Editorial

Critical care outreachservices—do they make adifference?

Following the publication of ComprehensiveCritical Care (DoH 2000), a considerablenumber of Acute Care Hospital Trusts, in theUnited Kingdom, have established Critical CareOutreach services. The remit of the service is to:

1. avert admissions by identifying patientswho are deteriorating and either helping toprevent admission or ensuring thatadmission to a critical care bed happens in atimely manner to ensure best outcome.

2. enable discharges by supporting thecontinuing recovery of discharged patientson wards and post discharge from hospital,and their relatives and friends.

3. share critical care skills with ward staff inwards and the community ensuringenhancement of training opportunities andskills practice and to use informationgathered from the ward and community toimprove critical care services for patientsand relatives. (DoH 2000, pp 14–15)

Examples of good practice were givenwithin the document, however the compositionof the service was not described. This has ledto a number of different models beingintroduced around the country, which a recentmeeting of the critical care sub-group of theNHS Modernisation Agency has confirmed.The service models comprise consultant nursesworking alone, consultant nurse led teams ofnurses who may be both senior and junior,consultant nurse led teams of nurses who alsohave a member of the medical staff involved ateither consultant or registrar level and teamsof nurses who are led by a senior nurse, butnot a consultant nurse. Physiotherapists mayalso be part of the service.The activity undertaken as a result of

introducing an outreach service also differs.Some provide a hospital wide service whose

team members respond to Early WarningSystem Criteria such as those suggested inTable 1. These are often described as Patient AtRisk Teams (PART) (Goldhill et al. 1999).Theteam then normally follows up patients whotrigger these criteria for a number of hours ordays, or until the patient no longer triggers theEarly Warning System (EWS) criteria. TheEWS criteria have also been modified and ascore is attributed to certain categories ofaltered physiological scores. The aim of theseparticular teams is to avert admission tocritical care through early recognition of thedeteriorating patient and to ensure early andtimely admission to critical care if it is required.Other Critical Care Outreach Services have

concentrated on the follow-up of patientsimmediately after discharge from the criticalcare unit and following discharge fromhospital. In this model all patients arefollowed up from discharge to the ward untilthey no longer trigger criteria such as those inTable 1 or until the particular nurses followingup the patient are convinced the patient is nolonger at risk of deterioration. Follow-upservices at discharge from hospital also exist inmany acute care hospital trusts. Again thesediffer in their composition. Some comprise aspecialist nurse working alone, or with amedical consultant (Hall Smith et al. 1997) andsome are provided by members of the criticalcare outreach team. Some Follow-up services,following discharge from hospital, alsoprovide clinical psychologists.Finally, multidisciplinary education in the

recognition and management of critically illpatients is being provided in some acute carehospital trusts. These entail such programmesas the Acute Life-threatening-illnessRecognition and Treatment (ALERT) course orthe How to Evaluate and Treat Life

© 2002 E l sev i e r S c i ence L td . A l l r i gh t s re se r ved . Intensive and Critical Care Nursing (2002) 18, 257–260 257

doi:10.1016/S0964-3397(02)00064-2

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Table 1 Early warning criteria

Early warning system Parameters

Respiratory rate <8 or >25Oxygen saturation <90% on 35% oxygenHeart rate <50 or >125Pyrexia >38 ◦CSystolic BP <90 or >200mmHgUrine output <30ml in 2h

