Together for Health A Delivery Plan for the Critically Ill 2013-2016 March 2015 Approved at CPG Board 25 th March 2015
1. BACKGROUND AND CONTEXT Together for Health a Delivery Plan for the Critically Ill was published in 2013 and provides a framework for action by Local Health Boards and NHS Trusts working together with their partners. It sets out the Welsh Government s expectations of the NHS in Wales in delivering high quality critical care ensuring the right patient has the right care at the right time. It therefore focuses on maximising efficiency and effectiveness, tackling variation in access and reducing inequalities in service provision across 5 themes. For each theme it sets out: Delivery expectations to ensure the right patient, in the right care and the right time Specific priorities for 2013 2016 Responsibility to develop and deliver actions Assurance measures that will be used to ensure that this plan is delivered and effective outcomes achieved. What do we want to achieve? The Delivery Plan sets out action to improve outcomes in the following key areas between now and 2016: Delivering appropriate, effective ward based care - The Right Patient Timely Admissions to Critical Care The Right Patient receiving the Right Care at the Right Time. Effective critical care provision and utilisation The Right Care Timely Discharge from Critical Care - The Right Patient receiving the Right Care at the Right Time. Improving information and Research
2. Betsi Cadwaladr University Health Board s (BCUHB) Delivery Plan - Critically Ill The Health Board produced its first Delivery plan in November 2013. In the Delivery Plan we set out the following priorities for 2014: Unmet need assessment Implementation of Acute Intervention Teams and National Early Warning Scores BCUHB wide Implementation of an Acute Kidney Injury strategy and action BCUHB wide Assess the need and feasibility of implementing Level 1 High Observation Bays within BCUHB Implementation of sepsis screening and pathways of care Development of efficiencies within critical care to reduce variation for example, Nurse Led Weaning guidance Scoping for service reviews and ensuring appropriate Critical Care provision for population need and service demand. Progress has been made in all priorities, some progress has been significant. Unmet need assessment o The North Wales Critical Care Network developed a methodology for undertaking a critical care needs assessment in acute hospitals for both known unmet need and unknown unmet need. o Piloted in North Wales, this study was replicated across Wales. o The results of this study were published by the Welsh Government in June 2014 Implementation of Acute Intervention Teams and National Early Warning Scores BCUHB wide o Acute Intervention Teams (AIT) have been established across BCUHB although not as yet 24/7 in Ysbyty Glan Clwyd. o A BCUHB wide audit to measure compliance with NEWS was undertaken in February 2014. o A full report was submitted to Quality Assurance Executive (QAE) in August with recommendations and actions for the QAE based on the audit outcome along with further proposals for AIT and executive leadership. Implementation of an Acute Kidney Injury (AKI) strategy and action BCUHB wide. o A BCUHB AKI Steering Group has been established in direct response to CMO letter and NICE guidance. o An AKI risk stratification tool is applied to acute admissions; incorporated in the BCUHB medical proforma (further work to be done for surgical admissions) o Strong links with Acute Intervention Teams with regards early identification, monitoring and education. Assess the need and feasibility of implementing Level 1 High Observation Bays within BCUHB.
