Prehospital Management of Evolving Critical Illness by the Primary Care Provider

Abstract

BACKGROUND: The factors that limit primary care providers (PCPs) from intervening for adults with evolving acute severe illness are less understood than the increasing frequency of management by acute care providers. METHODS: Rates of pre-hospital patient management by a PCP and of communication with the acute care teams were measured in a multi-center cross sectional descriptive study conducted in all four of the adult medical intensive care units (ICU) of the 3 hospitals in central Massachusetts that provide tertiary care. Rates were measured for 390 critical care encounters using a validated instrument to abstract the medical record and conduct telephone interviews. RESULTS: PCPs implemented pre-hospital management for 8 episodes of acute illness among 300 encounters. Infrequent pre-hospital management by PCPs was attributed to their lack of awareness of the patient's evolving acute illness. Only 21% of PCPs were aware of the acute illness before their patient was admitted to an ICU and 33% were not aware that their patient was in an ICU. Rates of PCP involvement were not appreciably different among provider groups, by patient age, sex, insurance status, hospital, ICU, or ICU staffing model. CONCLUSIONS: We identified lack of PCP awareness of the acute illness and high rates of PCP referral to acute care providers as the most frequent barriers to pre-hospital management of evolving acute illness. These findings suggest that implementing processes that encourage early patient-PCP communication and increase rates of prehospital management of infections and acute exacerbations of chronic diseases could reduce utilization of acute care services.