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Original Research: Critical Care |

Prehospital Management of Evolving Critical Illness by the Primary Care ProviderPrimary Care Provider Management of Acute Illness

Kerri A. Ellis, DNP; Alireza Hosseinnezhad, MD; Ashfaq Ullah, MD; Yuka-Marie Vinagre, MD, PhD; Stephen P. Baker, MScPH; Craig M. Lilly, MD, FCCP
Author and Funding Information

From the Graduate School of Nursing and the Department of Medicine (Dr Ellis), UMass Memorial Medical Center; Department of Medicine (Drs Hosseinnezhad and Ullah), and Department of Critical Care Medicine (Dr Vinagre), St. Vincent Hospital; and the Departments of Information Services and Cell Biology (Mr Baker), Graduate School of Biomedical Sciences, and Departments of Medicine Anesthesiology, and Surgery (Dr Lilly), Clinical and Population Health Research Program Graduate School of Biomedical Sciences, University of Massachusetts Medical School, Worcester, MA.

Correspondence to: Craig M. Lilly, MD, FCCP, UMass Memorial Medical Center, 281 Lincoln St, Worcester, MA 01605; e-mail: craig.lilly@umassmed.edu


Funding/Support: The authors have reported to CHEST that no funding was received for this study.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2013;144(4):1216-1221. doi:10.1378/chest.12-2906
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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 prehospital patient management by a PCP and of communication with acute care teams were measured in a multicenter, cross-sectional, descriptive study conducted in all four of the adult medical ICUs of the three 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 prehospital management for eight episodes of acute illness among 300 encounters. Infrequent prehospital 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 or by patient age, sex, insurance status, hospital, ICU, or ICU staffing model.

Conclusions:  We identified lack of PCP awareness of patients’ acute illness and high rates of PCP referral to acute care providers as the most frequent barriers to prehospital 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 use of acute care services.

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