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South East Wales Critical Care Network Senior Nurse Forum
Proposed Critical Care Outreach Service
1. Introduction
In line with the Designed for Life Quality Requirements for Wales and the
NICE clinical guideline 50 (CG50) for the development of a Critical Care
Outreach Service, the Senior Nurse Forum have produced a draft proposal to
take this forward within SE Wales. It is anticipated that the South East Wales
Critical Care Board will consider this draft paper and recommendations.
2. Background
In 2005 the National Confidential Enquiry into Patient Outcomes and Death
(NCEPOD) recommended each hospital should have a track and trigger
system that allows rapid detection of signs of early clinical deterioration and
an early and appropriate discharge. The outreach service should be available
24 hours per day, seven days per week.
The Designed for Life Quality Requirements for Critical Care in Wales was
published in 2006, highlighting Critical Care Outreach as a core requirement.
More recently the National Institute of Clinical Excellence (NICE) 2007
recommended that:
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Physiological track and trigger systems should be used to monitor all
adult patients in acute hospital settings.
Staff caring for patients in acute hospital settings should have
competencies in monitoring, measurement, interpretation and prompt
response to the acutely ill patient appropriate to the level of care they
are providing. Education and training should be provided to ensure
staff have these competencies, and they should be assessed to
ensure they can demonstrate this.
A graded response strategy for patients identified as being at risk of
clinical deterioration should be agreed and delivered locally.
Decision to admit a patient from a ward to Critical Care should involve
both the Consultant caring for the patient on the ward and the
Consultant in Critical Care.
The Senior Nurse Forum has considered all these elements in their core
principles for a proposed SE Wales Critical Care Outreach service,
recognising that specific details may vary between Trusts.
3. Core Principles for Outreach
The following core principles reflect the key priorities for implementation within
the CG50 and the Designed for Life Quality Requirement for Critical Care in
Wales. The Senior Nurse Forum considered all aspects and has agreed the
following as a framework from which to build:
SEW Critical Care Senior Nurse Forum June 2008
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The Critical Care Outreach service should cover 7 days a week, 24 hours
a day. The team will link with existing Hospital at Night services.
The Critical Care Outreach Team (CCOT) may be nurse-led with a
designated Critical Care Consultant for support.
The aim of the CCOT will primarily be focused on increasing the
knowledge and confidence of ward staff through training and sharing of
skills.
The Critical Care Outreach Nurse will be led by an advanced Critical Care
Practitioner. All Outreach Nurses will have a minimum of 4 years
experience in Critical Care Nursing with evidence of competency
achievement in critical care skills and management experience.
The CCOT will also provide formal multi-professional training to meet specific
learning needs.
The CCOT will rotate to work within Critical Care to maintain their
specialist skills and this will be agreed locally according to service need.
A graded response strategy for patients identified as being at risk of
deterioration will be agreed within each Trust and this may be based
around early Warning Scores (EWS), Modified Early Warning Scores
(MEWS) or coloured zone charts such as those used within a Medical
Emergency Team (MET) approach.
The CCOT will respond to triggers from all acute wards and will also
follow-up patients discharged from Critical Care to the acute ward areas
within a period of 24 hours based or as the patient condition requires
All referrals for admission to Critical Care will be made on a Consultant to
Consultant basis.
4. Measuring Outcomes
The aim of the audit will be to determine if the Critical Care Outreach Service
is implementing and is in compliance with the NICE guideline (CG50).
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Physiological observations:
o % of patients who have had their physiological observations
recorded at the time of their admission or initial assessment
o % of patients for whom a clear written monitoring plan that
specifies which physiological observations should be recorded
and how often is present within the health record.
Identifying patients whose clinical condition is deteriorating or is at risk of
deterioration:
o % of patients monitored using a physiological track and trigger
system
Identifying patients whose clinical condition is deteriorating or is at risk of
deteriorating:
o % of patients whose physiological observations were monitored
at least every 12 hours
SEW Critical Care Senior Nurse Forum June 2008
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o % of patients for whom there is evidence of increased frequency
of monitoring in response to the detection of abnormal
physiology
Graded response strategy:
o There is an agreed and locally delivered graded response
strategy in place for patients identified as being at risk of clinical
deterioration
o For patients admitted to Critical Care, the % of patients for
whom there is evidence that the decision to admit was made by
Consultant to Consultant referral
Transfer of patients from Critical Care to general wards:
o The % of patients transferred between 22.00 and 07.00hrs
o The % of those transferred between 22.00 and 07.00hrs
documented as an adverse event
Care on the general ward following transfer:
o % of patients for whom there is a formal structured handover of
care from Critical Care staff to ward staff (both medical and
nursing) supported by a written plan
o % of patients for whom a formal structured handover of care
(supported by a written plan) includes:
 summary of Critical Care stay including diagnosis and
treatment
 a monitoring and investigation plan
 a plan for on-going treatment including drugs and
nutrition plan infection status and any agreed limitations
of treatment
 physical and rehabilitation needs
 psychological and emotional needs
 specific communication or language needs
Calculation of compliance where % compliance can be measured can be
calculated as follows:
Number within the population group whose care is consistent with the criterion
X100
Number within the population group to whom the measure applies (that is the total population
group less any exceptions
As well as reporting the % compliance, it will often be useful to report the
actual numerator and denominator figures to give an idea of scale.
5. Recommendations
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That this draft paper is considered and discussed by the SIG
Feedback is given to the Senior Nurse Forum
A way forward is agreed
SEW Critical Care Senior Nurse Forum June 2008