An evaluation of the contribution of critical care outreach to the clinical management of the critically ill ward patient in two acute NHS trusts.

This paper reports on an evaluation of the role and contribution of outreach in the management of the critically ill ward patient using Stake's Responsive Model (Stake, 1975) and case study methodology (Simons, 1980). Twenty cases were examined, purposefully sampling all staff involved in the case identified by an initial interview with the outreach nurse. In total, 80 interviews were carried out, 20 with the outreach nurses and 54 with other members of health care teams involved in the cases, and six further targeted in-depth interviews with senior anaesthetic and nursing staff. The outreach contribution which emerged from the data analysis consisted of four core categories: action (getting things done, getting decisions made and following through), focus and vision (concentrating on one patient and having a vision of what action was needed to meet their care needs), orchestration (a communication and co-ordinating role) and expertise (bringing critical care skills and experience to the bedside). These categories were validated and developed in the six in-depth interviews. Three themes emerged from the data describing aspects of the acute care context in which outreach operates. The interviews revealed a battleweary workforce overwhelmed by the complex and increased demands of the critically ill ward patient. The medical and nursing teams at the bedside are inexperienced and often unsupported by senior clinical decision-makers. This is dealt with by 'passing the buck' creating gaps and delays in care management which are the problems addressed by the outreach contribution. Outreach may solve problems for the critically ill ward patient, but the underlying causes remain poorly understood.

Nursing observations on ward patients at risk of critical illness.

Research findings and anecdotal evidence from outreach nurses across the country have suggested that key indicators of critical illness (respiratory rate and fluid balance) are being missed on the wards and that critically ill patients are not being fed adequately. A group of outreach nurses in Kent carried out a survey to confirm or refute these claims and to ascertain the variation in outreach provision in Kent. The survey found widespread deficiencies in nursing care and observations, which represent a serious threat to patients' safety.

Points of view.

As a nurse in a small district general hospital, I have been called upon to accompany patients who are being transferred to London hospitals for specialist treatment of conditions such as renal or hepatic failure, acute head injury and ischaemic heart disease.