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Implementing improvements in care of critically ill, ward-based patients

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Jane Viner MSc, BSc (Hons), RNT, DPSN, RN.

Education Facilitator (Wards), Torbay Hospital, Torquay

Improving the care of critically ill patients has been identified as a major objective by the current Government. This is reflected in several Government publications including The NHS Plan (DoH, 2000a), Modernising Critical Care Services (NHSE, 2000) and Critical to Success (DoH, 1999).

Improving the care of critically ill patients has been identified as a major objective by the current Government. This is reflected in several Government publications including The NHS Plan (DoH, 2000a), Modernising Critical Care Services (NHSE, 2000) and Critical to Success (DoH, 1999).

However, there is recognition that the development of critical care services has lacked consistency and that poor organisation has led to wide variations in service development, with a third of trusts still having no high-dependency bed provision (DoH, 2000b; NCEPOD, 2000). Although national critical care capacity has risen in recent years (DoH, 2002), it is unlikely that it will keep pace with demand. Factors contributing to a greater demand for critical care beds include advances in anaesthesia, the success of complex surgical techniques and the increasing age of the population (Goldfrad et al, 2000; Parker et al, 1998).

Acute-care hospitals are busier with sicker patients, but the expansion of critical-care services has been insufficient (Hopkins et al, 2002; Lyons et al, 2000). Acutely ill and highly dependent patients being routinely cared for in general wards. This has resulted in a change in the care needs of ward patients and an increased level of patient dependency (Haines et al, 2001).

Wright (2000) suggests that, for these reasons, clinical staff need to acquire new knowledge and skills to meet the demands of a rapidly changing patient profile. However, recent studies indicate that ward-based clinical staff are not receiving the education and support required to meet this demand (McKenna, 2002).

Evidence suggests that ward patients are receiving a sub-optimal level of care leading to potentially avoidable deterioration (Goldhill et al, 1999, McGloin et al, 1999; Smith and Wood, 1998). McQuillan et al (1998) identified several reasons for this, including poor organisation, lack of knowledge, failure to appreciate clinical urgency, lack of supervision and failure to seek advice. The study indicates that for these reasons a significant number of patients are subject to sub-optimal care with adverse and life-threatening consequences.

The Comprehensive Critical Care review document (DoH, 2000c) identified a new classification system for acutely ill patients (Box 1) that introduced the concept of a critical care continuum from level 0 to 3 and recommended that the provision of critical-care services should not be determined by the patient's location but by the patient's care need. This would require a shift away from the traditional models of critical-care service provision in specialist units towards a more flexible patient-focused model where the majority of patients requiring level 1 and 2 care could be looked after in ward settings if adequate support and resource allocation were provided. In order for this to happen, however, appropriate education and training of ward staff is essential.

A key recommendation from the document Nursing Contribution to the Provision of Comprehensive Critical Care for Adults (DoH, 2001) is that systems should be developed to ensure that ward staff receive the education and training required to meet the needs of critically ill patients in all care settings. Others have recognised the need to improve critical care clinical skills education for ward staff (Walker, 2001; Haines and Coad, 2001; Wright, 2000).

The ENB (1999) called for greater emphasis on the assessment of practical 'critical care' skills in the workplace to ensure a competent workforce and the delivery of quality care. However, the current nursing shortage means that it can be difficult to release nurses to attend long courses and financial constraints reduce the number of places that can be funded. This means that critical care skills education must be provided in a flexible, accessible and cost-effective way.

The ALERT course
In order to improve the accessibility of critical care skills training for ward-based practitioners, the South Devon Healthcare NHS Trust applied for and obtained a grant from the Workforce Development Confederation for an education facilitator (wards) post. The primary remit of this post is the provision of critical care skills training to ward-based practitioners as part of the strategy to improve the care of level 1 and 2 critically ill patients in acute ward settings. The ALERT course is at the centre of this strategy. ALERT stands for: Acute Life-threatening Events; Recognition and Treatment. This one-day multidisciplinary course was developed by Dr Gary Smith of Portsmouth Hospitals NHS, to improve the management of acutely ill and deteriorating patients. The focus of the course is the early recognition and immediate treatment of acute life-threatening events (Smith, 2000).

Accreditation as a course provider requires the formation of a 'faculty' who must undertake a group training day and be assessed as competent to deliver the course. Our multidisciplinary faculty was formed in August 2001 and included medical staff, nursing staff, resuscitation training officers and a physiotherapist.

The ALERT system of patient assessment follows the primary survey model used in emergency departments and promotes the adoption of a structured approach to the assessment of all acutely ill patients. This involves the systematic evaluation and management of airway, breathing, circulation, disability and exposure. The course promotes the use of various teaching strategies including didactic lectures, audience participation and scenario-based teaching methods. See Box 2 for a breakdown of a typical ALERT course day.

