Critical Care Outreach Team Research Articles

Detecting and managing deterioration in children

32 Paediatric Nursing vol 17 no 1 February 2005 In the past, paediatric intensive care units (PICUs) were perceived by many as ivory towers. They often had poor relationships with other departments probably caused by them working in isolation, by poor communication and lack of admission and discharge planning. Similar issues in adult critical care resulted in the Department of Health recommending a hospitalwide approach to the identification and referral of critically ill adults (DoH 2000). This led to the development of critical care outreach teams in adult services and an improvement in interdepartmental working. The function of these outreach teams is to improve the provision of critical care prior to admission to intensive care and following discharge. Across the UK, adult critical care services have been setting up teams under various titles such as emergency medical team or emergency outreach team. Despite the various titles the teams have three shared aims: ❘❚❘ early detection of patients at risk of deterioration ❘❚❘ support and education of ward staff in caring for patients at risk of deterioration ❘❚❘ improved discharge and follow up after intensive care. This article summarises the process of setting up a paediatric critical care outreach team at Brighton and describes the development of a paediatric early warning Alan Monaghan describes how the introduction of a critical care outreach service and a Paediatric Early Warning Score improved management of acutely ill children

Setting standards for assessment of ward patients at risk of deterioration

Improving the care of critically ill patients is a key objective of the Department of Health (DoH, 2000). Research findings and anecdotal evidence suggest that the key indicators of developing critical illness (respiratory rate and fluid balance) are being missed on busy general medical and surgical wards. In order to address this issue, the East Somerset NHS Trust critical care outreach team, in collaboration with ward staff, created the Amber Project. This project aimed to identify clearly patients who were at risk of deterioration and provide qualified nurses with a clear framework and minimum standard for assessment and observation. The project ran from June to September 2003. Results indicated that on the ward using the amber system the frequency of patient observations increased compared to those found on two other general wards. Nursing staff reported feeling more confident with regard to assessment and prioritizing care. Junior medical staff, physiotherapy and nursing staff reported that multiprofessional communication had improved, resulting in identification and treatment of critically ill patients. The authors suggest that the Amber Project, which incorporates the use of a "track and trigger" warning system, has been an effective initiative in identifying patients at risk of developing critical illness on general wards. Its positive impact on the performance and confidence of qualified nurses working in difficult environments has resulted in the extension of the project to all other wards in the hospital.

Non-invasive ventilation in surgical patients in a district general hospital.

We have retrospectively audited the use of non-invasive ventilation (NIV) in surgical patients. We analysed the case notes of 38 surgical patients who received NIV over a 9-month period. Twenty-three patients received NIV following emergency surgery, eight after elective surgery, and seven did not have an operation. Co-morbidity was common. The commonest reasons for starting NIV were chest infection, acute respiratory distress syndrome and pulmonary oedema. NIV was often only one aspect of treatment in surgical patients with complex medical problems. With intensive support from the critical care outreach team, NIV can be safely delivered on a surgical ward, and may sometimes prevent intensive care unit admission. Use of NIV on the intensive care unit may obviate the need for tracheal intubation in some patients. In very ill surgical patients with a poor prognosis, NIV was frequently used as the ceiling of respiratory support.

Impact of a critical care outreach team on critical care readmissions and mortality.

The aim of a critical care outreach team is to facilitate discharges from critical care beds, educate ward staff in the management of deteriorating patients, facilitate transfer to critical care and reduce readmission rates to critical care. Although intuitively a good idea, there are few data to support outreach in terms of reducing the readmission rate to critical care and subsequent patient mortality. This retrospective observational study attempted to determine the change in the critical care readmission rate, an indicator of the quality of critical care, critical care mortality and in-hospital mortality following the introduction of a critical care outreach team in a major teaching hospital. A retrospective review of 1380 discharges from critical care was undertaken and the readmissions identified (n = 176). Readmission rate, mortality and other demographic data were compared between the pre and post-outreach periods. Critical care mortality, in-hospital mortality and 30-day mortality were all reduced in the post-outreach period amongst readmissions to critical care. There was also a decease in the overall mortality of all patients admitted to critical care. There were no apparent causative factors for this reduction in mortality before and following outreach. There are many confounding factors in assessing the impact of outreach teams in hospitals. This study tentatively concludes that outreach teams may have a favourable impact on mortality rate amongst readmissions to critical care, but more data is needed from multicentre trials.

Ball C, Kirby M, Williams S. Effect of the critical care outreach team on patient survival to discharge from hospital and readmission to critical care: non-randomised population based study. British Medical Journal 2003; 327:1014-1017.

This study was conducted at the Royal Free Hampstead NHS trust in London, a 1200 bed hospital with 13 active critical care beds. Patients admitted to the site during the study period were included in the study if it was their first or only admission during the study period. Patients were excluded if they died in the critical care unit, if their critical care stay spanned both the control and intervention period or if they were in the critical care unit in the control period, discharged and then were readmitted in the intervention period.

Effect of the critical care outreach team on patient survival to discharge from hospital and readmission to critical care: non-randomised population based study

Objectives To determine the effect of the critical care outreach team on patient survival to discharge from hospital after discharge from critical care and readmission to critical care.Design Non-randomised population...

Impact of an outreach team on re-admissions to a critical care unit.

Re-admissions have been cited as a measure of critical care quality and outreach teams have recently been introduced to improve critical care delivery. The aim of this study was to examine whether the number, causes and sequence of re-admissions to critical care altered as a result of the introduction of an outreach team. Re-admissions between April 2000 and November 2001 were examined. The reasons for re-admission were classified as (i) same pathology or disease process; (ii) new, but related, pathology; (iii) new and unrelated pathology; (iv) exacerbation of other comorbidities. During the two-year period, a total of 2546 patients were admitted to critical care of which 100 were re-admitted (49 before outreach and 51 after outreach). The reasons for re-admission did not vary before or after the introduction of the outreach team (same pathology 15 vs. 15; new, but related, pathology 17 vs. 23; new, but unrelated, 14 vs. 9; exacerbation of comorbidity 3 vs. 4, respectively, Chi-squared = 2.07, df = 3, p = 0.56). There was also no difference between the duration of stay on the general ward in between the critical care unit admissions before (median 2.93 [interquartile range 1.32-6.05] days) or after (median 2.25 [interquartile range 1.06-6.32] days) the introduction of an outreach team. As we could not detect any change in patterns of re-admissions as a result of the introduction of an outreach team, we would suggest that although outreach is an important development for critical care, its performance should be measured by other parameters.

This issue of JAN

This issue of JAN