McQuillan P, Pilkington S, Allan A, Taylor B, Short A, Morgan G, Nielsen M, Barrett D, Smith G, Collins C H
Department of Intensive Care Medicine, Queen Alexander Hospital, Cosham, Portsmouth, Hampshire PO6 3LY.
BMJ. 1998 Jun 20;316(7148):1853-8. doi: 10.1136/bmj.316.7148.1853.
To examine the prevalence, nature, causes, and consequences of suboptimal care before admission to intensive care units, and to suggest possible solutions.
Prospective confidential inquiry on the basis of structured interviews and questionnaires.
A large district general hospital and a teaching hospital.
A cohort of 100 consecutive adult emergency admissions, 50 in each centre.
Opinions of two external assessors on quality of care especially recognition, investigation, monitoring, and management of abnormalities of airway, breathing, and circulation, and oxygen therapy and monitoring.
Assessors agreed that 20 patients were well managed (group 1) and 54 patients received suboptimal care (group 2). Assessors disagreed on quality of management of 26 patients (group 3). The casemix and severity of illness, defined by the acute physiology and chronic health evaluation (APACHE II) score, were similar between centres and the three groups. In groups 1, 2, and 3 intensive care mortalities were 5 (25%), 26 (48%), and 6 (23%) respectively (P=0.04) (group 1 versus group 2, P=0.07). Hospital mortalities were 7 (35%), 30 (56%), and 8 (31%) (P=0.07) and standardised hospital mortality ratios (95% confidence intervals) were 1.23 (0.49 to 2.54), 1.4 (0.94 to 2.0), and 1.26 (0.54 to 2.48) respectively. Admission to intensive care was considered late in 37 (69%) patients in group 2. Overall, a minimum of 4.5% and a maximum of 41% of admissions were considered potentially avoidable. Suboptimal care contributed to morbidity or mortality in most instances. The main causes of suboptimal care were failure of organisation, lack of knowledge, failure to appreciate clinical urgency, lack of supervision, and failure to seek advice.
The management of airway, breathing, and circulation, and oxygen therapy and monitoring in severely ill patients before admission to intensive care units may frequently be suboptimal. Major consequences may include increased morbidity and mortality and requirement for intensive care. Possible solutions include improved teaching, establishment of medical emergency teams, and widespread debate on the structure and process of acute care.
研究重症监护病房（ICU）收治前护理欠佳的发生率、性质、原因及后果，并提出可能的解决办法。
基于结构化访谈和问卷调查进行前瞻性保密调查。
一家大型地区综合医院和一家教学医院。
连续100例成年急诊入院患者，每个中心50例。
两名外部评估者对护理质量的意见，尤其是对气道、呼吸和循环异常的识别、检查、监测及处理，以及氧疗和监测。
评估者一致认为20例患者护理良好（第1组），54例患者护理欠佳（第2组）。评估者对26例患者（第3组）的护理质量存在分歧。各中心及三组之间，由急性生理与慢性健康状况评价系统（APACHE II）评分确定的病例组合和疾病严重程度相似。第1组、第2组和第3组的ICU死亡率分别为5例（25%）、26例（48%）和6例（23%）（P = 0.04）（第1组与第2组比较，P = 0.07）。医院死亡率分别为7例（35%）、30例（56%）和8例（31%）（P = 0.07），标准化医院死亡率（95%可信区间）分别为1.23（0.49至2.54）、1.4（0.94至2.0）和1.26（0.54至2.48）。第2组中37例（69%）患者被认为入住ICU延迟。总体而言，至少4.5%至最多41%的入院病例被认为可能是可避免的。在大多数情况下，护理欠佳导致了发病或死亡。护理欠佳的主要原因包括组织不力、知识缺乏、未认识到临床紧迫性、缺乏监督以及未寻求建议。
重症患者在入住ICU前，其气道、呼吸和循环的管理以及氧疗和监测常常欠佳。主要后果可能包括发病率和死亡率增加以及对ICU的需求。可能的解决办法包括改进教学、组建医疗急救团队以及就急性护理的结构和流程展开广泛讨论。
