Iacknowledge all the members of my family for their unending supportthroughout the process of performing this dissertation. Again, Iexpress my utmost gratitude to my colleagues who supported me theywere of great help in completing the assignment as they gave meconfidence and strength. Finally, I express my sincere thanks andappreciation to (Supervisor) for insightful advice and supportthroughout the project.


Background:A substantial increase in the number of people being admitted orreadmitted at the Intensive Care Unit (ICU) has been alarming. Thishas been contributed by late ward patient management which has led tothe increase in the number of preventable SeriousAdverse Events(SEAs). Hence, the need for improvement of the healthcare service andward patient outcomes has prompted the need to have a Critical CareOutreach Team (CCOT).

Aim:The aim is to discover and examine the effectiveness of outreach teamin reducing or improving the rate of unplanned admission/ readmissionin ICU

Methodology:To support the changing process in the CCOT team, transformationalleadership has been recommended. In addition, the use of Tuckman’smodel evident in the study helped establish effective and successfuloutreach team. Finally, Plan, Do, Study, Act (PDSA) was applied forthe pilot project.

Results:Thestudy established successful formulation of CCOT. At the end of theprogram period, the response team used from the CCOT membersestablished that the outreach team successfully managed the rate ofward patients` admission/readmission to the ICU. The effectiveness ofthe outreach team was as a result of CCOT triggers such as the earlywarning score systems (EWSs) that alerted the team before the wardpatients situation became critical or in the case of SEAs.

Conclusion:The literature discussed the use of effective management style tomanage CCOTs. Again, it was evident that educational programs arecrucial in increasing the awareness of the ward nurses on how todetect ward patients SEAs. To enhance service improvement as well asresolve conflicts and challenges that arise, the management supportto the CCOTs is needed.

Keywords:Ward Nurses, Tuckman’s model, transformational leadership, serviceimprovement, critical care outreach team, CCOT triggers, andPlan-Do-Study-Act(PDSA).

Tableof Contents

Chapter1: Introduction

    1. Introduction………………………….…………………………………………7

    2. Background………………………….…………………………………………8

    3. Dissertation Aim……………………………………………………………….9

    4. Searching Strategy……………………………………………………………..9

1.5Search result……………………………………………………………………10

ChapterTwo:LiteratureReview (LR)



2.3Awareness and experience of ward nurses on SAEs….………………..…….11

2.4Methods used to trigger CCOT…………………….…………………..……..14

2.5Effectivenessof CCOT………………………………………………….……16


2.7Suggestionfor Local Practice Improvement………………………………….18

ChapterThree:Importance of Leadership in Facilitating Improvement


    1. Importance of leadership..……………………………………………………..20

    2. The Leadership Theory Transformational Leadership………………………..21

    3. Tuckman’s Model of Team Formation ………………………………………..23

3.4iForming Stage………………………………………………………………….24

3.4iiStorming Stage……………………………………………………………..…25

3.4iiiNorming Stage……………………………………………………………….27

  • Plan

  • Do

  • Study

  • Act


3.4vAdjourning Phase………………………………………………………………30

    1. Conclusion……………………………………………………………………….30


4.1 MainConclusion of the project…………………………………………………31


Listof In-Text Abbreviations

Sr. Number

































Intensive Care Unit

Critical Care Outreach Team

Medical Emergency Team

Medical Response Team

Serious Adverse Events

Medical Early Response Intervention and Treatment

Acute Life-Threatening Events Recognition and Treatment

Care of the Critically Ill Surgical Patient

How to Evaluate and treat Life-threatening Problems


Specific, Measurable, Achievable, Realistic, and Time-bound

Early Warning Score

alert, voice, pain, unresponsiveness

Strengths, Weaknesses, Opportunities and Threats

Rapid Response Team



Inmost parts of the world, critical care is a major problem facing thehealth sector. Intensive Care Units (ICU), which are scarce, aresuffocated by patients (Tarver&amp Stuenkel 2016).Some of these patents could otherwise be handled in the generalwards(Pattison&amp Eastham, 2012).To help alleviate this congestion in the ICUs, critical care outreachteams have been set up to reduce the pressure on ICUs. Critical CareOutreach Team (CCOT) is a care team that is led by a physician whohas specialized in critical care (Jung, et al., 2016). The team isalso made up of nurses who have been specially trained as well as thetherapists. According to Pattison&amp Eastham (2012), thenurses play a great role in the team in helping the patients incritical conditions. Critical Care Outreach Team work in the ICUwards as well as in the general wards of the hospitals (Sandroniet al., 2015).They do this by providing advanced care to patients in criticalconditions so as to avoid the admission of these patients into theICU from the general/surgical wards as well as preventingreadmission of patients who have been discharged from ICU (Stelfox etal., 2015). The teams offer an effective and complimentary safety tothe patients whose condition is deemed to be deteriorating(Al-Qahtani et al. 2013). They work in partnership with the admittedpatients as well as with nurses and general practitioners to find,assess and respond to the needs of the patients who are severely ill.They play essential roles in the hospitals, and the well-being ofcritically ill patients more or less depends on them (Winters et al.,2013).

Beforeproviding any health care to the patients, CCOT has to assess theirneeds, so that they understand what is good for the patients(Al-Qahtani et al. 2013). At times patients may be erroneouslyadmitted into ICU due to oversight by the clinician. The CCOT alsohandles such cases by assessing the severity of the cases anddetermining whether they necessitate ICU admission. According to theOman Nursing and Midwifery Council (ONMC 2011), the health careproviders should consult each other before taking any significantaction since with shared skills and knowledge they get to providequality health care to the patients. Also, failure to consult eachother leads to blame game, but the patient suffers most. Differenthealth care providers have varied types of knowledge and expertise.Sharing this knowledge leads to informed hybrid decisions thatbenefit the patient.


