I recently experienced a 14-day delay in repatriating a UK citizen to their local hospital’s ICU. Speaking to colleagues in the US and Europe, this isn’t unusual. In this case, the patient had been medically accepted and clinicians all appeared to agree that prompt return was the ideal – they simply didn’t have a bed. It begs the question, what on earth is going on in the UK when repatriation is delayed in this manner?
A Lancet report in 2010 stated that the UK has 3.5 ICU beds per 100,000 population; as a comparison, Germany has 24 per 100,000. The result is that UK ICU bed occupancy tends to run at about 96 per cent, leaving very little room for increases in demand such as seasonal flu or indeed the arrival of a patient from abroad. The government’s response is that the increased spending (such as staffing, training, or equipment costs) associated with opening extra beds that are then less regularly utilised is not a sensible option.
Then what about infection prevention? It is absolutely normal in UK ICUs to place all patients repatriated from abroad into an isolation cubicle until such time as their infection status may be determined. In the UK, we agonise about overprescribing of antibiotics and the consequent increase in multi-resistant bacterial strains that are produced. However, many countries sell antibiotics over the counter with no prescribing control. An outbreak of multi-resistant pathogens in a UK ICU would result in the unit’s closure pending decontamination, thereby placing yet more strain on an overloaded system. Whilst an entirely prudent policy, isolation means that even fewer beds are actually available in which to take admissions from abroad.
Finally, is there a clear understanding amongst UK clinicians or hospital managers concerning the logistics of long distance repatriation? ‘Ring fencing’ a bed several days in advance of arrival can be nigh on impossible, and yet we often need to position an aircraft to the point of collection, rest the crew appropriately and then move the patient to the UK – a process that can take some days. We need to know before launch that the bed will be available on arrival. My personal favourite is to be told by the UK hospital that they already have outliers (patients within nearby hospitals who require transfer to their unit) and so can’t possibly accept this patient; I reply that this patient is already one of their outliers, they’re just outlying in a different country! Indeed they’re an outlier with significantly greater need of a bed in the correct unit and may deserve a higher priority.
I recently presented on the topic of admission to ICU from overseas to National Health Service (NHS) Senior Critical Care Network leads and was met with a great deal of antipathy. The audience members in the room were from across the UK; all had stories of ICU patients being ‘dumped’, as they put it, on their ICUs without prior arrangement. This is something I’ve never done, and never would – a planned move of a patient requiring an ICU bed must always be accompanied with a planned admission to the receiving unit. However, if you don’t understand the UK system, are under extreme pressure to move the patient home and you don’t have this resource problem in your country, I can see how this happens. Just please don’t... ever!
It isn’t all bad, however. There are some very understanding teams in excellent hospitals that do their level best to find space for their patients from overseas. Perhaps they afford as much priority to these patients as they do to their elective surgical workload. They understand that issues such as ICU delirium are significantly worsened by an inability to communicate clearly, and how a prolonged stay away from home can place intolerable pressures on families. The Queen Elizabeth Hospital in Birmingham is a prime example. Maybe this relates to the hospital’s experiences with the British military, but they just seem to understand the logistics involved and will readily step up to the plate to make sure space is created.
So, what options do we have? It is possible to repatriate your patient to their local ICU while arranging to pay for them as a private patient then switching to NHS care as soon as staffing allows. That sounds great, until you consider that this will not necessarily decrease the insurer’s cost burdens quickly, as what are the incentives for the hospital to quickly move the patient back into NHS care?
The patient I started to describe was repatriated when a bed was ‘discovered’ after the patient’s family contacted their local member of parliament. The subsequent enquiry from the MP on behalf of a distraught family shook the tree and made things happen. Sometimes families contact the media with similar results.
The take-home message is to begin liaising with the local UK ICU early. Once you know that you’re likely to have an admission for an ICU, then let them know, discuss the case and involve them. Remain persistent, educate clinicians about the issues and never repatriate without a confirmed bed. △