Critical care outreach: A valuable resource?

Implementation of a critical care outreach team in a children's hospital

Introduction

Proactive surveillance by a critical care outreach team (CCOT) can promote early recognition of deterioration in hospitalized patients but is uncommon in pediatric rapid response systems (RRSs). After our children's hospital introduced a CCOT in 2019, we aimed to characterize early implementation outcomes. We hypothesized that CCOT rounding would identify additional children at risk for deterioration.

Methods

The CCOT, staffed by a dedicated critical care nurse (RN), respiratory therapist, and attending, conducts daily in-person rounds with charge RNs on medical-surgical units, to screen RRS-identified high-risk patients for deterioration. In this prospective study, observers tracked rounds discussion content, participation, and identification of new high-risk patients. We compared 'identified-patient-discussions' (IPD) about RRS-identified patients, and 'new-patient-discussions' (NPD) about new patients with Fisher's exact test. For new patients, we performed thematic analysis of clinical data to identify deterioration related themes.

Results

During 348 unit-rounds over 20 days, we observed 383 discussions - 35 (9%) were NPD. Frequent topics were screening for clinical concerns (374/383, 98%), active clinical concerns (147/383, 39%), and watcher activation (66/383, 17%). Most discussions only included standard participants (353/383, 92%). Compared to IPD, NPD more often addressed active concerns (74.3% vs 34.8%, p < 0.01) and staffing resource concerns (5.7% vs 0.6%, p < 0.04), and more often incorporated extra participants (25.7% vs 6%, p < 0.01). In thematic analysis of 33 new patients, most (29/33, 88%) had features of deterioration.

Conclusion

A successfully implemented CCOT enhanced identification of clinical deterioration not captured by existing RRS resources. Future work will investigate its impact on operational safety and patient-centered outcomes.

From bedside to recovery: exercise therapy for prevention of post-intensive care syndrome

BACKGROUND

As advancements in critical care medicine continue to improve Intensive Care Unit (ICU) survival rates, clinical and research attention is urgently shifting toward improving the quality of survival. Post-Intensive Care Syndrome (PICS) is a complex constellation of physical, cognitive, and mental dysfunctions that severely impact patients' lives after hospital discharge. This review provides a comprehensive and multi-dimensional summary of the current evidence and practice of exercise therapy (ET) during and after an ICU admission to prevent and manage the various domains of PICS. The review aims to elucidate the evidence of the mechanisms and effects of ET in ICU rehabilitation and highlight that suboptimal clinical and functional outcomes of ICU patients is a growing public health concern that needs to be urgently addressed.

MAIN BODY

This review commences with a brief overview of the current relationship between PICS and ET, describing the latest research on this topic. It subsequently summarises the use of ET in ICU, hospital wards, and post-hospital discharge, illuminating the problematic transition between these settings. The following chapters focus on the effects of ET on physical, cognitive, and mental function, detailing the multi-faceted biological and pathophysiological mechanisms of dysfunctions and the benefits of ET in all three domains. This is followed by a chapter focusing on co-interventions and how to maximise and enhance the effect of ET, outlining practical strategies for how to optimise the effectiveness of ET. The review next describes several emerging technologies that have been introduced/suggested to augment and support the provision of ET during and after ICU admission. Lastly, the review discusses future research directions.

CONCLUSION

PICS is a growing global healthcare concern. This review aims to guide clinicians, researchers, policymakers, and healthcare providers in utilising ET as a therapeutic and preventive measure for patients during and after an ICU admission to address this problem. An improved understanding of the effectiveness of ET and the clinical and research gaps that needs to be urgently addressed will greatly assist clinicians in their efforts to rehabilitate ICU survivors, improving patients' quality of survival and helping them return to their normal lives after hospital discharge.

Automated rapid response system activation-Impact on nurses' attitudes and perceptions towards recognising and responding to clinical deterioration: Mixed-methods study

AIM

To explore general ward nurses' attitudes and perceptions towards recognising and responding to clinical deterioration in a hospital with automated rapid response system activation.

BACKGROUND

There is growing interest in deploying automated clinical deterioration notification systems to reduce delayed or failed recognition and response to clinical deterioration of ward patients. However, little is known about its impact on ward nurses' perspectives and work patterns.

DESIGN

A mixed-methods study.

METHODS

Online survey of 168 registered nurses and individual interviews with 10 registered nurses in one acute hospital in Singapore. The study adhered to the STROBE checklist for cross-sectional studies and the COREQ guidelines for qualitative studies.

RESULTS

Many nurses (38.1%) rarely performed patient assessments or observations other than vital signs assessment to assess for early signs of clinical deterioration. About 30% were worried about being criticised for calling the primary team doctors. Four themes emerged from the qualitative analysis: automated rapid response system activation as a safety net, being more cautious with vital signs monitoring, the NEWS2 alone is inadequate, and ward nurses as the 'middleman' between the intensive care unit outreach nurse and primary team doctors.

CONCLUSIONS

Although nurses value the automated rapid response system activation as a safety net to minimise delays in accessing urgent critical care resources, it does not address the sociocultural barriers inherent in escalation of care. Although the automated system led nurses to be more cautious with vital signs monitoring, it does not encourage them to perform comprehensive patient assessments to detect early signs of deterioration.

