Suboptimal care should have been defined

EDITOR—McQuillan et al show that most patients receive suboptimal management of oxygen therapy, airway, breathing, circulation, and monitoring before admission to intensive care.1 In an area of medicine renowned for objective measurement it is surprising that this study should rely on the subjective opinions of two assessors about what constituted suboptimal care. Understandably, their opinions often disagreed.

The authors accept that there are difficulties in relying on assessors' opinions, but we must not underestimate these limitations. The assessors knew the outcomes of the patients, which must have biased their opinions, particularly since suboptimal care is not defined. How suboptimal care was defined is crucial to the paper's message, and more information about the data evaluated by the assessors would have been preferable to the lengthy discussion, much of which was not directly related to the data.

Unfortunately, many of the data are self fulfilling. It is unsurprising that the suboptimally managed group scored badly on oxygen therapy and airway, breathing, and circulation and that 67% of this group were late admissions to intensive care since these were presumably the factors used to determine suboptimal management.

Nevertheless, a key message is that most of the well managed patients were admitted to intensive care units within the first day of admission, with presumably some going straight from accident and emergency. These acutely ill patients are perhaps more easily identifiable as going to need intensive care. Conversely, those patients who arrived at hospital less ill and who deteriorated while on general wards were those who received suboptimal care. There was a longer time between admission to hospital and admission to intensive care in these patients. We are not told if any of the admissions to intensive care were delayed because of lack of beds. Although there is no excuse for suboptimal care, …