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

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.