adult critical care services: an irish perspective
TRANSCRIPT
Adult Critical Care Services
An Irish Perspective
Accessibility of Intensive Care Facilities in Ireland to critically ill patients. Report of ICSI Working Party Dublin (2001)
• 28 day clinical audit of ICU bed utilization in 9 University Teaching
Hospitals. • ICU occupancy averaged 97% in the adult ERHA hospitals, 95% in the
paediatric ERHA hospitals, and 98% in the non-ERHA hospitals • Emergency referrals could not be accepted in greater than 30% of ERHA
referrals • Elective major surgery deferral was common across all hospitals surveyed
• Premature unplanned discharging of patients was practiced across all hospitals surveyed ( 22.6% adult ERHA, 10.8% paediatric ERHA, 23.6% non-ERHA).
Conclusions
Critically ill adults and children are routinely denied timely
intensive care services in Ireland. Cancellation of major
surgery and premature discharge are routine. These
practices are known to increase patient mortality.
St. Vincent's Tallaght
St. J ames’s
Mater
Beaumont
J CMH
Loughlinstown
Naas
Eastern Region Critical Care Review 2004
SSTTEEEERRIINNGG GGRROOUUPP
Chairman Mr. Pat McLoughlin
Dept. of Public Health Dr. Colette Bonner
Midwifery & Nursing ERHA Ms. Eithne Cusack
Adelaide & Meath Hospital Inc. NCH, Dr. Marie Donnelly Mr. Des Rogan
Beaumont Hospital, Dr. Michael Power Ms. Margaret Swords Mater Misericordiae Hospital, Dr. Dermot Phelan Ms. Noirin Bannon
St J ames's Hospital, Dr. Tom Ryan Mr. Ian Carter
St Vincent's Hospital, Dr. Kieran Crowley Mr. Eamonn Fitzgerald
St Michael's Hospital, Dr. Tom Owens
J CM Dr. Tom Hogan
Naas Dr. J oe McDonnell Loughlinstown Ms. Annette O'Higgins
College of Anaesthetists Dr. J an Moriarty
IACCN Ms. Eugenie Heron
ICSI Dr. Brian Marsh
DATHs Nursing Ms. Ann Carrigy
NNUURRSSIINNGG SSUUBBGGRROOUUPP::
Chair Ms. Eithne Cusack
Mater Ms. Ann Carrigy
Beaumont Mr. Paul Gallagher
J ames's Ms. Nuala Carty
Vincent's Ms. Pauline Doyle
Naas Ms. Therese Dixon
AMNCH Ms. Imelda McCooey/Ms. Kathleen Wilkin
Loughlinstown Ms. Annette O'Higgins
J CM Ms. Mary Devlin
IACCN Ms. Eugenie Heron
TTAABBLLEE OOFF CCOONNTTEENNTTSS
Executive Summary Chapter 1: Introduction 1.1 Background
1.2 Definitions 1.3 Review Group 1.4 Terms of Reference Chapter 2: Literature Review
2.1 Classification of Critical Care 2.2 Comprehensive Critical Care 2.3 Bed Numbers 2.4 Optimal Unit Size 2.5 Occupancy Levels 2.6 Workforce:
2.6.1 Medical Staffing 2.6.2 Nursing Staffing 2.6.3 Allied Health Professionals
2.7 Information Systems 2.8 Bed Management 2.9 Funding of Intensive Care
Chapter 3: Systems Overview: Current Provision of Critical Care Services
3.1 Bed Numbers 3.2 Trends in Bed Numbers 3.3 ICU Activity 3.4 Occupancy Rates 3.5 Refusals & Early Discharge Rates 3.6 ICU Workforce
3.6.1 Medical Staff 3.6.2 Nursing Staff 3.6.3 Allied Health Professionals
3.7 Mobile Intensive Care Service (MICAS) Chapter 4: Planning for the Development of ICU Nursing Staff within the Eastern Region
4.1 Staffing levels, retention and Skill Mix 4.2 Education, Training/Clinical Skills and Competencies 4.3 Clinical Promotional Pathways and Career Planning 4.4 Service Delivery and Organisation of Care 4.5 Out Reach & Early Warning Systems 4.6 Leadership Development 4.7 Recommendations
Chapter 5: Discussion
5.1 Numbers of Beds 5.2 Information Systems 5.3 Bed Management 5.4 Funding of Critical Care 5.5 Workforce
Chapter 6: Recommendations
CCHHAAPPTTEERR 66.. RREECCOOMMMMEENNDDAATTIIOONNSS::
IMMEDIATE:
Priority has to be given to opening all of the existing critical care beds in
the region.
