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Critical Care Services on the Isle of Man

Executive Summary

Cheshire & Mersey Critical Care Network (CMCCN) were invited to visit the Isle ofMan to review critical care services at Noble's Hospital, Douglas. The hospitalfunctions as a district general with a range of general services provided on the island.Specialist services are generally accessed on the mainland predominantly by airtransfer. Although not an integral part of the UK NHS as a Crown Dependency theIsle of Man aspires to the same standards of care delivery and its professional staffare registered with the relevant UKbodies (e.g. GMC, NMC).The island health service lacks'c~mprehensive and reg-ular'benchmarking reviews byexternal bodies. Noble's management are conscious of this and keen to exploreavailable avenues to both review existing services and to gain support with serviceimprovement.It is_evident from.our initial visit thatthere are number-of areas where .currentstandards do not meet those expected of-district gene(al hospitals in' the NHSregarding delivery of critical care and allied acute care services at Noble's. Primarilythese concern the accessibility of consultant support for the ICU, the provision of acritical care outreach service, a lack of patient data to benchmark activity andoutcomes and the process and delivery of air transfer systems for the acutely/critically ill.The team visiting Noble's (Sarah Clarke, CMCCN Director & Lead Nurse, Dr GaryMasterson, CMCCN Medical Lead & ICS council member & Dr Jane Harper, ICShonorary secretary & previous network medical lead) would like to thank all thosewhom we met during our visit for their courtesy and hospitality. Clearly there are anumber of motivated individuals keen to progress standards at Noble's Hospital andthe hospital has a bed rock of good practice. A formal relationship with CMCCN (andother similar organisations) would give direction for and support positive change andgive the island health service some assurance that standards delivered to theirpatients are equitable with the mainland.

Introduction

The Isle of Man has a population circa 80,000. It is a UK Crown Dependency andstrives to deliver a full range of quality services to its population. It is dependent onexternal revenue and has in recent years been hit by a significant reduction due tochanges in UK taxation. This has led to revenue pressures with particular regard tonumbers employed by the island's government, including the health service.Although not an integral part of the UK NHSas a Crown Dependency the Isle of Manaspires to the same standards of health care delivery and its professional staff areregistered with the relevant UK bodies (GMC, NMC).

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The island health service lacks the comprehensive and regular benchmarking reviewsby external bodies available to the NHS. Noble's management and professionalleaders are conscious of this and keen to explore available avenues to both reviewexisting services and to gain support with service improvement. Following initialcontact via one of the hospital's consultants the CMCCN Director had a telephoneconversation with Noble's hospital manager (Barbara Scott) about the functions ofCMCCN and what we could offer to benchmark and support the improvement ofcare for the acutely or critically ill patient. Barbara expressed her support for theproposed visit of CMCCN to the island and it was agreed that following the visitCMCCNwould provide a report and the hospital would expect to enter into a formalrelationship with CMCCN. CMCCN's Director explained this would incur some costand a service level agreement would need to be established.

Our visit covered a lot of topics in a short time scale (see appendix 1). Although ourprimary concern is with critical care and associated acute care delivery (for examplethe provision of critical care outreach) it is not possible, particularly in such alocation to take these in isolation. We have therefore included in ourrecommendations some that are pertinent to healthcare provision and had evidentconsequences described during our visit.

Inherent to an island community is the need to find a health care model that meetsthe needs of the population, is sustainable, meets public expectations and makes thebest use of what the island can do well whilst acknowledging the limitations thatliving on a relatively small island without a land bridge bring. Hence there is a needto keep the health service the island delivers under regular review to ensure thatcare delivery on the island meets requisite (UK NHS) standards and that appropriateprocesses are in place to provide services the island cannot deliver. This will requirefor example safe and efficient transfer to mainland services, particularly for time-critical transfers, reciprocal arrangements regarding repatriations and partnershipwith mainland health care providers. It was evident from our discussions that manyof these arrangements are in place and working well for various patient groupsalthough improvements are needed in some areas. Similar health care models existsuccessfully around the globe.

Formal! membership of IJ6dres suGll as clinlcal networks provi e means ofbe'~chmarking against OKand international st;;dards of care, governance a~surancejr;d airection and support for improvements in care delivery and outcomes.

