Confidential inquiry into quality of care before admission to intensive care
BMJ 1998; 316 doi: https://doi.org/10.1136/bmj.316.7148.1853 (Published 20 June 1998) Cite this as: BMJ 1998;316:1853
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McQuillan's paper was of huge interest to us as Emergency Physicians at the West Middlesex University Hospital. It highlights a widely held belief that care of patients prior to their admission to intensive care units can be sub-optimal.
We were interested to note however that the role of the Accident & Emergency Department was not mentioned in the paper. Of particular relevance to Emergency Physicians would be how many patients originated from the Emergency Department and of these how many were directly transferred to the Intensive Care Unit and how many went via the wards. We believe this information will be of interest to a wide audience and that it would help emphasise the importance of the critical care axis between the Emergency Department and the Intensive Care Unit.
With our best wishes
Yours faithfully
Mr S Ahmad FRCS (Ed) Miss D Hulbert FRCS FFAEM
Specialist Registrar Consultant
Accident & Emergency Accident & Emergency
Accident & Emergency Department, West Middlesex University Hospital
1. McQuillan P, Pilkington S, Allan A, Taylor B, Short A, Morgan G, et al. Confidential Inquiry into quality of care before admission to intensive care. BMJ1998: 316:1853-8
We the undersigned authors of the enclosed letter declare that there is no conflict of interest involved in this matter
Competing interests: No competing interests
McQuillan et al's study (1) has highlighted an important
question facing hospitals today, namely how can patients receive a
tailored continuum of care in the face of the effects of Calman
training and the pressure to reduce ward nursing numbers and grades?
Certainly the list of recommendations whilst exhaustive are not all
achievable within an acceptable time frame. Individual hospitals must
find a solution that is locally achievable within present resources in
the first instance.
Following a critical incident involving a patient admitted
through the A&E Department to a medical ward and belatedly referred to
the Intensive Care Unit (ICU), we compiled a list of conditions for
which senior medical and intensive care advice must be sought. (List
appended). Unlike most guidelines these do not dictate a clinical
pathway but serve as a trigger for more senior involvement in the
management of patients at an earlier stage. A second major difference
was for the involvement of intensive care staff for patients that may
not necessarily require ventillation but do need correction of their
physiological parameters. Since the implementation of these
guidelines, ICU referrals have been earlier and appropriate. We plan
to augment this list with physiological parameters (2) and distribute
it to the acute medical and surgical wards.
With the increasing sub-specialisation of general medicine the
management of medical emergencies have been sidelined. This has
occurred at a time when the specialty of accident and emergency
medicine is beginning to come of age. All undiagnosed emergency
admissions should be admitted to hospital through the A&E Department
so an accurate assessment and appropriate onward transfer can be made.
Following the recent disquiet at unfavourable clinical outcomes, it is
increasingly untendable to rely on the salvage of ward patients in
extremis via cardiac arrest teams and ICU. Time to put systems in
place to ensure the matching of health care to the continuum of
illness is one thing we do not have.
1 McQuillan P, Pilkington S, Allan A, Taylor B, Short A,
Morgan G, et al.
Confidential inquiry into quality of care before
admission to intensive care.
BMJ 1998; 316: 1853-8.
2 Ridley SA. Intermediate care. Possibilities,
requirements and solutions.
Anaesthesia 1998: 53: 654-664.
Dr C McAllister MB MRCPI FFARCSI Mr S J McGovern FRCS
Lead Clinician, Intensive Care Unit Consultant in A&E Medicine
Craigavon Area Hospital Group Trust
68 Lurgan Road
Portadown
BT63 5QQ Northern Ireland
NO CONFLICT OF INTEREST
APPENDIX
1. All patients with suspected meningococcal septicaemia.
2. Altered level of consciousness in the poisoned patient in the
presence of arrhythmia, including tachycardia (120 beats per
minute).
3. Asthmatic patients who are not responding to maximal medical
therapy, or those who are becoming exhausted, or a high normal
CO2.
4. Status epilepticus (seizure activity 30 minutes).
5. Patients with signs of inhalation injury (Rem SAO2 is
unreliable).
6. Patients with unstable facial fractures.
7. Victims of near drowning.
8. Cerebrally agitated patients be it from brain contusion/
undiagnosed hypoxia/poisoning.
9. GCS in head injured patient <10 or rapidly falling.
Competing interests: No competing interests
McQuillan and colleagues1 have demonstrated that patients frequently
receive sub optimal care on wards prior to referral to the Intensive Care
team. We would like to highlight another serious factor which adversely
affects the provision of high quality intensive care to patients in the
North West of England. This is the frequency with which many hospitals are
unable to admit patients to their own Intensive Care Unit (ICU) because of
a shortage of staffed and available beds.
