adult intensive care capacity planning

ADULT INTENSIVE CARE CAPACITY PLANNING and DEVELOPMENT

in IRELAND

Intensive Care Society of IrelandOctober 2006

22 Merrion Square North, Dublin 2.Tel: 6614412 e-mail: [email protected]

mailto:[email protected]

Contents

IntroductionIntensive Care Society of IrelandDesignated acute hospital bed classification in Ireland Levels of Intensive Care in IrelandERHA, Hanly and HSE/Teamwork ReportsAdult Intensive Care in Ireland post-Hanly, post-HSE/TeamworkHSE North East Hospital Directive 8th September 2006Ballinasloe (Portiuncula) and Roscommon Hospitals HSE statement 13th September 2006Nenagh Hospital Critically ill patients may not access proper timely intensive care in Ireland (ICSI 2001)Critically ill patients not accessing intensive care sustain increased mortalityInequitable intensive care access. Intensive care 'rationing'.Forced or Premature Discharge from Intensive CareResuscitation, stabilisation and transfer of the critically ill patient (Level I intensive care with planned transfer)Futile intensive care. End-of-life care.Population growth and projected intensive care requirements. Current healthcare expenditure.National Hospitals' Office Planning and Development Directorate: National Critical Care Planning and Development AgencyHSE national intensive care manpower requirementsMedical Staffing Patterns- Current Best EvidenceMedical Manpower and Training in Intensive Care Medicine in IrelandNursing Staffing Requirements: Irish Association of Critical Care Nurses (IACCN): IACCN Position Statement on Nurse-Patient Ratios in Critical CareTransport of the critically ill patient: General PrinciplesMobile Intensive Care Ambulance Service (MICAS) Recommendations(Repeat) National Acute Hospital Bed Capacity Review- National Intensive Care Capacity RequirementsNational Influenza Pandemic Project- intensive care implicationsReferencesAuthors: Intensive Care Society of Ireland, October 2006

Introduction

Development of adult intensive care services in Ireland has historically been haphazard without a coordinated national intensive care development plan. Under the (old) Health Boards, intensive care beds were added on as an adjunct to other specialist services or in many cases as an adjunct to hospital development. Consequently, after some neglect, only recently has a broad realisation been arrived at that national intensive care planning and development is needed for the entire population.

Recently, there have been changes in the organisation, accountability and administration of healthcare and acute hospital care in Ireland with the Hanly Report (2003), Health Act (2004) and the establishment of the Health Services' Executive.

Critical care is an inalienable right of critically ill patients. Critically ill patients are treated as individuals on the basis of clinical need and not on the basis of age, gender, socio-economic class, nationality, race, colour, creed or any physical or intellectual disability.

The scope of this document is adult and paediatric intensive care capacity planning and development in Ireland- to maintain existing intensive care capacity and to plan and develop required extra intensive care capacity with appropriate manpower and transport requirements. High-dependency care is a stratum of acute hospital care. High-dependency care requirements, audit and manpower requirements are dealt with elsewhere.

The aim of this document is to inform government, policymakers, paymasters and commissioners, to shape future national critical care planning and development policy and to advise against closure of existing critical care capacity.

Intensive Care Society of Ireland

The Intensive Care Society of Ireland (ICSI) is the professional body representing Intensive Care medical practitioners, both south and north of the border, in Ireland. ICSI concerns itself with the appropriate availability of critical care resources for critically ill patients, adult and paediatric, in Ireland. Along with the three Royal Colleges (Anaesthetists, Surgeons and Physicians), the Society is a constituent member of the Conjoint Board of Intensive Care Medicine of Ireland which administers postgraduate Intensive Care Medicine training. The Society liaises closely with our colleague Intensive Care nurses' professional body, the Irish Association of Critical Care Nurses (IACCN). The professional interests of intensive care medical practitioners are dealt with separately by the separate intensive care medical practitioners group.

Designated acute hospital bed classification in Ireland

Critical care is a core function of acute hospital care worldwide. Critical care constitutes two of the four strata of acute hospital care. In Ireland, designated acute hospital beds are classified into four strata attracting particular nursing staffing ratios.

