Critical Care Capacity & Immediate Life Preserving Treatment K Moyna Bill President ACTACC Consultant Anaesthetist, RVH, Belfast

2 cases of delayed transfer of a neurosurgical patient to a specialist unit which contributed to their outcomes due to delayed operations. Reasons given by units refusing the patients – unavailability of ICU beds / clinical grounds Coroner Regulation / Sir Bruce Keogh (27.02.17) – not acceptable to refuse transfer of a patient for specialist clinical (neurosurgical) treatment due to lack of ICU beds

Sir Bruce Keogh’s letter “professional guidance includes recommendations that, admission to a regional neurosurgical unit for life-saving, emergency surgery should never be delayed and that neurosurgical units should not refuse admission to patients requiring emergency surgery from their catchment population. The lack of critical care beds must not be a reason for refusing admission for patients requiring urgent surgery.” ………… this should not exclude co-operation between neighbouring units if this can expedite patient care. Consultant to consultant referral and responsibility With the italic sentence – does this mean specialist units or ICUs?

National Critical Care Networks Medical Leads meetings “even in the immediate absence of critical care capacity in the receiving specialist centre, the patient should still be admitted to that hospital to undergo the emergency intervention.” Capacity would then need to be created on same site for appropriate level of care or transfer of a patient to another critical care facility. ”the same principle should apply to any immediately life-threatening event where an emergency procedure might improve outcome ……… and other areas where the procedure is time critical though the recipient is not in immediate danger, may also come under the same consideration” Meetings in March 2017 and then again in October 2017 (further cases of immediate life-saving procedures in non-neurosurgical patients)

Specialist treatment but no immediate intervention… Transfer should occur as soon as possible according to clinical guidelines If inadequate critical care resources…….. “the consultant at the specialist centre should be responsible for ensuring an appropriate bed is found in another specialist centre to enable the patient to receive necessary care without delay” When specialist treatment no longer required then responsibility of local hospital to ensure repatriation of patient in a timely manner (48 hrs max from request?) in line with local regional transfer policies Does the consultant at specialist centre mean intensivist or surgeon?

Summary Immediate lifesaving intervention / treatment where it can be performed immediately and delays that would have a significant adverse effect on outcome – transfer of patient should occur Responsibility of specialist consultant to arrange critical bed, transfer etc & also in situation where immediate transfer not required but urgent (may involve another specialist unit) Repatriation important – responsibility of referring hospital The flow diagram at end of document is helpful.

Is this relevant to cardiothoracic surgery / critical care? Isolated units Units with close neighbours Cardiac surgical / cardiothoracic ICUs Cardiothoracic surgery within general ICUs Super specialist units? Describe situation in Belfast. Plans for new critical care building & 2 x 20 beds for RICU. I’m old enough to have worked in RICU when we just had 17 ICU beds and no HDU.

Is this relevant to cardiothoracic surgery / critical care? Potential patient groups Aortic dissection / aneurysm Acute coronary syndrome Acute valvular disease requiring operation Chest trauma – myocardial, aortic, pulmonary Emergency thoracic / oesophageal Cardiac tamponade Out of hospital cardiac arrest (+ PPCI) / cardiology patients

What is the extent of the problem? The impact on our elective work / targets etc Should we keep capacity for an emergency??? If not we need to be prepared for when it happens. ACTACC will shortly be carrying out a survey on OHCA and our critical care units. Mostly on the logistics of the situation, practices in different areas, impact & repatriation. Talk about the case from 2 weeks ago Enough nursing staff? Surgeon not going to be happy if it impacts on Monday’s work Will RICU accept him back? Actually was in correct place!! Where cardiothoracic anaesthetists are the ones who attend in the cath lab is it more difficult to send pt elsewhere etc?

How should we handle this? Discussion How should we handle this?

In the acute situation Are there other ICUs in the hospital / region who could take a stable patient? Ventilation in theatre until bed available (or swap patients)? Use HDU / PACU?

Long-term Campaign for more ICU beds? Build relationships / protocols with other ICUs in hospital / region – this is not a unilateral process Develop protocols / guidelines within units / hospitals / regions for these scenarios – collaboration between CT surgeons, CT anaesthetists, other anaesthetists / intensivists, senior nursing staff, managers Develop cardiac/cardiothoracic critical care networks?

Remember to keep patient focused Work collectively & collaboratively towards appropriate local arrangements