In the North West region, each day an average of 3 patients are transferred
to another Intensive Care Unit. Some of these transfers involve long
distances or protracted transfer times. The number of transfers can rise
to 9 per day during peak periods.
All ICUs in the North West region are contacted four times daily by the
Regional Intensive Care Bed Information Service (ICBIS) to ascertain bed
availability. There are potentially 183 adult general intensive care beds
in the region. When only 10 beds are available an amber alert is declared
by the NHS Executive North West Regional Office and this information is
faxed to all Trusts. When only 5 beds remain a red alert is declared.
This system, however, under-reports the true situation since alerts cannot
be sent out from the Regional Office at night or at weekends. These alerts
also exclude all specialist services and paediatric beds. During June,
traditionally a quiet time of the year, there were 17 occasions when an
amber alert condition was met, and 6 occasions when a red alert could have
been issued.
The inability to satisfy the demands for intensive care in a hospital leads
to a number of consequences. People who, although no longer mechanically
ventilated, could still benefit from intensive care may be discharged
early. Patients who are deteriorating may have to be managed on a general
ward or another area where the facilities are less than ideal, and with
staff who do not work regularly with such critically ill patients. If
these patients are cared for in the operating theatres or recovery area,
then elective surgery may have to be cancelled. We cannot quantify the
resulting morbidity and mortality of these scenarios.
Furthermore, stabilisation and transfer of patients is time consuming (an
average of three and a half hours), and will either put an additional
burden on the already overstretched ICU staff, or place that burden on the
on-call anaesthetic service. There is often a dilemma; whether to use an
experienced hospital doctor for the transfer, which potentially leaves
inexperienced cover for the rest of the hospital.
McQuillan and colleagues rightly pointed out that audit is required to
monitor adherence to standards and guidelines. We have been auditing
intensive care transfers against locally published standards for two and a
half years. While this has demonstrated an increasing number of transfers
which meet the standards, it has also clearly demonstrated an increasing
number of transfers which are the result solely of the lack of staffed ICU
beds in the host hospital. Over this period, transfers for this reason
have increased by 300% in Greater Manchester, and 200% in the rest of the
North West region. Despite sharing this information with local and
regional managers, there appears to be an inability to address the
fundamental issue of insufficient investment in intensive care and high
dependency units in the North West of England. Political direction is
aimed towards reducing waiting times for elective surgery.
Unless McQuillan and colleagues' strategy to improve the care of the
acutely ill patient outside the ICU succeeds then, in the absence of
sufficient high dependency and intensive care beds, it seems inevitable
that patients will continue to require stabilisation and transfer to
distant ICUs.
References
McQuillan P, Pilkington S, Allan A, Taylor B, Short A, Morgan G, et al.
Confidential inquiry into quality of care before admission to intensive
care. BMJ 1998; 316:1853-8 (20 June)
Intensive Care Society. Guidelines for transport of the critically ill
adult. London: ICS, 1997; page 6, section 9.2
Royal College of Anaesthetists. Basic specialist training guide. London:
RCA, 1991; section 2.1
Dr Peter W Duncan Dr Peter Nightingale
Chairman Secretary
On behalf of the Association of North Western Intensive Care Units
Dr Ian Macartney
On behalf of the Intensive Care Bed Information Service
Dr Johanna Ryan
Regional Intensive Care Audit Co-ordinator
Dr Maire P Shelly
Local Advisor in Intensive Care Medicine
Intensive Care Unit
Withington Hospital
Nell Lane
West Didsbury
Manchester
M20 2LR
Competing interests: No competing interests
Preventing patients falling through the healthcare net requires a system wide approach - one which perceives the at-risk patient as being on a continuum of care from the pre-hospital and ward settings through to discharge from ICU, and which addresses the fact that these patients require time-critical attention. In New South Wales, Australia, the health authority has addressed this aspect of the problem. It has established in each of the health regions expert critical care committees which are charged with monitoring and correcting deficiencies in critical care within and between both district and larger teaching hospitals at any point in the continuum of care within the region.5
It is not enough to focus on patient care within each specialty area of medical practice, as critically ill patients do not respect arbitrary practice boundaries. Whatever strategies are used, it must be tested rigorously to show that it does improve patient outcome. Increased vigilance and improvements in the overall quality of patient care in the healthcare system are paramount if there is to be a reduction in the number of "preventable" morbidity and mortality cases.
1. McQuillan P, Pilkington S, Allan A, Taylor B, Short A, Morgan G, et al. Confidential inquiry into quality of care before admission to intensive care. BMJ 1998;316:1853-8.
2. Lee A, Lum ME, O'Regan WJ, Hillman KM. Early postoperative emergencies requiring an intensive care team intervention. Anaesthesia 1998;53:529-35.
