CRITICAL CARE IN NORTH WEST LONDON A Report on key issues and actions for the Network June 2012 CRITICAL CARE IN NORTH WEST LONDON North West London Critical Care Network June 2012 Page 1 of 10
A Report on key issues and actions for the Network Introduction, purpose and content 1. This report is based on consensus discussions within the Network, including material, discussions and presentations made at the Critical Care event held on 3 rd May 2012. The aim of the event was to bring together a range of clinical staff from critical care, to discuss the evolution of clinical models and service changes, and agree key issues and next steps for the Network and members. 2. In our recent discussions and during our event the key objectives have been to: Consider and update our Network Critical Care Strategic Framework (2008, rev. 2011) in the light of recent clinical drivers. Given that major site reconfigurations are likely as national and regional models evolve, use experience from existing critical care sites to consider: o o o Factors to consider in creating a bigger /consolidated critical care unit Critical care models for sites no longer able to sustain a level 3 unit Workforce issues Agree next steps 4. The event also considered Network quality measures, the further development of the Networks digital strategy, and received updates on the London Acute Kidney Injury Network, and the Olympic 2012 resilience preparations. 5. The programme for the event has been included as annex 1. A list of participants is included as annex 2. Several speakers provided presentations and with their kind permission these are available as a separate (due to size) annex 3 to this report. 6. The Critical Care Network would like to thank all those who participated in these discussions and the event for sharing their views, and in particular those who provided detailed presentations of latest evidence, on-going research, and current discussions. North West London Critical Care Network June 2012 North West London Critical Care Network June 2012 Page 2 of 10
Context clarifying needs and demands Clinical context 7. The North West London Critical Care Network is a large Network by UK and international standards. A core function is to drive standards and continually raise the quality of care for patients. The recent Network guidance A Framework for North West London is an example of this. Recognising the need for comparative data to drive standards and performance the Network has also developed the first fully-implemented UK set of quality benchmarking measures in Critical Care, which have now been successfully implemented across the network and are part of each acute Trust s contract with commissioners. 8. The clinical landscape within which Critical Care operates is rapidly changing. New configurations of services are being driven by changes in other services, including increasing regionalisation of services which were previously regarded as non-tertiary - for example acute vascular services, hyper-acute stroke units, and increasingly, emergency general surgery 9. These changes are driven by several factors. International, and UK (Royal Colleges, NCEPOD, and NHS NWL) recommendations favour higher volumes of activity in fewer centres, to drive the quality improvements expected; this needs to be set within a system of seamless care. 10. Technology which allows new techniques to be undertaken (e.g. endovascular aortic aneurysm repair), also tends to drives the clumping of services into larger units where this technology can be most efficiently and effectively utilised and with sustainable clinical rotas (e.g. more consistent provision of out-of-hours interventional radiology than at present, but at fewer centres, and similarly with acute general surgery including laparoscopy skills) 11. As well as individual speciality changes as above, emergency patient flows are likely to change significantly in future, as similar factors begin to affect the number of viable A&Es and emergency medical and surgical services. 12. The development of academic health science partnerships will alter the flow of patients and funding and further drive regionalisation, as larger centres (both teaching hospital and non-teaching hospital) will be better able to support clinical trial recruitment. 13. Underlying this, there is likely to be continued community and commissioner demand for local access to some unplanned services, including urgent care centres and a variable element of general medicine. 14. The Network increasingly considers that the current pattern of critical care services in NW London will not be sustainable as the changes above develop. The previous Network position, i.e. that every hospital with unplanned admissions must retain full Level 3 care, may become unsustainable if activity falls at some sites and those L3 units become too small to fulfil training, leadership, and skill mix requirements. North West London Critical Care Network June 2012 Page 3 of 10
15. This leads us to suggest that we need to move to a model of critical care services which can support: The continued provision of a large volume of local acute services The partial concentration of major acute services Streamlined access to specialist services 16. This model has to be achieved within the challenging future financial projections, and there will also be significant workforce issues involved in moving to and sustaining a new pattern of service. However the benefits are considerable, and they would help to support wider strategic developments, for example, the growth of the academic health service partnerships in London. 