Is admission to intensive care always the right answer?
A key part of life as a doctor in any discipline involves assessing a situation and deciding on the right course of action – in many specialties this involves considering whether a treatment can make a patient better. In intensive care, there are difficult decisions to be made that are literally life and death and, just as importantly, also relate to the quality of life and death.
Admission to ICU reduces mortality rates in critical illness. In 2017/18 there were approximately 314,000 admissions to UK intensive care units and, due to the specialist knowledge of the ICU teams, 82% of patients admitted to intensive care survive their critical illness. Elective admissions following high-risk surgery account for about 20% of ICU patients and 80% are emergency admissions directly from A&E or from other departments in a hospital, where identification of the risk factors that could lead to a rapid decline in a patient’s condition and speed of referral are critical.
The National Early Warning Score (NEWS) is used in clinical monitoring. It is a scoring system that allocates a value to physiological measurements (respiration rate, oxygen saturation, systolic blood pressure, pulse rate, level of consciousness or new confusion and temperature) and will provide an assessment of clinical risk based on the aggregate score. A change in NEWS could indicate that a patient should be referred to ICU for specialist care. An intensivist must work with a patient or, more often, their family to decide whether it is in the patient’s best interests to be admitted and treated within the intensive care unit. Many of the treatments in ICU are invasive and the patient’s ‘best interests’ cover a wide remit that involves psychological and sociological factors as well as quality of life and death.
From a medicolegal perspective, in order to assess whether admission to intensive care could or should have happened sooner, or was in the best interest of the patient, there are a number of factors that an intensivist can consider. An experienced intensive care physician will review NEWS scores along with a range of other measures. The NEWS scores are made up of six physiological parameters which form the basis of the scoring system:
- respiration rate
- oxygen saturation
- systolic blood pressure
- pulse rate
- level of consciousness or new confusion*
- temperature.
*The patient has new-onset confusion, disorientation and/or ag
Thorough analysis of all the information enables the intensivist to provide an assessment on the probability of survival had the patient had been treated in intensive care at an earlier point than they were admitted. Importantly, based on their unique knowledge and experience, they are also able to provide expert guidance on whether admission to ICU would have been in the patient’s best interest.
This is often a key decision factor in deciding whether there is a potential basis for a medical negligence claim and whether there is value in proceeding with a deeper analysis of the records and history. Securing an expert with the experience to give a reliable opinion at this stage is essential.