Critical care outreach: the need for effective decision-making in clinical practice (Part 1).

Since the publication of 'Comprehensive Critical Care' (2000) critical care outreach (CCOR) services have been developed to meet the needs of patients through critical care provision 'without walls'. Now embedded nationally, CCOR is a central part of health care delivery in the National Health Service (NHS). To date, approximately 75% of hospitals in England have introduced and developed the service according, at least to some extent, to local needs and resources. While this has resulted in a somewhat inconsistent approach to the development and configuration of these services, a number of common elements remain. Arguably, effective clinical decision-making by CCOR practitioners is fundamental to efficient patient care management and the success of these services. In its examination of CCOR service provision this, the first of two papers, addresses the theoretical background of clinical decision making and the knowledge that underpins practice in CCOR. In the second paper, through collaborative reflection and analysis of a case study, the authors bring these together in a process that illuminates the realities of clinical decision making for CCOR practitioners. From this, recommendations are made about the future development of CCOR practitioners and services.     

The effects of critical care outreach services before and after critical care: A matched-cohort analysis

Purpose

The purpose of the study was to evaluate the effect of visits from critical care outreach services (CCOS) before admission to and following discharge from critical care.

Materials and Methods

A cohort study was performed in 52 acute hospitals in England. A total of 23 234 patients received CCOS visits; 10 404 (45%) were admitted to a critical care unit, and 7078 (68%) were included in the analysis. Patients receiving CCOS visits before (n = 2203) and after (n = 5924) critical care were matched 1:1 to 3 control pools: historical admissions to the same unit before introduction of CCOS, admissions to a unit in a hospital with no CCOS, and contemporary admissions to the same unit not receiving CCOS visits. Matching was based on individual factors and on propensity.

Results

The CCOS visits preadmission were not associated with differences in severity of illness, but were associated with lower rates of cardiopulmonary resuscitation, longer prior hospital stay, and longer unit stay. The CCOS visits postdischarge were associated with lower hospital mortality and shorter hospital stay in 2 matches, but not when compared with contemporary admissions to the same unit.

Conclusions

Our results suggest a benefit to scheduled follow-up visits of patients discharged from critical care. Results for CCOS before critical care are inconclusive.     

Critical care outreach services and early warning scoring systems: a review of the literature

AIM: The aim of this paper is to explore the literature relating to critical care outreach services and the use of early warning scoring systems to detect developing critical illness. BACKGROUND: Several studies have identified how suboptimal care may contribute to physiological deterioration of patients with major consequences on morbidity, mortality and requirement for intensive care. In a review of adult critical care services, the Department of Health (DOH) (England) recommended in 2000 that outreach services be established to avert admissions to Intensive Care, to enable discharges and to share critical care skills. METHODS: A literature search was carried out of the BIOMED and NESLI databases using the key words "outreach", "early warning signs/systems" and "suboptimal care". The literature review was limited to the past 10 years, and primary research articles of particular relevance were included in the review. The literature is examined within the context of recent findings relating to the provision of suboptimal care within general wards prior to cardiac arrest and/or admission to Intensive Care Units (ICU), and subsequent government initiatives. Discussion. The discussion explores the potential contribution of critical care outreach services and early warning scoring systems to the care of patients in acute general wards, including the role that education can have in developing the knowledge base and assessment skills of ward nurses. CONCLUSION: The paper concludes that further study is required to evaluate the effectiveness of critical care outreach services and early warning scoring systems, and that ward staff need to be educated to identify those patients at risk of developing critical illness. Finally, it is suggested that nurses' decision-making in relation to calling the outreach team requires further investigation.     

A practical approach to establishing a critical care outreach service: An expert panel research design

BackgroundFor over two decades, nurse-led critical care outreach services have improved the recognition, response, and management of deteriorating patients in general hospital wards, yet variation in terms, design, implementation, and evaluation of such services continue. For those establishing a critical care outreach service, these factors make the literature difficult to interpret and translate to the real-world setting.AimThe aim of this study was to provide a practical approach to establishing a critical care outreach service in the hospital setting.MethodAn international expert panel of clinicians, managers, and academics with experience in implementing, developing, operationalising, educating, and evaluating critical care outreach services collaborated to synthesise evidence, experience, and clinical judgment to develop a practical approach for those establishing a critical care outreach service. A rapid review of the literature identified publications relevant to the study. A modified Delphi technique was used to achieve expert panel consensus particularly in areas where insufficient published literature or ambiguities existed.FindingsThere were 502 publications sourced from the rapid review, of which 104 were relevant and reviewed. Using the modified Delphi technique, the expert panel identified five key components needed to establish a critical care outreach service: (i) approaches to service delivery, (ii) education and training, (iii) organisational engagement, (iv) clinical governance, and (v) monitoring and evaluation.ConclusionAn expert panel research design successfully synthesised evidence, experience, and clinical judgement to provide a practical approach for those establishing a critical care outreach service. This method of research will likely be valuable in other areas of practice where terms are used interchangeably, and the literature is diverse and lacking a single approach to practice.     

