Implementation of a critical care outreach service: a qualitative study.

AIM: The aim of this study was to explore hospital staff perceptions of the perceived challenges and outcomes of implementing a critical care outreach service. BACKGROUND: A nurse-led critical care outreach service was designed and implemented to identify and treat acutely ill patients in a large tertiary care hospital in Iran. METHODS: A qualitative analysis of data from two focus groups and seven interviews was carried out using conventional content analyses techniques. A total of 24 hospital staff members participated, including critical care outreach team members, physicians, ward head nurses and ward staff. FINDINGS: Two main categories described the perceived challenges to the implementation of the critical care outreach service: 1) the hospital context, with four subcategories related to staff shortages, the instability of physician positions, the lack of specialized essential services and the absence of a system to establish do-not-resuscitate orders, and 2) staff resistance to different nursing priorities, routines and extra work. In two additional main categories, participants also described positive and negative perceived outcomes. The positive perceived outcomes included three subcategories of alleviating equipment shortages, improving nursing knowledge and patient care and improving patient and healthcare professional satisfaction. DISCUSSION: While critical care outreach has the potential to improve patient perceived outcomes and both patient and provider satisfaction with care, the contextual and clinical realities in hospitals are significant and must be examined during the planning and implementation of future outreach. CONCLUSION AND IMPLICATIONS FOR NURSING AND HEALTH POLICY: A critical care outreach service in the context of an Iranian hospital has the potential to improve ward nurse familiarity with the care of acutely ill patients and the quality of palliative care. However, attention ought to be paid to the hospital's structural and contextual factors. Alleviating nursing shortages, reducing staff resistance and preparing goals of care guidelines that address restrictions on resuscitation could facilitate implementation of critical care outreach services.

Effectiveness of regionalization of trauma care services: a systematic review.

OBJECTIVES: Improving trauma systems in various forms has always been an important aspect of health policy. While several papers have reported the implementation of a structured trauma system of care, research evidence on the effectiveness of such regionalization for improvement in trauma outcome is limited. STUDY DESIGN: Systematic review. METHOD: Medline, EMbase, EconLit and Health Management Information Consortium were searched, using sensitive search terms, for interventional studies that reported a trauma regionalization system as their intervention, and compared important outcomes such as mortality and preventable deaths. At least two authors assessed eligibility for inclusion and risk of bias, and extracted data from the included studies. As meta-analysis was not possible for all studies, two controlled before-after studies were included in the meta-analysis, and a narrative analysis was conducted for the other studies. RESULTS: After title and abstract sifting, 66 papers were retrieved. After reading the full texts, a total of 24 studies from the USA, UK, Canada, Australia, and the Netherlands were included in this review. In spite of variation in study specifications, most were before-after studies with a high risk of bias. Although a reduction in mortality was shown in most studies, only two studies were eligible for meta-analysis, and the results showed a significant reduction in mortality after implementation of an organized trauma system (odds ratio 0.840, 95% confidence interval 0.756-0.924; P = 0.00). CONCLUSION: Correlation was found between a regionalized network of trauma care and a reduction in trauma-related mortality, based on studies that did not exclude the effects of other concurrent changes on observed reductions. It is recommended that more studies with robust research designs should be conducted in a more diverse range of countries to assess the effectiveness of regionalization. Despite this limitation, the present findings support the regionalization of trauma care services.