Accordingto Elliottet al 2011, Oman is one of the countries that have scored high on theglobal rankings in healthcare transformation and ensuring healthservices are accessible. However, there still remains a lot to bedone. The hospital bed capacity which stands at just below two perevery 1,000 people (Elliottet al 2011)is something to be wary of. It means that the limited number ofhospital beds contributes to more deaths. The nursing baccalaureatecourse was only introduced in 2002, and currently, there are nospecialized nursing research institutions in Oman (Alshehriet al., 2015).In its health transformation process, Oman introduced some newstrategies, CCOT being one of them. The idea of Critical CareOutreach Team failed at one point after it was introduced(Nelson-Marten et al., 2015). For instance, only one hospitalsucceeded in developing the Critical Care Outreach Team in thecountry during the first quarter.

Justlike is the case with most countries worldwide, the number of ICUs inOman is inadequate for the population. Unnecessary admissions andreadmissions to ICU is a great contributor to the deaths since thebeds in ICUs are not sufficient to accommodate the high number ofpatients readmitted in ICU (Gantneret al., 2014).Also, the workload of the staff in ICU increases leading to poormanagement resulting from the skewed patient to doctor ratio(Maglangit, 2015). Recent researches indicate that the mortality rateof individuals who are readmitted to ICU is higher than that offirst-time admissions, and that does not make things any better(Sulistioet al., 2015). There is an urgent need for the Critical Care OutreachTeams in Oman’s hospitals to reduce the number of people who areadmitted and readmitted to the ICU for this will enhance efficiencythus saving life and resources.


Theaim of this dissertation is to evaluate the effectiveness of CriticalCare Outreach Team (CCOT) in reducing the admission of patients andthe rate of readmission to the ICU. A literature review has beenexamined in chapter two, and it is mainly based on how Critical CareOutreach Team (CCOT) should be implemented and their benefits.Afterward, chapter three will cover leadership and management and aproposal in the service enhancement and finally, chapter four willconclude.

1.4Search strategy

Therelevant books, journals, and electronic databases were the primarysearch strategies used for this paper. The total number of articlesused was 40 though I had found 50 but realized that ten were notrelevant. Most of the journals were related to the effectiveness ofCCO teams in improving the admission or readmission of patients tothe ICU. The articles used were published between 2006 and 2016.During the search, different keywords were used to search databasesfor relevant articles. Relevance ranking and retrieval came in handyin retrieving the most relevant articles. The table below summarizessearches.

Serial number

Databases and electronic journals

Key terms


Meta lib

Critical Care Outreach Team (CCOT)


Pub Med

ICU Critical Care Outreach Team (CCOT)


Cumulative Index of Nursing and Allied Health Literature

ICU admission/readmission.



Effective outreach team, RRT, strategies used in CCOT

1.5Search result Qualitativeand quantitative studies helped in assessing the rate at which theCCOT could a patient avoid being admitted to the ICU. The numberswere used to measure how effective CCOT was. In chapter two, there isa thorough analysis of the different study methods that are relevantand can be functional in the clinical practice.




Aliterature review is an examination of previous works pertaining acertain topic under study (Baglione,2012). The purpose of any literature review is to aid the researcherget a clear understanding and insight of his /her problem based onvarious studies done in the same field or related field. A review ofliterature gives the researcher an understanding of the past andpresent position in the study topic. This provides a premise on whichthe researcher builds their thesis (Galvan, 2015).

Criticalcare outreach teams have existed for close to two decadesinternationally. The establishment of critical care outreach teamswas premised on the grounds that patients with deterioratingconditions received low quality care in the general wards(Cuthbertson et al., 2007). The rate of incidences of admission ofpatients into ICU as well as readmission of patients who had beendischarged from ICU was alarmingly high. The establishment of theCCOTs gained popularity rapidly around the world before thoroughevaluation of their impact could be effectively researched (Elisabeth&amp Anne, 2012).

Theresearcher reviewed the past studies of what had been written byauthors under in line with the aim of the study. This literaturesurvey examines peer-reviewed journal articles, working papers,textbooks, and other published resources relevant to effectiveness ofcritical care outreach teams (CCOT) in reducing admissions andreadmissions in the ICU.


Thereview of literature brought about three themes. These are:empowerment and awareness of medical staff on CCOT, methods oftriggering CCOT and CCOT effectiveness. Firstly, Staff empowermentand awareness of CCOT have been discussed.

2.3Staff empowerment and awareness of CCOT

Accordingto Duckitt etal. (2007),SeriousAdverse Events(SAE)commonlyreferred to as the major adverse events (MAE) occur mostly in thepatient general wards than the specialist wards. Pattison andEastham (2011) note that most of the deteriorating cases occur inpatients with acute cases such as sepsis, neurologic events,respiratory failure, as well as cardiac arrhythmias. Serious healthconsequences are experienced by patients if the adverse eventshappen. These include death, permanent disability and onset ofrelated medical complications. In most cases the MAE occurs due tothe lack of proper capacity to detect signs of deterioration early,or lack of proper observation and in other cases where ward nurseshave no documentations about the patients (Duckitt etal.,2007). Different related research has been conducted to investigatethe nurses’ awareness of the adverse events and level of the wardnurse empowerment to detect cases that would turn to MAE.

