A documented induction program for all new staff (medical, nursing and allied health profes sionals) Incremental training programs for all staff Allocated time for training and assess ments for specialty- speci \201 c and generic mandatory training programs Access to online resources and appropriate e-learning packages \200 Further reading FFANZCA. Minimum standards for intensive care units. http:// www.anzca.edu. au/jficm/resources/policy/ic1_ 2003.pdf The evolution of the acute care common stem (ACCS) training programs should lead to more co nsistent and better organized training for future trainees in critical care, and the associ ated rotational training programs are likely to increase the numbers of trainees working in ICUs which have training approval. Trainee presence will also be dependent on the proporti on of those wishing to under- take specialist training in critical care medicine to either Step 1 or Step 2 levels and the number of posts that can be supported by the unit levels of activity. ICS. Standards for consultant staffing of intensive care units http://www.ics.ac.uk/icmprof/ Kmietowicz Z. Many trusts fail to monitor whether complaints have any effect, says watchdog. BMJ 2007; 335: 738 \200\2239. National Con \201 dential Enquiry into Patient Outcome and Death NCEPOD paper. http://www. ncepod.org.uk and http://www. ncepod.org.uk/2005.htm and http://www.ncepod. org.uk/2007.htm 550 G BRADBURY ICU staf \201 ng: nursing attention to the growing number of ICUs where nurses work 12h shifts. Comprehensive critica l care suggests appropriate levels of care based on patient requirement for organ support. The report also recommends that critical care be considered a process rather than a place, and that care is provided as a continuum. Interpretation of this report has led to many org anizations equating Level 3 care with intensive care, Level 2 care with high dependency car e, and then a further assumption that Level 3 care should be based on 1:1 nursing ratios an d Level 2 care based on 1:1.6 or 1:2 care. These assumptions become very problematic for cl inical staff when patients require increased supervision when show- ing signs of agitation or delirium, or are recovering from acute head injury, and require high levels of expert nu rsing supervision. It should be noted that there are variations in staf \201 ng skill mix when comparing urban and rural hospital/critical care settings. The nursing workforce tends to move to large cities early on in their clinical careers, for training and experience. L ater there is a tendency to move away from large urban centers, and they often become more estab- lished in smaller centers as \200\230career staff nurses \200\231. They comprise a stable workforce with differing impact on recruitment, retention and training needs. Nursin g estab- lishments may therefore be constructed to re \202 ect this stable workforce. Volumes have been written about the provision of nursing care to the critically ill over th e years. Nursing Managers have experienced \201 nancial glut, belt-tightening, the intro- duction of workload measurement systems, shortages of nurses, foreign recruitment and, mos t recently, Payment By Results. Hospital beds have decreased in numbers and patient LOS has shortened, compressing the acute/high intervention period of patients \200\231 hospitaliza tion. Tensions have been created within critical care as the staffing expenditure comes und er ever-increasing scrutiny. Table 33.5.1 Competing factors affecting the provision and cost of critical care nursing st af \201 ng Forces opposing current staf \201 ng patterns Forces driving increased need for critical care beds and nursing Technology Increased ageing population Payment by Results Caps on spending/reduction of critical care budgets Nursing shortage Diagnostic-related groups and shortened LOS Rapid interventions and improved pre-hospital c are Compressed acuity Increased complexity of patient care Rising health care costs Litigious society International perspective Critical care nursing varies from country to country, and this, t oo, must be taken into account when establishing nurse:patient ratios. In North America, sk illed practitioners such as Respiratory Therapists add to the total comple- ment of carers. In some European countries, nurse patient ratios of 1:2 exist, but the complement of medic al practi- tioners is higher than in the UK. In the UK, nursing roles have expanded over ti me, taking on expert roles in communication, management and organization of patient care. S uch national variations also mandate caution when comparing nursing establishments directly with other countries. There is also variation in the de \201 nition and staff- ing of ICU s. The UK had the smallest percentage of critical care beds (2.6%) per total hospital beds of any country in Europe, but also has the highest number of nurses per bed, the