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Vol. 37. Núm. 2.
Páginas 91-98 (Marzo 2013)
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Vol. 37. Núm. 2.
Páginas 91-98 (Marzo 2013)
Special article
DOI: 10.1016/j.medin.2012.12.004
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The future of intensive care medicine
El futuro de la medicina intensiva
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L. Blancha,b,c,??
Autor para correspondencia
lblanch@tauli.cat

Corresponding author.
, D. Annaned, M. Antonellie, J.D. Chichef, J. Cuñatg, T.D. Girardh,i, E.J. Jiménezj, M. Quintelk, S. Ugartel, J. Mancebom,
a Critical Care Center, Hospital de Sabadell, Corporacio Sanitaria Universitària Parc Taulí, Sabadell, Spain
b Universitat Autònoma de Barcelona, Spain
c CIBER Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
d General ICU, Raymond Poincaré Hospital, AP-HP, University of Versailles SQ, France
e Policlinico Universitario A. Gemelli, Università Cattolica del Sacro Cuore, Rome, Italy
f Réanimation Médicale & Dept de Biologie Cellulaire Hopital COCHIN & Institut Cochin 27 rue du Faubourg Saint-Jacques, Paris, France
g Department of Intensive Care Medicine, Hospital La Fe, Valencia, Spain
h Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, United States
i Geriatric Research, Education and Clinical Center Service, Department of Veterans Affairs Medical Center, Nashville, TN, United States
j University of Florida, University of Central Florida and Florida State University, Orlando, FL, United States
k Department of Anaesthesia and Intensive Care Medicine, University of Göttingen, Göttingen, Germany
l INDISA Clinic and Salvador's Hospital, University Andrés Bello, Santiago de Chile, Chile
m Department of Intensive Care Medicine, Hospital de Sant Pau, Barcelona, Spain
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Abstract

Intensive care medical training, whether as a primary specialty or as secondary add-on training, should include key competences to ensure a uniform standard of care, and the number of intensive care physicians needs to increase to keep pace with the growing and anticipated need. The organisation of intensive care in multiple specialty or central units is heterogeneous and evolving, but appropriate early treatment and access to a trained intensivist should be assured at all times, and intensivists should play a pivotal role in ensuring communication and high-quality care across hospital departments. Structures now exist to support clinical research in intensive care medicine, which should become part of routine patient management. However, more translational research is urgently needed to identify areas that show clinical promise and to apply research principles to the real-life clinical setting. Likewise, electronic networks can be used to share expertise and support research. Individuals, physicians and policy makers need to allow for individual choices and priorities in the management of critically ill patients while remaining within the limits of economic reality. Professional scientific societies play a pivotal role in supporting the establishment of a defined minimum level of intensive health care and in ensuring standardised levels of training and patient care by promoting interaction between physicians and policy makers. The perception of intensive care medicine among the general public could be improved by concerted efforts to increase awareness of the services provided and of the successes achieved.

Keywords:
Intensive care medicine
Intensivist
Organisation
Medical training
Medical specialty
Research
Innovation
Resumen

La formación en medicina intensiva, ya sea como especialidad primaria o a partir de una troncalidad común para después convertirse en supra-especialidad, debería incluir competencias clave que garanticen un cuidado estándar y homogéneo del paciente crítico, así como proveer al sistema sanitario del número de especialistas en medicina intensiva (intensivistas) de forma ajustada y anticipada al ritmo de crecimiento de la necesidad asistencial.

La organización de los cuidados intensivos desde la visión de las distintas especialidades o en unidades centralizadas y jerarquizadas, es heterogénea y está en constante evolución. No obstante el acceso y tratamiento precoz del enfermo crítico por parte de un intensivista, debería estar siempre garantizado, no únicamente en los servicios de medicina intensiva, sino en todos los departamentos de un hospital, actuando el intensivista como elemento central en la comunicación y coordinación entre los diferentes servicios y especialistas, a fin de lograr la más alta calidad y eficacia en la asistencia.

