Anaesthetics, Pain Relief & Critical Care Services Follow-Up Study REGIONAL REPORT. Performance Review Unit

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1 Anaesthetics, Pain Relief & Critical Care Services Follow-Up Study REGIONAL REPORT Performance Review Unit

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3 CONTENTS page I INTRODUCTION... 2 II PRE-OPERATIVEASSESSMENT... 4 III ANAESTHETIC STAFFING AND SERVICE STANDARDS IN OPERATING THEATRES... 6 IV ANAESTHETIC DRUGS AND EQUIPMENT... 9 V POST OPERATIVE PAIN RELIEF VI ANAESTHETIC SERVICES FOR WOMEN IN LABOUR HEALTH SERVICES VII SERVICES FOR PEOPLE WITH CHRONIC PAIN VIII MANAGEMENT OF ANAESTHETIC SERVICES IX PLANNING CRITICAL CARE SERVICES X MAKING THE BEST USE OF UNIT RESOURCES XI ASSURING QUALITY OF SERVICES XII CHIEF MEDICAL OFFICER S 2000 REPORT UPDATES XIII THE WAY FORWARD

4 I INTRODUCTION In 2003/2004 the Department of Health, Social Services and Public Safety commissioned a value for money follow-up audit of Anaesthetics, Pain Relief and Critical Care (APRCC) services at twelve Trusts and covering fourteen hospital sites. The original study had reported in 1999/2000. Detailed follow-up reports, together with action plans have been agreed locally with Trusts. The objectives of the follow-up review were to: Ascertain the progress made in implementing recommendations from the original study; Provide data to compare performance across Trusts in areas such as: - Pre-operative assessments; - Organisation of post-operative pain relief; - Organisation of chronic pain services; - Levels of admissions to critical care units; - Occupancy in critical care units; and Assess the extent of progress made by Trusts in the implementation of the Chief Medical Officer s (CMO) recommendations from Facing the Future Building on the Lessons of Winter 1999/ To enable comparisons across Trusts, data was collected for the financial year 2002/2003. In addition, relevant findings from the Audit Commission s Acute Hospitals Portfolio have also been included 2. The Acute Hospital Portfolio is a collection of reviews that are undertaken at acute and specialist Trusts. They focus on key service areas and are reported along the key performance criteria of patient experience, efficiency and capacity. Background Anaesthetists play a pivotal role within acute hospitals and not just within the operating theatre; they also have a range of responsibilities in acute and chronic pain management, intensive care, obstetrics, inter-hospital transfer, trauma, and resuscitation. Critical care describes a range of care for patients who have potentially recoverable conditions and who need closer observation, monitoring or more intensive treatment than can be provided on general wards. All acute Trusts have some form of critical care facilities, such as Intensive Care Units (ICUs) or High Dependency Units (HDUs). Critical care units constitute a complex, diverse network of general and specialist services that interact with all areas of the hospital

5 I INTRODUCTION Format of Regional Follow-Up Report This Northern Ireland regional follow-up summary sets out the main findings of the Anaesthetics, Pain Relief and Critical Care Services follow-up audit in 2003/2004, under the following section headings: - Pre-Operative Assessment; - Anaesthetic Staffing And Service Standards In Operating Theatres 3 ; - Anaesthetic Drugs And Equipment; - Post Operative Pain Relief; - Anaesthetic Services For Women In Labour; - Services For People With Chronic Pain; - Management Of Anaesthetic Services; - Planning Critical Care Services; - Making The Best Use Of Unit Resources; - Assuring Quality Of Services; - Progress With The CMO s Recommendations From 2000; and - The Way Forward. 3 The 1999/2000 Anaesthetics, Pain Relief and Critical Care Services Regional Summary looked at anaesthetics assistants and recovery staff as a separate topic area. This follow-up regional report does not make this distinction and looks at anaesthetic staffing in general under the Anaesthetic Staffing and Service Standards in Operating Theatres topic area 3