o Some preliminary work has been undertaken to review the feasibility of High Observation Bays however further work will be aligned with Service Review configurations (once known). Implementation of sepsis screening and pathways of care. o The Acute Intervention Team do ward health checks looking at all patients (not just those referred to them) on a given ward this includes screening for sepsis and seeing how many of those patients have been treated. o Sepsis screening implementation is monitored through the Ward to Board quality audits monthly. o New TRR chart (including sepsis six screening) is being rolled out across BCUHB in 16 th March 2015 Development of efficiencies within critical care to reduce variation for example, Nurse Led Weaning guidance o Weaning Guidelines have been developed and implemented across the three Critical Care Units. o The Severe Respiratory Failure Bundle has been revised in accordance with new evidence. o This Bundle has been audited and results presented to all staff. Learning points have been fedback. Scoping for service reviews o Significant work in relation to Critical Care modelling has been undertaken regarding actual and potential service reviews. In delivering critical care services, there are a number of service improvements that we have implemented locally that have had a real impact of patient care. Examples of this include: Despite similar case mixes there was a variance in average length of stay on mechanical ventilation (ALOSMV) across the Network. Multi-disciplinary Weaning Guidelines have therefore been developed and implemented in the three critical care units; this has resulted in a reduction in ALOSMV and empowered team working. This year we have enhanced the feedback of the transfer assessment grades directly to the teams undertaking critical care transfers. This includes positive feedback about good and excellent transfers as well as feedback where practice could be improved. From this we have seen an improved transfer form return rate, data completion and assessments. All three units are proactively reviewing all antimicrobials to ensure appropriateness of prescriptions. The Acute Intervention Team now follow-up all critical care discharges. Patients and ward staff appreciate the attention and help with specific problems, e.g. ongoing delirium. Recent reports (Francis, Keogh and Andrews) have necessitated the NHS to have a clearer focus on the delivery of dignified and compassionate care. Significant work has been undertaken by dignity champions, specifically and Ysbyty Glan Clwyd, to ensure and promote patient dignity.
Patient diaries have been implanted in all three critical care units. The diaries are used for discussions in follow up clinics using the diaries with the family and patient to feedback to staff where improve aspects of care or communication directly. Improved communication has been highlighted as a positive from patient diaries. Formal Handover has been introduced into critical care practice; this has ensured consistent safe management plans for all medical/nursing staff involved in the patients care. Implementation of Intensivist delivered Echocardiography assessment for patients has significantly improved patient care, potentially been life-saving. o In addition YGC has organised Wales' first "FICE" echocardiography course Standardisation of Morbidity and Mortality reviews has been taken across the three units to ensure lessons are shared and learnt. 3. The vision For our population we want: Patients and clinicians to discuss and agree appropriateness of critical care and level of escalation of care in time of need Patients to have timely access to (where appropriate for their condition and needs) and discharge from critical care Patients to be cared for in the correct facility with highly qualified specialists. Patients and carers to be as involved in their care as they feel appropriate. Patients to receive care that is clinically effective. 4. The Drivers There are clear reasons for caring for the critically ill to be a key priority in Wales. Patients requiring critical care are relatively low volume (around 9,000 per annum 1 for Wales) but, when critical care is required, access needs to be timely and often rapid. Critical care provision is very expensive. The major recurring costs relate to medical and nurse staffing, and drugs. Patients requiring intensive care (ventilated or three or more organ failure) cost in the region of 1,500 to 2,000 per bed day. This is L3 care. Patients requiring high dependency care (one or two organ failure not including ventilated care) cost in the region of 500 to 1,000 per bed day. The first Annual Report for the Critically Ill was published in 2014 and stated: On average, there are 3.2 critical care beds per 100,000 people in Wales. Across Wales, we have a rapidly ageing population, with the number of elderly and, especially the very elderly (over 80 years old), increasing rapidly. 1 Critical Care Minimum Dataset (CCMDS)
Survival rates are improving, the number of patients transferring back to the ward after admittance to critical care is increasing. In 2012, just over 80% of patients discharged to another ward, a slight increase from 79% in 2011. Demand for critical care has been slowly increasing over time. In 2011 there were 8,991 admissions and in 2012 there were 9,887 admissions an increase of 896 admissions, almost 10%. Readmissions to critical care within 48 hours are very low less than 2% of all discharges, showing that ward based care and the discharge process are effective. Since the introduction of the Critical Care Networks, huge improvements have been made in the safe transfer of critically ill patients who need to move between hospitals through training and continuous audit. 80% of all transfers are graded as good or excellent. As well as illustrating how performance had improved in these areas the annual report highlighted areas were performance has not been as good as anticipated. BCUHB performance is shown in comparison to all Wales performance: In Wales the average length of stay in critical care has been increasing slowly over time from 114 hours in quarter three 2010 to 123 hours for the same period in 2013. o The average length of stay in critical care in BCUHB in 2014 was 107.8 hours (WM 123hrs, YGC 86.5hrs, YG 113hrs) Across Wales 50% of patients were delayed from being discharged from critical care by over four hours in the last two quarters of 2013. This affected just over 1,100 patients. o On average, in 2014, 54% of BCUHB s patients were delayed from being discharged from critical care by over four hours (WM 64%, YGC 41.6%, YG 53%) In total in Wales 107,276 critical care bed hours were lost in 2013 due to patients awaiting discharge to ward beds; this equates to 12 beds in one year. o On average, in 2014, 795 critical care bed hours were lost per month (WM 1079hrs, YGC 484hrs, YG 735hrs) In 2013, 94% of all non-clinical transfers in Wales were due to a lack of a critical care bed. o Of the non-clinical transfers in North Wales, in 2014, 17 were for no bed available and two were for no equipment.