Ward nurses' evaluation of critical care outreach

Following the recommendation to introduce critical care outreach, two different models on two hospital sites were introduced within a large teaching Trust. To establish ward nurses' views and opinions of important components of the two outreach models, a questionnaire survey was undertaken involving 134 ward nurses on the awareness of outreach, accessibility of outreach and usage of outreach. The results identified a high level of user satisfaction amongst ward nurses. Awareness of critical care outreach and how to access the service within a hospital site was good, with little differences between the two different models. Outreach was found to provide ward nurses with better skills, more knowledge, advice and support. Providing a 24-h service and continual critical care education and training opportunities are the suggested ways to improve outreach in the future.     

Introducing Critical Care Outreach: a ward-randomised trial of phased introduction in a general hospital

Objective The purpose of the study was to investigate the effects of introducing a critical care outreach service on in-hospital mortality and length of stay in a general acute hospital.Design A pragmatic ward-randomised trial design was used, with intervention introduced to all wards in sequence. No blinding was possible.Setting Sixteen adult wards in an 800-bed general hospital in the north of England.Patients and participants All admissions to the 16 surgical, medical and elderly care wards during 32-week study period were included (7450 patients in total, of whom 2903 were eligible for the primary comparison).Interventions Essential elements of the Critical Care Outreach service introduced during the study were a nurse-led team of nurses and doctors experienced in critical care, a 24-h service, emphasis on education, support and practical help for ward staff.Measurements and results The main outcome measures were in-hospital mortality and length of stay. Outreach intervention reduced in-hospital mortality compared with control (two-level odds ratio: 0.52 (95% CI 0.32–0.85). A possible increased length of stay associated with outreach was not fully supported by confirmatory and sensitivity analyses.Conclusions The study suggests outreach reduces mortality in general hospital wards. It may also increase length of stay, but our findings on this are equivocal.Electronic Supplementary Material Supplementary material is available in the online version of this article at An editorial regarding this article can be found in the same issue ()     

Service Use and Costs of Support 12 Years after Leaving Hospital

Background There have been major changes in the provision and organization of services for people with intellectual disabilities in England over the last 30 years, particularly deinstitutionalization and the development of the mixed economy of care. The experiences of the people who participated in the Care in the Community Demonstration Programme in the mid‐1980s provide evidence of the immediate and longer‐term effects of the reprovision policy. Methods Cross‐sectional and longitudinal evidence was gathered on service use and costs for over 250 people 12 years after they left long‐stay hospitals for community living arrangements. Comparisons were made with the situation in hospital, and 1 and 5 years after leaving. Relationships between costs after 12 years and individual characteristics assessed before people left hospital were explored. Results Community care at the 12‐year follow‐up remained more expensive than hospital‐based support, although the average cost was lower than at either of the 1‐ or 5‐year community follow‐up points. Service users were living in a wide variety of accommodation settings. Management responsibility fell on National Health Service (NHS) trusts, local authorities, voluntary agencies, or to private organizations or individuals. After standardizing for users’ skills and abilities, costs in minimum support accommodation were significantly lower than those in residential and nursing homes, costs in staffed group homes significantly higher, and costs in hostels slightly lower. When looking at differences between individuals, no relationship was found between costs and outcomes although, overall, people were better off in the community than they had been when in hospital. Conclusions Reprovision planning for hospital and other institutional modes of care requires major and long‐term commitment of resources. Quality of life improvements can be achieved at a cost little different in the long‐run from that for hospital care. The link between needs and costs (reflecting the services intended to meet those needs) would be made stronger through the individualization of care.     