La investigación clínica en medicina intensiva está sustentada por la excelencia de conocimiento de sus profesionales, pero son necesarias estructuras de apoyo: la integración de la investigación e innovación en la rutina diaria y un incremento de la investigación traslacional, a fin de identificar áreas que muestren elementos potenciales de avance en el aspecto clínico y la aplicación de los principios de la investigación básica y fisiológica en el entorno de la medicina intensiva. Las tecnologías de la comunicación y la información ofrecen un marco idóneo para compartir y poner en común el conocimiento y apoyar la formación, la investigación y la innovación en medicina intensiva.

Ciudadanía, profesionales de la salud y responsables políticos deben apoyar que aquellos profesionales con el mejor conocimiento científico tomen las decisiones sobre las prioridades en la gestión del cuidado del enfermo crítico, dentro de un modelo económico sostenible. Las sociedades científicas tienen un papel crucial en la definición de los niveles mínimos de atención médica intensiva y también en asegurar estándares de capacitación, formación de intensivistas y acreditación, promoviendo la interacción entre especialidades, familias, sociedad y responsables políticos. La percepción del valour de la medicina intensiva entre la ciudadanía y la Administración debe ser constantemente mejorada mediante esfuerzos coordinados y dirigidos a incrementar el conocimiento que la medicina intensiva pone a su disposición y de los éxitos alcanzados por esta especialidad.

Palabras clave:
Medicina intensiva
Intensivista
Organización
Formación
Especialidad médica
Investigación
Innovación
Texto completo
Introduction

Intensive care medicine is a heterogeneous, complex and evolving specialty. While the need for specialised around-the-clock medical care for a subset of acute patients is universal, the organisation of care and training of specialist physicians varies in different countries and regions of the world.1–9 Intensive care medicine sets itself apart from many other areas of health care in that critically ill patients frequently have multiple interrelated issues that need to be managed rapidly and in a comprehensive manner to be effective. In addition, ethical considerations, which include personal, familial, cultural, religious and demographic values and expectations, influence patient management and outcome, the long-term consequences of which are borne by the individual patient, family and society as a whole.10,11 The demand for intensive care medicine is increasing as expectations for state-of-the-art medical care rise, compounded by the ageing of the general population in many countries and medical advances that improve the survival of patients who then require specialised care to recover as many former faculties as possible.12,13

Intensive care as a medical specialty lacks wide visibility among the general public and policy-making bodies, and yet both individuals and societies simultaneously expect that high quality care and the necessary resources are available when the need arises. The future of intensive care medicine requires advances in medical research and physician training as well as improvements in the organisation of patient management and public awareness.

This manuscript is based on a roundtable discussion by the international author group held during the national congress of the Sociedad Española de Medicina Intensiva, Crítica y Unidades Coronarias (SEMICYUC) that took place on 11 June 2012 in Santander, Spain.

Education, training and organisation of the specialtyIntensive care medicine as a medical specialty

The national commission on medical specialties in Spain defines intensive care as the medical specialty that manages severely ill patients with one or more dysfunctional organs and at high risk of death or permanent disability, but with the possibility of a complete recovery7. Specialists in intensive care medicine often serve as general physicians for severely ill patients, who may have been referred or are primarily managed by a variety of other medical departments. Intensive care therefore represents a medical specialty that must maintain horizontal relationships with a variety of other specialties within a medical institution.

Medical training and education

Intensive care medicine has existed as a primary medical specialty in Spain for approximately the past 35 years, as is the case in some countries in Latin America. In many other countries, however, including most of the rest of Europe, the United States and other parts of Latin America, training in intensive care medicine comprises secondary specialty education following primary training in internal medicine, anaesthesiology, surgery or emergency medicine.14,15 Parts of Western Europe, Africa and Southeast Asia are now initiating efforts to introduce and harmonise intensive care as a primary medical specialty. The international Competency Based Training programme in Intensive Care Medicine for Europe (CoBaTrICE; www.cobatrice.org) has identified key competencies that should be included as part of intensive care training and aims to serve as a basis for high-quality global training programmes, independent of the current system of training, to ensure a uniform standard of care.16–26

Unfortunately, the supply of physicians trained to provide intensive medical care has not kept pace with increasing demand, leaving many intensive care units (ICUs) understaffed with qualified personnel.13,27–29 Educational institutions and programmes need to implement measures to ensure that an adequate number of physicians are trained to provide intensive care to the population that may require these services.30–33 One potential strategy may be the exposure of medical students to intensive care departments at an early stage in the medical education curriculum, thereby increasing the chances that young physicians choose intensive care as a specialty.

