Friday 8 October 2021

GIRFT critical care report outlines steps to help the NHS cope with future COVID-19 surges

Recommendations aim to ensure equal access to services caring for the most severely ill patients

The latest report from the Getting It Right First Time (GIRFT) programme outlines a new model for critical care services which could help the NHS in England cope with future surges of the COVID-19 pandemic.

Download the GIRFT report here

Staffing and equipping units to provide more ‘enhanced care’, including non-invasive ventilation, as well as funding and developing transfer services to enable adult patients to be moved more easily, are among the measures in the national GIRFT report designed to ease some of the pressures on critical care services and ensure patients have equal access wherever they live.

The GIRFT report – written by Dr Anna Batchelor, a consultant anaesthetist and intensivist at Newcastle upon Tyne Hospitals NHS Foundation Trust – is based on visits to more than 100 critical care units in England before the pandemic hit, but is also informed by insights gained from caring for COVID-19 patients from spring 2020 onwards.

The data-driven review found variation in bed numbers and workforce levels between hospitals, with capacity, culture and resources affecting local decisions on who can be admitted to critical care. There is a need for more beds generally, but the report acknowledges that increasing the number of highest level beds (Level 3, offering advanced respiratory support) on standby for severely ill patients during COVID-19 surges is not practical.

Instead, a series of recommendations in the report aim to maximise the capacity in units to help cope with future waves, and avoid the need to delay or cancel surgery for other patients. These include:

Developing more ‘enhanced care’ areas– hospital wards staffed and equipped to provide flexible enhanced care, including non-invasive ventilation, can be used for post-operative care and to help the transfer of patients back from critical care to other wards, but can also be switched to care for COVID-19 patients during surges.

Establishing and funding adult transfer services– developing transfer services at a system level can ensure equal access for all patients, especially those in rural and remote areas, and allow regional cohorting of COVID-19 patients so that critical care units can maintain a ‘normal’ service.

Increasing hospital outreach – identifying patients from across the hospital whose condition is at risk of deterioration and taking steps to stabilise their condition can prevent organ failure and admission to critical care. This can lead to better patient outcomes and helps free up critical care beds for other patients.

Dr Batchelor said: “The COVID-19 pandemic has highlighted critical care services like no other event in the last 20 years, and staff working in units across the UK have gone above and beyond, under extreme pressure, to cope with this unprecedented crisis.

“During the first surge an amazing collaboration of ‘can do’ NHS workers prevented the service from being totally overwhelmed, but it would be inappropriate and inadvisable to expect this to happen again in the same way. By developing enhanced care services, and putting in place a competent workforce of doctors, nurses and allied health professionals (AHPs) to support them, a viable buffer can now be created.”

Around 200,000 people per year in the UK are admitted to critical care units, including those with severe cases of COVID-19, patients who have been in road traffic accidents or suffered serious burns, or patients recovering from planned surgery. The aim is to admit patients who have the capacity to recover from their condition. Nevertheless, 15–20% of patients admitted to UK intensive care units die in hospital.

As well as addressing the specialty’s high demand and constraints in staffing, equipment and space, the GIRFT report also makes recommendations for improvements to end of life care and organ donation protocols, calling for Advance Care Planning (ACP) to help understand a patient and their families’ end-of-life wishes and for every trust to have a clinical lead for organ donation (CL-OD) working with a specialist nurse for organ donation (SN-OD) so that donations can occur in a timely way.

Other key recommendations focus on patient recovery and rehabilitation. Developing post-operative pathways and rehabilitation, starting in critical care and following through to primary care after discharge, can help patients (including those who have survived COVID-19) cope with the physical, psychological and social consequences of their critical illness. There is a need to improve the data on long-term outcomes for critical care patients, including mortality, readmission to hospital, quality of life, new frailty and results of rehabilitation, to better inform decision-making around whether or not to admit a patient.

Dr Batchelor said: “Critical care units are central to the smooth running of hospitals and recent events have given the findings and recommendations in this report a new sense of urgency.

“Our specialty has, in the past, had its success measured by its survival rates. I hope that this report can be part of an evolution of critical care, to see that survival itself is not enough and be ambitious about improving the quantity and quality of life after critical care.”

The report is endorsed by both Intensive Care Society and the Faculty of Intensive Care Medicine.

President of the Intensive Care Society, Dr Stephen Webb, added: “We look forward to continue working with the GIRFT team and other national bodies to help realise the recommendations. The Society and FICM and the are already engaged in developing many of the areas recommended in the report and its publication will support their timely implementation”

Dr Alison Pittard, dean of the Faculty of Intensive Care Medicine, said: “The whole GIRFT team are to be commended for their comprehensive evaluation of the significant issues facing critical care. The report highlights the variability in access to critical care across the nation and this has to be addressed. It is essential that intensive care units and critical care teams are supported to deliver any improvements required and we hope the funding will follow for all the aspects of care alluded to in the recommendations.”

Download the GIRFT report here