third high est use of mechanical ventilation (55%) during the \201 rst 24h, and a higher mean SAPS I I score than other countries. Driving forces vary. In the state of California, public and n ursing concern about safe care in acute hospitals resulted in the California Department of Health Services being directed to establish nurse-to-patient staff- ing ratios by January 2 002. Workload and acuity measurement systems Current research A large number of different system s have been set up to assess the amount and type of care required by the criti- cally ill. Some quantify the amount of care required as a result of required medical interventions: AP ACHE II, TISS, SAPSII, GRASP, SOPRA and the recent AUKUH Adult Acuity and Dependency Measur ement Tool. The patient classi \201 cation systems ICU nurses are currently using lack pre cision and do not accurately quantify the amount and type of care required by patients. The y fail to include indi- rect nursing activity, skill mix, the knowledge and skill required for competent and expert practice, and unit geography. Nonetheless, some investigators are examining the rela- tionships between nursing workload and clinical severity. Clinical seve rity as measured by APACHE II was found to explain 25.6% of the daily variability of nursin g workload measured by PRN Rea. In a study of 99 ICUs in 15 countries, investigators were a ble to add 5 new items and 15 subitems describing nursing activities in the ICU. This new s ystem is the Nursing Activity Score (NAS) and explains 81% of nursing time as compared with 43% with TISS-28. Another study attempted to validate a new Intensive Care Nursing Scoring System (ICNSS) by comparing it with TISS-28 as a predictor of mortality. The ICNSS demonst rated higher scores for patients undergoing emergency treat- ment than electively operated patients. Encouragingly, the ICNSS included care of relatives in the 16 variables. This sin gle-center study requires replication, paying particular Future directions for the establishment of appropriate nursing staf \201 ng levels In a ma jor departure from validation of nursing workload measure, Ball and McElligot conducted a s tudy to make evident the complexity of issues associated with the delivery of care by nurse s to the critically ill. Their analysis demon- strated that an effective nursing resource w as dependent on knowledge, experience and exposure. The unit geo- graphy, case mix, activit y level and skill mix also had a sig- ni \201 cant effect on the ability of the nurses to contribute to 551 CHAPTER 33.5 ICU staf \201 ng: nursing Making the best use of current establishments ICUs vary greatly in size, complexity and cas e mix. It is logi- cal, therefore, to expect that staff roles and work patterns will also v ary. For example, a Cardiothoracic ICU in a Teaching Hospital with a predominance of electi ve cases and few emergency cases will have a much more predicta- ble workload and therefore staf \201 ng pattern than will a general ICU in a large urban setting which deals with tr auma, neurosciences and a busy Emergency Department. A general ICU in a District General Ho spital will similarly have a different mix of elective and emergency patients. Recognizing these patterns is key to utilizing staff ef \201 ciently. The Intensive Care National Audi t and Research Center (ICNARC) provides data that can be invaluable in describ- ing individ ual ICU work patterns. It is then possible to develop staff roles and work patterns/rosters that address the needs of patients in individual units (see Table 33.5.3) In conclusion, n ursing staf \201 ng has never been in a more dynamic situation. Health budgets are strenuo usly pushing for ef \201 ciencies, patients in acute hospitals have higher than ever acuit y, and patients are demanding a better hospital experience. This is fertile ground for rese arch which, by demonstrating the relationship of nursing to patient out- come, will help en sure nursing leaders are utilizing the nursing resource appropriately. the recovery of critically ill patients. They devised a model which demonstrated the factor s that optimized or com- promised nursing care and its impact on patient progres- sion and recovery, and concluded that \200\230the need to develop a valid and reliable tool which addresses patients \200\231 ne eds for nursing in terms of nurses \200\231 knowledge and experience, patient dependency an d decreasing clinical risk across the continuum of care. Current nursing workload tools and patient:nurse ratios were seen to lack validity because they do not appraise the context i n which the care is delivered, de \201 ne all nurses as equal and concentrate on activity rather than the effect nurses can have on the outcomes of the criti- (Ball and McElligot, 2 003, 226 \200\2237) cally ill. This has effectively moved the focus of nursing staf \201 n g lev- els from the activities \200\234done \200\235 to patients to the outcomes of skille d nursing care. Further work must be undertaken to establish a patient dependency tool that addresses patients \200\231 need for nursing tools or formulas developed for ICUs, taking into account their speci \201 c patient types and geographical set ups. In addition, the p revention of risks to patients must be made explicit, when developing unit-spe- ci \201 c staf \201 ng establishments. Clinical risks such as accidental extubation, nosocomial infe ction rates, complications, re- admission rates and medication errors have been associ- ate d with reduced nurse:patient ratios. The American Association of Critical Care Nurses \200 \231 Synergy Model for Patient Care was developed to create a match between patients \200 \231 need for care and nurses \200\231 competency to provide such care. Study of this model in the context of UK critical care may assist with the process of objective, measurable co nsumption of the nursing resource. Further reading Adomat R, Hewison A. Assessing patient category/dependence systems for dete rmining the nurse/patient ratio in ICU and HDU: a review of approaches, J Nurs Manag 2004;1 2: 299 \200\223308. Ball C, McElligot M. Realizing the potential of critical care nurses: an exploratory study of the factors that affect and comprise the nursing contribution to the recovery of critica lly ill patients. Intensive Crit Care Nurs 2003; 19: 226 \200\22338. The role of non-quali \201 ed staff in intensive care units \200\224healthcare asssitants (HCAs) The British Association of Critical Care Nurses (BACCN) has developed key points for action re \202 ecting the current evidence to support the use of non-qualified staff in I CUs. Signi \201 cant issues identi \201 ed are contained within Table 33.5.2. British Association of Critical Care Nurses. Position Statement on nurse \200\223patient ra tios in critical care, BACCN Working Party, 2000. British Association of Critical Care Nurses. Position Statement on the role of health care assistants who are involved in direct patient care activities within critical care areas, B ACCN Working Party, 2002. Kiekkas P, Brokalaki H, Manolis E, et al. Patient severity as an indicator of nursing workl oad in the intensive care unit. Nurs Crit Care 2007; 12: 34 \200\22341. Table 33.5.2 BACCN position statement on the role of HCAs. Tarnow-Mordi, WO, Hau C, Warden A, et al. Hospital mortality in relation to staff workload: a 4-year study in an adult intensive- care unit, Lancet 2000; 356: 185 \200\2239. Must bene \201 t patient care Need for a designated coordinator for training and role deve lopment Registered Nurses assess, plan and evaluate direct patient care activities Healthca re assistants (HCAs) must be trained and assessed by a quali \201 ed practitioner HCAs mus t work under the supervision of a quali \201 ed practitioner HCAs must work within a compe tency framework Work should be undertaken to establish national competencies A national dat abase of education and training for HCAs should be developed. www.dh.gov.uk/en/Policyandguidance/ Organisationpolicy/Financeandplanning/ NHSFinancialReforms Clearly there is much work to be done in order to prevent risks to patients, increased work load for individual Registered Nurses who are supervising HCAs, and job dis- satisfaction f or Registered Nurses who may believe that they are not providing quality care. 552 G BRADBURY Table 35.5.3 Factors to consider when constructing duty rosters Rostering elements In \202 uencing factors Establishment size Is this reviewed yearly against patient care activity? Do nurses and \201 nance managers review activity on a yearly basis? How stable is the st aff group? Establishment skill mix What are their requirements for development? How much supervision of staff is required? Does patient acuity require senior staff on duty 24/7? Are senior nursing staff allocated management time? How much? High percentage of emergency patients and unpredictable workload will in \202 uence the need for equal numbers of staff on all shifts, all week Day/night activities Predictable workload may allow for fewer staff on nights and weekends Agenda for Change all ows for varying amounts of annual leave based on time worked in the NHS; have individual un it budgets been adjusted for this? Annual leave Are staff asked to take annual leave in equal amounts across the entire year in order to av oid periods of short staf \201 ng? Do staf \201 ng budgets account for time spent in mand atory training? Is this time re-assessed each budget year? Education and training Are there new programs (e.g. CRS) which require additional training? Has the Trust policy for study leave been accounted for in the allowance for study leave in individual unit budgets? Are staff involved in roster patterns such as \201 xed rosters, self-rostering, writing rosters? Staff input Do staff work \202 