Intended for healthcare professionals


Suboptimal ward care of critically ill patients

BMJ 1999; 318 doi: (Published 02 January 1999) Cite this as: BMJ 1999;318:51

Suboptimal care should have been defined

  1. David Gorard, Consultant physician
  1. Wycombe Hospital, Buckinghamshire HP11 2TT
  2. Health Services Management Centre, University of Birmingham, Birmingham B12 2RT
  3. Department of Anaesthetics, North Manchester General Hospital, Manchester M8 5RB
  4. Department of Anaesthesia, Royal Lancaster Infirmary, Lancaster LA1 4RP
  5. Royal Devon and Exeter Hospital, Exeter EX2 5DW
  6. Intensive Care Unit, John Radcliffe Hospital, Oxford OX3 9DU
  7. Craigavon Area Hospital Group Trust, Portadown BT63 5QQ
  8. Royal Preston Hospital, Preston PR2 4HT
  9. Withington Hospital, Manchester M20 2LR
  10. North Manchester General Hospital, Manchester M8 6RB
  11. Bolton General Hospital, Bolton BL4 0JR
  12. Withington Hospital, Manchester M20 2LR
  13. Southampton University Hospitals NHS Trust, Southampton SO16 6YD
  14. Raven Department of Education, Royal College of Surgeons of England, London WC2A 3PN
  15. Intensive Care Unit, Liverpool Hospital, PO Box 103, Liverpool, Sydney, NSW 2170, Australia
  16. Intensive Care Unit, Southampton General Hospital, Southampton SO16 6YD
  17. Intensive Care Unit, Broomfield Hospital, Chelmsford CM1 7ET
  18. Intensive Care Unit, Royal Cornwall Hospital, Treliske, Truro TR1 3L
  19. Royal Devon and Exeter Hospital, Exeter EX2 5DW

    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, …

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