NORTH WALES CRITICAL CARE NETWORK

RITICAL ARE C C SERVICE DEVELOPMENT PLAN

2008-2011

NWCCN Service Development Plan [Final] Page 1 of 13 Sue O’Keeffe Jan ‘09 INDEX

1. Introduction

2. Strategic context 2.1 Designed for Life 2.2 Healthcare Standards for Wales 2.3 Quality Requirements for Adult Critical Care 2.4 Second Strategic Implementation Framework 2.5 Levels of Care 2.6 Critical Care Networks 2.7 Critical Care patients

3. Critical care Admissions

4. Achieving the Quality Requirements in North Wales

5. Efficient and Effective use of existing resources

6. Local Critical Care capacity 6.1 Population based survey 6.2 Mathematical modelling and Capacity Simulation

7. Improving acute care at level 0 and level 1 – critical care without walls

8. Specialist & tertiary services

9. Workforce development

10. Patient and carer involvement

11. Performance monitoring & information

12. Finance

References

NWCCN Service Development Plan [Final] Page 2 of 13 Sue O’Keeffe Jan ‘09 1. INTRODUCTION

This document highlights the key actions that Betsi Cadwaladr University Local Health Board (BCULHB) needs to take to comply with the Designed for Life: Quality Requirements for Adult Critical Care in Wales, published 2006.

In order to obtain a regional perspective the critical care units mapped and assessed their compliance against the Quality Requirements. From these results, (former) NHS Trust individual local delivery plans (LDPs) were developed identifying the actions plans required for compliance of both the Core and Priority Developmental QRs by 2011. These provider LDPs have been collated by the Network to form the overarching Network Delivery Plan.

This three year development plan has been produced to provide a Network statement of priorities to guide planning decisions towards achievement of the Quality Requirements, together with a statement of service redesign and investment priorities.

The detail of how these priorities are to be delivered is provided in the Network Work Programme and also within the aforementioned LDP which were developed to respond to the 2 nd Strategic Implementation Framework for Quality Requirements for Adult Critical Care in Wales (ML/EH/008/08).

2. STRATEGIC CONTEXT

2.1 Designed for Life – creating a World Class Health and Social Care for Wales in the 21 st century provides a vision and a strategy to deliver a world class health and social care service for Wales by 2015.

2.2 The Healthcare Standards for Wales sets out a high level framework of healthcare standards to support the NHS and partner organisations in providing effective, timely and quality services.

2.3 In March 2006, the Welsh Assembly Government published the Designed for Life: Quality Requirements for Adult Critical Care in Wales in order to improve the way critical care services are planned, organised and delivered across Wales.

The Quality Requirements for Adult Critical Care play a vital role in supporting local improvements in service quality and support healthcare organisations in delivering ‘Designed for Life’ and meeting ‘Healthcare Standards’.

Full compliance with the Quality Requirements for Adult Critical Care must be achieved in full by the end of March 2015. The Quality Requirements have been classified into two categories. Firstly the ‘core’ requirements are considered as essential and for urgent compliance, with an expected timescale for delivery by March 2008. Secondly the developmental requirements are expected to be achieved over time, up to 2015.

The Quality Requirements identify the services, support, staffing or equipment across 5 levels of acute care in respect of:- • Monitoring • Respiratory support • Other organ support • Access to diagnostics

NWCCN Service Development Plan [Final] Page 3 of 13 Sue O’Keeffe Jan ‘09 • Patient transport • Medical staff • Nursing Staff • Other Health Professionals • Policies and Governance

2.4 Second Strategic Implementation Framework for Critical Care Services in Wales The Welsh Assembly Government has published the second Strategic Implementation Framework 2008-2011 of ‘Designed for Life: Quality Requirements for Adult Critical Care in Wales’.

In response to this Framework, each (former) organisation has produced a Delivery Plan which identifies how they will deliver the key actions that fall to it to implement. Network level Delivery Plans are required with quarterly monitoring undertaken by Regional Offices.

Full implementation of the ‘core’ requirements was expected to have been achieved by March 2008 and any outstanding gaps will be addressed as high priority (ML/EH/008/08). Implementation of the ‘priority developmental’ requirements is to be achieved by 2011.

