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The development of critical care outreach nursing services

VOL: 102, ISSUE: 32, PAGE NO: 25

Terry Hainsworth, BSc, RGN, is clinical editor, Nursing Times

Patients who need critical care are among the sickest in a hospital and require a high level of clinical and techni…

Patients who need critical care are among the sickest in a hospital and require a high level of clinical and technical expertise (Department of Health, 2005). There has been a considerable amount of evidence on the effectiveness of the care this patient group receives and much of this resulted in the assertion that critical care should be regarded as a description of a patient’s care needs rather than a place of care (DH, 2000), and a recommendation that critical care outreach services be developed.

What is critical care outreach?Outreach services were introduced in the latter half of 2000 following the publication of the Audit Commission’s (1999) Critical to Success report, which first used the term ‘outreach’ in the context of critical care services. The idea was developed in the Comprehensive Critical Care report (DH, 2000) and critical care services were given responsibility for critically ill patients throughout hospitals, rather than only within specialist units.The development of outreach services was based only on evidence of problems with the care that critically ill patients received on the ward - there was limited evidence that outreach was the solution to these problems according to the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) published in 2005. However, funding was provided and hospitals devised their own critical outreach services according to local need and available resources. Nationally these vary from a single nurse providing education on the identification and management of the critical illness to multidisciplinary teams providing 24-hour cover with regular medical input. Most outreach teams are nurse led and their role includes (NCEPOD, 2005):- Averting admissions to critical care;- Facilitating timely admission to critical care and discharge back to the ward;- Sharing critical care skills and expertise through an educational partnership;- Promoting continuity of care;- Ensuring audit and evaluation of outreach services.Critical outreach aims to empower ward staff to deliver appropriate care by offering them support from critical care-trained nurses who visit the ward. One of the key elements of the service is the use of ‘early warning’ or ‘track and trigger’ scores to systematically assess the condition of patients and facilitate appropriate interventions (NCEPOD, 2005)Critical care outreach services are a link between ward and critical care services and ensure that acutely ill ward-based patients receive appropriate care. To some degree they are an attempt to compensate for the limited number of critical care beds.

Why is outreach needed?Several studies have identified that the needs of critical care patients were poorly served (Goldhill et al, 1998; McQuillan et al, 1998; Franklin and Mathew, 1994). Goldhill et al (1998) aimed to identify priorities for ICU intervention and research. The findings included data showing that hospital mortality was 32.5%, that intensive care unit patients admitted from wards had a higher mortality than those from the operating room/recovery or the emergency department and that 27% of all deaths occurred after discharge from the ICU. The researchers concluded that early identification of at-risk patients, both before admission and after discharge from ICU, may allow them to receive treatment and reduce mortality. They suggested that inadequate resources may be the cause of excess intensive care mortality.McQuillan et al (1998) examined the prevalence, nature, causes, and consequences of suboptimal care before admission to ICUs. They found that the main causes of suboptimal care were failure of organisation, lack of knowledge, failure to appreciate clinical urgency, lack of supervision and failure to seek advice. The solutions they suggested included improved teaching, establishment of medical emergency teams, and widespread debate on the structure and process of acute care.These studies support Franklin and Mathew (1994) who found that many patients who have an unexpected in-hospital cardiac arrest have a clear record of marked deterioration before the event and in many cases appropriate action had not been taken.All three studies show the difficulties of providing care to acutely unwell patients and the deficiencies have been confirmed by the NCEPOD (2005). One method of addressing the problem was the development of critical care outreach services.

What does it achieve?According to the NCEPOD (2005) there are geographical inequalities in the provision of critical care outreach services and also only one in four hospitals are using early warning or track and trigger systems to ensure that patients who are deteriorating are identified.A number of studies have investigated the effectiveness of critical care outreach including Ball et al (2003) and Priestley et al (2004).Ball et al (2003) aimed to ascertain the effect of the critical care outreach team on patient survival. They found that the introduction of a critical care outreach team improved survival by 6.8% and decreased readmission to critical care by 6.4%. Therefore, the researchers concluded that the activity of the critical care outreach team appears to improve patient survival to discharge from hospital and may reduce the number of readmissions to critical care.These results were later corroborated by Priestley et al (2004) who investigated the effects of introducing a critical care outreach service on in-hospital mortality and length of stay. They concluded that critical care outreach reduces mortality in general hospital wards.

The futureThe NCEPOD (2005) recommends that outreach services and track and trigger systems should be used throughout UK hospitals. However, it cautions that these should be complementary to, rather than a replacement for, the traditional role of medical teams in patient care. It suggests that 24-hour a day, seven-days a week outreach services should be developed that include:- The use of a track and trigger warning system to identify at-risk patients;- Rapid referral to appropriately equipped experts;- Timely transfer to ICU when needed;- Facilitation of discharge and rehabilitation of patients from critical care;- The development of effective systems and staff to manage level 1 patients on general wards.It seems logical that measures such as outreach and track and trigger should have a positive impact on patient care. However, services need to be based on evidence and a full evaluation of critical care outreach services is being undertaken by the NHS R&D Service Delivery and Organisation programme, the results of which are due later this year. However, the systematic review part of the evaluation was presented by Carol Ball at the 2006 RCN Critical Care Nursing Forum Annual conference and Exhibition.The review identified that there is insufficient research to assess the impact of outreach activity on patients or service outcomes. This highlights some of the problems encountered in ensuring high-quality methodology in studying outreach services such as using randomisation and controls. It is therefore important to wait for the completed review to understand more about how critical care outreach service will benefit patients in the future.- This article has been double-blind peer-reviewed.For related articles on this subject and links to relevant websites see www.nursingtimes.net

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