NORTH WALES CRITICAL CARE NETWORK
LEVELS OF CRITICAL CARE FOR ADULT PATIENTS
Throughout the work of the North Wales Critical Care Network reference to ‘Levels of
Care’ for the critically ill are frequently required. Examples of such are, amongst
others, when collecting data for the ‘patient flow’ studies or undertaking ‘unmet
demand’ studies throughout the entire acute Trusts.
Levels of Care are described in Designed for Life: Quality Requirements for Adult
Critical Care in Wales (WHC 009 2006). However, the Network work groups have
identified several difficulties with the interpretation of the definitions. This is partly
because they are sometimes confused with English definitions and often because they
are subjectively interpreted. Confusion is further compounded because the levels of
care are précised in the Welsh Standards for Adult critical Care in Wales (2003) but
additional definitive guidance is not provided.
It is for these reasons therefore that the Network has enhanced the levels of care
definitions by providing examples. Whilst it will be impossible to provide an example
for all patient scenarios it is hoped that these will aid clinical practice and reduce the
subjectivity in interpretations.
The definitions for level of care in Wales are as follows (All Wales Critical Care
Development Group 2003).
Level 0
Suitable for patients whose needs can be met through normal ward care in an
acute hospital.
Level 1
Suitable for patients at risk of their condition deteriorating, those recently relocated
from higher levels of care, and those whose needs can be met on an acute ward
with additional advice and support from the critical care team.
Level 2
Suitable for hospitalised patients requiring more detailed observation or
intervention, including support for a single failing organ system, postoperative care
and those stepping down from higher levels of care.
Level 3
Suitable for hospitalised patients requiring advanced respiratory support in addition
to the above, but the duration of multi-organ support or ability to manage multiple
patients might be limited by staffing or equipment constraints.
Level 3T
Organ support and monitoring for most body systems should be available at Level
3T and these facilities would normally be available to multiple patients
simultaneously. This level is suitable for critically ill patients requiring prolonged
support for multi-organ failure. Such units would have a significant teaching and
training role.
Levels of Care Examples [Final]
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QUICK GUIDE TO LEVELS OF CRITICAL CARE FOR ADULT PATIENTS
LEVEL 3 =
(FOR MORE DETAIL & DEFINITION PLEASE REFER TO FOLLOWING PAGES)
INCLUDE
EXCLUDE
2 ORGAN SUPPORT (DUE TO ACUTE ILLNESS)
ADVANCED RESPIRATORY SUPPORT
GI SUPPORT
1 CHRONIC ORGAN SUPPORT + 1 ACUTE ORGAN SUPPORT:
BASIC RESPIRATORY SUPPORT +
BASIC RESPIRATORY SUPPORT + RENAL SUPPORT = LEVEL 3
BASIC CARDIOVASCULAR SUPPORT =
BASIC RESPIRATORY SUPPORT + NEURO SUPPORT = LEVEL 3
LEVEL 2
BASIC RESPIRATORY SUPPORT + DERMATOLOGICAL SUPPORT = LEVEL 3
BASIC CARDIOVASCULAR SUPPORT + RENAL SUPPORT = LEVEL 3
BASIC CARDIOVASCULAR SUPPORT + NEURO SUPPORT = LEVEL 3
BASIC CARDIOVASCULAR SUPPORT + DERMATOLOGICAL SUPPORT = LEVEL 3
ADVANCED CARDIOVASCULAR SUPPORT + BASIC RESPIRATORY SUPPORT = LEVEL 3
ADVANCED CARDIOVASCULAR SUPPORT + RENAL SUPPORT = LEVEL 3
ADVANCED CARDIOVASCULAR SUPPORT + NEURO SUPPORT = LEVEL 3
ADVANCED CARDIOVASCULAR SUPPORT + DERMATOLOGICAL SUPPORT = LEVEL 3
NB BASIC RESPIRATORY SUPPORT + BASIC CARDIOVASCULAR SUPPORT = LEVEL 2
LEVEL 2 =
1 ORGAN SUPPORT (DUE TO ACUTE ILLNESS)
BASIC RESPIRATORY SUPPORT + BASIC CARDIOVASCULAR SUPPORT = LEVEL 2
PRE-SURGICAL OPTIMISATION REQUIRING INVASIVE MONITORING
EXTENDED POST-OP CARE
PATIENTS REQUIRING HIGH DEGREE MONITORING OR OBSERVATION
PATIENT RECENTLY LEVEL 3 BUT NOT WELL ENOUGH FOR LEVEL 1
PATIENT WITH UNCORRECTED ABNORMAL PHYSIOLOGICAL VARIABLES
LEVEL 1=
EPIDURAL ANALGESIA
RECENTLY DISCHARGED FROM HIGHER LEVEL OF CARE
OUTREACH SUPPORT REQUIRED
LEVEL 0
NORMAL WARD CARE
PRE-OP BED BLOCKING
ROUTINE POST-OP PATIENTS
DELAYED DISCHARGES
(See Appendix 1 for description of basic, advanced respiratory and cardiovascular etc support)
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Level of Care Definitions
(See Appendix 1 for description of basic, advanced respiratory and cardiovascular etc support)
Level 3 Criteria
Advanced respiratory
support
Monitoring and Support of
two or more organs due to
an acute illness (one of
which may be basic or
advanced respiratory
support).
