Irish National ICU Audit Annual Report 2017
The Irish National ICU Audit (INICUA) was established by the NOCA in 2013 and focuses on the care of patients in adult Intensive Care Units (ICUs) and Paediatric Intensive Care Units (PICUs). This is the first report from the audit and examines data from 6,186 adult patients and 1,463 paediatric patients across 14 Units.
The HSE should prioritise measures to bring ICU/HDU bed capacity in Ireland up to levels which can deal comfortably with day-to-day requirements and to provide some reserve capacity in order to cope with surges in demand or with a major disaster. ICUs must be resourced to deal with peak demand rather than average demand, as patients cannot wait for admission. The Health Service Capacity Review 2018 (Department of Health, 2018) recommended an increase of 100 beds in critical care capacity by 2031; the data in this Report support this recommendation.
The HSE should use the data in this report regarding occupancy, case complexity, requirements for organ support, out-of-hours discharges, and unanticipated ICU readmissions to identify the Units operating at or above capacity. Increased critical care bed capacity should be provided to these Units. As these are predominantly ‘hub’ hospitals, this would be consistent with the “Model of Care for Adult Critical Care (HSE Critical Care Programme, 2014).
The HSE should take measures to facilitate transfers of critically ill patients between hospitals in order to make optimal use of scarce critical care beds and to facilitate transfers for specialist care. The INICUA database can support a live ICU Bed Information System (BIS) in order to provide data on bed capacity in participating Units, and this BIS could also be used to improve communication for referrals.
The HSE should ensure that the specialist retrieval service for critically ill patients, the Mobile Intensive Care Ambulance Service (MICAS), is resourced to provide a comprehensive service 24 hours per day, 365 days per year.
Identifying the unmet need for ICU care is difficult. The proposed BIS (see item 3 above) would have the capacity to document all referrals to ICU and to document whether these referrals were admitted or not. It would also document the reason for ICU referral. The HSE should fund implementation of the BIS nationally, and local clinicians should ensure that the relevant data on Unit referrals that are not accepted are inputted for all referrals.
Hospitals should prioritise discharges from ICU when patients are ready for discharge. Doctors should clearly identify those patients ready for Unit discharge, and bed managers in hospitals should expedite these discharges.
Hospitals should minimise ICU discharges during night-time by performing timely discharges during normal working hours. A discharge summary with details of ICU care and a therapeutic plan should be provided in order to ensure seamless transition from Unit care to ward care.
Hospital management should ensure that there are always adequate audit resources in place to collect data, in order to ensure comprehensive data reporting.
Local clinicians and managers should benchmark their audit data against data from other Units in order to identify variance in their own activity metrics compared with other Units. This should be used to promote improvements in practice.
Local clinicians and audit coordinators should ensure that full documentation of the ‘time of decision to admit to ICU’ is kept in order to make the new HSE key performance indicator (KPI) for time to access ICU an effective measure of timeliness of ICU admission.
Consider ways to get more information on unmet need – patients who are not admitted to ICU because of a lack of beds.
Consider ways to get more information on the large number of patients who die after ICU discharge.
Consider ways to introduce patient-reported (or family-reported) outcome measures (PROMs) into the ICU Audit.
Put in place a national database for INICUA in order to expand the range of data analyses which can be provided.
Promote the development of national surveillance of catheter-related bloodstream infection in ICUs.
Target education on ICNARC definitions and output interpretation for ICU audit coordinators in training workshops.
The paediatric hospitals should increase bed capacity in PICUs as evidenced by the 94% bed occupancy across both Units in 2017. Increased bed capacity could be achieved by retention and recruitment of staff in order to open all available ICU capacity (31 beds), avoiding the need for an increase in structural bed capacity.
The HSE should prioritise the expansion of IPATS to a 24 hour / 7 day centralised transport service (CTS) in order to ensure safe transfer of all children to specialist PICU care in a timely manner; this requires investment in recruitment and retention of nurses and doctors.
Prioritise a national database for audit of adult ICUs, which will facilitate data collection and reporting on all children who are cared for in adult critical care. This information is critical to the health service for future planning of paediatric bed capacity and transport services.
Consider developing a dataset for rates of medical staffing per ICU bed for Ireland in consultation with PICANet.