exibly? Does unit management work \202 exibly? Are family friendly policies in place? Part-time staff Balance between staff convenience and unit need Is there an absence management program in p lace to improve attendance? Is there a system in place to obtain short-term help from unit staff, e.g. Cable/bank/on-call system? Absence management Managing staf \201 ng shortage during periods of high activity If temporary staff are required, are the agencies able to meet the need with appropriately trained/skilled staff? Are there systems in place (paper or electronic) to capture staff ut ilization, e.g. number of hours of \200\230bought \200\231 time, number of hours of all \200\230losses \200\231 Monitoring staff utilization This page intentionally left blank 554 M BORTHWICK ICU staf \201 ng: supporting professions expertise in other aspects such as choice of feeding route, types of enteral tube and impac t of organ dysfunction on nutritional requirements allows the patient to receive optimal nu tritional care. Whilst the medical and nursing professions make up the bulk of the workforce, a variety of other professions are routinely integrated into critical care practice, bringing different sets of skills, perspectives and knowledge to the multi-disciplinary team for the bene \201 t of patients. The following is a summary of roles and staf \201 ng levels. Staf \201 ng level 0.1 \200\2230.05 whole-time equivalents for every critical care bed at a senior dietitians grade. Clinical pharmacist Role Clinical pharmacists optimize drug therapy, improve patient outcom es and reduce costs in critical care. This is achieved through a variety of activities, ran ging from the drawing up of clinical guidelines, provision of general advice and teach- ing in drug utilization as well as through individualizing drug therapy to maximize bene \201 ts and reduce risks to patients. Pharmacists take into account side effects, interactions, pharmacokinetics (particularly with organ failures or arti \201 - cial organ support), ph armacodynamics, available routes of administration, drug compatibilities, cost-effectivenes s, allergies, drug history and a host of other factors on a policy or individual patient ba sis. A career structure and comprehensive competency frame- work is available to inform cri tical care units about the level of service various grades of pharmacist can offer, from a minimal level service to that provided by a Consultant Pharmacist . Speech and language therapists Role Speech and language therapists posses specialist knowl- edge and expertise about speech, language, communica- tion and swallowing. They can assess and diagnose issues pertaining to swallowing and provide advice on the use of communicatio n aids and speaking valves. Some also have experience of managing tracheostomies. Staf \201 ng level There are no recognized staf \201 ng levels for critical care, but rea dy access on an ad hoc basis to speech and language therapy services with formal referral i s important. Occupational therapists Role Occupational therapists facilitate the rehabilitation of criti - cally ill patients after their acute illness. The groundwork for this activity can occur whilst the patient is still critically ill (e.g. through the use of splints to prevent cont ractures). Provision of advice and teaching to other critical care staff in these technique s may improve the patient \200\231s quality of life after critical illness. Staf \201 ng level 0.1 whole time equivalent for every Level 3 bed and 0.1 whole time equi valent for every two Level 2 beds. The grade of pharmacist is dependent on factors such as size of unit, required level of service and support available from more senior critical car e pharmacists across institutes or networks. Staf \201 ng level There are no recognized staf \201 ng levels for critical care, but ready access on an ad h oc basis to occupational therapy services with formal referral is important. Physiotherapists Role Physiotherapists working in critical care have become experts in mana ging the cardiorespiratory system, provid- ing support and education to medical and nursing teams. Key aspects include the management of complications of ventilation, provision of we aning strategies, mobilization and facilitating the rehabilitation of patients throughout t he critical care stay and beyond. Much of physiotherapy prac- tice in the critically ill is based on common sense rather than a \201 rm evidence base, but is nevertheless regarded as a core feature of the care of the critically ill . Clinical psychologist Role Psychologists can identify patients with likely signi \201 cant psychological morbity and put in place plans to manage the patient \200\231s (and relative s \200\231) psychological state through the critical illness itself as well as the rehabili tation phase. The psychological impact of critical illness is well described and can