Confidential inquiry into quality of care before admission to intensive care

• Published in: BMJ 1998-06, Vol.316 (7148), p.1853-1858
• Main Authors: McQuillan, Peter, Pilkington, Sally, Allan, Alison, Taylor, Bruce, Short, Alasdair, Morgan, Giles, Nielsen, Mick, Barrett, David, Smith, Gary
• Format: Article
• Language: English
• Subjects: Adult; Aged; Biological and medical sciences; Breathing; Cardiac arrest; Cohort Studies; Critical Care - standards; Diseases; Emergency Service, Hospital - standards; England; Female; Health and social institutions; Health care quality; Hospital admissions; Hospital Mortality; Hospitals; Hospitals, District - standards; Hospitals, General - standards; Humans; Illnesses; Intensive care; Length of Stay; Male; Medical sciences; Medical specialists; Middle Aged; Morbidity; Mortality; Observer Variation; Organization; Outcome and Process Assessment (Health Care); Oxygen; Oxygen therapy; Patients; Physicians; Physiology; Prospective Studies; Public health. Hygiene; Public health. Hygiene-occupational medicine; Quality Indicators, Health Care; Quality of Health Care - statistics & numerical data; Questionnaires; Surveys and Questionnaires; Thoracic surgery
• ISSN: 0959-8138; 0959-8146; 1468-5833; 1756-1833
• DOI: 10.1136/bmj.316.7148.1853

Abstract Objective: To examine the prevalence, nature, causes, and consequences of suboptimal care before admission to intensive care units, and to suggest possible solutions. Design: Prospective confidential inquiry on the basis of structured interviews and questionnaires. Setting: A large district general hospital and a teaching hospital. Subjects: A cohort of 100 consecutive adult emergency admissions, 50 in each centre. Main outcome measures: Opinions of two external assessors on quality of care especially recognition, investigation, monitoring, and management of abnormalities of airway, breathing, and circulation, and oxygen therapy and monitoring. Results: Assessors agreed that 20 patients were well managed (group 1) and 54 patients received suboptimal care (group 2). Assessors disagreed on quality of management of 26 patients (group 3). The casemix and severity of illness, defined by the acute physiology and chronic health evaluation (APACHE II) score, were similar between centres and the three groups. In groups 1, 2, and 3 intensive care mortalities were 5 (25%), 26 (48%), and 6 (23%) respectively (P=0.04) (group 1 versus group 2, P=0.07). Hospital mortalities were 7 (35%), 30 (56%), and 8 (31%) (P=0.07) and standardised hospital mortality ratios (95% confidence intervals) were 1.23 (0.49 to 2.54), 1.4 (0.94 to 2.0), and 1.26 (0.54 to 2.48) respectively. Admission to intensive care was considered late in 37 (69%) patients in group 2. Overall, a minimum of 4.5% and a maximum of 41% of admissions were considered potentially avoidable. Suboptimal care contributed to morbidity or mortality in most instances. The main causes of suboptimal care were failure of organisation, lack of knowledge, failure to appreciate clinical urgency, lack of supervision, and failure to seek advice. Conclusions: The management of airway, breathing, and circulation, and oxygen therapy and monitoring in severely ill patients before admission to intensive care units may frequently be suboptimal. Major consequences may include increased morbidity and mortality and requirement for intensive care. Possible solutions include improved teaching, establishment of medical emergency teams, and widespread debate on the structure and process of acute care. Key messages Suboptimal management of oxygen therapy, airway, breathing, circulation, and monitoring before admission to intensive care occurred in over half of a consecutive cohort of acute adult emergency patients. This may be associ