Medical staff don't review the patients that nurses identify as highly dependent
EDITOR-McQuillan and colleagues report sub-optimal care before admission in 54% of patients admitted to intensive care units (ICU) in two hospitals (1).
In 1993 we performed an audit at the John Radcliffe Hospital to assess the number of patients in selected general wards who would be more appropriately cared for on an ICU or high dependency unit (HDU). The survey was performed daily over a two week period and included general medical, general surgical and cardiology wards. Preliminary identification of the most dependent patients was made by the night sister. During the study period 56 assessments were made of 39 patients. The grades of medical staff attending the patients and the frequency with which the patients were seen were recorded. Severity of nursing workload was assessed using the therapeutic intervention score (TISS). Of the patients referred for assessment, requirement for "more nursing" was given as the reason for referral in 87%. Seventy two percent were thought to require "more monitoring" and 47% were thought to require more "intensive treatment or organ support". The nursing staff directly looking after each patient were then asked to judge whether ICU or HDU admission was required. In 20 of 56 cases (36%) ICU or HDU admission was thought to be required. There were significant overlaps between the TISS scores of ward patients judged to require HDU or ICU (13-36), ward patients judged not to require HDU or ICU (11-32) and those on ICU at the time of the audit(24-70).
Of the patients identified as requiring more intensive care by the nursing staff only 11 (55%) were reviewed by a consultant on a daily basis and only 4 (20%) patients in this group were reviewed at least 4-6 hourly by a registrar.
This data suggests that nursing staff identify a significant number of patients on general wards who they feel warrant admission to an HDU or ICU. The majority of these patients identified during this audit were not reviewed on a regular basis by experienced medical staff.
Tim Ringrose Specialist Registrar
Christopher Garrard Director
Intensive Care Unit
The John Radcliffe Hospital
Oxford, OX3 9DU
References.
1. McQuillan P, Pilkington S, Allan A. Confidential enquiry into the quality of care before admission to intensive care. BMJ 1998;316:1853 (20 June)
Rapid Response:
Medical staff don't review the patients that nurses identify as highly dependent
EDITOR-McQuillan and colleagues report sub-optimal care before admission in 54% of patients admitted to intensive care units (ICU) in two hospitals (1).
In 1993 we performed an audit at the John Radcliffe Hospital to assess the number of patients in selected general wards who would be more appropriately cared for on an ICU or high dependency unit (HDU). The survey was performed daily over a two week period and included general medical, general surgical and cardiology wards. Preliminary identification of the most dependent patients was made by the night sister. During the study period 56 assessments were made of 39 patients. The grades of medical staff attending the patients and the frequency with which the patients were seen were recorded. Severity of nursing workload was assessed using the therapeutic intervention score (TISS). Of the patients referred for assessment, requirement for "more nursing" was given as the reason for referral in 87%. Seventy two percent were thought to require "more monitoring" and 47% were thought to require more "intensive treatment or organ support". The nursing staff directly looking after each patient were then asked to judge whether ICU or HDU admission was required. In 20 of 56 cases (36%) ICU or HDU admission was thought to be required. There were significant overlaps between the TISS scores of ward patients judged to require HDU or ICU (13-36), ward patients judged not to require HDU or ICU (11-32) and those on ICU at the time of the audit(24-70).
Of the patients identified as requiring more intensive care by the nursing staff only 11 (55%) were reviewed by a consultant on a daily basis and only 4 (20%) patients in this group were reviewed at least 4-6 hourly by a registrar.
This data suggests that nursing staff identify a significant number of patients on general wards who they feel warrant admission to an HDU or ICU. The majority of these patients identified during this audit were not reviewed on a regular basis by experienced medical staff.
Tim Ringrose Specialist Registrar
Christopher Garrard Director
Intensive Care Unit
The John Radcliffe Hospital
Oxford, OX3 9DU
References.
1. McQuillan P, Pilkington S, Allan A. Confidential enquiry into the quality of care before admission to intensive care. BMJ 1998;316:1853 (20 June)
Competing interests: No competing interests