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CME Intensive care medicine

The government report Comprehensivecritical care suggests radical changes tothe way critical care is delivered in theUK.1 One of its many recommendationswas the development of intensive careoutreach teams. This recommendationcompelled intensive care unit (ICU) staffto leave their traditional environmentand start delivering critical care to sickpatients around the hospital rather thanwaiting for them to deteriorate furtherand require ICU admission. Some havecalled this ‘breaking down walls’. Theaims of outreach services are to optimisepatient care across the hospital three-foldby:

• averting admission to ICU

• facilitating discharge from ICU, and

• sharing skills throughout thehospital.

Ideally, outreach teams should beformed from practitioners trained notonly in the clinical aspects of critical carebut also in effective ways of sharing skills.The outreach team should be multidisci-plinary, led by a qualified critical carepractitioner – though the report does notstate that this should be a doctor.

The contents of the report seemed clin-ically intuitive to ICU staff and have beensurprisingly widely accepted by medicaland surgical ward staff across the country.The need for such a system was derivedfrom studies demonstrating that up to41% of ICU admissions are potentiallyavoidable and up to 50% of patientsadmitted to ICU receive suboptimal careprior to their transfer.2–5 Furthermore, ithas been suggested that up to 70% of alladverse outcomes associated with medicalmanagement are preventable.6

Current evidence

The concept of outreach originated inLiverpool, New South Wales, in 1990 withthe development of medical emergencyteams (METs). Their original aim was toreduce the incidence and improve theoutcome of cardiopulmonary arrests,utilising the principles of early recogni-tion and rapid response to the deterio-rating patient.7 METs are clinician-ledand include an experienced ICU nurse. Ithas been suggested that such teams lead toimproved outcomes, with decreased inci-dence of respiratory failure, stroke, severesepsis, acute renal failure, emergency ICUadmission, death and reduced length ofhospital stay. However, no report offersmore than level 2 evidence.8–10

The large, randomised Medical EarlyResponse Intervention Therapy (MERIT)study in 23 Australian hospitals used acluster-randomised trial design to test theeffects of the introduction of the MET. Ithas just been completed and the resultsare eagerly awaited, although initial con-ference reports suggest no benefit in theintervention group. If the paper confirmsthese findings, this study will representthe first level 1 evidence in this field.

It could be argued, first, that manyaspects of the delivery of outreach ser-vices in the UK differ from MET inAustralia, and that these results cannotbe extrapolated to the outreach system inthis country which are currently pre-dominantly nurse-led; secondly, that if aclinician-led service does not improveoutcome, a nurse-led one is also unlikelyto do so – although it may possibly bemore cost-effective.

Nurse-led outreach in the UK

Evidence for the effectiveness of nurse-ledoutreach in this country is also lacking.There have been no randomised trials, buta number of published studies have exam-ined the impact of the implementation ofan outreach service:

1 Preistly and colleagues11 performeda randomised cohort trial of phasedintroduction of critical care outreachto a general hospital. A nurseconsultant led the team, with agroup of experienced nursesproviding 24-hour cover. Ward staffused a locally devised patient at-riskscoring system to trigger referral.There was a significant reduction inmortality in wards where the serviceoperated compared with thosewithout the service. Analysis ofwhether outreach increased thelength of hospital stay was equivocal,and data on cardiac arrest rate,hospital mortality, placement ofdo-not-resuscitate orders and ICUadmissions were not included andmust be presumed to be notsignificant.

2 A non-randomised population-based study by Ball and co-workers12

compared historical controls withpatients cared for by a nurse-only

Paul Holder FRCA, Specialist Registrar,Department of Anaesthesia and IntensiveCare, Aberdeen Royal Infirmary, Aberdeen,Scotland

Brian H Cuthbertson MD FRCA, SeniorLecturer, Department of Anaesthesia;Honorary Consultant, Anaesthesia andIntensive Care, Health Services ResearchUnit, Medical School, Polwarth Building,University of Aberdeen, Scotland

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Critical care

outwith the

intensive care unit

Despite widespread acceptance and intuitive belief of benefit, there is a lack ofevidence to support the use of outreach critical care

There is variation in the availability of outreach teams

No consensus exists about the ideal composition of outreach teams

No consensus exists for an appropriate set of triggers to activate referral

How outreach impacts on the hospital-at-night programme has not been studied

Key Points

KEY WORDS: acute medicine, high dependency care, intensive care, outreach criticalcare

outreach team available for 12 hoursa day. The operational policy of thisteam appears to have been limited tothose patients previously dischargedfrom the ICU rather than includingnew patients. After the introductionof the outreach team there was asignificant increase in survival tohospital discharge and a significantdecrease in ICU readmission rate –but only to the national averagereadmission rate. Althoughpresenting interesting findings, thisstudy was poorly controlled.

