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.     

Critical care outreach during the COVID-19 pandemic: An observational study

Background

Since the beginning of the coronavirus disease 2019 (COVID-19) outbreak, the Critical Care Outreach Team (CCOT) remained operational to provide critical care support to acutely ill and deteriorating patients on the wards.

Aim

We aimed to evaluate the demand and efficacy of the critical care outreach service during the COVID-19 pandemic.

Method

We prospectively evaluated all patients referred to critical care outreach enrolled during a twelve-month period. We reported the cumulative number of activities and interventions and baseline characteristics, acuity level and patients' clinical outcome. The rate of ICU admissions, activity plan, patients' acuity and mortality are compared to historical data pre-pandemic.

Results

Amongst 4849 patients referred, 3913 had a clinical review and of those 895 were COVID-19 positive. Non-invasive ventilation was mostly delivered to COVID-19 patients (COVID-19 +VE: 853/895, 95% vs. COVID-19 −VE: 119/3018, 4%) alongside awake prone positioning (COVID-19 +VE: 232/895, 26% vs. COVID-19 −VE: 0/3018, 0%). Compared to pre-pandemic, the cumulative number of patients assessed increased (observed: 3913 vs. historical: 3615; p = 0.204), patients meeting Level 2 acuity were higher (observed: 51% vs. historical: 21%; p = 0.003), but ICU admission rate did not increase significantly (observed: 12% vs. historical: 9%; p = 0.065), and greater mortality rate (observed: 14% vs. historical: 8%; p = 0.046) was observed.

Conclusion

Critical care outreach bridges the gap between the intensive care unit and general wards and supports the concept of ‘critical care without walls’ acting as a valuable resource in optimizing and triaging acutely unwell patients and potentially averting critical care admissions.

Relevance to Clinical Practice

The COVID-19 pandemic has generated an unprecedented surge of deteriorating and critically ill patients with has caused severe and sustained pressures on intensive care units (ICUs) and general wards. Acutely ill patients can deteriorate quickly, and early recognition is vital to commence critical intervention on the wards or transfer timely to ICU. The Critical Care Outreach Team can help staff and optimize acutely ill and deteriorating patients by providing timely critical care interventions at the patient bedside.     

Validation of a risk stratification tool for a Hospital Outreach Medication Review (HOMR) program

BackgroundEarly hospital readmissions are a challenging and costly experience for both patients and the healthcare service. Reducing hospital readmission rates is a priority for health services globally and this is evident with the establishment of multiple outpatient services to promote early follow-up and to initiate secondary preventative care measures. One such intervention has been the introduction of a pharmacist-led, Hospital Outreach Medication Review (HOMR) service. However, the demand for the service has meant reaching this target has become an increasingly ambitious goal within allocated resources.ObjectiveTo validate a risk-stratification tool to identify low-risk patients in whom a telephone medication review would be a safe and effective alternative to a home-based review.MethodA risk tool was derived and applied to a retrospective sample to act as the parent cohort. A prospective cohort was stratified into low and high-risk based on this tool, and received either a telephone or a traditional home medication review respectively.Results235 patients were included in final analysis (n = 113 prospective, n = 122 baseline controls). High-risk patients were more likely to be readmitted at 60 and 90 days in the baseline cohort (9/38 vs 7/84, p = 0.04 and 11/38 vs 9/84, p = 0.02 respectively), with a trend towards increased readmissions at 30 days (5/38 vs 3/84, p = 0.11). Logistic regression identified the risk tool as an independent predictor of hospital readmission (IRR 1.18, p = 0.04), whereas age and Charlson comorbidity were not (p = 0.80 and 0.31 respectively). There was no significant difference between the new model (incorporating phone reviews) and the parent cohort (p = 0.25).ConclusionOur risk score was able to identify those at highest risk of hospital readmission at 60 and 90 days. Utilising this risk score, a telephone HOMR for low-risk patients was a safe and efficient alternative to a traditional home review.     

