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Perceptions of critical care outreach within a network

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VOL: 102, ISSUE: 29, PAGE NO: 36

Catherine Plowright, MSc, BSc, ENB 100, is nurse consultant critical care, Medway NHS Trust, and honorary lecturer, Canterbury Christ Church University

Jayne Fraser, BSc, RN, ENB 100, is outreach sister, Kent and Sussex Hospital, Tunbridge Wells;Sally Smith, MSc, RN, DipHE, ENB 100, is nurse consultant outreach, Kent and Sussex Hospital, Tunbridge Wells;Stefa Buras-Rees, RN, DipN, ENB 100, is sister outreach, Queen Elizabeth the Queen Mother Hospital, Margate, Kent;Louise Dennington, BSc, RN, DipHe, ENB 100, is outreach sister, Medway Maritime Hospital, Gillingham, Kent;Debbie King, BSc Nursing, RN, ENB 100, is outreach sister, Maidstone Hospital, Kent;Claire MacLellan, RN, DipHE, ENB 100, is outreach senior sister, Darenth Valley Hospital, Dartford, Kent;Paul Seymour, BSc, RN, ENB 100, is outreach senior nurse, Princess Royal University Hospital, Farnborough, Kent;Glyn Scott, RN, BS, is matron medicine, Medway Hospital, Gillingham, Kent;Ann Brindle is clinical audit and effectiveness manager, Maidstone and Tunbridge Wells NHS Trust

Aim: The purpose of this study was to establish healthcare professionals' perceptions of critical care outreach.

Aim: The purpose of this study was to establish healthcare professionals' perceptions of critical care outreach.

Method: A multi-site survey approach was used to collect qualitative data.

Results: Most respondents felt that outreach assisted with patient care by enabling the admission and smooth discharge to and from the critical care units and providing useful education and training that changed practice. Respondents also thought that the audits undertaken by the outreach teams benefited patient care.

Conclusion: Overall, outreach was considered by healthcare professionals to enhance patient care and improve practice.

The need for critical care outreach services was highlighted in Critical to Success (Audit Commission, 1999) and Comprehensive Critical Care (Department of Health, 2000). Prior to these documents it had been evident for a number of years that patients in hospital showed signs of deterioration that were observed by medical and nursing staff but not acted on prior to cardiac arrest (Rich, 1999; Franklin and Mathew, 1994). There were comparable findings in studies of patients who were admitted to a critical care area of a hospital (Goldhill et al, 1999; McQuillan et al, 1998; Goldhill, 1997). Therefore the Audit Commission (1999) and the DH (2000) suggested that early identification and management of patients in a ward environment whose condition is deteriorating would improve patient outcomes.

Outreach services were found to have three key roles in achieving this (DH, 2000):

- To avert admissions to critical care by identifying patients who are deteriorating and either help to prevent admission or make sure that admission to a critical care bed happens in a timely manner to ensure best outcome;

- To enable discharges from critical care by supporting the continuing recovery of discharged patients on wards and after discharge from hospital, supporting their relatives and friends;

- To share critical care skills with staff in wards and community settings, enhance training opportunities and skills practice and use information gathered from the ward and community to improve critical care services for patients and their relatives or carers.

Outreach services across the country are currently developed locally to meet local needs and the requirements of individual hospitals. The composition of teams, models of practice and services provided therefore vary (DH, 2003; Coombs and Dillon, 2002). A number of outreach nurses in Kent teams use a 'track-and-trigger' system to enable ward staff to prioritise and recognise patients who may need assistance or who are becoming unwell.

In addition, admission to and discharge from critical care can be traumatic for patients, relatives and ward staff, who find the process stressful and demanding (Haines et al, 2001; Odell, 2000; Whittaker and Ball, 2000). The role of outreach teams in this is an interesting aspect to investigate.

