry
    • Strong focus on listening to staff and patients
    • Ratings to compare services
    • Do not seek to aportion blame
    • Quality summit to launch a quality improvement process
    • KLOE
      • Is it safe, track record on safety, lessons learnt and improvements made
      • Are services effective; qualified, appropriate staffing
      • Are services caring
      • Is organisation responsive
      • Is the service well-led at every level from board to clinical teams
    • Wide range of quality between hospitals
    • Marked variations between services, in some hospitals there is  variation within a service
    • Staffing is a major concern
    • Clinical governance and quality assurance is vital
    • Leadership at many levels was very variable and critical in the quality and safety of a service

 

  • SAFETY CULTURE IS KEY

 

  • What concerns have been found
    • Physical environment inadequate
    • Split units with different visions and standards
    • No benchmarking of outcomes
    • Outreach team variability
    • Leadership entrenched culture

References/Further reading

The future of small ICUs: the rematch

Jeremy Groves (Chesterfield ICU)

What is a small ICU?

  • Chesterfield 7 level 3 beds
  • 8 bedded level 2 unit

Is this small ? open to debate.

  • 70 units have 7 beds or less
  • 3981 beds declared on SITREP
  • 11 providers have 7 beds or less

Summary/Key messages

  • Drives for regionalisation
  • 7/7 services
  • Will reconfiguration save money
    • Possibly but there is a paucity of evidence and transport costs haven’t been fully assessed
  • staffing
  • volume outcome relationship is this clearly related?
    • In surgery it appears so
    • but not in all types of surgery
    • ICNARC could not demonstrate a relation in sepsis
    • Mechanically ventilated admissions shows some relationship but has clear study limitations
  • Is it clear small units deliver poor quality
    • ICNARC would indicate this is unlikely
  • GPICS/Core standards
    • Nurse staffing virtually no difference
    • Medical staffing may be an issue in smaller units
    • Do we need medical trainees
    • Networks can help assure quality
  • Service specification
  • Transfer harm we don’t know the outcome of this yet
  • System resilience
    • Closing small units is unlikely to be mirrored by increase in beds in bigger units
    • Fewer beds to manage a surge crisis
  • Lessons learnt at Mid Staffs
    • Don’t lose sight of the whole and concentrate on targets and cash
    • remember there is a patient at the end of all this
  • Evidence for centralisation is not robust