Urgent allocation of sufficient funds for planning and construction of
existing and required ICU building programs to increase regional ICU bed
complement .See ICU Development Proposals page 70.
Funding and management of critical care must reflect the costly nature
of the service provided
Critical Care Nursing staff recruitment, training & retention initiatives to be
instituted ( Chapter 4) and funded
ICU discharge - Investment in recognised acute hospital bed shortage (
Health Strategy 2002) and provision of appropriate long-stay beds.
Major incident planning – provision needs to be made to allow immediate
expansion of ICU facility in the event of major incident or terrorist event.
Such provision would include availability of portable ventilators for use in
high dependency areas of the hospital.
SHORT TERM (2-5 YEARS)
A phased increase in the number of adult high dependency beds from
the current level of 1.5 beds per 100,000 population up to a level of 11 per
100,000 should be prioritised. The final number of HDU beds should be
determined based on local and regional needs.
Establishment of a critical care development agency responsible for
drawing up critical care strategy, as a permanent agency within the
National Hospital Agency, with appropriate representation of all
stakeholders in intensive care service provision.
The introduction of information systems to support an agreed minimum
data set is essential from an operational and audit perspective.
Information such as cost per case treated, length of stay, vital signs
monitoring, standardised mortality rates for specific conditions should be
included. In addition such a system has the potential to operate in real
time and facilitate a “Bed Bureau” system so that timely information
regarding bed availability within units is available to facilitate inter-hospital
transfers if necessary. Any such system could be modelled on the Scottish
Audit System or the ICNARC (UK) audit system. Such systems should also
link to electronic patient monitoring technology.
The ICU clinical team should be appropriately supported with Information
and Communication Technology equipment and training. In view of the
current nursing shortage great potential exists to support the role of
nursing with the use of information technology and in particular electronic
patient monitoring. This technology will facilitate the exploration of
alternative models for staffing the future provision of Intensive Care
Nursing.
Bed management requires a system wide approach – this necessitates
the provision of additional critical care bed capacity, agreement on
admission and discharge criteria and availability of an adequate number
of HDU and ward beds to facilitate timely discharges.
Figure 1: Number of Critical Care beds per 100 acute hospital beds internationally (from Review for the NHS Executive of Adult Critical Care Services 1999)
__________________________________________ Country ICU beds ( %) __________________________________________
Austria 2.8 Belgium 3.7 Denmark 4.1 France 3.3 Germany 3.4 Holland 3.6 Spain 3.0 Sweden 3.3 Switzerland 3.8 United Kingdom 2.6
( Ireland ERHA 1.9 %)
TTAABBLLEE 22
Existing Critical Care Beds May 2004 Planned Critical Care
Beds
HOSPITAL
ICU Other HDU Currently Closed
For Commissioning
Currently operational
Potential Total
Critical Care
Recommended
Total ICU & HDU (Lyons)
End 2005
End 2010
Mater 17 9 4 6 HDU+1ICU 22 33 9
St. J ames's 15 6 4 2 - 23 25
St. Vincent's 8 6 0 16 16 7
Tallaght 9 0 9 9
Beaumont 10 10 0 20 20
St. Michaels 0 - 0 -
Loughlinstown 4 1 0 5 5
J CMH 4 0 1 4 5
Naas 4 0 2 2 4
Total 71 16 20 6 10 101 117 385 7 9
Bed requirement 2001 at “standstill” 100% occupancy: 35 new ICU beds
Since May 2004: SVH potential for 16 ICU Beds (but HDU a peri-op ward)
• Lyons et al for multi-centre ICU/HDU creates a figure of 51/500,000 ICU beds (10.2 per 100,000) and 87/500,000 HDU beds (17.4 per 100,000).
• For the ERHA, this works out as 142 ICU beds and 243 HDU beds for population of 1.4 million. See page 13 of this review.
Critical Care Planning
Meetings undertaken with the Intensive Care Society of Ireland to discuss current services demands and arrangements that need to be put in place for critical care planning nationally.
Review future critical care requirements in line with international best practice in this area and drawing on the Best Capacity Review Work.
