Introduction

A requirement for admission to the intensive care unit (ICU) is associated with increased morbidity and mortality, and strategies to prevent critical illness are based on early recognition and treatment of disease. The aims of admission to the ICU can be to support a patient who has developed organ dysfunction or to try to prevent the development of worsening organ dysfunction in a patient at risk. As such, when caring for the unstable patient, preventing admission to ICU entails preventing early organ dysfunction, recognizing deteriorating organ dysfunction and then responding with organ support in such a way as to minimize the duration and severity of an episode of organ failure.

Although preventing admission to critical care is desirable in terms of limiting the severity of a disease process, a critical care facility may be the most suitable venue in which to intervene when a patient has shown early signs of deterioration. An example of this is a haemodynamically unstable patient who is in need of fluid therapy: although fluid administration can be carried out on a haematology ward, it can be delivered more accurately and judiciously in a critical care facility with the use of cardiac output monitoring.

Finally, one must consider whether the critical care environment has the potential to introduce risk to the patient’s care. The risk of hospital-acquired infection may be higher in a critical care facility if the same levels of source isolation found on a haematology ward are not available. As with all areas of medicine, the benefit must outweigh the risk, and a judgement will frequently need to be made regarding whether admission to critical care is likely to be of overall clinical benefit.

The role of the critical care outreach team

Since 1999, critical care outreach teams (CCOT) have proliferated in UK hospitals. Among their many responsibilities and competencies, these teams aim to help in the early recognition and prompt treatment of patients at risk of developing organ failure. The service is ordinarily staffed by nurses and doctors with critical care training, and track and trigger systems are utilized by ward staff to inform the CCOT about patients who are at risk. Similar models exist throughout the world, and although there are differences in the way such teams are run, they share the common aim of reducing the impact of critical illness on a variety of patient groups.

Interventions delivered by CCOT include haemodynamic support through fluid management, physiotherapy, respiratory support and liaison between parent medical teams and the critical care unit. The clinical evidence to support such interventions is currently lacking, despite attempts to assess the impact of CCOT on morbidity and mortality. The difficulty of conducting an RCT in this area is clear: outcome measures, such as ICU admission rates and mortality, are difficult to link to the activity of a team that provides many different interventions and other supportive actions. As such, there is little evidence in the literature that demonstrates an impact on patient mortality [1]. At the same time, the principles of early recognition and treatment of critical illness underpin CCOT, and these are principles that few would oppose.