Wales Critical Care & Trauma Network (North)

Wales Critical Care & Trauma Network (North) CRITICAL CARE ADMISSION & DISCHARGE GUIDELINES Revised 2016 1

CONTENTS: 1.0 Introduction 1.1 Scope of the Guideline 1.2 Levels of Care 2.0 Admission Guidance 2.1 General Principles 2.2 Planned (Elective) Referrals/Admissions to Critical Care 2.2.1 Bed Booking Process 2.2.2 Bed Availability 2.2.3 Pre-Operative/Admission Visits 2.2.4 Cancelled Operations 2.2.5 Audit Process 2.3 Unplanned Referrals/Admissions to Critical Care 2.3.1 Repatriation from Tertiary and Other Centres 2.3.2 Admission for Organ Donation 2.3.3 Admission for Neuro-Prognostication 2.3.4 Admission when Critical Care is full 2.3.5 Transfer for Non-Clinical Reasons i.e. when Critical Care is full 2.3.6 Escalation of Critical Care Services 2.3.7 Admission of Children (16 years and under) 3.0 Discharge Guidance 3.1 General Principles 3.1.1 Complex Critical Care Patients 3.2 Discharge Process 3.3 Post Discharge Page: 3 3 3 3 3 4 4 4 4 5 5 5 5 6 6 6 6 7 7 7 7 8 8 8 Acknowledgements 10 References 10 Appendices Appendix 1: WG Levels of Care Appendix 2: Elective Bed Booking Form Appendix 3: Example: Discharge Summary and Rehabilitation Prescription/Plan 11 12 13 2

1.0 INTRODUCTION The following document sets out the admission and discharge guidelines for the Critical Care services in the Wales Critical Care & Trauma Network. This includes adult critical care (Level 3 and Level 2) beds, and flexible, extended provision of critical care where these exist. These guidelines outline best practice. 1.1 Scope of the Guideline The Wales Critical Care & Trauma Network (North) incorporates three Acute Hospitals within North Wales. Each Hospital has a Critical Care Unit with Level 2 and Level 3 beds in various configurations. This guideline relates to Critical Care services in Betsi Cadwaladr University Local Health Board (BCUHB), specifically: Wrexham Maelor Hospital o Intensive Care Unit/High Dependency Unit (Flexible units) Glan Clwyd Hospital o Intensive Care Unit/High Dependency Unit (Flexible units) Bangor Hospital o Intensive Care Unit and Surgical High Dependency Unit (2 separate units) 1.2 Levels of Care The Levels of Care referred to throughout this document align with the Quality Requirements for Adult Critical Care in Wales (2006). For more in-depth explanation regarding Levels of Care in Wales refer to; www.wales.nhs.uk/sites3/docmetadata.cfm?orgid=753&id=147816 With the development of more flexible and integrated Critical Care services the distinction between Level 2 and Level 3 care units has become blurred; the term Critical Care Unit is used throughout this document. For clarification Level 2 care was previously referred to as High Dependency Care (HDU) and Level 3 care was previously referred to as Intensive Care (ICU). For a quick guide to Levels of Care refer to Appendix 1. 2.0 ADMISSION GUIDELINE The objective of the Admission guideline is to ensure appropriate and timely admission of patients to critical care and to facilitate proper utilisation of limited capacity and staffing resource. 2.1 General Principles Critical Care may be defined as a service for patients who can benefit from more detailed observation, monitoring and treatment than is available on a general ward. It is not appropriate for this guideline to be too proscriptive about which patients should or should not be admitted however it is generally accepted that the clinical condition which has resulted in the patient requiring Critical Care should be identifiable, acute and potentially reversible*. Even when there is an acute reversible component, the patient s chronic health status and frailty may significantly affect the patient s ability to survive and benefit from an intensive care episode. This requires careful assessment and explicit assessment, but should not be prejudiced by age or disability alone. The decision to admit a patient to Critical Care should be based on the concept of potential benefit. Patients who are too well to benefit or those who have no hope of recovery to an acceptable quality of life should not be admitted. This is a clinical decision and can only be made for each individual patient at the time of referral. Patient autonomy should be respected. As far as is reasonably ascertainable, the person s past and present wishes, feelings, beliefs, values and other factors, for or against intensive care, stated or written, should be taken into account. The patient must be involved, as much as possible, in the decision to admit (Mental Capacity Act 2005). 3

