Intensive and Critical Care Nursing (2006) 22, 127—129

EDITORIAL

Whither critical care outreach?

The development of Critical Care Outreach Ser-vices (CCOS) has been exponential albeit in variousguises such as the Medical Emergency Team (MET)and Intensive Care Liaison nurse in Australia, theRapid Response Team in the USA and Patient atRisk teams in the UK. Their effectiveness or oth-erwise on patient survival and morbidity has yetto be demonstrated in prospective multi-centrestudies, the evidence base being predominantly

• Could we work more closely with the patient’sown medical and nursing team?

• Should these issues be considered afresh in thelight of the recently published guide to theimplementation of the Surviving Sepsis Campaign(2005)?

It is vital that the resuscitation of a patient withsuspected severe sepsis or sepsis induced hypop-

founded on retrospective level 3 studies. System-atic reviews of both CCOS and the use of physio-logically based early warning systems (frequentlyreferred to as track and trigger systems) are cur-rently being undertaken as part of a larger studyfunded by the UK National Health Service Researchand Development Service Delivery and OrganisationProgramme but these have yet to be published.This has not, however, prevented influential organ-isations such as the National Confidential Enquiryinto Patient Death and Outcome (NCEPOD) recom-mending CCOS be established in all hospitals ona 24/7 basis alongside the use of track and trig-ger systems ‘which should be linked to a responseteam that is appropriately skilled to assess and

erfusion should commence as soon as possible. Itshould not be delayed by a skills deficit in iden-tifying and managing the deteriorating patient ordependent on admission to the intensive care unit.However the measurement of blood pressure, oneof the key variables associated with the diagnosisof severe sepsis or septic shock, is neither sensi-tive nor specific. We are all aware of the problemsassociated with automated versus manual record-ings, the competency of the practitioner recordingthe blood pressure and whether the patient has arelative hypotension even if the systolic pressureis above 90 mmHg. There are also patient groups inwhom even accurate blood pressure recordings lack

manage the clinical problems.’ (NCEPOD, 2005, p.3

ttlatteTt

•

sensitivity and specificity. In particular young fitpeople who can compensate almost to the point ofcpddeai>tifs

t

0 eservd

).There are clearly great methodological difficul-

ies associated with research which seeks to inves-igate interventions which are systems based, noteast of which are the vagaries of the participantsnd the resultant Hawthorne effect. However doeshe way we work, and the track and trigger sys-ems with which we work, also lead to less thanffective management of the deteriorating patient?his editorial seeks to address the following ques-ions:

Are track and trigger systems sufficiently com-prehensive or do they require expansion?

964-3397/$ — see front matter © 2006 Elsevier Ltd. All rights roi:10.1016/j.iccn.2006.04.001

ardiac arrest and women with raised cardiac out-ut in the third trimester of pregnancy. Given theseifficulties it would be more effective to know theegree of tissue hypoperfusion a patient is actuallyxperiencing, particularly if infection is suspectednd general inflammatory variables are triggering,.e. core temperature < 36 ◦C > 38.3 ◦C, heart rate90/min, respiratory rate >25, altered mental sta-us. To this end the measurement of serum lactates important because it can identify tissue hypoper-usion in patients who are not known to be hypoten-ive.

One general drawback to this is that serum lac-ate only reflects a global reduction in perfusion

ed.

128 Editorial

rather than one which is organ specific. Never-theless it may be definitive in those discussionsrevolving around whether a patient requires moreintravascular ‘filling’ or not. A serum lactate of>2 mmol aids the diagnosis of tissue hypoperfusionand >4 mmol signals the need for goal directed fluidresuscitation, achieving a central venous pressureof >8 mmHg together with a superior vena cava oxy-gen saturation (ScvO2) of >70% or a mixed venousoxygen saturation (SvO2) of >65% (Townsend et al.,2005).

The measurement of serum lactate requiresarterial blood gas aspiration. This is to avoid ‘false’high lactate readings from peripheral venous sam-ples either due to poor peripheral blood flow orthe damage caused by the use of tourniquets. Goaldirected fluid resuscitation and the restoration ofcirculating volume necessitate the insertion of acentral venous catheter. These are advanced skillsboth for nurses involved in the CCOS and for juniordoctors. The MET system in Australia ensures theattendance of an intensive care doctor skilled inthese techniques; however in the UK where CCOSare predominantly led by nurses, this is not alwaysthe case.

rather then rely solely on the intensive careregistrar.