The development of telephone triage: historical, professional and personal perspectives

The authors examine the concept of nurse led services: professional, theoretical, developmental, and ethical implications for the nursing profession, patients, and their families. In the UK, the Scope of Professional Practice (1992) cleared the way for registered nurses to expand their role, ultimately to provide a better service and to develop the profession. The nursing profession has a strong tradition of adapting to change and responding positively to new health care needs ( DOH 1999). This nursing strategy for England makes particular reference to nurse led initiatives and direct reference to National Health Service (NHS) Direct; the 24-h nurse led telephone help and advice service available across England and Wales. Particular attention will be focused on a nurse led telephone triage which was developed in the authors’ own area of elective orthopaedics.     

A discussion of the British Society of Gastroenterology survey of emergency gastroenterology workload

An electronic survey of 188 acute NHS hospitals was carried out to assess the provision of out-of-hours services for gastrointestinal emergencies in England. The response rate was 167/188 (89%) for the main questionnaire and 157/188 (84%) for a supplementary questionnaire. The survey revealed that the majority of gastroenterologists (135/157, 86%) participate in acute general medicine. A rota for out-of-hours endoscopy was in place in only 82/167 (49%) of hospitals. Trained nurse endoscopy assistance was available in 51/82 (62%) of those hospitals with a formal rota. Two thirds of gastroenterologists were telephoned up to five times each month for advice when not on call; 64% felt their emergency endoscopy service provision was unsatisfactory and 38% thought it was unsafe. This paper concludes that there is serious under provision of services for patients presenting with gastrointestinal emergencies in England.     

Acute outreach service to nursing homes: A systematic review with GRADE and triple aim approach

Background

People living in nursing homes face the risk of visiting the emergency department (ED). Outreach services are developing to prevent unnecessary transfers to ED.

Aims

We aim to assess the performance of acute care services provided to people living in nursing homes or long-term homecare, focusing on ED transfer prevention, safety, cost-effectiveness and experiences.

Materials & Methods

This review was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Studies were eligible for inclusion if they were peer-reviewed and examined acute outreach services dedicated to delivering care to people in nursing homes or long-term homecare. The service models could also have preventive components. The databases searched were Scopus and CINAHL. In addition, Robins-I and SIGN checklists were used. The primary outcomes of prevented ED transfers or hospitalisations and the composite outcome of adverse events (mortality/Emergency Medical Service or ED visit after outreach service contact related to the same clinical condition) were graded with GRADE.

Results

Fifteen relevant original studies were found—all were observational and focused on nursing homes. The certainty of evidence for acute outreach services with preventive components to prevent ED transfers or hospitalisations was low. Stakeholders were satisfied with these services. The certainty of evidence for solely acute outreach services to prevent ED transfers or hospitalisations was very low and inconclusive. Reporting of adverse events was inconsistent, certainty of evidence for adverse events was low.

Conclusion

Published data might support adopting acute outreach services with preventive components for people living in nursing homes to reduce ED transfers, hospitalisations and possibly costs. If an outreach service is started, it is recommended that a cluster-randomised or quasi-experimental research design be incorporated to assess the effectiveness and safety of the service. More evidence is also needed on cost-effectiveness and stakeholders' satisfaction. Systematic review registration number: PROSPERO CRD42020211048, date of registration: 25.09.2020.     

Managing the unmanageable? Nurse Executive Directors and new role developments in nursing

This paper offers a unique insight into the factors affecting the functioning of the Nurse Executive Director(s) and their views on the realities of nursing management in the new National Health Service in England. It is based on the findings of the Exploring New Roles in Practice (ENRiP) project which was carried out for the Department of Health. As part of this project interviews were undertaken with Nurse Executive Directors from a 20% sample of acute hospital trusts in England. The interviews were designed to explore the Nurse Executive's perceptions of the process of new role development. The findings highlight a tension between the drive for professional development and the pragmatics of service delivery in a health care system which lacks dedicated funding for nursing development. It was evident that most Nurse Executives vacillated between responding either in an ad hoc way to internal and external pressures or leading and supporting managed development.     

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.     

Specialist educational intervention for acute inpatient mental health nursing staff: service user views and effects on nursing quality