RELEVANCE TO CLINICAL PRACTICE

Nurse education on assessing for clinical deterioration should focus on the use of broader patient assessment skills other than vital signs. Sociocultural barriers to escalation of care remain a key issue that needs to be addressed by hospital management.

NO PATIENT OR PUBLIC CONTRIBUTION

No patients, service users, care-givers or members of the public were involved in the study.

NURSE-LED proactive rounding and automatic early-warning score systems to prevent resuscitation incidences among Adults in ward-based Hospitalised patients

Objectives

In this study, we investigated the impact of critical care outreach implemented to overcome the problem of rapid response system (RRS) activation. The aim was to evaluate the impact of nurse-led proactive rounding on the rate of adverse events in a hospital setting using an automatic early-warning score system, without a call-activated team.

Methods

This observational study was conducted at a university hospital in Japan. Beginning in September 2019, critical care outreach via nurse-led proactive rounding of the general ward was conducted, using an automatic early-warning score system. We retrospectively assessed the computerised records of all inpatient days (N = 497,284) of adult inpatients admitted to the hospital from September 2017 to 2020. We compared the adverse event occurrences before and after implementation of the critical care outreach program. The main outcome measures were: unexpected death in the general ward, code blue (an in-hospital resuscitation request code directed towards all staff via broadcast) for non-intensive care unit inpatients and unexpected intensive care unit admissions from the general ward. The secondary outcome was the proportion of patients who received respiratory rate measurement.

Results

The incidence rate ratios of the occurrence of unexpected deaths (0.19, 95% confidence interval: 0.04-0.57) and code blue in the general ward (0.15, 95% confidence interval: 0.025-0.50) decreased. There was no change in unexpected intensive care unit admissions from the general ward (1.25, confidence interval: 0.84-1.82). The proportion of patients who received respiratory rate measurement increased (10.2% vs 16.2%).

Conclusion

Our results suggest that in RRSs, drastic control of the failure of the mechanism to activate a response team may produce positive outcomes. Proactive rounding that bypasses the mechanism to activate a response team component of RRSs may relieve ward nurses of activation failure responsibility and help them overcome the hierarchical hospital structure.

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

BACKGROUND

Critical 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.

OBJECTIVES

The 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.

METHODS

A 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.

RESULTS

The 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.

CONCLUSIONS

Critical care outreach-style physiotherapy services can be successfully implemented and are positively perceived by clinicians, but any effect on ICU readmissions is unclear.

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

BACKGROUND

For 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.

AIM

The aim of this study was to provide a practical approach to establishing a critical care outreach service in the hospital setting.

METHOD

An 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.

FINDINGS

There 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.

CONCLUSION

An 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.

Exploration of a rapid response team model of care: A descriptive dual methods study

BACKGROUND

Avoidable in-patient clinical deterioration results in serious adverse events and up to 80% are preventable. Rapid response systems allow early recognition and response to clinical deterioration.

OBJECTIVE

To explore the characteristics of a collaborative rapid response team model.

DESIGN

Dual methodology was used for this descriptive study.

SETTING

The study was conducted in a 500-bed tertiary referral hospital (Sydney, Australia).

PARTICIPANTS

Inpatients (>17 years) who received a rapid response team activation were included in an electronic medical audit. Participants were rapid response team members and nurses and medical doctors in two in-patient wards.

METHODS

A 12-month (January-December 2018) retrospective electronic health record audit and semi-structured interviews with nurses and medical doctors (July-August 2019) were conducted. Descriptive statistics summarised audit data. Interviews were transcribed and analysed thematically.

RESULTS

The rapid response team consulted for 2195 patients. Mean patient age was 67.9 years, and 46% of the sample was female. Activations (n = 4092) occurred most often in general medicine (n = 1124, 70.8%) units. Overall, 117 patients had >5 activations. The themes synthesised from interviews were i) managing patient deterioration before arrival of the rapid response team; ii) collaboratively managing patient deterioration at the bedside; iii) rapid response team guidance at the bedside; and iv) 'staff concern' rapid response activation.

CONCLUSIONS

Some patients received many activations, however few required treatment in critical care. The rapid response model was collaborative and supportive. The themes revealed a focus on patient safety, optimising early detection, and management of patient deterioration.

Parental experience of transition from a pediatric intensive care unit to a general ward: A Qualitative Study

AIM

To explore parental experience in transitioning from a pediatric intensive care unit to a general ward and to investigate parental involvement in caring for their critical illness children.

BACKGROUND

Parents have a major responsibility in caring for seriously ill children, but nursing staff fail to meet the expectations of parents regarding nursing care. Few studies have investigated the challenges and needs of Chinese parents during the transition from pediatric intensive care unit to general ward.

METHODS

Semi-structured interviews were conducted with 24 parents of children with critical illness in a pediatric hospital in Shanghai, mainland China to explore their views. Transcripts were entered into NVivo. Framework analysis was used to analyze the qualitative data.

