Outreach Nurse Research Articles

Primary care for the urban poor in India during the pandemic: Uninterrupted management of non-communicable diseases and home-based care of patients with COVID-19 infection.

The two waves of COVID-19 severely affected the healthcare system in India. The government responded to the first wave with a strict nationwide lockdown which disrupted primary care, including the management of non-communicable diseases (NCDs). The second wave overwhelmed healthcare facilities leading to inadequate access to hospital services. Collectively, these issues required urgent responses, including the adaptation of primary care. The Low-Cost Effective Care Unit (LCECU) of Christian Medical College, Vellore (CMC) has a network of community volunteers, community health workers, an outreach nurse, social workers and doctors who operate clinics in six poorer areas of Vellore. The network adapted quickly, responding to the lockdown during the first wave and ensuring ongoing primary care for patients with non-communicable diseases. During the second wave, the team developed a system in collaboration with other CMC departments to provide home-based care for patients with COVID-19. The LCECU is a 48-bed unit of the Department of Family Medicine, part of the 3,000-bed CMC. It originated in 1982, aiming to care for the poor populations of Vellore town. It has been actively working among urban communities since 2002, with a focus on delivering Community Oriented Primary Care (COPC), for six poor urban communities since 2016. During the first wave of COVID the LCECU team ensured patients with NCDs had uninterrupted primary care and medications by visiting them in their homes. The team also addressed food insecurity by organizing a daily lunch service for 600 people for over 2 months. In the second wave, the team responded to community needs by organizing and delivering home-based care to monitor patients affected by COVID-19. The COVID-19 pandemic raises many questions about the preparedness of health systems for disasters that disproportionately affect marginalized populations globally. COVID-19 is only one of the many potential disasters, including non-communicable diseases, mental health problems, pollution, climate change, and lifestyle illness. There is an urgent need to study models of care that support vulnerable communities in an accessible, cost-effective, and patient-oriented way, particularly in low- and middle-income countries. This paper outlines lessons on how the LCECU team addressed disaster management:1. The COVID-19 pandemic has highlighted the importance of primary care-based rapid response interventions in disaster management.2. The LCECU model demonstrated the effectiveness of a primary care intervention based on pre-existing networks and familiarity between primary care teams and the community.3. Establishing community-based health care via interdisciplinary teams, including community health workers, community volunteers, outreach nurses, and doctors, is key.4. Addressing other social determinants of health, such as food insecurity, is an important component of care delivery.

Evaluation of an Intensive Care Outreach Nurse Program in 4 UAE Hospitals.

Intensive care outreach nurses (ICONs) can reduce deterioration and death of patients in hospitals. Evaluate outcomes associated with implementation of the ICON role across 4 UAE hospitals. Trend analyses and χ 2 tests were used to measure changes before ICON program, during ICON year 1, ICON year 2, when the service coverage extended 24/7, and until the end of 2019. From year 1 to year 2, failures to escalate decreased from a rate of 14.8 to 5.6 episodes per 1000 admissions for all sites combined ( P < .001). The cardiac arrest rate went from 4.04 to 1.42 per 1000 admissions in year 2 and continued downward to 0.72 per 1000 ( P < .001). Transfer from ward or readmission to intensive care unit/high dependency unit varied by site, although there was a statistically significant trend for all hospitals combined. The ICON role contributed to fewer failure to escalate incidents and lower cardiac arrest rates.

Critical care nurses' perceptions of essential elements for an intensive care liaison or critical care outreach nurse curriculum

BackgroundFor over a decade, patients experiencing clinical deterioration have been attended to by specialised nurses, the most senior of which are intensive care unit liaison nurses (ICU LNs) or critical care outreach nurses. These roles have evolved without consistent and formal recognised educational preparation. To continue to advance patient safety, an understanding of the educational requirements for these vital roles is required. AimThe aim of this study was to ascertain nurses’ perceptions of the curriculum required to perform the roles of ICU LNs or critical care outreach nurses within an acute care sector rapid response system. MethodsAn exploratory descriptive study was conducted at an international rapid response system conference in 2016 following ethics approval. Using convenience sampling, extended response surveys were completed by nurses with rapid response system leadership experience and roles. Data were analysed using content analysis according to a priori themes of theoretical knowledge, skills, and attributes. ResultsSeventy-seven registered nurses volunteered to take part in the study, forming 14 groups, each with four to seven members. Participants identified key concepts for desired theoretical knowledge, practical skills, and personal attributes. Professional behaviours were more frequently emphasised than theoretical knowledge or practical skills, suggesting personal attributes were highly valued in these leadership roles. ConclusionsA curriculum designed to prepare patient safety leadership roles of the ICU LN or critical care outreach nurse has been identified. These findings can inform the development of postgraduate courses and training requirements, along with position descriptions and expectations of employers regarding the skill set expected in these leadership roles.

