The effectiveness of Critical Care Outreach Team (CCOT) in reducing the admission/readmission of medical/surgical (general) wards patients to ICU Abstract

The Effectiveness of Critical Care Outreach Team (CCOT) 15

The effectiveness of Critical Care Outreach Team (CCOT) in reducingthe admission/readmission of medical/surgical (general) wardspatients to ICU


The critical care outreach team play a fundamental role when it comesto the attainment of the best patient outcomes. Notably, they havethe duty to oversee quick recovery of patients and reduce oreliminate the development of a condition likely to cause thereadmission of patients to the ICU. However, the effectiveness withwhich the team executes the services entrusted to them is determinedby various factors, key among them being leadership. The paperevaluates the effectiveness of critical care outreach team when itcomes to the execution of services and the role of leadership in theimprovement of practice. A literature review is conducted with regardto the topic of discussion to help in understanding the conceptbetter.

Keywords: treatment, critical care, leadership


I am grateful to my supervisors and colleague students in helping mesuccessfully complete the dissertation. Their support has beenhelpful in the execution of the entire project.

Content List

S. No.


Page No.


Title page






Content list



Chapter One


    1. Background



Chapter two


2.1 Literature review


2.2 Search strategy


2.3 Staff Perception and Awareness of CCOT


2. 4 Methods used to trigger CCOT


2.5 Effectiveness of CCOT


2.6 Conclusion of literature review



Chapter three


3.1The Importance of Leadership Facilitating Improvement.


3.3 Models of change and strategies


3.4.1 Forming Stage


3.4.2 Storming Stage


3.4.3 Norming stage


3.4.4 Performing stage


3.5 Supportive Work Group Climate and Culture


3.6 Employee Attitudes.


3.7 Evidence-based Practice

3.8 Leadership Style

3.9 Service Improvement


3.8 Conclusion for Chapter Three



Chapter Four


4.1 Conclusion





The ability of patients who have received treatment at the generalwards or ICU to get better and avoid the readmission depends on thesucceeding form of care. The critical care outreach team have themandate to ensure that they deliver the best care to such patients asa way of ensuring the best outcomes are achieved to avoid thepossibility of admission or readmission to the ICU (Conroy 2014). Thetopic is of relevance in Oman for the impact it has on thetransformation of the healthcare system. The adoption of a policyregarding how the CCOT team should execute their duties is essentialin enhancing nursing practice. The topic influences futuredevelopment of nursing practice as it offers a guideline on hownurses specifically offering critical care should conduct themselves.The goal is to ensure that patient readmissions are reducedespecially in hospitals located in Oman. However, the team must seeto it that the nature of services employed have the ability toguarantee the best treatment. Various factors are attributed to theprevention of the possibility of such patients getting admitted tothe ICU. For example, leadership is of critical significance since itdictates how the critical outreach team executes the mandate assignedto them (Daly et al 2014). Notably, the leadership adopted dictatesthe conduct of the entire team in working towards ensuring that theobjective of preventing the readmission or admission of patients tothe ICU is achieved (Hauck, Winsett, and Kuric, 2013). The success ofCCOT in the quest of reducing admission and readmission into the ICU.They include the awareness and the perception of the staff on CCOT,methods used to trigger CCOT, and the effectiveness of the CCOT. Thehealthcare system seems to be on the right track with theimplementation of the CCOT despite a few setbacks such as some of thestaff not being acutely aware of the CCOT. Further, some of themethods used in triggering CCOT were not easily understood andutilized, but EWS, NEWS, and electronic monitors have proven to beuseful for the CCOT system and in improving patient care. The CCOTservices are effective in improving the quality of patient care inhospitals’ intensive care units as shown by Sandroni, (2015),Winters (2013), and Laurens and Dwyer (2011). In this chapter,we analyze leadership and service improvement regarding the provisionof quality patient care. According to Yonder-Wise (2011), thehealthcare management team has a vital role in enhancing theproductivity of its staff regarding optimization of the quality ofpatient care.


Healthcare service delivery is characterized by challenges especiallywhen it comes to optimization of treatment. Notably, patients whoreceive care for the first time could suffer a possible likelihood ofgetting readmitted to the hospital. Those who undergo surgery areparticularly at risk of getting readmitted to the intensive care unitif the intended patient outcomes are not achieved. However, thecritical care outreach in healthcare systems have been instrumentalin preventing such setbacks when it comes to provision of services.The CCOT team have adopted mechanisms that focus on the optimizationof treatment for the realization of the most effective treatmentoutcomes such that the patients do not get readmitted to the hospitala second time after receiving treatment (Pattison and Eastham, 2012).The leadership in charge has coordinated with the CCOT members toensure that they offer the best care to the patients and help themrealize quick recovery preventing their readmission to the intensivecare unit (Niven, Bastos, and Stelfox, 2014). The coordination ofsuch health care services has been instrumental in preventing thereadmission of such patients to the ICU. The dissertation focuses onunderstanding the role of the CCOT members in preventing thereadmission of patients to the ICU.

Aim of Dissertation

The dissertation seeks to elaborate the role played by the criticaloutreach team in reducing the readmission of patients to the ICU. Thepaper will evaluate literature on the topic and assess the perceptionof different researchers on the issue. Findings from the study willbe instrumental in helping come up with conclusive recommendations onthe topic. The goal is to evaluate the role of critical care outreachteam in preventing the readmission of patients to the intensive careunit.

Chapter Two

Literature Review

Searching strategy

Various techniques were adopted in conducting aliterature review to get information on the topic of discussion. Avariety of academic websites were sourced to get the material neededin executing the task. Professional journals such as PubMed Centralwere used in sourcing for information. Further, I used Google Scholarto get the perception of different researchers on the topic. Theinclusion criteria was based on papers published within ten years.The search was narrowed to articles discussing on leadership innursing and the role of critical care outreach team in providingquality services to patients. English was the language used inconducting the search. The search yielded a total of 57 articles butthe inclusion criteria was used to eliminate the non-relevantarticles.