Required nursing Acute Hospital Beds Patient Category FTE per bed approx.Ward Category 0 Patients whose needs can be met through normal ward care 0.5

in an acute hospital

At-risk Category 1 Patients at risk of their condition deteriorating, or those1 recently relocated from higher

levels of care, whose needs can be met on an acute ward with additional advice and support from the critical care team

Critical Care Beds

HDU Category 2 Patients requiring more detailed observation or intervention 3 including support for a single failing organ or post-operative care and those 'stepping down' from a higher level of care

ICU Category 3 Patients requiring advanced respiratory support alone or 6 basic respiratory support together with support of at least two organ systems. This level includes all complex patients requiring support for multi-organ failure.

Table. Acute hospital bed classification; Comprehensive Critical Care: A review of adult critical care services; United Kingdom Department of Health, 2000.

Currently, there are 195 adult ICU beds open in Ireland (category 3 acute hospital bed) and adult intensive care services in Ireland are delivered at 37 sites. Overall acute adult hospital bed stock is 11,811*. Consequently, the adult ICU bed to adult acute hospital bed ratio or “norm” is 1.65% (Ó Riain 2005). However, on 2nd May 2002, the then Minister for Health, Mr Martin, stated that 2.2% of the country's acute beds were in intensive care units, which, the Minister stated, was “in line” with international norms. This statistic is misleading. It erroneously includes neonatal, paediatric and high dependency unit beds. Paediatric and neonatal ICU beds are inaccessible to adults. For adults, this represents a 34% over-estimate error. Accordingly the norm of 1.65% signifies that Ireland currently is deficient in adult intensive care bed capacity. Consequently, critically ill patients are not accessing proper timely intensive care. The Society is not alone in its concern that critically ill patients who do not access intensive care sustain increased morbidity and mortality.

*Note: Adult acute hospital bed complement is total acute hospital bed complement including obstetric hospitals' bed complement minus complement of paediatric hospitals (OLHSC, Crumlin; Childrens' University Hospital, Temple St; NCH, Tallaght) and minus complement of NICUs (Rotunda; CWH; NMH; Erinville, Cork).

Levels of Intensive Care in Ireland

Healthcare is comprised of primary, secondary and tertiary and even quaternary healthcare. Similarly, intensive care is comprised of three levels of intensive care (levels I, II and III) (Haupt 2003). Level I intensive care achieves basic resuscitation and stabilisation and if necessary transfer for comprehensive or specialty care. Level II intensive care achieves comprehensive intensive care but requires transfer for specialty care. Level III intensive care achieves comprehensive and specialty intensive care.

Table. Levels of Intensive CareLevel III ICUs providing comprehensive care of the critically ill patient including multidisciplinary and medical specialty care (e.g. neurosurgery, cardiothoracic surgery, multiple trauma etc.)Level II ICUs providing comprehensive care of the critically ill patient but requiring transfer for specialty care Level I ICUs providing initial resuscitation and stabilisation of the critically ill patient but usually (depending on the patient's critical illness and available resources) requiring transfer for comprehensive and specialty care.Haupt MT et al, Task Force of the American College of Critical Care Medicine, Society of Critical Care Medicine; Guidelines on critical care services and personnel: Recommendations based on a system of categorization of three levels of care. Crit Care Med. 2003, 31(11):2677-83.

Table. Adult ICU Bed Capacity Ireland 2006.

ERHA, Hanly and HSE/Teamwork Reports

The (then) Eastern Regional Health Authority published Review of Critical Care Services in the Eastern Region in 2004. This document (amongst 27 recommendations) recommends “urgent approval and funding for planning and construction of existing and required (sic) ICU building programs to increase regional ICU bed complement”.

National intensive care planning begins, however, with the The Report of the National Taskforce on Medical Staffing (2003) (Hanly Report) which proposed that intensive care can “only” be provided in a Major hospital (3.9.3) or national/supra-regional hospitals. Accordingly, under Hanly, intensive care services appear as follows:

ICU Level HanlyNational/Supra-Regional hospital Level III YesMajor hospital Level II YesLocal hospital Level I No

Thus, at a stroke, Hanly abolishes Level I intensive care and closes 50 Level I ICU beds in 20 small existing ICUs in Ireland. The Society is concerned that if Hanly is implemented that ICU access for critically ill patients would worsen with a consequent adverse impact on critically ill patients nationwide, including, potentially, loss of life.

