2. Study method

3. Method Data collection during month of June 2003 Patients ≥ 16 years of age admitted to a general ICU regardless of outcome Patients identified by hospital and questionnaires circulated by hospital (local reporter or other contact within ICU) Two questionnaires for each case – physician and intensivist

4. Method (cont) Quantitative and qualitative analysis Multi-disciplinary advisor groups Intensivists – both medical and anaesthetic background Physicians Nurses

5. Data overview

6. Hospital participation

7. Clinical participation

8. Source of admission to ICU

9. Clinical reason for referral to ICU

10. Pre-ICU Care

11. Initial history and examination Acceptable history taken Total Yes31290% No3310% Sub-total345 Not answered94 Total439 Clinical exam complete at first contact Total Yes29787% No4313% Sub-total340 Insufficient data99 Total439

12. Initial treatment Initial treatment planTotal Yes29987% No4613% Sub-total345 Insufficient data94 Total439 If yes, treatment plan followed Total Yes26996% No114% Sub-total280 Insufficient data19 Total299

13. Appropriateness of initial treatment Total Prompt and appropriate25358% Prompt but inappropriate therapy286% Appropriate but apparent delay358% Inappropriate and delayed286% Insufficient information to comment9522% Total439

14. Consultant physician involvement 439 sets of notes reviewed Good data only obtainable in 40 cases 23 of 40 patients reviewed within 24 hours (58%) –28 patients with ward stay >24 hours prior to ICU °11 of 28 reviewed within 24 hours (39%)

15. Physiological derangement Cardiorespiratory arrest Respiratory rate: 30 breaths per minute Sa0 2 <90% on oxygen Difficulty speaking Pulse rate: 130 beats per minute Systolic blood pressure <90mmHg Repeated or prolonged seizures Any unexplained decrease in consciousness Agitation or delirium Concern about patient status not detailed above

16. Duration of instability Patients that were in hospital for more than 24 hours prior to ICU admission Time between first physiological instability and referral to ICU Patients that were in hospital for 24 hours or less prior to ICU admission

17. Key findings The quality of the initial hospital admission history and examination was acceptable in 90% of cases. Despite an acceptable history and examination, initial treatment was often delayed, inappropriate or both. Consultant physician involvement in first 24 hours low.

18. Key findings (cont) Of the patients who had been in hospital more than 24 hours prior to ICU admission, 66% exhibited physiological instability for more than 12 hours.

19. Recommendations 1.Trusts should ensure that consultant job plans reflect the pattern of demand of emergency medical admissions and provision should be made for planned consultant presence in the evenings (and perhaps at night in busier units). 2.A consultant physician should review all acute medical admissions within 24 hours of hospital admission.

20. Recommendations (cont) 3.Trusts should ensure that consultant physicians have no other clinical commitments when on take. This may be through the development of acute physicians. This will allow for greater involvement in the assessment and treatment planning of new admissions and the review of deteriorating inpatients. 4.More attention should be paid to patients exhibiting physiological abnormalities. This is a marker of increased mortality risk. 5.Robust track and trigger systems should be in place to cover all inpatients. These should be linked to a response team that is appropriately skilled to assess and manage the clinical problems.

21. Patient observations and review criteria

22. Observations requested No. of patients Total = 439 Observations requested (%) Not requested(%) Unknown(%) Pulse28 (6)337 (77)74 (17) Blood pressure33 (8)335 (76)71 (16) Respiratory rate18 (4)345 (79)76 (17) Urine output62 (14)303 (69)74 (17) Fluid balance56 (13)306 (70)77 (17) CVP19 (4)335 (76)85 (20) SpO 2 30 (7)334 (76)75 (17) Other12 (3)355 (81)72 (16)

23. Observations performed ObservationRate per patient Pulse3 days before referral to ICU 3.17 2 days before referral to ICU 4.24 1 day before referral to ICU 4.36 Day of referral to ICU 3.66 BP3 days before referral to ICU 3.87 2 days before referral to ICU 4.72 1 day before referral to ICU 5.09 Day of referral to ICU 3.66 ObservationRate per patient Resp rate3 days before referral to ICU 1.70 2 days before referral to ICU 2.48 1 day before referral to ICU 2.62 Day of referral to ICU 2.12 Sats3 days before referral to ICU 2.54 2 days before referral to ICU 3.71 1 day before referral to ICU 3.86 Day of referral to ICU 3.20

24. Assessment of initial treatment Nurse instructions to alert medical staff Total Yes184% No36695% Sub-total384 Insufficient data55 Total439

25. Early warning systems Early warning system usedNumber of hospitals (%) Medical Emergency Team31 The Patient at Risk Team199 The Early Warning Score2814 The Modified Early Warning Score8942 Combinations of above84 Other21 System not specified42 Sub-total15373 No early warning system used5827 Total211

26. Key findings Notes seldom contained written requests regarding the type and frequency of physiological observations. Instructions giving parameters that should trigger a patient review were rarely documented. Respiratory rate was infrequently recorded 27% of hospitals did not used an early warning system.