Aim
The aim of this multi-site survey was to investigate the views of staff of all disciplines about the outreach services offered and the impact staff perceived outreach to have on progressing patient care. Perceptions regarding the extent to which outreach was meeting the original objectives set out by the DH in Comprehensive Critical Care (2000) was sought along with the views and knowledge of healthcare professionals regarding the effectiveness of track-and-trigger scoring systems in place and outreach team audits.

Method
A survey approach was used for this study with qualitative data sought as comments and views. A survey approach enabled the group to obtain a wide and inclusive view of what was perceived by the respondents (Denscombe, 1998).

Sample
The target population was 200 healthcare professionals working in each district general hospital within the network on a particular day. This day was chosen mutually by the outreach nurses in the Kent group in order to allow the maximum number of outreach nurses to be available to distribute the questionnaire.

A total of 1,303 questionnaires were distributed across the network to staff on duty on that particular day. The sample was purposive in that the outreach nurses included 'typical subjects' in the sample (Burns and Grove, 1993) who they knew had experience of outreach.

The tool
The questionnaire was designed to determine views on the service provided by outreach teams across the network.

It was designed by the members of the group, who are all experienced outreach/critical care nurses, with the help of the clinical effectiveness and audit department at one of the trusts involved. The questionnaire was also reviewed by the critical care matrons and consultant nurses across the network, as well as the network critical care board, to help increase its validity.

Advice was sought from the clinical effectiveness department as to whether ethical approval was required (it was not, because the survey was considered to be an audit). The questionnaires were coded but only to identify each site so each outreach team could analyse its own data at a local level and develop action plans that addressed their specific issues. Individual participants were only identifiable by profession and department and anonymity was maintained throughout.

The questions were developed around themes to help the outreach teams ascertain whether they were perceived as having achieved the objectives set out in Comprehensive Critical Care (DH, 2000). These were:

- Averting admissions to ICU;

- Enabling ICU admissions and discharges;

- Sharing critical care skills.

Other themes included:

- The effectiveness of track-and-trigger scoring systems;

- Outreach team audits.

Closed questions were used, with room for some free-text answers.

Personal responses were an important aspect of the questionnaire, so views could be added if respondents wanted to help illustrate, elaborate and support answers provided to the closed questions.

The questionnaires were returned directly to the audit department or via the outreach teams in envelopes that were provided.

Pilot study
The questionnaire was piloted at one of the hospitals within the network where the outreach team had been established for a shorter time. A total of 40 questionnaires were distributed and 20 returned. The results from the pilot study were not included in the overall results. The pilot study showed that the questionnaire was clear and easy to understand. Two questions were thought to be ambiguous and these were amended accordingly.

Results
A total of 678 questionnaires were completed and returned giving an overall response rate of 52% - there were differences between each of the sites. The group believed this to be a good response rate as it is considered reasonable to have return rates of 30% for such questionnaires (Saunders et al, 1997). Of the returns 400 were from nurses of all grades, 120 from medical staff of all grades and the remainder from other healthcare professionals.

Awareness of and contacting the team
A total of 97.8% (n=662) of all respondents were aware of outreach services, and 85% (n=577) had contacted outreach in the previous six months with 304 contacting the teams more than three times. It was encouraging to see that 97% (n=602) of respondents found the outreach teams to be polite.

Respondents were asked why they contacted outreach. The most frequent reason cited was to refer critically ill patients on, followed by seeking advice (Fig 1, p37). Some respondents selected more than one option.

A total of 98% of respondents perceived that outreach responded in an appropriate time to meet patients' needs. However, comments were made that outreach was not always available because of the hours the teams worked - at the time of the survey only two teams worked seven days a week. Other comments included that sometimes the teams were busy elsewhere or short-staffed. Six hundred respondents reported that outreach had a positive effect on patient care and all felt the outreach teams helped in facilitating critical care referrals.

Contribution to admission and discharge
Respondents were asked whether or not they perceived that outreach benefited patients - both when they were transferred to critical care and when they remained on the wards. A total of 91% felt outreach benefited patients when they remained on the wards and 88% if they were transferred to critical care. In addition 93% felt that outreach involvement speeded up transfer to critical care.

