Leading change

Whittington Health NHS Trust’s Critical Care Outreach Nurse Practitioner working as part of the Critical Care Outreach Team (CCOT), led on the development of a more effective use of an existing triggering system as part of a care pathway for critically ill patients. This reduced unwarranted variation in the timely referrals of critically ill patients to the CCOT. This change enabled the provision of specialist care to be delivered earlier to patients, ensuring improved patient care, experience and outcomes as well as better use of resources.

Where to look

The care of an acutely ill patient in hospital may require input from critical care. The Department of Health (2000) recommends that this care should be classified based on the level of care individual patients need, regardless of location, identifying four levels of care (0-3). Clinical deterioration can occur at any stage of a patient’s illness, although there will be certain periods during which a patient is more vulnerable, such as at the onset of illness, during surgical or medical interventions and during recovery from critical illness. NICE (2017) recommends that physiological track and trigger systems should be used to monitor all adult patients in acute hospital settings.

The CCOT at Whittington Health NHS Trust considered the findings of an ongoing monthly audit which looked at all referrals made to the CCOT. They reviewed the patient medical observation charts of patients. They identified that patients could have been referred far earlier. The audit data over a 12-month period (August 2015 – July 2016) showed that an average of 60% of patients triggering a level 2/3 response (mandating referral to the CCOT within 1 hour) were referred in time. Analysis of the data showed that some patients were triggering for long periods of time prior to the referral having been made (> one hour). In the absence of a timely referral, it is not possible to provide early expert guidance to staff, nor is it possible to commence interventions for critically ill patients. There was a need to improve the management of deteriorating patients with evidence that this may be because their deterioration is not recognised, or because, despite indications of clinical deterioration, it is not appreciated or not acted upon sufficiently rapidly. NICE (2017) give clear guidance that local care pathway models need to ensure that ‘triggering patients’ need to be escalated urgently to prevent further deterioration & avoidable death.

What to change

The Critical Care Outreach Nurse Practitioner and CCOT identified the opportunity to improve the referral times and to increase patient safety and outcomes. It was evident the percentage of patients being referred within the hour needed to improve by identifying earlier the significant changes which trigger critical illness.

The CCOT team identified that an increased understanding amongst doctors and nurses of the trigger parameters was required. Staff also needed support to gain understanding of the CCOT role within the Trust.

How to change

The Critical Care Outreach Nurse Practitioner used an action research approach to arrange multidisciplinary focus groups to explore and identify issues with the triggering system and potential barriers to timely referrals as part of this service improvement. The key emerging themes were:

Communication and documentation:

• Lack of consistent use of structured referral communication tools such as SBAR (Situation, Background, Assessment, Recommendation);
• Documentation could be improved;
• Positive feedback about referring to CCOT, although some staff expressed stress in doing so.

Knowledge gaps and false assumptions:

• Knowledge deficit in how to convert oxygen l/min into percentage, rendering one CCOT trigger potentially ineffective;
• Temporary staff and Health Care Assistants (HCA) unfamiliar with local triggering system;
• Uncertainty around referral procedures.

Following the focus group feedback, the following actions were taken:

• an education package was developed to address gaps in knowledge and skills with support from senior nursing staff and educators. This was incorporated into staff induction teaching;
• study days and a presentation at the Trust’s international nurse’s day conference;
• SBAR teaching re-commenced following a period of drift. Using this tool as a mechanism to frame communications about the referral system promotes consistency in practice;
• referral stickers for notes were utilised to aid documentation process;
• CCOT discussion and supervision was enhanced;
• a laminated oxygen education sheet was created and placed at all O2 ports in clinical areas, as well as incorporated into teaching;
• new staff ward orientation was updated to include the local triggering system;
• liaison with HCA clinical educators;
• advocating for electronic observation recording and automatic referral of triggering patients.

Adding value

Better outcomes – This project has seen improved safety due to earlier involvement of experts in managing critically ill patients. The CCOT have seen an increase in timely referrals within the hour, the comparative yearly average of 60% (15/16) rising to 80% (16/17). This demonstrates that a greater awareness of staff can lead to timelier critical care interventions for the most unwell patients.

Better experience – The project has presented an earlier opportunity to discuss and establish patients’ wishes with regards to treatment escalation and DNACPR decisions. Feedback from staff at the initial focus groups included:

‘I like the CCOT team, anything I’m concerned about… I jump to call the CCOT…they are always happy to advise and come and assess if necessary’

‘My feeling has always been that the CCOT are really approachable and if you’re just concerned…. you’re never made to feel that this is a wasted referral.’

‘They’re also very supportive in terms of, you know you’re very much appreciated, you come to the wards if you’re asked to support, you will do education, you guys do plenty of training sessions for the staff.’

Better use of resources – This intervention supports earlier identification of patients who are showing signs of deteriorating clinically and improving timely referral to the CCOT. Although not measured, it is anticipated that this will have contributed to the wider aims of interventions in this area, namely to reduce mortality, morbidity and the cost implication of impact on length of stay in hospital including critical care (NICE 2017). This nurse led improvement has demonstrated earlier management of unwell patients by experts, whilst empowering staff to utilise their skills. The project has also promoted person-centred care that ensures patients and relatives have control in their decisions about treatment escalation and DNACPR. This enables more sensitive and appropriate professional interventions.

Electronic observation recording and automatic referrals have now been introduced into the trust via electronic NEWS2.

Challenges and lessons learnt for implementation

Qualitative research was used to improve the service with supporting quantitative measurements. The focus groups were conducted as part of an MSc study which strengthened the academic rigour of the service improvement.

Focus groups are incredibly valuable in gathering information, encouraging debate, fostering co-operation, networking and raising the profile of services. Within these focus groups, the recording of conversations is extremely useful so not to miss important as well as nuanced points.

It can be difficult to arrange multi-disciplinary focus groups in a busy NHS hospital.

Temporary workers and HCA’s need more support, the latter often doing the vital sign observations.

Those who haven’t referred to CCOT before will need support.

Feedback and transparency regarding CCOT audit results is important.

The dissemination of findings from the focus groups, the educational packages and audits are all ongoing.

The Trust continues to see an increase on timely referrals.

For more information contact

Rainer Bohlin
Resuscitation officer/ Critical Care Outreach Nurse Practitioner
Whittington Health NHS Trust
rainer.bohlin@nhs.net