Inclusion Criteria

Inclusion Criteria


Articles published after 2006


International papers


Papers in English Only


Qualitative Studies




Exclusion Criteria Number

Articles published before 2006


Cohort study


RCT papers (non-related topics)


Other papers


Seminar papers


According to Boswell and Cannon (2011), a literature review is anorganized group of studies correlated to a particular aspect, and therigor of the studies is examined to give proof for implementation. According to Fain (2009), the examination covers a collection ofconferred findings from journal articles and papers that discuss anidea and sum up the results conclusively. As such, scientific journalarticles were collected and evaluated to produce the following themesrequired in this context. The goal of the literature review in thisstudy is to critically examine studies related to Critical CareOutreach team to assess its efficiency in reducing admission andreadmission to the Intensive Care Unit.


In reviewing the literature three themes emerged. They include

  • Staff Awareness and Perception of Critical Care Outreach Team (CCOT)

  • Methods used to trigger CCOT

  • the effectiveness of CCOT.

The themes are elaborated in the following sections.

Staff Perception and Awareness of CCOT

The hospital setup has evolved in the recent past with theadvancement of science and technology. Better treatment remedies haveemerged that have resulted in better clinical outcome outcomes incritically ill patients, and the impact of the reduction ofreadmission for patients cleared from the ICU improves patient careoutcomes (Friedrich, 2015).

Brown (2012) conducted a research study to explore theknowledge and perceptions of the nurses’ towards the Rapid ResponseTeam. The study incorporated 63 nurses receiving responses from 57(90.4%). The sample size was above 30 which the least required numberis making the study reliable. Ethical approval was obtained from theResearch Committee and the nurses’ involvement in the study wasvoluntary. Data collection was through a questionnaire, and the datawas analyzed qualitatively according to the results obtained. Thedata collection tools have been used in other research areassuccessfully, and they show the validity. According to Holland andRees (2010), validity is the level at which data collected in thepaper obtained what was intended to be received and evaluated. Fromthe responses received the nurses were able to recognize thephysiological changes in patients’ conditions and commit to therules of RRT. The physicians on the other side had an inadequateresponse inactivating the RRT because they saw the process asunnecessary and the nurses did not allow them to activate theirwillingness to enable it. Further, the knowledge and understanding ofthe call criteria were essential, but knowledge regarding calling theRRT was less important for them.Therefore the mean knowledge scoreduring the study was average. Brown (2012) concluded thatdespite the nurse`s ability to identify the changes, there was stillweakness in pointing out changes that required the RRT and educationis necessary for the early identification of the critically illpatients.

In the same light, Cooper (2011) sort to examine the ability ofrural nurses to evaluate and manage patient deterioration in asimulated environment, by utilizing measures of skill performance,situation awareness and knowledge. The above study was based on thefact that concerns about the clinical expertise and the knowledge ofnurses required manage the worsening conditions of the patients andrescue failure is of vital interest to people. The purpose of thestudy explains the significance of the research in CCOT. The studyused the exploratory quantitative design. The collection of data wasdone using a questionnaire and video recordings. The participantswere thirty-five nurses from a single ward. The data collection toolsand the sample size were sufficient for the study and they depictthat the research was reliable and valid. The levels of awareness inpatients were measured at the final stage of each scenario andpatients who had deteriorating conditions with Acute MyocardialInfarction (AMI), and Severe Obstructive Pulmonary Disease (COPD)were the ones who were incorporated in the study. A limitation of thesurvey was that the nurses were from a single ward and that did notprovide vigor and had a possibility of bias. Cooper (2011)found out that the circumstance awareness score and competenceresults across the two adverse events were low (50%) with othercritical observations missing. The mean score of the information ofdeterioration management was 67%, and the range varied considerably(27%-91%). Many of the subjects tended to aim at the signs andsymptoms solely and failed to utilize a systematic approach to doinga patient evaluation.

Ludikhuize et al. (2012) led an observational review contemplate thatincluded 204 patients admitted to therapeutic and surgical wards.According to LoBiondo-Wood and Haber (2010), a retrospective study isa non-exploratory study that analyzes the relationship of the marvelin the past with the other phenomenon in the present. It intended tosurvey the ward medical attendants` documentation of vital signs byintroducing an adjusted EWS apparatus. This device considersmeasuring important signs as it is a robust instrument for recordingtemperature, heart rate, respiratory rate, systolic circulatorystrain, immersion, supplemented O2 (SPO2) and reaction rate. With theend goal of clarity, the scientists introduced the outcome in graphsand tables which show straightforwardness in displaying thediscoveries. Also, the researchers utilized a large sample size whichmakes the speculation that the study result is reliable. Concerningward staff`s familiarity with crucial signs documentation, some keysigns were disregarded and not recorded, for example, urine yield,such a level of awareness could severely affect the patient`s life.According to Viswanathan (2012), failure to report someobservations introduces reporting bias. However, 81 % of suddendeaths could be recognized by utilizing EWS devices. Unfortunately,the study exhibited deficient utilization of the EWS strategy by wardmedical attendants, with just a (30-66) % record of SPO2 andrespiratory rate. In Oman, EWS can without much of a stretch beactualized in light of the fact that every one of the parts of thescale can be measured by ward medical attendants.

In conclusion staff awareness and knowledge of the CCOT was notcomprehensive. Therefore, educational programs such as the AcuteLife-threatening Early Recognition and Treatment (ALERTTM)aid in the provision of necessary information and skill sets in acuteand critical care for nurses in wards in the larger area of theUnited Kingdom. Such programs can help in reducing the admission andreadmission rates in the intensive care unit from the general wards.

Methods used to trigger CCOT

Toolsthat can beutilized in triggering the Critical Care Outreach Team are in demand.Nurses are usually involved with the duty of taking care and nursingpatients in general wards. However, the patients in the general wardsmight experience unrecognized deterioration that can lead to cardiacarrests (Winters, 2013). The median time that a patient can exhibitsigns and symptoms before getting a cardiac arrest is around 6 hours,and it’s usually as a result of poor prognosis (Winters, 2013).Many healthcare facilities have gone ahead to implement Critical CareOutreach Teams over the past 15 years since the Department of Healthrecommended them in 2000 in England. Alam (2014) explain thatphysiological parameters such as blood pressure, respiratory rate,pulse, and body temperature precede acute deterioration in patientsof critically ill. Additionally, they state that early detection ofsuch parameters can be essential in the prevention of hospital-widemortality and serious adverse events such as heart attacks andstrokes.

