Scottish Intensive Care Society
Audit Group
Audit of Critical Care in Scotland 2012
Reporting on 2011
I
© NHS National Services Scotland/Crown Copyright 2012
First published October 2009
ISBN: 978­1­84134­014­2
Brief extracts from this publication may be reproduced provided the source is fully acknowledged. Proposals for reproduction of large extracts should be addressed to:
ISD Scotland Publications Information Services Division NHS National Services Scotland Gyle Square 1 South Gyle Crescent Edinburgh EH12 9EB
Tel: +44 (0)131­275­6233 Email: nss.isd­publications@nhs.net
Designed and typeset by: ISD Scotland Publications
Translation Service
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Contents
Foreword ...............................................................................................................II
Introduction ..............................................................................................................III
Summary and Key Findings ..................................................................................... V
Section 1 Activity .......................................................................................................1
1.1 Number of admissions ............................................................................. 1
1.2 Bed occupancy ........................................................................................ 5
1.3 Length of stay .......................................................................................... 6
1.4 Timing of critical care admissions and discharges ................................... 7
1.5 Delayed discharges ................................................................................. 9
1.6 Early discharges .................................................................................... 12
1.7 Readmissions to critical care ................................................................. 13
1.8 Source of admission .............................................................................. 14
1.9 Chronic health ..................................................................................... 15
1.10 Organ donation .................................................................................... 17
Section 2 Interventions in critical care ..................................................................18
2.1 Level of care .......................................................................................... 18
2.! Respiratory support ............................................................................... 20
2." Cardiovascular support ......................................................................... 22
2.4 Renal support ....................................................................................... 23
Section 3 Outcomes ................................................................................................24
Comment on funnel plots for Standardised Mortality Ratios ............................ 25
Conclusions ............................................................................................................27
Critical Care Capacity (Funded Beds) 2011 ...........................................................28
Location of Critical Care Units in Scotland (2012) ................................................30
!""#$%&'()( *+,("-./0#1(23)2(...............................................................................31
!""#$%&'(2( 45,("-./0#1(23)2 ..............................................................................37
Appendix 3 Methodology .....................................................................................45
3.1 Data collection ....................................................................................... 45
3.2 Data management ................................................................................. 45
3.3 Presentation of the data ........................................................................ 45
3.4 APACHE II ............................................................................................. 46
3.5 Level of care .......................................................................................... 49
3.6 Delayed discharges .............................................................................. 49
Appendix 4 Data quality ........................................................................................51
At point of data entry ...................................................................................... 51
Case­note validations ...................................................................................... 51
Central validation ............................................................................................ 52
!""#$%&'(6( +7-.$&8(7#90:7(%#/$&:&.$1(;!<!+4=(**(>#:7.%.0.?@A ...................54
Appendix 6 List of abbreviations ..........................................................................56
References .............................................................................................................58
Acknowledgements ..................................................................................................59
i
Foreword
This report is of the activity and outcomes in Scottish Intensive Care Units (ICU) and High Dependency Units (HDU) for 2011. It is the culmination of work which has produced a continuous database since 1995. Scottish Intensive Care Society Audit Group (SICSAG) is a national audit funded through Information Services Division (ISD). We exist to improve the quality of care delivered to critical care patients by monitoring and comparing activities and outcomes across Scottish critical care.
F.,#0&)*-#<%2-*2&,/#-%#1%&3*/.#02)#43%'5#'*-.#-.,#0))*-*%2#%"#;%3,#/6,<*0(*/-#!GH/#02)#IJH/5#02)#3,6%3-/#
%2#-.,#,K6,3*,2<,#%"#%L,3#@D5>>>#%"#%&3#.%/6*-0(/M#/*<+,/-#60-*,2-/#*2#A>??E#F.*/#0&)*-#3,;0*2/#-.,#%2($#0&)*-#
in the world to our knowledge which reports named ICU outcomes to this level of public scrutiny.
N,#.0L,#,/-0=(*/.,)#<%((0=%30-*%2#'*-.#I,0(-.#O3%-,<-*%2#P<%-(02)#8IOP:#-%#<%((,<-5#020($/,#02)#3,6%3-#
on Healthcare Associated Infection (HAI) surveillance across all Scottish ICUs over the last three years. A separate report of this national data is published annually by HPS in tandem with this SICSAG report. Measures of success include: continued downward trends in crude and case­mix adjusted mortality "%((%'*24#!GH#0);*//*%25#,/-0=(*/.,)#Q&0(*-$#*;63%L,;,2-#*2*-*0-*L,/#&/*24#IR!#/&3L,*((02<,#)0-0#02)#<03,#
=&2)(,/5#043,,)#S&0(*-$#!2)*<0-%3/#"%3#G3*-*<0(#G03,#=,*24#;,0/&3,)#"3%;#T02&03$#A>?A#02)#0#6%6&(03#
annual conference in conjunction with the Scottish Critical Care Trials Group and Scottish Intensive Care Society Evidence Based Medicine Group in Stirling. This will take place this year on 6th and 7th September. Details of this and further information are available at www.sicsag.scot.nhs.uk.
F.02+/#"%3#<%2-*2&,)#/&<<,//#%"#-.*/#0&)*-#%2<,#;%3,#4%#-%U#P<%--*/.#<3*-*<0(#<03,#<(*2*<0(#/-0""5#-.,#P!GPRV#
/-,,3*24#43%&65#R24,(0#W.02#8X0-*%20(#G(*2*<0(#G%Y%3)*20-%3:5#Z%3022,#Z0<V*((*L30$#8S&0(*-$#R//&302<,#
Z0204,3:5#G0-3*%20#I0))%'#8P,2*%3#!2"%3;0-*%2#R20($/-:#02)#-.,#2,-'%3+#%"#(%<0(#02)#3,4*%20(#X0-*%20(#
Audit Team co­ordinators. R/#!#,2-,3#;$#/*K-.#02)#[20(#$,03#0/#G.0*3;02#%"#P!GPRV5#!#'%&()#(*+,#-%#0<+2%'(,)4,#%&3#603-*<&(03#
thanks to Diana Beard as she moves on to new opportunities in 2012. Diana has been the ISD Project Z0204,3#"%3#P!GPRV#/*2<,#A>>DE#N*-.%&-#.,3#,K6,3-#4&*)02<,#02)#.03)#'%3+5#!#.0L,#2%#)%&=-#%&3#0&)*-#
'%&()#2%-#=,#*2#*-/#<&33,2-#/-3%24#.,0(-.$#6%/*-*%2E#\2#=,.0("#%"#&/#0((5#!#'*/.#J*020#',((#'*-.#.,3#2,K-#
venture.
Dr Brian Cook
Chairman
ii
Introduction
\2,#%"#-.,#0;=*-*%2/#%"#-.,#I,0(-.<03,#S&0(*-$#P-30-,4$#"%3#XIPP<%-(02)#A>?>1 is ‘ensuring that the most appropriate treatments, interventions, support and services will be provided at the right time to everyone !"#$!%&&$'()(*+,$-).$!-/+(01&$#2$"-2301&$4-2%-+%#)$!%&&$'($(2-.%5-+(.6. The Scottish Government have stated that ‘applying information from quality data$+#$.2%4($5#)/%/+()+&7$'(++(2$5-2($-52#//$89:$:5#+&-).6 is a key component of this.
P!GPRV#<%2-*2&,#-%#),L,(%6#2,'#'0$/#-%#,2/&3,#)0-0#03,#%"#.*4.#Q&0(*-$#8R66,2)*K#]:5#02)#-.0-#&2*-/#03,#
using their data to drive quality and service improvement. F.*/#$,035#',#03,#3,6%3-*24#%2#-.,#;0204,;,2-#%"#?>5CCA#60-*,2-/#0);*--,)#-%#!GH#02)#G%;=*2,)#H2*-/#
8&2*-/#'*-.#0#<%;=*20-*%2#%"#!GH#02)#IJH#=,)/:#02)#AC5^A?#60-*,2-/#0);*--,)#-%#IJH#)&3*24#A>??E#F.*/#
3,6%3-#/&;;03*/,/#)0-0#-.0-#.0L,#=,,2#<%((,<-,)#L*0#0#=,/6%+,#,(,<-3%2*<#)0-0=0/,#8N03)N0-<.,3:5#'*-.*2#
<3*-*<0(#<03,#&2*-/#*2#P<%-(02)E#F.,#"%3;0-#<%2-*2&,/#-%#"%((%'#-.,#60-*,2-M/#_%&32,$#-.3%&4.#-.3,,#/,<-*%2/U#
0<-*L*-$5#*2-,3L,2-*%2/#02)#%&-<%;,/#'*-.#)0-0#63,/,2-,)#*2#-0=(,/5#<.03-/#02)#0<<%;602$*24#-,K-#-%#0(,3-#
the reader to points of interest. The information presented is for comparative benchmarking and is not intended as a judgement of what */#`<%33,<-M#=&-#-%#.*4.(*4.-#)*"",3,2<,/#02)#*2"%3;#Q&0(*-$#*;63%L,;,2-E#N,#3,<%;;,2)#&2*-/#'.%#03,#
outliers (above or below 3 standard deviations) examine the reason for this. Appendix 3.3.1 explains how to interpret the control charts (funnel plots) used in this report and suggests some reasons units may be different.
F.,#<%),/#&/,)#*2#-.,#<.03-/#-%#*),2-*"$#,0<.#&2*-#<02#=,#"%&2)#*2#-.,#"3%2-#02)#=0<+#106/#%"#606,3#<%6*,/#
or on the last page of the electronic copy. B*+B!C(<-&.-&:&#1(23)2D)E
Quality Indicators
F.,#P<%--*/.#!2-,2/*L,#G03,#P%<*,-$#S&0(*-$#!;63%L,;,2-#V3%&6#.0/#6&=(*/.,)#-,2#S&0(*-$#!2)*<0-%3/#8S!/:#
for Critical Care in Scotland25#02)#3,6%3-*24#%"#/%;,#%"#-.,/,#=,402#*2#T02&03$#A>?A#*2#-.,#;%2-.($#3,6%3-/#
-.0-#03,#/,2-#-%#&2*-#(,0)/E#X,K-#$,03M/#022&0(#3,6%3-#'*((#.0L,#3,/&(-/#%2#0((#%"#-.,#S!/E#
F#890&G-9:&.$(.H(!<!+4=(**(
N%3+#*/#&2),3'0$#-%#3,<0(*=30-,#-.,#RORGI9#!!#;%3-0(*-$#63,)*<-*%2#;%),(5#&/*24#3,<,2-#P<%--*/.#%&-<%;,#
data. The recalibration will have the apparent effect of increasing the Scottish Standardised Mortality Ratio *2#-.,#A>?@#3,6%3-5#0(-.%&4.#-3,2)#)0-0#&/*24#-.,#.*/-%3*<#;%),(#'*((#0(/%#=,#;0),#0L0*(0=(,E#F.,#2,'#
model will be tested over 2012 in the monthly ICU unit reports. Please refer to the website for the latest information. Nurse User Group
This Group was set up to support and enable critical care nurses to access and utilise their own local audit data to drive and support quality improvement. It has evolved into a forum where nurses share and promote quality improvement initiatives and programmes which have improved patient care in their unit. Z,,-*24/#03,#.,()#,L,3$#/*K#;%2-./5#02)#"3,,#-%#-.%/,#0--,2)*24E##O(0<,/#03,#(*;*-,)#/%#,03($#=%%+*24#*/#
advised. Future dates will be published on the website.
iii
Reviewing the dataset and software
A subgroup has been set up to review the data currently collected through WardWatcher. A parallel project .0/#=,,2#,/-0=(*/.,)#-%#3,L*,'#-.,#/%"-'03,#&/,)#-%#<%((,<-#-.,#0&)*-#)0-05#02)#<033$#%&-#0#/<%6*24#,K,3<*/,#
for future development.
Unit leads have been asked for feedback as our main stakeholders. 4#90:7(<-.:#8:&.$(B8.:09$%(;4<BA
SICSAG continue to work collaboratively with HPS to report on the incidence of Healthcare Associated Infections in ICUs. Many units have received no additional resource to collect these data so the <%2-*2&0-*%2#%"#-.*/#63%430;;,5#%2<,#040*25#),;%2/-30-,/#-.,#),)*<0-*%2#02)#<%;;*-;,2-#%"#<3*-*<0(#<03,#
staff. The Central Line Insertion Bundle3 was updated in April 2012 following a literature review by HPS and work is under way to update the Ventilator Associated Pneumonia Prevention Bundle. Information Requests P!GPRV#3,/6%2)#-%#*2"%3;0-*%2#3,Q&,/-/#-%#/&66%3-#(%<0(#02)#20-*%20(#0&)*-#02)#3,/,03<.#63%_,<-/5#
,2/&3*24#-.,#L0/-#0;%&2-#%"#)0-0#.,()#*/#&-*(*/,)#"%3#;0K*;&;#=,2,[-E#R#2,'#/,<-*%2#%2#-.,#',=/*-,#'*((#
detail the results from these bespoke analyses. Regretfully due to limited analyst resource there has been a delay in processing some of these requests and we will endeavour to reduce the turnaround time in the future.
New units
SICSAG continues to expand with the addition of more specialist units and medical HDUs in 2011/12:
G03)*%-.%30<*<#!GH#02)#IJH5#a%$0(#!2[3;03$#%"#9)*2=&34.#8A>??:
Z,)*<0(#IJH5#V(0/4%'#a%$0(#!2[3;03$#8A>?A:
G03)*%-.%30<*<#!GH#02)#IJH5#V%(),2#T&=*(,,#X0-*%20(#I%/6*-0(#8A>?A:
Medical HDU Wishaw General Hospital (planned late 2012)
G03)*%-.%30<*<#IJH5#R=,3),,2#a%$0(#!2[3;03$#86(022,)#(0-,#A>?A:
Z0-,32*-$#IJH5#X*2,',((/#I%/6*-0(#5#J&2),,#86(022,)#(0-,#A>?A:
Angela Khan
National Clinical Coordinator
iv
Summary and Key Findings
SICSAG collects high quality data on all general intensive care patients as well as the majority of high dependency patients in Scotland. The coverage of HDUs has further expanded with four new units joining *2#A>??E#F.,#603-*<*60-*%2#%"#0))*-*%20(#/6,<*0(*/-#&2*-/#*/#',(<%;,)#02)#)0-0#03,#6&=(*/.,)#"%3#-.,#[3/-#-*;,#
on cardiothoracic ICU and HDU. Two large ICUs have combined with HDUs in 2011 and this should be borne in mind when interpreting trend data. SICSAG continues to be the only national audit to publish case­mix adjusted mortality rates for individual units. SICSAG does not limit itself to collecting data but actively works to improve patient outcomes. In the past year, existing care bundles have been updated, Quality Indicators for critical care (which will be included in next year’s report) been developed and collaboration continues with Health Protection Scotland to produce reports of Healthcare Associated Infection.
F.,#Q&0(*-$#%"#)0-0#<%((,<-,)#*/#3,4&(03($#3,L*,',)#02)#-.*/#3,6%3-#0<<&30-,($#3,1,<-/#<3*-*<0(#<03,#0<-*L*-$#*2#
Scotland. I#@(/$%&$?1
36,373 admissions to critical care were included in the audit in 2011. This is higher than in any previous $,035#02)#3,1,<-/#02#*2<3,0/,#*2#-.,#2&;=,3#%"#603-*<*60-*24#&2*-/E
In 2011, the bed occupancy rate for Scotland remained stable in both ICU and Combined Units and HDU, at around 75%. However, there was considerable variation between units, particularly in HDU.
Critical care is a 24/7 service with a considerable out of hours workload. Patients are predominantly admitted from emergency departments, operating theatres and hospital wards.
\&-#%"#.%&3/#)*/<.034,/#3,;0*2,)#/-0=(,#0-#?@b#"%3#!GH/#02)#?Cb#"%3#IJH/E#F'%#IJH/#.0)#/*42*[<02-($#
higher rates of out of hours discharges. F.,3,#<%2-*2&,#-%#=,#*//&,/#'*-.#)*/<.034*24#60-*,2-/#"3%;#<3*-*<0(#<03,#)&,#-%#)*"[<&(-$#*2#[2)*24#'03)#=,)/5#
although the recent upward trend in delayed discharges appears to be levelling off. Early discharges from critical care are those that happen before the patient is deemed medically ready, =,<0&/,#%"#63,//&3,#%2#=,)/#%3#/-0"[24E#F.,$#<02#=,#&/,)#0/#0#;03+,3#%"#*2/&"[<*,2-#3,/%&3<,/E#!2#A>??5#
/,L,30(#&2*-/#.0)#/*42*[<02-($#.*4.,3#(,L,(/#%"#/&<.#)*/<.034,/E#I%',L,35#*-#*/#3,0//&3*24#-.0-#*2#A>??5#
2%#&2*-#.0)#/*42*[<02-($#.*4.,3#3,0);*//*%2#30-,/E#a,0);*//*%2#-%#<3*-*<0(#<03,#;0$#=,#02#*2)*<0-%3#-.0-#
discharge was too early.
The intensity of treatment remains high with 75% of patients treated in ICU and Combined Units receiving level 3 care. The proportion of HDU episodes requiring only level 0 (ward care) increased from 6% in 2010 to 8% in 2011 which may be due to lack of resource in other hospital areas. The pattern of interventions is essentially unchanged from last year and continues to show the heterogeneity of units. It is important to realise that units are not identical; they admit patients with differing 63%=(,;/5#3,1,<-*24#-.,#)*"",3*24#/6,<*0(-$#;*K#=,-',,2#.%/6*-0(/E
The percentage of patients in ICU and Combined Units requiring invasive ventilation fell from 69% in 2010 to 66% in 2011. This is due to the increased number of combined units. AAb#%"#60-*,2-/#0);*--,)#-%#!GH#02)#G%;=*2,)#H2*-/#*2#A>??#)*,)#=,"%3,#.%/6*-0(#)*/<.034,5#3,1,<-*24#
the severity of illness in this population. Case­mix adjusted mortality fell again this year and is at its lowest since the audit began. The adjusted mortality rate has been reducing for the last ten years but it is impossible to attribute to any one change. It may be in part due to the introduction of care bundles as well as other quality improvement initiatives. v
Section 1 Activity
Data regarding critical care activity is presented in this section. These data are presented in a variety of formats; information on funnel plots is given in Appendix 3.3.
