Operational Standards and Competencies for Critical Care ...
Transcript of Operational Standards and Competencies for Critical Care ...
National Outreach Forum I Operational Standards and Competencies for Critical Care Outreach Services
The National Outreach Forum (NOrF)
The National Outreach Forum (NOrF) was founded back in 2004 by a group of enthusiastic professionals involved with the first Critical Care Outreach Teams. Since then it has evolved into a multi-professional interest group that seeks to promote excellence in the care of acutely unwell patients. NOrF provides a representative forum for Critical Care Outreach Service providers and recipients across the country who strive to optimise the quality of the acutely unwell patient’s treatment, care and experience.
Copyright
In order to encourage as many people as possible to use the material in this publication, there is no copyright restriction, but the National Outreach Forum as copyright holder should be acknowledged on any material reproduced from it. Note that high-quality versions is available to download, photocopy or print direct from our website at www.norf.org.uk/NOrF_operational_standards_competencies_CCOS.
Citation for this document
National Outreach Forum Operational Standards and Competencies for Critical Care Outreach Services. NOrF 2012
Review date: 2015
National Outreach Forumwww.norf.org.uk
Critical Care Networks-National Nurse Leads
1National Outreach Forum I Operational Standards and Competencies for Critical Care Outreach Services
Foreward
I am delighted to have the opportunity to endorse the NOrF Operational Standards and Competencies document on behalf of the Society for Acute Medicine (SAM).
Early recognition of the patient whose condition is deteriorating, and ensuring appropriate and timely intervention has been a key priority for SAM over the past decade; indeed this has been a major driving forces behind the development of the speciality of Acute Internal Medicine, Acute Medical Units and the National Early Warning Score. Recent reports have highlighted the enormous challenges which UK hospitals face, with rising numbers of emergency hospital admissions coinciding with significant financial and staffing pressures. In this environment, Critical Care Outreach Teams have become increasingly important, delivering high level skills at the bedside, wherever and whenever they are needed. They can also provide an invaluable educational resource, supporting and empowering all members of the multiprofessional team to take prompt remedial action if they believe a patient’s condition is deteriorating. This document represents a crucial step forward in ensuring that a high quality, consistent Critical Care Outreach service becomes firmly embedded in all hospitals, 7 days per week. If these standards are implemented across the UK, I have no doubt that this will have a major impact in improving safety for all hospital patients.
Dr Chris Roseveare BM FRCP President, Society for Acute Medicine
National Outreach Forum I Operational Standards and Competencies for Critical Care Outreach Services2 National Outreach Forum I Operational Standards and Competencies for Critical Care Outreach Services
Foreword
Critical Care Outreach Teams (CCOT) are one of the great successes of the developments following publication of Comprehensive Critical Care (DOH 2000). The recognition that practitioners from critical care had transferable skills that were relevant to the care of the general hospital patient was one of the light bulb moments of the last decade.
The extension of the natural multi-professional working practices of the best critical care units into the general hospital has brought nothing but benefit to patients and staff.
This set of operational standards puts the spotlight on the level of care to which NHS patients have the right to expect.
Dr Bob Winter President of The Intensive Care Society
3National Outreach Forum I Operational Standards and Competencies for Critical Care Outreach Services
Foreword
On behalf of the National Early Warning (NEWS) Score Development and Implementation Group of the Royal College of Physicians, London, I very much welcome this framework for Operational Standards and Competencies for Critical Care Outreach, which has been developed by the National Outreach Forum (NORF). We all recognise the importance of delivering fast and efficient critical care to acutely ill patients to improve their outcomes in our hospitals.
A key principal underlying our recent development of the NEWS was the importance of standardisation to ensure high quality acute care wherever and whenever it is delivered. Likewise, this framework from the National Outreach Forum sets out to standardise the approach of critical care outreach services across the NHS.
This will provide guidance and a much needed template for teams with the ultimate objective of improving outcomes for those patients with acute illness. I was particularly pleased to see the emphasis on the importance of the necessity, and 24/7 availability of ‘Outreach’ and Acute Care Teams in all organisations, which melds in a timely way with the NEWS recommendations and will be essential to deliver some of the key elements of the clinical response.
What is clear is that professionals across all clinical disciplines recognise what is important to deliver a step wise change in the quality and consistency of acute clinical care in our hospitals with the ultimate objective of improving patient outcomes. The challenge, as ever, is to take the good words into clinical practice and implement these recommendations.
Dr Bryan Williams MD FRCP FAHA Professor of Medicine, University College London, Chairman, National Early Warning Score Development Group, Royal College of Physicians London
National Outreach Forum I Operational Standards and Competencies for Critical Care Outreach Services4 National Outreach Forum I Operational Standards and Competencies for Critical Care Outreach Services
Introduction
This guidance is aimed at providing a standardised framework for the implementation and delivery of Critical Care Outreach Services and Acute Care teams across the United Kingdom.
The creation of this framework has been clinically led, is evidence based where possible and reflects current national practice and thinking.
This guidance was ratified at the National Outreach Forum 6th AGM on 4th November 2011 and has been endorsed by Dr Bob Winter, Intensive Care Society President and Professor Bryan Williams, Chair of the National Early Warning Scoring Design and Implementation Group - NEWSDIG, and Chris Roseveare
The framework covers the seven core elements of Comprehensive Critical Care Outreach: PREPARE and outlines the desired requirements for each element.
The aim is to provide a nationally recognised framework that will assist existing and newly developing services. It is anticipated that a standardised approach will improve equity of access and quality of care as well as providing guidance to assist teams achieve their aspirations for service development.
