Operational Standards and Competencies for Critical Care

National Outreach ForumOperational Standards and

Competencies for Critical Care Outreach Services

National Outreach Forum I Operational Standards and Competencies for Critical Care Outreach Services

The National Outreach Forum (NOrF)

The National Outreach Forum (NOrF) was founded back in 2004 by a group of enthusiastic professionals involved with the first Critical Care Outreach Teams. Since then it has evolved into a multi-professional interest group that seeks to promote excellence in the care of acutely unwell patients. NOrF provides a representative forum for Critical Care Outreach Service providers and recipients across the country who strive to optimise the quality of the acutely unwell patient’s treatment, care and experience.

Copyright

In order to encourage as many people as possible to use the material in this publication, there is no copyright restriction, but the National Outreach Forum as copyright holder should be acknowledged on any material reproduced from it. Note that high-quality versions is available to download, photocopy or print direct from our website at www.norf.org.uk/NOrF_operational_standards_competencies_CCOS.

Citation for this document

National Outreach Forum Operational Standards and Competencies for Critical Care Outreach Services. NOrF 2012

Review date: 2015

National Outreach Forumwww.norf.org.uk

Critical Care Networks-National Nurse Leads

1National Outreach Forum I Operational Standards and Competencies for Critical Care Outreach Services

Foreward

I am delighted to have the opportunity to endorse the NOrF Operational Standards and Competencies document on behalf of the Society for Acute Medicine (SAM).

Early recognition of the patient whose condition is deteriorating, and ensuring appropriate and timely intervention has been a key priority for SAM over the past decade; indeed this has been a major driving forces behind the development of the speciality of Acute Internal Medicine, Acute Medical Units and the National Early Warning Score. Recent reports have highlighted the enormous challenges which UK hospitals face, with rising numbers of emergency hospital admissions coinciding with significant financial and staffing pressures. In this environment, Critical Care Outreach Teams have become increasingly important, delivering high level skills at the bedside, wherever and whenever they are needed. They can also provide an invaluable educational resource, supporting and empowering all members of the multiprofessional team to take prompt remedial action if they believe a patient’s condition is deteriorating. This document represents a crucial step forward in ensuring that a high quality, consistent Critical Care Outreach service becomes firmly embedded in all hospitals, 7 days per week. If these standards are implemented across the UK, I have no doubt that this will have a major impact in improving safety for all hospital patients.

Dr Chris Roseveare BM FRCP President, Society for Acute Medicine

National Outreach Forum I Operational Standards and Competencies for Critical Care Outreach Services2 National Outreach Forum I Operational Standards and Competencies for Critical Care Outreach Services

Foreword

Critical Care Outreach Teams (CCOT) are one of the great successes of the developments following publication of Comprehensive Critical Care (DOH 2000). The recognition that practitioners from critical care had transferable skills that were relevant to the care of the general hospital patient was one of the light bulb moments of the last decade.

The extension of the natural multi-professional working practices of the best critical care units into the general hospital has brought nothing but benefit to patients and staff.

This set of operational standards puts the spotlight on the level of care to which NHS patients have the right to expect.

Dr Bob Winter President of The Intensive Care Society


Foreword

On behalf of the National Early Warning (NEWS) Score Development and Implementation Group of the Royal College of Physicians, London, I very much welcome this framework for Operational Standards and Competencies for Critical Care Outreach, which has been developed by the National Outreach Forum (NORF). We all recognise the importance of delivering fast and efficient critical care to acutely ill patients to improve their outcomes in our hospitals.

A key principal underlying our recent development of the NEWS was the importance of standardisation to ensure high quality acute care wherever and whenever it is delivered. Likewise, this framework from the National Outreach Forum sets out to standardise the approach of critical care outreach services across the NHS.

This will provide guidance and a much needed template for teams with the ultimate objective of improving outcomes for those patients with acute illness. I was particularly pleased to see the emphasis on the importance of the necessity, and 24/7 availability of ‘Outreach’ and Acute Care Teams in all organisations, which melds in a timely way with the NEWS recommendations and will be essential to deliver some of the key elements of the clinical response.

What is clear is that professionals across all clinical disciplines recognise what is important to deliver a step wise change in the quality and consistency of acute clinical care in our hospitals with the ultimate objective of improving patient outcomes. The challenge, as ever, is to take the good words into clinical practice and implement these recommendations.

Dr Bryan Williams MD FRCP FAHA Professor of Medicine, University College London, Chairman, National Early Warning Score Development Group, Royal College of Physicians London


Introduction

This guidance is aimed at providing a standardised framework for the implementation and delivery of Critical Care Outreach Services and Acute Care teams across the United Kingdom.

The creation of this framework has been clinically led, is evidence based where possible and reflects current national practice and thinking.

This guidance was ratified at the National Outreach Forum 6th AGM on 4th November 2011 and has been endorsed by Dr Bob Winter, Intensive Care Society President and Professor Bryan Williams, Chair of the National Early Warning Scoring Design and Implementation Group - NEWSDIG, and Chris Roseveare

The framework covers the seven core elements of Comprehensive Critical Care Outreach: PREPARE and outlines the desired requirements for each element.

The aim is to provide a nationally recognised framework that will assist existing and newly developing services. It is anticipated that a standardised approach will improve equity of access and quality of care as well as providing guidance to assist teams achieve their aspirations for service development.


