The Royal Marsden’s Critical Care Unit (CCU) is the largest facility of its type dedicated to cancer patients in the UK, and one of the biggest in Europe
of patients admitted to CCU are recovering from complex surgery
Providing a 24-hour, seven-day-a-week service, The Royal Marsden’s Critical Care Unit is specially staffed, equipped and designed to closely monitor patients who require intensive treatment.
The unit has 16 beds in Chelsea, with a two-bed Step-Up facility at the Sutton hospital where patients at risk of organ failure are transferred for intensive physiological monitoring and resuscitative care.
“We specialise in offering intensive care for critically unwell patients, most of whom are recovering from complex surgery,” says Dr Tim Wigmore, Critical Care Lead.
“Our team also provides highly specialised care to haematology patients suffering from bone marrow failure as a result of chemotherapy or bone marrow transplantation. Occasionally, we also care for patients who require complex symptom control, and we work closely with the Symptom Control and Palliative Care teams.”
The Trust’s CCU is the largest such unit dedicated to cancer patients in the UK, admitting more than 1,400 patients a year. It also admits a significant number of patients with haematological malignancy, of whom 50% are post-bone-marrow transplant.
Dr Wigmore says: “The unit aspires to be supportive and open, providing compassionate and personalised care to both the patients and their families. We pride ourselves on our family-centred model of care. We work closely with the rehabilitation team, putting our patients at the heart of everything we do.
“The Royal Marsden continues to score highly in the Intensive Care National Audit and Research Centre’s quarterly reports, both in terms of infrastructure and staffing levels, and for patient outcomes. We have also consistently been awarded the highest quality scores in the North West London Critical Network benchmarking exercise.”
patients are seen each month by the Critical Care Outreach Team
24/7 outreach service
The Critical Care Outreach Team (CCOT) is a 24/7 nurse-led service operating across both hospital sites. The highly skilled team of senior nurses works with staff on the wards to ensure the early detection of deteriorating patients. The National Early Warning Score (NEWS) is used to monitor patients and, if they fall below a certain score, the CCOT is contacted.
“We implement a treatment plan for the patient on the ward, but if they are really sick, we’ll admit them to the Step-Up facility or CCU,” says Emma Stilwell, Matron of Critical Care Outreach, Resuscitation & Simulation training & Interventional radiology.
“Our aim is to stop the patient deteriorating further to avoid an admission to intensive care. We also follow up with patients who’ve been discharged from CCU to enable a smooth, safe transfer to more traditional ward-based care.”
CCOT members have undergone advanced training in patient examination and diagnostics, and many are non-medical prescribers. They are also trained in Advanced Life Support (ALS) and Paediatric Immediate Life Support (PILS), which enables them to support the paediatric ward and anaesthetists when a young patient needs to be transferred to another hospital.
The team responds to all cardiac arrest calls across the Trust, and provides education and training sessions for staff on the wards.
Emma Stilwell follows up on discharged CCU patients
Trainee Advanced Critical Care Nurse Practitioner Jo-Anne Gilroy
nurses work in CCU
Evolving multidisciplinary roles
In June 2016, The Royal Marsden’s CCU was the first in London to introduce two trainee advanced critical care nurse practitioner (ACCNP) roles.
The position was developed to ensure that the highest quality of care is maintained for cancer patients at the Trust through collaborative multidisciplinary working, enhanced safety, and shared knowledge across different healthcare professionals.
Jo-Anne Gilroy and Alistair Ritchie were appointed to the roles, which involves 18 months’ training prior to qualifying as ACCNPs.
“While working autonomously, we provide support for medical and nursing staff in CCU, facilitating continuity of care for patients and their families,” says Jo-Anne.
ACCNP trainees carry out physical assessments of critically ill patients, perform diagnostic and therapeutic procedures, and prescribe medications and fluids under direct medical supervision, with a view towards independent practice after completion of the training programme.
“Once qualified, our ability to support the team in caring for patients will include carrying out advanced technical skills,” says Jo-Anne.
“This reduces the workload of the junior doctors, allowing them to deal with more complex cases, and offers an opportunity to provide multidisciplinary education and teaching at the bedside.”