One of the methods used intriggering the CCOT is the Early Warning Score system. The scheme isa scoring system that aids with the detection of physiologicalchanges (Winters, 2013) such as the respiratory rate of less than tenbreaths per minute or more than 30 breaths per minute or worseningdyspnoea. Further, a pulse rate of less than 45 heart beats perminute and more than 125 beats per minute, and a blood pressuregreater than 130 mmHg and less than 70 mmHg should also be reportedas early signs Alam (2014). It helps identify patients who areat risk for further deterioration. The Early Warning Score system hasbeen found to be effective in the reduction of admission andreadmission rates into the ICU by various researchers. Alam evaluated the impact of the EWS system on particular patients’results such as Patterns of ICU admission and usage, serious adverseevents of adults in medical admission units and general wards andcardiac arrests. The scholars did a systematic literature review ofarticles in PubMed, Cochrane Library, and all controlled,and empirical studies that included the parameters they wereinvestigating were incorporated, and independent reviews screened allthe appropriate titles and synopsis for eligibility by utilizing astandardized data worksheet. The selection and inclusion criteriaeliminate selection and confounding bias as explained by (2012). From the seven research studies that met the inclusioncriteria, it was found out that a positive trend towards betterclinical results due to the introduction of the EWS chart wasimminent. However, there were conflicting results as some studiesshowed a reduction in both mortality and cardiac arrests while othersshowed an increase in the cardiac arrest events.

A modification of the EWScalled the National Early Warning Score (NEWS) is recommended by theRoyal College of Physicians. Smith (2013) examined thecapability of the National Early Warning Score (NEWS) to distinguishpatients at high risk of early myocardial infarction, death, andunpredicted Intensive care unit admission. The study incorporated acomparative research design as it compared NEWS and EWS systems. TheAUROCS (Cl 95%) for 33 EWS were 0.57 to 0.827 for unanticipated ICUadmission, 0.611 to 0.710 for cardiac arrest, and 0.813 to 0.858 fordeath. The AUROCS (Cl 95%) for NEWS were 0.873 for mortality, 0.894for unpredicted ICU admissions and 0.710 for cardiac arrest. Inconclusion, the NEWS system was found to possess greater potentialthan EWS in discriminating patients with a high risk of unanticipatedintensive care unit admission, cardiac arrest, and death ( 2013).

The use of “electronicautomated advisory vital signs monitor” was suggested to have theability in aiding identify deterioration of patients on wards andenhance outcomes (Bellomoet al., 2012). In the research study, 349 patients were includedfrom Australia, Europe, and the United States. The study populationwas adequate, and the broad cross-section indicated that the resultscould be used in generalization. The research design was a“Before-and-aftercontrolled trial”and it improved the clarity of the outcome. Bellomo et al. (2012)stated that the electronic monitoring of vital signs is a criticaltool in triggering CCOT response. In conclusion, patients’ lengthof stay and the time taken in recording vital signs are reduced, andthe survival rate is increased.

Lynn and Alison (2013)performed a study to investigate the ward nurses sentiments onutilizing the EWS device and the adequacy of CCO. A Likert scalesurvey was conveyed among ward nurture in a New Zealand doctor`sfacility where CCOT was executed. As indicated by Holland and Rees(2010), this questionnairetechnique is viewed as a weak, fast strategy for insights gathering.The Likert scale is the primary scale utilized as a part of nursingin which the respondents need to demonstrate whether they firmlyconcur, concur, dissent, or firmly disagree (LoBiondo-Wood and Haber2010). The EWS apparatus was utilized with 270 patients. 58% ofmedical caretakers in wards found that the EWS instrument wasanything but difficult to use, and around 65% reported that the CCOattendant is receptive. CCO was observed to be instrumental inkeeping patients` disintegration in the wards.

Conclusively, methods thattrigger the CCOT such as EWS, NEWS, and the electronic monitors areessential to the effectiveness of the team in reducing the admissionand readmission of patients from the general ward to the intensivecare unit. Despite some of the methods offering difficulties to somehealth workers, they are easy and straightforward to use as they helpto influence positive clinical outcomes when coupled with theoutreach services.

Effectiveness of CCOT

Over the recent past years, a lot of work has been done on theeffectiveness of Critical Care Outreach Team or the Rapid ResponseTeam. The CCOT has had positive outcomes in some circumstances andothers there has been no shown significance. Therefore, it wasdifficult to quantify the effectiveness of the CCOT. Massey (2010)conducted a comprehensive literature review examining the impact ofthe CCOT on reducing the key adverse events undergone by worseningpatients in wards. In the analysis 16 research papers were utilized,and each of them was assessed critically and systematically. Theresearcher employed the Rapid Response Team framework that wasdeveloped by professionals in the area of Critical Care Outreach.Massey (2010) found out that six studies showed a positive impact onthe patients’ aftermaths while three of the studies showed nopositive result on the patient outcomes. The study reviewed onlypapers written in English, and its inclusion criteria exclude somecritical and relevant studies as it utilized data that explored theeffects of CCOT on admission to intensive Care Units, in hospitalCardiac Arrest and deaths. However, despite the limitations of thestudy, the method utilized by Massey (2010) was a model recommendedin the first accorded statement on CCOT to explore, investigate andcreate empirical data on the CCOT. Therefore, the study was empiricaland transparent regarding the effectiveness of the CCOT in combatingworsening ward patients’ clinical results. Conclusively, Massey(2010) did find the available literature evaluating the impact ofCCOT inconclusive.

Pirret (2008) examined the responsibility and effectiveness of anurse Practitioner controlled critical care outreach service. Thestudy design was comparative, and it evaluated the number ofreadmission cases in the Intensive Care Unit under seventy-two hourstwelve months before and twelve months after the implementation ofthe service. The parameters evaluated in the study were the length ofstay, ICU patient acuity, mortality due to readmission, APACHE @scores for ICU readmissions &lt72 hours and Medical emergency teamand cardiac arrest calls. Data analysis procedures were done usingdescriptive statistics and control charts. Analysis tools used in thestudy eliminate the element of bias and validate the research. In thefindings, ICU readmissions under 72 hours were 28 and theintervention group was 9. The severity of illness intervention groupwas 19, and the control group was 18, and the length of stay forreadmissions in the intervention group was three days and for thecontrol groups was five days. The graphical representations showed adecrease in the ward Cardiac arrests due to a reduction in ICUreadmissions. However, the mortality rate in the re-entry process wastoo small for evaluation within the research. The study limitationwas that it did not measure unplanned ICU admission and adversepatient events, making it inconclusive. In conclusion, from the dataobtained in the study, a nurse practitioner-led CCOT has a positiveimpact on the patient aftermaths as evidenced by a sustainedreduction in Intensive Care Units readmissions below 72 hours afterimplementation of the Critical Care Outreach System.