National Outreach Forum

Operational Standards and Competencies for Critical Care Outreach Services

1. NOrF Mission Statement and Purpose

1. To optimise the quality of the patients treatment, care and experience

2. To provide a representative forum for Critical Care Outreach Service providers and recipients across the country.

3. To meet the Department of Health’s objectives for critical and acute care, and to ensure there is a strategic approach to delivery of Critical Care Outreach Services nationally, which reflects that of the National Strategy and those of the Critical Care Networks.

4. To underpin Critical Care Outreach practice and service development with the best evidence where it is available.

2. Definition

Comprehensive Critical Care Outreach (3CO) can be defined as “a multidisciplinary organisational approach to ensure safe, equitable and quality care for all acutely unwell, critically ill and recovering patients irrespective of location or pathway”

3. Core Elements of Comprehensive Critical Care Outreach (3CO) as a continuum is exemplified by 7 core elements:

• Patient Track and Trigger

• Rapid response

• Education, training and support

• Patient safety and clinical governance

• Audit and evaluation; monitoring of patient outcome and continuing quality care

• Rehabilitation after critical illness (RaCI)

• Enhancing service delivery


4. Introduction

This document sets out an operational framework of standards and competencies for Critical Care Outreach and Acute Care Team Services. It responds to calls from National Outreach Forum (NOrF) members to provide a national document to standardise and benchmark existing services, to enable equity of access, and to provide guidance on future service development. The framework has been developed in a “RAG” rating format to allow users to self assess their service against the national recommendations thereby identifying areas that they may wish to develop.

RED — Not achieved and no current plans to review

AMBER — Partial provision and/or currently under development

GREEN — Fully achieved

5. Background

The introduction of Critical Care Outreach Services (CCOS) was recommended in Comprehensive Critical Care (2000) in response to the growing body of evidence demonstrating failure to recognise, and respond to obvious physiological deterioration. The aim was to ensure patients received timely intervention regardless of location, with Outreach staff sharing critical care skills with ward based colleagues to improve recognition, intervention and outcome. Subsequently there have been further recommendations for the implementation of CCOS inclusive of the Intensive Care Society (ICS) 2002, NOrF 2003, NCEPOD 2005 and the Critical Care Stakeholder Forum (CCSF) 2005.

In the absence of a national strategy for their implementation, CCOS and team configurations have developed on an ad hoc basis dependent upon perceived local need and resources available. Additionally, the level of investment in education and preparation of Outreach personnel also varies between organisations. The underpinning purpose of this document is therefore to re-address the absence of national guidance and provide a standardised operational framework of standards and competencies for Critical Care Outreach, Acute Care and Rapid Response Teams, whilst recognising the organisational links required with other hospital providers to facilitate provision of a robust 24hr service.


6. Origins of the Standards and Competencies Framework

This work has been led by the National Outreach Forum (NOrF) Executive Board in consultation with multidisciplinary expert members of NOrF. The document draws together the numerous statements and recommendations that have been published over the last 10 years and is set out using the PREPARE acronym which exemplifies the seven core elements of Comprehensive Critical Care Outreach (3CO).

Core Elements of Comprehensive Critical Care Outreach (3CO) as a continuum is exemplified by 7 core elements

RED AMBER GREENQUALIFYING

NOTES

Patient Track and Trigger

Rapid response

Education, training and support

Patient safety and clinical governance

Audit and evaluation

Rehabilitation after critical illness (RaCI)

Enhancing service delivery


RED

AM

BER

GRE

ENQ

UA

LIFY

ING

N

OT

ES

1. P

atie

nt T

rack

and

Tri

gger

1.1.

Tru

st w

ide

use

of N

EWS

or a

loca

lly v

alid

ated

Tra

ck a

nd T

rigge

r sy

stem

that

al

low

s ra

pid

dete

ctio

n of

the

signs

of e

arly

clin

ical

det

erio

ratio

n in

all

adul

t pa

tient

s ov

er 1

6yrs

, exc

ept p

regn

ant w

omen

& th

ose

requ

iring

pal

liativ

e ca

re (N

CEP

OD

, RC

P, N

OrF

)

1.2.

The

Tra

ck a

nd T

rigge

r sy

stem

sho

uld

incl

ude

the

follo

win

g ph

ysio

logi

cal

para

met

ers:

HR,

SBP

, RR,

Tem

p, S

aO2,

and

AVP

U. (

NIC

E C

G50

, RC

P, N

OrF

). O

ther

‘sta

nd a

lone

’ par

amet

ers

may

be

used

alo

ng s

ide

the

chos

en

trac

k an

d tr

igge

r sy

stem

. e.g

. Urin

e O

utpu

t

1.3.

Vita

l obs

erva

tions

with

a to

tal N

EWS/

EWS/

MEW

S s

core

sho

uld

be

unde

rtak

en a

min

imum

of 1

2 ho

urly,

with

esc

alat

ion

in fr

eque

ncy

of

reco

rdin

g as

par

t of a

n ag

reed

Tru

st w

ide

grad

ed r

espo

nse.

1.4.

Phy

siolo

gica

l obs

erva

tions

sho

uld

be u

nder

take

n an

d re

cord

ed b

y st

aff t

hat

have

bee

n ap

prop

riate

ly tr

aine

d an

d as

sess

ed a

s co

mpe

tent

in m

onito

ring,

m

easu

rem

ent,

and

inte

rpre

tatio

n.