be lon g lasting. The involvement of clinical psycholo- gists in follow-up clinics can be very use ful. Staf \201 ng level There are no recognized staf \201 ng levels for critical care. 0.05 wh ole-time equivalent of a consultant grade has been suggested. Alternatively the use of a fo rmal referral system may be deemed appropriate. Staf \201 ng level 0.2 whole time equivalents for every critical care bed. Consideration o f skill mix and career progression should also be born in mind when formulating the structu re of the service. Podiatrists/chiropodists Role Prevention and management of lower limb wounds and pathologie s. The podiatrist can assist in the rehabilitation of the critically ill patient to maximiz e their ability to ful \201 l every day activities. Dietitians Role Dietitians manage the nutritional needs of patients. They identify patients who are malnourished or are at risk of becoming malnourished, and ensure that strategies t o optimize nutritional status are put in place. All aspects of nutrition composition are ca lculated, from major compo- nents (protein, energy, \201 bre, water) to micronutrients su ch as electrolytes, trace elements and vitamins. Delivery of Staf \201 ng level There are no recognized staf \201 ng levels for critical care. The use of a formal referral system is appropriate. 555 CHAPTER 33.6 ICU staf \201 ng: supporting professions Radiographer Role Radiographers use a variety of imaging techniques that may be performed i n the imaging department, in theater or at ward level. Increasingly the role is extending, and radiogra- phers may provide interventional procedures. They can provide advice on the m ost appropriate imaging modality for a given clinical scenario and provide rapid reports on image appearance and evolution. 2 Clinical scientists and medical technical of \201 cers in medi- cal physics and engineering departments Providing physiological investigation, monitoring and equipment management services. 3 Medical technical of \201 cers Providing clinical perfusion, respiratory physiology, neu - rophysiology, cardiology, vascular technology services as well as support to other servic es such as in drugstore. Staf \201 ng level There are no recognized staf \201 ng levels for critical care. The ser vice is largely determined outside of critical care, but must be in \202 uenced by the cri tical care team for ef \201 cient use of these resources. Staf \201 ng level Dependent on case mix and type of critical care service; no speci \201 c recommendations are given. Clearly the service provided must be \201 t for purpose. Critical care technologist Role Critical care technologists use, maintain, develop and teac h other healthcare professionals how to use a variety of devices and technology utilized in the care of the critically ill patient (e.g. ventilators, haemo \201 lters, blood gas ana lys- ers, IABPs, NO delivery devices and a range of other devices that monitor or alter pat ient parameters). The exact role varies from institute to institute. Further reading Department of Health. Making the change: a strategy for the professions in healthcare science. Lodon: DoH, 2001. Department of Health. Adult critical care: specialist drugstore practice. London: DoH,2005 Intensive Care Society/NHS Modernisation Agency. Allied Health Professionals (AHP) and Heal thcare Scientists (HCS). Critical Care Staf \201 ng Guidance. 2003. Intensive Care Society. Guidance on Comprehensive Critical Care for Adults in Independent S ector Acute Hospitals. London: ICS, 2002. Staf \201 ng level There are no recognized staf \201 ng levels as the role is varied and still developing. Jones C, Grif \201 ths RD, Humphris G, et al. Memory, delusions and the development of acu te post traumatic stress disorder-related symptoms after intensive care. Crit Care Med 2001 ; 29: 573 \200\22380. Kane SL, Weber RJ, Dasta JF. The impact of critical care pharmacists on enhancing patient outcomes. Intensive Care Med 2003; 29: 691 \200\2238. Healthcare scientists Role A huge variety of roles is included under this generic term. Bro adly, they can fall into one of three areas, although there is considerable overlap: 1 Clin ical scientists and biomedical scientists in pathology NHS Modernisation Agency. AHP and HCS Advisory Group. The Role of Healthcare Professionals within Critical Care Services. London: NHS, 2002 Stiller K. Physiotherapy in intensive care: towards an evidence- based practice. Chest 2000; 118:1801 \200\22313. (Clinical Biochemistry, Microbiology, Blood Transfusion and Hematology), providing diagnost ic and interpretive services 556 J COCKINGS Fire safety Fire in the critical care unit fortunately is rare. When it occurs, however, it can be both devastating and frightening. During the period 1994/5 and 2004/5, there were 10,662 \201 re incidents reported from within the NHS. The cost of these has amounted to 14.6 millio n, with 17 