Introduction and Background The UK multi-agency Guidelines for the Provision of Intensive Care Services recommend deteriorating hospital ward patients should receive care from trained critical care outreach personnel.  In most NHS hospitals, this involves a team of specialist clinicians led by an experienced ICU registrar. This involves work away from the ICU (off unit work). Current guidelines state that NHS hospitals must have appropriate ICU staffing to ensure safe on unit and off unit patient care.  However, the amount and proportions of on and off unit work is not described in the literature. It is also unclear how many NHS hospitals carry out (recommended) outreach activity audit.  This audit quantified the on-unit and off-unit locations of ICU registrars within a tertiary NHS hospital.
Methods Real-time Location Devices (RTLDs), are portable devices which communicate with Wi-Fi network access points to determine position. We used T2 tags (Aeroscout Enterprise Visibility Solutions, Stanley Healthcare, Swindon). The tags provide a location update every 5 minutes, are light (35 grams) and have a 3 year battery life. We attached them to two ICU ‘baton’ pagers (pagers passed on at handover between shifts, Figure 1) carried by senior and junior doctor tiers. These pagers are linked to the current hospital Rapid Response System and non-urgent referral system. The audit population was Adult ICU trainee doctors working in the John Radcliffe Hospital (JRH). We collected data from April 1st - October 31st 2017. Location reliability was assessed by testing the tags against known times and locations. Figure 1 shows the method by which tags generate a location within the hospital.
Results We collected 212 days of data and 61,056 individual data points. At the JRH Adult ICU both doctors spend (on average) 16% of time off unit. 9% of this time is spent in ED/EAU and 7% of this time is spent in other areas of the hospital including radiology, theatres and the wards. More time is spent off unit at night (17%) and during evening shifts (16%) as compared to the day (13%). ICU doctor time spent in ED peaks during the evening shift (11%). The Adult ICU is unattended by both pager carrying doctors during day shifts 4% of the time whilst in the evening it increases to 7% and at night it peaks at 8%.
Discussion Provision of Intensive Care Medicine in NHS hospitals increasingly involves off unit activity. This activity is important but time consuming and hence expensive. By quantifying this activity, informed decisions about staffing and expected workload can be made, especially for night shifts. This in turn should improve patient safety and staffing efficiency. The RTLDs provide a simple means to quantify time worked at different locations in a hospital. By showing that roughly a day a week is spent (by each) ICU doctor off unit we have been able to protect staffing conditions, particularly at night. It has also enabled data driven discussions with other departments about the role of the Adult ICU doctors within their departments.
Limitations Inaccuracies such as ‘floor hopping’, whereby the tag reads a Wi-Fi server on the floor above or below, is common and is due to asymmetrical Wi-Fi layout. This accounted for an estimated 1% of readings. The five minute interval between location updates is inbuilt into the Stanley Healthcare software packages and cannot be shortened. This leads to missed episodes and inaccuracies. This system requires Aeroscout hardware and software to be installed within the hospital and a collaboration with skilled hospital IT technicians. This data is not linked to ICU registrar work type.
Conclusions RTLDs provide a reliable method of quantifying ICU registrar off unit activity. At the JRH, the Adult ICU is left unattended by a doctor at night (on average) 8% of the time. Each pager carrying registrar spends on average 16% of time off unit with 9% of this spent in ED/EAU.
1. Guidelines for the Provision of Intensive Care Services. 2015
2. National Institute for Health and Care Excellence. Nice Clinical Guideline 50: Acutely ill patients in hospital: recognition of and response to acute illness in adults in hospital. NICE 2007
3. NOrF. National Outreach Forum: Operational Standards and Competencies for Critical Care Services. NOrF 2012: http://www.norf.org.uk.