Vascular Endothelium

Response
(Damage to the intima
artherogenesis)
Media
Defects
Elastic
Degeneration
Bulging of the
Arterial Wall
Permanent thining of the
muscular media layer
Rupture
Risk Factors:
Genetics
Hypertension
Atherosclerosis
Age: 71years old
Lifestyle
Mechanical Factors:
Hemodynamic
Stresses (Pressure
and Shears)



Critical Care Outreach Team
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Service Summary
The outreach team is a multidisciplinary team comprising of senior nurses with a background in intensive care.
The team works closely with the nursing and anaesthetic staff in the intensive care units at both the Calderdale
Royal (CRH) and Huddersfield Royal Infirmary (HRI) sites.
The team was established in 2004 in order to support ward staff in the detection and management of critically ill
patients. Ward nursing staff use a Modified Early Warning Score (MEWS) in the assessment of all adult patients
within the trust. If a patients MEWS score is of concern then they are immediately referred to both a doctor and
a member of the critical care outreach team.
Our primary aim is to ensure that these patients receive appropriate and timely treatment in a suitable area. This
may be on a ward or involve transfer to the High Dependency Unit (HDU) or Intensive Care Unit (ICU). We also
provide a follow up service to support the continued recovery of patients when they leave the HDU/ICU areas
and return to the ward. Patients who have had a stay of four or more days in the HDU/ICU will receive an
information booklet, critical care follow up information and be invited back for clinic appointment six months after
leaving the HDU/ICU unit.
Intensive Care Follow up clinics
For those patients who have had a stay of four or more days in the HDU/ICU units, we run a follow up
clinic
Patients and their family are invited to the follow up clinic six months after leaving the HDU/ICU
Clinics are held in the outpatients department every month alternating between CRH and HRI and are
jointly run by the critical care outreach team and the intensive care staff.
The aim of the clinic is to give patients and their family the opportunity to discuss any problems or concerns they
may have in relation to their stay on the HDU/ICU. Trust staff are available to offer advice and if necessary to
refer to appropriate doctors and other health care professionals.

Where to find us
On the Intensive Care Units at CRH and HRI.

Who to contact to find out more
The critical care outreach co-ordinator is Gill Runkee available on: 07766 905571.
To contact the outreach team at HRI call 01484 342000 and ask switchboard to bleep 253.
To contact the outreach team at CRH call 01422 357171 and ask switchboard to bleep 8850.

Meet the team
The team are senior members of nursing staff, all with extensive knowledge and experience in the field of critical
care. The staff have recognised teaching and assessing qualifications and are ALERT TM trained. Individual
staff members have undertaken a variety of graduate qualifications relevant to the development of both
themselves and the role of the outreach practitioner. These include ALS (Advanced Life Support) training,
specialist degree programmes, short courses and advanced assessment modules.
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Implementing an ICU outreach team model.
Link/Page Citation
An aging population, rapid patient turnover, and advanced technologies are contributing to higher patient
acuity in hospitals. Unrecognized changes in patient condition can lead to major complications, including
death, and are referred to as failure to rescue (Thomas, VanOyen Force, Rasmussen, Dodd, & Whildin,
2007). Providing high quality care at the bedside is becoming increasingly challenging due to a nursing
shortage. Increasing workload pressures are reported for ICU staff and there is a push for them to shift
the focus of their work outside the walls of the ICU (Kerridge & Saul, 2003). Teams of health care
providers with critical care experience that can be called to the patient's bedside 24 hours a day, seven
days a week have been established in hospitals. There are a variety of names for these teams and
different models. An ICU outreach team (ORT) for delivering the service was formed in a tertiary care
hospital in Saskatoon to respond to calls from inpatient units to provide critical care expertise to patients
when the nurse is worried or concerned, or when signs of physiological distress appear. The team
comprises an ICU registered nurse (RN), respiratory therapist (RT), and a physician who is a critical care
associate (CCA). This team was formed to improve timeliness of patient care, to provide a resource for
nurses to access for their patients on inpatient units, and to provide an opportunity for education and
support for nurses on inpatient units. In this article, the development and implementation of an ICU ORT
in Saskatoon is discussed.

Planning

Literature review. Research has shown that providing early intervention to patients with deteriorating
conditions by critical care health care providers outside the walls of the ICU decreases the incidence of
cardiac arrest (Bellomo et al., 2003; DeVita et al., 2004), hospital mortality (Ball, Kirkby, & William, 2003;
Bellomo et al., 2003), death following cardiac arrest, length of hospital stay related to cardiac arrest
(Bellomo et al., 2003), post-operative adverse outcomes, post-operative mortality rate, and length of
hospital stay (Bellomo et al., 2004). Nova Scotia's Dartmouth General Hospital showed a 30 per cent
decrease in the number of documented cardiac arrests after implementation of a critical care team that
works outside of ICU (Canadian Healthcare Technology, 2007).

An ICU ORT is a method for increasing patient safety. The role of the ICU ORT is to assess and stabilize
the patient's condition, assist with organizing information to be communicated to the patient's physician,
provide education and support to the unit staff, and assist with transfer of the patient to a higher level of
care if warranted (Safer Healthcare Now! Campaign, 2006). Other strategies to identify and treat
deteriorating patients earlier or to prevent deterioration have been suggested, such as introducing
hospitalists, nurse practitioners, or increasing nursing staff (Winter, Pham, & Pronovost, 2006).

Although these alternatives have merit, financial and human resources are limiting factors. Nursing
shortages are reported nationally in all fields of nursing. Forty per cent of the RNs working in
Saskatchewan are over the age of 50 years (Canadian Institute of Health Information [CIHI], 2005).
Puckett (2007), president of the Saskatchewan Registered Nurses Association Council, states that the
province needs at least 150 more RNs to graduate each year if it is to offset the wave of retirements that
are impending in the next five to 10 years. Often there are insufficient experienced nurses on a unit to
mentor novice nurses. With the large number of impending retirements, there will be a further paucitof
expert nurses available to mentor. In 2005, RNs in their first five years of nursing experience accounted
for 23.4% of all RNs working in medical surgical units in Saskatchewan (CIHI, 2005).

Other names given to critical care teams practising outside ICU include medical emergency team (MET),
patients at risk team, and rapid response team (RRT). These names are used interchangeably throughout
the article. METs were initially implemented and evaluated in Australia in the 1990s (Ball et al., 2003).
These teams were usually medical, but included a senior nurse. After Australia's experiences, the United
Kingdom developed "patient at risk" teams, which were nurse-led teams. MET and patient at risk teams
responded to patients outside of ICU with early warning signs of physiological distress. ICU ORTs
developed in England and Wales were nurse-led and their role was to provide follow-up services during
the period between discharge from the ICU to discharge from hospital or re-admission to ICU. In the
United States, the Institute for Health Care Improvement (IHI) (n.d.) and its partners launched the
"100,000 Lives Campaign", encouraging the use of proven best practices to help hospitals extend or save
as many as 100,000 lives per year. One of these best practices was the introduction of RRTs to attend to
patients outside ICU when signs of decline were present. Based on the work of the IHI, Canada
implemented the "Safer Healthcare Now" (SHN) Campaign in April 2005 consisting of six interventions.
These have an evidence base indicating that appropriate implementation and practice can lead to
reduced morbidity and mortality (Purvis, n.d.). These six interventions are aimed at:

* preventing deaths among people hospitalized for acute myocardial infarction,

* preventing catheter-related blood stream infections,

* decreasing mortality, re-admission rates and length of hospital stay from surgical site infections,

* implementing strategies that are proven to prevent ventilator-associated pneumonia, and

* identifying and treating patients in distress before they have a cardiopulmonary arrest.

The IHI and SHN have encouraged hospitals in their respective countries to implement RRTs to prevent
deaths in patients who are progressively failing outside of ICU (Institute for Health Care Improvement,
n.d.; Safer Healthcare Now!, 2007). The goals of the Safer Healthcare Now! Campaign (2006) for RRTs
are to:

* reduce the number of cardiopulmonary arrests per 1,000 inpatient discharges by 50% in one year,

* decrease the number of cardiopulmonary arrests occurring outside of the ICU and emergency
department to zero, and

* increase the overall use of the RRT over time.

Other possible benefits of RRTs are better patient outcomes, decreased length of stay in ICU and in
hospital, improved relationships among health care workers, improved satisfaction for nurses, physicians
and patients, positive impact on nursing retention, and financial benefits. In Canada, names of critical
care teams working outside the walls of the ICU include METs, RRTs and ICU ORTs. Different models
are used to provide care for patients, depending on the team structure and service provided. The name of
the team does not differentiate the model.

The team structure can comprises various members of the health care team including an ICU RN, RT,
intensivist, resident, and hospitalist (Safer Health Care Now! Campaign, 2006). The structure is
influenced by the organization's resources that are available to respond immediately, are onsite and
accessible, and have the critical care skills necessary to assess and respond. The service provided by
the team may include daily patient assessments, interventions, and referrals for patients discharged from
ICU or are referred to the team, and/or attending to patients outside the ICU once they show signs of
deterioration.

Steering committee. A steering committee was formed in April 2006 to establish and implement an ICU
ORT. The committee consisted of the directors of ICU, a physician champion, a clinical nurse educator, a
nursing manager, ICU staff nurse, CCA, manager of RT and an RT. A clinical nurse educator was
seconded as a project leader to provide 40 hours of initial work. This project leader was a valuable
resource in establishing initial guidelines, creating documentation and data collection tools, establishing a
method of communicating ORT calls, and coordinating initial education sessions not only for ORT
members, but also for staff throughout the hospital. Although the additional time dedicated to the
implementation of the ICU ORT by the project leader was small, it had a large impact on moving this
project forward quickly. As members of the Canadian ICU Collaborative, committee members were able
to participate in collaborative calls and learning sessions, and had access to the listserv and website to
gain insights from other centres that had already implemented an ICU ORT.

The initial work of the committee included reviewing the current literature on ICU ORTs, establishing a
structure that was workable with the resources available in the hospital, determining the criteria for calling
the ICU ORT, and liaising with the switchboard to determine the most effective way to deploy the ORT
call. The committee members also held meetings and informal discussions with their respective
colleagues to explain about the ICU ORT, its role, when to call, and to answer questions about the
implementation of the ICU ORT.

In addition to the evidence supporting the implementation of ICU ORTs, other factors in this organization
that influenced the need to establish an ICU ORT included limited nursing resources and a large
percentage of novice nurses on inpatient units, and in-house physician coverage that was limited or not
available on nights and weekends for some of the nursing units. The co-directors of the Saskatoon Health
Region Department of Adult Critical Care were integral to establishing this team based on the needs
identified by the hospital. Prior to implementation, there was a two-tier emergency response system in
place: a Code Blue team with two ICU nurses, an RT and the CCA who responded to respiratory and
cardiac arrests; and CCAs who responded to stat calls for other critical events.

Defining the model. St. Paul's Hospital is a 200-bed tertiary care hospital in central Saskatchewan. An
ICU ORT was implemented using existing critical care resources. An RN, RT, and CCA from the ICU
respond to calls from inpatient units and the emergency department within the hospital to provide critical
care expertise to patients when nurses are concerned, or who have signs of physiological distress.

Criteria for calling the ICU ORT were established (Table One). A review of the literature found that call
criteria for critical care teams outside the ICU all contained physiological parameters related to airway,
breathing, circulation and neurological status. The criteria have been used by many teams and thought to
be legitimate reasons to call the team (Thomas et al., 2007). When a patient meets any of the call criteria,
the team should be activated. The team may be called by any member of the health care team in the
hospital by dialing the stat line.

All ICU nurses and RTs are assigned to the ICU ORT. Members are assigned to the ICU ORT for their
entire shift. The team members who respond to ICU ORT calls also respond to Code Blue calls. Where a
Code Blue call requires immediate response to a respiratory or cardiac arrest, the goal of the ORT is to
respond to all ORT calls within 10 minutes.

The role of the team is to partner with the staff on the unit that called, and assess and intervene to
stabilize the patient. The team assists and coordinates appropriate therapy and determines the best
location for the patient to receive care, either on the current unit, an observation unit, or the ICU. The
team participates in end-of-life care planning if indicated. The model of care adopted does not provide for
routine follow-up of patients discharged from the ICU or patients of previous ICU ORT calls.

Components--paging system, documentation, feedback mechanisms. ICU ORT calls are sent to the team
members on a pager with the room number of the patient. The patient care supervisor is also paged, to
aid in patient placement if transfer arrangements are needed, as are the clinical nurse educators during
business hours to assess nursing staff learning needs and to provide follow-up education as required.

Information about ICU ORT calls is documented on a standardized record that becomes a permanent part
of the patient's chart. It is a form used by all disciplines. The record is initiated by the staff on the nursing
unit calling the team.

[FIGURE 1 OMITTED]

Members of the ICU ORT continue to document interventions, time of arrival and leaving the call,
outcome of the call and follow-up plan. If there is a plan for follow-up by the ICU ORT, this will be
communicated to the initiating unit at the completion of the visit.

A copy of this record is returned to the ICU from which data are collected by the clinical nurse educator.
ICU ORT members are encouraged to make anecdotal comments, on the back of the copy form, that they
think are pertinent. The data are reported back to the steering committee and provide a way to track
needs, identify areas of concern, areas of success, and system pressures.

Implementation

Education/information strategies. Once care group leaders were aware of the pending implementation of
the ICU ORT, educational sessions were held for front-line staff on the nursing units and for members of
the critical care staff who would be assigned to the ORT. Education included instruction on use of the
(situation, background, assessment and recommendation (SBAR)) communication tool that was to be
used for communication among team members (Safer Healthcare Now! Campaign, 2006), criteria for
making a call, the importance of calling the patient's attending physician prior to calling the ICU ORT,
procedure for calling the ICU ORT, role of the ICU ORT, role of the team members on the initiating unit,
and documentation.

Education was necessary to define what type of call was the most appropriate for particular situations.
Differentiation was made between the need for a stat call for the CCA, an ICU consult, and an ICU ORT
call. If assistance was required sooner than 10 minutes, the CCA was to be paged stat. When unit staff
was able to provide care to the patient but ICU admission was questioned, an ICU consult was the most
appropriate as only the CCA was required to attend the call.

As well as information provided at the educational sessions on call criteria, the criteria were posted on all
inpatient units for staff to refer to, included on the assessment portion of the patient documentation form
as a check for the nurse on the calling unit, and is referred to when collecting data. Written material
pertaining to the ICU ORT was either printed on pink paper or distributed in pink folders so that it was
easily identifiable.

Due to a nursing and respiratory therapy shortage, the attainment of additional staff to implement this
program was not possible. It was clearly articulated to all hospital staff that it would not always be
possible for nursing and respiratory therapy staff to respond to all ORT calls, depending on staff
availability and acuity of patients in the ICU. One of the difficulties of implementing the ICU ORT without
additional resources was that the nurse responding to the ORT call almost always had a patient
assignment that had to be assumed by another nurse in the ICU. Care is usually transferred to a nurse in
the unit who is physically close to the patient and able to manage additional patient care on a temporary
basis. Unplanned increases in workload are an ongoing concern for nurses in the ICU.

Interim evaluation/feedback. On July 3, 2006, the ICU ORT became available to inpatient units as a six-
month pilot project. The intent was to expand the program to other acute care sites within the region,
pending successful implementation. Ongoing support through informal meetings was provided for
members of the team by the steering committee. Meetings were held monthly to review calls, discuss
challenges and successes, and implement changes as necessary. Utilization of the team by some units
was minimal. Reverting to previous practices of seeking assistance for failing patients and calling for
assistance later rather than early was observed. The need for ongoing education about the team and its
role was evident. This was addressed through meetings with care groups and peer groups, informal
discussion groups for nursing staff from inpatient units, newsletters to physicians and nurses, follow-up on
specific individual incidents with attending physicians, nursing manager or clinical nurse educator from
the inpatient unit, and education about utilization of the ICU ORT at general nursing orientation.

[FIGURE 2 OMITTED]

Evaluation

Tools/measures. Data collected from the documentation record include date, location of call, time of call,
time to respond, who initiated the call, if the attending physician was notified, previous ICU admission,
previous ORT call, reason for call, length of time spent at call by CCA, RN and RT, outcome of call, if
patient transferred, and any comments. Plans are underway for reporting calls to each unit on a quarterly
basis.

The data collected have been communicated to staff and the public within the hospital and region by a
hospital ICU ORT newsletter, a newsletter to physicians about the team, presentation at the regional
board meeting, local news coverage, poster presentation at regional quality awards, and a video
presentation on the local cable TV Health Show.

Code Blue records are reviewed to obtain monthly data of codes per 1,000 discharges, per cent of codes
outside of ICU and the emergency department. These data, along with utilization of the ICU ORT are
submitted to the SHN campaign.

A staff satisfaction survey was developed and distributed to nursing units. A five-point Likert scale was
used with strongly disagree to strongly agree used as anchors. Indicators evaluated were availability of
ICU ORT for help, approachability of the ICU ORT, and efficiency and effectiveness of the ICU ORT.
Additional comments were also solicited.

Outcomes. Sixteen months after implementation, patients are receiving better, more timely care. There is
surprise that only 26% of patients seen on ICU ORT calls are transferred to the ICU (Figure One). More
than 50% of patients remain where they are and do not require a change in level of care. The ICU ORT
has received 224 calls over the first 16 months of implementation with an average of 14 calls per month
(Figure Two). These results indicate that the ICU ORT is decreasing the number of ICU admissions
through early intervention as calls are being received in a timely fashion.

Eight staff satisfaction surveys have been returned. All of the returned surveys have shown satisfaction
with the ICU ORT. Informal discussion among the health care team members reveals that the ICU ORT is
a valuable resource, and staff feel encouraged to call the team rather than hesitant, due to worry
previously that the CCA would consider the call unwarranted. The results from the satisfaction survey, as
well as the informal feedback throughout the hospital indicate that the ICU ORT has provided a resource
for nurses to access for their patients and has provided education and support for the nurses on the
inpatient units.

Implementation of the ICU ORT has not met the goals of the Safer Healthcare Now! Campaign (2006) of
decreasing the incidence of codes per 1,000 discharges by 50%, the number of codes occurring outside
the ICU and emergency department to zero, or the hospital mortality rate. In the seven months prior to the
ICU ORT implementation and for the first 15 months of implementation, codes per 1,000 discharges have
remained consistent with a rate of 3.7 pre-implementation to 3.8 post-implementation. The percentage of
codes occurring outside the ICU and emergency departments remains at 40% as it did prior to
implementation of the ICU ORT. The average number of codes occurring in the hospital per month is 3.6.
Comparing hospital mortality for the 10-month period prior to implementation, to the current 15-month
period, hospital mortality has increased from 5.6% to 5.8%.

The time of day that the calls were made was quite similar, with 53% of calls on the night shift and 47%
on the day shift. It was anticipated that there would be more calls at night as there is less physician
coverage and decreased nursing resources in the hospital during that time period. Forty-eight per cent of
the calls have been to the surgical units, 38% to medicine, 7% to orthopedics, 4% to emergency, 2% to
hemodialysis, and 1% to the post-anesthetic care unit.

[FIGURE 3 OMITTED]

The ICU ORT accomplished its goal of responding to calls within 10 minutes in 96% of cases. An initial
concern expressed by critical care nursing staff and RTs was their availability to attend ORT calls with
their existing patient assignment. This has not been as difficult as anticipated as there have been only 3%
of calls when the nurse was unable to attend and 2% of calls when the RT has been unable to attend. In
these calls, the CCA and one of the other team members responded to the call. The length of time spent
at the call has varied: average times spent are 36 minutes by CCAs, 28 minutes by RNs and 30 minutes
by RTs. These data may be inaccurate as the documentation on arrival time and time of departure is not
always complete.

Initiation of the ICU ORT calls has been by RNs (86%), physicians (10%) and RTs (4%). The reason for
the ICU ORT call is usually a combination of the call criteria (Figure Three).

Although it has been difficult to show statistically that we are making a difference to patient outcomes,
anecdotally we do believe the ORT is having a positive effect in several ways. The provision of timely
patient care, provision of a resource for nurses to access for patients, and education and support of
nursing staff on inpatient hospital units are being addressed by the ICU ORT. The steering committee
decided to continue with the ICU ORT as a hospital resource when the six-month pilot project was
completed in December 2006.

Discussion. The outcomes at our site for reducing the number of codes per 1,000 discharges, reducing
the number of codes outside of the ICU and emergency department to zero, and decreasing hospital
mortality rate concur with the results found in the Merit study (Merit Study Investigators, 2005), a large
cluster-randomized controlled trial implementing METs in 12 Australia hospitals. Possible explanations for
these findings with the Merit study (2005) and our team are that the data that were collected occurred
over a short period of time, or previously the system to manage deteriorating patients outside of the ICU
was effective. Members of our steering committee have identified that the acuity of our hospital has
changed over the past two years due to the introduction of an acute care access line and service
alignment within our region. Thus, the pre-implementation data and post-implementation data are not
comparing like patient populations. This may explain why we have not seen a reduction in codes per
1,000 discharges, number of codes outside of the ICU and emergency department, and mortality rate.

Limitations. One of the remaining challenges is how to determine patients who were missed and should
have had an ORT call. Has there been a failure to rescue patients? The ICU ORT has prevented many
patients from failure to rescue, but the organization must be cognizant of any who were missed. These
patients can sometimes be identified retrospectively when a patient is admitted to the ICU who has met
criteria for an ORT call for a period of time.

No formal evaluation of staff satisfaction among critical care ICU ORT members has been undertaken.
Informally, nursing staff has identified a benefit to patient care and recognize the need for additional
support to the inpatient units. Staff members are engaged on the steering committee and provide
feedback from colleagues. Unfortunately no measurement was taken prior to implementing the team to
determine satisfaction with the previous method of calling the CCA stat when a patient deteriorated.

The need for nursing resources in ICU continues to be a challenge to meet the needs of patients. We
have successfully implemented this team with only 40 hours of additional resources at the time of
planning. Members of the critical care team have accepted this additional role as part of their existing
workload. With increased pressures for critical care beds in our region, there is continual evaluation of
whether this necessary service can be provided to our patients without additional funding and recruitment
of more critical care RNs. Recruitment and retention of critical care nurses is imperative so the current
level of service as an ICU ORT can be provided, as well as expansion to follow-up of patients discharged
from the ICU.

Future

The next step is spreading the ICU ORT model used at St. Paul's Hospital and adapting it to fit with the
needs and resources of the other acute care sites in our region. Initial spread of the model has started at
one of the acute care sites. Sharing the tools that were developed and the lessons learned from this
experience will assist with the implementation of the ICU ORT at the other sites.

Summary

The ICU ORT has improved timely patient care, provided a resource for nurses on inpatient units to
access for their patients, and provided opportunities for education of nurses on the inpatient units leading
to high nurse satisfaction. The ICU ORT was implemented to rescue patients who were deteriorating and
to treat them. Our evidence to date shows that the implementation of the ICU ORT has been a successful
strategy to rescue patients with deteriorating medical conditions.

References

Ball, C., Kirkby, M., & William, S. (2003). Effect of the critical care outreach team on patient survival to
discharge from hospital and readmission to critical care: Non-randomized population based study. British
Medical Journal, 327, 1014-1017.

Bellomo, R., Goldsmith, D., Uchino, S., Buckmaster, J., Hart, G.K., Opdam, H., et al. (2003). A
prospective before-and-after trial of a medical emergency team. Medical Journal Australia, 179, 283-287.

Bellomo, R., Goldsmith, D., Uchino, S., Buckmaster, J., Hart, G.K., Opdam, H., et al. (2004). Prospective
controlled trial of effect of medical emergency team on postoperative morbidity and mortality rates. Critical
Care Medicine, 32, 916-921.

Canadian Healthcare Technology. (2007, April, 13). Patient safety: More hospitals asked to join patient
safety campaign. Retrieved May 10, 2007, from www.canhealth.com/News570.html

Canadian Institute of Health Information. (2005). Workforce trends of registered nurses in Canada.
Retrieved May 10, 2007, from http://secure.cihi.ca/cihiweb/dispPage.jsp?
cw_page=download_form_e&cw_sku=SDRN2005PDF&cw_ctt=1&cw_dform=N

DeVita, M.A., Braithwaite, R.S., Mahidhara, S., Stuart, S., Foraida, M., Simmons, R.L., et al. (2004). Use
of medical emergency team responses to reduce hospital cardiopulmonary arrests. Quality Safer Health
Care, 13, 251-254.

Institute for Health Care Improvement. (n.d.). Overview of the 100,000 Lives Campaign. Retrieved May
10, 2007, from www.ihi.org/IHI/Programs/Campaign/100KCampaignOverviewArchive.htm

Kerridge, R.K., & Saul, W.P. (2003). The medical emergency team, evidence-based medicine and ethics.
Medical Journal of Australia, 179, 313-315.

Merit Study Investigators. (2005). Introduction of the medical emergency team (MET) system: A cluster-
randomized controlled trial. Lancet, 365, 2091-2097.

Puckett, F. (2007, March 8). RN shortage risk to public wellbeing. Star Phoenix. Retrieved May 10, 2007,
from www.srna.org/communications/documents/2007_RN_shortage.php

Purvis, M. (Ed.). (n.d.). Safer Healthcare Now! Edmonton, AB: Venture Publishing.

Safer Healthcare Now! (2007). Safer Healthcare Now! Retrieved May 10, 2007, from
www.saferhealthcarenow.ca

Safer Healthcare Now! Campaign. (2006). Getting started kit: Rapid response teams how to guide.
Retrieved May 10, 2007, from
http://www.saferhealthcarenow.ca/Default.aspx?folderId=82&contentId=186

Thomas, K., VanOyen Force, M., Rasmussen, D., Dodd, D., & Whildin, S. (2007). Rapid response team:
Challenges, solutions, benefits. Critical Care Nurse, 27(1), 20-27.

Winter, B.D., Pham, J., & Pronovost, P.J. (2006). Rapid response teams--walk, don't run. Journal of
American Medical Association, 296, 1645-1647.

About the author

Betty Wolfe, BSN, MN, Manager of Nursing, Intensive Care Unit St. Paul's Hospital, Saskatoon, SK.
Table One. Call criteria for ICU ORT

Acute change in Physiology

Airway/Breathing RR <8 or >28
Oxygen Sp02<90% despite 02

Circulation Sys BP< 90mmHg
HR <40 >130

Neurology Change in Level of Consciousness

Other Worried/concerned about the pt.
COPYRIGHT 2008 Canadian Association of Critical Care Nurses
No portion of this article can be reproduced without the express written permission from the copyright holder.
Copyright 2008 Gale, Cengage Learning. All rights reserved.

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Abstract
1. Top of page
2. Abstract
3. Plain language summary
4. Rsum
5. Rsum simplifi
6.
Background
Despite the fact that outreach and early warning systems (EWS) are an integral part of a hospital wide systems
approach to improve the early identification and management of deteriorating patients on general hospital wards, the
widespread implementation of these interventions in practice is not based on robust research evidence.
Objectives
The primary objective was to determine the impact of critical care outreach services on hospital mortality rates.
Secondary objectives included determining the effect of outreach services on intensive care unit (ICU) admission
patterns, length of hospital stay and adverse events.
Search methods
The review authors searched the following electronic databases: EPOC Specialised Register, The Cochrane Central
Register of Controlled Trials (CENTRAL) and other Cochrane databases (all on The Cochrane Library 2006, Issue 3),
MEDLINE (1996-June week 3 2006), EMBASE (1974-week 26 2006), CINAHL (1982-July week 5 2006), First Search
(1992-2005) and CAB Health (1990-July 2006); also reference lists of relevant articles, conference abstracts, and
made contact with experts and critical care organisations for further information.
Selection criteria
Randomised controlled trials (RCTs), controlled clinical trials (CCTs), controlled before and after studies (CBAs) and
interrupted time series designs (ITS) which measured hospital mortality, unanticipated ICU admissions, ICU
readmissions, length of hospital stay and adverse events following implementation of outreach and EWS in a general
hospital ward to identify deteriorating adult patients versus general hospital ward setting without outreach and EWS
were included in the review.
Data collection and analysis
Three review authors independently extracted data and two review authors assessed the methodological quality of
the included studies. Meta-analysis was not possible due to heterogeneity. Summary statistics and descriptive
summaries of primary and secondary outcomes are presented for each study.
Main results
Two cluster-randomised control trials were included: one randomised at hospital level (23 hospitals in Australia) and
one at ward level (16 wards in the UK). The primary outcome in the Australian trial (a composite score comprising
incidence of unexpected cardiac arrests, unexpected deaths and unplanned ICU admissions) showed no statistical
significant difference between control and medical emergency team (MET) hospitals (adjusted P value 0.640;
adjusted odds ratio (OR) 0.98; 95% confidence interval (CI) 0.83 to 1.16). The UK-based trial found that outreach
reduced in-hospital mortality (adjusted OR 0.52; 95% CI 0.32 to 0.85) compared with the control group.
Authors' conclusions
The evidence from this review highlights the diversity and poor methodological quality of most studies investigating
outreach. The results of the two included studies showed either no evidence of the effectiveness of outreach or a
reduction in overall mortality in patients receiving outreach. The lack of evidence on outreach requires further multi -
site RCT's to determine potential effectiveness.

Jump to

Plain language summary
1. Top of page
2. Abstract
3. Plain language summary
4. Rsum
5. Rsum simplifi
6.
Ward and organisational practices to recognise and manage patient deterioration in hospital
Research has shown that patients in general hospital wards often show early signs and symptoms, such as changes
in breathing and pulse, when their condition is getting worse. If treatment for these patients is delayed they could die
or require admission to intensive care (ICU). It is thought that if hospital staff could identify and manage these
patients earlier then there would be less deaths and ICU admissions. One way to identify and treat patients who are
deteriorating is to introduce outreach services. This usually includes the introduction of an Early Warning System to
record physiological observations, training of hospital staff to recognise signs or creating special teams to respond to
calls when a patient is deteriorating.
This summary of a Cochrane review presents what we know from research about the effect of outreach services for
patients on general hospital wards. The review found two studies which were of good quality. One study compared 12
hospitals with outreach services to 11 that did not. Another study compared 16 wards with outreach to general wards
without outreach.
One of the studies showed that outreach reduced the number of hospital deaths, while the other study found no
differences between hospitals with outreach and those with no outreach. It is not clear whether outreach reduces
hospital deaths or ICU admissions. High quality research is needed to determine the effect of outreach services.