The role of relatives in the case of an incapacitated patient is to represent their understanding of what the patient would wish for. Where a patient lacks capacity the admitting Consultants must discuss with other people (e.g. Carers, close relatives, friends or anyone interested in the person s welfare or anyone named by the person as someone to be consulted) taking into account their views as to what would be in the best interests of the person lacking capacity (Mental Capacity Act 2005). The final decision to admit or refuse admission of patients to the critical care unit is the responsibility of duty Critical Care consultant. Any disputes should initially be discussed between the duty Critical Care consultant and referring consultant. If further resolution is required this should involve the respective lead clinicians or clinical directors. All patients admitted to Critical Care will have their care directed by critical care staff. Whilst the referring team will be encouraged to regularly visit critical care and discuss the case with Critical Care staff the final decisions regarding changes to therapy will rest with the duty Critical Care consultant. There will be assessment of the rehabilitation needs of all patients within 24 hours of admission to Critical Care and NICE 83 eligible patients on discharge from Critical Care must receive a rehabilitation prescription (GPICS 2015). It is not an appropriate use of Critical Care resources to admit to, or delay discharge from the Critical Care Unit patients who can be managed on an appropriate general ward, due to purely organisational factors (e.g. ward staff shortages). Such organisational factors should be brought to the attention of the referring consultant and if required the Chief of Staff of the referring location. *For guidance regarding Admission for Non-Heartbeating Organ Donation (also known as donation after cardiac death) see section 2.3.2 2.2 Planned (Elective) Referrals/Admissions to Critical Care The referral for planned (elective) admissions should ideally be based on assessment of the patient s requirements rather than the procedure itself. In line with NICE CG50 Acutely ill patients in hospital (2007) if admission to a Critical Care area is clinically indicated, then the decision to admit for elective admissions should normally involve both the referring consultant and the consultant in Critical Care. When no other discharge/death/transfer are expected, the last Critical Care bed would not be offered to an elective patient except in specific circumstances and with the agreement of the Critical Care Consultant. 2.2.1 Bed Booking Process 1. Once a patient is identified as potentially requiring critical care postoperatively the Critical Care Bed Booking Form (Appendix 2) should be commenced at the earliest opportunity, this includes urgent planned (e.g. cancer) cases. 2. A copy of the form should be sent to the critical care unit to book a bed. 3. Bookings should be for named patients only. 2.2.2 Bed Availability Surgeons and anaesthetists who have booked elective cases must check on bed availability prior to starting the case. If a case is started in the knowledge that there are no Critical Care beds then the surgeon/anaesthetist must organise alternative suitable post-operative care. 2.2.3 Pre-Operative/Admission Visits Whenever possible, a member of the Critical Care nursing team will visit the patient pre-operatively. A visit to the Critical Care department will be offered. 4

2.2.4 Cancelled Operations Elective admissions that are cancelled due to lack of Critical Care capacity or staff should be re-booked as soon as possible. The deferment/cancellation and the reason why should be documented on the outcome section of the bed booking form. 2.2.5 Audit Process Critical Care Units should complete the outcome section of the Bed Booking Form (Appendix 2) to monitor booked planned admissions against actual admissions. It is a requirement of the Delivery Plan for the Critically Ill Adult that these will be audited. 2.3 Unplanned Referrals/Admissions to Critical Care Referral of patients to Critical Care services should be undertaken at consultant level (NICE CG50 2007). All potential patients should be discussed with the duty Critical Care consultant by the admitting consultant. Direct referrals from the Emergency Department should come from either the admitting consultant or the Emergency Medicine consultant. The Clinical Site Manager must also be made aware of these admissions to ensure recording of accurate bed availability. All patients formally referred for Critical Care should be reviewed by the Critical Care Consultant prior to admission (NICE CG50 2007). In certain circumstances this may not be practicable in which case these patients should be reviewed by the Critical Care consultant as soon as possible. It is the responsibility of the Critical Care service to assess patients suitability for Critical Care need. No patient should be admitted without the explicit agreement of the Critical Care Consultant. Overall frailty should be assessed and scored to aid the decision making process. The referring team shall maintain responsibility for the patient up to admission to Critical Care, and shall remain responsible for ongoing management if admission is refused or deferred. In circumstances of urgency, junior medical staff, nursing or allied health professional staff, or members of the Acute Intervention Team may need to alert Critical Care medical staff directly. In these cases the referring consultant must always be alerted and agree to the referral. Priority for admission is: Emergency in house Emergency in BCUHB Repatriation from outside BCUHB Repatriation from within BCUHB Urgent cases in house Elective cases in house This prioritisation list is only for guidance and can be superseded by clinical judgement/risk assessment after discussion with all parties involved. No Unit in the Network shall accept a patient for transfer from another hospital (any departmentwards/theatres/ed) unless he or she has been referred to the Critical Care team of the referring hospital and assessed as suitable for Critical Care. 2.3.1 Repatriation from Tertiary and Other Centres Patients should be repatriated, preferably to within the patient s locality as soon as a bed becomes available (see section 2.3 for priority of admissions). Refer to existing guidance http://www.wales.nhs.uk/sites3/documents/753/guidelines%20for%20the%20transfer%20of%20the%20critically%20 ill%20adult_approved.pdf 5