3. Goldhill DR. Introducing the postoperative care team. BMJ 1997;314:389.
4. Riley RH. An acute pain service and preventable deaths in hospitals. Med J Aust 1996;164:573.
5. O'Connell T, Ieraci S, Raper R, Lyle D, Hillman K, Burrell T, et al. New South Wales Metropolitan Critical Care Plan. Sydney: New South Wales Department of Health, 1996.
Anna Lee Research Fellow
Centre for Kidney Research, The New Children's Hospital, Parramatta NSW 2124 Australia
Tony O'Connell Staff Specialist
Department of Intensive Care, The New Children's Hospital, Parramatta NSW 2124 Australia
Correspondence to Anna Lee
Competing interests: No competing interests
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
Re: Confidential inquiry into quality of care before admission to intensive care, BMJ 1998; 316; 1853-63.
EDITOR-
The greatest number of intensive care (ICU) deaths and the highest percentage mortality are in patients admitted to ICU from hospital wards [1]. Dr McQuillan and colleagues [2] focus on the inadequate care received before admission to the intensive care unit. Similar concerns led us to examine deaths on our hospital wards. We hypothesised that some patients with potentially recoverable illnesses do not receive optimal treatment and arrest and die on the wards or deteriorate to the point where intensive care admission and resuscitation is deemed futile and a ‘Do Not Resuscitate’ (DNR) order is written.
There were 316 deaths on our hospital wards between 1st June and 30th November 1997. A DNR order was not made for 55 patients (17%). Their average age was 66.1 years (SD 14.7, range 21-90) and they were in hospital a median of 8 days (interquartile range 3-14) before death. Although 17 (31%) of them received CPR before death, resuscitation would not have been appropriate in many of the others.
A DNR order was in the notes of 261 (83%). In 11 we could not ascertain the date of the order. The average age of the remaining 250 patients was 74.9 years (SD 11.6, range 34-96) and they were in hospital a median of 11 days (interquartile range 4-25) before death. DNR orders were recorded a median of 3 days before death (interquartile range 1-7). In 17% the DNR order was made on the day of death and 18% on the day before death.
Most patients who died on the wards were in hospital for several days before death. Many DNR orders were made shortly before death suggesting that resuscitation was pointless at this time. However, earlier intervention, active management and ICU admission may have been of benefit in some of these patients as well as a proportion of those without DNR orders. Evidence suggests that most ward patients have physiological abnormalities before an arrest [3] and that failure to recognise critically ill patients or take appropriate action results in preventable deaths [4,5]. The patients admitted from wards to the intensive care unit are likely to represent the tip of the iceberg of preventable ward deaths. We can to better for many patients admitted to ICU from the wards. Others with potentially treatable conditions may be deteriorating on the wards beyond the point where intensive care admission can be of benefit.
References
1. Goldhill DR, Sumner A.
Outcome of intensive care patients in a group of British intensive care units.
In press Critical Care Medicine 1998.
2. McQuillan P, Pilkington S, Allan A, Taylor B, Short A, Morgan G, Nielsen M,
Barrett D, Smith G.
Confidential inquiry into quality of care before admission to intensive care.
BMJ 1998; 316: 1853-63.
3. Franklin C, Mathew J.
Developing strategies to prevent inhospital cardiac arrest: Analyzing responses of physicians and nurses in the hours before the event.
Critical Care Medicine 1994; 22: 244-7.
4. Dubois RW, Brook RH.
Preventable Deaths: Who, How Often and Why?
Annals of Internal Medicine 1988; 109: 582-9.
5. Neale G.
Risk management in the care of medical emergencies after referral to hospital.
Journal of the Royal College of Physicians of London 1998; 32: 125-9.
D R Goldhill, Senior Lecturer
L M Worthington, SpR
A J Mulcahy, SpR
M M Tarling, Research Nurse
The Anaesthetics Unit
The Royal London Hospital
London E1 1BB.
Telephone 0171 377 7725, Fax -0171 377 7126. Email D.Goldhill@mds.qmw.ac.uk
Competing interests: No competing interests
As an Intensive Care resident, the results of the excellent paper by McQuillan et al come as, unfortunately, no surprise.
Their recommendations for improving pre-Intensive Care management of patients, including the Medical Emergency team and better training, should all be supported. A problem not dealt with is detecting the acute physiological disturbance in the first instance.
I was on call for anaesthesia last weekend. On Sunday, the pre-registration house officer for surgery had 102 ward patients to look after. The medical PRHO was caring for 114 patients, with the help of one half of an SHO. Even with the best acute medical emergency training these doctors cannot be proactive in the care of this number of patients, most of whom the doctor has never met before. Under such pressure, these doctors can only react to problems identified to them. It would appear that we now rely on the ward nusres to call the "physiology police", but with more than 8 patients per trained nurse on the medical and sugical wards, detection of something physiologically abnormal is not reliable. I am sure this hospital is not unique in this situation.
