A confidential inquiry into the quality of care before admission to intensive care units (ICUs) found that suboptimal care was common, affecting 54 out of 100 patients studied. Assessors identified 20 patients as well-managed, 54 as receiving suboptimal care, and 26 as having disagreements about their care. Suboptimal care was associated with higher mortality rates, with 48% of patients in the suboptimal group dying in ICU compared to 25% in the well-managed group. The study also found that 37 out of 54 patients in the suboptimal group were admitted to ICU late, and that suboptimal care contributed to morbidity or mortality in most cases. The main causes of suboptimal care included failure of organisation, lack of knowledge, failure to appreciate clinical urgency, lack of supervision, and failure to seek advice. The study suggests that improved teaching, establishment of medical emergency teams, and widespread debate on the structure and process of acute care may help address these issues. The study also highlights the importance of early recognition of life-threatening dysfunction of the airway, breathing, and circulation, and the need for better training and supervision of clinicians. The findings suggest that suboptimal care before ICU admission can lead to increased morbidity and mortality, and that improvements in the quality of care before admission may reduce the need for ICU admission. The study also notes that the quality of care before ICU admission may influence outcomes, and that the use of APACHE II scoring may not fully capture the impact of suboptimal care. The study concludes that the management of airway, breathing, and circulation, and oxygen therapy and monitoring in severely ill patients before admission to ICU may frequently be suboptimal, with major consequences including increased morbidity and mortality and the need for ICU admission. The study recommends improved teaching, establishment of medical emergency teams, and widespread debate on the structure and process of acute care to address these issues.A confidential inquiry into the quality of care before admission to intensive care units (ICUs) found that suboptimal care was common, affecting 54 out of 100 patients studied. Assessors identified 20 patients as well-managed, 54 as receiving suboptimal care, and 26 as having disagreements about their care. Suboptimal care was associated with higher mortality rates, with 48% of patients in the suboptimal group dying in ICU compared to 25% in the well-managed group. The study also found that 37 out of 54 patients in the suboptimal group were admitted to ICU late, and that suboptimal care contributed to morbidity or mortality in most cases. The main causes of suboptimal care included failure of organisation, lack of knowledge, failure to appreciate clinical urgency, lack of supervision, and failure to seek advice. The study suggests that improved teaching, establishment of medical emergency teams, and widespread debate on the structure and process of acute care may help address these issues. The study also highlights the importance of early recognition of life-threatening dysfunction of the airway, breathing, and circulation, and the need for better training and supervision of clinicians. The findings suggest that suboptimal care before ICU admission can lead to increased morbidity and mortality, and that improvements in the quality of care before admission may reduce the need for ICU admission. The study also notes that the quality of care before ICU admission may influence outcomes, and that the use of APACHE II scoring may not fully capture the impact of suboptimal care. The study concludes that the management of airway, breathing, and circulation, and oxygen therapy and monitoring in severely ill patients before admission to ICU may frequently be suboptimal, with major consequences including increased morbidity and mortality and the need for ICU admission. The study recommends improved teaching, establishment of medical emergency teams, and widespread debate on the structure and process of acute care to address these issues.