The positive impact of the CCOT was supported by the systematicliterature review done by Winters (2013). In the study, thescholars examined the effectiveness and the implementation of theCritical Care Outreach Systems in Acute Care Environments. Literaturebetween January 2000 and October 2012 was utilized. The literaturereviewed covered a long range of years making it reliable as itcompared both recent and old studies. The documentation was obtainedfrom databases such as PubMed, CINAHL, and PsycINFO. The study wasnot biased regarding the language used as it incorporated articles inall the languages and also a reviewer analyzed the data and rated thequality of the research and the strength of the evidence. The resultswere of moderate strength from 18 studies, and 26 studies were of alower quality. The study had bias risks due to the before and afterdesign. The study found out that the mortality rates (RR, 0.96 [CI,0.84 to 1.09]) and cardiac arrest in the ICU (RR, 0.66 [95% CI, 0.54to 0.80]) were reduced. Snadroni (2015) also found out that theRRT intervention led to the reduction in cardiac arrest events(pooled risk ratio [RR] 0.64 [0.55–0.73] p  &lt  0.0001). Rees (2011) comments that significant P value means the differencein outcomes did not occur by chance but due to the intervention andthe results will be significant if the p-value is &lt 0.05 renderingthe study significant. In conclusion, Winters 2013 foundpositive outcomes regarding the intervention of the CCOT and thesystem they use. The response has helped hospitals reduce mortalityof patients admitted to the ICU and increase the recognition ofworsening conditions in the same patients.

Laurens and Dwyer (2011) tested the effectiveness of implementingMedical Emergency Response Team on admissions to the intensive careunit, cardiopulmonary arrests, and hospital-wide mortality rates inregional Queensland hospital. The study design was a prospectivecohort, and it was done in an Australian hospital that serves over85000 people. The inclusion criteria for the participants waspatients who were served by MET between 2004 and 2008. A large numberof participants in the study eliminates the aspect of selection biasas explained by Viswanathan (2012). The results showed thatthere were 296 CCOT activations. As a consequence of theimplementation of the MET, ICU admissions reduced from 22.4 to 17.6per every 1000 admissions (RRR: 21.4% p &lt 0.0001). Further, meanhospital-wide mortality rates decreased from 9.9 to 7.5 per every1000 admittances (absolute risk reduction, RRR: 24.2% p = 0.003).There was a significant decline in the inpatient cardiopulmonaryarrests intervention (77 versus 42, RRR: 45.5% p = 0.0025). Bias inthe study is observed in the increasing number of patients viewed notfor resuscitation and the CCOT underuse may have affected the deathrate outcomes. However, the results are reliable and can be termed tobe useful in and suitable for the clinical practice. In conclusion,Laurens and Dwyer (2011) showed that implementation of the CCOT inthe regional hospital had a positive outcome as evidenced by areduction in ICU admissions, Mortality rates in the hospital andcardiopulmonary arrests.

Williams (2010) evaluated the effect of a critical care nursingoutreach service on the outcomes of patients in discharged from theintensive care unit specifically from the time of admission to theICU, mortality in the hospital and readmissions to the ICU. The studydesign was before and after design together with a prospectiveintervention. The participants in the study involved patientsdischarged from the ICU between June and November 2007 in thepreintervention cohort and the post-intervention cohort includedpatients discharged between June and November 2008. The patientsrecruited were from Fremantle, Royal Perth, and Sir Charles GairdnerHospital. It is critical to highlight that conducting the trials inmore than one hospital by involving various participants with avariety of characteristics can enhance the generalizability of thestudy results (Fain 2013). Patients who passed away in the ICU orwere discharged directly from the ICU to another healthcare facilityor their homes were excluded. The researchers explain their inclusionand exclusion criteria vividly eliminating the aspect of reportingbias. The researchers obtained ethical accreditation for theirresearch, and the sample number of 3001 patients was adequate for anempirical and an excellent research study. The mean age of the beforegroup was 55 years and 54 years in the after group (t =–1.96, P = .05). The proportion of men was 65% in both thepre and post groups. The mean APACHE 2 score was 16.7 (standarddeviation 7.2) in the post group and 16. 8 in the before group (t= –0.37, P = .66). In their findings, a total of 1435patients were cleared to go home within the 6-month prospective studyperiod while 1566 were discharged in the pre-intervention cohort. Thereadmissions during the same hospital admissions did not differ muchduring pre and post intervention (5.6% vs. 5.4%, P = .83).Further, the hospital survival rate (P = .80) and the lengthof stay in from the time the patients entered into the ICU to themoment they were discharged (P = .85) also did not varybefore and after the implementation of the MET. Williams et al.(2010) concluded that even though previous studies have shownpositive effects of CCOT in the U.K and Australia, they did not findany improvements in LOS after admission to the Intensive Care Units,mortality, the introduction of the Critical Care Services andreadmission rates. However, lack of growth can be attributed to thefact that the admission and readmission rates are significantly lowin Australia. In the U.K the CCOT focuses more on the improving thecare of acutely ill patients rather than those discharged from theICU. McGaughrey et al. (2008) results are contradictory showing thatthe CCOT showed a significant reduction in Mortality (adjusted OR0.52 and 95% CI 0.32 to 0.85). Moreover, there was no significantchange in Australia (adjusted odds ratio (OR) 0.98 adjusted P value0.640 95% confidence interval (CI) 0.83 to 1.16).