When interpreting the unit­level charts it is very important to remember that each unit is unique in terms of <0/,#(%0)5#60-*,2-#<0/,Y;*K#02)#4,%4306.*<0(#"0<-%3/5#02)#-.,/,#;0$#0((#0<<%&2-#"%3#02$#)*"",3,2<,/#/,,2E
1.1 Number of admissions
Figure 1 Annual admissions to ICU and Combined Units (2002­2011)
Number of admissions
12000
10000
8000
All participating units
6000
4000
2000
11 (26)
10 (24)
09 (25)
08 (25)
07 (25)
06 (24)
05 (24)
04 (26)
03 (26)
02 (26)
0
Year (participating units)
There was an increase in admissions across Scotland in 2011. The increase of around 700 admissions '0/#*2#603-#)&,#-%#V(0/4%'#a%$0(#!2[3;03$#02)#c%3-.#d0((,$#a%$0(#I%/6*-0(#!GH/#=,<%;*24#G%;=*2,)#
H2*-/E#F.,#<03)*%-.%30<*<#!GH#0-#-.,#a%$0(#!2[3;03$#%"#9)*2=&34.#0(/%#_%*2,)#-.,#0&)*-#*2#A>??E
1
Figure 2 Annual admissions to HDU (2005­2011)
Number of admissions
30000
25000
20000
All participating units
15000
Cohort of same 21 units
10000
5000
11 (43)
10 (40)
09 (36)
08 (29)
07 (27)
06 (27)
05 (27)
0
Year (participating units)
F.,#2&;=,3#%"#0);*//*%2/#-%#IJH#<%2-*2&,)#-%#3*/,#*2#A>??E#R#2&;=,3#%"#&2*-/#<%;6(,-,)#-.,*3#[3/-#"&((#
$,03#%"#)0-0#<%((,<-*%2E##P-%=.*((#IJH#<(%/,)#*2#Z03<.#'.*(/-#7,("%3)#IJH5#I0*3;$3,/#;,)*<0(#IJH5#S&,,2#
Z03403,-#3,20(#IJH#82%'#(%<0-,)#*2#d*<-%3*0#I%/6*-0(5#W*3+<0()$:#02)#-.,#<03)*%-.%30<*<#IJH#0-#-.,#a%$0(#
!2[3;03$#%"#9)*2=&34.#0((#_%*2,)#-.,#0&)*-#-.*/#$,03E
The cohort line refers to units that had complete data for the last seven years.
2
Table 1 Number of annual admissions to ICU and Combined Units (2002­2011)
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
210
287
246
278
242
267
271
290
266
285
307
302
330
304
330
294
292
305
252
319
329
340
407
398
709
691
406
397
429
506
273
276
334
331
304
324
316
285
298
293
367
161
390
143
374
123
406
152
377
145
373
179
382
124
437
38
439
449
182
508
171
549
215
560
267
480
471
443
378
411
577
214
735
793
806
746
781
778
762
717
748
665
317
165
288
231
319
116
276
255
310
114
316
302
320
155
310
287
321
122
318
279
207
313
208
417
210
294
158
402
218
313
128
433
199
314
220
340
348
104
367
296
76
201
391
395
104
359
299
454
233
284
426
82
360
289
461
202
317
462
120
433
278
451
155
298
793
150
402
282
395
40
281
460
532
512
554
495
485
475
335
326
374
359
389
436
391
429
433
384
398
297
796
485
252
750
411
265
739
506
264
744
531
307
756
522
301
829
505
278
619
560
252
222
562
225
229
583
273
237
643
865
1123
1032
1059
1041
1092
968
1110
241
368
261
449
218
453
225
497
352
504
367
714
443
772
465
831
424
735
1177
188
444
705
310
159
8745
330
186
9120
327
150
9522
339
119
8991
352
163
9892
370
151
10451
404
156
10409
386
136
9757
357
122
9801
349
119
10552
NHS Ayrshire and Arran Ayr ICU
Crosshouse ICU
NHS Borders
BGH ICU/HDU
NHS Dumfries and Galloway DGRI ICU
NHS Fife SZI#!GH
dIW#!GHeIJH
NHS Forth Valley FVRH ICU/HDU1
SRI ICU2
FDRI ICU
NHS Grampian
ARI ICU
NHS Greater Glasgow and Clyde
GRI ICU / HDU3
IRH ICU
RAH ICU
SGH ICU
SGH Neurological ICU
Stobhill ICU4
VI ICU
Vale of Leven ICU
WIG ICU
NHS Highland
Raigmore ICU
NHS Lanarkshire
Hairmyres ICU/HDU
MDGH ICU
Wishaw ICU
NHS Lothian RIE ICU/HDU
RIE Cardiothoracic ICU5
PTI#!GHeIJH
WGH ICU/HDU
NHS Tayside
Ninewells ICU
PRI ICU
Total
Notes:
?#
A##
3 4 5 H2*-#%6,2,)#T&($#A>??
H2*-#<(%/,)#T&($#A>??
Combined unit since March 2011
Unit closed March 2011
Unit joined audit October 2011
NHS Health Boards
Shaded areas refer to periods with incomplete data collection
Combined Unit
3
Table 2 Number of annual admissions to HDU (2005­2011)
NHS Ayrshire and Arran
Ayr HDU
Crosshouse Medical HDU
Crosshouse Surgical HDU
NHS Borders
BGH Surgical Level 1
NHS Dumfries and Galloway
DGRI Medical HDU
DGRI Surgical HDU
NHS Fife
SZI#P&34*<0(#IJH
SZI#Z,)*<0(#IJH
SZI#a,20(#IJH
dIW#Z,)*<0(#IJH
NHS Forth Valley
Stirling HDU1
NHS Grampian
ARI Surgical HDU (ward 31/32)
ARI Neurological HDU
ARI Surgical HDU (ward 35) Dr Gray's HDU NHS Greater Glasgow and Clyde
GRI Surgical HDU2
IRH Surgical HDU RAH HDU
SGH Surgical HDU
SGH Neurological HDU
Stobhill Surgical HDU3
VI Surgical HDU
GGH HDU
WIG HDU
NHS Highland
Raigmore Medical HDU
Raigmore Surgical HDU
Belford HDU4
NHS Lanarkshire
Hairmyres Thoracic HDU
Hairmyres Medical HDU5
MDGH Surgical HDU
MDGH Medical HDU Wishaw Surgical HDU
NHS Lothian
RIE HDU
RIE Renal HDU
RIE Transplant HDU
RIE Vascular Level 1
RIE Cardiothoracic HDU6
WGH HDU
WGH Surgical HDU
WGH Neurological HDU
WGH Neurological Level 1
NHS Shetland
GBH HDU
NHS Tayside
Ninewells Surgical HDU
Ninewells Medical HDU Perth HDU
NHS Western Isles
WIH HDU Total
Total (21 units)
Notes:
?#
A##
3 4 5 6 H2*-#<(%/,)#T&($#A>??
a,)&<-*%2#*2#=,)/#"3%;#T&2,#A>??
Unit closed March 2011
Unit joined audit April 2011
Unit joined audit May 2011
Unit joined audit October 2011
2005
880
667
2006
966
657
2007
413
992
696
2008
2009
2010
542
997
728
527
974
711
498
1033
644
310
339
254
2011
487
1103
641
841
313
783
336
793
360
823
393
804
392
854
431
731
418
827
821
853
849
840
816
525
429
813
724
155
444
1089
963
992
558
684
90
654
170
587
251
582
237
623
235
780
797
714
241
814
1083
631
240
868
1169
899
693
1028
1051
905
691
591
353
608
796
1188
796
642
317
605
771
1201
809
703
327
702
849
1291
861
675
327
692
885
1053
266
1289
870
660
338
636
882
1026
432
1339
807
647
287
700
904
75
765
469
1459
693
621
58
812
755
413
588
685
651
672
732
714
718
620
730
677
811
669
803
669
74
354
340
443
632
628
601
593
56
602
569
278
532
154
274
565
288
546
1531
596
305
1530
607
269
1517
683
330
1541
667
338
1390
632
306
112
1369
674
345
452
491
1198
577
502
1229
450
117
1139
362
1366
675
298
378
214
1192
230
1126
285
1119
404
52
1136
476
418
54
72
64
63
49
58
74
703
652
723
832
499
536
569
623
742
558
644
754
641
618
794
673
625
17169
14405
17541
15069
18142
15644
19911
15971
145
22626
15570
414
25304
15875
448
25821
15682
NHS Health Boards
Shaded areas refer to periods with incomplete data collection
4
1.2 Bed occupancy
Figure 3 Bed occupancy rates for ICU and Combined Units (2011)
100%
X6
Occupancy
90%
80%
70%
C
A
60%
U
H
Q
PJ
V
E
YM
O
I F N
T
L G
ICU
X
Combined ICU/HDU
Specialist ICU
S
Q3 W
R
K
Note: Units O and M overlap almost completely
X%-,U#H2*-/#!5#c#02)#f#
overlap almost completely
D
50%
0
200
400
600
800
Number of admissions
1000
1200
Mean bed occupancy remained stable at 74%. Units X6 and X were above 3 Standard Deviations (SD) "3%;#-.,#P<%--*/.#;,025#/.%'*24#-.,$#.0)#/*42*[<02-($#.*4.,3#=,)#%<<&602<$#30-,/E
Figure 4 Bed occupancy rates for HDU (2011)
100%
W3
90%
Occupancy
80%
O4 X7
70% D2
60%
R4
S2
P3 O3 K2
O2
C2
X5
AA1
B2 G3
Q2 F2 P2
X4 H3
V2 I2 T2 N3 W4
A2
Y2
R5
X3 L2
I3
E2
W2 N2 H2
T3
G2
J2
R3
Surgical
X2
General
Medical
Specialist
50%
Note: Units W2 and Y2 overlap almost completely
X%-,U#H2*-/#V@5#SA#
and V2 overlap almost completely
AB1
40%
Z1
AC1
30%
20%
0
200
400
600
800
1000
Number of admissions
1200
1400
1600
Z,02#=,)#%<<&602<$#'0/#/*;*(03#-%#A>?>E##P*K#&2*-/#',3,#0=%L,#-.,#@#PJ#(*2,#8a]5#O@5#\@5#WA5#RR?5#TA:5#
02)#"%&3#&2*-/#=,(%'#-.,#@#PJ#(*2,#8RG?5#g?5#R7?5#IA:E
5
1.3 Length of stay
Figure 5 Mean length of stay in ICU and Combined Units (2011)
8
Number of days
7
ICU
C
6
V
N
5
A
Q
X6
EH G
D
4
I
L
F
P
J
Y
R
O
Combined ICU/HDU
Specialist ICU
K
Note: Units F and L overlap almost completely
W
S
T
X
Q3
M
3
U
2
0
200
400
600
800
Number of admissions
1000
1200
F.,#;,02#(,24-.#%"#/-0$#'0/#&2<.024,)#"3%;#A>?>#0-#]ED#)0$/E##H2*-#H#.0)#0#/*42*[<02-($#/.%3-,3#(,24-.#%"#
stay than the Scottish mean. Figure 6 6
Mean length of stay in HDU (2011) W3
G3
Number of days
5
Surgical
K2
4
D2 O4
3
AC1 X7
2
Z1
I2
X4
N3
V2
I3 X5
W2 P3
O2
S2
H3 R4 Q2
W4
X3 T2
Y2 F2 H2 L2
T3 A2
O3
E2 C2 N2
P2
R5 B2
AB1
General
G2
Medical
Specialist
AA1
R3
J2
Note: Units AC1 and g?#%L,3(06#0(;%/-#
completely
Note: Units P3 and X3 overlap almost completely
X2
1
0
0
200
400
600
800
1000
Number of admissions
1200
1400
1600
The mean length of stay was similar to previous years. One specialist unit (W3) and three surgical units 8!A5#V@5#02)#WA:#.0)#/*42*[<02-($#(%24,3#(,24-./#%"#/-0$E
Median lengths of stay for all units are published on the SICSAG website.
6
1.4 Timing of critical care admissions and discharges
J&?K-#(L(( M&>#(.H(9%>&11&.$(:.(*+,D+.>G&$#%(,$&:1(9$%(45,(;23))A(
80%
Admissions
60%
8:00am ­ 8.00pm
8:01pm ­ 12midnight
40%
0:01am ­ 7:59am
20%
0%
ICU/Combined
HDU
The distribution of time of admission to critical care was unchanged from previous years. ICUs and HDUs provide 24­hour service with respectively 42% and 32% of admissions occurring out of hours in 2011. Figure 8 Out of hours admissions to ICU and Combined Units (2011) 60%
V
Out of hours admissions
50%
D
40%
A
QE
30%
F
L N J T
I G
Y
O
H
M
P
W
C
R
K
X
Q3
ICU
S
Combined ICU/HDU
Specialist ICU
X%-,U#\&-#%"#.%&3/#*/#),[2,)#
as admissions between 8pm and 8am
U
20%
10%
X6
0%
0
200
400
600
800
Number of admissions
1000
1200
R/#*2#A>?>5#H2*-#H#.0)#0#)*"",3,2-#%&-#%"#.%&3/#0);*//*%2#63%[(,#-%#-.,#%-.,3#&2*-/#*2#P<%-(02)E#H2*-#hD#0(/%#
0);*--,)#/*42*[<02-($#",',3#60-*,2-/#%&-#%"#.%&3/#3,1,<-*24#*-/#63,)%;*202-($#,(,<-*L,#'%3+(%0)E
7
Figure 9 Out of hours admissions to HDU (2011) 60%
Out of hours admissions
O3
L2
50%
AC1
G2
N3
N2 P2
I3
H2
Q2
I2
X3
S2 X4
A2 C2
D2
T3 W2 G3
O2
V2
Z1
H3 B2
F2 K2 W4
O4
P3
R5
W3
Y2
T2
R4
X5
X7
40%
30%
20%
10%
AB1
E2
AA1
R3
Surgical
J2
General
X2
Medical
Specialist
X%-,U#\&-#%"#.%&3/#*/#),[2,)#
as admissions between 8pm and 8am
0%
0
200
400
600
800
1000
Number of admissions
1200
1400
1600
Note: Units T3 and H3 overlap almost completely
Note: Units S2 and I3 overlap almost completely
F.3,,#&2*-/#',3,#0=%L,#@#PJ#"3%;#-.,#;,02E##H2*-#VA#.0/#=,,2#0=%L,#-.,#@#PJ#(*2,#"%3#[L,#$,03/#02)#'0/#
joined by units O3 and L2 in 2011.
Figure 10 Out of hours discharges in ICU and Combined Units (2011) Out of hours discharges
30%
25%
ICU
E
20%
A
15%
10%
C
5%
D
0%
0
Combined ICU/HDU
Specialist ICU
Q
F
V
I
L
H
G J
O
N
Y
U
T
P
Q3
S
X
R
X%-,U#\&-#%"#.%&3/#*/#),[2,)#
as discharges between 8pm and 8am
K
M
X6
W
200
400
600
Number of live discharges
800
1000
F.,3,#'0/#2%#3,0(#<.024,#=,-',,2#A>?>#02)#A>??E##R/#*2#A>?>#&2*-#N#.0/#0#/*42*[<02-($#(%',3#30-,#-.02#
the rest of the Scottish units.
8
Figure 11 Out of hours discharges in HDU (2011) Out of hours discharges
35%
O3
30%
25%
20%
15%
10%
5%
0%
Surgical
X3
General
X4
N2
V2
S2
B2
I3
G2
Q2 H2
P2
AB1 E2
A2 C2 F2 O2
Z1
H3
P3 K2 N3
O4
D2
T3 I2 Y2 T2 L2
W3
R4 G3
X5
AC1
W2
W4
R5
X7
0
200
400
AA1
X2
Medical
J2
Specialist
R3
600
800
1000
Number of live discharges
1200
1400
1600
X%-,U#\&-#%"#.%&3/#*/#),[2,)#
as discharges between 8pm and 8am
X%-,U#H2*-/#g?#02)#JA#%L,3(06#
almost completely
X%-,U#H2*-/#fA5#X@#02)#\A#
overlap almost completely
H2*-/#\@#80/#*2#A>?>:#02)#h@#',3,#)*"",3,2-#"3%;#-.,#3,/-#%"#P<%-(02)E##F.*/#;0$#3,1,<-#0#<060<*-$#*//&,E
1.5 Delayed discharges
Percentage of live discharges
J&?K-#()2( 5#09@#%(%&1879-?#1(&$(*+,D+.>G&$#%(,$&:1(9$%(45,(;233LN23))A
30%
25%
20%
Note: See Appendix @ED#"%3#),[2*-*%2#%"#
delayed discharge
15%
10%
5%
0%
2007
2008
2009
2010
2011
2007
ICU / Combined Units
2008
2009
2010
2011
HDU
Year of admission
These data are collected differently in the newest version of WardWatcher (WardWatcher 2008). The change in WardWatcher may explain the increase seen between 2008 and 2010 although it is likely that the numbers for previous years were underestimated.
The most common reason for a delayed discharge recorded by staff was the lack of a downstream bed. 9
Figure 13 Reasons for delayed discharges in ICU and Combined Units (2011)
2%
4%
3%
<1%
3%
Ward bed shortage
HDU bed shortage
Other
24%
Nursing staff shortage
ICU bed shortage
64%
Transport problems
Other staff shortage
Figure 14 Reasons for delayed discharges in HDU (2011)
1%
4%
3%
1% <1%
1%
Ward bed shortage
HDU bed shortage
Other
Transport problems
Nursing staff shortage
ICU bed shortage
Other staff shortage
90%
10
Figure 15 Delayed discharges in ICU and Combined Units (2011)
50%
Delayed discharges
Q
40%
ICU
Q3
X
30%
F
C
20%
E
D
10%
A
J O
P
I
X6
V
G
N
L H
T
W
S
Note: These analyses only include delayed discharges where the delay recorded was greater than 6 hours
Note: Units V and X6 overlap almost completely
R
K
U
M
Combined ICU/HDU
Specialist ICU
Y
0%
0
200
400
600
Number of live discharges
800
1000
F.3,,#&2*-/#',3,#/*42*[<02-($#)*"",3,2-E##H2*-#h#'0/#0(/%#02#%&-(*,3#*2#A>?>E
Figure 16 Delayed discharges in HDU (2011)
Delayed discharges
50%
X2
G3
40%
Q2
30%
20%
Medical
200
400
600
Specialist
O2
V2
O3 P3 W4
T3
K2
D2
X7 S2
N2 H2 T2
10%
H3 A2 I2
N3
AC1
W2
X4 R5
R4
O4
P2
W3 X5 AB1 C2 Y2
0% Z1
0
General
L2
X3
F2
I3 B2 E2
Surgical
R3
800
AA1
J2
Note: These analyses only include delayed discharges where the delay recorded was greater than 6 hours
G2
1000
1200
1400
Number of live discharges
c*L,#&2*-/#.0)#0#/*42*[<02-($#.*4.,3#2&;=,3#%"#),(0$,)#)*/<.034,/E##
11
1600
)OP( =9-0@(%&1879-?#1
J&?K-#()L( =9-0@(%&1879-?#1(H-.>(*+,(9$%(+.>G&$#%(,$&:1(;23))A
Patients discharged early
25%
A
20%
ICU
15%
Combined ICU/HDU
Specialist ICU
D
10%
H
E L
S
I G J Y
C
U
F
P
V
M
Q X6 N O T Q3 W
5%
0%
0
200
400
X%-,U#903($#)*/<.034,#*/#),[2,)#
as a transfer that is not in the best interest of the patient but necessary due to pressure on =,)/#%3#/-0"[24
X%-,U#H2*-/#N#02)#S@#%L,3(06#
almost completely
X
R
K
600
800
1000
Number of live discharges
903($#)*/<.034,#"3%;#<3*-*<0(#<03,#<02#=,#&/,)#0/#0#;03+,3#%"#*2/&"[<*,2-#3,/%&3<,/E#F.*/#020($/*/#*/#=0/,)#
on the clinical assessment of the person doing each discharge. This is now the third year we have reported -.*/#*2"%3;0-*%2#02)#%L,30((#-.,#60--,32#*/#/*;*(03#-%#A>?>E##I%',L,35#&2*-#R#'0/#/*42*[<02-($#)*"",3,2-#*2#
2011.