5National Outreach Forum I Operational Standards and Competencies for Critical Care Outreach Services
National Outreach Forum
Operational Standards and Competencies for Critical Care Outreach Services
1. NOrF Mission Statement and Purpose
1. To optimise the quality of the patients treatment, care and experience
2. To provide a representative forum for Critical Care Outreach Service providers and recipients across the country.
3. To meet the Department of Health’s objectives for critical and acute care, and to ensure there is a strategic approach to delivery of Critical Care Outreach Services nationally, which reflects that of the National Strategy and those of the Critical Care Networks.
4. To underpin Critical Care Outreach practice and service development with the best evidence where it is available.
2. Definition
Comprehensive Critical Care Outreach (3CO) can be defined as “a multidisciplinary organisational approach to ensure safe, equitable and quality care for all acutely unwell, critically ill and recovering patients irrespective of location or pathway”
3. Core Elements of Comprehensive Critical Care Outreach (3CO) as a continuum is exemplified by 7 core elements:
• Patient Track and Trigger
• Rapid response
• Education, training and support
• Patient safety and clinical governance
• Audit and evaluation; monitoring of patient outcome and continuing quality care
• Rehabilitation after critical illness (RaCI)
• Enhancing service delivery
National Outreach Forum I Operational Standards and Competencies for Critical Care Outreach Services6 National Outreach Forum I Operational Standards and Competencies for Critical Care Outreach Services
4. Introduction
This document sets out an operational framework of standards and competencies for Critical Care Outreach and Acute Care Team Services. It responds to calls from National Outreach Forum (NOrF) members to provide a national document to standardise and benchmark existing services, to enable equity of access, and to provide guidance on future service development. The framework has been developed in a “RAG” rating format to allow users to self assess their service against the national recommendations thereby identifying areas that they may wish to develop.
RED — Not achieved and no current plans to review
AMBER — Partial provision and/or currently under development
GREEN — Fully achieved
5. Background
The introduction of Critical Care Outreach Services (CCOS) was recommended in Comprehensive Critical Care (2000) in response to the growing body of evidence demonstrating failure to recognise, and respond to obvious physiological deterioration. The aim was to ensure patients received timely intervention regardless of location, with Outreach staff sharing critical care skills with ward based colleagues to improve recognition, intervention and outcome. Subsequently there have been further recommendations for the implementation of CCOS inclusive of the Intensive Care Society (ICS) 2002, NOrF 2003, NCEPOD 2005 and the Critical Care Stakeholder Forum (CCSF) 2005.
In the absence of a national strategy for their implementation, CCOS and team configurations have developed on an ad hoc basis dependent upon perceived local need and resources available. Additionally, the level of investment in education and preparation of Outreach personnel also varies between organisations. The underpinning purpose of this document is therefore to re-address the absence of national guidance and provide a standardised operational framework of standards and competencies for Critical Care Outreach, Acute Care and Rapid Response Teams, whilst recognising the organisational links required with other hospital providers to facilitate provision of a robust 24hr service.
7National Outreach Forum I Operational Standards and Competencies for Critical Care Outreach Services
6. Origins of the Standards and Competencies Framework
This work has been led by the National Outreach Forum (NOrF) Executive Board in consultation with multidisciplinary expert members of NOrF. The document draws together the numerous statements and recommendations that have been published over the last 10 years and is set out using the PREPARE acronym which exemplifies the seven core elements of Comprehensive Critical Care Outreach (3CO).
Core Elements of Comprehensive Critical Care Outreach (3CO) as a continuum is exemplified by 7 core elements
RED AMBER GREENQUALIFYING
NOTES
Patient Track and Trigger
Rapid response
Education, training and support
Patient safety and clinical governance
Audit and evaluation
Rehabilitation after critical illness (RaCI)
Enhancing service delivery
National Outreach Forum I Operational Standards and Competencies for Critical Care Outreach Services8 National Outreach Forum I Operational Standards and Competencies for Critical Care Outreach Services
RED
AM
BER
GRE
ENQ
UA
LIFY
ING
N
OT
ES
1. P
atie
nt T
rack
and
Tri
gger
1.1.
Tru
st w
ide
use
of N
EWS
or a
loca
lly v
alid
ated
Tra
ck a
nd T
rigge
r sy
stem
that
al
low
s ra
pid
dete
ctio
n of
the
signs
of e
arly
clin
ical
det
erio
ratio
n in
all
adul
t pa
tient
s ov
er 1
6yrs
, exc
ept p
regn
ant w
omen
& th
ose
requ
iring
pal
liativ
e ca
re (N
CEP
OD
, RC
P, N
OrF
)
1.2.
The
Tra
ck a
nd T
rigge
r sy
stem
sho
uld
incl
ude
the
follo
win
g ph
ysio
logi
cal
para
met
ers:
HR,
SBP
, RR,
Tem
p, S
aO2,
and
AVP
U. (
NIC
E C
G50
, RC
P, N
OrF
). O
ther
‘sta
nd a
lone
’ par
amet
ers
may
be
used
alo
ng s
ide
the
chos
en
trac
k an
d tr
igge
r sy
stem
. e.g
. Urin
e O
utpu
t
1.3.
Vita
l obs
erva
tions
with
a to
tal N
EWS/
EWS/
MEW
S s
core
sho
uld
be
unde
rtak
en a
min
imum
of 1
2 ho
urly,
with
esc
alat
ion
in fr
eque
ncy
of
reco
rdin
g as
par
t of a
n ag
reed
Tru
st w
ide
grad
ed r
espo
nse.