Summary of recommendationsThis is the report of a visit to Noble's hospital to review current critical care services(see appendix 1). Noble's hospital is a recent new build and facilities within the ICUare of a good standard. The ICU at Noble's has dedicated nursing staff and there is awill to provide high quality service. How~v.er,_t.!1~!e~a~.area~; w5eJetl:)'~u~~gsbehind that in the UK and there are somemajor issues which ne~(rattention. Thefollowing are a summary of recommendations contained within this report brokendown into those that should be achieved in the short term «6 months), mediumterm (7 -18 months) and the long term (18 months - 3 years).

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Short term (expected 'Completion within 6 mont~s of rec~ipt of report)1. Introduction of a critical care outreach service, moving to full (24/7)

implementation covering accident and emergency department and all acuteinpatient beds within 18 months. We suggest this is led by a senior criticalcare nurse and accountable through the critical care lead consultant to themedical director. Baseline data should be collected prior to implementation.There should be a dedicated Outreach team provided by nursing staffexperienced in assessment and treatment of critically ill patients. The nursingstaff are willing to support this initially from among their existing numbers byamalgamating resuscitation, ICU and acute pain staff to provide the servicebetween 0730 and 2200 hrs. 7/7.

2. Nursing staff on the wards should be familiar with assessing patientsaccording to a recognised Early Warning Scoring system of physiological signsand have a clear escalation pathway that meets CMCCN/UK NHSstandards.

3. The hospital should consider ward-based consultants to facilitate theorganisation of ward rounds.

4. Introduction of formal data collection. The unit should subscribe to theICNARC (Intensive Care National Audit & Research Centre) case mixprogramme to collect data and benchmark its performance against othersimilar units in the UK patient database. This is essential to monitor patientactivity and outcomes, provide a baseline against which to measure progressand provide governance assurance of standards of care delivery.Consideration should be given to participation in the NW England clinicalincident reporting for critical care.

5. Improvement in medical leadership within critical care. There should be adearly designated lead consultant for critical care who should in turn feedinto the formal process for identifying and implementing improvementsacross the acutely ill patient pathway and audit of critically ill patienttransfers.

6. Care delivery should be benchmarked against the CMCCN ServiceSpecification for Adult Critical Care Services to provide a baseline to measurefuture progress against.

7. Impl~mentation of C_MCCNand UK best practice .standards inclirding carebundles. sepsis'patflway and consensus guidance.

8. Clinical pathways should be implemented to audit quality of care for patients.9. Action plan developed with formal monthly review against objectives by the

critical care lead consultant and reporting directly to the hospital governancecommittee. Clear time scales must be included and progress should beshared with hospital staff after each review.

10. Critical incidents and the results of root ca~ analyses sholJl_abe owned bynospital management and results should be commanicated throughout thrI"orgariis_a1!oQ.

11. Establishment of consistent robust process to manage equipment purchaseto ensure purchases are prioritised to meet clinical need.

12. Contingency plans should be implemented to enable increased capacity tomeet either unpredictable (major InCident) or predictable increases indemand for acute and critical carli- Increase<:!capacity snoula cover both

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staffing and other recS0urf,es_;include rnulti-professjonal workforce and the .air--.._ _- ,_ -._... - -- -

transfer service.13. There should be a medical lead for transfers of level 2 and 3 patients and a

rota for stafrwho can undertake such transfers. There should be appropriatetraining available and written guidelines to aid decision-making in whichpatients need transfer and which patients require medical and nursing staffto accompany them. Severely injured patients should be stabilised on the-island and then transfert~ olrtl6'prevehtJdelay in cdmplex managenrent.~ -

14. Formal membership of CMCCN with instigation of annual benchmarkingagainst established UK and international standards of care delivery,commencing autumn 2013. Progress against the recommendations in thisreport would also be assessed. CMCCNcan provide best practice standards,guidance and examples of service improvement on request(www.cmccn.nhs.uk )

Medium term (expected completion within 18 months of receipt of report)15. Consultants providing cover for ICU should have dedicated sessions without

cross cover for other services and with cover for their planned absence. Theamount of dedicated sessions should be increased at times of known highdemand.:llfhe ICUshould have a consultant on call rota. All admissions to ICUshould be discussed with this named consultant before admission. Admittedpatients should be seen by a consultant within 12 hours

16. Data (e.g. ICNARC) should be reviewed formally at clinical governancemeetings and variations to expected outcomes formally investigated throughclinical governance routes with remedial action taken where necessary.

