The Critical Care Outreach Team (CCOT) provides expert critical care nursing support to acute care nurses and patients across 14 acute care floors. The primary goals of this initiative were to improve early recognition of patient deterioration and eliminate out-of-intensive care unit (ICU) cardiac arrests. Through purposeful interdisciplinary collaboration, the CCOT seeks to improve the work environment of bedside nurses, expedite delivery of high acuity care, and improve patient outcomes.
Critical Care Outreach teams, sometimes referred to as rapid response teams (RRTs), have been instrumental in decreasing patient mortality and preventing failure to rescue (FTR) (Aitken et al., 2015; Barwise et al., 2016; Mullany et al., 2016). Additional research indicates FTR is a nurse-sensitive factor and therefore related to a nurse’s work environment and the availability of CCOT services (Mushta, 2018). Critical care outreach teams have been associated with improved patient safety, patient satisfaction, nurse satisfaction, decreased hospital length of stay, and decreased ICU admissions (Aitken et al., 2015; Stolldorf, 2016). Finally, early detection and management of patient deterioration saves hospital resources (Bonafide, 2014).
Successful development and implementation of the CCOT was dependent on cultivating and sustaining a healthy work environment as outlined by the American Association of Critical Care Nurses (n.d.). Skilled communication and interprofessional collaboration empowered clinical ICU nurses to develop a highly specialized team to address priority needs of patients and nurses. Shared visionary leadership afforded the CCOT to make decisions regarding implementation of best practice to shape hospital policy. The result of this unique innovation in emergency response staffing is a CCOT that sustains itself by consistently providing high-quality, effective services reflected in supporting metrics.
Body
Process:
Bedside critical care nurses were recruited to improve patient flow during episodes of high acuity. These nurses gained operational aptitude while developing collegial interdisciplinary relationships. This disruptive innovation served as the prototype for CCOT services. Many challenges were encountered as the team gained momentum. Outreach support services, while in high demand by the acute care nurses, were perceived as an expense competing for limited resources. This required dedication and shared vision in building a healthy work environment to improve patient and nurse outcomes. Interprofessional stakeholders (critical care medicine, emergency medicine, director of pharmacy, director of respiratory, medical faculty, nurse researchers) were identified to improve collaboration among hospital leaders and regular meetings were held to elicit support and accountability. Reporting directly to the associate vice president of nursing finance expanded the CCOT’s scope of practice beyond clinical expertise, providing mentorship in business acumen. The team is empowered to actualize evidence-based solutions that enhance individual, team, and institutional nursing practice.
Collection, analysis, and reporting of data are the primary factors in the growth and sustainability of the team. According to Stolldorf & Jones (2015), constructing a CCOT responsive to the needs of its institution is likely to achieve improved outcomes. Internal review and quality improvement initiatives ensure the CCOT services are congruent with the dynamic needs of the organization. In addition to patient-focused measures such as mortality, emergency response time, and ICU readmission, nurse and provider outcomes encompassing engagement, satisfaction, and educational support are also observed. Clinical presentations of patients preceding emergency response calls are tracked to assist with the development of targeted education in early detection and prevention of patient deterioration.
Outcomes:
The CCOT was created in the setting of a healthy work environment and, likewise, has strengthened and sustained a healthy work environment. Interprofessional collaboration, skilled communication, empowered decision making, and shared visionary leadership resulted in CCOT growth from 1.0 FTE to 10 FTE. In this manner, the achievements of the CCOT have received meaningful recognition and the CCOT has been supported in disseminating its practice at local, national, and international conferences.
CCOT staffing has resulted in fewer codes blue and a statistically significant increase in rapid response calls, suggesting a positive correlation between use of CCOTs and early recognition of patient deterioration. Emergency response time has decreased by seven minutes expediting patient treatment. ICU nurses no longer have to leave a patient assignment to respond to an emergency in the acute care area which improves continuity of care and saves over 500 care hours annually.
An electronic survey conducted in 2016 indicated 95% of bedside nurses believed the CCOT had a positive impact on patient throughput in expediting high acuity care. Bedside nurses reported improved job satisfaction (90%), patient safety (95%), and that the CCOT enhanced their skills and knowledge (87%). Physicians and providers perceived CCOT nurses as “great resources” that improve patient safety (88%) and provide advanced critical care nursing outside of the ICU setting (92%).
The use of early warning scores in early detection of patient deterioration has be extensively studied by the CCOT. Data from this hospital-based research was utilized to develop a post-ICU algorithm used to measure a patient’s risk for ICU readmission. Subjective nurse concern was also included in the algorithm as an effective measure of potential for deterioration (Aitken et al., 2015). As a result, the CCOT’s post-ICU algorithm demonstrated a statistically significant increase in sensitivity for identifying patients at risk for deterioration and ICU readmission.
Extensive interprofessional collaboration led to a shadowing program which began in 2015 affording 4th year medical students the opportunity to work with members of the CCOT to improve recognition and management of patient deterioration. Evaluation of this program is ongoing via electronic survey and has demonstrated improved interdisciplinary communication and understanding of professional roles and accountability.
Conclusion:
Inception of the CCOT has fostered an environment conducive to improved outcomes, innovative practice, and continual learning. Continual growth and interprofessional collaboration have presented new opportunities to address the use of early warning scores, implementation of an emergency response huddle, and formalized education for bedside nurses and unlicensed assistive personnel.
The CCOT is currently in the process of developing a Visiting Clinical Nurse Scholar program to facilitate international sharing of best practices based on relationships forged through dissemination of practice. Each initiative is derived through a healthy work environment and dedication to improving patient outcomes.