2. R

apid

Res

pons

e

2.1.

Tr

ust w

ide

use

of a

gra

ded

clin

ical

res

pons

e st

rate

gy c

onsis

ting

of 3

leve

ls (lo

w, m

ediu

m, &

hig

h) (R

CP,

NIC

E 20

07)

2.2.

Ea

ch le

vel o

f res

pons

e sh

ould

det

ail w

hat i

s re

quire

d fro

m s

taff

in te

rms

of

obse

rvat

iona

l fre

quen

cy, s

kills

and

com

pete

nce,

inte

rven

tiona

l the

rapi

es a

nd

seni

or c

linic

al in

volv

emen

t.

2.3.

It

shou

ld d

efine

the

spee

d/ur

genc

y of

res

pons

e, in

clud

ing

a cl

ear

esca

latio

n po

licy

to e

nsur

e th

at a

n ap

prop

riate

res

pons

e al

way

s oc

curs

and

is a

vaila

ble

24/7

.

2.4.

W

ho r

espo

nds,

i.e.

the

seni

ority

and

clin

ical

com

pete

ncie

s of

the

resp

onde

r/s

2.5.

Th

e ap

prop

riate

set

tings

for

on g

oing

car

e in

clud

ing

acce

ss to

mon

itorin

g eq

uipm

ent a

nd c

ritic

al c

are.

2.6.

Th

e fre

quen

cy o

f sub

sequ

ent c

linic

al m

onito

ring


RED

AM

BER

GRE

ENQ

UA

LIFY

ING

N

OT

ES

3. E

duca

tion

Tra

inin

g an

d S

uppo

rt

Cri

tica

l Car

e O

utre

ach

Pers

onne

l

3.1.

Ea

ch o

rgan

isatio

n sh

ould

ens

ure

patie

nts

rece

ive

care

from

app

ropr

iate

ly

trai

ned

Crit

ical

Car

e O

utre

ach

/ Acu

te C

are

Team

/ R

apid

Res

pons

e

Team

per

sonn

el

3.2.

Le

ad P

ract

ition

er s

houl

d ha

ve a

pos

tgra

duat

e qu

alifi

catio

n in

crit

ical

ca

re /

acu

te c

are

3.3.

Se

nior

pra

ctiti

oner

s id

eally

with

a m

inim

um o

f 3 y

ears

crit

ical

/acu

te c

are

expe

rienc

e sh

ould

del

iver

the

Out

reac

h se

rvic

e.

Team

s m

ay c

onsis

t of

nu

rses

, ph

ysio

ther

apist

s, d

octo

rs a

nd o

ther

hea

lthca

re p

rofe

ssio

nals.

3.4.

Al

l Crit

ical

Car

e O

utre

ach

/ Acu

te C

are

Team

/ R

apid

Res

pons

e Te

am

prac

titio

ners

sho

uld

poss

ess

a cl

inic

ally

rel

evan

t po

st b

asic

qua

lifica

tion

and

idea

lly b

e w

orki

ng t

owar

ds a

n M

Sc in

clin

ical

pra

ctic

e or

equ

ival

ent

rele

vant

clin

ical

mod

ules

3.5.

Th

ere

mus

t be

a d

ocum

ente

d m

anda

tory

ind

uctio

n pr

ogra

mm

e fo

r al

l ne

w s

taff

mem

bers

to

the

outr

each

tea

m.

An a

gree

d le

arni

ng c

ontr

act

to in

clud

e an

nual

com

pete

ncy

base

d as

sess

men

t of

cor

e an

d ad

ditio

nal

spec

ific

com

pete

ncie

s

3.6.

Th

e re

fere

nce

basis

of t

rain

ing

for

Crit

ical

Car

e O

utre

ach

/ Acu

te C

are

Team

/ R

apid

Res

pons

e Te

am p

erso

nnel

sho

uld

be d

irect

ed b

y th

e D

H

Com

pete

ncie

s fo

r re

cogn

ising

and

res

pond

ing

to a

cute

ly il

l pat

ient

s in

ho

spita

l (20

07).

3.7.

Al

l Crit

ical

Car

e O

utre

ach

/ Acu

te C

are

Team

/ R

apid

Res

pons

e Te

am

pers

onne

l mus

t be

trai

ned

and

asse

ssed

as

com

pete

nt to

func

tion

at a

m

inim

um o

f prim

ary

resp

onde

r le

vel,

(som

e m

ay d

evel

op p

artic

ular

ski

lls

to fa

cilit

ate

func

tioni

ng a

t a s

econ

dary

res

pond

er le

vel)

3.8.

Ea

ch p

ract

ition

er m

ust

be a

ble

to:-

Per

form

a c

ompr

ehen

sive

phys

ical

ex

amin

atio

n an

d de

mon

stra

te t

he a

bilit

y to

rec

ogni

se n

orm

al,

devi

atio

n fro

m n

orm

al fi

ndin

gs in

rel

atio

n to

the

follo

win

g sy

stem

s Ai

rway

, Re

spira

tory

, C

ardi

ovas

cula

r, G

astr

oint

estin

al,

Rena

l, N

euro

logi

cal

and

Endo

crin

e


RED

AM

BER

GRE

ENQ

UA

LIFY

ING

N

OT

ES

3.9.

