Evaluation of critical care outreach services in a tertiary care Hospital in India: A retrospective analysis.

BACKGROUND: Critical care outreach services (CCOS) is a relatively a new concept in India and is not as developed as in Western countries. Efficient utilization of limited intensive care service requires comprehensive CCOS. Appropriate activation of such services will limit excess burden on already scarce human resources. AIM: To evaluate the functioning of CCOS in a tertiary care hospital and also to identify factors leading to its overactivation.
MATERIALS AND METHODS: Data of 400 calls received in resuscitation room (RR) of the Trauma Center during January 2011-June 2011 was analyzed. Categorical variables were summarized by calculating the frequency and percentage. Records of the department sending the call, purpose of the calls, and designation of the person sending the calls were noted. Calls were grouped into appropriate or inappropriate.
RESULTS: Maximum calls were received from medicine wards (65.8%) followed by neurosurgery ward (12.5%). Of all, 26% of the calls were sent by senior doctors (senior resident), whereas 69.4% of the calls were sent by junior doctors. 66.2% of the calls were indicated for assessment and intensive care unit (ICU) transfer, whereas central venous/intravenous access constituted 14.8% of the calls. Intubation and ventilator settings constituted 7.3 and 7.8% calls, respectively. About one-third (36.2%) of all calls were inappropriate.
CONCLUSION: There is inefficient use of human resources in CCOS in our hospital. Lack of objective activation criteria and inefficient training in basic lifesaving skills and ventilator know-how were identified as primary factors for the same.

INTRODUCTION

The idea of critical care outreach services (CCOS) variously named as medical emergency teams (METs) in Australia; Rapid Response Teams in North America was first conceived in 1990s and thus is not new.[1] Although there are some differences between these services, they all have the same primary aim of preventing critical illness with its associated morbidity and mortality. Abundant western literature is available on the subject, but the services are still at a nascent stage in India. The Institute of Health Care Improvement (IHI) “saving 100,000 lives campaign” has vigorously advocated the deployment of Rapid Response Team (RRT) as a means to identify patients with various illnesses, at risk for cardiac and respiratory arrest; thereby preventing subsequent hospital deaths.[23] Because of resource limitation, the number of patients that can be monitored and treated in intensive care units (ICU) and high dependency units (HDUs) is restricted. The selection of the patients who might benefit from intensive care is therefore critical.[4] Several studies indicate that almost all critical inpatients events are preceded by warning signs for an average of 6-8 h.[5] Such warnings include change in vital sign (tachycardia, tachypnea, and hypotension), acute dyspnea, and change in level of consciousness. The Critical Care Response Team takes the skills and expertise of the critical care team beyond the walls of the ICU within minutes, to the bedside of deteriorating patients, whose condition may well progress to cardiac or respiratory arrest. This approach has been envisioned as “critical care without walls”.

In our hospital, these services are headed by a qualified anesthesiologist along with a junior doctor from the Department of Anesthesia to provide bedside care to the critically ill patients in the entire hospital round the clock. These services are rendered through a resuscitation room housed in the trauma center attached to the hospital. Calls are received from the casualty and wards for various indications requiring evaluation, workup, and resuscitation of the inpatient. Record of these calls is maintained in the resuscitation room (RR). For efficient utilization of these services, it is required that only appropriate calls are received. Overactivation of these services puts strain on already limited human resources. It is often the breakdown of communication, poor teamwork, failure to appreciate clinical urgency, and lack of supervision that leads to failure to manage a patient as efficiently as desired. All of this constitutes human resource wastage.[6]

Thus, this single center retrospective observational study was planned to review CCOS in our thousand bedded tertiary care hospital, with the aim of identifying the factors leading to overactivation and further improvement of these services in our hospital.

MATERIALS AND METHODS

After Institutional Review Board (IRB) approval this single center, retrospective, observational study was conducted. Data of 400 calls received in RR of the Trauma Center during January 2011-June 2011 was analyzed. Data was entered into a Microsoft Excel program for data management and analyses. Categorical variables were summarized by calculating the frequency and percentage. Records of the department sending the call, purpose of the calls, and designation of the person sending the calls were noted. Doctors with post graduate degree in particular specialization were termed senior doctors. Doctors in training in the specialized field (post graduates (PGs), junior residents (JR), and interns) with only undergraduate degree were termed junior doctors for the purpose of analysis. Calls were grouped into appropriate or inappropriate. Calls where no specialized anesthesiologist intervention like intubation, invasive and noninvasive ventilatory changes, inotropic support, specialized monitoring, intravenous access, or transferring to ICU was done; were taken as inappropriate calls.