Designed for Life: Welsh Guidelines for the transfer of the critically ill adult (2016) which essentially states that such repatriations should normally take precedence over elective admissions to the unit: A side room should be considered until infection screening is complete. Where possible, infection prevention to infection prevention team discussion should take place prior to repatriating. If a patient arrives without a named consultant, the on-take team in the relevant specialty at the time of arrival will be responsible for the care of the patient; they will be notified as such. 2.3.2 Admission for Organ Donation Patients initially assessed in EDs in whom organ donation is a possibility should be admitted wherever possible to an ICU in order that their clinical and broader interests (including the potential for donation) can be fully assessed. It is recognised that this course of action is dependent on the availability of resources. All ICUs should have a bed management protocol to manage situations where there is a potential donor but capacity issues are present (BTS / ICS consensus document from 2011). Please also refer and adhere to Betsi Cadwaladr University Health Board Organ Donation after Circulatory Death policy. 2.3.3 Admission to Critical Care for neuro-prognostication If an acute, severely brain injured patient has been declined for referral by a neurosurgical unit, it is often difficult to prognosticate in the acute setting. These patients should normally be admitted to the Critical Care Unit for assessment unless other co-morbidities or advanced directives preclude this. (A Welsh Government guideline is in the process of being produced) 2.3.4 Admission when Critical Care is full Whenever a resource is limited it is possible that demand may outstrip supply. The clinical team is responsible for allocating available critical care resources in the most effective way. When the Critical Care unit is full and another patient requires admission it will be necessary for the consultant and senior nurse responsible for the unit to consider the relative needs of all the patients. This will include many issues such as the dependencies of all the patients, any speciality requirements and suitability for transfer. The Critical Care team will undertake a balanced clinical risk assessment of the short-term strategies available to deal with further referrals for care, pending a definitive critical care bed: these may vary in each of the three localities but include flexing above capacity either within the unit, or by use of theatres/recovery, and premature discharge of Level 2 patients (Acute Intervention Team support where available). These decisions will be influenced by medical and nursing staff issues, and the availability of physical resources. Patients accepted for critical care will become the clinical responsibility of the Critical Care Intensivist, in collaboration with the referring team. Other resources e.g. additional staffing, equipment and placement will need to be arranged in collaboration with the Clinical Nurse Manager (in hours) and the Clinical Site Manager. 2.3.5 Transfer for Non-Clinical Reasons i.e. when Critical Care is full The decision of which patient to transfer has significant ethical and medico legal implications. BCUHB has a duty of care to all its patients inside and outside Critical Care, and must triage resources accordingly. Non clinical transfers should not take place where there are delayed transfers of care (DToCs) on the Critical Care Unit. 6

