Critical Care Outreach Services Research Articles

Learning by Visualize a Nurse-Led CCOS Using the Functional Resonance Analysis Method.

Quality improvements (QIs) in dynamic and complex health care contexts require resilience and take variability into account in quality improvement. The Functional Resonance Analysis Method (FRAM) helps us understand resilience and gain insight into (un)desirable variability in the complex system of daily practice. We explored how using FRAM in the Deming cycle of a QI project can help professionals and researchers learn from, reflect upon, and improve complex processes. We used FRAM in a Dutch hospital to study a QI: Critical Care Outreach Service (CCOS). The aim was to use FRAM before and after implementation to create a FRAM model and reflect to health care professionals the mismatch between Work As Imagined (WAI) and Work As Done (WAD). The WAI FRAM model was co-created with professionals before the implementation of CCOS. We used descriptions of tasks and processes for ICU nurses and verified them in 30-minute semistructured interviews (N = 2). WAD was created by input of semistructured interviews with key professionals in CCOS (N = 21) and 3 nonparticipant observations of trained CCOS nurses. We validated WAD in 2 dialogue sessions with key professionals (N = 11). Data collection continued until saturation. Juxtaposing the WAI and WAD models showed that WAD contained additional functions and highlighted unexpectedly complex functions. Reflecting on the application of FRAM with health care professionals revealed opportunities and challenges, especially time investment. FRAM helps professionals outline processes and tasks (WAI), learn from, and reflect upon their daily practice (WAD). FRAM models help professionals identify variability proactively to improve practices that enhance resilient performance.

Piloting a Nurse-Led Critical Care Outreach Service to Pre-Empt Medical Emergency Team Calls and Facilitate Staff Learning

A nurse-led critical care outreach service (NLCCOS) can support staff education and decision making in the wards, managing at-risk patients with ward nurses to avoid further deterioration. We aimed to investigate the characteristics of patients identified as at-risk, the types of treatments they required to prevent deterioration, the education initiated by the NLCCOS, and the perceived experiences of ward nurses. This prospective observational pilot study using mixed methods took place in one medical and one surgical ward at a university hospital in Denmark. Participants were patients nominated as at-risk by head nurses in each ward, the ward nurses, and nurses from the NLCCOS. In total, 100 patients were reviewed, 51 medical and 49 surgical patients, over a six-month period. Most patients (70%) visited by the NLCCOS had a compromised respiratory status, and ward nurses received teaching and advice regarding interventions. Sixty-one surveys were collected from ward nurses on their learning experience. Over 90% (n = 55) of nurses believed they had learned from, and were more confident with, managing patients following the experience. The main educational areas were respiratory therapy, invasive procedures, medications, and benefits of mobilization. Further research needs to measure the impact of the intervention on patient outcomes and MET call frequency over time in larger samples.

Strategies for the Facilitation of Self-Leadership Among Ward Nurses in a Nurse-Led Critical Care Outreach Service.

Nurses are responsible for monitoring and providing nursing care to patients. The early detection of a patient who is starting to deteriorate - and the activation of critical care outreach services (CCOS) - can improve patient outcomes. However, the literature indicates that CCOS are underutilised. Self-leadership is a process whereby persons influence their own behaviour. The purpose of this study was to develop strategies for the facilitation of self-leadership in ward nurses that will enable them to act proactively and promptly in utilising CCOS at a private hospital group in South Africa. A sequential exploratory mixed-method research approach was followed to develop strategies for the facilitation of self-leadership in nurses that will enable them to utilise CCOS proactively when a patient starts to deteriorate. An adapted version of Neck and Milliman's self-leadership strategic framework was used as the methodological steps of the study. The quantitative analysis extracted eight factors, which were used as the departure point to develop strategies for the facilitation of self-leadership among nurses in a CCOS. Five strategies were developed that related to self-motivation, role models, patient outcome, assistance and guidance from CCOS, and the power of self-confirmation; these strategies aligned with the themes and categories extracted from the qualitative data analysis. There is a need for self-leadership among nurses in a CCOS.

