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.

Patient- and relative-activated critical care outreach: a 7-year service review.

Five years following the introduction of a whole-hospital, 24-hour critical care outreach (CCO) service, an additional service was introduced that enabled patients and their families to directly call the CCO team if they had concerns that were not being acknowledged by the patient's clinical team. The aim of this review was to report on 7 years of patient and family referrals using quantitative and free text data extracted from the CCO referral database. Information on demographics, frequency, nature and reason for the referrals have been reported that highlight the feasibility of such a service, and the potential to prevent patient deterioration. By tapping into the rich source of information from family concerns, future hospital services could be designed that could not only have an impact on patient outcome, but also positively influence the quality of the patient experience.

Detection and management of the deteriorating ward patient: an evaluation of nursing practice.

AIMS AND OBJECTIVES: To audit ward nursing practice in the adherence to an early warning scoring protocol in the detection and initial management of the deteriorating ward patient and investigate factors that may impact on practice. BACKGROUND: Hospital inpatients can experience unexpected physiological deterioration leading to poor outcomes and death. Although deterioration can be signalled in the patients' physiological symptoms, evidence suggests that ward staff can miss, misinterpret or mismanage the signs. Rapid response systems have been implemented to address this problem. The rapid response systems consists of two phases: the afferent phase involves monitoring the patient, recognising deterioration and referring to more expert help and the efferent phase involves expert teams assessing and treating the patient. Research has tended to concentrate on the efferent phase of the process and has so far failed to show a significant impact on patient outcome. METHODS: Using cardiac arrest as a surrogate marker for deterioration, patient records were retrospectively reviewed during the 12 hours prior to the cardiac arrest event. Data relating to nursing practice and adherence to the early warning scoring protocol were extracted and analysed. FINDINGS: The findings suggest that ward nurses' monitoring of patients' observations has improved compared with earlier research, but errors in early warning scoring and nonadherence to referral protocols are still a problem. A number of potentially influential factors on nursing practice were tested, but only deterioration occurring outside normal weekdays was associated with a reduced quality of nursing adherence to protocol. CONCLUSIONS: The implementation of rapid response systems may have been an oversimplified solution to the highly complex problem of undetected patient deterioration. There are a multitude of contributory factors to the problem of noncompliance to early warning scoring protocols, and possible solutions will need to reflect the breadth, depth and complexity of the problem if we are to improve patient experience and outcome. RELEVANCE TO CLINICAL PRACTICE: An audit of nursing practice against an early warning scoring protocol based on national recommendations and standards in the recording of and response to physiological deterioration in the ward patient has shown that vital signs recording has improved, but early warning scoring accuracy and referral to more expert help remain suboptimal. By identifying areas of suboptimal practice, strategies for education and training and service development can be better informed. More in-depth evidence on factors that may impact the quality of nursing practice has been identified. Problems with rapid response systems assumptions have been highlighted, which may facilitate the implementation of more realistic solutions for managing the deteriorating ward patient.

An audit of independent nurse prescribing in a critical care outreach team.

BACKGROUND: In 2006, legislative changes enabled independent prescribers to prescribe any licensed medication within their field of expertise. This has transformed nurse prescribing and opened up more opportunities for nurses to develop their practice in acute care settings. The need for further evaluation in this developing area of advanced practice was highlighted in the British Association of Critical Care Nurses (BACCN) position statement published in 2009. AIMS: The aims of this audit were to describe the prescribing practices of nurses working in a critical care outreach (CCO) team by exploring: which medications were prescribed; the number of prescribing decisions being made and if prescribing practice changed during the out of hours period. The findings can be used to inform practice, develop CCO services, provide a basis for further research, and contribute to the debate in this developing area of CCO practice. METHODS: The prescribing practices of two independent non-medical prescribers in a CCO team were audited from January to April 2011. RESULTS: The findings showed that; there were a wide range of medications prescribed, that prescribing decisions increased over time and that the majority of prescriptions were written out of hours. CONCLUSIONS: This preliminary audit has shown that prescribing in a CCO setting which covers a wide patient population is manageable. By evaluating drug prescribing patterns, a 'critical care outreach formulary' can be developed to guide individuals and the team in their continuing professional and service development. The CCO teams ability to prescribe could have the potential to improve the patients' experience and outcome, and positively affect the efficiency of service delivery; however, an increase in CCO referrals can have an impact on the CCO service resource. Further evaluation and study are needed to explore this developing area of critical care delivery.