Organisation

Organisation within a medical institution may comprise so-called open ICUs that manage patients under the primary care of and physically located within other medical departments. In contrast, closed ICUs care for severely ill patients with a variety of medical indications under the primary care of intensive care physicians and physically located in a common facility with the necessary means, materials and expertise readily available. Key to the success of either model is the rapid detection and treatment of patients at risk of severe complications, thereby reducing or avoiding lengthy ICU stays.7,34–36

Another key component of optimal intensive patient care is the availability of a specialist trained in intensive care medicine at all times.37 Institutions with limited resources or located in remote areas may need to rely on consultation with trained specialists using virtual means, but ultimately an intensive care specialist should be available at every ICU bedside and at all hours of the day and night.7,27,38–44

Research and innovation: challenges and businessResearch

After more than 60 years of research in intensive care medicine, notable progress has been made in areas such as ventilation and renal replacement, changing clinical practice and improving patient outcomes. In parallel, the necessary infrastructure has been created to support the execution of randomised controlled trials (RCTs) in the intensive care setting now and in the future.45,46 While more well-designed RCTs that provide clear clinical guidance are required, the adaptation of RCT results to real-life clinical scenarios remains a challenge, and innovations in research design may be necessary to ease this transition.47

One notable failure, after three decades of research, has been the search for a universal treatment solution for septic patients.48 Future efforts will need to focus on successful translational research to address this and other remaining clinical needs. Important will be the training and recruitment of young physicians with an interest in performing translational research. The European Board of Intensive Care Medicine has prepared a set of recommendations for modifications to the European Commission's Clinical Trials Directive (2001/20/EC) that aim to streamline both the costs and time required for new treatment or management concepts to reach the clinic (http://ebicm.esicm.org/eu-activities/clinical-trial-directive). Coordinated changes in the way in which intensive care research is regulated, for example the use of centralised institutional review boards to approve larger multi-centre trials, may also serve to improve efficiency.

Research of any kind requires financial resources, and a disproportionate amount of money is spent on patient care in the ICU relative to research to support advances in the field.49 With a history of disappointing results in some areas of intensive care medicine,50–52 the pharmaceutical industry may be increasingly hesitant to support large RCTs without some reassurance of a successful outcome. Therefore, the aim of translational research should be to identify areas in which an investment in large RCTs is likely to be worthwhile.11 In the meantime, professional societies with an interest in this area may need to play a larger role in supporting translational research studies.

Clinical research efforts in both oncology and haematology over the past two decades have been successful in part because participation in clinical trials has become a routine component of clinical management. To ensure further progress in intensive care medicine, physicians should aim to include every ICU patient in at least one clinical trial.

Innovation

Future research will need to develop models that can accommodate both the clinical complexity and the multimodal interventions that are often required to treat critically ill patients. Electronic simulation of some conditions provides the opportunity to experiment with innovative treatment or management strategies without putting patients at risk. The use of biomarkers in the clinic is rapidly changing patient management in many areas of medicine and is likely to do so in the ICU setting, such as septic patients,53–57 as well.

The use of so-called electronic or tele-ICUs has gained in popularity, particularly in the United States, and is likely to continue to support patient care for units in remote areas, rapid response teams in the field and institutions that do not maintain around-the-clock intensive care staff.58–61 Institutions and countries with limited resources have also begun to develop means by which to perform collaborative research using electronic networks such as registry databases and surveys, which facilitate the collection and comparison of larger numbers of intensive care units and patients. This type of research will contribute to a global picture of ICU management and support efforts to establish a uniform standard of care. Collaborative projects between individual national or regional professional societies can also be enhanced using electronic networks.