As

sess

and

pro

vide

firs

t lin

e tr

eatm

ent

for

a pa

tient

with

acu

te o

r

deve

lopi

ng c

ritic

al il

lnes

s an

d th

ose

requ

iring

em

erge

ncy

assis

tanc

e of

ab

ove

syst

ems

incl

udin

g se

psis

3.10

. Pro

vide

bas

ic,

imm

edia

te a

nd a

dvan

ced

life-s

uppo

rt i

n ac

cord

ance

with

th

e le

vel o

f res

pons

e de

liver

ed.

3.11

. Rec

ogni

se s

ituat

ions

whe

re c

onsid

erat

ion

for

with

draw

al o

f tre

atm

ent

shou

ld b

e gi

ven

and

initi

ate

revi

ew b

y ap

prop

riate

med

ical

sta

ff, p

allia

tive

care

or

end

of li

fe te

ams.

3.12

. Pro

vide

effe

ctiv

e le

ader

ship

and

sup

port

for

criti

cal c

are

team

s an

d w

ard

staf

f whe

n ca

ring

for

acut

ely

ill w

ard

patie

nts

with

dev

elop

ing

criti

cal i

llnes

s

3.13

. Ens

ure

safe

tra

nsfe

r an

d tr

ansp

ort

of th

e ac

utel

y ill

patie

nt.

Idea

lly s

taff

unde

rtak

ing

intr

a an

d in

ter

hosp

ital t

rans

fers

sho

uld

have

rec

eive

d fo

rmal

tr

aini

ng in

this

skill.

(IC

S 20

11).

3.14

. Und

erst

and

clin

ical

lim

itatio

ns,

and

enab

le d

irect

ref

erra

l to

othe

r

mem

bers

of t

he m

ultid

iscip

linar

y sp

ecia

list

team

incl

udin

g Ph

ysio

ther

apy,

Pa

in t

eam

, D

iete

tics,

Spe

ech

and

Lang

uage

The

rapi

st, P

sych

olog

ist.

In a

ddit

ion

to D

H C

ompe

tenc

ies

for

reco

gnis

ing

and

resp

ondi

ng t

o ac

utel

y ill

pat

ient

s in

hos

pita

l (20

07),

sp

ecifi

c an

d re

gula

rly

dem

onst

rate

d co

mpe

tenc

ies

shou

ld id

eally

incl

ude

(NO

rF 2

003/

11):

3.15

. Per

form

and

inte

rpre

t cl

inic

al fi

ndin

gs o

n ch

est

and

abdo

men

au

scul

tatio

n

3.16

. Ini

tiate

labo

rato

ry c

linic

al t

ests

, ob

tain

blo

od v

ia v

enep

unct

ure

and

co

rrec

tly in

terp

ret

resu

lts:

Bioc

hem

istry

, H

aem

atol

ogy,

Coa

gula

tion

scre

enin

g


RED

AM

BER

GRE

ENQ

UA

LIFY

ING

N

OT

ES

3.17

. Pre

pare

for

and

carr

y ou

t int

rave

nous

can

nula

tion.

3.18

. Rec

ord

and

inte

rpre

t el

ectr

ocar

diog

raph

(EC

G)

3.19

. Ass

ess

the

indi

vidu

al’s

leve

l of c

onsc

ious

ness

, ut

ilisin

g AV

PU, G

lasg

ow

Com

a Sc

ale.

3.20

. Obt

ain

arte

rial b

lood

gas

sam

ple

and

dem

onst

rate

abi

lity

to in

terp

ret

resu

lts/r

ecog

nise

dev

iatio

n fro

m n

orm

al a

nd r

epor

t an

d tr

eat a

ccor

ding

ly.

3.21

. Req

uest

and

inte

rpre

t ra

diol

ogic

al e

xam

inat

ion

e.g.

che

st X

ray

, ab

dom

inal

X r

ay.

3.22

. Per

form

hae

mod

ynam

ic m

onito

ring

to o

btai

n ph

ysio

logi

cal m

easu

rem

ents

: co

ntin

uous

ele

ctro

card

iogr

aph,

cen

tral

ven

ous

pres

sure

and

art

eria

l pr

essu

re m

onito

ring

3.23

. Rec

ogni

se i

ndic

atio

ns f

or o

xyge

n th

erap

y an

d se

lect

app

ropr

iate

dev

ice

for

adm

inist

ratio

n of

oxy

gen

ther

apy.

3.24

. Adm

inist

er o

xyge

n th

erap

y at

rat

e an

d co

ncen

trat

ion

as p

resc

ribed

or

as

per

patie

nt g

roup

dire

ctiv

e.

3.25

. Est

ablis

h N

on-In

vasiv

e Ve

ntila

tion

Ther

apy

on p

atie

nts

in r

espi

rato

ry

failu

re a

nd a

ssist

in s

ubse

quen

t m

anag

emen

t.

3.26

. Adm

inist

er i

ntra

veno

us fl

uids

as

per

patie

nt g

roup

dire

ctiv

e / o

r as

an

inde

pend

ent

pres

crib

er

3.27

. Pos

sess

and

dem

onst

rate

effe

ctiv

e co

mm

unic

atio

n sk

ills fa

cilit

atin

g cl

ear

goal

set

ting

betw

een

all l

evel

s of

the

mul

ti-di

scip

linar

y te

am,

patie

nts

and

signi

fican

t ot

hers

.

