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Comprehensive critical care within the independent health-care sector

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Wayne Large, BA (Hons), RN, PGDip.

Critical Care Education Facilitator, BUPA Hospitals Ltd

The White Paper Comprehensive Critical Care (DoH, 2000) has far-reaching implications for both the public and the independent sector. Providing a smooth continuum of critical care is paramount, and breaking down barriers to effective critical care, thus taking the service to the patient, is crucial in any acute hospital.

The White Paper Comprehensive Critical Care (DoH, 2000) has far-reaching implications for both the public and the independent sector. Providing a smooth continuum of critical care is paramount, and breaking down barriers to effective critical care, thus taking the service to the patient, is crucial in any acute hospital.

Every acute health-care provider has a responsibility to respond to the changes in the way critical care is delivered in the UK (DoH, 2000; Audit Commission, 1999) and to implement these responsibilities in a professional and effective manner. That is why BUPA Hospitals took steps to capture the essence of these recommendations so that patients could be assured of prompt and appropriate critical care at any of its UK hospitals.

Every BUPA hospital has high-dependency facilities that provide level 1 and level 2 critical care. In some hospitals there are also intensive-care beds that provide level 3 services; usually to patients requiring cardiac care and mechanical ventilation postoperatively.

As more work is being done under the concordat agreement with the NHS (DoH, 2001), the demand for support for these patient groups has increased. These patients require the same standard of critical care as in the NHS. Furthermore, there are patients who are being nursed in acute wards who now require higher levels of observation and who are undergoing relatively complex interventions such as continuous positive airway pressure (CPAP).

Drivers of change in critical care
Many issues in the White Paper demand consideration. However, the focus of this paper is on the new classification of critical care patients and the specific issues regarding competency-based critical care training. Furthermore, it outlines one particular solution as interpreted by BUPA.

The White Paper outlined a new structure for the classification of critical care patients (Table 1). This classification seeks to move away from the old labelling of patients according to location; moving towards a system based on severity, thus fostering a continuum of care.

Another driver for change in critical care delivery is outlined in Comprehensive Critical Care (paragraph 19) and states that: 'All acute hospitals carrying out elective surgery must be able to provide level 2 care. They should either have level 3 care available on site or they should have protocols in place to arrange transfer to a suitable unit' (DoH, 2000). Paragraph 55 goes on to recommend that competence-based, high-dependency care training modules should also be set up for all ward staff.

Designing a training programme
With these points in mind, it was decided that a full critical care training programme be designed and implemented as soon as possible. It was essential to take a common-sense approach to this. The programme needed to be flexible so that nurses could easily access it at the appropriate point; taking into account and accrediting their prior experiences and learning (APEL) in critical care.

The training programme needed to cover the fundamental issues of critical care to provide a firm basis of both theoretical and practical knowledge and expertise. Above all, it needed to be relevant and applicable to the case-mix and activities undertaken in the independent sector. While it required a focus on elective, major and minor surgery, an emphasis on trauma or burns, for example, would clearly be unsuitable for the activities undertaken in this setting. Furthermore, the programme should not overlap significantly with others, such as advanced and intermediate life-support courses, to avoid duplication of well-established training pathways.

An important exception is where the programme clearly benefited from input from other areas relevant to the critically ill, such as the management of tissue viability, infection control and nutrition. Evidence suggests, for example, that malnutrition in the critically ill is often not diagnosed until it is well established (Kinn and Scott, 2001).

Maintaining a critical mass of expertise
The notion of a 'critical mass' of level 2 expertise was identified. The goal became to achieve a clinical environment in which there were always enough nurses with education and training available to care for level 2 patients within each hospital department, during any 24-hour period. Staffing levels and existing roles within each hospital were examined so these nurses would always be available and free to implement their critical care expertise.

Taking into account all relevant factors, such as the number and type of departments, staffing levels and shift patterns, an effective critical mass could be calculated. The number of nurses that form a critical mass is typically between 15 and 25 per hospital, dependent on the size of the hospital. This mass of nurses with level 2 care skills would undertake both level 1 and 2 tasks, but would specialise in providing specific treatments such as CPAP therapy and managing invasive monitoring techniques, such as central venous pressure (CVP) monitoring and arterial blood gas analysis.

