Surrey and Sussex Healthcare NHS Trust

• East Surrey hospital has a 16 bed (funded) mixed medical and surgical adult intensive care unit. There are 800 admissions to the unit every year with a large proportion of acutely unwell medical patients. Approximately 50% of patients are mechanically ventilated, more than 40% require renal replacement therapy, and over 45% are admitted with sepsis. Elective admissions mainly derive from major colorectal surgery for cancer or inflammatory bowel disease, and complex ENT surgery.

• East Surrey Hospital has a large catchment area, including Gatwick airport and a portion of the M25, looking after a population of approximately 740,000. The hospital has a busy Emergency Department resulting in many unplanned admissions to critical care, both medical and surgical. A substantial number of overseas patients, and patients from outside our catchment area, are frequently brought by ambulance from Gatwick airport. This contributes to the wide range of acute medical pathologies dealt with by our critical care department each year.

• The critical care unit was extremely busy during the Covid-19 pandemic and surge capacity was up to 35 level three beds. ICNARC data placed our unit amongst the top 12 comparator units nationally during the first wave (Standardised Mortality Ratio 0.55).

• There are twice weekly multidisciplinary team meetings. We have senior staff meetings every 6 weeks, monthly M&M meetings and ICM clinical governance meetings. The service is part of the Surrey Wide Critical Care Network and takes an active part in its activities. The critical care service is supported by 12 ICM consultants, over 100 nursing staff, ICNARC audit nurses and 16 trainee doctors.

• Our critical care equipment includes Hamilton ventilators, Nikkiso Aquarius haemofilter machines capable of running renal replacement therapy with heparin and citrate, and several Nasal High Flow Oxygen machines. We are well established in the use of prone positioning and APRV for patients who are difficult to oxygenate. We possess comprehensive ultrasound capabilities with strong links to our echocardiography department. Our department has a state-of-the-art GE Vivid S70 R2 echocardiography machine with reporting station installed within the ICU, 2 x GE Vivid IQs, and 3 x GE Venue Go’s. We assess well over 500 patients a year for haemodynamic status, fluid responsiveness, and valvular pathologies using echocardiography.

• We have strong links with St Thomas’ Lane Fox REMEO unit, a long-term domiciliary ventilation unit and all our consultants hold honorary consultant contracts with St Thomas’s hospital to facilitate this. The intensive care unit now uses CERNER as its electronic patient record system.

• Critical Care Outreach provides a valuable 24 h service 7 days a week. We have a dedicated critical care specialist psychologist, and an ICU follow up clinic is in place for patients to revisit the unit and discuss their stay with consultants and senior nursing staff. Full support areas for visitors and staff are also available, including a seminar room and an interview room. Our unit has consistently scored highly in Friends and Family surveys.

• There is no split site working within this Unit

EASY-CCRG (EAst SurreY Critical Care Research Group) has developed since 2018 due to the combined interest and enthusiasm of the ICU consultant body. Our active weekly journal club has inspired trainees to submit letters for publication in Thorax and Anaesthesia, and also to carry out various research and quality improvement projects on the intensive care unit (multiple abstracts published in Critical Care and Intensive Care Medicine).

One of our critical care consultants is also a qualified statistician and performs all statistical analyses required for publication of original research. Peer reviewed publications and research activity include

• 2021-2024: 22 abstracts presented at international conferences; several case reports published
• 2020 (limited due to COVID Pandemic): 1 peer reviewed case report, plus part of RECOVERY Trial Group
• 2019: 15 abstracts published. 11 trainees and 2 nurses presenting at international conferences.
• 2018: 18 abstracts, 3 letters, 1 review article. Several further articles and case reports have been submitted and are awaiting publication.

During 2024, 10 intensive care trainees also achieved international presentations following work done in the East Surrey critical care unit. We have now completed our first in-house Trust sponsored critical care research study (CRiSIS; ISRCTN 23174569), that is looking at how the heart functions in sepsis using novel methods. The unit has a long history of participating in NIHR portfolio multi-centre studies more recently including: POETICS, TEST-IT, A-STOP, EPIC III, COVID-OR, RECOVERY, GENOMICC.

There are 12 consultants in intensive care medicine who take turns in leading the unit on a weekly basis (see table below). During normal working hours, the “consultant of the week” is supported by a second consultant intensivist. There are two tiers of trainee doctors working in critical care. 8 doctors with airway skills work on a rolling rota comprised of a mixture of Stage 3 ICM trainees, anaesthetic trainees, and clinical fellows with at least 1-year anaesthetic experience. The non-airway trained rota is comprised of 8 doctors who do not have advanced airway management skills but are often experienced medics. 4 core medical trainees and 2 foundation year one doctors spend 4-month placements on ICU. We also have a fantastic team of dietitians, physiotherapists, pharmacists, an occupational therapist and a clinical psychologist (Dr Devon Rodwell).

