1. Introduction and context

While adult critical care transfer services (ACCTS) are regionally commissioned and delivered, they are nationally networked to provide resilience during periods of escalation and surge.

ACCTS provide co-ordination, triage, decision-support, and transfer of critically ill adult (≥16 years of age) patients between hospitals for escalation to specialist care, continuation of care, repatriation, and capacity reasons.

This standard operating procedure (SOP) forms part of a suite of NHS England SOPs covering the following services:

• adult critical care services
• paediatric intensive care services
• adult respiratory extra corporeal membrane oxygenation (ECMO) services
• paediatric respiratory ECMO.

It is recognised that:

• there are mutual interdependencies between these services
• surge pressures are not solely linked to winter and can occur at any time, such as during a major incident or mass casualty event. 

In the context of this SOP, the term surge describes pressure on the whole adult critical care system rather than an individual critical care unit or region.

All capacity reporting and bed management will use, as its basis, the NHS pathways directory of services (pathways DoS) system to monitor the bed availability for adult critical care in England.

2. Purpose

This standard operating procedure (SOP) sets out:

• a consistent national approach for England by which providers of the services covered by this document can escalate capacity pressures to their commissioners in NHS England
• how the services covered by this document and the stakeholders should act
• the process for the identification of current and potential capacity for the services covered by this document
• the anticipated escalation process nationally across the NHS in England, in support of the services covered by this document (including the NHS strategic command arrangements to be implemented by NHS England should they be required)
• the approach to supporting NHS England emergency preparedness, resilience and response (EPRR) planning in relation to any incident, event or outbreak of disease that may result in the need for adult critical care transfer.

All processes described take account of the specific commissioning arrangements for the services covered.

The need to reinstate the Critical Care Capacity Panel (CCCP) will be considered when/if there is a significant surge in activity (identified via the pathways DoS system) within our adult critical care (ACC) units or a declared level 4 national incident (control). Aligned to the CCCP, the National Critical Care Transfer Cell (NCCTC) will be reinstated to co-ordinate NHS England’s inter-regional transfer response. All surge issues should be referred to the NCCTC in-hours and to the NHS England EPRR team out-of-hours. Outside surge, the national clinical director should be contacted (see appendix 1).

3. Strategic aims

The strategic aims of this document are for the services covered to:

• prevent avoidable mortality and morbidity due to patients requiring care and not being able to access this in a timely manner
• maximise capacity in the health and social care system in a range of scenarios through a co-ordinated escalation and de-escalation approach across geographical footprints
• support national co-ordination of adult critical care capacity during periods of escalation
• ensure accurate and systematic data reporting to support service planning and response to all stages of surge and escalation, to enable national co- ordination of care for patients (where required).

Appendix 2 gives detail about adult critical care transfer services and their scope.

4. Target audience

The primary audiences for this document are:

• regional/integrated care system commissioners of adult critical care
• those involved in planning adult critical care transfer services
• others involved in the oversight of specialised services in NHS England
• those involved in strategic command arrangements out-of-hours in NHS England (ie emergency preparedness, resilience and response staff)
• providers of adult critical care transfer services
• providers of adult critical care.

5. Surge and escalation management arrangements

This section sets out the roles, responsibilities, actions and monitoring requirements for any surge and escalation situations including, but not limited to:

• any surge and escalation situations including pandemics such as COVID-19 and influenza
• major incidents
• mass casualty incidents.

Key points in each phase are summarised in the tables and action cards in appendix 3 and appendix 4.

Regions must have escalation plans and agreed triggers for:

• increasing adult critical care (ACC) capacity
• capacity transfer to manage operational pressure
• adult critical care transfer services (ACCTS) to increase operational capacity above the commissioned baseline in a stepwise fashion to meet regional and national surge and escalation requirements.

5.1 Pre-surge phase

The pre-surge phase occurs during most periods of higher activity (eg average winter) and is defined as the majority of critical care units declaring CRITCON 0-1.

ACCTS continue business as usual function within their commissioned baseline and facilitate capacity transfers within and between systems if required.

5.2 Surge phase

Surge represents expected winter pressures where critical care units, systems and regions are operating within regional winter planning assumptions with the majority of units declaring CRITICON 2. Frequent capacity transfers are occurring within regions with preparation to utilise capacity in geographically adjacent regions as required.

NHS England will consider standing up the Critical Care Capacity Panel (CCCP) to allow the National Critical Care Transfer Cell (NCCTC) to reinstate the structures to enable inter-regional mutual aid between geographically adjacent regions.

The NCCTC will establish a videoconference with a call frequency of twice weekly (or more frequent, if required) on Mondays and Thursdays at 9.30am to discuss the following:

• ACCTS activity, particularly capacity and mutual aid transfers
• establishing the structures for enabling inter-regional mutual aid between geographically adjacent regions
• confirmation of ability to increase capacity to meet regional surge planning requirements
• ACCTS equipment stock .

ACCTS will facilitate capacity transfers between systems and within their region. It is anticipated that during this phase, ACCTS may need to increase operational capacity to manage these transfers.

5.3 Escalation phase

Escalation occurs when critical care units, systems and regions are operating above expected winter pressures with the majority of units declaring CRITCON 2 and an increasing number of units declaring CRITCON 3. Multiple capacity transfers are required within a region and between geographically adjacent regions each day. The majority of critical care units are operating within their surge capacity and there will be a need for nationally co-ordinated inter-regional mutual aid within the next 48 to 72 hours.