Evaluating the Impact of Introducing Modified Early Warning Score to Identify Deteriorating Patients in the Wards at a Tertiary University Hospital - A before-after Study

BACKGROUND
 Modified early warning score (MEWS) is a scoring system being used in hospitals for the identification of patients who may deteriorate into medical emergencies or cardiac arrest. However, the mortality benefit of MEWS hasn’t been established. Also, there is limited data about the experience of MEWS being implemented in low-income countries. Hence, we conducted a before-after prospective observational study to evaluate the impact on ICU mortality post-introduction of the MEWS chart.
 METHODS
 MEWS before-after study is a single-centre prospective observational study in a tertiary university hospital conducted in the ICU at Kasturba Hospital, Manipal University, India. We trained ward nurses on MEWS and introduced the MEWS chart and compared the change in outcomes from two months prior (i.e. February-March 2018) to the subsequent two months (i.e. April-May 2018). The primary outcome measured was the ICU mortality between the samples. Our secondary outcomes were the length of stay (LOS) and hospital mortality. Student t-test was used to estimate the total sample size and we used the chi-square test for statistical analyses.
 RESULTS
 We enrolled 161 patients into each group and the patient demographics between groups did not show any statistically significant difference. The ICU mortality data did not show any statistically significant difference before the introduction of MEWS after using the chi-square test with a p-value of 0.33. There was no statistically significant difference in ICU LOS, ICU re-admission rates, hospital LOS, hospital mortality, bed occupancy rates, or incidence of CPR between the two periods.
 CONCLUSIONS
 Our study did not show a significant difference in the mortality after introduction of MEWS scoring charts to our wards. The introduction of critical care outreach services may improve the outcomes.

Self-leadership of nurses in a critical care outreach service: The development of a conceptual framework.

BackgroundGlobally, critical care outreach services (CCOS) were implemented in health care facilities; however, compliance with guidelines is poor. The authors have noticed that a gap exists in the literature on how self-leadership might influence nurses’ implementation of CCOS. Self-leadership is about leadership applied to oneself. Critical care outreach services assist nurses with the nursing care of a patient whose health is declining. Leadership is needed for the successful implementation of CCOS.AimThis article aims to outline the method the authors followed for developing the conceptual framework for how self-leadership amongst nurses influenced the functioning of CCOS.SettingThe research was conducted at a private hospital in Pretoria.MethodsA qualitative approach was followed to provide an accurate description of nurses’ experiences on their self-leadership in a CCOS. The practice-oriented theory of Dickoff (1968) was the reasoning map for developing and constructing the conceptual framework.ResultsBedside nurses experienced the following self-leadership strategies: constructive thought patterns, natural rewards and behaviours focused on their implementation of CCOS.ConclusionThe conceptual framework was part of another study and provided the authors with a rationale that guided the authors with the development of self-leadership strategies in a CCOS.ContributionThe conceptual framework provided the authors with an understanding of how nurses’ self-leadership influenced the implementation of CCOS. The conceptual framework can also assist in developing training programmes for nurses to improve their self-leadership and ultimately improve nurses’ competence in providing quality nursing care to patients.

High-flow nasal cannula oxygen in patients with haematological malignancy: a retrospective observational study.