J&?K-#()Q( =9-0@(%&1879-?#1(H-.>(45,(;23))A
W3
Patients discharged early
20%
Surgical
General
15%
Medical
5%
Specialist
P3
10%
O4
AC1
D2
Z1
0%
0
P2
I3 AB1
S2 B2 A2
H2
H3R5 R4V2 O3
N2 K2 O2
X4 E2 Q2 C2
F2
N3
Y2 X3
X5 T3
X7
W4 G2
T2
G3
L2
I2 W2
200
400
600
800
1000
AA1 X2 J2
R3
1200
Number of live discharges
1400
1600
Note: Early discharge is ),[2,)#0/#0#-302/",3#-.0-#*/#
not in the best interest of the patient but necessary due to 63,//&3,#%2#=,)/#%3#/-0"[24
Note: Units G3 and W2 overlap almost completely
X%-,U#H2*-/#7A5#I@#02)#aC#
overlap almost completely
H2*-/#N@5#O@#02)#OA#3,6%3-,)#/*42*[<02-($#;%3,#,03($#)*/<.034,/E#H2*-/#OA#02)#O@#03,#(%<0-,)#*2#-.,#/0;,#
hospital.
12
1.7 Readmissions to critical care
a,0);*//*%2/#-%#<3*-*<0(#<03,#;0$#=,#02#*2)*<0-%3#-.0-#)*/<.034,#'0/#-%%#,03($5#%3#-.0-#)%'2/-3,0;#<03,#
'0/#2%-#%"#0#/&"[<*,2-#/-02)03)E
For these analyses readmissions are now derived using records linked together by the CHI number. O3,L*%&/#020($/,/#&/,)#-.,#3,0);*//*%2#[,()#*2#N03)N0-<.,3E#F.,#.*/-%3*<#;,-.%)#'0/#"%&2)#-%#
underestimate readmissions; therefore comparison with previous years should be treated with caution.
Readmissions within 48 hours of discharge
Figure 19 Readmissions within 48 hours of discharge to ICU and Combined Units (2011)
4%
A
U
W
3%
ICU
D
V
2%
I
G
L
T
K
Y
Q
1%
Combined ICU/HDU
Specialist ICU
M
C
F
X6
H N
J
O
X
R
Q3
S
P
E
0%
0
200
400
600
800
1000
1200
Number of admissions
The mean readmission rate in ICUs and Combined Units in Scotland was 1.6%. Readmissions within 48 hours of discharge
Figure 20 Readmissions within 48 hours of discharge to HDU (2011)
4%
D2
R5 AB1
I3
X4
3%
W3
X7
2%
AC1
L2
X3
E2
C2
A2
P2
S2
G3
H2
T3
N2 W4 O2
Q2 P3
X5 H3
I2
N3
O3
Z1
1%
Y2
W2
V2
Surgical
R3
General
Medical
AA1
G2
F2 K2
Specialist
X2
J2
T2
B2
0%
0
200
400
600
800
1000
Number of admissions
13
1200
1400
1600
1.8 Source of admission
Figure 21 Source of admissions to ICU and Combined Units (2002­2011)
5000
Number of admissions
4000
Theatre in this hospital
Ward in this hospital
3000
ED in this hospital
2000
HDU in this hospital
Other hospital
1000
11 (10552)
10 (9801)
09 (9757)
08 (10409)
07 (10451)
06 (9892)
05 (8991)
04 (9522)
03 (9120)
02 (8745)
0
Year (total number of admissions)
!2#A>??5#@B#b#%"#0);*//*%2/#-%#!GH#02)#G%;=*2,)#H2*-/#',3,#"3%;#-.,#%6,30-*24#-.,0-3,5#A@b#"3%;#
-.,#,;,34,2<$#),603-;,2-#02)#?ib#"3%;#-.,#.%/6*-0(#'03)E#!2<(&),)#*2#-.*/#4306.#"%3#-.,#[3/-#-*;,#03,#
admissions from HDU which account for 12% of admissions to ICU.
Figure 22 Source of admissions to HDU (2005­2011)
Number of admissions
12000
10000
Theatre in this hospital
8000
Ward in this hospital
6000
ED in this hospital
4000
ICU in this hospital
2000
Other hospital
11 (25821)
10 (25304)
09 (22626)
08 (19911)
07 (18142)
06 (17541)
05 (17169)
0
Year (total number of admissions)
There was a slight drop in admissions from theatre to HDU balanced by an increase in admissions from the '03)/#02)#-.,#9;,34,2<$#J,603-;,2-j#-.*/#;0$#=,#*2#603-#)&,#-%#2%2Y/&34*<0(#IJH/#_%*2*24#-.,#0&)*-5#P-*3(*24#
IJH#;,34*24#'*-.#!GH#02)#V(0/4%'#a%$0(#!2[3;03$#P&34*<0(#IJH#3,)&<*24#-.,#2&;=,3#%"#"&2),)#=,)/E####
!2<(&),)#*2#-.*/#4306.#"%3#-.,#[3/-#-*;,#03,#0);*//*%2/#"3%;#!GH#%3#G%;=*2,)#H2*-/#'.*<.#0<<%&2-/#"%3#??b#
of admissions to HDU.
14
1.9 Chronic health Patients with chronic health conditions
J&?K-#(2E(( <9:&#$:1(R&:7(87-.$&8(7#90:7(8.$%&:&.$1(&$(*+,(9$%(+.>G&$#%(,$&:1(;23))A
40%
ICU
30%
A
Q
C
20%
D
10%
Q3
F
I
NP T U
V
J
E L
H G M O
X6
Y
X
W
R
Combined ICU/HDU
Specialist ICU
K
Note: Units M and O overlap almost completely
S
0%
0
200
400
600
800
1000
1200
Number of admissions
The spread across Scotland of patients admitted with one or more chronic health conditions (APACHE II ;,-.%)%(%4$5#/,,#R66,2)*K#C:#'0/#3,(0-*L,($#,L,2#0(-.%&4.#&2*-#h#'0/#/*42*[<02-($#)*"",3,2-E#F.*/#&2*-#-3,0-/#
0#(034,#2&;=,3#%"#60-*,2-/#'*-.#<.3%2*<#(*L,3#)*/,0/,#'.*<.#;0$#,K6(0*2#-.*/#[2)*24E#
The APACHE II (Acute Physiology and Chronic Health Evaluation) scoring system4 used in this audit <0(<&(0-,/#0#63,)*<-,)#;%3-0(*-$#"%3#,0<.#60-*,2-#-.0-#*/#<%;603,)#-%#-.,#0<-&0(#;%3-0(*-$5#-%#4*L,#-.,#
Standardised Mortality Ratio (SMR). This then allows the comparison of outcomes in units with a different case­mix of patients (Section 3). The predicted mortality is calculated from the APACHE II score and RORGI9#!!#)*042%/*/E#F.,#RORGI9#!!#/<%3,#*/#;0),#&6#%"#6%*2-/#4*L,2#"%3#<.3%2*<#.,0(-.5#04,#02)#0<&-,#
6.$/*%(%4$E#O0-*,2-/#'*-.#%2,#%3#;%3,#<.3%2*<#.,0(-.#<%2)*-*%2/#3,<,*L,#=,-',,2#-'%#02)#[L,#6%*2-/E#F.,3,#
03,#63,<*/,#<3*-,3*0#"%3#),[2*24#-.,#63,/,2<,#%"#<.3%2*<#%3402#<%2)*-*%2/5; which are built into WardWatcher with on screen prompts to encourage accurate data entry. Thirteen chronic health conditions are listed within the APACHE II scoring system. These are listed in Table 3 with the Scottish incidence per 100 admissions to ICU and Combined Units.
15
M9G0#(E(((<9:&#$:1(R&:7(87-.$&8(7#90:7(8.$%&:&.$1(&$(*+,(9$%(+.>G&$#%(,$&:1(;23))A
Condition
Severe respiratory disease
Image proven cirrhosis*
Portal hypertension
Immunosuppression
Very severe cardiovascular disease
Metastatic disease
Hepatic encephelopathy
Biopsy proven cirrhosis
Chronic renal replacement
Lymphoma
Chronic leukaemia
Acute leukaemia
AIDS
Rate per 100 admissions
4.5
4.0
3.8
3.3
2.1
2.1
1.6
1.4
1.3
0.8
0.4
0.3
0.2
k#X%-#603-#%"#-.,#%3*4*20(#RORGI9#!!#;%),(5#2%#6%*2-/#4*L,2#0-#-.*/#-*;,E##
!-#*/#*;6%3-02-#-.0-#<03,#*/#-0+,2#0-#-.,#-*;,#%"#)0-0#,2-3$#-%#,2/&3,#-.0-#-.,/,#<%2)*-*%2/#03,#<(0//*[,)#
<%33,<-($E#F.,#),[2*-*%2/#<&33,2-($#&/,)#=$#N03)N0-<.,3#03,#(*/-,)#*2#R66,2)*K#C#"%3#3,",3,2<,E#R#"&-&3,#
P<%--*/.#;%3-0(*-$#63,)*<-*%2#;%),(#;*4.-#<.%%/,#-%#3,L*/,#-.,#<%2-,2-#02)#),[2*-*%2/#%"#-.*/#(*/-#-%#3,1,<-#
-.,#<.024,/#*2#;,)*<0(#<03,#02)#,6*),;*%(%4$#/*2<,#W20&/M/#6&=(*<0-*%2#*2#?i^C4. SICSAG have recently carried out a review of the number of chronic health conditions entered in ICU 02)#G%;=*2,)#H2*-/#"%3#,0<.#/6,<*[<#<0-,4%3$#%2#A>?>#)0-0E#c%3#;%3,#*2"%3;0-*%2#/,,#R66,2)*K#]5#J0-0#
S&0(*-$E##
16
1.10 Organ donation Figure 24 Scottish deceased organ donors (2002­2012)
100
90
Number of donors
80
70
60
DCD
50
DBD
40
Note: donation after brain stem death (DBD); donation after cardiac death (DCD)
Source: data from NHS Blood and Transplant
30
20
10
0
2002­
2003
2003­
2004
2004­
2005
2005­
2006
2006­
2007
2007­
2008
2008­
2009
2009­
2010
2010­
2011
2011­
2012
Year of admission (financial)
Deceased organ donation rates from intensive care continue to increase in Scotland. In 2011/12 there were 53 organ donors after brain stem death and 28 organ donors following cardiac death. As a result of the ongoing early recognition and referral of potential donors by staff in ICU these numbers continue to increase. Increased public awareness and a rise in the number of people who have signed the organ donor register and made their end of life choices known may help explain these changes.
F.,#A>>^#\3402#J%20-*%2#F0/+#c%3<,#3,6%3-#`\3402/#"%3#F302/6(02-M6 set an ambitious target of a 50% *2<3,0/,#*2#),<,0/,)#%3402#)%20-*%2#=$#A>?@E#!-#*/#0#3,1,<-*%2#%"#-.,#.03)#'%3+#02)#<%2-*2&*24#,2404,;,2-#
by intensive care staff throughout Scotland that this goal has now been achieved.
17
Section 2 Interventions in critical care
2.1 Level of care
These data are collected from the WardWatcher Augmented Care Period (ACP) page. It allows direct comparisons of interventions and levels of care to be made between critical care units. Level of care is ),[2,)#*2#R66,2)*K#@ECE
The pattern of interventions is essentially unchanged from 2010 and continues to show the heterogeneity %"#&2*-/E#!-#*/#*;6%3-02-#-%#3,0(*/,#-.0-#&2*-/#03,#2%-#*),2-*<0(5#0/#-.,$#0);*-#60-*,2-/#'*-.#0#)*"",3,2-#3024,#%"#
63%=(,;/5#3,1,<-*24#-.,#)*"",3*24#/6,<*0(-$#;*K#=,-',,2#.%/6*-0(/E
Figure 25 Level 3 days in ICU and Combined Units (2011)
100%
Patient days at level 3
90%
A
D
80%
70%
60%
I
L
C E F
X6 V G
Q
H
N
J
Y T
P
W
R
X
K
O
ICU
Combined ICU/HDU
Specialist ICU
M
50%
U
40%
Q3
S
30%
0
200
400
600
800
1000
1200
Number of patient episodes
70% of patient days in ICU and Combined Units were recorded as level 3. The lower portion of this graph is dominated by Combined Units as would be expected. 18
Figure 26 Highest level of care in ICU and Combined Units (2011)
100%
80%
Episodes
Level 0
60%
Level 1
Level 2
40%
Level 3
* Scottish average
** Combined Units
S**
M**
Q3**
K**
U**
C
R**
H
O
*
T
P
Q
X**
V
G
F
E
D
X6
Y
W
I
J
A
N
0%
L
20%
Unit
R/#*2#(0/-#$,03M/#3,6%3-#-.,#)0-0#*/#63,/,2-,)#*2#%3),3#%"#),/<,2)*24#63%6%3-*%2#%"#(,L,(#@#<03,E#!2#A>??#
-.,#.*4.,/-#(,L,(#%"#<03,5#(,L,(#@5#'0/#3,Q&*3,)#*2#BCb#%"#60-*,2-#,6*/%),/#*2#!GH#02)#G%;=*2,)#H2*-/#
representing little change over the last three years. This allows resource planning to be more accurately
63,)*<-,)#%2#63,L*%&/#$,03/M#)0-0#02)#*2)*<0-,/#-.,#/*42*[<02-#3,/%&3<,#02)#/+*((Y;*K#*;6(*<0-*%2/#3,Q&*3,)#
by each unit in Scotland.
Figure 27 Highest level of care in HDU (2011)
100%
Episodes
80%
Level 0
60%
Level 1
Level 2
40%
Level 3
* Scottish
average
20%
K2
AC1
W2
E2
V2
B2
J2
X7
I2
Y2
W4
R3
G3
L2
O3
O2
H3
R5
AA1
P3
D2
G2
C2
F2
S2
X5
*
O4
X3
Z1
H2
X4
T2
P2
I3
AB1
T3
R4
Q2
A2
W3
N2
N3
X2
0%
Unit
It is reassuring that this graph shows that the highest level of care required for the majority of HDU
episodes is at the appropriate level (level 2). There is variation in the pattern of the highest level of care
demonstrating the heterogeneous nature of HDUs.
F.,#63%6%3-*%2#%"#IJH#,6*/%),/#3,Q&*3*24#%2($#(,L,(#>#<03,#.0/#*2<3,0/,)#"3%;#DY^b#'.*<.#;0$#3,1,<-#
3,/%&3<,#*//&,/#,(/,'.,3,5#02)#<%&()#.0L,#02#,"",<-#%2#0<<,//#-%#-.,/,#<3*-*<0(#<03,#=,)/E#
Unit O4 has a markedly higher proportion of patients requiring level 3 care.
19
2.! Respiratory support
Figure 28 Invasive ventilation at any time in ICU and Combined Units (2011) Episodes with invasive ventilation at any time
100%
X6 I
L
E
V
FG
Q
D A
80%
N Y
J
X
P
ICU
W
T
Combined ICU/HDU
Specialist ICU
H
60%
O
C
K
R
M
40%
S
U
Q3
20%
0
200
400
600
800
1000
1200
Number of patient episodes There was a small reduction in the percentage of patients requiring invasive ventilation to 66%. This was in part due to more units changing from ICUs to Combined Units. H2*-/#X5#l#02)#T#.0)#0#/*42*[<02-($#.*4.,3#6,3<,2-04,#%"#60-*,2-/#3,Q&*3*24#*2L0/*L,#L,2-*(0-*%2E#H2*-#X#'0/#
again an outlier with 89% of its patients requiring invasive ventilation. This has been similar for the last three years.
R40*25#-.,#(%',3#03,0#%"#-.,#4306.#*/#)%;*20-,)#=$#-.,#G%;=*2,)#H2*-/E
Episodes with NIV or CPAP at any time
J&?K-#(2S( T*U(9$%(+<!<(-9:#1(&$(*+,(9$%(+.>G&$#%(,$&:1(;23))A
20%
N
Q
15%
Q3
I
C
A
5%
D
V
X6
E
L
F
G
ICU
Combined ICU/HDU
Specialist ICU
O
H
10%
R
W
Note: Units P and Y overlap almost completely
M
P
Y T
J
U
S
X
K
0%
0
200
400
600
800
Number of patient episodes
20
1000
1200
The incidence of this method of respiratory support remains low in ICU and Combined Units. The percentage of admissions to ICU and Combined Units receiving Non­invasive Ventilation (NIV)/
G%2-*2&%&/#O%/*-*L,#R*3'0$#O3,//&3,#8GORO:#3,;0*2,)#/-0=(,#0-#^b#*2#A>??5#=&-#.0/#"0((,2#"3%;#?@b#*2#
2008.
H2*-#a#.0)#0#/*42*[<02-($#.*4.,3#63%6%3-*%2#%"#60-*,2-/#3,<,*L*24#X!deGOROE#F.*/#&2*-#*/#-.,#20-*%20(#3,",330(#
<,2-3,#"%3#I%;,#d,2-*(0-*%2#'.*<.#;0$#0<<%&2-#"%3#-.,*3#.*4.#30-,E#I%',L,35#%L,3#-.,#(0/-#-.3,,#$,03/#-.*/#
has fallen from over 20% to 15%. Episodes with NIV or CPAP at any time
J&?K-#(E3( T*U(9$%(+<!<(-9:#1(&$(45,(;23))A(
20%
S2
I3
C2
15%
H2
O3
I2
X2
P2
Surgical
G2
General
N2
Medical
Q2
10%
B2
E2
Specialist
N3
AC1
R4
Y2
5%
T2
A2
F2
X7
W2
H3 AB1
L2
Z1
V2 G3
T3
W4
O4 W3
R5
X4
P3 X3K2 O2
D2
0%
X5
0
200
400
600
800
1000
Note: Units P3 and X3 overlap almost completely
Note: Units W2 and G3 overlap almost completely
AA1
J2
R3
1200
1400
1600
Number of patient episodes
The proportion of admissions to HDU with NIV/CPAP was stable at 6%; however the emergence of more ;,)*<0(#IJH/#.0/#;,02-#-.0-#*2#A>??#-.,3,#',3,#;%3,#%&-(*,3/#'*-.#/*42*[<02-($#.*4.,3#30-,/E#\"#-.,/,5#/*K#
were medical HDUs and two were general HDUs. Units S2 and I3 are newly established Medical HDUs with nearly 20% NIV/CPAP.