Furthermore, Hanly appears to plan to close the ICU beds of “Local” Hospitals without a compensatory and commensurate increase in the ICU bed complement in Major Hospitals or National/Supra-Regional Hospitals. This would represent a net national decrease in adult ICU bed complement. In addition, as has been pointed out elsewhere, Hanly appears to wipe out a stratum of acute hospital care, the General Hospital.

Similarly, the HSE/Teamwork report (2006) “Improving safety and achieving better standards: an action plan for health services in the north east” states “there is no provision of acute critical care of any nature at the local level” (p44). The National Hospitals' Office Director has stated this report is the “blueprint” for the NHO. This “blueprint” perpetuates Hanly's planned closure of Local ICUs. Again, in the HSE/Teamwork report, after closing the ICUs in the Local hospitals, there is no stated plan for a compensatory and commensurate increase in ICU beds in the Regional hospital resulting, like Hanly, it appears, in a net national decrease in ICU beds. On the other hand, of course, a new state-of-the-art regional hospital build proposed in the HSE/Teamwork report would of course be very welcome and would contribute when it is open and properly resourced with the commensurate increased ICU bed complement.

Table. Projected adult ICU bed complement in Ireland post-Hanly, post-Teamwork, as stated.

Adult Intensive Care post-Hanly, post-HSE/Teamwork

If Hanly and HSE/Teamwork are implemented, as stated, based on the reports, the projected adult ICU bed complement will decrease from 195 to 145 beds, i.e. from a ratio of 1.65% to 1.22%, a truly massive 26% decrease in ICU bed complement. HSE has nevertheless stated that the Teamwork report is a national “blueprint”. Consequently, it appears that the HSE plan is to decrease national adult intensive care capacity.

HSE North East Hospital Directive 8 th September 2006

The Directive “all requests for transfer to the Cavan Hospital Site from Monaghan Hospital should be granted and processed immediately” and “emergency patients are accepted without question” has the following implications for a critically ill patient in Monaghan Hospital:1. Net loss of one ICU bed and 5-6 ICU nurses or 2 ICU beds and 10-12 ICU nurses (FTEs) in

Monaghan. No increase in ICU beds in Cavan. 2. If resuscitation and stabilisation of a critically ill patient is not achieved in Monaghan Hospital

by an in-house on-call resuscitation team, the patient may suffer morbidity or mortality.3. Hazardous transfer to Cavan Hospital of an (unresuscitated) critically ill patient by ambulance by

a team not specifically dedicated to transfer of critically ill patients and perhaps inexperienced in the transfer of severely critically ill patients may result in increased morbidity or even mortality for that critically ill patient.

4. Delay of initiation of proper intensive care of the critically ill patient during the transfer process of perhaps several hours.

5. Removal from Monaghan Hospital of specialist on-call medical and nursing staff for (up to 8) hours.

6. Arrival of a critically ill patient in Cavan where no ICU bed is available and ongoing delay of initiation of intensive care while an alternative ICU bed location is sourced at Cavan (temporary ICU bed) or even at another hospital if necessary

7. However, unnecessary transfer of a critically ill patient to a third hospital would of course be entirely unacceptable and would in effect be “shunting” critically ill patients around with obvious harmful effects in terms of morbidity and mortality.

It would appear that HSE Directive transfers critically ill patients from Monaghan to Cavan without any additional transport resource or resource at Cavan.

Ballinasloe (Portiuncula) and Roscommon Hospitals HSE statement 13 th September 2006 Clarification is required as to whether a single department of surgery (at Ballinasloe) will result in closure of ICU bed(s) at Roscommon. If an ICU bed in Roscommon is closed and no extra bed is opened in Ballinasloe, negative effects in terms of morbidity and mortality may ensue (see Cavan/Monaghan hospitals above).

Nenagh HospitalOf note, the Nenagh Hospital Action Group omits intensive care from its Proposal. It is assumed that Nenagh would maintain a Level I ICU. Alternatively, if Nenagh ICU is closed, similarly, critically ill patients face an a hazardous transfer to Limerick without extra ICU beds in Limerick.