3.28

. Use

of e

ffect

ive

com

mun

icat

ion

tool

s by

all

staf

f e.g

. RSV

P, SB

AR

3.29

. Doc

umen

t and

com

mun

icat

e cl

ear

patie

nt m

onito

ring

plan

s in

med

ical

not

es

3.30

. Pos

sess

and

dem

onst

rate

effe

ctiv

e ab

ility

to m

anag

e co

nflic

t an

d br

eaki

ng

bad

new

s


RED

AM

BER

GRE

ENQ

UA

LIFY

ING

N

OT

ES

Add

itio

nal c

ompe

tenc

ies

may

incl

ude

all o

r so

me

of t

he fo

llow

ing

(dep

endi

ng o

n or

gani

sati

onal

clin

ical

nee

d).

3.31

. Per

form

ver

ifica

tion

of e

xpec

ted

deat

h w

here

DN

ACPR

ord

er in

pla

ce

3.32

. Per

form

mal

e an

d fe

mal

e ur

inar

y ca

thet

erisa

tion.

3.33

. Ass

ist w

ith c

entr

al li

ne in

sert

ion

and

asse

ssm

ent o

f nee

d

3.34

. Und

erta

ke N

on-M

edic

al p

resc

ribin

g

3.35

. Ass

ist w

ith n

octu

rnal

res

pira

tory

sup

port

.

3.36

. Ass

ist w

ith in

tra

hosp

ital t

rans

fers

of p

atie

nts

requ

iring

add

ition

al te

sts

or

inte

rven

tion

3.37

. Ass

ist w

ith e

mer

genc

y tr

ans-

thor

acic

pac

ing

3.38

. Be

able

to a

sses

s pa

tient

s fo

r an

d un

dert

ake

chan

ging

of t

rach

eost

omy

tube

s, in

sert

ion

of m

ini t

rach

eost

omie

s an

d de

cann

ulat

ion.

Hos

pita

l / W

ard

Bas

ed P

erso

nnel

3.39

. Eac

h or

gani

satio

n sh

ould

pro

vide

acc

essib

le e

duca

tiona

l sup

port

for

re

gist

ered

and

non

-reg

ister

ed w

ard

staf

f in

carin

g fo

r th

e ac

utel

y ill

war

d pa

tient

in li

ne w

ith r

ecor

der

and

first

res

pond

er le

vel o

utlin

ed in

DH

co

mpe

tenc

ies

for

reco

gnisi

ng a

nd r

espo

ndin

g to

acu

tely

ill p

atie

nts

in

hosp

ital (

2007

).

3.40

. All

staf

f sho

uld

be tr

aine

d in

the

loca

lly u

sed

Trac

k an

d Tr

igge

r sy

stem

and

be

awar

e of

and

be

able

to in

stig

ate

the

refe

rral

pro

cess

.

3.41

. Clin

ical

com

pete

ncie

s sh

ould

be

cons

ider

ed d

epen

dent

on

serv

ice

pr

ovisi

on a

nd s

enio

r su

ppor

t ava

ilabl

e, w

ith a

nnua

l mon

itorin

g vi

a th

e

appr

aisa

l / P

ADR

syst

em

3.42

. Clin

ical

com

pete

ncie

s fo

r m

edic

al s

taff

shou

ld b

e as

sess

ed r

egul

arly

by

seni

or c

linic

ians

3.43

. Acc

urat

e re

cord

of n

urse

trai

ning

mai

ntai

ned

in r

elat

ion

to A

cute

Car

e

com

pete

ncie

s fo

r bo

th r

egist

ered

and

non

-reg

ister

ed n

urse

s / p

ract

ition

ers


RED

AM

BER

GRE

ENQ

UA

LIFY

ING

N

OT

ES

4. P

atie

nt S

afet

y an

d C

linic

al G

over

nanc

e

4.1.

Ea

ch o

rgan

isatio

n sh

ould

del

iver

the

sev

en c

ore

elem

ents

of

Com

preh

ensiv

e C

ritic

al C

are

Out

reac

h (3

CO

) PR

EPAR

E.

4.2.

Ea

ch o

rgan

isatio

n m

ust

have

a c

lear

ly

defin

ed r

efer

ral s

trat

egy

incl

udin

g C

ritic

al C

are

Out

reac

h / A

cute

Car

e Te

am /

Rap

id R

espo

nse

Team

ser

vice

to

sup

port

acu

tely

ill p

atie

nt a

ctiv

ity 2

4 ho

urs

7 da

ys p

er w

eek

4.3.

M

edic

al s

taff

with

crit

ical

car

e tr

aini

ng m

ust

be a

vaila

ble

to s

uppo

rt th

e gr

aded

res

pons

e

4.4.

Pr

ovisi

on o

f con

tinuo

us b

edsid

e su

ppor

t av

aila

ble

to w

ard

base

d st

aff

whe

n ne

cess

ary

(CC

SF).

4.5.