17. The evidence from recent public discussion is that people increasingly accept tertiary models of care for acute and planned interventions, but there is a continued demand for local access for other services. Models of supporting smaller units 18. To allow this to happen, the Network has considered precedents for a split site model of care for supporting smaller units. There are evolving models nationally, and the May 3 rd meeting included a presentation of operational experience from The Royal Marsden. This has a large unit of 16 beds supporting a smaller satellite unit of two beds. This small unit operates with staffing of a Senior Anaesthetic Fellow, Critical Care Unit ( CCU ) Consultant with CCU outreach from 8 am to 8 pm. There are clear protocols for admission, discharge and transfer, and use is made of telemedicine including cameras, Clinical Information systems and electronic patient record systems. Of the two patients a week on average in the unit, only a third need transfer to the larger unit. Following stabilisation, this is usually undertaken within 24-48 hours, where there is an optimal window and is planned. 19. The key factors for allowing the service to be sustained are that the smaller unit is paired with a designated larger unit (in this case within one trust), and there is close collaboration with medical and surgical teams on both sites. There is a senior anaesthetic fellow on site, and a transfer trained CCU outreach/anaesthetic team. Capacity at the major site is planned to ensure bed availability for transfers from the remote site. Most notably, there is full rotation of nursing and doctors between both sites, and a scheduling system which allows for capacity of beds. There is a recognition that there will be a premium in order to maintain these staffing levels in the smaller units, but this is necessary to maintain a seamless and comprehensive service. Transition to new patterns of service and new ways of working 20. The Network has considered the implications for the workforce of the changes required, and the impact of new ways of working when moving to a possible new configuration. If there is concentration of larger units on fewer sites, the same number of patients will need care from the same total number of staff, but there may be significant changes in North West London Critical Care Network June 2012 Page 4 of 10
where staff work. Network initiatives such as skills passports, training, and Trust arrangements including rotation, will all be necessary to facilitate any necessary staff movement. 21. The meeting considered the impact of service expansion at newly designated major acute sites. An example of establishing a new clinical service at Imperial College (which included critical service expansion and a new ICU) shows that this requires strong leadership and extensive user engagement both in design and in transition planning. It is essential to have a key single clinical project leader with dedicated time, who is able to co-ordinate multiple clinical user groups and with external agencies (project management, design, health planners, contractors). Considerable time was spent on learning from other sites, best practice, and national evidence base. The scheme was accompanied by an ambitious equipment renewal programme needing thorough training for both new site and new equipment. The result was felt very satisfactory both in terms of end result and unit design, and in the transition and move arrangements; the key message being to allow the clinical time and drive needed to enable this. 22. Clinical working models and staffing arrangements will need review, and team size and leadership need to be considered if there is significant re-sizing (cf. Royal London Hospital ICU, a new 44-bed space with 3 consultant-led clinical teams per day). The RLH experience was complicated by a very long timetable in which the staffing model changed, ending in logistical issues relating to running 3 clinical teams in a unit designed in 4 parts. As at St. Mary s, a very high and early degree of clinical planning enabled a smooth move process, although there were more complications from unit layout and engineering issues. Experience from this site (supplied via teleconference, prior to the May 3 rd meeting) reinforced the need for a high level of user engagement in the design process, and supplied some very helpful learning points for pick-up in a later session. 23. As part of the development process, clinical teams undergoing unit expansion and/or rebuild need to observe practice from other units, and to ensure the development of protocols and protocols with reference to the best practice observed; evidence- based data and where appropriate national protocols. It requires staffing to be managed creatively to ensure patient safety and staff supervision during changes, and to identify efficient and effective ways of working within resource constraints. It is vital that time is allowed for staff training to deal with new technology and practice in the new unit, and shift patterns will need to take account of this. 24. It was noted that in the case of unit expansion (which may be necessitated by concentration of services), cost should not be underestimated though incorrect assessment of cost per additional bed. A unit expanding from medium (<12) to large (>12) beds will need a different level of staffing change per bed than a unit changing from 8 to 12 beds, since senior leadership, number of clinical teams, training and practice development staff, will all need a step change, in order to maintain safety and quality. The default assumption to simply model a uniform and constant increment per extra bed, needs to be very carefully examined and compared to practice elsewhere. 25. The Network has also identified that any newer models of care that lead to concentration of critical care at fewer major sites, could be associated with an increase in transfers with implications for the London Ambulance Service and in particular its involvement in the transfers of patients. These proposals could lead to an increase in the North West London Critical Care Network June 2012 Page 5 of 10
