Reflection on 20 years of Critical Care Outreach at the Royal Berkshire Hospital
The Critical Care Outreach team at the Royal Berkshire NHS Foundation Trust is celebrating its 20th anniversary this month. This has prompted the team to reflect on their experience and share what we have learned and achieved on our journey.
Dr Mandy Odell, Nurse Consultant for Critical Care, started a Monday to Friday (8am -4pm) Critical Care Outreach Service in April 2001 with two other colleagues. With Mandy at the forefront of developing Critical Care Outreach services locally, nationally and internationally, the team has gone from strength to strength as we have developed our experience and skills. The team was expanded in 2004 (when I joined the team) to offer a weekend service. In January 2005 we had enough team members to be one of the first in the UK to start delivering a Trust-wide 24/7 365 day a year service.
UK prescribing legislation changes made in 2006, and again in 2012 enabled more opportunities for nurses to prescribe in acute care settings. The team continued to embrace change and in 2010 we had our first outreach nurses qualify as independent nurse prescribers. This enabled us to not only suggest, but also implement plans of care, which for me personally was transformational. It ensured timely access to treatment for our patients and shifted the dynamic of our relationships with the wider multidisciplinary team for the better.
Our latest evolution in 2017 was our development of the Advanced Nurse Practitioner role in Critical Care Outreach. Five of us have trained, using the Faculty of Intensive Care Medicine Advanced Critical Care Practitioner competencies. We can manage a patient all the way through their critical care journey and support ward nursing and medical teams along the way.
I reflected on my first Outreach night shift after I joined the team; I was working on my own and contacted by a nurse to review someone she was worried about. I was confronted with a rapidly deteriorating patient who was barely breathing. I had limited help and resources available, and I was on a distant ward. I remember feeling scared and realised that it was down to me to lead the response to his deterioration. As I rapidly assessed the patient he became less conscious and I had to start assisting his ventilation with a bag-valve-mask (my hands were shaking). I managed the patient until the medical team arrived; I think they arrived reasonably quickly but it felt like an eternity. I will never forget that feeling that I had of being alone, scared, on a dark nightingale ward in the middle of the night with a very sick patient! I never imagined after that night in 2004 that I would 17 years later be intubating patients, inserting invasive lines, and transferring them for CT Scans and admission to ICU. What a journey it has been!
Concerning the future, we have used hand held ultrasound machines for many years to assist in getting intravenous access. We are now starting to use point of care ultrasound (POCUS) to augment our assessment. I became a Focused Intensive Care Echo mentor 3 years ago and we are finding that bedside lung and cardiac ultrasound can really assist with rapid assessment and treatment of our patients.
If I could give advice to someone starting in his or her Outreach career it would be that to be an effective outreach nurse your communication skills are key. Teams have to feel comfortable to refer to you. You are invited by them to review their patient, and when you are on the ward you are their guest and you need to behave in such a way that you will be invited back. Ultimately, what people remember is not what you did but how you made them feel. No amount of advanced skills and techniques can overcome that. You have to be present at the bedside to deliver the best care for your patients, and that starts with the referral.
Advanced Nurse Practitioner in Critical Care Outreach