Critically ill patients may not access proper timely intensive care in Ireland (ICSI 2001)

In 2001 ICSI showed in a nation-wide prospective 28-day multi-center study that up to 30% of adult and paediatric patients who require ICU admission do not gain access to ICU (Charles, 2002).

Critically ill patients not accessing intensive care sustain increased mortality

Patients who fail to gain access to intensive care or for whom intensive care cannot be obtained sustain 1.7 -fold increase in mortality (Sinuff 2004). In other words, for every five patients refused intensive care, one more patient died (Sinuff 2004).

Sinuff T et al; Rationing critical care beds: a systematic review; Critical Care Medicine, 2004; 32: 1588-1597.

Inequitable Intensive Care Access. Intensive Care 'Rationing'.

At any time in any hospital two critically ill patients may present for intensive care in one ICU bed, the 'last' ICU bed. Some critically ill patients are transferred necessarily to national specialty hospitals for specialty care (Level III intensive care) if there is a bed available. In a hospital, resourced intensive care is a commodity comprising a fixed number of staffed ICU beds for that (same) number of patients. Thus, an ICU bed is indivisible and cannot be rationed so that, at any one time, two given critically ill patients in any hospital cannot access the resource of one ICU bed, the 'last' ICU bed. One patient receives proper timely intensive care with trained staff while the other patient with as yet unmet need for proper intensive care is 'rationed' to receive general acute hospital supportive care outside ICU perhaps by inexperienced hospital staff and perhaps without appropriate equipment and certainly in an unsuitable location while an alternative scarce ICU bed is being sourced elsewhere, either inside or outside the hospital, often with considerable difficulty. If the ICU is full, usually the setting up of a staffed temporary ICU bed in the same hospital is simply not feasible- neither sufficient resources nor trained staff exist or can be sourced at short notice. At that point, the only appropriate intensive care setting for this critically ill patient becomes an ICU bed in another hospital. Usually, after a not inconsiderable delay, such a vulnerable critically ill patient faces a hazardous journey by ambulance often out-of-hours to another ICU in another (distant) hospital perhaps by personnel inexperienced in the transport of critically ill patients during which time the patient is not receiving proper intensive care and at a time in that patient's life where an unnecessary inter-hospital transfer is potentially at its most harmful. This creates an inequitable and hazardous situation where one critically ill patient receives timely proper intensive care and the other critically ill patient does not.

Forced or Premature Discharge from Intensive Care

Forced or premature discharge of patients occurs commonly at night due to pressure on ICU beds. Such premature discharge is associated with increased hospital mortality in patients (Goldfrad Lancet 2000)

Resuscitation, stabilisation and transfer of the critically ill patient (Level I intensive care with planned transfer)

However, if after proper resuscitation and stabilisation at the base hospital, Level I intensive care, there is another extra commissioned ICU bed immediately available at another hospital and if safe transport of a critically ill patient can be effected by a dedicated available specialist intensive care ambulance(s) retrieval transfer service available 24/7 directly to the receiving hospital empty ICU bed, it is possible to redress this inequity and reduce the risk of excess morbidity and mortality. A specialist ICU transfer retrieval team is required because a transfer of a critically ill by medical personnel at the base hospital lasting many hours (up to 8 hours) curtails the base hospital capacity to treat all other patients. (AAGBI-ISC 2006)

Futile intensive care. End-of-life care.

In general terms, in intensive care, throughout the world, critically ill patients may present to ICU or it may arise during a critically ill patient's course in ICU that the burden of critical illness and perhaps other illnesses is or becomes very great and that the patient now faces or continues to face invasive supportive intensive care and treatment perhaps not without complication as well as a prolonged hospital stay also perhaps not without complication and that the prospect for this individual patient of a return to his or her independent life immediately before becoming ill outside the hospital is extremely remote or virtually nil. At this point the burden of critical illness and perhaps other illnesses and the burden of intensive care far outweighs the prospect of any meaningful recovery and intensive care becomes futile, undignified and perhaps even inhumane. At this point after consultation, the carers, including the family, decide to withhold or withdraw intensive care and medical care and with comfort measures only the patient is allowed to transition from intensive care to end-of-life care, while remaining in the ICU, and to come to the end of his or her life in peace and comfort. This of course is a challenging and complex area and there are many legal, social, religious, ethnic, cultural and ethical inputs, considerations and even imperatives. (Carlet 2004)

Population growth and projected intensive care requirements. Current healthcare expenditure.Intensive care is an expensive resource requiring much trained staff and facilities. OECD data released in 2006 shows that in 2004 other than Poland and the Slovak Republic Ireland had the lowest total annual health expenditure share of GDP at 7.1%. Society faces a choice between an expensive resource appropriately used or an unjust and harmful alternative, intensive care 'rationing'.