AIM: This paper reports a study to evaluate the impact of an innovative 18-day educational intervention for acute ward-based mental healthcare nursing staff on documented quality of nursing care and on service user views of that care. BACKGROUND: There are grave concerns internationally about the quality of inpatient mental health care for people with acute psychiatric problems. It is claimed that specialist educational courses are needed to improve these services. However, whilst such courses may lead to positive learning outcomes for participants, the impact on the actual care of service users is unknown. METHOD: An uncontrolled before-and-after evaluation of three acute mental health wards from different United Kingdom National Health Service trusts was carried out. Quality of nursing care was evaluated by extracting documentary evidence from service user records, assessed by two independent researchers according to predefined quality criteria. The views of a purposive sample of mental health service users, currently receiving services from the three designated wards, were ascertained by semi-structured interview. RESULTS: Both documentary evidence and service user views revealed some important baseline deficiencies in the quality of care offered at the study sites. Following the educational intervention, statistically significant improvements were observed in the quality of care planning, initial assessments and the provision of therapeutic care. No statistically significant changes were observed in the quality of risk assessments, medication management or external agency involvement. CONCLUSIONS: Education can have an impact on nursing care but may not be sufficient alone to change mental healthcare practices on acute inpatient wards in the radical manner demanded by policymakers and service user lobby groups. Educational interventions need to be implemented in conjunction with organizational changes that are specifically designed to maximize the opportunities presented by a newly skilled and positive workforce.     

A mixed method study to compare use and experience of hospital care and a nurse-led acute respiratory assessment service offering home care to people with an acute exacerbation of chronic obstructive pulmonary disease

BACKGROUND: Over the past 10 years hospital at home schemes for the treatment of an acute exacerbation of Chronic Obstructive Pulmonary Disease have proliferated throughout developed countries. For selected patients treatment at home is no less advantageous in terms of readmission rates and length of stay than treatment in hospital. Although care at home might seem to be a more desirable option than admission to hospital, little is known about care preferences and how people exercise service choice. OBJECTIVES: 1. to determine patients' recent use of and satisfaction with health care services during exacerbations of Chronic Obstructive Pulmonary Disease. 2. To determine and compare patients' and families' perceived future care preferences. 3. To complete an in-depth exploration of care experiences and preferences with a subset of respondents and their families. DESIGN: A mixed method design was used consisting of a postal survey and in-depth qualitative interviews with a subset of questionnaire respondents. SETTING: An outreach service provided by a large university hospital within Scotland, UK. PARTICIPANTS: One hundred and four out-patients registered with the Acute Respiratory Assessment Service and who had experienced hospital inpatient care during the past year, and their families. A subset of respondents was invited to take part in qualitative interviews. RESULTS: The majority of respondents indicated a preference for the home care service, and this was positively associated with high coping skills. There was a strong relationship between personal and family preferences. There was no linear relationship between a clinical measure of severity of lung disease and service use or care preferences. Results from the qualitative interviews endorsed and explained these findings. CONCLUSIONS: A range of factors combined to influence service use at a particular point in time, implying a need for increased self-management support from nurses and increased service provision.     

Critical care without walls: The role of the nurse consultant in critical care

BACKGROUND: The nurse consultant role was first described in 1999 and has undergone little evaluation since. Critical care nurse consultant roles have developed against a background of service innovation following a review of adult critical care and have resulted in a variety of job roles and titles. There is some evidence to suggest that these posts are developing differentially and with varied role content. AIMS: To provide a profile of the nurse consultant in critical care. To identify critical care roles in practice. METHOD: A national postal survey of all 72 critical care nurse consultants in post in England by August 2003; response rate 72% (n = 52). RESULTS: The majority (54%) of critical care nurse consultants were aged between 40 and 50 years with a mean of 18.4 years post registration experience. The majority held a higher degree (71%) and at least one additional professional qualification (96%); many (44%) continue to study. Most critical care nurse consultants (69%) reported that a nurse does not manage them operationally. Nurse consultants were taking the lead in developing care outside the traditional boundaries of the Intensive Care Unit (ICU) (mean involvement score, M = 4.25) and with outreach rounds on the wards (M = 3.78). Despite having an overall high involvement (M = 3.37) with the practice and service development function, they had a lower involvement with research activities (M = 2.87). They also had a low involvement with strategic organisations such as the Department of Health (M = 1.63), Strategic Health Authorities (M = 1.54) and Primary Care Trust's (M = 1.49). CONCLUSIONS: The critical care nurse consultants who responded to this survey were clinically experienced and educated to an advanced level. They were leading the care of critically ill patients outside the traditional boundaries of the ICU, but have significantly less involvement within the ICU. Nurse consultants' restricted involvement with strategic organisations may limit the development of the role.     

