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

The critical care outreach service (CCOS) was established in a large teaching hospital in the West of Ireland in 2014 to provide an extension of CCOS between the intensive care unit (ICU) and the wards outside ICU. With the ever-increasing pressure on ICU resources, CCOS seems to offer an additional service to patients who are critically ill and deteriorating in hospital wards. The aim of this study is to explore ward nurses' experiences and perceptions of the CCOS. A qualitative descriptive methodology aimed to obtain a descriptive account of ward nurses' experiences of the CCOS. Data were collected using semi-structured interviews. Twelve nurses from the West of Ireland participated in the study. Braun and Clarke's six-step thematic analysis was used to analyse the data. Three core themes identified in this study included clinical support and decision-making; sharing knowledge and skills, and communication. All 12 nurses identified the positive impacts that they felt the current outreach service provided to them on a daily basis. Study findings indicate that nurses value the role of the CCOS in supporting the care of the critically ill and deteriorating patients at ward level. The CCOS has become invaluable to the ward nurses in their daily practice especially at a time when resources are lacking and patient acuity is on the rise.

The deterioration of patients in general wards could go unnoticed owing to the intermittent monitoring of vital data. The delayed or missed recognition of deteriorating patients results in serious adverse events in general wards. These challenges have resulted in the development of a critical care outreach service. Australia was the first country to establish critical care outreach services in 1990. In South Africa, critical care outreach services were implemented in 2005 at a private hospital in Pretoria. The researcher has noticed certain phenomena supported by literature such as the hesitancy of nurses working in general wards to escalate a patient to a critical care outreach service, and incorrect interpretation of modified early warning scores which could cause delays in patients being referred to outreach nurse experts. In this study, nurses’ (professional, staff and auxiliary nurses) experiences in respect of their self-leadership in critical care outreach services were explored. To this end, a qualitative phenomenological research approach was followed. Focus groups were held with the nurses (all nurse categories) working in a South African private hospital which provides critical care outreach services. It is recommended that nurses be granted access to training sessions, workshops and information to provide appropriate nursing care. Nurses should be encouraged to focus on the positive outcomes of providing nursing care and to “applaud themselves mentally” when they have successfully assisted or cared for their patients. Nurses also need to identify and correct negative assumptions about their competence.

Quality improvements (QIs) in dynamic and complex health care contexts require resilience and take variability into account in quality improvement. The Functional Resonance Analysis Method (FRAM) helps us understand resilience and gain insight into (un)desirable variability in the complex system of daily practice. We explored how using FRAM in the Deming cycle of a QI project can help professionals and researchers learn from, reflect upon, and improve complex processes. We used FRAM in a Dutch hospital to study a QI: Critical Care Outreach Service (CCOS). The aim was to use FRAM before and after implementation to create a FRAM model and reflect to health care professionals the mismatch between Work As Imagined (WAI) and Work As Done (WAD). The WAI FRAM model was co-created with professionals before the implementation of CCOS. We used descriptions of tasks and processes for ICU nurses and verified them in 30-minute semistructured interviews (N = 2). WAD was created by input of semistructured interviews with key professionals in CCOS (N = 21) and 3 nonparticipant observations of trained CCOS nurses. We validated WAD in 2 dialogue sessions with key professionals (N = 11). Data collection continued until saturation. Juxtaposing the WAI and WAD models showed that WAD contained additional functions and highlighted unexpectedly complex functions. Reflecting on the application of FRAM with health care professionals revealed opportunities and challenges, especially time investment. FRAM helps professionals outline processes and tasks (WAI), learn from, and reflect upon their daily practice (WAD). FRAM models help professionals identify variability proactively to improve practices that enhance resilient performance.

The Recovery Period

Resuscitation highlights in 2011

Evaluation of a critical care outreach service in a middle-income country: A stepped wedge cluster randomized trial and nested qualitative study

Critical care outreach services--do they make a difference?

We explored the impact of critical care outreach activity on patient and service outcomes and aimed to contribute to developing a typology of critical care outreach services. Following a sample search of Medline 15 relevant electronic databases were systematically searched from 1996 to 2004. Searches for publications from nine key authors and citations of eight key articles were performed. Hand searches of journals, bibliographies of reports and review articles, and conference abstracts were conducted. Relevant experts were contacted. A further two studies published after the review date were also included. Two reviewers assessed studies for inclusion, conducted quality assessment and extracted data. Data were synthesised using narrative techniques. Seventeen papers and six brief reports were selected for inclusion from a list of 1,760 titles. As anticipated with a relatively new service such as critical care outreach, there were few controlled trials. There were two randomised controlled trials, 16 uncontrolled before and after studies, three quasi-experimental studies, one controlled before and after study and one post-only controlled study. The most frequent outcomes measured were mortality, cardiac arrest, unplanned critical care admissions from wards, length of stay, and critical care readmission rates. Although improvements in patient outcomes were found, the evidence in this review is insufficient to demonstrate this conclusively. The many differences in service delivery do not permit identification of service typology. Our findings point to a need for more comprehensive research of this expanding service in the United Kingdom.

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.

