Critical care outreach – the emergency department journey

The challenge

The critical care outreach service brings specialist care to seriously unwell patients in hospital wards and the emergency department. Its practitioners assess patients, prescribe treatment and support staff without patients first needing to move to an intensive care unit.

An evaluation at Royal Glamorgan Hospital found that emergency department staff were not routinely using the outreach service, although it was available to all hospital inpatients. Of the patients admitted to critical care from the emergency department, 75 per cent had not been referred to the outreach team. This did not capture patients referred directly to critical care who were not admitted, so the number who might have benefited from outreach support could have been higher.

While some patients did need immediate admission for specialist treatment, others could have benefited from earlier outreach support. These included patients with sepsis, a worsening chronic obstructive pulmonary disease, or a long-term lung condition. Some patients were waiting up to 72 hours for a ward bed, making access to support within the department particularly important.

Royal Glamorgan wanted to improve access to critical care outreach in the emergency department, providing timely support for seriously unwell patients as well as the staff caring for them.

Improvement

The hospital sought to establish a direct referral route from the emergency department to the outreach team, including an urgent call for help where appropriate.

Working with emergency department staff, they collaboratively developed a flowchart explaining when and how to contact the outreach service. Informal education sessions were also held within the department, while the outreach team visited daily to help establish the new approach and build relationships with staff.

Emergency department staff have been encouraged to use the National Early Warning Score 2 alert system to identify patients whose condition is worsening and request outreach support, following the same approach used by ward staff. The outreach team is available around the clock, and its advanced practitioners can prescribe and begin treatment while working alongside emergency, specialty, intensive care and anaesthetic teams.

Results

Following the changes, the proportion of patients reviewed by the outreach team before critical care admission rose from 25 to 52 per cent. Specialist treatment was also started earlier.

Emergency department staff reported greater confidence in using the service, while outreach staff described stronger working relationships.

Staff valued quicker support while awaiting senior review or when other teams were busy with emergencies or in theatre. The outreach team also helped junior staff plan care with senior specialist input.

Closer contact improved access to training on tracheostomy care, breathing support and specialist medicines, including bedside teaching. Staff could learn while caring for patients.

Although nurses usually made referrals, doctors also valued help with decisions about whether patients needed more intensive treatment. The outreach team is able to help support acutely unwell patients by working alongside the emergency department, surgical, medical and critical care teams seamlessly.

Overall critical care admissions did not fall, but staff reported benefits from closer contact and support.

An intensive care consultant reported that early treatment and joint working sometimes helped individual patients avoid intensive care admission. This mattered, given limited capacity and the psychological impact of admission. It was a reported benefit for some patients, not an overall reduction demonstrated by the project.

All emergency departments and critical care outreach teams across the trust have adopted the system and flowchart.

Lessons learned

Developing the flowchart proved complex. Support from the organisation’s quality improvement team helped resolve difficulties; future projects would involve them earlier.

Involving outreach staff from the outset encouraged ownership. Listening to concerns and adapting the approach, rather than treating challenges as barriers, strengthened engagement.

Strong relationships were central to the project. The outreach team now visits the emergency department regularly, often simply to check in.

Sustainability

Cross-departmental teaching sessions have been established to support shared learning.

A two-way feedback system is established to openly discuss case management.

Further information

For more detail on this improvement insight, contact:

Nia Bromage, Advanced Critical Care Outreach Practitioner, Cwm Taf Morgannwg University Health Board Nia.Bromage@wales.nhs.uk