3 Garcea and colleagues13 performed aretrospective observational study ofthe introduction of outreach servicesin surgical wards, using a before andafter methodology. The teamcomprised two senior nurses and anurse consultant, with an ICUconsultant as the lead clinician butwith an undefined level ofinvolvement. The team’s remitinvolved the follow-up of ICU andhigh dependency unit dischargesand the education of ward staffabout the recognition of the sickpatient. It was later expanded toinclude direct referral of patientshighlighted by an early warningscoring system. The tentativeconclusion was that outreach teamsmay have a favourable impact onmortality rate amongst readmissionsto critical care, but more data areneeded from multicentre trials.

The main published literature ofscoring systems used in medical environ-ments comes from a study by Subbeet al,14 which suggested a useful role for

the modified early warning score in acutemedical admissions. However, the resultsof the study did not provide strongsupport for this statement.

The evidence suggests, by no meansconvincingly, possible benefit of out-reach services as applied in the UK. Itrepresents more evidence than was avail-able in Comprehensive critical care, butclearly more work is required before out-reach can become an accepted standardof care.

The future

Outreach services are likely to continueto operate regardless of the evidence, butseveral key operational issues need to bedetermined and standardised (Table 1).There is striking heterogeneity in thelevel and coverage of service currentlyoffered across the UK. Published workand national surveys of practice revealmarked variation in temporal avail-ability, composition and coverage ofteams and the scoring systems utilised.To help standardise outreach services, ahigh quality research evidence base isrequired to guide practice and a nation-wide audit to allow comparisons andquality improvements in the serviceoffered. This would also allow establish-ment of evidence-based standards of bestpractice.

A standardised, validated scoringsystem is needed with a simple callingalgorithm that defines the situation andscenarios for activating referral to anoutreach team. A wide variety of existingscores utilise a varied set of physiologicalparameters and ranges, all lacking valida-tion. The inclusion of non-physiologicalcriteria such as ‘nursing concern’ and‘marginal deterioration in observations’would broaden the inclusion criteria andmight improve the sensitivity of scoresbut at the cost of reduced specificity.7,15

An example of a trigger chart is shown inTable 2.

The application of outreach wouldintuitively be most appropriate whenmedical and nursing staffing levels are attheir lowest, outside normal workinghours. This view has most recently beenexpounded in a recent report from theNational Confidential Enquiry intoPatient Outcome and Death (NCEPOD)suggesting that an over-reliance onjunior staff in the out-of-hours situationleads to suboptimal care for patients.16 Ifoutreach is to be effective, perhaps itshould be available either 24 hours or atnight only. This is partly enshrined in thehospital-at-night programme, but theimpact of such a change has not beenstudied.17

The composition of outreach teamsshould be examined in more detail as a

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• Unproven benefit

• Optimal composition of teams

• Definition of necessary skills andcompetencies

• Lack of national standards

• Meeting the aims of Comprehensivecritical care

• Relationship with medical take andcardiac arrest teams

Table 1. Current issues in outreachprovision.

A patient who fulfils one or more of the criteria below or is causing concern needsurgent intervention

Breathing Respiratory rate <8 or >25 per minOxygen saturation <90%, despite oxygenPaO2 <8 kPa on an arterial blood gas sample, despite oxygen

Circulation Pulse <45 or >125 per minSystolic blood pressure <90 or >200 mmHg or a sustained fall >40 mmHgfrom patient’s normal valuepH <7.3Base excess <–7 mmol/l

Renal Urine output <30 ml/hour for 3 consecutive hoursEvidence of deteriorating renal function

Conscious level Patient does not respond to voiceGlasgow Coma Score 8

OR patient looks unwell or you feel worried about their clinical condition

Care of all patients remains the responsibility of the admitting team

Phone 2222 and ask for the Critical Care Outreach Team

Table 2. The Princess Alexandra Hospital NHS Trust Critical Care Outreach Teampatient assessment using the Harlow Outreach Team (HOT) tool.