We read with interest the recent correspondence on critical care outreach (Kuehne. Anaesthesia 2002; 57: 183). The author suggested that lack of training for doctors in the care of the critically ill is one of the reasons for ‘inadequate or late initiation of appropriate intensive medical treatment at ward level’. Introductory training in acute/intensive care was recommended for all pre-registration house officers (PRHO). At the Sheffield Hospitals NHS Trust, we have tried to address this problem by providing the ALERT (Acute Life Threatening Events Recognition and Treatment) course [1] to PRHOs and other ward staff as part of several tailored educational packages. Since the introduction of ALERT, we have noticed that documentation by PRHOs in the medical notes appears to be more structured following the A, B, C approach advocated on the course. Aware of the need to evaluate the impact of outreach services in general, but more particularly with respect to this new resource, we have carried out a small audit to explore this further. Twenty sets of medical notes from one surgical ward were reviewed. All notes contained reviews of sick ward patients by PRHOs, prompted by a trigger of our in-house Patient at Risk scoring system. Eleven sets of notes had patient reviews prior to the introduction of ALERT, and 12 sets of notes contained reviews post ALERT. An arbitrary scoring system was used, awarding points for desirable records such as: time and date of review, name and bleep number being clearly recorded, documentation of respiratory rate and capillary refill, use of an airway, breathing, circulation approach, and clear instructions being written for nursing staff regarding observations to be carried out. From a total score of 12, the mean score from the pre-ALERT notes was 4.54 (range 3–6), and from the post ALERT notes was 7.75 (range 5–10), an improvement of 70%. The results of this small audit appear to suggest that the ALERT course has some impact, encouraging PRHOs to adopt the ABC approach to assessing␣sick patients, and improving documentation and communication. The ALERT course has consistently evaluated extremely well. All ward staff participants agree that it has increased their confidence and ability to care for sick patients on the wards. We advocate this course as a part of an educational␣approach to outreach critical care practice.

ObjectiveTo provide a detailed characterisation of clinicians’ work management strategies.Design1002.3 h of observational data were derived from three previous studies conducted in a teaching hospital in Sydney, Australia, among emergency...

Does the use of a “track and trigger” warning system reduce mortality in trauma patients?

This report presents the key findings of a travel scholarship to selected paediatric centres in the United Kingdom (UK), Australasia and the United States of America, where services provision for the care of acutely ill children within ward areas was investigated. In total, 15 centres were visited over a 5-month period, and comprehensive programs of information exchange were arranged in all locations. Key areas of interest discussed were the concepts of paediatric critical care outreach services and the use of paediatric early warning assessment tools. Information was collated and applied to the existing service provision within a tertiary children's hospital in the UK. It is hoped that the information gained during this professional study tour will add to the current available literature. It has helped to clarify the position of other key centres with regard to the care provision for acutely ill children in ward areas and confirmed the potential value of a support system and/or use of clinical assessment tool for staff caring for these children.

A survey of ward nurses attitudes to the Intensive Care Nurse Consultant service in a teaching hospital

Back to table of contents Next article Taking IssueFull AccessHalf Full or Half Empty?Gregory A. Miller M.D., M.B.A.,Lisa B. Dixon M.D., M.P.H.,Gregory A. Miller M.D., M.B.A.Search for more papers by this author,Lisa B. Dixon M.D., M.P.H.Search for more papers by this author,Published Online:1 Sep 2010AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail Not long ago, conventional wisdom held that psychiatric hospitals could not be entirely smoke free. Such policies, it was thought, would be impossible to enforce, and attempts to do so would increase the risk of patient violence and fires from clandestine smoking. Now we know that these concerns are unfounded. Well-implemented smoke-free policies have resulted in care environments that show improved outcomes in smoking-related incidents of restraint and seclusion, and staff resistance has not been insurmountable. In fact, patients and staff alike can and should be significant resources for successful implementation of smoke-free policies. Mental health care settings can create environments that promote a tobacco-free lifestyle to consumers, in the same way that virtually all medical centers and hospitals across the country have already done.However, the adoption of smoke-free policies is only a first step toward addressing the devastating health effects and early death that smoking causes among mental health consumers. In this issue Hollen and colleagues report survey data showing that many state psychiatric hospitals that have adopted smoke-free policies have not taken the next step by offering evidence-based smoking cessation interventions or providing staff with specialty training in smoking cessation.Our knowledge of smoking and serious mental illness has grown tremendously in recent years. Although nicotine dependence is at the heart of cigarette addiction, the clinical reality becomes more complex with serious mental illness. Multiple lines of evidence suggest that the nicotinic cholinergic system may play a role in the pathophysiology of schizophrenia and make it more difficult for individuals with schizophrenia to quit smoking. Smoking interacts with psychoactive drug metabolism. Quit attempts, if not well managed, can be thwarted by symptom emergence or drug interactions. When people with serious mental illness engage in mainstream smoking cessation approaches, their failure rate is about twice that of the general population. Even so, evidence abounds that people with serious mental illness want to quit smoking and look for help in doing so. Treatment interventions, both psychosocial and pharmacologic, must be developed that specifically address the needs of this population.Cigarette smoking by people living with serious mental illness is a problem that requires the full attention of psychiatrists and mental health professionals, who understand the complexity of serious mental illness and who are uniquely equipped to help patients plan for success in their efforts to quit. When smoke-free policies reflect significant increases in specialty training and intensification of treatment for nicotine dependence, we will know that the glass is becoming fuller.New York State Office of Mental HealthDepartment of Psychiatry, University of Maryland School of Medicine, and VA Capitol Network Mental Illness Research, Education and Clinical Center FiguresReferencesCited byDetailsCited byManagement Aspects of e-Government ProjectsInternational Journal of Public Administration in the Digital Age, Vol. 1, No. 3Are You Being Served?International Journal of Electronic Government Research, Vol. 7, No. 4 Volume 61Issue 9 September, 2010Pages 859-859PSYCHIATRIC SERVICES September 2010 Volume 61 Number 9 Metrics PDF download History Published online 1 September 2010 Published in print 1 September 2010