Abstract
1. Top of page
2. Abstract
3. Plain language summary
4. Rsum
5. Rsum simplifi
6.
Background
Despite the fact that outreach and early warning systems (EWS) are an integral part of a hospital wide systems
approach to improve the early identification and management of deteriorating patients on general hospital wards, the
widespread implementation of these interventions in practice is not based on robust research evidence.
Objectives
The primary objective was to determine the impact of critical care outreach services on hospital mortality rates.
Secondary objectives included determining the effect of outreach services on intensive care unit (ICU) admission
patterns, length of hospital stay and adverse events.
Search methods
The review authors searched the following electronic databases: EPOC Specialised Register, The Cochrane Central
Register of Controlled Trials (CENTRAL) and other Cochrane databases (all on The Cochrane Library 2006, Issue 3),
MEDLINE (1996-June week 3 2006), EMBASE (1974-week 26 2006), CINAHL (1982-July week 5 2006), First Search
(1992-2005) and CAB Health (1990-July 2006); also reference lists of relevant articles, conference abstracts, and
made contact with experts and critical care organisations for further information.
Selection criteria
Randomised controlled trials (RCTs), controlled clinical trials (CCTs), controlled before and after studies (CBAs) and
interrupted time series designs (ITS) which measured hospital mortality, unanticipated ICU admissions, ICU
readmissions, length of hospital stay and adverse events following implementation of outreach and EWS in a general
hospital ward to identify deteriorating adult patients versus general hospital ward setting without outreach and EWS
were included in the review.
Data collection and analysis
Three review authors independently extracted data and two review authors assessed the methodological quality of
the included studies. Meta-analysis was not possible due to heterogeneity. Summary statistics and descriptive
summaries of primary and secondary outcomes are presented for each study.
Main results
Two cluster-randomised control trials were included: one randomised at hospital level (23 hospitals in Australia) and
one at ward level (16 wards in the UK). The primary outcome in the Australian trial (a composite score comprising
incidence of unexpected cardiac arrests, unexpected deaths and unplanned ICU admissions) showed no statistical
significant difference between control and medical emergency team (MET) hospitals (adjusted P value 0.640;
adjusted odds ratio (OR) 0.98; 95% confidence interval (CI) 0.83 to 1.16). The UK-based trial found that outreach
reduced in-hospital mortality (adjusted OR 0.52; 95% CI 0.32 to 0.85) compared with the control group.
Authors' conclusions
The evidence from this review highlights the diversity and poor methodological quality of most studies investigating
outreach. The results of the two included studies showed either no evidence of the effectiveness of outreach or a
reduction in overall mortality in patients receiving outreach. The lack of evidence on outreach requires further multi -
site RCT's to determine potential effectiveness.

Jump to

Plain language summary
1. Top of page
2. Abstract
3. Plain language summary
4. Rsum
5. Rsum simplifi
6.
Ward and organisational practices to recognise and manage patient deterioration in hospital
Research has shown that patients in general hospital wards often show early signs and symptoms, such as changes
in breathing and pulse, when their condition is getting worse. If treatment for these patients is delayed they could die
or require admission to intensive care (ICU). It is thought that if hospital staff could identify and manage these
patients earlier then there would be less deaths and ICU admissions. One way to identify and treat patients who are
deteriorating is to introduce outreach services. This usually includes the introduction of an Early Warning System to
record physiological observations, training of hospital staff to recognise signs or creating special teams to respond to
calls when a patient is deteriorating.
This summary of a Cochrane review presents what we know from research about the effect of outreach services for
patients on general hospital wards. The review found two studies which were of good quality. One study compared 12
hospitals with outreach services to 11 that did not. Another study compared 16 wards with outreach to general wards
without outreach.
One of the studies showed that outreach reduced the number of hospital deaths, while the other study found no
differences between hospitals with outreach and those with no outreach. It is not clear whether outreach reduces
hospital deaths or ICU admissions. High quality research is needed to determine the effect of outreach services.
Implementing an ICU outreach team model.
Link/Page Citation
An aging population, rapid patient turnover, and advanced technologies are contributing to higher patient
acuity in hospitals. Unrecognized changes in patient condition can lead to major complications, including
death, and are referred to as failure to rescue (Thomas, VanOyen Force, Rasmussen, Dodd, & Whildin,
2007). Providing high quality care at the bedside is becoming increasingly challenging due to a nursing
shortage. Increasing workload pressures are reported for ICU staff and there is a push for them to shift
the focus of their work outside the walls of the ICU (Kerridge & Saul, 2003). Teams of health care
providers with critical care experience that can be called to the patient's bedside 24 hours a day, seven
days a week have been established in hospitals. There are a variety of names for these teams and
different models. An ICU outreach team (ORT) for delivering the service was formed in a tertiary care
hospital in Saskatoon to respond to calls from inpatient units to provide critical care expertise to patients
when the nurse is worried or concerned, or when signs of physiological distress appear. The team
comprises an ICU registered nurse (RN), respiratory therapist (RT), and a physician who is a critical care
associate (CCA). This team was formed to improve timeliness of patient care, to provide a resource for
nurses to access for their patients on inpatient units, and to provide an opportunity for education and
support for nurses on inpatient units. In this article, the development and implementation of an ICU ORT
in Saskatoon is discussed.

Planning

Literature review. Research has shown that providing early intervention to patients with deteriorating
conditions by critical care health care providers outside the walls of the ICU decreases the incidence of
cardiac arrest (Bellomo et al., 2003; DeVita et al., 2004), hospital mortality (Ball, Kirkby, & William, 2003;
Bellomo et al., 2003), death following cardiac arrest, length of hospital stay related to cardiac arrest
(Bellomo et al., 2003), post-operative adverse outcomes, post-operative mortality rate, and length of
hospital stay (Bellomo et al., 2004). Nova Scotia's Dartmouth General Hospital showed a 30 per cent
decrease in the number of documented cardiac arrests after implementation of a critical care team that
works outside of ICU (Canadian Healthcare Technology, 2007).

An ICU ORT is a method for increasing patient safety. The role of the ICU ORT is to assess and stabilize
the patient's condition, assist with organizing information to be communicated to the patient's physician,
provide education and support to the unit staff, and assist with transfer of the patient to a higher level of
care if warranted (Safer Healthcare Now! Campaign, 2006). Other strategies to identify and treat
deteriorating patients earlier or to prevent deterioration have been suggested, such as introducing
hospitalists, nurse practitioners, or increasing nursing staff (Winter, Pham, & Pronovost, 2006).

Although these alternatives have merit, financial and human resources are limiting factors. Nursing
shortages are reported nationally in all fields of nursing. Forty per cent of the RNs working in
Saskatchewan are over the age of 50 years (Canadian Institute of Health Information [CIHI], 2005).
Puckett (2007), president of the Saskatchewan Registered Nurses Association Council, states that the
province needs at least 150 more RNs to graduate each year if it is to offset the wave of retirements that
are impending in the next five to 10 years. Often there are insufficient experienced nurses on a unit to
mentor novice nurses. With the large number of impending retirements, there will be a further paucity of
expert nurses available to mentor. In 2005, RNs in their first five years of nursing experience accounted
for 23.4% of all RNs working in medical surgical units in Saskatchewan (CIHI, 2005).

Other names given to critical care teams practising outside ICU include medical emergency team (MET),
patients at risk team, and rapid response team (RRT). These names are used interchangeably throughout
the article. METs were initially implemented and evaluated in Australia in the 1990s (Ball et al., 2003).
These teams were usually medical, but included a senior nurse. After Australia's experiences, the United
Kingdom developed "patient at risk" teams, which were nurse-led teams. MET and patient at risk teams
responded to patients outside of ICU with early warning signs of physiological distress. ICU ORTs
developed in England and Wales were nurse-led and their role was to provide follow-up services during
the period between discharge from the ICU to discharge from hospital or re-admission to ICU. In the
United States, the Institute for Health Care Improvement (IHI) (n.d.) and its partners launched the
"100,000 Lives Campaign", encouraging the use of proven best practices to help hospitals extend or save
as many as 100,000 lives per year. One of these best practices was the introduction of RRTs to attend to
patients outside ICU when signs of decline were present. Based on the work of the IHI, Canada
implemented the "Safer Healthcare Now" (SHN) Campaign in April 2005 consisting of six interventions.
These have an evidence base indicating that appropriate implementation and practice can lead to
reduced morbidity and mortality (Purvis, n.d.). These six interventions are aimed at:

* preventing deaths among people hospitalized for acute myocardial infarction,

* preventing catheter-related blood stream infections,

* decreasing mortality, re-admission rates and length of hospital stay from surgical site infections,

* implementing strategies that are proven to prevent ventilator-associated pneumonia, and

* identifying and treating patients in distress before they have a cardiopulmonary arrest.

The IHI and SHN have encouraged hospitals in their respective countries to implement RRTs to prevent
deaths in patients who are progressively failing outside of ICU (Institute for Health Care Improvement,
n.d.; Safer Healthcare Now!, 2007). The goals of the Safer Healthcare Now! Campaign (2006) for RRTs
are to:

* reduce the number of cardiopulmonary arrests per 1,000 inpatient discharges by 50% in one year,

* decrease the number of cardiopulmonary arrests occurring outside of the ICU and emergency
department to zero, and

* increase the overall use of the RRT over time.

Other possible benefits of RRTs are better patient outcomes, decreased length of stay in ICU and in
hospital, improved relationships among health care workers, improved satisfaction for nurses, physicians
and patients, positive impact on nursing retention, and financial benefits. In Canada, names of critical
care teams working outside the walls of the ICU include METs, RRTs and ICU ORTs. Different models
are used to provide care for patients, depending on the team structure and service provided. The name of
the team does not differentiate the model.

The team structure can comprises various members of the health care team including an ICU RN, RT,
intensivist, resident, and hospitalist (Safer Health Care Now! Campaign, 2006). The structure is
influenced by the organization's resources that are available to respond immediately, are onsite and
accessible, and have the critical care skills necessary to assess and respond. The service provided by
the team may include daily patient assessments, interventions, and referrals for patients discharged from
ICU or are referred to the team, and/or attending to patients outside the ICU once they show signs of
deterioration.

Steering committee. A steering committee was formed in April 2006 to establish and implement an ICU
ORT. The committee consisted of the directors of ICU, a physician champion, a clinical nurse educator, a
nursing manager, ICU staff nurse, CCA, manager of RT and an RT. A clinical nurse educator was
seconded as a project leader to provide 40 hours of initial work. This project leader was a valuable
resource in establishing initial guidelines, creating documentation and data collection tools, establishing a
method of communicating ORT calls, and coordinating initial education sessions not only for ORT
members, but also for staff throughout the hospital. Although the additional time dedicated to the
implementation of the ICU ORT by the project leader was small, it had a large impact on moving this
project forward quickly. As members of the Canadian ICU Collaborative, committee members were able
to participate in collaborative calls and learning sessions, and had access to the listserv and website to
gain insights from other centres that had already implemented an ICU ORT.

The initial work of the committee included reviewing the current literature on ICU ORTs, establishing a
structure that was workable with the resources available in the hospital, determining the criteria for calling
the ICU ORT, and liaising with the switchboard to determine the most effective way to deploy the ORT
call. The committee members also held meetings and informal discussions with their respective
colleagues to explain about the ICU ORT, its role, when to call, and to answer questions about the
implementation of the ICU ORT.

In addition to the evidence supporting the implementation of ICU ORTs, other factors in this organization
that influenced the need to establish an ICU ORT included limited nursing resources and a large
percentage of novice nurses on inpatient units, and in-house physician coverage that was limited or not
available on nights and weekends for some of the nursing units. The co-directors of the Saskatoon Health
Region Department of Adult Critical Care were integral to establishing this team based on the needs
identified by the hospital. Prior to implementation, there was a two-tier emergency response system in
place: a Code Blue team with two ICU nurses, an RT and the CCA who responded to respiratory and
cardiac arrests; and CCAs who responded to stat calls for other critical events.

Defining the model. St. Paul's Hospital is a 200-bed tertiary care hospital in central Saskatchewan. An
ICU ORT was implemented using existing critical care resources. An RN, RT, and CCA from the ICU
respond to calls from inpatient units and the emergency department within the hospital to provide critical
care expertise to patients when nurses are concerned, or who have signs of physiological distress.

Criteria for calling the ICU ORT were established (Table One). A review of the literature found that call
criteria for critical care teams outside the ICU all contained physiological parameters related to airway,
breathing, circulation and neurological status. The criteria have been used by many teams and thought to
be legitimate reasons to call the team (Thomas et al., 2007). When a patient meets any of the call criteria,
the team should be activated. The team may be called by any member of the health care team in the
hospital by dialing the stat line.

All ICU nurses and RTs are assigned to the ICU ORT. Members are assigned to the ICU ORT for their
entire shift. The team members who respond to ICU ORT calls also respond to Code Blue calls. Where a
Code Blue call requires immediate response to a respiratory or cardiac arrest, the goal of the ORT is to
respond to all ORT calls within 10 minutes.

The role of the team is to partner with the staff on the unit that called, and assess and intervene to
stabilize the patient. The team assists and coordinates appropriate therapy and determines the best
location for the patient to receive care, either on the current unit, an observation unit, or the ICU. The
team participates in end-of-life care planning if indicated. The model of care adopted does not provide for
routine follow-up of patients discharged from the ICU or patients of previous ICU ORT calls.

Components--paging system, documentation, feedback mechanisms. ICU ORT calls are sent to the team
members on a pager with the room number of the patient. The patient care supervisor is also paged, to
aid in patient placement if transfer arrangements are needed, as are the clinical nurse educators during
business hours to assess nursing staff learning needs and to provide follow-up education as required.

Information about ICU ORT calls is documented on a standardized record that becomes a permanent part
of the patient's chart. It is a form used by all disciplines. The record is initiated by the staff on the nursing
unit calling the team.

[FIGURE 1 OMITTED]

Members of the ICU ORT continue to document interventions, time of arrival and leaving the call,
outcome of the call and follow-up plan. If there is a plan for follow-up by the ICU ORT, this will be
communicated to the initiating unit at the completion of the visit.

A copy of this record is returned to the ICU from which data are collected by the clinical nurse educator.
ICU ORT members are encouraged to make anecdotal comments, on the back of the copy form, that they
think are pertinent. The data are reported back to the steering committee and provide a way to track
needs, identify areas of concern, areas of success, and system pressures.

Implementation

Education/information strategies. Once care group leaders were aware of the pending implementation of
the ICU ORT, educational sessions were held for front-line staff on the nursing units and for members of
the critical care staff who would be assigned to the ORT. Education included instruction on use of the
(situation, background, assessment and recommendation (SBAR)) communication tool that was to be
used for communication among team members (Safer Healthcare Now! Campaign, 2006), criteria for
making a call, the importance of calling the patient's attending physician prior to calling the ICU ORT,
procedure for calling the ICU ORT, role of the ICU ORT, role of the team members on the initiating unit,
and documentation.

Education was necessary to define what type of call was the most appropriate for particular situations.
Differentiation was made between the need for a stat call for the CCA, an ICU consult, and an ICU ORT
call. If assistance was required sooner than 10 minutes, the CCA was to be paged stat. When unit staff
was able to provide care to the patient but ICU admission was questioned, an ICU consult was the most
appropriate as only the CCA was required to attend the call.

As well as information provided at the educational sessions on call criteria, the criteria were posted on all
inpatient units for staff to refer to, included on the assessment portion of the patient documentation form
as a check for the nurse on the calling unit, and is referred to when collecting data. Written material
pertaining to the ICU ORT was either printed on pink paper or distributed in pink folders so that it was
easily identifiable.

Due to a nursing and respiratory therapy shortage, the attainment of additional staff to implement this
program was not possible. It was clearly articulated to all hospital staff that it would not always be
possible for nursing and respiratory therapy staff to respond to all ORT calls, depending on staff
availability and acuity of patients in the ICU. One of the difficulties of implementing the ICU ORT without
additional resources was that the nurse responding to the ORT call almost always had a patient
assignment that had to be assumed by another nurse in the ICU. Care is usually transferred to a nurse in
the unit who is physically close to the patient and able to manage additional patient care on a temporary
basis. Unplanned increases in workload are an ongoing concern for nurses in the ICU.

Interim evaluation/feedback. On July 3, 2006, the ICU ORT became available to inpatient units as a six-
month pilot project. The intent was to expand the program to other acute care sites within the region,
pending successful implementation. Ongoing support through informal meetings was provided for
members of the team by the steering committee. Meetings were held monthly to review calls, discuss
challenges and successes, and implement changes as necessary. Utilization of the team by some units
was minimal. Reverting to previous practices of seeking assistance for failing patients and calling for
assistance later rather than early was observed. The need for ongoing education about the team and its
role was evident. This was addressed through meetings with care groups and peer groups, informal
discussion groups for nursing staff from inpatient units, newsletters to physicians and nurses, follow-up on
specific individual incidents with attending physicians, nursing manager or clinical nurse educator from
the inpatient unit, and education about utilization of the ICU ORT at general nursing orientation.

[FIGURE 2 OMITTED]

Evaluation

Tools/measures. Data collected from the documentation record include date, location of call, time of call,
time to respond, who initiated the call, if the attending physician was notified, previous ICU admission,
previous ORT call, reason for call, length of time spent at call by CCA, RN and RT, outcome of call, if
patient transferred, and any comments. Plans are underway for reporting calls to each unit on a quarterly
basis.

The data collected have been communicated to staff and the public within the hospital and region by a
hospital ICU ORT newsletter, a newsletter to physicians about the team, presentation at the regional
board meeting, local news coverage, poster presentation at regional quality awards, and a video
presentation on the local cable TV Health Show.

Code Blue records are reviewed to obtain monthly data of codes per 1,000 discharges, per cent of codes
outside of ICU and the emergency department. These data, along with utilization of the ICU ORT are
submitted to the SHN campaign.

A staff satisfaction survey was developed and distributed to nursing units. A five-point Likert scale was
used with strongly disagree to strongly agree used as anchors. Indicators evaluated were availability of
ICU ORT for help, approachability of the ICU ORT, and efficiency and effectiveness of the ICU ORT.
Additional comments were also solicited.

Outcomes. Sixteen months after implementation, patients are receiving better, more timely care. There is
surprise that only 26% of patients seen on ICU ORT calls are transferred to the ICU (Figure One). More
than 50% of patients remain where they are and do not require a change in level of care. The ICU ORT
has received 224 calls over the first 16 months of implementation with an average of 14 calls per month
(Figure Two). These results indicate that the ICU ORT is decreasing the number of ICU admissions
through early intervention as calls are being received in a timely fashion.

Eight staff satisfaction surveys have been returned. All of the returned surveys have shown satisfaction
with the ICU ORT. Informal discussion among the health care team members reveals that the ICU ORT is
a valuable resource, and staff feel encouraged to call the team rather than hesitant, due to worry
previously that the CCA would consider the call unwarranted. The results from the satisfaction survey, as
well as the informal feedback throughout the hospital indicate that the ICU ORT has provided a resource
for nurses to access for their patients and has provided education and support for the nurses on the
inpatient units.

Implementation of the ICU ORT has not met the goals of the Safer Healthcare Now! Campaign (2006) of
decreasing the incidence of codes per 1,000 discharges by 50%, the number of codes occurring outside
the ICU and emergency department to zero, or the hospital mortality rate. In the seven months prior to the
ICU ORT implementation and for the first 15 months of implementation, codes per 1,000 discharges have
remained consistent with a rate of 3.7 pre-implementation to 3.8 post-implementation. The percentage of
codes occurring outside the ICU and emergency departments remains at 40% as it did prior to
implementation of the ICU ORT. The average number of codes occurring in the hospital per month is 3.6.
Comparing hospital mortality for the 10-month period prior to implementation, to the current 15-month
period, hospital mortality has increased from 5.6% to 5.8%.

The time of day that the calls were made was quite similar, with 53% of calls on the night shift and 47%
on the day shift. It was anticipated that there would be more calls at night as there is less physician
coverage and decreased nursing resources in the hospital during that time period. Forty-eight per cent of
the calls have been to the surgical units, 38% to medicine, 7% to orthopedics, 4% to emergency, 2% to
hemodialysis, and 1% to the post-anesthetic care unit.

[FIGURE 3 OMITTED]

The ICU ORT accomplished its goal of responding to calls within 10 minutes in 96% of cases. An initial
concern expressed by critical care nursing staff and RTs was their availability to attend ORT calls with
their existing patient assignment. This has not been as difficult as anticipated as there have been only 3%
of calls when the nurse was unable to attend and 2% of calls when the RT has been unable to attend. In
these calls, the CCA and one of the other team members responded to the call. The length of time spent
at the call has varied: average times spent are 36 minutes by CCAs, 28 minutes by RNs and 30 minutes
by RTs. These data may be inaccurate as the documentation on arrival time and time of departure is not
always complete.

Initiation of the ICU ORT calls has been by RNs (86%), physicians (10%) and RTs (4%). The reason for
the ICU ORT call is usually a combination of the call criteria (Figure Three).

Although it has been difficult to show statistically that we are making a difference to patient outcomes,
anecdotally we do believe the ORT is having a positive effect in several ways. The provision of timely
patient care, provision of a resource for nurses to access for patients, and education and support of
nursing staff on inpatient hospital units are being addressed by the ICU ORT. The steering committee
decided to continue with the ICU ORT as a hospital resource when the six-month pilot project was
completed in December 2006.

Discussion. The outcomes at our site for reducing the number of codes per 1,000 discharges, reducing
the number of codes outside of the ICU and emergency department to zero, and decreasing hospital
mortality rate concur with the results found in the Merit study (Merit Study Investigators, 2005), a large
cluster-randomized controlled trial implementing METs in 12 Australia hospitals. Possible explanations for
these findings with the Merit study (2005) and our team are that the data that were collected occurred
over a short period of time, or previously the system to manage deteriorating patients outside of the ICU
was effective. Members of our steering committee have identified that the acuity of our hospital has
changed over the past two years due to the introduction of an acute care access line and service
alignment within our region. Thus, the pre-implementation data and post-implementation data are not
comparing like patient populations. This may explain why we have not seen a reduction in codes per
1,000 discharges, number of codes outside of the ICU and emergency department, and mortality rate.

Limitations. One of the remaining challenges is how to determine patients who were missed and should
have had an ORT call. Has there been a failure to rescue patients? The ICU ORT has prevented many
patients from failure to rescue, but the organization must be cognizant of any who were missed. These
patients can sometimes be identified retrospectively when a patient is admitted to the ICU who has met
criteria for an ORT call for a period of time.

No formal evaluation of staff satisfaction among critical care ICU ORT members has been undertaken.
Informally, nursing staff has identified a benefit to patient care and recognize the need for additional
support to the inpatient units. Staff members are engaged on the steering committee and provide
feedback from colleagues. Unfortunately no measurement was taken prior to implementing the team to
determine satisfaction with the previous method of calling the CCA stat when a patient deteriorated.

The need for nursing resources in ICU continues to be a challenge to meet the needs of patients. We
have successfully implemented this team with only 40 hours of additional resources at the time of
planning. Members of the critical care team have accepted this additional role as part of their existing
workload. With increased pressures for critical care beds in our region, there is continual evaluation of
whether this necessary service can be provided to our patients without additional funding and recruitment
of more critical care RNs. Recruitment and retention of critical care nurses is imperative so the current
level of service as an ICU ORT can be provided, as well as expansion to follow-up of patients discharged
from the ICU.

Future

The next step is spreading the ICU ORT model used at St. Paul's Hospital and adapting it to fit with the
needs and resources of the other acute care sites in our region. Initial spread of the model has started at
one of the acute care sites. Sharing the tools that were developed and the lessons learned from this
experience will assist with the implementation of the ICU ORT at the other sites.

Summary

The ICU ORT has improved timely patient care, provided a resource for nurses on inpatient units to
access for their patients, and provided opportunities for education of nurses on the inpatient units leading
to high nurse satisfaction. The ICU ORT was implemented to rescue patients who were deteriorating and
to treat them. Our evidence to date shows that the implementation of the ICU ORT has been a successful
strategy to rescue patients with deteriorating medical conditions.

References

Ball, C., Kirkby, M., & William, S. (2003). Effect of the critical care outreach team on patient survival to
discharge from hospital and readmission to critical care: Non-randomized population based study. British
Medical Journal, 327, 1014-1017.

Bellomo, R., Goldsmith, D., Uchino, S., Buckmaster, J., Hart, G.K., Opdam, H., et al. (2003). A
prospective before-and-after trial of a medical emergency team. Medical Journal Australia, 179, 283-287.

Bellomo, R., Goldsmith, D., Uchino, S., Buckmaster, J., Hart, G.K., Opdam, H., et al. (2004). Prospective
controlled trial of effect of medical emergency team on postoperative morbidity and mortality rates. Critical
Care Medicine, 32, 916-921.

Canadian Healthcare Technology. (2007, April, 13). Patient safety: More hospitals asked to join patient
safety campaign. Retrieved May 10, 2007, from www.canhealth.com/News570.html

Canadian Institute of Health Information. (2005). Workforce trends of registered nurses in Canada.
Retrieved May 10, 2007, from http://secure.cihi.ca/cihiweb/dispPage.jsp?
cw_page=download_form_e&cw_sku=SDRN2005PDF&cw_ctt=1&cw_dform=N

DeVita, M.A., Braithwaite, R.S., Mahidhara, S., Stuart, S., Foraida, M., Simmons, R.L., et al. (2004). Use
of medical emergency team responses to reduce hospital cardiopulmonary arrests. Quality Safer Health
Care, 13, 251-254.

Institute for Health Care Improvement. (n.d.). Overview of the 100,000 Lives Campaign. Retrieved May
10, 2007, from www.ihi.org/IHI/Programs/Campaign/100KCampaignOverviewArchive.htm

Kerridge, R.K., & Saul, W.P. (2003). The medical emergency team, evidence-based medicine and ethics.
Medical Journal of Australia, 179, 313-315.

Merit Study Investigators. (2005). Introduction of the medical emergency team (MET) system: A cluster-
randomized controlled trial. Lancet, 365, 2091-2097.

Puckett, F. (2007, March 8). RN shortage risk to public wellbeing. Star Phoenix. Retrieved May 10, 2007,
from www.srna.org/communications/documents/2007_RN_shortage.php

Purvis, M. (Ed.). (n.d.). Safer Healthcare Now! Edmonton, AB: Venture Publishing.

Safer Healthcare Now! (2007). Safer Healthcare Now! Retrieved May 10, 2007, from
www.saferhealthcarenow.ca

Safer Healthcare Now! Campaign. (2006). Getting started kit: Rapid response teams how to guide.
Retrieved May 10, 2007, from
http://www.saferhealthcarenow.ca/Default.aspx?folderId=82&contentId=186

Thomas, K., VanOyen Force, M., Rasmussen, D., Dodd, D., & Whildin, S. (2007). Rapid response team:
Challenges, solutions, benefits. Critical Care Nurse, 27(1), 20-27.

Winter, B.D., Pham, J., & Pronovost, P.J. (2006). Rapid response teams--walk, don't run. Journal of
American Medical Association, 296, 1645-1647.

