Editorial II

Outreach critical care—cash for no questions?

B. H. Cuthbertson1

1 Academic Unit of Anaesthesia and Intensive Care, Institute of Medical Sciences, University of Aberdeen, Foresterhill, Aberdeen AB25 2ZD, UK E-mail: b.h.cuthbertson@abdn.ac.uk

Outreach critical care appears to be such a good idea that sometimes we forget that there is little evidence to support it. It seems clinically and biologically plausible that early recognition of critical illness, followed by timely interventions undertaken by appropriately trained staff, should improve patient outcomes. Indeed, there are many good reasons why we should push this new development forward, but there are also reasons why we should exercise caution.

The outreach concept originated in Liverpool, New South Wales, in 1990 with the development of the Medical Emergency Team (MET).1 The MET was described as an effort to reduce the incidence and improve the outcome of cardiopulmonary arrests, by a team modelled on the principles of early recognition and rapid response. The MET replaced the traditional cardiac arrest team with a more proactive team of critical care doctors and nurses who would use a specified calling system to allow them to recognize impending critical illness and intervene to improve outcome.1 Outreach services are an integral part of the review of adult critical care services published as the paper Comprehensive Critical Care by the Department of Health in 2000.2 This paper describes Outreach as having three essential objectives: (i) ‘To avert ICU admissions by identifying patients who are deteriorating and either helping to prevent admission or ensuring that admission to a critical care bed happens in a timely manner to ensure best outcome’; (ii) ‘To enable ICU discharges by supporting both the continuing recovery of discharged patients on wards and after discharge from hospital’; and (iii) ‘To share critical care skills with staff in wards and the community, ensuring enhancement of training opportunities and skills practice and using information gathered from the ward and community to improve critical care services for patients and relatives’.2 It is interesting to note that the report of the short-life working group on critical care issues for Scotland (Better Critical Care) took the view that ‘Outreach teams and follow-up would not significantly affect ICU workload, optimal patient care, or bed requirements.’3

The concept of Outreach has many enthusiastic supporters. For many years, clinical experience has suggested that care offered to patients in the period preceding transfer to the ICU is often suboptimal, and there is good-quality ‘level-2’ evidence (evidence derived from high-quality cohort studies of case-controlled studies) to support this claim.46 Outreach has been advocated by many as an answer to the problem of suboptimal ward care, and many clinicians involved in supplying critical care generally support the concept.4 5 In an ideal world, we all appreciate the importance of evidence-based medicine, but pragmatic clinicians may not see the rationale in waiting for strong supportive evidence, given that Outreach seems such a sensible and intuitive practice. Experienced critical care nurses support the concept of Outreach for the same reasons, but they also recognize that Outreach offers an ideal framework for the enthusiastic nurse consultant to exhibit their skills. The government seems to like the idea (as part of the recommendations of Comprehensive Critical Care) as it appears to satisfy the public and medical professions’ demands for critical care reform and allows the spotlight to move away from this emotive area.

Given the apparent enthusiasm for Outreach and given that the government has chosen to spend £142 million to support the practice, why should we exercise caution?2 Is it not prudent to accept the cash and ask no questions? The additional funding has been rapidly spent on establishing ‘Outreach services’, along with a modest increase in the number of ICU beds. The entire process was so rapid that hospitals had little time to produce detailed development plans for the first round of funding, and by the time that many hospitals had prepared more detailed proposals, the second round of funding had been redirected away from critical care. Scotland and Wales were not so lucky: they did not receive any additional monies as part of the critical care development programme.3

The first reason for caution is the lack of supportive evidence for Outreach critical care. As stated, the MET system was the first report of this system but did not offer supportive evidence as such.1 This was followed by several reports describing other scoring systems and Outreach teams structured along a similar theme.712 None of these reports offers more than level-2 evidence in support of their Outreach systems, and most merely present the concepts of the systems described.612 More recently, more supportive evidence has appeared in the literature in the form of two cohort studies looking at the effects of the implementation of the MET system in Australian hospitals.13 14 The first paper suggests a reduction in unexpected ICU admissions but without an improvement in mortality.13 The second suggests a reduction in the incidence and mortality from ‘unexpected’ cardiac arrest, and a reduction in hospital mortality.14 In the latter paper, some or all of these effects may be explained by the authors’ unusual definition of cardiac arrest, or by the increased placement of ‘do not resuscitate’ orders by the MET.14 15 The presence of the ‘Hawthorne effect’ (the ability to alter outcomes by the process of studying an intervention), may also be important and will always introduce a source of potential bias into clinical research of this nature.16 One would therefore have to conclude that there is inadequate evidence in the literature to support the clinical implementation of Outreach services, although steps have been taken towards achieving this end and more work is underway. Despite this fact, Comprehensive Critical Care recommends Outreach critical care, whereas Better Critical Care suggests that Outreach would not improve ‘optimum patient care’.2 3 Neither of these recommendations can be supported from the literature!

Next is that, in the rush to have ‘critical care without walls’, perhaps we should remind ourselves why these walls existed in the first place. Intensive care services were introduced in the 1970s to fill the ‘gap’ in care offered to the critically ill patient who would previously have been cared for in the ward setting. We took these patients ‘behind walls’ to offer concentrated clinical expertise with effective and efficient staffing and resource utilization. In the 1980s it was recognized that another ‘gap’ existed between ward and ICU care, and high-dependency care was introduced.17 Again, we felt it was rational to concentrate resources into identifiable clinical areas. Now we are attempting to fill yet another ‘gap in care’ through the development of Outreach, and we have been asked to break down the walls we worked so hard to create. Surely, it is not the walls that are the problem; it is a lack of functioning doors that impedes the supply of effective critical care.