Refer to existing guidance Designed for Life: Welsh Guidelines for the transfer of the critically ill adult (2009) which essentially states that an ethical decision needs to be made whether to transfer a stable patient already on the critical care unit, or the new patient requiring critical care. The guidance advocates moving the new patient to a place of safety i.e. transferring, however it also recognises that there will be instances when moving the stable patient is the best option: http://www.wales.nhs.uk/sites3/documents/753/guidelines%20for%20the%20transfer%20of%20the%20critically%20 ill%20adult_approved.pdf 2.3.6 Escalation of Critical Care Services There is a Welsh Government expectation that all Critical Care Units in Wales have plans in place to escalate 100% Level 3 capacity should the need arise i.e. mass casualty event, pandemic flu. Health Boards must demonstrate clearly that their arrangements for critical care escalation meet the requirements of the WG (2016) guidance. Each Local Health Board and Critical Care Network needs to assure themselves that they have plans in place to respond swiftly to such demand for services. Principles include (not exclusive): Health boards must plan for a 100% increase in level 3 adult critical care capacity, ensuring plans are realistic and sustainable Equity of access to care Minimise non-clinical transfer of patients All efforts must be made to maximise the efficient use of critical care - minimise DToCs from critical care and avoid unnecessary admissions e.g. maximising vaccinations, providing public health advice. Patients requiring discharge from a critical care facility must take precedence above all other patient flow issues. 2.3.7 Admission of Children (16 years and under) Depending on local practice and facilities, some adult critical care units may admit children in the shortterm, especially where there are capacity issues at the tertiary centre. Standards of care for children admitted to adult critical care units are set out by the Paediatric Intensive Care Society (2015). Such admissions should ideally be cared for in a side room with continued Paediatric nurse presence. If this is not possible a Paediatric nurse should be available for advice, and the child should be reviewed twice daily by Paediatric senior medical and nursing staff. Clinical management will be the joint responsibility of the Paediatricians (or referring specialist) and the Intensivists, supported by Paediatric Intensivists at the tertiary centre as required. 3.0 DISCHARGE GUIDELINE The objective of the Discharge guideline is to support well organised, safe and timely discharge of patients from Critical Care. 3.1 General Principles Once patient dependency is assessed as having changed to that consistent with ward care the patient should be discharged. Prior to discharge all patients must have a clinical assessment to identify their current rehabilitation needs and agreement of their short and medium term physical and non-physical rehabilitation goals as described in NICE CG83 (2009), this includes a rehabilitation prescription, incorporating physical, emotional, psychological and communication needs (GPICS 2015). Finding the most appropriate ward bed may take a short time but it is important that patient discharge should not be delayed longer than four hours from the time a bed was requested (WAG 2010, GPICS 2015). Discharges after four hours will be classed as a delayed discharge (DoH 2005, GPICS 2015). After the decision to transfer a patient from a critical care area to the general ward has been made, the patient should be transferred as early as possible during the day (GPICS 2015). Transfer from critical care 7

areas to the general ward between 22.00 and 07.00hrs should be avoided whenever possible, and should be documented as an adverse incident if it occurs (NICE CG50 2007). 3.1.1 Complex Critical Care Patients Discharge of any patient from Critical Care requires planning however it is especially important to plan the discharge of long term or complex patients. Defining this group may be difficult but should include all patients who have required Critical Care for more than four weeks. Patients, their relatives and ward staff all need time to prepare for the discharge. Specific needs must be identified as soon as practically possible and will require multidisciplinary liaison. Specialist services will need time to coordinate all aspects required for continuing care. This may take several days but the process should start before the predicted discharge date i.e. discharge planning should not be a reason for patients staying beyond their need for Critical Care and involve the admitting physician/surgeon. 3.2 Discharge Process 1. Critical Care team decide that the patient is ready for discharge. 2. The admitting/on-call Physician/surgical team are informed. 3. The Acute Intervention Team are informed 4. Critical Care staff to inform the Clinical Site Manager of the need for a patient discharge as soon as patient is ready. Time of call should be noted. Any additional/special requirements should be stated at this time. 5. This time should be recorded onto the Data Collection Tool (DCT) to ensure the correct time is recorded on to WardWatcher (and thus CCMDS). 6. Clinical Site Manager will facilitate discharge to an appropriate ward in partnership with the ward staff. This may be facilitated by the Acute Intervention Team where available. 7. The Critical Care team will commence the Rehabilitation Prescription/ticket to ward and document accordingly. 8. The Critical Care team and the receiving ward team should jointly ensure that there is continuity of care through a formal structured handover of care from critical care staff to ward staff (including both medical and nursing staff); this should be supported by a written plan, which is NICE CG50 (2007) compliant in a Discharge Summary and Rehabilitation Plan (see Appendix 3). This should include (GPICS2015): A summary of Critical Care stay, including diagnosis, treatment and changes to chronic therapies A monitoring and investigation plan A plan for ongoing treatment Rehabilitation assessment and prescription, incorporating physical, emotional, psychological and communication needs Follow-up arrangements. 3.3 Post Discharge The impact of critical care and poor quality rehabilitation on patients, and the ripple effect on families, should be regarded as a major public health issue (NICE CG83 2009). All patients being discharged from Critical Care should have a Rehabilitation plan/prescription (GPICS 2015). After discharge from critical care patients should be followed up by the Acute Intervention Team and/or physiotherapy team. This should be on a daily basis until it is no longer deemed necessary. All patients, and their families, who had a Critical Care admission of five days or more should be offered an appointment to the Follow-Up Clinic. 8