Figure. Source: Central Statistics Office 2002 Ireland Population Census

National Hospitals' Office Planning and Development Directorate: National Critical Care Planning and Development Agency

ICSI is now concerned that the apparent current national HSE adult intensive care plan as stated is to decrease national adult intensive care capacity resulting likely in inequitable ICU access or even inaccessible ICUs and consequent ICU bed 'rationing' with a now known increased critically ill patient morbidity and mortality. ICSI recommends that the National Hospitals' Office Planning and Development Directorate, now incorporated, includes a national intensive care planning and development agency from inception that maintains current ICU bed complement and develops national ICU bed capacity. The 2004 ERHA Review recommends a “critical care development agency responsible for drawing up critical care strategy as a permanent agency within the National Hospital Agency”. ICSI is not aware of any plans currently to build new adult ICUs in Ireland in public hospitals. The current HSE national intensive care development plan does not extend past reopening any closed ICU beds in certain hospitals while closing ICU beds in other hospitals. Therefore there appears currently to be no national intensive care planning and development.

HSE national intensive care manpower requirements

The HSE/Teamwork report makes no reference to regional critical care capacity requirements or nursing staffing requirements but refers solely to Hanly's intensive care medical manpower recommendations.

Medical Staffing Patterns- Current Best Evidence“High intensity” or intensive care consultant ICU staffing is associated with decreased mortality for critically ill patients (Pronovost 2002). However, high ICU medical and nursing workload is associated with increased mortality and errors for critically ill patients (Landrigan 2004, Tarnow-Mordi 2000). Therefore, optimal medical, nursing and paramedical staffing levels are required for optimal ICU patient outcomes.

Medical Manpower and Training in Intensive Care Medicine in Ireland

Traditionally, Intensive Care Medicine in Ireland has been the remit of anaesthetists, at consultant and trainee level, with the exception of Neonatal Intensive Care. The recent change in the Comhairle na n-Ospideal definition of an Intensivist has opened this area of practice to doctors from an anaesthesia, internal medicine or surgical primary post-graduate training, provided they have undertaken appropriate training in Intensive Care Medicine. Up to now all doctors pursuing a career in Intensive Care Medicine have completed their training abroad, primarily in Australia. The Irish Board of Intensive Care Medicine which is a conjoint board of the College of Anaesthetists, the Royal College of Surgeons in Ireland, the Royal College of Physicians of Ireland and the Intensive Care Society of Ireland, is currently pursuing the establishment of a national training rotation in Intensive Care Medicine which would meet the national requirements for intensivists.

The European Society of Intensive Care Medicine recommends between 3 and 5 physicians per 6-8 beds, depending on the level of intensity.

A recent survey by the ICSI showed that only 84 of 186 consultants who provided an intensive care service out of hours had any fixed sessional commitment, either designated in their contract or by local arrangement. Those consultants with dedicated ICU sessions are primarily based in the major teaching hospitals. The DATHS group, Cork University Hospital, the Mercy Hospital, the Mid-Western Hospital, University Hospital Galway, Waterford Regional Hospital, St Lukes Hospital Kilkenny and Our Lady of Lourdes Drogheda all have consultants who fulfil the current definition of a consultant with an interest in Intensive Care Medicine. However their sessional commitment is variable and in no institution does it provide full consultant cover Monday to Friday.

There are 36 Intensive Care Units in the country varying from Level I to III with a total capacity of

195 beds. There are 24 consultants with a designated interest in Intensive Care Medicine, although most Departments of Anaesthesia have other consultants who participate in the provision of Intensive Care services. Each hospital with a level I or II ICU should have at least two trained intensivists or anaesthetists with a special interest in Intensive Care to lead the service as a minimum standard as per Hanly recommendations. Level III ICUs have a higher manpower requirement to provide 24 hour cover. Networking of intensive care units would be a desirable development. Hanly recommended an increase to 77 consultants by 2009. However this will not be adequate to staff all ICUs to an internationally recognised level.