2.5 Levels of Care With the development of more flexible and integrated critical care services, the distinction between level 2 and level 3 care units is becoming blurred and the term critical care unit is therefore used throughout this document.

For clarification Level 2 care was previously referred to as High Dependency Care and Level 3 care was previously referred to as Intensive Care. The definitions for Critical Care levels of care, used in the Quality Requirements for Adult Critical Care in Wales, are as follows (All Wales Critical Care Development Group 2003).

Level 0 Suitable for patients whose needs can be met through normal ward care in an acute hospital .

Level 1 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 .

Level 2 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 .

Level 3 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 .

Level 3T 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 .

The Quality Requirements identify that units treating patients at Level 3 must have a minimum throughput of 200 Level 3 cases per annum.

NWCCN Service Development Plan [Final] Page 4 of 13 Sue O’Keeffe Jan ‘09 2.6 Critical Care Networks In 2007, three Critical Care Networks were established across Wales to plan, organise and support the delivery of effective critical care services. The role of the Network is to support and advise its stakeholders on the implementation of the national Quality Requirements, to monitor service performance and use this information to inform the commissioning process.

Critical Care Networks have a primary focus on Critical Care services providing care at Levels 2, 3 and 3T, but recognise that there is a need to influence and inform the development and delivery of acute care at Levels 0 and 1.

2.7 Critical Care patients Intensive Care Medicine combines intensivists, surgeons, physicians nurses and allied health professionals in the co-ordinated and collaborative management of patients with life-threatening single or multiple organ system failure, including stabilisation after complex surgical interventions. It is continuous (i.e. 24hr) management including monitoring, diagnostics, support of failing organs as well as the treatment of underlying diseases (European Union of Medical Specialists 1997). Modern medicine is underpinned and made possible by intensive care.

Admission for critical care is only appropriate however if the patient can be reasonably expected to survive and receive sustained benefit in quality of life. An increasing requirement for organ support is not in itself a reason to admit a patient who is suffering their final illness and who has no apparent avenue of recovery.

Even when there is an acute reversible component, the patient’s chronic health status (impairment of organ systems or physiological reserve) may significantly affect the patient’s ability to survive and benefit from an intensive care episode. This requires careful assessment, but should not be prejudiced by age or ethnicity.

3. CRITICAL CARE ADMISSIONS

Patients requiring critical care are the sickest in the hospital and require extensive facilities, equipment and skilled staff to care for them.

Critical Care units represent resource intensive, demand led but essential parts of the flow of patients through acute hospital care. Critical care is a low volume, high cost specialty.

In North Wales there are 34 adult critical care beds (19 Level 3 and 15 Level 2 beds) against a total of 1841 beds in the three acute hospitals in the region, therefore 1.8% of beds are designated Adult Critical Care Beds level 2, 3 or 3T.

Critical Care Minimum Data Set (CCMDS) identifies that the number of completed critical care episodes between April 2007 and March 2008 were as follows:-

North Wales NHS Trust Wrexham Maelor Hospital 629 Glan Clwyd Hospital 649 North West Wales NHS Trust Bangor Hospital 476 TOTAL NORTH WALES 1754

It should be noted that no episodes were recorded for YG’s Surgical HDU patients or Wrexham’s Medical HDU patients. In addition the first year’s completion of Critical

NWCCN Service Development Plan [Final] Page 5 of 13 Sue O’Keeffe Jan ‘09 Care Minimum Data set identified issues of concern in the completeness and accuracy of the recording and reporting of CCMDS which may affect the above figures.

The All Wales Cost per patient day has been identified from the Trust Annual costing returns for 2006-7 as:-

- £828 for Adult HDU - £1,564 for Adult ICU - £1,167 for combined ICU/HDU

In North Wales, the cost per patient per day was or varied between:-

- £1270 for Adult ICU - £854 - £1851 for Adult HDU - £1065 for Combined ICU/HDU

It should also be noted that due to the wide variation in the consistency of reporting critical care costs, these figures are not regarded as robust or accurate. The Network teams are currently working with the Welsh Assembly Government to develop robust costing arrangements. The Network are awaiting the costing returns for 2007-8.