1.4.
Phy
siolo
gica
l obs
erva
tions
sho
uld
be u
nder
take
n an
d re
cord
ed b
y st
aff t
hat
have
bee
n ap
prop
riate
ly tr
aine
d an
d as
sess
ed a
s co
mpe
tent
in m
onito
ring,
m
easu
rem
ent,
and
inte
rpre
tatio
n.
2. R
apid
Res
pons
e
2.1.
Tr
ust w
ide
use
of a
gra
ded
clin
ical
res
pons
e st
rate
gy c
onsis
ting
of 3
leve
ls (lo
w, m
ediu
m, &
hig
h) (R
CP,
NIC
E 20
07)
2.2.
Ea
ch le
vel o
f res
pons
e sh
ould
det
ail w
hat i
s re
quire
d fro
m s
taff
in te
rms
of
obse
rvat
iona
l fre
quen
cy, s
kills
and
com
pete
nce,
inte
rven
tiona
l the
rapi
es a
nd
seni
or c
linic
al in
volv
emen
t.
2.3.
It
shou
ld d
efine
the
spee
d/ur
genc
y of
res
pons
e, in
clud
ing
a cl
ear
esca
latio
n po
licy
to e
nsur
e th
at a
n ap
prop
riate
res
pons
e al
way
s oc
curs
and
is a
vaila
ble
24/7
.
2.4.
W
ho r
espo
nds,
i.e.
the
seni
ority
and
clin
ical
com
pete
ncie
s of
the
resp
onde
r/s
2.5.
Th
e ap
prop
riate
set
tings
for
on g
oing
car
e in
clud
ing
acce
ss to
mon
itorin
g eq
uipm
ent a
nd c
ritic
al c
are.
2.6.
Th
e fre
quen
cy o
f sub
sequ
ent c
linic
al m
onito
ring
9National Outreach Forum I Operational Standards and Competencies for Critical Care Outreach Services
RED
AM
BER
GRE
ENQ
UA
LIFY
ING
N
OT
ES
3. E
duca
tion
Tra
inin
g an
d S
uppo
rt
Cri
tica
l Car
e O
utre
ach
Pers
onne
l
3.1.
Ea
ch o
rgan
isatio
n sh
ould
ens
ure
patie
nts
rece
ive
care
from
app
ropr
iate
ly
trai
ned
Crit
ical
Car
e O
utre
ach
/ Acu
te C
are
Team
/ R
apid
Res
pons
e
Team
per
sonn
el
3.2.
Le
ad P
ract
ition
er s
houl
d ha
ve a
pos
tgra
duat
e qu
alifi
catio
n in
crit
ical
ca
re /
acu
te c
are
3.3.
Se
nior
pra
ctiti
oner
s id
eally
with
a m
inim
um o
f 3 y
ears
crit
ical
/acu
te c
are
expe
rienc
e sh
ould
del
iver
the
Out
reac
h se
rvic
e.
Team
s m
ay c
onsis
t of
nu
rses
, ph
ysio
ther
apist
s, d
octo
rs a
nd o
ther
hea
lthca
re p
rofe
ssio
nals.
3.4.
Al
l Crit
ical
Car
e O
utre
ach
/ Acu
te C
are
Team
/ R
apid
Res
pons
e Te
am
prac
titio
ners
sho
uld
poss
ess
a cl
inic
ally
rel
evan
t po
st b
asic
qua
lifica
tion
and
idea
lly b
e w
orki
ng t
owar
ds a
n M
Sc in
clin
ical
pra
ctic
e or
equ
ival
ent
rele
vant
clin
ical
mod
ules
3.5.
Th
ere
mus
t be
a d
ocum
ente
d m
anda
tory
ind
uctio
n pr
ogra
mm
e fo
r al
l ne
w s
taff
mem
bers
to
the
outr
each
tea
m.
An a
gree
d le
arni
ng c
ontr
act
to in
clud
e an
nual
com
pete
ncy
base
d as
sess
men
t of
cor
e an
d ad
ditio
nal
spec
ific
com
pete
ncie
s
3.6.
Th
e re
fere
nce
basis
of t
rain
ing
for
Crit
ical
Car
e O
utre
ach
/ Acu
te C
are
Team
/ R
apid
Res
pons
e Te
am p
erso
nnel
sho
uld
be d
irect
ed b
y th
e D
H
Com
pete
ncie
s fo
r re
cogn
ising
and
res
pond
ing
to a
cute
ly il
l pat
ient
s in
ho
spita
l (20
07).
3.7.
Al
l Crit
ical
Car
e O
utre
ach
/ Acu
te C
are
Team
/ R
apid
Res
pons
e Te
am
pers
onne
l mus
t be
trai
ned
and
asse
ssed
as
com
pete
nt to
func
tion
at a
m
inim
um o
f prim
ary
resp
onde
r le
vel,
(som
e m
ay d
evel
op p
artic
ular
ski
lls
to fa
cilit
ate
func
tioni
ng a
t a s
econ
dary
res
pond
er le
vel)
3.8.
Ea
ch p
ract
ition
er m
ust
be a
ble
to:-
Per
form
a c
ompr
ehen
sive
phys
ical
ex
amin
atio
n an
d de
mon
stra
te t
he a
bilit
y to
rec
ogni
se n
orm
al,
devi
atio
n fro
m n
orm
al fi
ndin
gs in
rel
atio
n to
the
follo
win
g sy
stem
s Ai
rway
, Re
spira
tory
, C
ardi
ovas
cula
r, G
astr
oint
estin
al,
Rena
l, N
euro
logi
cal
and
Endo
crin
e
National Outreach Forum I Operational Standards and Competencies for Critical Care Outreach Services10 National Outreach Forum I Operational Standards and Competencies for Critical Care Outreach Services
RED
AM
BER
GRE
ENQ
UA
LIFY
ING
N
OT
ES
3.9.
