Investigating the effectiveness of Critical Care Outreach Services: A systematic review

Electronic supplementary material

S.T 1: Conference abstracts searched

British Association of Critical Care Nurses conference (BACCN) / All abstracts from 1999 to 2004 published in Nursing & Critical Care
Royal College of Nursing (RCN) Critical Care Forum / All abstracts from 1999 to 2004 published in Intensive & Critical Care Nursing
Intensive Care Society (ICS) State of the Art meetings / Hard copies of all conference abstracts were searched for the years 1995 and 1997 to 2004
Intensive Care Society (ICS) Spring meetings / Hard copes of all conference abstracts were searched for the years 1995 to 2004
European Society of Intensive Care Medicine (ESICM) Annual Congress / All abstracts from 1999 to 2004 published in Intensive Care Medicine
Society of Critical Care Medicine Annual Congress / All abstracts published from 1999 to 2004 in Critical Care Medicine
National Outreach Forum (NORF) Conference on Critical Care Outreach Services / Handouts of conference presentations hand-searched from the meeting in 2004

S.T2: Included studies: quality assessment ratings, intervention & patient numbers

Included Study / Study design / Selection bias QA / Allocation bias QA / Confounders QA / Blinding QA / Data collection methods QA / Withdrawals & dropouts QA / Details of CCOS and intervention / Setting / Patient No.
Priestley (2004) 32 / RCTa / Strong / Strong / Strong / Weak / Strong / Strong / CCOS: Led by nurse consultant with a team of 'experienced nurses' providing 24 hour cover. Critical care medical support available when required.
Intervention: critical care outreach service including direct bedside clinical support, education of ward staff and use of PAR score. / England, GTHj, 800 beds / Cv= 1428 Iw= 1475
Merit (Hillman 2005) 28 / Cluster RCT / Strong / Strong / Strong / Weak / Strong / Strong / Composition of MET varied between participating centres. At least one doctor and a nurse from the emergency department or ICU.
Intervention: MET including direct bedside support and single parameter warning system / Australia: 23 public hospitals with>20,000 admissions per yr & ICU / C=11 hospitals
I= 12 hospitals
Ball (2003) 11 / UBA
b / Strong / Weak / Strong / Weak / Strong / Strong / CCOS:5 senior critical nurses led by a consultant nurse. Service available 12 hours a day.
Intervention: critical care outreach service including post critical care discharge follow-up and use of a single parameter warning system. / England, TRH k
1200 beds / C = 201 I = 269
Buist (2002) 37 / UBA / Strong / Weak / Strong / Weak / Strong / Strong / CCOS: Two doctors, 1 senior ICU nurse.
Intervention: MET including direct bedside support, education of ward staff and single parameter warning system / Australia,
MTH,l
20,000 beds (500-600 admissions to ITU per year) / C = 19, 317 I = 22,847
Bristow (2000) 36 / POC
c / Strong / Weak / Moderate / Weak / Strong / Strong / ICU registrar and senior nurse, and medical registrar in intervention hospital, which replaced existing cardiac arrest team. Compared to control hospitals where the arrest team consisted of the ICU registrar, medical registrar, and ICU or coronary care nurse. No information on availability. Intervention: MET including direct bedside support and single parameter warning system / Australia, 3 x PH m
Ranged between 380 and 530 beds / C 1 ax= 13059 C 2 a= 19545 I (MET) = 18338
Story (2004) 38 / UBA / Strong / Weak / Strong / Weak / Moderate / Strong / CCOS: A critical care nurse in addition to existing MET. Monday to Friday only. Intervention: Critical care outreach in addition to existing MET. Included follow-up of all high risk post-operative patients for the first 3 days after transfer to general wards from theatre recovery or from ICU and staff education. / Australia, ‘Large' THn, NFIo / C = 319 I = 345
