Suboptimal care of patients before admission to intensive care

During the past decade deficiencies in the quality of medical care have precipitated detailed scrutiny in the form of national confidential inquiries. These inquiries have examined perioperative deaths (NCEPOD), maternal deaths, and more recently, babies’ deaths.^1–3 The 1993 NCEPOD report showed that two thirds of perioperative deaths occurred three or more days after surgery, usually from cardiorespiratory complications and in a ward environment. The riskiness of ward care is illustrated again this week in a different sort of confidential inquiry.

On p 0000 McQuillan and colleagues present the results of a confidential inquiry into the quality of care received by 100 patients admitted to intensive care (p 0000).⁴ After conducting structured interviews with the referring and intensive care clinical teams, the investigators completed a questionnaire that focused on the recognition, investigation, monitoring, and management of each patient’s airway, breathing, and circulation (ABCs). Two independent assessors (a nephrologist and an anaesthetist) evaluated the resulting questionnaires. Both agreed that 54 of the 100 patients received suboptimal care. Mortality in the intensive care unit for these patients was 48%, almost twice that of the 20 patients who they agreed had been managed well. In addition, two thirds of these 54 patients were admitted late to intensive care.

Although these findings have a disturbing familiarity, we need to ask whether they are representative of care across the United Kingdom. A recent report by McGloin et al from a London teaching hospital suggests that these deficiencies in care are not limited to the south coast of England.⁵ Together these findings provide a strong case for undertaking a national confidential inquiry into events triggering admission to an intensive care unit.

Important resource implications arise from deficiencies in the quality of general ward care. Intensive care is a scarce resource that needs to be carefully meted out to those most in need.⁶ However, we may have created an additional population of critically ill patients by failing to deliver the basic elements of ward care. Of the admissions reported by McQuillan et al as few as 4.5% and as many as 41% (depending on the individual assessors’ judgments) could have been avoided had earlier care been properly provided.

The assessors categorised the deficiencies in care as failures of organisation, lack of knowledge, failure to appreciate clinical urgency, lack of supervision, and failure to seek advice.⁴ With such a multiplicity of problems, where should we begin to seek a remedy? McQuillan et al venture possible solutions that relate to organisation and structure, clinical practice, and clinical guidelines.

Changing the process of care should reap the most rapid benefit. One option might be to increase the seniority of the doctors assessing and treating these patients. In Oxford the trauma surgeons now have 24 hour, resident, consultant cover which ensures all victims of major trauma are assessed and have their treatment planned by a consultant. The efficacy of this experiment has yet to be reported, but in the north west Midlands an increase in the proportion of trauma cases assessed by consultants from 28% to 70% had no effect on mortality and a questionable effect on morbidity.⁷

An alternative solution might be the formation of a medical emergency team along the lines suggested by Lee et al⁸ and others.⁹ This is a similar concept to the shock and trauma teams first described in the 1960s and 1970s,¹⁰ and the idea has considerable merit. The medical emergency team has much in common with the cardiac arrest team, but the criteria for calling the team are widened to include patients with severe physiological or biochemical abnormalities or specific high risk conditions. Extending the role of the cardiac arrest team acknowledges the fact that cardiac arrests are commonly preceded by premonitory signs and symptoms.¹¹ It is more rational to prevent cardiac arrests than to treat them after they occur. However, an emergency team can help only if summoned, so referral should not be limited to medical staff. Doctors are not always adept at following guidelines¹² and experienced nurses and other paramedical professionals should be able to contact the team directly.

A medical emergency team can do much for the patient on the ward, but the more serious, less reversible problems may require admission to an intensive care unit or high dependency unit. High dependency units provide an environment where high risk patients can be cared for by appropriately trained medical and nursing staff ⁶ and has been shown to reduce cardiac arrests in hospital and improve outcome on intensive care units.¹³

How can medical training be improved to facilitate the recognition of life threatening events? The medical emergency team must serve an educational as well as a troubleshooting role; otherwise there is a risk that ward based junior medical and nursing staff will become deskilled, potentially compounding rather than improving the situation. The high dependency unit can also provide a valuable educational role if medical and nursing staff regularly rotate through the unit. Finally, intensive care units themselves must adopt a hospital wide educational role. They can no longer function as isolated islands of expertise, but must become integrated into a continuum of hospital care. Intensive care should become part of the core curriculum for medical students and junior medical staff. The intercollegiate board for training in intensive care medicine, acting with the support of the royal colleges of medicine, surgery, and anaesthetics, have clarified the critical care training requirements for physicians, surgeons, and anaesthetists. Future generations of medical trainees will undertake intensive care training during their years as senior house officers and specialist registrars so that they will be better prepared to recognise patients at risk.

Little will be gained from apportioning blame or resorting to recrimination for the failings that McQuillan et al have identified. Their findings need to be confirmed as part of a national confidential inquiry so that the full extent of the problem can be realised. Meanwhile, we should re-evaluate the process of care on our wards and the training we offer our junior medical staff.

Papers p 1853