Chronic dysfunction of
one or more organs
sufficient to restrict daily
activities and who receive
monitoring and support for
one other organ due to an
acute illness
Levels of Care Examples [Final]
Examples
Respiratory failure from any cause that requires
invasive, ventilatory support. Examples may
include patients with:
• Neurological depression
o GCS <8
o Neuromuscular failure
• Respiratory failure
o Acute or chronic lung problems requiring
ventilation e.g. COPD, ARDS, pneumonia,
pulmonary oedema etc
• Severe Cardiovascular instability
o E.g. Shock – sepsis, cardiogenic etc
Include
Mechanical ventilatory support
Acute dysfunction of two or more organs. Examples
may include patients with:
• Respiratory and cardiovascular failure
o Invasive ventilation and intravenous
vasoactive drugs
• Respiratory and renal failure
o Invasive ventilation and heamofiltration
• Respiratory and neurological dysfunction1
o Airway protection for GCS< 8
• Major surgery who require advanced respiratory
support (above) and monitoring / support of
other organs
• Continuous IV medication to control seizures
and supplementary oxygen/airway monitoring
Basic respiratory and renal,
neurological or dermatological
support
Examples may include patients with:
• Severe ischaemic heart disease and major
perioperative haemorrhage
• COPD requiring home oxygen presenting with
sepsis related to immunosuppression
Angina on mild exercise and pneumonia requiring
CPAP
3
Exclude
BIPAP / CPAP via ET tube
Mask BIPAP
Extracorporeal respiratory
support
CPAP via trache
Non-invasive mask
ventilation
See page 6 for algorithm
Basic cardiovascular and renal,
neurological or dermatological
support
Gastrointestinal
support
Basic
cardiovascular plus
basic respiratory =
Level 2
Advanced cardiovascular and
basic respiratory or renal or
neurological or dermatological
support
Gastrointestinal
support
Basic
cardiovascular plus
basic respiratory
support = Level 2
NWCCN Informatics Group Revised December ‘09
(See Appendix 1 for description of basic, advanced respiratory and cardiovascular etc support)
Level 2 Criteria
Admissions receiving
monitoring and support for
one organ due to an acute
illness
Examples
Examples may include patients with:
• Respiratory supporto >50% inspired oxygen2
o A tracheostomy inserted in the last 24
hours
o NIV or mask CPAP
o The requirement for physiotherapy or
suctioning at least every 2 hours
• Cardiovascular supporto Cardiovascular instability requiring
continuous ECG and invasive pressure
monitoring
o Haemodynamic instability due to
hypovolaemia/haemorrhage/sepsis
o Haemodynamic instability requiring
balloon pump
o A single infusion of vasoactive drug
requiring appropriate monitoring4
• Central nervous system supporto CNS depression sufficient to compromise
airway and protective reflexes
• Acute impairment of renal, electrolyte or
metabolic function
o Renal replacement therapy
o DKA
o Profound hypothermia
Include
Basic cardiovascular
support and basic
respiratory support = one
organ dysfunction = Level
2
Admissions receiving presurgical optimisation
requiring invasive monitoring
and treatment to improve
organ function
Examples may include patients requiring:
Haemodynamic/respiratory resuscitation or
optimisation.
