Unexpected deaths and referrals to intensive care of patients on general wards. Are some cases potentially avoidable?

J R Coll Physicians Lond. May-Jun 1999;33(3):255-9.

Abstract

Objectives: (i) To determine the incidence of unexpected deaths occurring on general wards, and whether any were potentially avoidable; (ii) to assess whether the quality of care on general wards prior to admission to intensive care affected subsequent outcome.

Design: Six-month audit in teaching hospital. Review of medical, nursing and physiotherapy notes, bedside charts and laboratory data in ward patients either dying unexpectedly (i.e. not having a prior 'do not resuscitate' order) or requiring intensive care unit (ICU) admission. Panel assessment of quality of ward care prior to unexpected ward death or ICU admission.

Subjects: Adult general ward patients admitted to ICU or dying unexpectedly.

Outcome measures: ICU and hospital mortality.

Results: (i) In the six-month study period, 317 of the 477 hospital deaths occurred on the general wards, of which 20 (6%) followed failed attempts at resuscitation. Thirteen of these unexpected deaths were considered potentially avoidable: gradual deterioration was observed in physiological and/or biochemical variables, but appropriate action was not taken; (ii) in the same period, 86 hospital inpatients were admitted on 98 occasions to the ICU, 31 of whom received suboptimal care pre-ICU admission due either to non-recognition of (the severity of) the problem or to inappropriate treatment. Both ICU (52% vs 35%) and hospital (65% vs 42%) mortality was significantly higher in these patients compared to well managed patients (p < 0.0001).

Conclusions: Patients with obvious clinical indicators of acute deterioration can be overlooked or poorly managed on the ward. This may lead to potentially avoidable unexpected deaths or to a poorer eventual outcome following ICU admission. Early recognition and correction of abnormalities may result in outcome benefit, but this requires further investigation.

MeSH terms

  • Adolescent
  • Adult
  • Age Distribution
  • Aged
  • Cause of Death*
  • Child
  • Child, Preschool
  • Death, Sudden / epidemiology*
  • Female
  • Hospital Mortality / trends*
  • Humans
  • Incidence
  • Infant
  • Infant, Newborn
  • Intensive Care Units / statistics & numerical data*
  • Male
  • Medical Audit*
  • Middle Aged
  • Outcome Assessment, Health Care
  • Patients' Rooms / standards*
  • Referral and Consultation / statistics & numerical data*
  • United Kingdom