When patients are transferred to the general ward from a critical care area, they should be offered information about their condition and encouraged to actively participate in decisions that relate to their recovery. The information should be tailored to individual circumstances. If they agree, their family and carers should be involved. Staff working with acutely ill patients on general wards should be provided with education and training to recognise and understand the physical, psychological and emotional needs of patients who have been transferred from critical care areas. 9

Acknowledgments To the Critical Care Networks in Northern Ireland, West Yorkshire, Mid Trent and South East Wales as well as the former North Wales Critical Care Network Admission and Discharge Guideline Working Group which was chaired by Dr Pierre Peyrasse. References Department of Health (2005) Quality Critical Care: Beyond 'Comprehensive Critical Care'. A report by the Critical Care Stakeholder Forum. http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4 121050.pdf Designed for Life: Quality Requirements for Adult Critical Care in Wales (2006). http://wales.gov.uk/topics/health/publications/health/guidance/qualityrequirementsadultcritical?lang=en Designed for Life: Welsh Guidelines for the transfer of the critically ill adult (2016) http://www.wales.nhs.uk/sites3/documents/753/guidelines%20for%20the%20transfer%20of%20the%20c ritically%20ill%20adult_approved.pdf Guidelines for the Provision of Intensive Care Services (2015). http://www.ics.ac.uk/ics-homepage/latest-news/guidelines-for-the-provision-of-intensive-care-services/ Mental Capacity Act (2005). London, Stationary Office http://www.legislation.gov.uk/ukpga/2005/9/contents NICE CG50 (2007) Acutely Ill Patients in Hospital http://guidance.nice.org.uk/cg50/guidance/pdf/english NICE CG83 Rehabilitation after critical illness http://guidance.nice.org.uk/cg83/guidance/pdf/english North Wales (and All Wales) Critical Care Levels of Care www.wales.nhs.uk/sites3/docmetadata.cfm?orgid=753&id=147816 Paediatric Intensive Care Society: Quality Standards for the Care of Critically Ill Children http://picsociety.uk/wp-content/uploads/2016/05/pics_standards_2015.pdf 10

Appendix 1 Designed for Life; Quality Requirements for Adult Critical Care in Wales Levels of Care (Welsh Assembly Government) Level 0 Level 1 Level 2 Level 3 Level 3T Suitable for patients whose needs can be met through normal ward care in an acute hospital. Suitable for patients at risk of their condition deteriorating, those recently relocated from higher levels of care, and those whose needs can be met on an acute ward with additional advice and support from the critical care team. Suitable for hospitalised patients requiring more detailed observation or intervention, including support for a single failing organ system, postoperative care and those stepping down from higher levels of care. Suitable for hospitalised patients requiring advanced respiratory support in addition to the above, but the duration of multi-organ support or ability to manage multiple patients might be limited by staffing or equipment constraints. Organ support and monitoring for most body systems should be available at Level 3T and these facilities would normally be available to multiple patients simultaneously. This level is suitable for critically ill patients requiring prolonged support for multi-organ failure. Such units would have a significant teaching and training role. 11

Appendix 2 Elective Bed Booking Form 12

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Appendix 3 An Example of a Discharge Summary and Rehabilitation Prescription/Plan 14

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