4. ACHIEVING THE QUALITY REQUIREMENTS IN NORTH WALES

WHC (2006) 009 set out the Assembly Government’s specific requirements of the NHS and Health Commission Wales (HCW) to have mapped and assessed current services against the Quality Requirements and agreed Network level action plans, supported by milestones, that will lead to full compliance with the Quality Requirements by 2015.

In September 2007, the Networks issued a self assessment audit tool in September 2007. Gaps against the Quality Requirements were reported to the Network Board in January 2008 and cascaded to NHS Trust, LHBs and HCW Chief Executives, followed up with local health community meetings to identify and agree local action required.

4.1 Priorities for 2008-2011

4.1.1. Betsi Cadwaladr University Local Health Board Actions • Local delivery plans were developed by the former NHS Trusts in order to address the identified gaps against the ‘core’ and ‘priority developmental’ Quality Requirements. High priority is to be given to addressing the areas of non-compliance against the ‘core’ requirements in respect of:- o Nursing staffing levels o Consultant sessions for weekend working in critical care o Critical Care Outreach o Dedicated Junior medical staff for critical care o Nurse qualifications • Delivery of these plans will be essential prior to any consideration for increasing the critical care capacity as only a service achieving the Quality Requirements should be considered as suitable for expansion.

Full detail of the actions required for each critical care unit together with milestones and timescales should be reflected the Local Delivery Plans to deliver the 2 nd Strategic Implementation framework for Critical Care in Wales.

NWCCN Service Development Plan [Final] Page 6 of 13 Sue O’Keeffe Jan ‘09 4.1.2. Network Actions • Identify and agree a programme to review and update the local Critical Care Policies and Procedures for adoption by local organisations

5. EFFICIENT AND EFFECTIVE USE OF EXISTING RESOURCES

The former NHS Trusts and LHBs all agreed that one of the key priorities for the Critical Care Network is to maximise the efficient use of the existing critical care resources across the region before any consideration should be given to increasing the critical care capacity within the region.

Key issues that have been identified by the Network are:- • Delayed Transfers of care from Critical Care • A volume of Level 1 patients in beds designated for Level 2 and 3 patients • Variations in the elective admissions to critical care across sites in North Wales

5.1 Priorities for 2008-2011

5.1.1. Betsi Cadwaladr University Local Health Board Actions • Reduce the number and length of Delayed Transfers of Care from Critical Care to general acute wards. • Review the necessity for Level 1 patients in designated critical care beds • Review the elective admissions and planned length of stay into critical care units.

5.1.2. Network Actions • Continue to work with critical care units to model and report patient flow and possible areas for service development • Work with the tertiary centres to develop referral guidance between critical care and specialist services • Develop Network wide Admission & Discharge policy for adoption by local Critical Care units

6. CRITICAL CARE CAPACITY ACROSS NORTH WALES

It has been widely acknowledged that there is a shortfall in critical care provision within Wales

It is apparent from the results of the audit of Critical Care services against the Quality Requirements that in some hospitals, action and/or investment is required to change the service model and staffing resource.

The North Wales regional plan recognised the need the Network to define the capacity needed across the region in terms of the number of beds at levels 2 and 3 and where these need to be sited and for a regional framework to support local planning and development of Critical Care Services.

To ensure a whole system approach to the capacity assessment in North Wales varying methods were utilised: 1. To calculate regional requirements for Critical Care capacity the population based survey (Lyons et al. 2000), as referenced in the Designed for Life: Quality Requirements for Adult Critical Care in Wales has been used.

NWCCN Service Development Plan [Final] Page 7 of 13 Sue O’Keeffe Jan ‘09 2. To identify the requirement for individual hospital’s capacity mathematical modelling and capacity simulation , which analyses raw (ICNARC) data, was used. 3. To answer the question posed about the effectiveness and efficiency of current capacity utilisation and to identify areas for service improvements Patient Flow studies have been undertaken. 4. To assess critical care unmet demand a point Prevalence study of the Acute Trusts has been undertaken.

