Confidential inquiry into quality of care before admission to intensive care

Abstract Objective: To examine the prevalence, nature, causes, and consequences of suboptimal care before admission to intensive care units, and to suggest possible solutions. Design: Prospective confidential inquiry on the basis of structured interviews and questionnaires. Setting: A large district general hospital and a teaching hospital. Subjects: A cohort of 100 consecutive adult emergency admissions, 50 in each centre. Main outcome measures: Opinions of two external assessors on quality of care especially recognition, investigation, monitoring, and management of abnormalities of airway, breathing, and circulation, and oxygen therapy and monitoring. Results: Assessors agreed that 20 patients were well managed (group 1) and 54 patients received suboptimal care (group 2). Assessors disagreed on quality of management of 26 patients (group 3). The casemix and severity of illness, defined by the acute physiology and chronic health evaluation (APACHE II) score, were similar between centres and the three groups. In groups 1, 2, and 3 intensive care mortalities were 5 (25%), 26 (48%), and 6 (23%) respectively (P=0.04) (group 1 versus group 2, P=0.07). Hospital mortalities were 7 (35%), 30 (56%), and 8 (31%) (P=0.07) and standardised hospital mortality ratios (95% confidence intervals) were 1.23 (0.49 to 2.54), 1.4 (0.94 to 2.0), and 1.26 (0.54 to 2.48) respectively. Admission to intensive care was considered late in 37 (69%) patients in group 2. Overall, a minimum of 4.5% and a maximum of 41% of admissions were considered potentially avoidable. Suboptimal care contributed to morbidity or mortality in most instances. The main causes of suboptimal care were failure of organisation, lack of knowledge, failure to appreciate clinical urgency, lack of supervision, and failure to seek advice. Conclusions: The management of airway, breathing, and circulation, and oxygen therapy and monitoring in severely ill patients before admission to intensive care units may frequently be suboptimal. Major consequences may include increased morbidity and mortality and requirement for intensive care. Possible solutions include improved teaching, establishment of medical emergency teams, and widespread debate on the structure and process of acute care. Key messages Suboptimal management of oxygen therapy, airway, breathing, circulation, and monitoring before admission to intensive care occurred in over half of a consecutive cohort of acute adult emergency patients. This may be associated with increased morbidity, mortality, and avoidable admissions to intensive care At least 39% of acute adult emergency patients were admitted to intensive care late in the clinical course of the illness Major causes of suboptimal care included failure of organisation, lack of knowledge, failure to appreciate clinical urgency, lack of supervision, and failure to seek advice A medical emergency team may be useful in responding pre-emptively to the clinical signs of life threatening dysfunction of airway, breathing, and circulation, rather than relying on a cardiac arrest team The structure and process of acute care and their importance require major re-evaluation and debate

[1]  Rachel Jenkins.  Health of the nation. , 1969, British medical journal.

[2]  P. Milner,et al.  Local confidential inquiry into avoidable factors in deaths from stroke and hypertensive disease. , 1993, BMJ.

[3]  S Capewell,et al.  The continuing rise in emergency admissions , 1996, BMJ.

[4]  Olof Johnell,et al.  Hormone replacement therapy and risk of hip fracture: population based case-control study , 1998, BMJ.

[5]  Douglas G. Altman,et al.  Practical statistics for medical research , 1990 .

[6]  A. Redmond.  Management of Patients with Major Injuries , 1988, The Lancet.

[7]  T. Delbanco,et al.  Incidence and characteristics of preventable iatrogenic cardiac arrests. , 1991, JAMA.

[8]  H. Davies,et al.  Assessing the quality of care , 1995, BMJ.

[9]  Jane Smith.  Consultants of the future , 1995, BMJ.

[10]  E. Draper,et al.  APACHE II: A severity of disease classification system , 1985, Critical care medicine.

[11]  S. Office.  Report on Confidential Enquiries into Maternal Deaths in the United Kingdom 1991-1993 , 1996 .

[12]  J A Paris,et al.  Royal College of Physicians of London , 1848, Provincial medical & surgical journal.

[13]  R. Jeffreys,et al.  AVOIDABLE FACTORS CONTRIBUTING TO THE DEATH OF HEAD INJURY PATIENTS IN GENERAL HOSPITALS IN MERSEY REGION , 1981, The Lancet.

[14]  N J Harper,et al.  Ability of hospital doctors to calculate drug doses , 1995, BMJ.

[15]  K. Hillman,et al.  Do nurses know when to summon emergency assistance? , 1994, Intensive & critical care nursing.

[16]  L. Dillner.  Babies' deaths linked to suboptimal care , 1995, BMJ.

[17]  D. Goldhill,et al.  Mortality predicted by APACHE II , 1996, Anaesthesia.

[18]  B. Folk,et al.  Pre-arrest morbidity and other correlates of survival after in-hospital cardiopulmonary arrest. , 1989, The American journal of medicine.

[19]  P. Rothwell,et al.  Physiological scoring systems and audit , 1993, The Lancet.

[20]  B. Thwaites,et al.  Can Consultants Resuscitate? , 1992, Journal of the Royal College of Physicians of London.

[21]  C. Franklin,et al.  Developing strategies to prevent inhospital cardiac arrest: Analyzing responses of physicians and nurses in the hours before the event , 1994, Critical care medicine.

[22]  J P Kassirer,et al.  The quality of care and the quality of measuring it. , 1993, The New England journal of medicine.

[23]  M. Mcnicol,et al.  Rethinking Consultants: Alternative models of organisation are needed , 1995, British medical journal.

[24]  R. Elkeles,et al.  Attitudes of consultant physicians to the Calman proposals: a questionnaire survey , 1995, BMJ.

[25]  C. Sprung,et al.  Clinical antecedents to in-hospital cardiopulmonary arrest. , 1990, Chest.

[26]  O. Boyd,et al.  Physiological scoring systems and audit , 1993, The Lancet.

[27]  M. Stoneham,et al.  Knowledge about pulse oximetry among medical and nursing staff , 1994, The Lancet.

[28]  M. Charlson,et al.  Medical patients at high risk for catastrophic deterioration. , 1987, Critical care medicine.

[29]  J. Eyre,et al.  Avoidable factors contributing to death of children with head injury. , 1990, BMJ.

[30]  M. New,et al.  Book reviewStatistics for the behavioural sciences: S. Weinberg and K. Goldberg: Cambridge University Press, Cambridge U.K. (1990). xiii + 621 pp. £25.00 , 1994 .

[31]  J. H. Cohen.  The Penguin Dictionary of Quotations , 1986 .

[32]  J O Sundin,et al.  Assessing quality of care. , 2000, CMAJ : Canadian Medical Association journal = journal de l'Association medicale canadienne.

[33]  T Delamothe,et al.  Wanted: guidelines that doctors will follow. , 1993, BMJ.

[34]  H Montgomery,et al.  Interpretation of electrocardiograms by doctors , 1994, BMJ.

[35]  T. Gould,et al.  A survey of the intended management of acute postoperative pain by newly qualified doctors in the South West region of England in August 1992 , 1994, Anaesthesia.

[36]  R H Brook,et al.  Preventable deaths: who, how often, and why? , 1988, Annals of internal medicine.