National Public Health Service for Wales
Critical care public health tool –updated overview of evidence base
Critical care public health
tool – overview of
evidence base
Author: Dr Nina Williams, Consultant in Public Health
Date: May 2009
Version: 1
Status: Final
Intended Audience: Public (Internet) / NHS Wales (Intranet) / NPHS (Intranet) /
Critical Care Networks
Purpose and Summary of Document:
This tool draws together updated evidence upon critical care. It is formatted to assist
the critical care networks in identifying current best evidence and to provide
summaries of key messages.
Publication/Distribution:

Publication in NPHS Document Database HSCQ Team

Link from NPHS e-Bulletin

Link from Stakeholder e-Newsletter

Inform networks directly
Author: Dr Nina Williams, Consultant
in Public Health
Version: 1. Published May 2009
Review Date March 2010
Date: 310509
Status: Final
Page: 1 of 7
Intended Audience: Public (Internet) /
NHS Wales (Intranet) / NPHS (Intranet)
/ Critical Care Networks
Critical care public health tool – updated overview of evidence base
National Public Health Service for Wales
Critical care public health tool - overview of the evidence base for best practice in critical care
This is one of series of regular evidence updates, which are undertaken by LKMS as part of NPHS support to the All Wales Critical Care Advisory
Group. The aim is to “research and identify the evidence base for the best practice and new technology for the management of critically ill
patients based on a strong national and international evidence base.” 1 A systematic search methodology is followed so the results are easily
updated and reproducible. Details of full methodology, search results and literature review are available from LKMS.2
The initial searches identified very few papers of high quality evidence (systematic reviews, RCTs and meta-analyses). Most are single centre
primary research studies.
The focus is on outcomes in terms of ICU quality measures like average length of stay, ICU mortality, patient/family satisfaction, sub optimal
pain management, effectiveness and cost effectiveness, care bundle compliance e.g. prevention of ventilator associated pneumonia, rate of
infections related to instrumentation.
Intervention
Reference
National Institute for Health and Clinical
Excellence. Rehabilitation after critical
illness. London: NICE; 2009 Available at:
http://www.nice.org.uk/guidance/CG83
Welsh Assembly Government. Designed for
Life: Welsh guidelines for the transfer
of the critically ill adult. Cardiff: WAG;
2009
Comment
Issued with EH/ML/0010/09.
Available at:
http://howis.wales.nhs.uk/doclib/EHML-010-09-new.pdf
1
2
Designed for Life: Quality requirements for adult critical care in Wales. EH/ML/008/08
LKMS, National Public Health Service for Wales, NPHS, 36, Orchard St, Swansea. 01792 607331 Email : LKMS
Author: Dr Nina Williams, Consultant in Public Health
Version: 1. Published May 2009
Review Date March 2010
Date: 310509
Page: 2 of 7
Status: Final
Intended Audience: Public (Internet) / NHS Wales (Intranet) /
NPHS (Intranet) / Critical Care Networks
Critical care public health tool – updated overview of evidence base
National Public Health Service for Wales
Intervention
Care bundles, quality measures
Reference
Comment
See Summary of main findings from the
Critical care literature provided for Critical
Care Advisory Group
Type III evidence
Weaning
NHS Modernisation Agency Critical care
programme. Weaning and long term
ventilation. Leicester: NHS Modernisation
Agency; 2002.
Type III evidence
Author: Dr Nina Williams, Consultant in Public Health
Version: 1. Published May 2009
Review Date March 2010
Date: 310509
Page: 3 of 7
From Institute for Healthcare
Improvement, ventilator and sepsis care
bundles describe a collection of evidence
based elements put together to improve
clinical outcomes and both these bundles
were associated with improvement in
mortality. The bundles themselves have
not undergone RCTs.
A systematic review of interventions that
improved patient outcomes identified
quality measures that could be applied to
improve ICU care.
Non-invasive ventilation (NIV) reduces the
need for intubation, duration of ventilation
and mortality in patients with acute
exacerbation of COPD. May lead to
reduction in ICU admissions.
NIV reduces complication rates e.g.
reduces infection as a consequence of
intubation
The number of patients needing prolonged
mechanical ventilation and their outcomes
can be improved by specific approaches to
weaning and the use of weaning protocols.
It is estimated that a 50% cost saving per
patient day could be made in the UK by
caring for chronically ventilated patients at
level 2 setting rather than at level 3.
Status: Final
Intended Audience: Public (Internet) / NHS Wales (Intranet) /
NPHS (Intranet) / Critical Care Networks
Critical care public health tool – updated overview of evidence base
National Public Health Service for Wales
Intervention
Reference
Comment
A specialist non-invasive ventilation
service is recommended provided by
specialist units experienced in the
provision of long term and domiciliary
ventilatory support.
Zilberberg MD et al. Anemia, transfusions
and hospital outcomes among critically ill
patients on prolonged acute mechanical
ventilation: a retrospective cohort study.
Critical Care 2008; 12(2):R60,
Patients receiving prolonged acute
mechanical ventilation (PAMV) are at high
likelihood of being transfused with multiple
units of blood at relatively high
hemoglobin levels. Transfusions
independently contribute to increased risk
for hospital death, length of stay, and
costs. Reducing exposure of PAMV patients
to blood may represent an attractive
target for efforts to improve quality and
efficiency of health care delivery in this
population
Type IV evidence
Patient safety
National Public Health Service for Wales.
An NPHS review to inform the patient
safety initiative in Wales. Cardiff: NPHS;
2007.
Author: Dr Nina Williams, Consultant in Public Health
Version: 1. Published May 2009
Review Date March 2010
Date: 310509
Page: 4 of 7
updated the evidence base on the Institute
of Healthcare Improvement Initiatives
http://www.ihi.org/IHI/Topics/CriticalCare
/
Status: Final
Intended Audience: Public (Internet) / NHS Wales (Intranet) /
NPHS (Intranet) / Critical Care Networks
Critical care public health tool – updated overview of evidence base
National Public Health Service for Wales
Intervention
Reference
Type III evidence
Comment
and recommended 4 for prioritisation
which have relevance to critical care:
National Institute for Health and Clinical
Excellence. Acutely ill patients in hospital.
CG50. London: NICE; 2007

