Annexure 3 AWCCAG report Long Term Ventilation

Annexure 3
Date of meeting
Action Required
Progressive Care for Long Term Ventilation and
Specialist Weaning
SE Wales Network Manager & Lead Clinician
17th June 2008
To approve the establishment of a project group
Critical Care Networks in Wales have been established to: Support implementation of the Quality Requirements for Adult Critical Care in
 Improve the effectiveness and efficiency of the existing critical care resource
 Identify the local need of critical care services
The purpose of this paper is to describe a current issue identified by Critical Care
Networks which affects the effective and efficient use of critical care resources in
Wales regarding long term ventilated patients and to provide the All Wales Critical
Care Advisory Group with a proposal to establish a Project Group to develop a
Progressive Care for Long Term Ventilation and Specialist Weaning Service in
Summary of main issues
An issue identified by Networks affecting the effectiveness and efficiency of critical
care services in Wales is that of long stay patients within a critical care unit (ie 30
days plus).
All units can identify individual patients who have remained (and in many cases still
remain) in a critical care bed. Many of these patients have experienced spinal cord
injuries and although they are ventilatory dependent, they are often not “critically ill”
and from governance perspective could be considered as inappropriately placed.
Not only are critical care beds amongst the most costly resource within a secondary
care service, but more importantly this presents a clinical risk to the patients
concerned and may limit access for other critically ill patients.
English NHS Modernisation Agency “Critical Care Programme”
This issue has already been recognised and well documented in England. The NHS
Modernisation Agency “Critical Care Programme – Weaning & Long Term
Ventilation” report1 recognises that
 “The majority of patients who require invasive mechanical ventilatory support
either wean successfully or die during their Critical Care admission. However
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a small, but significant, sub group require either a prolonged Critical Care stay
in order to wean, or may become ventilator dependent”
Long term ventilated patients are major resource users with Critical Care
The report defined: Ventilatory dependence: the need for ventilatory support applied either
invasively or non invasively in order to prevent or treat respiratory failure
o Acute – requirement for minimum 6 hrs per day, more than 2 weeks. If
this persists for 3 weeks it is termed “weaning failure”
o Chronic – regularly each day or night, exceeding 1 month. Ventilatory
support usually received in the home rather than hospital.
 Weaning – the process of becoming independent from ventilatory support.
The report recommended:1. Delayed Weaning - A specialist Non-invasive ventilation service to which
patients who suffer delayed weaning can be referred to be established in a
small number of NHS Trusts
2. Failed weaning, long term ventilatory support & NIV - A service for the
provision of long term invasive and non invasive support and for patients who
have failed weaning
3. Acute respiratory failure and the use of NIV – an NIV service established in
each acute Trust.
The report provides examples of a number of best practice Intensive Care Weaning
services/units including: Newcastle General Hospital Intensive Care Weaning Service
 Lane Fox Respiratory Unit Weaning Programme, St Thomas Hospital
 Progressive Care Programme, Papworth Hospital
NHS Wales Service Development & Commissioning Directives – Respiratory
In Wales, the “Service Development & Commissioning Directives – Respiratory
Conditions”2 (consultation in 2006) recognises the need for support and services for
patients with chronic respiratory conditions.
Whilst this Directive focuses on the care pathways and services for the effective
treatment and management of people with respiratory conditions outside of critical
care services and progresses the 3rd recommendation above it does not consider the
current issues regarding long stay ventilatory dependence, failed weaning patients
who remain in critical care.
Cost Effectiveness
The All Wales Cost per patient day has been identified in the 2006-7 NHS Trust
Annual costing exercise as:£828 for Adult HDU
£1,564 for Adult ICU
£1,167 for combined ICU/HDU
Whilst it must be recognised that the 2006-7 critical care costing exercise in Wales
resulted in wide variations due to the differences in counting activity and consistency
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of service elements included in the returns, this would mean that 1 patient occupying
a Level 3 bed for a full year would cost in the region of £570,860 pa.
In Specialist Care and Ventilation units in England, an approximate cost per day is in
the region of £400 (depending on patient assessment) with a full year approximate
cost of £146,000.
Patient Experience
A critical care ward (or cubicle) is clearly not the appropriate location for a long stay
patient who is no longer acutely ill. There is currently 1 patient in Llandough Hospital,
Cardiff who has been occupying a critical care bed for the last 2 years due to lack of
suitable alternative, progressive care in Wales.
In many cases, clinicians seek suitable rehabilitation placements within England.
These units often have lengthy waiting lists and also result in relocating the patient at
extreme distances from their family.
Critical Care Service Development
It is clear that a gap in service provision in Wales is:-
Critical Care
Given the geographical nature of Wales, it is envisaged that 2 supraregional centres
(North and South) would be required to provide a specialist service for patients who
experience delayed weaning, failed weaning and long term ventilatory support.
These centres would need to be separate from, but integrated with, critical care
services to provide 24 hr ventilation specialist advice and support.
This gap in Welsh services was also recognised within the discussions between the
Welsh Critical Care Networks and the Welsh Assembly Government Neuroscience
review (due to report in summer 2008).
Project Structure
In line with the Terms of Reference of the All Wales Critical Care Advisory Group and
the Establishment Agreement of the Critical Care Networks, Clinical/Topic/sub groups
can be established in order to progress key areas of work.
In order to progress this development within Wales, it is recommended that a Project
Group be established with a remit to:1.
Undertake a Needs Assessment
a. To identify the types of patients (by diagnosis) that may present with
problems in weaning or that require long term ventilation (ie patients
ventilated more than 30 days with single organ support)
b. To assess what the current demands on the service are related to the
different types of patient
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Service description/specification
a. To develop a service description/specification which includes
i. Patients covered
ii. Unit staffing
iii. Unit characteristics
Financial Requirements
a. Identify cost of patient care if all patients were to be transferred to
English service provision
b. Identify cost of service (staffing, equipment, capital, transport)
c. Potential for income generation
Financial Implications
It is clear that such a development within Wales will require a significant capital and
revenue investment. However it should be noted that this would be in addition to any
gaps identified by Critical Care Networks in local critical care capacity.
The AWCCAG is asked to consider the issues outlined in the report and the
establishment of a Project Group to progress a
 Needs Assessment
 Service Description/specification
 Financial Requirements
NHS Modernisation Agency – Critical Care Programme. Weaning & long
term ventilation
Service Development & Commissioning Directives: Respiratory conditions
Consultation 2006
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