Youngeret al. (2015) note that there is evidence that patients in hospitalgeneral wards show indications of deterioration but are not actedupon by the nursing staff. They document that most cardiac arrestsand deaths occur as a result of failure by the nurses to respondappropriately and in a timely manner to deteriorating conditions ofpatients A major ailment in this category is cardiac arrest. Elliottet al. (2011)opine that variable standards of care before admission into the ICUhas a bearing on the morbidity and mortality of critically illpatients.

Astrothet al. (2015) posit that increased mortality rates are attributed tothe suboptimal care that nurses give to patients in the general wardsbefore the transfer to ICU. They recommend that nurses should betrained to detect clinical deterioration cases early enough andmanage the same to avert crises. Inadequate supervision in thegeneral wards is also a contributing factor to the high numbers ofpatients admitted to ICU (Agency for Healthcare Research and Quality,2015). There are very few senior clinicians working in the generalmedical wards. Most of the nurses are junior staff, who are prone toerrors due to lack of expertise and experience. According to theAgency for Healthcare Research and Quality (2015), these medicalerrors can result in the health condition of a patient worsening,thus necessitating admission of the patient into ICU. Involvement ofsenior clinicians in the earlier stages may help avert errors andenhance quality of care in the general wards.

Ina qualitative research where 1,058 nurses were interviewed by thenational patient safety agency of Oman as Robsonetal.(2007) reports, there was poor knowledge about the CCOT. All thenurses were voluntarily taken through the interview process that tookone week to identify whether they were aware of what ward patient’schanges they were supposed to observe and if they were able toidentify the changes before the situation was identified as MAE. Outof this number, 85% indicated that they had no knowledge about thedeteriorative signs that they ought to investigate. The studyrevealed a significant P value &lt0.05= (0.006) an indication thatthe nurses were not aware of the CCOT role in diagnosing signs thatif not early identified would lead to MAE. The research furtherrecommended the need to continually educate nurses on strategies thatthey can apply in the patients wards in order to detect early thesigns of deterioration among patients.

Inaddition, Esmonde etal.(2006) conducted a quantitative study where 480 ward nurses wereissued with questionnaires. The nurses participated out of freewill.This research intended to investigate their awareness levels ofMAE in the two large hospitals located in Great London. The resultsindicated that 60% of the patients admitted experienced MAE whichnurses were not able to detect on time. In this case, it was notedthat 50% of these adverse events would have been prevented if earlydetection was done. The report by these researchers indicated thatthe primary cause of the MAE was as a result of improper wardmanagement, use of improper drugs because of lack of proper recordkeeping and poor patient management in the general wards. Again, itwas established by the authors that most of the ward nurses were notaware of other related medical situations of their patients whichcontributed to improper diagnosis and patient assessments. As aresult, the patients experienced MAE without the knowledge of thenurses or because of early discharge from the hospitals withoutproper diagnosis of other related health issues. As part of theirrecommendations Esmonde etal.(2006) noted the need to have educational programs offered to wardnurses similar to those offered to the CCOT response team as a way ofimproving the awareness and empowering the nurses with knowledgerequired to manage the MAE conditions in the wards.

Further,retrospective study conducted byInstitute of Health and Welfare (2008) citingHarvard Medical Practice Study (HMPS) where the research investigatedthe cases relating to MAE it Australia and USA. The study where 240nurses took part indicated that from the hospital admissions,37% of the nurses are not aware of the MAE. The lack of awarenesslead to 14% of the ward deaths and 50% from ward to ICU cases. Thesurvey P value &lt0.05 showed significance of the study where thestudy P-value was 0.001. This indicates that there was evidence thatpatients admitted to the ICU from the ward were as a result of theadverse events that are either experienced during admissions or atthe wards.

Empowermentof ICU staff is also not at the desired level. Some patients aretransferred from the ICU prematurely. This transfer of patients fromICU is associated with a number of factors, which include conflictingobjectives of medical staff, limited healthcare resources such asICUs and bed availability, and the necessity of follow-up services(James et al., 2013). Lin et al. (2009) note that a majority ofdischarges from ICUs does not follow the written guidelines onpatient discharge. This can be blamed for the increased stress andworkload experienced by ward nurses.

Patientswho have been discharged from ICU are at a particularly higher riskof medical adverse events. As noted by Williams et al. (2010), thisis due to the severity of their health conditions and complex carethat is required. Therefore, discharging critically ill patients fromICU before they attain the desired level of recovery worsens therisks of readmission since in most cases the general medical wardsdo not have appropriate resources to care for post-ICU patients(Gantner,et al).

In summary,overall literature revealed that there is insufficient awareness ofward nurses to MAEs. Similarly, ICU staff also do not have therequisite empowerment needed to reduce the rates of readmission ofpatients into ICU. The ward nurses experience plays a vital role incritical events decision making. In the next section, triggers ofCCOT are presented.

2.4Methods that can be used to trigger CCOT

Fromthe evaluations on the MAE, it is evident that there is critical needto trigger and implement the CCOT in hospitals in an effort to dealwith the MAE cases and also provide proper medical support toinpatients outside the ICU settings. McGloin etal.(2006) Noted that the critical function of MET is to have a clearmethod that can be used to detect emergency patients’ needs. One ofthe major systems established by this team is the Rapid ResponseSystems (RRS) that are established to detect patients at risk ofdeterioration after which they trigger response. Majority of the setRRS are used through criteria of predetermined objective whichinvolves the measurement, assessment, and detection of the vitalsigns of the patients under examination (McGloin etal.,2006).