Ea

ch o

rgan

isatio

n m

ust

have

a c

lear

Ope

ratio

nal

Polic

y fo

r C

ritic

al C

are

Out

reac

h / A

cute

Car

e Te

am /

Rap

id R

espo

nse

Team

tha

t del

inea

tes

the

team

’s re

mit

and

incl

udes

the

sev

en c

ore

elem

ents

of c

ompr

ehen

sive

criti

cal c

are

outr

each

(3C

O)

PREP

ARE.

Th

is sh

ould

be

ratifi

ed a

t Tru

st

Boar

d le

vel.

4.6.

O

pera

tiona

l pol

icy

shou

ld in

clud

e ex

plic

it gu

idan

ce o

n pa

tient

ref

erra

l to

the

team

and

ref

erra

l ont

o ot

her

mul

tidisc

iplin

ary

prof

essio

nals

4.7.

C

onsid

er T

rust

wid

e in

trod

uctio

n of

pat

ient

or

care

r ac

tivat

ed c

alls

to th

e C

ritic

al C

are

Out

reac

h Te

am.

4.8.

Ea

ch te

am s

houl

d ha

ve a

sys

tem

atic

app

roac

h to

pol

icy

prot

ocol

de

velo

pmen

t and

rev

iew

util

ising

nat

iona

l and

loca

l gui

danc

e, a

nd

agre

ed b

y go

vern

ing

body

with

in th

e Tr

ust

4.9.

Al

l nat

iona

l sta

ndar

ds s

houl

d be

follo

wed

whi

ch r

elat

e to

the

acut

ely

ill pa

tient

(whe

re a

ppro

pria

te).

4.10

. Eac

h te

am s

houl

d ha

ve a

sys

tem

in p

lace

for

repo

rtin

g, in

vest

igat

ing

and

lear

ning

from

adv

erse

inci

dent

s an

d ne

ar m

isses

. Th

is sh

ould

feed

into

the

Trus

t wid

e cl

inic

al g

over

nanc

e pr

oces

s to

faci

litat

e Tr

ust w

ide

scru

tiny

of

prac

tice

(Pat

ient

Saf

ety

Firs

t 200

8).

4.11

. Eac

h te

am s

houl

d re

gula

rly p

artic

ipat

e in

spe

cial

ity b

ased

mor

talit

y &

m

orbi

dity

mee

tings

(NC

EPO

D)


RED

AM

BER

GRE

ENQ

UA

LIFY

ING

N

OT

ES

5. A

udit

and

Eva

luat

ion;

Mon

itor

ing

of P

atie

nt O

utco

mes

and

Con

tinu

ing

Qua

lity

of C

are.

Idea

lly a

ll C

riti

cal C

are

Out

reac

h Te

ams

to p

arti

cipa

te in

the

“N

atio

nal C

riti

cal C

are

Out

reac

h A

ctiv

ity

Out

com

e

Dat

a S

et”

(NO

rF 2

011)

. Ess

enti

al m

onth

ly d

ata

colle

ctio

n sh

ould

incl

ude:

5.1.

N

umbe

r of

inp

atie

nt c

alls

to th

e ca

rdia

c ar

rest

team

5.2.

C

ritic

al c

are

“Fol

low

-ups

”

5.3.

N

umbe

r of

indi

vidu

al p

atie

nts

follo

wed

up

afte

r cr

itica

l car

e di

scha

rge

5.4.

N

umbe

r of

clin

ical

rev

iew

s (v

isits

) for

pat

ient

s fo

llow

ed u

p af

ter

criti

cal c

are

disc

harg

e

5.5.

Ea

rly r

e-ad

miss

ions

to c

ritic

al c

are

(with

in 4

8 hr

s of

disc

harg

e).

5.6.

In

Pat

ient

s -

eith

er in

crit

ical

car

e or

bei

ng fo

llow

ed u

p af

ter

criti

cal c

are

(tr

igge

rs o

r re

ferr

als)

5.7.

N

umbe

r of

cal

ls to

Out

reac

h

5.8.

N

umbe

r of

indi

vidu

al in

patie

nts

refe

rred

to O

utre

ach

5.9.

N

umbe

r of

indi

vidu

al p

atie

nts

atte

nded

by

Out

reac

h

5.10

. Num

ber

of c

linic

al r

evie

ws

(visi

ts) f

or n

on-c

ritic

al c

are

refe

rred

pat

ient

s

Des

irab

le m

onth

ly d

ata

colle

ctio

n sh

ould

incl

ude:

5.11

. Hos

pita

l sta

ndar

dise

d m

orta

lity

ratio

.

5.12

. Med

ian

Out

reac

h re

spon

se t

ime.

5.13

. Med

ian

“Sco

re–2

–doo

r” t

ime.

Ogl

esby

et a

l (20

11)

5.14

. Med

ian

leng

th o

f sta

y (s

urvi

vors

pos

t cr

itica

l car

e).