As
sess
and
pro
vide
firs
t lin
e tr
eatm
ent
for
a pa
tient
with
acu
te o
r
deve
lopi
ng c
ritic
al il
lnes
s an
d th
ose
requ
iring
em
erge
ncy
assis
tanc
e of
ab
ove
syst
ems
incl
udin
g se
psis
3.10
. Pro
vide
bas
ic,
imm
edia
te a
nd a
dvan
ced
life-s
uppo
rt i
n ac
cord
ance
with
th
e le
vel o
f res
pons
e de
liver
ed.
3.11
. Rec
ogni
se s
ituat
ions
whe
re c
onsid
erat
ion
for
with
draw
al o
f tre
atm
ent
shou
ld b
e gi
ven
and
initi
ate
revi
ew b
y ap
prop
riate
med
ical
sta
ff, p
allia
tive
care
or
end
of li
fe te
ams.
3.12
. Pro
vide
effe
ctiv
e le
ader
ship
and
sup
port
for
criti
cal c
are
team
s an
d w
ard
staf
f whe
n ca
ring
for
acut
ely
ill w
ard
patie
nts
with
dev
elop
ing
criti
cal i
llnes
s
3.13
. Ens
ure
safe
tra
nsfe
r an
d tr
ansp
ort
of th
e ac
utel
y ill
patie
nt.
Idea
lly s
taff
unde
rtak
ing
intr
a an
d in
ter
hosp
ital t
rans
fers
sho
uld
have
rec
eive
d fo
rmal
tr
aini
ng in
this
skill.
(IC
S 20
11).
3.14
. Und
erst
and
clin
ical
lim
itatio
ns,
and
enab
le d
irect
ref
erra
l to
othe
r
mem
bers
of t
he m
ultid
iscip
linar
y sp
ecia
list
team
incl
udin
g Ph
ysio
ther
apy,
Pa
in t
eam
, D
iete
tics,
Spe
ech
and
Lang
uage
The
rapi
st, P
sych
olog
ist.
In a
ddit
ion
to D
H C
ompe
tenc
ies
for
reco
gnis
ing
and
resp
ondi
ng t
o ac
utel
y ill
pat
ient
s in
hos
pita
l (20
07),
sp
ecifi
c an
d re
gula
rly
dem
onst
rate
d co
mpe
tenc
ies
shou
ld id
eally
incl
ude
(NO
rF 2
003/
11):
3.15
. Per
form
and
inte
rpre
t cl
inic
al fi
ndin
gs o
n ch
est
and
abdo
men
au
scul
tatio
n
3.16
. Ini
tiate
labo
rato
ry c
linic
al t
ests
, ob
tain
blo
od v
ia v
enep
unct
ure
and
co
rrec
tly in
terp
ret
resu
lts:
Bioc
hem
istry
, H
aem
atol
ogy,
Coa
gula
tion
scre
enin
g
11National Outreach Forum I Operational Standards and Competencies for Critical Care Outreach Services
RED
AM
BER
GRE
ENQ
UA
LIFY
ING
N
OT
ES
3.17
. Pre
pare
for
and
carr
y ou
t int
rave
nous
can
nula
tion.
3.18
. Rec
ord
and
inte
rpre
t el
ectr
ocar
diog
raph
(EC
G)
3.19
. Ass
ess
the
indi
vidu
al’s
leve
l of c
onsc
ious
ness
, ut
ilisin
g AV
PU, G
lasg
ow
Com
a Sc
ale.
3.20
. Obt
ain
arte
rial b
lood
gas
sam
ple
and
dem
onst
rate
abi
lity
to in
terp
ret
resu
lts/r
ecog
nise
dev
iatio
n fro
m n
orm
al a
nd r
epor
t an
d tr
eat a
ccor
ding
ly.
3.21
. Req
uest
and
inte
rpre
t ra
diol
ogic
al e
xam
inat
ion
e.g.
che
st X
ray
, ab
dom
inal
X r
ay.
3.22
. Per
form
hae
mod
ynam
ic m
onito
ring
to o
btai
n ph
ysio
logi
cal m
easu
rem
ents
: co
ntin
uous
ele
ctro
card
iogr
aph,
cen
tral
ven
ous
pres
sure
and
art
eria
l pr
essu
re m
onito
ring
3.23
. Rec
ogni
se i
ndic
atio
ns f
or o
xyge
n th
erap
y an
d se
lect
app
ropr
iate
dev
ice
for
adm
inist
ratio
n of
oxy
gen
ther
apy.
3.24
. Adm
inist
er o
xyge
n th
erap
y at
rat
e an
d co
ncen
trat
ion
as p
resc
ribed
or
as
per
patie
nt g
roup
dire
ctiv
e.
3.25
. Est
ablis
h N
on-In
vasiv
e Ve
ntila
tion
Ther
apy
on p
atie
nts
in r
espi
rato
ry
failu
re a
nd a
ssist
in s
ubse
quen
t m
anag
emen
t.