About the author

Betty Wolfe, BSN, MN, Manager of Nursing, Intensive Care Unit St. Paul's Hospital, Saskatoon, SK.
Table One. Call criteria for ICU ORT

Acute change in Physiology

Airway/Breathing RR <8 or >28
Oxygen Sp02<90% despite 02

Circulation Sys BP< 90mmHg
HR <40 >130

Neurology Change in Level of Consciousness

Other Worried/concerned about the pt.
COPYRIGHT 2008 Canadian Association of Critical Care Nurses
No portion of this article can be reproduced without the express written permission from the copyright holder.
Copyright 2008 Gale, Cengage Learning. All rights reserved.












modynamic Monitoring: Techniques &
Troubleshooting
By Janice M. Wojcik, MS, RN, CS, CCRN, CNS, C
View Comments (2)Print Article
Since its introduction in 1970, the pulmonary artery (PA) catheter has become commonplace in intensive care units. The PA
catheter is used to provide information about right and left intracardiac pressures as well as cardiac output. Specially designed
catheters can also monitor mixed venous oxygen saturation, assess right ventricular volumes and ejection fraction, and provide
temporary atrial or ventricular pacing.
1

The critical care nurse plays a vital role in the process of maintaining and troubleshooting the PA catheter system, as well as
monitoring, measuring and recording readings from the catheter. In order to provide meaningful information, the critical care
nurse should be knowledgeable regarding techniques to obtain accurate data and about troubleshooting the system when
problems arise.
Preventing Infection
The critical care nurse's role in preventing infection related to the presence of the PA catheter begins with the initial setup of the
hemodynamic monitoring system and continues until removal of the central venous catheter. Recommendations from the Centers
for Disease Control and Prevention for the prevention of infection related to intravascular devices
2
should be incorporated into
your institution's policies related to hemodynamic monitoring.
Handwashing, aseptic insertion and care techniques, continuous flush devices, use of disposable (rather than reusable)
transducers and minimizing entry into the system are important aspects of care. The transducers and other components of the
system should be replaced at 96-hour intervals. The pulmonary artery catheter itself should be replaced every 5 days.
2

Obtaining Accurate Information
There are several variables that must be taken into account when obtaining hemodynamic data. Referencing, transducer zeroing,
dynamic response, patient position, the effects of ventilation, catheter location in a physiological lung zone and proper balloon
inflation must be considered by the critical care nurse.
Referencing. Inaccuracies in data obtained from the PA catheter can occur if the system is incorrectly referenced. The stopcock
nearest the transducer is known as the air-fluid interface. This component of the monitoring system is positioned level with the
patient's left atrium.
Hydrostatic pressure is the weight of blood in the vasculature. When the air-fluid interface is not in the correct position, the
effects of hydrostatic pressure cause an inaccurate estimate of left atrial pressure.
3
For every 1 cm above the left atrium the
catheter is referenced, the pressure measurement is underestimated by 0.74 mm Hg; the reverse is true for systems that are
referenced below the left atrium.
4
The reference point for the left atrium in patients in the supine position is the phlebostatic axis.
A measuring device should be used to locate the reference point. "Eyeballing" the level of the monitoring system and estimating
measurements can result in referencing errors.
The phlebostatic axis is externally landmarked on the patient as the intersection of two points. The first point is found where the
fourth intercostal space joins the sternum. An imaginary line is drawn out to the side of body and marked. From that mark,
measure the distance between the anterior and posterior surfaces of the chest, again drawing an imaginary line. The midpoint of
the second line on the lateral chest surface (midanteroposterior diameter) is the landmark for the left atrium. Place a mark on the
patient to identify the reference point. The midaxillary line should not be used for landmarking the phlebostatic axis, as the result
may be a measurement error of up to 6 mm Hg.
4
The air-fluid interface will have to be referenced whenever the patient is
repositioned.
Transducer Zeroing. Zeroing calibrates the hemodynamic monitoring system to read only the pressure generated within the
patient without the interference of external factors. When the transducer is isolated from the effect of hydrostatic pressure on its
diaphragm, the monitoring system can be zeroed.
5

To zero the transducer, the stopcock closest to the transducer is closed to the patient. Remove the sterile protective cap from the
stopcock port, exposing the hemodynamic monitoring system to air. The monitor's zero function key is activated to offset
pressure in the transducer, setting the pressure to zero. Open the stopcock to the patient and replace the sterile cap on the
stopcock port. Zeroing ensures that when the transducer stopcock is open to the patient and closed to air, the only pressure on the
transducer will be from the vessel/heart chamber being monitored.
5

Dynamic Response. Dynamic response is the ability of the transducer system to reproduce the pressure variations within the
patient's vasculature.
5
To ensure an adequate dynamic response, it is important that the tubing is the correct type and length.
Tubing used for hemodynamic monitoring systems is less compliant than regular intravenous tubing. The length should be no
more than 4 feet.
5
Long tubing, tubing that has had too many components added (e.g., excessive stopcocks, extensions), or tubing
that is too flexible can interfere with dynamic response.
Patient Position. Critically ill patients do not always tolerate supine positioning with the backrest flat (0 degrees elevation). If
the monitoring system's air-fluid interface is correctly referenced, the supine patient's backrest may be positioned up to 60
degrees without affecting the accuracy of measurements.
5-7
Because some patients may produce variable readings in different
positions, it is a good idea to compare measurements in a variety of positions as a baseline. Consistency should be used in patient
position when obtaining hemodynamic readings. Any variation in the patient's position at different data collection times should
be documented.
5

The Effects of Ventilation. Hemodynamic measurements should be obtained at end expiration for patients who are breathing
spontaneously as well as those receiving positive pressure mechanical ventilatory support. End expiration is the point in the
ventilation cycle where there is the least effect of pleural pressure on intracardiac pressures. Removing the patient from the
ventilator does not improve accuracy of PA readings and is not recommended because it may be detrimental to the
patient.
5,8,9
Using a respiratory or airway pressure monitor can help identify end expiration when obtaining hemodynamic data.
Lung Zones. Lung zones are physiologic states related to blood distribution rather than anatomic locations within the lung.
Pressures vary from zone to zone (see Table 1). The optimal pressure state for obtaining hemodynamic data exists in zone 3,
which is generally considered to be found in the area of the lung below the left atrium.
5,10

Use of positive end expiratory pressure (PEEP) in excess of 10 cm H
2
O may affect the accuracy of the pulmonary artery wedge
pressure (PAWP) to serve as an indicator of left atrial pressure. The discrepancy may be reduced when the PA catheter is
positioned in zone 3.
4,5,11

Table 1: Characteristics of Lung Zones
Zone 1 Zone 2 Zone 3
Blood Flow Absent Intermittent Constant
Pressures
Alveolar >
Arterial and
Venous
Arterial >
Alveolar and Venous
Arterial and
Venous > Alveolar
Balloon Inflation. Overinflation of the balloon can cause damage to the pulmonary artery and to the balloon itself. The balloon
should be inflated with a volume of 1.5 mL of air or less. As the inflated balloon floats into small vessels, the flow of blood is
stopped and the PA waveform dampens. Stop balloon inflation as soon as dampening occurs. The balloon should not remain
inflated for more than four respiratory cycles. Allow passive balloon deflation - do not pull back on the balloon plunger to
deflate. Always ensure that the PA waveform reappears on the monitor following balloon deflation. When the balloon is deflated,
remove the syringe and expel the air before reattaching it to the balloon inflation port. Ensuring that there is no air in the syringe
and that the gate valve is closed with the syringe in place decreases the chance of accidental wedging of the PA catheter.
1

Graphic vs. Digital Readings
Use of graphic strip recordings to obtain hemodynamic measurements improves the accuracy of the data. Digital measurement
has been found to be inaccurate in measuring data with or without variations in the respiratory pattern. Digital errors of 4 mm Hg
and more were commonly reported in research studies.
11-13

Troubleshooting
Problems obtaining accurate hemodynamic data occur for two reasons: human error and monitoring system problems. Always
obtain and record baseline data. If you suspect a problem, comparing the current situation to previous data is important. The
hemodynamic profile should reflect the patient's clinical picture. The critical care nurse is clued in that troubleshooting is
necessary when the clinical status and the hemodynamic data conflict. Troubleshooting always begins with patient assessment.
After assessing the patient, review the techniques used to obtain the data. If any errors in technique were present, repeat data
collection. If correct techniques were used, review the monitoring system (see Table 2).
Table 2: Troubleshooting Hemodynamic Monitoring Problems
Problem Possible Causes Troubleshooting
Dampened Waveform Incorrect scale selected on monitor

Incorrect referencing
Air in the system



Spontaneous wedging of catheter
Check the monitor to ensure
the correct scale is in use
Check referencing
Check pressure in bag
Check for loose connections
Remove air bubbles
Flush system
see below-Spontaneous Wedge
Overdamping
(diminished systolic peak,
loss of dicrotic notch,
rounder wave forms)
Compliant tubing
Large air bubbles
Clots/blood in system
Loose connections

Kinked catheter or catheter
tip against vessel wall
Check tubing-right tubing, no air, no clots, no blood
Check for loose connections
Flush tubing
Perform square wave test
Collaborate with physician as
needed to reposition/remove
catheter as indicated
Underdamping
(falsely high systolic
peak,
falsely low diastolic
value, artifact)
Pressure tubing is too long



Too many components
(i.e., stopcocks)
Small air bubbles
Defective transducer
Ensure that the correct tubing is in use - shorten if
necessary
Ensure that there are no tubing extensions added
Remove extra components

Remove air bubbles
Change transducer
Erratic Waveform
with Highly Variable
Pressures
Catheter whip/catheter fling is being caused by
excessive movement ofthe catheter tip within
the vessel
The catheter will probably have to be repositioned to a
less turbulent area of the vessel
Spontaneous Wedge Catheter is advanced too far or is too flexible Do not flush catheter
Assess for other causes of
dampened waveform-see above
Reposition or ask the patient
to cough
Catheter will require repositioning -pull back slowly
until PA waveform appears (if allowed by institution
P&P)
Notify physician of need to
reposition catheter
Unable to Obtain
Wedge
Air returns to syringe - catheter is probably not
advanced far enough
into the PA

Air does not return to syringe - balloon is
probably ruptured
Catheter will require repositioning as permitted by
institution P&P
Notify physician of need to
reposition catheter
Notify physician of need to remove catheter
Overwedging Excessive air volume is injected
into the balloon

Catheter is advanced too far
Observe waveform on monitor
while injecting air - stop injecting
as soon as the waveform dampens
Allow passive deflation of balloon
Catheter will require repositioning
- pull back slowly until PA wave-
form appears (if allowed by
institution P&P)
Notify physician of need to
reposition catheter
Absent Waveform Disconnect of monitoring system
Incorrect scale in use
Loose or cracked transducer dome
or air in dome
Defective transducer
Check connections
Set correct scale on monitor
Change transducer

Change transducerr
Inadequate pressure in pressure bag
Check for kinks in the system
Catheter tip or lumen totally occluded
Adjust pressure to 300 mm Hg
Remove kinks
Slowly aspirate to check for blood
return - if no blood return, notifyphysician of need to
removecatheter
Damping. Damping is a term used to describe alterations in the dynamic response of the monitoring system. The dynamic
response may be evaluated by performing a square wave test. Fast flush the catheter. A characteristic square wave appears on the
monitor, indicating an appropriate dynamic response. Normal dynamic response is indicated by the two peaks that follow the
square wave - the second peak is less than one-third the height of the first and no more than 1 mm distance from the first. An
overdamped waveform will produce no downward spike following the square wave. An underdamped waveform will produce
multiple spikes/oscillations following the square wave before returning to the PA waveform.
5,14
When damping problems occur,
check to ensure that the balloon is deflated. Verify that the correct scale is set on the monitor and that the air-fluid interface is
referenced correctly. Check the pressure bag to ensure that it is inflated to 300 mm Hg, and flush the system.
Catheter Whip/Fling. Catheter whip (fling) is caused by turbulent flow in the vessel near the tip of the catheter. There is an
erratic waveform with artifact on the oscilloscope. The monitored numbers are often highly variable and inaccurate. To eliminate
catheter whip, the catheter will have to be repositioned to a less turbulent area of the vessel.
15

Spontaneous/Continuous Wedge. A spontaneous wedge occurs with the balloon deflated. A spontaneous or continuous wedge
may be seen if the PA catheter is advanced too far or if the catheter is flexible.
15
Ensure that the balloon is deflated by removing
the syringe from the open inflation port. Assess for other causes of dampening. Assist the patient to a different position or ask the
patient to cough, if possible, to help float the catheter out of the wedge position. Do not flush a wedged catheter, as flushing may
lead to PA rupture. If there are no other reasons for the waveform to dampen, the catheter will have to be withdrawn until the PA
waveform appears on the monitor.
16

Inability to Obtain Wedge. When you are unable to obtain a wedge tracing on the monitor, deflate the balloon. If the air returns
to syringe, the PA catheter is probably not in far enough and will require repositioning. If the air does not return to the syringe,
the balloon is probably ruptured and will need to be removed.
16

Overwedging. Overwedging occurs when too much air is injected into the balloon or when the catheter is in too far. When an
overwedge is detected, remove the syringe from the inflation port and allow passive deflation of the balloon. Reconnect the air-
filled syringe and slowly inflate while watching the waveform. Stop air injection when the waveform dampens (even if the full
volume of air in the syringe has not been injected) and measure wedge pressure.
16

Absent Waveform. The waveform may be absent when there is a disconnection or a problem with the monitoring system. A
large leak in the system, use of the incorrect monitor scale, a loose or defective transducer, incorrect stopcock position,
inadequate pressure on the continuous flush bag, kinks in the system, or occlusion of the catheter are all factors that may lead to
loss of the waveform.
15
Check the transducer, all connections, the monitor setup, the pressure bag and stopcock positions to
correct the problem. If you are still unable to obtain a waveform, there may be a problem with PA catheter occlusion.
Conclusion
Hemodynamic monitoring can provide valuable information about the critically ill patient. An understanding of proper
techniques for maintenance of the system can improve patient outcomes through data accuracy.
Janice M. Wojcik is an advanced practice nurse, critical care, at St. Joseph's Regional Medical Center, Paterson, NJ.


Hemodynamic Monitoring: Techniques & Troubleshooting Next >
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Thank you for accepting me as a member in Advance Healthcare Network Nurses

Laila Abed-Eddin, Deputy Nursing Director and He, Prince
Sultan Cardiac Center
September 25, 2014
Buridah Qssim


I am embarking on obtaining my NP. I am interested in first hand information from other NP's in respect to the
best area to practice etc. I am doing the Family NP tract and plan to also obtain Mental Health NP. I am
interested in practicing in both areas. I would appreciate any input and would highly value advise from those that
have already practicing. Be Blessed!

Tandy Barco October 20, 2013
Oneonta, AL



Ports or Lumens of a Pulmonary Artery Catheter


Lumen Location Data Provided Special
Considerations
Proximal RA CVP Used for meds
and fluids
Distal PA PAS, PAD Pressurized
Heparin drip,
no meds
Balloon Wedged in PA PAW, wedge Intermittent
reading. Close
to PAD and
reflects the
LVEDP, or the
preload of the
LV
Thermistor PA Cardiac Output Temperature
sensor for core
and calculates
CO







1. What does CVP measure and what is a normal CVP? What would this
mean in the care of my clients?
~ CVP is a measure of blood volume and venous return. It reflects RIGHT-SIDED
filling pressures. It is primarily used to monitor fluid volume status.
~ Normal range for CVP is 2-8 cm H20 or 2-6 mmHg
~ Hypovolemia and shock DECREASE the CVP.
Fluid overload, vasoconstriction, and cardiac tamponade INCREASE CVP.
~ If CVP is decreased, client needs fluid to increase preload.
If CVP is increased, client needs diuresis, vasodilation to decrease afterload, or
treatment for cardiac tamponade!

2. What is a PA catheter; what does a PA catheter measure, and where is it
placed?
~ A PA catheter is a flow-directed, balloon-tipped catheter, a.k.a. the Swan-
Ganz. PA = pulmonary artery.
~ A PA catheter measures pressures in the right atrium, pulmonary artery, and left
ventricle. It is used to evaluate left ventricular and overall cardiac function.
~ It is inserted into a central vein and threaded into the right atrium. A small
balloon allows the catheter to be drawn into the right ventricle and from there into
thepulmonary artery. Once in place, the balloon is deflated and the multiple
lumens of the catheter allow measurement of pressures in the right atrium,
pulmonary artery, and left ventricle.

3. What is a normal PA pressure and under what conditions would a PA
pressure be increased? What does it mean in the care of my clients?
~ Normal PA is around 25/10 mmHg. Normal mean artery pressure is about 15
mmHg.
~ Pulmonary artery pressure is increased in left-sided heart failure. Manifestations
of left-sided heart failure result from pulmonary congestion and decreased cardiac
output. PA pressure measurement allows restoration of fluid balance while
avoiding overcorrection of the problem. Nursing interventions for heart failure
would be appropriate.

4. What is PAWP (PCWP or PWP); what does it measure and what does this
value mean? How does it relate to the Left Ventricular End Diastolic
Pressure (LVEDP)?
~ PAWP is pulmonary artery wedge pressure. It measures pressures generated by
the left ventricle. It is used to assess left ventricular function. Normal PAWP is 8-
12 mmHg. PAWP is increased in left ventricular failure and pericardial
tamponade. It is decreased in hypovolemia.
~ PAWP reflects LVEDP under normal conditions, that is, when LVEDP (ventricular
preload) is increased, PAWP is increased also.

5. How is PAWP obtained?
The measurement of PAWP is obtained by slowly inflating the balloon with 1.5 mL
of air while observing the distal lumen pressure tracing. As the line becomes
wedged, the tracing changes shape and amplitude. When the tracing changes
from arterial to atrial, the catheter is said to be wedged and PAWP is measured at
the end of expiration.

6. What is cardiac output/cardiac index and what do these values
mean? What is normal cardiac output/cardiac index?
~ Cardiac output/cardiac index are used to assess the hearts ability to meet the
bodys oxygen demands. Because body size affects overall cardiac output, the
cardiac index is a more precise measurement of heart function.
~ The cardiac index is a calculation of cardiac output per square meter of body
surface area. The normal cardiac index is 2.8-4.2 L/min/m2. CO = SV x
HR. Normal resting CO is 4-8 L/min and varies with body size.

7. What is SVR; How is it determined? What is MAP?
~ SVR is systemic vascular resistance. SVR is primarily determined by vessel
diameter and distensibility (compliance.)
Factors such as SNS input, circulating hormones (epinephrine, norepinephrine,
atrial natriuretic hormone, and vasopressin) and the renin-angiotensin system
affect SVR.
~ SVR is calculated by: SVR = (MAP CVP) x 80/cardiac output * MAP is mean
arterial pressure is the amount of arterial that is necessary to maintain adequate
perfusion of vital organsusually 60 mmHg and is calculated by Systolic BP + 2
(Diastolic BP) divided by 3

Introduction

The purpose of this course is to review the methods and measurement of
hemodynamic parameters. Parameters such as CVP measurement, mean
arterial pressure, cardiac output and intracardiac pressures are important to
the care and treatment of critically ill patients. Nurses are responsible for the
collection, measurement and interpretation of these dynamic patient status
parameters.
Until the advent of indwelling intravascular catheters, hemodynamics, or the
forces circulating blood, had to be measured indirectly. Clinicians assessed
the patient's hemodynamic status with: history taking, physical assessment,
palpation, auscultation,sphygmomanometer* and the
electrocardiogram. Direct measurement, via indwelling catheters, provides
additional real time information that allows intervention prior to organ or
system failure.
This course will begin with methods of noninvasive hemodynamic monitoring,
and then continue on to invasive monitoring with Central Venous Pressure
(CVP), Arterial Pressure, and Pulmonary Artery Catheter (PAC) monitoring.

Instant Feedback:
Hemodynamics are the forces which circulate blood through the body.
True
False


*Sphygmomanometers are indirect blood pressure measuring devices.
Hemodynamics: Basics

As already mentioned, hemodynamics are the forces which circulate blood
through the body.
Specifically, hemodynamics is the term used to describe the intravascular
pressure and flow that occurs when the heart muscle contracts and pumps
blood throughout the body. It is important to remember that the vascular
system is a closed circuit. Pressure and flow variations in the venous
compartment will necessarily affect the arterial compartment and vice versa.
Therefore, a hemodynamic measurement is not simply a number in relation to
a norm. Rather, it is the minute to minute pressure and flow variations that
ocur within and between compartments.
Heart function is the main focus of hemodynamic studies but the heart is not
the only factor influencing pressure and flow. There are four factors which
influence hemodynamics. They are the three hemodynamic components to
the circulation of blood in the body pluschronotropy.
Intravascular volume: the amount of fluid circulating in the vasculature.
This can be affected by dehydration, diuresis, and volume overload due
to heart or kidney failure.
Intropy: the strength of myocardial contractions. Myocytes are the only
muscle cells which are able to vary the strength of contraction. Intropy
can be affected by exercise, stress and pharmaceutical agents, which
increase the strength of myocardial contractions, or by cardiac diseases
such as heart failure, which decrease the strength of contractions.
Vasoactivity: the expanding and contracting of blood vessels to
accommodate the variation in blood flow, regulate arterial pressure, and
meet the metabolic demands of the organs and body tissues. Certain
hormones also affect vasoactivity. They are angiotenson II, epinephrine,
norepinephrine, and vasopressin.
The fourth factor is chronotropy. Chronotropy involves the timing, or
rate of heart contraction. This component affects tissue perfusion and is
not considered a hemodynamic component. However, a person needs
to have all four components functioning normally to remain
hemodynamically stable.

Instant Feedback:
Of the 4 factors influencing hemodynamics, which one is concerned with the strength of
myocardial contractions?
Intravascular volume
Intropy
Chronotropy
Vasoactivity
Blood Flow: Review

In order to grasp the concepts of measuring and interpreting hemodynamic
values, it is important to understand how blood flowing through the heart is
related to the cardiac cycle.
Diastole:
1. The heart is at rest and the
myocardium is relaxed.
2. The atria and ventricles
passively fill. AV valves
allow blood to pass
3. The aortic and pulmonary
artery semilunar valves are
closed because the blood in
those vessels is at a higher
pressure than the
ventricles.
4. Blood continues to fill atria

and ventricles, stretching
the compliant heart cells.
Systole:
1. The atria contract and eject
the final amount of blood
into the ventricles. At rest,
the atrial contraction
contributes only about 10%
to the total ventricular
volume. If the heart rate is
high and the ventricles don't
have time to fill completely,
atrial systole can contibute
as much as 40%.
2. Atria relaxation causes
atrial pressure to be lower
than ventricular pressure.
3. High ventricular pressure
relative to the atria causes
the AV valves to close,
preventing backflow while
the ventricles contract.
4. The ventricles continue to
contract, ejecting blood
through the semilunar
valves out to the lungs and
rest of the body.

Fluid flows from high
pressure to lower
pressure.
Blood within the
cardiovascular system
adheres to this rule. This is
evidenced by the direction
of blood flow. The higher
pressure generated by the
left heart produces a gradient which moves blood from the left heart, through
the body and into the right side of the heart.
When the left ventricle (LV) contracts, it generates a systolic blood
pressure of 100-140 millimeters of Hg (mm Hg).
1. The aortic diastolic pressure is usually 60-90 mm Hg. The LV/aortic
pressure gradient causes blood to pass through the aortic valve.
2. Blood flowing from the LV to the aorta raises the aortic pressure to
equal the LV pressure.
3. A momentary aortic systolic pressure of 100-140 mm Hg is then
dissipated across the capillary beds.
4. Capillary pressure exceeds that of the venuoles. The capillary/venuole
gradient causes blood to flow into the low pressure venous system.
5. Low pressure venous blood is returned to the right atrium, aided by
skeletal muscle compression, negative intra-thoracic pressure and a
multitude of one-way valves that advance the blood toward the vena
cavae.
The pressure of blood within the right atrium is the central venous
pressure (CVP). The blood pressure of the vena cavae is similar to the CVP
because there are no valves or flow obstructions between the vena cavae
(VC) and the RA. The VC and heart's right side can be viewed as one
chamber with a contractile portion at the distal end. The CVP averages
between 2-6 millimeters of mercury (mm Hg).
During right ventricular (RV) diastole, the pressure within the RV is
between 0-5 mm Hg. Elasticity and compliance of the ventricular myocardium
help generate a lower intraventricular pressure. Lower intraventricular
pressure, aided by atrial systole, causes blood to flow across the open
atrioventricular AV valve.
Right ventricular systolic pressure is usually from 20-30 mm Hg. This
exceed the right atrial pressure. The pressure gradient applies greater
pressure to the ventricular side of the AV valve, which causes it to close.
The pulmonary artery (PA) pressure, prior to systole, is normally 8-12
mm Hg. During RV systole the PA pressure will rise to equal the RV pressure,
usually 20-30 mm Hg. The systolic PA pressure of 20-30 Hg is quickly
dissepated by the compliance of the pulmonary vascular bed to a diastolic
pressure of 8-12 Hg.
Blood leaves the pulmonary vasculature at about 4-12 mm Hg, passively
entering the pulmonary veins. The pulmonary veins empty directly into the
left atrium. Elasticity and compliance of the ventricular myocardium help
generate a slightly lower intraventricular filling pressure. Lower intraventricular
pressure, aided by atrial systole, causes blood to flow across the open
atrioventricular AV valve.

LV systole generates 100-140 mm Hg. Aortic diastolic pressure is usually
60-90mm Hg. The pressure gradient of 100-140/60-90 mm Hg drives blood
into the aorta and onward to the rest of the body. The cycle is complete.

Instant Feedback:

What causes the AV valve to close.
low atrial pressurel/high ventricular pressure
high atrial pressure/low ventricular pressure


Hemodynamic Measurement Terminology

There are a number of hemodynamic terms that you will need to understand
in order to properly interpret the hemodynamic measurements.
The following table illustrates common values associated with a hemodynamic
printout.
Please be aware that these normal values may vary depending on your
instrumentation, so always rely on your institution's policies and procedures.
Some of the values are actual measurements of pressure (mm Hg), volume (ml),
or flow speed (L/min), and other values are calculated or "derived" from
formulae. Click on the name of the parameter to link to the actual formula, if
applicable.
Parameter Normal value
Blood Pressure
Systolic (SBP) 90-140 mmHg
Diastolic (DBP) 60-90mmHg
Mean Arterial Pressure (MAP) 70 - 100 mm Hg
Cardiac Index (CI) 2.5-4 L/min/m2
Cardiac Output (CO) 4-8 L/min
Central Venous Pressure
(CVP) (also known as Right Atrial Pressure
(RA))
2-6 mmHg
Pulmonary Artery Pressure (PA)
Systolic 20-30
mmHg (PAS)
Diastolic 8-12
mmHg (PAD)
Mean 25 mmHg
(PAM)
Pulmonary Capillary Wedge Pressure
(PWCP)
4-12 mmHg
Pulmonary Vascular Resistance (PVR)
37-250
dynes/sec/cm5
Right Ventricular Pressure (RV)
Systolic-20-30
mmHg
Diastolic 0-5 mmHg
Stroke Index (SI) 25 - 45 ml/m2
Stroke Volume (SV) 50 - 100 ml
Systemic Vascular Resistance (SVR)
800-1200
dynes/sec/cm5
Afterload: Afterload describes the resistance that the heart has to
overcome, during every beat, to send blood into the aorta. These
resistive forces include vasoactivity and blood viscosity.
Cardiac Index (CI): The amount of blood pumped by the heart, per
minute, per meter square of body surface area.
Cardiac Output (CO): The volume of blood pumped by the heart in one
minute.
o Increased cardiac output may indicate a high circulating volume.
o Decreased cardiac output indicates a decrease in circulating
volume or a decrease in the strength of ventricular contraction.
Central Venous Pressure (CVP): CVP readings are used to
approximate the Right Ventricular End Diastolic Pressure (RVEDP). The
RVEDP assesses right ventricular function and general fluid status.
o Low CVP values typically reflect hypovolemia or decreased
venous return.
o High CVP values reflect overhydration, increased venous return
or right sided cardiac failure.
Mean Arterial Pressure (MAP): Reflects changes in the relationship
between cardiac output (CO) and systemic vascular resistance (SVR)
and reflects the arterial pressure in the vessels perfusing the organs.
o A low MAP indicates decreased blood flow through the organs.
o A high MAP indicates an increased cardiac workload.
Preload: Preload occurs during diastole. It is the combination of
pulmonary blood filling the atria and the stretching of myocardial fibers.
Preload is regulated by the variability in intravascular volume.
o Volume reduction decreases preload
o Volume increase will increase preload, mean arterial pressure
(MAP) and stroke index (SI).
Pulmonary Artery Pressure (PA Pressure): Blood pressure in the
pulmonary artery.
o Increased pulmonary artery pressure may indicate: a left-to-right
cardiac shunt, pulmonary artery hypertension, COPD or
emphysema, pulmonary embolus, pulmonary edema, left
ventricular failure.
Pulmonary Capillary Wedge Pressure (PCWP or PAWP): PCWP
pressures are used to approximate LVEDP (left ventricular end diastolic
pressure).
o High PCWP may indicate left ventricle failure, mitral valve
pathology, cardiac insufficiency, cardiac compression post
hemorrhage.
Pulmonary Vascular Resistance (PVR): The measurement of
resistance or the impediment of the pulmonary vascular bed to blood
flow.
o An increased PVR or "Pulmonary Hypertension" is caused by
pulmonary vascular disease, pulmonary embolism, or pulmonary
vasculitis, or hypoxia.
o A decreased PVR is caused by medications such as calcium
channel blockers, aminophylline, or isoproterenol or by the
delivery of O2.
Right Ventricular Pressure (RV Pressure): A direct measurement that
indicates right ventricular function and general fluid status.
o High RV pressure may indicate: pulmonary hypertension, right
ventricle failure, congestive heart failure.
Stroke Index or Stroke Volume Index: (SI or SVI): The amount of
blood ejected from the heart in one cardiac cycle, relative to Body
Surface Area (BSA). It is measured in ml per meter square per beat.
o An increased SVI may be indicative of early septic shock,
hyperthermia, hypervolemia or be caused by medications such as
dopamine, dobutamine, or digitalis.
o A decreased SVI may be caused by CHF, late septic shock, beta
blockers, or an MI.
Stroke Volume (SV): The amount of blood pumped by the heart per
cardiac cycle. It is measured in ml/beat.
o A decreased SV may indicate impaired cardiac contractility or
valve dysfunction and may result in heart failure.
o An increased SV may be caused by an increase in circulating
volume or an increase in inotropy.
Systemic Vascular Resistance (SVR): The measurement of
resistance or impediment of the systemic vascular bed to blood flow.
o An increased SVR can be caused by vasoconstrictors,
hypovolemia, or late septic shock.
o A decreased SVR can be caused by early septic shock,
vasodilators, morphine, nitrates, or hypercarbia.

Instant Feedback
Afterload is increased if the circulating blood is concentrated and/or if systemic blood
vessels are constricted.
True
False


Instant Feedback
After a significant hemorrhage, preload will be increased.


True
False
Non Invasive Hemodynamic Assessment

A patient's hemodynamic status can be evaluated noninvasively by performing
a comprehensive cardiovascular assessment. This assessment should be
conducted in addition to invasive monitoring.
The table below describes some cardiovascular assessment points and their
rationale.
Assessment Rationale
Take vital signs: Assess pulse for
rhythm, strength and rate. Assess
blood pressure.
Blood pressure is
determined by cardiac
output, peripheral
vascular resistance,
circulating blood
volume, blood
viscosity, and vessel
elasticity.
Precordium: Inspect the anterior
chest for heaves and an increase in
visible pulsatility.
Palpate the PMI (point of
maximum impulse) for a normal 2+
pulse.
Heaves indicate
ventricular
hypertrophy due to an
increased workload.
A PMI that is
displaced down and
to the left indicates
ventricular
hypertrophy which
may be due to volume
overload. An increase
in force and duration
of the pulse may
indicate an increase
in pressure without
volume overload.
Percuss the chest to determine
the size of the heart.
Increase in heart size
may indicate
increased ventricular
volume or wall
thickness.
Auscultate the aortic, pulmonic,
second pulmonic (Erb's point),
mitral, and tricuspid areas of the
precordium.
Listen for normal
S1S2 and for
abnormal sounds
such as S3 or S4,
murmurs, clicks, or
rubs which could
indicate heart
pathology.
Peripheral Vascular: Inspect and
palpate the skin for color, texture,
moisture and turgor.
Changes in skin
indicate a change in
tissue perfusion and
cardiac output.
Palpate the peripheral pulsesand
check nailbed capillary refill which
is normally less than 3 seconds.
Changes in pulses
indicate a change in
cardiac output and
tissue perfusion.
Inspect the neck for jugular
venous distention (JVD).
Indicates CVP. Full
distention as the
patient sits at a 45
degree angle
indicates an increase
in CVP.
Auscultate and palpate the
carotid arteries to assess arterial
blood flow.
A decrease in pulse
amplitude indicates a
decrease in stroke
volume.
Assess for hepatojugularreflux. A positive
hepatojugular reflux
indicates heart failure.

