Irish ICUs are safe – but more beds needed to meet demands

The Irish National ICU Audit Annual Report 2017 shows that most Irish ICUs work at the limits of their capacity, but provide high quality care with similar patient outcomes to the UK,” according to Dr Rory Dwyer, Clinical Lead for the Audit Report. Maureen Browne reports.

The Audit covered only 58% of ICU activity, but a fuller picture will be available in the 2018 report, which will have 78% coverage.

Irish Units are very busy, with 91% bed occupancy in adult ICUs and 94% bed occupancy in paediatric ICUs in 2017.

In addition, the audit has no way of identifying patients who should be in ICU or HDU based on clinical criteria but are not because of limited Unit bed capacity. The scale of this ‘unmet need’ and the effects on patient outcomes are not known.

Key Findings from the Report were:

Irish Units are very busy, with 91% bed occupancy in adult ICUs and 94% bed occupancy in paediatric ICUs in 2017. The recommended occupancy levels are 70-80%.

Outcome measures in Irish Units were comparable to UK Units, including risk-adjusted hospital mortality rates. This is reassuring and suggests that, despite the strains placed on them, Irish Units provide a high quality of care for patients and are a relatively safe environment for critically ill patients.

The average length of stay in adult ICUs was five days, which is comparable to the UK. However, the overall length of stay in the hospital after discharge from ICU was 24 days in Ireland, compared with 15 days in the UK.

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.

Illness severity and the predicted risk of death at the time of admission to ICU were higher for Irish adult patients than in the UK. These data indicate that Irish patients need to be sicker to be admitted to ICU. For a given illness severity, they spend less time in ICU before discharge back to the ward, which is more likely to happen at night.

Key recommendations for the HSE included:

1. 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 190 beds in critical care capacity by 2031; the data in this Report support this recommendation.
2. 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).
3. 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.
4.  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.
5. 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.
6. Hospitals should minimise ICU discharges during night-time by performing timely discharges during normal working hours.
7. Hospital management should ensure that there are always adequate audit resources in place to collect data, in order to ensure comprehensive data reporting.
8. 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.
9. 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.

FOR Irish Paediatric ICUs – Key Findings
The number of bed days delivered in the ROI was approximately 10,000 annually from 2015–2017. Children under the age of one made up 57% of admissions to Our Lady’s Children’s Hospital, Crumlin (OLCHC) and 38% of admissions to Temple Street Children’s University Hospital (TSCUH).

Bed occupancy in both Irish paediatric ICUs (PICUs) was high in 2017 (97% in OLCHC and 86% in TSCUH). These are above the recommended levels for safe patient care and are likely to make staff retention more difficult.

There was an improvement in journey commencement times in 2017 for the Irish Paediatric Acute Transport Service (IPATS). Transfer commencement times of less than one hour increased from about 40% in 2015 and 2016 to around 70% in 2017. However, IPATS only operates on weekdays during the daytime, leaving a major gap in service provision outside of normal working hours.

Key Recommendations included:

1. 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.
2. 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.
3. 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.
4. Consider developing a dataset for rates of medical staffing per ICU bed for Ireland in consultation with PICANet.