Please continue to use this guideline but be aware that it is in review (16/12/2024).

Introduction

This document lays out the process for admission and discharge of patients from the Critical Care Departments in the Frimley Health NHS Foundation Trust (FHFT) which incorporates both Adult Intensive Care Units at Frimley and Wexham Park. This is in accordance with Guidelines for the provision of Intensive Care Services1.

It is acknowledged that both units are currently part of different operational delivery networks (ODN)

The overriding principle for the critical care service is that of a referral service for consideration for a higher level of care than can be provided where the patient is currently located.

The underlying philosophy of critical care is for shared care and joint responsibility with the referring consultants/teams.

Both critical care sites aim to support each other with provision of the required levels of care in relation to critical care admissions the Trust.

Scope of the Policy

This policy relates to adult critical care services in:

• Frimley Park Hospital
• Wexham Park Hospital

The minimum age for admission being 16 years of age and no maximum age limit. Those less than 16 years of age should be discussed with and treated within a paediatric ICU (PICU). In exceptional circumstances children younger than 16 years may be admitted to adult ICU if this is deemed to be the most appropriate location of care based on individual needs while waiting for or instead of transfer to specialist PICU. This must be discussed with the regional PICU.

Children transitioning to adult care (16 and 17 year olds) should be discussed with the local paediatric team and if necessary, based on complexity of the patient or disease be discussed with regional PICU

Whilst this document provides clarity, it cannot be substituted for the use of clinical judgement in difficult and complex situations.

Critical care is described as a spectrum over 4 levels as defined by the Intensive Care Society (ICS) in association with the Department of Health (DH) and revised in 2010². Clinical judgement should be used to determine the most appropriate level of care required by a patient but this will not be determined by their location. The level of care attributed to a patient will influence, but not determine, staffing requirements.

Patients must be first referred to the critical care team prior to any discussion with the patient and/or family regarding admission to critical care.

The decision for admission to a critical care area lies with the duty consultant intensivist.

Trainee medical staff working in critical care should not decide critical care to be inappropriate for a referred patient without consultation with the duty consultant intensivist.

Once a patient has been accepted for critical care admission, it is the responsibility of the critical care team to manage the patient whether admitted locally or transferred out of the hospital.

The nurse in charge of the critical care area will be consulted with, prior to accepting a referral, to ensure a bed can be made available and that there are adequate numbers of staff.

Both critical care services must adhere to the local escalation policy if no bed is immediately available in critical care in order to avoid non-clinical transfers (cf appendix for flow chart SOP for capacity management).

Non-clinical transfers should be avoided. In the event of a non-clinical transfer every attempt should be made to accommodate this within FHFT in the first instance.

The trust admin on call, the lead nurse, clinical lead for ITU and trust critical care lead should be informed of all inter-hospital non-clinical transfers and an incident form completed.

The duty consultant intensivist will be ultimately responsible for all inter-hospital transfers of critically ill patients, referred to them.

Critical care consultant review of any patient admitted to critical care must be undertaken within 12 hours of admission to critical care.

Patients should not be admitted to critical care if explicit advanced directives to the contrary exist or an individual with legal rights over their medical treatment decisions expresses to the contrary.

A patient’s status in relation to infection must be declared prior to any movement/transfer.

The trust’s cross-site lead for critical care and the Critical Care Delivery Group must have oversight and governance of the admissions policy and receive exception reports.

All referrals for critical care from other hospitals should be processed through the duty consultant intensivist with relevant clinical information

It is the decision of the duty consultant for critical care whether the referral is accepted and transferred

An ‘accepted’ patient must also be accepted by a parent speciality team before transfer.

Refer to the specific guidance document for transfers between Heatherwood and Wexham Park Hospital.

A retrieval service is not offered by the trust other than for Heatherwood Hospital.

Advanced age is not an exclusion criterion to admission.

Once a patient is deemed appropriate for critical care admission, expedient facilitation to admission into the critical care unit should take place i.e. within four hours of the decision to admit into the critical care unit. The trust has a commitment to admitting within one hour. This should be monitored and delays investigated.

From the outset, there should be clear and documented criteria for admission set for the patient with a treatment plan and capping of therapy (where applicable).

Even when there is an acute reversible component, the patient’s chronic health status may significantly affect the patient’s ability to survive and benefit from an intensive care episode. This will require careful assessment.

In areas of doubt or conflict, a second opinion from a critical care consultant should be sought. If following this there is still doubt, consideration should be given to admit for a period of observation and treatment.

The parent team consultant should be made aware of the referral and decision of the duty intensivist.

Elective surgical patients with a high predicted mortality should be considered for admission to ICU for optimal post-operative care.

Admission to critical care must receive careful consideration if patients have previously verbally expressed their wishes not to be admitted.

Communication at the outset of the admission is paramount with the patient and their next of kin/ carers regarding the goals of treatment in the critical care unit.

All planned admissions to critical care should be booked in advance with the critical care team by the referring consultant’s team or through pre admissions. The responsible team should check on the morning of the procedure for critical care bed availability and the agreement to proceed with surgery/procedure. If more than one patient requires critical care and only one bed is available, the relevant parties should discuss prioritisation at the earliest opportunity, i.e. before surgery commences. In the event of an impasse, the duty intensivist will make the overriding decision.