It was considered that it be mandatory for all remaining nurses working in acute areas to undertake critical care training, at least to care level 1. This would also be offered to new nurses along with other mandatory training such as manual handling, advanced life support (ALS), intermediate life support (ILS) and customer care. In specific hospitals where level 3 services are provided, the recruitment and retention of nurses trained and experienced in level 3/critical care would continue as necessary.

Nursing leadership
A nurse was identified within each hospital as the clinical lead in critical care. The educational and professional profile of this lead person was examined. It was felt that the clinical lead person required recognised qualifications in both critical care and in teaching and assessing others; as is typical throughout the NHS. Most hospitals already had nurses with nationally recognised qualifications such as the ENB 100 (intensive care nursing), A75 (high-dependency nursing) and ENB 249 (cardiothoracic nursing) together with a recognised teaching and assessing qualification such as the ENB 998. Some of these people were also graduates or were working towards graduate or postgraduate level. These nurses fitted the profile to provide clinical leadership in critical care. Other hospitals recruited suitable nurses to undertake this role.

The role of the critical care lead person was, essentially, to identify and train those nurses who would form the critical mass of those able to undertake and deliver level 2 care. The training was delivered within the hospital by the lead nurse or other suitably qualified nurses, or organised using external expertise.

In some cases, university lecturers and training and development consultants were used with good effect. Some hospitals, which enjoyed a particularly close relationship with their local NHS trust, sent nurses to NHS critical care units to gain essential practical experience and assessment. This has proved beneficial in forging relationships between the public and the independent sector.

Another essential role of the critical care lead nurse was to provide clinical advice and guidance, ensuring that all patients requiring critical care are cared for appropriately. In effect, the lead nurse has become the outreach nurse for the hospital, ensuring the appropriate use of high-dependency and intensive-care beds, the sharing of critical care skills and the constant availability of appropriate expertise and equipment. The lead nurse must ensure that appropriate support is always available for the continuing recovery of ward patients (DoH, 2000).

The programme's design
A pathway was identified to meet the needs of the business and to provide an efficient solution for all (Figure 1). The training programme was designed to be user-friendly and flexible. A learning climate that fostered a non-threatening, non-judgmental atmosphere (Hinchcliffe, 1996) - in which participants are expected to share in the responsibility for their learning - was essential.

The programme was underpinned by a core set of competence-based 'key skills'. Each was sub-divided into the individual competencies required to undertake a particular task safely. In order that each skill is achieved, the required theoretical and practical elements needed to be demonstrated by the participant. This process was measured first by self-assessment. The participant would indicate a need for training to achieve a particular goal.

A participant, for example, might assess themselves as competent in the theoretical aspects of managing a patient undergoing respiratory support such as CPAP. However, this theoretical knowledge might never have been put into practice. A learning contract, therefore, would be identified whereby the participant would undertake practical training in the form of clinical skill stations (workshops), in much the same way as recommended by the Resuscitation Council UK (2001) for advanced life support (ALS) training. This training could be delivered using mannikins, scenarios and simulations in a real clinical setting. Access to the programme, and the pathway recommended for each nurse, depended on their current qualifications and experience in critical care. Account needed to be taken, where possible, of different learning styles, and a match was sought on an individual basis.

Where a mismatch occurred, the participant would be less likely to learn (Honey and Mumford, 1995), thus presenting a barrier to effective learning. Nurses with formal critical care qualifications such as ENB 100 and A75 could access the programme at any point to update and maintain their clinical knowledge and skills. Nurses with significant critical care experience but no formal qualifications were given the chance to formalise their knowledge by taking a 'fast-track' pathway with self-study and practical skill stations learning - leading to formal assessments. Nurses with little or no critical care experience took the full programme.

Education components
The complete programme was based on theory and practice, with a strong emphasis on clinical skills. The preparatory, theoretical component consisted of an initial set of readings from a set textbook by Sheppard and Wright (2000). The book was chosen for the sake of consistency and the relative ease with which a standard text can be distributed across a geographically diverse organisation, in much the same way as The Open University distributes course materials. Participants were asked to read set chapters. This was supplemented with specifically designed study packs for infection control, pain management, nutrition management and psychological care of the critically ill. Participants were encouraged to supplement their preparatory studies with wider reading from other sources. This preparatory study approach was similar in nature to that used by the Resuscitation Council UK (2001) in its advanced life support programmes.