Unit X2 has consistently been an outlier. 21
2." Cardiovascular support J&?K-#(E)( ,1#(.H(V91.98:&V#(9$%D.-(9$:&N9--7@:7>&8(%-K?1(&$(*+,(9$%(+.>G&$#%(,$&:1(
(2011)
Episodes with vasoactive and /or antiarrhythmic drugs at any time
80%
Q
60%
D
A
C
40%
NP
V
L
X6 H
F
E I
G
20%
J
ICU
W
O
U
T
Y
R
S
Q3
X
K
Combined ICU/HDU
Specialist ICU
M
0%
0
200
400
600
800
1000
1200
Number of patient episodes
The proportion of patient episodes with vasoactive and/or antiarrhythmic drugs in ICU and Combined Units remained stable at 45%. J&?K-#(E2( ,1#(.H(V91.98:&V#(9$%D.-(9$:&N9--7@:7>&8(%-K?1(&$(45,(;23))A
Episodes with vasoactive and /or antiarrhythmic drugs at any time
40%
Z1
30%
Surgical
General
H2
20%
Q2
Medical
P3
AB1
T3
A2 I2
T2 W4
O2
K2
X7
N3
D2
L2
H3 B2 V2G3 X3
E2
N2
O4 X4
P2
W2
O3
W3
C2 F2
X5
R4
Y2
R5
S2
AC1
10%
0%
0
I3
200
400
600
800
AA1
G2
1000
J2
R3
1200
Specialist
X2
1400
Note: Units Y2 and C2 overlap almost completely
1600
Number of patient episodes
Use of vasoactive and/or antiarrhythmic drugs in HDU has remained stable at 10%. F.,3,#',3,#-.3,,#%&-(*,3/j#SA#.0/#<%2/*/-,2-($#=,,2#02#%&-(*,3#'.*<.#;0$#3,63,/,2-#;%3,#"%3;0(*/,)#*26&-#
from Intensivists.
22
Figure 33 Cardiac output monitoring in ICU and Combined Units (2011)
Episodes with cardiac output monitoring at any time
50%
40%
D
N
ICU
Combined ICU/HDU
Specialist ICU
30%
C
H
20%
Q
X6
L
P
I
10%
A
V
F
200
K
W
O
E
0%
0
U
G
Q3
S
J
M
Y T
400
X
R
600
800
1000
1200
Number of patient episodes There has been a fall in cardiac output monitoring over the last three years from 18% to 11%.
2.4 Renal support Figure 34 Renal Replacement Therapy in ICU and Combined Units (2011)
Episodes with RRT at any time
30%
25%
I
20%
15%
A
D
10%
5%
W
S
Combined ICU/HDU
Specialist ICU
R
U
Y
C
0
M
X
K
Q3
X6
0%
ICU
P
V H
O
L N
T
G
E
J
Q
F
200
400
600
800
1000
1200
Number of patient episodes
The provision of renal replacement therapy (RRT) across Scotland remained stable at 12%.
23
Section 3 Outcomes
Figure 35 Scottish crude mortality of patients in ICU and Combined Units (2002­2011)
40%
35%
Ultimate hospital
Mortality
30%
Hospital
ICU
25%
Note: Only includes patients with mortality prediction.
20%
15%
10%
5%
0%
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
Year
Crude mortality in patients admitted to ICU continues to improve year on year in Scotland. This year a total of 21.8% of patients died before their ultimate discharge from hospital. Conversely 78.2% of patients survived critical illness and intensive care admission and were discharged from acute hospital care. A continued improvement has been seen in intensive care mortality. In 2011 unit mortality was 15.2% down =$#AE@#6,3<,2-04,#6%*2-/#%2#A>?>M/#[4&3,E#F.*/#3,/&(-#*/#=0/,)#%2#^^i>#3,<%3)/#02)#?@CC#),0-./#*2#!GH/#
across Scotland. This continues a year on year trend but is a somewhat larger reduction in mortality than that seen in previous years. There have also been smaller improvements in both hospital and ultimate hospital mortality. Figure 36 Scottish Standardised Mortality Ratios in ICU and Combined Units (2002­2011) Standardised Mortality Ratio
1.10
1.05
1.00
0.95
0.90
0.85
0.80
0.75
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
Year
It is not possible to determine from crude mortality whether this is a result of real changes in outcomes across Scotland in 2011 or simply a different case­mix compared with that seen in previous years. 24
Adjustment for case­mix removes this uncertainty. It is clear from Figure 36 that year on year standardised mortality ratios (SMR) across Scotland continue to fall. SMR is the observed mortality divided by the expected mortality as predicted on a population basis from the APACHE II scoring that is carried out on patients admitted to ICUs and Combined Units. It can be seen from the error bars that the SMR in 2011 is now statistically different from any year before 2010 as the error bars do not overlap.
It is planned that SICSAG will recalibrate the APACHE II model that the SMR is based on in time for next $,03M/#3,6%3-E#F.*/#'*((#.0L,#-.,#,"",<-#%"#06603,2-($#*2<3,0/*24#-.,#PZa#"%3#P<%-(02)E#P,,#-.,#',=/*-,#"%3#
more details on this work www.sicsag.scot.nhs.uk Comment on funnel plots for Standardised Mortality Ratios
SICSAG will always highlight units outside 2 SD from the mean as “might be different” and outside 3 SD as “are different”. It should be recognised that in a comparison of 25 units there is a considerable chance of an outlier at the 2 SD (5% or 1 in 20) level. \L,3#-.,#-*;,#-.0-#-.,#0&)*-#.0/#=,,2#*2#,K*/-,2<,5#L03*%&/#&2*-/#.0L,#=,,2#%&-(*,3/#0-#A#PJ#(,L,(E#N,#.0L,#
sought reasons as to why they might be different and informed and supported individual units in seeking an explanation. No unit has been a consistent outlier over years. Being an outlier at this level may be ,K6(0*2,)#=$#)0-0#Q&0(*-$5#Q&,/-*%2/#%L,3#/-02)03)/#%"#<03,5#)*"",3,2-#3,",330(#60--,32/5#0);*//*%2#6%(*<*,/#
%3#3,/%&3<,/#=&-#*-#0(/%#;0$#=,#)&,#-%#302)%;#L03*0-*%2E#F.,3,"%3,5#',#03,#&/*24#0#L,3$#/-3*24,2-#),[2*-*%2#
%"#L03*02<,E#c%3#<%;603*/%25#I%/6*-0(#PZa/7 produced for the Scottish Patient Safety Programme by Information Services Division will use 3 SD level to identify outliers.
Figure 37 Standardised Mortality Ratios in ICU and Combined Units (2011)
Standardised Mortality Ratio
1.1
1.0
0.9
A E
T
V
M
0.8
N
I
H
C
Q
D
0.6
Y
O
ICU
K
R
Combined ICU/HDU
Specialist ICU
W
X
P
G
0.7
J
L
F
U
S
Q3
0.5
0
50
100
150
200
250
Expected mortality
300
350
Note: X6 do not collect this data due to the majority of their patients being admitted following coronary artery bypass surgery. These patients are excluded from APACHE II scoring4.
Note: Units S and U overlap completely
Figure 37 shows the SMR for ICU and Combined Units (excluding X6). These data have now been publicly 0L0*(0=(,#"%3#-.,#(0/-#[L,#$,03/E#
!-#*/#6(,0/*24#-%#2%-,#-.*/#$,03#-.0-#"%3#-.,#[3/-#-*;,#*2#-.3,,#$,03/#0((#&2*-/#.0L,#02#PZa#=,(%'#-.,#&66,3#
<%2[),2<,#(*;*-#8-.,#A#PJ#0=%L,#-.,#;,02#(*2,:#02)#/%#-.,3,#03,#2%#.*4.#PZa#%&-(*,3/#'*-.#02#,(,L0-,)#
SMR that may be statistically different from the other units. H2*-#S@#'0/#=,(%'#-.,#(%',3#A#PJ#(*2,#02)#-.*/#&2*-#;0$#=,#/-0-*/-*<0(($#)*"",3,2-#"3%;#%-.,3#&2*-/#*2#
Scotland.
25
Figure 38 Standardised Mortality Ratios with pre­sedation GCS in ICU and Combined Units (2011)
Standardised Mortality Ratio
1.1
1.0
0.9
V
A
0.8
E
0.7
C
0.6
D
Q
M
I
H
G
Y
ICU
O
T
N
K
J
P
L
U
F S
Combined ICU/HDU
Specialist ICU
R
W
X
Q3
0.5
0
50
100
150
200
250
300
350
Note: Units S and U overlap almost completely
Note: Units E and M overlap almost completely
Note: Units O and T overlap completely
Expected mortality
F.,#V(0/4%'#G%;0#P<0(,#8VGP:#3,<%3),)#*2#-.,#[3/-#A]#.%&3/#*2#&2*-#*/#0#<%;6%2,2-#%"#-.,#RORGI9#!!#
;%3-0(*-$#63,)*<-*%2#;%),(E#!"#0#60-*,2-#.0/#3,<,*L,)#/,)0-*%2#0"",<-*24#-.,*3#VGP#"%3#0((#%"#-.*/#6,3*%)#8[3/-#
A]#.%&3/:5#-.,2#02#0<<&30-,#VGP#'*((#2%-#=,#0L0*(0=(,#02)#-.,#;%),(#0//&;,/#0#2%3;0(#L0(&,5#),10-*24#-.,#
63,)*<-,)#;%3-0(*-$E#R2#0(-,320-*L,#-%#0//&;*24#-.,#2%3;0(#L0(&,#%"#VGP#*/#-%#&/,#-.,#63,Y/,)0-*%2#VGP5#
which is recorded prior to the patient being sedated in another unit (eg on admission to the emergency department prior to intubation). This may increase the predicted mortality and thus the overall SMR is lower when using pre­sedation GCS.
!2#c*4&3,#@^5#-.,#&2*-/#03,#43%&6,)#<(%/,3#-%4,-.,3#02)#0((#&2*-/#03,#'*-.*2#-.,#&66,3#02)#(%',3#A#PJ#
<%2[),2<,#(*;*-/E#R/#/&<.#-.,3,#*/#2%#/-0-*/-*<0(#)*"",3,2<,#=,-',,2#02$#%"#-.,#&2*-/#*2#A>??E#
26
Conclusions The SICSAG audit remains a comprehensive report of activity and outcome from critical care across the entire Scottish population.
P!GPRV#<%2-*2&,/#-%#43%'#02)#),L,(%65#02)#.0/#"&(($#,2404,)#'*-.#-.,#P<%--*/.#V%L,32;,2-#I,0(-.<03,#
S&0(*-$#R4,2)0E#N,#<%2-*2&,#-%#<%((0=%30-,#'*-.#%-.,3#=%)*,/#*2#P<%-(02)#*2#6&3/&*-#%"#-.*/E
The downward trend in crude and case­mix adjusted mortality continues year on year. While this may *2#603-#3,1,<-#<.024*24#;%),(/#%"#<03,#'*-.#0#.*4.,3#63%6%3-*%2#%"#=,)/#63%L*),)#*2#G%;=*2,)#H2*-/5#*-#
63%=0=($#0(/%#3,1,<-/#*;63%L*24#/-02)03)/#%"#<03,E
N.*(,#-.,3,#*/#/%;,#L03*0-*%2#*2#630<-*<,#0<3%//#<3*-*<0(#<03,#&2*-/5#',#/.%&()#0((#=,#3,0//&3,)#-.,3,#'0/#2%#
(0/-*24#/*42*[<02-#L03*0-*%2#*2#%&-<%;,/#"3%;#<3*-*<0(#*((2,//#0<3%//#-.,/,#&2*-/E
G3*-*<0(#<03,#&2),36*2/#,;,34,2<$#02)#,(,<-*L,#0<-*L*-$#*2#0((#%&3#0<&-,#.%/6*-0(/E#R/#/,3L*<,/#<.024,5#*-#*/#
vital that SICSAG continues to provide scrutiny and benchmarking which informs healthcare providers and the public.
27
Critical Care Capacity (Funded Beds) 2011
Hospital
ICU/Combined Units Level 3/2
NHS Ayrshire and Arran
AYR Crosshouse
VHK
NHS Forth Valley
SRI FVRH Specialist ICU
Level 2/1
4
5
9
7 Closed 13/7/2011
7/12 Opened 11/7/2011
4 SHDU
8 MHDU/CCU
8 SHDU
5 MHDU
3 MHDU
2 Renal HDU 01/01/11
10 HDU Closed 13/7/2011
12.5 8 SHDU (31/32)
9 SHDU (35) Dr Gray’s
10 HDU
NHS Greater Glasgow and Clyde
GRI 9
12 SHDU
Combined with 8 30/5/2011
HDU 21/3/11
12/4 !!12/8
30/5/2011
IRH
3
4 SHDU1
12 HDU
RAH
7
Stobhill
4 4 SHDU
Closed Closed 20/3/2011
20/3/2011
SGH
5
6 SHDU
WIG/
GGH
Level 2/1
4 HDU 8/4 SHDU
8/4 MHDU
NHS Grampian
ARI
VIG
Specialist HDU
Level 3
NHS Borders
BGH 3/2
NHS Dumfries and Galloway
DGRI
4
NHS Fife
QMH HDU
5
7 8 21/3/2011
8 SHDU
4 HDU 8 HDU
28
4 Neuro 6 Neuro 6 Neuro Hospital
*+,D+.>G&$#%(
Units HDU
Specialist ICU
W#V#0(2D)
W#V#0(ED2
NHS Highland
Raigmore
7 6 SHDU
4 MHDU
2 HDU
2EDXD23))
MDGH
5.2
Wishaw
NHS Lothian
RIE
5.3
4 MHDU
)D6D23))
8 SHDU
4 MHDU
6.7 SHDU
16/2
10 HDU
3.2/1.8
10/6
6/4 SHDU
SJH
WGH
NHS Shetland
GBH
NHS Tayside
Ninewells
PRI
NHS Western Isles
WIH
Total3
W#V#0(2D)
Level 3
Belford NHS Lanarkshire
Hairmyres
Specialist HDU
5.25/4
9 Cardio
)LD)3D23)) 6 + 2 Renal/ HDU
4 Transplant 0/4 Vascular 8 Cardio )LD)3D23))
4 Neuro
0/3 Neuro 1 HDU2
7.5
10 SHDU
6 MHDU
3
4 HDU
)XEDEP
4 HDU 23)D)P
W,$U#
MHDU ­ Medical HDU
SHDU ­ Surgical HDU
Neuro ­ Neurological
Cardio ­ Cardiothoracic
Changes or new units to the audit in 2011 are in red text.
Note: 1 Predominantly surgical but admits medical patients.
2 No allocated funding.
@## F%-0(/#03,#=0/,)#%2#"&2),)#=,)/#0-#-.,#,2)#%"#A>??#02)#[4&3,/#03,#3%&2),)E
29
15
EPDL
Location of Critical Care Units in Scotland (2012)
This map only includes units participating in SICSAG.
P
Health Board
Greater Glasgow & Clyde
Lothian
Lanarkshire
Grampian
Tayside
Fife
Ayrshire & Arran
Highland
Forth Valley
Dumfries & Galloway
Borders
Western Isles
Shetland Islands
Orkney Islands
<."K09:&.$
?5A?>5AC]
^]^5BAB
CD@5?^C
CCC5A^>
]>C5BA?
@DB5AiA
@DD5^i>
@??5iD>
AiC5C]?
?]^5>D>
??@5?C>
AD5>^>
AA5C>>
A>5?D>
AB1
AA1
AC1
ICU and/or HDU participating in audit 8(,--,3#<%33,/6%2)/#-%#.%/6*-0(#+,$#%2#<%L,3#106: J0-0#*2#2,K-#$,03M/#3,6%3-
30
Appendix 1 ICU profiles 2012 <9-:()Y(+9"98&:@(9$%(ZK0:&N%&18&"0&$9-@(M#9>(*$H.->9:&.$
Hospital
AYR
Crosshouse
BGH
DGRI
dIW
FVRH
ARI
GRI
IRH
RAH
SGH General
SGH Neuro
VIG
WIG
Raigmore
Hairmyres
MDGH
Wishaw RIE
PTI
WGH
Ninewells
PRI
Actual beds
5
6
9
6
10
19
16
20
4
8
6
9
5
9
8
10
6
6
19
7
16
9
3
Funded Trained ICU Daily beds nursing pharma­
contact ;W#V#0(ED2A [M=D0#V#0(
cist
from micro­
3 bed biologist
4
6.50
Yes
No
5
6.70
No
Yes
3/2
6.42
Yes
Yes
4
8.10
Yes
Yes
9
6.56
Yes
Yes
7/12
6.70
Yes
Yes
12.5
6.80
Yes
Yes
12/8
5.79
Yes
Yes
3
5.50
Yes
Yes
7
6.00
Yes
Yes
5
6.56
Yes
Yes
6
5.85
Yes
Yes
5
5.90
Yes
Yes
8
5.90
Yes
Yes
7
6.86
Yes
No
5.25/4
5.63
Yes
Yes
5.2
5.38
Yes
Yes
5.3
5.17
Yes
No
16/2
5.97
Yes
Yes
3.2/1.8
6.53
Yes
Yes
10/6
6.30
Yes
Yes
7.5
5.50
Yes
Yes
3
7.00
Yes
Yes
31
Daily physio­
therapy review
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Dietetic review for all patients
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
<9-:(2Y(Z#%&890(B:9HH(*$H.->9:&.$
Hospital
Weekday ward rounds done by ICM Consultant
AYR
Yes
Crosshouse Yes
Weekend Source of trainees ward rounds done by ICM Consultant
No
Anaesthetic; ACCS
Yes
Anaesthetic; ACCS
BGH
Yes
No
Anaesthetic; FY2 and above; Staff grades
DGRI
Yes
Yes
Anaesthetic
dIW
Yes
Yes
FVRH
Yes
Yes
Anaesthetic; ACCS; Specialty Doctor
Anaesthetic;FY2;FY1
ARI
Yes
Yes
GRI
Yes
Yes
IRH
RAH
No
Yes
No
Yes
SGH General
SGH Neuro
VI
WIG
Raigmore
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
No
Hairmyres
Yes
No
MDGH
Yes
Yes
Wishaw Yes
No
Trainees cover Advanced other areas Critical Care <-98:&:&.$#-1
Yes
Emergency theatre OOH
OOH cover "%3#-.,0-3,/5#
obstetrics and A&E
Emergency theatre OOH
No
No
No
No
No
No
Yes­ Yes
“Anaesthesia at night” covers critical care at night.