RESULTS

Four themes were identified by data analysis: changes in the child during post pediatric intensive care unit periods; experiencing a wide range of emotions; factors involved in the transition; and suggestions for improving transitional care.

CONCLUSIONS

Due to the unmet needs of parents, a more flexible visiting policy and social media support were highly desirable. Getting accurate information, establishing family integrated care, and strengthening ward-based critical support services were also listed as important needs of parents caring for critically ill children.

IMPLICATIONS FOR NURSING MANAGEMENT

A profound understanding of parental experiences during the transitional period can help nursing staff to assess the effects on children and their families, improve ward-based intensive care, support parental participation, and improve visitation policies. Based on these findings, nurse managers can develop reasonable intervention programs in order to improve nursing quality and patient outcomes.

Features and perceptions of a critical care outreach physician role

Objective: To describe the tasks completed by the critical care outreach physician (CCOP) and staff perceptions of the CCOP role. Design: Prospective observational study and survey of intensive care unit (ICU) staff. Setting: University-affiliated teaching hospital in Australia. Participants: ICU consultants, registrars and nurses. Interventions: Implementing a dedicated ICU consultant to review deteriorating patients outside the ICU. Main outcome measures: Prospective collection of CCOP tasks and survey of ICU staff. Results: During 101 clinical shifts, the CCOP had 1524 encounters (mean, 15.1 [standard deviation, 6.1]; median, 14 [interquartile range, 10-19] per day). The three commonest interventions were emergency department visits, direct consultant communication, and coordinating ICU admissions. Involvement in Medical Emergency Team (MET) calls, expediting patient care, and goals of care discussions were also relatively common. Survey responses were obtained from 55/84 (66%) eligible participants. Most respondents thought the CCOP would improve the predefined processes of care and patient-centred outcomes. The areas of greatest perceived benefit included supporting the MET registrar and coordinating simultaneous emergencies outside the ICU. Areas where the role was perceived to be less beneficial included improving handover, identifying patients at clinical risk outside the ICU, and reducing repeat MET calls. Conclusions: The tasks of a CCOP involved high level communication, coordination of care, and supervision of ICU staff. The effect of this role on patient-centred outcomes requires further research.

Staff education by the critical care outreach team: evaluating the effect of a study day on nurses' knowledge levels

Critical care outreach teams were developed in the UK from the early 2000s onwards in response to evidence that the management of severely ill patients on hospital wards before admission to the intensive care unit was frequently suboptimal. Most hospitals in the UK have some form of CCOT, which is usually composed of senior nurses with extensive critical care experience. One of the goals of CCOTs is to provide educational support to staff to enhance their skills at recognising and managing deteriorating patients. However, the evidence regarding the effects of CCOTs is conflicting. This article describes a service evaluation conducted at an acute NHS trust in England to assess the effects of educational sessions designed and delivered by the local CCOT. The CCOT offered a study day on non-invasive ventilation for patients with type 2 respiratory failure to a group of ten nurses from different clinical areas. A pre-and post-study day questionnaire showed that all participants had increased knowledge levels at the end of the study day. If positive effects of CCOT-led study days on nurses' knowledge were consistently demonstrated, these study days could be considered as a practical and effective method of meeting the learning needs of nurses.

Routine critical care step-down programmes: Systematic review and meta-analysis

BACKGROUND

Patients discharged from critical care to general hospital wards are vulnerable to clinical deterioration, critical care readmission, and death. In response, routine critical care stepdown programmes (CCSDPs) have been widely developed, which involve the review of all patients on general wards following discharge from critical care by multidisciplinary Outreach teams with critical care skills.

AIMS AND OBJECTIVES

This review aims to answer the question: do routine CCSDPs reduce readmission and/or mortality among patients discharged from critical care?

DESIGN

Systematic review of quantitative studies and meta-analysis.

METHODS

Six databases were comprehensively searched from inception (CENTRAL, Cochrane Reviews, MEDLINE, Embase, CINAHL and web of Science), alongside grey literature and trial registers. Studies investigating the effect of routine CCSDPs delivered by Outreach nurses on readmission and/or mortality following discharge from adult critical care to general hospital wards were included. Study quality was assessed using the Cochrane ROBINS-I tool.

RESULTS

Eight studies met the inclusion criteria, with data from 6 studies pooled in 3 meta-analyses. Among patients exposed to routine CCSDPs, pooled data estimated a statistically nonsignificant reduction in the risk of readmission to critical care (risk ratio [RR] 0.85; 95% confidence interval [CI] 0.66-1.09; P = .19), a statistically significant increase in the risk of readmission to critical care within 72 hours (RR 1.49; 95% CI 1.05-2.12; P = .03), a statistically non-significant reduction in risk of mortality following critical care discharge (RR 0.90; 95% CI 0.75-1.07; P = .22), and no association with mortality within 14 days of discharge.

CONCLUSION

This review is unable to definitively conclude whether routine CCSDPs reduce critical care readmission or mortality following critical care discharge.

RELEVANCE TO CLINICAL PRACTICE

While the synthesized evidence does not suggest a change in policy and practice are warranted, neither does it support routine CCSDPs in the absence of high-quality evidence.