News Release

Critical/intensive care: Huge investments needed for increasing demand in rich and poor countries; UK has one of lowest numbers of intensive care beds per head in developed world

Peer-Reviewed Publication

The Lancet_DELETED

Critical (intensive) care is a resource that many people assume will always be available in high-income countries, but is not given the priority it deserves by health-policy makers. Increasing demand in this sector is being driven not only by ageing populations worldwide, but by a lack of effective interventions in some aspects of this field including acute lung injury. Currently, the UK has one of the lowest numbers of intensive care unit (ICU) beds in the developed world (3.5 per 100,000 population), while Germany (24.6) and the USA (20.0) have the highest. These and other issues are explored in the first paper in The Lancet Series on Critical Care, written by a team led by Dr Gordon D Rubenfeld, Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada.

Critical care medicine is thought to have begun in 1953 in Denmark when Danish patients with polio received invasive mechanical ventilation. Expansion of ICU departments followed advances in understanding in pathology of major organs, including lungs, heart, kidneys and liver. Monitoring devices that have developed in this era include central venous, pulmonary artery, and intracranial pressure catheters. Dialysis machines and a whole range of other now-standard devices have been created for use in the ICU.

Patients in ICU are generally in three categories: those with acute organ dysfunction and whose outcome is unclear; those who have had a major surgical procedure and are recovering, and those whose time in ICU has not prevented their decline and are receiving end-of-life care.

Doctors in ICU have to simultaneously resuscitate, diagnose, and prevent deterioration in ICU patients, and deal with complications. They also face the devastating challenge of engaging in decisions about the appropriate extent of life-support for patients who have avoided immediate death but who are unlikely to have any quality of life if they survive.

Sepsis, acute lung injury, multiple organ dysfunction, and requirements for mechanical ventilation are all regular events in the ICU. Sepsis is body-wide inflammation related to infection, while acute lung injury can also be due to severe infections such as pneumonia, and also trauma and burns. US studies suggest a prevalence of 300 cases of serious sepsis per 100,000 people per year, with acute lung injury cases at around 80 per 100,000 per year. Countries that can provide organ transplantation, intensive chemotherapy, and cardiovascular interventions will all add to their own critical care burden through these procedures.

Although variation exists between countries on the definition of an ICU bed, the UK appears to be lagging considerably behind its European neighbours and the USA and Canada, both in terms of ICU beds per 100 hospital beds and ICU beds per 100,000 population. "There is no uniform definition of what an ICU bed is, so that would account for some of this variation," says Dr Rubenfeld.* "However, it is clear that the UK is at the low end of ICU bed capacity, and thus would have decreased ability to cope with a large scale disaster with many critically injured casualties."

However, large scale disasters aside, there is no evidence, says Dr Rubenfeld, about which of the two ends of the spectrum—high numbers of ICU beds or low numbers—is better. "Countries with high numbers of ICU beds per head may be operating them inefficiently at very high cost, preventing use of these resources elsewhere in the healthcare system," he adds*.

Mortality in the ICU can be 8% to 18% if data for patients admitted for routine monitoring are included (eg post routine operations), but in patients with acute lung injury it is 35% to 45%; in those with septic shock it can be as high as 60%. Following a routine heart attack, mortality in developed nations is 7% and still falling. Reasons for high mortality include clinicians' failure to recognise a critical illness before advanced organ dysfunction has occurred. Secondly, there are few effective specific treatments for problems such as acute lung injury, and the few that exist can be difficult to universally apply.

Critical care demands are expected to sharply increase in future. As the boundaries of medicine are pushed further in all fields of medicine, the demands for critical care will increase with them. Increasing numbers of older people will also see demand rise. Extrapolation of current US data suggest that by 2030, more than 330,000 cases of acute lung injury will occur in a year, 50% higher than current figures. In developing countries, demand will be many times the rate of supply, leading to civil unrest and other pressures.

Demand for ICU care could also increase in a preventive fashion, because ICU teams are increasingly called on to ensure that high-risk patients on general wards do not deteriorate to the point of needing dedicated ICU care (which would increase costs). However this is still using up the resources of the ICU team, just not within the ICU unit itself. Efficiency could be found in centralising ICUs, but having ICUs at a greater distance from patients creates its own problems. Climate change and events such as wars can and will add further pressures.

Regarding the potential shortage of ICU specialists, the authors say: "Potential solutions to this shortfall are increased development and dissemination of guidelines and protocols, training of non-physician clinicians to substitute for intensivists, and telemedicine to allow experienced physicians and nurses to expand the geographical scope of their care. The training and telemedicine approaches would need additional human and technological resources, which might be feasible in middle-income or high-income settings, but would challenge the capacity of health systems in the developing world. The evidence that either approach is a safe and effective substitute for intensivist staffing is slight."

They conclude: "Although intensive care capacity is scarce in the developing world, efforts to improve the care of the critically ill in these settings are emerging. Unlimited expansion of intensive care to meet the needs of an ageing population and handle the consequences of natural disasters, conflict, inadequate primary care, and high-risk treatments for very sick patients, will be challenged by high costs at a time of economic constraint. To meet this challenge, the specialty of intensive care will need to measure better the global burden of critical illness and develop both preventive and therapeutic interventions for the sickest patient. These interventions will need to be scalable across health-care systems at all the world's latitudes."

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Dr Gordon D Rubenfeld, Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada. T) +1 647 998 7385 E) gordon.rubenfeld@sunnybrook.ca

For full Series paper 1, see: http://press.thelancet.com/cc1.pdf

Note to editors: *quote direct from Dr Rubenfeld and cannot be found in text of Series

NOTE: THE ABOVE LINK IS FOR JOURNALISTS ONLY; IF YOU WISH TO PROVIDE A LINK TO THE FREE ABSTRACT OF THIS PAPER FOR YOUR READERS, PLEASE USE THE FOLLOWING, WHICH WILL GO LIVE AT THE TIME THE EMBARGO LIFTS: http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(10)60446-1/abstract


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