Making judgements about ourselves and others is a universal human phenomenon repeated daily in social intercourse, examination halls, or courts of law. It is the desire to do this in an objective, repeatable, reliable and constructive manner that underpins the principle of professional self-regulation. However, this principle has been challenged by evidence of error in healthcare worldwide, and in the UK by several high-profile individual failures which have exposed flaws in regulatory systems. The subsequent public enquiries and their reports have stimulated modifications to training and assessment including regular appraisal and continuing professional development to ensure competence, introduction of a national system for reviewing doctors in difficulty, and several reviews of the concept of professionalism. In short, we will only retain the high level of public trust currently accorded to the medical profession if we combine effective assessment of competence with continued monitoring of performance. Assessment is thus an essential part of ensuring safe and effective patient care.

So much is obvious. But are we not doing this already? The medical profession has from earliest times made a commitment to place the interests of the patient before those of the practitioner and to maintain the highest standards of practice through examination and peer review. The problem is that this commitment may not be shared by all members of the profession. The absence of explicit standards and transparency makes assessment of performance difficult and therefore limits accountability.

This review will examine audit in intensive care (systems of quality assurance), and audit of intensive care (what intensive care has achieved). An approach to intensive care audit, and the framework of the review, is given in Figure 20.1. It may be helpful to start by defining the main terms used in this chapter.

Key definitions

Intensive care is a multi-disciplinary specialty providing a comprehensive diagnostic and therapeutic service for patients with acute failure of two or more organ-systems, or with isolated acute respiratory failure. Patients with single organ-system failures may also require intensive care if their condition is unstable. A minimum 1:1 nurse:patient ratio is required, in intensive care units (ICUs) together with continuous cover by consultants and resident junior doctors.

High dependency units (HDUs) are intended to care for patients with acute failure of not more than one organ-system, excluding acute failure of the respiratory system. HDUs are not suitable places for caring for patients requiring mechanical ventilation or complex organ-system support. They have an important prophylactic role in preventing organ-system dysfunction and in treating postoperative pain following major surgery. Specialist HDUs such as coronary care, renal medicine and transplant units are often best sited within the relevant specialist clinical area, but general service HDUs (for hospital-wide work) should be placed close to the ICU in order to ensure fair access to all clinical services, and to make efficient use of existing medical management and nursing expertise.