Subbe (2003) 39 / UBA / Strong / Weak / Strong / Weak / Moderate / Strong / CCOS: Introduction of MEWS only.
Intervention: MEWS in medical admissions unit. / Wales, DGHp, NFI / C = 659 I = 1695
Devita (2004) 40 / UBA / Strong / Weak / Weak / Weak / Strong / Strong / CCOS: 8 members led by ICU physician, and including 2 ICU nurses, floor nurse (bedside nursing), anaesthesia or critical care member, respiratory care member and 2 physicians.
Intervention: Introduction of criteria for MET activation which increased MET activity. MET activity included direct bedside support and a single parameter warning system. / USA, TTHq
622 licensed beds / C = 143,776 I = 55,248
Leary, T (2003) 12 / UBA / Strong / Weak / Weak / Weak / Strong / Strong / CCOS: ‘Normal working hours'. No information on composition of team. Intervention: Critical care outreach service including follow-up of patients discharged from ICU / England, UHTr 1000 bed (Trust). 8 ICU beds and 6 HDU beds / C ICU = 500 HDU = 791, I ICU = 530 HDU = 825
Salamons-on (2001) 34 / QEd / Strong / Moderate / Weak / Weak / Moderate / Strong / CCOS: An intensive care registrar who leads the team with an intensive care/coronary care unit nurse, a medical registrar from emergency dept. & 2 non-clinical staff. 24 hour availability.
Intervention: MET including direct bedside support and single parameter warning system. / Australia, NTHs, 200 beds. 8 intensive care/coronary care unit / Yr 1 C = 58 I = 24, Yr 2 C = 46 I = 34, Year 3 C = 36 I =42.
Ingleby (2002) 33 * / QE / Strong / Moderate / Weak / Weak / Moderate / Strong / CCOS: Introduction of an EWS only.
Intervention: An EWS in a Medical Admissions Unit / England, TRH, NFI / C = 107 I = 235
Barnes (2003) 41 * / UBA / Strong / Weak / Weak / Weak / Moderate / Strong / CCOS: 2 senior nurse and a nurse consultant, Monday-Friday 8am-4pm. Out of hours cover by ICU senior nurse and doctors.
Intervention: Critical care outreach service including direct bedside clinical support and use of modified MEWS scoring system / England, AHst, NFI / C = 46 I = 52
Bellomo (2004) 31 $ / UBA / Strong / Weak / Weak / Weak / Moderate / Strong / CCOS: Duty intensive care fellow & designated intensive care nurse. If available, receiving medical fellow encouraged to attend. ICU specialist available if requested, from 8am-8pm. After hours, an ICU specialist was available and would attend within 15-30 mins if required.
Intervention: MET including direct bedside support and single parameter warning system. / Australia, TRH & TH, 400 beds and 21 intensive care beds / C = 1116 with 1369 operations. I = 1067 with 1313 operations
Bellomo (2003)30 / UBA / Strong / Weak / Weak / Weak / Moderate / Strong / CCOS: Duty intensive care fellow & designated intensive care nurse. If available, receiving medical fellow encouraged to attend. ICU specialist available if requested, from 8am-8pm. After hours, an ICU specialist was available and would attend within 15-30 mins if required.
Intervention: MET including direct bedside support and single parameter warning system. / Australia, TRH & TH, 400 beds and 21 intensive care beds / C = 21090 I = 20921
Durham (2004) 42 * / UBA / Strong / Weak / Weak / Weak / Moderate / Strong / CCOS: Nurse led 24 hour/ 7 day service.
Intervention: Critical care outreach service including education of ward staff, EWS/ track & trigger tool. / England, DGH, 850 beds; 8 level 3 beds, 10 level 2 beds / C (2001) = Med 13602, Surg 9195, Elderly 6820 I in 2002 = Med 15510, Surg11283, Elderly 9888, I after 2003 Med 12761, Surg 9919, Elderly 9000
Garcea (2004)43 / UBA / Strong / Weak / Weak / Weak / Moderate / Strong / CCOS: Two senior grade nurses and a consultant nurse specialist. A consultant intensivist acts as lead clinician for the team.
Intervention: Critical care outreach service including direct bedside clinical support, education of ward staff, follow-up all discharges from the ITU and HDU on a daily basis, use of a EWS/track and trigger system. / England, TH, NFI / C=547 I=833