Patients with haematological malignancies (HM) face high rates of intensive care unit (ICU) admission and mortality. High-flow nasal cannula oxygen (HFNCO) is increasingly used to support HM patients in ward settings, but there is limited evidence on the safety and efficacy of HFNCO in this group. We retrospectively reviewed all HM patients receiving ward-based HFNCO, supervised by a critical care outreach service (CCOS), from January 2014 to January 2019. We included 130 consecutive patients. Forty-three (33.1%) were weaned off HFNCO without ICU admission. Eighty-seven (66.9%) were admitted to ICU, 20 (23.3%) required non-invasive and 34 (39.5%) invasive mechanical ventilation. ICU and hospital mortality were 42% and 55% respectively. Initial FiO2 < 0.4 (OR 0.27, 95% CI 0.09-0.81, p = 0.019) and HFNCO use on the ward > 1day (OR 0.16, 95% CI 0.04, 0.59, p = 0.006) were associated with reduced likelihood for ICU admission. Invasive ventilation was associated with reduced survival (OR 0.27, 95%CI 0.1-0.7, p = 0.007). No significant adverse events were reported. HM patients receiving ward-based HFNCO have higher rates of ICU admission, but comparable hospital mortality to those requiring CCOS review without respiratory support. Results should be interpreted cautiously, as the model proposed depends on the existence of CCOS.

Managing deteriorating patients with a physiotherapy critical care outreach service: A mixed-methods study

BackgroundCritical care outreach teams support ward staff to manage patients who are seriously ill or after discharge from the intensive care unit (ICU). Respiratory deterioration is a common reason for (re)admission to the ICU. Physiotherapists are health professionals with skills to address acute respiratory concerns. Experienced respiratory physiotherapists play a role in supporting junior clinicians, particularly in managing deteriorating patients on the ward. ObjectivesThe objective of this study was to evaluate a novel respiratory physiotherapy critical care outreach–style service. The primary objective was to describe service referrals and the patient cohort. Other objectives were to compare the effects of this model of care on ICU readmission rates to a historical cohort and explore clinician perceptions of the model of care and its implementation. MethodsA new physiotherapy model of care worked alongside an existing nurse-led outreach service to support physiotherapists with the identification and management of patients at risk of respiratory deterioration or ICU (re)admission. Purpose-built and pre-existing databases were used for prospective data collection and for a historical ICU readmissions control group. Questionnaires and semistructured group interviews were utilised to evaluate clinician satisfaction and perceptions. ResultsThe service accepted referrals for 274 patients in 6 months (on average 2.25/working day; commonly after trauma [29%] and abdominal surgery [19%]). During the implementation period of the model of care, fewer preventable respiratory ICU readmissions were reported (n = 1/20) than in the historical cohort (n = 6/19: Fisher's exact test, p < 0.05). Likelihood of respiratory ICU readmission, compared to all-cause readmissions, was not affected (intervention: 31%, historical control: 41%; odds ratio: 0.63 [95% confidence interval: 0.29 to 1.4]). Postimplementation surveys and focus groups revealed clinicians highly valued the support and perceived a positive impact on patient care. ConclusionsCritical care outreach–style physiotherapy services can be successfully implemented and are positively perceived by clinicians, but any effect on ICU readmissions is unclear.

Ward nurses' experiences and perceptions of the critical care outreach service: A qualitative study undertaken in a large teaching hospital in the West of Ireland.

The critical care outreach service (CCOS) was established in a large teaching hospital in the West of Ireland in 2014 to provide an extension of CCOS between the intensive care unit (ICU) and the wards outside ICU. With the ever-increasing pressure on ICU resources, CCOS seems to offer an additional service to patients who are critically ill and deteriorating in hospital wards. The aim of this study is to explore ward nurses' experiences and perceptions of the CCOS. A qualitative descriptive methodology aimed to obtain a descriptive account of ward nurses' experiences of the CCOS. Data were collected using semi-structured interviews. Twelve nurses from the West of Ireland participated in the study. Braun and Clarke's six-step thematic analysis was used to analyse the data. Three core themes identified in this study included clinical support and decision-making; sharing knowledge and skills, and communication. All 12 nurses identified the positive impacts that they felt the current outreach service provided to them on a daily basis. Study findings indicate that nurses value the role of the CCOS in supporting the care of the critically ill and deteriorating patients at ward level. The CCOS has become invaluable to the ward nurses in their daily practice especially at a time when resources are lacking and patient acuity is on the rise.

A workforce survey of critical care nurses in the National Health Service.