Establish a multidisciplinary critical care planning group to identify priorities for development of critical care nationally and for the related transport services e.g. MICAS, Paediatric and neonatal transport services.
Action plan to be developed in 2007.
NHO
Health Service Executive
National Service Plan 2007
National Perspective
HSE Network Hospital ICU HDU Cardiac ICUNeurosurgical
ICU Hepatology
Total Critical Care = ICU + HDU
Burns Unit
Total 184 89 12 10 4 299 4
Private Blackrock Clin 8Mater Private 9Galway Clin 3Bon Secours Cork 1BonS Dublin 4BonS Tralee 5Beacon 1Total 22
Grand Total Adult Critical Care Capacity = ICU + HDU 330
Preliminary Survey of Adult Critical Care Capacity, Activity and Medical Staffing in Ireland
S Ó Riain, M Power on behalf of the Intensive Care Society of Ireland
Total ICU admission numbers from 35 of the 39 hospitals for 2003 were
17,575.
Only 86 consultants had any fixed in-hours sessions, designated or by
arrangement, in ICU, out of 184 consultants providing an out-of-hours on-call
service.
Irish Journal of Medical Science 2005
What happens to those 17,000+ pts?
• No national dataset
• No national collaborative audit
• HIPE capture unreliable for CCM
• HIPE dataset unable to separate out CCU from CCM (ICU & HDU)
• Local audit generally voluntary and not resourced
In total, 14 Hospitals participated in the audit: (C01) AMNCH Tallaght Hospital (C02) Mid Western Region Hospital, Limerick (C03) University College Hospital, Galway (C04) St James's Hospital (C05) Beaumont Hospital (C06) Mater Miscericordiae University Hospital (C07) Cork University Hospital (C08) St Vincent's Hospital (C09) Our Lady of Lourdes Hospital (C10) Altnagelvin Hospital (C11) Antrim Area Hospital (C12) Mater Hospital, Belfast (C13) Royal Victoria Hospital (C14) Ulster Hospital
Irish Critical Care Trials GroupDemographic Study 2006
Site No. Percent (C01) 64 6.2% (C02) 64 6.2% (C03) 91 8.8% (C04) 55 5.3% (C05) 104 10.1% (C06) 226 22.0% (C07) 96 9.3% (C08) 15 1.5% (C09) 19 1.8% (C10) 13 1.3% (C11) 36 3.5% (C12) 23 2.2% (C13) 164 15.9% (C14) 59 5.7%
Total:1029
Reasons for Admission
10(1.0%)
723(70.3%)
211(20.5%)
85(8.3%)
0100200300400500600700800
Missing EmergencyAdmissions
Major Elective Surgery Inter Hospital Tranfer
Admissions
Nu
mb
er
of
Ad
mis
sio
ns
Percentage of Participants according to Age Groups.
3.72.0
7.0 6.8
11.4
16.718.4
23.4
10.6
0
5
10
15
20
25
0-15years
16-19years
20-29years
30-39years
40-49years
50-59years
60-69years
70-79years
80 plusyear
Age Group
Per
cen
t
Top 10 reasons for admission to ICU
Name Total PercentPneumonia 106 10.30%Cardiac Surgery 84 8.20%Traumatic Brain Injury 65 6.30%Neurological 60 5.80%Abdominal Sepsis 57 5.60%Major Elective Surgery 55 5.40%Respiratory Failure 55 5.40%Cardiac Arrest 47 4.60%Vascular Surgery 47 4.60%
Source Count PercentWard 184 17.88%Theatre 318 30.90%A & E 165 16.03%CCU 14 1.36%HDU 56 5.44%Other Hospital 122 11.86%Missing* 170 16.52%
Total 1029 100.00%
SOURCE OF ADMISSION
Top 10 reasons for admission to ICU from A&E
Diagnoses Frequency PercentTraumatic Brain Injury 19 11.80%Cardiac Arrest 18 11.20%Neurological 18 11.20%Trauma 17 10.60%Pneumonia 16 9.90%Overdose 15 9.30%Seizures 9 5.60%Respiratory Failure 6 3.70%Cardiac Failure 4 2.50%
Top 10 reasons for admission to ICU from Ward
Diagnoses Frequency PercentRespiratory Failure 38 21.00%Pneumonia 31 17.10%Sepsis 16 8.80%Cardiac Arrest 13 7.20%Neurological 8 4.40%Abdominal Sepsis 7 3.90%Seizures 6 3.30%Traumatic Brain Injury 6 3.30%Acute Renal Failure 5 2.80%
Alive Dead Missing*Ward 130 50 4 38%Theatre 291 20 7 6.80%A & E 127 35 3 27%CCU 8 6 0 75%HDU 40 13 3 32%Other Hospital 96 24 2 25%
Total 810 178 41 22%
PATIENT STATUS / SOURCE OF ADMISSION
Source of Admission Patient Status
%mortality
System Pressure
Pie chart of Percentage Readmission
No, 930(90%)
Yes, 72(7%)
Missing, 27(3%)
TOD Frequency Percent8.00 am - 6.00 pm604 58.76.01pm - 7.59 am 197 19.1
Audit of Mobile Intensive Care Ambulance Service in Ireland.