17. Data submission for critical care activity and outcomes including outreach,should comply with CMCCN/UK standards.

18. Critical care outreach should cover 24/7 with regular audit and activityreports. Evidence should be provided to demonstrate quality improvementand that remedial action has been taken wherever necessary across theacutely ill patient pathway. Outreach reports and activity should be anintegral part of the hospital's governance processes.

19. Transfer arrangements, both in terms of decision-making and arrangingappropriate staff to undertake them, should meet national (UK) standards.Staff accompanying acutely/critically ill patients must be competent to carefor the critically ill in transit, available through a formal on-call arrangementand at times of known high demand robust arrangements must be in place toincrease capacity. All transfers should be formally audited and reviewed,both internally and externally (for example through the NW critical carenetworks).

Long term20. A formal political process should take place on a regular basis (for example

every 3 - 5 years) about which services should be provided on the island andwhich should be sourced elsewhere. Those provided on the island must besustainable and hence long-term succession planning should take place

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alongside this process. It is not acceptable for gaps in service delivery to beleft unresolved for long periods of time. The hospital needs to have a realisticdiscussion with politicians and patients detailing which services it can providewell and which services patients should receive on the mainland.

21. Critical care nurse training on the island should be benchmarked against UKcompetency standards on a regular basis. Where gaps are identifiedpartnership arrangements should be established with UK NHS organisationsto ensure that staff are competent and have opportunities to maintain andenhance their skills.

22. Medical staff who are the sole representatives of their specialty on the islandshould have regular updates of their skills and competence, with clearobjectives, in partnership with UK NHSorganisations.

23. All consultants should be subject to robust peer review.

Cheshire & Mersey Critical Care Network is part of the NHS. CMCCNacts as aresource, co-ordinator, and facilitator for all its stakeholders to achieve acollaborative approach to safe, equitable and effective CriticalCareServices.

Sarah ClarkeDirector & lead NurseCheshire & Mersey Adult Critical Care & Major Trauma Operational DeliveryNetworks & Interim Director, Cheshire & Mersey Neonatal NetworkSarah.clarke@cmccn.nhs.uk

Dr Gary MastersonConsultant Intensivist, CMCCNMedical lead & ICScommittee memberGary.masterson@rlbuht.nhs.uk

Dr Jane HarperConsultant Intensivist, ICSHonorary Secretary & previous CMCCNmedical lead

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Appendix 1.

Report of the visit by Cheshire,& Mersey Cr!tLe-_!1~a!e ~e!wg~ to Nobl~":losplt!l!~Jlsle ~f~Ma.!'O~15t~~~lll_!)~t..,.

IntroductionIn July of 2012, Dr James Uoyd contacted the Intensive Care Society asking for adviceabout intensive care services provided on the Isle of Man and about networkingopportunities for the hospital. Dr Jane Harper, Honorary Secretary of the Society &previous network medical lead, Dr Gary Masterson, CMCCN Medical Lead & ICScouncil member & Sarah Clarke, CMCCNDirector & Lead Nurse), visited the hospitalon the is" April 2013. This is a summary of the findings from conversations withdoctors and nurses at the hospital. The observations and opinions are those of theindividuals concerned.

We were impressed with how open and honest the individuals we spoke to were andwith the real desire to improve how care is delivered to patients. However, there areseveral areas where practice lags behind that in the United Kingdom as a whole andwe will present some of these aspects in this report. This is not intended to bedismissive of the problems unique to the Isle of Man in providing healthcare to itspopulation but is intended as a constructive contribution to a debate about whatservices can be provided to a high standard with reasonable cost in thisenvironment. At this time, post-Francis report in England, we feel that it is importantfor all hospitals to examine the way they care for, especially, their sickest patients.

Intensive Care - a core serviceIntensive care units care for the sickest patients in the hospital, providing lifesupport in the form of mechanical ventilation, support for other organ systemsfailure, such as renal dialysis. Patients requiring multiple organ support aredesignated as level three patients, patients requiring single organ support are leveltwo patients. Level three patients are nursed with one nurse to one patient; leveltwo patients, one nurse to two patients.

lin_the UK, intensive eare is seen as a core ser~ce fora cute hospitals. Any hospitalaccepting emergency patients has to have access to intensive care. In the late 1990s,there was a crisis in intensive care provision, which led to an investigation of criticalcare services and publication of Comprehensive Critical Care.' This has led to achange in the way critical care services are provided in the UK. Most intensive careunits now work collaboratively across their regions, through Critical Care Networks.These networks ensure sharing of best practice, setting of standards and serviceimprovement. Units are benchmarked through data collection and comparison; mostunits belong to the Intensive Care National Audit and Research Centre case mixprogramme, which collects data and produces reports on units' activity. In addition,

in recognition that there were many patients on wards at risk of deterioration whowere not receiving intensive care in a timely way, most UK units now haveintroduced early warning scores and Outreach teams to identify and treat wardpatients early. Fina y, units operate as 'dosed' units, run by a designated medicallead and with consultants who are responsible for the care of critical ill patients.