Staff's Perception of the Intensive Care Outreach Nurse Role: A Multisite Cross-sectional Study.

Rapid Response Systems are emerging internationally to provide a patient-focused approach to prevent potentially avoidable deaths and serious adverse events. This study focused on ward nurses in the United Arab Emirates (UAE) government hospitals who were perceived to lack the confidence and knowledge to detect and/or respond to deteriorating patients. A cross-sectional study design was used to evaluate the Intensive Care Outreach Nurse (ICON) role from the perspectives of the ICONs, their managers/educators, and ward-based physicians and nurses. ICONs are intensive care experienced nurses with additional education in the role of rapid responder to the deteriorating patient. An ICON role was implemented across 4 hospitals to respond to and support clinicians in the recognition and management of the deteriorating patient on general inpatient wards. ICON skills perceived as most beneficial by respondents included staff education, respiratory therapy, medication administration, and intravenous access. The ICON role is able to support recognition and management of the deteriorating patients.

Tekicihila Unpo (Love One Another): Confronting Human Trafficking With the Guidance of Traditional Lakota Wisdom in Nursing Practice.

Human trafficking emerged as a serious social issue in North Dakota during the Bakken oil field boom in the western part of the state. The oil industry has seen a dramatic decrease in production in recent years. However, the presence of human trafficking continues to dominate the scene in the state. As the RN Case Manager and Community Outreach Nurse for a Healthcare for the Homeless grantee clinic in Fargo, the author is the only nurse outside of a traditional environment who works with victims of trafficking in the largest metropolitan area of North Dakota. The majority of the current targets for this heinous industry are young Native American women. The author, a Lakota woman, employs an approach with trafficking victims that seeks to reestablish the view of self as a being with significant value and ability to contribute to the world in a way that no other being can. In advocacy, she teaches professionals about the Lakota view of the Earth as a living being whose destruction may be correlated with the increased violence against women.

A 5-year retrospective audit of prescribing by a critical care outreach team.

UK prescribing legislation changes made in 2006 and 2012 enabled appropriately qualified nurses to prescribe any licensed medication, and all controlled drugs in schedule 2-5 of the Misuse of Drugs Regulations 2001, for any medical condition within their clinical competence. Critical Care Outreach nurses who are independent nurse prescribers are ideally placed to ensure that acutely ill patients receive treatment without delay. The perceived challenge was how Critical Care Outreach nurses would be able to safely prescribe for a diverse patient group. This study informs this developing area of nurse prescribing in critical care practice. The aims of the audit were to: identify which medications were prescribed; develop a critical care outreach formulary; identify the frequency, timing and number of prescribing decisions being made; identify if prescribing practice changed over the years and provide information for our continuing professional development. This article reports on data collected from a 5-year retrospective audit; of prescribing activity undertaken by nine independent nurse prescribers working in a 24/7 Critical Care Outreach team of a 600-bedded district general hospital in the UK. In total, 8216 medication items were prescribed, with an average of 2·6 prescribed per shift. The most commonly prescribed items were intravenous fluids and analgesia, which were mostly prescribed at night and weekends. The audit has shown that Critical Care Outreach nurse prescribing is feasible in a whole hospital patient population. The majority of prescribing occurred after 16:00 and at night. Further research would be beneficial, particularly looking at patient outcomes following reviews from prescribing critical care outreach nurses. The audit is one of the only long-term studies that describes prescribing practice in Critical Care Outreach teams in the UK.

The Art of Parenting at Night.

Jessica Begley is the Founder, The Baby Sleep Geek, Gray, ME. She can be reached via e-mail at [email protected] Kelley Bowden is the Perinatal Outreach Nurse Educator, Maine Medical Center, Portland, ME. The authors declare no conflicts of interest.

