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Implementing Call 4 Concern © (C4C) patient and relative activated Critical Care Outreach

Marie-Clare Ratcliffe 21 Jun 2023

Implementing the Call 4 Concern (C4C) service: patient and relative activated Critical Care Outreach.

Clinical staff identify patient deterioration by assessing their physiological vital signs in conjunction with an Early Warning Scoring system, however this process can fail if protocol is not followed, observations are misinterpreted, or deterioration is not adequately managed and escalated. The C4C © service recognises that friends and relatives possess the ability to recognise ‘soft signs’ of deterioration in their loved one before it becomes apparent to staff or identifiable through scoring systems, enabling the ability to rescue at risk patients at the earliest opportunity, preventing continued clinical deterioration.

C4C is essentially a patient safety initiative, providing an extra layer of vigilance for deteriorating patients through recognising relative input and enabling a fresh-eyes timely clinical patient review. Friends or relatives can contact the Critical Care Outreach Team (CCOT) directly via phone to relay their concern and activate the service.

The model for C4C was inspired by a similar system enabling an ‘in-hospital 911’ born out of several historical tragic cases that identified poor communication and the inaction to parent and relative concerns as causal factors in patient fatality. It is also rooted in validating the concept of nursing intuition whereby nurses report suspected patient deterioration through intuitive reasoning rather than objective clinical indicators.

A quick google search will identify several harrowing recent cases that still echo the issues of poor communication and non-recognition of concerns as contributory to patient death. C4C is a positive action all NHS trusts can implement to attempt to mitigate repetition of these mistakes and provide the best patient experience and outcomes possible, and it seems to be gaining in popularity #Call4Concern.

Our team are now 12 months into delivering the service, but there have been issues along the way. Pre-rollout parent teams were protective and sceptical, however, CCOT are in the privileged position of being a member of everyone’s team and well respected within the trust. Each encounter is treated like any clinical review we undertake, and post service implementation, C4C has been accepted as such. Another challenge is the nature of the concern not being rooted in clinical deterioration and the service being used for ward based clinical issues, e.g. pain management, diagnostics chasing, chronic condition advice, or simply to make a complaint. These calls are straightforward to redirect or resolve on the ward and doing so contributes to positive patient experience. 

However, there have been three calls since starting where the team felt we rescued a patient who was deteriorating and that if not for the service the outcome would have been significantly more detrimental to the patient. They each required immediate therapies and escalation to higher levels of care for treatment and monitoring. 

It is those three patients that demonstrate the value and importance of C4C as a crucial element of the service we provide as a team to deteriorating patients within our trust. All trusts should look to be implementing Call 4 Concern.


© Royal Berkshire NHSFT 2010 

Mandy O’Dell et al. 2010. Call 4 Concern: patient and relative activated critical care outreach. Br J Nurs. (19)22 10.12968/bjon.2010.19.22.1390 

Marie-Clare Ratcliffe

Marie-Clare Ratcliffe

Critical Care Outreach Practitioner, Frimley Health Foundation NHS Trust

Currently works as a Critical Care Outreach Practitioner in a Rapid Response Team covering two acute hospital sites. Previously worked in a general Intensive Care Unit for ten years. 

Page last updated - 21/06/2023