Critical care outreach physiotherapy response to deteriorating patients on acute hospital wards: An observational cohort study.

UK prescribing legislation changes made in 2006 and 2012 enabled appropriately qualified nurses to prescribe any licensed medication, and all controlled drugs in schedule 2-5 of the Misuse of Drugs Regulations 2001, for any medical condition within their clinical competence. Critical Care Outreach nurses who are independent nurse prescribers are ideally placed to ensure that acutely ill patients receive treatment without delay. The perceived challenge was how Critical Care Outreach nurses would be able to safely prescribe for a diverse patient group. This study informs this developing area of nurse prescribing in critical care practice. The aims of the audit were to: identify which medications were prescribed; develop a critical care outreach formulary; identify the frequency, timing and number of prescribing decisions being made; identify if prescribing practice changed over the years and provide information for our continuing professional development. This article reports on data collected from a 5-year retrospective audit; of prescribing activity undertaken by nine independent nurse prescribers working in a 24/7 Critical Care Outreach team of a 600-bedded district general hospital in the UK. In total, 8216 medication items were prescribed, with an average of 2·6 prescribed per shift. The most commonly prescribed items were intravenous fluids and analgesia, which were mostly prescribed at night and weekends. The audit has shown that Critical Care Outreach nurse prescribing is feasible in a whole hospital patient population. The majority of prescribing occurred after 16:00 and at night. Further research would be beneficial, particularly looking at patient outcomes following reviews from prescribing critical care outreach nurses. The audit is one of the only long-term studies that describes prescribing practice in Critical Care Outreach teams in the UK.

<h3>Background</h3> Patients with life limiting illnesses commonly present to hospital acutely and are referred to the Critical Care Outreach Team (CCOT). It is frequently concluded that escalation of care is inappropriate due to the partially or completely irreversible nature of deterioration. In such cases escalation of palliative care is fundamental. We performed a retrospective service evaluation of patient outcome following critical care outreach review in patients deemed unsuitable for critical care admission and evaluated appropriateness of referral to the Specialist Palliative Care Team (SPCT). <h3>Methods</h3> This was a two-centre study. Paper medical notes from a were reviewed. SPCT involvement was assessed for appropriateness using a conceptual framework. <h3>Results</h3> 50 patients' (evaluated by CCOT but unsuitable for a higher level of care between October and December 2018) notes were reviewed. 34 (68%) died and 16 (32%) were discharged. Of those who died, the median time from initial CCOT review to death was 4.5 days. 6 (12%) of patients were referred to the SPCT. A further 7 (14%) were reviewed by the SPCT who proactively identified patients as end of life care through the discontinuation of physiological observations. However, 45 (90%) should have been referred. <h3>Conclusions</h3> CCOTs identify patients who are inappropriate for higher-level care. Most of these patients are unlikely to survive their hospital admission and the vast majority would benefit from SPCT review for appropriate symptom management and Advanced Care Planning (ACP). The term Acute Palliative Intervention (API) could be utilised to change the language and culture of care decisions.

To improve understanding of afferent limb behaviour in acute hospital ward settings, to define and specify who needs to do what differently and to report what afferent limb behaviours should be targeted in a subsequent multi-phase, theory-based, intervention development process. Focused ethnography was used including direct observation of nursing staff enacting afferent limb behaviours and review of vital signs charts. An observation guide focused observation on "key moments" of the afferent limb. Descriptions of observations from between 7 January 2019-18 December 2019 were recorded in a field journal alongside reflexive notes. Vital signs and early warning scores from charts were reviewed and recorded. Field notes were analysed using structured content analysis. Observed behaviour was compared with expected (policy-specified) behaviour. Observation was conducted for 300hr. Four hundred and ninety-nine items of data (e.g., an episode of observation or a set of vital signs) were collected. Two hundred and eighty-nine (58%) items of data were associated with expected (i.e. policy-specified) afferent limb behaviour; 210 (42%) items of data were associated with unexpected afferent limb behaviour (i.e. alternative behaviour or no behaviour). Ten specific behaviours were identified where the behaviour observed deviated (negatively) from policy or where no action was taken when it should have been. One further behaviour was seen to expedite the assessment of a deteriorating patient by an appropriate responder and was therefore considered a positive deviance. Afferent limb failure has been described as a problem of inconsistent staff behaviour. Eleven potential target behaviours for change are reported and specified using a published framework. Clear specification of target behaviour will allow further enquiry into the determinants of these behaviours and the development of a theory-based intervention that is more likely to result in behaviour change and can be tested empirically in future research.