27. Recommendations 1.A clear physiological monitoring plan should be made for each patient. This should detail the parameters to be monitored and the frequency of observations. 2.Part of the treatment plan should be an explicit statement of parameters that should prompt a request for review by medical staff or expert multidisciplinary team.

28. Recommendations (cont) 3.The importance of respiratory rate monitoring should be highlighted. This parameter should be recorded at any point that other observations are being made.

29. Referral process

30. Referral to ICU Health professional who referred patient Consultant physician25623% Registered nurse101% SHO23821% SpR year 1 / 225523% SpR year 3+22920% Staff Grade/Associate Specialist686% Other747% Sub-total1,130 Not answered105 Total1,235

31. Consultant physician involvement Physician notifiedTotal Yes32043% No42256% Sub-total742 Unknown181 Not answered56 Total979

32. Reviews prior to ICU admission Outreach reviewTotal Yes23723% No78077% Sub-total1,017 Unknown130 Not answered88 Total1,235 Intensive care reviewTotal Yes85882% No19118% Sub-total1,049 Unknown126 Not answered60 Total1,235

33. Delays Delay between referral and review Total Yes455% No89595% Sub-total940 Unknown146 Not answered149 Total1,235 Delay between ICU acceptance and admission Total Yes16216% No87284% Sub-total1,034 Unknown58 Not answered143 Total1,235

34. Appropriateness & timeliness of referral Appropriateness of referral Yes38792% No348% Sub-total421 Insufficient data18 Total439 Timeliness of referral Yes28978% No8122% Sub-total370 Insufficient data69 Total439

35. Key findings A high percentage of patients were referred to critical care by staff in training. 21% of referrals were made by SHOs. Consultant physicians had no knowledge or input into 57% of referrals to critical care. Delays between referral to critical care and review (5%) and between decision to admit to critical care and admission (16%) were common. A significant factor in delay was the lack of appropriate staff and ICU beds. 18% of patients were admitted to ICU without prior review by the intensive care service.

36. Recommendations 1.Consultant physicians should be more involved in the referral of patients under their care to ICU. 2.It is inappropriate for referral to ICU and acceptance to ICU to happen at SHO level. 3.Any delay in admission to critical care should be recorded as a critical incident through the appropriate hospital incident monitoring and clinical governance system. 4.All inpatient referrals to ICU should be assessed prior to ICU admission. Only in exceptional circumstances should a patient be accepted for ICU care without prior review.

37. ICU admission process

38. Frequency distribution of time of ICU admission Time of admission Outcome DiedSurvivedUnknownTotal%Died%Lived Day2544571172236%64% Evening170312548735%65% Night126314344329%71% Sub-total5501,083191,652 Not answered 1013225 Total5601,096211,677 Day: 08:00 - 17:59 Evening: 18:00 – 23:59 Night: 00:00 – 07:59

39. Who accepts ICU referrals? Accepting grade Admitting time slot DayEveningNightNot answered Total ICU consultant43582%35472%21463%10762%1,11073% Staff/Associate Specialist 51%184%113%6 403% SpR6312%9118%7823%4728%27918% SHO163%214%227%95%684% Registered nurse122%41%2 2 181% Other2<1%61%103%11%191% Sub-total5334943371721,534 Not answered812103262 Total5415063472041,596

40. Consultant presence Consultant present Admitting time slot DayEveningNightNot answered Total Yes39982%27950%6917%754%75451% No8818%27950%34083%646%71349% Sub-total487558409131,467 Unknown244112279 Not answered152410150 Total526623431161,596

41. Time to consultant review Proportion of patients reviewed by an intensivist Time since ICU admission (Hours)

42. Key findings Evening (18:00 – 23:59) was the busiest time for new medical admissions to ICU, followed by night (00:00 – 07:59) and lastly day (08:00 – 17:59). One in four patients were admitted to the ICU without consultant intensivist involvement. Amongst the 40% cases for which data were available, approximately one in four patient were not reviewed by a consultant intensivist within 12 hours of admission

43. Recommendations 1.Trusts should ensure that consultant job plans reflect the pattern of demand for emergency admission to ICU and provision should be made for planned consultant presence in the evenings (and perhaps at night in busier units). 2.Patients should rarely be admitted to ICU without the prior knowledge or involvement of a consultant intensivist. 3.A consultant intensivist should review all patients admitted to ICU within 12 hours of admission. Regular audit should be performed against this standard.

