Intensive care death rates ‘too variable’

A national inquiry into intensive care has found a significant difference in death rates around the country, with twice as many patients dying in some hospital units as in others.

A report by the audit commission, published today, revealed a worrying and variable picture of intensive care units, with death rates in some hospitals inexplicably higher than in others and patients occupying intensive care beds when they should be on a general ward.

The commission said only that the differences in death rates were "significant", but Nick Black, a scientific adviser to the intensive care national audit and research centre, which supplied data from 52 units, said the difference between best and worst was probably twofold.

Professor Black said there would be variations in care in any specialty and that allowances had to be made for the seriousness of illnesses, but "the worst mortality is probably one and a half times what we would expect, which is still quite a lot."

Normally 30% of patients would die in intensive care. Some units do better, but in those with the highest death rates 45% are dying.

The report corroborated research in the British Medical Journal last year which found that half the patients admitted to intensive care had received inadequate care on the ward.

A quarter of all intensive care patients have come from elsewhere in the hospital. Dick Waite, project manager at the commission, said: "There is evidence that a proportion of patients deteriorate into a need for critical care once they are on the ward.

"It is not normally what you expect in a hospital. You expect them to get better. In a proportion, that deterioration is preventable, but trainee doctors on the ward don't have the skills or time to recognise that deterioration."

The commission said junior doctors and nurses should be better trained to recognise the danger signs preceding a heart attack or other critical conditions.

While a number of factors might explain the varying death rates, it found a strong link with the shift patterns of consultants covering the unit.

Where the consultants worked for a week at a time in the unit, followed by a week or two of other duties, death rates were lower than if they worked a regular Monday or Tuesday and spent the rest of the week elsewhere.

Dipping in to intensive care once a week might not be enough. "There is evidence that doctors are not specialised enough in critical care to keep up to date," said Mr Waite.

Consultants covering the units are usually anaesthetists or general doctors, because there are no full-time specialists in intensive care.

The report identified several kinds of patients who should not normally be in intensive care. The terminally ill patient should be nursed on the ward, in accordance with department of health guidelines. But it was difficult for the doctor to take the decision that a patient would not recover and justify it to relatives if there was even a 1% chance of recovery.

Patients recovering from surgery should be in a specialised unit and not intensive care, it said.

Intensive care beds are under considerable pressure around the country, and the government's drive to improve cancer and heart disease care may increase that pressure. Demand for beds often outstrips supply, and patients have to be moved to another hospital, have their operation cancelled or be discharged early.

Intensive care costs about £700m a year. But the commission said investing more money was not the only answer. It recommended better organisation and more flexible working, with staffing according to the needs of the patients in the unit, not on the basis of one nurse per bed.

Families and friends of the patients needed help too. They might be shocked and worried, and the patient might be unable to talk to them. Many patients who went home had disabilities or a reduced quality of life and should get more follow-up.

Paul Lawler of the Intensive Care Society, representing doctors and nurses who work in the units, said the report highlighted "the poor state of critical care facilities". The reorganisation recommended by the commission was reasonable but might be hard to achieve.

"Money is the issue. We do not have enough money in the NHS, and that is coming home to roost.

"The lack of facilities in intensive care is showing up because of the lack of facilities around it. There are no nurses on the ward, no consultants to say you can't admit this patient who is dying. Patients are in intensive care because there is nowhere else to go."

Main findings

• Death rates in some hospital intensive care units are higher than in others. Consultants' shift patterns may be a factor.

• Too many patients deteriorate on the ward and end up in intensive care.

• Terminally ill and some surgical cases should not be in intensive care.

• Flexible staffing works as well as a one nurse to a bed.

• Little information on how well treatments work.

• Relatives and friends need more help.

Patient's torture by coke

The rare intensive care units that have run follow-up clinics have found, contrary to what they had always believed, that patients do remember how they felt under sedation. They now treat them differently.

One former patient said he had heard his nurse opening a can of fizzy drink. "I was thirsty. Hearing a can of Coke being opened was torture knowing it was not for me," he said.

Another patient said that when sedation was lifted but she was still on ventilation "everyone spoke too fast and I did not have enough time to respond".

Another said unfamiliar noises she heard on the unit, which nobody explained to her, were very disturbing.