#2. Enhanced Care Guidelines | EBPOM 2020 London

TopMedTalk.

Anna Batchelor: Hello. And thank you for asking me to speak at a very unusual EBPOM Conference. Thank you to Ramadi and Mike for setting the scene for what I'm about to talk about. So how do we get a quart into a pint pot? So for the last three years, I've been the technical lead for critical care for the GIRFT program. And it's been fascinating. I've learned an awful lot of things. Not everywhere looks like the place that I work in. Not everywhere does the job in the same way I do. And there absolutely is not equity of access to critical care. There's a huge variety of things that change and influence how we work in our critical care unit. The culture, the resource that we have to work with, the history of the- the space we have, the people who've worked there, and the geography. The geography either of the space in the hospital, or the geography of where we are in England. And our connections to other places.

And one of the most important things I've learned, and that you will be aware of, is that there are undoubtedly units that are haves, and those that are have-nots. Those that have most of the resources you need to deliver an adequate critical care service for that hospital, and those that are struggling, that don't have enough beds, enough doctors, enough of the nurses, and certainly not enough allied health professionals.

So I did a lot of deep-dive visits, and I learned a lot of things. And then something happened. A virus rather deflected the project, so we are no longer able to do our deep dives, but I think I've probably seen enough to be pretty sure what it is that we need to be changing in our critical care services, and how they can work well with perioperative services.

Critical care has a moment in time, a moment where we can make some big changes, a moment of opportunity. We've had one of these before. We had this around about the turn of the century, withwhen we saw the publication of comprehensive critical care. Towards the end of the 1990s, a lot of patients were being transferred between critical care units, because there weren't enough beds. There was lots of negative publicity. And we had patients dying in the back of ambulances, because they couldn't find a bed somewhere. So what happened in the early 2000 was that we got high-dependency units, outreach services, trust-wide critical care delivery groups to embed critical care within the hospital service. We got networks which have now developed into operational delivery networks, but most importantly of all, we got a 140 million quid, and that made a huge difference to how we can deliver our service.

Does critical care work? So both Ramadi and Mike have suggested to you that admitting patients after surgery to critical care does in fact improve outcomes. And indeed, we can demonstrate that critical care has produced better outcomes over the last 10 years. So [inaudible 00:03:53] relative- frequently has to recalibrate its SMR calculation. Otherwise, we would all have SMRs significantly less than one. So this is data for the last 10 years, which shows that our outcomes are improving. Something interesting to look at is what bed days we've been using for the last 10 years. So the blue lines are the level-three bed days. And you can see that there's been very little increase over the last 10 years in those level-three days. And that despite the population of England increasing by 3.3 million people. Greater expectations from clinicians and patients. The pale blue line is level-two bed days.

So we've seen a big increase in those level-two bed days over the last 10 years. Does that tell us anything about level-three bed days? Now, I can't prove this, but I would like to think that by embedding critical care within the service, by having earlier recognition through the use of new scoring, and early intervention by bringing patients in to a level-two bed before they become, you know, particularly ill with multi-organ failure, that we are able to reduce the number of level-three patients that we have in our critical care units. And that's a benefit to our patients, because that means they're cheaper, and it means they're more likely to have a better recovery afterwards. So who is in those level-two beds? Well, overall, if we look at the patients who are admitted to critical care, more than half of them are patients with acute medical conditions.

If we go back 10 years, that was about two thirds of admissions to critical care were from a medical background. But the big increase, uh, and all of these percentages are average across England, There were very large variations between units, is in elective surgical admissions. But we can't get a quart into a pint pot, and SNAP-II showed us that the only patient level predictor for cancellation was requirement for a critical care bed. So the patients, the surgeons, the anesthetists get them worked up- selves worked up for a big procedure and then we tell them, "No. Sorry. It can't happen." Quite ridiculously, if we look at the advice in GPICS-II, we expect this. We think that it's normal. We look at ways of making this service work, accepting that we are going to cancel surgery. Many of you will have watched the absolutely amazing series of hospital programs, and I vividly remember one, where a patient was expecting a oesophagectomy, and he was brought into the pre-operative area.

I was told, on television, that there was a patient with an emergency aneurysm coming in from another hospital. If that patient didn't make it, then this oesophagectomy patient could have the bed. What a dreadful conversation to have. What a dreadful way to be thinking that we are running an adequate service.

So how do we make this better? Well, we need more beds. Do we need those beds in critical care, or do we need to be thinking of something else? So what do many of our patients need, postoperatively? Now, some of them will still require critical care. That is absolutely certain. But for many of them having major procedures, the thing they require is more nursing. That is absolutely the magic of the job that we do. We also need the availability of someone who can intervene, or prescribe, if things aren't going as well as they might do. They need the rapid availability of a high-level decision maker. Do they need machines? I don't know. They need some, but they certainly don't need to be tied to them 24 hours a day. This needs to be part of an enhanced recovery program, so patients need to be on their journey towards recovery.

So when we developed high-dependency units back at the beginning of this century, it was to address a gap. A gap between the world where patients are almost able to take- mostly able to take themselves to the loo, all of those things. And the intensive care unit where we have the breathing machine, and all the other machines. We put high-dependency units in the middle. But we still have a gap. A huge gap. High-dependency units have two patients to one nurse. When we go to our wards, there is something like 6 to 10 patients to one nurse. And as I've already said, the magic of critical care is the nursing. We still have a gap. What could we put in that gap? Enhanced care.