We have two dedicated echocardiography / ultrasound fellows who partake fully in the junior on-call rota. Out of hours, the 16-bed critical care unit is staffed by one senior tier doctor and one junior tier doctor supported by a consultant intensivist on call. Critical care doctors work alongside additional RCoA trainees, anaesthetic clinical fellows and specialty doctors working on call for theatres and obstetrics. Echo / ultrasound fellows are allocated one half day per week for echo / ultrasound training. Trainees at ST5+ are allocated one SPA per 2 weeks in accordance with training requirements. All rotas are EWTD compliant.

• Training in point of care ultrasound 
• Opportunity to attend theatre for airway experience 
• Exposure to paediatric emergencies 
• Interhospital transfers 
• Opportunity to attend a Cardiac Catheterisation lab 
• Acting up as an ICM Consultant (for Stage 3 trainees) 

ESH has ICM training posts available in the following areas:

• Two Stage 3 ICM posts in critical care
• One Stage 1 ICM post in anaesthetics
• One Stage 1 ICM post in acute medicine
• Echo SSY (Special Skills Year)
• Education SSY (Special Skills Year)    

Our critical care is GMC approved for ICM training at all levels.  All ICM trainees based in ESH (whether completing a critical care rotation or working in their dual specialty) receive ICM educational supervision and are actively encouraged to attend weekly ICM teaching and journal club. In addition, the Echo Special Skills Year has successfully taken its first trainee through completion of level 1 BSE TTE accreditation. 

Stage 3 ICM training opportunities include:

• “Consultant of the Week” step-up experience. Our unit offers the opportunity to spend a full week on ICU acting as lead under the safe supervision and mentorship of experienced ICM consultants. This includes leading handovers, safety briefs, ward rounds, and MDTs; making decisions regarding admissions and discharges; liaising with nursing staff, site team and exec regarding bed management. Trainees receive support throughout this process with detailed individual feedback. Those trainees who have taken up the opportunity have unanimously found this beneficial and given strongly positive feedback.
• Stage 3 trainees are expected to work with our critical care outreach team for at least 1 day in their rotation to gain exposure to the wider needs of the hospital
• Advanced trainees are encouraged to take on leadership roles and develop both clinical and non-clinical management skills. Time off the unit can be arranged to attend Trust board meetings.
• All ICM trainees will be taken through FUSIC Heart, if not already obtained during their training.
• Advanced trainees can arrange to take part in a 5-day Rapid Process Improvement Workshop, part of the Virginia Mason Institute, to develop their management CV.
• Trainees are expected to take an active role in journal club and teaching.
• Regional ICM teaching takes place at East Surrey Hospital and the advanced trainee would be encouraged to take part in the organisation of this.
• The critical care unit at East Surrey hospital supports the Lane Fox Remeo satellite unit. We have an integrated teaching programme with input from respiratory specialist consultants from St Thomas’ Hospital. Interested trainees can spend time on the Lane Fox satellite unit learning specifically about domiciliary weaning, obesity hypoventilation syndrome, NIV for COPD, neuromuscular disease, etc. 

Pre-stage 3 ICM training opportunities:

• All ICM trainees are actively encouraged and supported to attend and present at weekly ICM teaching and journal club. We have strong links with the anaesthetic and AMU departments, and all are aware that ICM journal club happens every Wednesday! This is also a good opportunity for local ICM trainees to keep in touch with one another to keep up to date with ICM training news.
• Stage 1 and 2 trainees working in critical care are encouraged to lead ward rounds under supervision with clearly defined learning outcomes agreed with the supervising consultant.
• ICM trainees in acute medicine can expect good exposure to a range of medical pathologies, the opportunity to lead solo ward rounds, and lead procedure clinics.
• The anaesthetic department has over 30 anaesthetic consultants with a wide range of interests and skills. They are an enthusiastic and energetic team who enjoy teaching. Novice anaesthetists can expect to spend a good deal of time working in CEPOD, dealing with emergencies in resus and around the hospital, taking part in paediatric resuscitations, as well as learning the management of elective major colorectal, orthopaedic, ENT and dental cases etc.
• All trainees are encouraged to attend and present at M&M sessions
• Active ICM supervision and mentorship with careers support and advice (with individual support for ARCP preparation)
• Support to prepare for examinations, job applications, interview preparation etc
• Support to carry out QIPs, research, writing up projects for publication or presentation 