Moody and Griffiths (2011), did a systematic literature review todetermine the impact of CCOT services on particular patient andservice aftermaths, admissions and readmissions to the ICU, adversepatient events, in-patient cardiac arrests and the sternness ofillness. The study involved available literature from January 2003and October 2011. It reviewed both the primary and secondaryresearch, therefore, eliminating selection bias. Ten studies wereincluded out of the selected 100 results. The studies included tworandomized control trials and seven pre and post open trials.Different studies showed variable individual outcomes with someshowing no significant impact while others showed positive effects ofthe CCOT. In conclusion, Moody and Griffiths (2011) found that theCCOT services were effective in improving patient and practiceassociated outcomes. Niven (2014) systematic meta-analysisreview on the effectiveness of CCOT in reducing the risk ofreadmission to the ICU affirms Moody and Griffiths (2011)conclusions. Niven (2014) found a reduction in readmissions tothe intensive care unit due to the CCOT services. Moriartyet al. (2014) came to the same conclusion that the CCOT servicesreduced serious adverse events and failure to rescue incidences.However, there was an increase in unplanned ICU admissions to 15.2transfers per 1000 floor days (P &lt 0.001),and no significant reductions in pre and post implementation for bothmortality (P = 0.480)and cardiac arrests (P = 0.480).Moriarty et al. (2014) study design was longitudinal, and thepatients who were included in the survey were inpatients clearedbetween September 2005 and December 2010 in two educationalhealthcare facilities in Midwest, USA. The reduction in FTR wasaccustomed to the increase in CCOT calls and the patients beingtransferred to the ICU meaning that the calls must reach a particularthreshold, for the CCOT efforts to be significant,

Conclusion for Chapter Two

The literature review highlights the fundamental role played by thecritical care outreach team when it comes to the aspect of reducingthe admission or readmission of surgical patients into the intensivecare unit. Indeed, the methods adopted by the team in caring for thepatient significantly determines whether or not the particularpatient will be readmitted to the ICU. The scholarly articles pointout to the fact that the critical care outreach team must be in aposition to use their skill and expertise to identify patients whoare ill and institute timely treatment before the conditionaggravates.

Chapter Three

The Importance of Leadership Facilitating Improvement

Strategies and Models for Improving Service.

Many models and strategies that are crucial to the improvement ofservice in the healthcare system. According to Gage (2013), they areessential in the determination of the quality of care and the amountof outcome obtained regarding the condition of patients. Inimplementing change in the healthcare setting, various models such asTuckman’s model, Kotter’s model, and Rapsies]’s model areapplied. Tuckman’s model is the best regarding developing a team(Chong 2007). The model undergoes four stages forming, storming,norming and performing. Each stage consists of three principlesincluding team members’ behavior and feelings, stage content andthe response of the leader (Miller, 2014).

Tuckman Model

Tuckman’s Model

Tuckman’s model is the best regarding developing a team (Chong2007). The model undergoes four stages forming, storming, normingand performing. Each stage consists of three principles includingteam members’ behavior and feelings, stage content and the responseof the leader (Miller, 2014).

Forming stage

This step is aimed at setting the roles and responsibilitiesfor each CCOT member, CCO team interactions, and familiarization, andplanning the project. The forming stage usually occurs after the CCOteam has already been created (Kelly, 2012). The team leaderintroduces themselves to the team and appreciates their involvementinto the CCO team. According to Miller (2014), this stage aims togather information and avoid conflicts hence its quite comfortable.Team leaders have the responsibility of informing the CCO team aboutthe vision and provide sufficient evidence about the project becausethe roles and responsibilities of each CCOT member have not yet beenestablished.

In order to improve service improvement, planning which includesinvolving the CCO team members is vital to its success. The teammembers can be gathered formally or informally in a conference roomand informed about the dimensions of the project. The team leader cangather ideas on how the rates of admission and readmission can bereduced by initiating a brainstorming session among the members. Thismove will help the leader know what his team needs which could beimportant in explaining the dimensions of the project. Theteam leader should seek the support of the upper-level managementsince they could help in implementing the project (Travaglia et al.(2011). Nursing supervisors are perceived to know the impact ofreadmission and admission rates to the patient and they can help indeveloping an agreement more easily.

Moody and Griffiths (2010)Pirret et al. (20150 Niven et al. (2014), and Laurens and Dwyer(2011) have all shown the effectiveness of the CCOT and the leadersare required to conduct regular meetings and gather information withthe aim of improving quality care. Members of the team might notembrace the idea at first, and the leadership might face somerejections, but they should believe in the abilities of the membersto perform the required tasks. However, when it is presented withenough evidence, it can be accepted. After the project dimensionshave been laid out to the team and the management, workshops andregular meetings can be done to collect new ideas for serviceimprovement. At the end of the forming stage, the leader can givequestionnaires to evaluate their knowledge and preparedness for thestorming stage.

Storming stage

In this juncture, the directoris required to identify the driving forces for the CCOT team such asteamwork, positive attitude for the CCOT, organization support andimprovement of the patients’ outcome. Moreover, they should alsoidentify both the driving and restraining forces and how to overcomelatter. Oman Nursing and MidwiferyCouncil (ONMC 2011) stated that “the nurse must develop andmaintain a cooperative relationship with co-workers and otherdisciplines involved in the delivery of healthcare.&quotFrustrations might be encountered by the nurses as they may be unableto identify vital signs (Brown, 2012) or fail to use the EWSand electronic monitors effectively. Further, medical professionalscan also conflict with the CCOT as they may think that the CCOT mightinterfere with their patient treatment and management strategies(Pusateri, 2011). The leader plays a role in conflictresolution as he/she will explain the importance of both the CCOT andthe medical staff and facilitate teamwork between the two. All theteam members do decision making and after the conflict is resolvedthe next stage can be done.


In this phase, all the membersof the CCOT are familiar with the implementation of the system andthe leader lays out the goals of the team. Gage (2013) stated thatthe leader has the principal responsibility for planning for thedesired outcome. The goals of the team should be specific,measurable, achievable, realistic, and time constrained (SMART). TheCCOT members should be able to plan to do, study and act to beeffective as measured by the PDSA cycle.

Plan: Accordingto IHI (2015) the team leader of the CCOT has to specify theobjectives of the project in alignment to improve the service providethe team. The team members should be involved in the planning as itwill help in motivating and empowering them (Kerridge, 2012).The leader needs to act tooffer guidance, bolster and energize the colleagues. The team leaderalso needs to delegate duties to every member of the group. It isimperative to arrange instructive projects for ward nurses abouttheir role in advancing patient safety and when to trigger a CCOgroup. At the end of the planning, a questionnaire can be issued andthe data analyzed to determine areas that require improvement.

