BMJ 1998;316:1853-1858 ( 20 June )

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Confidential inquiry into quality of care before admission to intensive care

Editorial by Garrard and Young

Peter McQuillan, consultant in intensive care and anaesthesia, a Sally Pilkington, senior registrar in anaesthesia, a Alison Allan, registrar in anaesthesia, a Bruce Taylor, consultant in intensive care and anaesthesia, a Alasdair Short, consultant in intensive care, c Giles Morgan, consultant in anaesthesia and intensive care, d Mick Nielsen, consultant in intensive care and anaesthetics, b David Barrett, senior lecturer, e Gary Smith, director of intensive care. a

a Department of Intensive Care Medicine, Queen Alexander Hospital, Cosham, Portsmouth, Hampshire PO6 3LY, b Intensive Care Unit, Southampton General Hospital, Southampton SO16 6YD, c Intensive Care, Broomfield Hospital, Chelmsford, Essex CM1 7ET, d Intensive Care, Royal Cornwall Hospital, Treliske, Truro, Cornwall TR1 3L, e School of Mathematical Studies, University of Portsmouth, Mercantile House, Hampshire Terrace, Portsmouth, Hampshire PO1 2EG

Correspondence to: Dr McQuillan

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



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Good Ward Care Starts Focusing Training To Where It Is Needed
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S Ahmad
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Mark G Coulthard
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