Alasdair Short

Confidential inquiry into quality of care before admission to intensive care

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 associated with increased morbidity, mortality, and avoidable admissions to intensive care At least 39% of acute adult emergency patients were admitted to intensive care late in the clinical course of the illness Major causes of suboptimal care included failure of organisation, lack of knowledge, failure to appreciate clinical urgency, lack of supervision, and failure to seek advice A medical emergency team may be useful in responding pre-emptively to the clinical signs of life threatening dysfunction of airway, breathing, and circulation, rather than relying on a cardiac arrest team The structure and process of acute care and their importance require major re-evaluation and debate

Intensive Care Society's APACHE II study in Britain and Ireland--II: Outcome comparisons of intensive care units after adjustment for case mix by the American APACHE II method.

OBJECTIVES--To compare outcome between intensive care units in Britain and Ireland both before and after adjustment for case mix with the American APACHE II method and to validate the American APACHE II method in Britain and Ireland. DESIGN--Prospective, cohort study of consecutive admissions to intensive care units. SETTING--26 general intensive care units in Britain and Ireland. SUBJECTS--8796 admissions to the study intensive care units. MAIN OUTCOME MEASURE--Death or survival at discharge from intensive care unit and hospital. RESULTS--At discharge from both intensive care unit and hospital there was a greater than twofold variation in crude mortality between the 26 units. After adjustment for case mix, variations in mortality were still apparent. For four intensive care units the observed numbers of deaths were significantly different from the number predicted by the American APACHE II equation. The overall goodness of fit, or predictive ability, of the APACHE II equation for the British and Irish data was good, being only slightly inferior to that obtained when the equation was tested on the data from which it had been derived. When patients were grouped by various factors such as age and diagnosis, the equation did not adjust across the subgroups in a uniform manner. CONCLUSIONS--The American APACHE II equation did not fit the British and Irish data. Use of the American equation could be of advantage or disadvantage to individual intensive care units, depending on the mix of patients treated.

Intensive Care Society's APACHE II study in Britain and Ireland--I: Variations in case mix of adult admissions to general intensive care units and impact on outcome.

OBJECTIVES--To describe the extent of variation in the case mix of adult admissions to general intensive care units in Britain and Ireland and investigate the impact of such variation on outcome. DESIGN--Prospective, cohort study of consecutive admissions to intensive care units. SETTING--26 general intensive care units in Britain and Ireland. SUBJECTS--9099 admissions to the intensive care units studied. MAIN OUTCOME MEASURE--Death or survival at discharge before and after adjustment of case mix (age, history of chronic conditions, surgical status, diagnosis, and severity of illness) according to the APACHE II method. RESULTS--Important differences in case mix were found, with large variations between the units. Hospital mortality was significantly associated with most of the case mix factors investigated. CONCLUSIONS--Comparing crude death rates in hospital between intensive care units may be misleading indicators of performance. The collection of data on case mix needs to be standardised and differences in case mix adjusted for when comparing outcome between different intensive care units.

A new risk prediction model for critical care: The Intensive Care National Audit & Research Centre (ICNARC) model*

Objective:To develop a new model to improve risk prediction for admissions to adult critical care units in the UK. Design:Prospective cohort study. Setting:The setting was 163 adult, general critical care units in England, Wales, and Northern Ireland, December 1995 to August 2003. Patients:Patients were 216,626 critical care admissions. Interventions:None. Measurements and Main Results:The performance of different approaches to modeling physiologic measurements was evaluated, and the best methods were selected to produce a new physiology score. This physiology score was combined with other information relating to the critical care admission—age, diagnostic category, source of admission, and cardiopulmonary resuscitation before admission—to develop a risk prediction model. Modeling interactions between diagnostic category and physiology score enabled the inclusion of groups of admissions that are frequently excluded from risk prediction models. The new model showed good discrimination (mean c index 0.870) and fit (mean Shapiro’s R 0.665, mean Brier’s score 0.132) in 200 repeated validation samples and performed well when compared with recalibrated versions of existing published risk prediction models in the cohort of patients eligible for all models. The hypothesis of perfect fit was rejected for all models, including the Intensive Care National Audit & Research Centre (ICNARC) model, as is to be expected in such a large cohort. Conclusions:The ICNARC model demonstrated better discrimination and overall fit than existing risk prediction models, even following recalibration of these models. We recommend it be used to replace previously published models for risk adjustment in the UK.

Intensive Care Society's Acute Physiology and Chronic Health Evaluation (APACHE II) study in Britain and Ireland: a prospective, multicenter, cohort study comparing two methods for predicting outcome for adult intensive care patients.

ObjectiveTo compare the ability of two methods—Acute Physiology and Chronic Health Evaluation (APACHE II) and Mortality Prediction Model (MPM)—to predict hospital outcome for a large group of intensive care patients from Britain and Ireland. DesignProspective, multicenter, cohort study. SettingTwenty-six general intensive care units in Britain and Ireland. PatientsA total of 8,724 patients admitted to the study. InterventionsNone. Measurements and Main ResultsProbabilities of hospital death for patients were estimated by applying APACHE II and MPM. Predicted risks of hospital death were compared with observed outcomes using four methods of assessing the overall goodness of fit. APACHE II performed better than MPM; the calibration curve for APACHE II lay closer to the line of perfect predictive ability. Lemeshow-Hosmer chi-square statistics were 81 and 57 for APACHE II, and 2515 and 1737 for MPM. The overall correct classification rate for APACHE II was 79%, and this classification rate was 74% for MPM, applying a decision criterion of 50%. The area under the receiver operating characteristic curve was 0.83 with APACHE II and 0.74 with MPM. Even after modifications to the MPM for the assessment of coma, the performance of APACHE II was superior. ConclusionsAPACHE II demonstrated a higher degree of overall goodness of fit, which was superior to MPM for groups of intensive care patients from Britain and Ireland. (Crit Care Med 1994; 22:1392–1401)