ContextThe Isle of Man has a population of approximately 80,000, which swells byapproximately 50% during the n and Grand Prix races. Approximately 50% of thepermanent population were born on the island. People generally expect the samestandard of health care as in the UK.

Healthcare services are provided through the Isle of Man government. There is nocommissioning as in the United Kingdom; instead, the government provides a budgetwithin which the hospital provides services. The financial position is difficult,especially since the UK government reallocated VAT payments reimbursed to theisland, resulting in a decrease in income of approximately 30%. In order to prevent apension time bomb, the government has stipulated that the number of 'heads' -individuals - employed by the hospital must remain constant. This means that anyservice development must be provided without an increase in the number of 'heads'providing that service, or by diverting 'heads' from other departments. In addition,there is no funding for the purchase of new equipment except through applicationfor charity monies. This can lead to anomalies in developing services, dependant onthe interests of the consultant staff. Thus the hospital has two machines to performCPEX testing, which are not currently used, but has no equipment to institutetherapeutic hypothermia post-cardiac arrest, which is the current state of the arttreatment.

The Health Care Commission from the UK inspected the hospital in 2006 and equallyfound committed staff but equally, a lack of clearly stated priorities and keyindicators. There was a noticeable influence of local politicians in the running of thehospital, borne out by the fact that elected representatives complained about theirconstituents' care directly to the ward managers in the hospital. This had the effectof diverting time from patient care to respond to complaints, skewing the prioritiesof the organisation away from their overall strategic goals. It was not clear that therecommendation regarding risk assessment of guideline adherence had beenimplemented. The Healthcare Commission found that there was a lack of designatedleadership for clinical services and information about clinical outcomes; certainly thelatter does not appear to have been addressed.

Air AmbulanceTransfers of patients needing more complex care off the island are performed by theair ambulance service. AlttlQugFt.tbi~ provide.s 'a~orld class' servi~ for level O,arrd.......level 1patients, transfer of eve.12 and lev patientS-requiring-organ suppC?n-"yduring transfer is less than optimal. There were 17 such transfers in 2010, 21 in

~Ol1, 16 In 2012 and 4 to date in 2013. The ICShave published standards for suchtransfers; these patients need both medical and nursing accompanying personnel

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8---and appropriate levels of...monitoringand interve_,ution.These transfers are currently'arranged on an ad hoc basis, with staff ringing cC!,lIeaguesto find vOlunteers -to ~undertake transfers. There is no designated medical lead for such transfers and it is"not clear that the dedsion-making behind who is transferred is conslstent.;:

The HospitalNoble's Hospital has 314 beds and approximately 50 consultants. Most medicalspecialties are represented (e.g. cardiology, respiratory, renal, etc.) and surgicalspecialties apart from cardiac and neurosurgery are provided. Elective colorectalservices have been temporarily suspended because of a series of complications butwill resume after a structured retraining in enhanced recovery. The hospital employsapproximately 1,000 staff. There are approximately 30,000 A+E attendances peryear.

The hospital belongs to the Cheshire and Mersey Cancer network, Burns networkand North West paediatric network, but not to the Critical Care Network nor theMajor Trauma network. The hospital meets the Cancer Network two-week waittarget, but it appears not to comply with elements of the care pathway. The hospitalis not legally bound to follow guidelines generated in the UK (e.g. NICEguidance) butits staff members are registered with the General Medical or Nursing Councils. Theprofessional Royal Colleges do not visit the island to assesshealth services, nor doesthe CQe. The hospital does not collect HESdata nor HSMR data; it is not part of therenal registry although there is a business case in progress to join the registry. Thehospital does not submit trauma data to TARN.

Medical StaffingMedical staff are recruited from the UK and overseas. There are no specialisttrainees, although there are Foundation doctors-in-training from the MerseyDeanery. Middle grade cover is provided by specialty doctors (i.e. non-consultantgrade doctors); we did not meet any of these doctors during our visit. Recruitmentcan be difficult; currently of five middle-grade doctors in anaesthesia, three arelocurns.