6 II PRE-OPERATIVE ASSESSMENT Scope This module focused on the process of pre-operative assessment, when it occurred, and what information was provided to patients. Progress Identified from Regional Summary Report (1999/2000) Pre-Operative Assessment Recommendations APRCC Services Regional Report (1999/2000) Progress Identified in APRCC Follow-up Study Trusts need to develop appropriate pre-operative assessment arrangements for inpatients prior to admission. Progress has been made. However, there is still variability across Trusts in the actual timing of pre-assessment i.e. before or after admission. Key Findings The follow-up review found that pre-operative assessments were taking place across Trusts although there was variation in when these occurred. Table 1: Percentage Of Trust Sites Undertaking Pre-operative Assessments & Timing Of Assessment Day Surgery In-Patients Admitted In-Patients Admitted on Day of Surgery Before Day of Surgery Before Admission 64% 40% 33% After Admission 36% 53% 53% Does Not Occur - - 7% Other - 7% 7% Source: Trust Data Returns 2003/04 Since the original study was undertaken a number of Trusts have introduced nurse-led pre-operative assessment clinics to help ensure the fitness of patients for surgery and reduce the possibility of cancellations. 4

7 II PRE-OPERATIVE ASSESSMENT The follow-up study found that ten Trust sites were using pre-admission checklists for all of their day surgery patients. Five Trust sites were using preadmission checklists for in-patients admitted before the day of their surgery. A further five Trust sites indicated that they were not using checklists for any of their in-patients admitted before the day of their surgery. It is generally accepted that the provision of written information to patients prior to surgery helps informed decisions about options for pain control to be made. It was found that of the fourteen Trust sites involved, seven provided written information about anaesthesia, eight provided information about postoperative pain relief and five supplied information on options for pain control after surgery. Good Practice Eight Trusts have developed written information packs containing information about either post-operative pain relief or giving options for pain control after surgery. These are given to patients prior to admission. 5

8 III ANAESTHETIC STAFFING AND SERVICE STANDARDS IN OPERATING THEATRES Scope This section of the review looked at assessing whether the deployment and supervision of anaesthetists working in operating theatres was appropriate and met relevant standards. Progress Identified from Regional Summary Report (1999/2000) Anaesthetic Staffing and Service Standards Recommendations APRCC Services Regional Report (1999/2000) Progress Identified in APRCC Follow-up Study Regular review of anaesthetic practice in operating theatres is necessary to assess whether changes are required to meet standards. Monitoring of staff and review of anaesthetic practice is in place although there is scope for further development in auditing the appropriateness of staff. Smaller Trusts need to work with commissioners and the Department of Health, Social Services and Public Safety to address their shortage of trainee anaesthetists. There has been varying degrees of success with recruitment across Trusts. Currently concerns centre around the impact of the Working Time Directive on workloads. Key Findings The National Confidential Enquiry into Patient Outcomes and Deaths (NCEPOD) 4 has recommended that only life-saving operations needing to be done within one hour should be undertaken at night. Operations of lower urgency should be scheduled at other times of the day when experienced doctors are on site to perform them or provide supervision and immediate support. In the 1999/2000 study the percentage of operations being undertaken outside of scheduled sessions ranged between 5% and 30% with an average of 17%. The follow-up study found that the percentage of operations performed outside of scheduled sessions ranged from 5% to 34%, with an average of 17%. 4 Formerly known as the National Confidential Enquiry into Peri-Operative Deaths 6

9 III ANAESTHETIC STAFFING AND SERVICE STANDARDS IN OPERATING THEATRES Chart 1: Total Operations Performed In And Out Of Scheduled Sessions As A Percentage Of Total Operations 2002/ % a 2b TRUST a 10b NI Av 2003 NI Av 1999 No. of operations outside scheduled sessions No. of operations in scheduled sessions Source: Trust Data Returns 2003/04 As part of the Acute Hospitals Portfolio study, a six-week survey of operating theatres across sixteen theatre sites was undertaken in September and October One of the indicators produced was the relative number of emergency operations undertaken at night. Chart 2 presents the findings for the sixteen Northern Ireland operating theatre sites. The average index score for Northern Ireland Trusts was 62 and for GB Trusts it was 85. 7

10 III ANAESTHETIC STAFFING AND SERVICE STANDARDS IN OPERATING THEATRES 250 Chart 2: Relative Number Of Emergencies Done At Night Across Northern Ireland Trusts 200 INDEX a a a 2b 4 10b 12b 12c NI Av GB Av TRUST Source: Acute Hospitals Portfolio, Operating Theatres 2002/03 In 1999/2000, six of the twelve Trusts participating in the study reported that they had audited the deployment of staff in the twelve months prior to the study. As Table 2 illustrates, during the follow-up review all Trusts indicated that they were monitoring staff present at operations. However, only four Trusts had undertaken an actual audit of the appropriateness of staffing in the previous twelve months. A review of anaesthetic practice had occurred in the twelve months prior to the study in eleven out of the fourteen Trust sites reviewed. Table 2: Monitoring In Operating Theatres Across Northern Ireland Trust 1 2a 2b a 10b Monitoring of Staffing Present at Operations Auditing Appropriateness of Staffing in Previous 12 Months Review of Anaesthetic Practice in Previous 12 Months 8

