Audit of care provided prior to ICU admission

Introduction

Our hypothesis was that critically ill patients admitted to our district general ICU were frequently receiving suboptimal resuscitative care and monitoring prior to ICU admission. A confidential enquiry over 10 years ago in two hospitals in England found such a situation [1].

Methods

All patients admitted to our ICU from 1 January to 8 March 2008 had their case notes, monitoring charts and drug prescriptions reviewed by an ICU consultant. The adequacy of resuscitative care and monitoring was assessed using a 10 cm visual analogue scale (VAS). Where care was felt to be inadequate, reasoning was documented. If a central venous catheter (CVC) had been inserted, the specialty of the doctor who performed the procedure was documented.

Results

There were 64 admissions during the study period, eight were excluded (ICU transfers from other hospitals) and all 56 remaining were analysed. Median VAS scores for adequacy of resuscitative care and monitoring are presented in Table 1. In nine (17%) patients care was felt to be inadequate. The two most common reasons (five patients each) were inadequate circulatory management, particularly failure to commence inotropic/vasopressor therapy, and inadequate monitoring, particularly fluid balance and invasive cardiovascular monitoring. CVCs were inserted by ICU/anaesthetic staff on 56% of occasions, by emergency department staff on 25% of occasions, surgical staff on 13% and medical staff on 6%.

Table 1 Adequacy of resuscitative care and monitoring VAS scores

Conclusion

Suboptimal resuscitative care and monitoring prior to ICU admission is present in a significant minority of our patients and appears particularly related to the management of hypotension and shock. Further training focusing on these areas (including CVC insertion) for noncritical care trained staff may help improve patient care and outcome.