Improving referral to the Critical Care Outreach Team

To establish why referral times are below the recommended standards and come up with an action plan in order to improve the referral time of deteriorating patients to the CCOT so expert review and care can be implemented in a faster manner.

My CCOT at Whittington Health NHS Trust considered the findings of an ongoing monthly audit which looked at all referrals made to the CCOT. We reviewed the medical observation charts of patients.

We 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.

I conducted multi-disciplinary focus groups in order get answers to the following questions: How does the multidisciplinary ward teamwork with and experience the Early Warning Score (EWS).

Further questions that crystallised to be of importance to me became:

1) Is the hospital’s observation chart clear and easy to use?

2) Is the triggering system and escalation procedure clear?

3) Are there any barriers to referring patients to the CCOT on time?

Difficulties: arranging focus groups in a busy NHS trust can be hard especially in the busy winter months. I had to invest my own spare time to conduct the focus groups and complete the project. Gaining ethics approval from hospital and university is also a complex and time-consuming process but engagement with stakeholders was otherwise easy as it was considered a very important endeavour by most.

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 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 project 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.

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 especially in winter time. Offering coffee/tea and a snack during the focus groups are useful incentives for participants to take part.

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 wider dissemination of findings from the focus groups, the educational packages and audits need to be well planned and ongoing.