6.1 Population Based Survey There is disquiet around the methodology of the Lyon’s et al. (2000) population based research. It has been criticised (Ridley and Morgan 2000), and considered to have inflated the perceived need for Critical Care beds (Costa et al. 2006). However, the Network has used the Lyon’s et al. (2000) modelling (as well as the other methodologies) because; • it is referenced and quoted in Designed for Life: Quality Requirements for Adult Critical Care in Wales (2006), • it is used for calculating capacity shortfalls by colleagues in other Critical Care Networks • comparisons with the validated commissioned model can be made.

The Lyons population based survey of critical care need identifies that for a population for 500,000 people, 23 Level 3 General Intensive Care Unit beds are needed to meet demand on 95% of occasions and 34 Level 2 High dependency beds.

o The capacity required for the population of North Wales (676,000k) on a single critical care site would be 31 Level 3 beds and 46 level 2 beds (resulting in a shortfall of 15 Level 3 and 36 Level 2 beds)

6.2 Mathematical Modelling and Capacity Simulation The Network has commissioned mathematical modelling and capacity simulation. Using such a model the precise location of additional critical care beds can be identified. Because the model uses actual unit data it includes the demands of Non- Contracted Activity (unlike the population based model).

This model, developed by Southampton University in collaboration with Critical Care Consultants (Costa et al. 2006; Shahani, Ridley and Nielson 2008), includes population flows, arrival profiles, length of stay, unmet need as well as case-mix, inter-hospital transfers and accommodating emergency overflows etc. Validation of this model has been asserted (Shahani, Ridley and Nielson 2008).

In order to fully assess the Critical Care capacity required for each unit in North Wales this computer simulation planning for Critical Care has been applied to the unit’s historical critical care i.e. ICNARC data. The model is set at the individual patient level and can be tuned to mimic the flow of patients through the particular Critical Care unit.

The outcomes of this study, which examined local critical care data from April 2007- March 2008, indicate that current critical care occupancy is at 68% in Wrexham Maelor, 78.5% in Glan Clwyd and 82.3% in Bangor. Clearly during this time there will have been peaks and troughs in all of the units however the Intensive Care Society (1997) recommends that occupancy should run at about 70%. Persistent occupancy of more than 70% suggests a unit to too small. Occupancy over 80% will result in non-clinical transfers and increased mortality (Intensive Care Society 1997).

NWCCN Service Development Plan [Final] Page 8 of 13 Sue O’Keeffe Jan ‘09 Using current case-mix and workloads preliminary results suggest that, to accommodate present workload i.e. to reduce cancelled operations due to lack of critical care beds, to reduce non-clinical transfers and reduce unmet demand, two additional beds are required in both Glan Clwyd and Bangor hospitals.

Further modelling work is being undertaken for all three hospitals to assess (near) future demands. For example, the need to accommodate patients as a result of the secondary care review, changes to orthopaedic practices and predictions for 2.5% compounded increase per year.

Prior to the consideration of investment/increase in critical care capacity the Network, on behalf of Commissioners and the Welsh Assembly Government, would wish to be assured that critical care units are complying with the Quality Requirements and delivering an effective and efficient service.

6.3 Priorities for 2008-2011

6.3.1 Betsi Cadwaladr University Local Health Board Actions • Efficient and effective use of existing critical care resource • Compliance with the Quality Requirements • Develop plans for an increase in capacity. • Ensure sufficient critical care beds are available across the Critical Care network to meet the needs of the local population.

6.3.2 Network Actions • Finalise the regional Capacity Assessment for Critical Care services in North Wales.

7. IMPROVING ACUTE CARE AT LEVEL 0 AND LEVEL 1 – CRITICAL CARE WITHOUT WALLS

The Quality Requirements for Adult Critical Care in Wales also specifies the service requirements for Levels 0 and 1 (i.e. general acute care). Whilst general acute care is not within the direct remit of the Critical Care Networks it is clear that Networks and Critical Care services need to influence service organisation and provision outside of critical care services.