Accordingto McGaughey etal.,(2007), there are two devises available for triggering CCOT as theirstudy identified. The Single Parameter System (SPS) is used toperiodically observe the vital signs and compare them with the vitalsigns that are set by the response team as criteria. This criterionalso has a threshold which is predefined, where if the criteria ismet, a response algorithm/ trigger is activated. One of thewell-researched trigger and track system is the Early Warning Score(EWS). The EWS has five physiological parameters which are pulserate, the mnemonic, temperature, systolic blood pressure andrespiratory rate AVPA (alert, voice, pain, unresponsiveness)(McGaughey etal.,2007). From the 259 patients under investigation to identify the mosteffective trigger between the two triggers, P value =&lt0.55 showedthat the use of EWSs provided significant results in triggering CCOT.Nonetheless, the researchers could not leave out the fact that theEWS tools were being misused. However, this cannot justify that thetriggers are not beneficial in triggering the CCOT among surgicalpatients and other critical conditions such as the acute renalfailure, neurological events, and other acute conditions.

NationalInstitute of Clinical Effectiveness recommended that TTS trigger isused to safely identify the ward patient at risk of healthdeterioration as. CCOT triggers were developed predominantly to alertthe “ramp-up” team of any risk of deterioration for patients inwards. The triggers mainly implemented are the EWS which areimplemented through standing orders, protocols and directives of thepatient groups (Nice, 2007). Further, Esmonde etal.,(2006) cited that 70% of these systems have had high capability totrigger responses for patients at risk to the CCOT. Again, 30% of theCCOT at Oman as (RE) noted uses the Modified EWS (MEWS) which havefurther improved the CCOT trigger. The CCOT have been very criticalgiven that hours of nurses’ operations differ and this may causeMAE cases without response team that can be readily available toexecute emergency services to the patients at risk of MAE at alltimes during the weekends and on 24/7 basis.

Finally,the research by Gardnerand colleagues (2006)evaluated the effectiveness of MEWS among 200 nurses where 334surgical patient cases using questionnaire method. Questionnaireswere utilised because of their ease in used and the use of Linkertscale ensured a controlled response. The results indicated that 60%out of the investigated 334 surgical patients, an activationalgorithm was triggered, where 5% of these patients were taken to theICU and admitted. The results were significant given P value of 0.005&lt 0.05. Using the Score of five, the researchers’ states thatthe specificity and sensitivity of MEWS to the patients taken to ICUor HDU (high dependency unit) was 75% and 83% respectively.Nonetheless, it is important to note that this study only includedthe patients who had undergone surgery and therefore this may not begeneralized to be the case for the entire hospital. However, it isindisputable that there was a high score of MEWS where its ability toreduce the MAE was viewed to be 80% by this research.

Fromthe above research findings, it is evidentthat the use of CCOT triggers has helped to fast access the wardpatients which has contributed to immediate implementation ofcollective measures. The use of MEWs as demonstrated from thissection has been of great help in predicting the changes inconditions of patients. The trigger has been important in providinginsightful guidelines for making clinical decisions. In the sectionthat follows, the effectiveness of CCOT has been explored.

2.5Effectiveness of CCOT

Itis evident that the worth of the critical care outreach team can onlybe realised if the clinical outcomes are improved. However, it hasbeen hard to quantify the value of the outcomes in the deterioratingward patient. Nice (2007) argued that one of the key factors that hasled to this trend is because CCOT was found to have inadequatequality studies which prevented making a clear recommendation on theCCOT role in improving the outcomes of patients who are acutely ill.Nonetheles, many studies have been conducted to investigate theeffectiveness of the CCTO especuially in inward patient managementsas actions to prevent readmission and admision rate to the ICU.

Thestudy by Gardner etal.(2006) evaluated the effectiveness of MET who are expected to behighly capable team in responding to emergency cases for acutely illpatients outside ICU. The study by Dacey etal.(2007) indicated that the improvement of patient outcomes was linkedto the MET methodology diversity and service delivery. Specifically,their study noted that the use of CCOT in ward patients played avital role in ensuring that patients are properly monitored, whichdecreased the occurencies of the MAE, leading to reduced mortalityrates in the wards, readmision an admission to the ICU.

Inaddition, McGaughey etal. (2007)evaluated the role of CCOT. The researchers randomised the trialevaluation control to see the effectiveness of this team and it wasstatistically proved that in hospitals where these teams exist. Therandom study included a group of 524 ward nurses from 6 selected Omanhospitals. Among the hospitals were three identified not to have CCOTand three which had CCOT response teams. The results indicated asignificant P value of 0.0016 less than 0.05. The results of thesurvey where questionnaires were issued to randomly selected andwilling nurses indicated that as a result of CCOT response teams inthe hospitals, the mortality rates were reduced by 95% for theinpatient words and the rates of readmission to the ICU reduced by80% as compared to where there were no CCOTs.

Again,Esmonde etal.(2006) studied a general hospital in the UK over a period of 32 weekswhere 116 adults’ patient wards were randomly taken into randomtrials. ACCOT team of 40 nurses was introduced in these wards to see theireffectiveness in responding to emergency cases and identification ofMAE cases among patients in the general wards. The results werethereafter identified to assess the intervention and assessmentactivities of the MET. In summary, the report indicated that theclinical outcomes in the 16 wards were improved by 65% where theresponse rate to vulnerable patients was increased. In addition, itwas also identified that the teams have highly valid data on thepatient’s progress and this reduced cases of readmissions ofpatients in the 16 wards. The rate of readmission to the ICU wasreduced by70% (p&lt0.001) from the previous readmission records in the generalhospital. The improvement of the outcomes of the patients is anindication that that the CCOT are effective which supports that thereis need to implemet CCOT in Oman hospitals.

