Outreach and the evolution of critical care

We were intrigued by Drs Fletcher and Cuthbertson’s outreach editorial [1]. We have been running a hospital outreach team for a number of years and we are confessed enthusiasts [2].  However, we do see the limitations of evidence based medicine in this area. Our personal, anecdotal and probably highly biased opinion of critical care outreach is that the use of an outreach team works. Since the inception of the outreach team in our trust in 2000, including an early warning system, we clearly see far fewer ward “disasters”. It would be a sad day if we were held hostage by a lack of evidence base and compelled to withdraw our service.

However, it has become clear to us that one vital role that our outreach service has taken on is that of the critical care gatekeeper. We ensure that treatment plans are made in advance for high risk ward patients, such that if they deteriorate, all staff are aware of the treatment ceiling. This may or may not mean admission to critical care. This information is now kept in a document we have created and called a Treatment Escalation Plan (TEP). We have now replaced DNR (Do-Not-Resuscitate) forms with our TEP. We are convinced that this initiative has ensured that patients only get the treatments appropriate to their individual circumstances. Before the time of outreach embracing the TEP intervention, decisions on escalation of care would usually have been rushed in the midst of a clinical emergency, with scant recourse to the wishes of the patient and their family. We feel this improvement in patient care alone justifies the outreach service in our trust.

No external funding and no conflicts of interest declared.

M Mercer

H Robinson 

South Devon Healthcare NHS Foundation Trust

Torquay, UK

E-mail: michael.mercer@nhs.net

References

1. Fletcher SJ, Cuthbertson BH. Outreach, epistemology and the evolution of critical care. Anaesthesia, 2010; 65: 115-118.

2. Mercer M. Fletcher SJ, Bishop GF. Medical Emergency teams improve care. British Medical Journal 1999; 318: 51.