Critical Care Units provide care to those patients who traditionally need “organ support”.¹ There is variation in provision and “admission criteria” across the UK,^2,3 and although Level 2 admissions have been increasing this often reflects increasing perioperative demand and largely ignores the unmet and often unmeasured medical need.

Enhanced or Level 1 Critical Care was defined in a consensus review of the Levels of Adult Critical Care, which reflects the modern delivery of critical care and the changing demands upon it. It merges the pre-existing level 0 and level 1 into ward care and frees up ‘level 1’ of critical care to represent the emerging Enhanced Care, with Level 2 and 3 remaining largely unchanged.⁴

There are potentially many different patient groups who may benefit from enhanced care, especially as patient acuity and interventions become more complex.
Perioperative enhanced care recognises that many perioperative patients benefit from enhanced monitoring but overall, do not require Level 2 or 3 critical care.⁵
Respiratory Support Units (RSUs) were introduced as an area of enhanced care that enables a higher level of monitoring and respiratory intervention than would be expected for a routine ward environment, for patients who require respiratory support (Non-Invasive Ventilation) but not critical care.⁶

Medical patients often fall between the void of not needing critical care per se but requiring a higher level of monitoring or multi-professional intervention than can be provided on a conventional ward. For example, patients with diabetic ketoacidosis, those requiring monitoring of electrolyte infusions, or perhaps even low dose vasoactive medications.

To address this gap in provision, the Intensive Care Society and Society for Acute Medicine developed guidance specific to patients within Acute Medicine. The specialty has grown to look after a wide range of acutely unwell adult patients, increasingly with complex co-morbidities and overlapping acute pathologies. This often requires greater nursing and medical resource than can be offered within a ‘standard’ ward, although currently in most AMUs these complex patients continue to be looked after in conventional ward areas with traditional staffing levels and mobile monitoring equipment.

Some enhanced care units allied to AMUs have grown organically to begin to meet this demand, and the Society for Acute Medicine has developed a database to facilitate information sharing about best practice around this. Current units range from 4 bedded areas with enhanced nursing ratios to 24 bed units with the capability to deliver invasive monitoring and vasoactive medications. Each of these units has developed in response to local demand, clinician skill mix and critical care capacity, and their presence should be celebrated as reflecting the progressive approach to care at these sites.

There is a need to develop consistency of approach to these units and to provide guidance to support the development of new areas. It is our opinion that eventually most AMUs should have an enhanced care area to allow the most appropriate care to be delivered to the most at-risk patients seen within Acute Medicine. How this looks in each site will be driven in part by local factors, but the underlying principles of providing enhanced nursing ratios, with close monitoring and clinical staff locally available to respond promptly must be at the core.

It is for these reasons that some principal recommendations within this guidance centre around improving the nursing ratios; a maximum of four patients per nurse is recommended, dropping to two where side rooms, non-invasive respiratory support or vasoactive medications are used. The Royal College of Nursing has endorsed this document and by extension the nursing ratios, providing units with a clear mandate to work to these numbers. As well as improved nursing staff ratios, permanent monitoring in each bedspace linked to a central console is recommended. There are clear recommendations on the governance of enhanced care units, and the need for professional leads from Medicine, Nursing, Allied Healthcare Professionals and Pharmacy.⁷ As with everything within Acute Medicine, the multidisciplinary approach to these areas will be pivotal.

Senior medical and nursing input will be necessary to these areas, and we provide guidance around this. We recommend a senior nurse oversees the running of the unit day to day, distinct from those delivering clinical care. As with AMUs currently, twice daily Consultant input and rapid access to senior decision makers at all times is necessary. For all unwell patients decisions around goals of treatment should be made early, and we strongly recommend this for anyone admitted to an ECU. Seven-day access to core allied healthcare professionals and pharmacy services will be key.

There are a host of other recommendations provided within the document that should allow these areas to develop according to local need, but with a standardised approach to the core structure. We acknowledge within this work that much is led by expert opinion rather than a strong evidence base, and the first recommendation (and perhaps one of the most important) is that both societies should prioritise research and data collection in this area to help inform future iterations of the guidance.

We hope that one of the lasting legacies of this work – beyond improving the care for this group of patients – will be closer working and collaboration between our two societies. The connections between acute and critical care are core to the delivery of unscheduled care, and the development of enhanced care areas within Acute Medicine will only serve to strengthen the relationships between our specialties both in individual hospitals and on a national policy level.

References

1. https://ics.ac.uk/resource/gpics-v2.html Last accessed Feb 15 2023
2. Bassford CR, Krucien N, Ryan M, Griffiths FE, Svantesson M et al. U.K. Intensivists’ Preferences for Patient Admission to ICU: Evidence From a Choice Experiment. Crit Care Med. 2019; 47(11): 1522-1530. Doi: 10.1097/CCM.0000000000003903. PMID: 31385883; PMCID: PMC6798748
3. https://www.gettingitrightfirsttime.co.uk/wp-content/uploads/2021/08/Adult-Critical-Care-Aug21L.pdf Last accessed Feb 15 2023
4. https://ics.ac.uk/resource/levels-of-care.html Intensive Care Society March 2021, last accessed 15th Feb 2023
5. https://cpoc.org.uk/guidelines-resources-guidelines/enhanced-perioperative-care, last accessed 15th Feb 2023
6. https://www.brit-thoracic.org.uk/delivery-of-care/respiratory-support-units/, last accessed 15th Feb 2023
7. https://ukclinicalpharmacy.org/wp-content/uploads/2022/01/Services-for-enhanced-care-Feb2022.pdf, last accessed 15th Feb 2023