3.26
. Adm
inist
er i
ntra
veno
us fl
uids
as
per
patie
nt g
roup
dire
ctiv
e / o
r as
an
inde
pend
ent
pres
crib
er
3.27
. Pos
sess
and
dem
onst
rate
effe
ctiv
e co
mm
unic
atio
n sk
ills fa
cilit
atin
g cl
ear
goal
set
ting
betw
een
all l
evel
s of
the
mul
ti-di
scip
linar
y te
am,
patie
nts
and
signi
fican
t ot
hers
.
3.28
. Use
of e
ffect
ive
com
mun
icat
ion
tool
s by
all
staf
f e.g
. RSV
P, SB
AR
3.29
. Doc
umen
t and
com
mun
icat
e cl
ear
patie
nt m
onito
ring
plan
s in
med
ical
not
es
3.30
. Pos
sess
and
dem
onst
rate
effe
ctiv
e ab
ility
to m
anag
e co
nflic
t an
d br
eaki
ng
bad
new
s
National Outreach Forum I Operational Standards and Competencies for Critical Care Outreach Services12 National Outreach Forum I Operational Standards and Competencies for Critical Care Outreach Services
RED
AM
BER
GRE
ENQ
UA
LIFY
ING
N
OT
ES
Add
itio
nal c
ompe
tenc
ies
may
incl
ude
all o
r so
me
of t
he fo
llow
ing
(dep
endi
ng o
n or
gani
sati
onal
clin
ical
nee
d).
3.31
. Per
form
ver
ifica
tion
of e
xpec
ted
deat
h w
here
DN
ACPR
ord
er in
pla
ce
3.32
. Per
form
mal
e an
d fe
mal
e ur
inar
y ca
thet
erisa
tion.
3.33
. Ass
ist w
ith c
entr
al li
ne in
sert
ion
and
asse
ssm
ent o
f nee
d
3.34
. Und
erta
ke N
on-M
edic
al p
resc
ribin
g
3.35
. Ass
ist w
ith n
octu
rnal
res
pira
tory
sup
port
.
3.36
. Ass
ist w
ith in
tra
hosp
ital t
rans
fers
of p
atie
nts
requ
iring
add
ition
al te
sts
or
inte
rven
tion
3.37
. Ass
ist w
ith e
mer
genc
y tr
ans-
thor
acic
pac
ing
3.38
. Be
able
to a
sses
s pa
tient
s fo
r an
d un
dert
ake
chan
ging
of t
rach
eost
omy
tube
s, in
sert
ion
of m
ini t
rach
eost
omie
s an
d de
cann
ulat
ion.
Hos
pita
l / W
ard
Bas
ed P
erso
nnel
3.39
. Eac
h or
gani
satio
n sh
ould
pro
vide
acc
essib
le e
duca
tiona
l sup
port
for
re
gist
ered
and
non
-reg
ister
ed w
ard
staf
f in
carin
g fo
r th
e ac
utel
y ill
war
d pa
tient
in li
ne w
ith r
ecor
der
and
first
res
pond
er le
vel o
utlin
ed in
DH
co
mpe
tenc
ies
for
reco
gnisi
ng a
nd r
espo
ndin
g to
acu
tely
ill p
atie
nts
in
hosp
ital (
2007
).
3.40
. All
staf
f sho
uld
be tr
aine
d in
the
loca
lly u
sed
Trac
k an
d Tr
igge
r sy
stem
and
be
awar
e of
and
be
able
to in
stig
ate
the
refe
rral
pro
cess
.
3.41
. Clin
ical
com
pete
ncie
s sh
ould
be
cons
ider
ed d
epen
dent
on
serv
ice
pr
ovisi
on a
nd s
enio
r su
ppor
t ava
ilabl
e, w
ith a
nnua
l mon
itorin
g vi
a th
e
appr
aisa
l / P
ADR
syst
em
3.42
. Clin
ical
com
pete
ncie
s fo
r m
edic
al s
taff
shou
ld b
e as
sess
ed r
egul
arly
by
seni
or c
linic
ians
3.43
. Acc
urat
e re
cord
of n
urse
trai
ning
mai
ntai
ned
in r
elat
ion
to A
cute
Car
e
com
pete
ncie
s fo
r bo
th r
egist
ered
and
non
-reg
ister
ed n
urse
s / p
ract
ition
ers
13National Outreach Forum I Operational Standards and Competencies for Critical Care Outreach Services
RED
AM
BER
GRE
ENQ
UA
LIFY
ING
N
OT
ES
4. P
atie
nt S
afet
y an
d C
linic
al G
over
nanc
e
4.1.
Ea
ch o
rgan
isatio
n sh
ould
del
iver
the
sev
en c
ore
elem
ents
of
Com
preh
ensiv
e C
ritic
al C
are
Out
reac
h (3
CO
) PR
EPAR
E.
4.2.
Ea
ch o
rgan
isatio
n m
ust
have
a c
lear
ly
defin
ed r
efer
ral s
trat
egy
incl
udin
g C
ritic
al C
are
Out
reac
h / A
cute
Car
e Te
am /
Rap
id R
espo
nse
Team
ser
vice
to
sup
port
acu
tely
ill p
atie
nt a
ctiv
ity 2
4 ho
urs
7 da
ys p
er w
eek
4.3.
M
edic
al s
taff
with
crit
ical
car
e tr
aini
ng m
ust
be a
vaila
ble
to s
uppo
rt th
e gr
aded
res
pons
e
4.4.
Pr
ovisi
on o
f con
tinuo
us b
edsid
e su
ppor
t av
aila
ble
to w
ard
base
d st
aff
whe
n ne
cess
ary
(CC
SF).
4.5.
