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Critical care patients are amongst the sickest in the hospital requiring specialist care and multi-organ support. Patients requiring critical care are relatively low in number but, when critical care is required, access needs to be timely and often rapid. By the very nature of the multidisciplinary care provided, critical care beds are amongst the most costly resource within the health service. Demand for critical care services is increasing due to a number of factors including significant changes in the size and age of the population, increasing prevalence of relevant comorbidities, changing perceptions as to what critical care can offer and new/emerging diseases or treatments.
Building on the work of the 2013 and 2017 Delivery Plan for the Critically Ill, the next phase of service improvement for people who are critically ill must address variation, build on consensus in priority areas, deliver the recommendations of the nationally directed critical care programme (as set out in the Task and Finish Group report - July 2019), maintain national leadership, local engagement and collaboration. The Guidelines for the Provision of Intensive Care Services (GPICS) provide a definitive source for the planning, delivery and quality of adult critical care services across the UK.
The introduction of quality statements was signalled in A Healthier Wales and has been described in the National Clinical Framework as the next level of national planning for specific clinical services ensuring there is a long-term and consistent approach to improving outcomes. Quality statements form part of the enhanced focus on quality and will be integral to the future planning and accountability arrangements for the NHS in Wales.
This quality statement was launched following the COVID-19 pandemic, which had a particularly significant impact on critical care services and the staff working within them. The quality statement includes the immediate, short-term focus on recovery and also consideration of the medium and longer-term potential for transformation during the new Parliamentary term.
Health boards and trusts are responsible for planning and delivery of critical care services in line with professional standards and the quality attributes set out below. Health boards and trusts will be directed, supported and enabled to deliver improved services for people who are critically ill by the NHS Executive function.
This will be discharged through its Wales Critical Care and Trauma Network Board. The clinical network will work collaboratively to set out a rolling, three-year implementation plan that identifies and prioritises service developments based on the quality attributes described below. Detailed service specifications will also be developed to support the planning and accountability arrangements for the NHS in Wales; these will be set out in annex A as they become available.
The National Clinical Framework places specific emphasis on the development of national clinical pathways and the Quality Safety Framework emphasises the importance of systemic local use of the quality assurance cycle. This quality statement focuses on development of critical care services including enhanced care to support improvement address unwarranted variations in care. There also needs to be a focus on cross-working with other groups to address areas such as public health, rehabilitation, care for those at end of life as well as collaboration with conditions specific groups such as cardiac, cancer and vascular.
Quality attributes of services for people who are critically ill in Wales
1. National approach to service improvement led by the NHS Executive through its network board for critical care.
2. Cross health board collaboration between critical care services to support equity of access, consistency in standards of care, address unwarranted variation and provide mutual aid when necessary.
3. Services for people who are critically ill will be measured and held accountable using metrics, clinical data (ICNARC), PROMs and peer review that reflect the quality of patient care and its outcomes.
4. Critical care workforce is supported and developed, to address staff retention, GPICS standards and ensure it is sustainable and grown to meet demand with a focus on areas such as extended roles and allied health professionals.
5. Equal access to appropriate clinical trials supported by the provision of appropriate infrastructure for all forms of health research.
6. An immediate system-level focus on transforming services to build capacity above pre-pandemic levels, such as the expansion of critical care units and development of post anaesthetic care units (PACU).
7. Services which cannot meet required standards will be reconfigured to ensure standards can be met consistently and sustainably.
8. A national approach (as set out in the nationally directed programme and GPICS standards) to the provision of critical care services including a national transfer service, long term ventilation, critical care outreach and follow-up/rehabilitation.
9. Nationally optimised evidence-based pathways for people who are critically ill embedded in local service delivery to improve survival, such as from major trauma or out of hospital cardiac arrest.
10. A national approach to informatics systems that enables greater integration of care and provides relevant, high quality, standardised data to drive service improvement.
11. Collaborative and equitable approach to person-centred care which is culturally embedded and supported by a common approach to referral, escalation of care and critical care follow-up/rehabilitation.
12.Timely access to appropriate critical care services in line with patient need including early recognition and intervention for patients whose condition is at risk of deteriorating to prevent conditions such as acute kidney injury (AKI) and sepsis where possible.
13. Facilitate timely discharge from critical care services.
14. Maintain ability to surge level 3 capacity in line with escalation arrangements (escalation plans much ensure suitable provision for staff redeployment, equipment and consumables).
Annex A - service specifications
The NHS Executive will develop service specifications for critical care to inform accountability discussions. These will be added as they become available.