44. Patients who died

45. Who is referring patients expected to die? Referring practitionerNo. of patients expected to die Not referred by consultant physician Referred by registered nurse1 Referred by SHO36 Referred by SpR Yr 1 / 230 Referred by SpR Yr 3+30 Referred by Staff Grade/ Associate Specialist 8 Other7 Sub-total112 (71%) Consultant physician notified in these cases? Yes45 No57 Unknown10 Referred by consultant41 (26%) Referring practitioner not supplied4 (3%) Total157

46. Who is accepting patients expected to die? Accepting gradeNumber of patients where death was expected Intensive care consultant108 Staff Grade/ Associate Specialist4 SpR17 SHO7 Registered nurse2 Other3 Sub-total141 Not answered5 ICU questionnaire not available11 Total157

47. Was ICU admission avoidable? Admission avoidableTotal Yes8321% No31379% Sub-total396 Insufficient data43 Total439 Different care could have prevented need for admission – 21 cases Treatment limitation decision could have avoided admission – 58 cases

48. Assessment of clinical care Airway Breathing Circulation Monitoring Oxygen therapy

49. Airway Management 0 10 20 30 40 50 60 70 80 90 123456789 Scale ExcellentVery Poor

50. Assessment of clinical care - poor Airway11% Breathing16% Circulation14% Monitoring13% Oxygen therapy14%

51. Assessment of other aspects Ability to seek advice from senior doctors Appreciation of clinical urgency Clinical knowledge Organisational aspects of care Supervision

52. Advice from senior doctors 0 5 10 15 20 25 30 35 40 45 50 123456789 PoorExcellent Scale Source – 212 casenotes

53. Appreciation of clinical urgency 0 20 40 60 80 100 120 123456789 PoorExcellent Scale Source – 372 casenotes

54. Supervision 0 5 10 15 20 25 30 35 40 45 50 123456789 PoorExcellent Scale Source – 234 casenotes

55. Assessment of other aspects Ability to seek advice from senior doctors30% Appreciation of clinical urgency21% Supervision28%

56. Overall assessment of care Advisors overall assessment of careNumber of cases % Good practice20653% Room for improvement – clinical10026% Room for improvement – organisational308% Room for improvement – both clinical and organisational226% Less than satisfactory308% Sub-total388 Insufficient data51 Total439

57. Overall assessment of care (cont) Did deficiencies contribute to death? Total Yes4134% No8368% Sub-total124 Insufficient data58 Total182

58. Key findings Management of the airway, breathing, circulation, monitoring and oxygen therapy were generally rated highly. However, even in these categories a high proportion of cases (11,16,14,13 and 14% respectively) were rated at the very poor end of the spectrum. The most worrying domains were ability to seek advice, appreciation of clinical urgency and supervision. 30%, 21% and 28% of cases respectively were rated at the very poor end of the spectrum.

59. Key findings (cont) ICU admission was thought to be avoidable in 83 of 396 cases (21%). Care was classified as less than good practice in 182 of 388 cases (47%). In 41 cases where care was classified as less than good practice the deficiencies were considered to be of such significance that they might have contributed to death. This represents 33% of cases classified as less than good care (41/122) and represents 11% of all cases reviewed (41/388).

60. Recommendations 1.Training must be provided for junior doctors in the recognition of critical illness and the immediate management of fluid and oxygen therapy in these patients. 2.Consultants must supervise junior doctors more closely and should actively support juniors in the management of patients rather than only reacting to requests for help. 3.Junior doctors must seek advice more readily. This may be from specialised teams e.g. outreach services or from the supervising consultant.

61. Outreach

62. Presence of outreach Outreach service CountryYesNoNot answeredTotal England108652175 Independent hospitals57113 Wales39012 Northern Ireland0909 Guernsey0101 Isle of Man0101 Total116923211

63. Use of Early Warning System Early Warning SystemTotal Yes15373% No5828% Total211

64. Impact of outreach Review time slot Outreach service YesNoUnknownNot answered Total Day10348%21732%4243%2038%38236% Evening7937%28642%3435%2343%42240% Night3315%18327%2222%1019%24824% Sub-total21568698531,052 Not answered 22943235183 Total237780130881,235

65. Key findings There was geographical inequality in the presence of outreach services, with the majority being provided in English hospitals. One in four hospitals did not use some form of track and trigger system to allow early identification of deteriorating patients.

