GUIDELINES FOR THE PROVISION OF INTENSIVE CARE SERVICES

The Faculty ofIntensive Care MedicineGUIDELINES FOR THE PROVISIONOF INTENSIVE CARE SERVICESEdition 2June 2019

CONTENTSENDORSING ORGANISATIONS. 5SUPPORTING ORGANISATIONS. 5FOREWORD. 6SECTION 1 – CRITICAL CARE SERVICES: STRUCTURE . 81.1Levels of Critical Care. 91.2Outcomes .111.3Level 2 and 3 Physical Facilities.141.4Clinical Information Systems .171.5Clinical Equipment.201.6Cardiothoracic Critical Care.231.7Neurocritical Care .27SECTION 2 – CRITICAL CARE SERVICES: WORKFORCE .312.1Medical Staffing.322.2Registered Nursing Staff.362.3Workforce, Induction & Training of Medical and Nursing Staff .402.4Advanced Critical Care ts .492.7Dietitians .532.8Speech and Language Therapists.562.9Occupational Therapists.602.10Psychologists .632.11Healthcare Scientists Specialising in Critical Care.662.12Support Staff.692

2.13Smaller Remote and Rural Critical Care Units .71SECTION 3 – CRITICAL CARE SERVICES: PROCESS.753.1Admission, Discharge and Handover .763.2Capacity Management.793.3Critical Care Outreach and Rapid Response Systems .823.4Infection Control.853.5Interaction with Other Services: Microbiology, Pathology, Liaison Psychiatry andRadiology.883.6Rehabilitation.913.7Intensive Care Follow Up.953.8The Patient and Relative Perspective .983.9Staff Support. 1023.10Inter and Intra Hospital Transfer of Critically Ill Patients . 1053.11Care at the End of Life. 1093.12Organ Donation . 1133.13Legal Aspects of Capacity and Decision Making . 115SECTION 4 – CRITICAL CARE SERVICES: CLINICAL CARE. 1194.1Respiratory Support. 1204.2Weaning from Prolonged Mechanical Ventilation and Long-Term Home VentilationServices . 1234.3Renal Support . 1264.4Gastrointestinal Support and Nutrition. 1294.5Liver Support . 1334.6Cardiovascular Support . 1364.7Echocardiography and Ultrasound . 1384.8Neurological Support . 1423

4.9Burns. 1464.10Care of the Critically Ill Pregnant (or Recently Pregnant) Woman . 1494.11Care of the Critically Ill Child in an Adult Critical Care Unit . 1524.12Standardised Care of the Critically Ill Patient. 156SECTION 5 – CRITICAL CARE SERVICES: ADDITIONAL COMPONENTS . 1595.1Research and Development. 1605.2Audit and Quality Improvement . 1635.3Clinical Governance . 1665.4Critical Care Networks. 1695.5Critical Care Commissioning. 173SECTION 6 – CRITICAL CARE SERVICES: EMERGENCY PREPAREDNESS . 1766.1Fire . 1776.2Major Incidents. 1816.3High Consequence Infectious Diseases: Initial Isolation and Management . 1846.4Surge and Business Continuity Planning . 187APPENDICES . 189APPENDIX 1 GPICS AUTHORS . 190APPENDIX 2 LIST OF CONTRIBUTING REVIEWERS. 196APPENDIX 3 PROCESS TABLE. 197APPENDIX 4 LIST OF STANDARDS AND RECOMMENDATIONS. 1984

ENDORSING ORGANISATIONSFaculty of Intensive Care MedicineIntensive Care SocietyAssociation of Cardiothoracic Anaesthesia and Critical CareBritish Association of Critical Care NursesBritish Burn AssociationBritish Dietetic AssociationChartered Society of PhysiotherapistsCritical Care NetworksCritical Care Networks – National Nurse LeadsICUstepsNational Outreach ForumNeuroanaesthesia and Critical Care SocietyNHS Blood and TransplantNorthern Ireland Intensive Care SocietyPaediatric Intensive Care SocietyPharmacy Forum NIRoyal College of AnaesthetistsRoyal College of Emergency MedicineRoyal College of NursingRoyal College of Occupational TherapistsRoyal College of PhysiciansRoyal College of Speech and Language TherapistsRoyal College of Surgeons of EdinburghScottish Intensive Care SocietySociety of Critical Care TechnologiesUK Clinical Pharmacy AssociationUK Critical Care Nursing AllianceWelsh Intensive Care SocietyWelsh Critical Care & Trauma NetworkSUPPORTING ORGANISATIONSRoyal Pharmaceutical Society5