Further,a retrospective study that was conducted by Dacey etal.(2007) to investigate the effectiveness of CCOT when provided MEWShad positive hypothesis. In this study, a group of 56 word nurseswere offered two days training on how to use the MEWS and laterdeployed to the wards. The results indicated that 60% unplannedadmissions to the ICUs and hospital mortality were reduced because ofMEWS high capacity to detect MAE on time and triggering the MET totake corrective measures. In addition, the authors indicated thatthis positive impact has also been identified in the westerncountries and Australia where there has been considerable growth inthe MET response team in that hospital mortality, readmission casesand unplanned admission to the ICUs has to a great extent reduced.The study indicates that using MET has played a great role inreduction of the readmissions of ward patients to the ICU.

Ingeneral, we can conclude from the findings of this section that CCOTare very effective in reducing admission and readmission rates to theICU as well as reducing MAEs as well as ward mortality rate. The MEWSwere also found to play a vital role in early detection of MAEsproviding the CCOT response team a chance to take collective measureson time. The CCOT was also found as very effective when it comes tothe treatments of patients from the wards with deterioratingconditions. The deaths of patients who have been attended to by thecritical care outreach team cannot be solely attributed to CCOT torender the team ineffective it is a multifactorial phenomenonranging from the lack of early detection of deteriorating cases,errors relating to inexperience and hasty discharge of patientsbefore the appropriate time.


Itis evident that the nurses in wards of critically ill people fail insome ways such as in recording signs of patients on admission. Also,they are unable to detect vital signs of deteriorating illnesses ofpatients. However, since the introduction of Critical Care OutreachTeam, there have been changes though minimal. There is a need to comeup with more ways in which the awareness of ward nurses will beimproved to reduce the high number of admission and readmission inthe ICU as well as the deaths and disabilities that result frominappropriate medical care.

Thejunior nurses, who attend to most of the patients in the generalwards are prone to medical errors that result in unnecessaryadmission of patients into ICU.

2.7Suggestion for local service improvement

Thereis a need for the hospitals to address the issue of increasingawareness of nurses in the wards where patients with criticalillnesses are admitted. To achieve this, they should publish guidanceon indicators of success for the critical care outreach services suchas the audit and education programs and track and trigger system.There is also a need for the hospital administrators to ensure thatnurses take the necessary actions before admitting any patient. Theyshould get the heartbeat, temperature and all other crucialinformation that is needed. It would be vital to ensure that thenurses can detect signs of deteriorating illnesses to avoid admissionin the ICU. In addition, there is technology advancement onidentifying the signs of patients who are critically ill. Hospitalsshould acquire modern machines to help the nurses.

Thereview also revealed that the absence of senior clinicians in thegeneral wards is a contributing factor towards the increased rate ofadmission of patients from the general wards into ICU. Seniorclinical staff should be involved in the general wards to helpidentify deteriorating conditions of patients and arrest thesituations before it gets to the point of necessitating ICUadmission. Senior clinicians will also play a supervisort role, thushelping curtail medical errors in these wards.

Further,the literature review indicated there was little ward nurse awarenesson how to manage the deteriorating conditions of the ward patients.For this reason, it is suggested that training programs be offered tothe nurses in order to increase the knowledge and awareness levels.We cannot over-emphasize the need for ward stuff to develop andacquire the sophisticated and advanced skills required to offerquality and effective care for critically ill patients, both new andpost-ICU. Staff working in ICU and general wards should be involvedin the discharge of patients from ICU as well. This arrangement mayhelp to enhance patient outcomes and curtail adverse events andreadmission of patients to the ICU (Chaboyer et al., 2012). Thiswill play a vital role in reducing the mortality rate and thereadmission rates to the ICU. Finally, there is a need for furtherresearch on ways of reducing admission and readmission in the ICU.

Chapterthree will examine the ways in which critical care outreach team canbe implemented, and it will be supported by the pieces of literaturethat have been mentioned in chapter two.




Asidentified from the review of related literature, it is evident thatthe implementation of CCOT has played a major role in reducing theadmission and readmission of patients to the ICU. Nonetheless, it isevident that the success of this team has been attributed to theawareness of nurses about SAEs in the wards. The discussions fromchapter two also identified that as a result of successfulimplementation of CCOT, there has been reduced cases of SAE in therecent past as a consequence of the effectiveness of CCOT`s (Nice,2007). Chapter three focuses on the need of appropriate leadership infacilitating the implementation of CCOT. Where, the transformationalleadership theory has been recommended and to develop effective CCOTteams, the Tuckman’s model was evaluated.

3.2The Importance of leadership Facilitating Improvement

CCOTshave played a significant role in substantially reducing the hospitalmortality rate, readmission and also unplanned admission to the ICUsas well as cases associated with SAE in hospitals using the CCOT orMET. Again, the levels of service improvement have increased as aresult of the development of the outreach team, which saw the nurseswork as teams to enhance positive improvement of service and patientsafety outside the setting of ICU. However, the study by McIntyres etal.(2013) noted that most of the CCOT are underutilized in hospitals.For instance, out of the 706 CCOT in the study by the researchers,only 150 were actively involved. This is a clear indication that CCOTis not activated appropriately or are underutilized prompting theneed to have proper management to facilitate the improvement of thistrend. Therefore, the study suggests evaluation of leadership of theoutreach teams, and how the leadership can intervene towards having asuccessful team through their ability to influence and leadindividuals to achieve the set desired goals (Mackintoshetal.,2012).