11 IV ANAESTHETIC DRUGS AND EQUIPMENT Scope This module focused on the introduction of new drugs and the replacement of equipment. Progress Identified from Regional Summary Report (1999/2000) Anaesthetic Drugs and Equipment Recommendations APRCC Services Regional Report (1999/2000) Progress Identified in APRCC Follow-up Study The efficient use of low flow anaesthesia and equipment to ensure the economic use of agents needs to be monitored and reviewed consistently. On the whole low flow anaesthesia equipment and monitoring arrangements are in place across NI Trusts. Systems to replace equipment need to be put in place and adhered to. The majority of Trusts have a replacement equipment programme in place. However, there are still a number of Trusts with a high proportion of equipment approaching the end of normal useful lives. Key Findings Ten out of the fourteen hospital sites examined as part of the follow-up review had a procedure in place for the introduction of new anaesthetic drugs, an increase from nine in the original study. All Trusts indicated that they monitored expenditure on anaesthetic drugs used in operating theatres. Twelve Trust sites had consultants nominated with a lead responsibility for operating theatre equipment, compared to eleven in the original review. At the time of the follow-up study, ten Trust sites had a planned equipment replacement programme, the same as in the original study. As part of the Acute Hospitals Portfolio work in 2002/03, information was gathered on ten different types of theatre equipment with a view to producing an indicator focusing on the equipment replacement cost burden as a percentage of total all new cost. Across Northern Ireland Trusts the equipment replacement cost burden ranged from 0% to 88% with an average of 40% (Chart 3). For England and Wales Trusts the range was from 0% to 91% with an average of 38%. A high percentage indicates that Trusts have a high proportion of equipment ready for replacement. 9

12 IV ANAESTHETIC DRUGS AND EQUIPMENT Chart 3: Equipment Replacement Cost Burden As A Percentage Of Total All New Cost % c 10a 7 2b 12a 12b 2a 3 TRUST b NI Av GB Av Source: Acute Hospitals Portfolio, Operating Theatres 2002/03 Good Practice One Trust is phasing out their anaesthetic rooms and linking all operating theatre anaesthetic machines to a computerised recording system to record and monitor anaesthetic data. 10

13 V POST OPERATIVE PAIN RELIEF Scope This element of the review focused on funding, staffing and audit arrangements for post-operative pain relief services. Progress Identified from Regional Summary Report (1999/2000) Post Operative Pain Relief Recommendations APRCC Services Regional Report (1999/2000) Progress Identified in APRCC Follow-up Study There is a need to standardise the scoring of pain for patients. All but one Trust is now using a standard system for scoring pain. Current written information provided to in-patients preoperatively on aspects of pain relief needs to be developed more, and kept under review. Eight Trust sites indicated providing information about postoperative pain relief. Five were providing information on options for pain control after surgery. 11

14 V POST OPERATIVE PAIN RELIEF Key Findings Figure 1 highlights the main issues arising from the follow-up review in relation to post-operative pain relief. Figure 1: Post Operative Pain Relief In Northern Ireland Trusts: Staffing, Funding & Pain Scoring Staffing All but one Trust site had a consultant to lead on acute patient pain and this was similar to the situation found in the original study. Twelve of the fourteen Trust sites had specialist support for ward nurses, for example, a pain specialist doctor or nurse in post. In a number of Trusts specific pain teams have been set up since the original study was undertaken. Funding Pain Scoring All but one Trust site reviewed as part of the follow-up study use a standard system for scoring patient pain. Eight Trust sites had completed an audit of the pain experienced by in-patients in the twelve months prior to the study. Only two Trust sites had completed such an audit of day patient pain. The majority of Trust sites fund their post-operative pain service through anaesthetic directorate monies with other sources including general Trust funding or specific commissioner funding. In some cases funding is received from more than one source. Source: Trust Data Returns and Update to Action Plans 2003/04 12

