Clinical outcome indicators in acute hospital medicine

The practice of intensive care medicine is increasingly being seen as extending outside the four walls of the intensive care unit (ICU). Systems are operating for the detection and rapid resuscitation of patients at the earliest possible stage, before and after discharge from the ICU. And yet, current scoring systems used for evaluating intensive care outcomes assume the interventions occur only within the geographical boundaries of the unit. Broader indicators that measure the continuum of care for seriously ill patients across the entire hospital include deaths, cardiorespiratory arrests and unexpected admission to the ICU. Analysis of these indicators can identify potentially preventable cases, where early identification and resuscitation may have prevented their occurrence. Hospital deaths and cardiorespiratory arrests can be further categorized into unexpected events by excluding patients with 'do not resuscitate' orders. This, in itself, assists in changing the culture of a hospital to being more explicit about dying patients. Unless global measurements of care of the seriously ill occurs it is difficult to estimate the impact of care before and after ICU admission; to evaluate ICU admission and discharge policies; to estimate the need for high dependency beds; or to evaluate care of the seriously ill in sites other than the ICU. The system must also develop targeted methods of distributing the data in order to have a maximum impact. Indicators which estimate the quality of care of the seriously ill across the whole hospital are a critical part of any system designed to improve management.