Referral to intensive care: who and when?

Introduction

Intensive care beds in the UK are a limited resource and deciding whether or not to admit a patient to intensive care is often a difficult decision. It is increasingly felt that, as intensive care consultants are involved in the decision-making process for every admission, the consultant from the referring team should also be involved in the referral process. The Scottish Intensive Care Society Trainee Group found that this occurred in less than 50% of occasions during the Referral and Review Audit of 2007 [1]. We wished to establish what the referral process was like in our hospital.

Methods

We undertook a prospective audit of all referrals to a five-bed teaching hospital ICU between April and July 2009. Data were collected regarding time of referral, seniority of referrer, involvement of referring consultant, seniority of ICU trainee, involvement of ICU consultant and whether or not the referral resulted in intensive care admission.

Results

Ninety-eight referrals were received during the audit period. Of 31 medical referrals, 21 were out of hours, 16 had no consultant involvement and ultimately 27 patients were admitted. Of nine surgical patients, three were out of hours, three had no consultant involvement and seven were eventually admitted. Thirty patients were referred by the emergency department, of whom 18 were out of hours, 23 had no consultant involvement and 26 resulted in admission. Twenty-eight patients were referred by anaesthetics, all of whom had been seen by a consultant and were admitted.

Conclusions

General medicine is the most significant contributor to out-of-hours work of the intensive care medical staff. Over 50% of medical referrals have no referring consultant involvement, although ultimately many of these patients are admitted and are seen by an intensive care consultant within a few hours of admission. Most surgical patients are admitted postoperatively and thus are referred by a consultant anaesthetist, resulting in a very high conversion rate for referrals to admissions. Emergency medicine is increasingly a consultant delivered service with increased presence in the department into the extended working day, a fact that is sadly not reflected in our results. It is regrettable that despite repeated recommendations that intensive care admission should be on the basis of consultant to consultant referral, 43% of patients are referred to intensive care without any referring consultant involvement.