Adult Critical Care

Increase critical care and enhanced care beds. This should be particularly focused on Level 2 and enhanced care beds, but also more Level 3 beds in some areas where required. a Trusts and Operational Delivery Networks (ODNs) should undertake a review of critical care need to reduce delayed admissions, overnight discharges, admissions with four or more organ failures and non-clinical transfers. This should include at least a 50:50 Level 2 to Level 3 bed split. b GIRFT will work with trusts to develop plans for enhanced care beds across medicine and surgery.

Consider and develop national postoperative pathways for patients requiring enhanced or critical care management to ensure consistency. a GIRFT will work with Faculty of Intensive Care Medicine (FICM), NHS England and NHS Improvement (NHSE/I) and ODNs to agree national standards for postoperative pathways into critical care. b GIRFT will support ODNs and trusts on implementing these locally.

Promote the development of enhanced care areas, ensuring appropriate governance and staffing arrangements for patients are in place. a GIRFT to support the FICM, Intensive Care Society (ICS), Royal College of Physicians (RCP), Royal College of Surgeons (RCS), UK Critical Care Nursing Alliance (UKCCNA) and Royal College of Anaesthetists (RCoA) to develop workforce plans and governance for the roll-out of comprehensive enhanced care areas.

Fund and develop adult critical care transfer services based on Operational Delivery Networks (ODN) or Sustainability and Transformation Partnerships (STP)/Integrated Care Systems (ICS) footprints to support equitable access and surge capacity. a GIRFT to support ODN's, Intensive Care Society/STPs and NHSE/I to develop these.

Implement full 24/7 outreach services in every hospital with a critical care unit. If using a Hospital at Night service as part of this provision, the team members should have sufficient critical care training. a GIRFT to support audit of all 24/7 outreach services across England to identify trusts for service implementation.

Put Advance Care Planning and shared decision-making protocols in place, in order to know patient and families' wishes and help to inform appropriate referrals to critical care. a All trusts should review, update and implement their protocols and referrals so they are following end of life guidance. b GIRFT will work with NHS England and NHS Improvement (NHSE/I) and individual trusts to ensure policies/guidance such as Advance Care Planning and shared decision-making are implemented.

Ensure there is a Clinical Lead for Organ Donation (CL-OD) that links with a Specialist Nurse for Organ Donation (SN-OD) for each trust with a critical care unit to enable national pathways to be followed and for donation to occur in a timely manner. a GIRFT to support NHS Blood and Transplant, Operational Delivery Networks (ODN) and individual trusts to audit national requirements for CL-ODS and SN-ODs to ensure appropriate coverage.

Ensure critical care discharges are discussed pre-emptively at hospital-wide daily bed management meetings and given the same level of priority as hospital admissions to ensure optimal patient flow and allow for new critical care admissions to be made in a timely manner. a GIRFT will support trusts to implement pathways that will facilitate optimal patient flow and timely discharges from and admission to critical care units.

Develop a patient multi-disciplinary rehabilitation pathway starting in critical care and following through to primary care after discharge. Obtain necessary funding to support this. a GIRFT to work with Faculty of Intensive Care Medicine (FICM), Intensive Care Society (ICS), NICE, GPICS2 Guidelines and NHS England and NHS Improvement (NHSE/I) (people team) to secure funding for a rehabilitation pathway including investment for Allied Health professionals (AHPs).

Develop pathways for post-critical care follow-up, and consider which approach best meets patient needs. a GIRFT to support trusts and Operational Deliver Networks (ODNs) to develop pathways and to ensure that they adhere to upcoming guidance from FICM.

Meet GPICS2 Guidelines standards for the critical care workforce (where stated) and where no numbers are currently recommended, trusts should ensure all patients able to access appropriate care. a GIRFT to support Faculty of Intensive Care Medicine (FICM) and Intensive Care society (ICS) on guidance that ensures the following: • chest and rehabilitative physiotherapy is available 7/7; • speech and language therapy is available 5/7; • a dietician is available 5/7; • occupational therapy is available 5/7; • psychology services are available 5/7. b GIRFT to support research to identify and quantify numbers and skills mix across the MDT where numbers are not currently recommended.