15 VI ANAESTHETIC SERVICES FOR WOMEN IN LABOUR Scope The focus of this module was on staffing responsibilities, levels of activity and timeliness of anaesthetic service provision for women in labour. Progress Identified from Regional Summary Report (1999/2000) Anaesthetic Services for Women in Labour Recommendations APRCC Services Regional Report (1999/2000) Progress Identified in APRCC Follow-up Study Trusts should periodically undertake audits of waiting times for epidural pain relief for women in labour. Seven of the ten Trusts providing maternity services indicated they monitor response times to epidural requests. Key Findings The follow-up study found that all ten Trust sites where maternity services were provided had a named consultant to lead on obstetric services. Table 3: Indicators For Anaesthetic Services For Women In Labour Trust 1 2a a NI Average Named Consultant to Lead on Services No. of Deliveries 4,720 1,032 2,381 1,004 2,648 1,719 2,530 1,226 1,173 2,249 2,068 No. of Caesarean Sections 34% 25% 25% 25% 31% 24% 21% 19% 20% 25% 27% as a % of Total Deliveries % of Deliveries Involving Epidurals 70% 31% 44% 55% 57% 44% 49% 19%* 23% 56% 53%** &/or Caesarean Sections Source: Trust Data Returns 2003/04 *Caesarean sections only **Excludes Trust site 10a 13

16 VI ANAESTHETIC SERVICES FOR WOMEN IN LABOUR The data collected demonstrates that the proportion of caesarean sections (planned and emergency) across Northern Ireland Trusts was, in almost all cases, higher than the GB mean of 21% as reported by the Royal College of Obstetrics and Gynaecologists in their 2002 core statistics report 5. As in the original study, the follow-up revealed variations in the number of deliveries involving epidurals and/or caesarean sections at Trust sites. In the original study a range of between 14% and 71% of deliveries were found to be caesarean and/or involve epidurals with a mean of 42%. In the follow-up, the range found was 19% to 70% with a mean of 53%. Six Trust sites were identified as having epidural anaesthetics for women in labour available twenty-four hours per day during weekdays and weekends. Seven of the ten Trust sites providing maternity services indicated that they monitored response times to epidural requests

17 VII SERVICES FOR PEOPLE WITH CHRONIC PAIN Scope This section of the review examined funding, staffing and types of clinic attendance in relation to services for people with chronic pain. Progress Identified from Regional Summary Report (1999/2000) Services for People with Chronic Pain Recommendations APRCC Services Regional Report (1999/2000) Progress Identified in APRCC Follow-up Study Work with commissioning bodies to consider the future provision of chronic pain services in light of demands placed on the service. Trusts need to develop a multidisciplinary approach to the treatment of chronic pain. Effective discharge policies for patients with chronic pain need to be put into place. Three of the eleven Trust sites providing chronic pain services had an identified budget for chronic pain in 2002/2003, compared to one Trust in 1999/2000. Chronic pain clinics are still primarily anaesthetist led but input from other professionals is evolving such as nurse specialists, psychologists and physiotherapists. Five of the eleven Trust sites providing chronic pain services had a discharge policy in place in 2002/2003. There were no discharge policies in place in 1999/2000. Key Findings At the time of the original study only one Trust had an identified budget for chronic pain services. The follow-up study found that three of the eleven Trust sites providing this service had an identified budget. Figure 2 provides an overview of chronic pain service provision across Trusts. 15

18 VII SERVICES FOR PEOPLE WITH CHRONIC PAIN Figure 2: Overview Of Chronic Pain Service Provision By Trusts Multidisciplinary Working Multi-disciplinary team working occurred in four Trusts. Although anaesthetists were taking the lead in service provision in all Trusts providing services, six Trusts also involved nurse specialists and six Trusts involved allied health professional staff. Ratio of New to Follow-up Attendances The ratio of new to follow-up attendances at chronic pain clinics was variable across Northern Ireland. The ratio ranged from 14% to 74% with an average of 28%. Discharge Policies Five Trust sites had a discharge policy in place, which compares to none in the original study. It was highlighted at interviews that it could be difficult to discharge an individual with chronic pain because of its ongoing nature. Waiting Times A range of 2 to 28 weeks for an urgent consultation was reported as part of the follow-up study. Waiting times of 20 weeks to over 3 years for routine consultations were identified. In the original study waiting times ranged from 3 months to over 2 years. Source: Trust Data Returns and Updates to Action Plans 2003/04 Good Practice One Trust has obtained Health Quality Service accreditation for their chronic pain service, which involves multi-disciplinary working across a range of professionals including psychologists and physiotherapists. 16