5.15

. Hos

pita

l mor

talit

y am

ongs

t cr

itica

l car

e su

rviv

ors

5.16

. Num

ber

of m

onth

ly h

ospi

tal a

dmiss

ions

5.17

. An

audi

t of

com

plia

nce

with

per

form

ance

sta

ndar

ds m

ust

be fe

d ba

ck to

Tr

ust

Boar

ds a

nd N

etw

orks

incl

udin

g co

mpl

ianc

e w

ith C

G50


RED

AM

BER

GRE

ENQ

UA

LIFY

ING

N

OT

ES

5.18

. Eac

h tr

ust

shou

ld d

evel

op a

n au

dit

tool

to a

sses

s ut

ilisat

ion

of th

eir

Tr

ack

and

Trig

ger

and

gra

ded

resp

onse

sys

tem

w

ith c

lear

gov

erna

nce

proc

edur

es f

or a

ctio

n of

poo

r co

mpl

ianc

e tr

ust

wid

e

5.19

. Und

erta

ke a

nnua

l pat

ient

& c

arer

sat

isfac

tion

surv

eys

(CC

SF)

6. R

ehab

ilita

tion

aft

er C

riti

cal I

llnes

s (F

ollo

w-u

p)

6.1.

Th

is m

ay b

e un

dert

aken

by

diffe

rent

tea

ms

loca

lly b

ut th

e pr

oces

s m

ust

incl

ude

com

plia

nce

with

the

NIC

E 83

gui

delin

es “

Reha

bilit

atio

n af

ter

a pe

riod

of c

ritic

al il

lnes

s” e

nsur

ing

reha

bilit

atio

n an

d tr

aditi

onal

med

ical

and

nu

rsin

g ca

re a

re a

ligne

d.

6.2.

Ea

ch T

rust

mus

t ha

ve a

reh

abilit

atio

n po

st c

ritic

al il

lnes

s pa

thw

ay /

op

erat

iona

l po

licy.

The

se s

houl

d re

flect

the

NIC

E 83

gui

danc

e w

ith

clea

r lin

es o

f acc

ount

abilit

y, b

ut b

e re

leva

nt a

nd a

chie

vabl

e w

ithin

the

ir

orga

nisa

tion.

Th

is sh

ould

be

alig

ned

to th

e N

etw

ork

wid

e R

aCI p

athw

ay

whe

re o

ne e

xist

s

6.3.

Al

l org

anisa

tions

mus

t in

volv

e an

exp

ert

patie

nt o

r pa

tient

adv

isor

grou

ps

e.g.

ICU

Ste

ps in

des

igni

ng,

form

ulat

ing

and

revi

ewin

g lo

cal g

uida

nce

6.4.

Ea

ch T

rust

sho

uld

prov

ide

regu

lar

audi

ts (

min

imum

ann

ually

) th

at m

easu

re

the

com

plia

nce

with

CG

83 r

ehab

ilitat

ion

follo

win

g cr

itica

l illn

ess,

re

view

ing

and

adap

ting

serv

ice

deliv

ery

as r

equi

red

6.5.

Ea

ch o

rgan

isatio

n sh

ould

pro

vide

aw

aren

ess

trai

ning

, ed

ucat

iona

l sup

port

an

d su

perv

ision

or

men

torin

g fo

r re

gist

ered

and

non

reg

ister

ed w

ard

staf

f in

the

requ

irem

ents

and

hol

istic

app

roac

h to

reh

abilit

atin

gthe

crit

ical

ly il

l pa

tient

6.6.

C

linic

al e

xper

ts s

houl

d de

vise

the

reh

abilit

atio

n pl

ans

for

patie

nts

es

tabl

ishin

g cl

ear

time

orie

ntat

ed in

terv

entio

ns t

hat c

an b

e fo

llow

ed a

nd

impl

emen

ted

by a

ll w

ard

staf

f who

hol

d th

e co

mpe

tenc

ies

to fu

lfil t

hese

re

quire

men

ts.


RED

AM

BER

GRE

ENQ

UA

LIFY

ING

N

OT

ES

7. E

nhan

cing

Ser

vice

Del

iver

y

Sta

ffing

Req

uire

men

ts

7.1.

Se

para

tely

ros

tere

d C

ritic

al C

are

Out

reac

h te

am a

vaila

ble

24 h

ours

per

day

, 7

days

a w

eek

(NC

EPO

D, C

CSF

, NO

rF).

7.2.

Su

fficie

nt s

taff

to d

eliv

er 3

CO

/ PR

EPAR

E 24

hou

rs p

er d

ay, 7

day

s pe

r w

eek

7.3.

C

ritic

al C

are

Out

reac

h te

am s

uppo

rt b

y se

ssio

nal c

omm

itmen

t fro

m

Con

sulta

nt In

tens

ivist

or

Con

sulta

nt in

Acu

te C

are

Med

icin

e

7.4.

Sh

ared

trai

nee

med

ical

sta

ff w

ith c

ritic

al c

are

units

and

acu

te c

are

who

hav

e no

res

pons

ibilit

ies

othe

r th

an th

ose

dire

ctly

rel

ated

to p

rovi

ding

the

grad

ed

resp

onse

7.5.

Se

nior

Phy

sioth

erap

ist w

ith s

essio

nal c

omm

itmen

t to

Crit

ical

Car

e O

utre

ach

suffi

cien

t to

follo

w u

p pa

tient

s di

scha

rged

from

crit

ical

car

e an

d re

ceiv

e

appr

opria

te r

efer

rals.

7.6.

Al

lied

heal

th p

rofe

ssio

nals

(pha

rmac

y, d

iete

tics,

spe

ech

and

lang

uage

and

oc

cupa

tiona

l th

erap

y) a

vaila

ble

for

Crit

ical

Car

e O

utre

ach

refe

rral

s

Org

anis

atio

n

7.7.