3.3The Leadership Theory Transformational Leadership

Inthe past two decades, Avolio etal.(2013) argued that there has been a significant concern in the recentfailures in the nursing leadership which have had adverse effects notonly on the nursing leadership but also on the quality of the workenvironment that nurses find themselves in. There are different typesof leadership styles used in nursing, some of these are the servantleadership, transformational, democratic, autocratic andLaissez-faire leadership. Servant leadership involves relationshipbuilding among teams where the leader leads by example and all themembers of the team input in the decision making of values and ideasof the organization (Hutchinson &amp Jackson, 2013). On the otherhand, democratic encourages communication that is open betweenmanagement and healthcare givers who participate in decision givingcollectively. Laissez-faire leadership is where leaders give no orlittle supervision or direction and like taking the approach ofhands-off. Autocratic leadership does not consider the opinion ofnursing staff when making decisions while transformational leadershipis based on building relationships between the staff members by useof shared mission and vision of the organization.

Transformationalleadership is widely accepted because of the excellent outcomes thatwere achieved because of adopting it. Some of these results as notedby Doody and Doody (2012) are clinical outcomes efficiency as well asthe impressive quality of work where nursing staff work towardsachieving the shared vision.

Basedon Patidar (2013) arguments, the behaviors of employees were basedupon the reward systems for the ones who complied (Transaction) ormotivation with the aim of meeting the high needs order(transformation). These two concepts have been popularized in theleadership theories by scholars. Therefore, it can be argued that thetheory of transformational leadership has given more attention to theleader’s characteristics and how these characteristics influencethe follows whom the transformational leaders lead. The nursingworkplace requires leadership that not only motivates them but alsoappeals to moral values and higher ideas even as the medicalpractitioners undertake their duties (Hutchinson &amp Jackson,2013).

Giventhe significant role played by the CCOT that in most cases come withchallenges, Belle (2013) argued that it is important that theresponse team is inspired and empowered at all times. In the nursingsetting, effective leadership is required to deal with issues thatarise from change management (Leachand Mayo, 2013.Hence, it is evident that the transformational leadership style is analternative strategy that can be used to promote better outcomes forpatient care.

Sandroniet al.(2015) argued that work control and job demands are two criticalelements of the work environment. When transformational leadership isimplemented in a hospital set up, it was proved by Patidar (2013)that nurses can cope with high job strains from the high job demandsthat require less control. Only inspired employees can work underhigh job demand situations, and to inspire employees, they have towork with highly supportive management and healthy work environmentthat raises the quality of work life where they are required toPlan-Do-Study-Act(PDSA). ThePDSA is a framework that guides the acceleration of work improvement.PDSA is imperative in team formation where it helps to determine themost suitable teams and identify how the overall performance has beenimproved by forming the teams (Northouse, 2015).

Northouse(2015) noted that transformational leadership and PDSA strategy arenot enough if CCOT does not comprise of members who have clear goals.To review the formation of CCOT teams, the Tuckman’s Model wasanalyzed below. Again, the application of the PSDA in team leadershipwill be discussed under this model.

3.4Tuckman’s Model of Team Formation

Patidar(2013) argued that it takes the initiative of people in anorganization to function as a team to achieve the organizationalstated objectives and goals. The extent of the failure or success ofa project relates to the team formation stages, in the pursuance ofthe objectives and goals of an organization that needs to be clearcut. In addition, it takes time to form a working team in a nursingenvironment, and members are most routinely required to go throughdifferent stages so that they can change from the status of beingincomplete status and unite as a group to achieve the common goal(Doody &amp Doody, 2012). Tuckman`s model provides five stages offorming successful CCOT teams which can serve the purposes ofattending ill patients outside the ICU setup and preventingoccurrences of SAEs which would have been prevented.

Thefive stages put forward in the Tuckman’s model are Forming,Storming, Norming and Performing, Adjourning (Belle, 2013). Inaddition, the Tuckman’s model lays emphasis on the change in thestyle of leadership so as to facilitate effective implementation ofthe five stages of team formation as Bell (2013) reviewed. At thestorming stage, leaders have a role of coaching their team memberswith an objective of coming out of conflict same as the selling phaseof the transformational style of leadership model. Again, leadershave to facilitate the development of teams’ standards and at theperforming stage, duties are delegated to the members of the teams,this is similar to the delegation of tasks in the transformationalleadership. Hence, Winters etal.(2007) argued that the transformational leadership style best fit theTuckman’s model of CCOT team formation. As discussed below are thephases of CCOT team formation using the transformational style ofleadership.

3.4iForming Phase

Thefirst stage isForming this is the stage at which CCOT teams areestablished, and new members of a team get an opportunity to meet.Again, the purpose of the team is identified and the terms ofcomposition and reference defined as viewed by Nuti, Pernas, andKrishnan, (2015). Further, the members of the team endeavor to give atest to each other and at this point, personal identity isestablished. The impression is created with consideration provided inthe code of conduct structure of the teams, individualresponsibilities, as well as the overall objectives, defined. Somechallenges may arise when forming the CCOT teams, especially whendealing with diverse teams such as the multicultural groups which maytake longer to get to know each other. This is a sensitive stage forsuch teams because they have common characteristics such asconfusion, caution when dealing with each other, courtesy andcommonality. Spiers etal.(2015) argued that taking the team to performing is critical for theleadership because teams are created to perform.

