Attachment 1
Report on Mid and West Wales Critical Care Education
Introduction
This report is intended to give an overview of the training and education that is
available and accessed by critical care units within the mid and west Wales
Region. Possibilities for action by the critical care network are also discussed
following a survey of senior nurses from each of the units.
There are 8 level 3 general critical care units in 5 Trusts throughout the Mid
and West Wales region. This report does not consider education or training for
Coronary Care Units (CCUs) or specialist intensive care units (ICUs) in cardiac,
neurology or burns services.
The majority of
refer to nursing
However much
multidisciplinary
quality requirements that deal with training and education
as this represents the largest workforce upon critical care.
of the training that is discussed in this report is
in nature.
The Critical Care Quality Requirements (CCQR) state that level 2, 3 and 3T
staff must have ‘access to competency based training from induction through
to specialist training’ (CCQR p11, core requirement). I have therefore
considered the provision of training and education in the following categories:
Induction to critical care

Post registration critical care qualification

Advanced skills

Acute identification and treatment of the critically ill

Associated qualifications and skills

Outreach
Induction to Critical Care
All units provide a period of induction for nursing staff to ensure a level of
competence prior to unsupervised practice.
The structure and formality of assessment of these induction courses varies
widely between units with Carmarthen holding an induction and HDU skills
course for new and junior staff whilst the induction period in Bronglais hospital
lasts 6 months.
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Action
Whilst all units are satisfied with the training afforded to new staff, there may
be some value in the commissioning, by the network, of a piece of work to
strengthen and standardise the links between the induction competencies and
the Knowledge and Skills Framework (KSF) of Agenda for Change (A4C).
Post Registration Critical Care Qualification
It is a CCQR core requirement that 70% of nurses on a 3T unit should have a
specialist qualification in critical care and that there should be an ongoing
education programme.
By 2011 it is a CCQR priority requirement that 70% of level 2, 3 and 3T nurses
should have a higher qualification in critical care.
As all nurses in Wales now qualify at graduate level it seems unlikely that
diploma level qualifications in critical care will continue and therefore all
qualifications will be at degree or Masters level with a credit accumulation and
transfer scheme (CATS) award of between 20-40 points.
Post registration qualifications are accessed from Higher Education Institutions
(HEIs) at Swansea, Cardiff and the University of Glamorgan. There is however
no standardisation of curriculum for what constitutes a critical care
qualification even when two similar courses are accredited by the same HEI.
This is particularly noticeable when considering 3 courses accredited by
Swansea School of Health Science: The Greater Manchester Competency Based Education for Critical Care
Staff.

40 CATS points 1 year course

15 workbooks

28 half day workshops

Comprehensive competency assessment

6 small reflections

4000 word case study assignment.
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Swansea Critical Care Foundation Course

