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Critical care outreach team sees fall in cardiac arrests

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VOL: 97, ISSUE: 31, PAGE NO: 34

Nick Fox, BSc, RGN, is critical care outreach charge nurse at Pilgrim Hospital, United Lincolnshire Hospitals NHS Trust, Boston, Lincolnshire

Jan Rivers, RGN, is resuscitationist at Pilgrim Hospital, United Lincolnshire Hospitals NHS Trust, Boston, Lincolnshire

The integration of critical care services beyond the physical boundaries of the high-dependency unit (HDU) or intensive care unit (ICU) was one of the key themes of last year’s government review of adult critical care services (Department of Health, 2000). But to develop a critical care service without walls, it is important to have experienced critical care staff working in the general ward environment. This is the role of the critical care outreach team.

 

The integration of critical care services beyond the physical boundaries of the high-dependency unit (HDU) or intensive care unit (ICU) was one of the key themes of last year’s government review of adult critical care services (Department of Health, 2000). But to develop a critical care service without walls, it is important to have experienced critical care staff working in the general ward environment. This is the role of the critical care outreach team.

 

 

Why have a critical care outreach team?
The precursors of critical care outreach teams were medical emergency teams, which were pioneered in Australia at Liverpool Hospital ICU in New South Wales. Their function was to manage seriously ill patients with the aim of preventing further clinical deterioration or cardiopulmonary arrest (Lee et al, 1995). About 80% of patients admitted to ICU from the wards had abnormal respiratory and heart rates and oxygenation levels in the previous 24 hours (Goldhill et al, 1999a).

 

 

The effects of suboptimal care on critically ill patients on the wards was first observed by McQuillan et al (1998), who also noted the effect this had on patient morbidity, mortality and the subsequent need for admission to ICU.

 

 

There are many reasons for the delivery of inadequate care. For example, more patients are now treated as outpatients or on day units so hospital wards deal with patients who are more seriously ill than was previously the case. This, coupled with the drive to increase hospital activity and reduce patient stays, has led to an inevitable increase in the workloads of medical and nursing staff. The result is that they have less time to spend on patient assessment, investigation, treatment and recovery.

 

 

Patient-at-risk teams, which were developed and first implemented at the Royal London Hospital, have shown that early intervention decreases the number of cardiopulmonary arrests on the wards and is likely to decrease the mortality rate (Goldhill et al, 1999b).

 

 

Team objectives
The review of adult critical care services (Department of Health, 2000) set out objectives for critical care outreach teams, including:

 

 

- To reduce admissions by identifying patients whose conditions are deteriorating and helping to prevent admission or ensuring that they are admitted to a critical care bed in time to achieve the best outcome;

 

 

- To facilitate discharge by supporting patients’ continuing recovery, both on the ward and after discharge, and providing support for their relatives and friends;

 

 

- To share critical care skills with staff on the wards and in the community, enhancing training opportunities and skills practice, and use the data gathered on the wards and in the community to improve critical care services for patients and relatives.

 

 

The Pilgrim Hospital in Boston, Lincolnshire, set up a critical care outreach team last year. It includes a consultant intensivist, two critical care outreach nurses, a clinical nurse educator and a physiotherapist, and has access to a dietitian, the hospital acute pain team service and clinical nurse specialists.

 

 

The two critical care outreach nurses have a background in critical care, each with a number of years’ experience at sister/charge nurse level in this specialty. The outreach role is their sole remit, while other members have responsibilities outside the team.

 

 

The hospital decided to adopt a novel approach to the appointment of its critical care outreach team nurses. Once the service is established, the nurses will rotate back to HDU/ICU, enabling them to keep their critical care skills up to date. Conversely, a sister/charge nurse from the HDU/ICU will take on the responsibilities of the critical care outreach nurse, helping to improve communication between the general wards and HDU/ICU and enabling them to share skills and experience.