number of transfers, both planned and unplanned. This will have resource implications for training, capacity and vehicles. Discussion on potential reconfiguration of critical care services (para 26-37 are notes from interactive workshop/whiteboard exercise, May 3 rd) : 26. The discussion at the event highlighted the need for the reconfiguration of Critical care services across NW London. The following key clinical, organisational and workforce issues which flow from that were discussed by participants: Networking and Balance of services between sites 27. Reconfiguration of other clinical specialities (those which refer to critical care, and those which support critical care) is very likely to produce a pressing requirement to move toward fewer, larger critical care units for the overriding reasons of volume, quality, and maximization of technology. At present these factors are seen as applying largely to the primary specialities (with secondary implications for critical care configuration), but there may also be a growing argument that the larger-unit benefits are relevant to critical care itself. In addition, some smaller units, possibly with a new model of care and linked closely with designated larger units, will also be needed to support local services. 28. The benefits of larger units are The larger number of patients leads to lower mortality and better patient outcomes They allow better use of equipment and technology They can assist infection control They provide better patient flows and improved liaison with other disciplines The pooling of resources leads to greater cost effectiveness They give opportunities for new skill mix and new roles to be created. 29. The necessary move toward larger units will also bring challenges. Evidence from elsewhere in London is that these larger units will need clear leadership, and will need processes to manage the complex demands of the larger numbers of staff. Key interdependencies between services 30. Patient expectations will need managing, and clear processes will be needed to allow for repatriation of patients. There will need to be clear communication between trauma centres and larger units, and the smaller units. There could be an increase in transfers North West London Critical Care Network June 2012 Page 6 of 10
between units, so there will need to be robust transport arrangements. Clear protocols are required between services. 31. Some developments that could be considered include: Moving staff rather than patients Developing retrieval teams Delivering more care to where the patient is (through telecare/ telemedicine) Maintaining critical care support to mainly elective services 32. Maintaining critical care support to mainly elective services will require significant organisation and support. There will need to be: Careful management of capacity Good risk assessment of co-morbidities (example of Mount Vernon) Clarity over who owns patient and links with A&E Clarity over management of patients unfit to transfer, and a retrieval service for receiving hospitals. 33. It is proposed that protocols be developed to cover: Medical cover to small sites and training requirements The minimum size of a unit How many transfers are appropriate Which patients can be appropriately and safely transferred. Issues for the workforce 34. The move to a different pattern of service has significant workforce issues, both at a strategic and unit level. There needs to be a clear workforce relationship between the larger and smaller units. It is essential that staff in smaller units are supported by larger units, and that there is rotation between staff. This will be necessary to attract and retain staff, and discussions will be needed with the college. On-going education and training is vital, particularly during time of change so that staff have exposure to new skill sets. 35. There is the opportunity both in larger and smaller units to consider new grades and types of staff, particularly in nursing. In the smaller units greater autonomy would be required, and the flexibility and ability to step up the units to level 3 on occasion. The relationship with staff providing support in the rest of the hospital is important, and a mature relationship over the need for staff to cover other areas. The role that Education teams can play was emphasised. 36. Efficient physical layouts of units also need consideration. The largest units will need splitting into sub units, whilst small units need flexibility. This needs to be part of Trust estate strategies. North West London Critical Care Network June 2012 Page 7 of 10
Conclusions rising to the challenge 37. After considering the ways in which changes in clinical practice, technology, staffing, and standards will affect future configuration of services across multiple acute specialities, the Network concludes that it: Supports the development of larger units with streamlined access, in parallel with national trends for reconfiguration and consolidation of referring and supporting specialities onto fewer sites (emergency medicine, acute services, tertiary services, and diagnostics). Recognises the challenges and opportunities offered by expansion of medium-sized units to larger, consolidated units, which will include (a) the need for step changes in operational management, training, and medical and nursing leadership; and (b) significant capital projects with strong clinical leadership and engagement. Accepts that there may be a clinical need for the retention of some smaller units in certain circumstances, with the flexibility to escalate temporarily to level 3 to allow safe stabilisation prior to transfer. This model exists in specialist services (e.g. cancer) but would represent a new and unproven model in the context of acute services (e.g. to support limited acute medicine services, or a dedicated elective hospital). It would need detailed further planning of staffing, practice and protocols to be sustainable, and can only function in close collaboration with a designated major centre and with adequate recognition of the costs involved. Needs further work on the level of transfers, and the best practice for these. Quality measures in critical care in North West London 38. For a service such as critical care, having evidence to support its performance and outcomes is crucial. The Network serves a population of 1.5 million adults and has developed a clinician-led performance measurement tool for gathering a wide range of quality measures, with benchmarking, across thirteen NHS sites. The measures are selected by evidence base, reliability and reproducibility, and minimal administrative burden, and enable meaningful quarterly reporting and feedback to ICUs and improvement over time as well as useful comparison between units. They are likely to impact on unit development, commissioning, and reconfiguration decisions in future. 