Q J Med 2002; 95: 56-57
© 2002 Association of Physicians
Correspondence |
The right patient in the right place at the right time
Prescot, Merseyside
Sir,
We compliment Dr Goldhill on exploring and exposing problems of selection for intensive care.1 His observations are worth more than a dozen statistical analyses or reports and are supported by our own experience and research from 1962. General intensive care is an important branch of high technology medicine, the aim of which must be that its benefits exceed its burdens.2 Put simply, this means ensuring the right patient is in the right place at the right time.3 In the UK, general intensive care started in 19593 and yet this goal still remains elusive. Intensive care can benefit patients with very varied diagnoses, but does the lack of the necessary comprehensive knowledge and experience explain the too-many errors? For some diseases, such as severe acute asthma, we have shown that simple observations made quickly will suffice4 and the results can then be near perfect.5 In contrast, assessing closed trauma to the abdomen can be difficult. The detection of patients who should benefit from intensive care can be helped by routine screening of simple bedside observations. An example, the Modified Early Warning Score (MEWS), was recently published by Subbe et al.6
For three decades, decision-making by hospital nurses and doctors has been influenced by published policies (guidelines, protocols). Such policies were used at our hospital from 1962 to 1983, and encompassed intensive care, drug prescribing and resuscitation.7 It was soon appreciated that such policies were doomed to failure unless they were enforced; the policies then became rules. The anticipated cry of infringement of clinical freedom was countered by Professor Hampton's edict ‘clinical freedom is dead and should have been buried years ago’.8
The 40 years of failing to get the right patient in the right bed at the right time pales into insignificance against the 140 years of lack of progress in patient nutrition. In 1859, Florence Nightingale stated ‘every careful observer of the sick will agree in this, that thousands of patients are annually starved in the midst of plenty’.9 Although nutrition of in-patients is easily achieved, it is not widely applied. Recently, Kelly et al. have repeated this message: ‘since there are serious consequences (to malnutrition), and effective simple treatment is readily available, increased awareness is required, with routine assessment of nutritional status in all patients’.10 Similarly, patients or relatives have no problem in deciding whether part of a hospital is dirty.11 What an indictment of existing staff that outsiders are needed to show them the truth.12 It appears that criteria for admission to intensive care should join these other topics awaiting solution. A simplistic answer could be more training and yet more training, but the underlying problem would remain: getting hospital staff to use basic medical knowledge allied to simple patient observation. If we don't achieve this, Florence Nightingale's words may continue to ring true into the next century.
References
1.
Goldhill DR. The critically ill, following your MEWS. Q J Med2001; 94:507–10.
2. Jennett B. High Technology Medicine: Benefits and Burdens, 2nd edn. Oxford University Press, 1986.
3. Jones ES. Raison d'etre. In: Jones ES, McWilliam D, Coakley J. The Really Useful Book on Intensive Care. Carnforth, Martin Lister Publishing, 1998:3–15.
4.
Davis B, Gett PM, Jones ES. A service for the adult asthmatic. Thorax1980; 35:111–13.
5. Henderson A, Wright M. Status asthmaticus: experience of 100 consecutive admissions to an intensive care unit. Clin Intens Care1992; 3:148–52
6.
Subbe CP, Kruger M, Rutherford P, Gemmel L. Validation of a modified Early Warning Score in medical admissions. Q J Med2001; 94:521–6.
7. Gordon IJ, Jones ES. Effective clinical policies in a district general hospital. Health Care Anal1998; 6:295–304.[Medline]
8. Hampton JR. The end of clinical freedom. Br Med J1983; 287:1237–8.
9. Nightingale F. Notes on Nursing, 3rd edn. London, Churchill Livingstone, 1980.
10.
Kelly ID, Tessier S, Cahill A, Morris SE, Crumley A, McLaughlin D, McKee RF, Lean MEJ. Still hungry in hospital: identifying malnutrition in acute hospital admissions. Q J Med2001; 93:93–8.
11. Charter D, Coates S. Patients dish the dirt on Britain's ‘clean’ hospitals. The Times2001; Jan 13th:12.
12. The NHS Plan—Clean Hospitals. NHS Estates2001.
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