There are clearly lessons to be learned regarding the implementation of new services as a move to implement Outreach services. In 2001, 84 of 166 (50%) hospitals surveyed in England had established ‘Outreach services’. In over half of these units there was no medical input to the service, the majority did not offer care after 5 p.m., and eight different alerting systems were used (personal communication; Richard Morgan, Victoria Hospital, Blackpool, UK). It seems, perhaps because of the lack of a clear evidence base, that the implementation of Outreach critical care has so far been somewhat unsystematic. Even if Outreach is the answer to our problems, there can only be one best framework to allow the effective implementation and practice of Outreach critical care. Saying that, any framework must be flexible enough to recognize that individual units will have specific problems that require local solutions. I believe that a minimum standard of clinical care must be defined to allow quality clinical practice and comparative audit whilst we await a supportive evidence base.

In conclusion, I make the following requests and suggestions.

(i) We must encourage research into the development of validated, sensitive and specific scoring systems to allow the early detection of the deteriorating patient.

(ii) We must study whether Outreach systems are able to improve outcomes, and attempts should be made to delineate whether the individual components of Outreach (such as ‘near-patient’ education) can bring about independent improvements in outcome.

(iii) In designing such studies we need to recognize the following points. Rather than solely attempting to validate existing scoring systems that may contain too many or inappropriate physiological variables to allow quantification of their sensitivity and specificity, we need to study the role of individual physiological variables and test their predictive power. Randomized controlled trials (RCTs) may not be the most suitable method to determine an outcome benefit for a system of care as opposed to an individual intervention. This may mean that level-1 evidence (evidence derived from RCTs with low risk of bias) may never become available. Outcomes such as critical physiological events, cardiac arrest, and the development of complications, may be more powerful in determining benefit, although ultimately it must be mortality in which we are most interested. Confounders such as the ‘Hawthorne effect’ may be difficult to control in study design. Large, well designed, multicentre studies may be required to answer these questions.

(iv) We must define a standard of care and a framework for development for Outreach services, in order to avoid unsystematic service implementation and practices as we await evidence. These standards and frameworks require enough flexibility to allow centres to meet their local needs. I believe that the NHS Modernisation Agency and national representative bodies such as the Intensive Care Society have an important role here.

(v) Finally, although many practitioners have already implemented changes in their practice to encompass Outreach, they must appreciate that Outreach still represents an untried clinical development. In the future we may be required to withdraw or withhold what may come to be seen as ‘an established standard of care’, to allow it to undergo rigorous scientific evaluation. After all, even at this late stage, it is undesirable for any clinical intervention to become ‘a standard of care’ without rigorous assessment and evaluation.

References

1 Lee A, Bishop G, Hillman KM, Daffurn K. The Medical Emergency Team. Anaesth Intensive Care 1995; 23: 183–6[ISI][Medline]

2 Department of Health. Comprehensive Critical Care. A Review of Adult Critical Care Services. London: Department of Health, 2000

3 Scottish Executive; Health Department. Better Critical Care – Report of a Short-life Working Group on ICU and HDU Issues. Edinburgh: Scottish Executive, 2000

4 McQuillan P, Pilkington S, Allan A, et al. Confidential enquiry into quality of care before admission to intensive care. Br Med J 1998; 316: 1853–8[Abstract/Free Full Text]

5 Garrard C, Young JD. Sub-optimal care of patients before admission to intensive care. Br Med J 1998; 316: 1841–2[Free Full Text]

6 Harbour R, Miller J. A new system for grading recommendations in evidence based guidelines. Br Med J 2001; 323: 334–6[Free Full Text]

7 Morgan RJM, Williams F, Wright MM. An early warning scoring system for detecting developing critical illness. Clin Intensive Care 1997; 8: 100

8 Goldhill DR, Singh SR, Tarling MM, et al. The patient at risk team: identifying and managing critically ill ward patients. Br J Anaesth 1998; 81: 812P

9 Goldhill DR, Mulcahy AJ, Tarling MM, et al. Patients admitted to the ICU from the ward: effect of the patient at risk team. Br J Anaesth 1998; 81: 812–3P

10 Stenhouse C, Coates S, Tivey M, Allsop P, Parker T. Prospective evaluation of modified EWS score etc. Br J Anaesth 2000; 84: 663P

11 Subbe CP, Kruger M, Rutherford P, Gemmel L. Validation of a modified Early Warning Score in medical admissions. Q J Med 2001; 94: 521–6

12 Rogers J, Fuller HD. Use of the APACHE II score to predict individual patient survival rate. Crit Care Med 1994; 22: 1402–5[ISI][Medline]

13 Bristow PJ, Hillman KM, Chey T, et al. Rate of in-hospital arrest, deaths and intensive care admissions: the effect of a Medical Emergency Team. Med J Austral 2000; 173: 236–40[ISI]

14 Buist MD, Moore GE, Bernard SA, Waxman BP, Anderson JN, Nguyen TV. Effects of a medical emergency team on reduction of incidence of and mortality from unexpected cardiac arrests in hospital: preliminary study. Br Med J 2002; 324: 387–90[Abstract/Free Full Text]

15 Smith GB, Nolan J, King A, et al. Medical emergency teams and cardiac arrests in hospital. Br Med J 2002; 324: 1215[Free Full Text]

16 Campbell JP, Maxey VA, Watson WA. The Hawthorne effect: implications for pre-hospital research. Ann Emerg Med 1995; 26: 590–4[ISI][Medline]

17 Dhond G, Ridley S, Palmer M. The impact of a high-dependency unit on the workload of an intensive care unit. Anaesthesia 1998; 53: 841–7[CrossRef][ISI][Medline]





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