A service evaluation examining the requirement for Level 2 critical care in a major trauma centre

P. Galea, K. Joyce, Sarah Galea, F. Loughnane
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Abstract

Critical care provision is fundamental in all developed health systems in which severe disease and injury is managed. This is especially true in major trauma centres and high-acuity establishments, where acutely unstable patients can be admitted at any time, requiring clinical monitoring and interventions appropriate for their burden of illness. This single-centre, prospective service evaluation applied validated scoring systems to a surgical population, sampling and following those considered “high-risk” through to discharge or death, alongside all intensive care unit (ICU) admissions during 2019. Primarily we aimed to quantify the number of patients objectively suitable for Level 2 critical care, conventionally provided in a high-dependency unit (HDU) setting. Secondary outcome measures included ICU readmission rate, in-hospital mortality, and delays to ICU admission and discharge. Of the “high-risk” surgical patients, more than eight per week were found to have peri-operative Portsmouth Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (P-POSSUM) scores that would advocate critical care admission. Only one individual received scheduled peri-operative critical care. Post-operative mortality in this group was 6.1%, though none of these patients was admitted to ICU prior to death. There were 605 ICU admissions in 2019, with 32.1% of admitted days spent at the equivalent of Level 2 critical care, which could have been administered in a HDU if one was available. The ICU readmission rate was 6.45%. This data demonstrates substantial unmet critical care needs, with patients not uncommonly managed in clinically inappropriate areas for extended periods due to delays accessing ICU. A designated HDU may mitigate clinical risk from this subgroup, reducing morbidity and in-hospital mortality, and this methodology for assessing requirements could be used in other similar institutions.
对大型创伤中心2级重症监护要求的服务评估
在所有管理严重疾病和伤害的发达卫生系统中,提供重症监护是至关重要的。这在主要的创伤中心和高敏锐度机构尤其如此,在那里,急性不稳定的患者可以随时入院,需要进行适合其疾病负担的临床监测和干预。这项单一中心的前瞻性服务评估将经验证的取芯系统应用于外科人群,对那些被认为“高风险”的患者进行采样和随访,直到出院或死亡,以及2019年所有重症监护室(ICU)的入院情况。我们的主要目的是量化客观上适合2级重症监护的患者数量,通常在高依赖病房(HDU)环境中提供。次要结果指标包括ICU再入院率、住院死亡率以及ICU入院和出院延迟。在“高危”手术患者中,每周有超过8名患者的朴次茅斯生理和手术严重性死亡率和发病率增加评分(P-POSSUM)支持重症监护入院。只有一个人接受了预定的围手术期重症监护。该组患者术后死亡率为6.1%,但这些患者在死亡前均未入住ICU。2019年共有605人入住重症监护室,32.1%的入住天数相当于2级重症监护,如果有HDU的话,可以在HDU中进行。ICU的再入院率为6.45%。这一数据表明,重症监护需求得到了实质性满足,患者因延迟进入ICU而长期管理倾斜不合适的区域并不罕见。指定的HDU可以减轻该亚组的临床风险,降低发病率和住院死亡率,这种评估需求的方法也可以用于其他类似的机构。
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