The duty consultant intensivist has the responsibility for making the decision for discharge from a critical care area in association with the multidisciplinary team (MDT).

Night time discharges (22.00–07.00) should ideally be avoided and occur only in exceptional circumstances. They must be incident reported.

Discharges home direct from critical care should be avoided as far as possible unless for clinical reasons.

The ICU team must inform the parent team at the time of discharge. Out of hours, this should be to the relevant on shift doctor (ST3 and above).

A clear discharge summary (medical and nursing) and appropriately prescribed drug chart must accompany the patient.

The timescale for actual discharge from critical care should be within four hours from the decision for discharge. Decision to discharge should be clearly documented in the notes and the NiC should also document this onto ward watcher.

It is the principle ethos and responsibility of each critical care unit to facilitate repatriation of patients as a priority if possible.

It is the responsibility of each critical care unit to monitor their outliers within each hospital they were transferred to on a regular basis.

All repatriations are dependent upon critical care bed availability.

The duty consultant intensivist should have the ultimate decision on a repatriation.

All critical care transfers should be undertaken in accordance with national transfer guidance provided by the Intensive Care Society.

All attempts will be made to contain the critical care demand: a) within the individual Hospital ICU; b) within the Trust.

Adherence to the principles of Guidelines for the Transport of the Critically Ill Adult Patient3.

Any issues with critical care transfers must be reviewed within the Trust’s Critical Care Delivery Group meetings.

Patient infection status should not be an exclusion to transfer.

All patients should have appropriate level of nursing and medical care, monitoring and documentation prior to and during transfer.

The original case notes or full copies of the notes, together with other documentation, X-rays, CT Scans etc. must accompany the patient.

A letter of referral detailing the patient’s current admission and treatment should accompany the patient.

Standard Operating Procedure

Calculated patient dependency should not exceed the number of nurses available

If patient dependency is ≥1 above nursing numbers see Section 3 below

1. Discharge Planning

• Patients suitable for discharge should be identified by the Critical Care consultant as early in the day as possible.

• Once a patient has been identified to the bad managers as fit for discharge that discharge should occur within four hours.

  • Patients fit for discharge will be identified to the flow team by the nurse in charge of critical care.
  • If the discharge is delayed this must be acknowledged at the bed meeting.

• The bed state, patient dependency and nursing numbers will be reported at the morning, afternoon and evening bed management meetings.

  • This data will be reported for all higher care areas (Critical Care, MADU, SADU, post-anaesthesia care unit (PACU) and CCU).

• The bed management should be such that one “admission bed” is always available for emergency crash admissions.

2. Routine Capacity Management

• All available higher care capacity should be utilised in order to maximise capacity.

• The Critical Care Outreach Consultant should liaise with S/MADU every morning identifying potential discharges.

  • The flow team will ensure that appropriate patients are discharged from S/MADU in order to ensure that appropriate capacity is available to facilitate discharge from Critical Care.

• PACU to provide additional augmented care (“buffer”) bed capacity, which will be available 7 days per week.

  • The duty consultant intensivist will decide how this capacity will be utilised.
  • Critical care patients may be transferred to PACU for on-going management if appropriate.

3. In the event of insufficient critical care capacity

The steps below should only be considered if all of the above steps have been reviewed and completed.

• If patient dependency (or anticipated dependency) is ≥1 higher than the number of nurses available, taking into account the staffing numbers going forward by shift, this must be notified to the Head of Nursing (HoN) for Critical Care/ Matron during working hours and ICU consultant lead. Consider utilising PACU staff in ICU. Out of hours this should be reported to admin on call. They will decide whether to inform the Director on call- dependant on degree of variance and its frequency.

• Medical review of critical care patients for safe discharge to augmented care area (e.g. MADU, SADU, PACU). Alternatively, (but less preferable) consider admission directly to PACU in order to avoid non-clinical transfer. Inform matron and critical care consultant lead.

• If all of the above steps have been explored and critical care cannot safely accept a further admission, the most appropriate patient should be transferred to another hospital.

  • Non clinical patient transfer should only occur after all other options have been exhausted.
  • The HoN for critical care, trust critical care lead and Chief of Service for Theatres, Anaesthetics and Critical Care should be notified of the need for transfer at the earliest convenience.
  • It is the preference of the trust to retain the patient within FHFT if possible.
  • All transfers should be incident reported.

Decision made by critical care consultant

This guideline has been registered with the trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt contact a senior colleague or expert. Caution is advised when using guidelines after the review date. This guideline is for use in Frimley Health NHS Foundation Trust hospitals only. Any use outside this location will not be supported by the Trust and will be at the risk of the individual using it.

References

1. Guidelines for the provision of Intensive Care Services – ICS 2015
2. Levels of Critical Care for Adult Patients: The Intensive Care Society (2009)
3. Guidelines for the Transport of the Critically Ill Adult Patient: Intensive Care Society (2011)