To measure key aspects of the critical care nursing workforce across the National Health Service (NHS) and compare these with recommended standards where they exist. The provision of high-quality and safe critical care services is dependent on adequate numbers of highly skilled nurses. Understanding the issues and challenges within critical care services across the NHS is key to future planning and policy in this area. A stakeholder-driven consensus development approach was adopted to design a workforce survey by members of the Critical Care National Network Nurse Leads (CC3N) Forum. The survey was conducted across all the critical care units in England, Northern Ireland, Wales, and Scotland. Data were collated to enable presentation of descriptive statistics. Data returns were received from 240 of the 272 units in England and Northern Ireland. Scotland and Wales data were excluded from analysis and reporting. Differences in the sample and data returns limited comparison with the previous survey in some aspects. Stability was seen in vacancy and sickness rates. Improvements were seen in safe nurse: patient ratios, supernumerary "nurse in charge," critical care outreach service cover, use of national competency framework, and agency use. Dependency on overseas nurses in some units remains high. Specialist critical care training levels in many units do not meet current required standards. Clear improvements have been made. There is significant stability. Some challenges remain. Continued review of resource allocation is important in the coming years, as is policy and strategy to ensure recruitment, appropriate training, and support for staff well-being. The reader will gain insight into the critical care nursing workforce in the NHS in England and Northern Ireland. The results are useful for nurses, nurse managers, and policymakers.

Self-Leadership in a Critical Care Outreach Service for Quality Patient Care

The deterioration of patients in general wards could go unnoticed owing to the intermittent monitoring of vital data. The delayed or missed recognition of deteriorating patients results in serious adverse events in general wards. These challenges have resulted in the development of a critical care outreach service. Australia was the first country to establish critical care outreach services in 1990. In South Africa, critical care outreach services were implemented in 2005 at a private hospital in Pretoria. The researcher has noticed certain phenomena supported by literature such as the hesitancy of nurses working in general wards to escalate a patient to a critical care outreach service, and incorrect interpretation of modified early warning scores which could cause delays in patients being referred to outreach nurse experts. In this study, nurses’ (professional, staff and auxiliary nurses) experiences in respect of their self-leadership in critical care outreach services were explored. To this end, a qualitative phenomenological research approach was followed. Focus groups were held with the nurses (all nurse categories) working in a South African private hospital which provides critical care outreach services. It is recommended that nurses be granted access to training sessions, workshops and information to provide appropriate nursing care. Nurses should be encouraged to focus on the positive outcomes of providing nursing care and to “applaud themselves mentally” when they have successfully assisted or cared for their patients. Nurses also need to identify and correct negative assumptions about their competence.

Critical care outreach services- a way for limited resource countries. A case study from Ghana

Critical care outreach services- a way for limited resource countries. A case study from Ghana

Critical care outreach: A valuable resource?

Critical Care Outreach Services (CCOS) were recommended by the Department of Health in the United Kingdom in 2000. Despite being an established service, research studies have not explicitly demonstrated its efficacy. To explore the impact of CCOS from the perspective of hospital ward staff to inform service improvement potential. A pilot formative process evaluation was used to meet the study aims, including the development of a self-completion questionnaire. The exploratory questionnaire was distributed to a purposive sample of clinical staff (health care assistants, nurses, therapists, and doctors) on two medical and two surgical wards to establish the value of CCOS from the perspective of ward staff. The questionnaire was distributed to 195 staff members, of who 58 replied (30%). A descriptive analysis of quantitative data and content analysis of free-text responses demonstrated that staff knew how and when to use the service, that it was highly valued by all members of the multidisciplinary team, and that CCOS were perceived to have diverse responsibilities. Service improvement suggestions included increased staffing and longer hours of operation. Despite the lack of quality research supporting the efficacy of CCOS in previous research studies, the results of this project support the findings of previous evaluations that the value of the service lies in the support offered to ward staff and in the quality of care provided to patients. Because of the size of this evaluation, it was impossible to draw any generalizable conclusions. However, results clearly indicate that value is given to the support that the Critical Care Outreach Service provides to ward staff.

