6. Referral process

Delays

Delays, both in time to ICU review and time to ICU admission, were examined. Table 6 shows that delays between referral and review were reported by the referring physician in 5% of the cases.

The cause of delay was not specified in 20/45 cases and was attributed to lack of resources in 14/45 cases (primarily ICU beds and staff). The remainder were due to clinical reasons. Table 7 demonstrates that the time of day has little impact on the delay to ICU review.

Table 8a shows the delay between decision to admit a patient to ICU and the actual admission.
As can be seen there is a problem with delayed admission in 16% of cases. Many of these cases were due to the need for stabilisation or investigation but worryingly 36% (59/162) were due to a lack of a critical care bed. The referring physician was asked to assess whether or not any delay had an adverse effect on patient outcome (Table 8b). This was thought to be likely in only one case. Critically ill patients have little physiological reserve and need prompt and appropriate therapy if they are to stand the best chance of recovery. The lack of perceived impact of delayed critical care review and admission is therefore surprising and may reflect poor expectations of a critical care service that has for years been underprovided.

The advisor groups were asked to consider appropriateness and timeliness of critical care referral. Tables 9a and 9b show this data. It can be seen that in 92% (387/421) of cases, referrals were considered appropriate. The remainder were considered inappropriate due to poor predicted outcome. In addition, it was found that 22% (81/370) of referrals were not made in an appropriate timescale.
These were almost entirely considered to be patients who would have potentially benefited from early referral to critical care.

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