Instant Feedback:
Tissue perfusion can be assessed by checking nailbed capillary refill. Normal refill
should occur in less than 4 seconds.


True
False

Arterial Blood Pressure Monitoring

Intra-arterial catheters ("art lines") offer clinicians a low risk and reliable
method to continuously monitor systemic blood pressure. Critically ill patients,
with unstable cardiopulmonary status, often benefit from such continuous
monitoring. Clinicians are better able to promptly manage changes in blood
pressure which may signal perfusion deficits.
A secondary benefit of an art line is the ability to do serial blood sampling.
Arterial blood gas evaluations can be performed without the need for repeated
painful needle sticks. Arterial blood gas monitoring is vital to the successful
treatment of respiratory failure, whatever the cause.
Arterial pressure monitoring begins with an accurate patient history and
assessment. A history of peripheral vascular disease could raise the risk of
complications from arterial line insertion. Skin changes, scars, sores,
discoloration, swelling, excess warmth or swelling etc., could indicate the
presence of peripheral vascular disease.
Palpation, capillary refill and the Allen test are necessary steps to determine
the suitability of a limb for insertion of an arterial line. The Allen test
determines the patency of the arm's radial and ulnar arteries. The Allen test
must be done prior to arterial line insertion, in order to reduce the risk of
ischemia due to arterial occlusion.
Ask seated patient to place hand, palm up, on the knee.
Using both of your thumbs, compress the radial and ulnar arteries.
Ask patient to open and close a fist several times, watch for blanching of
the palm.
Release only the radial artery; palm should become pink in seconds.
Repeat process this time releasing only the ulnar artery.
If the palm remains blanched when either the radial or ulnar arteries are
released, there may not be sufficient circulation if a catheter were to be
inserted.
Follow your institutional guidelines when inserting or assisting in the
placement of an arterial line. The necessary equipment for placement will
include:
Skin cleansing supplies
Positioning aides
Sterile gloves
Sterile angiocath
Airless, sterile and flushed pressure tubing/ transducer assembly
Sterile supplies to secure and dress the angiocath (sterile suture and
scissors).
Monitor
Once the catheter is inserted, it is connected to the flushed and airless
tubing/transducer assembly. The transducer should be positioned level with
the heart, then zeroed to negate the pressure applied by the heparinized
flush. When zeroed, the transducer will reflect changes in the intra-arterial
pressure.



Waveform evaluation is the best method to determine correct placement.
A normal wave form will be:
within normal blood pressure limits,
present a characteristic shape and
synch with the EKG waveform.
Correlation of pressure readings with blood pressure cuff should be done
periodically, if possible.

The normal peripheral arterial waveform will display the peak systolic pressure
after the QRS. This phenomenon reflects the time it takes the cardiac systolic
pressure wave to reach the peripheral catheter and sensor. The dicrotic notch
reflects the closure of the aortic valve. Of course, the same time delay applies
to the dicrotic notch. The aortic valve has closed prior to the display of the
notch.
The time delay is a function of both distance and compliance or elasticity of
the vessels. The waveform of a patient with arteriosclerotic disease would be
steeper in ascent and descent, therefore shorter in duration and the notch
would be less well defined.

Instant Feedback
The normal arterial waveform will display a "dicrotic" notch, reflecting the closure of the
aortic valve.

True
False

Central Venous Pressure Monitoring

Central venous pressure is considered a direct measurement of the blood
pressure in the right atrium and vena cava. It is acquired by threading a
central venous catheter (subclavian double lumen central line shown) into any
of several large veins. It is threaded so that the tip of the catheter rests in the
lower third of the superior vena cava. The pressure monitoring assembly is
attached to the distal port of a multilumen central vein catheter.

Assisting with CVP placement
Adhere to institutional Policy
and Procedure.
Obtain history and assess the
patient.
Explain the procedure to the
patient, include:
o local anesthetic
o trendelenberg
positioning
o draping
o limit movement
o need to maintain sterile
field.
o post procedure chest X-
ray
Obtain a sterile, flushed and
pressurized transducer
assembly
Obtain the catheter size, style
and length ordered.
Obtain supplies:
o Masks
o Sterile gloves
o Line insertion kit
o Heparin flush per policy
Position patient supine on bed
capable of trendelenberg
position
Prepare for post procedure
chest X-ray
The CVP catheter is an important tool used to assess right ventricular function
and systemic fluid status.
Normal CVP is 2-6 mm Hg.
CVP is elevated by :
o overhydration which increases venous return
o heart failure or PA stenosis which limit venous outflow and lead to
venous congestion
o positive pressure breathing, straining,
CVP decreases with:
o hypovolemic shock from hemorrhage, fluid shift, dehydration
o negative pressure breathing which occurs when the patient
demonstrates retractions or mechanical negative pressure which
is sometimes used for high spinal cord injuries.
The CVP catheter is also an important treatment tool which allows for:
Rapid infusion
Infusion of hypertonic solutions and medications that could damage
veins
Serial venous blood assessment

Instant Feedback:
The CVP reading helps assess the function of the right ventricle and fluid status.

True
False


There are two ways to read a CVP waveform:

1. Find the mean of the A wave.
read the high point of the A wave
read the low point of the A wave
add the high point to the low point
divide the sum by 2
the result is the mean CVP
The A wave starts just after the P wave ends and represents the atrial contraction. The
high point of the A wave is the atrial pressure at maximum contraction. During the A
wave the atrial pressure is greater than the ventricular diastolic pressure. At that point,
the atrium is contracted, the tricuspid is open. Therefore, the high point of the A wave
closely parallels the right ventricular end diastolic pressure. Remember, when the
tricuspid valve is open and the right ventricle is full, the ventricle, atrium and vena cavae
are all connected. Therefore, that point is the CVP.
2. Find the Z-point.
Find the Z-point which occurs mid to end QRS
Read the Z-point
The Z-point coincides with the middle to end of the QRS wave. It occurs just
before closure of the tricuspid valve. Therefore, it is a good indicator of right
ventricular end diastolic pressure. The Z-point is useful when A waves are not
visible, as in atrial fibrillation.(The c-wave occurs at closure of the tricuspid
valve. The crest of the c-wave is the atrial pressure increase caused by the
tricuspid valve bulging back into the atrium.)

Instant Feedback:
Find the Z-point to read a CVP waveform, when A waves are not visible.

True
False

Purpose of a PAC

Thus far, we have covered invasive hemodynamic monitoring with
arterial lines and CVP catheters. The Pulmonary Artery catheter
(PAC) is another invasive way to obtain hemodynamic
measurements.
The purpose of this catheter is to:
Indirectly measure the left ventricular end-diastolic pressure.
Evaluate the hemodynamic treatments and measure the
patients hemodynamic status.
Draw mixed venous blood samples.
Obtain central vascular pressures measurements.
Measure cardiac output.
There are certain indications for using a PA catheter. They are:
Conditions of shock such as septic and hypovolemic shock.
Evaluation of fluid volume status.
Evaluation of cardiac output in complex medical situations.
Prophylactic insertion for high-risk surgeries.

Instant Feedback:
PA catheters are useful to measure cardiac output in complex
medical situations and evaluate fluid volume status in hypovolemic
and septic shock.

True
False

You may choose to view the YouTube video "Swan Ganz Numbers:
presented by Dr. Gallagher's Neighborhood" for a quick and
practical explanation of PAC utility.


Components of the Pulmonary Artery
Catheter

The proximal port, commonly
termed the CVP port, is used
to measure right atrial or
central venous pressure. It is
also used for medication
infusion and fluid boluses for
cardiac output measurement.
The distal port is used
for PA pressure measurements
and PCWP measurements when the balloon is inflated. Mixed
venous blood gases can also be drawn from this port. The balloon
port which is located at the tip of the catheter is inflated with a
small amount of air (less than 1.5cc). When inflated, this balloon
allows the catheter to float into a pulmonary artery branch vessel.
This is refered to as a wedge position. This position allows pressure
measurements to be made that indirectly reflect left ventricular end
diastolic pressure.
The thermistor port is connected to the patients monitor via a
cable and allows the display of continuous temperature readings.
These temperature readings are essential to calculate cardiac
output measurements. The actual thermistor is located just
proximal to the balloon. In order to determine the cardiac output
value, cool injectate is delivered rapidly through the proximal port
of the PA catheter. A temperature curve is plotted over time as the
cool injectate causes the pulmonary artery temperature to fall. It
then rises back to the previous core temperature as warm blood
continues in circulation.

Click here to open a new page and visit the London Health Sciences
Critical Care website for a detailed cardiac output procedure and
rationale.
(When your finished, close the page to return to your place at
RnCeus.com)
Be prepared to answer the following question: Solution for the
measurement of cardiac output is injected while the patient is inhaling, or
exhaling?

The PA catheter is inserted by a
physician with the assistance of the
critical care RN. Patient safety
requires strict adherence to your
facility policy and procedure when
assisting line insertion.
While the PA catheter is inserted, the
monitor will display the various
pressure waveforms associated with
the catheters position in the heart
and vessels. The following section
will discuss hemodynamic waveforms
and their interpretation.

During the insertion procedure, the
first waveform will be the right atrial
pressure. This wave will resemble
a CVP wave. The following
waveform will be the right ventricular pressure as the catheter
Reduce Catheter Related Bloodstream Infections
(CR-BSI)
Prepare patient regarding: positioning,
immobility, local anesthetic, site prep, sterile
draping, sterile prep, post insertion safety,
etc.
Avoid accessing femoral vein in adults
Hand hygiene - Decontaminate hands with
approved solutions before and after gloving
and patient contact.
Barrier protection
o Personal Protective Equipment:
Standard Precautions
o Maximal sterile barriers including:
gloves, gowns, chlorhexidine
insertion site prep,
drapes and dressing .
o Caps and masks required. Patient
masked when drape separation not
possible.
Dressing
o Chlorhexide impregnated sponge
(per protocol)
o Transparent semi-permeable
dressing
Placement verification
Daily review of line necessity and prompt
removal
passes through the right ventricle. During this time, the patient may
experience some ventricular dysrhythmias that disappear as soon as
the catheter exits the right ventricle. The catheter will enter
the pulmonary artery and this will be its resting place for the
majority of the time. Finally, when the balloon is inflated, the
catheter will float into the pulmonary capillary and the resulting
waveform will be the wedge pressure. The following diagrams
illustrates the waveforms associated with inserting the pulmonary
artery catheter.



You may choose to view the YouTube video, New England Journal of
Medicine PERFORMING MEDICAL PROCEDURES - Pulmonary-Artery
Catheterization by Christopher R. Kelly, M.D. and Leroy E. Rabbani
M.D.



Interpretation and Clinical Examples

After invasive hemodynamic catheters are inserted, and the initial pressures
and cardiac outputs are measured, maintenance of the patient is usually left to
the critical care nurse. These tasks may include assessing the patients
hemodynamic status, measuring and documenting pressures, and adjusting
the vasoactive or inotropic drips as necessary. It is essential that the nurse
have a clear understanding of how activity and pharmocologic intervention
affect the hemodynamic status of the patient.
This portion of the module will use several case examples for practicing
interpretation of hemodynamic pressures.
Case example 1
Mrs. Rainey, a resident of a skilled nursing facility, was found in her bed with a
decreased level of consciousness, increased respirations, and a temperature
of 102 degrees F. The SNF staff report that she had been suffering from
vomiting and diarrhea for the past week. Mrs. Rainey was transferred to the
ICU. A subclavian central line was placed and the physician ordered vital
signs and CVP readings q2h, a fluid bolus of 500cc over 2 hours followed by a
continuous IV of D51/2NS at 125cc/hr. A foley catheter was in place already.
Urine was strong smelling, concentrated, and the hourly output was about
20cc/hr.
The following are Mrs. Raineys initial vitals signs prior to the fluid bolus:
HR 120 B/P 84/40 mm Hg
SaO2 90% on room air RR 24
CVP 1 mm Hg

and after the fluid bolus:
HR 90 B/P 100/62 mm Hg
SaO2 90% on room air RR 14
CVP 4 mm Hg
Interpretation:
Mrs. Rainey is hypotensive and tachycardic and her CVP indicates
hypovolemia. A conservative fluid bolus gives her some additional volume
without risking overhydration.
Case example 2
Mr. Felder is s/p "whipple procedure" and is in your ICU for post operative
observation. He was transferred to you directly from the operating room with
an arterial line in place in the left wrist and a triple lumen central line in the
right subclavian. He is extubated and on O2 at 40% via face mask. You notice
that Mr. Felder's arterial line waveform is dampened.
The following are Mr. Felder's vital signs:
HR 84 via arterial line B/P 82/50 mm Hg
SaO2 100% RR 12
CVP 6 mm Hg

Interpretation:
A dampened arterial waveform suggests that Mr. Felder's arterial line may be
positional. His CVP, HR, and RR are all within normal limits. Nursing
interventions included flushing the arterial line, repositioning Mr. Felder's wrist,
and checking the arterial line reading with a cuff blood pressure.
Case example 3
Mr. Smyth was admitted to the ICU with epigastric pain and shortness of
breath. A diagnosis of acute inferior myocardial infarction was made. While in
the ICU, he developed cardiac dysrhythmias and experienced a decrease in
blood pressure. A pulmonary artery catheter was inserted and 40% oxygen by
face mask was applied. Drips of Lidocaine at 2 mg/min, and dobutamine at 8
mcg/kg/min were started. Urine output was marginal at 40 ml/hr. The following
table contains some of the hemodynamic parameters obtained via the PA
catheter.
HR 108 B/P 130/56 Hg
CO 4.06 L/min PA 52/32 mm Hg
CI 2.26 L/min/m2 SVR 1540 DS/cm5
PAWP 17 mm Hg PVR 549 DS/cm5
CVP 9 mm Hg

Interpretation:
Mr. Smyth is normotensive and slightly tachycardic. His cardiac output and
cardiac index are normal, but is PA pressures and PAWP are elevated. The
dobutamine, an inotropic agent, strengthens cardiac contractions that
subsequently support the CO and BP. This intervention sometimes results in
vasoconstriction and could be responsible for the elevated PA pressures and
SVR.

Case Example 4
Mrs. Jones was admitted to the ICU after an MVA for observation. During the
first 24 hours she developed an increased heart rate and decreased BP. Her
level of consciousness started to decrease and she was placed on 02 40% by
face mask. A PA catheter was placed for evaluation of her fluid status. The
follow table contains some of the parameters:
HR 120 B/P 90/40 mm Hg
CO 2.06 L/min PA 12/4 mm Hg
CI 1.14 L/min/m2 SVR 1540 DS/cm5
PAWP 3 mm Hg PVR 549 DS/cm5
CVP 2 mm Hg


Interpretation:
Mrs. Jones is suffering from hypovolemic shock. The PA pressures and BP
demonstrate a low fluid volume and increased HR reflects the compensation
for this low volume. The SVR is also elevated as the body tries to constrict the
blood vessels in order to compensate for the low fluid volume. Mrs. Jones
may be suffering from internal bleeding and needs fluids immediately.
Nursing Responsibilities

Site Care and Catheter Safety:
A sterile dressing is placed over the insertion site and the catheter is
taped in place. The insertion
site should be assessed for infection and the dressing changed every
72 hours and prn.
The placement of the catheter, stated in centimeters, should be
documented and assessed every shift.
The integrity of the sterile sleeve must be maintained so the catheter
can be advanced or pulled back without contamination.
The catheter tubing should be labeled and all the connections secure.
The balloon should always be
deflated and the syringe closed and locked unless you are taking a
PCWP measurement.
Patient Activity and Positioning:
Many physicians allow stable patients who have PA catheters, such as
post CABG patients, to get
out of bed and sit. The nurse must position the patient in a manner that
avoids dislodging the
catheter.
Proper positioning during hemodynamic readings will ensure accuracy.
Dysrhythmia Prevention:
Continuous EKG monitoring is essential while the PA catheter is in
place.
Do not advance the catheter unless the balloon is inflated.
Antiarrhythmic medications should be readily available to treat lethal
dysrhythmias.
Monitoring Waveforms for Proper Catheter Placement:
The nurse must be vigilant in assessing the patient for proper catheter
placement. If the PA waveform suddenly looks like the RV or PCWP
waveform, the catheter may have become misplaced. The nurse must
implement the proper procedures for correcting the situation.
Monitoring Hemodynamic Values for Response to Treatments:
The purpose of the PA catheter is to assist healthcare team members in
assessing the patients condition and response to treatment. Therefore,
accurate documentation of values before and after treatment changes is
necessary.
Assessing the Patient for Complications Associated with the PA
Catheter:
Occluded ports
Balloon rupture caused by overinflating the balloon or frequent use of
the balloon.
Pneumothorax - may occur during initial placement.
Dysrhythmias - caused by catheter migration
Air embolism - caused by balloon rupture or air in the infusion line.
Pulmonary thromboembolism - improper flushing technique, non-
heparinized flush solution.
Pulmonary artery rupture - perforation during placement, overinflation of
the balloon, overuse of the balloon.
Pulmonary infarction - caused by the catheter migrating into the wedge
position, the balloon left inflated, or thrombus formation around the
catheter which causes an occlusion.

Instant Feedback:
PA catheter migration may cause which of the following complications?
Pulmonary infarcation
Dysrhythmias
Inaccurate measurements
All of the above
Formulae

Body Surface Area (BSA) = ( [Height (cm) x Weight (kg) ] / 3600 )1/2
Cardiac Index (CI) = Cardiac Output (CO) / Body Surface Area (BSA)
Mean Arterial Pressure (MAP) = (2 x DBP) + SBP / 3
Pulmonary Vasular Resistance (PVR) = PAM - PCWP / CO X 80
Stroke Index (SI) = Stroke Volume (SV) / Body Surface Area (BSA)
Stroke Volume (SV) = is the amount of blood ejected by the left ventricle into
the vasculature in one heart beat.
Systemic Vascular Resistance (SVR) = (MAP - CVP) / CO X 80
Exam & Evaluation (Hemodynamic Monitoring: An Introduction)



Questions: Please respond to following statements.
1 Hemodynamics are measured with which of the following?
PA catheter
IV catheter
Urinary catheter
Arterial catheter
2 The term hemodynamics describes:
Intravascular volume
Intropy
Vasoactivity
All of the above
3 Chronotropy is considered a hemodynamic parameter.
True False
4 The blood received by the right atrium is:
Hyperoxygenated
Oxygen depleted
Normally Oxygenated
None of the above
5 Diastole refers to:
The heart contracting
Heart failure
The heart at rest
A myocardial infarction
6 During diastole all the heart valves are closed.
True False
7 Atrial systole refers to:
The heart at rest
Artrial contraction and ejection of blood into the ventricles
Heart failure
A myocardial infarction
8 During atrial systole, the AV heart valves are closed.
True False
9 Preload is a measure of
ventricular end systolic volume
ventricular end diastole volume
atrial contraction
atrial relaxation
10 When afterload increases, cardiac output decreases.
True False
11 Indications for using a PA catheter are:
Conditions of shock
Evaluation of fluid status
Evaluation of cardiac output
All of the above
12 The thermistor port of the PA catheter measures:
PCWP
Pulmonary artery pressure
Blood temperature
BP
13 When the balloon is inflated, the distal port of the PA catheter measures:
PCWP
Pulmonary artery pressure
Blood temperature
BP
14 When the balloon is deflated, the distal port of the PA catheter measures:
PCWP
Pulmonary artery pressure
Blood temperature
BP
15 Nursing care of the patient with the PA catheter includes:
Patient safety
Assessing activity tolerance
Site care
All of the above
16 Noninvasive assessment of central venous pressures includes which of the following?
Inspection of the neck for jugular venous distention.
Auscultation of heart sounds.
Chest percussion to determine heart size.
Inspection of the chest for heaves.
17 When preparing to place an arterial line, which of the following tests is necessary?
Hepatojugular reflex test
Allen's test
Pedal capillary refill test
Pulse pressure test
18 In order to measure cardiac output via the thermodilution method, there must be a
temperature difference between the blood and the injectate.
True False
19 PA catheter migration may cause which of the following complications?
Pulmonary infarcation
Dysrhythmias
Inaccurate measurements
All of the above
20 The PA catheter balloon should always remain inflated and locked when not in use.
True False
21 According to the London Health Sciences Critical Care website, solution for cardiac output
measurement is injected while the patient is inhaling.
True False
Please Evaluate the course. Choose the appropriate button to rate the following.
A The relationship of objectives to the overall purpose/goal of this interactive independent study
activity.
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1. Discuss cardiac physiology as it relates to blood flow and hemodynamic monitoring.
Excellent Very Good Good Fair Poor
2. Understand the terminology and normal values associated with hemodynamic monitoring.
Excellent Very Good Good Fair Poor
3. Review methods of noninvasive hemodynamic monitoring.
Excellent Very Good Good Fair Poor
4. Describe components, and purposes, of invasive monitoring, including arterial, central
venous and pulmonary artery catheters.
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5. Discuss issues related to nursing care for patients with invasive hemodynamic catheters.
Excellent Very Good Good Fair Poor
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graphics, video clips, Internet links, Instant Feedback).
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and evaluation. Please confirm by entering the number "240" in this box.

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Author

This course is a collaborative product of the RnCeus.com Education
Committee.
ANDREA DIANE POSEY, RN, MSN is the content specialist for this
course. Andrea is an Assistant Professor of Nursing University of
Alaska Anchorage.







Bibliography and Recommended Reading

Chulay, M, Guzzetta, C, & Dossey, B. (1997). AACN Handbook of Critical
Care Nursing. Appleton & Lange: Stamford, CT.
Cook NF, Melby V. (1999). Acute MI: Analysing health status and setting
immediate priorities. British Journal of Nursing, 11-24;8(3):150-2, 154, 156-8.
Dahlen R, Roberts SL. (1995). Nursing management of congestive heart
failure. Part I. Intensive Critical Care Nursing, 11(5):272-9.
Daily EK. (2001). Hemodynamic waveform analysis. Journal of Cardiovascular
Nursing, 15(2):6-22.
Darovic G. (1999). Handbook of Hemodynamic Monitoring. W B Saunders.
Ganong, WF. (1999). Review of Medical Physiology. Appleton & Lange:
Stamford, CT.
Jarvis, C. (2000). Physical Examination and Health Assessment. 3rd ed. WB
Saunders: Philadelphia.
Quaal SJ. (2001). Improving the accuracy of pulmonary artery catheter
measurements. Journal of Cardiovascular Nursing, 15(2):71-82.
Williams, S. (1990). Decision Making in Critical Care Nursing. B.C. Decker:
Toronto.

HEMODYNAMIC MONITORING
1. Live Well Library

2. Adult Health Advisor

3. Hemodynamic Monitoring


o

View image

View image
WHAT IS HEMODYNAMIC MONITORING?
Hemodynamic monitoring measures the blood pressure inside the veins, heart, and arteries. It also
measures blood flow and how much oxygen is in the blood. It is a way to see how well the heart is
working.
WHEN IS IT DONE?
Many treatments depend on seeing small changes in the way the heart is working. These changes
happen first deep inside the body. It may take time for these changes to show at the body surface,
where they can be observed more easily. Hemodynamic monitoring can detect these changes early
by testing samples of blood from deep inside the body.
Hemodynamic monitoring helps your healthcare provider know if you will need blood or fluid
transfusions. It shows whether the lungs are getting enough oxygen. It checks how well the heart is
pumping by measuring the total blood flow per minute.
This test may be done, for example, if you are in intensive care recovering from a heart attack or if
you have fluid around your heart.
WHAT HAPPENS DURING THE TEST?
Blood pressure in the arteries can be checked by putting a short, thin tube through your skin and into
one of your arteries, usually a wrist artery. (Before the tube is inserted, you will be given a shot to
numb the area.) The blood pressure measurement is displayed on a TV. The tube in your artery also
makes it easy to get blood samples to measure the oxygen level in the blood.
A very thin, flexible tube called a catheter may be used to allow your healthcare provider to measure
the blood pressure in your pulmonary artery. This is the artery that brings blood to the lungs. Your
provider puts the catheter through your skin and into a vein. The veins most commonly used are in
the neck, under the collarbone, or in the leg. A small balloon at the tip of the catheter helps the
catheter float through the heart and into the pulmonary artery. When the catheter is in the right
position, the balloon is deflated and the catheter is left in place. The catheter does not cause any
pain. This catheter may be called a right heart catheter, a pulmonary artery catheter (PAC), or a
Swan-Ganz catheter.
The pulmonary artery catheter can also measure the amount of blood pumped by the heart and the
amount of oxygen in the blood. These measurements show how well the heart's left ventricle is
working. The left ventricle is the main pumping chamber of the heart. Very small changes in your
blood flow and the pumping ability of your heart can be detected with this catheter.
Most hemodynamic monitoring is done for just a few days.
WHAT ARE THE BENEFITS OF THIS TEST?
This test can find problems with how the heart is working. Treating problems early may prevent
complications. This is very important for some people who need to have surgery or who are very
sick.
WHAT ARE THE RISKS OF THIS TEST?
Complications from this test are rare. Possible risks include:
The test can cause irregular heart rhythms, which might need treatment.
You may have bleeding where the catheter was put into your blood vessel.
A blood clot could form around the catheter when it is in an artery. The clot could block the
artery.
The catheter may damage an artery, for example, the vessel in the groin or arm where the
catheter was inserted.
In rare cases, you may have an allergic reaction to the drug used in the anesthesia.
While not common, a heart attack or stroke might be triggered by the test.
Rarely, a collapse of a lung when the tube is inserted into the heart.
You should ask your healthcare provider how these risks might apply to you.
Developed by RelayHealth.
Published by RelayHealth.
Copyright 2014 McKesson Corporation and/or one of its subsidiaries. All rights reserved.
References