The main core of the theoretical input for the programme took place through formal study sessions delivered in a traditional format, using computer-based presentations. Many were designed by individuals in one department and distributed throughout the organisation to help others.

Clinical skills were delivered in the form of skill stations and real-time simulations. Real-life events, such as vomiting and naso-pharyngeal suction, could then be simulated. Scenarios were also used to lead the participant from one situation to another and the emphasis was placed firmly on the early recognition of potentially adverse events. Feedback from these sessions has been exclusively positive. Several hospitals have continued these practical sessions on an ongoing basis; acting as a form of regional clinical skill centre. This allows other hospitals to access clinical training as part of their own critical care programmes.

The programme was designed with continuous professional development in mind. An objective was to enable participants to progress smoothly to other critical care modules at diploma or degree level. Links forged with several UK universities mean a nurse achieving level 2 critical care status can not only gain a BUPA certificate of competence, but also join several other critical care degree modules to gain credits towards their degree (Figure 1). There are several joint educational posts between BUPA and the universities to allow these closer relationships to exist. This collaboration has worked so well with other courses that it will soon be possible for a BUPA nurse to gain a degree through the organisation, in association with a particular university, as many NHS trusts already do.

Level 1, 2 and 3 care delivery is not the same as level 1, 2 and 3 academically. For example, undertaking level 2 high-dependency training does not necessarily mean that this training is academically pitched at level 2 (diploma qualification).

The assessment process for participants in the training is described in Box 1.

Progress so far and future considerations
The effects of the project are far-reaching throughout the organisation, and the benefits are gradually becoming apparent. At the time of writing, more than 450 nurses are undertaking critical care training within BUPA Hospitals and more than 50 have completed it. Others will start it as workload and staffing levels allow. Early evidence shows confidence is increasing in nurses, who now feel better prepared to deal with challenging situations. In some cases, early recognition skills have been enhanced and appropriate treatment is delivered promptly. Some hospitals have reported the use of some treatments, mainly CPAP, for the first time. The programme has been well received by medical staff; some are helping with training.

These are early signs that need to be investigated further to measure the programme's effectiveness. Some measures already in place are giving us valuable information. Patient satisfaction and that of the health-care team, including our medical lead clinicians who use the service, are two examples. So, too, are levels of adverse incidents and patient outcomes; all are measured and need to be studied in terms of patients who have received critical care services.

Studies should be undertaken to survey the attitudes of nurses delivering critical care services, to look at at clinical outcomes of patients who have received specific nursing and medical care, and to examine the uptake of new services and procedures that require critical care. Also important is that efforts in this area need to link closely with those in the NHS and other health-care organisations. Membership of critical care networks and adhering to national standards is essential to achieve a smooth continuum of critical care.

Conclusion
This critical care project seems to be influencing the independent health-care organisation in a positive way. The first impressions are that patient care may be enhanced and the organisation will be able to increase the complexity of care offered. But further investigation is needed. What is certain is that nurses are showing enthusiasm, confidence and pride, which we hope will lead to enhancements in recruitment and retention. Overall, it is becoming apparent that it is possible to deliver a truly comprehensive critical care service in the independent sector.

Audit Commission. (1999) Critical to Success: The place of efficient and effective critical care services within the acute hospital. London: Audit Commission.

Department of Health. (2000)Comprehensive Critical Care: A review of adult critical care services (White Paper). London: The Stationery Office.

Department of Health. (2001)A Concordat with the Private and Voluntary Health Care Provider Sector. London: The Stationery Office.

Hinchcliffe, S. (1996)The Practitioner as Teacher (2nd edn). London: Baillière Tindall.

Honey, P., Mumford, A. (1995)Using Your Learning Styles. Maidenhead: Peter Honey Publications.

Kinn, S., Scott, J. (2001)Nutritional awareness of critically Ill surgical high-dependency patients. British Journal of Nursing 10: 11, 704-709.

Resuscitation Council UK. (2001)CPR Guidance for Clinical Practice and Training in Hospitals. London: Resuscitation Council UK. Available at: www.resus.org.uk

Sheppard, M., Wright, M. (2000)Principles and Practice of High Dependency Nursing. London: Baillière Tindall.

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