1. Daily review of diagnosis and Treatment Escalation Plan (TEP) for HDU patients in small and remote units
A full review of the patient's condition must be undertaken daily by a senior decision maker(s) (please see definitions drop-down section below) and the Multi-Disciplinary Team.
The review should consider:
- Diagnosis
- Severity of illness
- Reversibility of the illness and existing co-morbidities
- Treatment Escalation Plan (TEP)
- Patients and family preferences for where they wish to be treated
- Capabilities of the receiving hospital
- The trajectory of the patient’s condition (i.e. static, improving or deteriorating)
A TEP must be established on admission to the critical care area and may be amended depending on the patient’s progress.
Based on this daily review, deteriorating patients should be considered for escalation of care within the small and remote unit, and/or transfer to another facility.
2. Small and remote units should have agreed Standard Operating Procedures (SOPs) with receiving hospitals
All patients with increased level of care requirements and considered suitable for escalation by the Senior Decision Maker, should be discussed with the appropriate intensive care clinician(s) at the receiving hospital.
This process should:
- Support and advice for HDU patients not yet requiring transfer
- Help review the TEP for specific patients
In cases of escalation, the referring hospital must know who to contact and how (e.g. an on-call designated clinician).
If transfer is being considered, the rationale must be clearly documented in the patient’s notes.
The final transfer destination will be agreed by all parties and coordinated by, and involve ScotSTAR/EMRS (Emergency Medical Retrieval Service) early in decision making.
A transfer letter must accompany the patient to the receiving hospital.
Receiving hospital specialists must be involved in care escalation and fully aware of the transfer.
Small and remote clinicians should have knowledge of specialist referral pathways (e.g.Neurology, Neurosurgery, Liver and Cardiology).
3. Small and remote units should have protocols in place to support de-escalation of care
These protocols should support patient step down to ward-based care to free up critical care beds and ensure care continues in the most appropriate setting.
Ongoing support should also be arranged as part of de-escalation planning.
4. Health Boards should consider and agree formal transfer pathways for care escalation
Health Boards should confirm formal pathways between partner hospitals and establish Service Level Agreements (SLAs).
During transfers, the required level of care must be maintained. Referring hospitals should ensure that SAS (Scottish Ambulance Service) or accompanying hospital staff have:
- The necessary knowledge, skills and experience
- Appropriate equipment and medications
- Insurance coverage and transport options
They should also be prepared to manage any deterioration during transfer.
Referring hospitals should have strong clinical, operational and governance links with local and regional SAS teams. This should include a joint review of incidents and outcomes (e.g. adverse events, complaints, deaths and failed transfers).
Responsibility for the transfer of a patient lies with the referring hospital, until such a point that the patient is in the receiving hospital. The only exception to this would be where the care of a patient has been accepted for transfer and comprehensively handed over to a retrieval team or one of its members, e.g. an air paramedic.
Further guidance can be found in the Intensive Care Society Transfer of the critically ill adult guidelines
5. Small and remote units should work with partner hospitals to design, agree and resource sustainable support
This may include:
- Appropriate SLAs in place (as above)
- Ongoing team development
- Access to telemedicine tools (e.g. Microsoft Teams, conference calls)
- Digital tools to support communication and share imaging/results
- Site visits in both directions
- Joint training
- Sharing clinical assessment and clinical management tools (e.g. shared documentation)
Critical care