The recognition of acute illness is often delayed and its subsequent management may be inappropriate. This may result in late referral and avoidable admissions to critical care, and may lead to unnecessary patient deaths, particularly when the initial standard of care is suboptimal.

In July 2007, the National Institute for Health & Clinical Excellence (NICE) issued Clinical Guideline No 50 “Acutely ill patients in Hospital – recognition of and response to acute illness in adults in hospital” . The 1000 Lives Campaign Improving Critical Care element will support Trusts in implementing this guidance.

7.1. Priorities for 2008-2011

7.1.1 Betsi Cadwaladr University Local Health Board Actions • Participation in the 1000 Lives campaign with a key focus on improving care of acutely ill patients outside of critical care services

NWCCN Service Development Plan [Final] Page 9 of 13 Sue O’Keeffe Jan ‘09 7.1.2 Network actions • Continue to support the BCULHB with the development of a structured handover between critical care and the general ward supported by Network Discharge Summary.

8. SPECIALIST & TERTIARY SERVICES

One of the recommendations of the Welsh Neuroscience External Expert Review was that the population of North Wales should continue to receive neurocritical care at the Walton centre. However, in order to facilitate this Walton Neuro Centre will require additional capacity.

8.1 Priorities for 2008-2011 The review has an impact of the planning, organisation and delivery of specialist neurocritical care services which need consideration by Betsi Cadwaladr University Local Health Board the Network.

8.1.1 Betsi Cadwaladr University Local Health Board Actions • Implementation of the Network Severely Head Injured Pathway to ensure consistency of referral, maintenance care and repatriations of severely head injured patients. • Ensure sufficient funding for neurocritical care services at the tertiary centre for the population of North Wales.

8.1.2 Network actions • Finalise the Severely Head Injured Pathway • Support BCULHB in the implementation and auditing of the Pathway. • Continue to work with the North Wales Neuroscience Review Group to provide project management support. • Continue to work with HCW (and BCULHB from October) to advise the Transitional Board around priorities for neurocritical care. • Develop other treatment specific pathways were necessary e.g. spinal care

9. WORKFORCE DEVELOPMENT

Developing the workforce to ensure all patients receive appropriate, effective and timely care from skilled staff, from all disciplines, at all levels will be a significant challenge for all involved in the provision of effective critical care services.

There have recently been major changes relating to staff employment within the National Health Service including the new Consultant Contract, Agenda for Change and the European Working Times Directive. These call for radical change in roles and function of clinical staff, both in terms of defining roles and responsibilities and in terms of working patterns and need to be considered when planning and developing the workforce to deliver effective critical care services.

The importance of clinical leadership is paramount not only in developing and maintaining functional teams but also in developing new roles and ways of working.

NWCCN Service Development Plan [Final] Page 10 of 13 Sue O’Keeffe Jan ‘09 10. PATIENT AND CARER INVOLVEMENT

Designed for Life (2005) and the NHS Healthcare Standards for Wales recognise that public and patient involvement is fundamental to improving health and health care services in Wales and emphasises the need to promote service user involvement.

10.1 Priorities for 2008-2011

10.1.1 Network Actions • Work with the Community Health Council to review current questionnaires and develop a regional questionnaire to seek patient and carer views regarding the service they have received.

11. PERFORMANCE MONITORING & INFORMATION

The role of a Network is described as ‘to support and advise its stakeholders on the implementation of the national Quality Requirements, to monitor service performance and use this information to inform the commissioning process’.

This is recognised as an issue by the Welsh Assembly Government in the 2 nd Strategic Implementation framework for Critical Care Services with the need to:-

• Develop a performance monitoring framework to report activity, safety and patient outcomes of critical care services taking account of the Key Quality indicators and to enable regional and all Wales performance comparison. This will require NHS Trusts to agree to share non personalised information with the Networks

A Performance Monitoring framework was approved by the AWCCAG in June 2008 and has been adopted by the North Wales Critical Care Network Board. This framework brings together the range of information currently recorded and reported by critical care services through the production of CCMDS, ICNARC, Infection Surveillance, and staffing information.

The Network has commenced development of a Dashboard with the relevant information currently readily available.

