An acute problem? A report of the National Confidential Enquiry into Patient Outcome and Death

This latest report from National Confidential Enquiry into Patient Outcome and Death (NCEPOD) was published and launched in London on 11 May 2005 (NCEPOD, 2005). The report looks at the care of medical patients admitted to level 3 care (Intensive Care Society, 2002). NCEPOD operates under the umbrella of the National Patient Safety Agency (NPSA), a special health authority created to co-ordinate the efforts of all those involved in healthcare, and more importantly, to learn from adverse incidents occurring in the NHS. The full report can be viewed on the NCEPOD website (http://www.ncepod.org.uk). Data were collected on medical patients over the age of 16 years who were admitted to level 3 care in general intensive care units (ICUs) during the month of June 2003. The aim of the study was to include all 261 general ICUs in England, Wales, Northern Ireland, Guernsey, the Isle of Man, the Defence Secondary Care Agency and hospitals in the independent sector, identified as having level 3 provision. Of these, 226 (88%) hospitals participated. Of the medical admissions reviewed, 93% were emergencies, 43% from A Consultant physician involvement in the first 24 h remains low; Patients often had prolonged periods of physiological instability prior to admission to ICU; Forty-four percent of hospitals did not provide an outreach service., Only 15% of hospitals provided an outreach service overnight; Respiratory rate was infrequently recorded; Twenty-seven percent of hospitals did not use a track and trigger system (e.g. MEWS or PART score); Consultant physicians had no knowledge or input into 57% of referrals to ICU; A significant factor in the delay to admission to ICU was the lack of staff and beds; One in four patients were admitted to ICU without consultant intensivist involvement; One in four patients were not seen by a consultant intensivist within 12 h of admission; Ten percent of patients have an incomplete history and examination at admission; Of those patients who died, ICU admission was thought to be avoidable in 21% of cases. The study found evidence of suboptimal care at all stages of the patients admission and subsequent transfer to ICU. The factors contributing to these findings have already been well documented in the literature (Schein et al., 1990; McQuillan et al., 1998; McGloin et al., 1999), and it must be a concern that we are still not learning from, or acting on, this evidence; however, the fact that over one-third of Trusts did not have any kind of outreach service could be considered a factor in this. Recommendations from the report include ensuring the presence of consultant physicians during a greater span of hours in order to review all admissions and be involved in referrals to ICU. This is hoped to be achieved by recommending realistic job plans and updating the organization of healthcare systems to allow physicians to adequately deal with the emergency and elective workload. This recommendation makes the assumption, of course, that the consultant physician has the competence to recognize and manage critically ill patients. This assumption was challenged at the report-launch meeting. Indeed, if only 6–7 patients out of the estimated average 1200 medical patient admissions per month are transferred to ICU, do physicians have the exposure and experience to maintain competence in this field? Feedback from physicians at the report-launch meeting confirmed that their focus of care is towards diagnosis and pathology, rather than recognizing the importance and urgency of treating abnormal physiology. Recommendations from the Royal College of Physicians have recognized these problems, and the field of acute medicine is now developing ( Royal College of Physicians, 2004). While intensivists may feel confident in the care for the critically ill medical patient, the evidence from the report suggests that 25% of medical admissions to ICU occur without consultant intensivist involvement, and there are some patients who are not reviewed by a consultant for more than 12 h after admission to ICU. Delays in transfer to ICU were relatively common (16%), and the main factor was put down to lack of ICU beds and appropriate staff. The feeling is that we still do not have adequate level 3 bed provision in the UK. The recent announcement by John Reid that critical care bed provision has increased by 36% (Department of Health, 2005) may only include 70 level 3 beds. Outreach was not a major feature of the report; however, a major recommendation is that outreach services and early warning scoring systems, which are largely nurse led, be adopted by all Trusts managing acutely ill patients. This emphasis on 24 h/7 day/week outreach services could have a strong impact on the quality of care of these acutely ill patients. There are two main reasons for this: (1) Expertise in the management of acutely ill patients is available at all times and (2) outreach services can act as a mirror to reflect the standard of care achieved especially, if they present clinical audit to individual specialties through the clinical governance process (Braithwaite et al., 2004). This strong recommendation is good news, but the current lack of these services across the UK, with no apparent funding and appropriate staff is a concern, and this needs to be adequately resourced and audited. This is unlikely to be the case until the outreach study for the service delivery and organization research programme being undertaken by ICNARC is reported and is favourable. John Welch, speaking on behalf of the National Outreach Forum, suggested the time was ripe to rethink our approach to outdated resuscitation practices, which don't work, and reinvest our resources into prevention. This may be the future direction for resuscitation and outreach services to work together. The issue of relevant and timely observation, especially of respiratory rate, was duly noted. This is firmly in the nursing arena and an opportunity for nurses on acute medical wards and A&E departments to make a real difference to the care of the acutely ill medical patient. Adequate nursing resources are essential in these areas, and the reliance on unregistered healthcare assistants needs to be accompanied by robust training and supervision from trained and competent nursing staff. The most important message from the report and launch which was reiterated by several speakers including Dr George Findlay, the report lead, was the need for all disciplines and all specialties to work as a team. Critical care teams are well ahead of most of their colleagues in this, and it is another important achievement that critical care could share with acute medicine. The recommendations from comprehensive critical care (Department of Health, 2000) have begun to break down the barriers between ICUs and the rest of the hospital, and this report encourages an approach where skills are shared, trainees are adequately supervised and supported and nurses play their part in recognizing and treating the critically ill patient. In addition, the increasing percentage of in patients with acute illness in acute hospital beds adds more weight to the argument for pre-registration education to incorporate the skills of recognition and management of acutely ill patients into the curriculum. One factor the report does not address but which is important for all critical care is the effect of the report's recommendation of 24 h outreach services. This is likely to add another drain on the limited number of critical care trained nurses (Adam, 2004). In the near future, there will be severe staffing shortages, as demographic factors come into play and as some of the overseas recruited nurses return home. If this is not addressed by a commensurate increase in the number of available training places for critical care, we will face severe restrictions to the ability of many hospitals to offer an appropriate level of critical care to their patients.