4. Pre-ICU care

Admission history

The advisors found that overall the initial history, examination, differential diagnosis and treatment planning was of an acceptable standard (Tables1-4). In one in 10 cases the initial history and examination was judged to be unacceptable or incomplete by the advisors and no initial treatment plan could be identified. In addition to the assessment of clinical examination and history, the standard of care given in the initial period after hospital admission was scored using the system given in Table 5. 58% of cases were classified as receiving prompt and appropriate therapy. It is concerning that up to 42% of cases received inappropriate or delayed therapy. Frequent examples were the use of inappropriately low concentrations of oxygen in profoundly hypoxic patients and the delayed administration of sufficient fluids to hypotensive patients. These findings reveal that despite a largely adequate hospital admission process (history, examination, diagnosis and plan) there are concerns over timely and appropriate interventions. The reasons for this are not clear but may include organisational factors which introduce delays into treatment plans and the reliance on doctors still undergoing training to initiate the correct therapy and drive care forward. It may be felt that the advisors were being particularly harsh and being wise after the event. However, the findings of deficiencies in history, examination, treatment planning and initial therapy were much worse in a similar study performed recently ³ and we feel confident that the level of deficiency has not been overstated.

In addition to the initial medical admission, we sought to collect information about medical staff involvement; specifically the grade of medical staff that reviewed the patients and the time delay from admission to first consultant physician review. Unfortunately the quality of the medical records was such that this information was difficult to obtain. There were 2,234 reviews among 439 patients. The grades
of the reviewers were recorded in only 37% of reviews. Table 6 shows the grade of medical staff that undertook patient reviews in the three days prior to ICU admission. As can be seen, more than 50%
of patient reviews were performed by PRHOs or SHOs.

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