Drugs and pregnancy--outcomes of women engaged with a specialist perinatal outreach addictions service

Substance misuse during pregnancy may result in harm to both mother and child. The aims of this study were to assess changes in outcomes of women seen by a specialist perinatal addictions outreach service (1989-1991 versus 2002-2005) and compare outcomes to the local hospital maternity population (2004-2005). A cross-sectional audit of health-care records was conducted comparing the outcomes of women in 2002-2005 with earlier data from 1989-1991 and the local maternity population (2004-2005). The service was attended by 126 women, of whom 83% of opioid-dependent women started/continued opioid maintenance treatment. Of 118 babies delivered, there were two stillbirths and one early neonatal death, 20% were premature, 28% were low birth weight, 21% required the Special Care Baby Unit and 21% of babies born to opioid-dependent mothers were treated for neonatal abstinence syndrome (NAS). Fewer babies required treatment for NAS in 2002-2005 compared to 1989-1991 (21% versus 44%). There were higher rates of miscarriage (3% versus <1%), low birth weight (28% versus 9%) and premature babies (20% versus 9%) compared to the local maternity population (2004-2005). Integrated perinatal addictions treatment may deliver benefits; however, engaging women into treatment earlier and reducing substance use before conception remains the objective.     

Multifaceted support to improve clinical decision making in diabetes care: a randomized controlled trial in general practice.

AIMS: To evaluate the effectiveness of a multifaceted intervention to improve the clinical decision making of general practitioners (GPs) for patients with diabetes. To identify practice characteristics which predict success. METHODS: Cluster randomized controlled trial with 124 practices and 185 GPs in The Netherlands. The intervention group received feedback reports and support from a facilitator; the control group received no special attention. Outcome measures were the compliance rates with evidence-based recommendations pertaining to discussion of body weight control, discussion of problems with medication, blood pressure measurement, foot examination, eye examination, initiating anti-diabetic medication or increasing the dosage in cases of uncontrolled blood glucose, and scheduling a follow-up appointment. RESULTS: The GPs reported on their clinical decision making in 1410 consultations with Type 2 diabetic patients at baseline and 1449 consultations after the intervention period. The intervention resulted in statistically significant improvement for two of the seven outcome measures: foot examination (odds ratio 1.68; 95% confidence interval 1.19-2.39) and eye examination (1.52; 1.07-2.16). Discussion of problems with medication showed a near significant trend towards increased benefit for the intervention group (1.52; 0.99-2.32). Practice characteristics were not found to be related to the success of the intervention. CONCLUSIONS: Feedback reports with support from facilitators appear to increase rates of foot examination and eye examination in general practice. Alternative interventions should be explored to improve the pursuit of metabolic control by GPs.     

A National Registry for People With All Stages of Kidney Disease: The National Kidney Foundation (NKF) Patient Network

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A multidisciplinary safety briefing for acutely ill and deteriorating patients: A quality improvement project

BackgroundSafety briefings can help promoting situational awareness, interprofessional communication and improve patient safety.Local problemA clinical survey highlighted that 90% of the participants including the medical team and the critical care outreach team nurses perceived the meeting for escalating acutely ill and deteriorating patients during the out-of-hours period (20.00 to 08.00) to have unconstructive and unwelcoming atmosphere with belittling, hostility and unhelpful criticisms. The participants reported that the communication across teams lacked in structure and clear information given; but staff also self-reported lacking confidence in communicating key issues.MethodA quality improvement project with Plan-Do-Study-Act was adopted to design and implement a dedicated multidisciplinary safety briefing with a structured format.ResultsThe multidisciplinary safety briefing was to 90% of clinicians, and it took a median of 10 min to complete. Delayed referrals to the critical care outreach team were reduced by 46%. Positive changes included increased situational awareness and clearer communication across teams. Barriers identified were variable usage and need for face-to-face presence. Considering all the findings and the time constraint during the SARS-CoV-2 pandemic, we changed to a telephonic safety briefing directly to the team leaders.ConclusionA structured multidisciplinary safety briefing can improve patient safety and support management of deteriorating and acutely ill patients on the wards during the out-of-hours period.