title: Critical care outreach referrals: a mixed-method investigative study of outcomes and experiences.
abstract: OBJECTIVE
  To explore referrals to a critical care outreach team (CCOT), associated factors around patient management and survival to discharge, and the qualitative exploration of referral characteristics (identifying any areas for service improvement around CCOT).
  
  
  METHODS
  A single-centre mixed method study in a specialist hospital was undertaken, using an explanatory design: participant selection model. In this model, quantitative results (prospective and retrospective episode of care review, including modified early warning system (MEWS), time and delay of referral and patient outcomes for admission and survival) are further explained by qualitative (interview) data with doctors and nurses referring to outreach. Quantitative data were analysed using SPSS +17 and 19, and qualitative data were analysed using grounded theory principles.
  
  
  RESULTS
  A large proportion of referrals (124/407 = 30·5%) were made by medical staff. For 97 (97/407 = 23·8%) referrals, there was a delay between the point at which patients deteriorated (as verified by retrospective record review and MEWS score triggers) and the time at when patients were referred. The average delay was 2·96 h (95% CI 1·97-3·95; SD 9·56). Timely referrals were associated with improved outcomes; however, no causal attribution can be made from the circumstances around CCOT referral. Qualitative themes included indications for referral, facilitating factors for referral, barriers to referral and consequences of referral, with an overarching core theory of reassurance. Outreach was seen as back-up and this core theory demonstrates the important, and somewhat less tangible, role outreach has in supporting ward staff to care for at-risk patients.
  
  
  CONCLUSIONS
  Mapping outreach episodes of care and patient outcomes can help highlight areas for improvement. This study outlines reasons for referral and how outreach can facilitate patient pathways in critical illness.
authors.affiliation: N Pattison, Clinical Nursing Research Fellow, CCU Outreach Office, The Royal Marsden NHS Foundation Trust, Sutton, Surrey SM2 5PT, UK. natalie.pattison@rmh.nhs.uk
authors.forename: Natalie
authors.initials: N
authors.lastname: Pattison
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Eastham
mesh_terms: D001291:Attitude of Health Personnel; D003422:Critical Care / Q000458:organization & administration*; D006801:Humans; D017063:Outcome Assessment, Health Care; D010348:Patient Care Team; D011446:Prospective Studies; D036301:Qualitative Research; D012017:Referral and Consultation / Q000706:statistics & numerical data*; D012189:Retrospective Studies; D016019:Survival Analysis; D013997:Time Factors