Half patients in intensive care receive suboptimal care

A report has recommended that consultants need to be more available to supervise emergency medical admissions to improve the care of acutely sick patients.

A study by the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) shows that a quarter of patients who were admitted to intensive care units in England and Wales in one month in 2003 died. Nearly half of these patients received care that was judged to be less than good practice. And deficiencies in care in a third of the admitted patients may have contributed to their death, it says.

NCEPOD aims to maintain and improve medical and surgical care. Its report covered all 1677 patients who were admitted to intensive care units in hospitals in England and Wales in June 2003. Of these patients 560 died, and 439 of the deaths were investigated fully by the charity.

In general, senior house officers were left in charge of caring for severely ill patients, especially in the evening and at night—the busiest time for new admissions to intensive care units. In nearly 6 out of 10 cases consultants had no knowledge or input into the referral, and one in four patients had to wait for more than 12 hours before being seen by a consultant.

"Patients should rarely be admitted to ICU [intensive care units] without the prior knowledge or involvement of a consultant intensivist," the report says.

Creating new acute physician posts may help in the long term to improve the care of patients who need intensive care, says the report. But in the short term consultants' job plans should reflect the pattern of demand for emergency admissions, especially at the busiest times in the evenings and at night, it recommends. "Provision should be made for planned consultant presence in the evenings (and perhaps at night in busier units)," it says.

The report also calls for better training for junior doctors in how to recognise critical illness and the role of fluid and oxygen treatment in managing emergency patients. It adds that consultants should supervise junior doctors more closely.

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Contraceptive risks

Women, even broadly well-educated women in a prosperous part of England, do not know how effective various forms of contraceptive are, nor are they able to judge the absolute or relative risks of different methods.

A recent study involved a series of focus groups with women of different ages and backgrounds in and around Oxford. There were four groups. Two involved mothers, two unmarried women, of middle and lower socioeconomic groups, with and without long-term partners, with professional, non-professional, and student backgrounds. The age range was 18 to 45 years.

Overall, 41 women were involved. They participated in semi-structured groups examining knowledge of contraceptive effectiveness, and their knowledge of the risks of adverse effects of hormonal contraceptives. Their attitudes to adverse events was sought.

Women were asked about the effectiveness of various forms of contraception. There were large differences between groups, both in terms of the correct guesses or knowledge, and in the over- or underestimate of the effectiveness of different methods.

Only for the male and female condom and male sterilisation did about a half or more know or guess the correct answer. Women consistently over-estimated the effectiveness of female sterilisation, but tended to underestimate the effectiveness of intrauterine devices, contraceptive implants, and hormonal oral contraceptive.

Knowledge of the risk of thrombosis in healthy women, women using hormonal contraception, and pregnant women was not correctly known by most women in these focus groups. There was a tendency, all three circumstances, for the risks of thrombosis to be over estimated.

When it came to common adverse events with contraceptives, women were generally unhappy with any weight gain of 3 kg or more, but generally happy with weight loss of 3 kg, but not of 6 kg. Amenorrhea was more acceptable than not, but bleeding plus spotting were not acceptable to many women, and prolonged bleeding to hardly any women.

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Attempts to prevent postnatal depression

A systematic review has concluded that the many psychosocial or psychological interventions tested so far in trials do not effectively prevent postnatal depression.

This is an important disorder arising from around one in eight births. As little as 20 years ago, however, there was debate about whether postnatal depression was an important problem.

In 1989 the prevalence of depression among women eight months after birth in population based surveys in Australia, was 15.4% and two subsequent studies found very similar prevalences and confidence intervals.

The response of an anonymous obstetrician to the 1989 findings was highly critical: "Severe postnatal depression occurs in very few women (probably only 5 in every 1000 delivered) but minor problems in psychiatric condition are seen in many women during the first weeks after the birth of a child as they learn to cope with a new baby and all its demands, along with all of the demands of living in the 1980s and 1990s. To imply that the vast majority of these women have postnatal depression is surely a fabrication of the truth."

But a follow-up study of the first survey found that almost a third of the women scoring as depressed (or probably depressed) at eight months were still depressed, or were depressed again, 12 to 18 months later. Only 15% of the women defined as depressed had sought help from, or been referred to, any  mental health professional. The lack of referral to mental health practitioners was striking.

Many of the women who were  depressed in that survey rejected the term "postnatal depression." When interviewed they agreed that they were depressed but saw this as "depression" rather than "postnatal depression." The term postnatal depression implied to them, unacceptably, that their feelings were caused by their babies.

Work on reducing other important and common health problems in populations—such as smoking, road deaths, and cardiovascular disease shows that a shared understanding and belief about the key risks and possibilities for prevention is crucial. The absence of mental health practitioners and researchers from many of the trials of prevention in postnatal depression is a sign that a shared understanding is still some distance away.

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