Ea
ch o
rgan
isatio
n m
ust
have
a c
lear
Ope
ratio
nal
Polic
y fo
r C
ritic
al C
are
Out
reac
h / A
cute
Car
e Te
am /
Rap
id R
espo
nse
Team
tha
t del
inea
tes
the
team
’s re
mit
and
incl
udes
the
sev
en c
ore
elem
ents
of c
ompr
ehen
sive
criti
cal c
are
outr
each
(3C
O)
PREP
ARE.
Th
is sh
ould
be
ratifi
ed a
t Tru
st
Boar
d le
vel.
4.6.
O
pera
tiona
l pol
icy
shou
ld in
clud
e ex
plic
it gu
idan
ce o
n pa
tient
ref
erra
l to
the
team
and
ref
erra
l ont
o ot
her
mul
tidisc
iplin
ary
prof
essio
nals
4.7.
C
onsid
er T
rust
wid
e in
trod
uctio
n of
pat
ient
or
care
r ac
tivat
ed c
alls
to th
e C
ritic
al C
are
Out
reac
h Te
am.
4.8.
Ea
ch te
am s
houl
d ha
ve a
sys
tem
atic
app
roac
h to
pol
icy
prot
ocol
de
velo
pmen
t and
rev
iew
util
ising
nat
iona
l and
loca
l gui
danc
e, a
nd
agre
ed b
y go
vern
ing
body
with
in th
e Tr
ust
4.9.
Al
l nat
iona
l sta
ndar
ds s
houl
d be
follo
wed
whi
ch r
elat
e to
the
acut
ely
ill pa
tient
(whe
re a
ppro
pria
te).
4.10
. Eac
h te
am s
houl
d ha
ve a
sys
tem
in p
lace
for
repo
rtin
g, in
vest
igat
ing
and
lear
ning
from
adv
erse
inci
dent
s an
d ne
ar m
isses
. Th
is sh
ould
feed
into
the
Trus
t wid
e cl
inic
al g
over
nanc
e pr
oces
s to
faci
litat
e Tr
ust w
ide
scru
tiny
of
prac
tice
(Pat
ient
Saf
ety
Firs
t 200
8).
4.11
. Eac
h te
am s
houl
d re
gula
rly p
artic
ipat
e in
spe
cial
ity b
ased
mor
talit
y &
m
orbi
dity
mee
tings
(NC
EPO
D)
National Outreach Forum I Operational Standards and Competencies for Critical Care Outreach Services14 National Outreach Forum I Operational Standards and Competencies for Critical Care Outreach Services
RED
AM
BER
GRE
ENQ
UA
LIFY
ING
N
OT
ES
5. A
udit
and
Eva
luat
ion;
Mon
itor
ing
of P
atie
nt O
utco
mes
and
Con
tinu
ing
Qua
lity
of C
are.
Idea
lly a
ll C
riti
cal C
are
Out
reac
h Te
ams
to p
arti
cipa
te in
the
“N
atio
nal C
riti
cal C
are
Out
reac
h A
ctiv
ity
Out
com
e
Dat
a S
et”
(NO
rF 2
011)
. Ess
enti
al m
onth
ly d
ata
colle
ctio
n sh
ould
incl
ude:
5.1.
N
umbe
r of
inp
atie
nt c
alls
to th
e ca
rdia
c ar
rest
team
5.2.
C
ritic
al c
are
“Fol
low
-ups
”
5.3.
N
umbe
r of
indi
vidu
al p
atie
nts
follo
wed
up
afte
r cr
itica
l car
e di
scha
rge
5.4.
N
umbe
r of
clin
ical
rev
iew
s (v
isits
) for
pat
ient
s fo
llow
ed u
p af
ter
criti
cal c
are
disc
harg
e
5.5.
Ea
rly r
e-ad
miss
ions
to c
ritic
al c
are
(with
in 4
8 hr
s of
disc
harg
e).
5.6.
In
Pat
ient
s -
eith
er in
crit
ical
car
e or
bei
ng fo
llow
ed u
p af
ter
criti
cal c
are
(tr
igge
rs o
r re
ferr
als)
5.7.
N
umbe
r of
cal
ls to
Out
reac
h
5.8.
N
umbe
r of
indi
vidu
al in
patie
nts
refe
rred
to O
utre
ach
5.9.
N
umbe
r of
indi
vidu
al p
atie
nts
atte
nded
by
Out
reac
h
5.10
. Num
ber
of c
linic
al r
evie
ws
(visi
ts) f
or n
on-c
ritic
al c
are
refe
rred
pat
ient
s
Des
irab
le m
onth
ly d
ata
colle
ctio
n sh
ould
incl
ude:
5.11
. Hos
pita
l sta
ndar
dise
d m
orta
lity
ratio
.
5.12
. Med
ian
Out
reac
h re
spon
se t
ime.
5.13
. Med
ian
“Sco
re–2
–doo
r” t
ime.
Ogl
esby
et a
l (20
11)
5.14
. Med
ian
leng
th o
f sta
y (s
urvi
vors
pos
t cr
itica
l car
e).