fatalities and 651 injuries. Fires involving critical care areas are particu- la rly complicated by the high dependency nature of the patients, the open space nature of uni t design and the equipment required for patient support. The infrequent nature of \201 re s in critical care areas means that prevention and response relies heavily on structural de sign, opera- tional policies and staff training, rather than real-life experi- ence for mos t staff. The principles of \201 re safety in an intensive care area are based on: \200 \200 \200 \200 Staff should undergo regular \201 re safety training which should cover prevention strate gies and early response pro- cedures, as well as isolation and evacuation policies. There s hould also be appropriate rules for visitors as well as tar- geted notices clearly visible to assist visitors unfamiliar to the hospital. One example is smoking; smoking is now banne d in most NHS buildings. Until recently, there were often designated smoking areas. More re cently, many Trusts have moved to a total no smoking policy despite argu- ments surrounding individual human rights. Such a move has been for reasons of both health and \201 re saf ety. Fire detection and alarm systems design and use is now covered by Firecode document HT M 05-03 (replacing HTM 82). This document describes differing alarm systems for areas conta ining dependent or highly dependent occu- pants, which applies to critical care areas, as c ompared with other areas which contain either ambulant independ- ent patients or staff. The function of \201 re alarms in critical care areas is to give warning to staff in the eve nt of a \201 re so that an early call to the \201 re and rescue service, \201 rst-aid \201 re- \201 ghting and evacuation may be carried out. In contrast to most other areas , it may not be necessary, desirable or even possible to give warning to the patients thems elves. Alarms for critical care areas should be two-stage alarms, i.e. a different indicati on for an evacuation requirement from an alert of a \201 re in a neighboring compartment or subcompartment. All \201 re detection systems used in NHS buildings housing a critical care area since the 1980s have used addressable rather than conventional systems. The cent ral control panel of a conventional system could only identify the zone of activation. In t he addressable system, the control panel can identify each and every detector. This aids in pinpoint- ing the source, and better recognition of false alarms, lead- ing to a more time ly and targeted response. The detectors (or sensors) in addressable systems are usually ana log sensors rather than the older two-state devices; the sen- sors continuously transmit to the control equipment a sig- nal level that represents the amount of heat, smoke or \202 ame being sensed. The decision as to whether or not this constitutes a \201 re condition is taken at the control panel. A two-state device simply rests in the activated or inactiv ated state depending on a \201 xed threshold, which is less informa- tive at the control panel. prevention and early detection containment the \201 re service response evacuation and co mpartment isolation procedures. Policies for critical care or high dependency areas form part of larger coordinated Trust-w ide policies. Within the NHS, these are based on and conform to the Department of Health \201 re safety policy. This includes the Firecode suite of documents speci \201 cally cove ring \201 re safety in the NHS in England (see Further reading). It considers management, functional requirements and operational provisions, and should be viewed in conjunction wi th the HBN 57 docu- ment, the NHS estates Facilities for critical care for all design and b uilding of critical care areas in England. Where an alternative solution to Firecode is pro posed within the NHS, the designer must demonstrate that the approach does not result in a lower standard of \201 re safety than if Firecode had been applied. The \201 re safety law regarding non-domestic premises in England and Wales changed in October 2006. The main effect of the change is: \200 a greater emphasis on \201 re prevention and reducing risk and abolishing the need for \201 re certi \201 cates. Instead, each organization now must have a designated person res pon- sible for \201 re risk assessment. Fire safety in the critical care area is the responsibility of everyone; responsibility lie s with government, Trust management, individual staff, general public visitors and patients alike. Containment of \201 re by design Building design for containment of \201 re in the NHS is described in Firecode document HTM 05-02. It is often nei- ther possible nor desirable i n critical care areas to under- take rapid and total evacuation. Restricted mobility and de pendence on immobile support equipment prevents such a task. Location of critical care area s on