9. Outreach

Availability of outreach services

We have earlier shown that the presence of outreach systems was variable and geographically biased towards England (Table 1). This lack of uniformity is unacceptable given the support to outreach from the Department of Health, the Intensive Care Society and the Royal College of Physicians. Unfortunately, we did not collect data concerning the availability of outreach services throughout the 24 hour period.

In addition, many hospitals did not use a track and trigger system to allow early recognition of patients who are at increased risk of death (Table 2).

This study was not designed to show any effect of outreach on outcome but has uncovered data
of interest.

Table 3 shows the time of day that patients were reviewed by critical care services for hospitals with
and without an outreach service. It can be seen that hospitals with an outreach service were more likely to highlight patients during daytime and have reduced referrals at night. This may be due to earlier recognition of deteriorating patients and would be consistent with the rational for outreach services.

The advisor groups considered the appropriateness and timeliness of admission to ICU (Tables 4
and 5). As can be seen in this study there was no measurable effect of outreach services on either variable. In a study of this size it is not surprising that no measurable effect on these domains could be shown. The effect of outreach on these variables is likely to be lessened by other factors that we have shown earlier in the report. These factors (lack of senior doctor involvement in patient management and admission decisions, delays in ICU review and admission, lack of 24 hour 7 day per week cover by outreach services) will potentially reduce the proposed benefit of outreach. However, the result that there is no measurable difference in this small study should not be interpreted as lack of evidence of benefit
of outreach.

Table 6 shows patient outcome according to the presence of an outreach service. It can be seen that there was no positive association between outreach services and outcome within this study. Again this is not surprising given the confounding factors mentioned above. In addition, it may be that hospitals with an effective outreach team will facilitate management of some patients on the ward and avoid admission to ICU. This will have the effect of increasing the severity of illness of patients admitted to ICU (by removing the less unwell patients who remain on the ward) and may worsen crude ICU mortality.

It should be noted that a large multi-centre study evaluating the utility of outreach services has been commissioned by the Department of Health and is being taken forward by the Intensive Care National Audit and Research Centre(ICNARC). Results from this study should be available in 2007.

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