Do: atthis phase, the team leader oversees implementation of the project’sSMART objectives aimed at service improvement. Further, the teamleader will also assess the effectiveness of the team and determineareas of improvement.

Study: ASWOT analysis will be done to analyze the internal and externalfactors that might affect the study outcomes. Strengths such asteamwork and critical care skills might be identified. Weakness dueto lack of adequate knowledge about the CCOT and the methods used intriggering the CCO as explained in the literature review can bedetermined. The gaps offer an opportunity for service improvement asthe established threats are sought to be minimized.

Act: Theteam leader will evaluate the entire process based on the informationobtained and adjust the action plan to meet the need for serviceimprovement.

Performing Stage:

The main aim of the team is toachieve the goals of the project. The team leader delegates the tasksas the members of the CCOT are ready to implement the mission.According to Kerridge (2012), at this stage, the members maintain ahigh level of autonomy and the team leader acts to empower andmotivate them. The project will be assessed, and continuous trainingwill be given to the nurses to ensure they are competent in providingand improving patient care. The leader also has a role in providingthe continuity of the project and sharing the success with CCOTmembers. The top level should be involved at this stage since theyought to provide financial support which is essential for the CCOTactivities.

Adjourning: itis the final stage of project implementation. The team leader ensuresthe team celebrates its success in reducing the readmission andadmission rate and the members get an opportunity to bid farewell toeach other. The best practices reported during the CCOT activitiescan be documented and used in the future by the healthcare facility.

Supportive Work Group Climate and Culture

Schneider &amp Barbera (2014) defineorganizational culture as the values and beliefs that describeorganizations as transmitted by the interaction experiences newcomerspossess, myths and stories people tell about their corporations andthe decisions stated by the management. Organizational culture playsa vital role in many of the organization’s outcomes which includethe performance, motivation and attitudes of the staff (Aaron,2014). Competing Value Framework is used to assess the culture inhealthcare. According to Zohar and Hofmann (2012), a strategicorganization culture and climate are functions of the implementedvalues and priorities of the leadership team. Jacobs (2014)analyzed the relationship between the organizational performance andthe senior management team culture in NHS trusts, and they concludedthat the two parameters were related. Different organizations havedifferent cultures and depending on the culture that is in place theperformance of the team varies too. For the CCOT to be useful in theprevention of admission and readmission in the ICU, a strategicorganization culture must be implemented that incorporatestransformational leadership in it.

Work climate is defined as the shared meaningworkers embrace to the practices, policies and procedures theyencounter and the behaviors they see getting supported rewarded andexpected (Schneider and Barbera, 2014).There are two types oforganizational climates: molar climate refers to the extent to whichthe workers a positive work environment. It encompasses manydimensions such as leadership support, autonomy, role stress andwarmth. The other is the focused climate that refers to theemployee`s perceptions of the length to which a firm’s practices,events and procedures associate with and support specific criteria ofinterest such as an organizational process (Aaron, 2014).Robbins, &amp Harrison (2011)show that leaders play a critical role in influencing the climate andperformance of the healthcare organization. West (2011) agreethat in groups that had clear objectives and the staff saw theirleaders with positivity recorded highest patient satisfaction.Therefore, for improvement of the quality of patient care by the CCOTa climate that ensures staff satisfaction is critical. The immediatemanagers supervising the nurses need to be supportive, and as aresult, the patients will experience better comfort and quality carethat will ensure the readmission rates dwindle. According to (2011), adequate training, learning and developmentopportunities provided by the managers were linked to fewer patientmortality cases. One of the roles of the CCOT team is to reducemortality rates. Studies byWinters (2013) and Williams (2010) showedthe CCOT effectiveness in reducing the mortality rates in the ICU. Apositive work climate championed by the management is, therefore,important in improving the quality of patient care. The links betweenleadership, climate and culture are essential in improving theoutcome of a healthcare system and a CCOT should factor in theseelements for them to be effective reducing admission and readmissionrates in the ICU from the general wards.

Employee Attitudes.

The opinions of the members in the CCOT is vital for its success andeffectiveness. The leadership program that is implemented by aparticular hospital or organization influences the behavior andattitudes of the employees working there. Lee (2011) agree thata high-performance work system affects the kind of employee reactionand the quality of service given to the patients. Management of thehealthcare organization can improve the quality care given to itspatients and satisfaction through employee engagement and efficientoperations. Effective team leadership is vital for the effectivefunctioning of the team as it influences the behavior and attitude ofthe team and the behavior of the employees is associated with safeand quality patient care (Reader and Cuthbertson, 2014). Singer also agree that the leadership provided to the frontline staffinfluences their behavior, and their active engagement improvespatient care. When trust is struck between the employees and themanagement, a positive climate is established, and as a result, thepatients get better satisfaction from the services offered by thestaff. From the implementation of the CCOT, trust and positivebehavior and attitudes should be established and maintained toimprove the quality of healthcare and reduce admission/readmissionrates into the ICU.

Evidence-based practices.

EBP integrates patients’ values, clinical expertise and the bestresearch evidence in making correct decisions about the care of apatient. Clinical research data is obtained from clinically relevantresearch done using a valid and empirical methodology. Implementationof the EBP is essential for the provision of quality care inhealthcare. Leaders at the management level are often responsible forthe implementation of novel practices and organizational strategies(O`Reilly 2010). In the provision of CCOT services, EBPs arevital in providing quality healthcare to the patients and preventingthe rates of admission and readmission to the ICU. System levelleadership is essential regarding the allocation of funds to supportthe implementation and execution of EBP (Aaron, 2015).According to Chreim (2012), even though the top managementleadership makes the decision on the implementation of the EBPs, itseffectiveness is driven by the healthcare workers who deliver theactual service. The administration should create an environment thatsupports the application of such practices. The methods used totrigger the CCOT are usually novel to the staff when they areintroduced in the first place. Nursesbeing part of the CCOT play a significant role in detecting the earlywarning signs of the patients in severe conditions so that they canknow when to call for the rest of the CCOT. The response time for theCCOT is critical in saving the patient and avoiding high admissionand readmission rates into the Intensive Care Unit. Thehospital administration has the duty to ensure that they introduceeducational programs that endow the CCOT team with skills that enablethem execute their mandate effectively. Therefore, for them to beimplemented and executed successfully, leaders who understand,respect and have their teams best interests in mind will make aneffort in ensuring that their teams understand and effectively usethose methods (Hutchinson &amp Jackson 2013).

