Level 1 CCU Medical Area

PLEASE NOTE: this model of care is NOT currently in use, with Medicine looking after Level 2 and Level 1 patients within CCU, with no Level 1 beds available in D8.

Overview

1. Level 1 is defined as ‘Patients at risk of their condition deteriorating, or those recently relocated from higher levels of care, whose needs can be met on an acute ward with additional advice and support from the critical care team’.
2. There are 4 beds allocated to and the responsibility of the Medical Division within CCU for intended Level 1 care.
3. It is important to acknowledge that enhanced care requires both medical plans and nursing staffing, and therefore the Capacity Managers (ext 33999) will be best placed to understand the current B2, D8 and CCU capacity and should be actively involved.
4. An acutely ill patient who is very likely to require level-2/3 care in next 12 hours should be admitted directly to the Level-2/3 unit by referring to the ICU team. This is particularly important to consider overnight.
5. Level 2 and 3 patients remain the responsibility of the ICU Team
6. There is separate guidance on Managing Level 1 Critical Care Patients on General Medical Wards available by clicking this link

Tracheostomy Suitable for Medical Level 1 Area

1. Click here to go to page on Admitting Patients with Tracheostomy to DGRI

Respiratory Suitable for Medical Level 1 Area

1. Patients with home NIV or CPAP systems, prior to hospital admission, who have their own systems and who are on a low Fi0₂ and not confused or agitated, maybe suitable for level 1 area if they cannot be managed on ward B2

Cardiovascular Suitable for Medical Level 1 Area

1. Monitoring ACS or significant arrhythmias (if suitable for escalation if they deteriorate [HFNC, inotropes, CPR] or if no Level 1 beds are available in D8)
2. GTN IV infusions
3. Low dose metaraminol/phenylephrine infusion or low dose metaraminol infusion with a specified time-limit of 24hrs for patients deemed unsuitable for escalation to level-2/3 care.

Neurological Suitable for Medical Level 1 Area

1. Frequent neurological observations (Glasgow Coma Score) 2 hourly or more
2. Patients stable on IV infusion of Naloxone (if GCS>13)
3. Agitation / delirium (CVS/RS stable) for medications including Haloperidol and close observation to stop falls/injuries.
4. A patient that requires frequent physical restraint then the patient needs either transfer to level 2/3 or 1:1 with a band 2 nurse on ward or level-1 area.
5. Neurological monitoring for patients post-seizures or sedative drugs, who do not improve quickly to GCS 13 or more.

Drugs / Medications Suitable for Medical Level 1 Area

1. DKA can be managed in level 1 area unless signs of severe illness after initial resuscitation in the Emergency Dept (H⁺>80 / HCO₃ <5, shock with raised lactate / hypotension, severe renal impairment or GCS<15), in which case care should be provided in the level 2/3 area
2. Medications requiring Central Access or ECG monitoring including:
3. Amiodarone, GTN infusion, Metaraminol (see above), Aminophylline, Phenytoin (can also use ward bed & telemetry)
4. Refeeding syndrome or other situations requiring multiple electrolyte replacement (including via CVC)

Miscellaneous

1. Continuous non-invasive monitoring required
2. Arterial Line (for monitoring, blood sampling or can guide low dose metaraminol in patients considered unsuitable for escalation to Level-2/3)

Patients NOT Suitable for this Area and Should Transfer for Level 2/3 Care

1. High Flow Nasal Cannulae
2. NIV, CPAP, Invasive Ventilation
3. Vasopressor support beyond low dose Metaraminol if appropriate for escalation (reconsider overall goals if not achieving targets with Metaraminol and not for escalation)
4. Acutely ill patient very likely to require level 2 or 3 therapy within the next 12 hours. This is particularly important to consider if patient is admitted overnight
5. Evidence of airway obstruction including needing nasopharyngeal airway
6. Reduced conscious level GCS<13, low respiratory rate
7. Severe hyponatraemia with altered conscious level or need for hypertonic saline

Admission to the Level-1 CCU Area

1. The Acute Medical Team or out-of-hours (>8pm weekday and all-day weekends) the On-call consultant have a gatekeeper function and any patient requiring one of these beds requires agreement of the AMU team or On-call Consultant.
2. Prior to admission a clear management plan including care to be received in Level-1 area, goals of care and escalation plans should be completed. This will be part of the conversation with the AMU/On-call Consultant.
3. Acute Admissions to this area should be post-taked by the duty AMU or On-call Consultant before admission to this area.
4. Overnight, protocolised admissions such as DKA within the remits above do not require the On-call Consultant to be called unless there is concern from Bed Managers or others. If the capacity of the unit has been reached then the consultant will need contacted.
5. Monitoring for risk of deterioration in a level-1 area is only appropriate as part of a plan to manage any deterioration.
6. In hours, ward patients should already have been escalated to their responsible consultant or team to ensure appropriate care. The conversation with the AMU/ On-call Consultant should therefore happen between middle grade, specialty doctor or consultant and the AMU Team.
7. Ward level patients identified at risk of deterioration should have a Treatment Escalation Plan in situ agreed with the relevant senior before end of normal working hours.
8. The Acute Medical Team or On-call Consultant reserve the right to discuss alternatives or direct teams to more appropriate care if the case requires it. This may include referral to ICU, use of D8 Level-1 beds (for Cardiology, Diabetes or Renal patients), palliation or requesting clearer goals of care/treatment plans.

Day-to-day/Ongoing care and Flow

1. The Critical Care team may need to help with specialist procedures, such as the insertion of central & arterial lines, within the level 1 area, but not the routine care.
2. The CCU medical middle-grader, or MG designated for this area (the 2nd oncall for Medicine when out-of-hours) is the first point of call for nursing or other staff regarding the general clinical management of these cases.
3. The admitting consultant (until a specialty agrees ongoing care) retains responsibility for the ongoing clinical care of the patient. This recognises the benefits of continuity of care. In out-of-hours or emergencies, the On-call Consultant or duty CAU consultant through switchboard can be contacted. Disputes about responsibility should be resolved at consultant level.
4. Specialty teams remain in charge of the clinical care of these patients, recognising the benefits of early specialty input into critical care patients.
5. If there is no appropriate specialty input on a day due to such members being off-site, the responsibility to find cover remains that of the specialty with agreement with the covering team.
6. The Acute Medical Consultants (or On-call Consultants at weekends) will visit CCU late morning to discuss with the middle grade and nursing staff the progress of these patients to ensure appropriate care is in place and where necessary prompting for review in uncertain cases. They will also, in conjunction with the Bed Managers, determine who can be stepped down. In hours, the specialty team should also be involved in the discussion.
7. These patients will have paper written notes but observations and nursing notes will be within the ICCA system.
8. Step downs should be reviewed by the ward team (or HaN team) within the same shift to ensure no deterioration in the patient’s condition.

Governance

1. This interim agreement was agreed at Medical Division on the 4th March 2021 with the review period of a month
2. Patients referred to this area will be audited in terms of inclusion/exclusion criteria, length of stay and destination on discharge from this area.