Transfer of the critically ill adult is an integral part of working life for intensive care staff in Wales and the rest of the UK. The numbers of inter-hospital transfers have been increasing year on year (approximately 550 last year) due to greater pressures on intensive care beds and greater specialisation at tertiary centres. Transfers have traditionally taken place in an ad hoc way with poor co-ordination between the stakeholders. In the North Wales Critical Care Network (NWCCN), holistic steps have been taken to improve the service and have succeeded in making the process of transfer safer. Although this work has been led by the network, it has been approached in a collaborative way working closely with the South East Wales Network (SECCN) and the Mid- and West- Wales Network (MWCCN), as well as the Welsh Ambulance Service, Welsh Air Ambulance and the Royal Air Force search and rescue. This article describes the process.

MethodsThis DGH ICU comprises eight beds, six funded as level 3 and two level 2, but run flexibly. It is the sole critical care facility for a population estimated at 200,000, with a trust bed stock of about 900. Mean occupancy is 75%. Nursing ratios are 5.5-6 whole-time equivalents (WTEs) per bed, with 0.5 WTE provided to practice development and 0.5 WTE to outreach. Medical cover is provided on a week at a time basis, with dedicated 'office hours' cover by a consultant intensivist. Out of hours, cover is provided with a dedicated intensivist on-call rota. In terms of junior staff, two are allocated 'office hours,' while out of hours, two trainee doctors on shifts share cover with theatres and obstetrics.Patient safety is a major challenge and goal for NHS trusts. This paper describes the experiences of a district general hospital (DGH) intensive care unit (ICU) implementing change methodology under the auspices of the Safer Patients' Initiative (SPI). The team applied small tests of change (PDSA -Plan, Do, Study, Act) and, supported by education and measurement, introduced bundles of care, without the need for significant investment. Ventilator and central line bundles were applied, along with multidisciplinary ward rounds and daily goal sheets. Over a two year period, average length of stay fell from 6 to 2.7 days. The rate of ventilator-acquired pneumonia (VAP) decreased from 24.39 per 1,000 intubated days to 0. As a consequence, there was increased available capacity and admissions increased by one third. At the same time, overall drug costs fell. The application of the change methodology has made a significant difference to the performance of this DGH ICU.