ECHOCARDIOGRAPHY FELLOWSHIPS  

Our critical care unit currently can employ 2 echo fellows the non-airway trained tier rota. Amongst our consultant intensivists we have

• 6 x FUSIC Heart mentors
• 1 x FUSIC Heart supervisor
• 2 x FUSIC Lung, Abdo and vascular mentors
• 2 x FUSIC Lung, Abdo, and vascular supervisors
• 2 x Level 1 BSE TTE Supervisor
• 1 x Level 2 BSE TTE Supervisor 

Echo fellows are expected to complete FUSIC Heart, Lung, Abdo and Vascular at the very least but enthusiastic fellows are encouraged to achieve Level 1 BSE during their fellowship year. We have successfully taken over 20 individuals through FUSIC Heart accreditation and 10 individuals through level 1 BSE accreditation since 2018. Particularly dedicated trainees can begin or complete Level 2 BSE accreditation. There are opportunities to spend time in echo clinic with a fully BSE accredited critical care consultant, and to present interesting cases on Wednesday afternoons following Journal Club.  All echo fellows are actively involved in ongoing research in the department, taking an active role and learning the processes involved in getting research REC approved and published.  

EDUCATION FELLOWSHIP

We’re delighted to have appointed our first fellow in education for critical care in 2024. The post has already made a significant difference to the quality and delivery of teaching in our department. The education fellow works alongside the education SSY to improve and coordinate the delivery of education, teaching and simulation to trainees and nursing staff for our unit. They are also responsible for the ICM ‘Hot Topics’ lecture series that is due to air in January 2025.

OTHER TRAINEES WORKING IN CRITICAL CARE: 

ANAESTHETIC TRAINEES 

Anaesthetic trainees completing a module in critical care take full part in the airway-trained on call rota including daytime and out-of-hours cover. Any anaesthetic trainees working within the critical care on call rota but not completing a module in critical care are NOT expected to spend normal working daytimes in ICU - they are protected in attending their anaesthetic training lists.  Anaesthetists are encouraged to take full advantage of their time in critical care to develop their technical and non-technical skills as detailed below. Many of our trainees have been able to achieve publications and international presentations through work completed in ICU. 

CORE MEDICS AND FOUNDATION DOCTORS 

Core medical trainees and FY1 doctors are an asset to our unit and very much encouraged to take full advantage of all training opportunities in critical care. Many of our trainees have been able to publish original work with our support. Even those trainees focussed on careers outside critical care can use their time to develop essential clinical and non-clinical skills. There are ample opportunities to complete quality improvement work and get involved in clinical governance.  

SUMMARY 

We have consistently received excellent feedback for training and support on our critical care unit. In addition to the specific training elements detailed above, the following training opportunities are available to all doctors working in the ICU: 

CLINICAL 

* Procedures regularly performed on intensive care (tracheostomy, bronchoscopy, chest drain insertion etc)

* Echocardiography – although we have specific echo fellows, there is ample support for non-fellows wishing to learn or improve their echo / ultrasound skills including learning FUSIC.

* Ultrasound – regular chest, abdominal and vascular ultrasound is performed on the unit. Enthusiastic trainees may wish to aim to complete FUSIC accreditation.

* Resuscitation and stabilisation skills – a large proportion of our admissions are emergency medical admissions requiring resuscitation and advanced ventilatory, cardiovascular and renal support.

* Advanced respiratory techniques – we regularly use prone positioning and APRV  

NON-CLINICAL 

* Weekly journal club (all junior doctors are expected to present at least once per 4 months)

* Weekly ICM teaching (enthusiastic trainees can arrange to present specific teaching / simulation sessions)

* Regular M&M – with the opportunity for trainees to present cases

* Research – the majority of trainees working on intensive care achieve at least one publication and presentation at national or international level.

• Weekly journal club (Wednesdays 13.15 – 14.00)

• Weekly consultant led teaching (Wednesdays 14.00 – 14.45)

• Regular M&M at clinical governance meetings

• Monthly ICM / anaesthetics teaching including sessions

• Frequent ad hoc bedside ultrasound and echocardiography teaching

• Annual ICM regional teaching day

• Simulation led by our education fellow and education SSY

Monthly clinical governance meetings including M&M

Senior staff meetings every 6 weeks (stage 3 trainees are encouraged to attend)

• Staff parking is available 24/7 and payment can be coordinated through the Trust app (further details can be obtained at induction).

• There are specific doctor areas within the unit where trainees can rest during night shifts, but we do not have any dedicated rest rooms for staff.

• Vending machines are available 24/7, and the units staff room has facilities to warm food and keep food refrigerated.

• There is also an ICU seminar room, trainee doctors’ room, patient relatives’ room and visitors room.