Little research has examined the involvement of critical care outreach teams in end-of-life decision making. To establish how much time critical care outreach teams spend with patients who are subsequently subject to limitation of medical treatment and end-of-life decisions and how much influence the teams have on those decisions. A single-center retrospective review, with qualitative analysis, in a large cancer center. Data from all patients referred emergently for critical care outreach from October 2010 to October 2011 who later had limitation of medical treatment or end-of-life care were retrieved. Findings were analyzed by using SPSS 19 and qualitative free-text analysis. Of 890 patients referred for critical care outreach from October 2010 to October 2011, 377 were referred as an emergency; 108 of those had limitation of medical treatment and were included in the review. Thirty-five patients (32.4%) died while hospitalized. As a result of outreach intervention and a decision to limit medical treatment, 56 (51.9%) of the 108 patients received a formal end-of-life care plan (including care pathways, referral to palliative care team, hospice). About a fifth (21.5%) of clinical contact time is being spent on patients who subsequently are subject to limitation of medical treatment. Qualitative document analysis showed 5 emerging themes: difficulty of discussions about not attempting cardiopulmonary resuscitation, complexities in coordinating multiple teams, delays in referral and decision making, decision reversals and opaque decision making, and technical versus ethical imperatives. A considerable amount of time is being spent on these emergency referrals, and decisions to limit medical treatment are common. The appropriateness of escalation of levels of care is often not questioned until patients become critically or acutely unwell, and outreach teams subsequently intervene.

Introduction: The process and outcomes of a novel Critical Care Outreach Team (CCOT) staffed with dedicated critical-care advanced practice providers (APPs) collaborating virtually with an intensivist responding to rapid response team (RRT) activations is described. Methods: Upon RRT activation, the CCOT APP responds to the bedside to assess the patient and acute clinical situation while the CCOT intensivist reviews the electronic medical record for situational awareness of the patient’s hospital course. The CCOT APP and Intensivist in conjunction with the primary team develop a clinical care plan to manage the acute event. The CCOT APP remains with the patient until stabilization or escalation to the intensive care unit (ICU). The CCOT intensivist helps facilitate communication with primary and ICU teams, ensuring timely ICU transfers. CCOT interventions include medications, diagnostics, facilitating consults, transport, escalation of care, transitioning to comfort care, timely follow-up, and multidisciplinary communication. Results: CCOT evaluated 1,862 patients from July 2021 to June 2022 in a large, academic adult hospital. The average time spent on activations was 52 minutes with an average of seven interventions/patient. The ICU transfer rate decreased (37.0% from 46.6%) with no change in mortality (9.0% to 9.8%). Stepdown transfer increased from 3.7% to 9.3%. RRT documentation increased to 100% from 74%. Conclusions: A CCOT with dedicated APPs collaborating with a virtual intensivist can stabilize acutely deteriorating patients by remaining at the bedside, providing advanced interventions, improving communication with bedside providers, and decreasing the need for ICU transfers without increasing mortality. Improved documentation provided improved communication and billing for the institution.

Patients at risk of catastrophic deterioration are often identified too late. Delayed identification of sick patients and delayed referral to intensive care units might be associated with poor outcomes. The goal of the review is to assess the potential impact of systems that enable early detection of critically ill surgical patients. A Medline search was performed in September 2004. Other articles were identified using the bibliographies of papers found through Medline. All interventional trials reviewing the effect of Critical Care Outreach and Medical Emergency Teams were reviewed. There is evidence that simple algorithms based on bedside observations can identify a large proportion of sick patients on general wards. Non-randomised studies have shown mixed results on impact of these interventions on mortality, cardiopulmonary arrests and intensive care admissions. The majority of studies do not specifically address surgical patients. A ward-based randomised trial from the UK seems to suggest improved mortality following the introduction of a Critical Care Outreach service with an Early Warning Score. The literature about Critical Care Outreach and Medical Emergency teams is characterised by methodological weaknesses. However there is a common suggestion that early detection might improve outcome of critically ill surgical patients.

