Sharing Best Practice

This area is for guidance and shared practice on unit management. It is relevant to any unit looking after critically ill patients (Emergency Department, acute wards, HDU, ICU, peri-operative areas).

Topics in this section include:

  • Patient admission, discharge, and transfer in critical care units (shared with ‘managing the patient’)
  • Capacity planning, escalation, and contingency plans for normal running/winter pressures
  • Emergency planning and resilience for extraordinary circumstances
  • Information, links, and help guides for the temporary management of a critically ill child in an adult unit, which may be necessary in any of the above

This material is provided on a reference basis only. Responsibility for selection and clinical application of information rests with individual clinicians at all times.

Critical care capacity may vary according to:

  • Physical capacity and equipment
  • Management decisions (i.e. number of funded beds at a particular period)
  • Short term staffing fluctuations (staffing levels, vacancies, sickness, Agency availability)
  • Patient flow (delayed discharges, step-down capacity)

Capacity determines access for patients: failure of access may include:

  • Inability to admit an unplanned emergency patient, causing delayed admission, care in an inappropriate area, or transfer
  • Cancellation of elective procedure due to lack of appropriate bed
  • Inability to admit a tertiary referral admission needing critical care.

Lack of capacity

Failure of access to critical care can be life-threatening. Local capacity decisions (e.g. planned change in staffed bed numbers) will have knock-on effects on other units and hospitals in the Network and in London, and on wider patient flows and commissioning.

  • For example, a local unit which is temporarily one bed down due to sickness or other absence on one shift, or a temporarily closed bed, may result in a patient being transferred to another part of London for a potentially long stay, at a cost which exceeds that of the single bed-day/shift that was saved locally.
  • In addition this is an avoidable clinical risk for that patient, and potentially a greatly increased travel burden for relatives.

Reporting capacity

For these reasons, the Network monitors capacity-related issues particularly at times of high pressure (e.g. winter).

  • Questionnaires and guidelines on maximising capacity are issued according to circumstances, and findings may be shared back with units, Trust critical care delivery groups, and commissioners.
  • Units and Trusts can help to maintain communications and Sector-wide planning by making early notification of planned or unplanned changes in bed numbers and activity.

CRITCON is designed as an easy to collect, easy to report, and easy to interpret, tool for ICU capacity under conditions of system stress (e.g. winter, pandemic, or major incident).

CRITCON – example dated 2013-14

  • CRITCON is declared by units and can be posted on to the Capacity Management System (CMS) website in use in London.

History

  • CRITCON was initially designed within NW London Critical Care Network in 2009 in response to the H1N1(2009) influenza pandemic and the potential threat of triage by resource (critical care rationing). It was discussed and adopted by the London H1N1 Pandemic Planning Group on behalf of NHS London, and subsequently by several SHAs in England during the 2009 pandemic.
  • CRITCON was adapted for Winter 2010 and currently remains in modified use in London, following further review by the NHS London Critical Care Steering Group.

Principles

  • The principle behind CRITCON is to allow each unit to declare itself in simple terms compared to its normal capacity (CRITCON 0-4, corresponding to ‘business as usual’, ‘normal winter’, ‘unprecedented’, ‘last resort’, and ‘triage’). This enables units under unusual stress to be instantly visible and to trigger mutual aid, for example through neighbouring units stopping elective activity or opening reserve beds.
  • Under low to medium stress conditions (e.g. a ‘bad winter’), CRITCON serves as a low-workload reporting tool that minimises reporting burden and is easy to interpret as it does not need detailed knowledge of each unit’s bed numbers.
  • In extreme scenarios, CRITCON is designed to ensure that no unit reaches triage conditions (CRITCON 4), and thus no patient should be denied critical care through rationing, until all possible mutual aid has been triggered, and every other unit in the region and the country is at CRITCON 3 i.e. maximum physical capacity including all expansion areas in use.