19 VIII MANAGEMENT OF ANAESTHETIC SERVICES Scope The focus of this module was on the management of anaesthetic services in terms of the identification of lead responsibilities for different services, and the processes in place for the management of performance, standards and planning. Progress Identified from Regional Summary Report (1999/2000) Management of Anaesthetic Services Recommendations APRCC Services Regional Report (1999/2000) Progress Identified in APRCC Follow-up Study Consultant work plans should be reviewed annually to ensure their most effective deployment. Annual review of consultant job plans is in place. This is generally incorporated as part of the staff appraisal process. Key Findings It was found that in all but three cases, Trusts had named consultants to lead on: - Obstetrics; - Equipment; - Acute pain; - Chronic pain; - Clinical audit; - Rota co-ordination; and - Training. In two Trusts there was no lead consultant in place for equipment and one Trust did not have a named consultant to lead on acute pain. As part of the Acute Hospital Portfolio in 2002/03, information was collected that scored Trusts in terms of the management of performance, standards and planning. A maximum score of 10 was possible. The Northern Ireland Trust scores ranged from 0.6 to 6.7 with an average score of 4 (Chart 4). For England and Wales the average score was 5. 17

20 VIII MANAGEMENT OF ANAESTHETIC SERVICES Chart 4: Management Of Performance, Standards And Planning Score Across Northern Ireland Trusts SCORE a a 1 10b 11 4 TRUST 7 12b 12c 2a 8 2b 6 NI Av GB Av Source: Acute Hospitals Portfolio, Operating Theatres 2002/03 The key areas that each Trust was scored against were: - The number of times management information had been produced in the previous twelve months and to whom it was copied. The range of theatre information that was scored included providing detail on cancelled scheduled lists, cancelled operations, utilisation of scheduled theatre hours and review of list start and finish times; - If there were agreed standards of performance in place with theatre users for areas such as cancelled operations, utilisation of scheduled theatre hours; and - Whether there was a theatre policy in place that included an operational definition of a list start and finish time. Good Practice The follow-up study found that, in line with CREST guidelines, the majority of Northern Ireland operating theatres had a theatre director who was either a consultant surgeon or consultant anaesthetist. 18

21 IX PLANNING CRITICAL CARE SERVICES Scope This section of the study involved reviewing the planning of critical care services in terms of collecting and reviewing data to support the monitoring of critical care units. Progress Identified from Regional Summary Report (1999/2000) Planning Critical Care Services Recommendations APRCC Services Regional Report (1999/2000) Progress Identified in APRCC Follow-up Study Trusts need to work with commissioning bodies to secure funding for the appropriate number of critical care beds to meet demand. Increases in bed capacity need to include adequate funding for nursing and medical inputs. Activity information in units should be recorded and monitored on a regular basis. Admission and discharge criteria for units should be kept under review to ensure the most effective use is being made of limited resources. There has been an increase in critical care bed provision in line with the CMO recommendations. However, some limiting factors were identified by Trusts, such as, recruitment difficulties and, in other cases, physical space limitations. Information was widely available for occupancy and levels of admissions to critical care units. However, only a few Trusts were recording information, firstly, on refused admissions because units were full and, secondly, on early discharges because of pressure on beds. Ten Trusts had reviewed their admission and discharge criteria within the twelve months prior to the follow-up audit. As part of the update to the CMO report Trusts reported that regional admission and discharge guidelines had not been agreed. 19

22 IX PLANNING CRITICAL CARE SERVICES Key Findings At the time of the follow-up review, intensive care, high dependency or a combination of both services were provided across thirteen hospital sites by sixteen critical care units 6. Seven sites noted that there were instances when they provided critical care outside of the designated unit. Nine Trust sites had a named consultant with overall responsibility for critical care services. In a number of other cases, Trusts reported that the effective head was the Trust s medical director. Since the original study was undertaken, the total number of funded ICU and HDU beds in Northern Ireland has increased in line with the CMO s report (Facing the future Building on the Lessons of Winter 1999/2000). This report has influenced the development of critical care services across Northern Ireland and is further discussed in Section XIII of this report. Figure 3 provides an overview, on a Board basis, of the information provided by Trusts regarding equipped, funded and available beds. The total number of equipped beds (i.e. those beds which have full equipment capability) differs from the funded (officially funded beds) and available beds (those beds actually available for patient use) primarily due to space limitations in some critical care units. This restricts the number of beds that will physically fit in the unit. In addition, difficulties in the recruitment of specialist staff, particularly nursing, were identified by Trusts as resulting in an inability to staff beds and contributing to variances between equipped, funded and available beds. 6 Not all these sixteen units are reflected in all the activity information that is detailed in this section due to problems in providing some of the level of detail required and with comparability issues. 20