Leadership Style

Efficient management is vital to the success of any team in thehealthcare system. According to West (2015), leaders in thehealth system are required to ensure that their staff works togethereffectively across their professional boundaries to provide highquality care. The CCOT under effective leadership should worktogether to improve the quality of patient care and prevent theadmission and readmission of patients in the ICU. Dawson (2011)explain that when the staff in the health service are well led andexperience high levels of satisfaction with their management team,the patients are in turn treated with compassion respect and givenquality care. The overall culture of the workplace is essential and apositive climate that is supportive as provided by efficientmanagement influences the quality care provided by the staff.

Frandsen (2014) identifies five main leadership styles which includeservant, democratic, transformational. Autocratic and Laissez-faire.The autocratic leadership technique is essential during emergencysituations. However, it can lead to the loss of trust within theteam. The autocratic leader reinforces his team majorly on emergencysituations since there is no time for discussion. In theLaissez-Faire style, the manager takes no action, and it creates alot of conflict in the leadership as most of the staff seem to makeindividual decisions rather than working as a team or following thedirections of the leader. As indicated by Frandsen (2014), democraticleadership style encourages communication and discussion among theteam members and with the head of the group. According to West, Teamwork is essential to the success of any organization anda good team should have clear team objectives, be committed toexcellence, support innovation being able to communicate with theirleader in a democratic manner will enhance its effectiveness. Nageland Andenoro (2012) describe servant leadership as based on emotionalcare, awareness, and presence and they perceive it as effective inproviding healing to the patients. Transformational leadershipis the most satisfactory and influential style in medical leadershipas identified by various researchers.

Service Improvement.

Service improvement in healthcare is the process of constructing aneffective intervention to enhance the quality of patient care in thehealthcare setting (Health Foundation, 2013). The need to developeffective outreach services is crucial in the management of patientswho require critical care and need their complications to beprevented (Martin et al. 2015). According toYoder-Wise (2011), leadership and service improvement go hand in handas nurses who provide care to the patients in the ICU have a positiveimpact on the recovery of the patients when provided with sufficientleadership. Searle (2013) agrees that for the efficientimplementation of the CCOT expert staff with excellent knowledgebackground knowledge and skills. According to West (2013), agood leader should have the technical competence to win over therespect of their team members, conceptual skills to understandcomplex situations and interpersonal skills. Moreover, to achieveservice improvement, the CCOT should have self-confidence, highenergy levels, stress tolerance, emotional maturity, internal locusof control, achievement orientation, small needs for affiliation andpersonal integrity (West, 2013).

Leaders develop strategies that are aimed at the improvement of careto patients. They formulate the goals that should be achieved by therest of the team to ensure the best patient outcomes. However, it iscritical to consider the fact that the leaders have to gain the trustof the team and have them work toward the realization of theidentified goals. The ability to mobilize the health care team toadhere to the identified goals and strategies is essential in theachievement of improvement at the hospital environment. Differentleaders adopt a variety of methods to help in the improvement ofpatient outcomes.

Proper leadership has been linked with a variety of functions thataim at improving the patient outcomes reducing cases of admission orreadmission of the general surgery patients to the ICU. Theleadership is essential in ensuring that patients get access totimely care, efficient services and improved performance by thehealthcare practitioners (Curtis et al. 2011). Through the same, itwould be possible to reduce the possibility of patients gettingadmitted to the intensive care unit. The ability of a particularleader to mobilize the team players to adhere to the established modeof service delivery would be instrumental in facilitating improvementat the hospital (Downey et al. 2011). Leaders provide the guidanceneeded by the junior members on what needs to be done and in what wayto ensure the best patient outcomes are realized resulting inimprovement.

The role of leaders in facilitating care and achieving the bestpatient outcomes is reiterated in the Darzi Report (2014). It isagreed that leaders have the mandate of ensuring that there isconsistency in the provision of high quality services for patientsleading to efficient care. The guidance provided by the leaders isinstrumental in enabling the rest of the team work toward a focusedgoal which is improved patient outcomes (Doody &amp Doody 2012).Through the same, chances are that there would be an improved levelof care to the patients. The critical care outreach team evidentlyworks in a strenuous environment defined by challenges in practice.They have the duty of ensuring that patients who have previouslyreceived general surgical services do not develop infections that islikely to subject them into being admitted to the intensive careunit. The team must work in coordination with other service providersfor the realization of the best patient outcomes. However,effectiveness in the work executed by the team may not yield the bestresults if there is no sound leadership. Such is a reflection of thefundamental role played by leadership in ensuring the best patientoutcomes (Giltinane 2013).

Leaders have the ability to exercise the skill and expertise theyhave gained in the course of practice and have the rest of the teammembers emulate the same. The decision to lead by example serves as amotivation to the rest of the team to execute the tasks assigned tothem in a similar manner. For example, a leader who is caring for aparticular patient admitted at the general wards will focus on thebest patient outcomes (Remus &amp Kennedy 2012). They will beexecuting the mandate based on the need to have the best outcomes forthe patient. The level of care provided would be of the highestquality that is line with the established mode of practice. As theleader performs such duties, the rest of the team is likely toemulate the same and try to employ the strategy when caring for thepatients (Schreuder et al. 2011). If the rest of the critical careoutreach team decides to embrace the same style of leadership,chances are that there would be improved patient outcomes (Jeffery2013). The effect is an improved level of care to the patients.

Transformational leaders challenge the rest of the team to deliverthe best services to the patients. The critical care outreach teamembrace the need to deliver the best patient services reducing casesof readmission to the intensive care unit. However, it is essentialto acknowledge the fundamental role played by the transformationalleader who constantly reminds the team of their mandate to deliverthe best care to the patients. As indicated byGopee and Galloway (2014),the transformational leader style contributes effectively regardingthe motivation and inspiration of the organization in achieving itsset goals. The motivation of the members is vital to the improvementof service delivery. The transformational leadership style enhancesand develops the relationship between the group members (Zori,2010).

