NORTH CUMBRIA UNIVERSITY HOSPITALS NHS TRUST EXTERNAL REVIEW OF ANAESTHETIC SERVICES 9.11.14 EXECUTIVE SUMMARY Anaesthetic and intensive care doctors underpin substantial amounts of activity in other specialties that are dependent on their services. The planning of elective activity is relatively straightforward, but out of hours cover and the move to 7 day services makes planning for emergency surgery, intensive care and obstetric services more complex. There are national standards set for intensive care and anaesthetic input to obstetrics. These set out the capabilities of the individual doctors, and the capacity needed to deliver the service. A base line level of capacity is required irrespective of the size of an intensive care unit or medically led obstetric unit. The national standards are clear that both require a dedicated resident doctor. The current service provision mitigates a small amount of the risk at WCH but it is not compliant with national standards for intensive care or for obstetrics. At CIC a dedicated resident anaesthetist for obstetrics is needed so that an epidural service can be provided and as a side-effect improve the critical care medical staffing. To provide a safe and sustainable anaesthetic service for the Trust these issues need to be addressed. This will either require further recruitment, noting the national position and existing difficulties, or it will require a re-adjustment of the configuration of existing anaesthetic resources. West Cumberland Hospital not being recognised for anaesthetic training adds additional complexity. The existing non-compliance with national standards makes recruitment more difficult. CONTEXT North Cumbria University Hospitals NHS Trust (NCUH) is the secondary care provider in North Cumbria. It provides services to 340,000 people predominantly from its 2 sites, the Cumberland Infirmary at Carlisle (CIC), and the West Cumberland Hospital (WCH) in Whitehaven. The geographical distribution of the population and the distance between the 2 hospitals provides particular challenges especially with the historic service provision model. Dr PM Upton provided a report entitled North Cumbria Secondary Care Service Configuration Proposals 14 th July 2014 after having been commissioned by the Trust to conduct a high level clinical strategic review. This work has been further developed as the Trust s Clinical Strategy has progressed, and this has been recently published. 1
As the considerations about the configuration of clinical services at the 2 hospital sites evolve it has become evident that the anaesthetic services that underpin many other specialties activity are key to the overall service provision. A desktop review has therefore been commissioned to provide an external opinion on the anaesthetic services and capacity of those services within the Trust. The Terms of Reference were provided by NCUH s Medical Director. ANAESTHETIC SERVICES An acute hospital Trust has a number of different functions provided by its anaesthetic department. At the highest level the core components can be considered as:- 1. Elective surgical services anaesthetic provision in theatres 2. Emergency surgical services anaesthetic provision in theatres 3. Intensive care services provided in an intensive care unit, for high dependency care and for resuscitation, stabilisation and transfer of patients between hospitals 4. Obstetric care provision of elective and emergency theatre services and an epidural service 24/7 5. Others including specialist services e.g. trauma units, pain, pre-operative assessment, out of theatre anaesthetic services as well as education, research, governance, audit and management REQUIREMENTS OF EACH COMPONENT OF AN ANAESTHETIC SERVICE It is possible to define, using nationally agreed standards what capability and capacity is needed to provide these services. Whilst the capacity of any component of a service can be flexed (above a core minimum) depending on the size of a particular site on which the service is provided, the capability cannot. For any of the emergency components of an anaesthetic service it is also possible to define minimum acceptable response times. These should be provided whenever possible, accepting that there can be peaks in demand which potentially can lead to response times being slower than desired. 1. Elective surgical services. The anaesthetic capabilities needed vary depending on the individual patients on each operating list and are beyond the scope of this review. The capacity is calculated using the nationally widely accepted quota of 1.25 DCC (Direct Clinical Care) per elective operating list. Review of the NCUH job planning data for the anaesthetic services suggests this is in line with national practice. 2. Emergency surgical services. This can be broken down into planned and un-planned activity. Although an emergency is never planned, there is often sufficient 2