20 CATS points 5 months course

30 hours contact time

Workbook

Clinical competencies

5 small reflections

3000 word reflective assignment
Withybush Hospital High Dependency Course

20 CATS points 6 months course

40 contact hours

Clinical competencies

2000 word reflective assignment
All three courses represent no cost to the ICU as they are either free, as is the
case with the Greater Manchester course or are funded from the Trust’s post
basic education contract.
However, all courses require almost complete management and teaching
responsibility to lie with a clinical educator.
The ICU is not recompensed for this educator’s time although the cost to the
Trust for a module of this size would be £600-£800 per student.
Bro Morgannwg and Ceregigion Trusts also access post registration courses from
Cardiff and University of Glamorgan.
Action
There is widespread support for the standardisation of a critical care
qualification although there is likely to be some disagreement as to which
qualification should be adopted.
There is a real demand for greater opportunities to enrol on these programmes
but both study time and the necessity of travelling long distances are real
obstacles
The CCQR supports the concept of practice development nurses and clinical
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educators and it is apparent that much of the teaching on these courses is
performed by staff with limited protected time devoted to this purpose.
The network may wish to set up a task and finish group with the purposes of
standardising the critical care qualification and investigating how HEI’s could
contribute to the provision of clinical educators at a local level.
Advanced training
The CCQR refers to specialist practitioners and a higher level of practice in
both the core and priority requirements.
It is possible that with the changes in rotation time that are a consequence of
modernising medical careers (MMC) there will emerge a need for a critical care
practitioner with enhanced responsibilities in the ICU.
Bro Morgannwg access the nurse practitioner course from the University of
Glamorgan but there is no uptake of the advanced practitioner module which is
offered by Swansea School of Health Science.
The degree module in monitoring and assessment of the critically ill from
Swansea is well utilised although numbers of places can be limited by the
obstacles of travel and study time.
Action
There is widespread support for the promotion of an advanced practitioner role
and, due to geographical remoteness and lack of medical cover nurses in some
units are already acting with greater autonomy than elsewhere.
The network may want to consider the development of a standard of advanced
practice and to work with HEIs in the development of educational courses to
meet this requirement.
Identification and treatment of ‘at risk’ patients.
It is a core CCQR that systems for identification and response to ‘at risk’
patients should be in place and the priority requirement of ‘full time medical
cover for resuscitation duties’ (CCQR p15) indicates that the onus of this
responsibility rests upon the ICU.
The courses that are offered in this region are the Advanced and Immediate
Life Support Courses (ALS/ILS) from the Resuscitation Council and the Acute
Life-threatening Events Recognition and Treatment (ALERT) course which is
bought in from Portsmouth hospitals.
Although these programmes are provided by a faculty organised through the
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hospital’s resuscitation training department, the ICU staff generally play a huge
part in organising and teaching on these courses.
The ALS course is provided in Carmarthenshire, Swansea and North Glamorgan
Trusts and is accessed by senior nurses from all regional ICUs and all medical
students training in Swansea.
All but one Trust considered it essential that all nursing staff should undergo
ILS training, frequently in conjunction with the ALERT course and Bro
Morgannwg, Carmarthenshire and Ceredigion ICUs are extremely active in
rolling out this training to ward staff.
Action
The network may question whether for critical care staff, especially those with
a responsibility for outreach, life support training should be considered
mandatory on a par with manual handling or violence and aggression training.
There may be a role for the network in standardisation of this training and to
act as liaison with Trusts negotiating responsibility for early warning systems.
Associated qualifications and skills
A variety of associated courses are undertaken by critical care staff including
qualifications in infection control, diabetes, wound care, cannulation and ECG
interpretation
These qualifications are either undertaken through the local HEI or provided by
commercial companies as part of the after sales service.
Paediatric competence
Although critically ill paediatric patients are now routinely retrieved, there
remains in some ITUs a requirement to stabilise and maintain the paediatric
patient prior to this retrieval.
Swansea and Bro Morgannwg Trusts do not follow this practice but, due to
geography, the three Western Trusts’ ITUs may care for paediatric patients for
several hours prior to the arrival of the retrieval team.
This rarely occurs but there is a strong feeling that this is all the more reason
for staff to remain updated in paediatric critical care competencies.
Alison Oliver, paediatric training nurse from UHW provides on site paediatric
training as requested and this is combined with paediatric advanced life
support (PALS) courses on an ad hoc basis.
Nurses from Carmarthenshire ICU have placements on UHW PICU although
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depending upon bed occupancy their actual paediatric contact may be limited.
Action
The geography of the region and the relatively low incidence of admissions may
be interpreted as constituting a special case for regular training in paediatric
critical care. The network should consider whether it has a role in providing
this training.
Transfer Course
It is a priority CCQR that level 3 and 3T units should have staff who are
‘suitably skilled in transfer and retrieval’.
There is, at present, no provision for transfer or retrieval training within the
region. Some networks in England have bought in the Safe Transfer and
Retrieval (STaR) course and Some ICUs in Wales, including that at Bronglais,
have accessed the Road and Air Transfer Safety (RaATS) course that is
organised by North East Wales NHS Trust in collaboration with the RAF and the
Ambulance Service.
Action
The proposal for a transfer and retrieval course was extremely popular amongst
all critical care staff. The network should urgently investigate a means of
introducing such a course, utilising local skills, knowledge and resources, in the
near future.
Outreach
The CCQR (p9) states that all medical staff should have access to Medical Early
Warning Systems (MEWS)/Outreach training.
The term ‘outreach’ is used in Bro Morgannwg to describe an effective service
where the Outreach nurse is involved in training the ward staff in identification
of at risk patients, organising the life support and ALERT courses as well as
having a rapid response role.
It is apparent though that all ICU’s play a significant role as a skill and
knowledge resource to the hospital.
Carmarthenshire, Pembrokeshire and Ceredigion units all contribute hugely to
the organisation and delivery of High Dependency and Alert courses and all
units routinely perform out of hours tasks such as taking blood, cannulation,
assessment of deteriorating patients and post ICU follow up.
Although considered essential by the ICUs so as to prevent deterioration of
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ward patients this work is largely unacknowledged and therefore unfunded.
Action
This invisible work obviously attracts no funding, nor whilst it remains invisible
is it subject to any regulation.
There is strong support for the funding of outreach practitioners whose role
would be in the education and upskilling of ward staff in the early
identification and treatment of at risk patients as well as post ICU discharge
follow up.
This role could be on an individual Trust basis or shared across the region.
Recommendations
There is support across the region and within the CCQR for the network to
investigate and develop the following areas:  Links between critical care induction and the KSF.
 Standardisation of a competency based post registration critical care
degree module.
 Collaboration with the HEIs in the financial support of practice educators
 Standardisation of advanced practitioner role and development of
educational package to support this.
 Support the provision of life support and ALERT courses and collaborate
with Trusts in the development of early warning systems.
 Co-ordinate paediatric critical care training
 The provision of a transfer course
 Support the development of an Outreach practitioner role.
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