As each member of the CCOT executes the mandate endowed on them, thefocus is in achieving improved patient outcomes. The leadership isparticularly instrumental in inspiring the team members while at thesame time reminding them of what is expected of them when it comes tothe realization of the best care to the patients (Buckner et al.2014). The effect of the leadership approach is instrumental inguiding the rest of the team toward the realization of improved careat the hospital reducing admission of patients to the intensive careunit.

Participatory leadership can equally be adopted for the realizationof improvement concerning patients recently treated at the generalwards. The participatory leadership acknowledges the contribution byeach member of the team toward the achievement of the best patientoutcomes (Galuska 2012). For example, the opinion of each nurse issought to determine the best way through which improvement can beachieved. The style of leadership appreciates the contribution ofeach member toward the achievement of the best care (Macphee et al.2012). The identification of change needed for improvementestablishes room for contribution of ideas on how best to realize theidentified objectives. The leader creates an avenue through whicheach member of the team is allowed an equal opportunity to contributeon the best way to realize the improvement (McKenzie &amp Manley2011). The leader evaluates the contribution by each member andmakes the final decision on what works best for the patient leadingto an improvement. The leaders who adopt such a strategy have thebenefit of leading the rest of the team in facilitating improvement(Scott &amp Miles 2013). It is an appropriate style of leadershipsince the opportunity to have every member contribute ideas on howbest to provide quality care to the patients (Gottlieb et al.2012). The team members are likely to get motivated in focusingtoward improvement of care because their contributions are valued.The impact of such a move is enhanced morale among the healthcareproviders leading to a commitment toward the provision of the bestcare leading to improvement.

Conclusion for Chapter Three

Leadership plays a fundamental role when it comes to the improvementof services at the health care centers. The critical care outreachteam entrusted with the mandate of preventing the admission orreadmission of medical/surgical ward patients to the ICU need to haveaccess to sound leadership that will help them in executing theirtasks effectively. Leaders have the legal and moral obligation ofensuring that there is improved patient outcomes at the stations theyare serving (Parand, Dopson, Renz, and Vincent, 2014). The leaderstake part in the formulation of policies that determine the overallprocess of care to the patients. The leaders equally decide on theparticular procedures that can be employed when it comes to theprovision of care to patients. The development of the policies orprocedures is often followed by their implementation. Leaders in thepractice environment have the mandate of guiding the rest of the teamthrough the process of implementation to achieve the best patientoutcomes (Mannix et al. 2013). The type of leadership provideddictates the patient outcomes. It is essential that leaders work withthe goal of realizing the best patient outcomes. The rest of the CCOTmembers need to understand that as they deliver services to thepatients, focus is on attainment of better patient outcomes. Theleadership is instrumental in passing along such sentiments to therest of the team as a way of encouraging them to dedicate all theycan in provision of care (Weberg 2012). A combination of theidentified leadership styles and theories is essential in theachievement of the best outcomes for the patients. The approach willsignificantly reduce the number of patients readmitted to the ICU.


Effective leadership is essential for the provision and improvementof quality healthcare. Transformational leadership is so far the beststyle of leadership in the healthcare setting. It influenceseffective management to the CCO team members and enhances positivepatients’ outcomes. The Tuckman’s model is helpful in guiding achange process in the CCOT as it aids in formulating objectives andthe team’s responsibilities. Aspects such as employee attitudes,evidence-based practice, and the workplace culture and climate areinfluenced by the kind of leadership in place. These elementscontribute to the provision and improvement of quality care topatients. In conclusion, the administrationfacilitates processes that are vital in nurturing positive employeework attitudes, commitment to organizational change, positiveattitudes towards evidence-based practices (EBP) and a supportivework group climate and culture. Therefore, to improve quality care inhealthcare, the leaders should provide effective leadership to theCCOT as it’s vital for preventing the admission and readmission ofpatients into the ICU. In the next chapter, the overall conclusion ofthe dissertation is included. Effective implementation andexecution of the EBP as facilitated by the leadership improves thequality of patient care in hospitals. The culture or environment thatsupports the implementation of the EBPs influences the formation ofthe best clinical decisions that result in positive patient outcomes.EBP enhances high quality healthcare including improving healthoutcomes, decreasing mortality and readmission rates and reducingvariations in the overall cost. Barriers such as resistance by theleadership or staff cripple the strategies put in place in improvingthe quality of healthcare. Further, incorporation of EBP competenciesinto the healthcare system by the leadership can aid drive reliable,quality and a consistent healthcare system and reduce costs. Researchhas depicted the effectiveness of the CCOT in the hospital setup.Positive outcomes have been registered in patients with severeadverse events, cardiac arrests, mortality and in admission andreadmission rates of the general ward patients in intensive careunits. A better method that triggers the CCOT should also be designedand implemented so as to improve clinical outcomes in the ICU. Mostnurses who work in the CCOT should be conversant with the methods andbe able to make relevant decisions that will aid them detect earlysigns in critically ill patients and avoid admissions andreadmissions to the ICU. Advancements in both the fields of scienceand technology have led to machines that can be used to measurephysiological changes in patients in real time, therefore,strengthening the effectiveness of the CCOT. Further, all CCOTmembers should embrace them and strive to provide better patientcare. Education programs that will enhance the knowledge of thehospital staff on the awareness and perspective of the CCOT should beencouraged as they have the potential in improving the efficiency ofthe CCOT. The early detection of physiological signs and symptoms inacute and critical patients and it can help prevent admission andreadmission of general ward patients into the ICU.

Different leadership styles have been adopted by leaders to help inthe improvement of services at the hospital set up. Leaders havetheir unique styles of managing the rest of the team toward theachievement of the best patient outcomes. Transformational leadershiphas particularly been instrumental in ensuring that there isimprovement in service delivery. Transformational leaders are visionoriented and focused toward the realization of a particular goal. Theleaders work with the team members to identify areas that need changeand develop a vision toward the realization of the same. The criticalcare outreach team have the ability to identify sections that need tobe rectified to reduce the chances of such patients ending up at theICU especially after treatment. Through the same, they would be ableto reduce cases of readmission to the ICU. The leaders working incoordination with the team have the ability to identify such areasand introduce measures aimed at achieving the change that would inthe long-run result in the improvement of the patient outcomes. Theleader motivates the rest of the team to focus toward the realizationof the identified goals with the ultimate goal of getting the bestpatient outcomes. The adoption of appropriate leadership skills isessential in improving the overall patient outcomes.

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