Health economic implicationsMedical need

The conflict between rising health care costs, the availability of complex medical procedures, increasing demand created by ageing populations and limited resources may require changes in the allocation as well as the management of health care. While extreme medical measures may be applied to any patient, independent of the cost or likely benefit, a rational balance must be achieved between the level of care that is possible and that which is appropriate to the individual situation. Such ethical considerations are delicate to approach, awkward to discuss and preferentially avoided by both individuals and policy makers. Unfortunately, intensive care patients, their families and medical caregivers are often confronted with end-of-life decisions that require a rapid consensus.

Some of the awkwardness and insecurity associated with health care decisions for critically ill patients could be alleviated by increasing awareness of the necessity for individuals to contemplate and discuss the options and consequences of intensive medical care and clearly document their preferences before the medical need arises.62 One consideration for both individuals and societies is the personal and economic costs compared to the likely benefits to be achieved by a particular intervention. Age, life situation, the type of likely disability to be expected and longer-term quality of life issues all factor into treatment decisions that look beyond simple mortality.

Economic reality

Because a large proportion of societal resources in many countries are spent on critical care medicine,13,63,64 physicians and institutions often find themselves faced with pressure to reduce costs by any means.65 Research advances in intensive care medicine reflect progress in medical care as a whole; therefore more, rather than less, investment to support innovation, increase efficiency and improve patient outcomes is needed and might well achieve the same economic goals in the long run.66 Unfortunately, the bodies that generally support research are not necessarily the same communities that may benefit if a patient can be fully rehabilitated, however, carefully designed health-economic research can lend support to these arguments by showing the relationships between the risk of mortality and morbidity, cost of care in the ICU, cost of long-term care if the patient survives with sequelae, negative cost if the patient is partially or fully rehabilitated and quality of life measures.39,67,68

Medical advances require the synergistic efforts of physicians, patients, regulatory bodies and industrial partners. Without economic incentives to develop new products and cooperation in bringing these products into clinical use, industrial interests may focus on other areas of medicine that present lower thresholds to be overcome.

While medical advances may ultimately reduce the direct and indirect costs of critical care medicine, structural changes may contribute more immediately to savings. By identifying patients likely to require intensive care and initiating treatment early, ICU stays may be shortened or avoided entirely.67–69 Particularly in countries or regions with limited resources, the definition of a minimum level of care that should be available to all who require it would provide the basis on which policy makers can base allocation of the resources that are available. Medicare, the health care reimbursement system for the elderly in the United States, plans to withhold reimbursement from hospitals that do not implement, assess and adhere to minimum quality standards.70 Government agencies and contributors of economic support could use similar tools to ensure the implementation of a minimum level of critical care.

Professional societies and institutions: leadership roles at the macro and micro levelsProfessional scientific societies

One of the major functions of professional medical or scientific societies is to provide a link between physicians and the society at large, represented by its political bodies. Individual physicians are affiliated with institutional and national organisations, which can in turn cooperate with regional, continental and global organisations, the collaborative efforts of which are more likely to produce results at the level of public policy than individual smaller organisations. Aside from patient advocacy organisations, scientific societies also indirectly represent patient interests, thereby providing a voice for the patient community.

Scientific societies also serve as a structure within which physicians and industry can meet to exchange knowledge and research advances and ensure a standardised level of high-quality care. The Declaration of Vienna, generated by the European Society of Intensive Care Medicine (ESICM) and signed by a long list of national and international intensive care organisations, outlines the principles that should support patient safety and quality of care, including measures to avoid human error, optimisation of existing treatment modalities, processes and careful monitoring of new medications and technologies.10 Professional societies also have an important function in defining and promoting a universal minimum standard of care that should be implemented with the support of government policy makers.