66. Recommendations 1.Each hospital should have a track and trigger system that allows rapid detection of the signs of early clinical deterioration and an early and appropriate response. 2.Although this recommendation does not emerge from the findings in this report, NCEPOD echoes other bodies and recommends that Trusts should ensure each hospital provides a formal outreach service that is available 24 hours per day, 7 days per week. The composition of this service will vary from hospital to hospital but it should comprise of individuals with the skills and ability to recognised and manage the problems of critical illness.

67. Quality of medical records and audit

68. Record quality Poor legibility 2,234 entries assessed 1,330 with insufficient contact details

69. Resuscitation Status Resuscitation status documented Total Yes4211% No34889% Sub-total390 Insufficient data49 Total439 Risk of death at hospital admissionTotal Not expected4012% Small but significant risk5817% Definite risk18253% Expected4714% Unable to define154% Sub total342 Not answered97 Total439 Risk of death on leaving the wardTotal Not expected1<1% Small but significant risk72% Definite risk23468% Expected9127% Sub total333 Not answered106 Total439

70. Resuscitation status - discussion Patient discussionTotal Yes2 No21 Sub-total23 Insufficient data19 Total42 Family discussionTotal Yes17 No8 Sub-total25 Insufficient data17 Total42

71. Morbidity & mortality meetings - organisational Mortality meetings Total Yes12560% No8340% Sub-total208 Not answered3 Total211 Health professionals attendTotal Anaesthetists94 Intensive care consultants114 ICU trainees96 Microbiologists/infection control20 Nurses76 Nutrition/dietetic staff15 Operating department practitioners5 Pathologists2 Pharmacists17 Physiotherapists28 Referring physicians14 Referring surgeons19 Other13

72. Morbidity & mortality meetings - patients Patient’s management to be reviewed at M&M meeting Total Yes16820% No68680% Sub-total854 Unknown178 Not answered564 Total1,596

73. Morbidity & mortality meetings – referring physician participation Physician informedTotal Yes2127% No5773% Sub-total78 Unknown29 Not answered61 Total168 Physician presentTotal Yes633% No1267% Sub-total18 Unknown2 Not answered1 Total21

74. Key findings The quality of medical records was poor. Documentation of resuscitation decisions rarely happened, even in patients at high risk of deterioration. Retrospective review of patients’ management was infrequent. Where retrospective review did occur there was a low level of participation by referring physicians.

75. Recommendations 1.All entries in the notes should be dated and timed and should end with a legible name, status and contact number (bleep or telephone). 2.Each entry should clearly identify the name and grade of the most senior doctor involved in the patient episode. 3.Resuscitation status should be documented in patients who are at risk of deterioration.

76. Pathology

77. Pathology - autopsy data 1.Numbers 2.Quality 3.ONS cause of death 4.Cirrhosis & MRSA 5.Mortality meetings

78. Pathology - autopsy data. Numbers Autopsy rate = 16% (91/560 deaths) Compares with England & Wales average 23% of all deaths examined after death Autopsy reports received = 48% (44/91) Reason for autopsy 18% consented in-hospital autopsy 80% ordered by coroner (1 – could not tell)

79. Pathology – autopsy data. Overall quality of reports 50% = Satisfactory or better Reasons for less than satisfactory: Clinico-pathological summary – 48% None in 34% (15/44) Poor in another 7 cases Lack of histology Poor formulation of cause of death The same comments as made in NCEPOD reports since 1990 ……………………

80. Pathology – autopsy data. ONS cause of death 1. Patient died following paracetamol overdose Report: 1a. bronchopneumonia 1b. intracerebral haemorrhage 1c. hypertension 2. obesity, enlarged fatty liver More accurate and useful? 1a. bronchopneumonia 1b. liver failure 1c. paracetamol toxicity 2. hypertension, intracerebral haemorrhage

81. Pathology – autopsy data. ONS cause of death 2. Patient died of lung cancer with sepsis Report: 1a. multi-factorial 1b. hepatorenal failure 1c. pyelonephritis 2. primary lung cancer More accurate and useful? 1a. multi-organ failure 1b. sepsis 1c. carcinoma of lung

82. Liver cirrhosis

83. Pathology – autopsy data. Cirrhosis and MRSA infection Cirrhosis – 9% (4/44) 1 known pre-mortem 3 established by autopsy Significance for intensive care outcomes MRSA – 2/44 from clinical history Neither mentioned in autopsy report Part of clinical governance

84. Pathology – autopsy data. Mortality meetings Pathologists comprise 1% (2/202) of the health professionals attending mortality and morbidity meetings. Not invited? Not wanted? Not relevant? Teamwork

85. www.ncepod.org.uk