23 IX PLANNING CRITICAL CARE SERVICES Figure 3: Number Of ICU And HDU Beds Across Northern Ireland NI Critical Care Beds HDU ICU Equipped Funded Available Board 1 HDU ICU Equipped Funded Available Board 2 HDU ICU Equipped 5 7 Funded 5 7 Available 5 6 Board 3 HDU ICU Equipped 13 5 Funded 13 5 Available 11 5 Board 4 HDU ICU Equipped 3 11 Funded 2 9 Available 2 9 Source: Trust Data Returns 2003/04 In the original study occupancy levels across ICUs and HDUs ranged from 65% to 95%. At the time of the follow-up study, occupancy levels ranged from 42% to 96%. In general, ICUs had higher occupancy than HDUs. Chart 5: Occupancy In Northern Ireland Critical Care Units 2002/ % ICU 1 HDU 3 ICU 3 HDU 4 HDU 5 ICU/ HDU 6 ICU/ HDU 7 ICU 8 HDU 9 ICU 9 HDU 10 A HDU 10 B HDU 11 ICU 12 ICU NI Av TRUST Source: Trust Data Returns 2003/04 21

24 IX PLANNING CRITICAL CARE SERVICES Table 4: Information On Critical Care Activity In Northern Ireland Trusts (2002/03) Trust / Unit Total % Of Admissions % Of Unit % Of Unit Admissions Which Were Admissions Which Admissions Which Readmissions Were Elective Were Emergency Admissions Admissions 1 ICU 538 2% 12% 88% HDU 122 6% 14% 86% 2a HDU 139 6% 53% 47% 3 ICU 317 9% 20% 80% HDU 456 N/A 68% 32% 5 Combined 337 4% 8% 92% 6 Combined 283 4% 1% 99% 7 ICU 412 5% 15% 85% 8 HDU 169 N/A 18% 82% 9 ICU 310 N/A N/A N/A HDU 408 N/A N/A N/A 10a HDU 204 1% 91% 9% 10b HDU 142 2% 66% 34% 11 Combined % 3% 97% 12 ICU 294 8% 9% 91% Source: Trust Data Returns 2003/04 N/A - Not collected / unable to be provided Of the thirteen units detailed in Table 4 that provided information on the level of emergency admissions, nine Trusts had a level of emergency admissions of 80% or over in 2002/2003. Of the sites that were able to provide the required detail, the total number of readmissions to critical care units ranged from 1% to 15% of total admissions. The average length of stay in critical care units ranged from 1 to 13 days with a mean of 5 days. ICUs had a mean length of stay of 6 days, HDUs 3 days and combined units 9 days. The availability of critical care beds locally is important for both continuity of care and to the patient and their relatives. As part of the follow-up study the number of patients transferred in from a different Trust ranged from 0% to 19%, with a mean of 10%. Since the original study the Northern Ireland Critical Care Transport Service for adults has been developed. At the time of the follow-up study there had been no corresponding development of a dedicated service for paediatrics and neo-nates. 22

25 IX PLANNING CRITICAL CARE SERVICES The monitoring of demand depends on recording and analysing appropriate data. Across those sites providing critical care services, two indicated relying solely on manual recording, four relied on manual recording of data with some entry into a computer system, and seven sites used a computer system for automatic recording of some data with paper records for others. Only four Trust sites were able to supply information, both on the number of admissions refused to units because the unit was full, and on the number of patients discharged early because of pressure on beds. 23