Anaesthetic; ACCS; Acute No
Yes
Medicine; Emergency Medicine; FY1; General Surgery; Core medical training; Clinical fellows
Anaesthetic; ACCS; No
No
Emergency Medicine
Anaesthetic; Staff grade
Yes
No
Anaesthetic; ACCS; Acute No
No
medicine; Emergency Medicine
Anaesthetic; ACCS
No
No
Anaesthetic
Anaesthetics; ACCS
Anaesthetic; ACCS
Anaesthetic; ACCS; Emergency Medicine; FY1
Anaesthetic; ACCS
Yes
No
No
Yes
No
No
No
No
Emergency theatre OOH
No
Yes
Anaesthetic; ICM to advanced; ACCS; Medical STs; Critical Care O30<-*-*%2,3/5
Anaesthetic; ACCS; FY1
No
32
Yes
Yes <9-:(2Y(Z#%&890(B:9HH(*$H.->9:&.$
Hospital
RIE
PTI
WGH
Ninewells
PRI
Weekday Weekend Source of trainees ward rounds ward rounds done by ICM done by ICM Consultant
Consultant
Yes
Yes
FY2; ACCS Anaesthesia; Acute Medicine; Emergency Medicine; ST 1­2 Anaesthesia; ST 4 Emergency Medicine; ST 3­7 Anaesthesia; ST 3­7 ICM Yes
No
Anaesthetic
Yes
Yes
Anaesthetic; ACCS; Acute Medicine; Emergency Medicine
Yes
Yes
Anaesthetic; ACCS; Acute Medicine; Emergency Medicine
Yes
Yes
Anaesthetic; ACCS
33
Trainees cover Advanced other areas Critical Care <-98:&:&.$#-1
No
Yes
Yes
No
No
Yes
No No
F.,0-3,5#
No
0<&-,#60*25#
3,/&/<*-0-*%25##
and hospital at night/weekend
<9-:(EY(\K90&:@(*>"-.V#>#$:(Z#91K-#1(;1$9"(17.:(.$0@A
Hospital
AYR
MDT ward round ­ 59@1DR##]
5/7
MDT ward round attendees
M & M meetings ­ frequency
M & M attendees
Type of Data incident to reporting B<B<
Type of care bundle
Medical; Nursing; Pharmacy
Monthly
Medical; Nursing
Datix
Yes
SPI­2 moved on to SPSP
Crosshouse 7/7
Medical; Nursing; Physio/
microbiology/
dietetic input as available
Weekly
Medical; Nursing
Datix; Incident report forms via anaesthetic dept
Yes
VAP prevention; CVC insertion & maintenance; PVC insertion & maintenance
BGH
7/7
Medical; Nursing; Outreach; Pharmacy; Microbiology.
S&03-,3($
Medical; Nursing; Referring specialists
Datix
Yes
VAP prevention; CVC insertion & maintenance; PVC insertion & maintenance
DGRI
7/7
Medical; Nursing
Monthly
Medical staff
Datix
Yes
VAP prevention; CVC insertion & maintenance
dIW
5/7
Medical; Nursing; Pharmacy; Microbiology
Monthly
Medical; Nursing
Datix
Yes
VAP prevention; CVC insertion & maintenance; PVC insertion & maintenance
FVRH
7/7
Medical; Nursing
Monthly
Medical staff
IR1 and Yes
departmental critical incident reporting
VAP prevention; CVC insertion & maintenance; PVC insertion & maintenance
ARI
5/7
Medical; Nursing; Pharmacy
Weekly
Medical and others if available
Datix; Critical Yes
incident
VAP prevention; CVC insertion & maintenance; PVC insertion & maintenance
GRI
7/7
Medical; Nursing; Pharmacy; Dietetics; Physiotherapy
Monthly
Medical; Nursing; Pharmacy
Datix
Yes
VAP prevention; CVC insertion & maintenance; PVC insertion & maintenance; Sepsis
IRH
1/7
Medical; Nursing; Pharmacy; Microbiology
S&03-,3($
Medical Datix; Critical Yes
staff; Other incident specialities by reporting
invitation
VAP prevention; Sepsis
RAH
5/7
Medical; Nursing; Pharmacy; Dietetics
Weekly
Medical; Datix
Nursing; Pharmacy; Dietetics; Physiotherapy; Microbiology
Yes
VAP prevention; CVC insertion & maintenance; PVC insertion & maintenance; A line
SGH General
5/7
Medical; Nursing; Pharmacy; Physiotherapy
Monthly
Medical; Nursing
Yes
VAP prevention; CVC insertion & maintenance
34
Datix
<9-:(EY(\K90&:@(*>"-.V#>#$:(Z#91K-#1(;1$9"(17.:(.$0@A
Hospital
MDT ward round ­ 59@1DR##]
MDT ward round attendees
M & M meetings ­ frequency
M & M attendees
Type of Data incident to reporting B<B<
Type of care bundle
SGH Neuro
6/7
Medical; Surgeons; Nursing
S&03-,3($
Medical; Datix
Nursing (surgeons have separate monthly M & M meeting)
Yes
VAP prevention; CVC insertion & maintenance
VIG
5/7
Medical; Nursing; Pharmacy; Dietetics; Microbiology
Weekly
Medical; Datix
Nursing; Physiotherapy; Microbiology
Yes
VAP prevention; CVC insertion & maintenance; Thrombo­
prophylaxis
WIG
7/7
Medical; Nursing; Pharmacy
Weekly
Medical; Datix
Nursing; Physiotherapy; Microbiology; Pharmacy
Yes
VAP prevention; CVC insertion & maintenance; PVC insertion & maintenance; Thrombo­
prophylaxis
Raigmore
5/7
Medical; Nursing; Pharmacy; Dietetics; Physiotherapy
Monthly
Medical staff
Datix and local
Yes
VAP prevention; CVC insertion & maintenance; PVC insertion & maintenance; Arterial line; Urinary catheter; Skin; Mouthcare/
eyecare
Hairmyres
5/7
Medical; Nursing; Pharmacy; Microbiology
Every 6­8 weeks
Medical staff
Datix; ITU Incident Report forms
Yes
VAP prevention; CVC insertion & maintenance; PVC insertion & maintenance
MDGH
1/7
Medical; Nursing; Pharmacy; Dietetics; Physiotherapy
Monthly
Medical; Nursing
Datix and WHO ICU trigger tool
Yes
VAP prevention; CVC insertion & maintenance; PVC insertion & maintenance
Wishaw 5/7
Medical; Nursing; Pharmacy; Microbiology
Weekly
Medical; Nursing; Microbiology; Pharmacy
Datix and in­
house
Yes
VAP prevention; CVC insertion & maintenance; PVC insertion & maintenance
RIE
5/7
Medical; Nursing; Pharmacy; Advanced Critical Care Practitioners
Weekly
Medical; Nursing; P-&),2-/5##
Advanced Critical Care Practitioners
Datix
Yes
VAP prevention; CVC insertion & maintenance; PVC insertion & maintenance; Blood cultures
PTI
7/7
Medical; Nursing; Pharmacy Dietetics
Monthly
Medical staff
Datix
Yes
VAP prevention; CVC insertion & maintenance; PVC insertion & maintenance
35
<9-:(EY(\K90&:@(*>"-.V#>#$:(Z#91K-#1(;1$9"(17.:(.$0@A
Hospital
MDT ward round ­ 59@1DR##]
MDT ward round attendees
M & M meetings ­ frequency
M & M attendees
Type of Data incident to reporting B<B<
Type of care bundle
WGH
5/7
Medical; Weekly
Nursing; Pharmacy Dietetics; Physiotherapy; Microbiology
Medical; Nursing; Pharmacy
Datix
Yes
VAP prevention; CVC insertion & maintenance; PVC insertion & maintenance
Ninewells
5/7
Medical; Every 6 Nursing; weeks
Physiotherapy; Pharmacy; Renal
Medical staff
IR1
Yes
VAP prevention; CVC insertion & maintenance; PVC insertion & maintenance; Glucose; Extubation; Reintubation; Early discharge; Readmission
PRI
1/7
Medical; Nursing; Physiotherapy
Medical staff
Anaesthetic incident forms
Yes
VAP prevention; CVC insertion & maintenance; PVC insertion and maintenance
N,,+($5#0/#
part of the MDT round
36
Appendix 2 HDU profiles 2012
<9-:()Y(+9"98&:@(9$%(ZK0:&N%&18&"0&$9-@(M#9>(*$H.->9:&.$
Hospital
Ayr HDU
Crosshouse Surgical HDU
Crosshouse Medical HDU
DGRI Medical HDU
DGRI Surgical HDU
dIW#P&34*<0(#
HDU
dIW#Z,)*<0(#
HDU
dIW#a,20(#
HDU
ARI Surgical HDU (31/32)
ARI Surgical HDU (35)
Funded Nursing Dedicated Dedicated W#V#0(2D)( [M=DW#V#0(
HDU HDU beds 2 bed
Consultant pharmacist
N(%9@1D
week
4
3.06
0
Yes
8/4
2.45
0
Yes
Micro­
biologist ­ daily contact
<7@1&.N
Dietetic therapy review for review ­ all patients
daily
No
No
Yes
Yes
Yes
Yes if referred
No
8/4
2.67
0
Yes
Yes
Yes
8
3.15
0
No
No
No
4
4.17
0
Yes
No
Yes
8
3.12
5/7
Yes
No
Yes
8
2.61
0
Yes
No
Yes
Yes if referred
Yes if referred
Yes if referred
Yes 3 Shared with renal ward
8
1.81
0
No
Yes
Yes
Yes
0
Yes
No
Yes
Yes
9
2.00
0
No
No
No
ARI Neurological HDU
4
2.00
0
No
Yes
Dr Gray's HDU
GRI Surgical HDU
GRI Medical HDU
IRH Surgical HDU
RAH HDU
10
2.08
0
Yes
No
Not weekends unless requested
Not weekends unless requested
Yes
8
2.82
0
Yes
Yes
Yes
Yes if referred
Yes
6
1.50
5/7
Yes
No
Yes
No
4
2.00
0
Yes
No
Yes
Yes
12
2.87
0
Yes
No
Yes
SGH Surgical HDU
6
3.16
0
Yes
No
SGH Neurological HDU
6
3.00
0
Yes
No
Not weekends unless requested
Yes
Yes if referred
Yes if referred
37
Yes
Yes
<9-:()Y(+9"98&:@(9$%(ZK0:&N%&18&"0&$9-@(M#9>(*$H.->9:&.$
Hospital
VI Surgical HDU
Funded Nursing Dedicated Dedicated W#V#0(2D)( [M=DW#V#0(
HDU HDU beds 2 bed
Consultant pharmacist
N(%9@1D
week
8
2.13
0
Yes
Micro­
biologist ­ daily contact
Yes
Yes
Yes
No
2.94
7/7
0­5 Depending on leave 0
Not weekends unless requested
Yes
Yes
Yes
No
Yes
4
3.15
0
No
No
Belford HDU
2
0.305
0
No
No
Hairmyres MHDU
4
1.89
0
Yes
No
MDGH Surgical HDU
MDGH Medical HDU
Wishaw Surgical HDU
RIE HDU
8
2.58
0
Yes
No
Not weekends unless requested
Not weekends unless requested
Not weekends unless requested
Yes
4
2.40
5
WIG HDU
GGH HDU
4
8
2.95
2.75
Raigmore Surgical HDU
Raigmore Medical HDU
6
No
<7@1&.N
Dietetic therapy review for review ­ all patients
daily
Yes if referred
Yes if referred
Yes if referred
Yes
Yes if referred
Yes if referred
Yes if referred
Yes
No
No
No
2.35
5/7 Shared with CCU
0
Yes
Yes
Yes
10
3.00
5/7
Yes
No
Yes
RIE Renal HDU
8
3.4
0
Yes
No
RIE Transplant HDU
4
Established within a wider budget
0/4 Shared with vascular ward
6/4
3.07
0
No
Yes
0
No
No
Not weekends unless requested
Not weekends unless requested
Yes
Yes if referred
Yes if referred
Yes
0
Yes
No
If referred
3.43 5 sessions/
week
No
No
Yes
RIE Vascular (Level 1)
WGH Surgical HDU
WGH Neurological (Level 1)
4/3
38
Yes
Yes if referred
Yes if referred
Yes
<9-:()Y(+9"98&:@(9$%(ZK0:&N%&18&"0&$9-@(M#9>(*$H.->9:&.$
Hospital
Balfour HDU
GBH HDU
Ninewells Surgical HDU
Ninewells Medical HDU
PRI HDU
WIH HDU
Funded Nursing Dedicated Dedicated Micro­
<7@1&.N
Dietetic W#V#0(2D)( [M=DW#V#0(
HDU HDU biologist therapy review for beds 2 bed
Consultant pharmacist
­ daily review ­ all patients
N(%9@1D
contact
daily
week
2 Resourced 2/7
No
Yes (from Yes
Yes
from the NHS Acute Ward Grampian)
A#=,)/5#603-#
From 5/7
No
No
Not Yes if of general surgical weekends referred
surgical ward as unless ward required
requested
funding
10
4.4
0
Yes
Yes
Yes
Yes
6
3.33
0
No
No
Yes
4
3.19
0
Yes
No
Yes
4
1.4
0
Yes
No
If referred ­ no weekend cover
39
Yes if referred
Yes if referred
Yes if referred
<9-:(2Y(\K90&:@(*>"-.V#>#$:(Z#91K-#1(;1$9"(17.:(.$0@A
Hospital
Ayr HDU
MDT MDT ward M & M M & M ward round meetings ­ attendees
rounds ­ attendees frequency
%9@1D
week
None
n/a
None
n/a
Type of Data to incident B<B<
reporting
Datix
Yes
Type of care bundle
CVC insertion & maintenance; PVC; Hand hygiene;
CVC insertion & maintenance; PVC; Skin care
CVC insertion & maintenance; PVC;CAUTI
CVC insertion & maintenance
None
Crosshouse None
Surgical HDU
n/a
Surgical M Medical staff
& M
Datix
Yes
Crosshouse None
Medical HDU
n/a
None
n/a
Datix
Yes
DGRI Medi­ None
cal HDU
DGRI Surgi­ None
cal HDU
dIW#P&34*<0(# None
HDU
n/a
None
n/a
Datix
Yes
n/a
None
n/a
Datix
Yes
n/a
Monthly
Medical staff
Datix
Yes
n/a
None
n/a
Datix
Yes
Medical; S&03-,3($
Medical; Nurs­ Datix
Nursing; ing Physiother­
apy; Oc­
cupational Therapy; Dietetics
n/a
Six monthly Open to MDT Datix
Yes
CVC insertion & maintenance; PVC; CDiff
Yes
ARI Surgical None
HDU (35)
n/a
Two monthly
Open to MDT
Datix
Yes
ARI Neuro­
logical HDU
Dr Gray's HDU
None
n/a
None
n/a
Datix
Yes
None
n/a
Monthly
Open to MDT
Datix
Yes
Medical; Nursing; Dietetics; Specialist nurse
Monthly
Medical; Ward Datix
nursing staff Yes
CVC insertion & maintenance; PVC; Hand hygiene; SBAR; Safety brief
CVC insertion & maintenance; PVC
PVC; Catheter care
CVC insertion & maintenance; PVC; CDAD; CAUTI CVC insertion & maintenance; PVC; SBAR; Daily Goals
dIW#Z,)*<0(# None
HDU
dIW#a,20(# 3/7
HDU
ARI Surgical None
HDU (31/32)
GRI Surgical Variable
HDU
40
CVC insertion & maintenance; PVC; CDiff
CVC;PVC
<9-:(2Y(\K90&:@(*>"-.V#>#$:(Z#91K-#1(;1$9"(17.:(.$0@A
Hospital
MDT MDT ward M & M M & M Type of Data to Type of care ward round meetings ­ attendees
incident B<B<
bundle
rounds ­ attendees frequency
reporting
%9@1D
week
GRI Medical None
n/a
Two Medical; Nurs­ Datix
Yes
JWRj#P,6/*/
HDU
monthly
ing
IRH Surgical None
n/a
Monthly
Open to MDT Datix
Yes
CVC insertion HDU
& maintenance; Safety brief; SBAR; Hand hygiene; Cath­
eter care
RAH HDU
7/7
Medical; Monthly
Surgical M & Datix
Yes
CVC insertion Nursing
M ­ clinicians & maintenance; only Medical M PVC; Hand & M ­ Medical hygiene; Multi & nursing staff disciplinary rounds; Daily Goals; Safety brief
SGH Surgical None
n/a
Monthly
Medical staff
Datix
Yes
CVC insertion HDU
& maintenance; SBAR; Daily goals; Safety brief; Hand hy­
giene; PVC
SGH Neuro­ 7/7
Medical; None
n/a
Datix
Yes
CVC insertion logical HDU
Nursing; & maintenance; Physiother­
PVC; PAC/
apy
PPW!X
VI Surgical None
n/a
Monthly Medical; Nurs­ Datix
Yes
CVC insertion HDU
surgical M ing
& maintenance; & M. Six PPW!Xj#GS!
monthly combined anaesthetic M & M
WIG HDU
7/7
Medical; Weekly
Medical; Nurs­ Datix
Yes
CVC insertion Nursing; ing; Microbiol­
& maintenance; Pharmacy
ogy; Pharmacy
PVC; Arterial line
GGH HDU
0­5
Medical; None
n/a
Datix
Yes
CVC insertion Nursing; & maintenance; Pharmacy
PVC
Raigmore 7/7
Medical; Weekly
Medical staff
Datix
Yes
CVC insertion Surgical HDU
Nursing
& maintenance; PVC; Skin care
Raigmore None
n/a
None
n/a
Datix
Yes
CVC insertion Medical HDU
& maintenance; PVC; Safety brief; SBAR
41
<9-:(2Y(\K90&:@(*>"-.V#>#$:(Z#91K-#1(;1$9"(17.:(.$0@A
Hospital
MDT MDT ward M & M M & M ward round meetings ­ attendees
rounds ­ attendees frequency
%9@1D
week
Belford HDU 5/7
Medical; Weekly Medical staff
X&3/*245#
with Raig­
Physiother­ more. apy; Oc­
Belford cupational presents Therapy; 2 monthly Pharmacy at these meetings. Hairmyres 5/7
Medical None
n/a
MHDU
staff; Nurs­
ing; HECT (hospital emergency care team)
MDGH Surgi­ 7/7
Medical; None
n/a
cal HDU
Nursing; Physiother­
apy
MDGH Medi­ 5/7
Medical; None
n/a
cal HDU
Nursing
Type of Data to incident B<B<
reporting
Datix.