Another possible role for the CCOS in tandemwith acute physicians would be to engage in pre-ventative management. Currently, care bundles areused within the domain of intensive care but theirintroduction to ward areas could potentially reducethe incidence of acute deterioration and criticalillness. Based on the evidence that exists alreadyit would be possible to introduce an ‘acute care’care bundle to ward areas for every patient admit-ted to acute hospitals. This would include DVTand stress ulcer prophylaxis, sitting patients upat 45◦ or more, keeping the blood sugar below10 mmol/l (as this was correlated with mortality invan den Bergh’s (2001) study) and the institution ofthe sepsis resuscitation bundle should the patientdemonstrate early signs of sepsis (Townsend et al.,2005).

Integration of CCOS and cardiac resuscitationteams is a further possibility, where medical staffare already aligned to resuscitation. The outcomeof cardiac arrest is very poor particularly in thosewho present with pulseless electrical activity (Cohnet al., 2004). The introduction of CCOS was, inpmiy2wtktsapcdant

bevalthmobtat

There are several solutions to this dilemma. Theintroduction of advanced nurse practitioners withacute care skills, as in the USA, is one possibility. Ifthis were to be considered, the role should be onewhich extends beyond cannulation to incorporatethe ordering of diagnostic tests, in particularchest X-ray, chemical pathology, full blood countand clotting to identify inflammatory variablestogether with prescribing rights for antibiotics andindependence in relation to intravascular filling.It is unlikely that in severe sepsis a single 250 mlcolloid challenge will be sufficient to restoretissue perfusion. This introduction of the advancednurse practitioner would not necessarily developthe acute care skills of the patient’s medicaland nursing team however. Problems could alsoarise in the interpretation of specific tests ifthe advanced practice nurse were unaware ofthese reflecting the patient’s underlying pathologyrather than the effect of inflammatory mediators.An example of this could be an elevated lactateprimarily due to decreased clearance by the liver.Another solution is the introduction of the acutephysician (NCEPOD, 2005) who could be accessedby the CCOS for support in the managementof deteriorating patients. This would have theadded benefit of being a ward-based role whichpotentially could, through role modelling, improvethe management of deteriorating patients. Itwould also increase the critical mass of staffable to manage acutely deteriorating patients

art, a response to this indicating the need toanage patients more effectively and reduce the

ncidence of cardiac arrest, although research haset to demonstrate this effect (Hillman et al.,005). One of the main limitations of this studyas the Hawthorne effect, alluded to earlier in

his editorial, where resuscitation teams had priornowledge of the MET system and began to func-ion in a similar manner. Given that outcomes areo poor and that prevention is better than cure

combined CCOS/Resus force, aligned to acutehysicians, focused on prevention, swift identifi-ation and effective management may togetherecrease the morbidity and improve the survivalssociated with acute deterioration and critical ill-ess which has yet to be demonstrated across mul-iple sites.

In conclusion, the future of CCOS continues toe one of change rather than atrophy. An increasedmphasis now needs to be placed on the pre-ention of acute deterioration through the avoid-nce of adverse events such as pulmonary embo-us, acute gastro-intestinal bleeding and respira-ory tract infection. Earlier identification of tissueypoperfusion should be evident through measure-ent of serum lactate rather than an over reliance

n blood pressure readings. Finally, systems shoulde in place to achieve this through the poten-ial introduction of advanced nurse practitioners orcute physicians and a combined team of resusci-ation and CCOS.

Whither critical care outreach? 129

References

Cohn AC, Wilson WM, Yan B, Joshi SB, Heily M, Maruf P, et al.Analysis of clinical outcomes following in hospital cardiacarrest. Internal Med J 2004;34:398—402.

Hillman K, Chen J, Cretikos M, Bellomo R, Brown D, Doig G, et al.,MERIT study investigators. Introduction of the medical emer-gency team (MET) system: a cluster-randomised controlledtrial. Lancet 2005;365:2091—7.

NCEPOD. An Acute Problem June; 2005.Townsend S, Dellinger RP, Levy MM, Ramsey G. Implementing the

Surviving Sepsis Campaign. Society of Critical Care Medicine,

European Society of Intensive Care Medicine, InternationalSepsis Forum; 2005.

van den Bergh G, Wouters P, Weekers F, Verwaest C, BruyninckzF, Scetz M, et al. Intensive insulin therapy in the critically illpatients. N Engl J Med 2001;345:1359—67.

Editor-in-ChiefCarol Ball

Pond Street, London NW3 2QG, United Kingdom

E-mail address: Carol.Ball@royalfree.nhs.uk