26 X MAKING THE BEST USE OF UNIT RESOURSES Scope This element of the study reviewed critical care unit staffing and the use of admission and discharge criteria. Progress Identified from Regional Summary Report (1999/2000) Making the Best Use of Unit Resources Recommendations APRCC Services Regional Report (1999/2000) Progress Identified in APRCC Follow-up Study Trusts should review the skill mix of critical care units to ensure that they are appropriate to meet the specialist type of work undertaken. Trusts should ensure adequate opportunities are available for trainee nurses in critical care units. Trusts should monitor and manage staff sickness occurring in critical care units to minimise the impact on unit staffing. Written information, services and facilities should be provided to all patients and their families. All but one Trust indicated having reviewed their staff skill mix to ensure sufficient skill being available to meet the specialist type of work undertaken in critical care units. However, the recruitment of specialist staff was identified as an ongoing challenge. All Trusts reported that opportunities for pre-registration and post-registration students to gain experience in critical care areas were available. All Trusts were monitoring sickness levels on a routine basis. All Trusts reported that they had a range of written information available for patients and their families. Whilst facilities for families were available, the standard of these varied across Trusts. Key Findings The number of fixed consultant half-day sessions for critical care services varied across the eleven Trusts that provided this information. The range for ICU sessions was 10 to 25 per week, and the range for HDU sessions was 5 to 10 per week. However, not all these sessions were totally dedicated, with a number of Trusts reporting that staff may also be providing cover for areas such as A&E. In the original study a range of 4 to 15 dedicated sessions per week was found. 24

27 X MAKING THE BEST USE OF UNIT RESOURSES The original study reported that there were issues concerning the availability of experienced critical care staff and also the grading of staff in critical care units. At the time of the follow-up study: - All but one Trust had reviewed their staff skill mix to ensure sufficient skill was available to meet the specialist type of work undertaken in critical care units; - All Trusts indicated that opportunities for trainee nursing staff, both undergraduate and post-graduate, were made available in the critical care unit; and - All Trusts had a period of induction for new nurse recruits whereby they remained supernumerary. However, Trusts indicated that it was impractical to rotate general ward nurses on induction through critical care units due to the specialised nature of these units. Monitoring of staff levels is essential to ensure minimal disruption on critical care units. As part of the follow-up study all Trust sites indicated that they monitor sickness levels. For the ten Trusts that supplied sickness rates, there was a range of between 4% and 8% for the year ended 31 March At the time of the follow-up study, ten Trusts had reviewed their admission and discharge criteria within the twelve months prior to the audit. As part of the update to the CMO report, Trusts reported that regional admission and discharge guidelines had not as yet been agreed. 25

28 XI ASSURING QUALITY OF SERVICES Scope This section of the study looked at how Trusts assure the quality of their services by examining their participation in external quality review, and reviewing the type of information and services provided to patients and relatives. Progress Identified from Regional Summary Report (1999/2000) Assuring Quality of Services Recommendations APRCC Services Regional Report (1999/2000) Progress Identified in APRCC Follow-up Study Trusts should participate in the Intensive Care National Audit and Research Centre audit initiative. Of the thirteen hospital sites providing critical care services, eight sites indicated participating in ICNARC. Another three sites indicated involvement with organ donation and/or NCEPOD. Two sites were not participating in any such initiatives at the time of the study. Key Findings Eight sites indicated participating in ICNARC, while another three sites indicated involvement with organ donation and/or NCEPOD. The two Trusts, which were not participating in any formal audit initiative, both provide only HDU services. Trusts reported that the results of the ICNARC group, which are national, are not currently fed back to Trusts at a regional level. As such, there was a view that this limited its usefulness in benchmarking services on an ongoing basis in Northern Ireland. The provision of information regarding critical care services to patients and their families is important, as is access to a range of non-clinical services. All Trusts reported that they had a range of written information available to patients and their families. However, in some cases this information was not specific to the critical care unit and was part of a generic hospital information pack. All Trusts had reviewed the level of clinical supervision on wards for the transfer of critical care unit patients and had introduced strategies to improve the transfer of information from the critical care unit to the ward. 26

29 XI ASSURING QUALITY OF SERVICES As reported in the original study, a mixture of services and facilities were in place across Trusts to support patients and families. The most common example of services was counselling for patients and/or their families. The facilities offered for relatives varied but included dedicated relatives rooms, overnight stay rooms and private bathrooms. Trusts reported that the physical size of their units was a limiting factor in their ability to offer a range of facilities for relatives. Good Practice One Trust has introduced a counselling service that gives patients a single telephone number to call for advice and support after their discharge from the critical care unit. This service is also available to those relatives who have suffered bereavement on the critical care unit. Two Trusts have developed an outreach team which visits patients recently discharged from the critical care unit. 27