D Rohan, R Dwyer, J Costello, D Phelan. MICAS activity by year (1996- 2004)
0
10
20
30
40
50
60
70
80
1996 1997 1998 1999 2000 2001 2002 2003 2004
Yearly transfers
No.
of
tran
sfer
s
Arterial Line
Inotropes
0
20
40
60
80
100
Intubation Inotropes
Figure 1 HSE Area Population 1981-2006
0
200000
400000
600000
800000
1000000
1200000
1400000
Years
population
Dub/NEast Dub/Mid-Lein West South
Dub/NEast 733562 748328 741877 761054 831899 927525 Dub/Mid-Lein 952299 993939 1006515 1046582 1139870 1215711 West 857734 876508 861876 880294 941462 1010690 South 899810 921868 915451 938157 1003972 1080999
1981 1986 1991 1996 2002 2006
According to the 2006 census there are 4,234,925 people living in the Republic of Ireland, compared with 3,917,203 in 2002. This represents an increase of 8.1%.
HSE Population1981-2006
Figure 2 Population Projections 2005-2019
0
1000000
2000000
3000000
4000000
5000000
6000000
2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019
NCB CSO High CSO Low ESRI High ESRI Low
With the exception of the CSO low data, all the other projections seem to be following a similar growth pattern, with the population
estimated to reach five million by 2019
Population Projections2005-2019
ICM Reports
• Accessibility Report 2002• Eastern Region Critical Care Review 2004• MICAS Report 2005• Planning and Development Report 2006• ICSI Demographic Study 2006• Bed Capacity Review (PA Consulting) 2007
Intensive Care Specialist Staffing Recommendations
AustraliaReview IC-2 (2000)
For the daytime, ward round based component of practice, the maximum number of patients managed by a single specialist should not exceed 12 to 16
• Victoria 1 FTE : 4.09 ICU beds
• Australia1 FTE : 4.62 ICU beds
• Victoria 1.22 FTE : 100,000 pop.
• Australia1.39 FTE : 100,000 pop
• Ireland 206 public ICU beds
50 FTE required for ICU alone (not HDU)
Jurisdiction Medical Director
Intensive Care Specialist / patient ratio
In-Training Dr/
Patient ratio
Australia
(Joint Faculty)
Yes
Intensivist
1:12 daytime unclear
Netherlands
(Richtijn 2005)
Yes
Intensivist
0.45 : 1 0.6 : 1
UK Yes
Intensivist
15 PAs : 8 beds
(=1.5 wte:8 beds)
ESICM Yes
Intensivist
5 : 6-8 beds
(rota)
unclear
IBICM Yes
With ICM sessions
Not stated Not stated
COMHAIRLE na nOSPIDEAL
QUALIFICATIONS: - Anaesthesia
- Emergency Medicine
- Medicine
- Intensive Care
1. CONSULTANT IN INTENSIVE CARE MEDICINE
2. CONSULTANT ANAESTHETIST WITH
SPECIAL INTEREST IN INTENSIVE CARE
MEDICINE
ICM Training & Graduation
• > 100 DIBICM graduates to date since 1996• EDIC 2 numbers from Ireland quite small
However:
Many in-post already
All dual qualified
98% from Anaesthesia base specialty
Access to modular one year posts very limited
Training within SpR programme of parent specialty
0.45 WTE / Bed?
• Aim to align with international best practice• ICM training posts – accredited and standalone• ICM needs to be attractive as a specialty
» Better resourced» Appropriate bed capacity» Appropriate occupancy rates» Increasing emphasis on role of acute medicine
• ICM needs to be a Specialty