5. Organisational Profile Organisational Overview BCUHB is the largest health organisation in Wales. It provides a full range of primary, community, mental health and acute hospital services for a population of around 676,000 people across the six counties of North Wales (Anglesey, Gwynedd, Conwy, Denbighshire, Flintshire and Wrexham) as well as some parts of mid Wales, Cheshire and Shropshire. BCUHB employs around 16,772 staff and has a budget of around 1.2 billion. It is responsible for the operation of three district general hospitals (Ysbyty Gwynedd in Bangor, Ysbyty Glan Clwyd in Bodelwyddan and Wrexham Maelor Hospital). Each of the hospitals has a critical care unit proving Level 2 (HDU) and Level 3 (ICU) care. Hospital Level 3 Level 2 Total capacity capacity Wrexham Maelor 5 7 12 Glan Clwyd 6 4 10 Bangor 6 5 11 Total 17 16 33 The throughput to critical care has increased year on year despite BCUHB having one of the lowest number of intensive care beds L3 in Wales, unchanged from last year at 2.5 per 100,000 population versus the Welsh average 3.5. 70-75% of the critical care admissions are unplanned, of these 50-60% are nonsurgical. Elective surgery, which is obviously easier to model for, only accounts for 25-30% of the caseload. Planned and unplanned admissions to critical care beds per 100,000 population in Wales are higher than European age-standardised rates. Overview of Local Health Need and Critical Care Challenge The demography of North Wales is elderly; 18.5% of the resident population of North Wales is aged 65 and over; slightly higher than the Welsh average of 17.5%. In the North Wales critical care units the majority of the patients admitted are in the age groups between 60 and 79 years of age. The average age of admission to critical care in North Wales is 64, two years older then the rest of Wales. Population projections suggest that North Wales will experience a significant decrease in the number of people aged between 0-44 over the next twenty years, whilst the number of people aged 45 and over will increase significantly. It is well understood that the elderly tend to be more vulnerable and to suffer from more comorbidities than younger patients; the elderly population for North Wales therefore place additional demands on the critical care units and hospitals as a whole. According to the Welsh Index of Multiple Deprivation North Wales has some of the most deprived areas in Wales. It is known from previous work that the number of unplanned admissions to critical care increases significantly in areas of deprivation,
probably due to increased co-morbidities due to deprivation. This needs to be borne in mind when planning and providing critical care services. Like all regions in Wales, BCUHB is in the process of reviewing its service provision. It is likely that some services will need to transfer from one location to another to ensure both sustainability and patient safety. To align with both known and potential changes critical care modelling has been undertaken to review what critical care needs to be provided where for both population need and service provision. 6. Development of BCUHB Cadwaladr University Health Board s Local Delivery Plan for the Critically Ill In response to the Together for Health A Delivery Plan for the Critically Ill (2013), health boards are required, together with their partners, to produce and publish a detailed local service delivery plan to identify, monitor and evaluate action needed within timescales. Progress is reported formally to Boards against the milestones in the delivery plans and health boards are required to publish these reports on their websites at least annually. Following our assessment of progress against priorities BCUHB continues to review how service provision may need to change, we have drawn up actions to be undertaken during the period of the national delivery plan and in particular actions and outcomes we want to see happen this year. Lead clinicians have been tasked with assessing what we are currently doing, to look at what we can do differently or collectively and to set priorities for 2015-16 within this Plan. In addition to this for 2015-16 BCUHB are taking a proactive stance in Performance Managing all Delivery Plans to ensure alignment to the Three Year Operational Plan. 7. The priorities for the coming year The Together for Health Delivery Plan sets out action to improve outcomes in some areas between now and 2016. For 2015-16 the following national priorities have been agreed: Reducing Delayed Transfers of Care by 10% per quarter. Deliver integrated end of life planning for patients. Reconfiguration of critical care service to meet standards as cited in the Strategic Vision for Wales. In addition to these national priorities BCUHB highlights the following priorities for 2015/16 which reflect the needs of the local population. Many of these priorities are continued on from the previous year to ensure that actions are continued, completed and embedded.