• Elective major surgery but pre-optimisation
• Emergency surgery but resuscitation
Insertion of invasive
monitoring
Admissions receiving
extended post surgical
Examples may include patients with:
• Major elective surgery
Levels of Care Examples [Final]
Renal support
Exclude
Gastrointestinal support
NIV- long standing or
established care
Neurological support
Dermatological support
Step down (relevant when
no other support ticked –
no longer needs ITU care
but requires greater
monitoring / observations
than could be provided on
a general ward)
Invasive lines in for
‘convenience’ e.g. taking
blood or IV access for
drugs that could be given
peripherally3
Pre-operative admissions
to ‘reserve’ the critical
care bed
Routine post operative
patients
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care either because of the
procedure and/or the
condition of the admission.
•
•
•
Emergency surgery who are unstable or high
risk
An increased risk of post operative complications
or interventions
Intermediate surgery but who are >70 years or
> ASA III (i.e. severe system disease with
functional limitation or worse)
Admissions receiving a
greater degree of
observation and
monitoring than level 1
care
Examples may include patients requiring:
• Observation and monitoring that cannot be
safely provided at level 1 or 0, judged on the
basis of clinical circumstances and ward
resources
o Complex surgery, trauma requiring
multiple blood transfusions
o Treatment for severe DKA
o Complex surgery requiring strict
monitoring e.g. Free flap surgery, major
vascular surgery, cardiac surgery, neuro
surgery etc
o Confused or fitting patients
Admissions moving to stepdown care
Examples are patients who were recently level 3 or
3T but are not well enough to be classed as level 1
or 0.
Admissions with
uncorrected physiological
abnormalities receiving
level 2 care as above
Examples may include patients with:
• Respiratory rate >40 breaths/min or >30
breaths/min for >6 hours
• Heart rate >120 beats/min
• Temperature <350C for >1 hour
• Systolic BP <80 mmHg for >1 hour
• Glasgow Coma Scale (GCS) <10 and at risk of
deterioration
Levels of Care Examples [Final]
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Patients requiring
significant nursing time
e.g. Patients requiring
‘specialing’
Routine post operative
patients
Delayed discharges from
critical care where the
patient is now classed as
level 1.
NWCCN Informatics Group Revised December ‘09
(See Appendix 1 for description of basic, advanced respiratory and cardiovascular etc support)
Level 1 Criteria
Recently discharged from
higher level of care
Examples
Examples are patients who were recently level 2
but are not well enough to be classed as level 0.
Include
All ITU/HDU discharges
(unless classed level 2)
Critical care outreach
service support required
Examples may include patients with:
• Abnormal vital signs but not requiring a
higher level of care
Additional monitoring,
clinical input or advice
required
Examples may include patients requiring:
• >level 0 care
• Observations at least 4 hourly
• Physiotherapy or suctioning at least 6 hourly,
but not more than 2 hourly (see level 2)
Care from specialist staff /
requiring additional facilities
for one or more aspects of
critical care on ward
Examples may include patients requiring:
• Renal replacement therapy (stable chronic
renal failure)
• Epidural analgesia
• Tracheostomy care
Patients requiring
‘specialing’
Level 0 Criteria
Receiving normal ward care
Examples
Examples may include patients requiring:
• Oral medication
• Bolus IV medication
• Patient controlled analgesia (PCA)
• Observations less frequently than 4 hourly
Include
Exclude
Exclude
Additional Notes: Tracheosotomies per se do not contribute to levels of care.
1. If patients are intubated solely for airway protection then this triggers basic respiratory support only. It will generally also trigger
neurological support as many of these patients will also have decreased level of consciousness due to brain dysfunction. See example in
level 3
2. If patient are on 50% or less oxygen this does not trigger either advanced or basic respiratory care i.e. patients have to be on 51% or
more.
3. Most patients will have their invasive monitoring in situ until just prior to leaving the unit, for patient comfort and our convenience. CVC or
IA lines should only contribute to CVS level of care if you would replace or insert the line if it was not in situ at this point in time, and it
would be beneficial to patient monitoring.
4. To trigger advanced CVS level of care then a patient must be on more than one inotropes or more than one rhythm control drugs.
Being of one of each only triggers basic CVS.
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Appendix One (Reference CCMDS DSCN (2006) 14 pgs 15-17)
1. Basic Respiratory Support
Indicated by one or more of the following:
More than 50% oxygen delivered by face mask.
