In October 1999, the publication in the UK of the Audit Commission's Critical to Success - the place of efficient and
GCS Temp Creat MAP pH WBC Resp Oxygen Pulse
Figure 1.1 Abnormal physiological values (%) before admission to ICU. Reproduced with permission from Theta Press Ltd (Goldhill D. Medical Emergency Teams. Care of the Critically III. 2000;16:209-12. Creat, creatinine; GCS, Glasgow Coma Score; MAP, mean arterial pressure; Resp, respiratory rate; Temp, temperature, WBC, white blood cells
effective critical care services within the acute hospital re-emphasised the concept of the patient at risk - patients at risk of their condition deteriorating into a need for critical care. The report advocated better training of medical and nursing staff, early warning scoring systems and "outreach" critical care. The Commission commented that intensive care is something that tends to happen within four walls, but that patients should not be defined by what bed they occupy, but by their severity of illness (Box 1.2).
Following this, Comprehensive Critical Care - a review of adult critical care services was published by the Department of Health. The report reiterated the idea that patients should be classified according to their severity of illness and the necessary resources mobilised. This includes critical care outreach teams. In the USA and parts of Europe, there is considerable provision of high dependency units (HDUs). In most UK hospitals it is recognised that there are not enough HDU facilities. A needs assessment survey in Wales, using
Box 1.2 New UK severity of illness classification
• Level 0: Patients whose needs can be met through normal ward care in an acute hospital
• Level 1: Patients at risk of their condition deteriorating, or those recently relocated from higher levels of care, whose needs can be met on an acute ward with additional advice and support from the critical care team
• Level 2: Patients requiring more detailed observation or intervention including support for a single failing organ system or post-operative care and those 'stepping down' from higher levels of care
• Level 3: Patients requiring advanced respiratory support alone or basic respiratory support together with support of at least two organ systems. This level includes all complex patients requiring support for multi-organ failure
Level 2 is equivalent to previous HDU care; Level 3 is equivalent to previous ICU care. Reproduced with permission from DOH
(Comprehensive critical care. London, Department of Health, 2000).
objective criteria for HDU and ICU admission, found that 56% of these patients were being cared for on general wards rather than in critical care areas. A 1-month needs assessment in Newcastle, UK found that 26% of the unselected emergency patients admitted to a medical admissions unit required a higher level of care: 17% needed level 1 care, 9% needed level 2 care and 05% level 2 care. This would indicate the need for far higher level 1-2 facilities in the UK than at present.
Early warning scores have been developed and advocated as a means of targeting resources early and therefore more effectively (Table 1.1). Increasingly abnormal vital signs mean that the patient is sick and a high score requires early assessment and intervention by experienced staff. Whilst these scores could lead to a false sense of security if they are normal, evidence is emerging that early warning scores can reduce CPR rates and ICU mortality (Figure 1.2).
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