Centralisation of Specialist Critical Care Services

Meadows, Chris; Rattenberry, William; Waldmann, Carl

doi:10.1177/175114371101200202

Cited by 5 publications

(4 citation statements)

References 31 publications

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“…Traumatic injuries are one of the leading causes of death around the world, with the World Health Organization (WHO) [1] noting that the estimated five million traumatic injury-related deaths annually was equivalent to the combined deaths associated with human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS), malaria and tuberculosis. It is known that one of the most significant factors affecting health outcomes in trauma patients is time [2], with the period before commencement of healthcare support and then while transferring a patient from the original incident site to a health service considered critical to reducing mortality and improving recovery for the individual [3]. The concept of a ‘golden hour’, the length of time immediately after the trauma and until care is provided, is often used as a key performance measure for emergency medical care, although the validity of the implied ‘60 minutes’ timeframe is open to question [4].…”

Section: Introductionmentioning

confidence: 99%

Factors Impacting Patient Outcomes Associated with Use of Emergency Medical Services Operating in Urban Versus Rural Areas: A Systematic Review

Alanazy

Wark

Fraser

et al. 2019

IJERPH

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The goal of this systematic review was to examine the existing literature base regarding the factors impacting patient outcomes associated with use of emergency medical services (EMS) operating in urban versus rural areas. A specific subfocus on low and lower-middle-income countries was planned but acknowledged in advance as being potentially limited by a lack of available data. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed during the preparation of this systematic review. A comprehensive literature search of PubMed, EBSCO (Elton B. Stephens Company) host, Web of Science, ProQuest, Embase, and Scopus was conducted through May 2018. To appraise the quality of the included papers, the Critical Appraisal Skills Programme Checklists (CASP) were used. Thirty-one relevant and appropriate studies were identified; however, only one study from a low or lower-middle-income country was located. The research indicated that EMS in urban areas are more likely to have shorter prehospital times, response times, on-scene times, and transport times when compared to EMS operating in rural areas. Additionally, urban patients with out-of-hospital cardiac arrest or trauma were found to have higher survival rates than rural patients. EMS in urban areas were generally associated with improved performance measures in key areas and associated higher survival rates than those in rural areas. These findings indicate that reducing key differences between rural and urban settings is a key factor in improving trauma patient survival rates. More research in rural areas is required to better understand the factors which can predict these differences and underpin improvements. The lack of research in this area is particularly evident in low- and lower-middle-income countries.

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Section: Introductionmentioning

confidence: 99%

Factors Impacting Patient Outcomes Associated with Use of Emergency Medical Services Operating in Urban Versus Rural Areas: A Systematic Review

Alanazy

Wark

Fraser

et al. 2019

IJERPH

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“…It is also possible that the relevance of a comparison between bypass and selective transfer will continue to recede over the duration of any trial, secondary to continued regionalisation of emergency and trauma services. 121 Alternative non-randomised research designs to investigate the effectiveness of bypass are likely to be at very high risk of bias. Future cohort or case-control studies of neuroscience care compared with non-neuroscience care are critically limited by confounding, cannot provide valid evidence of comparative effectiveness and would add nothing to the existing weak evidence base.…”

Section: Implications For Future Researchmentioning

confidence: 99%

The Head Injury Transportation Straight to Neurosurgery (HITS-NS) randomised trial: a feasibility study

