Managing the Patient

Many patients will make a straightforward and quick recovery from critical illness.

However, significant numbers may suffer continuing problems, both physical (weakness, loss of energy, physical complications of ICU stay) and non-physical (anxiety, depression, post-traumatic stress disorder, impaired cognitive function). These may occur with short or long ICU stay, and may impact on family members as well as the patient.

Comprehensive patient information (local or generic, e.g. ICU STEPS, pp 13-21) may provide useful information and reassurance, and help the patient understand their symptoms and rehabilitation needs.

NICE Guidance (CG83, ‘Rehabilitation after Critical Illness’, 2009) recommends clinical assessment and identification of rehabilitation requirements and goals at important points in the patient’s stay, both in and outside ICU. Full implementation requires collaboration between clinical teams, including primary care.

Some units in NW London have piloted initiatives including patient diaries and photographs, and/or operate ICU follow-up clinics, which may serve an important role in monitoring and diagnosing physical and non-physical effects of an ICU stay.

Many patients will make a straightforward and quick recovery from critical illness.

Deteriorating Patients

Early identification and pre-emptive management of the deteriorating patient, by front line clinical staff, can help to prevent or reduce organ failure and greatly improve patient survival, as well as potentially averting ICU admission or reducing length of ICU stay.

With the appropriate awareness, training, and organisational response, such action can help the patient at any stage in their pathway, from primary and pre-hospital care through to emergency department and general hospital wards.

As part of the Network’s strategy to optimise care for deteriorating patients in North West London, we had workstreams for:

• Implementation of the National Early Warning Score (NEWS) across all Network sites
• Education to improve the standard of patient observations, and ensuring quality of care to improve the rescue of critically ill patients
• Service improvements and organisational changes to improve critical illness recognition and response pathways within secondary care in North West London
• Early identification and pre-emptive management of the deteriorating patient, by front line clinical staff, can help to prevent or reduce organ failure and greatly improve patient survival, as well as potentially averting ICU admission or reducing length of ICU stay.

In addition, we will be helping Trusts and clinical to implement guidance in early management of sepsis and acute kidney injury (AKI).

NEWS in the Network

All Trusts in the Network are expected to achieve compliance with NICE (CG50) requirements for early detection and action on critical illness in ward patients (http://www.nice.org.uk/CG50). This is assessed as part of Network Quality Measures (link).

The National Early Warning Score was developed multilaterally by professional bodies and published in July 2012: National Early Warning Score. In December 2017 an update was released as NEWS 2.

Critical Care representatives from all Trusts in the Network agreed to adopt NEWS as a standard measure and to work with acute Trust nursing, acute medical, and Executive colleagues to facilitate implementation across North West London.

The NEWS implementation group is now re-designated the “Care of the Deteriorating Patient Working Group”, and meets on an ad hoc basis depending on need. The group is open to new members. Please contact us here if you are interested in contributing to this work or have a topic you would like us to consider. The Network group has updated the Statement of intent (2015) which can be found here.

The Network approach was that NEWS is only effective if implemented with appropriate training and organisational changes, especially around escalation mechanisms for higher-scoring patients. A standardised set of recommendations was developed and circulated to Trust CEOs as an organisation checklist.

Working within this standardised checklist, different sites have differing documentation due to the need to gain local ownership and reflect local infrastructure. The NEWS charts and escalation pathways are being used by all across the Network

Acute Kidney Injury

The North West London Critical Care Network, in collaboration with the West London Renal and Transplant Centre, functions as one of the five sector networks taking part in the London Acute Kidney Injury Network (LAKIN) initiative.

The organisations share the goal of improving acute kidney care in London through collaborative delivery of AKI pathways supported by education, audit, innovation and research.

The London AKI Network has published clinical guidelines, available in various formats , which are fully endorsed by and compatible with North West London Critical Care Network’s Acute Kidney Injury workstream.

Within this wider programme, the North West London Critical Care Network;

• is developing and piloting a simplified Acute Kidney Injury care bundle for use with emergency and elective patients outside the ICU
• is developing an audit that will look at patients with Acute Kidney Injury receiving care within a critical care unit
• will look for the tools, if successful, to be adopted more widely and integrated with the London-wide guidelines in 2013
• transfer governance process is being used to inform the work about renal patients being transferred within North West London.

It is vital that critically ill or injured patients are treated rapidly in an acute hospital in order to stabilise them or limit their injuries. However, there are several instances when such management may be followed by further (secondary) transfer to another acute hospital:

• Clinical transfer– when the facilities needed for definitive treatment are not available at the initial hospital.
• Capacity transfer– when the initial hospital has inadequate equipment, bed capacity, staffing or monitoring to provide the necessary care.
• Repatriation–highly specialised hospitals may need to transfer patients to ensure they can treat the next patient who needs their specialist facilities. Patients may also be moved back to hospitals nearer to their home and family. In these cases, patients will have had their specialist treatment, are almost always stable and the transfer may involve a step-down in the level of their care.