Atthis juncture, the team members may be polite and confident, but amajority of them are anxious because they have no full understandingof what work they are supposed to do on the team. Others would onlyfeel excited about the task ahead of them. This is where the criticalrole of nursing leadership comes in because there are no clearresponsibilities of the team and tasks (Hutchison &amp Jackson,2013). This stage, therefore, plays a critical role in seeing thefailure or success of the leadership of such project and theachievement of the set goals of the teams. It is the role of leadersto ensure that all the members of the CCOT group feel that theybelong to the team to make the stage complete (Kovacs,2016.).Hence, it is equally important that at this stage the leaders incharge of different CCOT teams explain the responsibilities, goals,and roles of the team as well as make an effort to introduce eachmember of the team so that trust can be built between members of theteams.

Interestingly,Simmesetal.(2012) discussed that the CCOT forming stage requires the competenceof both the leaders and members, members be given an opportunity toask open-ended questions, and leaders need to be fair and maintainequality. Besides, listening without judging or making an assumptionis critical as well as leadership help to make the teams understandand articulate the overriding goals as well as the purpose of theteam. Other important issues to consider when forming the nursingCCOT is facilitating communication while observing the communicationpatterns, using communication patterns that are inclusive andincluding all the members of the teams in the communication process.

3.4iiStorming Phase

Thesecond stage is Storming, most of the Oman CCTOs have failed at thisjuncture because of conflicts that may exist as a result of thenatural working styles of the team members. Among members of CCOTteam, tension and criticism is prominent and may cause conflict toarise as a result of competition in different approaches by the teammembers as they try to achieve the goals of the teams independently.Disagreements about responsibilities and behaviors related to theappropriate task may arise. In Oman teams, as Barocas(2014) reviewed, members can also have disagreements about who shouldbe the team leaders and the amount of power that the team leadermight have which in most cases might lead to a redefinition ofspecific tasks of the team and the overall goals of the CCOTs.

Teammembers may also want to have an autonomous decision on thecommitment level towards the group’s task and the extent to whichthey are attracted to the teamwork, therefore, leading to theresistance of control that the team imposes. This may lead in mostcases to the non-achievement of the goals of CCOT teams which is aquick response to the ward patients to prevent occurrences of SAE.When this reaches this level Nadler etal.(2014) Terzi (2012) argued that withdrawal of some members of theteam may be experienced hence leading to the failure of the projectobjectives. This stage serves an important role in the effectivenessand survival of the team

Therefore,it is important to acknowledge that people have different ways ofworking (Ayolio and Yammarion, 2013). However, various working stylescan bring unforeseen problems that leave team members frustrated.This stage becomes necessary for defining the role that each teammember should play to prevent overwhelming some members. Leaders aretherefore required to ask clear team goals that relate to the task.The clear goals of the CCOT are providing a 24 hours’ response teamthat can act to the triggers of the CCOTs at the quickest possibleincreasing the positive outcomes of the patient and reducing the SAErate hence reducing the admission and readmissions of word patientsto the ICU (Nadler etal.,2014).

Conflictsmust be resolved besides maintaining trust among CCOT members. Thekey points to note is the requirement for the competence ofleadership and team members, use of inclusive behaviors and language,the establishment of a work plan that must be agreed upon, emotionalexpressions are managed and ensuring that mediation skills areemployed (Terzi, 2012). Also, appropriate feedback giving andreceiving is encouraged.

3.4iiiNorming Phase

Thethird phase is Norming, whereby people start resolving theirdifferences and appreciating the aptitudes of their colleagues(Huber, 2013). Here, team members know each other and even worktogether to help each other and provide feedbacks that areconstructive to the management. Further, team members exchange andaccept views from each other on the approach to use to perform thetask ahead.

Leadersare required to enable and facilitate their teams with the standardsthat help them reach the stage of performing. Therefore, when thisphase is complete, some common regulations should be establishedwhere team members are allowed to form their norms and standards(Butcher, 2016). Decisions are made jointly among team members, wheresome of the decisions viewed minor by the management areassigned/delegated to individuals in the team.

Thegroup leaders re-evaluate the goals set so that at the time the teamis at performing phase, they can perform as per the set goals. Theuse of SMART was recommended by Spiers etal.(2015) as a way of evaluating the goals of the CCOT team. SMARTstands for Specific, Measurable, Achievable, Realistic and Timedgoals. The specific goal of the CCOT should be to reduce theadmission as well as the readmission rate of the ward patients to theICU. The goals should also be Measured, Nuti, Pernas and Krishnan(2015) recommend the uses of (Plan, Do, Study, Act) scale (PDSA) tomeasure the goals which have been discussed in this paragraph. Thegoals should also be Achievable and Realistic. The CCOT goals arerealistic because they have been successful in other countries suchas the Australia and United Kingdom, which implies that in the caseof Oman local hospitals, the same goals can be achieved. Finally, thegoals should have a particular Time span at which the objectives ofthe team are re-evaluated. In most cases of CCOT goals, they aremeasured after one month, and this is the time span allowable for theOman local hospitals.