30 XII CHIEF MEDICAL OFFICER S 2000 REPORT UPDATE In 2000 the Chief Medical Officer (CMO) released a report The Way Forward Building on the Lessons of Winter 1999/2000. This report set out a number of regional and local recommendations to take forward the provision of critical care services. Part of the follow-up audit involved examining the progress that Trusts and Boards had made with the implementation of the CMO recommendations. Examples of the areas within the CMO report where Trusts have indicated the greatest progress are highlighted below. Key Findings Additional Bed Capacity All Boards had, as part of their Health and Well-Being Investment Plans, provided for an increase in critical care bed numbers and all Trusts had, subject to recruitment difficulties, increased their critical care bed provision in line with the CMO recommendations. Trusts identified recruitment difficulties, and in some cases physical space limitations, as limiting their ability to implement all the recommendations in the report. Short Term Care And Inter-Hospital Transfer All Trusts are able to provide short-term ventilatory support for adults and paediatrics. This can occur in an ICU, HDU, operating suite or A&E department. The transfer of adults between critical care units is now co-ordinated by the Northern Ireland Critical Care Transport Service (NICATS). However, the development of a separate formal service for paediatrics and neo-nates remained outstanding. Clinical Networks Although there was no formal clinical network, an informal group of critical care clinicians were meeting on a regular basis to discuss topics of interest. There was some difference of opinion amongst Trusts as to whether a formal network would improve care, with a number of smaller Trusts concerned about the potential dominance of the larger units. 28

31 XII CHIEF MEDICAL OFFICER S 2000 REPORT UPDATE Staffing All Trusts identified opportunities for pre-registration and post-registration students to gain experience in critical care areas. Queen s University and the University of Ulster have developed a nursing course. However, not all Trusts seemed aware of it at the time of the follow-up work. There has been varying degrees of success across Northern Ireland with enhancing staffing levels. Trusts were also concerned about the impact of new EU regulations on doctor s working hours and on the number and grade of medical staff required at a time when recruitment was already a challenging area. Systems And Audit Audit, primarily through ICNARC or NCEPOD occurs in the majority of Trusts. However, results are not, as yet, fed back on a regional basis. Trusts indicated that information and management systems were evolving. 29

32 XIII THE WAY FORWARD In order to further progress anaesthetic, pain relief and critical care services in Northern Ireland it is recommended that: Pre-Operative Assessment Trusts review the level and type of written information provided to patients about anaesthesia, post-operative pain relief and pain control after surgery. Trusts review the timing of pre-operative assessments undertaken to assist in identifying those patients not suitable for surgery. Anaesthetic Staffing and Service Standards in Operating Theatres Trusts should promote the recommendations of the National Confidential Enquiry into Patient Outcomes and Deaths by monitoring and formally auditing the timing and appropriateness of staffing at operations. Anaesthetic Drugs and Equipment Trusts should continue to monitor the age and cost of theatre equipment. Post-Operative Pain Relief Trusts should conduct regular formal audits of the level of pain experienced by in-patients and day patients. Anaesthetic Services for Women in Labour Trusts should continue to promote the availability of epidurals for women in labour and monitor the availability and response times of requests. Services for People with Chronic Pain Trusts should work with commissioners to identify dedicated funding for chronic pain services with a view to further developing multidisciplinary team working and helping to minimise patient waiting times for the service. Trusts should seek to review the implementation of discharge protocols for chronic pain services. 30

33 XIII THE WAY FORWARD Management of Anaesthetic Services Trusts should have agreed standards of performance in place to help promote management of anaesthetic services including the regular discussion and dissemination of activity information at both an operational and strategic level. Planning Critical Care Services Trusts should review the mechanisms in place for recording and monitoring activity information for critical care units to support the provision of care and the effective use of resources. Making the Best Use of Unit Resources Trusts should continue to work with commissioners to recruit and retain the right skill-mix of staff for critical care units, while ensuring these staff are appropriately supported and receive opportunities for further training. Assuring Quality of Service Trusts and the Department should consider liaising with the Intensive Care National Audit and Research Centre Audit with a view to making specific information available to facilitate on-going critical care monitoring at a regional level. 31

34 NOTES 32

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36 For further information please contact: Performance Review Unit Finance Directorate DHSSPS Castle Buildings Stormont Belfast BT4 3SQ Telephone: (028)