RESULTS

Single center retrospective observational study was conducted by collecting data of 400 calls recorded in the RR during 6 months period. Data was presented as mean (standard deviation (SD)) were normally distributed and as frequency (percentages). The mean age of the patients was 45.5 ± 18.45 years [Table 1]. 43.2% of the patients were female and 56.8% were male [Table 2]. Maximum calls were received from medicine wards (65.8%) followed by neurosurgery ward (12.5%), surgery wards (11.8%), and burns and plastics ward (7.5%) [Table 3 and Figure 1]. Of all 26.5% of the calls were sent by senior doctors (senior resident), whereas 69.4% of the calls were sent by junior doctors (PGs, JR, and interns), and 4% calls were received from nurses [Table 4 and Figure 2]. Most calls were indicated towards assessment and ICU transfer (66.2%), followed by central venous/intravenous line access (14.8%), intubation (7.3%), and ventilator settings (7.8%) [Table 5]. 36.2% of the calls were judged inappropriate according to the defined criteria [Table 6]. Surgery was the department with most number of inappropriate calls (44.6%) followed by medicine (38%) and burns and plastics (26.6%) [Table 7 and Figure 3].

Table 1

Age distribution

Table 2

Sex distribution

Table 3

Distribution of department sending the calls

Figure 1

Distribution of departments sending the calls

Table 4

Designation of person the sending calls

Figure 2

Designation of person sending the call

Table 5

Indications of the calls

Table 6

Appropriate and inappropriate calls

Table 7

Department wise distribution of inappropriate calls

Figure 3

Department wise destribution of appropriate calls

DISCUSSION

Studies in US,[7] Canada,[8] Australia,[9] and UK[10] estimate that adverse events occur in 10% of the hospitalized patients with the mortality rate of 5-8%,[89] half of which are preventable.[8] These countries have implemented various methods of working for the critically ill patients for bringing intensive care expertise to any acutely ill patient irrespective of location in the hospital, but in more organized way by team work. These teams are variably named as Rapid Response Team (RRT) in US, Medical Emergency Teams (MET) in Australia, Critical Care Response Team (CCRT) in Canada and Critical Care Outreach Team (CCOT) in UK.[11] Buist et al., reported a reduction in unexpected deaths in hospitals from 3.77 to 2.05 per 1,000 hospital admissions after implementation of MET and a decrease in cardiac arrests from 77 to 56%.[12] Bellomo et al., showed reductions in cardiac arrests of 65% (P = 0.001), deaths from cardiac arrest of 56% (P = 0.005), duration of ICU stay post arrest of 80% (P = 0.001), and inpatient deaths of 25% (P = 0.004).[13]

Rapid response system (RRS) has four essential components namely afferent limb, efferent limb, administrative limb, and quality improvement limb. An afferent limb consists of ward healthcare givers, who would recognize a deteriorating patient and activate the RRT. This component is critical as it links actual team with at-risk patient. In our hospital this limb is constituted by junior doctors (PGs, JR, and interns) and nurses most of the times, who fail to judge the urgency and validity of the call. Our result shows that more than half of the total calls (69.4%) received in RR are sent by junior doctors. Clinical evaluation by these young doctors cannot always be relied upon. This was one of the reasons for receiving a large number of inappropriate calls (36.2%) in our study. Other important reason was the lack of an objective parameter that would effectively activate RRS and thus reduce the number of false alarms. Modified Early Warning Scoring System (MEWS) has been shown to be useful and appropriate risk management tool for all the critically ill surgical inpatients.[14] Validity of MEWS in medical patients has also been well established.[8] MEWS is a simple physiological scoring system suitable for bedside application. Application of MEWS for emergency admissions is useful for triage, to identify patients at highest risk of deterioration. Appropriate intervention can thus be targeted in small number of patients.[4] A sizable portion of the calls was constituted by calls for venous access (14.8%) and basic ventilatory setup (7.8%). Burden of such calls can be reduced by basic training in such skills at the first place. This will withdraw some of the pressure on already overburdened RRS.

An efferent limb should have a team with ability and authority to prescribe medications, advanced airway management, and cardiac life support skills; and ability to provide ICU level of care at bedside. Our hospital has a senior doctor and a junior doctor on duty for attending all the calls in the hospital which is grossly inadequate for efficient functioning of the system, and thus critical review and improvement of the strategy is required to improve the functioning.

An administrative limb should oversee all the components and empowers the team to be able to function and provide needed resources. A quality improvement limb periodically reviews the functioning and provides feedback on team function.

CONCLUSION

This study highlights the inefficient use of human resource in CCOS in our hospital. Lack of uniform protocols leads to increased work load for these services. Early warning scores probably can improve the identification of patients who truly requires ICU care and thus reduce the false activation of RRS. Teaching the ward healthcare personnel regarding basic lifesaving skills and ventilatory knowhow will go long way in reducing the unnecessary burden on the system.