Nursebob's MICU/CCU Survival Guide
Hemodynamics in Critical Care
Hemodynamic Monitoring Overview
12/04/00
What is hemodynamic monitoring?
There are both invasive and noninvasive techniques that can be used to determine the hemodynamic status of the
patient. Taking a simple blood pressure with a cuff is a hemodynamicmeasurement. By taking a blood pressure, you
can determine three homodynamic parameters. The systolic pressure, the diastolic pressure, and, using these two
numbers, you can calculate themean pressure. Hemodynamic monitoring can be much more involved than a simple
blood pressure reading. It may involve actual measurements of pressures directly within the heart. For our purposes
we will be primarily talking about the latter. That is, invasive homodynamic monitoring. With the arrival of our
modern technology, and improvements in biomedical engineering, we are now able to monitor the hemodynamic
status of patients continuously. Invasive hemodynamic monitoring allows the nurse to have access too much more
information about the status of the patient that is available by simple physical examination. However, keep in mind
that hemodynamic monitoring will never replace hands on patient assessment. Parameters said chest cardiac output
(CO), cardiac index (CI), pulmonary artery wage pressures (PAWP), and cardiac index (CI) are just a few of the
pressures which can be monitored to a special indwelling catheter, the Swan-Gantz or pulmonary artery catheter.
The primary purpose of invasive hemodynamic monitoring is the early detection, identification, and treatment of
life-threatening conditions such as heart failure and cardiac tampanade. By using invasive hemodynamic monitoring
the nurse is able to evaluate the patient's immediate response to treatment such as drugs and mechanical support.
The nurse can evaluate the effectiveness of cardiovascular function such as cardiac output, and cardiac index.
The nurse cares for the hemodynamicly unstable patient as well as the equipment required to conduct hemodynamic
monitoring. It is essential that the nurse be able to interpret the data and make clinical decisions based on that data.
The nurse must know how to detect and prevent complications of this clinical tool.
Indications for Hemodynamic Monitoring:
One of the obvious indications for hemodynamic monitoring is decreased cardiac output. This could be from
dehydration, hemorrhage, G. I. bleed, Burns, or surgery. All types of shock, septic, cardiogenic, neurogenic, or
anaphylactic may require invasive hemodynamic monitoring. Any deficit or loss of cardiac function: such as acute
MI, cardiomyopathy and congestive heart failure may require invasive hemodynamic monitoring.
Components of a Hemodynamic Monitoring System
There may be some small variations of the requirements of a hemodynamic monitoring system depending on the
manufacturer requirement and the type of system employed by your institution. Generally there are three
components of a hemodynamic monitoring system.
The amplifier is located inside the bedside monitor. It increases the size of signal from the transducer. There must be
a recorder or monitor to display the signal and record information. A transducer is needed which changes the
mechanical energy or the pressures of pulse into electrical energy. In addition to these three components there is
some supplemental equipment which is required. Pressure tubing is necessary since changes in pressure from tubing
distention will affect your readings. The tubing must have a continuous flush device as well as a manual one with
transducer. There must be a pressure bag containing a heparin solution of 1000 units in 500 ml of normal saline.
Some institutions require the transducer be mounted on an IV pole. There should be a pressure cable that carries
information from the transducer to the amplifier.
The Pulmonary Artery Catheter (PA catheter, Swan, Swan-Gantz)
The pulmonary artery catheter normally has four ports. The proximal port can be used to measure central venous
pressure and as an injectate port during the measurement of cardiac output. There is a distal port which bills to the
pulmonary artery and which is connected to the pressure line. A balloon port is also present where a 1.5-ml special
syringe is connected. This is used during the determination of pulmonary artery wedge pressure. No more than 1.5
ml of air should ever be injected into a pulmonary artery catheter during wage determination.
The pulmonary artery catheter has several functions. It allows for continuous bedside hemodynamic monitoring. So
that vascular tone, myocardial contractility, and fluid balance can be assessed and managed. It measures pulmonary
artery pressure, central venous pressure, and allows for hemodynamic calculations to be determined. Cardiac output
can be determined using the thermodilution method. Transvenous pacing can be done. The administration of fluids
is not recommended with a pulmonary artery catheter.
Pulmonary Artery Catheter Insertions
The bedside monitor should be turned on 10 to 15 minutes before insertion. The pulmonary artery catheter should be
selected based on physicians preference and size of the patient. The introducer should be selected. The pressure
monitoring system should be set up. This is the same monitoring system as used for an arterial line. The bedside
monitor should zeroed and calibrated. Before insertion, the integrity of the pulmonary artery catheter should be
checked. The insertion of the introducer is much the same as that of a central line placement. After insertion, the
pulmonary artery catheter is attached to the pressure line. Then it is inserted through the introducer into the vena
cava. When the pulmonary artery catheter enters the right atrium, a waveform and pressure registers on the monitor.
The physician may request that the balloon be inflated at this time. The inflated blame will act as a sail to float
the tip of the catheter into the pulmonary artery. The pressures and waveforms would change as the tip of the
catheter enters the right ventricle and again as it enters the pulmonary artery and then again when the balloon is
wedged in an artery that is too small to allow it to go any further.
Normally the right atrium will have a mean pressure of 2-6 mm Hg. The right ventricle will have a systolic pressure
of 15 to 25 mm hg, while the right ventricle will have 0-8 mm Hg.
The pulmonary arterial pressure should have a systolic of between 20 to 30 mm Hg, a diastolic of 6 to 12 mm Hg.
with a mean of 10 to 15 mm Hg. The pulmonary artery wedge pressure should have a mean of 6 to 15 mm Hg.
Insuring Accuracy of Hemodynamic Monitoring
The transducer should be level with the phlebostatic axis to counter the effects of hydrostatic pressure. It should be
at the same level as the bill right atrium. You can estimate this by intersecting lines from the fourth intercostal space,
mid axillary line.
The transducer must be zeroed to negate atmospheric pressure. The reference port on the transducer should be open
and the appropriate zero buttons on the bedside monitor should be pushed. This should be done every eight hours.
Some institutions require ever for hours. When the monitor is turned on it should be allowed to warm up for 15
minutes.
The pressure in the continuous flush device must be maintained at 300 mm Hg. continuously. As a result of this, the
devise will deliver a preset amount of flush solution through the pulmonary artery catheter continuously. This is
designed to prevent clots from forming at the catheter tip. The pulmonary artery catheter should be fast flesh every
eight hours. However, this may vary from institution to institution.
Manifestations of Altered Hemodynamics
Altered hemodynamic signs and symptoms are varied. The symptoms can be anything from cardiac dysfunction,
pulmonary edema, rales, increased jugular vein size, pulmonary edema, complete cardiovascular collapse, and
profound shock. Symptoms can include weakness, pallor, confusion, cold clammy skin, diminished or absent pulses,
cardiac arrhythmias, low arterial blood pressure, and decreased cardiac output. New murmurs and heart sounds may
develop.
Fluid Challenges
By obtaining additional information of left ventricular performance, treatment can be altered according to pressure
measurements. This is known as a fluid challenge.
Preload (Pulmonary wedge pressure, PAWP, Wedge)
Preload is the degree of muscle fiber stretching present in the ventricles right before systole. It could be looked at as
the amount of blood available to be ejected at systole. Central venous pressure or right atrial pressure affects right
ventricular preload. Normally 2-8 mm Hg. This also measures right ventricular end diastolic pressure.
Left ventricular preload, on the other hand, is reflected by the pulmonary artery wedge pressure, which measures the
left ventricular end diastolic pressure. The pulmonary diastolic pressure estimates it. The pulmonary wage pressure
(PAWP) measures the additional fluid, which stretches the left ventricle just prior to contraction. This is determined
by the volume of blood in the right ventricle at the end of filling. Normally this measurement is 4-12 mm Hg.
A decrease in preload may be caused by hypovolemia as a result of hemorrhage, surgery, diuresis, dehydration,
vomiting and diarrhea. Resulting in a decrease filling time for the heart may also cause it. Consequently, the blood
does not have time to enter the heart to be circulated resulting in hypovolemia. Another reasons for decreased
preload may be vasodilation that causes pooling. Hypothermia and sepsis must also be considered.
An increase in preload may be caused by vasoconstriction as a result of sympathetic stimulation or hypothermia. It
may also be caused by hypovolemia after heart surgery, renal problems, or heart failure. Generally, anything that
changes circulating blood volume such as dehydration, hemorrhage, or hypervolemia will affect preload. Likewise,
anything that changes about blood returning to the heart, such as vasoconstriction, vasodilation or exercise will
affect it. And anything that changes the ventricular filling time such as congestive heart failure, cardiac tampanade,
and increased or decreased heart rate will also affect preload.
Afterload (CVP, Central Venous Pressure)
Any resistance against which the ventricles must pump in order to eject its volume is called afterload. The resistance
to the ventricular ejection, which is measured, by the pulmonary vascular resistance by the systemic vascular
resistance, is afterload. Right side preload is normally 1-6 mm Hg. This central venous pressure (CVP) and right
atrial pressure (RA) gives an indication of amount of blood returning to the right side of the heart. Vasodilation as a
result of sepsis or hypothermia, low blood pressure, or the effective nitrates, will cause a decrease in afterload. On
the other hand, vasoconstriction as a result of hypovolemia, hypothermia, aortic stenosis, hypertension or the affect
of vasopressive agents may cause an increase in afterload.
Afterload can be managed by the manipulation of peripheral vascular resistance or systemic vascular resistance. By
increasing the preload, the length of the fiber stretch will also increased thereby increasing the hearts myocardial
contractibility resulting in decreased afterload, causing an increase cardiac output.
Both mechanical and pharmaceutical agents may accomplish this. Frequently the administration of dopamine, which
will increase preload, while simultaneously titrating Nipride to decrease afterload, is done. The nurse must carefully
balance both of these vasotonic agents in order to assist the failing heart.
Remember, the greater the preload, the greater the stroke volume (SV), and therefore, the greater the cardiac output
(CO). This is a direct relationship he can be measured by a pulmonary artery catheter (Swan-Gantz). The blood
pressure (BP) is an indirect reflection of afterload; therefore BP usually equals afterload.
Cardiac output and afterload have an inverse relationship. That is, the lower the cardiac output the greater the
afterload.
Systemic Vascular Resistance
Systemic vascular resistance (SVR) can be calculated from the main arterial pressure (MAP), central venous
pressure (CVP) and cardiac output (CO).
SVR=MAP-CVP/CO*80
Afterload is not completely measured by vascular resistance. Blood viscosity and valvular resistance will all affect
vascular resistance thus afterload. We can normally measured two types of vascular resistance, systemic vascular
resistance (SVR) reflects left ventricular afterload. Normally systemic vascular resistance is 900 to 1300
dynes/second/cm2 times per second.
The left ventricle faces increased resistance to as in hypertension so the aim be aimed to reduce systemic vascular
resistance. On the other hand of the patient was suffering from symptoms such a shock, the treatment would be
aimed at improving cardiac output. Some other causes may be decreased pathologic response due to an
inflammatory process, diseases due to increased collateral circulation, or neurogenic induced central vasodilation.
The pulmonary vascular resistance (PVR) is a reflection of right ventricular afterload. It is normally 40 to 220
dynes/second/cm2.
Cardiac Output (CO)
The cardiac output (CO) can be calculated if we know the heart rate and the stroke volume.
CO=HR*SV dynes/Cm2 Normal 4-8 L/min
Poor ventricular filling such as may be found in hypovolemia can cause a decrease in cardiac output. It may be due
to poor emptying and as a result of decrease myocardial contractility. This is usually found with a myocardial
infarction, cardiac ischemia, arrhythmias, or papillary muscle dysfunction. It can also be found with vasodilatation
as a result of vasopressors or sepsis.
An increase in cardiac output may occur whenever there is an increase in oxygen demand, psychological
stimulation, and a response to a systemic inflammation, hepatic disease, viral toxic doses, or neurogenic mediated
vasodilation.
Tissue oxygenation may be maintained provided that cardiac parameters are adequate. If these parameters are
abnormal, the nurse must suspect a threat to tissue oxygenation and consider interventions aimed at improving
cardiac function. The numbers must be closely watched. Usually by the time the patient loses pulses, has a changing
level of consciousness, or has a decrease in urinary output the situation may be irreversible. Therefore invasive
cardiac monitoring through the use of pulmonary arterial catheter is essential. It is one of the most accurate tools for
the early assessment of critical patients.
Before cardiac parameters can be obtained the cardiac monitor at the bedside must be programmed. These
requirements may vary depending on the type of monitor available. Generally, the nurse must first program the
monitor with the type of pulmonary artery catheter in use, the volume of injectate, the temperature of injectate, as
well as a computation constant. Each of these requirements may vary slightly from manufacturer to manufacture.
Keep in mind that those patients suffering from abnormal cardiac valves (tricuspid) are unstable cardiac rhythms
may present inaccurate readings.
Restoring the patients normal cardiac output is the goal of treatment. The initial short-term goal should be aimed at
regulating stroke volume. There are three factors that regulate stroke volume, preload, afterload, and contractility.
The nurse must keep in mind that cardiac output changes are a symptom of a problem and not the actual problem
itself. The underlying causes of decreased CO must always be identified and treated before cardiac output can return
to normal.
Cardiac Index (CI)
The cardiac index is an adjustment of the cardiac output based on the size of the persons body. It is the most and
individualized cardiac parameter that the nurse can use. It is based on body surface area (BSA). The formula for
calculating cardiac index is CI= CO/BSA. The normal value for this parameter is 2.5 to 4L/min/m2
Heart Rate (BPM, HR)
One of the most often overlooked hemodynamic parameters is the heart rate. Critical care patients should be
continuously monitored for arrhythmias.
Cardiac dysrhythmias such as bradycardia or tachycardia will affect cardiac output and may make it difficult for the
nurse to obtain accurate hemodynamic readings. Additionally, they are potentially life threatening. Persistent
tachycardia may increase myocardial oxygen consumption. Normally the heart rate should the 60 to 100 beats per
minute. Any rate greater than 120 beats per minute results in decreased cardiac output as a result of the decreased
ventricular filling time. Dysrhythmias result in a decrease cardiac output due to a loss of synchronization of atrial
and ventricular filling and injection. Bradycardia, that is a heart rate less than 60 beats per minute, are caused by
vagel stimulation such as a valsalva maneuver or straining, heart blocks or conduction defects, and maybe caused by
drugs. Hypoxia, fear, anxiety, hypovolemia, catecholamines or pain may cause tachycardia, rates greater than 100
beats per minute.
Stroke Volume (SV)
The volume of blood injected with each heartbeat is stroke volume. Whenever there is a condition with results in
cardiac dysfunction stroke volume will eventually declined. This reduction in stroke volume might not be apparent
initially. Therefore, it should be used in conjunction with additional hemodynamic parameters. Normally the stroke
volume is 60 to 130 ml/beat ml. This parameter can be calculated by: SV=CO/HR
Any parameter that affects stroke volume will also affect cardiac output. These include preload, after load, and
contractility.
Stroke Index (SI)
Stroke index (SI) like cardiac index (CI) is a more useful measure for determining hemodynamics that is based on
the patient size. It can be calculated: SI=SV/BSA
Ejection Fraction (EF)
The ejection fraction is a measurement of how well the left ventricle, or the heart's main pumping chamber, works.
It is expressed as a percentage of blood that leaves the heart with each beat. Normally the left ventricle ejects 55 to
70 percent of the blood during each heartbeat. Generally, the lower the Ejection Fraction the more severe the
symptoms
When heart muscle is destroyed by a heart attack, persistent hypertension, or viral infections can lower the Ejection
Fraction and cause an enlarged heart. When the EF is to low Congestive Heart Failure may occur. This results in
symptoms of heart failure that may include swollen ankles, fatigue, weakness, and shortness of breath.
Contractility
Contractility is the ability of the cardiac muscle to contract. According to Starlings Law, fluid volume expansion
causes an increase in myocardial end diastolic fiber length. The greater the stretch of the muscle fibers, the greater
the force of contraction and volume of blood ejected. This increases the force of the ventricular contraction. There is
a direct relationship betweencontractility and cardiac output.
This is defined, as how much blood is pumped with each contraction in relation to how much blood is available to
be pumped. The ejection fraction (EF) can change before the stroke volume in certain conditions, such as left
ventricular failure and sepsis. The nurse must remember that contractility is not directly measured by hemodynamic
monitoring, it is estimated by the stroke volume index (SVI) from cardiac calculations, and the ejection
fraction which can be estimated via echocardiogram.
Fluids may be pushed until adequate central venous pressure (CVP) and pulmonary artery wage pressures (PAWP
or Wedge) pressures are reached. This is assuming the patient is suffering from uncomplicated hypovolemia. This
increase of fluids will return the patient to normal volemic state. However, if the central venous pressure and wedge
pressure rises with fluid challenge and the patient remains hypotensive, the possibility of heart failure must be
considered.
Central Venous Pressure
The central venous pressure is a measurement of the pressure in the right atrium. This reflects the right ventricular
diastolic pressure, or the ability of the right side of the heart to pump blood. This is a valuable tool for assessing the
relationship between cardiac action, vascularity, and blood volume. However, keep in mind that the central venous
pressure is not accurate for the measurement of left ventricular function and maybe the last parameter to change.
Still, for those patients in whom fluids are a concern, it is a valuable diagnostic tool. On the basis of central venous
pressure readings, decisions for the replacement are restrictions of fluids can be prescribed more accurately. The
normal reading for central venous pressure is to 2-6 mm Hg.
One of the most frequent causes of a decrease in central venous pressure is hypovolemia, which results in an
increased venous return. Most of the time with this condition, the stroke volume will also be low. You may also see
this with neurogenic and anaphylactic shock
An increase in central venous pressure may result from over hydration causing increased venous return or right-
sided heart failure. If the stroke volume is high, with an increase central venous pressure, right ventricular
dysfunction is assumed. Cardiac tampanade, constrictive pericarditis, pulmonary hypertension, tricuspid stenosis and
regurgitation may also cause increases in central venous pressure.
Right Ventricular Pressure (RV)
The right ventricular pressure (RV) can only be measured if a pulmonary artery catheter (Swan-Gantz) has been
inserted into the right atrium and the tip of the catheter is advanced and allowed to travel through the tricuspid valve
with blood into the right ventricle. The normal pressures within the right ventricle should be between 20 to 30 mm
Hg systolic and less than five mm Hg diastolic.
Pulmonary Artery Pressure (PAP)
The catheter is allowed to move into the pulmonary artery. Remember that the pulmonary artery is always venous
blood because it is leaving the right ventricle on its way to the lungs to receive oxygen. The waveform is distinctive
the dicrotic notch should be present due to the pulmonary valve closure and left-sided heart function. Normally the
pressure is 20-30 mm Hg systolic and 8 to 12 mm Hg diastolic.
The systolic pulmonary pressure may be increased from such things as a pulmonary embolus, pneumothorax,
hypoxia, or acute respiratory distress syndrome. The diastolic pressure of the right ventricle may be increased by
constrictive pericarditis or cardiac tampanade. A decrease in pulmonary artery pressure is also caused by
hypovolemia and distributed shock.
Pulmonary Artery Wedge Pressure (PAWP, PACWP, Wedge)
The pulmonary artery catheter is inflated. As the pulmonary artery catheter makes its way into small capillary
vessels and becomes wedged. The pulmonary artery wage pressures (PAWP) may be measured. Generally, this
measurement is more important than the central venous pressure. If there is left ventricular dysfunctions, such as
with a myocardial infarct or cardiomyopathy, a threat to tissue oxygenation and low cardiac output may exist. Left
ventricular function may be assessed by using the pulmonary catheter wedge pressure, which would provide an
indirect measurement of preload. With a normal stroke volume the wedge pressure should be for 4-12 mm Hg.
Nursing Considerations in Hemodynamic Monitoring
To ensure accuracy of the hemodynamic values obtained from any transducer system, the nurse must level and zero
the system as follows:
Leveling is performed to eliminate the effects of hydrostatic pressure on the transducer. It should be done before and
after connecting the pressure system to the patient, with every change in bed height or changes in the elevation of
the head of the bed, with any significant change in patients hemodynamic variables, and prior to zeroing and
calibration.
Zeroing is performed to eliminate the effects of atmospheric pressure on the transducer. Zeroing should be
performed before and after connecting the pressure system to the patient, with any leveling, and whenever there is a
significant change in the hemodynamic variables.
All values should be rated at the end of expiration. The transducer should be leveled visibly with static axis. The
transducer should be leveled, is a road, and calibrated every eight hours depending on institutional policy. Readings
can be taken with ahead a bed elevated, as long as a transducer is leveled to the plane to static axis. Readings cannot
be taken with a patient and a lateral position.
Precautions
The same electrical equipment that is invaluable in critical care monitoring and resuscitation also may be a potential
risk to the patient; the most hazardous of which is ventricular fibrillation. Respect of electrical safety monitoring
guidelines is crucial. A defibrillator, emergency crash cart and medications must be readily available.
Complications
Patients who have a pulmonary artery catheter are subject to the same complications of other patients who have
central venous liens. Among these are increased risk for infection, thrombosis, and emboli.
One complication that must to be avoided is a constant wedging of the pulmonary artery catheter. This occurs when
the balloon is left inadvertently inflated. The catheter will migrate down straining to a smaller pulmonary vessel is
can result in pulmonary artery ischemia and lung ischemia. It can also be a cause of pulmonary infarction, and
pulmonary artery perforation. If this occurs it is considered an emergency. The nurse must rapidly capable import
and a flight to blame if necessary. The patient should be repositioned usually from the side to the back. The patient
should cost. The pulmonary artery catheter should be rapidly flashed. And the catheter may be pulled back slightly.
Keep in mind that this is a complication that is preventable by being careful with the position of the syringe.
Ventricular irritation from the catheter is another hazard the nurse must be aware of. This occurs when the catheter
floats back into the right ventricle or is looped through the ventricle. The hazard to the patient with this condition is
ventricular dysrhythmias. If this happens the nurse must check waveform pressures. If the catheter tip is in the right
ventricle the waveform will be taller with a diastolic of 0-5. Notify the physician if the catheter needs to be floated
back into the pulmonary artery. Rarely the catheter will require pulling back slightly.
Air embolism may occur when the bowling ruptures. This can result in pulmonary embolism. When inflating the
balloon the nurse must feel for resistance and watch for a dampened waveform. No resistances, along with no wedge
are the indications of a ruptured balloon. The nurse should remove the syringe, close the port, and label the port that
the balloon is ruptured.
A dampen waveform may be caused by kinks, bubbles, within the IV system, clots may be present, or the catheter
may be against the vessel wall. The Nurse must check for air bubbles or air in the system. The cable and catheter
should be checked for kinks. The pressure bag must be inflated to 300 mm Hg. Check for the ability to aspirate the
line and flush line. The patient may cough, be repositioned, or the catheter may have to be repositioned.
At times the pulmonary artery line cannot be flushed. Again the nurse must check for kinks, adequate fluid and
pressure within the flesh bag, and check to stopcocks for correct position.
If there is no waveforms the connections of the tubing, cables, and stopcocks should be checked. Check for blood or
air within the system.
If the nurse keeps getting a low reading or a false high reading, the transducer should be leveled, zeroed, and
calibrated. The connections should be checked. And in the air or blood within the system should be removed.
When the balloon will not wedge, the artery is too large for the inflated balloon to inflate. The pulmonary artery
catheter might have migrated back into the ventricle. This would require repositioning by the physician. The balloon
may have ruptured.
Hemodynamic Parameters
Hemodynamic Parameters Abbreviations
Normal
Values
Mean Arterial Pressure MAP 70-90 mm Hg
Right Atrial Pressure RAP 2-6 mm Hg
Central Venous Pressure CVP 2-8 mm Hg
Pulmonary Artery Systolic Pressure PAS 20-30 mm Hg
Pulmonary Artery Diastolic Pressure PAD 6-12 mm Hg
Pulmonary Artery Mean Pressure PAM 10-15 mm Hg
Pulmonary Artery Wedge Pressure PAWP, Wedge 8-12 mm Hg
Cardiac Output CO 4-8 L/min
Cardiac Index CI 2.5-4 L/min
Stroke Volume SV 60-130 ml
Stroke Volume Index SVI 40-50 ml/m2
Systemic Vascular Resistance SVR
800-1200
dynes
Systemic Vascular Resistance Index SVRI
2000-2400
dynes
Pulmonary Vascular Resistance PVR 150-300 dynes








References:
Brunner, Charlotte, Little Rock Critical Care Course, Hemodynamic Monitoring, Lecture Notes, 1998.


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Clinical Effectiveness of a Critical Care Nursing
Outreach Service in Facilitating Discharge From the
Intensive Care Unit
1. Teresa Ann Williams, RN, PhD, M Hlth Sci, Grad Dip Clin Epi, ICU Cert,
2. Gavin Leslie, RN, PhD, ICU Cert, BAppSc(Nsg),
3. Judith Finn, PhD, MEdStud, GradDipPH, BSc, DipAPPSc(Nsg), ICU Cert, RN, RM,
4. Linda Brearley, RN, BEc, ICU Cert,
5. Mariyam Asthifa, RN,
6. Ben Hay, RN,
7. Karen Laurie, RN, ICU Cert,
8. Tim Leen, RN,
9. Keith OBrien, RN,
10. Michael Stuart, RN, BHlthSc(Nsg), ICU Cert and
11. Michelle Watt, RN, BSci(Nsg), Grad Cert ICU
+ Author Affiliations
1. Teresa Ann Williams is a nurse researcher in the critical care division at Royal Perth Hospital
and a research fellow at Curtin University in Perth, Western Australia. Gavin Leslie is the
director of research and development and a professor of critical care nursing in the School of
Nursing and Midwifery at Curtin Health Innovation Research Institute, Curtin University and
Royal Perth Hospital in Perth, Western Australia. Judith Finn is chair of nursing research in the
School of Population Health at The University of Western Australia and the Centre for Nursing
Research, Innovation and Quality, Sir Charles Gairdner Hospital, Nedlands, Western Australia.
Linda Brearley is nursing director in the critical care division of Royal Perth Hospital in Perth,
Western Australia. Mariyam Asthifa is a research associate at Sir Charles Gairdner Hospital in
Nedlands, Western Australia. Ben Hay is a clinical nurse in the intensive care unit at Sir Charles
Gairdner Hospital, Nedlands, Western Australia. Karen Laurie is a clinical nurse specialist in
the intensive care unit at Sir Charles Gairdner Hospital, Nedlands, Western Australia. Tim Leen
is a clinical nurse specialist in the intensive care unit at Royal Perth Hospital, Perth, Western
Australia. Keith OBrien is a clinical nurse specialist in the intensive care unit at Royal Perth
Hospital, Perth, Western Australia. Michael Stuart is a clinical nurse at Fremantle Hospital,
Fremantle, Western Australia. Michelle Watt is a clinical nurse manager in the intensive care
unit at Fremantle Hospital, Fremantle, Western Australia
1. Corresponding author: Teresa Williams, RN, PhD, Critical Care Division, Royal Perth Hospital,
Wellington Street, Perth, Western Australia 6000 (e-mail: Teresa.Williams@health.wa.gov.au).

Next Section
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.
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

Australia has 167 hospitals with intensive care units (ICUs).
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 patients 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] 0.260.87) 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, 1.001.18),
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, 0.730.96), in
after-hours ICU admissions (95% CI, 0.840.97), and in mean physiology score
9
(95% CI, 0.312.12) but
neither ICU mortality (95% CI, 0.871.08) nor in-hospital mortality changed significantly.
10

The ICU outreach role is to avert readmission to the ICU (and in-hospital death) after ICU discharge.
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 projects 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
1215
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.
Previous SectionNext Section
Materials and Methods
Objectives
The goal of this study was to evaluate the effect of a critical care nursing outreach service on the outcomes of
patients discharged from the ICU, specifically, LOS in hospital from the time of admission to ICU, hospital
mortality, and readmissions to ICU.
Design
A before-and-after study design was used, along with historical controls and a prospective intervention. Six
months of retrospective data were collected before 6 months of prospective data collection after
implementation of the outreach service. Patients who were discharged from the ICU between June 2 and
November 30, 2007, comprised the preintervention cohort, and patients discharged between June 2 and
November 30, 2008, were recruited for the postintervention cohort.
Participants and Setting
Patients discharged from the ICU in 1 of the 3 adult tertiary-referral hospitals in Perth (Royal Perth Hospital, Sir
Charles Gairdner Hospital, and Fremantle Hospital) were recruited. The level III ICUs
17
operate as closed ICUs,
which is customary in Australia and New Zealand. Patients who died in the ICU or were discharged directly
from the ICU to home or to another hospital or institution were excluded.
Ethical Considerations
The need to obtain formal consent from the patient was waived after a review by the institutional ethics
committee in accordance with the Australian National Health and Medical Research Council guidelines.
18
All
patients in the prospective data collection were subject to the intervention. The change in practice at the study
hospitals is considered best practice in several ICUs in Australia and the United Kingdom. Approval to conduct
the study was obtained from the department heads. The confidentiality of participants has been maintained;
data are reported in ways that ensure that individuals are not identifiable. The information collected is kept in a
secure environment, and electronic data are stored on a password-protected computer. Any publication arising
from the study does not identify individual participants.
Critical Care Nursing Outreach Service
The service involved assessments before discharge from the ICU and follow-up visits by critical care nurse
specialists, who reviewed and assessed patients before and after discharge from the ICU to the general care
areas. The nurse specialists provided coverage 7 days a week during business hours (8 AM to 5 PM). In
addition, they provided education and clinical support to the staff in the general care areas. A protocol for the
processes to be undertaken at the bedsideand the actions to be taken in responsewas developed in
consultation with a multidisciplinary team informed by guidelines already developed in the United Kingdom.
19

Minimal modification was required at each hospital, to accommodate the differing structures and processes for
patient care at the individual hospitals.
Implementation of the Service
Development of the job description and selection criteria enabled the recruitment of 2 outreach nurses at each
site. The outreach nurses were provided with a 2-week orientation period to enable them to familiarize
themselves with their role. Hospital staff were informed about the study through newsletters, personal
communication, and education sessions. The promotion of the outreach service continued throughout the
implementation phase.
Outcomes
The primary outcome was LOS in the hospital from the time of admission to the ICU to hospital discharge for
patients first admission to the ICU during the study. Secondary outcomes were (1) the number of ICU
readmissions during the same hospital admission, (2) survival to hospital discharge, (3) day of week
discharged from the ICU, (4) time of day discharged from the ICU, (5) activities of the outreach nurse, and (6)
delay to discharge from the ICU.
Data Sources
Data for the primary outcome were abstracted from the Western Australian Health Departments administrative
computer system (The Open Patient Administration System), in which all patient admissions, transfers, and
discharges are recorded.
Statistical Analysis
Time zero for the calculation of the primary outcome was taken as the date and time that the patient was
admitted to the ICU for the first time. Each of the study outcomes was first analyzed by using univariate
statistics to compare the outcomes before and after the intervention. (Percentages may not total 100% because
of rounding.) Severity of illness was assessed by using the worst score on the Acute Physiology and Chronic
Health Evaluation (APACHE) II during the first 24 hours.
20
Length of stay was calculated from the time of
admission to the ICU to the time of discharge from the hospital. Readmissions during the same hospital stay
were defined as early, those within 48 hours
10
and therefore most likely to be attributable to ICU-related care, or
late, those occurring more than 48 hours after discharge from the ICU and more likely to be associated with an
issue in the general care area. Time of day discharged from ICU was categorized as daytime (7 AM to 5:59
PM), evening (6 PM to 9:59 PM), and nighttime (10 PM to 6:59 AM). Patients discharge from the ICU was
defined as delayed when patients who were deemed suitable for discharge from the ICU were not discharged
for more than 8 hours.
11
For cases in which multiple reasons were given for the delay, medical condition took
precedence, followed by lack of availability of a bed in the general care area.
Outreach teams support the ward staff by following up patients recently discharged from the ICU.
Categorical variables were reported as frequencies and compared by using a
2
test. Continuous data were
reported as medians and interquartile ranges (IQRs) and compared by using the Student t test for normally
distributed data and nonparametric tests for data that were not normally distributed. Multiple linear regression
was used to examine the independent effect of the intervention on the primary outcome, adjusted for age and
sex. The outcome measure, inhospital LOS from the time of ICU admission, was log-transformed because
these data were not normally distributed. Data were analysed by using SPSS, version 17.0 (SPSS Inc,
Chicago, Illinois). Where data were missing, the number of available observations is reported and no
assumptions are made about the missing data. Two-sided comparisons with 95% CIs were used, and P values
less than .05 were considered statistically significant.
Sample Size
According to the 2002 data for all patients discharged alive from the ICU at Royal Perth Hospital (n = 1345), the
mean LOS in the hospital after discharge from the ICU was 13.2 days (SD, 28.0 days). Therefore, for a 20%
reduction in post-ICU LOS in hospital (ie, to reduce the mean LOS from 13.2 to 10.5 days), for a power of 0.90,
and an alpha of 0.05, a minimum of 1320 patients was required. According to 2007 data obtained from each of
the 3 study hospitals, approximately 60 patients are discharged (alive) from the ICU each week, with the
weekends having the lowest proportion of discharges. Thus, based on an estimate of 60 patients per week for
26 weeks, a total of 1560 post-ICU patients were expected during the 6-month intervention period. If one
estimates that 10% of patients will not be suitable to enter the study (eg, died in the ICU or were discharged to
another facility or directly home from the ICU), the number of patients discharged from the 3 ICUs would be
sufficient to meet the required sample size of 1320 patients.
Neither ICU nor hospital length of stay differed from before to after use of critical care outreach.
Previous SectionNext Section
Results
Of the total of 3001 patients discharged from the 3 ICUs during the study period, 1566 patients were in the
2007 before intervention cohort and 1435 patients were in the 2008 after intervention cohort. The
characteristics of both cohorts are compared in Table 1. The cohorts from before and after the intervention
were not significantly different. The mean age was 55 (SD, 19) years in the before group compared with 54
(SD, 19) years in the after group (t = 1.96, P = .05). The proportion of men was 65%, the same for both
cohorts. From available data for 2762 patients, the mean APACHE II score was 16.8 (SD, 7.4) in the before
group and 16.7 (SD, 7.2) in the after group (t = 0.37, P = .66).
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Table 1
Characteristics of cohorts before and after intervention
Primary Outcome
The LOS for the ICU patients in the before cohort (median, 1.9 days; IQR, 1.04.0 days) was not significantly
different (z = 0.57, P = .57) from that in the after cohort (median, 1.8 days; IQR, 0.94.8 days). The median
LOS in the hospital from admission to the ICU until hospital discharge was 9.8 (IQR, 6.019.5) days in the
before cohort and 10.1 (IQR, 5.920.6) days in the after cohort (z = 0.18, P = .86). After adjustment for patients
age and sex, the LOS after admission to the ICU did not differ significantly between the cohorts (95% CI,
0.096 to 0.041, P =.42).
Secondary Outcomes
Secondary outcomes were (1) number of ICU readmissions during the same hospital admission, (2) survival to
hospital discharge, (3) day of week discharged from the ICU, (4) time of day discharged from the ICU, (5)
activities of the outreach nurse, and (6) delay to discharge from the ICU.
Before the outreach service was implemented, 5.4% of patients were readmitted to the ICU during the same
hospital admission, with 40% of the first readmissions within 48 hours of discharge from the ICU. After
implementation of the outreach service, 5.6% of patients were readmitted to the ICU during the same hospital
admission, with 33% of the first readmissions within 48 hours of discharge from the ICU. Readmission rates did
not differ significantly between cohorts (1
2
= 0.04, P = .83). Although the proportion of later admissions was
lower after the introduction of the critical care outreach service, this difference was not statistically significant
(1
2
= 0.94, P = .33). Hospital mortality was similar between cohorts: 5.5% before the outreach service was
implemented compared with 5.4% after the service was implemented (2
2
= 0.03, P = .86).
The day of discharge did vary between the 2 cohorts (6
2
= 18.8, P = .005), as shown in Figure 1. Most patients
were ready for discharge on weekdays and least often on Sundays in both cohorts, but discharges on Sundays
decreased almost by half after the outreach service was implemented compared with before.