39. The Network uses this to regularly compare the performance of individual units, inform future reporting locally and to identify common areas that require a Network approach or Network events. 40. The Network has reviewed this system after its first year. Against its original objectives the system has delivered a clinically developed benchmarking system which has been North West London Critical Care Network June 2012 Page 8 of 10
tested and validated in practical use. It is usable by commissioners and clinicians, and is fair across the range of units (from national/ specialist to local) in the Network. In most cases there is a minimal extra reporting burden. Over the last year this system has seen increased compliance with evidence based care across the Network with improved performance. 41. The Network intends to continue to develop the use of quality measures tool and is considering a Network event on user/patient involvement. Other initiatives could include a national early warning scoring system and NICE 50 compliance, identification of site specific capacity shortfalls, and further transfer work. The development of an Information and quality group would support this further development. Digital strategy and communication 42. The Network also has a digital strategy, which aims to support innovation and problem solving, disseminate and share information, support the spread of good practice and showcase work. A new website is being established which will support this strategy by providing access to documents, reports, and data, information and results on projects. It will also provide digital training solutions to commonly experienced problems. 43. The digital critical care transfer training course, Network emergency resilience and Network activity videos are being directly loaded by Trust IT departments onto all critical care and ED IT platforms across North West London. Feedback from pilots has been extremely positive. 44. Network members submitted priorities for future areas to be covered and confirmed their approval of the new website structure and functionality. Links with other specialist services 45. The Network is developing its links with other specialist Networks. A brief update was given on the work of the London Acute Kidney Injury Network, and joint work being considered including an audit in critical care units in the Autumn. 2012 Resilience Olympics 46. A presentation and update on assumptions, anticipated impact and the resilience planning to support the NHS during the games period was provided. The three core aims were to meet the Games bid commitments, maintain business as usual, and have contingency provision. 47. As well as having hospitals designated for specific Olympic groups, the emphasis is on business as usual. Challenges would arise in transport and travel and various tools were available for staff to support journey management. Business as usual included reviewing normal lists and rescheduling in advance where appropriate, but not cancellation. North West London Critical Care Network June 2012 Page 9 of 10
48. Resilience and contingency included business continuity, stockpiling and training, testing and exercising. Access to sterile supplies/equipment was being assured. 49. Guidance on day to day operational communications and reporting would be available shortly. It was agreed that Olympic lead contacts for each site would be shared so that any issues arising for clinicians, could be taken locally. Actions to take forward in 2012/13 50. The Network proposes the following actions: Continue to analyse, inform, and support the next steps in clinical service configuration within NWL, to ensure congruence between best-practice critical care and the changes in other specialities. Actively develop clinical models and consensus guidance for o (a) Implementation and best-practice operation of larger units at emerging major acute sites, particular at sites with previously medium-sized units where this may represent a step change in clinical model, leadership and staffing arrangements. o o (b) safe, practicable, high-quality models for providing critical care support at hospital sites which can no longer support full general L3 services. (c) guidance on best practice for capital (physical rebuild) requirements and transition arrangements for each of the above scenarios. Work with trusts, including the London Ambulance Service and transport providers to develop further guidance on transfer processes and protocols which can support the new strategy. Disseminate good practice over workforce and staff management. Continue the development of the quality measures and further engage commissioners in their use as a performance tool. Information and quality group to support Network development areas. Launch and develop the website to provide immediate and transparent access to Network activity, policies, guidance, individual unit information, training, and patient and carer information. Reflecting Network member feedback, intranet and web distribution and universal availability of the extensive Network training video programme will be a priority. Support an Acute Kidney Injury audit in conjunction with the London AKI Network. Annex 1: Workshop Agenda Annex 2: Workshop Participants Annex 3: copies of presentations on 3 May 2012 (separate file due to size) critcarenetworknwl@nhs.net North West London Critical Care Network June 2012 Page 10 of 10