Confidential inquiry into quality of care before admission to intensive care.

Introduction

Seriously ill patients may be identified by the clinical signs of life threatening dysfunction of the airway, breathing, or circulation, but these may be missed, misinterpreted, or mismanaged by clinicians of all grades. Avoidable components therefore contribute to physiological deterioration, with major consequences on morbidity, mortality, requirement for intensive care, and cost. Such deficiencies may be described as suboptimal care.[1-6] We aimed to investigate the prevalence of suboptimal care before admission to intensive care, to examine its nature, causes, and consequences, and to suggest possible solutions.

Subjects and methods

We prospectively studied the quality of care received by 50 consecutive, adult emergency patients before their admission to intensive care units in each of two centres (Portsmouth and Southampton). The study was conducted in the winter of 1992-3 after approval by local ethics committees and all acute unit consultants.

On the basis of methodology used for confidential inquiries[1 2 6] detailed questionnaires were completed by us during structured interviews with (a) the admitting clinical team and (b) the intensive care team. The interviews concentrated on events between hospital admission and admission to intensive care. The questionnaires comprised tick and data entry boxes and a page for summarising history, clinical findings, assessment, thought processes, resuscitation, treatment, and response to treatment. Emphasis was placed on the recognition, investigation, monitoring, and management of abnormalities of airway, breathing, circulation, and oxygen therapy and monitoring. Interviews took place as soon as possible after a patient's admission to intensive care, which ranged from minutes to days. Severity of illness was recorded using the acute physiology and chronic health evaluation (APACHE II[7]) scoring system, using most extreme values in the first 24 hours in intensive care. Data on duration of stay in intensive care and intensive care and hospital outcomes were also collected. Casemix adjusted expected mortality was calculated from the APACHE data[7] and compared with actual mortality to produce a standardised mortality ratio.

Data from the questionnaires were made anonymous and sent to two extraregional intensivist assessors (GM, primary specialty anaesthesia and AS, primary specialty nephrology). Clinical notes were not included.

The assessors specifically considered quality of medical care and appropriateness and timeliness of admission to intensive care. Care considered suboptimal was defined and the causes outlined. A 10 cm linear analogue scale was used to score the adequacy of management of (a) oxygen therapy, (b) airway, (c) breathing, (d) circulation, and (e) monitoring.

The database was analysed with Microsoft Excel (Microsoft, Seattle, WA) and Minitab (Minitab, PA). Non-parametric data were compared using [chi square] and Kruskal-Wallis tests. A sample size of 100 was arbitrarily chosen and no estimate of clinical effect or power analysis was undertaken.

Results

Of the 100 patients admitted to intensive care, 51 were general medical, 28 general surgical, eight orthopaedic, three obstetrics and gynaecology, three urology, two neurosurgery, two ophthalmology, one ENT, one haematology, and one thoracic surgery. No significant differences were found between the two centres in age, sex distribution, incidence of inappropriate admission, late admission, or suboptimal care, and the casemix was broadly similar. Severity of illness was greater in Portsmouth than in Southampton (median APACHE scores 21.6 and 16 respectively) (P = 0.03).

The assessors agreed that 20 patients (group 1) were well managed and that 54 patients (group 2) received suboptimal care. They disagreed on the quality of care before admission to intensive care in 26 patients (group 3) (table 1). For internal validation, assessors were separately asked to classify patients according to quality of care: 10.5% received excellent care (AS 4%, GM 17%), 21.5% received good quality care (AS 20%, GM 23%), 17.5% received adequate care (AS 25%, GM 10%), and 50.5% received inadequate care (AS 51%, GM 50%). In each quality of care group the casemix was broadly similar, with no significant differences in APACHE II scores between groups (table 1).

[TABULAR DATA 1 NOT REPRODUCIBLE IN ASCII]

Agreement between assessors was moderate[8]: [Kappa] values for questions on late admission, appropriateness, and suboptimal care were 0.50, 0.50, and 0.42 respectively. The weighted [Kappa] value for categorisation into excellent, good, adequate, or inadequate care classes was 0.53. In groups 1, 2, and 3 intensive care mortalities were 5 (25%), 26 (48% and 6 (23%) respectively (P = 0.04). By partitioning the 3 x 2 …