VOL: 98, ISSUE: 01, PAGE NO: 34
Sheila Adam, MSc, BN, RGN, is nurse consultant in expanded critical care, University College London Hospitals NHS TrustWhen the idea of nurse consultants was first mooted by prime minister Tony Blair in 1998, it received a mixed reception. Was it just another political strategy or did it herald a new era in nursing? Was nursing trying to emulate the medical profession again or was this a sign of independence?
When the idea of nurse consultants was first mooted by prime minister Tony Blair in 1998, it received a mixed reception. Was it just another political strategy or did it herald a new era in nursing? Was nursing trying to emulate the medical profession again or was this a sign of independence?
The health service circular Making a Difference gave a limited explanation of the role (NHS Executive, 1999) and set out three policy objectives:
- To provide better outcomes for patients by improving the service and quality of care;
- To strengthen leadership;
- To retain experienced nurses, midwives and health visitors in practice.
The health service circular Nurse, Midwife and Health Visitor Consultants (NHS Executive, 1999) provided detailed information on the nurse consultant role and its function. It stated that, although each post should be adapted to local needs, there should be four core functions:
- Expert clinical practice for 50% of the time;
- Professional leadership and consultancy;
- Education, training and development;
- Practice and service development.
At University College London Hospitals (UCLH) NHS Trust, McGloin et al (1999) carried out an audit reviewing care on the wards before sudden death or admission to intensive care and found that it could be improved. The intensive care directorate concluded that a nurse consultant could develop a service to bridge the gap between wards and intensive care units, and to support ward staff in caring for patients both before and after ICU admission. Different elements of the role are outlined in detail as follows.
Elements of the nurse consultant's role
- Leading a patient emergency response team (PERT) which operates round the clock;
- Supporting all staff in caring for acutely ill ward patients;
- Providing education programmes to empower staff in caring for these patients;
- Developing policies and protocols to guide these interventions.
- Working with the critical care delivery group to ensure that intensive care meets the trust's needs and that trust processes and services are compatible with the care of critically ill patients;
- Working with ICU clinicians and managers in developing a responsive and seamless critical care service;
- Working with other ICUs to support a development network of care in London.
- Leading the follow-up of patients discharged from intensive care;
- Developing links and discharge policies to ensure optimal communication between ICUs and wards;
- Supporting and developing the follow-up clinic for patients discharged from hospital after intensive care.
The service as a whole is called critical care outreach and includes the PERT. The critical care nurse consultant's role is to act on many of the recommendations made in the Comprehensive Critical Care report (Department of Health, 2000) and the findings of the Critical to Success report (Audit Commission, 1999). In particular, the nurse consultant's role addresses concerns about the gap in experience and resources when patients are moved from a highly staffed ICU to the ward.
The requirements of clinical governance and the Commission for Health Improvement support the need for improved care delivery across geographical and departmental boundaries to prevent errors caused by negligence and/or ignorance. Therefore, the critical care nurse consultant should focus on this with the aim of improving outcome, continuity and quality of care.
Development of a new team
Despite the presence of staff who are comprehensively trained in basic and advanced life support, once a patient has a cardiac arrest the chances of survival are slim (Gwinnutt et al, 2000). If the arrhythmia is not responsive to defibrillation, the chances of survival are virtually nil.
Schein et al (1990) and Franklin and Mathew (1994) have shown that 66-84% of patients had documented evidence of clinical deterioration before their cardiac arrest. Survival rates in Schein's study were only 8%. Therefore, it is possible that early recognition of deterioration and correct responses may improve patient outcomes and decrease the incidence of cardiac arrest.
Goldhill et al (1999) set up a patient-at-risk team that aimed to identify seriously ill patients at an early stage. The study followed all patients seen by the PERT and all ICU admissions from the ward. In the 28 patients seen by the team, the incidence of cardiac arrest was 3.6% and the ICU mortality rate was 25%. But in the 69 people admitted to ICU without being seen by the team, the incidence of cardiac arrest was 30.4% and the ICU mortality rate was 31%. The latter group will include patients with sudden cardiac events. However, even allowing for this, there still appears to be an improvement in outcome with team intervention, although the numbers reviewed were small.
McQuillan et al (1998) found that, of 100 consecutive ICU admissions from wards in two acute hospitals, an expert panel declared 54 to have been sub-optimally managed. The mortality rate in this group was 56% compared with 35% in the well-managed group in the study. Although not statistically significant, it was highly indicative that best practice could result in improved outcomes.
A study carried out at the UCLH trust in 1996 over a six-month period looked at 98 admissions from the wards to ICU. It also compared outcome in those admissions considered well managed with those considered sub-optimally managed. The former group's mortality rate was 35% compared with 52% in the sub-optimally managed group (McGloin et al, 1999).
This evidence, and the recommendations of the Audit Commission (1999) and Department of Health (2000) reports, added weight to the need to set up a PERT (see Box 1). Led by the nurse consultant, it aimed to decrease the incidence of preventable cardiac arrests, support and empower ward staff, and improve the recognition and management of acutely ill patients.
One of the most important ways to achieve this is through improved staff education. This can be done via a number of programmes, such as the ALERT (Acute Life-threatening Events Recognition and Treatment) course, which is designed to help ward nurses and preregistration house officers to manage critically ill patients.
The PERT currently provides a round-the-clock response, based on calling criteria (see Box 2).
One of the main aspects of the nurse consultant's remit is to evaluate the effectiveness of both the PERT and the nurse consultant role itself. Assessments will be carried out after a year and again after two years.
These include setting up and running a formal educational programme for medical and nursing staff. This will cover: recognising and responding to acute situations; establishing group protocols for nurse prescription in emergency situations; validating calling criteria and developing trust-wide policies for discharge from ICU to the ward; use of monitoring on the ward; and observing acutely ill patients. This education programme is underpinned by the findings of research on the effectiveness of the critical care outreach service.
Most staff have responded well to the creation of the nurse consultant role. The development of the PERT and critical care outreach is continuing and the workload is increasing. Patient continuity, communication and quality of care from ward to ICU and vice versa have improved.
Patients now receive a service that takes them from their first episode of acute illness through to hospital recovery and either follow-up into the community or to a special follow-up clinic for those who spend more than six days in ICU.
In the future, as more nurse consultants are appointed, it is possible to imagine a supportive network developing which will provide a huge reservoir of clinical critical care nursing expertise.
Although nurse consultants are able to lead and influence services, because they are not part of the management structure it is difficult for them to access the appropriate level of information on trust strategy and operation. This means they are excluded from some decision-making. We hope the development of trust-wide critical care delivery groups will overcome this problem.
It is particularly difficult for nurse consultants to protect the 50% of their time that should be spent in expert clinical practice when there are so many demands on them. There is no typical timetable for any week, but the nurse consultant's week at UCLH could include the following: reviewing patients; reviewing the evidence for an ICU policy; discussing patient management with consultants; clinical leadership mentoring and attending a regional critical care reference group.
The core functions of the role are enormously time-consuming and it is difficult to see the nurse consultant being able to research and audit effectiveness as well as delivering trust-wide educational requirements.
Looking to the future
Many nurse consultants act as advisers to the NHS at regional and national level. This benefits the nursing profession and patients by providing a direct link between strategic-level decision-making and hands-on expert patient care. It is likely that this aspect of nurse consultants' work will expand. This should mean that wider aspects of nursing and patients' experiences will be taken into account when decisions on critical care are made.