Plugging the gap – critical care skills are the current universal commodity

From 1st August 2004, doctors in training will be subject to the weekly working time limits enacted by the 1998 UK working time regulations and extended to include medical staff in 2003 [The Working Time (Amendment) Regulations, 2003]. All employers of doctors in training will be required to ensure that compliance with these regulations occurs. The current system of cover within the medical profession has retained a traditional dependence on junior staff ‘resident on-call’ systems with a requirement to continue work the next day. As from 1st August 2004: A trainee doctor may not work continuously for more than 13 h without a minimum period of 11 h off between duty periods. A trainee doctor may not work for more than 58 h per week, but in the UK, this will be contractually limited to 56 h actual work/ week, averaged over a 26-week period. A trainee doctor is considered to be working if he or she is required to be in the hospital, whether awake or asleep. (Academy of Medical Royal Colleges, 2004). The significance of point 3 was determined by the SiMAP ruling. SiMAP, a Spanish doctors’ union, brought a case to the European Court of Justice that clarified that time spent ‘on call’ in residence at the place of work constituted working time whether awake or asleep (Thompson's Labour and European Law Review, 2000). Therefore, any resident on-call working will count as full working hours within these limitations. In order to meet these regulations, many acute Trusts have been forced to make alternative arrangements to the way that out of hours medical care is delivered, and shift systems allowing speciality cover only until 2200 hours have been introduced. For many Trusts, the introduction of a multidisciplinary Hospital at Night team is one significant new way of working and helps to meet these regulations. This initiative aims to provide a single team across the hospital with appropriate levels of competency to respond to patients’ overnight needs. A survey of 11 acute trusts has resulted in collation and review of large amounts of data on the type and distribution of work required by patients during the evening and night period (NHS Modernization Agency, 2004). The findings indicated that evenings (up till midnight) tend to be very busy and night time (midnight until 0800 hours) tend to be fairly quiet). When broken down, it was found that 7% of night calls related to life- or limb-threatening conditions; 62% were calls to patients who were considered physiologically unwell; but 31% of the calls were to patients who were physiologically normal. The conclusion made in the Hospital at Night report was that ‘a significant proportion of the night-time work is non-urgent and could be brought into the day’ (NHS Modernization Agency, 2004, 1.1.5). However, to respond to the acute and emergency situations, critical care assessment and intervention skills are vital in the Hospital at Night teams (Ibid 1·1.12). The competencies needed in this team have been delineated (see Table 1) and suggest that critical care trained nurses are particularly able to meet the major part of these needs. Thus, many Hospital at Night teams have started to recruit critical care nurses, in an attempt to fill the gap left by reducing the number of doctors available. This recent recruitment is over and above those critical care nurses now working in Critical Care Outreach teams. It provides yet another drain on a valuable (and limited) resource but also provides further endorsement that these skills are universally necessary for an increasing number of acute hospital patients. The acknowledged increase in acuity of ward patients has affected the necessary competencies that nursing and medical staff require in order to care for them. Between 1999 and 2003, the percentage of hospital beds specified for acute patients has risen from 57 to 59%, and this trend looks set to continue (Department of Health, hospital activity data). In the same time period, the percentage of critical care beds has risen by only 0·7%. This suggests that the number of patients requiring more than normal ward care but remaining in a ward bed has risen and will continue to rise unless this trend is halted. The altered need for acute care has not immediately been reflected in the pre-registration curriculum (Smith and Poplett, 2002). This may change as pre-registration students are exposed to critical care experiences in the latter part of their programme (Department of Health, 1999) and more qualified acute care staff attend programmes such as ALERT and HELP (Department of Health, 2003). A significant educational impact has been achieved by critical care staff through outreach into the ward environment (National Outreach Survey, 2002). However, more must be done to provide a better and more universal understanding of caring for the acutely ill patient. As a starting point, this might be achieved by the introduction of a fifth branch of pre-registration nursing that is focusing on the care of acute and critically ill patients (Scholes, 2004). Widespread acquisition of critical care skills and competencies are likely to be of enormous benefit to patients. Some of these are already in evidence from critical care outreach, including improved mortality (Priestley et al., 2004), reduced cardiac arrest incidence (Bellomo et al., 2004), reduced readmission rates to critical care areas and improved survival post-ICU discharge (Ball et al., 2003). Less easily demonstrable are the cultural changes likely to result from this. A multidisciplinary approach based on mutual respect for each profession's skills is the norm in the critical care environment but is less evident in many general ward areas. Effective communication is essential for effective multidisciplinary working (Freeman et al., 2000), and this strength is associated with critical care teams working in acute situations but would benefit the ward areas. The culture of proactive intervention and prevention is also common within critical care areas, yet less frequently seen in wards and even less commonly seen at night in ward areas. Transfer of this style of working is likely to have a beneficial effect on patients, which will have a greater impact overall, than a simple increase in level of skill or knowledge will do. The setting up of a team approach at night is the first step in transferring some of this culture, and the use of critical care nurses is likely to provide a strong impetus to change overall. Ultimately, this alternative way of working will be highly beneficial to patients, but it may result in yet another drain on an already over-stretched resource, the skilled, experienced critical care nurse. At a time when we face a major demographic crisis (one in four nurses on the NMC register in 2003 was over 50) and we see an increasing need for level 2 and 3 critical care beds, there may not be enough nurses around to fill the demand. To meet this need, it is essential for more acute physiology and assessment skills to be taught and intervention skills assessed in the pre-registration curriculum (Scholes, 2004). Regular placements for staff within critical care areas with specific objectives and competencies to acquire would also assist their recognition and understanding of the acutely deteriorating patient. This should apply not only to nurses but also to medical and other staff. Ideally, acute assessment skills with appropriate and timely responses should be seen as an essential part of any preparation for caring for hospital patients. For the long-term future, this is the only viable option. Less generally beneficial are the proposals to add in a plethora of assistants with technical skills (such as the doctor's assistant) or the trained technical health care support worker. While these roles are all individually effective in reducing the demands on nurses’ and doctors’ time, overall they tend to divide the patient into a series of technical tasks without the global assessment skills, understanding and recognition, which comes with viewing the patient as a whole. Thus, many tiny clues that build up a picture of the patient will be missed. It is time that the universal importance of some specific aspects of critical care skills are recognized and built in to the general preparation of nurses and doctors working with acutely ill patients. These skills cannot continue to be borrowed in order to fill the gap left by education, legislation or skills/knowledge limitation. Sheila Adam 1 1 Nurse Consultant Critical Care, UCLH Trust