VOL: 97, ISSUE: 43, PAGE NO: 34
Peter Groom, RGN, is charge nurse, outreach team for ICUs, Southampton University Hospitals NHS TrustThe intensive care unit (ICU) has long been seen as a 'no go area' within hospitals, where the staff are elitist and the doors are shut. It functions as a separate entity to the wards and the hospital it serves, acting in isolation from departments that supply and siphon its patients. But all this is changing.
The intensive care unit (ICU) has long been seen as a 'no go area' within hospitals, where the staff are elitist and the doors are shut. It functions as a separate entity to the wards and the hospital it serves, acting in isolation from departments that supply and siphon its patients. But all this is changing.
The Department of Health review document, Comprehensive Critical Care: A Review of Adult Critical Care Services (2000), confirmed some of these negative opinions and called for a hospital-wide approach to the care of critically ill patients. The nursing section of the document states that 'each critically ill patient, wherever they are located in the hospital, should have skilled critical care nursing available either to care directly for them, or to advise on the care required to meet their needs'.
This document and the Audit Commission's report, Critical to Success (1999), created the impetus for establishing critical care outreach services in their many forms. Medical emergency teams (MET), patient at risk teams (PAR), outreach teams and even patient emergency response teams (PERT) may have arrived in a trust near you. They all aim to deliver care to the critically ill patient nursed outside the ICU or high-dependency unit (HDU).
The role of critical care outreach services
The DoH (2000) outlined three key objectives for critical care outreach services:
- To avert ICU admissions;
- To enable ICU discharges;
- To share critical care skills.
Although the objectives were clear, the methods for achieving them were left open to individual trusts. Hospitals have had to evaluate what is appropriate for their patients and the likely demand for such a service. For example, not all hospitals require a 24-hour, seven-days-a-week service; some hospitals provide designated staff from critical care areas to be available to wards, while others offer a ward-based service with defined links to ICU.
The national expert group involved with Comprehensive Critical Care suggested that patients could be placed on a scale of clinical need (see Box 1) that would indicate the level of support they required. Outreach services aim to support patients between levels one and three, preventing their deterioration and supporting staff who care for these patients on the general wards.
Both Comprehensive Critical Care and the Audit Commission's report were backed by research highlighting less than optimal care before ICU admission and its consequent effect on mortality. A confidential inquiry (McQuillan et al, 1998) found half of patients admitted to ICU had received care before admission. The main causes of their poor care were a lack of knowledge, failure to appreciate clinical urgency, lack of supervision and failure to seek advice (McGloin et al, 1999).
Patients with obvious signs of deterioration can be overlooked or ineffectively managed on the ward. This may lead to potentially avoidable unexpected deaths or to a poorer eventual outcome following ICU admission. Outreach services aim to have an impact at the point of deterioration - identifying clinical indicators, assisting with management of the deteriorating patient, and supporting the ward team by sharing experience and critical care skills.
At Southampton General Hospital, the critical care outreach service is one of three initiatives to improve the care of critically ill patients. The other two initiatives are:
- The modified early warning system (MEWS) which enables all staff to 'score' the sicker ward patients and identify those at risk;
- The ALERT course (licensed from Portsmouth Hospitals NHS Trust), attended by all junior doctors, physiotherapists and ward nursing staff. It equips staff to initiate immediate treatment for sick ward patients and to communicate their concerns effectively to other members of the team.
The critical care outreach team
Southampton General Hospital is a large university teaching hospital where the outreach service provides 24-hour, seven-days-a-week cover. Our team is made up of six full-time experienced critical care nurses, who carry the outreach bleepers and coordinate the team. An anaesthetic senior house officer is continually available.
A nurse consultant and anaesthetist are responsible for the outreach team's strategic direction and development. Physiotherapy input is essential and outreach services may include their own physiotherapists or have fast-track links to physiotherapy assessment.
The critical care outreach service
The team offers support both to sick ward patients and the ward team caring for the patient. By sharing critical care skills and experience, acutely ill patients can be cared for safely on the ward. Outreach teams also aim to identify patients for whom ICU or HDU care is required. This promotes earlier admission to ICU and may also have a role in identifying those patients who would not benefit from admission on grounds of futility of treatment.
Discharge from ICU is sometimes an area of dispute between the ICU and ward teams and this can be reduced by continued support from the outreach service. Education plays a key role: members of the outreach team not only support the staff caring for the patient, but also provide information and skills so that the ward staff can develop their own practice.
Outreach services need to be audited, to evaluate effectiveness and patient outcomes. There needs to be a mechanism for feedback between team members and the ward staff to learn from experience and identify problems. Critical care outreach services can have a positive impact on patients and ward staff - as the case studies above testify - but must not be seen as a remedy for reduced ward staffing, limited medical cover or a lack of ICU/HDU beds.
Critical care outreach services should bring down the barrier between critical care units and the wards by focusing not on where patients are placed, but on what level of care they need. These new services can create seamless care and improve channels of communication to the benefit of both patients and nurses.