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Figure 1
Comparison of day of discharge before and after implementation of a critical care nursing outreach service.
The time of discharge did not differ significantly from before to after the introduction of the critical care outreach
service (2
2
= 3.0, P = .22). The most common time for discharge was in the daytime (77% before and 78% after
implementation of the outreach service). Further comparison showed that evening discharges were more
frequent after than before the intervention; nighttime discharges were more frequent after (10%) than before
(8%) the intervention (Figure 2).

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Figure 2
Comparison of time of discharge between before and after implementation of a critical care nursing outreach
service.
Outreach Service
After the outreach service was implemented, 1435 patients were discharged from the ICU. The following results
relate only to this postintervention cohort. Of these 1435 patients, the critical care outreach nurses visited 1198
patients before their discharge from the ICU (83% of patients admitted to the ICU during the study period).
Some patients had more than 1 visit from the outreach nurses before their discharge, giving a total of 1459
visits.
Predischarge Visits
Fourteen percent of the patients who received a predischarge visit required 2 or more visits (range, 17 visits).
The time taken for visits conducted before the patients discharge from the ICU ranged from 2 to 260 (median,
15; IQR, 1530) minutes. Issues most often encountered were respiratory (70% of visits), related to catheters
(52% of visits), gastrointestinal (52% of visits), renal (48% of visits), and cardiovascular (45% of visits). Up to
14 types of referrals, 1115 in total, were made for 456 patients at these predischarge visits. The 5 most
common referrals were to the ICU team (52%), a physiotherapist (23%), a dietitian (19%), a specialty team,
(19%) and a speech pathologist (16%).
Care Needs on Discharge From the ICU
From a total of 1435 patients discharged from the ICU after implementation of the outreach service, just more
than half (56%) had no requirements for special accommodation on discharge from the ICU. For the others,
accommodation needs included 1:1 nursing care (29 discharges, 2%), isolation/single rooms (70 discharges,
5%), 1:1 nursing care and isolation (5 discharges, 0.3%), high-dependency unit (335 discharges, 23%),
coronary care unit (28 discharges, 2%), and other requirements related to nursing staffing (135 discharges,
9.4%). Thirteen discharged patients (1%) required other care requirements (eg, patient care assistant to guard
patient, burns room, larger 2-bed room for bariatric patient). Three percent of patients had some order
restricting resuscitation (do not resuscitate in 23 patients [2%], no cardiopulmonary resuscitation/MET
activation/escalation of treatment in 16 patients [1%]) before discharge from the ICU. Most discharged patients
had vascular catheters (93%): 66% of discharged patients had central catheters, and 83% required some form
of respiratory therapy, including tracheostomy in 9%. Urinary catheters (84%) also were common, 43% of
patients had concerns associated with intravenous fluids, and 81% had issues related to fluid balance that
required monitoring in the general care area. Thirty-three percent of patients had cardiovascular intervention:
cardiac monitoring, drains, pacing, and/or vasoactive infusions. Confusion or delirium was present in 11% of
patients.
Postdischarge Review
Most patients (89%) from the cohort after the outreach service was implemented were reviewed while in the
general care area after their discharge from the ICU. Of the 3721 reviews conducted among 1285 patients
discharged from the ICU, 93% were considered routine. The number of reviews performed by the critical
outreach team ranged from 1 to 49 visits (median, 1; IQR, 13). The mean time spent for each review was 18
(SD, 16.9) minutes but ranged from 4 to 450 minutes. At the Royal Perth Hospital, most patients were
discharged to postsurgical care areas, but most reviews were conducted in medical care areas. The reviews by
the critical care outreach nurses were conducted primarily for reasons related to the patient (95%) but
education (n = 251), clinical issues (n=218), advice (n=121), equipment (n=119), staff in the general care area
(n = 94), adverse events (n = 90), and relatives (n = 32) were also the primary or secondary reason(s) for
conducting the review.
Interventions (categorized as manipulation of existing therapy, recommending a practice change, education, or
referral) were related to respiratory (18%), gastrointestinal (13%), catheter (7%), renal (6%),
psychiatric/psychological (6%), electrolyte (5.5%), cardiac (5%), neurological (3%), pain management (4%),
wound care (3.5%), activities of daily living (3%), hematological, metabolic (3%), micro-biological (2%), and
musculoskeletal (2%) issues.
Patients (n = 173) were referred to specialist services on 1026 occasions. For patients who had a referral, the
median number of referrals was 2 (IQR, 13) but as many as 38 referrals per patient were made. Most referrals
were to the patients specialty team (Table 2).
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Table 2
Number of referrals made at the review after discharge from the intensive care unit (3721 visits)
Delays in Discharge
Of 1261 discharged patients for whom data on when they were deemed suitable for discharge were available,
36% of patients had their discharge from the ICU delayed by more than 8 hours. Among these patients, no bed
being available or a delay in a bed becoming available were the most common reasons for the delay,
accounting for 45% of discharge delays. Medical concerns accounted for 21% of delays in discharge; no
reason was given for 27% of delays. Other reasons were staff shortages (4%), skill mix issues (2%), and lack
of suitable accommodation (1%). The distribution pattern of the day the patient was deemed suitable for
discharge from the ICU differed significantly (6
2
= 39.3, P < .001) between patients whose discharge was
delayed and patients whose discharge was not delayed. Delayed discharges occurred most often on Mondays
and Sundays. Patients whose discharge was delayed were more likely to be discharged after hours than were
patients whose discharge was not delayed (2
2
= 89.7, P < .001).
Previous SectionNext Section
Discussion
In this large, multicenter study, duration of stay in the hospital from the time of admission to the ICU, in-hospital
mortality, and readmission to the ICU during the same hospital admission did not change significantly after the
introduction of a critical care nursing outreach service. Although more than 3000 patients were recruited for our
study (1566 before and 1435 after the introduction of the critical care nursing outreach service), it is possible
that a larger sample is needed to show a significant difference in LOS. It is not surprising that mortality and
readmission rate did not change significantly after the outreach service was implemented. Both mortality and
readmission rates for the study hospitals ICU are already low by Australian
21
standards, and a larger sample is
more likely to be necessary for a significant difference to be detected for this low-frequency outcome.
Reports describing outcomes from a critical care outreach service have conflicting results.
15,16,2224
The
randomized controlled trial conducted by Ball and colleagues
7
in the United Kingdom found improved outcomes
after an outreach service was introduced. The LOS and readmissions before the intervention, however, were
higher than those reported in Australian centers, and this difference may explain why the study by Ball et al
showed a positive result. Also, the services operate in different health care environments, and there are
differences in service delivery. In the United Kingdom, outreach care was developed to improve the care of
acutely ill patients in general care areas of hospitals and not specifically to focus on patients who have been
discharged from the ICU.
2527
Outreach care in the United Kingdom consists of a range of services from a fully
comprehensive 24-hour-a-day/7-day-a-week emergency response service and a follow-up service for after
critical care (a combination of the MET service and the follow-up service) to a limited education and support
service focused on improving the recognition of deteriorating condition and the improved delivery of care to
acutely ill patients in general care areas.
In the Australian context, several reports have described the beneficial effects of the use of an ICU nurse
liaison, although beneficial outcomes such as reducing hospital LOS and readmissions to ICU have not been
clearly demonstrated.
15,22,24
Our results are similar to those reported by Eliott and colleagues,
16
who found no
difference in hospital LOS, readmissions, or mortality after implementation of an ICU liaison nurse service at a
metropolitan university teaching hospital in Victoria, Australia. Differences in health care contexts, the services
provided (eg, having a MET system), the focus of the intervention (on all acute care patients in the general care
area vs patients discharged from the ICU), and the outcomes reported are all likely reasons for these
discrepancies. In a recent integrative review, Endacott and colleagues
28
noted that a range of research
methods have been used to evaluate critical care nursing outreach services, but it was not possible to conclude
unequivocally that such outreach services improve outcomes. This conclusion was supported by the results of
an earlier systematic review performed by Esmonde and colleagues.
29

The benefit of the critical care outreach service in facilitating the discharge process was difficult to gauge. We
believe that the discharge process was facilitated by the critical care nursing outreach service, as demonstrated
by the large number of referrals before patients were discharged from the ICU. Qualitative data from focus
groups conducted before and after the intervention (unpublished data) also showed positive comments about
the service. For example, patients were less afraid of the transition process, and staff found the support and
education beneficial. Chaboyer and colleagues
22
did not find that use of a nurse liaison was associated with a
reduction in pretransfer anxiety among patients discharged from the ICU to the general care area. It is likely
that the method of assessing the benefits of use of a critical care nursing outreach team should be reevaluated
to better measure the actual effect of such a team on the discharge process.
Almost a third of patients had their discharge from the ICU delayed by more than 8 hours, equivalent to 1 or
more traditional nursing shifts. Although no information was available on delays in discharge from the ICU
before implementation of the outreach service to compare with delays after implementation, a higher proportion
of patients may have had their discharge delayed after implementation because of issues identified by the
critical care outreach team. This premise is supported by the large number of delays for medical reasons. In
contrast, Chaboyer and colleagues
12
reported a reduction in discharge delays from the ICU after introduction of
a nurse liaison service, although their definition of discharge delay differed from ours and they had a
comparison group.
A range of research methods have been used to evaluate the outreach role, making conclusions difficult.
Our study confirmed the complexity of the care that patients require when discharged from the ICU. Many
patients were discharged with central catheters, oxygen therapy, and urinary catheters, and a large number of
interventions were delivered by the outreach nurses. Although the reviews were conducted primarily for
reasons related to patients, the outreach nurses provided education and advice, assisted with equipment
issues, and supported staff and relatives. Referrals were made primarily to medical teams (specialty, ICU), but
support from physical therapists and dieticians also were important.
The benefit of ICU outreach in facilitating the discharge process was difficult to gauge.
Because this was a multicenter study, differences in management practices from hospital to hospital may have
affected the outcomes of the outreach service in the different hospitals. The 2 larger tertiary-care hospitals
have clinical nurse specialist support available both during office hours (7 AM to 5 PM) in the general care
areas and after hours (after 5 PM) throughout the hospital, but the third hospital did not. More benefits may
have been observed at the third hospital, but the sample size may have been too small for a significant
difference to be detected. The short follow-up time of 6 months may have been insufficient to determine the
true effect of the intervention. Certainly a criticism of the MERIT study
6
was that a complex intervention such as
the introduction of a MET or, as in this article, a critical care follow-up service, may require considerably longer
than 6 months to have a significant effect. Eliott and colleagues
16
conducted a before-and-after study for 36
months and did not find a difference in outcomes. Funding constraints prevented a longer duration of follow-up
for our study.
Previous SectionNext Section
Conclusion
Although several studies have shown beneficial outcomes for a critical care nurse lead outreach service in
Australia and the United Kingdom, we found no improvement in LOS after admission to ICU, readmission rate,
or hospital mortality after introduction of such a service. However, it may well be that the true benefits of the
service (eg, improvement of the transition from the ICU to the general care area for both the staff in the general
care area and patients, and the provision of educational support for junior staff in the general care area) are not
reflected by the more quantitative outcomes measured in this study.
Previous SectionNext Section
Footnotes
FINANCIAL DISCLOSURES
Funding was provided by the Western Australian Department of Health Innovation Fund 2008.
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_for_the_introduction_of_outreach_2003. Accessed June 29, 2010.
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Print ISSN: 1062-3264
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American Journal of Critical Care
Clinical Effectiveness of a Critical Care
Nursing Outreach Service in Facilitating
Discharge from the Intensive Care Unit
Teresa Ann Williams, RN, PhD, M Hlth Sci, Grad Dip Clin Epi, ICU Cert, Gavin Leslie, RN, PhD, ICU Cert, BAppSc(Nsg),
Judith Finn, PhD, MEdStud, GradDipPH, BSc, DipAPPSc(Nsg), ICU Cert, RN, RM, Linda Brearley, RN, BEc, ICU Cer, ,
Mariyam Asthifa, RN, Ben Hay, RN, Karen Laurie, RN, ICU Cert, Tim Leen, RN, Keith O'Brien, RN, Michael Stuart, RN,
BHlthSc(Nsg), ICU Cert, Michelle Watt, RN, BSci(Nsg), Grad Cert ICU
Disclosures
American Journal of Critical Care. 2010;19(5):e63-72.

Comment
Print
Abstract and Introduction
Materials and Methods
Critical Care Nursing Outreach Service
Results
Discussion
References
Sidebar
Related Links
Factors Influencing Physical Functional Status in Intensive Care Unit Survivors Two Years After Discharge
Mitigating Risks for Multiple IV Infusions: HumanEra Project
Futile Treatment Delays Care for Others Waiting for ICU Beds
Critical Care Nursing Outreach Service
The service involved assessments before discharge from the ICU and follow-up
visits by critical care nurse specialists, who reviewed and assessed patients before
and after discharge from the ICU to the general care areas. The nurse specialists
provided coverage 7 days a week during business hours (8 AM to 5 PM). In
addition, they provided education and clinical support to the staff in the general
care areas. A protocol for the processes to be undertaken at the bedsideand the
actions to be taken in responsewas developed in consultation with a
multidisciplinary team informed by guidelines already developed in the United
Kingdom.
[19]
Minimal modification was required at each hospital, to accommodate
the differing structures and processes for patient care at the individual hospitals.
Implementation of the Service
Development of the job description and selection criteria enabled the recruitment
of 2 outreach nurses at each site. The outreach nurses were provided with a 2-week
orientation period to enable them to familiarize themselves with their role. Hospital
staff were informed about the study through newsletters, personal communication,
and education sessions. The promotion of the outreach service continued
throughout the implementation phase.
Outcomes
The primary outcome was LOS in the hospital from the time of admission to the
ICU to hospital discharge for patients' first admission to the ICU during the study.
Secondary outcomes were (1) the number of ICU readmissions during the same
hospital admission, (2) survival to hospital discharge, (3) day of week discharged
from the ICU, (4) time of day discharged from the ICU, (5) activities of the
outreach nurse, and (6) delay to discharge from the ICU.
Data Sources
Data for the primary outcome were abstracted from the Western Australian Health
Department's administrative computer system (The Open Patient Administration
System), in which all patient admissions, transfers, and discharges are recorded.
Statistical Analysis
Time zero for the calculation of the primary outcome was taken as the date and
time that the patient was admitted to the ICU for the first time. Each of the study
outcomes was first analyzed by using univariate statistics to compare the outcomes
before and after the intervention. (Percentages may not total 100% because of
rounding.) Severity of illness was assessed by using the worst score on the Acute
Physiology and Chronic Health Evaluation (APACHE) II during the first 24
hours.
[20]
Length of stay was calculated from the time of admission to the ICU to
the time of discharge from the hospital. Readmissions during the same hospital
stay were defined as early, those within 48 hours
[10]
and therefore most likely to be
attributable to ICU-related care, or late, those occurring more than 48 hours after
discharge from the ICU and more likely to be associated with an issue in the
general care area. Time of day discharged from ICU was categorized as daytime (7
AM to 5:59 PM), evening (6 PM to 9:59 PM), and nighttime (10 PM to 6:59 AM).
Patients' discharge from the ICU was defined as delayed when patients who were
deemed suitable for discharge from the ICU were not discharged for more than 8
hours.
[11]
For cases in which multiple reasons were given for the delay, medical
condition took precedence, followed by lack of availability of a bed in the general
care area.
Categorical variables were reported as frequencies and compared by using a
2
test.
Continuous data were reported as medians and interquartile ranges (IQRs) and
compared by using the Student t test for normally distributed data and
nonparametric tests for data that were not normally distributed. Multiple linear
regression was used to examine the independent effect of the intervention on the
primary outcome, adjusted for age and sex. The outcome measure, inhospital LOS
from the time of ICU admission, was log-transformed because these data were not
normally distributed. Data were analysed by using SPSS, version 17.0 (SPSS Inc,
Chicago, Illinois). Where data were missing, the number of available observations
is reported and no assumptions are made about the missing data. Two-sided
comparisons with 95% CIs were used, and P values less than .05 were considered
statistically significant.
Sample Size
According to the 2002 data for all patients discharged alive from the ICU at Royal
Perth Hospital (n = 1345), the mean LOS in the hospital after discharge from the
ICU was 13.2 days (SD, 28.0 days). Therefore, for a 20% reduction in post-ICU
LOS in hospital (ie, to reduce the mean LOS from 13.2 to 10.5 days), for a power
of 0.90, and an alpha of 0.05, a minimum of 1320 patients was required. According
to 2007 data obtained from each of the 3 study hospitals, approximately 60 patients
are discharged (alive) from the ICU each week, with the weekends having the
lowest proportion of discharges. Thus, based on an estimate of 60 patients per
week for 26 weeks, a total of 1560 post-ICU patients were expected during the 6-
month intervention period. If one estimates that 10% of patients will not be
suitable to enter the study (eg, died in the ICU or were discharged to another
facility or directly home from the ICU), the number of patients discharged from the
3 ICUs would be sufficient to meet the required sample size of 1320 patients.

American Journal of Critical Care
Clinical Effectiveness of a Critical Care Nursing
Outreach Service in Facilitating Discharge from the
Intensive Care Unit
Teresa Ann Williams, RN, PhD, M Hlth Sci, Grad Dip Clin Epi, ICU Cert, Gavin Leslie, RN, PhD, ICU Cert,
BAppSc(Nsg), Judith Finn, PhD, MEdStud, GradDipPH, BSc, DipAPPSc(Nsg), ICU Cert, RN, RM, Linda
Brearley, RN, BEc, ICU Cer, , Mariyam Asthifa, RN, Ben Hay, RN, Karen Laurie, RN, ICU Cert, Tim Leen, RN,
Keith O'Brien, RN, Michael Stuart, RN, BHlthSc(Nsg), ICU Cert, Michelle Watt, RN, BSci(Nsg), Grad Cert ICU
Disclosures
American Journal of Critical Care. 2010;19(5):e63-72.
Comment
Print
Abstract and Introduction
Materials and Methods
Critical Care Nursing Outreach Service
Results
Discussion
References
Sidebar
RELATED LINKS
Factors Influencing Physical Functional Status in Intensive Care Unit Survivors Two Years After
Discharge
Mitigating Risks for Multiple IV Infusions: HumanEra Project
Futile Treatment Delays Care for Others Waiting for ICU Beds
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] 0.260.87) 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, 1.001.18),
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, 0.730.96), in after-hours ICU admissions (95% CI, 0.84
0.97), and in mean physiology score
[9]
(95% CI, 0.312.12) 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
[1215]
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.
Materials and Methods
Objectives
The goal of this study was to evaluate the effect of a critical care nursing outreach
service on the outcomes of patients discharged from the ICU, specifically, LOS in
hospital from the time of admission to ICU, hospital mortality, and readmissions to
ICU.
Design
A before-and-after study design was used, along with historical controls and a
prospective intervention. Six months of retrospective data were collected before 6
months of prospective data collection after implementation of the outreach service.
Patients who were discharged from the ICU between June 2 and November 30,
2007, comprised the preintervention cohort, and patients discharged between June
2 and November 30, 2008, were recruited for the postintervention cohort.
Participants and Setting
Patients discharged from the ICU in 1 of the 3 adult tertiary-referral hospitals in
Perth (Royal Perth Hospital, Sir Charles Gairdner Hospital, and Fremantle Hospital)
were recruited. The level III ICUs
[17]
operate as closed ICUs, which is customary in
Australia and New Zealand. Patients who died in the ICU or were discharged directly
from the ICU to home or to another hospital or institution were excluded.
Ethical Considerations
The need to obtain formal consent from the patient was waived after a review by the
institutional ethics committee in accordance with the Australian National Health and
Medical Research Council guidelines.
[18]
All patients in the prospective data
collection were subject to the intervention. The change in practice at the study
hospitals is considered best practice in several ICUs in Australia and the United
Kingdom. Approval to conduct the study was obtained from the department heads.
The confidentiality of participants has been maintained; data are reported in ways
that ensure that individuals are not identifiable. The information collected is kept in a
secure environment, and electronic data are stored on a password-protected
computer. Any publication arising from the study does not identify individual
participants.
Critical Care Nursing Outreach Service
The service involved assessments before discharge from the ICU and follow-up visits by critical care
nurse specialists, who reviewed and assessed patients before and after discharge from the ICU to
the general care areas. The nurse specialists provided coverage 7 days a week during business
hours (8 AM to 5 PM). In addition, they provided education and clinical support to the staff in the
general care areas. A protocol for the processes to be undertaken at the bedsideand the actions
to be taken in responsewas developed in consultation with a multidisciplinary team informed by
guidelines already developed in the United Kingdom.
[19]
Minimal modification was required at each
hospital, to accommodate the differing structures and processes for patient care at the individual
hospitals.
Implementation of the Service
Development of the job description and selection criteria enabled the recruitment of 2 outreach
nurses at each site. The outreach nurses were provided with a 2-week orientation period to enable
them to familiarize themselves with their role. Hospital staff were informed about the study through
newsletters, personal communication, and education sessions. The promotion of the outreach
service continued throughout the implementation phase.
Outcomes
The primary outcome was LOS in the hospital from the time of admission to the ICU to hospital
discharge for patients' first admission to the ICU during the study. Secondary outcomes were (1) the
number of ICU readmissions during the same hospital admission, (2) survival to hospital discharge,
(3) day of week discharged from the ICU, (4) time of day discharged from the ICU, (5) activities of
the outreach nurse, and (6) delay to discharge from the ICU.
Data Sources
Data for the primary outcome were abstracted from the Western Australian Health Department's
administrative computer system (The Open Patient Administration System), in which all patient
admissions, transfers, and discharges are recorded.
Statistical Analysis
Time zero for the calculation of the primary outcome was taken as the date and time that the patient
was admitted to the ICU for the first time. Each of the study outcomes was first analyzed by using
univariate statistics to compare the outcomes before and after the intervention. (Percentages may
not total 100% because of rounding.) Severity of illness was assessed by using the worst score on
the Acute Physiology and Chronic Health Evaluation (APACHE) II during the first 24 hours.
[20]
Length
of stay was calculated from the time of admission to the ICU to the time of discharge from the
hospital. Readmissions during the same hospital stay were defined as early, those within 48
hours
[10]
and therefore most likely to be attributable to ICU-related care, or late, those occurring more
than 48 hours after discharge from the ICU and more likely to be associated with an issue in the
general care area. Time of day discharged from ICU was categorized as daytime (7 AM to 5:59 PM),
evening (6 PM to 9:59 PM), and nighttime (10 PM to 6:59 AM). Patients' discharge from the ICU was
defined as delayed when patients who were deemed suitable for discharge from the ICU were not
discharged for more than 8 hours.
[11]
For cases in which multiple reasons were given for the delay,
medical condition took precedence, followed by lack of availability of a bed in the general care area.
Categorical variables were reported as frequencies and compared by using a
2
test. Continuous
data were reported as medians and interquartile ranges (IQRs) and compared by using the
Student t test for normally distributed data and nonparametric tests for data that were not normally
distributed. Multiple linear regression was used to examine the independent effect of the intervention
on the primary outcome, adjusted for age and sex. The outcome measure, inhospital LOS from the
time of ICU admission, was log-transformed because these data were not normally distributed. Data
were analysed by using SPSS, version 17.0 (SPSS Inc, Chicago, Illinois). Where data were missing,
the number of available observations is reported and no assumptions are made about the missing
data. Two-sided comparisons with 95% CIs were used, and P values less than .05 were considered
statistically significant.
Sample Size
According to the 2002 data for all patients discharged alive from the ICU at Royal Perth Hospital (n =
1345), the mean LOS in the hospital after discharge from the ICU was 13.2 days (SD, 28.0 days).
Therefore, for a 20% reduction in post-ICU LOS in hospital (ie, to reduce the mean LOS from 13.2 to
10.5 days), for a power of 0.90, and an alpha of 0.05, a minimum of 1320 patients was required.
According to 2007 data obtained from each of the 3 study hospitals, approximately 60 patients are
discharged (alive) from the ICU each week, with the weekends having the lowest proportion of
discharges. Thus, based on an estimate of 60 patients per week for 26 weeks, a total of 1560 post-
ICU patients were expected during the 6-month intervention period. If one estimates that 10% of
patients will not be suitable to enter the study (eg, died in the ICU or were discharged to another
facility or directly home from the ICU), the number of patients discharged from the 3 ICUs would be
sufficient to meet the required sample size of 1320 patients.
3 of 5
Previo
Results
Of the total of 3001 patients discharged from the 3 ICUs during the study period, 1566
patients were in the 2007 "before intervention" cohort and 1435 patients were in the 2008
"after intervention" cohort. The characteristics of both cohorts are compared in Table 1. The
cohorts from before and after the intervention were not significantly different. The mean age
was 55 (SD, 19) years in the before group compared with 54 (SD, 19) years in the after group
(t = 1.96, P = .05). The proportion of men was 65%, the same for both cohorts. From
available data for 2762 patients, the mean APACHE II score was 16.8 (SD, 7.4) in the before
group and 16.7 (SD, 7.2) in the after group (t = 0.37, P = .66).
Primary Outcome
The LOS for the ICU patients in the before cohort (median, 1.9 days; IQR, 1.04.0 days) was
not significantly different (z = 0.57, P = .57) from that in the after cohort (median, 1.8 days;
IQR, 0.94.8 days). The median LOS in the hospital from admission to the ICU until hospital
discharge was 9.8 (IQR, 6.019.5) days in the before cohort and 10.1 (IQR, 5.920.6) days in
the after cohort (z = 0.18, P = .86). After adjustment for patients' age and sex, the LOS after
admission to the ICU did not differ significantly between the cohorts (95% CI, 0.096 to
0.041, P =.42).
Secondary Outcomes
Secondary outcomes were (1) number of ICU readmissions during the same hospital
admission, (2) survival to hospital discharge, (3) day of week discharged from the ICU, (4)
time of day discharged from the ICU, (5) activities of the outreach nurse, and (6) delay to
discharge from the ICU.
Before the outreach service was implemented, 5.4% of patients were
readmitted to the ICU during the same hospital admission, with 40% of the
first readmissions within 48 hours of discharge from the ICU. After
implementation of the outreach service, 5.6% of patients were readmitted
to the ICU during the same hospital admission, with 33% of the first
readmissions within 48 hours of discharge from the ICU. Readmission
rates did not differ significantly between cohorts (

). Although the proportion of later admissions was lower after the
introduction of the critical care outreach service, this difference was not
statistically significant (

). Hospital mortality was similar between cohorts: 5.5% before the outreach
service was implemented compared with 5.4% after the service was
implemented (

).
The day of discharge did vary between the 2 cohorts (

), as shown in Figure 1. Most patients were ready for discharge on weekdays
and least often on Sundays in both cohorts, but discharges on Sundays
decreased almost by half after the outreach service was implemented
compared with before.

(Enlarge Image)
Figure 1.
Comparison of day of discharge before and after implementation of a
critical care nursing outreach service.
The time of discharge did not differ significantly from before to after the
introduction of the critical care outreach service (

). The most common time for discharge was in the daytime (77% before and
78% after implementation of the outreach service). Further comparison
showed that evening discharges were more frequent after than before the
intervention; nighttime discharges were more frequent after (10%) than
before (8%) the intervention (Figure 2).