The use of scenario-based teaching means that delegate numbers are limited to 20 per course. These places are allocated to ensure that each group is diverse and includes registered nurses, student nurses, and HCAs, as well as doctors and allied health professionals. This facilitates the use of a multidisciplinary shared-learning approach to education with members of the different professions learning together and sharing experiences. Basford (1999) suggests that shared-learning approaches to education foster collaborative and co-ordinated working practices that are essential to the development of a more effective and efficient health service.

Evaluating the value of the ALERT course
Methodology - In order to assess the impact of the course on delegates and on patient care we have developed a two-stage evaluation process. An initial questionnaire is completed on the day of the course and focuses on what participants think they have gained from attendance. A second questionnaire is sent out three months after the course to evaluate the value of the concepts to clinicians and patients through the application of theory to clinical practice. Both questionnaires enable voluntary and confidential participation in the course evaluation process.

Results and discussion - The first questionnaire elicited a 92% response rate (n=78) with most respondents submitting a completed questionnaire. All but one of those who completed the questionnaire felt that the course was relevant to their clinical practice. When asked to list the three facts remembered from the day, common themes emerged. These included the ABCDE pathway of patient assessment (70%), improved communication (38%) and not to give frusemide for low urine output (32%).

Other themes listed included the importance of effective pain management (10%), the usefulness of capillary refill (19%) and the AVPU (Alert, Voice, Pain, Unresponsive) approach to the neurological assessment (15%). When asked how the course will help to improve patient care many of the responses highlighted the importance of using the systematic approach to patient assessment in order to prioritise care and enable a quicker response (62%). There was also an emphasis on the importance of effective communication and teamwork (55%). All of the respondents found the scenarios a useful way of putting theory into practice, though some suggested that they were initially daunted by the prospect.

The second questionnaire elicited a response rate of 60% (n=40). Respondents indicated that the course is of value, with common themes such as enhanced knowledge and confidence identified along with valuable skills acquisition, improved communication skills and a perception of improved clinical ability. One element of the questionnaire requires delegates to describe an incident where knowledge gained on the course helped them improve patient care. The responses indicate that the ALERT course is being used in practice to improve patient care and possibly outcome. Some of the incidents described are listed in Box 3.

These preliminary course evaluation results indicate that the ALERT course increases the knowledge and skill of the practitioner leading to increased confidence and improved communication between health-care professionals. Anecdotal evidence supports this conclusion with ward managers, senior nurses and medical staff stating that delegates are using the knowledge gained on the course to improve patient care. Further support for the course comes from the outreach team who claim to be receiving earlier referrals from medical and nursing staff. They are also noticing improved documentation in the patient records following the ALERT principles of ABCDE assessment.

Although in isolation the ALERT course does not meet the critical care educational needs of clinical staff in ward settings, it is a useful adjunct to other clinical skills development strategies. It provides a means of addressing some of the causes of sub-optimal care identified by McQuillan et al (1998). The course teaches the fundamental principles of acute care practice and the initial management interventions required to recognise, delay or avoid patient deterioration. It has provided a baseline for clinical skills training development within the trust.

Introducing the course has led us to consider the development of patient group directives for fluid and oxygen therapy so that competent practitioners can implement the interventions taught on the course. This will improve patient care by empowering nursing staff to initiate early treatment and reduce treatment delays. The course has also prompted an evaluation of vital signs monitoring within the trust and the development of strategies to improve clinical observation skills. A programme of ward-based teaching has also been developed so that the ALERT message is communicated widely to all clinical staff, ensuring that they have access to the knowledge and skills required to care for the deteriorating and acutely ill patient.

Since introducing the course, support has increased and the second round of publicity elicited over 100 responses. Our faculty has expanded to include staff from the emergency and psychology departments. We are currently in the process of making the course available to local private and primary sector community hospitals.

The results of this preliminary evaluation process are not generalisable due to the small sample size and methodological limitations. However, this evaluation process has proved to be an informative and useful undertaking that has generated some interesting results. These will be used to develop a more comprehensive research project.

- The authors would like to acknowledge the help and support of Torbay Hospital's ALERT facility and the delegates who took the time to complete the questionnaire.

Basford, L. (1999) Shared learning: a phenomena for celebration and a challenge to health educators. Nurse Education Today 19: 345-346.

Department of Health. (2002)Chief Executives Report to the NHS: March 2001-April 2002. London: The Stationery Office.

Department of Health. (2001)The Nursing Contribution to the provision of Comprehensive Critical Care for Adults: A strategic programme for action. London: The Stationery Office.

Department of Health. (2000a)The NHS Plan. London: The Stationery Office.

Department of Health. (2000b)The National Beds Enquiry. London: The Stationery Office.

Department of Health. (2000c)Comprehensive Critical Care: A review of adult critical care services. London: The Stationery Office.

Department of Health. (1999)Critical to Success: The place of efficient and effective critical care services within the acute hospital. Audit Commission Report for Local Authorities and the National Health Service in England and Wales. London: The Stationery Office.

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