Features and perceptions of a critical care outreach physician role

OBJECTIVE: To describe the tasks completed by the critical care outreach physician (CCOP) and staff perceptions of the CCOP role. DESIGN: Prospective observational study and survey of intensive care unit (ICU) staff. SETTING: University-affiliated teaching hospital in Australia. PARTICIPANTS: ICU consultants, registrars and nurses. INTERVENTIONS: Implementing a dedicated ICU consultant to review deteriorating patients outside the ICU. MAIN OUTCOME MEASURES: Prospective collection of CCOP tasks and survey of ICU staff. RESULTS: During 101 clinical shifts, the CCOP had 1524 encounters (mean, 15.1 [standard deviation, 6.1]; median, 14 [interquartile range, 10–19] per day). The three commonest interventions were emergency department visits, direct consultant communication, and coordinating ICU admissions. Involvement in Medical Emergency Team (MET) calls, expediting patient care, and goals of care discussions were also relatively common. Survey responses were obtained from 55/84 (66%) eligible participants. Most respondents thought the CCOP would improve the predefined processes of care and patient-centred outcomes. The areas of greatest perceived benefit included supporting the MET registrar and coordinating simultaneous emergencies outside the ICU. Areas where the role was perceived to be less beneficial included improving handover, identifying patients at clinical risk outside the ICU, and reducing repeat MET calls. CONCLUSIONS: The tasks of a CCOP involved high level communication, coordination of care, and supervision of ICU staff. The effect of this role on patient-centred outcomes requires further research.

Four consecutive yearly point-prevalence studies in Wales indicate lack of improvement in sepsis care on the wards

The ‘Sepsis Six’ bundle was promoted as a deliverable tool outside of the critical care settings, but there is very little data available on the progress and change of sepsis care outside the critical care environment in the UK. Our aim was to compare the yearly prevalence, outcome and the Sepsis Six bundle compliance in patients at risk of mortality from sepsis in non-intensive care environments. Patients with a National Early Warning Score (NEWS) of 3 or above and suspected or proven infection were enrolled into four yearly 24-h point prevalence studies, carried out in fourteen hospitals across Wales from 2016 to 2019. We followed up patients to 30 days between 2016–2019 and to 90 days between 2017 and 2019. Out of the 26,947 patients screened 1651 fulfilled inclusion criteria and were recruited. The full ‘Sepsis Six’ care bundle was completed on 223 (14.0%) occasions, with no significant difference between the years. On 190 (11.5%) occasions none of the bundle elements were completed. There was no significant correlation between bundle element compliance, NEWS or year of study. One hundred and seventy (10.7%) patients were seen by critical care outreach; the ‘Sepsis Six’ bundle was completed significantly more often in this group (54/170, 32.0%) than for patients who were not reviewed by critical care outreach (168/1385, 11.6%; p < 0.0001). Overall survival to 30 days was 81.7% (1349/1651), with a mean survival time of 26.5 days (95% CI 26.1–26.9) with no difference between each year of study. 90-day survival for years 2017–2019 was 74.7% (949/1271), with no difference between the years. In multivariate regression we identified older age, heart failure, recent chemotherapy, higher frailty score and do not attempt cardiopulmonary resuscitation orders as significantly associated with increased 30-day mortality. Our data suggests that despite efforts to increase sepsis awareness within the NHS, there is poor compliance with the sepsis care bundles and no change in the high mortality over the study period. Further research is needed to determine which time-sensitive ward-based interventions can reduce mortality in patients with sepsis and how can these results be embedded to routine clinical practice.Trial registration Defining Sepsis on the Wards ISRCTN 86502304 https://doi.org/10.1186/ISRCTN86502304 prospectively registered 09/05/2016.

Lack of improvement in sepsis care on the wards: results of four consecutive yearly point-prevalence studies in Wales

Background: The ‘Sepsis Six’ bundle was promoted as a more deliverable tool outside of the critical care settings, but there is very little data available on the progress and change of sepsis care outside the critical care environment in the UK. Our aim was to compare the yearly prevalence, outcome and the Sepsis Six bundle compliance in patients at risk of mortality from sepsis in non-intensive care environments. Methods: Patients with a National Early Warning Score (NEWS) of 3 or above and suspected or proven infection were enrolled into four yearly 24-hour point prevalence studies, carried out in fourteen hospitals across Wales from 2016-2019. Results: Out of the 26,947 patients screened 1,651 fulfilled inclusion criteria and were recruited. The full ‘Sepsis Six’ care bundle was completed on 223 (14.0%) occasions, with no significant difference between the years. On 190 (11.5%) occasions none of the bundle elements were completed. There was no significant correlation between bundle element compliance, NEWS or year of study. One hundred and seventy (10.7%) patients were seen by critical care outreach; the ‘Sepsis Six’ bundle was completed significantly more often in this group (54/170, 32.0%) than for patients who were not reviewed by critical care outreach (168/1385, 11.6%; p<0.0001)Overall, 1349 patients (81.2%) survived to 30 days with a mean survival time of 26.5 days (95% CI 26.1-26.9) with no difference between each year of study. 90-day survival for years 2017 – 2019 was 74.7%, with no difference between the years. In multivariate regression we identified older age, heart failure, recent chemotherapy, higher frailty score and do not attempt cardiopulmonary resuscitation orders as significantly associated with increased 30-day mortality. Conclusions: Our data suggests that despite efforts to increase sepsis awareness within the NHS, there is poor compliance with the sepsis care bundles and no change in the high mortality over the study period. Further research is needed to determine which time-sensitive ward-based interventions can reduce mortality in patients with sepsis and how can these results be embedded to routine clinical practice.Trial registration: Defining Sepsis on the Wards ISRCTN 86502304 https://doi.org/10.1186/ISRCTN86502304 prospectively registered 09/05/2016

High Flow Nasal Cannula Oxygen in Patients With Haematological Malignancy: A Retrospective Observational Study

BackgroundPatients with haematological malignancies (HM) face high rates of Intensive Care Unit (ICU) admission and mortality. High flow nasal cannula oxygen (HFNCO) is increasingly used to support HM patients in ward settings, but there is limited evidence on the safety and efficacy of HFNCO in this group. MethodsWe retrospectively reviewed all HM patients receiving ward-based HFNCO, supervised by a critical care outreach service (CCOS), from January 2014 - January 2019. ResultsWe included 130 consecutive patients. Forty-three (33.1%) were weaned off HFNCO without ICU admission. Eighty-seven (66.9%) were admitted to ICU, 20 (23.3%) required non-invasive and 34 (39.5%) invasive mechanical ventilation. ICU and hospital mortality were 42% and 55% respectively. Initial FiO2 <0.4 (OR 0.27, 95% CI 0.09-0.81, p=0.019) and HFNCO use on the ward >1 day (OR 0.16, 95% CI 0.04, 0.59, p=0.006) were associated with reduced likelihood for ICU admission. Invasive ventilation was associated with reduced survival (OR 0.27, 95%CI 0.1-0.7, p=0.007). No significant adverse events were reported.ConclusionHM patients receiving ward-based HFNCO have higher rates of ICU admission, but comparable hospital mortality to those requiring CCOS review without respiratory support. Results should be interpreted cautiously, as the model proposed depends on the existence of CCOS.