Effect of a 2-tier rapid response system on patient outcome and staff satisfaction

BackgroundRapid response systems (RRS) have been recommended as a strategy to prevent and treat deterioration in acute care patients. Questions regarding the most effective characteristics of RRS and strategies for implementing these systems remain. AimsThe aims of this study were to (i) describe the structures and processes used to implement a 2-tier RRS, (ii) determine the comparative prevalence of deteriorating patients and incidence of unplanned intensive care unit (ICU) admission and cardiac arrest prior to and after implementation of the RRS, and (iii) determine clinician satisfaction with the RRS. MethodA quasi-experimental pre-test, post-test design was used to assess patient related outcomes and clinician satisfaction prior to and after implementation of a 2-tier RRS in a tertiary metropolitan hospital. Primary components of the RRS included an ICU Outreach Nurse and a Rapid Response Team. Prevalence of deteriorating patients was assessed through a point prevalence assessment and chart audit. Incidence of unplanned admission to ICU and cardiac arrests were accessed from routine hospital databases. Clinician satisfaction was measured through surveys. ResultsPrevalence of patients who met medical emergency call criteria without current treatment reduced from 3% prior to RRS implementation to 1% after implementation; a similar reduction from 9% to 3% was identified on chart review. The number of unplanned admissions to ICU increased slightly from 17.4/month prior to RRS implementation to 18.1/month after implementation (p=0.45) while cardiac arrests reduced slightly from 7.5/month to 5.6/month (p=0.22) but neither of these changes were statistically significant. Staff satisfaction with the RRS was generally high. ConclusionThe 2-tier RRS was accessed by staff to assist with care of deteriorating patients in a large, tertiary hospital. High levels of satisfaction have been reported by clinical staff.

Establishing the role of the neonatal surgical outreach nurse for neonates requiring general paediatric surgery

BackgroundMost paediatric surgical centres are located in major regional hospitals and are refusing at least 10–20% of neonatal referrals because of lack of surgical cots,1 necessitating the transporting of sick...

From ICU top Outreach: A South African experience

Introduction. The lack of critical care resources in South Africa can result in critically ill patients being nursed in the wards. Ward staff often lack the knowledge and skills to care for these patients adequately. Studies done internationally have revealed that ward patients often receive sub-optimal care before admission to the intensive care unit, with possible causes being cited as institutional failure, lack of knowledge, failure to appreciate urgency, and failure to seek advice. Furthermore, patients prematurely discharged from the ICU to the wards have an increased mortality rate. Internationally the critical care community is responding to these findings by taking steps to become proactive rather than reactive. This shift has led to the development of various approaches to assist in the recognition and early treatment of the deteriorating patient in the general wards. One such approach, introduced in the UK in 2000, is the Critical Care Outreach Programme instituted by the Department of Health as part of the Modernisation Programme. Reports in the literature suggest that this programme has positively impacted on emergency ICU admissions, ICU readmission rates, in-hospital mortality, and an improved level of knowledge and skills among ward nurses. An adapted form of this programme has been introduced in an urban public hospital in KwaZulu-Natal. Method. A Critical Care Outreach Nurse was appointed at the target hospital to introduce the programme. The adapted form of the programme was introduced in two phases. Phase 1 consisted of following up of patients discharged from the ICU to the wards, and phase 2 incorporated the introduction of the Modified Early Warning Scoring System (MEWS) and referral algorithm to the surgical wards in the hospital. Owing to staff constraints the main focus of the programme was empowerment through knowledge. In this way a training programme was developed and implemented. Results. Compliance with the scoring system was initially problematic but improved with the introduction of new forms. Night staff appears to be less compliant than day staff in the majority of wards. Respiration, the most sensitive indicator of critical illness, is recorded at 20 breaths/min in 77% of cases. Although the calculation of MEWS scores has improved it is still done inaccurately in 9% of cases. Scoring urine output is also problematic. Poor communication and lack of resources when managing acutely ill patients may potentially impact on the success of the scoring system. The nursing staff have generally responded positively to the MEWS, but there still appears to be a lack of awareness among medical staff. Conclusion. Introduction of MEWS into the general wards in South Africa is potentially achievable but requires ongoing evaluation. The introduction of MEWS and Outreach may create a unique opportunity to improve the quality of care rendered to the patient in the general wards by relationship building and the sharing of ICU knowledge and skill through education and training. Southern African Journal of Critical Care Vol. 24 (2) 2008: pp. 50-55

An evaluation of the contribution of critical care outreach to the clinical management of the critically ill ward patient in two acute NHS trusts

This paper reports on an evaluation of the role and contribution of outreach in the management of the critically ill ward patient using Stake's Responsive Model (Stake, 1975) and case study methodology (Simons, 1980). Twenty cases were examined, purposefully sampling all staff involved in the case identified by an initial interview with the outreach nurse. In total, 80 interviews were carried out, 20 with the outreach nurses and 54 with other members of health care teams involved in the cases, and six further targeted in-depth interviews with senior anaesthetic and nursing staff. The outreach contribution which emerged from the data analysis consisted of four core categories: action (getting things done, getting decisions made and following through), focus and vision (concentrating on one patient and having a vision of what action was needed to meet their care needs), orchestration (a communication and co-ordinating role) and expertise (bringing critical care skills and experience to the bedside). These categories were validated and developed in the six in-depth interviews. Three themes emerged from the data describing aspects of the acute care context in which outreach operates. The interviews revealed a battleweary workforce overwhelmed by the complex and increased demands of the critically ill ward patient. The medical and nursing teams at the bedside are inexperienced and often unsupported by senior clinical decision-makers. This is dealt with by 'passing the buck' creating gaps and delays in care management which are the problems addressed by the outreach contribution. Outreach may solve problems for the critically ill ward patient, but the underlying causes remain poorly understood.

