Identifying Priorities in Intensive Care : a description of a system for collecting intensive care data, an analysis of the data collected, a critique of aspects of severity scoring systems used to compare intensive care outcome, identification of priorities in intensive care and proposals to improve outcome for intensive care patients.

Abstract

This thesis reviews the requirements for intensive care audit data and describes the development of ICARUS (Intensive Care Audit and Resource Utilisation System), a system to collect and analyse intensive care audit information. By the end of 1998 ICARUS contained information on over 45,000 intensive care admissions. A study was performed to determine the accuracy of the data collection and entry in ICARUS. The data in ICARUS was used to investigate some limitations of the APACHE II severity scoring system. The studies examined the effect of changes in physiological values and post-intensive care deaths, and the effect of casemix adjustment on mortality predicted by APACHE II. A hypothesis is presented that excess intensive care mortality in the United Kingdom may be concealed by intensive care mortality prediction models. A critical analysis of ICARUS data was undertaken to identify patient groups most likely to benefit from intensive care. This analysis revealed a high mortality in critically ill patients admitted from the wards to the intensive care unit. To help identify critically ill ward patients, the physiological values and procedures in the 24 hours before intensive care admission from the ward were recorded: examination of the results suggested that management of these patients could be improved. This led to the setting up of a patient at risk team (PART). Two studies report the effect of the PART on patients on the wards and on the patients admitted from the wards to the intensive care unit. Additional care for surgical patients on the wards is suggested as a way of improving the management of high-risk postoperative patients. The thesis concludes by discussing the benefits of the ICARUS system and speculating on the direction that should be taken for intensive care audit in the future.