Questions were asked regarding patients discharged from critical care. In particular participants were asked whether they were provided with a future management plan for these patients. In total 75% of the respondents said they had a management plan for patients discharged from critical care (Fig 2). However, 138 participants gave no answer and 28 said the question was not applicable. This may be because some of the respondents were from professions allied to health, such as dietitians and pharmacists, who would not expect a management plan on discharge.

At the time of the survey all teams within the critical care network followed up patients who were discharged from critical care. When asked if outreach follow-up was timely 92% of respondents said it was, and 98% felt the support offered by outreach teams was beneficial to patients. However, while the majority of respondents thought it was timely and beneficial, 41% felt that the discharge process from critical care could be improved upon. Suggestions made included:

- 'Supply full discharge summaries';

- 'Update their paperwork. Show a more holistic approach instead of technical info - blood gas results. We need to know, do they have MRSA? Pressure ulcers? Are they unstable? We do get this info when prompted';

- 'Patients not always transferred at a 'good' time, more liaising needed between ward and critical care to ensure when patient arrives on the ward there are staff and equipment that are needed';

- 'Better documentation of future care plans and appropriateness (or not) to return to intensive treatment or high dependency unit and better documentation of this discussion with relatives';

- 'Better communication with ward staff and medical staff';

- 'Accompany patients to ward and remain until staff are happy that patient is stable'.

Education and sharing of skills
We were interested to know whether respondents were aware of the critical care education provided by outreach teams and found that 279 respondents (43%) had attended study days. These included:

- ALERT courses;

- Tracheostomy care;

- Non-invasive ventilation;

- Vital signs monitoring;

- Patient assessment;

- Fluid management;

- Oxygen therapy.

The ALERT course was the best-known course provided by the outreach teams but this may be because the respondents included medical staff. However, 27% were unaware of any sessions, 7% could not attend because of staff shortages, 11% did not have the time and 30% said it was not appropriate for their job. This may well have been because the questionnaire was given to staff from a number of different health professions.

We wanted to know what the respondents thought of these education sessions. We found that 98% (n=295) perceived them to be useful and 91% (n=289) reported that what they had learnt had changed their practice (Fig 3, p40). The remaining respondents did not indicate whether or not their practice had altered.

Staff were asked what other sessions they would like to see made available. Topics included:

- Insulin control in ICU patients;

- Total parenteral nutrition feeding and care of central venous pressure lines;

- More ALERT courses so that all nurses can attend;

- Neurological assessment;

- Continuous positive airway pressure and bi-level positive airway pressure;

- More sessions for healthcare assistants;

- Chest drains;

- Spending 1-2 days with an outreach nurse;

- Renal failure and its management.

Use of track-and-trigger systems
Questions were asked referring to track-and-trigger scoring systems. Different systems are used in the network and of those that had used a system 90% (n=331) said it was useful. The authors' perception is that this is incorrect as some teams had audited the usage of their own particular scoring system and found these to be much underused. On reflection the group believes respondents did not fully understand what was meant by a track-and-trigger system.

Outreach audits
Finally, questions were asked about audits. The group had carried out three audits on patient observations of patients at level 1 or above and other local audits had been carried out in the previous three years (Chellel et al, 2002). Some 40% (n=253) of respondents were aware of the audits done by the outreach teams, 51% (n=167) said that results had been communicated to them, and 71% (n=147) said that changes had been recommended as a result of the audit. The audits were seen to benefit patient care by 95% (n=245) of these participants. (Note: not all respondents answered all questions so sample numbers differ.)

Limitations
Although this was a large study conducted over seven hospitals there were some limitations. It was the first time any of the outreach services had sought to discover what users perceived about the service provided, and perhaps the correct questions were not sought. Also there was always a possibility that those who responded were satisfied with the service and it is the 48% who did not respond who may have been less satisfied, and perhaps knew little about outreach. As previously stated the questionnaires were distributed by members of the outreach teams in each of the hospitals, and this may have influenced the response rate, in that there could have been a tendency to distribute to members of the multidisciplinary team who were known to be advocates of outreach and who were thought to be likely to return completed questionnaires. Also the data collated only enabled simple descriptive statistics to be obtained.