 

 

It was decided to implement the new service on the surgical wards first. This was because, historically, most patients admitted to ICU and HDU at the hospital came from surgical wards and included both elective and emergency admissions.

 

 

Initially, both outreach nurses spent time on the surgical wards to familiarise them with the pressures of working there. This also gave them an opportunity to build communication networks, establish working relationships with ward staff, and inform staff about and discuss the aims of the team and the service it would provide.

 

 

The critical care outreach team also organised presentations to medical staff, nurses, health care support workers, physiotherapists and departmental managers. These presentations were used to introduce outreach team members and explain the mechanics of how the service would operate.

 

 

Central to the role of any critical care outreach team is the identification of patients who are critically ill or at risk of becoming critically ill. The James Paget Healthcare NHS Trust, Great Yarmouth, devised an early warning score to identify patients at risk. This tool was developed at the Queen’s Hospital, Burton upon Trent, resulting in the Modified Early Warning Score.

 

 

Essentially, this tool measures physiological parameters which the nurse routinely records at the patient’s bedside. These observations produce an aggregate score and, if it exceeds a certain level, the nurse is empowered to seek assistance. The Modified Early Warning Score and tools like it trigger an early response to changes in the patient’s condition. The system used at the Pilgrim Hospital is the Patient at Risk Score (Fig 1), which has been adapted from the Modified Early Warning Score.

 

 

Education is also an important issue and an integral part of the critical care outreach nurse’s role. The benefits of the work done by the outreach team will be diminished if opportunities to share critical care skills in patient assessment and interventions are not taken up.

 

 

Without the sharing of skills and knowledge, there is a risk of deskilling ward staff. Moving critically ill patients from wards to HDUs and ICUs may deny them exposure to, and responsibility for, caring for such patients (Goldhill, 2000). To this end, the clinical nurse educator at Pilgrim Hospital has developed an HDU skills course that offers ward staff the chance to enhance their theoretical knowledge and clinical skills in patient assessment and interventions.

 

 

The programme encourages staff to critically analyse and develop their own practice in their own ward areas, with the support of the critical care outreach nurses, who not only act as facilitators and a knowledge resource for ward staff but also participate in more formal classroom-based education on the HDU skills course.

 

 

The team effect
This year, the critical care outreach team has received an average of 61 new referrals each month, of which 79% are patients transferred from HDU to general wards. These referrals have been made by staff nurses, ward sisters, senior house officers, registrars, consultants and physiotherapists.

 

 

Anecdotally, the intervention of the critical care outreach team, working in conjunction with ward staff, has enabled the recovery and the subsequent discharge of patients who might otherwise have died. The team has coordinated the early admission of patients to HDU who, without this intervention, may have needed intensive care. The support of the critical care outreach team has also helped ward staff to gain confidence and competence in caring for seriously ill patients on the wards.

 

 

In the five months between November 1999 and April 2000 there was a total of 15 cardiac arrests on general surgical and orthopaedic wards at the Pilgrim Hospital. Between May and October 2000, there were 17 cardiac arrests on the surgical and orthopaedic wards.

 

 

In the first five months of the critical care outreach team’s operation, there were 12 cardiac arrests on the surgical and orthopaedic wards, so the incidence of cardiac arrests on general surgical and orthopaedic wards has fallen. Whether there is a direct correlation between the establishment of the team and the reduction in the number of cardiac arrests on the wards remains to be proven, but the evidence is compelling. It shows:

 

 

- A 29% decrease (five) in the incidence of cardiac arrests compared with the preceding five months (May to October 2000).

 

 

- A 20% decrease (three) in the incidence of cardiac arrests compared with the same period the previous year (November 1999 to April 2000).

 

 

Although this data is not conclusive, it supports claims about the efficacy of the critical care outreach team. More detailed analysis is required to assess the effectiveness of the development of such teams in the UK, but the anecdotal evidence and the drop in the incidence of cardiac arrests on general wards appears to point to the fact that critical care outreach teams improve patient outcomes.

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