The Acute Care Undergraduate TEaching (ACUTE) Initiative : consensus development of core competencies in acute care for undergraduates in the United Kingdom

BackgroundThe care of the acutely ill patient in hospital is often sub-optimal. Poor recognition of critical illness combined with a lack of knowledge, failure to appreciate the clinical urgency of a situation, a lack of supervision, failure to seek advice and poor communication have been identified as contributory factors. At present the training of medical students in these important skills is fragmented. The aim of this study was to use consensus techniques to identify the core competencies in the care of acutely ill or arrested adult patients that medical students should possess at the point of graduation.DesignHealthcare professionals were invited to contribute suggestions for competencies to a website as part of a modified Delphi survey. The competency proposals were grouped into themes and rated by a nominal group comprised of physicians, nurses and students from the UK. The nominal group rated the importance of each competency using a 5-point Likert scale.ResultsA total of 359 healthcare professionals contributed 2,629 competency suggestions during the Delphi survey. These were reduced to 88 representative themes covering: airway and oxygenation; breathing and ventilation; circulation; confusion and coma; drugs, therapeutics and protocols; clinical examination; monitoring and investigations; team-working, organisation and communication; patient and societal needs; trauma; equipment; pre-hospital care; infection and inflammation. The nominal group identified 71 essential and 16 optional competencies which students should possess at the point of graduation.ConclusionsWe propose these competencies form a core set for undergraduate training in resuscitation and acute care.

The increasing burden of alcoholic liver disease on United Kingdom critical care units: secondary analysis of a high quality clinical database

OBJECTIVES To investigate the effect of increasing alcohol consumption on the number of admissions to adult, general critical/intensive care units (ICUs) in England and Wales with alcoholic liver disease, their case mix, mortality, and impact on critical care and hospital activity by extrapolating from admissions to ICUs over the last 10 years. METHODS Secondary analysis of a high quality clinical database from a national clinical audit using data from 385,429 admissions to174 ICUs in England and Wales between December 1995 and July 2005, of which 4219 (1.1%) had alcoholic liver disease. The extrapolated total number of admissions with alcoholic liver disease and total number of ICU bed-days occupied were calculated. Changes over time in the case mix (age, sex and APACHE II and ICNARC risk prediction models), mortality at ultimate discharge from acute hospital, and length of stay in ICU and in hospital were explored. RESULTS The percentage of ICU admissions with alcoholic liver disease increased from 0.65% in 1996 to 1.35% in 2005, but the case mix remained similar. Mortality decreased and length of stay increased over this period. The extrapolated total number of admissions to all 229 adult, general critical care units in England and Wales increased from 550 in 1996 to 1513 in 2005, and the extrapolated total number of bed-days occupied by these admissions increased from around 3100 to over 10,000. CONCLUSIONS Admissions to ICUs in England and Wales with alcoholic liver disease tripled over the 10-year period from 1996 to 2005. The continuing increase in alcohol consumption means that this trend is likely to continue.

ABC of intensive care. Renal support.

Oliguria and renal dysfunction are common in critically ill patients. In most cases the kidney is an innocent bystander affected secondarily by the primary disease process. As patients with acute renal failure usually have multiple organ dysfunction and often require respiratory or circulatory support, they are increasingly referred to intensive care units rather than to specialist renal units. Nevertheless, close liaison with nephrologists is advisable, particularly when primary renal disease is suspected. It is rare for patients to develop acute renal failure after admission to intensive care unless a new problem has occurred or the primary process has not been controlled.

Comparing mortality among adult, general intensive care units in England with varying intensivist cover patterns: a retrospective cohort study

IntroductionResearch has demonstrated that intensivist-led care of the critically ill is associated with reduced intensive care unit (ICU) and hospital mortality. The objective of this study was to evaluate whether a relation exists between intensivist cover pattern (for example, number of days of continuous cover) and patient outcomes among adult general ICUs in England.MethodsWe conducted a retrospective cohort study by using data from a pooled case mix and outcome database of adult general critical care units participating in the Intensive Care National Audit & Research Centre (ICNARC) Case Mix Programme. Consecutive admissions to participating units for the years 2010 to 2011 were linked to a survey of intensivist cover practices. Our primary outcome of interest was mortality at ultimate discharge from acute-care hospital.ResultsThe analysis included 80,122 patients admitted to 130 ICUs in 128 hospitals. Multivariable logistic regression analysis was used to assess the relation between intensivist cover patterns (days of continuous cover, grade of physician staffing at nighttime, and frequency of daily handovers) and acute hospital mortality, adjusting for patient case mix. No relation was seen between days of continuous cover by a single intensivist or grade of physician staffing at nighttime and acute hospital mortality. Acute hospital mortality and ICU length of stay were not associated with intensivist characteristics, intensivist full-time equivalents per bed, or years of clinical experience. Intensivist participation in handover was associated with increased mortality (odds ratio, 1.27; 95% confidence interval, 1.04 to 1.55); however, only nine units reported no intensivist participation.ConclusionsWe found no relation between days of continuous cover by a single intensivist or grade of physician staffing at nighttime and patient outcomes in adult, general ICUs in England. Intensivist participation in handover was associated with increased mortality; further research to confirm or refute this finding is required.