What would happen if we took the walls off the ICU?

Feb 8, 2019 | News

In the early 90s, research identified that patients who went into cardiac arrest had documented signs of clinical deterioration 8 to 24 hours prior to coding. Upon further investigation, these patients progressed to cardiac arrest because of one (or more) of these three factors: failure to recognize early signs of clinical deterioration, failure to communicate, and/or failure to intervene.

“If you're not familiar with something like sepsis or you’re new in your clinical career, you might miss the early warning signs or be hesitant to voice your concerns about a patient because you can’t necessarily name what is wrong; you just know that something is,” explains Critical Care Outreach Team (CCOT) lead and Critical Care CNS Vininder (Vini) Bains. “As a result, these early warning signs aren’t being treated as aggressively as they could be, and we end up having a patient go into cardiac arrest.”

Critical care is a need, not a place

Australia was first place that tried mobile critical care teams, based on the idea of, “an ICU without walls” with incredibly positive results, such as reduced cardiac arrest rates, lower mortality and shorter hospital stays.

CCOT will be comprised of a multidisciplinary team of an ICU RN, a registered respiratory therapist, and a critical care physician. The CCOT RN will respond to calls and be at bedside in 5 to 15 minutes, and can immediately access support from the other team members as required. The goal is to bring critical care knowledge and skills out of the ICU to support the primary care team, both nurses and physicians, in delivering excellent care to their patients.

“I think that one of the most exciting parts of this initiative is that we’re bringing critical care to the patient, versus waiting for the patient to arrive in ICU,” says Vini, who has been working for two years to implement this program. “When we look through our numbers, we admit an average of 790 patients per year to the ICU.”  27% or 200 patients a year are admitted from in-patient wards, and our data shows they have a significantly higher hospital mortality (i.e., 31% vs 21%) and length of stay (i.e., 34 days vs 16 days) than those patients who were so sick they were admitted directly to the ICU.

In short?

“Early intervention is key,” says ICU CNE Mia Marles. “Successful outreach teams depend on the ward team to call early, and call often. You don't have to be able to put a finger on “the why” – just that you have a feeling that something isn’t right with your patient is enough of a reason to pick up the phone and call us.”

Early Warning Signs:

  • Threatened airway
  • Oxygen saturation less than (<) 90% and/or increasing oxygen needs
  • Respiratory rate less than (<) 10 or greater than (>) 30 breaths/minute
  • Systolic blood pressure less than (<) 90 or greater than (>) 210 mmHg
  • Heart rate less than (<) 40 or greater than (>) 140 beats/minute
  • Sudden change/decrease in LOC
  • Urine output less than (<) 100 mL over the past 4 hours
  • Elevated MEWS score
  • Clinician / caregiver concern - being worried is reason enough

Multi-pronged approach

Launching in mid-February, St. Paul’s CCOT is keen to increase hospital-wide awareness around the team’s presence, and how they are able to support staff in the hospital’s inpatient programs.

“We want hospital staff to have a good understanding of how we can help, and to emphasize that that we're not there to take over care – we're here to work collaboratively with primary care nurses and physicians,” says Vini.

In addition to the CCOT, the modified early warning system (MEWS) is another tool being rolled out in all acute, adult inpatient units at St. Paul’s and Mount St. Joseph’s Hospital to support early detection of changes in a patient's condition(1). MEWS is an aggregate score generated from a number of physiologic measures such as heart rate, blood pressure, respiratory rate, temperature and neurologic status. Clinical deterioration can be detected earlier when using  MEWS because it factors in a number of parameters, rather than relying on a single abnormal vital sign to trigger action. This can make a life-saving difference a patient. When both MEWS and CCOT were implemented in 12 Dutch hospitals, cardiac arrest rates went down from 1.94 to 1.22 events per 1000 admissions(2). How do we compare? We have a code a day. Our in-hospital cardiac arrest rates in non-critical care areas is 3.34 arrests per 1000 admissions(3), so we have room to improve.

“Our clinical objective is to prevent in-hospital cardiac arrests,” says Vini. “using these two systems to cut our cardiac arrest rate in half would feel like a great success.”

Set up for success

For staff long-tenured enough to recall, your memory isn’t playing tricks on you: there was a previous trial of ICU Outreach at St. Paul’s in 2008. “At that time, it was the first of its kind in BC. As early adopters, this nurse-led model was a wonderful support for ward staff but could not achieve the hoped-for improvements on patient outcomes. A decade later, with the benefit of our and others experience, we recognise the importance of a comprehensive rapid response system, supporting both the call for help and the response,” explains Dr. Ruth MacRedmond, Intensivist and CCOT MD Lead.  


Dr. Ruth MacRedmond, Intensivist and CCOT MD Lead.

There are several factors identified to help us achieve these ambitious goals. “We now know that a multidisciplinary team is necessary, and that the members of the team require not only clinical expertise, but also excellent communication and mentorship skills,” Vini adds. Other keys to success include, “fast response times to all CCOT calls (i.e., within 5 minutes); that the service is reliably available 24-7 with no missed calls, delays, or gaps in service; and consistent, collaborative responses from expert critical care clinicians.”

The most important factor to the success of the CCOT service however is the patient’s primary care team.  “They are the fourth member of the CCOT team, because they are the eyes and ears. We won’t succeed in saving patients’ lives without attentive, proactive hospital staff to call CCOT early so we all can make that difference.”  Be on the lookout in late February because the CCOT Team will be visiting in-patient wards to introduce the service, members of the team and answer any questions staff may have.

CCOT Cole’s Notes:

  • The CCOT is a dedicated, 24/7 service that makes specialized critical care a phone call away.
  • The aim is to respond to all calls within 5 minutes: 604-319-3536.
  • Being worried is reason enough. Call early, call often.

Early Warning Signs:

  • Threatened airway
  • Oxygen saturation less than (<) 90% and/or increasing oxygen needs
  • Respiratory rate less than (<) 10 or greater than (>) 30 breaths/minute
  • Systolic blood pressure less than (<) 90 or greater than (>) 210 mmHg
  • Heart rate less than (<) 40 or greater than (>) 140 beats/minute
  • Sudden change/decrease in LOC
  • Urine output less than (<) 100 mL over the past 4 hours
  • Elevated MEWS score
  • Clinician / caregiver concern - being worried is reason enough.

Additional information

  • Look for posters on your unit for the details on early signs and the number to call (see attached), as well as phone stickers and lanyard cards, which will be distributed to ward staff for quick reference.
  • Posters will also be posted through St. Paul’s for general awareness of the CCOT.
  • If you would like an in-person overview of the CCOT, how it works and how the team can work collaboratively with your unit, please email Vini:VBains@providencehealth.bc.ca
  • Head to the ICU website and read up on the CCOT: http://icu.providencehealthcare.org/who-we-are/our-team/ccot


The ICU CCOT, ready to spring into action whenever you might need them. They're just a phone call away!

References

1. Carleton J. Boiled Frog Fable is the story of the Modified Early Warning System (MEWS). Care Connection 2019 January 17, 2019;9.

2. Ludikhuize J, Brunsveld-Reinders AH, Dijkgraaf MG, et al. Outcomes Associated With the Nationwide Introduction of Rapid Response Systems in The Netherlands. Critical Care Medicine 2015;43(12):2544-51.

3. As per St. Paul’s Hospital Cardiac Arrest Database for April 2009 to March 2018.

PDF icon poster-icu-ccot-unit.pdf

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