The role of a critical care outreach service in the management of patients with haematological malignancy.

Although improvement in survival from haematological malignancies has been reported, a substantial number of these patients develop life threatening complications. Critical care outreach services (CCOS) aim to avert inappropriate ICU admissions, while ensuring timely patient review. We retrospectively analysed patients with haematological malignancy reviewed by an outreach service between January 2014 and December 2015 at a single institution. The aim of our study was to describe the patient population assessed by a well-established outreach team, identify predictors of ICU admission, as well as ICU and hospital mortality. Sixty of 126 patients reviewed (47.6%) were admitted to ICU. ICU and hospital mortality were 25.3% and 45.2%, respectively. The odds of being admitted to ICU was 13 times higher (p = 0.013) if the patient was referred for hypoxia, 20 times higher (p = 0.006) if they were referred for sepsis or 14 times higher (p = 0.027) if they were referred to CCOS for hypotension, compared to when the team was automatically alerted. The odds of not surviving hospital admission increased 1.27 times for every extra day of CCOS review (p = 0.02). When a patient was referred having a refractory or progressive haematological condition, the odds of not surviving to hospital discharge increased by four or 12 times, respectively, compared to when the referred patient was in remission. Receiving high flow nasal cannula oxygen (HFNCO) was associated with a reduction in ICU admission (p = 0.03), irrespective of the underlying diagnosis, performance status or location of delivery. The CCOS participated in end-of-life discussions in 29% patients. ICU and hospital mortality of patients with haemato-oncological malignancy continue to improve. CCOS are heavily involved in the recognition and management of these patients, as well as in the facilitation of end-of-life discussions. Sepsis was associated with increased risk of ICU admission and mortality. Initiation of HFNCO outside ICU appears to be feasible and safe and was not associated with increasing risk in this single centre study.

Patient- and relative-activated critical care outreach: a 7-year service review.

Five years following the introduction of a whole-hospital, 24-hour critical care outreach (CCO) service, an additional service was introduced that enabled patients and their families to directly call the CCO team if they had concerns that were not being acknowledged by the patient's clinical team. The aim of this review was to report on 7 years of patient and family referrals using quantitative and free text data extracted from the CCO referral database. Information on demographics, frequency, nature and reason for the referrals have been reported that highlight the feasibility of such a service, and the potential to prevent patient deterioration. By tapping into the rich source of information from family concerns, future hospital services could be designed that could not only have an impact on patient outcome, but also positively influence the quality of the patient experience.

A nurse-led critical care outreach program to reduce readmission to the intensive care unit: A quasi-experimental study with a historical control group

IntroductionVarious critical care outreach services have been developed and evaluated worldwide; however, the conflicting findings indicate the need to strengthen the outreach service research. This study aimed to evaluate the effects of a nurse-led critical care follow-up program on intensive care unit (ICU) readmission and hospital mortality in patients with respiratory problems discharged from the ICU in Hong Kong. MethodsA quasi-experimental study design, with a historical control and a prospective intervention for 13 months, was used. The intervention group received a nurse-led, multidisciplinary ICU follow-up program in addition to the usual care. The outcome measures included ICU readmission within 72 h after ICU discharge, all ICU readmission (ICU readmission irrespective of the time frame after ICU discharge), hospital mortality, and 90-day mortality rate. Logistic regression analysis was used to determine the predictors for ICU readmission within 72 h. ResultsA total of 369 participants (the intervention group: 185; the control group: 184) were recruited. A significant reduction in ICU readmission within 72 h was observed in the intervention group compared to the control group (p = 0.001), even after controlling for confounders (odds ratio: 0.158, p = 0.007). The intervention group also demonstrated a significant reduction in all ICU readmission (p < 0.001) and hospital mortality (p = 0.042), but not on 90-day mortality (p = 0.081), when compared with the control group. This nurse-led ICU follow-up program was shown to be cost-effective, saving an estimated US$ 145,614 for a period of 13 months. ConclusionThe findings demonstrated that a nurse-led multidisciplinary ICU follow-up program was a beneficial and cost-saving strategy to avert ICU readmission in patients with respiratory problems after ICU discharge. It also highlighted the competent role of ICU nurses in planning and leading the implementation of a multidisciplinary program. The results contributed to the database of an innovative follow-up program to inform the practice worldwide.