Yes
CVC insertion & maintenance; Arterial line
Datix
Yes
CVC insertion & maintenance; PVC
Datix
Yes
Datix
Yes
CVC insertion & maintenance; PVC; Arterial line
CVC insertion & maintenance; PVC
CVC insertion & maintenance; PVC; Blood glucose; Hand hygiene; MDT rounds; Daily goals
CVC insertion & maintenance; PVC
CVC insertion & maintenance; PVC; CDiff; Name bands; Falls; FFN; MUST; PAC; Arterial line; Drains
CVC insertion & maintenance; PVC; CDiff; VTE
Wishaw Sur­
gical HDU
None
n/a
None
n/a
Datix
Yes
RIE HDU
None
n/a
Weekly
Medical; Nurs­ Datix
ing
Yes
RIE Renal HDU
2/7
Medical; Nursing: Dietetics; Pharmacy
Two monthly
Medical; Nurs­ Datix
ing; Others as required
Yes
RIE Trans­
plant HDU
5/7
Medical; Nursing: Dietetics; Pharmacy
Monthly
Medical Staff
Yes
42
Type of care bundle
Datix
<9-:(2Y(\K90&:@(*>"-.V#>#$:(Z#91K-#1(;1$9"(17.:(.$0@A
Hospital
MDT MDT ward M & M M & M ward round meetings ­ attendees
rounds ­ attendees frequency
%9@1D
week
RIE Vascular 5/7
Medical; Monthly
Medical Staff
(level 1)
Nursing; Physi­
otherapy; Dietetics
WGH Surgi­
cal HDU
Type of Data to incident B<B<
reporting
Datix
Yes
None
n/a
None
n/a
Datix
Yes
WGH Neuro­ None
logical/Level 1 HDU
Balfour HDU 7/7
n/a
Monthly
Medical Staff
Datix
Yes
Medical; Nursing
Two monthly
Medical; Nurs­ Datix
ing
Yes.
Medical; Nursing
Monthly
Ninewells None
Surgical HDU
n/a
None
Medical; Nurs­ Datix
Yes
ing; Physio­
therapy; Phar­
macy; Clinical governance staff
n/a
!a?5#H/*24# Yes
the AIM reporting system
Ninewells 7/7
Medical HDU
Medical; Nursing
Every six weeks
PRI HDU
Medical; None
Nursing; Physiother­
apy
GBH HDU
7/7
7/7
Open to MDT
n/a
43
!a?5#H/*24# Yes
the AIM reporting system
IR1 re­
Yes
porting
Type of care bundle
CVC insertion & maintenance; PVC; MUST; Name band; Falls; CDiff; SEWS; Dis­
charge; Daily goals
CVC insertion & maintenance; PVC; FFN; PAC; SEWS
CVC insertion & maintenance; PVC
CVC insertion & maintenance; PVC; CAUTI
CVC insertion & maintenance; PVC; Respira­
tory care
CVC insertion & maintenance; PVC ;MUST; Pressure Ulcer; Falls ;Skin bun­
dle; Epidural; Tracheostomy; Drain; Wound; Arterial Line
CVC insertion & maintenance; PVC; Arterial line
CVC insertion & maintenance; PVC; Pressure ulcer
<9-:(2Y(\K90&:@(*>"-.V#>#$:(Z#91K-#1(;1$9"(17.:(.$0@A
Hospital
WIH HDU
MDT MDT ward M & M M & M ward round meetings ­ attendees
rounds ­ attendees frequency
%9@1D
week
None
n/a
None
n/a
44
Type of Data to incident B<B<
reporting
Datix
Yes
Type of care bundle
CVC insertion & maintenance; VAP preven­
tion; PVC; Hand hygiene
Appendix 3 Methodology 3.1 Data collection
J0-0#',3,#<%((,<-,)#63%/6,<-*L,($#"3%;#0((#4,2,30(#0)&(-#!GH/5#G%;=*2,)#H2*-/#02)#-.,#;0_%3*-$#%"#IJH/#
&/*24#-.,#N03)N0-<.,3#/$/-,;#),L,(%6,)#"%3#-.*/#6&36%/,E#!2#Z03<.#A>?A5#02#*2*-*0(#,K-30<-#%"#A>??#)0-0#
'0/#/,2-#-%#!PJ#/,3L,3/E#d0(*)0-*%2#Q&,3*,/#3,(0-*24#-%#)*/<.034,/5#%&-<%;,/5#04,/#02)#;*//*24#-3,0-;,2-#
information were then issued and fed back to individual units for checking by local and regional audit <%%3)*20-%3/E#R#[20(#L0(*)0-,)#,K-30<-#'0/#/&=;*--,)#-%#!PJ#*2#R63*(#A>?A5#'.*<.#.0/#=,,2#&/,)#"%3#-.*/#
report. R(%24#'*-.#-.,#;,0/&3,/#-0+,2#-%#,2/&3,#)0-0#L0(*)*-$5#-.,#<%;63,.,2/*L,2,//#%"#-.,#)0-05#*2<%36%30-*24#
)0-0#%2#0((#60-*,2-/#3,<,*L*24#<03,#*2#603-*<*60-*24#&2*-/#)&3*24#A>??5#,2/&3,/#-.0-#-.,#[2)*24/#*2<(&),)#*2#
-.*/#3,6%3-#.0L,#0#.*4.#),43,,#%"#3,(*0=*(*-$#0-#-.,#20-*%20(5#.,0(-.#=%03)#02)#*2)*L*)&0(#&2*-#(,L,(E##
3.2 Data management
SICSAG data has undergone an extensive review. All SICSAG data from 1995 onwards is now stored '*-.*2#0#30-*%20(*/,)#/,-#%"#)0-0=0/,/5#02)#L03*0=(,/#02)#L0(&,/#.0L,#=,,2#;0),#<%2/*/-,2-E#P!GPRV#03,#
constantly striving to improve data quality through ongoing validation and therefore the SICSAG database should be regarded as dynamic and the data may be subject to change.
All SICSAG data from 1998 to 2011 have been through a linkage process that aims to match SICSAG <3*-*<0(#<03,#,6*/%),/#-%#!PJM/#PZa>?#)0-0#/<.,;,#'.*<.#<%((,<-/#)0-0#%2#0((#4,2,30(#e#0<&-,#*260-*,2-#
and day case admissions. All patients recorded in the SICSAG database should have SMR01 records relating to the same hospital stay. 96% of all SICSAG episodes have been matched to an SMR01 stay. F.*/#63%L*),/#02#0(-,320-*L,#/%&3<,#%"#*2"%3;0-*%2#%2#.%/6*-0(5#02)#&(-*;0-,#.%/6*-0(5#)*/<.034,#)0-,/#02)#
%&-<%;,/E#N.,3,#-.,#L0(&,#%"#-.,/,#[,()/#*/#2%-#)%<&;,2-,)#*2#P!GPRV5#*-#.0/#=,,2#%L,3'3*--,2#'*-.#-.,#
value derived from linkage to SMR01.
EOE( <-#1#$:9:&.$(.H(:7#(%9:9
F.,#020($/*/#%"#-.,#)0-0#02)#-.,#63,/,2-0-*%2#%"#-.,#[2)*24/#03,#=0/,)#%2#-.0-#0)%6-,)#*2#63,L*%&/#022&0(#
reports.
R))*-*%20(#-0=(,/5#0(%24#'*-.#;%3,#),-0*(,)#)0-0#%2#/&=_,<-#03,0/#-.0-#03,#2%-#*2<(&),)#*2#-.*/#3,6%3-5#03,#
available on the SICSAG website www.sicsag.scot.nhs.uk. Further information on the interpretation of funnel plots is also published on this website. WardWatcher was upgraded in all units during 2008/2009 and some changes to the data set were made. A>?>#'0/#-.,#[3/-#<%;6(,-,#$,03#%"#)0-0#=0/,)#%2#-.,#&6430),)#L,3/*%2#%"#N03)N0-<.,3E#G.024,/#-.0-#
will affect trend data have been referred to in the text. Please refer to the 2009 Report85#0L0*(0=(,#%2#-.,#
website www.sicsag.scot.nhs.uk for information on when hospitals were upgraded.
3.3.1 Funnel plots
A number of the clinical indicators within this report are presented in graphs called control charts. A control <.03-#*/#0#/*;6(,#'0$#%"#63,/,2-*24#)0-0#-.0-#<02#.,(6#4&*),#Q&0(*-$#*;63%L,;,2-#0<-*L*-*,/5#=$#1044*24#&6#
03,0/#'.,3,#-.,3,#066,03/#-%#=,#;03+,)#L03*0-*%2#02)#'.,3,#"&3-.,3#(%<0(#*2L,/-*40-*%2#;*4.-#=,#=,2,[<*0(E#
G%2-3%(#<.03-/#.0L,#=,,2#&/,)#'*),($#*2#-.,#;02&"0<-&3*24#*2)&/-3$5#02)#.0L,#;%3,#3,<,2-($#=,,2#066(*,)#
*2#.,0(-.<03,#/,--*24/E#N.*(,#-.,#63,/,2-0-*%2#%"#<(*2*<0(#*2)*<0-%3/#0/#(,04&,#-0=(,/#*/#0)L*/,)#040*2/-5#-.,#
use of control charts has become increasingly popular.
Within this report funnel plots (a type of control chart) have been used to allow comparisons to be made =,-',,2#)*"",3,2-#/,3L*<,/#63%L*),3/5#*2#-.*/#<0/,#G3*-*<0(#G03,#H2*-/E
45
R#6,3"%3;02<,#*2)*<0-%3#*/#/.%'2#%2#-.,#$Y0K*/5#'.*(,#4,2,30(($#-.,#2&;=,3#%"#0);*//*%2/#*/#/.%'2#%2#-.,#
KY0K*/E#F.,3,#*/#0#)0-0#6%*2-#"%3#,L,3$#&2*-#*2#-.,#"&22,(#6(%-E#F.,3,#03,#[L,#+,$#(*2,/#*2#-.,#"&22,(#6(%-/#&/,)#
*2#-.*/#3,6%3-E#F.,#[3/-#*/#-.,#0L,304,#"%3#-.,#-$6,#%"#G3*-*<0(
G03,#H2*-#8,*-.,3#`!GH#%3#G%;=*2,)#H2*-/M#%3#`IJHM:E#O(%--,)#%2#,*-.,3#/*),#%"#-.,#0L,304,#03,#-'%#/,-/#%"#
'032*24#(*;*-/E#N032*24#(*;*-/#03,#6(%--,)#0-#A#02)#@#/-02)03)#),L*0-*%2/#"3%;#-.,#;,02E#90<.#%"#-.,#[L,#+,$#
lines is depicted in red on the charts.
Data points within the control limits (the red lines) are said to exhibit common cause variation or to be ‘in <%2-3%(ME#J0-0#6%*2-M/#%&-'*-.#-.,#<%2-3%(#(*;*-/#03,#/0*)#-%#,K.*=*-#/%;,-.*24#<0((,)#`/6,<*0(#<0&/,#L03*0-*%2M#
8/%;,-*;,/#3,",33,)#-%#0/#`%&-(*,3/M:E
SICSAG will always highlight units outside 2 standard deviations from the mean as “might be different” and outside 3 standard deviations as “are different”. Differences may arise from many sources: differences *2#)0-0#0<<&30<$5#<0/,Y;*K5#/,3L*<,#63%L*/*%2#%3#630<-*<,E##P%;,-*;,/#0#)*"",3,2<,#'*((#=,#_&/-#0#302)%;#
difference caused by chance alone. SICSAG would encourage readers to use the data to examine practice in the context of the factors listed. c%3#/%;,#6,3"%3;02<,#*2)*<0-%3/5#;%3,#-.02#0#",'#&2*-/#03,#%&-/*),#-.,#%&-,3#<%2-3%(#(*;*-/E#F.*/#-$6*<0(($#
03*/,/#'.,2#-.,#&2*-/#03,#.,-,3%4,2,%&/5#"%3#*2/-02<,#!GH#L,3/&/#G%;=*2,)#H2*-/5#%3#P&34*<0(#L,3/&/#
Medical HDUs. Then small institutional factors contribute to more variability than would be expected by chance alone. These differences may not be particularly important nor point to real differences in the 6,3"%3;02<,#*2)*<0-%3/E#R(-.%&4.#-.,#6%/*-*%2/#%"#-.,#&2*-/#)*"",3#*2#-.,#/-0-*/-*<0(#/,2/,5#-.,$#;*4.-#2%-#=,#%"#
02$#<(*2*<0(#/*42*[<02<,E#
To account for excess variability the control limits can be adjusted in several ways. In this report they are calculated with a procedure derived from Spiegelhalter9.
EOX( !<!+4=(**
F.,#%&-<%;,#;,0/&3,#&/,)#=$#P!GPRV#*/#-.,#60-*,2-/M#/&3L*L0(#/-0-&/#80(*L,#%3#),0):#'.,2#-.,$#[20(($#
(,0L,#.%/6*-0(#8,L,2#*"#-.*/#*/#2%-#-.,#%3*4*20(#.%/6*-0(:E#O0-*,2-/#0);*--,)#-%#!GH#03,#0-#/*42*[<02-5#=&-#L03*,)5#
risk of death. Simply comparing the proportion of patients who die in each unit can give a misleading *;63,//*%2#=,<0&/,#-.,#/,L,3*-$#%"#-.,*3#*((2,//,/#*/#)*"",3,2-E#F%#%L,3<%;,#-.*/5#',#&/,#-.,#RORGI9#
II system to adjust for case­mix4. This is a validated scoring system105#'.*<.#-0+,/#0<<%&2-#%"#=%-.#-.,#
60-*,2-/M#0<&-,#<%2)*-*%2#02)#-.,*3#<.3%2*<#.,0(-.E#
Certain groups of patients are excluded: m Less than 16 years of age
m Unit stay less than 8 hours
m Readmitted to unit during the same hospital admission m O3*;03$#)*042%/*/#"%3#'.*<.#-.,#/$/-,;#'0/#2%-#),L,(%6,)U#=&32/5#<%3%203$#03-,3$#=$60//#430"-5#02)#
liver transplant.
WardWatcher provides similar codes as reasons for excluding unit admissions from RORGI9#!!#/<%3*24E##F0+*24#*2-%#0<<%&2-#2%2Y3,/6%2/,5#-.,/,#',3,#3,Y<%),)#-%#3,1,<-#-.,#.*,303<.$#%"#
),<*/*%2Y;0+*24#'*-.*2#&2*-/E##R&-%;0-*<#,K<(&/*%2/#/&<.#0/#`)*042%/*/M5#`60-*,2-#&2),3#?DM#02)#`60-*,2-#
/-0$,)#"%3#(,//#-.02#,*4.-#.%&3/M#',3,#,K<(&),)#[3/-#02)#,K*/-*24#<%),/#<.024,)#-%#3,1,<-#-.*/#63*%3*-*/0-*%2E##
a,0);*//*%2/#',3,#,K<(&),)#2,K-5#"%((%',)#=$#`%-.,3M#<0/,/#'.,3,#2%#30-*%20(,#"%3#0&-%;0-*<#,K<(&/*%2#
'0/#63%L*),)E##F.,#3,;0*2*24#,K<(&/*%2/#',3,#%6-*%20(5#'.,3,#*-#'0/#6%//*=(,#-%#4,2,30-,#0#/<%3,#=&-#-.*/#
was not done (eg HDU patients). !"#&2*-#0);*//*%2/#03,#/<%3,)5#<0/,Y;*K#0)_&/-,)#;%3-0(*-$#,/-*;0-,/#;0$#%2($#=,#<0(<&(0-,)#*2#<0/,/#'.,3,#
an appropriate diagnosis is available. All exclusions and cases with missing or inappropriate diagnoses (eg liver transplant) are shown schematically in the decision tree on page 48. 46
RORGI9#!!#63%)&<,/#02#,K6,<-,)#;%3-0(*-$#30-,#"%3#0#&2*-5#'.*<.#<02#=,#<%;603,)#-%#-.,#0<-&0(#%=/,3L,)#
;%3-0(*-$#30-,#-%#4*L,#0#/-02)03)*/,)#;%3-0(*-$#30-*%#8PZa:E##R2#PZa#/*42*[<02-($#43,0-,3#-.02#?#/&44,/-/#
-.0-#;%3-0(*-$#*/#.*4.,3#-.02#,K6,<-,)5#02)#0#L0(&,#%"#(,//#-.02#?#-.0-#*-#*/#(%',3#-.02#,K6,<-,)E##!-#*/#
important to interpret SMRs with caution. It should be appreciated that whilst the APACHE II scoring system 0)_&/-/#"%3#<0/,Y;*K5#*-#)%,/#2%-#)%#/%#6,3",<-($E#F.*/#/<%3*24#/$/-,;#*/#2%'#2,03($#@>#$,03/#%()E#Z02$#
&2*-/#0);*-#0#3,(0-*L,($#/;0((#2&;=,3#%"#60-*,2-/#,0<.#$,03#02)#-.,#<%2[),2<,#*2-,3L0(/#03%&2)#-.,#PZa#
03,#-.,3,"%3,#'*),E#9K0<-#<%2[),2<,#*2-,3L0(/#"%3#PZa#03,#<0(<&(0-,)#=$#-.,#;,-.%)#),/<3*=,)#=$#H(;#
(1990)11.
47
J&?K-#(!EY(=0&?&G&0&:@(H.-(!<!+4=(**(18.-#1(9$%(1#0#8:&.$(H.-(9$90@1&1
ALL unit admissions
36,373
HDU
ICU/HDU
ICU
25,821
4,785
5,767
Diagnosis
Diagnosis
116 (2.4%)
177 (3.1%)
Under 16
Under 16
24 (0.5%)
100 (1.7%)
<8hr stay
<8hr stay
186 (3.9%)
307 (5.3%)
Readmission
Readmission
219 (4.6%)
270 (4.7%)
Missing data on physiology
Missing data on physiology
20 (0.4%)
33 (0.6%)
Unit decision
not to score
Unit decision
not to score
44 (0.9%)
128 (2.2%)
Missing score
Missing score
1 (0.0%)
8 (0.1%)
Missing diagnosis
Missing diagnosis
­
5 (0.1%)
Missing ultimate hospital outcome
Missing ultimate hospital outcome
11 (0.2%)
13 (0.2%) Episodes Included in SMR Calculation
Episodes Included in SMR Calculation
4,164 (87.0%)
4,726 (81.9%)
Exclusions
Although APACHE II scores were calculated for 449 (1.7%) HDU unit admissions, these are excluded from the SICSAG analysis.