Dr Vimal Grover, Consultant in Critical Care and Anaesthetics and one of the programme’s mentors, says: “The advantages of this role extend beyond developing our workforce to meet the changing needs of the modern NHS. We believe the introduction of ACCNPs will lead to better continuity of care for patients, and enhanced safety and multidisciplinary working.”
The unit aspires to be supportive and open, and we pride ourselves on our family-centred model of care
Dr Vimal Grover
The pharmacy's Rudyard Lewis and Katie Warren assist in checking and ordering medications
towards the cost of the CCU was contributed by supporters of The Royal Marsden Cancer Charity
An improved environment
A fire at The Royal Marsden in Chelsea in 2008 destroyed part of the hospital’s roof and damaged the original CCU. The new unit opened in August 2010 and doubled the Trust’s previous capacity for complex post-operative care. Designed around patients to optimise their experience and recovery. it has seven isolation rooms, including two dedicated teenage and young adult bays.
“We are now able to care for even more patients, and have increased our already world-class survival rates,” says Dr Pascale Gruber, Consultant in Critical Care and Clinical Director for Surgery and Inpatients. “A number of the side rooms have direct access to a decked area outside. For patients who are rehabilitating, getting some fresh air in such a safe environment is important. It also helps them adjust to a natural waking and sleeping cycle, which is key during periods of recovery.”
As well as the trainee ACCNPs, seven intensive care consultants, 10 junior doctors, 75 nurses and 10 healthcare assistants work in the unit. The wider multidisciplinary team includes a dedicated critical care pharmacist, a dietitian, a team of physiotherapists, speech and language therapists, a medical microbiologist, a symptom control team and complementary therapists.
Katie Warren, Critical Care Specialist Pharmacist, says: “The multidisciplinary team participates in the consultant-led ward rounds each morning in order to get an in-depth understanding of the patients and their complex needs. Therefore, we’re able to personalise the care that we provide for each patient, helping to improve their recovery during their stay on the unit.”
The physiotherapists see patients after surgery to encourage early mobilisation, which aids in preventing complications and respiratory problems. They also support patients who have more complex needs as a result of being critically unwell, by providing exercises and rehabilitation to help them regain function in performing everyday tasks.
“Physiotherapy is really important for CCU patients, because it helps them regain their independence and minimise the side effects of critical illness,” says Jess Whibley, Critical Care Physiotherapist.
Dr Natalie Pattison (left) and Geraldine O'Gara are investigating if aromatherapy can aid recovery
Jess Whibley helps patients regain independence via physiotherapy
An exciting research programme is under way in CCU to help reduce complication rates and improve outcomes after cancer surgery. In collaboration with The Institute of Cancer Research, the team is investigating the effect of the perioperative period on cancer outcomes.
The Royal Marsden is one of 20 hospitals in the UK recruiting patients to the PREVENTT trial, which is looking at new ways of managing anaemia in those undergoing surgery.
“Our goal is to improve perioperative care so that patients’ health is optimised prior to surgery and their recovery is as smooth as possible after their operation,” says Dr Shaman Jhanji, Consultant and Research Lead in Critical Care and Anaesthesia.
“We want to find out whether giving iron intravenously helps increase people’s blood count before their operation and reduces the need for blood transfusion.” The Trust is also taking part in PRISM – an international trial recruiting 4,800 patients who are undergoing major abdominal surgery. Participants wear a tight-fitting oxygen mask for four hours immediately after their surgery to see if it helps to prevent respiratory complications.
Rest is a key aspect of recovery, but critically ill patients often have broken and disrupted sleep. So Dr Natalie Pattison, Senior Clinical Nursing Research Fellow, and Geraldine O’Gara, Nurse Researcher, are investigating whether aromatherapy massage can help patients in CCU to sleep. “Evidence suggests that adequate sleep may reduce the psychological impact of being in CCU,” says Dr Pattison, “as well as leading to shorter hospital and critical care stays.”
A patient’s perspective
Susan Rogers, 62
“I had a major operation for womb cancer and spent the evening in CCU. Less than 24 hours later, I was transferred to Ellis Ward where I was seen by Danny from the Critical Care Outreach Team.
“He checked my progress and gave me advice on how to get well as soon as possible. It was really helpful to have that. Sometimes you can feel like you’re being kicked out of one place and into another with new people – it was nice that they continued to care for me.
“I have had such good care here and everyone has been very nice and helpful. All the nurses tell you their name and are incredibly kind.”