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Developing roles in critical care outreach

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A sick patient is often a quiet patient, and easy to overlook on a busy ward. Critical care outreach nurses teach and support staff so they notice the early signs of deteriorating health and provide prompt, appropriate intervention.

The need for critical care skills on the wards was highlighted by the Department of Health in 2000. Its report Comprehensive Critical Care called on trusts to avert ICU admissions by implementing optimal management before patients became severely unwell. It was also a springboard for the development of critical care outreach nursing.

There were already signs of the emerging specialty. Sheila Hennessy, now lead critical care outreach sister at King’s Mill Hospital in Sutton-in-Ashfield near Nottingham, recalls regular interactions with the wards in her days on the ICU.

‘When staff were concerned about a patient they would phone the unit, and we would pop into the wards to offer informal advice.

‘Then the government review recommended making the service available to patients wherever they were, whether or not an ICU bed was available.’

The development of early warning systems for identifying sick patients was one of the central recommendations of the government’s review.

At King’s Mill the Augmented Care Assessment Tool (ACAT) is used to produce a score based on routine observations. An ACAT score of above five is an indication for referral to the house officer, and then to the critical care outreach team if the patient shows no improvement.

The outreach nurses assess the patient, and advise the nurses, junior medical staff and some of the senior doctors on the care that is needed. When the score is high, say nine or ten, the team is called in immediately.

‘In these cases we make sure a senior doctor is involved. And if the patient needs to come into the ICU, we facilitate the transfer,’ says Ms Hennessy.

‘If a nurse is concerned about someone who scores less than five, and can’t put a finger on why, we are happy to go to the ward, talk to the patient, look at the observations and test results and have a discussion with the doctor.’

The team also sees patients on the wards after they have been transferred from ICU. As well as facilitating continuity of care, this service provides reassurance at a time when patients and relatives feel particularly vulnerable.

Staff education is also an important aspect of the outreach role, which Ms Hennessy estimates accounts for about 40 per cent of the team’s workload.

‘Every nurse in the hospital does our course on high dependency skills. It covers topics such as respiratory, renal and cardiovascular symptoms, fluid management and shock. It helps nurses to recognise sick patients and prioritise what to do for them.’

The ward nurses also have a portfolio for critical care skills. For example, as they develop expertise in patient assessment or tracheostomy care, they can call on the outreach team, the critical care nurse educator or the critical care nurse consultant to appraise and document their competence.

The efficacy of the training is evident from the outreach team’s increasing workload. ‘We know it’s working because we get more calls,’ says Ms Hennessy. ‘And that’s exactly what we want.’

Ms Hennessy had been the senior sister in the ICU for 12 years when the critical care report came out. She decided to join the new outreach team because it involved more patient care at a time when her managerial workload largely precluded clinical duties.

She now heads a team of three - herself and two critical care outreach sisters - providing cover from 8am to 9pm Monday to Friday, and finishing at 4pm at weekends. On evenings during the week they review patients and informally alert the oncoming anaesthetist about cases that may be a cause for concern.

There are plans to extend the hours of the service, probably to around midnight, alongside the Hospital at Night project, which will mean recruiting more nurses.

Perhaps surprisingly, ICU experience is not a prerequisite for the role. When King’s Mill advertised it stipulated experience of nursing sick patients in an acute setting.

However, the nurses on the King’s Mill team keep their critical care skills up to date by working shifts on the ICU. ‘Ideally we each do a session a week. We need to keep up to date because if the ICU is full we may be pulled in to look after a severely ill patient in a recovery bay. It also means the doctors see us and know we have current ICU experience.’

Outreach is just one aspect of the changing face of critical care. In 2000, the government injected new money into the service and called for strong links to be forged between neighbouring ICUs.

For King’s Mill ICU that meant joining with several other units in the area to form the Mid-Trent Critical Care Network, which provides a forum for lead nurses and lead clinicians to get together and discuss service delivery.

There are also additional opportunities in critical care, including the development of nurse educators and nurse consultants in the specialty.

Many ICUs now have service improvement groups.

The outreach team at King’s Mill is moving forward with the development of patient group directives to allow nurses to prescribe oxygen and bolus fluids and to change tracheostomy tubes. There are also plans for a post-ICU outpatients clinic.

All in all, these are exciting times for Ms Hennessy and her colleagues. ‘You can see it’s an expanding job,’ she says, ‘with lots and lots of potential.’

How to become a critical care outreach nurse:

THIS COULD BE FOR YOU IF: you are interested in acute nursing and close liaison with medical and nursing staff throughout most of the hospital.

YOU NEED TO BE GOOD AT: communication, diplomacy.

YOU NEED TO HAVE: about three years’ postregistration experience, a post-basic course in an acute setting, experience of nursing sick people.

YOU DO NOT NEED TO HAVE: a qualification in critical care.

OTHER SIMILAR JOBS YOU COULD CONSIDER: nursing on the ICU or in other acute settings.

WHERE TO FIND MORE INFORMATION: British Association of Critical Care Nurses, Crown House, 28 Winchester Road, Romsey, Hampshire SO51 8AA. Tel: 01794 521767. Website:

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