48
3.5 Level of care
Level of care is calculated on a daily basis from the Augmented Care Period (ACP) page of WardWatcher. N03)N0-<.,3#/<%3,/#(,L,(/#%"#<03,#=0/,)#%2#/&66%3-#%"#[L,#%3402#/$/-,;/U#3,/6*30-%3$5#<03)*%L0/<&(035#
3,20(5#2,&3%(%4*<0(#02)#),3;0-%(%4*<0(E
Level 3
m Advanced respiratory support (connected to a ventilator via ETT or tracheostomy) OR
m Two or more organ systems are being supported (except basic respiratory and basic cardiac) OR m One organ system is being supported and a different system is in chronic failure Level 2
m One organ supported Level 1
m Epidural or/and m General observations requiring more monitoring than can be provided on a general ward
Level 0
m R#60-*,2-#*/#0//,//,)#0/#(,L,(#>#*"#2%-#0//,//,)#0/#(,L,(#?5#A#%3#@#8,E4E#2%#%3402#/&66%3-#02)#0),Q&0-,#
monitoring could be provided on a general ward) 3.6 Delayed discharges J&?K-#(!EO)Y([9-%[9:87#-(K$&:(%&1879-?#("9?#
J,(0$,)#)*/<.034,#)0-0#*/#<%((,<-,)#%2#-.,#&2*-#)*/<.034,#604,#%"#N03)N0-<.,3#8c*4&3,#R]:E#F.,#[3/-#
Q&,/-*%2#0/+/#'.,-.,3#-.,#60-*,2-#*/#a,0)$#"%3#)*/<.034,#8),[2,)#0/#0#;,)*<0(#),<*/*%2#-%#)*/<.034,#0#
60-*,2-#-%#02%-.,35#;%3,#0663%63*0-,#&2*-:E#F.*/#;0$#=,#0#(%',3#(,L,(#%"#<03,#%3#0#/6,<*0(*/-#03,0E#X%#8X:#
49
is entered if the patient is discharged early or self discharges against medical advice. If the patient is ready for discharge Yes (Y) is entered then the date and time when this decision was made. The date and time when the patient physically leaves the unit (Actually discharged from this unit) is then entered. The `406M#=,-',,2#-.,/,#-'%#-*;,/#*/#<0(<&(0-,)#02)#-.,#[20(#Q&,/-*%2#0/+/#&/,3/#-%#<%2/*),3#-.*/#406#8V06#
considered) as normal or abnormal. Normal delay would be the time taken by unit staff to get the patient ready for discharge and assemble relevant documents required for discharge. R=2%3;0(#),(0$#.0/#/,L,2#/&=#<0-,4%3*,/U#N03)#=,)#/.%3-04,5#IJH#=,)#/.%3-04,5#!GH#=,)#/.%3-04,5#
2&3/*24#/-0""#/.%3-04,5#%-.,3#/-0""#/.%3-04,5#-302/6%3-#63%=(,;#%3#%-.,3E##
The upgraded version of WardWatcher enforces staff to enter a time delay and objective reason as to '.$#-.,#),(0$#.0/#%<<&33,)E#P!GPRV#.0L,#2%-#),[2,)#02$#/6,<*[<#-*;,#),(0$#0/#0<<,6-0=(,#0/#,0<.#
.%/6*-0(#'*((#)*"",3#*2#630<-*<,5#.%',L,3#',#*2<(&),#020($/*/#%2#),(0$,)#)*/<.034,/#-.0-#03,#<%2/*),3,)#
0=2%3;0(#02)#'.,3,#-.,#406#*/#;%3,#-.02#/*K#.%&3/E#c%3#;%3,#<(03*-$#(%<0(($#',#0)L*/,#&2*-/#-%#),[2,#/-3*<-#
guidelines relevant to their area (eg some units have agreed that any gap of more than four hours should be considered as delayed). This information is part of the monthly report data sent to unit leads. 50
Appendix 4 Data quality
R#.*4.#/-02)03)#%"#)0-0#Q&0(*-$#*/#,//,2-*0(#-%#,2/&3,#-.,#P!GPRV#)0-0=0/,#*/#0<<&30-,5#<%2/*/-,2-#02)#
<%;6030=(,#0<3%//#-*;,5#02)#=,-',,2#.%/6*-0(/E##F.*/#'*((#,2/&3,#),<*/*%2/#-%#*;63%L,#Q&0(*-$#%"#<03,#02)#
/,3L*<,#63%L*/*%2#0-#.%/6*-0(5#=%03)#02)#20-*%20(#(,L,(#03,#=0/,)#%2#<%33,<-#*2"%3;0-*%2E
N*-.%&-#Q&0(*-$5#*-#'%&()#=,#*;6%//*=(,#-%#*2-,363,-#3,/&(-/#'*-.#02$#0<<&30<$#%3#<%2L*<-*%2E###
The data quality processes undertaken by SICSAG are incorporated into the following:
m At point of data entry
m Case­note validations
m Central validations
At point of data entry The WardWatcher (WW) data collection tool has been programmed to carry out some data quality assurance processes at point of entry. The screenshot below is an example of a validation query that WW generates. This example indicates the validation query generated when the date entered for the unit discharge is before the unit admission date.
J&?K-#(!XY(='9>"0#(.H([9-%[9:87#-(V90&%9:&.$(
Case­note validations
Case­note validations are undertaken monthly by the Local or Regional Audit Co­ordinators; and in some *2/-02<,/#=$#-.,#S&0(*-$#R//&302<,#Z0204,3#02)#X0-*%20(#G(*2*<0(#G%Y%3)*20-%3#'.,2#%2#/*-,#L*/*-/E##J0-0#
"3%;#-.,#0);*//*%25#.*/-%3$5#/,L,3*-$5#02)#R&4;,2-,)#G03,#O,3*%)#8RGO:#604,/#%"#NN#03,#63%/6,<-*L,($#
L0(*)0-,)#=$#<%;603*24#)0-0#*2#NN#'*-.#)0-0#*2#-.,#<0/,Y2%-,/E##P,L,3*-$#)0-0#<022%-#=,#L0(*)0-,)#*2#IJH5#
as it is not collected.
The main outcome measure is the level of agreement. When the data taken from the case­notes is the /0;,#0/#-.,#3,<%3)*24/#*2#NN5#-.,#-'%#/%&3<,/#%"#*2"%3;0-*%2#03,#*2#043,,;,2-E#N.,2#-.,#)0-0#-0+,2#"3%;#
-.,#<0/,Y2%-,/#*/#)*"",3,2-#"3%;#-.,#3,<%3)*24/#*2#NN5#-.,#-'%#/%&3<,/#%"#*2"%3;0-*%2#03,#*2#)*/043,,;,2-E#
When information is documented in the case­notes but not recorded in WW it is recorded as not yet entered.
51
F.,#3,/&(-/#*2)*<0-,#-.0-#-.,#)0-0#Q&0(*-$#;,0/&3,)#*/#%"#0#L,3$#.*4.#/-02)03)5#'*-.#%2($#0#Db#(,L,(#%"#
)*/043,,;,2-#*2#!GH#02)#G%;=*2,)#H2*-/5#02)#0#]b#(,L,(#%"#)*/043,,;,2-#*2#IJHE##F.,#3,/&(-/#%"#-.,/,#
prospective validations are fed back the lead audit consultants and/or lead nurses. This information is used to identify any areas where further training or support is required. Central validation
Database linkage
R((#3,<%3)/#*2#-.,#P!GPRV#)0-0=0/,#.0L,#=,,2#-.3%&4.#-.,#(*2+04,#63%<,//E##F.*/#,20=(,/#-.,#*2[((*24#%"#
&23,<%3),)#%&-<%;,/#02)#)0-,/5#02)#63%L*),/#0#',0(-.#%"#%66%3-&2*-*,/#"%3#3,/,03<.#86(,0/,#/,,#R66,2)*K#
3.2 ­ Data Management for further information).
Z&11&$?(%9:9D%9:9(V90&%9:&.$
P*K#;%2-.($#L0(*)0-*%2/#03,#<%((0-,)#02)#/,2-#%&-#-%#,*-.,3#-.,#f,0)#R&)*-#G%2/&(-02-5#%3#-%#-.,#f%<0(#R&)*-#
G%Y%3)*20-%3E##Z*//*24#)0-0#[,()/#'*((#=,#Q&,3*,)5#02)#L0(*)0-*%2/#<033*,)#%&-#%2#,K-3,;,/#%"#04,#02)#(,24-.#
of stay. Any inconsistencies with the CHI number will also be queried. Any changes to the data are made locally and the data re­extracted.
U90&%9:&$?(:7#(!<!+4=(**(%&9?$.1&1(G@(891#N$.:#(V90&%9:&.$(&$(*+,(9$%(+.>G&$#%(,$&:1((
(2011)
R/#-.*/#<0/,Y;*K#-%%(#*/#2,03($#@>#$,03/#%()5#P!GPRV#03,#3,<0(*=30-*24#-.,#RORGI9#!!#;%),(#&/*24#3,<,2-#
Scottish outcome data. Validating the APACHE diagnosis code and Chronic Health Points recorded in WardWatcher is an essential part of this process. A random sample of patients will be selected from the central SICSAG database. The case notes for these patients will be requested from medical records and the information held within the case notes compared with that held centrally. The focus will be on the data used to calculate the APACHE II Score and mortality prediction. If the pilot demonstrates that there */#0#.*4.#(,L,(#%"#*20<<&30<$5#-.,2#',#'%&()#/,,+#"&2)*24#-%#3%((#-.*/#%&-#0/#0#20-*%20(#63%_,<-#-%#3,L*,'#-.,#
APACHE II diagnosis in all ICUs. SICSAG have set up a subgroup (made up of members of the Steering Group) to work on this project. The *),2-*[,)#6*(%-#/*-,#*/#9)*2=&34.#a%$0(#!2[3;03$#"%((%'*24#0#/&<<,//"&(#066(*<0-*%2#"%3#G0()*<%--#0663%L0(E
Chronic health points in ICU and Combined Units (2010)
F.,#RORGI9#!!#/<%3,#*/#*21&,2<,)#=$#<.3%2*<#.,0(-.#6%*2-/#8O0/-#;,)*<0(#.*/-%3$#%2#-.,#I*/-%3$#604,#
%"#NN:E#!"#<.3%2*<#.,0(-.#<%2)*-*%2/#.0L,#=,,2#,2-,3,)#*20663%63*0-,($5#-.,#;%3-0(*-$#63,)*<-*%2#'*((#=,#
03-*[<*0(($#.*4.#02)#-.,#PZa#(%'E##O%*2-/#03,#0//*42,)#-%#60-*,2-/#'*-.#%2,#%3#;%3,#/-3*<-($#),[2,)#<.3%2*<#
.,0(-.#<%2)*-*%2/E##F.,#63,<*/,#),[2*-*%2#3,Q&*3,)#=$#-.,#RORGI9#!!#;%),(#*/#0L0*(0=(,#-.3%&4.#-.,#I,(6#
function within the History page.
P!GPRV#3,L*,',)#<.3%2*<#.,0(-.#6%*2-/#,2-,3,)#=$#0((#!GH#02)#G%;=*2,)#H2*-/#*2#A>?>#"%3#,0<.#/6,<*[<#
category.
P%;,#&2*-/#',3,#0=%L,#@#PJ#"3%;#-.,#;,02#"%3#/6,<*[<#<.3%2*<#.,0(-.#<%2)*-*%2/E##!2#,0<.#*2/-02<,5#-.,#
f,0)#R&)*-#G%2/&(-02-#'0/#<%2-0<-,)#02)#0/+,)#-%#3,L*,'#-.,*3#%'2#&2*-M/#)0-0#02)#3,L*,'#&2*-#630<-*<,#
,2/&3*24#-.0-#-.*/#*2"%3;0-*%25#'0/5#02)#*/#3,<%3),)#'*-.#3,",3,2<,#-%#-.,#),[2*-*%2/E
F.3,,#%"#-.,#&2*-/#*),2-*[,)#02#&2&/&0(#<0/,#;*K#'.*<.#,K6(0*2,)#'.$#-.,*3#&2*-/#',3,#)*"",3,2-E##F.,#"%&3-.#
&2*-#*),2-*[,)#%L,3#3,<%3)*24#02)#.0L,#-0+,2#/-,6/#-%#L0(*)0-,#-.,*3#)0-0#3,-3%/6,<-*L,($#02)#,2/&3,#-.0-5#*2#
"&-&3,5#<%((,04&,/#,2-,3*24#-.,#)0-0#0).,3,#-%#-.,#),[2*-*%2/#8/,,#R66,2)*K#C#"%3#<.3%2*<#.,0(-.#),[2*-*%2/E#
U90&%9:&$?(!<!+4=(**(8.%&$?(.H(^".1:(89-%&98(9--#1:_(&$(*+,(9$%(+.>G&$#%(,$&:1(;2336N23)3A
!-#*/#3,0/%20=(,#-%#,K6,<-#-.0-#0((#0);*//*%2/#'*-.#0#3,<%3),)#RORGI9#!!#)*042%/*/#%"#`6%/-#<03)*0<#033,/-M#
should also have had CPR in 24 hours prior to admission to the Unit.
F.*/#)*042%/*/#'0/#L0(*)0-,)#040*2/-#-.,#[,()#`GOa#*2#A]#.%&3/#63*%3#-%#0);*//*%2#-%#-.,#H2*-M5#&/*24#
52
P!GPRV#3,<%3)/#8A>>CYA>?>:#*2#!GH#02)#G%;=*2,)#H2*-/5#'*-.#02#RORGI9#!!#)*042%/*/#%"#`6%/-#<03)*0<#
033,/-M#0/#-.,#),2%;*20-%3E#
iAb#%"#-.,/,#3,<%3)/#.0)#=,,2#<%),)#0/#.0L*24#`GOa#*2#A]#.%&3/#63*%3#-%#0);*//*%2#-%#-.,#H2*-ME##F.,3,#
was little variability across the units.
U90&%9:&$?(!<!+4=(**(8.%&$?(.H(^1#":&8(17.8]_(&$(*+,(9$%(+.>G&$#%(,$&:1(;23)3A
c%3#-.*/#L0(*)0-*%25#*-#'0/#0//&;,)#-.0-#0((#60-*,2-/#'*-.#0#3,<%3),)#RORGI9#!!#)*042%/*/#%"#`/,6-*<#/.%<+M#
%2#0);*//*%2#/.%&()#.0L,#3,<,*L,)#L0/%0<-*L,#-.,306$#'*-.*2#-.,#[3/-#-'%#)0$/#%"#0);*//*%2E#RGO#)0-0#
',3,#&/,)#-%#L,3*"$#-.*/E#^^b#%"#0((#60-*,2-/#'.%#.0)#02#RORGI9#!!#)*042%/*/#%"#`/,6-*<#/.%<+M#.0)#3,<,*L,)#
vasoactive therapy across all units.
U90&%9:&$?(!<!+4=(**(8.%&$?(.H(^"$#K>.$&9_(&$(*+,(9$%(+.>G&$#%(,$&:1(;23)3A
F.,#0//&;6-*%2#"%3#-.*/#L0(*)0-*%2#'0/#-.0-#60-*,2-/#'*-.#0#3,<%3),)#RORGI9#!!#)*042%/*/#%"#`62,&;%2*0M#
',3,#(*+,($#-%#.0L,#=,,2#<%22,<-,)#-%#0#L,2-*(0-%3#'*-.*2#-.,#[3/-#-'%#)0$/#%"#0);*//*%2#8*2L0/*L,#%3#2%2Y
invasive ventilation).
R<3%//#P<%--*/.#&2*-/5#BDb#%"#0);*//*%2/#'*-.#3,<%3),)#RORGI9#!!#)*042%/*/#%"#`62,&;%2*0M#03,#3,<%3),)#
0/#.0L*24#=,,2#<%22,<-,)#-%#0#L,2-*(0-%3#'*-.*2#-.,#[3/-#-'%#)0$/#%"#0);*//*%2#8*2L0/*L,#%3#2%2Y*2L0/*L,#
ventilation). SICSAG will strive to continually improve the quality of the data used to support the care of critically ill patients.
53
Appendix 5 Chronic health definitions ;!<!+4=(**(>#:7.%.0.?@4)
Very severe cardiovascular diseaseU#/6,<*[,/#'.,-.,3#-.,#60-*,2-#.0/#"0-*4&,5#<(0&)*<0-*%25#)$/62%,0#
%3#024*20#0-#a9PFE#N.,3,#02$#0<-*L*-$#*2<3,0/,/#/$;6-%;/5#/$;6-%;/#;&/-#=,#)&,#-%#;$%<03)*0(#%3#
6,3*6.,30(#L0/<&(03#)*/,0/,E#c&2<-*%20(($5#-.*/#60-*,2-#<022%-#/-02)#0(%2,5#'0(+#/(%'($#%3#)3,//#'*-.%&-#
/$;6-%;/E#J,[2*-*%2#,Q&0(/#-.,#X,'#l%3+#I,03-#R//%<*0-*%25#G(0//#!dE#
Very severe cardiovascular disease must be documented prior to or at admission to your unit. Severe respiratory diseaseU#/6,<*[,/#'.,-.,3#-.,#60-*,2-#.0/#6,3;02,2-#/.%3-2,//#%"#=3,0-.#N!FI#
f!VIF#RGF!d!Fl5#)&,#-%#6&(;%203$#)*/,0/,E#c&2<-*%20(($5#-.*/#60-*,2-#*/#&20=(,#-%#'%3+#02)#.0/#/.%3-2,//#
%"#=3,0-.#6,3"%3;*24#;%/-#2%3;0(#0<-*L*-*,/#%"#)0*($#(*L*24#8,E4E#'0(+*24#A>#;,-3,/#%2#(,L,(#43%&2)5#'0(+*24#
/(%'($#*2#-.,#.%&/,5#<(*;=*24#%2,#1*4.-#%"#/-0*3/j#%3#)3,//*24#%3#/-02)*24:E#
Severe respiratory disease must be documented prior to or at admission to your unit. Biopsy proven cirrhosis: Biopsy proven cirrhosis must be documented prior to or at admission to your unit. Imaging proven cirrhosis: Imaging proven cirrhosis must be documented prior to or at admission to your unit. X7U#F.*/#.0/#=,,2#*2<(&),)#"%3#3,/,03<.#6&36%/,/#%2($5#02)#*"#02/',3,)#$,/#'*((#2%-#3,<,*L,#02$#<.3%2*<#
health points towards patients APACHE score.
<.-:90(7@"#-:#$1&.$: Evidence of portal hypertension is the presence of oesophageal or gastric varices ),;%2/-30-,)#=$#/&34,3$5#*;04*24#%3#,2)%/<%6$j#%3#-.,#),;%2/-30-*%2#%"#3,-3%430),#/6(,2*<YL,2%&/#1%'#=$#
ultrasound. DO NOT include GI bleeding without the evidence of portal hypertension.