Re-admissions have been cited as a measure of critical care quality and outreach teams have recently been introduced to improve critical care delivery. The aim of this study was to examine whether the number, causes and sequence of re-admissions to critical care altered as a result of the introduction of an outreach team. Re-admissions between April 2000 and November 2001 were examined. The reasons for re-admission were classified as (i) same pathology or disease process; (ii) new, but related, pathology; (iii) new and unrelated pathology; (iv) exacerbation of other comorbidities. During the two-year period, a total of 2546 patients were admitted to critical care of which 100 were re-admitted (49 before outreach and 51 after outreach). The reasons for re-admission did not vary before or after the introduction of the outreach team (same pathology 15 vs. 15; new, but related, pathology 17 vs. 23; new, but unrelated, 14 vs. 9; exacerbation of comorbidity 3 vs. 4, respectively, Chi-squared = 2.07, df = 3, p = 0.56). There was also no difference between the duration of stay on the general ward in between the critical care unit admissions before (median 2.93 [interquartile range 1.32-6.05] days) or after (median 2.25 [interquartile range 1.06-6.32] days) the introduction of an outreach team. As we could not detect any change in patterns of re-admissions as a result of the introduction of an outreach team, we would suggest that although outreach is an important development for critical care, its performance should be measured by other parameters.

Critical care outreach teams were developed in the UK from the early 2000s onwards in response to evidence that the management of severely ill patients on hospital wards before admission to the intensive care unit was frequently suboptimal. Most hospitals in the UK have some form of CCOT, which is usually composed of senior nurses with extensive critical care experience. One of the goals of CCOTs is to provide educational support to staff to enhance their skills at recognising and managing deteriorating patients. However, the evidence regarding the effects of CCOTs is conflicting. This article describes a service evaluation conducted at an acute NHS trust in England to assess the effects of educational sessions designed and delivered by the local CCOT. The CCOT offered a study day on non-invasive ventilation for patients with type 2 respiratory failure to a group of ten nurses from different clinical areas. A pre-and post-study day questionnaire showed that all participants had increased knowledge levels at the end of the study day. If positive effects of CCOT-led study days on nurses' knowledge were consistently demonstrated, these study days could be considered as a practical and effective method of meeting the learning needs of nurses.

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The aim of this study was to explore hospital staff perceptions of the perceived challenges and outcomes of implementing a critical care outreach service. 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. 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. 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. 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. 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.

Background shared decision-making (SDM) has been recommended as the gold standard for decision making in end of life care when decisions may be complex and involve multiple possible courses of...

Hospitalised patients are at risk of temporary or permanent loss of functioning which impacts their future independence. Implementation of a rehabilitative approach in everyday nursing in the acute care setting may produce good therapeutic results and promote independent daily living of patients. Thus, the aim of the study was to explore and understand the patterns of a rehabilitative approach in acute hospital wards from the perspective of interdisciplinary team members. Specifically, our aim was to identify the factors promoting and preventing a rehabilitative approach. We conducted four focus group interviews with 21 participants, including multidisciplinary team members from acute hospital wards. Data were analysed with conventional inductive content analysis. The findings highlighted that the rehabilitative approach, as a personal way of working and personal working attitude, was a part of comprehensive nursing. The main goals of the rehabilitative approach were to support the physical functioning of the patients and their independent initiative and individuality during clinical care in hospital ward. The promoting and preventing factors that influenced the development of the rehabilitative approach consisted of personal factors, organisational factors and the physical settings of the hospital wards. The findings of this study indicate that the rehabilitative approach in nursing focused on supporting the physical functioning, independence and self-confidence of the patient. The staff highlighted that interdisciplinary teamwork was one feature of the rehabilitative approach. The rehabilitative approach in nursing should be established as a part of everyday activity in clinical practice.

Discharge delay, room for improvement?