(Confidential inquiry into quality of care before admission to intensive care)
(Suboptimal care of patients before admission to intensive care)
Emergency admissions have risen by 50 per cent since 1984, but this increase in quantity should not be at the expense of quality, say Dr Peter McQuillan et al from intensive care units in the UK in this week's BMJ. They present the result of their confidential inquiry into the quality of care received by 100 patients admitted to intensive care. They found that 54 of the 100 patients received suboptimal care and nearly half of these (48 per cent) patients died (almost twice the rate of those whose care was managed well). In addition, two thirds of the 54 patients who were not treated adequately were admitted late into intensive care.
The authors discovered that the problems lay in suboptimal management of oxygen therapy, airway, breathing, circulation and monitoring before admission to intensive care which led to increased morbidity, mortality and avoidable admissions. They believe that these problems were caused by poor organisation, lack of knowledge, failure to appreciate clinical urgency, lack of supervision and failure to seek advice.
McQuillan et al conclude that the structure and process of acute care and their importance require major re-evaluation and debate and suggest that one solution may be to create medical emergency teams who respond pre-emptively to airway, breathing or circulation problems.
In an accompanying editorial, Christopher Garrard and Duncan Young from the Intensive Care Unit at the John Radcliffe Hospital in Oxford, note that "little will be gained from apportioning blame or resorting to recrimination for the failings that McQuillan et al have identified". They say that the findings need to be investigated on a national scale to ascertain the full extent of the problem and advocate an national confidential inquiry.
They suggest that one way of dealing with the problem may be to increase the seniority of the doctors assessing and treating this type of patient. (For example in Oxford, the trauma surgeons now have 24 hour, resident, consultant cover which ensure all victims of major trauma are assessed and have their treatment planned by a consultant.) Alternatively, they suggest that medical emergency teams should be formed and that their role should be educational as well as troubleshooting.
Contact:
Dr Peter McQuillan, Consultant in Intensive Care and Anaesthesia, Department of Intensive Care Medicine, Queen Alexandra Hospital, Cosham, Portsmouth
Christopher Garrard, Consultant Physician or Duncan Young, Consultant Anaesthetist, Intensive Care Unit, John Radcliffe Hospital, Oxford.