The Intensive care UnitThere are six intensive care beds and two isolation cubicles, one with negative-pressure ventilation capabllitv. There is one room capable of renal dialysis and twohaemofiltration machines in addition. The unit is HBN 57 compliant, with adequatespace and stock. Monitoring is of a high standard and all mechanically ventilatedpatients have capnography monitored.

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..The unit is staffed for two level three beds and four level two beds (22 whole timeequivalents (WTEs), 26 nurses) and the beds used flexibly i.e. when patients requirelevel three care, the beds will be used as level 3 beds rather than the patienttransferred. !h_~rt[ L~'conti~g~ncy for increasing the numb_ersof beds irr-tirnes of -Grlsis(e.g. during the IT races) by mechanically ventilating patients in the recoveryroornfhowever the recovery nurses are not leu trainetr. The.coronary care unit.canact as a medical high dependency unit for level-two patients,

The unit treats 300-400 level 2 and level 3 patients per year; 40-60 of these areelective, usually post-operative major surgery patients. Approximately one third ofthese patients are level three patients. There are 10-20 patients receiving acutehaemodialysis per year, although this number may increase as there is a newconsultant nephrologist based in the hospital. Ten to 20 percutaneoustracheostomies are performed by medical staff per year. Occupancy levels areapproximately 65%, which has led to loss of nursing staff to wards, based on an idealoccupancy of 85%. However, during the IT races, staff have cared for up to 8mechanically ventilated patients with sub-optimal staffing on those occasions.

The perception of the medical and nursing staff is that emergency patients arefrequently referred too late to gain maximum benefi;t: There are plans to introducean early warning score (EWS) system to the wards with an appropriate escalationpolicy, but there-is no Outreach service-corrently in place.

The consultant responsibility for ·the unit rests with the anaesthetic departmentw~ose co.nsultants have.diff~ring fQtere.st in ..critlca!!y ill.,patients. The aosence ofmedIcal input is problematic in providing good patient care.

Data collection is sparse. There is no electronic data collection currently and noHSMRs available. There is an leu register which the numbers above have beengenerated from.

Untoward incidents are-reported through the- h~pital PRISM systeitl~i;lCidents--reported by leu staff are often re-referred to leu for investigatjofrThe governancearrangements are unclear.

There is a Safety Officer in the hospital. In recognition of some of the weakness ingovernance arrangements and in response to several critical incidents, there arecurrently five working parties in the hospital examining for example, incidentreporting, referrals and escalation, clinical governance etc. These group seem.tooverlap in some instances, and do not appear to have a deadline ora process to patrecomrnendatiobs in place.

There are unit guidelines for use of medical and nursing staff; these were notreviewed during our visit. Patients are screened for MRSA, ESBLand Acinetobacteron admission and repatriated patients are isolated until the results of screening areknown.

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There is a unique Noble's intensive care course for nurses which 58% of ICU nurseshave completed, and well supported courses in resuscitation. One third of staff haveattended an ALERTcourse (acute ...) and courses such as the BEACHcourse for HCSsand the IMPACT course are being developed. However, the practice educatorls notsupernumerary while on duty as they would be-in most cases in the UK, diluting theireducational impact. Nursing staff expressed some frustration with the degree ofmedical cover, the lack of Outreach, lack of budget and support'for trainingt-ourses,inappropriate admissions a'nd 'aiffiCiJlty ge_tting'lJatient5 review~d by medical st~ff.Two-way communication needs improvement.

Service SpecificationCheshire and Mersey Critical Care Network has developed a service specification forcritical care (see appendix) based on best practice and quality indicators available inthe UK. The intensive care unit fulfils the requirement for HDU/ ICU co-location andability to accept referrals, but does not comply with requirements for medical coveror data collection. There are small numbers of level three patients to maintaincompetencies among staff. There is no developed sepsis pathway. Contingency plansfor response to increased demand are in place.

ConclusionProviding health care services on the Isle of Man presents a real challenge at alllevels. The staff at the Hospltal are dedicated and want to-move forward to keep upwith the changing environment. While it is unlikely that the island would attract fulltime intensivists, there are c!iar:'lgesthat .tdll:~1)d·should be madg to impro e-tnestandard-ofcare-fortne population and the satiSfaction ofthestatf.