5.15
. Hos
pita
l mor
talit
y am
ongs
t cr
itica
l car
e su
rviv
ors
5.16
. Num
ber
of m
onth
ly h
ospi
tal a
dmiss
ions
5.17
. An
audi
t of
com
plia
nce
with
per
form
ance
sta
ndar
ds m
ust
be fe
d ba
ck to
Tr
ust
Boar
ds a
nd N
etw
orks
incl
udin
g co
mpl
ianc
e w
ith C
G50
15National Outreach Forum I Operational Standards and Competencies for Critical Care Outreach Services
RED
AM
BER
GRE
ENQ
UA
LIFY
ING
N
OT
ES
5.18
. Eac
h tr
ust
shou
ld d
evel
op a
n au
dit
tool
to a
sses
s ut
ilisat
ion
of th
eir
Tr
ack
and
Trig
ger
and
gra
ded
resp
onse
sys
tem
w
ith c
lear
gov
erna
nce
proc
edur
es f
or a
ctio
n of
poo
r co
mpl
ianc
e tr
ust
wid
e
5.19
. Und
erta
ke a
nnua
l pat
ient
& c
arer
sat
isfac
tion
surv
eys
(CC
SF)
6. R
ehab
ilita
tion
aft
er C
riti
cal I
llnes
s (F
ollo
w-u
p)
6.1.
Th
is m
ay b
e un
dert
aken
by
diffe
rent
tea
ms
loca
lly b
ut th
e pr
oces
s m
ust
incl
ude
com
plia
nce
with
the
NIC
E 83
gui
delin
es “
Reha
bilit
atio
n af
ter
a pe
riod
of c
ritic
al il
lnes
s” e
nsur
ing
reha
bilit
atio
n an
d tr
aditi
onal
med
ical
and
nu
rsin
g ca
re a
re a
ligne
d.
6.2.
Ea
ch T
rust
mus
t ha
ve a
reh
abilit
atio
n po
st c
ritic
al il
lnes
s pa
thw
ay /
op
erat
iona
l po
licy.
The
se s
houl
d re
flect
the
NIC
E 83
gui
danc
e w
ith
clea
r lin
es o
f acc
ount
abilit
y, b
ut b
e re
leva
nt a
nd a
chie
vabl
e w
ithin
the
ir
orga
nisa
tion.
Th
is sh
ould
be
alig
ned
to th
e N
etw
ork
wid
e R
aCI p
athw
ay
whe
re o
ne e
xist
s
6.3.
Al
l org
anisa
tions
mus
t in
volv
e an
exp
ert
patie
nt o
r pa
tient
adv
isor
grou
ps
e.g.
ICU
Ste
ps in
des
igni
ng,
form
ulat
ing
and
revi
ewin
g lo
cal g
uida
nce
6.4.
Ea
ch T
rust
sho
uld
prov
ide
regu
lar
audi
ts (
min
imum
ann
ually
) th
at m
easu
re
the
com
plia
nce
with
CG
83 r
ehab
ilitat
ion
follo
win
g cr
itica
l illn
ess,
re
view
ing
and
adap
ting
serv
ice
deliv
ery
as r
equi
red
6.5.
Ea
ch o
rgan
isatio
n sh
ould
pro
vide
aw
aren
ess
trai
ning
, ed
ucat
iona
l sup
port
an
d su
perv
ision
or
men
torin
g fo
r re
gist
ered
and
non
reg
ister
ed w
ard
staf
f in
the
requ
irem
ents
and
hol
istic
app
roac
h to
reh
abilit
atin
gthe
crit
ical
ly il
l pa
tient
6.6.
C
linic
al e
xper
ts s
houl
d de
vise
the
reh
abilit
atio
n pl
ans
for
patie
nts
es
tabl
ishin
g cl
ear
time
orie
ntat
ed in
terv
entio
ns t
hat c
an b
e fo
llow
ed a
nd
impl
emen
ted
by a
ll w
ard
staf
f who
hol
d th
e co
mpe
tenc
ies
to fu
lfil t
hese
re
quire
men
ts.
National Outreach Forum I Operational Standards and Competencies for Critical Care Outreach Services16 National Outreach Forum I Operational Standards and Competencies for Critical Care Outreach Services
RED
AM
BER
GRE
ENQ
UA
LIFY
ING
N
OT
ES
7. E
nhan
cing
Ser
vice
Del
iver
y
Sta
ffing
Req
uire
men
ts
7.1.
Se
para
tely
ros
tere
d C
ritic
al C
are
Out
reac
h te
am a
vaila
ble
24 h
ours
per
day
, 7
days
a w
eek
(NC
EPO
D, C
CSF
, NO
rF).
7.2.
Su
fficie
nt s
taff
to d
eliv
er 3
CO
/ PR
EPAR
E 24
hou
rs p
er d
ay, 7
day
s pe
r w
eek
7.3.
C
ritic
al C
are
Out
reac
h te
am s
uppo
rt b
y se
ssio
nal c
omm
itmen
t fro
m
Con
sulta
nt In
tens
ivist
or
Con
sulta
nt in
Acu
te C
are
Med
icin
e
7.4.
Sh
ared
trai
nee
med
ical
sta
ff w
ith c
ritic
al c
are
units
and
acu
te c
are
who
hav
e no
res
pons
ibilit
ies
othe
r th
an th
ose
dire
ctly
rel
ated
to p
rovi
ding
the
grad
ed
resp
onse
7.5.
Se
nior
Phy
sioth
erap
ist w
ith s
essio
nal c
omm
itmen
t to
Crit
ical
Car
e O
utre
ach
suffi
cien
t to
follo
w u
p pa
tient
s di
scha
rged
from
crit
ical
car
e an
d re
ceiv
e
appr
opria
te r
efer
rals.
7.6.
Al
lied
heal
th p
rofe
ssio
nals
(pha
rmac
y, d
iete
tics,
spe
ech
and
lang
uage
and
oc
cupa
tiona
l th
erap
y) a
vaila
ble
for
Crit
ical
Car
e O
utre
ach
refe
rral
s
Org
anis
atio
n
7.7.