Understanding the use of the National Early Warning Score 2 in acute care settings: a realist review protocol.

INTRODUCTION: Failure to recognise and respond to patient deterioration in an appropriate and timely manner has been highlighted as a global patient safety concern. Early Warning Scores (EWSs) using vital signs were introduced to address this concern, with the aim of getting the patient timely and appropriate treatment. The National Early Warning Score 2 (NEWS2) is in use across the NHS, and many other settings globally. While patient improvements have been shown, research has identified that the NEWS2 is not always used as intended. Therefore, this review will use a realist approach to understand what the mechanisms are that influence appropriate use (or not) of the NEWS2 in acute care settings, how, for whom and in which contexts. The findings will inform clinicians of what helps and/or hinders appropriate use of the NEWS2 in clinical practice, thus helping to facilitate successful implementation. METHODS AND ANALYSIS: Our realist review will follow Pawson's iterative six step process: (1) Development of initial programme theory. (2) Searching the literature; an information scientist will develop, pilot and refine the search strategy. A systematic search will be completed, based on subject relevancy on the following databases: Cumulative Index to Nursing and Allied Health Literature (CINAHL), Medline, Embase (OvidSP), Web of Science (Science Citation Index and Social Science Citation), Cochrane Database of Systematic Reviews, Joanna Briggs Institute, Ethos, Proquest Dissertations and Theses Global, and Google Scholar for documents dating from 1997 (date of the first published EWS) to present. To retrieve additional relevant data 'snowballing' (finding references and authors by hand, contacting authors, searching reference lists and citation-tracking using Google Scholar) will be used. Inclusion criteria include all documents (including grey literature) that relate to the use of EWSs/NEWS2 in the English language only. Documents set in the paediatric, maternity and primary care settings will be excluded. (3) Selecting documents and quality appraisal. (4) Extracting and organising the data. (5) Synthesising the data. (6) Disseminating the findings. We will recruit a group of stakeholders comprised of experienced clinicians who use the NEWS2 as part of their clinical practice to provide feedback throughout the review. Step 1 has already begun with the development of an initial programme theory. This initial programme theory presents how the NEWS2 is supposed to work (or not), it will now be developed, tested and refined. ETHICS AND DISSEMINATION: Ethical approval is not required for this study as it is secondary research. Dissemination will include a peer-reviewed publication and conference presentations. Findings will also be amplified through social media platforms with user friendly summaries. Our stakeholder group will also contribute to dissemination of findings in their clinical areas and among existing networks. PROSPERO REGISTRATION NUMBER: CRD42022304497.

Human factors and patient safety: changing roles in critical care.

The high numbers of patients suffering from adverse incidents has resulted in wide spread commitment to improving patient safety. While a lack of technical skill can play a part, there is growing evidence that poor non-technical skills can be a major cause of error in healthcare. Non-technical skills, or human factors, play an important role in improving team function and improving these skills can drive improvements in patient safety and outcome. This editorial challenges traditional role stereo-types, and argues that fundamental changes in the behaviour of professionals need to be made, and sustained, in order that the whole team can make a valuable contribution to the patient safety agenda.

When patients (and families) raise the alarm: Patient and family activated rapid response as a safety strategy for hospitals.

Patients and those close to them often have an intimate understanding of their condition and can participate in a broad range of clinical processes. During times of deterioration, their concerns might go unheard. Advocacy of family and friends can fulfil an important safety function and can support patients and healthcare professionals looking after them. If concerns by patients are not heard by the patient's primary team in hospital, patient and family activated rapid response systems allow patients and family members to alert critical care outreach teams directly. These types of systems are stipulated by regulators in Australia and in parts of the USA, and there are examples in the UK built around the 'Call for Concern' model championed by the Royal Berkshire Hospital. Implementation is not without its problems and requires a deep understanding of barriers and enablers. Empowering patients to escalate directly might help to change safety culture and have protective effects for patients and staff. Policy makers are urged to consider standardised regulation to aid implementation.

