Ward and organisational practices to recognise and manage patient deterioration in hospital

Research has shown that patients in general hospital wards often show early signs and symptoms, such as changes in breathing and pulse, when their condition is getting worse. If treatment for these patients is delayed they could die or require admission to intensive care (ICU). It is thought that if hospital staff could identify and manage these patients earlier then there would be less deaths and ICU admissions. One way to identify and treat patients who are deteriorating is to introduce outreach services. This usually includes the introduction of an Early Warning System to record physiological observations, training of hospital staff to recognise signs or creating special teams to respond to calls when a patient is deteriorating.

This summary of a Cochrane review presents what we know from research about the effect of outreach services for patients on general hospital wards. The review found two studies which were of good quality. One study compared 12 hospitals with outreach services to 11 that did not. Another study compared 16 wards with outreach to general wards without outreach.

One of the studies showed that outreach reduced the number of hospital deaths, while the other study found no differences between hospitals with outreach and those with no outreach. It is not clear whether outreach reduces hospital deaths or ICU admissions. High quality research is needed to determine the effect of outreach services.

Authors' conclusions: 

The evidence from this review highlights the diversity and poor methodological quality of most studies investigating outreach. The results of the two included studies showed either no evidence of the effectiveness of outreach or a reduction in overall mortality in patients receiving outreach. The lack of evidence on outreach requires further multi-site RCT's to determine potential effectiveness.

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Background: 

Despite the fact that outreach and early warning systems (EWS) are an integral part of a hospital wide systems approach to improve the early identification and management of deteriorating patients on general hospital wards, the widespread implementation of these interventions in practice is not based on robust research evidence.

Objectives: 

The primary objective was to determine the impact of critical care outreach services on hospital mortality rates. Secondary objectives included determining the effect of outreach services on intensive care unit (ICU) admission patterns, length of hospital stay and adverse events.

Search strategy: 

The review authors searched the following electronic databases: EPOC Specialised Register, The Cochrane Central Register of Controlled Trials (CENTRAL) and other Cochrane databases (all on The Cochrane Library 2006, Issue 3), MEDLINE (1996-June week 3 2006), EMBASE (1974-week 26 2006), CINAHL (1982-July week 5 2006), First Search (1992-2005) and CAB Health (1990-July 2006); also reference lists of relevant articles, conference abstracts, and made contact with experts and critical care organisations for further information.

Selection criteria: 

Randomised controlled trials (RCTs), controlled clinical trials (CCTs), controlled before and after studies (CBAs) and interrupted time series designs (ITS) which measured hospital mortality, unanticipated ICU admissions, ICU readmissions, length of hospital stay and adverse events following implementation of outreach and EWS in a general hospital ward to identify deteriorating adult patients versus general hospital ward setting without outreach and EWS were included in the review.

Data collection and analysis: 

Three review authors independently extracted data and two review authors assessed the methodological quality of the included studies. Meta-analysis was not possible due to heterogeneity. Summary statistics and descriptive summaries of primary and secondary outcomes are presented for each study.

Main results: 

Two cluster-randomised control trials were included: one randomised at hospital level (23 hospitals in Australia) and one at ward level (16 wards in the UK). The primary outcome in the Australian trial (a composite score comprising incidence of unexpected cardiac arrests, unexpected deaths and unplanned ICU admissions) showed no statistical significant difference between control and medical emergency team (MET) hospitals (adjusted P value 0.640; adjusted odds ratio (OR) 0.98; 95% confidence interval (CI) 0.83 to 1.16). The UK-based trial found that outreach reduced in-hospital mortality (adjusted OR 0.52; 95% CI 0.32 to 0.85) compared with the control group.

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