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Call 4 Concern: the impact of a patient-and-relative-activated service

23 November 2023
Volume 32 · Issue 21


The aim of this project was to introduce and evaluate the Call 4 Concern© (C4C) service, which provides patients and relatives with direct access to critical care outreach services (CCOS). This allows patients and relatives an additional platform to raise concerns related to the clinical condition and facilitate early recognition of a deteriorating patient. The introduction of Call 4 Concern at a district general hospital was inspired by the Royal Berkshire Hospital, where staff have been pioneering the service in the UK since 2009. They were able to demonstrate the potential to prevent clinical deterioration and improve the patients' and relatives' experiences. The project was originally inspired by the Condition H(elp) system in the USA, which was set up following the death of an 18-month-old child who died of preventable causes. Similar tragic cases in the USA and the UK have prompted campaigning by affected families, resulting in the widespread adoption of comparable services. The project was rolled out in the authors' trust for all adult inpatients. There was a 2-week implementation phase to raise awareness. Between 22 February 2022 and 22 February 2023, the CCOS team received 39 C4C referrals, representing approximately 2.13% of the total CCOS activity. Clinical deterioration of a patient was prevented in at least three cases, alongside overwhelming positive feedback from service users.

There has been widespread use of clinical systems to improve the recognition and response to deteriorating patients, including the National Early Warning Score (NEWS 2) (Royal College of Physicians (RCP), 2017) and the introduction of teams such as critical care outreach teams and rapid response services. Despite this, complications within hospitals continue to occur, resulting in patients experiencing unexpected physiological deterioration that can lead to critical illness, intensive care unit (ICU) admission, cardiac arrest and/or death (McGaughey et al, 2017; National Institute for Health and Care Excellence (NICE), 2017). Organisations vary in their ability to manage deteriorating patients (McDonnell et al, 2013), with one organisation escalating only 57% of patients with a high NEWS 2 score (Spiers et al, 2015).

The causes of missed deterioration are complex but have been attributed to a failure to assess the patient and monitor vital signs promptly, alongside potential time pressures, workload constraints, inadequate staffing or a lack of available equipment. Other causes include insufficient education on the identification and management of deteriorating patients. It was found that there was an inability to escalate the patient, either by not following protocol or not being able to use a structured communication tool, a lack of senior support and sometimes even a fear of reprimand (Chua et al, 2013; Johnston et al, 2015; Massey et al, 2017; McGaughey et al, 2017; Eddahchouri et al, 2021). It is widely acknowledged that a delay or failure to recognise deterioration can lead to worse outcomes for patients, including higher mortality rates, which is why additional resources need to be used to improve detection and management of deteriorating patients (Keogh, 2013; Johnston et al, 2015; Barwise et al, 2016).

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