Discussion
The survey elicited favourable responses from participants, with outreach seen as having a positive influence on patient care. Most requests to outreach were either patient referrals or for advice. Although analysis of types of patients referred was not included in this survey, the fact that outreach was perceived to be a service that helped and gave advice readily meets the original objectives of the service.

Approachability is an important value to the outreach nurses in the Kent network, whose practice is based on the philosophy of being guests within the ward areas, and to empower ward staff. Being perceived as polite may enable this to be achieved and subsequently ensure that staff feel able to call outreach for advice and support with patients.

Timeliness of help from outreach was also perceived positively. Given the stretched resources within some of the outreach teams, and the lack of a 24-hour service, this was an interesting perception. Recent guidance from the National Confidential Enquiry into Patient Outcome and Death (Cullinane et al, 2005) proposes a 24-hour outreach service to best manage risk associated with the recognition and management of the acutely unwell patient. Many staff stated that they wished for a more comprehensive service that worked round the clock, which reflects the recommendations in this report. In the meantime, with one person on duty and several calls at the same time, the outreach teams rely on simple prioritisation and clinical judgement to meet ward needs. This was perceived on the whole as satisfactory in this survey given these constraints.

Transfers to and from critical care were felt to be enhanced by the involvement of outreach but still require some aspects to be improved. This very much reflects the literature to date around themes of communication, feelings of abandonment, and the anxieties of relatives and the ward staff (Whittaker and Ball, 2000).

The comments here about discharges had previously been demonstrated in another unpublished study undertaken network-wide on the experiences of visitors of critical care patients, in which communication was a strong theme and required improvement. Because of these responses outreach teams at each trust are planning to address the critical care ward discharge process in order to ensure they have a smooth process that meets the requirements of patients and staff alike. Much of this may be achieved through simple changes to documentation and the handover process in order to improve the perceptions of this aspect of the patient pathway.

Education and the sharing of critical care skills is an important aspect of the outreach teams' work. This appeared to be valued by the participants, and the sessions were perceived to be changing their practice. Innovative ways of delivering education and training are a constant challenge due to the activity of ward areas and the working patterns of the different disciplines. This is compounded by the fact that some of the outreach teams have only one person on duty. If they were to undertake formal teaching there would be no outreach available for clinical advice at that time. If more resources were made available to critical care, this issue might be addressed, although the efficacy of education and training in practice does need to be examined in a robust way.

Track-and-trigger systems are used in some trusts in the network in order to allow the early recognition of the acutely unwell patient. It transpired that many staff are not utilising this tool in their practice. Track-and-trigger systems have been cited as useful (DH, 2003) and as a result the outreach teams are developing ways to promote the systems to staff and to educate them about their benefit.

Audits carried out by the outreach teams were perceived to be positive, although the systems of informing staff about these may need to be improved. Nearly half of the respondents were unaware of this work.

Audits are time-consuming, and with the rotation training of medical staff and the turnover of nursing staff it may be that people are missing the information. In the meantime, the outreach teams will continue to ensure that relevant staff are aware of audit activity and are informed of the findings, recommendations and action plans this generates. This work should be scheduled again at a future date to re-evaluate whether there has been an improvement.

Conclusion
Our findings suggest that outreach in each of the hospitals surveyed needs to continue with all of the services that they provide, and needs to improve on those areas that were perceived as needing this, such as the discharge of patients back into the ward from critical care units, and the use of discharge management plans. Many of the survey respondents thought that although outreach reacted in a timely manner and assisted them with their patients the service could usefully be extended to provide more of a service throughout the week. This is an area that each of the outreach teams is trying to use to influence service configuration changes within their own trust. Outreach within the acute healthcare sector is here to stay as it is perceived as bringing positive benefits for patient care (Cullinane et al, 2005).

- 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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