Training in Intensive Care Medicine is currently through Anaesthesia in most ICUs. St James and the Mater have a total of 3 posts which are specifically Intensive Care training posts. The number of Intensive Care Training posts need to be expanded to meet the consultant expansion and would need to be increased to 10 immediately to meet the figure projected in Hanly.

Nursing Staffing Requirements: Irish Association of Critical Care Nurses (IACCN):IACCN Position Statement on Nurse-Patient Ratios in Critical Care Every critically ill patient should have access to care at his or her point of need.Care provision to include access to the required specialty of an Intensive Care or High Dependency unit. (ICU / HDU).Every Critically ill patient should have the immediate access to a registered nurse with a post registration qualification in the specialty.There should be congruence between the needs of the critically ill person and the core competency of the registered nurse.The unconscious ventilated patient should have a minimum of 1:1 nurse to patient ratio in the level 3 ICU. The level 2 HDU provision should be at a 1:2 nurse to patient ratio.

Transport of the critically ill patient: General Principles

Inter-ICU inter-hospital transport of the critically ill patient is required for specialty care on the basis of clinical need and available expertise and requires a dedicated round-the-clock ICU ambulances, staff and drivers. For patients with head injury, in order to achieve timely effective care and to prevent harmful delays, patients should be transferred to neurosurgical centres for appropriate care without delay (AAGBI 2006). Currently, the (sole) Mobile Intensive Care Ambulance (MICAS) provides an in-hours service only. Occasionally, for mechanical reasons, the ambulance is not available. This service needs to be developed nationally. MICAS ambulances need to be placed at multiple sites nationally so that critically ill patients can access necessary care not available to them. It has been shown in an analogous study that rural patients with myocardial infarction experience significantly increased delay times in accessing specialist care (O'Neill 2003). Closure of level I ICUs in local hospitals would further increase the delay time for critically ill patients to access intensive care.

Mobile Intensive Care Ambulance Service (MICAS) Recommendations1. The pilot project has been a success and consolidation of the MICAS service is

recommended.2. A public announcement or launch is recommended.3. It is recommended that the scope of the MICAS be expanded by developing a weekend

service as an immediate priority. A more formal administrative interaction with other acute medical services, e.g. helicopter patient transport and the Northern Ireland 24hr retrieval service (NICATS) would be beneficial.

4. Current operational features should be retained, e.g. ambulance safety protocols and the mechanisms of deploying various (including medical / nursing) personnel. To facilitate item 3 above, recommended developments are :

a.) An additional ambulance driver / attendant

b.) A new vehicle

c.) Expansion of the Hospital rota by at least one to include St James’ Hospital 5. New management structures are recommended :

New ERHA-based Management Committee

Smaller committee with remit of maintaining and developing the service

MICAS co-ordinator recommended

National Acute Hospital Bed Capacity Review- Repeat- National Intensive Care Capacity

Requirements

The Acute Hospital Bed Capacity, A National Review with supplemental Technical Report incorporating Supporting Data and Analysis published in 2002 are both erroneous in respect of adult ICU bed capacity. In the last Review, all adult intensive care and high dependency beds were called ICU beds. It is misleading to call HDU beds ICU beds as different patient activities and nursing ratios pertain. The ICU occupancy data is erroneous. On page 71 of the Technical Report it states “the occupancy levels are not routinely available. It is therefore assumed that the occupancy level of ICU is at least the same as that of the Hospital as a whole”. Consequently the ICU bed occupancy tables on pages 70 and 71 of the Technical Report are simply relabelled acute hospital bed occupancy data from pages 66-68.

The Intensive Care Society of Ireland recommends that the National Acute Hospital Bed Capacity Review should include adult, paediatric and neonatal intensive care and high dependency capacity separately in terms of existing bed stock and of capacity requirements at a national level. Similarly ICSI requests that accurate specific critical care occupancy data are collated and included.

The Intensive Care Society of Ireland is concerned about the deficiency in critical care capacity in Ireland. The Society feels that the first step is to establish accurate existing adult critical care bed stock figures with subsequent national adult critical care service planning.

