Clinical Effectiveness of a Critical Care Nursing Outreach Service

Abstract and Introduction

Abstract

Background: Improved discharge planning and extension of care to the general care unit for patients transferring from intensive care may prevent readmission to the intensive care unit and prolonged hospital stays. Morbidity, mortality, and costs increase in readmitted intensive care patients.
Objectives: To evaluate the clinical effectiveness of a critical care nursing outreach service in facilitating discharge from the intensive care unit and providing follow-up in general care areas.
Methods: A before-and-after study design (with historical controls and a 6-month prospective intervention) was used to ascertain differences in clinical outcomes, length of stay, and cost/benefit. Patients admitted to intensive care units in 3 adult teaching hospitals were recruited. The service centered on follow-up visits by specialist intensive care nurses who reviewed and assessed patients who were to be or had been discharged to general care areas from the intensive care unit. Those nurses also provided education and clinical support to staff in general care areas.
Results: In total, 1435 patients were discharged during the 6-month prospective period. Length of stay from the time of admission to the intensive care unit to hospital discharge (P = .85), readmissions during the same hospital admission (5.6% vs 5.4%, P = .83), and hospital survival (P = .80) did not differ from before to after the intervention.
Conclusions: Although other studies have shown beneficial outcomes in Australia and the United Kingdom, we found no improvement in length of stay after admission to the intensive care unit, readmission rate, or hospital mortality after a critical care nursing outreach service was implemented.

Introduction

The major role of intensive care units (ICUs) is to save lives that would otherwise be lost to conditions such as severe infection, trauma, burns, drug overdose, or acute respiratory failure. Australia has 167 hospitals with ICUs that, in 2003, admitted 143000 patients.[1] Overall survival is good, with 85% of patients being discharged from the hospital. However, critical care is expensive. In the United States in 2000, critical care costs represented 13.3% of hospital costs, 4.2% of national health expenditures, and 0.56% of the gross domestic product. The number of ICU admissions and the cost per day of ICU care in Australia are unknown but are most likely substantially lower than in the United States (eg, 0.1% of gross domestic product, which corresponds to about 900 million per annum). However, demand for intensive care services is increasing, and intensive care is growing at a rate that is higher than the average for all health services.[2] Demand for increasingly sophisticated technology in clinical care, increasing numbers of older patients with concomitant comorbid diseases, and increased consumer expectations all contribute to this increased demand for intensive care services.[3]

Given the financial burden of critical illness, there is considerable impetus to consider strategies to reduce the demand for intensive care services, ideally by preventing critical illness in the first place. Once a patient has been selected for discharge from ICU, however, the goal is to expedite their discharge from the ICU and then from the hospital by preventing deterioration that requires readmission to the ICU or a prolonged hospital stay. Patients who are readmitted to the ICU have increased morbidity, mortality, and costs.[4]

Timely detection of critically ill patients or patients in deteriorating condition is of paramount importance in improving their outcomes. Indeed, attempts to facilitate the early management of patients who exhibit signs of deteriorating condition underpinned the implementation of “medical emergency teams” (METs) in hospitals (initially) throughout Australia[5] and now throughout the world. The MET concept, however, relies on the staff in general care areas being able to recognize that the patient’s condition is deteriorating and then to call for the MET to attend. In a cluster randomized controlled trial to compare outcomes with a MET versus without a MET, researchers found no improvement in the incidence of cardiac arrest, unplanned ICU admissions, or unexpected death with an MET, which suggests that this approach may not be as effective as initially reported.[6] An alternative strategy for post-ICU patients is use of an ICU outreach team (in the United Kingdom)[7] or an ICU liaison nurse (in Australia).[8] The principle underpinning ICU “outreach” services is to avert readmission to the ICU (and in-hospital death) once patients are discharged from the ICU. Readmission is avoided by monitoring the post-ICU discharge progress and promptly recognizing when patients are unwell or in deteriorating condition so as to permit initiation of appropriate interventions. In a landmark study[7] that galvanized interest in this outreach concept, researchers reported a reduction in readmissions to the ICU by 6.4% (95% confidence interval [95% CI] 0.26–0.87) after the introduction of a critical care (nurse) outreach team in the United Kingdom. Hospital survival in ICU patients was increased by 6.8% (relative risk 1.08, 95% CI, 1.00–1.18), although the difference was not statistically significant.[7] The characteristics of the ” before” and “after” cohort of ICU patients in that study did not differ significantly, thus reducing the likelihood that the improvements in outcomes were due to confounding. In a more recent multicenter survey of 108 units in the United Kingdom, the critical care outreach service was associated with significant decreases in the proportion of patients admitted to the ICU who had received cardiopulmonary resuscitation before admission (95% CI, 0.73–0.96), in after-hours ICU admissions (95% CI, 0.84–0.97), and in mean physiology score[9] (95% CI, 0.31–2.12) but neither ICU mortality (95% CI, 0.87–1.08) nor in-hospital mortality changed significantly.[10]

A critical care nursing outreach service thus extends critical care services beyond the confines of the ICU, to function within a service and educational partnership between the ICU and the general care areas. The outreach teams support the staff in general care areas by following up patients recently discharged from the ICU, as well as participating in discharge planning for ICU patients. Discharge planning is important for enabling timely discharge to the general care area. In a study conducted at one of this project’s study sites in 2000 and 2001, the researchers detected a significant delay in transfer from the ICU in 27% of patients, even in patients who had been ready for transfer to the general care area for several days.[11] These delays not only result in unnecessarily higher costs, but the delays block potential admissions to the ICU and can result in hastily performed discharges after hours if an ICU bed is needed in an emergency. Although bed availability was an issue that delayed discharge, having adequate support for specialized services in the general care areas was also identified as a factor in delaying transfer.

In reports[12–15] of previous evaluations of the use of liaison nurses in Australian hospitals, researchers have described positive outcomes. Chaboyer et al[12] reported a 3-fold reduction in delays of at least 2 hours in discharge from the ICU and a decrease of about 2.5 times in delays of 4 hours or more when a liaison nurse service was implemented. Furthermore, use of liaison nurses was positively evaluated by nursing staff in the general care areas[13] and by patients and their families.[14] Green and Edmonds[15] found the proportion of medical readmissions to the ICU decreased from 2.3% to 0.5% after the liaison nurse service was introduced. However, in a more recent 3-year study, researchers found no significant change in median length of stay (LOS) in the ICU, median hospital LOS, or ICU or hospital mortality before and after use of an ICU liaison nurse was implemented.[16]

Few studies have been done to evaluate the effect of use of Australian liaison nurses on outcomes in a large cohort of critically ill patients. This study was intended to evaluate the clinical effectiveness of the critical care nursing outreach service in 3 tertiary hospital sites in Perth, Western Australia.

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