Do nurse-led critical care outreach services impact inpatient mortality rates?

Previous systematic reviews have assessed the effect of critical care outreach services, but none have focused solely on nurse-led services. To perform a systematic review examining the impact of nurse-led critical care outreach services on inpatient mortality rates as the primary outcome. Secondary outcomes include arrest call rates and patient length of stay. A comprehensive search of several electronic databases was carried out, including the Cumulative Index to Nursing and Allied Health Literature and Medline. Non-catalogued literature was searched, and contact was made by e-mail with expert authors. All studies were in the English language, and although heterogeneous in design, only quantitative data were extracted for analysis. All included studies were assessed for quality using recognized quality appraisal tools. Meta-analysis was not possible because of heterogeneity. Ten studies involving almost 72 000 participants were identified. The reduction in mortality rates with nurse-led critical care outreach services was reported to be 80%, but the statistical significance was low-four studies showed reductions ranging from 0·1% to 0·22%. Greater statistical significance was reported in arrest call rates, with two studies claiming decreased rates of 58·7% and 29·6%. Two studies reported a decrease in patient length of stay-the findings of a third study were equivocal. Half of the included studies scored poorly in terms of quality and validity, and all were single-centre studies, thereby limiting generalisability. Nurse-led critical care outreach services demonstrate benefits in terms of patient care and reduction in adverse events. Higher-quality research, including multicentre randomized controlled trials, with meta-analysis is recommended. Nurse-led critical care outreach services have the potential to improve patient outcomes. Uniformity of team composition and nomenclature would benefit data collection and reporting.

Recognising and responding to in-hospital clinical deterioration: An integrative review of interprofessional practice issues.

To identify, appraise and synthesise current evidence regarding organisation-wide interprofessional practice issues that facilitate or inhibit effective recognition and response to clinical deterioration, using a theoretical rapid response system model. Recognition and response to clinical deterioration, in adult general medical-surgical ward patients, is embedded as routine interprofessional practice in acute healthcare organisations worldwide. The process of care escalation is complex and sometimes involves multiple health professionals from different disciplines with varying levels of expertise. While a theoretical rapid response system model offers a formalised structured approach to escalate patient care, it is unclear how the implementation of this model, or similar, influences rapid response system-wide interprofessional practices to effectively recognise and respond to clinical deterioration. An integrative review. This review was conducted using key words to systematically search four electronic bibliographic databases (PubMed, CINAHL, ProQuest Central, Cochrane Library). Twenty-nine eligible full-text papers were identified. Quality appraisal of methods was performed using recommended guidelines. Study findings were narratively coded, themed and conceptualised in the context of an organisation-wide rapid response system using an interprofessional collaborative practice framework. Five main themes aligned with the four interprofessional collaborative practice competency domains and a learning continuum of professional development: Organisational culture, Role perceptions and professional accountability, Communication of clinical needs, Team-based practices, and Interprofessional learning opportunities in recognising and responding to clinical deterioration. Within these themes, three notable interprofessional practice issues were highlighted: professional reporting hierarchies (inhibiting), critical care outreach services (facilitating) and interprofessional relationships (facilitating). A unique approach for exploring organisation-wide interprofessional practice issues has been presented using an interprofessional collaborative practice framework. Further interpretive organisation-wide research is necessary to develop a more in-depth and meaningful understanding of interprofessional collaborative practice issues that facilitate or inhibit effective recognition and response to clinical deterioration. This review presents a unique system-wide approach for exploring how health professionals interprofessionally collaborate in practice to effectively recognise and respond to clinical deterioration.