The Network, in producing regular CCMDS reports across the region, has identified inconsistencies in the recording and reporting of critical care information through Critical Care Minimum Data Set.

11.1. Key priorities for 2008-2011

11.1.1 Betsi Cadwaladr University Local Health Board Actions • Regularly review the CCMDS data recording and compliance with data definitions. • Implementation of WardWatcher interfaces to the PAS and Lab information systems. • Participation in the ICNARC Case Mix programme and signed agreements to share the information with the Networks • Agreements to share the ICU Infection Surveillance data with the Network

11.1.2 Network actions

NWCCN Service Development Plan [Final] Page 11 of 13 Sue O’Keeffe Jan ‘09 • Implementation of the Critical Care Performance Monitoring framework and working with critical care units to support improvements in data recording and reporting.

12. FINANCE

The planning and provision of critical care services in Wales is complex. Critical Care costings have not been identified consistently by (former) NHS Trusts resulting in considerable variations across Wales.

Critical Care is not a service identified within service level agreements between providers and commissioners and therefore there is no clear picture on the resources spent or the critical care activity in North Wales.

12.1 Key priorities for 2008-2011

12.1.1 Network actions

• Work with the Programme Management Unit within the Welsh Assembly government to extend the guidance to BCULHB in respect of annual Welsh Costing Returns for Critical Care services adopting the Cost Block programme methodology

References:

NWCCN Service Development Plan [Final] Page 12 of 13 Sue O’Keeffe Jan ‘09 Costa AX., Ridley SA., Shahani AK., Harper PR., DeSenna V and Nielson MS. (2003) Mathematical modelling and simulation for planning critical care. Anaesthesia; 58: 320-27.

Designed for Life: Quality Requirements for Adult Critical Care in Wales (2006) http://wales.gov.uk/docrepos/40382/dhss/guidance/Quality_Requirements_Adult_2.pdf?lang =en

Designed for Life: creating a World Class Health and Social Care for Wales in the 21 st Century (2005) http://wales.gov.uk/dhss/publications/health/strategies/designedforlife/designedforlifee.pdf;j sessionid=GVj3Jd9Px45T3rnlflsJnk25n9qp8mYc2TypQQ6kvvs7dvbsLprn!-98953499?lang=en

European Union of Medical Specialists (1997) http://www.uems.be/mjcicm-d.htm

Healthcare Standards for Wales (2005) http://www.wales.nhs.uk/sites3/Documents/465/Healthcare%5FStandards%5FEnglish.pdf

Intensive Care Society. Standards for intensive care units. London (1997) http://www.ics.ac.uk/icmprof/downloads/ICSstandards4302.pdf

Lyons RA, Wareham K, Hutchings HA, Major E and Ferguson B. (2000) Population requirement for adult critical care beds: a prospective quantitative and qualitative study. The Lancet; 355: 595-598.

Ministerial letter. Designed for Life: Quality Requirements for Adult Critical Care in Wales 2 nd Strategic Framework (2008) Ministerial Letter EH/ML/008/08 - Designed for Life: Quality requirements for adult critical care in Wales 2008-11: Second Strategic Framework

Network Board Report - Audit of services in North Wales against the Quality Requirements for Adult Critical Care – January 2008.

NICE Clinical Guidance No 50 Acutely Ill patients in hospital http://www.nice.org.uk/nicemedia/pdf/CG50FullGuidance.pdf

Ridley SA. and Morgan GA. (2000) Critical Care Beds: the numbers. The Lancet; 355: 1997-8.

Shahani AK, Ridley SA, Nielsen MS. (2008) Modelling patient flows as an aid to decision making for critical care capacities and organisation. Anaesthesia; 63(10): 1074-80.

Standards for Adult Critical Care in Wales (2003). All Wales Critical Care Development Group. http://wics.awardspace.com/docs/CCDGstandardsSep.doc

Welsh Health Circular (2006) 009 and Designed for Life Quality Requirements for Adult Critical Care in Wales.

NWCCN Service Development Plan [Final] Page 13 of 13 Sue O’Keeffe Jan ‘09