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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: 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 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). 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 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 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