Portal hypertension must be documented prior to or at admission to your unit. Hepatic encephalopathy: episode of hepatic encephalopathy grade 1 or greater (see below). The ,6*/%),/#%"#,2<,6.0(%60-.$#;&/-#.0L,#%<<&33,)#!X#FI9#P!h#Z\XFIP#63*%3#-%#0);*//*%2#-%#$%&3#&2*-5#02)#
must be documented prior to or at admission to your unit. Grading of hepatic encephalopathy:
m Grade 1: no abnormality detected
m V30),#AU#/(%'2,//#%"#<,3,=30-*%25#*2-,3;*--,2-#;*()#<%2"&/*%2#02)#,&6.%3*0
m V30),#@U#<%2"&/,)#;%/-#%"#-.,#-*;,5#*2<3,0/*24#)3%'/*2,//
m V30),#]U#/,L,3,#<%2"&/*%25#3%&/0=(,5#3,/6%2)/#-%#/*;6(,#<%;;02)/
m V30),#CU#&2<%2/<*%&/5#3,/6%2)/#-%#60*2"&(#/-*;&(&/
Acute leukaemiaU#-.,#60-*,2-#.0/#0<&-,#;$%(%4,2%&/#(,&+0,;*05#0<&-,#($;6.%<$-*<#(,&+0,;*0#%3#;&(-*6(,#
myeloma. The presence of such conditions must have been evident in the SIX MONTHS PRIOR to admission to your unit and must be documented prior to or at admission to your unit. Chronic leukaemia: the patient has chronic myelogenous leukaemia or chronic lymphocytic leukaemia. The presence of such conditions must have been evident in the SIX MONTHS PRIOR to admission to your unit and must be documented prior to or at admission to your unit. Metastatic diseaseU#-.,#60-*,2-#.0/#)*/-02-#8X%-#3,4*%20(#($;6.#2%),:#;,-0/-0/,/5#)%<&;,2-,)#=$#/&34,3$5#
imaging or biopsy. The presence of metastases must have been evident in the SIX MONTHS PRIOR to admission to your unit and must be documented prior to or at admission to your unit. 54
LymphomaU#-.,#60-*,2-#.0/#0<-*L,#($;6.%;0#)%<&;,2-,)#=$#/&34,3$5#*;04*24#%3#=*%6/$E#F.,#63,/,2<,#
of lymphoma must have been evident in the SIX MONTHS PRIOR to admission to your unit and must be documented prior to or at admission to your unit. AIDSU#-.,#60-*,2-#.0/#0#),[2*-*L,#)*042%/*/#%"#R!JP#0<<%3)*24#-%#<&33,2-#NI\#),[2*-*%2E#F.,#60-*,2-#*/#I!d#
6%/*-*L,#'*-.#<(*2*<0(#<%;6(*<0-*%2/E#G(*2*<0(#<%;6(*<0-*%2/#*2<(&),#62,&;%<$/-*/#<03*2**5#W06%/*M/#/03<%;05#
($;6.%;05#F75#02)#-%K%6(0/;0#*2",<-*%2E#J\#X\F#*2<(&),#R!JPY3,(0-,)#<%;6(,K#%3#I!d#6%/*-*L*-$#0(%2,E#
AIDS must be documented prior to or at admission to your unit. Immunosuppression: the patient has received 0.3mg per kg or more of prednisolone or an equivalent )%/04,#%"#02%-.,3#<%3-*<%/-,3%*)5#JR!fl#c\a#FI9#P!h#Z\XFIP#Oa!\a#-%#0);*//*%2#-%#$%&3#&2*-E#N.,3,#
-.,#=%)$#',*4.-#%"#02#0)&(-#*/#&2+2%'25#$%&#/.%&()#02/',3#l#8$,/:#*"#-.,#60-*,2-#.0/#3,<,*L,)#A>;4#%3#
;%3,#6,3#)0$#%"#63,)2*/%(%2,#%3#02#,Q&*L0(,2-#)%/04,#%"#02%-.,3#<%3-*<%/-,3%*)5#JR!fl#c\a#FI9#P!h#
MONTHS PRIOR to admission to your unit.
Chronic renal replacement: the patient currently requires chronic renal replacement therapy (chronic .0,;%)*0($/*/5#.0,;%[(-30-*%2#%3#6,3*-%2,0(#)*0($/*/:#"%3#*33,L,3/*=(,#3,20(#)*/,0/,E##
55
Appendix 6 List of abbreviations
ACCS Acute Care Common Stem
ACP Augmented Care Period
CAUTI Catheter Associated Urinary Tract Infection
CCU Coronary Care Unit
GJRJ# #
G(%/-3*)*&;#J*"[<*(,#R//%<*0-,)#J*/,0/,
GJ*""# #
G(%/-3*)*&;#J*"[<*(,
CPAP Continuous Positive Airway Pressure
CVC Central Venous Catheter
DVT Deep Vein Thrombosis
ccX#
#
c%%)5#c(&*)#02)#X&-3*-*%2
FY Foundation Year (medical)
GCS Glasgow Coma Scale
HAI Healthcare Associated Infection
HAN Hospital at Night
HDU High Dependency Unit
HELICS Hospitals in Europe Link for Infection Control through Surveillance
HPS Health Protection Scotland
ICM Intensive Care Medicine
ICS Intensive Care Society
ICU Intensive Care Unit
IR1 Incident Record 1
ISD Information Services Division
M & M Morbidity and Mortality
MDR Multi Disciplinary Round
MDT Multi Disciplinary Team
Z9NP##
Z%)*[,)#903($#N032*24#P<%3,
MUST Malnutrition Universal Screening Tool
NICE National Institute of Clinical Excellence
NIV Non Invasive Ventilation OOH Out of hours
PAC Pressure Area Care
PVC Peripheral Vascular Cannula
RRT Renal Replacement Therapy
SAB Staphylococcus Aureus Bacteraemia
P7Ra# #
P*-&0-*%25#70<+43%&2)5#R//,//;,2-5#a,<%;;,2)0-*%2
56
SCCTG Scottish Critical Care Trials Group
SD Standard Deviation
SEWS Standardised Early Warning Score
SICS Scottish Intensive Care Society
SICSAG Scottish Intensive Care Society Audit Group
SMR Standardised Mortality Ratio
SPI Scottish Patient Initiative
SPSA Scottish Patient Safety Alliance
SPSP Scottish Patient Safety Programme
PPW!X##
P&3"0<,5#P+*2#*2/6,<-*%25#W,,6#;%L*245#!2<%2-*2,2<,5#X&-3*-*%2
ST Specialist Trainee (medical)
VTE Venous Thrombo Embolism
VAP Ventilator Associated Pneumonia
WTE Whole Time Equivalent
WW WardWatcher
57
References 1. F.,#P<%--*/.#V%L,32;,2-#I,0(-.<03,#S&0(*-$#P-30-,4$#"%3#XIP#P<%-(02)#Z0$#A>?>E#n%2(*2,o# http://www.scotland.gov.uk/Resource/Doc/311667/0098354.pdf#n0<<,//,)#^-.#T&2,#A>?Ao
2. F.,#P<%--*/.#!2-,2/*L,#G03,#P%<*,-$#S&0(*-$#!;63%L,;,2-#V3%&6E#S&0(*-$#!2)*<0-%3/#"%3#G3*-*<0(#G03,#*2#
P<%-(02)#d,3/*%2#AE>#T02&03$#A>?A#n%2(*2,o# .--6Uee'''E/*</04E/<%-E2./E&+eS&0(*-$eS&0(*-$p!2)*<0-%3/pA>?AE6)"#n0<<,//,)#^-.#T&2,#A>?Ao
3. Scottish Intensive Care Society Audit Group HAI Subgroup. Central Line Insertion Bundle Version 2.0. April 2012 http://www.sicsag.scot.nhs.uk/HAI/SICSAG­central­line­insertion­bundle­120418.pdf n0<<,//,)#?@-.#T&2,#A>?Ao
4. W20&/#NR5#J306,3#9R5#N042,3#JO5#g*;;,3;02#T9E#RORGI9#!!U#0#/,L,3*-$#%"#)*/,0/,#<(0//*[<0-*%2#
system. Critical Care Medicine 1985;13(10): 818–29
5. a%'02#WZ5#W,33#TI5#Z0_%3#95#Z<O.,3/%2#W5#P.%3-#R5#d,//,$#ZOE#!2-,2/*L,#G03,#P%<*,-$M/#RORGI9#!!#
study in Britain and Ireland­I: Variations in case mix of adult admissions to general intensive care units 02)#*;60<-#%2#%&-<%;,E#7ZT#?ii@j#@>B8Di?>:U#iBAYB
6. Department of Health. Organs for transplants: a report from the Organ Donation Taskforce. London A>>^E#n%2(*2,o#
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/
JIp>^A?AA#n0<<,//,)#^-.#T&2,#A>?Ao##
7. !2"%3;0-*%2#P,3L*<,/#J*L*/*%25#XIP#X0-*%20(#P,3L*<,/#P<%-(02)E#I%/6*-0(#PZa/E#A>?AE##http://www.
indicators.scot.nhs.uk/#n0<<,//,)#??-.#T&2,#A>?Ao
8. The Scottish Intensive Care Society Audit Group: Audit of Critical Care in Scotland 2009 – Reporting on A>>^#n%2(*2,o .--6Uee'''E/*</04E/<%-E2./E&+eO&=(*<0-*%2/eP!GPRVpa,6%3-A>>iE6)"#n0<<,//,)#^-.#T&2,#A>?Ao
9. P6*,4,(.0(-,3#JTE#I02)(*24#%L,3Y)*/6,3/*%2#%"#6,3"%3;02<,#*2)*<0-%3/E#S&0(*-$#02)#P0",-$#*2#I,0(-.#G03,#
2005; 14 347­351
10. f*L*24/-%2#7Z5#Z0<W*3)$#cX5#I%'*,#TG5#T%2,/#a5#X%33*,#TJE#R//,//;,2-#%"#-.,#6,3"%3;02<,#%"#[L,#
intensive care scoring models within a large Scottish database. Critical Care Medicine 2000; 28(6) 1820­7
11. H(;#WE#P*;6(,#;,-.%)#-%#<0(<&(0-,#-.,#<%2[),2<,#*2-,3L0(#%"#0#/-02)03)*q,)#;%3-0(*-$#30-*%#8PZa:E#
R;,3*<02#T%&320(#%"#96*),;*%(%4$#?ii>j#?@?8A:U@B@YC
58
Acknowledgements
This report was written by the Report Writing Subgroup of the SICSAG Steering Group. F#".-:([-&:&$?(BKG?-.K"(23)3D23))
Name
Dr Stephen Cole
Title
Vice Chairman Address
Consultant in Critical Care X*2,',((/#I%/6*-0(5#J&2),,
Dr Brian Cook
Chairman
Associate Division Medical Director NHS Lothian
Ms Catriona Haddow
Senior Information Analyst
National Clinical Coordinator
S&0(*-$#R//&302<,#
Manager
P!GPRV5#!2"%3;0-*%2#P,3L*<,/#J*L*/*%2 NHS National Services Scotland
P!GPRV5#!2"%3;0-*%2#P,3L*<,/#J*L*/*%2 NHS National Services Scotland
P!GPRV5#!2"%3;0-*%2#P,3L*<,/#J*L*/*%2 NHS National Services Scotland
Dr Louie Plenderleith
Consultant
Consultant in Critical Care N,/-,32#!2[3;03$5#V(0/4%'
J3#T*;#a&))$
Consultant
Dr Steve Stott
Consultant
Dr Charles Wallis
Consultant
Consultant in Critical Care Z%2+(02)/#J*/-3*<-#V,2,30(#I%/6*-0(5#R*3)3*,
Consultant in Critical Care R=,3),,2#a%$0(#!2[3;03$
Consultant in Critical Care N,/-,32#V,2,30(#I%/6*-0(5#9)*2=&34.
Z3/#R24,(0#W.02
Ms Moranne MacGillivray
59
Hospital
Abbreviation Unit
Letter
Hospital
Abbreviation Unit
Letter
Inverclyde Royal Hospital
IRH
AYR
dIW
PRI
G3%//.%&/,#I%/6*-0(5#W*(;032%<+
Crosshouse
P-%=.*((#I%/6*-0(5#V(0/4%'
Stobhill
Borders General Hospital
BGH
Ayr Hospital
AYR
Dumfries & Galloway Royal !2[3;03$
DGRI
ICU
HDU
ICU
Medical HDU
Surgical HDU
ICU/HDU
Surgical (Level 1)
ICU
E
E2
G
G2
G3
U
U2
H
P%&-.,32#V,2,30(#I%/6*-0(5#
Glasgow
SGH
A
A2
B2
C
C2
D
D2
E
E2
F
Ayr Hospital
d*<-%3*0#I%/6*-0(5#W*3+<0()$
O,3-.#a%$0(#!2[3;03$
ICU
Surgical HDU
Medical HDU
ICU
HDU
ICU
Surgical HDU
ICU
HDU
ICU
S&,,2#Z03403,-#I%/6*-0(5#
Dunfermline
SZI
Crosshouse
F2
G
G2
G3
H
H2
H3
O
G3%//.%&/,#I%/6*-0(5#W*(;032%<+
Surgical HDU
ICU
Medical HDU
Surgical HDU
ICU
Medical HDU
Surgical HDU
ICU
Medical HDU
Surgical HDU
ICU
Surgical HDU
Medical HDU
ICU
HDU
ICU/HDU
Surgical HDU
ICU
Surgical HDU
ICU/HDU
ICU
Medical HDU
Surgical HDU
ICU
H2
H3
I
I2
I3
T
TA
W
WA
L
L2
M
N
N2
N3
O
Surgical HDU
Medical HDU
Renal HDU
Medical HDU
ICU
HDU
ICU/HDU
ICU
Surgical HDU (31/32)
Neurological HDU
Surgical HDU (35)
HDU
ICU/HDU
Surgical HDU
ICU
Surgical HDU
ICU
HDU
ICU
O2
O3
O4
B2
S
SA
S@
W
W2
Surgical HDU
Medical HDU
Renal HDU
ICU
Medical HDU
Surgical HDU
ICU
HDU
ICU/HDU
ICU/HDU
O2
O3
04
P
P2
P3
S
SA
S@
R
Surgical HDU
Neurological ICU
Neurological HDU
ICU
Surgical HDU
ICU
Surgical HDU
ICU
HDU
HDU
F2
Y
Y2
D
D2
L
L2
T
T3
T2
Surgical (Level1)
Neurological HDU
Neuro (Level 1) HDU
ICU/HDU
Medical HDU
ICU
HDU
HDU
R3
R4
R5
S
S2
T
T3
T2
U
U2
V
V2
W
W2
ICU
Medical HDU
Surgical HDU
HDU
ICU/HDU
Medical HDU
ICU
Surgical HDU
Medical HDU
ICU
Surgical HDU
ICU/HDU
HDU
Renal HDU
Transplant HDU
Vascular (Level 1)
Cardiothoracic ICU
Cardiothoracic HDU
ICU/HDU
ICU/HDU
P
P2
P3
AC1
S
S2
I
I2
I3
V
V2
X
X2
X3
X4
X5
X6
X7
M
R
Y2
g?
AA1
AB1
AC1
Surgical (Level1)
Neurological HDU
Neuro (Level 1) HDU
HDU
ICU
Medical HDU
Surgical HDU
ICU
HDU
HDU
R3
R4
R5
g?
N
N2
N3
C
C2
AB1
Dumfries & Galloway Royal !2[3;03$
Z%2+(02)/#JVI5#R*3)3*,
DGRI
MDGH
a%$0(#R(,K02)30#I%/6*-0(5#O0*/(,$ RAH
V(0/4%'#a%$0(#!2[3;03$
GRI
d*<-%3*0#!2[3;03$5#V(0/4%'
VI
P-#T%.2r/#I%/6*-0(5#f*L*24/-%2
X*2,',((/#I%/6*-0(5#J&2),,
PTI
Ninewells
S&,,2#Z03403,-#I%/6*-0(5#
Dunfermline
SZI
a0*4;%3,#I%/6*-0(5#!2L,32,//
Raigmore
P-*3(*24#a%$0(#!2[3;03$#
SRI
Forth Valley Royal Hospital
N,/-,32#V,2,30(#I%/6*-0(5#
Edinburgh
FVRH
WGH
I0*3;$3,/#I%/6*-0(5#90/-#W*(=3*),
Hairmyres
N,/-,32#!2[3;03$5#V(0/4%'
WIG
V03-20L,(#V,2,30(#I%/6*-0(5#
Glasgow
Borders General Hospital
GGH
Wishaw General Hospital
Wishaw
R=,3),,2#a%$0(#!2[3;03$
ARI
P%&-.,32#V,2,30(#I%/6*-0(5#
Glasgow
SGH
ICU/HDU
Surgical (level 1)
ICU
Surgical HDU
ICU
Surgical HDU (31/32)
Neurological HDU
Surgical HDU (35)
ICU/HDU
HDU
Renal HDU
Transplant HDU
Vascular (Level 1)
Cardiothoracic ICU
Cardiothoracic HDU
Neurological ICU
V*(=,3-#70*2#I%/6*-0(5#P.,-(02)
J3#V30$M/#I%/6*-0(5#9(4*2
N,/-,32#!/(,/#I%/6*-0(5#P-%32%'0$
7,("%3)#I%/6*-0(5#c%3-#N*((*0;
GBH
J3#V30$M/
WIH
Belford
Neurological HDU
HDU
HDU
HDU
HDU
a%$0(#!2[3;03$#%"#9)*2=&34.
BGH
RIE
d*<-%3*0#I%/6*-0(5#W*3+<0()$
P-*3(*24#a%$0(#!2[3;03$#
dIW
SRI
Forth Valley Royal Hospital
R=,3),,2#a%$0(#!2[3;03$
FVRH
ARI
J3#V30$M/#I%/6*-0(5#9(4*2
V(0/4%'#a%$0(#!2[3;03$
J3#V30$M/
GRI
Inverclyde Royal Hospital
IRH
a%$0(#R(,K02)30#I%/6*-0(5#O0*/(,$ RAH
P%&-.,32#V,2,30(#I%/6*-0(5#
Glasgow
W3
W4
X
X2
X3
X4
X5
X6
X7
Y
SGH
P-%=.*((#I%/6*-0(5#V(0/4%'
Stobhill
d*<-%3*0#!2[3;03$5#V(0/4%'
VI
N,/-,32#!2[3;03$5#V(0/4%'
WIG
V03-20L,(#V,2,30(#I%/6*-0(5#
Glasgow
a0*4;%3,#I%/6*-0(5#!2L,32,//
GGH
7,("%3)#I%/6*-0(5#c%3-#N*((*0;
I0*3;$3,/#I%/6*-0(5#90/-#W*(=3*),
Belford
Hairmyres
Z%2+(02)/#JVI5#R*3)3*,
MDGH
Wishaw General Hospital
Wishaw
a%$0(#!2[3;03$#%"#9)*2=&34.
RIE
P-#T%.2r/#I%/6*-0(5#f*L*24/-%2
N,/-,32#V,2,30(#I%/6*-0(5#
Edinburgh
PTI
WGH
Raigmore
V*(=,3-#70*2#I%/6*-0(5#P.,-(02)#
X*2,',((/#I%/6*-0(5#J&2),,
GBH
Ninewells
O,3-.#a%$0(#!2[3;03$
PRI
N,/-,32#!/(,/#I%/6*-0(5#P-%32%'0$ WIH
60
W3
W4
AA1
W
WA
A
A2
T
TA
F
www.sicsag.scot.nhs.uk
www.scottishintensivecare.org.uk
61