title: 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 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.
authors.affiliation: Graduate School of Nursing and the Department of Medicine, UMass Memorial Medical Center.
authors.forename: Kerri A
authors.initials: KA
authors.lastname: Ellis
authors.affiliation: Department of Medicine, St. Vincent Hospital.
authors.forename: Alireza
authors.initials: A
authors.lastname: Hosseinnezhad
authors.affiliation: Department of Medicine, St. Vincent Hospital.
authors.forename: Ashfaq
authors.initials: A
authors.lastname: Ullah
authors.affiliation: Department of Critical Care Medicine, St. Vincent Hospital.
authors.forename: Yuka-Marie
authors.initials: YM
authors.lastname: Vinagre
authors.affiliation: Departments of Information Services and Cell Biology, Clinical and Population Health Research Program Graduate School of Biomedical Sciences, University of Massachusetts Medical School, Worcester, MA.
authors.forename: Stephen P
authors.initials: SP
authors.lastname: Baker
authors.affiliation: Graduate School of Biomedical Sciences and Departments of Medicine Anesthesiology and Surgery, Clinical and Population Health Research Program Graduate School of Biomedical Sciences, University of Massachusetts Medical School, Worcester, MA. Electronic address: craig.lilly@umassmed.edu.
authors.forename: Craig M
authors.initials: CM
authors.lastname: Lilly
mesh_terms: D000368:Aged; D016638:Critical Illness / Q000628:therapy*; D004632:Emergency Medical Services; D005260:Female; D006801:Humans; D008297:Male; D011320:Primary Health Care