Quantification and characterisation of work done by intensive care doctors outside the ICU

Introduction

The National Confidential Enquiry into Patient Outcome and Death (NCEPOD) published a report in 2005 criticising the care of medical patients being admitted to ICUs in the United Kingdom. In particular it criticised the low level of consultant involvement in management of patients being admitted to the ICU. Little is known, however, about patients referred to the ICU but not admitted. These referrals, whether for advice only, requests for practical skills or for decisions on suitability of a patient for the ICU, reflect a large proportion of work done by intensive care doctors outside the ICU.

Methods

Data on all referrals were collected prospectively from all 24 ICUs in Scotland over 2 weeks. All referrals for admission, from all specialties, were included. Referrals not resulting in admission were stratified into five groups: advice only; too well; too sick; skill sought; and other. These data were anonymised and analysed from a national perspective.

Results

Of the 857 referrals made during the study period, the majority (585, 68%) were not admitted. The reasons for referral and the rationale for nonadmission are shown in Figure 1. Of those 132 patients deemed too sick for admission, 43% were cardiac arrest calls. Excluding the cardiac arrest calls, the referring team consultant was aware of 60% of cases compared with the ICU consultants' 87%.

Figure 1

Reasons for referral and rationale for nonadmission. Data complete 583/585.

Conclusion

This study demonstrates that the majority of work done by ICU doctors is underestimated by counting admissions alone. This has important manpower planning implications. The low rates of consultant involvement from the referring team in patients deemed too sick for ICU admission is a significant concern. The results of this study suggest that there is similar room for improvement in this patient group as well as the group who are admitted to the ICU as highlighted in the NCEPOD report.