1. Critical Care Outreach
Critical Care Outreach Team Leeds Teaching Hospitals Trust

2. Learning Outcomes Understand Critical Care Outreach
Understand NEWS and its use
Be able to assess a patient using ABCDE approach

3. Critical Care Without Walls
Review of Critical Care Services by Department of Health in 2000
Bringing critical care expertise to patients in ward environments
Prevent acute deterioration and provide timely transfer to critical care environments
Supporting patient rehabilitation following discharge from critical care
Education of hospital staff involved in patient care

4. Critical Care Outreach Team
Senior nursing staff with extensive critical care experience
Nurse led service with dedicated ICU Consultant available for Outreach Team

5. Outreach Service Availability at LTHT
08: :00 at SJUH
08: :00 at LGI
Overnight outreach cover is provided by ICU team.....currently
Contactable by bleep or ask for outreach office at LGI and SJUH

6. Outreach in practice Assessment and review of patient using:
ABCDE assessment of patient
History and clerking notes
NEWS recording
Fluid balance
Blood results, radiological reports eg CXR, ECHO
Level of care required and ceilings of care

7. Right Patient - Right Bed
Level 0 - Ward based care IVI and b.d obs
Level 1 - Patients needing additional clinical input e.g. continuous oxygen, chest drains, 4 hourly observations, GCS 4 hourly
Level 2 - Patient requiring single organ support eg more than 50% O2, CPAP or BIPAP, vasoactive drug infusions, hourly observations for potential deterioration
Level 3 - Advanced respiratory support or more than one organ failure
The 4th years need explanation about different ICU categories, they do not already know this

8. National Early Warning System
Track and Trigger system of recording physiological parameters to detect changes in patient’s condition
Score aggregate has a graded response to alert senior clinical input and increase frequency of observations
Measures six physiological parameters but unusual stand alone changes should also trigger a response eg reduction in AVPU

9. Text

11. Need to highlight Outreach contact details, actions required for different track and trigger systems.

12. ABCDE - a reminder Airway - Patency, O2 (15 litres NRB)
Breathing - Examine, O2 saturations, RR, Auscultate , ABG, CXR
Circulation - Examine, Pulse, BP, CRT, IV access, Bloods, Fluids
Disability - AVPU, Pupils, BM, GCS
Exposure - Temp, Rash, Abdomen, Bleeding, Legs, drug charts, history, all results

13. Patient Scenario
Jane is a 55 year old lady who has had a temperature following her laparoscopic cholestectomy two days ago She has been on ward post - operatively feeling unwell. You are asked to see her as her NEWS is high and your senior is in theatre…

14. Assessment
A – patent
B – RR 28, SaO2 88%, increased work of breathing, coughing++
C – HR 136bpm, BP81/46 CRT 4 secs, T 39.4
D – Alert but drowsy
E – Feels thirsty, not on any medicines. Bowel sounds present – bowels opened yesterday, wound sites dry. Calves SNT
A – Oxygen 15l NRB
B – Auscultate then consider ABG and CXR and sputum sample for m,c&s
C – IV access, bloods, fluid challenge, 12 lead ECG, - is she passing urine?
D – GCS, pupils and glucose
E – NEWS = 11 Review notes/Op notes/ Drug Chart? Blood results, BUFALO, fluid balance chart started ?catheterise

15. What needs to be done? ABCDE approach
What investigations are you going to do and in what order!
What would you like the nursing staff to do?
Who needs to know about this lady?

16. Text

17. NEWS > 5….Does your patient have:
Systemic Inflammatory Response Syndrome
2 or more signs of inflammation:
T >38 or <36
HR >90
WCC>12 or <4
RR>20
Altered conscious level
BM >7.7 (if not diabetic)
If patient is neutropenic then just 1 of the above
Sepsis? SIRS AND clinical evidence of infection Red Flag Sepsis SBP <90mmHg despite fluid challenge Lactate >2mmol/l Heart Rate >130/min Respiratory Rate >25/min Oxygen Saturations <91% Responds to Voice/Pain or Unresponsive Purpuric rash

18. BUFALO in Sepsis

19. New plans for the patient?
Outreach referral + senior review
Review NEWS, blood results, CXR, ABG
Urinary catheter
Further fluid resuscitation - how much?
Has she had his antibiotics yet?
What level of care do they need?

20. The End Result
This patient responded well to IV fluids and antibiotics her NEWS reduced to 4.
She stayed on the ward with outreach support.
She was discharged home with oral antibiotics after 4 days.

21. Summary
Use the assessment checklists and skills you have been provided with
Get support from your seniors and outreach sooner rather than later
Document, document, document

22. References
Standardising the Assessment of Acute Illness Severity in the NHS:‘Recommendations for a NHS Early Warning Score (NEWS)’. A report from the Royal College of Physicians: July 2012
National Patient Safety Agency (2007) Recognising and responding appropriately to early signs of deterioration in hospitalised patients London
Department of Health (2000) Comprehensive Critical Care: A Review of Adult Critical Care Services London, Department of Health