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Original Article

DOI: 10.4103/2229-5151.128006 Quick Response Code:

Evaluation of critical care outreach services in a tertiary care Hospital in India: A retrospective analysis Nidhi Srivastava, Mohan Deep Kaur1, Sandeep Sharma2

ABSTRACT 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.

Department of Anaesthesiology and intensive care, Pushpanjali Crosslay Hospital, Vaishali, Gaziabad, Uttar Pradesh, 1Department of Anaesthesiology and intensive care, Post Graduate Institute of Medical Education and Research, Dr. Ram Manohar Lohia Hospital, 2 Department of Anaesthesiology, Institute of Liver and Biliary Sciences, New Delhi, India Address for correspondence: Dr. Sandeep Sharma, Senior Resident, Department of Anaesthesiology, Institute of Liver and Biliary Sciences, New Delhi. E-mail: [email protected]

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. Key Words: Appropriate calls, critical care outreach services, early warning scores, human

resource wastage

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

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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.[2,3] 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.

International Journal of Critical Illness and Injury Science | Vol. 4 | Issue 1 | Jan-Mar 2014

Evaluation of critical care outreach services

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

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 Age (years)

Standard deviation

18.45

Table 2: Sex distribution Sex

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.

Mean

45.58

Frequency

Percentage

227 173

56.8 43.2

Male Female

Table 3: Distribution of department sending the calls Department

Medicine Neurosurgery Surgery Burns and plastics Coronary care unit Obstetrics and gynecology Urology Ear, nose, and throat Orthopedics

Frequency

Percentage

263 50 47 30 2 2 4 1 1

65.8 12.5 11.8 7.5 0.5 0.5 1 0.2 0.2

Table 4: Designation of person the sending calls Designation

Senior resident Post graduate (teaching) Junior resident (non‑teaching) Intern Sister/nurse

International Journal of Critical Illness and Injury Science | Vol. 4 | Issue 1 | Jan-Mar 2014

Frequency

Percentage

106 133 80 65 16

26.5 33.2 20 16.2 4

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Evaluation of critical care outreach services 



  

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

Critical care outreach services (CCOS) is a relatively a new concept in India and is not as developed as in Western countries. Efficient utilization o...
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