the ground \202 oor, although desirable, is not essential. If a ground \202 oor lo cation is not possible, it is recommended that such areas be no higher than 12m above groun d \202 oor (typically 3 \202 oors). However, the preferred and initial basic strategy f or \201 re evacuation for such areas should be to move them on their bed or in wheelchair s to a safer area on the same \202 oor. Critical care areas should therefore be designed with such isolation and horizontal evacuation strategies in mind, rather than external evac uation in the \201 rst instance. Prevention and early detection Central to reduced harm from \201 re is prevention and ear ly detection. This requires \200 \200 \200 building planning and design behavioral responsibilities, and the use of \201 re detectio n and alarm systems. All NHS buildings are expected to conform to or exceed the building and design standards la id out in the Firecode suite of documents. These contain elements relating to building desi gn and departmental physical relationships which minimize \201 re risk. All new electrica l equipment intro- duced into service should conform to minimum electrical safety standards and also should be checked and approved by the relevant department in the Trust locally. 557 CHAPTER 33.7 Fire safety than mechanical devices. The intensive care staff should ensure that the hospital switchboa rd has raised the \201 re alarm. Once the \201 re service has been alerted, the princip le for critical care areas is local containment with or without staged internal evacuation until the \201 re service has arrived and controlled the \201 re. There are three stage s of evacua- tion described in the Firecode documents: \200 Critical care areas should be located away from high \201 re risk departments. These incl ude \202 ammable stores, kitch- ens, boilerhouses, the laundry and main electrical switch - gear areas. The risk of \201 re in a compartment adjacent to the critical care area is thus reduced. Critical care \201 re com- partments should also be more resistant to \201 re than other patient areas. This is achieved by enhanced \201 re-resistant separato rs, the use of protective lobbies, and speci \201 c air conditioning and heating requireme nts. Critical care areas should be divided into at least two sub- compartments; nursing or patient areas (such as bed areas and clean and dirty utility rooms) should be separated fro m utility areas (such as staff changing and rest areas, and equipment storage areas), and l arger units should be divided into two patient areas to facilitate horizontal evac- uation from one compartment to another while retaining full critical care facilities for patients not able to be safely evacuated to a non-critical care area. Enhanced \201 re-resist- ant separators demand the use of at least 60min \201 re-resist- ant imperforate construction , together with mechanical methods of \201 re suppression which are activated automati- c ally in compartments adjacent to the critical care area. Such systems may include water spr inklers and CO2 \202 ood- ing systems. Every door opening in the critical care compartmen t wall should be provided with a protected lobby. This comprises a double door system conta ining an area large enough to contain a bed and ancillary equipment and staff, with space f or maneuvering as necessary. The lobby doors should provide a minimum of 30min \201 re re sistance each. Heating, ventilation and air conditioning (HVAC) systems provided to critica l care areas are designed so that the pressure within the department is maintained at a lev el slightly above that of the adjacent area. In a \201 re emergency, the continuing opera tion of these systems will assist in pre- venting smoke and other products of combustion fr om entering. Speci \201 cally, the HVAC systems should be designed so that they do continu e to operate in a \201 re emergency. Stage 1 is horizontal evacuation from a subcompartment where the \201 re originates to an adjoining subcompart- ment or compartment. Stage 2 is horizontal evacuation from the entir e com- partment to an adjoining compartment on the same \202 oor, and Stage 3 is vertical evacuation to a lower \202 oor substan- tially remote from the \202 oor of origin of t he \201 re (at least two \202 oors below), or to the outside. Critical care evacuations are almost always practically limited to stage 1 or 2. Stage 3 ev acuations of the critically ill are particularly slow and dif \201 cult, and increase pote ntial mortality of patient and staff. If the \201 re is small, staff should make attempts to control the \201 re with equipment availa- ble, provided they do not endanger themsel ves or others in the process. There should be advance provision for horizontal evacua- tion procedures. These include availability of equipment stored within the critical care compar tment, ideally within the patient