Implementation of a critical care outreach service: a qualitative study.

The aim of this study was to explore hospital staff perceptions of the perceived challenges and outcomes of implementing a critical care outreach service. A nurse-led critical care outreach service was designed and implemented to identify and treat acutely ill patients in a large tertiary care hospital in Iran. A qualitative analysis of data from two focus groups and seven interviews was carried out using conventional content analyses techniques. A total of 24 hospital staff members participated, including critical care outreach team members, physicians, ward head nurses and ward staff. Two main categories described the perceived challenges to the implementation of the critical care outreach service: 1) the hospital context, with four subcategories related to staff shortages, the instability of physician positions, the lack of specialized essential services and the absence of a system to establish do-not-resuscitate orders, and 2) staff resistance to different nursing priorities, routines and extra work. In two additional main categories, participants also described positive and negative perceived outcomes. The positive perceived outcomes included three subcategories of alleviating equipment shortages, improving nursing knowledge and patient care and improving patient and healthcare professional satisfaction. While critical care outreach has the potential to improve patient perceived outcomes and both patient and provider satisfaction with care, the contextual and clinical realities in hospitals are significant and must be examined during the planning and implementation of future outreach. A critical care outreach service in the context of an Iranian hospital has the potential to improve ward nurse familiarity with the care of acutely ill patients and the quality of palliative care. However, attention ought to be paid to the hospital's structural and contextual factors. Alleviating nursing shortages, reducing staff resistance and preparing goals of care guidelines that address restrictions on resuscitation could facilitate implementation of critical care outreach services.

Role of Transitional Care Measures in the Prevention of Readmission After Critical Illness.

Transitioning from the critical care unit to the medical-surgical care area is vital to patients' recovery and resolution of critical illness. Such transitions are necessary to optimize use of available hospital resources to meet patient care needs. One in 10 patients discharged from the intensive care unit are readmitted to the unit during their hospitalization. Critical care readmission is associated with significant increases in illness acuity, overall length of stay, and health care costs as well as a potential 4-fold increased risk of mortality. Patients with complex illness, multiple comorbid conditions, and a prolonged initial stay in the critical care unit are at an increased risk of being readmitted to the critical care unit and experiencing poor outcomes. Implementing nurse-driven measures that support continuity of care and consistent communication practices such as critical care outreach services, transitional communication tools, discharge planning, and transitional care units improves transitions of patients from the critical care environment and reduces readmission rates.

Evaluation of a critical care outreach service in a middle-income country: A stepped wedge cluster randomized trial and nested qualitative study

PurposeThis trial evaluates implementation of critical care outreach in a middle-income country. Materials and methodsCritical care outreach delivered by a team of intensive care nurses was implemented across general hospital wards in an Iranian university hospital. The order of implementation was randomized with wards stratified by predicted mortality rates. Effectiveness was evaluated using a stepped wedge cluster randomized controlled trial design, comparing outcomes between patients admitted before and after implementation. The primary outcomes were inhospital mortality and cardiopulmonary resuscitation. A nested qualitative study explored challenges to implementation and contextualized the trial outcomes. ResultsBetween July 2010 and December 2011, 13 wards were sequentially randomized to implement the critical care outreach: 7802 patients were admitted before implementation and 10 880 after implementation. There were 370 deaths (4.74%) among patients admitted before implementation and 384 deaths (3.53%) after implementation. Adjusting for clustering and temporal trends, the odds ratio for mortality was 1.03 (95% confidence interval, 0.68-1.53). Results for other outcomes were broadly similar. Focus groups revealed a lack of endorsement of the intervention by management and ward nurses. ConclusionsThis pragmatic evaluation of critical care outreach in a middle-income country did not show a reduction in mortality or other outcomes.