(Enlarge Image)
Figure 2.
Comparison of time of discharge between before and after implementation
of a critical care nursing outreach service.
Outreach Service
After the outreach service was implemented, 1435 patients were discharged
from the ICU. The following results relate only to this postintervention
cohort. Of these 1435 patients, the critical care outreach nurses visited 1198
patients before their discharge from the ICU (83% of patients admitted to
the ICU during the study period). Some patients had more than 1 visit from
the outreach nurses before their discharge, giving a total of 1459 visits.
Predischarge Visits
Fourteen percent of the patients who received a predischarge visit required
2 or more visits (range, 17 visits). The time taken for visits conducted
before the patient's discharge from the ICU ranged from 2 to 260 (median,
15; IQR, 1530) minutes. Issues most often encountered were respiratory
(70% of visits), related to catheters (52% of visits), gastrointestinal (52% of
visits), renal (48% of visits), and cardiovascular (45% of visits). Up to 14
types of referrals, 1115 in total, were made for 456 patients at these
predischarge visits. The 5 most common referrals were to the ICU team
(52%), a physiotherapist (23%), a dietitian (19%), a specialty team, (19%)
and a speech pathologist (16%).
Care Needs on Discharge from the ICU
From a total of 1435 patients discharged from the ICU after
implementation of the outreach service, just more than half (56%) had no
requirements for special accommodation on discharge from the ICU. For
the others, accommodation needs included 1:1 nursing care (29 discharges,
2%), isolation/single rooms (70 discharges, 5%), 1:1 nursing care and
isolation (5 discharges, 0.3%), high-dependency unit (335 discharges,
23%), coronary care unit (28 discharges, 2%), and other requirements
related to nursing staffing (135 discharges, 9.4%). Thirteen discharged
patients (1%) required other care requirements (eg, patient care assistant to
guard patient, burns room, larger 2-bed room for bariatric patient). Three
percent of patients had some order restricting resuscitation (do not
resuscitate in 23 patients [2%], no cardiopulmonary resuscitation/MET
activation/escalation of treatment in 16 patients [1%]) before discharge
from the ICU. Most discharged patients had vascular catheters (93%): 66%
of discharged patients had central catheters, and 83% required some form
of respiratory therapy, including tracheostomy in 9%. Urinary catheters
(84%) also were common, 43% of patients had concerns associated with
intravenous fluids, and 81% had issues related to fluid balance that
required monitoring in the general care area. Thirty-three percent of
patients had cardiovascular intervention: cardiac monitoring, drains,
pacing, and/or vasoactive infusions. Confusion or delirium was present in
11% of patients.
Postdischarge Review
Most patients (89%) from the cohort after the outreach service was
implemented were reviewed while in the general care area after their
discharge from the ICU. Of the 3721 reviews conducted among 1285
patients discharged from the ICU, 93% were considered routine. The
number of reviews performed by the critical outreach team ranged from 1 to
49 visits (median, 1; IQR, 13). The mean time spent for each review was 18
(SD, 16.9) minutes but ranged from 4 to 450 minutes. At the Royal Perth
Hospital, most patients were discharged to postsurgical care areas, but
most reviews were conducted in medical care areas. The reviews by the
critical care outreach nurses were conducted primarily for reasons related
to the patient (95%) but education (n = 251), clinical issues (n=218), advice
(n=121), equipment (n=119), staff in the general care area (n = 94), adverse
events (n = 90), and relatives (n = 32) were also the primary or secondary
reason(s) for conducting the review.
Interventions (categorized as manipulation of existing therapy,
recommending a practice change, education, or referral) were related to
respiratory (18%), gastrointestinal (13%), catheter (7%), renal (6%),
psychiatric/psychological (6%), electrolyte (5.5%), cardiac (5%),
neurological (3%), pain management (4%), wound care (3.5%), activities of
daily living (3%), hematological, metabolic (3%), micro-biological (2%), and
musculoskeletal (2%) issues.
Patients (n = 173) were referred to specialist services on 1026 occasions.
For patients who had a referral, the median number of referrals was 2 (IQR,
13) but as many as 38 referrals per patient were made. Most referrals were
to the patient's specialty team (Table 2).
Delays in Discharge
Of 1261 discharged patients for whom data on when they were deemed
suitable for discharge were available, 36% of patients had their discharge
from the ICU delayed by more than 8 hours. Among these patients, no bed
being available or a delay in a bed becoming available were the most
common reasons for the delay, accounting for 45% of discharge delays.
Medical concerns accounted for 21% of delays in discharge; no reason was
given for 27% of delays. Other reasons were staff shortages (4%), skill mix
issues (2%), and lack of suitable accommodation (1%). The distribution
pattern of the day the patient was deemed suitable for discharge from the
ICU differed significantly (

) between patients whose discharge was delayed and patients whose
discharge was not delayed. Delayed discharges occurred most often on
Mondays and Sundays. Patients whose discharge was delayed were more
likely to be discharged after hours than were patients whose discharge was
not delayed (

).
4 of 5
Discussion
In this large, multicenter study, duration of stay in the hospital from the
time of admission to the ICU, in-hospital mortality, and readmission to the
ICU during the same hospital admission did not change significantly after
the introduction of a critical care nursing outreach service. Although more
than 3000 patients were recruited for our study (1566 before and 1435 after
the introduction of the critical care nursing outreach service), it is possible
that a larger sample is needed to show a significant difference in LOS. It is
not surprising that mortality and readmission rate did not change
significantly after the outreach service was implemented. Both mortality
and readmission rates for the study hospitals' ICU are already low by
Australian
[21]
standards, and a larger sample is more likely to be necessary
for a significant difference to be detected for this low-frequency outcome.
Reports describing outcomes from a critical care outreach service have
conflicting results.
[15, 16, 22 24]
The randomized controlled trial conducted by
Ball and colleagues
[7]
in the United Kingdom found improved outcomes
after an outreach service was introduced. The LOS and readmissions before
the intervention, however, were higher than those reported in Australian
centers, and this difference may explain why the study by Ball et al showed
a positive result. Also, the services operate in different health care
environments, and there are differences in service delivery. In the United
Kingdom, outreach care was developed to improve the care of acutely ill
patients in general care areas of hospitals and not specifically to focus on
patients who have been discharged from the ICU.
[2527]
Outreach care in the
United Kingdom consists of a range of services from a fully comprehensive
24-hour-a-day/7-day-a-week emergency response service and a follow-up
service for after critical care (a combination of the MET service and the
follow-up service) to a limited education and support service focused on
improving the recognition of deteriorating condition and the improved
delivery of care to acutely ill patients in general care areas.
In the Australian context, several reports have described the beneficial
effects of the use of an ICU nurse liaison, although beneficial outcomes
such as reducing hospital LOS and readmissions to ICU have not been
clearly demonstrated.
[15, 22, 24]
Our results are similar to those reported by
Eliott and colleagues,
[16]
who found no difference in hospital LOS,
readmissions, or mortality after implementation of an ICU liaison nurse
service at a metropolitan university teaching hospital in Victoria, Australia.
Differences in health care contexts, the services provided (eg, having a MET
system), the focus of the intervention (on all acute care patients in the
general care area vs patients discharged from the ICU), and the outcomes
reported are all likely reasons for these discrepancies. In a recent
integrative review, Endacott and colleagues
[28]
noted that a range of
research methods have been used to evaluate critical care nursing outreach
services, but it was not possible to conclude unequivocally that such
outreach services improve outcomes. This conclusion was supported by the
results of an earlier systematic review performed by Esmonde and
colleagues.
[29]

The benefit of the critical care outreach service in facilitating the discharge
process was difficult to gauge. We believe that the discharge process was
facilitated by the critical care nursing outreach service, as demonstrated by
the large number of referrals before patients were discharged from the ICU.
Qualitative data from focus groups conducted before and after the
intervention (unpublished data) also showed positive comments about the
service. For example, patients were less afraid of the transition process, and
staff found the support and education beneficial. Chaboyer and
colleagues
[22]
did not find that use of a nurse liaison was associated with a
reduction in pretransfer anxiety among patients discharged from the ICU to
the general care area. It is likely that the method of assessing the benefits of
use of a critical care nursing outreach team should be reevaluated to better
measure the actual effect of such a team on the discharge process.
Almost a third of patients had their discharge from the ICU delayed by
more than 8 hours, equivalent to 1 or more traditional nursing shifts.
Although no information was available on delays in discharge from the ICU
before implementation of the outreach service to compare with delays after
implementation, a higher proportion of patients may have had their
discharge delayed after implementation because of issues identified by the
critical care outreach team. This premise is supported by the large number
of delays for medical reasons. In contrast, Chaboyer and
colleagues
[12]
reported a reduction in discharge delays from the ICU after
introduction of a nurse liaison service, although their definition of
discharge delay differed from ours and they had a comparison group.
Our study confirmed the complexity of the care that patients require when
discharged from the ICU. Many patients were discharged with central
catheters, oxygen therapy, and urinary catheters, and a large number of
interventions were delivered by the outreach nurses. Although the reviews
were conducted primarily for reasons related to patients, the outreach
nurses provided education and advice, assisted with equipment issues, and
supported staff and relatives. Referrals were made primarily to medical
teams (specialty, ICU), but support from physical therapists and dieticians
also were important.
Because this was a multicenter study, differences in management practices
from hospital to hospital may have affected the outcomes of the outreach
service in the different hospitals. The 2 larger tertiary-care hospitals have
clinical nurse specialist support available both during office hours (7 AM to
5 PM) in the general care areas and after hours (after 5 PM) throughout the
hospital, but the third hospital did not. More benefits may have been
observed at the third hospital, but the sample size may have been too small
for a significant difference to be detected. The short follow-up time of 6
months may have been insufficient to determine the true effect of the
intervention. Certainly a criticism of the MERIT study
[6]
was that a complex
intervention such as the introduction of a MET or, as in this article, a
critical care follow-up service, may require considerably longer than 6
months to have a significant effect. Eliott and colleagues
[16]
conducted a
before-and-after study for 36 months and did not find a difference in
outcomes. Funding constraints prevented a longer duration of follow-up for
our study.
Conclusion
Although several studies have shown beneficial outcomes for a critical care
nurse lead outreach service in Australia and the United Kingdom, we found
no improvement in LOS after admission to ICU, readmission rate, or
hospital mortality after introduction of such a service. However, it may well
be that the true benefits of the service (eg, improvement of the transition
from the ICU to the general care area for both the staff in the general care
area and patients, and the provision of educational support for junior staff
in the general care area) are not reflected by the more quantitative
outcomes measured in this study.





A literature Review: Do Rapid Response Systems reduce the incidence of
major
adverse events in the deteriorating ward patient?
Objectives
To conduct a literature review that explores the impact of Rapid Response
Systems on
reducing major adverse events experienced by deteriorating ward patients.
Background
Patients located on hospitals wards are older, often have multiple co-
morbidities and
are often at risk of life threatening clinical deterioration. Rapid Response
systems
have been developed and implemented to provide appropriate and timely
intervention
to these patients.
Design
A comprehensive review of the literature.
Methods
This review used the Rapid Response System framework recently developed
by
experts in the area of Rapid Response System. MEDLINE, CINAHL,
EMBASE and
Cochrane databases were searched from January 1995 to June 2009. 16
papers were
selected that most clearly reflected the research aim. Each paper was
critically
appraised and systematically assessed. Major themes and findings were
identified for
each of the studies.
Results
The effectiveness of Rapid Response Systems in reducing major adverse
events in the
deteriorating ward patients remains inconclusive. Six Studies demonstrated
that the
introduction of a Rapid Response System positively impacted on patient
outcomes but
three studies demonstrated no positive impact on patient outcomes.
Nursing staff
appear reluctant to utilise Rapid Response Systems but the rationale for
this is
unclear. However, the continued underutilisation and inactivation may be
one reason
why research findings evaluating Rapid Response Systems have been
inconclusive.
Rapid response systems are multidimensional models. They are relatively
new
innovations that have important implications for clinical research and
implementation
policy. This review contributes to the emerging debate on Rapid Response
Systems.
Conclusions
The paper illustrates two important gaps within the literature. Firstly,
ramp up
systems have not been subjected to formal evaluation. Secondly, Rapid
Response
Systems are under activated and underutilised by nursing staff. There is an
urgent
need to explore the reasons for this and identify interventions to improve
the
activation of these systems in an effort to promote safe and effective care to
the
deteriorating ward patient.
Key words: Rapid Response Systems, the deteriorating patient, integrative
review,
Medical Emergency Teams, Critical Care Outreach Teams.Relevance to
clinical practice

Implementing an ICU outreach team model.
Link/Page Citation
An aging population, rapid patient turnover, and advanced technologies are
contributing to higher patient acuity in hospitals. Unrecognized changes in
patient condition can lead to major complications, including death, and are
referred to as failure to rescue (Thomas, VanOyen Force, Rasmussen,
Dodd, & Whildin, 2007). Providing high quality care at the bedside is
becoming increasingly challenging due to a nursing shortage. Increasing
workload pressures are reported for ICU staff and there is a push for them
to shift the focus of their work outside the walls of the ICU (Kerridge &
Saul, 2003). Teams of health care providers with critical care experience
that can be called to the patient's bedside 24 hours a day, seven days a week
have been established in hospitals. There are a variety of names for these
teams and different models. An ICU outreach team (ORT) for delivering the
service was formed in a tertiary care hospital in Saskatoon to respond to
calls from inpatient units to provide critical care expertise to patients when
the nurse is worried or concerned, or when signs of physiological distress
appear. The team comprises an ICU registered nurse (RN), respiratory
therapist (RT), and a physician who is a critical care associate (CCA). This
team was formed to improve timeliness of patient care, to provide a
resource for nurses to access for their patients on inpatient units, and to
provide an opportunity for education and support for nurses on inpatient
units. In this article, the development and implementation of an ICU ORT
in Saskatoon is discussed.

Planning

Literature review. Research has shown that providing early intervention to
patients with deteriorating conditions by critical care health care providers
outside the walls of the ICU decreases the incidence of cardiac arrest
(Bellomo et al., 2003; DeVita et al., 2004), hospital mortality (Ball, Kirkby,
& William, 2003; Bellomo et al., 2003), death following cardiac arrest,
length of hospital stay related to cardiac arrest (Bellomo et al., 2003), post-
operative adverse outcomes, post-operative mortality rate, and length of
hospital stay (Bellomo et al., 2004). Nova Scotia's Dartmouth General
Hospital showed a 30 per cent decrease in the number of documented
cardiac arrests after implementation of a critical care team that works
outside of ICU (Canadian Healthcare Technology, 2007).

An ICU ORT is a method for increasing patient safety. The role of the ICU
ORT is to assess and stabilize the patient's condition, assist with organizing
information to be communicated to the patient's physician, provide
education and support to the unit staff, and assist with transfer of the
patient to a higher level of care if warranted (Safer Healthcare Now!
Campaign, 2006). Other strategies to identify and treat deteriorating
patients earlier or to prevent deterioration have been suggested, such as
introducing hospitalists, nurse practitioners, or increasing nursing staff
(Winter, Pham, & Pronovost, 2006).

Although these alternatives have merit, financial and human resources are
limiting factors. Nursing shortages are reported nationally in all fields of
nursing. Forty per cent of the RNs working in Saskatchewan are over the
age of 50 years (Canadian Institute of Health Information [CIHI], 2005).
Puckett (2007), president of the Saskatchewan Registered Nurses
Association Council, states that the province needs at least 150 more RNs to
graduate each year if it is to offset the wave of retirements that are
impending in the next five to 10 years. Often there are insufficient
experienced nurses on a unit to mentor novice nurses. With the large
number of impending retirements, there will be a further paucity of expert
nurses available to mentor. In 2005, RNs in their first five years of nursing
experience accounted for 23.4% of all RNs working in medical surgical
units in Saskatchewan (CIHI, 2005).

Other names given to critical care teams practising outside ICU include
medical emergency team (MET), patients at risk team, and rapid response
team (RRT). These names are used interchangeably throughout the article.
METs were initially implemented and evaluated in Australia in the 1990s
(Ball et al., 2003). These teams were usually medical, but included a senior
nurse. After Australia's experiences, the United Kingdom developed
"patient at risk" teams, which were nurse-led teams. MET and patient at
risk teams responded to patients outside of ICU with early warning signs of
physiological distress. ICU ORTs developed in England and Wales were
nurse-led and their role was to provide follow-up services during the period
between discharge from the ICU to discharge from hospital or re-admission
to ICU. In the United States, the Institute for Health Care Improvement
(IHI) (n.d.) and its partners launched the "100,000 Lives Campaign",
encouraging the use of proven best practices to help hospitals extend or
save as many as 100,000 lives per year. One of these best practices was the
introduction of RRTs to attend to patients outside ICU when signs of
decline were present. Based on the work of the IHI, Canada implemented
the "Safer Healthcare Now" (SHN) Campaign in April 2005 consisting of
six interventions. These have an evidence base indicating that appropriate
implementation and practice can lead to reduced morbidity and mortality
(Purvis, n.d.). These six interventions are aimed at:

* preventing deaths among people hospitalized for acute myocardial
infarction,

* preventing catheter-related blood stream infections,

* decreasing mortality, re-admission rates and length of hospital stay from
surgical site infections,

* implementing strategies that are proven to prevent ventilator-associated
pneumonia, and

* identifying and treating patients in distress before they have a
cardiopulmonary arrest.

The IHI and SHN have encouraged hospitals in their respective countries to
implement RRTs to prevent deaths in patients who are progressively failing
outside of ICU (Institute for Health Care Improvement, n.d.; Safer
Healthcare Now!, 2007). The goals of the Safer Healthcare Now! Campaign
(2006) for RRTs are to:

* reduce the number of cardiopulmonary arrests per 1,000 inpatient
discharges by 50% in one year,

* decrease the number of cardiopulmonary arrests occurring outside of the
ICU and emergency department to zero, and

* increase the overall use of the RRT over time.

Other possible benefits of RRTs are better patient outcomes, decreased
length of stay in ICU and in hospital, improved relationships among health
care workers, improved satisfaction for nurses, physicians and patients,
positive impact on nursing retention, and financial benefits. In Canada,
names of critical care teams working outside the walls of the ICU include
METs, RRTs and ICU ORTs. Different models are used to provide care for
patients, depending on the team structure and service provided. The name
of the team does not differentiate the model.

The team structure can comprises various members of the health care team
including an ICU RN, RT, intensivist, resident, and hospitalist (Safer
Health Care Now! Campaign, 2006). The structure is influenced by the
organization's resources that are available to respond immediately, are
onsite and accessible, and have the critical care skills necessary to assess
and respond. The service provided by the team may include daily patient
assessments, interventions, and referrals for patients discharged from ICU
or are referred to the team, and/or attending to patients outside the ICU
once they show signs of deterioration.

Steering committee. A steering committee was formed in April 2006 to
establish and implement an ICU ORT. The committee consisted of the
directors of ICU, a physician champion, a clinical nurse educator, a nursing
manager, ICU staff nurse, CCA, manager of RT and an RT. A clinical nurse
educator was seconded as a project leader to provide 40 hours of initial
work. This project leader was a valuable resource in establishing initial
guidelines, creating documentation and data collection tools, establishing a
method of communicating ORT calls, and coordinating initial education
sessions not only for ORT members, but also for staff throughout the
hospital. Although the additional time dedicated to the implementation of
the ICU ORT by the project leader was small, it had a large impact on
moving this project forward quickly. As members of the Canadian ICU
Collaborative, committee members were able to participate in collaborative
calls and learning sessions, and had access to the listserv and website to
gain insights from other centres that had already implemented an ICU
ORT.

The initial work of the committee included reviewing the current literature
on ICU ORTs, establishing a structure that was workable with the resources
available in the hospital, determining the criteria for calling the ICU ORT,
and liaising with the switchboard to determine the most effective way to
deploy the ORT call. The committee members also held meetings and
informal discussions with their respective colleagues to explain about the
ICU ORT, its role, when to call, and to answer questions about the
implementation of the ICU ORT.

In addition to the evidence supporting the implementation of ICU ORTs,
other factors in this organization that influenced the need to establish an
ICU ORT included limited nursing resources and a large percentage of
novice nurses on inpatient units, and in-house physician coverage that was
limited or not available on nights and weekends for some of the nursing
units. The co-directors of the Saskatoon Health Region Department of
Adult Critical Care were integral to establishing this team based on the
needs identified by the hospital. Prior to implementation, there was a two-
tier emergency response system in place: a Code Blue team with two ICU
nurses, an RT and the CCA who responded to respiratory and cardiac
arrests; and CCAs who responded to stat calls for other critical events.

Defining the model. St. Paul's Hospital is a 200-bed tertiary care hospital in
central Saskatchewan. An ICU ORT was implemented using existing critical
care resources. An RN, RT, and CCA from the ICU respond to calls from
inpatient units and the emergency department within the hospital to
provide critical care expertise to patients when nurses are concerned, or
who have signs of physiological distress.

Criteria for calling the ICU ORT were established (Table One). A review of
the literature found that call criteria for critical care teams outside the ICU
all contained physiological parameters related to airway, breathing,
circulation and neurological status. The criteria have been used by many
teams and thought to be legitimate reasons to call the team (Thomas et al.,
2007). When a patient meets any of the call criteria, the team should be
activated. The team may be called by any member of the health care team in
the hospital by dialing the stat line.

All ICU nurses and RTs are assigned to the ICU ORT. Members are
assigned to the ICU ORT for their entire shift. The team members who
respond to ICU ORT calls also respond to Code Blue calls. Where a Code
Blue call requires immediate response to a respiratory or cardiac arrest, the
goal of the ORT is to respond to all ORT calls within 10 minutes.

The role of the team is to partner with the staff on the unit that called, and
assess and intervene to stabilize the patient. The team assists and
coordinates appropriate therapy and determines the best location for the
patient to receive care, either on the current unit, an observation unit, or
the ICU. The team participates in end-of-life care planning if indicated. The
model of care adopted does not provide for routine follow-up of patients
discharged from the ICU or patients of previous ICU ORT calls.

Components--paging system, documentation, feedback mechanisms. ICU
ORT calls are sent to the team members on a pager with the room number
of the patient. The patient care supervisor is also paged, to aid in patient
placement if transfer arrangements are needed, as are the clinical nurse
educators during business hours to assess nursing staff learning needs and
to provide follow-up education as required.

Information about ICU ORT calls is documented on a standardized record
that becomes a permanent part of the patient's chart. It is a form used by all
disciplines. The record is initiated by the staff on the nursing unit calling
the team.

[FIGURE 1 OMITTED]

Members of the ICU ORT continue to document interventions, time of
arrival and leaving the call, outcome of the call and follow-up plan. If there
is a plan for follow-up by the ICU ORT, this will be communicated to the
initiating unit at the completion of the visit.

A copy of this record is returned to the ICU from which data are collected
by the clinical nurse educator. ICU ORT members are encouraged to make
anecdotal comments, on the back of the copy form, that they think are
pertinent. The data are reported back to the steering committee and
provide a way to track needs, identify areas of concern, areas of success,
and system pressures.

Implementation

Education/information strategies. Once care group leaders were aware of
the pending implementation of the ICU ORT, educational sessions were
held for front-line staff on the nursing units and for members of the critical
care staff who would be assigned to the ORT. Education included
instruction on use of the (situation, background, assessment and
recommendation (SBAR)) communication tool that was to be used for
communication among team members (Safer Healthcare Now! Campaign,
2006), criteria for making a call, the importance of calling the patient's
attending physician prior to calling the ICU ORT, procedure for calling the
ICU ORT, role of the ICU ORT, role of the team members on the initiating
unit, and documentation.

Education was necessary to define what type of call was the most
appropriate for particular situations. Differentiation was made between the
need for a stat call for the CCA, an ICU consult, and an ICU ORT call. If
assistance was required sooner than 10 minutes, the CCA was to be paged
stat. When unit staff was able to provide care to the patient but ICU
admission was questioned, an ICU consult was the most appropriate as
only the CCA was required to attend the call.

As well as information provided at the educational sessions on call criteria,
the criteria were posted on all inpatient units for staff to refer to, included
on the assessment portion of the patient documentation form as a check for
the nurse on the calling unit, and is referred to when collecting data.
Written material pertaining to the ICU ORT was either printed on pink
paper or distributed in pink folders so that it was easily identifiable.

Due to a nursing and respiratory therapy shortage, the attainment of
additional staff to implement this program was not possible. It was clearly
articulated to all hospital staff that it would not always be possible for
nursing and respiratory therapy staff to respond to all ORT calls, depending
on staff availability and acuity of patients in the ICU. One of the difficulties
of implementing the ICU ORT without additional resources was that the
nurse responding to the ORT call almost always had a patient assignment
that had to be assumed by another nurse in the ICU. Care is usually
transferred to a nurse in the unit who is physically close to the patient and
able to manage additional patient care on a temporary basis. Unplanned
increases in workload are an ongoing concern for nurses in the ICU.

Interim evaluation/feedback. On July 3, 2006, the ICU ORT became
available to inpatient units as a six-month pilot project. The intent was to
expand the program to other acute care sites within the region, pending
successful implementation. Ongoing support through informal meetings
was provided for members of the team by the steering committee. Meetings
were held monthly to review calls, discuss challenges and successes, and
implement changes as necessary. Utilization of the team by some units was
minimal. Reverting to previous practices of seeking assistance for failing
patients and calling for assistance later rather than early was observed. The
need for ongoing education about the team and its role was evident. This
was addressed through meetings with care groups and peer groups,
informal discussion groups for nursing staff from inpatient units,
newsletters to physicians and nurses, follow-up on specific individual
incidents with attending physicians, nursing manager or clinical nurse
educator from the inpatient unit, and education about utilization of the ICU
ORT at general nursing orientation.

[FIGURE 2 OMITTED]

Evaluation

Tools/measures. Data collected from the documentation record include
date, location of call, time of call, time to respond, who initiated the call, if
the attending physician was notified, previous ICU admission, previous
ORT call, reason for call, length of time spent at call by CCA, RN and RT,
outcome of call, if patient transferred, and any comments. Plans are
underway for reporting calls to each unit on a quarterly basis.

The data collected have been communicated to staff and the public within
the hospital and region by a hospital ICU ORT newsletter, a newsletter to
physicians about the team, presentation at the regional board meeting,
local news coverage, poster presentation at regional quality awards, and a
video presentation on the local cable TV Health Show.

Code Blue records are reviewed to obtain monthly data of codes per 1,000
discharges, per cent of codes outside of ICU and the emergency
department. These data, along with utilization of the ICU ORT are
submitted to the SHN campaign.

A staff satisfaction survey was developed and distributed to nursing units. A
five-point Likert scale was used with strongly disagree to strongly agree
used as anchors. Indicators evaluated were availability of ICU ORT for help,
approachability of the ICU ORT, and efficiency and effectiveness of the ICU
ORT. Additional comments were also solicited.

Outcomes. Sixteen months after implementation, patients are receiving
better, more timely care. There is surprise that only 26% of patients seen on
ICU ORT calls are transferred to the ICU (Figure One). More than 50% of
patients remain where they are and do not require a change in level of care.
The ICU ORT has received 224 calls over the first 16 months of
implementation with an average of 14 calls per month (Figure Two). These
results indicate that the ICU ORT is decreasing the number of ICU
admissions through early intervention as calls are being received in a timely
fashion.

Eight staff satisfaction surveys have been returned. All of the returned
surveys have shown satisfaction with the ICU ORT. Informal discussion
among the health care team members reveals that the ICU ORT is a
valuable resource, and staff feel encouraged to call the team rather than
hesitant, due to worry previously that the CCA would consider the call
unwarranted. The results from the satisfaction survey, as well as the
informal feedback throughout the hospital indicate that the ICU ORT has
provided a resource for nurses to access for their patients and has provided
education and support for the nurses on the inpatient units.

Implementation of the ICU ORT has not met the goals of the Safer
Healthcare Now! Campaign (2006) of decreasing the incidence of codes per
1,000 discharges by 50%, the number of codes occurring outside the ICU
and emergency department to zero, or the hospital mortality rate. In the
seven months prior to the ICU ORT implementation and for the first 15
months of implementation, codes per 1,000 discharges have remained
consistent with a rate of 3.7 pre-implementation to 3.8 post-
implementation. The percentage of codes occurring outside the ICU and
emergency departments remains at 40% as it did prior to implementation
of the ICU ORT. The average number of codes occurring in the hospital per
month is 3.6. Comparing hospital mortality for the 10-month period prior
to implementation, to the current 15-month period, hospital mortality has
increased from 5.6% to 5.8%.

The time of day that the calls were made was quite similar, with 53% of calls
on the night shift and 47% on the day shift. It was anticipated that there
would be more calls at night as there is less physician coverage and
decreased nursing resources in the hospital during that time period. Forty-
eight per cent of the calls have been to the surgical units, 38% to medicine,
7% to orthopedics, 4% to emergency, 2% to hemodialysis, and 1% to the
post-anesthetic care unit.

[FIGURE 3 OMITTED]

The ICU ORT accomplished its goal of responding to calls within 10
minutes in 96% of cases. An initial concern expressed by critical care
nursing staff and RTs was their availability to attend ORT calls with their
existing patient assignment. This has not been as difficult as anticipated as
there have been only 3% of calls when the nurse was unable to attend and
2% of calls when the RT has been unable to attend. In these calls, the CCA
and one of the other team members responded to the call. The length of
time spent at the call has varied: average times spent are 36 minutes by
CCAs, 28 minutes by RNs and 30 minutes by RTs. These data may be
inaccurate as the documentation on arrival time and time of departure is
not always complete.

Initiation of the ICU ORT calls has been by RNs (86%), physicians (10%)
and RTs (4%). The reason for the ICU ORT call is usually a combination of
the call criteria (Figure Three).

Although it has been difficult to show statistically that we are making a
difference to patient outcomes, anecdotally we do believe the ORT is having
a positive effect in several ways. The provision of timely patient care,
provision of a resource for nurses to access for patients, and education and
support of nursing staff on inpatient hospital units are being addressed by
the ICU ORT. The steering committee decided to continue with the ICU
ORT as a hospital resource when the six-month pilot project was completed
in December 2006.

Discussion. The outcomes at our site for reducing the number of codes per
1,000 discharges, reducing the number of codes outside of the ICU and
emergency department to zero, and decreasing hospital mortality rate
concur with the results found in the Merit study (Merit Study Investigators,
2005), a large cluster-randomized controlled trial implementing METs in
12 Australia hospitals. Possible explanations for these findings with the
Merit study (2005) and our team are that the data that were collected
occurred over a short period of time, or previously the system to manage
deteriorating patients outside of the ICU was effective. Members of our
steering committee have identified that the acuity of our hospital has
changed over the past two years due to the introduction of an acute care
access line and service alignment within our region. Thus, the pre-
implementation data and post-implementation data are not comparing like
patient populations. This may explain why we have not seen a reduction in
codes per 1,000 discharges, number of codes outside of the ICU and
emergency department, and mortality rate.

Limitations. One of the remaining challenges is how to determine patients
who were missed and should have had an ORT call. Has there been a failure
to rescue patients? The ICU ORT has prevented many patients from failure
to rescue, but the organization must be cognizant of any who were missed.
These patients can sometimes be identified retrospectively when a patient
is admitted to the ICU who has met criteria for an ORT call for a period of
time.

