Intensivist department
The team is a group of Peripatetic Intensivists that provide perioperative care at the centre. The predominant service this group of consultants provide is post-operative care. However, they also liaise with Anaesthetists and Surgeons to optimise and prepare patients for surgery, as well as review recent discharges for any acute issues.
- The group of Intensivists are resident 24 hours per day at the centre and provide total medical care;
- each patient is reviewed at least once a day on a formal ward round together with the Nurse-in-charge and a pharmacist;
- all acute complications, as well as any chronic conditions of relevance, are attended to rapidly and therapy instituted in good time to ameliorate the burden of insult to the patient as well as the organisation;
- acutely and critically unwell patients are cared for in the Post Anaesthesia Care Unit (PACU) that can provide Level 3 care.
Having 24/7 Consultant Intensivist cover rather than Junior Doctors, enables senior decision-making at every bed in the Centre, this enables a reduction in length of stay with an approximate saving of £400 per bed day. A Junior Doctor or Resident Medical Officer (RMO) model means lower level of experience and confidence, potentially more diagnostic requests and a longer length of stay. The Intensivist model and skill mix of staff enables the Centre to treat patients of all ASA grades and with complex comorbidities. While an RMO model may have a slightly lower associated cost, this is outweighed by the wider savings due to senior decision-making, shorter length of stay, ability to treat all patients and provide equity of access. This makes it a more cost-effective model.
With highly skilled nurses and Allied Health Professionals, discharge is Nurse and Therapy led. This model is also integral to the post-discharge review of patients having concerns or complications post-surgery and thereby reducing the number of potential readmissions. Patient’s concerns and complications are managed by the specialist surgical team rather than the GP or A&E.
The service was set up in 2004, it remains an innovative and unique service.
The team interacts with all necessary specialists and services, including; Surgeons, Radiologists, Cardiologists, Haematologists and laboratories. These Consultants work in the same way as they would in their own intensive care units.
This team is resident at SWLEOC, the Intensivists work in PACU and the wards.
The IT systems used are those of the main Trust as well as those specific to SWLEOC. These include electronic Preoperative Assessment software (LifeBox), Patient Management Systems (Bluespier), Clinical Management System (iSOFT), Picture Archiving & Communication System (PACS) (Sectra IDS7) etc.
It is vital to identify a core group of Intensivists that are appropriately motivated to provide such a service. The group should be small enough to provide continuity of care but also large enough not impact on primary commitments as well as leave.
- Provision of a sound business case. It may appear expensive at first sight; however, it is in fact cost-effective compared to other models of care when the burden of complications is considered.
- Identifying a team that would be willing to undertake the job and be resident. These should be Physicians experienced in perioperative care.
- Providing sufficient incentives, particularly remuneration, to encourage participation and retention.
- Regular and repeated pressures to work within financial constraints.
- Setting up standards of care, protocols/guidance, processes etc. that are acceptable to all parties.
- Build a cohesive team that will work well together, communicate effectively (e.g., through WhatsApp) and provide support for absences;
- the team should work together and bring their collective knowledge and experience to establish best practices, and be prepared to introduce new ways of working;
- full engagement with anaesthetic and surgical colleagues, and not working in isolation;
- refrain from introducing the dogmas of critical care and resist temptation of ordering too many (probably unnecessary) investigations;
- maintain the best standards and quality.
The team were lucky to have established very good practices from the outset. Teaching non-anaesthetic colleagues nerve blocks made a difference. Avoiding central neuraxial opioids as far as possible was beneficial.
Losing several critical care-trained nursing staff means that we can no longer keep patients requiring Level 3 care for more than a few days.
Ours is a unique service!
Staff
Staff Member: Consultant
PACU and wards are covered 24/7 by one of 18 Consultant Intensivists on a bank basis:
- postoperative care: management of pain or medical complications;
- preoperative optimisation;
- review of discharge complications;
- liaison with subspecialists and services for further investigations;
- liaison with subspecialists for transfer to tertiary centres;
- teaching nursing/therapy staff;
- liaison with Primary Care for communication of complications or further management.