An Intensive Care Trilogy

Its 8:30 am on ITU.The morning traffic of surgeons, anaesthetists, trainees, nurses, physiotherapists scuttling through the unit. The charge nurse deep in thought looking through the list of elective cases needing our care. I catch her eye.The ventilator alarm sounds and the phone starts to ring. We do not flinch. Our eyes continue to stare at each other. We sense the shared despair as the cognitive storm hurtles towards us. We enter a strange paradoxical world, where for the next 10 hours we only have each other and all other assistance is hindrance.

Our daily juggling act begins ... Time to work through the bed status … yet again …

One of the rather complex areas in a hospital is the Intensive Care Unit. At least the intensivists amongst us would certainly like to think so. In these days of reorganisation and centralisation an NHS Trust with 3 intensive care units is almost a novelty. Couple this with 3 different size units, a small, a medium and a large unit and you almost have a bit of mundane mixed in with something rather extraordinary with triple the quirks. No two units anywhere have an identical culture. Each unit has its unique case mix. This is compounded in three units. 

Supremacy

The question of ‘supremacy’… figuratively speaking, this is part and parcel of a normal human psyche. ‘Supremacy’ in terms of “we are the best” or “we are the most evidence based” or  even a case of “we are the busiest”. Is the larger unit likely to be the best because it serves more specialties or because it is also likely to be the busiest? This mix of different sized units within a trust does have the advantage of constantly ensuring that practice is challenged and only the best is practiced, which whilst being quite onerous and draining on the ones involved can also be gratifying as it is constantly revisited. Healthy competition can ensure good outcomes for patients and in our Trust with its 3 units we don’t always have to look outwards to the competition.

Policies that bind units together are a great way to ensure joined up thinking. But where culture transcends these policies, they can sometimes become worth less than the paper they are written on. Fortunately, the nursing and medical staff that work across the sites to allow for safe staffing on these units are the binding glue that ensure best practices transcend boundaries.

Having 3 consultants on call for intensive care during a 4 day bank holiday weekend can be rather reassuring if one is suddenly lumbered with a complex issue. It also allows for bed capacity to be juggled and patients moved to where the most appropriate care can be provided within the Trust. The issues crop up around the support specialties which aren’t co-located in all the hospitals within the Trust.This makes some level of moving around for patients including those that need intensive care part of the norm. In addition, smaller hospitals make it easier for staff to be familiar with colleagues from other specialties, which in its own way allows for more seamless discussion and for advice to be given and taken.

Autonomy

... We humans love autonomy. Smaller units allow for shaping that autonomy and for more of a say in how things are delivered. And our big brothers like ICNARC ensure that we stay on the straight and narrow when it comes to our patient outcomes which we are delighted to find are comparable.

Trainees that pass through our units can find the 'less is more approach' a bit daunting at first but, as they are far more supervised and treated as part of the larger team, the interactions and the discussions (some rather spicy discussions amongst colleagues) add to the flavour of the learning environment. The number of trainees that complete their time with us wishing to take up intensive care as a career option is testament to the fact that we must really be doing something right. If only we could work out the magic sequence!

Research provision is certainly challenging to deliver in a coordinated way as teams are split, everything has to be multiplied by 3. There are more people to convince. There is a level of duplication of work not just for the clinical teams involved but also the research teams. However, these challenges (in some way) make being part of the delivery and successful completion of the research projects a whole lot sweeter.

Wellbeing

A huge plus for a small unit is the well-being and peer support. There is more cohesiveness, more understanding of the trials and tribulations and hence a willingness to chip in and help and be there when the going gets tough. Being small certainly makes the catering side of things, when baking and celebrating with the cakes and chocolates, much, much easier. Organising the parties … be it the a new appointment or retirement do or the Christmas party, everything is a lot simpler and allows for a wonderful way to let ones hair down and to mingle and be merry. In addition many small units are surrounded by areas of exceptional natural beauty which can itself be uplifting and all of this allows for a far better work life balance.

At a time when intensivists are like gold dust, staffing 3 units provides its own constraints.This forces a situation where specialties like anaesthetics chip in. This can prove a very satisfying arrangement for some that enjoy working on the ITU but don't want to do it full time. This is now evolving to allow our medical specialties to also dip into intensive care and having a respiratory and an emergency medicine consultant as part of our units, shows us how this can continute to work in the future.

Despite the differences and challenges our 3 units survive in harmony like one large extended family with its internal disagreements and disputes but hinged on a united front. Whilst some might find our set up less than ideal the solution lies somewhere in between a dedicated specialty and cross pollination with other specialties. And whilst we try and conjure up more intensivists and organise and reorganise the workforce this type of smaller unit cohesive working is here to stay for the future.