Haji-Michael (2004)31* / BA
e / Strong / Weak / Weak / Weak / Moderate / Strong / CCOS: An adult leukaemia unit within the hospital. Critical care consultant sessions & a senior critical care nurse. No information on availability. Intervention: Critical care outreach service including post ICU follow-up, direct bedside clinical support, education of ward staff, use of MEWS. / England, OHu, Hospital has a surgical HDU, but no ICU, NFI / C adult leukaemia patients = 12 after adult leukaemia patients = 15 C gen. oncology = 10 I gen. oncology = 10
Ricketts (2004)44* / UBA / Strong / Weak / Weak / Weak / Moderate / Strong / CCOS: 4 senior intensive care nurses, consultant anaesthetist. Available 7 days/ week from 7am to 3pm. Utilising MEWS scores; Follow all ICU discharges; Dr/nurse referrals and any sick patients causing concern.
Intervention: Critical care outreach service including post ICU follow-up, direct bedside clinical support, education of ward staff, use of MEWS. / England, DGH, 400 beds and 9 intensive care beds / Unclear
Kenward (2004) 45 / UBA / Strong / Weak / Weak / Weak / Moderate / Strong / CCOS: A 24 hour, 7 day service. No information given on composition of team. Intervention: Critical care outreach service including clinical bedside support. / England, DGH,
700 beds. 6 ICU beds, 5 HDU beds & 4 CCU beds / Not stated
Norwood (2005) 29 / BA / Strong / Weak / Weak / Weak / Moderate / Strong / Respiratory physiologist and an ITU sister team. Out of hours support is provided by critical care medical team.
Intervention: A tracheostomy service including post ITU follow-up, education of ward staff. / England, TH, 8 ITU beds, 4 HDU beds, 4 level 1 beds, 83 acute surg. beds, 175 acute med. beds / C = 51 I = 119
Mercer (2004)46 / UBA / Strong / Weak / Weak / Weak / Moderate / Strong / Intervention: Critical care outreach service but little detail given. / England, NFI / C = 2843 I = 2742
Pittard (2003)10 / UBA / Moderate / Weak / Weak / Weak / Moderate / Strong / CCOS: Team of senior critical care nurses and medical staff. Available 9am-5pm, Monday to Friday.
Intervention: Critical care outreach service including direct bedside clinical support, post critical care follow-up and use of a modification of the MEWS. / England, AH, NFI / C = 328 I = 297
Goldhill (1999) 7 / QE / Moderate / Moderate / Moderate / Weak / Moderate / N/A / CCOS: ICU consultant or deputy, senior ICU nurse, & duty medical or surgical registrar.
Intervention: Patient at Risk team including direct clinical support, use of multiple parameter warning system. / England, AH, NFI, described as 'not typical' with a higher than usual no. emergency, trauma and seriously ill patients / C=28 I = 69

a Randomised controlled trial b uncontrolled before and after study c post-only controlled study d quasi-experimental study e before and after study f data reported relates only to the part of this study relevant to this review, i.e. the impact of the EWS on outcomes, g data reported relates only the part of the study relevant to this review, i.e. the impact of the MET versus no MET on outcomes h data reported relates only to the part of the study relevant to this review ie. the impact of the outreach service on outcomes i The data reported here relates only to the part of the study relevant to this review ie the impact of the MET on outcomes. j general teaching hospital k tertiary referral hospital l metropolitan teaching hospital m public hospitals n teaching hospital o no further information p district general hospital q tertiary teaching hospital r university hospital trust s non-teaching hospital t acute hospital u oncology hospital v control group of patients w group of patients that received the intervention x cardiac arrest team only

*Unpublished study $report different aspects of study reference 26

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