A 27-year-old Man With Marfan Syndrome and “Tearing” Nonradiating Chest Pain

Kevin High is Flight Nurse and Clinical Outreach Nurse, Vanderbilt LifeFlight, Vanderbilt University Medical Center, Nashville, Tenn. Angela M. Gleaves is Flight Nurse, Vanderbilt LifeFlight, Vanderbilt University Medical Center, Nashville, Tenn. For reprints, write: Kevin High, 6915 Flat Creek Rd, College Grove, TN 37046; E-mail: kevin.high@vanderbilt.edu. J Emerg Nurs 2005;31:26-7. Available online 21 July 2004. 0099-1767/$30.00 Copyright n 2005 by the Emergency Nurses Association. doi:10.1016/j.jen.2004.05.002

Palliative care in the community for children with cancer in South East England

In-depth interviews and discussions were held with 40 different professionals in South East England involved in managing palliative care for children with cancer in the community. Participants included paediatric oncologists and outreach nurse specialists in tertiary centres, paediatricians in shared care units, children's community nurses, general practitioners, social workers and child psychologists. The research examined palliative care services available in the region, exploring attitudes to both current provision and possible service improvements. Providing palliative care in the community involves multi-agency collaboration and the study highlighted a range of different approaches to case management with the diversity of resources available. Key improvements proposed by health-care professionals included: better communication and liaison between all the professionals involved; clearer allocation of roles and responsibilities; 24-hour availability of specialist advice on palliative care for children with cancer; faster access to social work and psychology services at the community level; continuity of nursing and respite care. The provision of specialist local palliative care services for children with cancer was generally rejected. The participants favoured improving community palliative care for all children with life-limiting or life-threatening conditions with community nursing teams providing continuity of care and outreach nurses providing specialist advice and support.

Botulinum Toxin for People With Dystonia Treated by an Outreach Nurse Practitioner: A Comparative Study Between a Home and a Clinic Treatment Service

Objective:To study whether a trained outreach nurse practitioner could provide a service that is as good as, or better than, that provided at a hospital outpatient clinic for people who had been diagnosed with dystonia and required treatment with botulinum toxin. Design:Randomized trial. Setting:An outpatient department of a regional neurorehabilitation center and patients' homes in northern England. Patients:Eighty-nine patients with a clinical diagnosis of spasmodic torticollis, blepharospasm, or hemifacial spasm who had ongoing treatment of dystonia with botulinum injections. Interventions:Individuals were randomly allocated either to receive ongoing botulinum injections at home by the nurse practitioner or to continue attending the hospital outpatient clinic and be injected by medical staff. Main Outcome Measures:The following measures were recorded at each visit: demographic descriptors, dosage of botulinum toxin, treatment interval, side-effect profile, external referrals, and a questionnaire to determine qualitative opinion. Results:Efficacy and duration of the botulinum was similar in both groups. Botulinum dosage and side-effect profiles were similar in both groups except for significantly less dysphagia (p < .018) in the home group (7 vs 24 occasions). Subjective opinion by the patients indicated statistically significant preference for home injections. Economic analysis indicated that the overall cost of the treatment was less in the home injection group (total cost per visit $36.90 [£23.36] vs $79.00 [£50.01]), but this difference was not statistically significant. Conclusion:A trained outreach nurse practitioner provided a service that was as good as, and in certain aspects better than, that provided by a hospital outpatient clinic. The nurse practitioner provided a more flexible, much appreciated, safe, and cost-effective service for this client group. Wider use of outreach nurse practitioners for dystonia should be encouraged.

186. Botulinum Toxin Treatment for People with Dystonia Treated by an Outreach Nurse Practitioner Michael P. Barnes and J. Whitaker (Newcastle upon Tyne, UK

186. Botulinum Toxin Treatment for People with Dystonia Treated by an Outreach Nurse Practitioner Michael P. Barnes and J. Whitaker (Newcastle upon Tyne, UK