Delivery Theme 1: Delivering appropriate, effective ward based care - The Right Patient The priorities for 2015-16 are: To consolidate previous work to continue to ensure all patients have National Early Warning Scoring (NEWS) and an escalated referral where indicated. To consolidate previous work to continue to ensure all acute admissions are assessed for the risk of developing acute kidney injury. To enhance previous work to ensure all acute admissions to secondary care are reviewed by a consultant within 12 hours of admission with a clearly documented decision about DNACPR and escalation of care. To consolidate previous work to continue to ensure all acutely unwell patients are screened for sepsis and appropriate care pathway delivered where indicated. To put in place a process to ensure all patients requiring general surgery have their mortality risk calculated - those with a score of predicted mortality greater than 10% will require assessment for post operative critical care admission Delivery Theme 2: Timely Admissions to Critical Care The Right Patient receiving the Right Care at the Right Time The priorities for 2015-16 are: Continue to review and allocate critical care units as appropriate, aligning with Service Redesign, ensuring workforce requirements are set out in BCUHB s Operational Plan. Continue to ensure systems are in place to provide prompt access to critical care and, if not available on site, to quickly and safely transfer patients. Continue to monitor delayed admissions to critical care and the impact of the delay; for example, out of hours discharges. Continue to monitor and report cancelled operations and non-clinical transfers due to lack of critical care beds. Delivery Theme 3: Effective critical care provision and utilisation The Right Care The priorities for 2015-16 are: To work towards ensuring that critical care patients are managed by dedicated critical care consultants and middle tier doctors, as outlined in the Strategic Vision for Wales. Further develop Advanced Nurse Practitioners. To continue to model and align critical care delivery with Service Reviews whilst continuing to ensure patient safety of unselected admissions. To continue to work with 1000 Lives Plus to implement service improvements, monitoring compliance with care bundles, national guidance etc.
To continue to review the delivery of effective and efficient care of critically ill patients; including increasing provision or enhancing services to care for Level 1 patients outside of critical care where appropriate. To continue to ensure that, where critically ill patients do require transfer, these are done by appropriately trained staff safely and effectively. These transfers will continue to be audited by the Critical Care Networks. Delivery Theme 4: Timely Discharge from Critical Care - The Right Patient receiving the Right Care at the Right Time. The priorities for 2015-16 are: To reduce the number of hours lost to DTOC by 10% every quarter until we reach a position of no more than 5% of bed occupancy lost to DToCs. To continue to monitor and report to Board level committees the percentage of discharges achieved within 4 hours To continue to undertake ongoing assessment of impact of DToCs Delivery Theme 5: Improving information and Research The priorities for 2015-16 are: To continue to monitor and record performance against the measures cited in this Delivery Plan; use the results to inform and improve service planning and delivery. To continue to ensure full (100%) participation in mandatory national clinical audits, report key findings to the Local Health Board and ensure that findings are acted on. Actively support research participation through Research and Development and NISCHR. 8. Performance Measures/Management The Welsh Government s Delivery Plan for The Critically Ill (2013) contained an outline description of the national metrics that LHBs and other organisations will publish: Outcome indicators which will demonstrate success in delivering positive changes in outcome for the population of Wales. NHS assurance measures which will quantify an organisation s progress with implementing key areas of the delivery plan. Progress with these outcome indicators will form the basis of BCUHB s annual report on the Critically Ill. The first of these annual reports was published in 2014 and the next one will be published in May 2015. BCUHB also reports progress against the local delivery plan milestones to the Board annually and via our website.