Close observation due to the potential for acute deterioration to the point of
needing advanced respiratory support (e.g. severely compromised airway or
deteriorating respiratory muscle function).
Physiotherapy or suction to clear secretions at least two hourly, whether via
tracheostomy, minitracheostomy, or in the absence of an artificial airway.
Patients recently extubated after a prolonged period of intubation and
mechanical ventilation, via an endotracheal tube for more than 24 hours.
Mask continuous positive airway pressure CPAP or non-invasive ventilation.
Patients who are intubated to protect the airway but needing no ventilatory
support and who are otherwise stable.
2. Advanced Respiratory Support
Indicated by:
Invasive mechanical ventilatory support (excluding mask / hood continuous
positive airway pressure (CPAP) or mask pressure support ventilation (BiPAP) or
CPAP applied via a tracheal tube).
Summary algorithm that explains the differences between basic (BRS) and advanced respiratory
support (ARS).
Ventilation
ARS
Trans-laryngeal
BiPAP or CPAP
INTUBATION?
Tracheostomy
No ventilation
BRS
Ventilation
ARS
BiPAP
CPAP
No ventilation, long term
airway access only
BRS
No ARS or BRS
3. Basic Cardiovascular Support
Indicated by one or more of the following:
Treatment of circulatory instability due to hypovolaemia from any cause.
Use of a central venous pressure CVP line for basic monitoring of central
venous pressure and / or the provision of central venous access to deliver
titrated fluids to treat hypovolaemia.
Use of an arterial line for basic monitoring of arterial pressure or sampling of
arterial blood.
Single intravenous vasoactive drug used to support arterial pressure, cardiac
output or organ perfusion.
Intravenous drugs to control cardiac arrhythmias.
Non-invasive measurement of cardiac output (e.g. echocardiography, thoracic
impedance).
4. Advanced Cardiovascular Support
Indicated by one or more of the following:
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Multiple intravenous vasoactive and/or rhythm controlling drugs. When used
simultaneously to support or control arterial pressure, cardiac output or organ
perfusion (e.g. inotropes, amiodarone, nitrates)
Patients resuscitated after cardiac arrest where critical care is considered
clinically appropriate.
Observation of cardiac output and derived indices (e.g. pulmonary artery
catheter, lithium dilution, pulse contour analyses, oesophageal doppler).
Intra aortic balloon pumping and other assist devices.
Insertion of a temporary cardiac pacemaker (criteria valid for each day of
connection to a functioning external pacemaker unit).
Placement of a gastrointestinal tonometer.
5. Renal Support
Indicated by:
Acute renal replacement therapy (e.g. haemodialysis, haemofiltration etc.) or
the provision of renal replacement therapy to a chronic renal failure patient
who is requiring other acute organ support in a critical care situation.
6. Neurological Support
Indicated by one or more of the following:
Central nervous system depression sufficient to prejudice the airway and
protective reflexes, excepting that caused by sedation prescribed to facilitate
mechanical ventilation or poisoning (e.g. self administered overdose, alcohol,
drugs etc).
Invasive neurological monitoring e.g. Intracranial pressure ICP, jugular bulb
sampling. external ventricular drain.
Severely agitated or epileptic patients requiring constant nursing attention
and/or heavy sedation.
Continuous intravenous medication to control seizure and/or continuous
cerebral monitoring.
Therapeutic hypothermia using cooling protocols or devices.
7. Gastrotintestinal Support
Indicated by:
Feeding with parenteral or enteral nutrition.
8. Dermatological Support
Indicated by one or more of the following:
Patients with major skin rashes, exfoliation or burns (e.g. greater than 30%
body surface area affected).
Use of multiple trauma dressings (e.g. multiple limb or limb and head
dressings).
Use of complex dressings (e.g. large skin area greater than 30% body surface
area, open abdomen, vacuum dressings or large trauma such as multiple limb
or limb and head dressings).
9. Liver Support
Indicated by:
Extracorporeal liver replacement device bioartificial liver or charcoal haemoperfusion.
Acknowledgments
Much of this document is based on the Intensive Care Society Levels of Care for
adult patients standards and guidelines (2002) and work from the Critical Care team
in Ysbyty Gwynedd ICU.
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