Lecky

Russell

Fuller

et al. 2016

Health Technol Assess

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BackgroundReconfiguration of trauma services, with direct transport of traumatic brain injury (TBI) patients to neuroscience centres (NCs), bypassing non-specialist acute hospitals (NSAHs), could potentially improve outcomes. However, delays in stabilisation of airway, breathing and circulation (ABC) and the difficulties in reliably identifying TBI at scene may make this practice deleterious compared with selective secondary transfer from nearest NSAH to NC. National Institute for Health and Care Excellence guidance and systematic reviews suggested equipoise and poor-quality evidence – with regard to ‘early neurosurgery’ in this cohort – which we sought to address.MethodsPilot cluster randomised controlled trial of bypass to NC conducted in two ambulance services with the ambulance station (n = 74) as unit of cluster [Lancashire/Cumbria in the North West Ambulance Service (NWAS) and the North East Ambulance Service (NEAS)]. Adult patients with signs of isolated TBI [Glasgow Coma Scale (GCS) score of < 13 in NWAS, GCS score of < 14 in NEAS] and stable ABC, injured nearest to a NSAH were transported either to that hospital (control clusters) or bypassed to the nearest NC (intervention clusters). Primary outcomes: recruitment rate, protocol compliance, selection bias as a result of non-compliance, accuracy of paramedic TBI identification (overtriage of study inclusion criteria) and pathway acceptability to patients, families and staff. ‘Open-label’ secondary outcomes: 30-day mortality, 6-month Extended Glasgow Outcome Scale (GOSE) and European Quality of Life-5 Dimensions.ResultsOverall, 56 clusters recruited 293 (169 intervention, 124 control) patients in 12 months, demonstrating cluster randomised pre-hospital trials as viable for heath service evaluations. Overall compliance was 62%, but 90% was achieved in the control arm and when face-to-face paramedic training was possible. Non-compliance appeared to be driven by proximity of the nearest hospital and perceptions of injury severity and so occurred more frequently in the intervention arm, in which the perceived time to the NC was greater and severity of injury was lower. Fewer than 25% of recruited patients had TBI on computed tomography scan (n = 70), with 7% (n = 20) requiring neurosurgery (craniotomy, craniectomy or intracranial pressure monitoring) but a further 18 requiring admission to an intensive care unit. An intention-to-treat analysis revealed the two trial arms to be equivalent in terms of age, GCS and severity of injury. No significant 30-day mortality differences were found (8.8% vs. 9.1/%;p > 0.05) in the 273 (159/113) patients with data available. There were no apparent differences in staff and patient preferences for either pathway, with satisfaction high with both. Very low responses to invitations to consent for follow-up in the large number of mild head injury-enrolled patients meant that only 20% of patients had 6-month outcomes. The trial-based economic evaluation could not focus on early neurosurgery because of these low numbers but instead investigated the comparative cost-effectiveness of bypass compared with selective secondary transfer for eligible patients at the scene of injury.ConclusionsCurrent NHS England practice of bypassing patients with suspected TBI to neuroscience centres gives overtriage ratios of 13 : 1 for neurosurgery and 4 : 1 for TBI. This important finding makes studying the impact of bypass to facilitate early neurosurgery not plausible using this study design. Future research should explore an efficient comparative effectiveness design for evaluating ‘early neurosurgery through bypass’ and address the challenge of reliable TBI diagnosis at the scene of injury.Trial registrationCurrent Controlled Trials ISRCTN68087745.FundingThis project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full inHealth Technology Assessment; Vol. 20, No. 1. See the NIHR Journals Library website for further project information.

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“…[5] Regionalisa-tion or consolidation of ICU services across clinical networks and within individual hospitals into a single integrated service is one key strategy resulting new organisational models for service delivery. [2,6,7] A large-capacity multi-specialty integrated ICU service model, referred to as an ICU "hot-floor" (see Figure 1), is emerging as a preferred organisational approach in tertiary referral hospitals where traditionally sub-specialty ICUs typically operated in isolation. [8][9][10] Multiple pods (or units) of ICU and high dependency unit (HDU), or "step down", beds are physically collocated and managed as a single integrated service.…”

Section: Introductionmentioning

confidence: 99%

Intensive care unit organisation and nurse outcomes: A cross-sectional study of traditional and “hot-floor” structures

Abbenbroek

Duffield

Elliott

2017

JHA

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Aim: To explore the relationship between the practice environment and nurse outcomes in two Intensive Care Unit (ICU) models. Background: Internationally the demand for intensive care is increasing. A large capacity multi-specialty integrated critical care service, the "hot-floor", is emerging as the preferred organisational model. Benefits include resource consolidation and improved utilisation, operational synergies, operational flexibility and demand management. A large clinical workforce with commensurate frontline management, education and support positions are required. The association between these factors, within the ICU hot-floor work environment, and nurse outcomes is not known. Methods: Registered nurses (RNs) working in two ICUs, one a hot-floor model and one traditional ICU, completed a structured questionnaire. Nurse perceptions of work-life and organisational factors, and dimensions of burnout were examined using the Practice Environment Scale-Nursing Work Index (PES-NWI) and Maslach's Burnout Inventory (MBI). Results: Units matched on service level characteristics, training accreditation, patient casemix, operational and clinical care processes. Nurses in had similar demographic characteristics, professional attributes and experience. Workforce structures were also similar though the hot-floor had relatively less dedicated resources for frontline nurse management and clinical education positions. Hot-floor nurses worked more paid overtime and were redeployed less frequently to external wards. Nurse manager leadership and support was less effective, and nurses expressed lower personal accomplishment. Conclusions: Improved demand management achieved through greater operational flexibility is a key driver for the hot-floor model. Planning for enhanced organisational effectiveness requires corresponding improvements in the work environment to optimise nurse retention to ensure organisational sustainability.

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Centralisation of Specialist Critical Care Services

Cited by 5 publications

References 31 publications

Factors Impacting Patient Outcomes Associated with Use of Emergency Medical Services Operating in Urban Versus Rural Areas: A Systematic Review

Factors Impacting Patient Outcomes Associated with Use of Emergency Medical Services Operating in Urban Versus Rural Areas: A Systematic Review

The Head Injury Transportation Straight to Neurosurgery (HITS-NS) randomised trial: a feasibility study

Intensive care unit organisation and nurse outcomes: A cross-sectional study of traditional and “hot-floor” structures

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