National Influenza Pandemic Project- intensive care implications

In the event of a patient requiring ventilatory support, an index case of pandemic influenza there is a requirement to manage this patient in a negative-pressure isolation in an ICU (HSE-HPSC 2006). In the event of an influenza pandemic, using epidemic models with various case-attack-rates, surges and ventilation requirements, a surge increase of 100-200% in ICU beds and ventilators is anticipated (Menon 2005). Such an influenza pandemic would create a need for over 100 temporary ICU beds and ventilators, adult and paediatric, in Ireland in excess of current capacity.

References

Association of Anaesthetists of Great Britain and Ireland; Recommendations for the safe transfer of patients with brain injury, 2006.

Association of Anaesthetists of Great Britain and Ireland- Irish Standing Committee; Inter-hospital transfer of the critically-ill patient in the Republic of Ireland- Guidelines for Anaesthetists in referring units, 2006.

Association of Paediatric Anaesthetists, Association of Surgeons of Great Britain and Ireland, British Association of Paediatric Surgeons, Royal College of Paediatrics and Child Health, Senate of Surgery for Great Britain and Ireland; Joint Statement on General Paediatric Surgery provision in District General Hospitals in Great Britain and Ireland, August 2006.

Carlet J et al; European Society of Intensive Care Medicine Statement: Challenges in end-of-life care in the ICU; Statement of the 5th International Consensus Conference in Critical Care; Intensive Care Medicine 2004, 30: 770-84.

Charles R et al on behalf of the Intensive care Society of Ireland; Accessibility of intensive care facilities in Ireland to critically ill patients; Irish Medical Journal 2002, 95: 72-74.

ERHA Eastern Regional Health Authority; Review of Critical Care Services in the Eastern Region, 2004.

Goldfrad C et al; Consequences of discharges from intensive care at night; Lancet 2000, 355: 1138

Haupt MT et al, Task Force of the American College of Critical Care Medicine, Society of Critical Care Medicine; Guidelines on critical care services and personnel: Recommendations based on a system of categorization of three levels of care. Crit Care Med. 2003, 31(11):2677-83.

HSE-HPSC; Algorithm for the management of persons with acute febrile respiratory illness who may have avian influenza; 2006. www.hpsc.ie.

Landrigan CP et al; Effect of reducing interns' work hours on serious medical errors in intensive care units; NEJM 2004, 351:1838.

McCarthy K et al, Audit of Paediatric Intensive Care referrals andtransfers, Paediatric Intensive Care "State of the Art" Symposium,Killarney, June 2006.

Menon DK et al on behalf of the Intensive Care Society; Modelling the impact of an influenza pandemic on critical care services in England; Anaesthesia 2005, 60: 952-54

Nenagh Hospital Action Group; Small Hospital, Big Service: Working Proposal for the Future of Nenagh Hospital, The Way Forward for Smaller Acute General Hospitals in Ireland; 2006

O'Neill J et al; Patients presenting with acute myocardial infarction to a district general hospital: baseline results and effect of audit; Irish Medical Journal 2003, 96: 70.

Ó Riain S et al, Irish Journal of Medical Science 2005, volume 174 (electronic supplement), abstracts of the Intensive Care Society Meeting 10-11 June 2005.

Pearson G et al, "Should Paediatric Intensive Care be centralised?Trent versus Victoria. Lancet, 1997 Apr 26;349 (9060):1213-7.

Pronovost PJ et al; Physician staffing patterns and clinical outcomes in critically ill patients; JAMA 2002, 288:2151.

Shann F, Paediatric Intensive Care "State of the Art" Symposium,Killarney, June 2006.

Sinuff T et al; Rationing critical care beds: a systematic review; Critical Care Medicine, 2004; 32: 1588-1597.

Tarnow-Mordi WO et al; Hospital mortality in relation to staff workload: a 4-year study in an adult intensive-care unit; Lancet 2000, 356:185.

United Kingdom Department of Health, Acute hospital bed classification; Comprehensive Critical Care: A review of adult critical care services; 2000.

http://www.hpsc.ie/

Authors

Intensive Care Society of Ireland, October 2006

adult intensive care capacity planning

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