Develop national, evidence-based, costed recommendations for the employment of critical care pharmacists. a GIRFT to support NHS England and NHS Improvement (NHSE/I) hospital pharmacy team and people team to invest in critical care pharmacists.

Develop a sustainable mechanism for training more Advanced Care Critical Care Practitioners (ACCPs) and possibly develop networks, to make it easier for smaller hospitals to employ them. a GIRFT to support other stakeholders in creating a new funding model for training for ACCPs. b GIRFT to support FICM to develop an ACCP apprencticeship.

Use learning from COVID-19 and subsequent research as a basis to develop a robust evidenced-based nursing workforce model for the future. a Support research by National Institute for Health Research (NIHR) into staffing requirement and models in light of COVID-19 experience.

Ensure research and quality improvement are an integral part of the work of each critical care unit to build on the momentum of COVID-19, exemplified by the RECOVERY, RECOVERY-RS and REMAP-CAP research studies. This would include contributing to the delivery of Best Research for Best Health: The Next Chapter through NIHR portfolio studies, as well as national benchmarking data sets, such as ICCQUIP, and QI programmes. a GIRFT will support trust critical care units alongside the National Institute for Health Research (NIHR) to establish: • a quality improvement lead to oversee data national collection and to support unit continuous QI; • a research lead, to establish a link with NIHR and participate in multi-centre trials; • any necessary support from trust research infrastructure.

Collect Patient Related Outcome Measures (PROMs) following critical care. a Scope other data sources for linkage and look to automate data collection. b Research to identify whether these data sources perform sufficiently well.

Identify gaps in research and develop a national research strategy. This would include understanding more about outreach services. a FICM, ICS, Critical Care Leadership Forum (CCLF), ICNARC and NIHR to work with patient groups to produce a national research strategy for critical care.

Enable improved procurement of devices and consumables through cost and pricing transparency, aggregation and consolidation, and by sharing best practice. a Use sources of procurement data, such as SCS and relevant clinical data, to identify optimum value for money procurement choices, considering both outcomes and cost/price. b Identify opportunities for improved value for money, including the development of benchmarks and specifications. Locate sources of best practice and procurement excellence, identifying factors that lead to the most favourable procurement outcomes. c Use Category Towers to benchmark and evaluate products and seek to rationalise and aggregate demand with other trusts to secure lower prices and supply chain costs.

Reduce litigation costs by application of the GIRFT Programme's five-point plan. a Clinicians and trust management to assess their benchmarked position compared to the national average when reviewing the estimated litigation cost per activity. Trusts have received this information in the GIRFT 'Litigation data pack'. b Clinicians and trust management to discuss with the legal department or claims handler the claims submitted to NHS Resolution included in the data set to confirm correct coding to that department. Inform NHS Resolution of any claims which are not coded correctly to the appropriate specialty via CNST.Helpline@resolution.nhs.uk. c Once claims have been verified clinicians and trust management to further review claims in detail including expert witness statements, panel firm reports and counsel advice as well as medical records to determine where patient care or documentation could be improved. If the legal department or claims handler needs additional assistance with this, each trusts panel firm should be able to provide support. d Claims should be triangulated with learning themes from complaints, inquests and serious untoward incidents (SUI)/serious incidents (SI)/Patient Safety Incidents (PSI) and where a claim has not already been reviewed as SUI/SI we would recommend that this is carried out to ensure no opportunity for learning is missed. The findings from this learning should be shared with all front-line clinical staff in a structured format at departmental/directorate meetings (including Multidisciplinary Team meetings, Morbidity and Mortality meetings where appropriate). e Where trusts are outside the top quartile of trusts for litigation costs per activity GIRFT we will be asking national clinical leads and regional hubs to follow up and support trusts in the steps taken to learn from claims. They will also be able to share with trusts examples of good practice where it would be of benefit.