Call 4 Concern: patient and relative activated critical care outreach.

Patients can experience unexpected deterioration in their physiological condition that can lead to critical illness, cardiac arrest, admission to the intensive care unit and death. While ward staff can identify deterioration through monitoring physiological signs, these signs can be missed, interpreted incorrectly or mismanaged. Rapid response systems using early warning scores can fail if staff do not follow protocols or do not notice or manage deterioration adequately. Nurses often notice deterioration intuitively because of their knowledge of individual patients. Patients and their relatives have the greatest knowledge of patients, and can often pick up subtle signs physiological deterioration before this is identified by staff or monitoring systems. However, this ability has been largely overlooked. Call 4 Concern (C4C) is a scheme where patients and relatives can call critical care teams directly if they are concerned about a patient's condition- it is believed to be the first of its kind in the UK. A C4C feasibility project ran for six months, covering patients being transferred from the intensive care unit to general wards. C4C has the potential to prevent clinical deterioration and is valued by patients and relatives. Concerns of ward staff could be managed through project management. As it is relatively new, this field offers further opportunities for research.

Are early warning scores the only way to rapidly detect and manage deterioration?

A systematic literature review recently highlighted the complexity of nursing practice in terms of detecting and managing deteriorating ward patients (Odell et al, 2009). The findings suggest that rapid response systems, including early warning scores, may not be the only solution to the problems of detecting and managing signs of deterioration. This article summarises the findings of this review.

Understanding 'do not attempt resuscitation' orders.

This article outlines the issues that influence the process of writing a 'do not attempt resuscitation' order. It discusses advance directives, the Mental Capacity Bill and patient and relative involvement, and their impact on making decisions about cardiopulmonary resuscitation (CPR).

Sepsis: early detection and care.

Nurses need to be aware of the signs and symptoms of sepsis. Staff education to encourage the early identification of this life-threatening condition will be aided by a new resource kit.

A review of nursing skill-mix to optimise care in an acute trust.

The main resource of the NHS is its workforce. However, achieving the correct mix of staff is crucial if it is to provide high-quality patient care in a cost-effective manner. When an acute trust was singled out in an independent analysis as having 'too rich' a skill-mix (compared with the rest of the strategic health authority), an internal review was undertaken to determine the ratio of qualified to unqualified nursing staff, and to compare these with acuity and dependency in each clinical area. The information was used to revise the nursing skill-mix within the trust.

Nurses' role in detecting deterioration in ward patients: systematic literature review.

AIM: This paper is a report of a review conducted to identify and critically evaluate research investigating nursing practice in detecting and managing deteriorating general ward patients. BACKGROUND: Failure to recognize or act on deterioration of general ward patients has resulted in the implementation of early warning scoring systems and critical care outreach teams. The evidence of effectiveness of these systems is unclear. Possible mechanisms for low effectiveness may be inconsistent recording of patient observations by ward staff, or inconsistent application of 'calling criteria' for outreach teams, even when observations have been recorded. METHODS: The literature was searched between 1990 and 2007 using four sources: electronic databases, reference lists, key reports and experts in the field. Three broad search categories were used: nursing observations, physiological deterioration and general ward patients. All research designs describing nursing observations (vital signs) on deteriorating adult patients in general hospital wards were included. RESULTS: Fourteen studies met the inclusion and quality criteria. The findings were grouped into four main themes: recognition; recording and reviewing; reporting; and responding and rescuing. The main findings suggest that intuition plays an important part in nurses' detection of deterioration, and vital signs are used to validate intuitive feelings. The process is highly complex and influenced by many factors, including the experience and education of bedside nurses and their relationship with medical staff. CONCLUSION: Greater understanding of the context within which deterioration is detected and reported will facilitate the design of more effective education and support systems.

The critical care outreach service and the early warning system on surgical wards.

The implementation and evaluation of a modified early warning system (MEWS) on surgical wards are described. The MEWS was found to be a useful adjunct to the outreach service. Early data have shown that MEWS can help direct critical intervention. Ward staff have benefit from both the MEWS and the outreach service.