FOREWORDOn behalf of the Faculty of Intensive Care Medicine (FICM) and the Intensive Care Society (ICS),welcome to the second edition of Guidelines for the Provision of Intensive Care Services (GPICS).The first edition of GPICS (2015) was a landmark publication that built on the earlier CoreStandards for Intensive Care Units (2013). GPICS has become the definitive reference source forthe planning, commissioning and delivery of Adult Critical Care Services in the UK. Many unitshave found the standards and recommendations within GPICS invaluable in developing successfulbusiness cases to enhance their local services and improve patient care. GPICS has also been usedas the benchmark by which local services are peer reviewed and assessed by healthcareregulators, such as the Care Quality Commission (CQC).One of the challenges with producing a document such as GPICS can be the lack of a hard evidencebase for some of the standards and recommendations that may be, by necessity, based onprofessional opinion and established practice. It is therefore essential that standards andrecommendations are subject to regular review and revision, as new evidence becomes availableand practice changes. In undertaking this significant review and revision to GPICS, the FICM and ICSconsulted widely, both with the key stakeholder organisations and through an open public survey.One of the criticisms of the first edition was the underrepresentation of authors from smaller unitsand the devolved nations; we have addressed this in the second edition, recognising that themajority of critical care is not delivered in large tertiary centres.Each chapter has been written by at least two authors with expertise in the area who are, wherepossible, from geographically separate units. All chapters have been subject to extensive peerreview and collaboration between FICM, and ICS and stakeholder organisations. The open publicconsultation that followed resulted in a considerable amount of constructive feedback, which hasbeen incorporated into the final version.The standards from the first edition have not been changed unless there has been new evidencepresented, or widespread professional views expressed, to justify modification. The second editionfocuses on service delivery, quality and safety with less emphasis on specific clinical practiceguidelines. Individual chapters relating to the provision of support for each of the main organsystems have replaced the previous clinical sections. Any relevant, high quality, evidence basedguidelines produced by other professional bodies are signposted within these chapters. A number ofnew chapters relating to service delivery, including capacity management, focussed ultrasound andserious infection outbreak have been added.Terminology describing our specialty has not been standardised with terms ‘critical care’, ‘intensivecare’ and ‘high dependency care’ often being used interchangeably. Within this document we haveattempted to standardise and used the term critical care when describing units and services andintensive care when referring to our specialty.The role of a document such as GPICS, is to improve the standards of care that critically ill patientsreceive and to reduce geographical variation. Standards are ’musts’, and are the key elements thatshould be used to make commissioning priorities for UK critical care units. Recommendations arestatements that the authors feel should be routine practice in UK Intensive Care Medicine and whichare endorsed by both the FICM, ICS and stakeholder organisations. GPICS is written to assist andsupport units in developing their services in order that patient care is of the highest quality. Forevery unit, there will be some aspects of GPICS that are not currently met and we hope that units6

will use these gaps as a driver and focus of where to develop and enhance their local service for thebenefit of patient care.Peter MacnaughtonChairFICM Professional Affairs and Safety CommitteeStephen WebbChairICS Standards and Guidelines CommitteeCover photograph courtesy of ICCU, City Hospital Sunderland NHSFT7

Section OneCritical Care Services:Structure

1.1Levels of Critical CareAuthors: Gary Masterson & Anna BatchelorINTRODUCTIONThe Intensive Care Society 2009 Levels of Care classification describes the levels of care required bycritically ill patients in hospital according to their clinical needs, regardless of patient location. Thedefinitions were originally published in 20021, after the publication of Comprehensive Critical Care2 in2000, and latterly revised to reflect the Critical Care Minimum Dataset3 (CCMDS), which has beenmandated since April 2006.STANDARDS1. All patients admitted to a critical care unit must be included in a national clinical auditprogramme in which Levels of Care data are collected.2. Level of Care classification must not be used in isolation to decide upon a patient’s staffingrequirements.RECOMMENDATIONSNo recommendations.BACKGROUNDLevel 0Level 1Level 2Level 3Patients whose needs can be met through normalward care in an acute hospital.Patients at risk of their condition deteriorating, orthose recently relocated from higher levels of care,whose needs can be met on an acute ward withadditional advice and support from the critical careteam.Patients requiring more detailed observation orintervention including support for a single failingorgan system or post-operative care or those‘stepping down’ from Level 3 care.Patients requiring advanced respiratory supportalone, or basic respiratory support together withsupport of at least two organ systems. This levelincludes all complex patients requiring support formulti-organ failure.Clinical judgement should be used to determine which level of care would be most appropriate basedon the criteria in the table above. Although a lower level of care will usually require a lower nurse-to9

patient ratio or reduced critical care support, this may not apply in all circumstances, and the aimshould be flexibility in the provision of staff resources to meet the needs of the patient. The level ofcare assigned to a patient will influence, but not determine, staffing requirements.It is important to note that Levels of Care classification (particularly for Level 2) is wider than thepresence or absence of organ failure per se.There is ongoing work into the development of enhanced care 4 in the UK and this work may lead tothe modification of the levels of care in the future.REFERENCES1.2.3.4.Intensive Ca re Society. Levels of Cri tical Ca re for Adult Pa tients. 2002.Department of Health. Comprehensive Cri tical Care: A Review of Adult Cri tical Ca re Services. Ma y 2000.Cri ti ca l Ca re Minimum Dataset. Ava ilable from:http://www.datadictionary.nhs.uk/data dictionary/messages/supporting data sets/data sets/critical care minimum da ta set fr.asp (accessed 29 Ja n 2019)FICM. Cri ti cal Futures: Current Workstreams. Available from: ks treams/enhanced-care [Accessed 29 Ja nuary 2019].10