To have any chance of improving the quality of acute medical care on general wards, there must be either less patients or more medical and nursing staff. Treatment can only start once the patients acute problem is identified.
Competing interests: No competing interests
The researchers in the confidential inquiry into quality of care before admission to intensive care are to be congratulated in a paper that sadly confirms impressions of ward care. The difficulty is to decide how to improve care. Superficially, more senior staff is attractive, but Mather and Elkeles BMJ 311:1060-1062 concluded that most consultant physicians are not prepared to resume emergency duties and COULD NOT DO SO (my emphasis ) without retraining in practical procedures. Using the cardiac arrest team as a medical emergency team is attractive, but this produces "turf wars" where surgeons object to physicians being called to their acutely ill patients, when their own staff are delayed. Possibly the solution is to use the cardiac arrest team, but with an absolute requirement that a consultant is contacted at whatever time day or night the team is called. In this way the experience of the consultant may be married to the practical skills of the juniors. It must be accepted that the status quo cannot continue.
Competing interests: No competing interests
We have seen in the past few weeks two articles suggesting various forms of suboptimal care on NHS general medical and surgical wards (1,2). McQuillan (1) undertook a confidential enquiry into the care of patients on the wards before admission to ITU. They showed that over 50% of admissions should have been avoidable with improved care in the preceding hours and days. They indicate that many fundamental aspects of acute care are poorly done. It has been suggested by some (3) that special teams should be set-up to look for, and intervene with, such acutely ill patients, and that this may obviate some admissions as well as reduce mortality & morbidity.
Smith & Power (2) reviewed a recent Audit Commission report that showed that there is a significant problem in pain control in post surgical patients from the initial first two days onwards. It is suggested that changes in organisation and service provision are required.
The common denominator in both of these (and many other such) issues is not a lack of care – this is thankfully rare amongst clinical staff – but an inability by both nursing and medical staff to give effective treatment in some of the most basic aspects of patient care.
One aspect of this is a deficiency of resource. This will be familiar to most within the NHS. Effective monitoring, treatment and review of acutely ill and postoperative patients not on ITU takes considerable time. This time is not (and currently unlikely to become) available within the current resource. Many are already fighting to improve this situation.
The second and perhaps more fundamental aspect is that of training. It was noted by McQuillan (& in other studies) that there is a deficiency in application of fundamental principles of airway, breathing, circulation, pain control, physiology etc. Care of emergencies and basic acute care, postoperative care and pain control is the bread and butter of surgical and medical SHO & PRHO work. Yet more and more we see how inadequately medical training prepares us for this.
It is suggested that more consultant input and more specialist teams are required. Surely, it would be more effective to train our medical students in these skills early on. Current training prepares well for exams –I could probably have passed my MRCP Pt I before qualifying. But my colleagues and I were ill prepared for meeting the needs of my patients. I had minimal practical training in spotting the signs of a patient in physiological decline. One of the cardinal signs of hypovolaemia is an increased capillary refill time; most junior SHO and PRHOs will not appreciate this basic sign. Thus they may discuss the intricacies of the surgery on the consultant ward round while the patient travels further on the round into renal failure. This is not a failure of care by them (although would be seen as such by the public and the court) but of there training. I had to wait six years after qualifying to have the opportunity to be taught how to recognise a sick child and to give the treatment needed while waiting for further help. Most medical student can quote all the causes of Polyarteritis Nodosa (which they may never see) but few of EMD (which they will see often). This list is almost endless.
While pain, ITU and anaesthetic specialist will always be required to intervene with ward patients – this should only need to occur on request and while the basic measures are already well underway. Most aspects of basic monitoring (look, listen, feel – will still tell us more than the most sophisticated monitors), ABC, fluid management and pain control should be well within the ability of properly trained students by the time of qualification.
1.McQuillan P, Pilkington S, Allan A, Taylor B, Short A, Morgan G, Nielsen M, Barrett D, Smith G. Confidential inquiry into quality of care before admission to intensive care. BMJ 1998;316:1853-1857.
2.Smith G, Power I. Audit and bridging the analgesic gap [Editorial]. Anaesthesia 1998;53(6):521.
3.Garrard C, Young D. Suboptimal care of patients before admission to intensive care. BMJ 1988;316:1841-2.
Competing interests: No competing interests
Questionnaire?
Would it be possible for Dr McQuillan to publish or e-mail directly
to me a copy of the detailed questionnaire that was used during the
structured interview in this quality study?
Competing interests: No competing interests