Threatening Problems (HELP) course. Bothcourses utilise patient scenarios to aidlearning, rather than the use of talk and chalk.From the above description it can be seen

that an enormous amount of energy iscurrently being invested in to the recognitionand management of the patient at risk ofcritical illness. As yet there is little evaluativedata which supports the continued activity ofthe service. Evaluation in itself will be fraughtwith difficulty due to the different models ofservice delivery identified above. However,evaluation is extremely important if evidenceon effectiveness is to be demonstrated. Someevidence is currently available in relation tothe first example given above, the Patient AtRisk Team. Buist et al. (2001) has found thatthe early intervention of a Medical EmergencyTeam reduced the incidence of unexpectedcardiac arrest by about half. In this examplethe team comprised a medical registrar, anintensive care registrar and a senior intensivecare nurse. This format is different from thosedescribed above but nevertheless a reductionin cardiac arrest could be an importantmeasure of the impact of patient at riskactivity. Other important measures might beease of transfer into the critical care unit andperhaps a corresponding drop in admissionAPACHE score which might demonstrate thatalthough the patient still had to be admittedperhaps deterioration had been halted earlierin its course, thus possibly effecting survivalfrom critical illness.Follow-up after discharge from critical care

has also suffered from a lack of publishedevaluative data, despite evidence indicatingthat early discharge from intensive care isassociated with increased mortality (Daly et al.2001). We have recently concluded an audit ofthis activity at the Royal Free Hampstead NHSTrust and found that patient survival to

Table 2 A comparison of hospital outcome ofsurvivors admitted to critical care floor 4, 6 monthsbefore and after the introduction of the CCOTa

Outcome Before CCOT After CCOT

Number Percentage Number Percentage

Alive 92 74.2 114 88.4Dead 32 25.8 15 11.6Total 124 100 129 100

a t = 2.94; P = 0.004.

discharge from hospital has improvedsignificantly following the introduction of thisservice (Table 2). This could of course be dueto differences in the level of morbidity andphysiological reserve of the two patientgroups, or that survival from intensive carewas improved but as Tables 3 and 4demonstrate there was no significantdifference in the patient groups when boththese factors were reviewed. The resuscitationpolicy in the hospital also did not changeduring this time period. Readmission ratesalso dropped from 7.4% (n = 28), comparedwith 4.8% (n = 19) in the year following theintroduction of the follow-up service. We hopeto publish this data in the near future.Evaluation of follow-up of patients who

have recovered from critical illness following

Table 3 Probability of hospital mortality foradmissions to critical care floor 4, before and after theintroduction of the CCOTa

UK APACHE II probabilityof hospital mortality

Before CCOT After CCOT(n = 89) (n = 91)

Median 25.2 25.2Inter-quartile range 12.4–41.0 14.0–45.4

a Z = 0.15; P = 0.614.

Table 4 A comparison of mortality on discharge fromcritical care floor 4, before and after the introductionof the CCOTa

Outcome Before CCOT After CCOT

Number Percentage Number Percentage

Alive 124 66 129 70.4Dead 64 34 54 29.5Total 188 100 183 100

a t = 0.94; P = 0.35.

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Critical care outreach services

discharge from hospital has demonstrated thatpatients who choose to attend the clinic are ableto discuss residual problems associated withtheir critical illness and receive appropriatereferral (Jones et al. 1998, 2001a; Jones &Griffiths 2000). Recent work by Jones et al.(2001b) has demonstrated a positive impact onsmoking cessation following the introductionof a rehabilitation programme after criticalillness. However, more evaluative data isrequired in terms of reducing the readmissionof patients from the community who areknown to be at risk such as those who havereceived long term ventilation (Douglas et al.2001) and the elderly (Nierman et al. 2001),albeit that the measurement of health outcomesis fraught with difficulty (Hayes et al.2000). Future studies are therefore required toincorporate rigorous methodologies andtriangulation if patient outcomes, followingcritical illness, are to be examined adequately.Finally, educational evaluation frequently

stops at the immediate request to rate thestudy day in terms of utility and presentation.What remains unknown is whether one studyday makes a difference to the early recognitionand management of critically ill patients.Obviously there are many factors at play here,and it would be extremely difficult to evaluatethe impact on patient care and outcome overtime. Nevertheless a considerable amount ofresources are consumed in the developmentand delivery of these courses, not only interms of faculty time but also in releasingmedical and nursing staff to attend. Some longterm evaluation does therefore appear to bewarranted, even if this is qualitative in nature,for example ascertaining how much of thecourse has been retained six months after thestudy day or the utilisation of this knowledgefollowing triggered EWS criteria. This wouldnot, however, indicate the EWS criteria that hadbeen missed in the hospital. In this instancereview of admissions to critical care from thewards could be helpful, perhaps using thecriteria provided by McQuillan et al. (1998) of:

• Failure of organisation;• Lack of knowledge;• Failure to appreciate clinical urgency;• Lack of supervision;• Failure to seek advice.

