Features

Critical care outreach: Supporting ward nurses and saving lives

At London’s University College Hospital a highly successful nurse-led team brings expert care to deteriorating patients wherever they are in the hospital. The impact of the critical care outreach role has been enormous since its introduction to the UK in 2000

At London’s University College Hospital a highly successful nurse-led team brings expert care to deteriorating patients wherever they are in the hospital. The impact of the critical care outreach role has been enormous since its introduction to the UK in 2000

De_Souza_web_Nathan_Clarke
Rebecca de Souza, a member of the critical care outreach team at UCLH,
examines a patient. Picture: Nathan Clarke

For many ward nurses, seeing a patient begin to deteriorate can be extremely worrying and stressful. In most hospitals support comes from the expert nurses who work in critical care outreach teams.

‘These are the sickest patients in the hospital and we make nurses, not doctors, the first line of defence,’ says John Welch, nurse consultant for critical care and outreach at University College London Hospitals NHS Foundation Trust (UCLH).

‘It’s remarkable that in three quarters of hospitals, nurses are the backbone of recognising and managing deteriorating patients who are high risk, with a mortality of 20-25%. And there’s a core group of band 6 and 7 nurses who carry that responsibility.’

John_Welch_web_Nathan_Clarke
John Welch: We make nurses, not
doctors, the first line of defence. 
Picture: Nathan Clarke

Not widely celebrated

Mr Welch, who was instrumental in setting up one of the first of these services at Kingston Hospital in Surrey, joined UCLH’s existing service in 2009. Around four years ago they were joined by colleagues working in resuscitation and are now called the patient emergency response and resuscitation team (PERRT).

Today, 19 nurses – the majority of whom are band 6 – provide prompt critical care to patients whenever it’s needed and wherever they are in the hospital. ‘The creation of the critical care outreach role in the UK is the most important development in acute nursing, certainly in my working life, yet it’s not very widely celebrated,’ says Mr Welch.

Critical care outreach teams began in the UK in 2000, based on an idea that originated in Australia. Their creation followed research that found patients admitted to intensive care from hospital wards had much worse outcomes – including being two to three times more likely to die – than those from the emergency department or operating theatre.

Unreported and untreated

Other studies showed that some patients on wards had sub-optimal care, with deterioration going unrecognised, unreported or untreated. ‘The reports were a revelation,’ says Mr Welch.

In practice, the team usually takes referrals from ward staff on the basis of defined physiological triggers, with UCLH using the National Early Warning Score (see box). The team also encourages staff to get in touch if they are worried.

‘The creation of the critical care outreach role in the UK is the most important development in acute nursing, certainly in my working life, yet it’s not very widely celebrated’

John Welch, nurse consultant for critical care and outreach

‘We aren’t dismissive of concerns and sometimes we will stay and help, even if the real issue is that the patient just needs to be sat up in bed so they can clear their chest,’ says Mr Welch.

Winning hearts and minds

‘It’s important to set up a service that’s helpful and nice. Here we’ve been very good at winning hearts and minds by not being overly critical. In my view, having these interpersonal skills is as important as what we bring clinically.’

It’s this ability to understand, interact and communicate with the ward nurses that is key to the success of critical care outreach, he believes. ‘If they don’t recognise and respond to a patient’s escalating deterioration, then everything else is irrelevant,’ says Mr Welch. ‘And it’s the outreach team’s job to work alongside them, in partnership.’

‘You can feel at the end of your shift how much of a difference you’ve made to patients and staff’

Rebecca de Souza, band 7 sister

He believes that when services like this began, some ward staff felt intimidated rather than supported.

‘Experienced intensive care nurses would go onto the ward when they were called, then roll their eyes and criticise the staff for not doing observations properly or not calling early enough,’ recalls Mr Welch. ‘They failed to see that often wards had one nurse for eight or ten patients and much less in the way of senior support than an intensive care unit.’

Welcome sight

With a background in haematology, oncology and intensive care, Anna Welch (no relation to Mr Welch) joined UCLH in October and is one of the team’s ten band 6 nurses. ‘I remember being a ward nurse and how pleased I was to see the critical care outreach team arrive after they’d been called for help,’ she says.


Anna Welch: I remember as a ward
nurse and how pleased I was to see
the critical care outreach team arrive.
Picture: Nathan Clarke

‘Ward nurses are not always used to seeing deteriorating patients so they need help, and that’s what we provide. One of the ward nurses here told me she was always happy to see us and that we were very helpful. It was really positive feedback that was good to hear.’