The network audits all critical care patient transfers within North West London. We use this information about direct patient experiences to help local clinicians and managers improve access, efficiency and safety.

Intra Hospital Transfers

Transferring critically ill or injured patients within and around (intra) the hospital requires the preparation, equipment and thought processes to be the same as transferring patients going in the back of an ambulance as the potential hazards are the same.
Each organisation will have their own intra hospital policy and documentation.

Following evaluation of current intra hospital transfer documentation across the NWL the Network Transfer faculty agreed to look at standardised intra hospital transfer forms. A new intra hospital transfer form was designed (by Dr Melissa Dransfield) and after consultation and refinement was agreed at the Network Joint Clinical Forum Board and launched at the Network event in December 2014.

Each site in NWL is implementing this standardised form and auditing locally to inform practice, support clinical staff undertaking critical care patient transfers and improve patient safety for level 2 and level 3 intra hospital transfers.

In 2018 we developed a Transfer Triage Tool which was launched in draft format at the Network Education event 19th December 2018 and is being rolled out across Trusts in NWL in early 2019.  This is designed to help and support staff and to enhance safety for patients.

Chelsea and Westminster

West Middlesex Hospital

Hillingdon Hospital 

Imperial College Healthcare Trust – Charing cross, Hammersmith, St Mary’s

London North West Healthcare Trust – Central Middlesex, Ealing, Northwick Park and St Mark’s

Royal Brompton and Harefield NHS Trusts– Brompton and Harefield hospitals

Royal Marsden Hospital

Royal National Orthopaedic Hospital

Inter Hospital (Between Hospitals) Transfers

When transferring critically ill or injured patients whether 100 miles or 100 yards the same principles should be applied
High quality patient transfers result from appropriate training, meticulous preparation and appropriate documentation.

Appropriate training – a full day training course based on the transfer training course handbook is supported by the transfer faculty who are all clinicians from critical care and emergency departments across London. There is also a series of educational videos available which provide the key points for those staff undertaking transfers

Transfer training course handbook

Meticulous preparation – The mantra, when transferring critically ill or injured patients whether 100 miles or 100 yards the same principles should be applied underpins the transfer training. Prior preparation prevents poor performance is another used. The network aide memoir gives some top tips on what to have thought about and checked when preparing to transfer a critically ill or injured patient.

Aide memoire from the NWL critical care network transfer training course

Appropriate documentation

In North West London the inter hospital transfer form is used to support these patient transfers.
Network Inter hospital transfer form

Please note that this is an example and not to be printed and used for transfers.Transfer forms are available is all Critical care units and Emergency Departments across NWL. If you want to order additional books of the form please contact your transfer lead for the Trust or the critical care network letting us know which Trust and department you are from.

In 2018 we developed a Transfer Triage Tool which was launched in draft format at the Network Education event 19th December 2018 and is being rolled out across Trusts in NWL in early 2019.  This is designed to help and support staff and to enhance safety for patients.

Major Trauma Pathway

Major Trauma

Changes in the management of major trauma patients mean that primary bypass of the nearest Emergency Department is in place in North West London so major trauma patients will only arrive in Emergency Departments other than St Mary’s Hospital Major Trauma Centre if the

• patient was under triaged
• patient has a compromised airway/catastrophic haemorrhage and London Ambulance Service need immediate assistance from nearest Emergency Department
• patient self presents at an Emergency Department

Transferring patients to the Major Trauma Centre

Once the decision to transfer the patient and contact has been made with the Major Trauma Centre, it remains the responsibility of the Trauma Unit to provide the transfer escorts and equipment. The escorts should have appropriate training and skills to manage the patient during the transfer, be familiar with the equipment and processes surrounding transferring critically ill or injured patients.

This video outlines the roles of the Major Trauma Centres and the Trauma Units in London and addresses some of the common questions asked.

This video addresses the “scoop and run” versus “stay and play” conundrum facing clinicians treating critically ill or injured patients.

This document provides guidance for transferring critically ill or injured patients to a Major Trauma Centre

Major trauma secondary transfer protocol

In North West London the inter hospital transfer form is used to support these patient transfers.

Network Inter hospital transfer form

Please note that this is an example and not to be printed and used for transfers.Transfer forms are available in all Critical Care Units and Emergency Departments across North West London. If you want to order additional forms please contact your transfer lead for the Trust or email here .

Severe Respiratory Failure and ECMO

There are 5 centres in England commissioned to offer ECMO for severe acute respiratory failure in adults. These are:

Royal Brompton and Harefield NHS FT

Guy’s and St Thomas’ Hospital NHS FT

Papworth Hospital NHS FT

University Hospitals of Leicester NHS Trust

University Hospital of South Manchester NHS FT

Each of the centres cover a defined geographical area (see picture below) and a number of established critical care networks that exist.This ensures that any patient that requires critical care services are able to access them.