All of which should be improved followingexperience of ALERT or HELP courses.The evaluation of outreach services as they

exist in the UK today, in all their many guises,may be difficult, but in contrast to MedicalEmergency Teams the majority of outreachservices are nurse led, in the United Kingdom,and it is vital that these services are evaluatedfor their effect. Otherwise as with otherinitiatives in nursing which have beenaccompanied by a lot of activity andenthusiasm, evaluation is absent, the impactunknown and the service discontinued.

References

Buist MD, Moore GE, Bernard SA, Waxman BP, AndersonJN, Nguyen TV 2001 Effects of a medical emergencyteam on reduction of incidence of and mortality fromunexpected cardiac arrests in hospital: a preliminarystudy. British Medical Journal 324: 387–390

Daly K, Beale R, Chang RWS 2001 Reduction in mortalityafter inappropriate early discharge from intensivecare unit: logistic regression triage model. BritishMedical Journal 322: 1–5

Department of Health 2000 Comprehensive Critical Care:A Review of Adult Critical Care Services. TheStationary Office, London

Douglas SL, Daly BJ, Brennan PF, Gordon NH, Uthis P2001 Hospital readmission among long-termventilator patients. Chest 120: 1278–1286

Goldhill DR, White SA, Sumner A 1999 Physiologicalvalues and procedures in the 24 h before ICUadmission from the ward. Anaesthesia 54: 529–534

Hall Smith J, Ball C, Coakley J 1997 Follow up servicesand the development of a clinical nurse specialist inintensive care. Intensive and Critical Care Nursing13: 243–248

Hayes JA, Black NA, Jenkinson C, Young JD, Rowan KM,Daly K, Ridley S 2000 Outcome measures for adultcritical care: a systematic review. Health TechnologyAssessment

Jones C, Humphris GM, Griffiths RD 1998 Psychologicalmorbidity following critical illness—the rationale forcare after intensive care. Clinical Intensive Care 9:199–205

Jones C, Griffiths RD 2000 Identifying post intensive carepatients who may need physical rehabilitation.Clinical Intensive Care 11: 35–38

Jones C, Griffiths RD, Humphris G, Skirrow PM 2001aMemory, delusions, and the development of acuteposttraumatic stress disorder-related symptoms afterintensive care. Critical Care Medicine 29: 573–580

Jones C, Griffiths RD, Skirrow P, Humphris G 2001Smoking cessation through comprehensive criticalcare. Intensive Care Medicine 27: 1547–1549

McQuillan P, Pilkington S, Allan A, Taylor B, Short A,Morgan G, Nielsen M, Barret D, Smith G 1998Confidential inquiry into quality of care before

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admission to intensive care. British Medical Journal316: 1853–1858

Nierman DM, Schechter CB, Cannon LM, Meier DE 2001Outcome prediction for very elderly critically illpatients. Critical Care Medicine 29: 2020–2021

Carol BallEditor-in-Chief

Royal Free HospitalNurse Consultant in Critical CarePond Street, NW3 2QG LondonUK. Tel: +44 (0) 20 7472 6137

Fax: +44 (0) 20 7472 2469E-mail: carol.ball@rfh.nthames.nhs.uk

260 Intensive and Critical Care Nursing (2002) 18, 257–260 © 2002 E l sev i e r S c i ence L td . A l l r i gh t s re se r ved .