emergency activity so that it becomes effectively a planned activity. NCEPOD 2003 Who Operates When continued the drive towards emergency operating being done in extended office hours and by senior medical staff whenever possible. This activity requires consultant anaesthetists to be the primary anaesthetist, and the capacity can be calculated using job planning. There is some controversy about whether 1.25 DCC is allowed per 4 hours or 1.00 DCC as pre-operative and post-operative input is different compared with elective activity. Un-planned, out of hours surgery requires 24/7 anaesthetic cover, and requires consultant level capability and capacity. Many hospitals no longer have a trainee anaesthetist overnight for emergency surgical provision it is a consultant delivered service for life and limb threatening surgery only. This has been adopted with the 22.00 rule where the presence of a consultant surgeon and anaesthetist is mandated. These consultants are non-resident but need to be able to attend the hospital within 30 minutes. This does not apply for obstetrics where a duty anaesthetist must be immediately available see point 4. 3. Intensive care. The Core Standards for Intensive Care Units published in 2013 by a partnership of 8 interested organisations sets out medical staffing levels and provides the evidence base for their recommendations. Specifically consultant cover must be available 24/7, and when covering the ICU, they should not be providing cover to other services e.g. obstetrics. These standards have been adopted by NHS North via the northern intensive care network, without any significant modifications. Whilst a cardiac arrest team does not need an anaesthetist, if a patient requires urgent intubation rather than emergency intubation, then a resident anaesthetist is required. In smaller hospitals the resident anaesthetist is usually part of the arrest team and is often the most senior member of the team. Section 2.17 of the report states geographically remote ICUs should have an established review/referral relationship with a bigger centre. It goes on to say provision of mechanical ventilation and simple invasive cardiovascular monitoring for more than 24 hours is acceptable if the treating specialist is not a Fellow/Associate Fellow of the Faculty if there is on-going daily discussion with the bigger centre. 4. Obstetric care. Safer Childbirth Minimum Standards for the Organisation and Delivery of Care in Labour was published in October 2007 by the Royal Colleges of Obstetrics and Gynaecology, Midwives, Anaesthetists and Paediatrics and Child Health. In section 4.3 of the report about anaesthetic staffing levels it states there must be a duty anaesthetist immediately available for the obstetric unit 24 hours a day. As standards and expectations increase an epidural service is also seen as an essential component of a medical led obstetric unit. A duty anaesthetist who is immediately available, is also able to provide this epidural service. It is 3
recommended that a medically led obstetric unit has 40 hours of consultant anaesthetic cover. 5. Other anaesthetic services. This is beyond the remit of this review, but it is important to recognise that an anaesthetic service needs to include the functions set out above to provide the appropriate support to other specialties. Governance, teaching/education and management are all essential if well led, safe, high quality anaesthetic services are to be delivered. Specific to NCUHs is the vascular surgical network and the designation of the CIC as a Trauma unit which means immediate access to anaesthetic support is required. HOW DOES THIS TRANSLATE TO NCUH? The existing issues are the lack of a dedicated duty anaesthetist for obstetrics at CIC, with the consequence that a reliable epidural service is not provided and the intensive care unit does not have the medical capacity that it needs. At WCH even during office hours there is only one non consultant grade anaesthetist covering both the intensive care and the obstetric units. This individual is supported by 10 consultant sessions on intensive care and 2 consultant sessions of elective obstetrics for caesarean sections. During office hours the 2 nd on call is provided by the ITU consultant. Out of hours the one resident doctor covers both units, as does the 2 nd on call who is a nonresident consultant. The 3 rd on call is also non-resident but can provide capacity if it is busy or for transferring patients. The 40 hours of a consultant anaesthetist on the obstetric unit that should be provided is in reality only 8 hours. To provide out of hours consultant cover to either intensive care or to obstetrics, consultants should have regular day time sessions on each. This does not happen. By referring to the national publications on standards relating to anaesthetic services it is possible to set out what anaesthetic capability and capacity is required on each site, depending on the overall clinical service configuration. It is important to reference the Five Year Forward View published by NHS England in October 2014. This recognises that one size does not fit all, and that a new care model viable smaller hospitals will be developed. A review of future models for maternity units is being commissioned to report by summer 2015. Equally, it must be acknowledged that to provide safe and sustainable services requires adherence to these national standards which organisations such as the CQC use as their benchmarks. 4