Tomeasure the goals as identified in the previous paragraph the PDSAwhich is a cycle that can be applied as a short time pilot tore-evaluate the effectiveness of accomplishment of the stated CCOTgoals over a short span of even one month is applied. Step one isPlan,where planning of the CCOT Project done. At this stage, the goals andobjectives of the teams are re-evaluated and compared with theexpected outcomes of the CCOT which is to improve the ward patient’shealth outcomes reducing the rates of admission to the ICU as aresult of SAEs (Mackintoshetal.,2012). The second step is Do.At this step, the goals or the definite plans are implemented.Leaders work together with the teams to establish the problems andissues that may occur to facilitate improvement. The step of Studyis where the planned outcomes are analyzed against performance aftera specific period to measure progress or the success of the team andidentify if there is any need for change. According to Rutt andLockenhoff (2016), relevant data such as the CCOT performance for aparticular period should be evaluated and should be found from the Dostage where it is compared with the SWOT analysis. This helpsidentify the opportunities and strengths that may improve theperformance of the team and also the threats and weaknesses such ascommunication skills, unskilled medical practitioners among othersthat may affect the performance of the team (Patidar, 2013). The Actstep is the final step, and this is where the leaders are supposed tocome up with a choice on whether to progress with the set plan orshould altogether change the plans. In this case, the information andfeedback collected from the CCOT are important as it helps leadersknow the action to take. However, if the plan is still working well,it means that the set goals are feasible hence the team can move tothe stage of performing.

3.4ivPerforming Phase

Atthe fourth phase is Performing. People of the same team are workinghard with no conflict of goals and friction and support each other toensure that the set goals are achieved (Rutt etal.,2016). This is argued to be the most critical stage of CCOT, wherethe processes and structures have been put in pace and are supportedby each team member. However, leaders have an important role ofdelegating most of the work to the team members to ensure teamsuccess (Avolio &amp Yammarino, 2013).

Further,Winters etal.(2007) stated that the morale of the team at this stage is very high,and team members are focused on the task at hand with no relationshipissues. Therefore, duties are delegated to the members of the teamfrom the leader. The actual performance of the team task happens atthis stage, Northouse (2015) noted that delegation of tasks that areinappropriate to the CCOT members might lead to the project failurewhich is also a failure to the management. The competence of theleader and the members is needed, changing and adapting to change,the establishment of processes that allows teams to accommodatechange and also be in a capacity to take in new members withoutconflict as well as sharing leadership among the group.

3.4vAdjourning Phase

Thefinal stage is adjourning, where the goal has been achieved, andteams can be dissolved. Adjourning for CCOT happens for variousreasons one of the major one being restructuring the team toincorporate members with high skills of accomplishment of the teamgoals. Huber (2013) indicated that it is only when the task forceCCOT members accomplish their goals that they are disbanded orbecause they are performing poorly. Nonetheless, if it happens, thenthis final stage is characterised by closure, communication,consensus and compromise (Hutchinson &amp Jackson, 2013).


Havingdiscussed the need of appropriate leadership in facilitating theimplementation of CCOT. Where the transformational leadership theoryhas been recommended and to develop effective CCOT teams and theTuckman’s model being evaluated as a strategy of forming successfulteams, chapter four provides conclusions of the study.




Thecare of general ward patients and critically ill patients isparamount. This is the primary reason for the formation of CCOT thatensures that the outcomes of the critically ill patients especiallythe ones outside the ICU settings are high. Thegoal of this outreach team is preventing the arrest or evenpre-arrest situation to patients with deteriorating situationsoutside the settings of the intensive care. By preventing the arrestsituation for patients outside the ICU, the deaths of these patientsis prevented where cardiac arrest is reduced, the length of stay atthe ICU and ensuring improvement to Critical Care access of patientswith deteriorating situations. Some of the deteriorating cases wherethere has been the occurrence of MAE which has increased the need forCCOT are among patients with diseases such as sepsis, neurologicevents, respiratory failure, as well as cardiac arrhythmias. Serioushealth consequences are experienced by patients if the adverse eventshappen because in most cases the MAE occurs due to the lack of propercapacity to early detect signs of deterioration, or lack of properobservation and in other situations where ward nurses have nodocumentations about the patients. Fromthe evaluations on the MAE, it is evident that there is critical needto trigger and implement the CCOT in hospitals in an effort to dealwith the MAE cases and also provide proper medical support toinpatients outside the ICU settings. One of the well-researchedtrigger and track systems is the Early Warning Score (EWS). The EWShas five physiological parameters which are pulse rate, the mnemonic,temperature, systolic blood pressure and respiratory rate AVPA(alert, voice, pain, unresponsiveness) and has been proved to be themost effective.

ICUstaff should be empowered with the requisite knowledge and techniquesto avert cases of readmission to ICU and putting the well-being ofpatients at risk. This will also ease pressure on the general wardshence curtail the stress and pressure the general ward staffexperience. It is vital to follow the guidelines of dischargingpatients from the ICU to the latter. Timing of discharge should alsobe appropriate. Patients should not just be discharged from the ICUimmediately after showing signs of recovery or upon completion of aprocedure. They should be discharged at the right time. That is,after attaining the desired level of recovery and fitness. Therapiesshould be offered as follow up to patients discharged from ICU tohelp them recover better.

Applicationof transformational leadership has played a critical role in thesuccess of CCOTwhen performing their tasks. In the rapid changing and complexnursing environment, the ability to motivate nurses and aspire themfrom a transformational perspective is important. Transformationalleadership has played a great role in ensuring that CCOT is inspired,this creates a sense of commitment among the team members and levelof satisfaction with the work environment provided. Tuckman’smodel provides five stages of forming successful CCOT teams which canserve the goals of attending ill patients outside the ICU setup andpreventing occurrences of SAEs which would have been prevented. Thefive stages put forward in the Tuckman’s model are Forming,Storming, Norming, Performing, and Adjourning. Proper leadership isevery essential as it helps improve the effort to promote effectiveand safe care by the CCOTs.


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