Outreach: Evaluation of outreach services in critical care

Background

In 2000, as part of its “vision for future critical care services”, the Department of Health promoted the establishment of critical care outreach services. These teams, usually led by experienced critical care nurses, aim to help staff on general wards identify deteriorating patients, provide advice or treatment, ensure swift admission into a critical care unit, and share skills.

Physiological track and trigger warning systems have been developed for use outside critical care areas with the objective of ensuring timely recognition of deteriorating patients. These track and trigger systems use periodic observation of basic vital signs (heart rate, blood pressure, etc.) together with pre-determined criteria for requesting the attendance of more experienced staff, usually the critical care outreach service.

Design

The evaluation of critical care outreach services aimed to: explore the existing evidence for critical care outreach services; describe their introduction, implementation and models of delivery across the NHS; and explore and evaluate their impact using both quantitative and qualitative methods.

The evaluation of physiological track and trigger warning systems aimed to: describe the existing information on the development and testing of track and trigger systems; describe their introduction and use across the NHS; review their validity and utility and evaluate their reproducibility; and elicit stakeholders’ views.

Results

There was insufficient rigorous research on the impact of critical care outreach services on patient or service outcomes. Outreach services have evolved quickly with diverse models of delivery. Characteristics of patients admitted to critical care were somewhat different before and after the introduction of outreach services. When matched with patients that did not receive a critical care outreach service visit following discharge from critical care, those that did receive a visit had lower hospital mortality, a shorter stay in hospital and lower costs. Interviews with staff identified the reassurance given to ward staff as the most important quoted impact.

There was little rigorous evidence for the validity and utility of track and trigger systems, however almost all hospitals reported using some form of track and trigger system. The sensitivity of track and trigger systems to identify patients with critical illness was low and there was some evidence that trigger thresholds were placed artificially high to manage workload. Interviewees suggested that track and trigger systems helped inexperienced staff identify sick and deteriorating patients.

Conclusion

Critical care outreach services are being delivered in many different ways across the NHS, appearing to fill gaps according to local need. There was no clear evidence that critical care outreach services have a big impact on the outcomes of patients admitted to critical care, or for characteristics of what should form the optimal model of delivery.

Physiological track and trigger warning systems will not identify all deteriorating patients and should be used as an aid to clinical judgement and experience. However, accurate use of a track and trigger system and response algorithm may improve the pathway of care for recognition and management of acutely ill patients on the general ward.

Impact

The results of this study informed the development of the National Institute for Health and Care Excellence clinical guideline on recognition of and response to acute illness in adults in hospital (NICE CG50).

Who led the study?

Professor Kathy Rowan, ICNARC

This study was funded by the National Institute for Health Research (NIHR) Service Delivery and Organisation Programme (Project: 74/2004)

Publications

Harrison DA, Gao H, Welch CA, Rowan KM. The effects of critical care outreach services before and after critical care: a matched-cohort analysis. J Crit Care 2010; 25(2):196-204. http://dx.doi.org/10.1016/j.jcrc.2009.12.015

Subbe CP, Gao H, Harrison DA. Reproducibility of physiological track-and-trigger warning systems for identifying at-risk patients on the ward. Intensive Care Med 2007; 33(4):619-24.

Rowan KM, Harrison DA. Recognising and responding to acute illness in patients in hospital. BMJ 2007; 335(7631):1165-6. http://dx.doi.org/10.1136/bmj.39395.497928.80

Rowan K, Adam S, Ball C, Bray K, Baker-McLearn D, Carmel S, Daly K, Esmonde L, Gao H, Goldhill D, Harrison D, Harvey S, Mays N, McDonnell A, Morgan R, North E, Rashidian A, Rayner C, Sinclair R, Subbe C, Young D. Evaluation of outreach services in critical care. NIHR SDO Programme 2007; .

McDonnell A, Esmonde L, Morgan R, Brown R, Bray K, Parry G, Adam S, Sinclair R, Harvey S, Mays N, Rowan K. The provision of critical care outreach services in England: findings from a national survey. J Crit Care 2007; 22(3):212-8.

Gao H, McDonnell A, Harrison DA, Moore T, Adam S, Daly K, Esmonde L, Goldhill DR, Parry GJ, Rashidian A, Subbe CP, Harvey S. Systematic review and evaluation of physiological track and trigger warning systems for identifying at-risk patients on the ward. Intensive Care Med 2007; 33(4):667-79.

Gao H, Harrison DA, Parry GJ, Daly K, Subbe CP, Rowan K. The impact of the introduction of critical care outreach services in England: a multicentre interrupted time-series analysis. Crit Care 2007; 11(5):R113. http://dx.doi.org/10.1186/cc6163

Esmonde L, McDonnell A, Ball C, Waskett C, Morgan R, Rashidian A, Bray K, Adam S, Harvey S. Investigating the effectiveness of critical care outreach services: a systematic review. Intensive Care Med 2006; 32(11):1713-21.