The CCCP will meet regularly and provide strategic direction for inter-regional capacity transfers.

The NCCTC will establish a videoconference with a call frequency of daily to discuss the following:

• ACCTS activity, particularly capacity and mutual aid transfers
• daily submission of regional transfer requirements
• co-ordinating inter-regional mutual aid under the strategic guidance of the national CCCP
• confirmation of ability to increase capacity to the required national surge planning levels
• ACCTS equipment stock.

ACCTS will facilitate capacity transfers within and out of their region. It is anticipated that during this phase, ACCTS will need to further increase operational capacity to a maximum to manage these transfers.

5.4. Heightened escalation phase

Heightened escalation occurs when critical care units, systems and regions are operating under severe pressures, and multiple capacity transfers are required within and between adjacent regions each day.

The CCCP will meet regularly and provide strategic direction for inter-regional capacity transfers.

The NCCTC will establish a videoconference with a call frequency of daily to discuss the following:

• ACCTS activity, particularly capacity and mutual aid transfers
• daily submission of regional transfer requirements
• co-ordinating inter-regional mutual aid under the strategic guidance of the national CCCP
• confirmation of the increase in capacity to the required national surge planning levels
• ACCTS equipment stock.

ACCTS will facilitate capacity transfers within and out of their region. It is anticipated that during this phase, ACCTS will need to further increase operational capacity to a maximum to manage these transfers.

5.5 Major or mass casualty incidents

A major incident or mass casualty incident is declared regionally or nationally. ACCTS are a key element of each region’s critical care response.

Regional ACCTS leads should inform the NCCTL(s) of the declaration via the secure messaging application.

5.6 Recovery phase

The recovery phase is defined as the point at which surge, and escalation phases (or initial response and consolidation phases) have passed, and pre-surge arrangements are reinstated. This position is confirmed by the NCCTC in-hours.

ACCTS may experience a prolonged period of increased activity depending on the nature of the incident. Transfer of critical care patients may be required to facilitate the restoration of business-as-usual functions within trusts and systems. Depending on the nature of the incident, this phase may be when transfer activity is at its highest and increased ACCTS capacity is most required.

The NCCTC will:

• co-ordinate a debrief of ACCTS involved in the incident
• prepare a report including recommendations for improvement of this surge plan
• implement changes agreed.

6. Interdependencies/links with other services

Adult critical care transfer services (ACCTS) will work under the strategic guidance of critical care operational delivery network(s) within their operating geographical region and NHS England regional response teams.

The following services have links with ACCTS and may provide additional surge transfer or transport capability:

• Paediatric critical care transport services: Each service should have a standard operating procedure for the transfer of adult patients, including how team availability is recorded, how teams are tasked, how clinical advice is accessed and how patient records are maintained.
• Extra corporeal membrane oxygenation (ECMO) retrieval teams: ECMO services may enter surge and escalation alongside ACC and ACCTS. There should be regular communication between services to utilise available capacity in both directions, depending on operational requirements.
• NHS ambulance service trusts: Each ACCTS should have a formal agreement with its corresponding regional NHS ambulance service trust(s) to provide additional vehicles and drivers in the event of heightened escalation.

Appendix 1: Contact details

National Critical Care Transfer Service in-hours

Please email the Adult Critical Care Programme: england.npoc-trauma@nhs.net

National Critical Care Transfer Service out-of-hours

NHS England Emergency, Preparedness, Resilience and Response (EPRR) team: england.eprr@nhs.net

0844 822 2888 ask for ‘NHS 05’

In the event either of the 2 in-hours leads are unavailable (eg because of annual leave), the role will usually be undertaken by the other in-hours lead. An out-of-office message will be left in response to emails and a voicemail message in response to phone calls.

Appendix 2: Background to adult critical care transfer services

Adult critical care transfer services (ACCTS) ensure critically unwell patients receive high standards of critical care throughout the referral and transfer process. They co-ordinate, triage and provide decision support to all referrals for critical care transfer, regardless of the provider undertaking the transfer.

The service specification commissioned by NHS England includes the following care pathway:

• Electronic referral and single point of access telephone number.
• Real-time consultant-led joint decision-making involving referring and receiving clinicians, transfer service and specialty teams to ensure a concurrent and efficient referral process.
• Coordination and triage to regionally agreed criteria, including circumstances where the ACCTS does not undertake the transfer.
• Consultant-delivered decision-support throughout the referral and transfer pathway.
• Consultant-led dedicated transfer teams, equipment and vehicles.
• Adult critical care (ACC) patients (those requiring, or likely to require, specialist critical care clinical escort and intensive monitoring, organ support, and/or specialist treatment) requiring transfer for:
  • time critical and urgent escalation of care
  • repatriation
  • continuation of care.
• Operational ACC capacity transfer coordination and management within and between regions during periods of high operational activity.
• Clear protocols for handover from referring to receiving units.

ACCTS work collaboratively as part of a national network of services during business-as-usual times to support transfer between regions, when required.

Appendix 3: Surge summary and action cards

Appendix 4: Major incident and mass casualty incident summary and action cards

Publication reference: C1373