N
omin
ated
lea
d of
ser
vice
at T
rust
Boa
rd le
vel w
ith a
ppro
pria
te
com
mun
icat
ion
casc
ade
(Com
preh
ensiv
e C
ritic
al C
are
DH
200
0).
7.8.
Le
ad M
edic
al C
onsu
ltant
with
a q
ualifi
catio
n in
eith
er in
tens
ive
care
or
acut
e ca
re s
peci
ality
to
supp
ort
serv
ice
deve
lopm
ent
and
deliv
ery.
7.9.
Le
ad P
ract
ition
er a
nd C
onsu
ltant
int
egra
l to
Crit
ical
Car
e D
eliv
ery
Gro
up
to fa
cilit
ate
Trus
t w
ide
disc
ussio
n on
acu
te c
are
war
d ba
sed
issue
s.
17National Outreach Forum I Operational Standards and Competencies for Critical Care Outreach Services
RED
AM
BER
GRE
ENQ
UA
LIFY
ING
N
OT
ES
7.10
. Mec
hani
sms
in p
lace
to
ensu
re fu
ll en
gage
men
t of
war
d ba
sed
colle
ague
s (e
.g. “
Link
Nur
se S
yste
m”)
.
7.11
. Mec
hani
sms
in p
lace
to
ensu
re v
iew
s an
d op
inio
ns o
f pat
ient
s an
d ca
res
are
refle
cted
in s
ervi
ce d
evel
opm
ent.
7.12
. Ful
l eng
agem
ent
with
reg
iona
l Crit
ical
Car
e N
etw
ork
7.13
. Crit
ical
Car
e O
utre
ach
/ Acu
te C
are
/ Rap
id R
espo
nse
Team
s sh
ould
re
gula
rly r
evie
w s
ervi
ce p
rovi
sion
to fa
cilit
ate
proa
ctiv
e ap
proa
ches
in
or
der
to m
atch
ser
vice
con
figur
atio
n ag
ains
t lo
cal d
eman
ds.
The
se
shou
ld b
e re
flect
ed in
the
oper
atio
nal
polic
y
National Outreach Forum I Operational Standards and Competencies for Critical Care Outreach Services18 National Outreach Forum I Operational Standards and Competencies for Critical Care Outreach Services
Advisory Contributors
Caroline Barclay Critical Care Outreach Lead,
University Hospitals of Leicester NHS Foundation Trust
Carmel Gordon-Dark
Critical Care Outreach Sister
The London Clinic, London
Alison Dinning Critical Care Outreach Sister,
Nottingham University Hospitals NHS Trust
Lesley Durham Network Director,
North of England Critical Care Network
Isabel Gonzalez Consultant Critical Care,
The James Cook University Hospital, Middlesbrough
Tracey Moore Senior Lecturer Head of Taught Studies,
University of Sheffield
Sarah Quinton Critical Care Outreach Lead Nurse,
Heart of England NHS Foundation Trust
Elizabeth Smith Patient Safety Manager,
Wales Patient Safety Team
Catharine Thomas Consultant Respiratory Physiotherapist,
Tameside Hospital NHS Foundation Trust
Duncan Watson Consultant Anaesthesia and Critical Care,
University Hospital of Coventry and Warwickshire
John Welch Nurse Consultant Critical Care,
University College London Hospitals
19National Outreach Forum I Operational Standards and Competencies for Critical Care Outreach Services
REFERENCES
Department of Health (2000) Comprehensive Critical Care: A Review of Adult Critical Care Services London, Department of Health http://www.doh.gov.uk/pdfs/criticalcare.pdf
Department of Health (2007) Competencies for recognising and responding to acutely ill patients in hospital http://www.doh.gov.uk/pdfs/criticalcare.pdf
Comprehensive Critical Care: A Review of Adult Critical Care Services London, Department of Health http://www.doh.gov.uk/pdfs/criticalcare.pdf
Intensive Care Society (2002) Levels of critical care for adult patients London, Intensive Care Society
Intensive Care Society (2011) Guidelines for the transport of the critically ill adult London, Intensive Care Society
National Outreach Forum 2003 Critical Care Outreach 2003: Progress in Developing Services NHS Modernisation Agency.
National Outreach Forum 2010 http://www.norf.org.uk
NCEPOD (2009) “Adding insult to injury”. A review of the care of patients who died in hospital with a primary diagnosis of acute kidney injury. National Confidential Enquiries into Patient Outcome and Death (NCEPOD), June 2009
NCEPOD (2007) A Journey in the right direction? A Report of the National Confidential Enquiry into Patient Outcome and Death London
NCEPOD (2005) “An Acute problem” - A report of the National Confidential Enquiry into Patient Outcome and Death.
NICE Clinical Guideline 50 (2007) acutely ill patients in hospital: recognition of and response to acute illness in adults in hospital London
NICE Clinical Guideline 83 (2009) Rehabilitation after critical illness London
National Patient Safety Agency (2007) Recognising and responding appropriately to early signs of deterioration in hospitalised patients London
National Patient Safety Agency (2007) safer care for the acutely ill patient; learning from serious incidents. London
Patient Safety First Campaign 2008 http://www.patientsafetyfirst.nhs.uk/content.aspx?path=/
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: Draft 3 National Stakeholder Consultation March 2011
‘Score to Door Time’ – a benchmarking tool for rapid response systems: a pilot multi- centre service evaluation Critical Care 2011 15: R180 Oglesbyk K, Durham L, Welch J, Subbe C.