CIC There has been an increase in activity and complexity of the work at CIC. The capability and capacity planning for elective and planned emergency theatre work has already been done. It is clear that an anaesthetic on-call consultant covering theatre and obstetrics is essential for out of hour s service provision. Equally there must be an intensive care consultant available 24/7. This would appear to be the normal level of consultant cover for a blue light admitting hospital with emergency surgery and a medically led maternity unit. The resident anaesthetic team need 2 core capabilities, the first being urgent intubation and stabilisation of critically ill patients, and the second being the immediate availability to support the obstetric unit. These 2 core capabilities should not be provided by one individual, as is currently the case overnight at CIC. The provision of a dedicated anaesthetist to the obstetric service at all times would immediately mitigate the risk and provide an epidural service. The CQC comment in May 2014 was ensure there is an epidural service at the Cumberland Infirmary. It is noted that the current caesarean section rate at the CIC is 27.7% which is above the national average of 25.3%, whereas the WCH rate is 19.4%. Whether this is related to not having an epidural service or different case mix is not known. However, if it is as a result of more complex cases at CIC this reinforces the need to have an epidural service. The NCUH critical care capacity review was clear that a significant physical expansion of Critical Care is required, along with associated staffing. It is likely that a 3 rd resident doctor is required to provide the necessary pairs of hands to deliver the capacity to support this expansion in a sustainable way, although advance nurse practitioners could be used. There is a recommendation to have one resident doctor for each 8 intensive care beds. Many hospitals do not have sufficient anaesthetic staff to deliver this medical capacity so a nonanaesthetic doctor is often used as the more junior pair of hands in the intensive care, allowing the senior trainee to provide wider ranging support across the hospital e.g. to a high dependency unit or the ED. This 3 rd resident is often a surgical or medical trainee, and they gain valuable experience and training in intensive care medicine. WCH The capability and capacity planning for anaesthetic services to support elective surgery has been completed. The emergency surgery activity was moved from WCH to CIC following safety concerns in late 2013. There is therefore no requirement for anaesthetic cover for theatres overnight or at weekends at WCH. It appears clear from the national standards that if a medically led obstetric unit exists it should have a duty anaesthetist immediately available. This can be provided at consultant or sub-consultant level but the individuals must be experienced anaesthetists capable of 5
providing obstetric anaesthesia in emergency circumstances. This is irrespective of the size of the unit, as a Category One caesarean section can be required at a moment s notice. This is where there is an immediate threat to the mother or foetus s life and the target is to have the baby delivered within 45 minutes of the decision to deliver. This issue was identified by the CQC inspection in May 2014 resulting in a must do action to provide a dedicated anaesthetist at all times. For the intensive care unit there will remain the need to provide single system support to critically ill patient s e.g. respiratory support or cardiovascular support. Patients with multisystem failure are likely to be transferred on clinical grounds to the CIC. However, if patients are receiving mechanical ventilation, then a resident anaesthetist is essential. This person must have the skills to carry out an urgent intubation and to stabilise a patient for at least 24 hours on the ICU. With no trainee doctors at WCH it appears all the more important that the resident ICU doctor is not involved in providing theatre or obstetric anaesthetic services (except possibly on request epidurals). The current mitigation of having a 3 rd on call person, who is not resident overnight and at weekends, has mitigated the clinical risk of not being able to attend to simultaneous life threatening emergencies during that time period to some extent. However, even with this, as the 3 rd on call is not resident, at some point a Category One caesarean section will occur at the same time that a patient requires urgent intubation. The likelihood of that occurring is difficult to quantify but the risk needs to be minimised. There appears to be no alternative in the long term to having a resident doctor with airway skills for intensive care and a resident anaesthetist dedicated to the medically led obstetric unit. With these 2 resident anaesthetists the consultant cover could be provided safely by one individual given that there are then 3 capable pairs of hands available. This is not however, entirely consistent with the core standards for intensive care units as the consultant covering the intensive care is not expected to have any responsibility for obstetric or theatre cases. Consultants should also have day time sessions in any specialty to which they provide out of hours emergency cover. The anaesthetic cover required for WCH would be significantly different if a midwife led obstetric unit was implemented. One resident intensive care doctor supported by an on-call consultant would provide appropriate cover compliant with national standards. Dr PM Upton Consultant Anaesthetist Medical Director Royal Cornwall Hospitals Trust 2009 2013 Managing Director, BusinessDoc Ltd EHI National award for Clinical Informatics Leadership 2014 6
DOCUMENTS REVIEWED Who operates when? NCEPOD 2003 Safer Childbirth Minimum Standards for the Organisation and Delivery of Care in Labour Oct 2007 A guide to consultant job planning BMA and NHS Employers Jul 2011 Core Standard for Intensive Care Units 2013 North Cumbria Secondary Care Service Configuration Proposals Dr Upton Jul 2014 Anaesthetic Staffing, current workforce deficit plan Dr O Dowd Jul 2014 West Division anaesthetic staffing issues Dr O Dowd Jul 2014 NCUH critical care capacity review Jul 2014 Maternity services improvement update (draft) A Musgrave M Matar Oct 2014 Five Year Forward View NHS England Oct 2014 7