Professional scientific societies can play a leading role in working to achieve recognition of intensive care medicine as a primary medical specialty as discussed above at the European level and beyond. Leadership will also be required in the definition and standardisation of intensive care training, ensuring both efficiency and quality.71

Medical institutions

Leadership by scientific societies begins with an active collaboration between intensive care specialists and other medical specialties within each institution. Intensivists are ideally situated to coordinate activities from different specialties and encourage an atmosphere of open cooperation, especially in crisis situations.36,72

Medical institutions have an important role to play in the establishment of collaborations to ensure a high level of patient care, reduced costs and improved patient outcomes (www.ihi.org).66 These cooperative efforts may include quality assurance monitoring, scientific exchange or the sharing of expertise using electronic networks. One tool that may be required to achieve this goal is a common language which defines an ICU, an ICU patient, and a patient who should be admitted to the ICU; these definitions can then be universally applied to both outcome and quality assessment research. The application of scientific principles of peer review to quality assurance assessments may be beneficial and could be coordinated by institutional, governmental or scientific bodies.

The social role and visibility of intensive care medicine

Support for the maintenance and further development of intensive care medicine may be improved by increasing public awareness of the need for high-quality critical care services. Critical illness is an integral part of everyday life for society as a whole but one that most individuals prefer not to think about until confronted with a need62; it is therefore often ignored by the population at large and its political representatives.

The perception of intensive care medicine among the general public is often negative, with critical care regarded in close association with death. This image reflects the fact that few members of society at large have a detailed awareness of the services provided by an ICU, the contributions of the medical personnel and especially the high rates of treatment success.73 The highly technical nature of many interventions may also exert an intimidating effect. Public relations campaigns using simple messages that aim to create a more realistic image of post-ICU survival with and without disabilities may improve the way in which critical care medicine is viewed and valued.74,75 Efforts to educate political representatives about the contributions high-quality intensive care medicine can make to society as a whole may also be required. We can show these efforts in the next websites:

Different sorts of mass media may be effectively used to increase awareness and improve the prestige of intensive care medicine. Prominent persons with a high level of social impact and who require critical care services can be engaged after recovery from their critical illness to serve as positive examples or spokespersons for the cause. Intensive care physicians and other medical personnel can play an important role in providing the public with information about their work, for example, an ongoing effort aims to establish a worldwide “Sepsis Day” (www.world-sepsis-day.org). Continued efforts to encourage lay persons to learn CPR may provide further opportunities for interaction and create advocacy. Social media and patient “survivor” organisations might also contribute to greater awareness of the service to individuals and societies provided by critical care medicine.

An inherent value conflict frequently arises between the formal aim of critical care medicine to preserve life and the personal and societal consequences of survival with sequelae. Hospital administrators, payors and governmental bodies often require justification for the high cost of intensive care medicine in terms of morbidity and quality measures. The criteria applied and priorities defined by the patient community that legitimise the existence of ICU services, however, may be entirely different. For the individual patient, the 28-day survival that is used as a standard for many assessments may be less important than measures of long-term quality of life. Future research needs to examine the quality of life and (health) economic consequences that arise when patients survive with disabilities, and societies as a whole will need to develop policies and mechanisms with which to better manage this value conflict.

Conclusions

Access to high-quality intensive care medicine should be ensured by establishing a uniform standard of care, key competencies for physician training and the availability of an adequate number of qualified physicians to meet demand. Physicians, professional scientific societies and policy makers will need to work together to ensure advances in patient care and to find a balance between evolving medical and economic demands.

Conflict of Interest

The authors have no conflict of interest to declare.

Acknowledgements

This manuscript is based on a roundtable discussion held during the national congress of the Sociedad Española de Medicina Intensiva, Crítica y Unidades Coronarias (SEMICYUC) that took place on 11 June 2012 in Santander, Spain. Medical writing support was provided by Physicians World Europe GmbH (Mannheim, Germany) supported by the SEMICYUC.

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All authors contributed equally to the manuscript content.

Copyright © 2012. Elsevier España, S.L. and SEMICYUC
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