The Faculty of Intensive Care Medicine produced a document on this just earlier this year. So what is enhanced care? Well, it's an area that does have more nursing, that can observe patients more closely, but it's also a better environment, a more appropriate environment. It's calmer, it's welcoming. You can have your relatives to visit. Single-sex space, a place where you can start your recovery. Not a place where you can be stressed by 24-hour a day noises, and all of the scary things that happen in a critical care unit.

So what do we need to do, to make these enhanced recovery areas work? Well, we need to sort out appropriate governance. How are they going to be organized? Who's going to be the people who look after the patients? Where is it going to be? What are the operational systems? How do we look after the quality? What data are we going to collect? What quality improvement programs are we going to have? Who is responsible for that? How do we benchmark the activity between different units? As I said earlier, there is huge variability between what happens in different hospitals about how patients are looked after in different hospitals, and the spaces they go to after operations, or when they're acutely-ill medical patients. We need some standardization. We need to know that what patients can expect in one hospital is the same as they can expect somewhere else.

So what might this service model look like? Well, we're going to need to decide where these beds are going to go, where the patients have access to toilets, to showers. All of the things that make up a standard ward, but also where they're able to operate- we're able to provide a higher level of care. We need risk management processes, and one of the most important aspects for me of risk management is these areas need to be set up properly. It's going to be hugely tempting for the cash-strapped NHS, we've already spent a huge amount of money on the coronavirus pandemic this year, to stick up a sign over the door that says enhanced care area, and then not pay attention to how the place is adequately staffed and supported, and the patient's care is delivered.

It might look like you solved the problem, but you just create a different set of problems downstream. Who's going to staff it? We certainly need more nurses, and there is a bit of a problem. We do know that we have a shortage of 40,000 nurses in the NHS before we started this, but we've had a lot of nurses who've come in to help us in critical care over the last few months, and they've developed a lot of skills and knowledge, and it would be really useful if we could retain some of that and use that in enhanced care areas. Which doctors are going to look after these patients? Is it going to be surgeons? Is it going to be anesthetists? Who I would suggest are really well-placed to be part of this perioperative pathway. Or is it going to be critical care physicians?

I'm not sure it matters, but the important thing is that everybody knows he's going to be doing it. It's clear who people call when they need to see somebody. One of the things that was very clear in my deep-dive visits in critical care, is that there was huge variability in the availability of allied health professionals. So physiotherapists in many places are only available five days a week, but patients are expected to recover seven days a week. We don't have availability of occupational therapy, psychology, speech and language therapy, dietetics, pharmacy in anywhere like as many places as we should have.

And that really does need to be addressed.

We need to work out how the patient pathway is going to work. How does the patient get in? Do we have a booking system? Is this all arranged from the pre-assessment clinic, so it is known how many patients are expecting to get into the enhanced care area each day? So we can make sure that we don't create another place for the patient's operation to be canceled, because there's no room at the end. Who's going to be delivering the care while they're in the unit? And what are the standard protocols we've got for keeping the blood pressure up, for supplying oxygen, of those things? What happens if a patient's deteriorating? What does the escalation pathway look like? How do the patients get upgraded to high-dependency? And then particularly, how do the patients get out?

One of the huge problems that we see in critical care is being able to discharge patients to the road. More than 60% of patients who are declared fit to leave are still there at four hours, and almost a quarter are still there the next day. These enhanced care areas will not work at all effectively if we don't have adequate discharge pathways, and appropriate patient flow. So what space are we going to use for these enhanced care areas? It could be a bay on a specialty ward, but we do need to bear in mind that a small area with two beds is really difficult to staff, because two beds, one nurse, if you've got the same ratio as high-dependency, you may as well put them in a high-dependency unit.

A full bedded area. One nurse. That's fine. And so, if she wants to go on a break or to lunch, all of these things need to be worked through. One possibility, which is certainly worth considering, is having a

post-op enhanced care ward so that patients of any specialty can go there, and it has all of the systems in place to look after it. It makes it easier to nurse. You can have flexible nursing, or if not a relatively small hospital, maybe it just needs to be an extra part of critical care, and as well as having an area of one to one nursing, a one to two nursing, you also have an area of one to four nursing. The optimal way of doing things is going to be something that works for your patients, your service, and your hospital. It needs to be worked out as part of a team.

So this is a huge opportunity for us. It's an opportunity to avoid canceled surgery. It's a huge waste of time. It's distressing for the patient. It certainly makes surgeons crossed as they march up and down the surgery corridor wondering whether they can start their operation. It's a waste of time and money. We could do much better. We can get the right patient in the right place, and we can make enhanced care part of the perioperative care pathway for our high-risk surgical patients.

Though we have another opportunity. The coronavirus has not gone away. We'll almost certainly be seeing second, third, more waves. We will almost certainly be seeing a need for critical care spaces where we can, as the waves hit, manage extra coronavirus patients. An opportunity from having an enhanced care post-op ward is when those surges hit, we have a space that's equipped with oxygen monitoring, that is staffed with people who have enhanced care skills, able to manage oxygen devices, invasive blood pressure monitoring, that know about monitoring unwell patients.

So it's an opportunity to- to balance our service in what is going to be an uncertain future. But most of all, this is going to be an opportunity to deliver the best care we can for post-operative surgical patients in England. Thank you.

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