Crossing boundaries,re-defining care: the role of the critical care outreach team

There is clear indication that both government and professional policy in the United Kingdom supports a radical change in the role of healthcare practitioners, with a move towards a patient-focused service delivered by clinical teams working effectively together. Recent health service imperatives driving the agenda for flexible clinical teams have occurred simultaneously with an increased public and political awareness of deficits in availability of critical care services. Against this policy backdrop, working across professional and organizational boundaries is fundamental to supporting quality service improvements. In the acute care sector, the development of critical care outreach teams is an innovation that seeks to challenge the traditional support available for sick ward patients. Activity data and observations from the first 6-month evaluation of two critical care outreach teams identify the need for clinical support and education offered by critical care practitioners to ward-based teams. The experiences from such flexible clinical teams provides a foundation from which to explore key issues for intradisciplinary and interdisciplinary working across clinical areas and organizational boundaries. Adopting innovative approaches to care delivery, such as critical care outreach teams, can enable clinical teams and NHS trusts to work together to improve the quality of care for acutely ill patients, support clinical practitioners working with this client group, and develop proactive service planning.     

An integrative review and meta‐synthesis of the scope and impact of intensive care liaison and outreach services

Aim. To determine activities and outcomes of intensive care unit Liaison Nurse/Outreach services. The review comprised two stages: (1) integrative review of qualitative and quantitative studies examining intensive care liaison/outreach services in the UK and Australia and (2) meta‐synthesis using the Nursing Role Effectiveness Model as an a priori model. Background. Acute ward patients are at risk of adverse events and patients recovering from critical illness are vulnerable to deterioration. Proactive and reactive strategies have been implemented to facilitate timely identification of patients at risk. Design. Systematic review. Methods. A range of data bases was searched from 2000–2008. Studies were eligible for review if they included adults in any setting where intensive care unit Liaison Nurse or Outreach services were provided. From 1423 citations and 65 abstracts, 20 studies met the inclusion criteria. Results. Intensive care liaison/outreach services had a beneficial impact on intensive care mortality, hospital mortality, unplanned intensive care admissions/re‐admissions, discharge delay and rates of adverse events. A range of research methods were used; however, it was not possible to conclude unequivocally that the intensive care liaison/outreach service had resulted in improved outcomes. The major unmeasured benefit across all studies was improved communication pathways between critical care and ward staff. Outcomes for nurses in the form of improved confidence, knowledge and critical care skills were identified in qualitative studies but not measured. Conclusion. The varied nature of the intensive care liaison/outreach services reviewed in these studies suggests that they should be treated as bundled interventions, delivering a treatment package of care. Further studies should examine the impact of critical care support on the confidence and skills of ward nurses. Relevance to clinical practice. Advanced nursing roles can improve outcomes for patients who are vulnerable to deterioration. The Nursing Role Effectiveness Model provides a useful framework for evaluating the impact of these roles.     

Effect of non-clinical inter-hospital critical care unit to unit transfer of critically ill patients: a propensity-matched cohort analysis

Introduction

No matter how well resourced, individual hospitals cannot expect to meet all peaks in demand for adult general critical care. However, previous analyses suggest that patients transferred for non-clinical reasons have worse outcomes than those who are not transferred, but these studies were underpowered and hampered by residual case-mix differences. The aim of this study was to evaluate the effect of transferring adult general critical care patients to other hospitals for non-clinical reasons.

Methods

We carried out a propensity-matched cohort analysis comparing critical care patients who underwent a non-clinical critical care unit to unit transfer to another hospital with those who were not transferred. The primary outcome measure was mortality at ultimate discharge from acute hospital. Secondary outcomes were mortality at ultimate discharge from critical care, plus length of stay in both critical care and acute hospital.

Results

A total of 308,323 patients were admitted to one of 198 adult general critical care units in England and Wales between January 2008 and September 2011. This included 759 patients who underwent a non-clinical transfer within 48 hours of admission to the unit and 1,518 propensity-matched patients who were not transferred. The relative risk of ultimate acute hospital mortality was 1.01 (95% confidence interval = 0.87 to 1.16) for the non-clinical transfer group, compared with patients who were not transferred but had a similar propensity for transfer. There was no statistically significant difference in ultimate critical care unit mortality. Transferred patients received on average three additional days of critical care (P < 0.001) but the difference in length of acute hospital stay was of only borderline significance (P = 0.05).

Conclusion

In our analysis the difference in mortality between non-clinical transferred and nontransferred patients was not statistically significant. Nevertheless, non-clinical transfers received, on average, an additional 3 days of critical care. This has potential ramifications in terms of distress, inconvenience and cost for patients, their families, and the National Health Service. We therefore need further evidence, including qualitative data from family members and cost-effective analyses, to better understand the broader effects of non-clinical transfer.