No formal evaluation of staff satisfaction among critical care ICU ORT
members has been undertaken. Informally, nursing staff has identified a
benefit to patient care and recognize the need for additional support to the
inpatient units. Staff members are engaged on the steering committee and
provide feedback from colleagues. Unfortunately no measurement was
taken prior to implementing the team to determine satisfaction with the
previous method of calling the CCA stat when a patient deteriorated.

The need for nursing resources in ICU continues to be a challenge to meet
the needs of patients. We have successfully implemented this team with
only 40 hours of additional resources at the time of planning. Members of
the critical care team have accepted this additional role as part of their
existing workload. With increased pressures for critical care beds in our
region, there is continual evaluation of whether this necessary service can
be provided to our patients without additional funding and recruitment of
more critical care RNs. Recruitment and retention of critical care nurses is
imperative so the current level of service as an ICU ORT can be provided, as
well as expansion to follow-up of patients discharged from the ICU.

Future

The next step is spreading the ICU ORT model used at St. Paul's Hospital
and adapting it to fit with the needs and resources of the other acute care
sites in our region. Initial spread of the model has started at one of the
acute care sites. Sharing the tools that were developed and the lessons
learned from this experience will assist with the implementation of the ICU
ORT at the other sites.

Summary

The ICU ORT has improved timely patient care, provided a resource for
nurses on inpatient units to access for their patients, and provided
opportunities for education of nurses on the inpatient units leading to high
nurse satisfaction. The ICU ORT was implemented to rescue patients who
were deteriorating and to treat them. Our evidence to date shows that the
implementation of the ICU ORT has been a successful strategy to rescue
patients with deteriorating medical conditions.

References

Ball, C., Kirkby, M., & William, S. (2003). Effect of the critical care outreach
team on patient survival to discharge from hospital and readmission to
critical care: Non-randomized population based study. British Medical
Journal, 327, 1014-1017.

Bellomo, R., Goldsmith, D., Uchino, S., Buckmaster, J., Hart, G.K., Opdam,
H., et al. (2003). A prospective before-and-after trial of a medical
emergency team. Medical Journal Australia, 179, 283-287.

Bellomo, R., Goldsmith, D., Uchino, S., Buckmaster, J., Hart, G.K., Opdam,
H., et al. (2004). Prospective controlled trial of effect of medical emergency
team on postoperative morbidity and mortality rates. Critical Care
Medicine, 32, 916-921.

Canadian Healthcare Technology. (2007, April, 13). Patient safety: More
hospitals asked to join patient safety campaign. Retrieved May 10, 2007,
from www.canhealth.com/News570.html

Canadian Institute of Health Information. (2005). Workforce trends of
registered nurses in Canada. Retrieved May 10, 2007, from
http://secure.cihi.ca/cihiweb/dispPage.jsp?
cw_page=download_form_e&cw_sku=SDRN2005PDF&cw_ctt=1&cw_dfo
rm=N

DeVita, M.A., Braithwaite, R.S., Mahidhara, S., Stuart, S., Foraida, M.,
Simmons, R.L., et al. (2004). Use of medical emergency team responses to
reduce hospital cardiopulmonary arrests. Quality Safer Health Care, 13,
251-254.

Institute for Health Care Improvement. (n.d.). Overview of the 100,000
Lives Campaign. Retrieved May 10, 2007, from
www.ihi.org/IHI/Programs/Campaign/100KCampaignOverviewArchive.ht
m

Kerridge, R.K., & Saul, W.P. (2003). The medical emergency team,
evidence-based medicine and ethics. Medical Journal of Australia, 179, 313-
315.

Merit Study Investigators. (2005). Introduction of the medical emergency
team (MET) system: A cluster-randomized controlled trial. Lancet, 365,
2091-2097.

Puckett, F. (2007, March 8). RN shortage risk to public wellbeing. Star
Phoenix. Retrieved May 10, 2007, from
www.srna.org/communications/documents/2007_RN_shortage.php

Purvis, M. (Ed.). (n.d.). Safer Healthcare Now! Edmonton, AB: Venture
Publishing.

Safer Healthcare Now! (2007). Safer Healthcare Now! Retrieved May 10,
2007, from www.saferhealthcarenow.ca

Safer Healthcare Now! Campaign. (2006). Getting started kit: Rapid
response teams how to guide. Retrieved May 10, 2007, from
http://www.saferhealthcarenow.ca/Default.aspx?folderId=82&contentId=
186

Thomas, K., VanOyen Force, M., Rasmussen, D., Dodd, D., & Whildin, S.
(2007). Rapid response team: Challenges, solutions, benefits. Critical Care
Nurse, 27(1), 20-27.

Winter, B.D., Pham, J., & Pronovost, P.J. (2006). Rapid response teams--
walk, don't run. Journal of American Medical Association, 296, 1645-1647.

About the author

Betty Wolfe, BSN, MN, Manager of Nursing, Intensive Care Unit St. Paul's
Hospital, Saskatoon, SK.
Table One. Call criteria for ICU ORT

Acute change in Physiology

Airway/Breathing RR <8 or >28
Oxygen Sp02<90% despite 02

Circulation Sys BP< 90mmHg
HR <40 >130

Neurology Change in Level of Consciousness

Other Worried/concerned about the pt.
COPYRIGHT 2008 Canadian Association of Critical Care Nurses
No portion of this article can be reproduced without the express written
permission from the copyright holder.
Copyright 2008 Gale, Cengage Learning. All rights reserved.

Please bookmark with social media, your votes are noticed and
appreciated:
The impact of critical care outreach: is there one?
Brian H Cuthbertson
Correspondence: Brian H Cuthbertson b.h.cuthbertson@abdn.ac.uk
Author Affiliations
Clinical Senior Lecturer in Critical Care and Consultant in Intensive Care Medicine, Health Services Research
Unit, Health Sciences Building, University of Aberdeen, Foresterhill, Aberdeen AB25 2ZD, UK
Critical Care 2007, 11:179 doi:10.1186/cc6179


See related research by Gao et al., http://ccforum.com/content/11/5/R113


The electronic version of this article is the complete one and can be found online at:
http://ccforum.com/content/11/6/179

Published: 30 November 2007
2007 BioMed Central Ltd
Abstract
An evaluation of critical care outreach services was published in the previous issue of Critical Care that fails
to demonstrate any important outcome benefit associated with these services. It is now time to ask some
difficult questions about the future of outreach, including whether the lack of evidence should lead to
disinvest-ment in such services.
Commentary
Medical emergency teams (METs) and critical care outreach are no longer new ideas [1]. The services were
founded in Australia in the 1990s with the concept of METs using the well-recognised principle that early
recognition and aggressive intervention improves outcome from critical illness [2]. The systems have now
developed into a variety of incarnations around the globe becoming critical care outreach services (CCOS)
in the United Kingdom, and the rapid response teams in North America [3-5]. Although there are some
differences between these services, they all have the same primary aim of preventing critical illness with its
associated morbidity and mortality.
CCOS losing its youth produces an urgent requirement for efficacy and cost-effectiveness to be
demonstrated. The most detailed evaluation to date of these systems is the MERIT study from Australia,
which was a multicentre cluster randomised trial of METs [6]. Sadly, the study failed to demonstrate a
reduction in intensive care unit (ICU) admissions, cardiac arrests or inhospital mortality. There are some
weaknesses in the trial but it still represents by far the highest level of evidence to date on METs/CCOS. The
publication of this disappointing result led to a rapid distancing of CCOS from their MET parent, clearly
fearing that this result would tarnish their new-found status. Indeed, since the publication of the MERIT
study, proponents of CCOS have commonly stated that CCOS cannot be tested using a randomised
controlled trial design, and some proponents seemed to believe that supportive evidence was not required at
all [1].
Thankfully, in the previous issue of Critical Care a detailed evaluation of CCOS in the United Kingdom from a
group based at the Intensive Care National Audit & Research Centre in London was published [1]. In the
paper the authors restate the principle that 'CCOS cannot now be evaluated using the gold-standard
research design, a multicentre, randomised controlled trial', and instead one must use an interrupted time-
series method. The analysis was performed on the Intensive Care National Audit & Research Centre case-
mix programme (a high-quality clinical database of nearly 400,000 ICU admissions) and on data taken from
a large national survey of CCOS. A range of outcomes designed to 'reflect the CCOS objectives of averting
admissions, ensuring timely admission and enabling discharge were investigated', including the proportion of
admissions direct from wards, the length of ICU stay, ICU mortality and hospital mortality. Sadly, despite
reductions in cardiopulmonary resuscitation rates and physiological disturbance in the time before ICU
admission, CCOS were not associated with an improvement in ICU mortality or hospital mortality [7,8].
Further, the authors were unable to identify which of the many highly variable operational characteristics of
the CCOS were optimal. Interestingly, they observed that there was no 'doseresponse' relationship for
CCOS that could have implied that the greater the CCOS coverage, the better the outcomes that can be
achieved. Finally, the authors observed that '... changes in admission characteristics may be attributable in
part to the use of physiological track and trigger warning systems', despite the fact that this group's
previous work demonstrated very poor sensitivity and specificity for such scores [9].
So where does this leave us with regard to future of CCOS in the United Kingdom and beyond? The
continued inability of studies to demonstrate the efficacy of CCOS and a complete lack of evidence for cost-
effectiveness is worrying. A recent guideline by the National Institute for Health and Clinical Excellence on
the management of the acutely ill hospital patient was unable to recommend outreach services due to a lack
of supportive evidence [10]. The National Institute for Health and Clinical Excellence did feel able to
recommend the use of early warning scoring systems but was unable to identify a particular system or cutoff
points due to the lack of evidence of accuracy for these scores in clinical practice [9]. Despite the lack of
evidence, the Institute of Healthcare Improvement recommends 'deploying rapid response teams' as one of
their 12 interventions 'proven to prevent morbidity and mortality' in their 100,000 lives campaign [10]. The
Institute of Healthcare Improvement clearly has access to an evidence base that the rest of us do not.
There are therefore many questions to be answered:
1. Do early warning systems actually allow early identification of sick patients, or are their diagnostic
accuracies too low to justify use in clinical practice?
2. Is there an optimal configuration for CCOS that can actually lead to an improvement in important patient-
based outcomes?
3. If CCOS can be demonstrated to be efficacious will it prove to be cost-effective?
4. Should countries that fund CCOS now disinvest and spend these resources in more effective ways?
It is time to answer these difficult questions!
Abbreviations
CCOS = critical care outreach services; ICU = intensive care unit; MET = medical emergency team.
Competing interests
The authors declare that they have no competing interests.
References
1. Gao H, Harrison DA, Parry GJ, Daly K, Subbe CP, Rowan K: The impact of the introduction
of critical care outreach services in England: a multicentre interrupted time-series
analysis.
Crit Care 2007, 11:R113. PubMed Abstract | BioMed Central Full Text
Return to text
2. Lee A, Bishop G, Hillman KM, Daffurn K: The medical emergency team.
Anaesth Intensive Care 1995, 23:183-186. PubMed Abstract
Return to text
3. Department of Health: Comprehensive Critical Care: A Review of Adult Critical Care Services.
London: Department of Health; 2000.
Return to text
4. Department of Health and NHS Modernisation
Critical Care Outreach Service
The Critical Care Outreach Service (CCOS) is a nurse-led service that supports ward nurses and doctors who are caring for
acutely ill in-patients. CCOS nurses are all highly experienced, senior Critical Care trained nurses who have also undergone
advanced training in patient examination and diagnostics. We take patient referrals throughout the 24 hour period, 365 days of
the year.
CCOS serves the adult in-patient population on the Leighton Hospital site of Mid Cheshire NHS Foundation Trust, including
maternity inpatients. All of Leightons adult inpatients have their vital signs monitored using an Early Warning Score system,
(EWS). The EWS system helps staff to recognise quickly if a patients condition changes or deteriorates. At Leighton we use
EWS to trigger timely patient reviews, by prompting staff to call doctors and CCOS to assess acutely unwell / deteriorating
patients.
The purpose of CCOS is to:
Assess acutely ill / deteriorating patients on wards, and advise the patients team on monitoring, investigations and management
plans. The aim is to stabilise and improve patients at ward level and so avoid the need for admission to Critical Care. This is the
case for the vast majority of cases referred to CCOS.

Ensure timely referral and admission to a Critical Care bed for those patients who require a higher level of monitoring or support
than can be provided at general ward level.
Follow up patients who have been transferred from Critical Care to ward areas. Whilst many patients have little or no memory of
their Critical Care stay, many also have some anxiety when they have improved and are ready for transfer to a general ward.
Critical Care Follow-up promotes a seamless transition between Critical Care and ward areas and gives opportunities for CCOS
staff to assess patients progress both physically and emotionally. During a CCOS follow-up visit, staff have the opportunity to
spend time talking to the patient about their recent Critical Care stay. This allows the staff not only to make sure that the patient
is making progress with their recovery but that the patient has an understanding of why he / she was admitted to Critical Care and
what treatment they received to get them better.
Share our knowledge and skills with ward staff, both at the bedside and through formal education programmes within the Trust.
We provide training to nurses, allied health professionals and junior doctors, with an emphasis on subjects related to the acutely
ill patient and tracheostomy care.
Critical care outreach teams - a prayer
answered?
25 October, 2001
VOL: 97, ISSUE: 43, PAGE NO: 34
Peter Groom, RGN, is charge nurse, outreach team for ICUs, Southampton University Hospitals
NHS Trust
The intensive care unit (ICU) has long been seen as a 'no go area' within hospitals, where the
staff are elitist and the doors are shut. It functions as a separate entity to the wards and the
hospital it serves, acting in isolation from departments that supply and siphon its patients. But all
this is changing.
The intensive care unit (ICU) has long been seen as a 'no go area' within hospitals, where the
staff are elitist and the doors are shut. It functions as a separate entity to the wards and the
hospital it serves, acting in isolation from departments that supply and siphon its patients. But all
this is changing.
The Department of Health review document, Comprehensive Critical Care: A Review of Adult
Critical Care Services (2000), confirmed some of these negative opinions and called for a
hospital-wide approach to the care of critically ill patients. The nursing section of the document
states that 'each critically ill patient, wherever they are located in the hospital, should have
skilled critical care nursing available either to care directly for them, or to advise on the care
required to meet their needs'.
This document and the Audit Commission's report, Critical to Success (1999), created the
impetus for establishing critical care outreach services in their many forms. Medical emergency
teams (MET), patient at risk teams (PAR), outreach teams and even patient emergency response
teams (PERT) may have arrived in a trust near you. They all aim to deliver care to the critically
ill patient nursed outside the ICU or high-dependency unit (HDU).
The role of critical care outreach services
The DoH (2000) outlined three key objectives for critical care outreach services:
- To avert ICU admissions;
- To enable ICU discharges;
- To share critical care skills.
Although the objectives were clear, the methods for achieving them were left open to individual
trusts. Hospitals have had to evaluate what is appropriate for their patients and the likely demand
for such a service. For example, not all hospitals require a 24-hour, seven-days-a-week service;
some hospitals provide designated staff from critical care areas to be available to wards, while
others offer a ward-based service with defined links to ICU.
The national expert group involved with Comprehensive Critical Care suggested that patients
could be placed on a scale of clinical need (see Box 1) that would indicate the level of support
they required. Outreach services aim to support patients between levels one and three, preventing
their deterioration and supporting staff who care for these patients on the general wards.
Both Comprehensive Critical Care and the Audit Commission's report were backed by research
highlighting less than optimal care before ICU admission and its consequent effect on mortality.
A confidential inquiry (McQuillan et al, 1998) found half of patients admitted to ICU had
received care before admission. The main causes of their poor care were a lack of knowledge,
failure to appreciate clinical urgency, lack of supervision and failure to seek advice (McGloin et
al, 1999).
Patients with obvious signs of deterioration can be overlooked or ineffectively managed on the
ward. This may lead to potentially avoidable unexpected deaths or to a poorer eventual outcome
following ICU admission. Outreach services aim to have an impact at the point of deterioration -
identifying clinical indicators, assisting with management of the deteriorating patient, and
supporting the ward team by sharing experience and critical care skills.
Southampton's approach
At Southampton General Hospital, the critical care outreach service is one of three initiatives to
improve the care of critically ill patients. The other two initiatives are:
- The modified early warning system (MEWS) which enables all staff to 'score' the sicker ward
patients and identify those at risk;
- The ALERT course (licensed from Portsmouth Hospitals NHS Trust), attended by all junior
doctors, physiotherapists and ward nursing staff. It equips staff to initiate immediate treatment
for sick ward patients and to communicate their concerns effectively to other members of the
team.
The critical care outreach team
Southampton General Hospital is a large university teaching hospital where the outreach service
provides 24-hour, seven-days-a-week cover. Our team is made up of six full-time experienced
critical care nurses, who carry the outreach bleepers and coordinate the team. An anaesthetic
senior house officer is continually available.
A nurse consultant and anaesthetist are responsible for the outreach team's strategic direction and
development. Physiotherapy input is essential and outreach services may include their own
physiotherapists or have fast-track links to physiotherapy assessment.
The critical care outreach service
The team offers support both to sick ward patients and the ward team caring for the patient. By
sharing critical care skills and experience, acutely ill patients can be cared for safely on the ward.
Outreach teams also aim to identify patients for whom ICU or HDU care is required. This
promotes earlier admission to ICU and may also have a role in identifying those patients who
would not benefit from admission on grounds of futility of treatment.
Discharge from ICU is sometimes an area of dispute between the ICU and ward teams and this
can be reduced by continued support from the outreach service. Education plays a key role:
members of the outreach team not only support the staff caring for the patient, but also provide
information and skills so that the ward staff can develop their own practice.
Outreach services need to be audited, to evaluate effectiveness and patient outcomes. There
needs to be a mechanism for feedback between team members and the ward staff to learn from
experience and identify problems. Critical care outreach services can have a positive impact on
patients and ward staff - as the case studies above testify - but must not be seen as a remedy for
reduced ward staffing, limited medical cover or a lack of ICU/HDU beds.
Conclusion
Critical care outreach services should bring down the barrier between critical care units and the
wards by focusing not on where patients are placed, but on what level of care they need. These
new services can create seamless care and improve channels of communication to the benefit of
both patients and nurses.
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Early Warning Systems: Scorecards That Save Lives
For the past few years, the Institute for Healthcare Improvement (IHI) has
challenged hospitals across the United States to reduce cardiac arrests and
other sudden, life-threatening events in patients on general medical floors
by implementing a system of Rapid Response Teams. Such a system
involves empowering staff nurses, and in a small but growing number of
hospitals a family member, to summon a designated group of clinicians to a
patients bedside to critically and quickly evaluate signs of a worsening
condition. Steps can then be taken to head off the worst, including
transferring the patient to an intensive care unit if necessary.

As part of IHIs 100,000 Lives Campaign some 1,500 hospitals are now
actively using and/or implementing Rapid Response Teams. Cardiac arrest
rates, mortality rates, and lengths of stay in the intensive care unit (ICU)
are dropping, and hospitals with Rapid Response Teams are moving their
cultures toward a team-based approach to clinically challenging situations.

Currently, most Rapid Response Teams in the United States are triggered
by one parameter at a time, and that parameter often represents a
significant change in a particular vital sign. For example, a significant
change in blood pressure might trigger a call to the Rapid Response Team,
or a significant change in skin color might trigger a call. In some cases, a
general feeling that something is not right might lead to a call. Many teams
report that approximately 40 percent of calls to the Rapid Response Team
are generated because the caller feels there is something just not right
with the patient.

While a single-parameter approach has been effective, what if organizations
could identify at-risk patients even before a significant vital sign change?
What if a system were created that could respond to multiple parameters at
the same time and identify at-risk patients at the first sign of a subtle
change in vital signs? Such an Early Warning Scoring System (EWSS),
experts say, could yield even more benefits for patients and hospitals by
identifying deteriorating patients even earlier.

Kathy Duncan, RN, faculty expert on Rapid Response Teams for IHI, says
an EWSS can add another layer of early detection to the Rapid Response
Team system. We want to encourage recognition of high-risk patients as
soon as possible. The Rapid Response Team cannot be effective if it is not
called to the patient bedside in time. An EWSS can prompt nurses to make
that call even earlier, says Duncan.

The idea of an Early Warning Scoring System is very new within
the United States; however, in the United Kingdom this concept is
being used with success in many hospitals. Ysbyty Glan Clwyd
(YGC), located in Rhyl, Denbighshire, in central North Wales, is
one such facility. YGC is a 900-bed acute care hospital that
serves as headquarters of the Conwy & Denbighshire National
Health Service (NHS) Trust. The Trust is part of the IHIs Safer
Patients Initiative (SPI), conducted in collaboration with The
Health Foundation, an independent charity working to improve
the quality of health care in the UK. SPI is actively working to
improve the quality and safety of health care in the UK by
encouraging the uptake and spread of best practices.

Like many organizations, Ysbyty Glan Clwyd implemented a Rapid
Response Team, which they also refer to as an outreach team,
to improve how quickly patients experiencing a sudden decline
receive clinical attention, get admitted to intensive care if
needed, and are able to leave the ICU because of a better way to
monitor patients throughout the hospital. The team is made up of
a dedicated part-time senior ICU sister (the UKs equivalent of a
unit leader) and a rotating senior ICU staff nurse.

After creating the outreach team, the organization found that not
all at-risk patients were being identified. Nurses didnt have a
complete set of criteria to identify a failing patient early and
trigger a call to the team. We found that nurses were not calling
the team, and we needed to establish some clear criteria that
would prompt the nurses to make the call and take action to
address the patients needs, says Delyth Williams, ICU and
outreach sister for Ysbyty Glan Clwyd. Just as the outreach team
was not effective by itself, one of our medical wards had tried to
introduce a set of early warning criteria for nurses to use before
we had the outreach team in place; that, too, failed. So, the
challenge became one of taking that same Modified Early Warning
System (or MEWS) and marrying
it to the outreach team.

How the MEWS Works
When a nurse at Ysbyty Glan Clwyd takes a patients vital signs and records
them on the patients chart (see Figure 1 below), if any one of the following
six vital signs falls in to a red zone, the nurse is prompted to determine a
MEWS score for the patient:

Respiratory rate

Heart rate

Systolic blood pressure

Conscious level

Temperature

Hourly urine output (for previous 2 hours)

Determining a MEWS score involves assigning a number between 0 and 3
to each of the six vital signs (see Figure 2 below). For example, if a patients
systolic blood pressure is between 71 and 80, or if it is more than 200, the
nurse would assign that vital sign a score of 2. The sum of the scores of the
six vital signs yields the patients total MEWS score. If the total score is 4 or
greater, this prompts the nurse to call the patients physician and also the
organizations outreach team.

We try to let the doctor and the patients nurse take the lead in this
response system, all the while the outreach team contributes to the medical
assessment, presents recommendations, and offers support to both the
nurse and doctor, says Williams. Although similar to Rapid Response
Teams in the United States, Ysbyty Glan Clwyds outreach team is designed
to play a more consultative role. Because the outreach team is small, we
cannot take over clinically every time we are called. Not only would we
spread ourselves too thin, but it wouldnt empower the participation of the
doctor and nurse so that everyone works together to address the patients
needs, says Williams.

The beauty of Ysbyty Glan Clwyds system, say its proponents, is that the
MEWS logically fits within processes that nurses are already doing. Nurses
are taking vital signs anyway, and the color-banded patient chart gives a
visual cue as to when to calculate a MEWS score, helping prompt a faster
call to the outreach team, says Pat Anderton, senior staff nurse of the ICU
outreach team. We redesigned our patient charts to highlight those visual
cues.






Educating Staff on the System
To help familiarize the staff with MEWS, the outreach team developed
laminated pocket cards, with the MEWS algorithm on the back, for all the
ward nurses. Delyth Williams and Pat Anderton also attended staff
meetings and education sessions and discussed the purpose of the outreach
team, the importance of an Early Warning Scoring System, and how the
system would work. The team also participated in monthly study days, in
which both registered nurses and other nurses receive training on a variety
of topics. We came to these study days and talked about the outreach team
and the Early Warning Scoring System, and we also provided training on
patient assessment skills, says Williams. Such skills included how to
effectively assess a patients airway, breathing, and circulation.

Providing education in basic assessment skills is critical to the success of
the MEWS, because the system can yield false positives and negatives at
times and strong assessment skills can help identify those situations, says
Williams. For example, a patient whose vital signs normally fall outside of
the assigned parameters may trigger a score that leads to a call to the
outreach team when he or she is not that sick. To ensure the MEWS
protocol is regularly followed, nurses must always notify the outreach team
when a trigger score is reached. However, if the nurse has justifiable
reasons to hold off having the doctor and outreach team come to the patient
bedside, he or she is empowered to make that decision.

Conversely, a patient who is sick may not trigger a score if his or her vital
signs do not fall within the predetermined high-risk values. We have found
that, with experience and improved assessment skills, the ward nurses are
able to recognize that a patient is unwell, although the nurse cant put his or
her finger on why, says Williams. Therefore, the outreach team encourages
ward staff to contact the team if the patient gives cause for concern, with
or without a trigger score. It is essential that outreach team members are
non-judgmental and respectful of the ward nurses concerns. Making them
feel foolish for potentially inappropriate referrals could prevent ward staff
members from using the team in the future, therefore putting their patients
at risk, says Williams.

Gaining Staff Support
Initially, the nurses and doctors at Ysbyty Glan Clwyd were less than
enthusiastic about the MEWS and outreach team. They often considered
us the enemy and, in some cases, they thought we were just interfering,
says Williams. To overcome this resistance, the outreach team frequently
visited every ward, asking to see anyone with a high MEWS score. Your
face gets known after awhile, and people realize you are there to help, not
take over their job. As more and more nurses saw the benefits to using the
scoring system and having the team as a resource, they began using us
more often, says Anderton. We also carefully considered the personnel
who would be on the team. You need someone who can act as a mediator
and educate without stepping on toes. Both Delyth and I serve in this
capacity.

Measuring Success
Ysbyty Glan Clwyd began examining the success of the MEWS and outreach
team by using the IHIs critical care team measures. Much to our dismay,
we discovered that people werent calling the team as much as they should,
and nurses werent recording respiratory rates or documenting MEWS
scores, nor were they reacting to trigger scores, says Williams.

To address this, the organization began conducting rapid-cycle Plan-Do-
Study-Act (PDSA) tests of change.

The organization began with one ward and did weekly chart audits using a
compliance checklist (see figure below). When the weekly chart audits
werent sufficient to yield change, we began picking five random charts to
audit daily and provided immediate education to improve compliance,
says Williams. Within a week, that first ward was compliant. We then
moved to another ward until all the wards were compliant with the
process. By moving to daily chart audits, the organization was able to call
attention to the MEWS process and encourage nurses to document MEWs
scores and react to trigger scores.

Ysbyty Glan Clwyd has continued its auditing process to ensure that things
dont slip back the way they were. We have shifted auditing responsibility
to a designated nurse on each ward. The outreach team does monthly spot
checks to ensure that standards are being maintained, says Williams. If
we had to do the implementation piece of this program over again, we
would have done a pilot program and then rolled it out housewide. That
could have saved us some time, energy, and frustration, says Williams.

Achieving Results
Now that the nurses and doctors across the organization are using the
MEWS and outreach team, the organization has seen an increase in the
number of calls to the team and a decrease in the number of cardiac
arrests. Since March 2005, the organization has cut its crash call rate in
half, going from approximately eight crash calls per 1,000 discharges to
four.

The MEWS and outreach team have also improved the response time to
deteriorating patients. For example, historically, if a junior doctor needed
assistance in assessing and responding to a patient, there were no other
options but to call up the ranks. This was typically a slow process. With the
MEWS and outreach team working together, we can get senior personnel to
the scene much faster. The system enables ward nurses to contact senior
doctors and get the patient the assistance he or she needs, says Williams.

Other Organizations Pursuing Early Warning Scoring Systems
While the concept and components of an Early Warning Scoring System
are not yet being widely adopted in the United States, the tools and
resources to implement EWSS (as part of the Rapid Response Teams
intervention) are now part of IHIs 5 Million Lives Campaign, the follow-on
to the 100,000 Lives Campaign (see the updated How-to Guide for Rapid
Response Teams).

One organization ahead of the curve is the Order of Saint Francis (OSF)
Saint Josephs Medical Center,
a 154-bed acute care hospital located in Bloomington, Illinois, and
part of OSF Healthcare System, a multi-state health care system operating facilities in Illinois and Michigan. OSF
Saint Josephs has developed an automated EWSS. When nurses take patient vital signs, they enter them into the
patients electronic medical record. Those vital signs automatically populate a data warehouse that supports a
patient risk tool that includes early warning scores for the previous four days as well as patient lab values for the
last eight hours, key medications, and so forth. The patient risk tool also shows graphs of patient vitals for the past
48 hours. The report gives a snapshot of where the patient is at, says John Whittington, MD, Director of
Knowledge Management and Patient Safety Officer for OSF Healthcare System. At a predetermined time, the
computer prints out any patient risk reports for the supervisory nurse to review. He or she looks at each report and
determines whether to call the attending physician, alert the Rapid Response Team, or continue to monitor the
patient, depending on what the report shows.

While the OSF St. Josephs system is automated, Whittington cautions that organizations should not let a lack of
technology stop them from creating some kind of EWSS. The most important thing is to identify patients earlier
and have a structure in place to respond to that identification.

A Call to Action
While the Rapid Response Team plays a critical role in saving patients lives, an Early Warning Scoring System can
help organizations take the next step, identifying at-risk patients sooner and saving more lives. IHI will be
encouraging organizations to investigate and implement a multiparameter EWSS as part of their Rapid Response
Team effort, says the 5 Million Lives Campaigns Kathy Duncan. Such a system can help build reliability into the
Rapid Response Team system and attempt to or try to guarantee that no at-risk patients are missed.

There is no perfect way to do this, continues Duncan. Organizations should consider how they can identify at-
risk patients sooner and develop processes that are appropriate for their staff, patients, and culture. This may
involve piloting concepts before rolling them out housewide and using rapid cycle plan-do-study-act (PDSA) tests of
change to help drive improvement. The goal of these efforts should be to determine how an EWSS can be
incorporated into the nursing workflow.

The work in creating an EWSS will not necessarily be easy, and the path to success may not be straight. However,
organizations that can implement a system that reliably identifies deteriorating patients early and responds to their
needs quickly can help reduce patient mortality and save lives.