subcompartment. Such equipment includes ready-packed tran sportation equipment and drugs. Most critical care departments will already have this in th e form of a transportable transfer bag or pack for intra-hospital move- ment of patients. S enior clinicians will have the job of lead- ership within the intensive care team and makin g triage decisions. If an alert is activated indicating a \201 re in a nearby compartment , but not in the direct vicinity of intensive care, patients should be prepared for evacuat ion but not actually moved. Staff should ensure that all \201 re resistance barriers are closed and that automatic closure devices have functioned correctly to seal off the critica l care com- partment. Aspects of patient management may have to be changed to render moveme nt of the patient easier with least risk. This might include, for example, cessation of RRT or attempts at respiratory weaning. Transportation equipment and drugs should be gathered, checked and distributed to the patient bedside. Senior clinical staff should establish a r ank order for evacuation should this become necessary and make the coordinated plan clear t o all staff. Of note, with the most common cause of death in a \201 re being inhalation o f toxic gasses or fumes, patients connected to a closed ventilator circuit may be better pr otected than a self-ventilating patient for longer, and this should be taken into account w hen planning evacuation. In general terms, patients closest to the source, those self-venti lating and those least dependent should be moved \201 rst. Those whose evacuation would b e slow and where the patient \200\231s chance of survival may be signi \201 cantly comprom ised by movement may be best left contained in the hope that the \201 re will be containe d without the need for evacuation. Fire service response The \201 re service takes time to arrive, and its purpose is to con tain, limit or extinguish the \201 re for the purpose of pri- marily limiting personal in jury and loss of life, and second- arily minimizing loss or damage to the building. The res ponse time and the number of \201 re engines, or appli- ances, which are sent is pre-dete rmined and pre-agreed, depending on the assessed risk and location of the building. This is the pre-determined attendance. In a city center, the pre-determined attendance will usuall y require that three appliances attend, two within 5min, and a third within 8min. In a rura l area, the response must be one appliance within 20min. Evacuation and isolation procedures All staff should receive mandatory training on local Tr ust \201 re policies and procedures. The response to a \201 re should be a coordinated one between hospital staff, the nomi- nated local \201 re of \201 cer and the attending \201 re service. It is rare that any staff member has prior real experience of \201 re evacuation procedures; a smooth effective response is achieved by adequate training and a l evel-headed approach with clear leadership. The \201 rst step is alerting the local \201 re of \201 cers and activating the \201 re service. Most \201 res in health- care settings are \201 rst detected by direct observation rather Further reading NHS Estates. Firecode \200\224 \201 re safety in the NHS. Health Technical Memorandum 05-03: operational provisions Part L: NHS \201 re statistics 1994/5 \200\2232 004/5. 2007. NHS Estates. Firecode \200\224 \201 re safety in the NHS. Health Technical Memorandum 05-01: managing healthcare \201 re safety. 2006. 558 J COCKINGS NHS Estates. Firecode \200\224 \201 re safety in the NHS. Health Technical Memorandum 05-0 3: operational provisions Part F: arson prevention in NHS premises. 2006. NHS Estates. Firecode \200\224 \201 re safety in the NHS. Health Technical Memorandum 05-0 2: guidance in support of functional provisions for healthcare premises. 2007. NHS Estates. Firecode \200\224 \201 re safety in the NHS. Health Technical Memorandum 05-0 3: operational provisions Part G: Laboratories on Healthcare premises. 2006. NHS Estates. Firecode \200\224 \201 re safety in the NHS. Health Technical Memorandum 05-0 3: Operational provisions Part B: \201 re detec- tion and alarm systems. 2006. NHS Estates. Firecode \200\224 \201 re safety in the NHS. Health Technical Memorandum 05-0 3: operational provisions Part H: reducing unwanted \201 re signals in healthcare premise s. 2006. NHS Estates. Firecode \200\224 \201 re safety in the NHS. Health Technical Memorandum 05-0 3: operational provisions Part D: commercial enterprises on healthcare premises. 2006. Ridley SA, Parry G. Guidelines for \201 re safety in the intensive care NHS Estates. Firecode \200\224 \201 re safety in the NHS, Health Technical Memorandum 05-0 3: operational provisions. Part E: escape lifts in healthcare premises. 2006. unit. London: Intensive Care Society, 1998. This page intentionally left blank 560 A COHEN Legal issues and the Coroner