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truly multidisciplinary approach is mostlikely to be beneficial. The teams shouldinclude senior clinicians and nurses fromaround the hospital (not just ICU staff)incorporated into teams, rather than apurely nurse-led service. Again, the com-parison between the two systems has notbeen studied. If the former approachwere to be adopted it would represent aresource issue above the already signifi-cant cash injection of £142.5 millionwhich followed Comprehensive criticalcare.

Finally, the question of education mustbe raised. The changes in junior doctors’hours leads to less exposure to criticallyill patients, so outreach teams shouldinclude junior medical and nursing stafffor training purposes. If trainee medicalstaff are no longer responsible for therecognition of the failing patient, theirability to respond to such individuals willbe further diminished.

All these functions could best be stan-dardised and monitored by a nationalbody such as the Intensive Care Societyor the NHS Modernisation Agency. Theyare both well placed to audit the applica-tion and effectiveness of such guidanceon a national level to ensure they are assensitive and specific as possible.18

Conclusions

The weight of evidence grows slowly insupport of outreach critical care outsidethe physical boundaries of the ICU in theUK, but it is not strong in other nationalsettings. Many questions are left unan-swered as to how best to deliver this service. These questions should beaddressed before there is further invest-ment in such services.

References

1 Department of Health. Comprehensive crit-ical care. A review of adult critical careservices. London: DH, 2000.

2 McQuillan P, Pilkington S, Allan A, Taylor Bet al. Confidential inquiry into quality ofcare before admission to intensive care. BMJ1998;316:1853–8.

3 McGloin H, Adam SK, Singer M.Unexpected deaths and referrals to intensivecare of patients on general wards. Are somecases potentially avoidable? J R CollPhysicians Lond 1999;33:255–9.

4 Goldhill DR, White SA, Sumner A.Physiological values and procedures in 24 hbefore ICU admission from the ward.Anaesthesia 1999;54:529–34.

5 Garrard C, Young D. Suboptimal care ofpatients before admission to intensive careis caused by a failure to appreciate or applythe ABCs of life support. BMJ 1998;316:1841–2.

6 Wilson RM, Harrison BT, Gibberd RW,Hamilton JD. An analysis of the causes ofadverse events from the Quality inAustralian Health Care Study. Med J Aust1999;170:411–5.

7 Lee A, Bishop G, Hillman KM, Daffurn K.The Medical Emergency Team. AnaesthIntensive Care 1995;23:183–6.

8 Bristow PJ, Hillman KM, Chey T, Daffurn Ket al. Rates of in-hospital arrest, deaths andintensive care admissions: the effect of amedical emergency team. Med J Aust 2000;173:236–40.

9 Buist MD, Moore GE, Bernard SA, WaxmanP et al. Effects of a medical emergency teamon reduction of incidence of and mortalityfrom unexpected cardiac arrests in hospital:preliminary study. BMJ 2002;324:387–90.

10 Bellomo R, Goldsmith D, Uchino S,Buckmaster J et al. Prospective controlledtrial of effect of medical emergency team onpostoperative morbidity and mortalityrates. Crit Care Med 2004;32:916–21.

11 Preistly G, Watson W, Rashidian A, MozleyC et al. Introducing Critical Care Outreach:a ward-randomised trial of phased intro-duction in a general hospital. Intensive CareMed 2004;30:1398–404.

12 Ball C, Kirby K, Williams S. Effect of thecritical care outreach team on patient sur-vival to discharge from hospital and read-mission to critical care: non-randomisedpopulation based study. BMJ 2003;327:1014–7.

13 Garcea G, Thomasset S, McClelland L,Leslie A, Berry DP. Impact of a critical careoutreach team on critical care readmissionsand mortality. Acta Anaesthesiol Scand 2004;48:1096–100.

14 Subbe CP, Kruger M, Rutherford P, GemmelL. Validation of a modified Early WarningScore in medical admissions. QJM 2001;94:521–6.

15 Parissopoulos S, Kotzabassaki S. Criticalcare outreach and the use of early warningscoring systems; a literature review. ICUSNurs Web J 2005;21.www.nursing.gr/WARNING.pdf

16 National Confidential Enquiry into PatientOutcome and Death. An acute problem?London: Department of Health, 2005.

17 Department of Health. Findings and recom-mendations from the Hospital at Nightproject. London: NHS ModernisationAgency, 2004.