Delivering reliable evidence based
care for chronic heart failure

Reducing health
infections

Preventing and
complications

Preventing
medicines
harm
care
associated
reducing
from
surgical
high
risk
In addition, physiological track and trigger
systems were recommended by NICE in
2007 to monitor all adult patient patients
in acute hospital settings.
Type II evidence
Prevention of ventilator-associated
pneumonia
National Institute for Health and Clinical
Excellence.
Technical patient safety solutions for
prevention of ventilator-associated
pneumonia in adults. London: NICE; 2008.
Author: Dr Nina Williams, Consultant in Public Health
Version: 1. Published May 2009
Review Date March 2010
Date: 310509
Page: 5 of 7
On the basis of low potential for harm and
supported by credible efficacy data and
expert advice, the following actions were
considered to be relatively easy to
implement and associated with little or no
Status: Final
Intended Audience: Public (Internet) / NHS Wales (Intranet) /
NPHS (Intranet) / Critical Care Networks
Critical care public health tool – updated overview of evidence base
National Public Health Service for Wales
Intervention
Reference
Type II evidence
Comment
additional resource:


Mechanically ventilated patients who
are intubated should be positioned
with their upper body elevated (in a
semi-recumbent or seated position)
for as much of the time as possible.
For some patients this will not be
appropriate (for example, those
with spinal injuries).
Oral antiseptics (for example,
chlorhexidine) should be included as
part of the oral hygiene regimen for
all patients who are intubated and
receiving mechanical ventilation.
The Committee examined evidence which
suggested that selective decontamination
of the digestive tract (SDD) using topical
antibiotics may reduce the incidence of
VAP and that SDD regimes that include
systemic antibiotics may also reduce
mortality. However Specialist Advisers
stated that UK intensive care specialists
had particular concerns about the risk of
infection with Clostridium difficile and the
induction and/or selection of resistant,
including multiresistant, microorganisms
as a result of SDD.
Therefore the Committee recommended
further research into SDD in a UK
Author: Dr Nina Williams, Consultant in Public Health
Version: 1. Published May 2009
Review Date March 2010
Date: 310509
Page: 6 of 7
Status: Final
Intended Audience: Public (Internet) / NHS Wales (Intranet) /
NPHS (Intranet) / Critical Care Networks
Critical care public health tool – updated overview of evidence base
National Public Health Service for Wales
Intervention
Reference
Comment
setting.
National Institute for Health and Clinical
Excellence. Technical patient safety
solutions for prevention of ventilatorassociated pneumonia in adults. PSG002.
London: NICE; 2008
Although the evidence supported the use
of elements of care bundles, there was
insufficient evidence to recommend a care
bundle of any specific design.
Type II evidence
Critical care services
Wunsch H et al. Variation in critical care
services across North America and
Western Europe. Critical Care Medicine
2008;36(10):2787-93, e1-9,
Type IV evidence
Author: Dr Nina Williams, Consultant in Public Health
Version: 1. Published May 2009
Review Date March 2010
Date: 310509
Page: 7 of 7
The number of intensive care unit beds per
capita is not strongly correlated with
overall health expenditure, but does
correlate strongly with mortality (the UK
did not compare favourably to Germany
based on a one year snapshot). These
findings demonstrate the need for critical
care data from all countries, as they are
essential for interpretation of studies, and
policy decisions regarding critical care
services.
Status: Final
Intended Audience: Public (Internet) / NHS Wales (Intranet) /
NPHS (Intranet) / Critical Care Networks