Around a quarter of the patients the team sees will be moved to intensive care, while the rest will continue to be managed on the wards. Working alongside the ward staff, the team also brings local knowledge.

This includes where equipment is located within the hospital and what they know about a particular ward, assessing who is on duty, the skill mix of the staff and the likely needs of other patients they are looking after.

‘We do a holistic overview, as part of the decision-making process,’ explains Mr Welch. ‘We can then work out their ability to care for that patient. It’s only the nurses who are in a position to do all of that – doctors don’t have that background knowledge.’

Increasing patients’ understanding

In a service that is focused predominantly on saving lives, recognising when that’s not the best course of action is among the challenges. ‘Around one third of patients in hospital are in the last year of their life,’ says Mr Welch.

‘We’ve come to understand that some of these patients can’t be saved. So while you may be called out to see them, what really needs to happen is that they are moved to an end of life care pathway rather than being given aggressive treatment. We’ve had to learn that skill and we’ve been helped by linking closely with the palliative care team.’

He would like to increase patients’ understanding of what it is like to be treated for a severe illness, encouraging them to think in advance whether they want to be transferred to intensive care, with all that it entails. ‘It’s probably a debate that we need to have as a society,’ he says.


Some of the critical care outreach team at UCLH, including John Welch (rear, second
from left), Rebecca de Souza (standing next to him), and Anna Welch (right).
Picture: Nathan Clarke

An audit of the service’s results shows that the team is getting it right about 93% of the time. Its figures demonstrate that patients are admitted to intensive care in a timely way, and those managed on the wards are on average getting better 24 hours later.

If a patient dies, it is predicted and dignified, with a ‘do not attempt resuscitation’ order in place. In addition they monitor in-hospital cardiac arrests, which average one a week at UCLH, placing it in the best 10% in the country. They also evaluate readmission rates for patients within 48 hours of leaving intensive care, again doing better than the average.

Respected and listened to

Sometimes the team can be a victim of its own success, says Rebecca de Souza, one of seven band 7 sisters. ‘As we’ve been shown to make such a difference, sometimes there can be an over-reliance on our team, making us feel quite stretched.’

But she finds the role immensely satisfying. ‘We’re senior nurses who are respected and listened to throughout the hospital, so that’s a big bonus for our team.’

For Ms de Souza the impact on patient care and colleagues is the most important aspect. ‘You can feel at the end of your shift how much of a difference you’ve made to patients and staff, through your recommendations or a plan you’ve jointly put in place,’ she says.

‘We’re seeing patients at their sickest and most stressed, so often they don’t remember us. We don’t tend to get any “thank you” cards. But that’s not why we do it.’

Critical care outreach

Broadly speaking, the service’s aim is to provide equity of care for all critically ill patients, regardless of where they are in a hospital. Typically nurse-led, teams may also include other allied healthcare professionals and doctors.

Responsibilities include:

  • Identifying patients at risk
  • Supporting ward staff caring for at-risk patients and those recovering from critical illness
  • Providing immediate expert critical care and resuscitation skills
  • Educating ward staff to recognise signs of deterioration
  • Auditing and improving basic standards of critical care to minimise risk and optimise treatment of critically ill patients throughout the hospital

National Early Warning Score: huge potential benefits from standardisation

Developed by the Royal College of Physicians in 2012 and revised last year, the National Early Warning Score (NEWS) is currently used by an estimated 70% of trusts in England, according to NHS England.

It wants to see the system being used in every acute and ambulance setting by 2019, enabling NHS staff who move between trusts to have a consistent set of measures for diagnosing patients. This standardisation could potentially save more than 1,800 lives a year, says NHS England.

British achievement

‘It’s an important national development,’ says Mr Welch. ‘We should be pleased, because in many ways NEWS is a great British achievement. We’re the only country in the world that has a standardised score like this, which is based on research.’

The system is based on analysis of a large database of patients’ vital signs, recorded in different acute hospitals. In practice, a patient’s vital signs are measured then compared with a set of reference values.

For NEWS, this includes their respiratory rate, oxygen saturation, heart rate, systolic blood pressure, level of consciousness and temperature. Measures above or below designated points are used as triggers for escalation, with improvement or further deterioration tracked over time.


Lynne Pearce is a freelance health journalist

Further information

National Early Warning Score (NHS England)

Online training resource for National Early Warning Score

 

This article is for subscribers only

Jobs