N

omin

ated

lea

d of

ser

vice

at T

rust

Boa

rd le

vel w

ith a

ppro

pria

te

com

mun

icat

ion

casc

ade

(Com

preh

ensiv

e C

ritic

al C

are

DH

200

0).

7.8.

Le

ad M

edic

al C

onsu

ltant

with

a q

ualifi

catio

n in

eith

er in

tens

ive

care

or

acut

e ca

re s

peci

ality

to

supp

ort

serv

ice

deve

lopm

ent

and

deliv

ery.

7.9.

Le

ad P

ract

ition

er a

nd C

onsu

ltant

int

egra

l to

Crit

ical

Car

e D

eliv

ery

Gro

up

to fa

cilit

ate

Trus

t w

ide

disc

ussio

n on

acu

te c

are

war

d ba

sed

issue

s.


RED

AM

BER

GRE

ENQ

UA

LIFY

ING

N

OT

ES

7.10

. Mec

hani

sms

in p

lace

to

ensu

re fu

ll en

gage

men

t of

war

d ba

sed

colle

ague

s (e

.g. “

Link

Nur

se S

yste

m”)

.

7.11

. Mec

hani

sms

in p

lace

to

ensu

re v

iew

s an

d op

inio

ns o

f pat

ient

s an

d ca

res

are

refle

cted

in s

ervi

ce d

evel

opm

ent.

7.12

. Ful

l eng

agem

ent

with

reg

iona

l Crit

ical

Car

e N

etw

ork

7.13

. Crit

ical

Car

e O

utre

ach

/ Acu

te C

are

/ Rap

id R

espo

nse

Team

s sh

ould

re

gula

rly r

evie

w s

ervi

ce p

rovi

sion

to fa

cilit

ate

proa

ctiv

e ap

proa

ches

in

or

der

to m

atch

ser

vice

con

figur

atio

n ag

ains

t lo

cal d

eman

ds.

The

se

shou

ld b

e re

flect

ed in

the

oper

atio

nal

polic

y


Advisory Contributors

Caroline Barclay Critical Care Outreach Lead,

University Hospitals of Leicester NHS Foundation Trust

Carmel Gordon-Dark

Critical Care Outreach Sister

The London Clinic, London

Alison Dinning Critical Care Outreach Sister,

Nottingham University Hospitals NHS Trust

Lesley Durham Network Director,

North of England Critical Care Network

Isabel Gonzalez Consultant Critical Care,

The James Cook University Hospital, Middlesbrough

Tracey Moore Senior Lecturer Head of Taught Studies,

University of Sheffield

Sarah Quinton Critical Care Outreach Lead Nurse,

Heart of England NHS Foundation Trust

Elizabeth Smith Patient Safety Manager,

Wales Patient Safety Team

Catharine Thomas Consultant Respiratory Physiotherapist,

Tameside Hospital NHS Foundation Trust

Duncan Watson Consultant Anaesthesia and Critical Care,

University Hospital of Coventry and Warwickshire

John Welch Nurse Consultant Critical Care,

University College London Hospitals


REFERENCES

Department of Health (2000) Comprehensive Critical Care: A Review of Adult Critical Care Services London, Department of Health http://www.doh.gov.uk/pdfs/criticalcare.pdf

Department of Health (2007) Competencies for recognising and responding to acutely ill patients in hospital http://www.doh.gov.uk/pdfs/criticalcare.pdf

Comprehensive Critical Care: A Review of Adult Critical Care Services London, Department of Health http://www.doh.gov.uk/pdfs/criticalcare.pdf

Intensive Care Society (2002) Levels of critical care for adult patients London, Intensive Care Society

Intensive Care Society (2011) Guidelines for the transport of the critically ill adult London, Intensive Care Society

National Outreach Forum 2003 Critical Care Outreach 2003: Progress in Developing Services NHS Modernisation Agency.

National Outreach Forum 2010 http://www.norf.org.uk

NCEPOD (2009) “Adding insult to injury”. A review of the care of patients who died in hospital with a primary diagnosis of acute kidney injury. National Confidential Enquiries into Patient Outcome and Death (NCEPOD), June 2009

NCEPOD (2007) A Journey in the right direction? A Report of the National Confidential Enquiry into Patient Outcome and Death London

NCEPOD (2005) “An Acute problem” - A report of the National Confidential Enquiry into Patient Outcome and Death.

NICE Clinical Guideline 50 (2007) acutely ill patients in hospital: recognition of and response to acute illness in adults in hospital London

NICE Clinical Guideline 83 (2009) Rehabilitation after critical illness London

National Patient Safety Agency (2007) Recognising and responding appropriately to early signs of deterioration in hospitalised patients London

National Patient Safety Agency (2007) safer care for the acutely ill patient; learning from serious incidents. London

Patient Safety First Campaign 2008 http://www.patientsafetyfirst.nhs.uk/content.aspx?path=/

Standardising the Assessment of Acute Illness Severity in the NHS: ‘Recommendations for a NHS Early Warning Score (NEWS)’. A report from the Royal College of Physicians: Draft 3 National Stakeholder Consultation March 2011

‘Score to Door Time’ – a benchmarking tool for rapid response systems: a pilot multi- centre service evaluation Critical Care 2011 15: R180 Oglesbyk K, Durham L, Welch J, Subbe C.

Documents

Operational Standards and Competencies for Critical Care