Abstract
Objective
The purpose of the study was to investigate the effects of introducing a critical care outreach service on in-hospital mortality and length of stay in a general acute hospital.
Design
A pragmatic ward-randomised trial design was used, with intervention introduced to all wards in sequence. No blinding was possible.
Setting
Sixteen adult wards in an 800-bed general hospital in the north of England.
Patients and participants
All admissions to the 16 surgical, medical and elderly care wards during 32-week study period were included (7450 patients in total, of whom 2903 were eligible for the primary comparison).
Interventions
Essential elements of the Critical Care Outreach service introduced during the study were a nurse-led team of nurses and doctors experienced in critical care, a 24-h service, emphasis on education, support and practical help for ward staff.
Measurements and results
The main outcome measures were in-hospital mortality and length of stay. Outreach intervention reduced in-hospital mortality compared with control (two-level odds ratio: 0.52 (95% CI 0.32–0.85). A possible increased length of stay associated with outreach was not fully supported by confirmatory and sensitivity analyses.
Conclusions
The study suggests outreach reduces mortality in general hospital wards. It may also increase length of stay, but our findings on this are equivocal.
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References
Audit Commission (1999) Critical to success: the place of efficient and effective critical care services within the acute hospital. Audit Commission, London, p 79
Department of Health (2000) Comprehensive critical care: a review of adult critical care services. Department of Health, London, p 15
Smith G (2000) To MET or not to MET—that is the question. Care Crit Ill 16:8–9
McArthur-Rouse F (2001) Critical care outreach services and early warning scoring systems: a review of the literature. J Adv Nursing 36:696–704
Cuthbertson BH (2003) Outreach critical care: cash, for no questions? Br J Anaesth 90:4–5
Schein RMH, Hazday N, Pena M, Ruben BH, Sprung CL (1990) Clinical antecedents to in-hospital cardiopulmonary arrest. Chest 98:1388–1392
George AL, Folk BP, Crecelius PL, Campbell WB (1989) Pre-arrest morbidity and other correlates of survival after in-hospital cardiopulmonary arrest. Am J Med 87:28–34
Sax FL, Charlson ME (1987) Medical patients at high risk for catastrophic deterioration. Crit Care Med 15:510–515
Goldhill DR, White SA, Sumner A (1999) Physiological values and procedures in the 24 h before ICU admission from the ward. Anaesth 54:529–534
Smith AF, Wood J (1998) Can some in-hospital cardio-respiratory arrests be prevented? A prospective survey. Resuscitation 37:133–137
McQuillan P, Pilkington S, Allan A, Taylor B, Short A, Morgan G, Nielsen M, Barrett D, Smith G (1998) Confidential inquiry into quality of care before admission to intensive care. Br Med J 316:1853–1858
Hourihan F, Bishop G, Hillman KM, Daffurn K, Lee A (1995) The medical emergency team: a new strategy to identify and intervene in high-risk patients. Clin Intensive Care 6:269–272
Daly FS, Sidney KL, Fatovich DM (1998) The Medical Emergency Team (MET): a model for the district general hospital. Aust NZ J Med 28:795–798
Buist MD, Moore GE, Bernard SA, Waxman BP, Anderson JN, Nguyen TV (2002) Effects of a medical emergency team on reduction of incidence of and mortality from unexpected cardiac arrests in hospital: preliminary study. Br Med J 324:1–6
Goldhill DR, Worthington L, Mulcahy A, Tarling M, Sumner A (1999) The patient-at-risk team: identifying and managing seriously ill ward patients. Anaesthesiology 54:853–860
Subbe CP, Kruger M, Rutherford P, Gemmel L (2001) Validation of a modified Early Warning Score in medical admissions. Q J Med 94:521–526
Le Gall J-R, Lemeshow S, Saulnier F (1993) A new simplified acute physiology score (SAPS II) based on a European/North American multicentre study. J Am Med Assoc 270:2957–2963
Auriant I, Vinatier I, Thaler F, Tourneur M, Loirat P (1998) Simplified Acute Physiology Score II for measuring severity of illness in intermediate care units. Crit Care Med 26:1368–1371
Rasbash J, Browne W, Goldstein H, Yang M, Plewis I, Healy M, Woodhouse G, Draper D, Langford I, Lewis T (2002) A users’ guide to MLwiN. Institute of Education, London
Cox DR, Oaks D (1984) The analysis of survival data. Chapman and Hall, London
Pittard AJ (2003) Out of our reach? Assessing the impact of introducing a critical care outreach service. Anaesthesiology 58:882–885
Ball C, Kirkby M, Williams S (2003) Effect of the critical care outreach team on patient survival to discharge from hospital and readmission to critical care: non-randomised population based study. Br Med J 327:1014–1016
Mayo E (1933) The human problems of an industrial civilization. MacMillan, New York
Leary T, Ridley S (2003) Impact of an outreach team on readmission to a critical care unit. Anaesthesiology 58:328–332
Acknowledgements
We thank the following people for their support for this study: K. Martin, K. Harrison, H. Paw, G. Cundill, M. Reeder, I. Woods, C. Barr, M. Clubbs, J. Miles, M. Yang, G. Dunn and E. Grant. This work was supported by the York Research Innovation Fund (York Hospitals NHS Trust).
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An editorial regarding this article can be found in the same issue (http://dx.doi.org/10.1007/s00134-004-2269-6)
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Priestley, G., Watson, W., Rashidian, A. et al. Introducing Critical Care Outreach: a ward-randomised trial of phased introduction in a general hospital. Intensive Care Med 30, 1398–1404 (2004). https://doi.org/10.1007/s00134-004-2268-7
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DOI: https://doi.org/10.1007/s00134-004-2268-7