Hi Julie, I am not sure exactly what you are looking at with the question - is it in relation to how the decision is made to admit, concern with delays till recognition of the deteriorating patient or inappropriate admissions, or barriers to getting patients accepted by the specialty service (or all of the above plus more?) There are several processes used in NZ that may address some aspects of the question - firstly in terms of recognition and rapid response to deteriorating ward patients, the increased use of early warning scores and links from scores to required actions has shown an increase in confidence on the part of staff to pursue concerns and recommend an ICU review and potential transfer, and also the introduction of the ICU outreach nurse, where senior ICU nurses will review ward patients and assess their status. Not sure if this is helpful, but an interesting and complex topic

Hi Sandra, Thank you for your reply which is extremely helpful to a complex topic. I am trying to answer the question in respect to the following:

The number of patients who require ICU admission is sometimes greater than the number of ICU beds available. When admission to the ICU is delayed it is considered to be an ‘untimely admission’. This phenomenon has been associated with longer length of stay (LOS) further advanced respiratory support and increased mortality rates. Locally it is speculated that patients are more likely to be a delayed admission due to ICU beds being occupied by ward able patients, who no longer require a ICU bed, yet bed pressures throughout the trust will impact on those patients already occupying a bed on ICU and therefore contribute to the obstructed flow and movement of patients into the designated ward.

This often means that the acutely ill patient has to be either cared for on the hospital wards by the critical care outreach team (CCOT) alongside non specialized staff; this has been associated with higher mortality. Literature has suggested that the timely admission to ICU has both a positive and greatly impacts on survival within the first 72 hours.

With an aging population on the increase and medical advances to stem chronic illness, the availability of ICU beds is becoming a further challenge with timely access and prompt movement of ward able patients to the correct designated wards is becoming increasingly important. Although this study is not looking at mortality rates in conjunction with delayed admission; it is an important fact that; the consequences of untimely admissions to ICU will and can effect mortality.

Hi Julie - yes, I see the same in the ED setting, there is a considerable body of literature in relation to aspects of ED and hospital overcrowding, and I think for most specialty areas, where the back flow from high levels of hospital occupancy has resulted in failure of patient flow. It becomes a hospital wide problem (and essential a social problem as well) as wards cannot accommodate the patients from ICU due to their lack of space, which is linked to inability to discharge patients often associated with inadequate or insufficient community support systems. One of the challenges is to address the 'silo' effect that often occurs in health care, where individual areas focus on their own concerns without looking at the 'bigger picture'. It can be difficult to get buy in to processes aiming to improve patient flow, with out recognition that it needs to be a hospital wide approach.

Unfortunately, responses often do not occur until sentinel events raise the profile of the issue, and as you identify this is often in the form of increased mortality. Certainly in relation to ED practice, one of the factors that has led to greater priority in relation to overcrowding has been the development of research that has clearly linked patient outcomes (increased length of stay and mortality in particular) to this phenomenon. It has been shown that failure to be able to move patients on to the more appropriate areas is linked with measurable negative outcomes. I think that the need for such research is one way to highlight the issue and its severity. There also need to be moves ant a socio-political level, with increased public awareness of the issues and the potential outcomes, and a willingness to re-look at the traditional processes and priorities within the health care system. As you so rightly note, with the increasingly aged population, chronic disease and co-morbidities associated this issue will only expand.

Thank you Anthony, I certainly agree with both you and Sandra Richardson, that at a socio-political level, it is those which govern the intensive care unit /communities who should be responsible for managing their particular resources. Whilst I agree with your point of the ICU is merely one aspect of the health care system, it is a system which is being increasingly relied upon. The nurse / patient ratio is by far superior to that of our colleagues on the general wards, but I believe that the pure nature of ICU requires this as do the emergency departments, in fact all health care providers should provide adequate nurse / patient ratio. Unfortunately the ward nurse / patient ratio historically has nearly always been poor, a socio-political dilemma on its own. It will however be interesting to acknowledge the impact of the Francis report and how it has impacted on patients and families receiving care in the NHS. Even if all the recommendations as suggested by the Francis report were to be implemented it can only be achieved if patient care is the foremost responsibility of all health care providers.

This will be a massive shift in health care culture and can only be achieved if the flexibility of health care personnel allows patient management to be directed to the most appropriate facility in a timely manner. As Sandra rightly suggests, the need for research is a necessity to highlight the issues of severity and outcome, but intervention must be at a socio-political level. As previously highlighted an increasingly ageing population, chronic disease and co-morbidites will continue to expand and agitate the issues one hopes to explore in the opening question.