Referral

All patient referrals for Severe Respiratory Failure and/or ECMO in the NWLCC Network should be made DIRECT to the Royal Brompton Hospital.

If you wish to refer a patient for ECMO please complete the referral on the pathway and then contact the ECMO Retrieval Team on 020 7351 8585

·The ECMO team will be notified of your online referral and will be expecting your callThe online referral is in 2 stages and there are videos on the pathway to assist you with this process.

Through completing the online referral:

·You will provide the ECMO team with more robust and rigorous information about your patient, allowing clear and appropriate decisions to be made.

·The whole team surrounding the patient is able to register and link to the patient to see the information and advice given. Guidance on how to do this is in the videos.

·The pathway also allows you to log on and see how your patient is doing whilst they are at Royal Brompton

·You will be able to view information about the patient when they are ready for repatriation back to you, which will allow you to prepare your multidisciplinary team.

Royal Brompton includes imaging reviews (sent via CD, IEP, or bbRad), thoracic surgical input, extracorporeal carbon dioxide removal and ECMO support.

Advice should be obtained sooner rather than later for patients in whom adequate arterial blood gases cannot be achieved using lung protective tidal volumes and pressures.

The potential survival benefits of ECMO as a lung protective strategy diminish sharply after one week of conventional ventilation at high pressure and high inspired oxygen concentration.

Typical Patients: will include those with reversible disease associated with one or more of:

• Severe hypoxaemia (e.g. PaO₂/FiO₂< 13.3kPa)
• Severe hypercapnic acidosis (e.g. pH<7.20)
• Inability to achieve lung protective tidal volumes and pressures (tidal volume < 6 mL/Kg predicted body weight, plateau pressure < 30 cmH₂O)
• Failure to improve with rescue therapies e.g. high frequency oscillation and prone positioning
• Significant air leak/bronchopleural fistula

Retrieval: A “consultant-delivered” retrieval service (including mobile ECMO) is available from the Royal Brompton Hospital 24/7. Specific transfer equipment is available which the team will bring with them.

Referring hospital: If ECMO is to be instituted at the referring hospital, the ECMO retrieval team will need access to an operating theatre, anaesthetist, scrub nurse, radiographer with image intensifier, and 2 units of blood. The patient’s relatives should be asked to be available for discussion about retrieval and extracorporeal support.

ECMO centre coordination: In the event that the Royal Brompton cannot take a patient who is considered appropriate for ECMO, the Royal Brompton will coordinate onward referral to another designated centre. All five designated ECMO centres (Royal Brompton, GSTT, Papworth, Glenfield, and Wythenshawe) will work in this way to manage referrals and capacity.

Step-down and repatriation: Generally, patients will not be repatriated to the referring hospital until it is clear that they are very unlikely to need further escalation of respiratory support.Repatriation to the referring site will be carried out by the Royal Brompton transfer team.

The North West London Renal Network is a collaboration between the NW London Critical Care Network and the West London Renal Centre (Hammersmith Hospital). It operates as one of the 5 regional segments of the London Acute Kidney Injury Network

Patients referred to the West London Renal Centre are triaged and prioritised for renal replacement therapy on a daily basis, according to the following criteria:

1. renal transplant candidates
2. diagnostic emergencies (glomerulonephritis)
3. patients receiving renal support on another ICU, known to renal team with known history of chronic kidney disease (CKD)
4. patients receiving renal support on another ICU, presumed acute tubular necrosis (ATN), who have failed to recover renal function after 10-14 days while on renal support (presumed evidence of secondary chronic kidney impairment)

The renal centre’s logic for prioritising CKD patients before ATN patients, is that the latter may potentially recover renal function, and it is in their best interest to remain closer to home and/or near to their referring specialities if so, until lack of reversibility AKI is confirmed. CKD patients who develop a need for renal replacement, are unlikely to recover their renal function at all, and are therefore accepted before ATN patients.

Specialised burn service – LSEBN

The LSEBN publishes burn care guidance and guidelines for health care professionals. The documents have been developed by senior clinical members of the burns multi-disciplinary team, and approved by the ODN Board.

Documentation for transfer to specialised burn service

The LSEBN publishes burn care guidance and guidelines for health care professionals. The documents have been developed by senior clinical members of the burns multi-disciplinary team, and approved by the ODN Board.

Burn care guidance

The LSEBN publishes burn care guidance and guidelines for health care professionals. The documents have been developed by senior clinical members of the burns multi-disciplinary team, and approved by the ODN Board.

Blister management

The LSEBN publishes burn care guidance and guidelines for health care professionals. The documents have been developed by senior clinical members of the burns multi-disciplinary team, and approved by the ODN Board.