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The pulmonary physician in critical care: towards comprehensive critical care?
  1. M J D Griffiths,
  2. T W Evans
  1. Unit of Critical Care, NHLI Division, Imperial College of Science, Technology & Medicine, Royal Brompton Hospital, London SW3 6NP, UK
  1. Correspondence to:
    Professor T W Evans, Unit of Critcal Care, NHLI Division, Imperial College of Science, Technology & Medicine, Royal Brompton Hospital, Sydney Street, London SW3 6NP, UK;
    t.evans{at}rbh.nthames.nhs.uk

Abstract

This overview of intensive care medicine in Europe and the United States is an introduction to the review series on “The pulmonary physician in critical care” which starts in this issue of Thorax.

  • intensive care

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In Europe intensive care medicine has been one of the most recent clinical disciplines to evolve. During a polio epidemic in Denmark in the early 1950s mortality was dramatically reduced by the application of positive pressure ventilation to patients who had developed respiratory failure, concentrating them in a designated area with medical staff in constant attendance. This focus on airway care and ventilatory management led to the gradual introduction of intensive care units (ICU), principally by anaesthesiologists, throughout Western Europe. The development of sophisticated physiological monitoring equipment in the 1960s facilitated the diagnostic role of the intensivist, extending their skill base beyond anaesthesiology and attracting clinicians trained in general internal medicine into the ICU. Moreover, because respiratory failure was (and still is) the most common cause of ICU admission, pulmonary physicians, particularly in the USA, were frequently involved in patient care. Many advances in the care of the critically ill have been made since the last series on intensive care medicine was published in Thorax in 1992,1 and we have attempted to summarise some of these. The number and range of contributions to this series has therefore increased considerably and the current series will run over 17 issues. We have attempted to reflect the growing subspecialty interest of respiratory physicians in managing patients in ICU and high dependency facilities, as well as the large number of respiratory diseases causing or complicating critical illness that may require a respiratory opinion.

TRAINING IN INTENSIVE CARE MEDICINE

It would be satisfying to conclude that increased understanding of the pathophysiology of critical illness alone has been responsible for improvements in ICU outcome. However, improved clinical training and organisational changes have undoubtedly played their part. The global status of intensive care medicine is evolving. Board certification is established in the United States, albeit through either respiratory medicine or anaesthesia as base specialties. Furthermore, intensive care medicine is now a recognised specialty in two European Union member states (Spain and the UK). Where available, training in intensive care medicine is of variable duration and its accessibility to clinicians of differing base specialties varies. In Spain 4 years of training are required to achieve specialist status, 2 years of which is in intensive care medicine. In France, Germany, Greece, and the UK 2 years of training in intensive care medicine is required in addition to that needed for the base specialty (usually anaesthesiology, pulmonology, or general internal medicine). In Italy only anaesthesiologists may legally practise intensive care medicine. Currently, there is considerable variation between member states of the European Union regarding the amount of exposure to intensive care medicine in the training of pulmonary physicians as a mandatory (M) or optional (O) requirement: France and Greece 6 months (O), Germany 6 months (M, as part of general internal medicine), UK 3 months (O), Italy and Spain none. Respiratory specialist registrars who want to develop an interest in this area should be encouraged to know that 6 months of anaesthesia and 6 months of intensive care medicine may contribute to their training in general internal medicine and respiratory medicine, respectively.

DOES INTENSIVE CARE WORK?

Does intensive care work and does the way in which it is provided affect patients' outcomes? A higher rate of attributable mortality has been documented in patients who are refused intensive care, particularly on an emergency basis.2 Clinical outcome is improved by the conversion of so-called “open” intensive care units to closed facilities in which patient management is directed primarily by intensive care specialists.3,4 Superior organisational practices emphasising strong medical and nursing leadership can also improve outcome.5 The emergence of intermediate care, high dependency, or step down facilities emphasises the growing gap between clinical practice in the ICU and the general wards. Hence, the time at which patients are discharged from intensive care affects their outcome.6 Early identification of patients at risk of death—both before admission and after discharge from the ICU—may decrease mortality.7 Patients can be identified who have a low risk of mortality and who are likely to benefit from a brief period of high dependency care.8 The impact of specialist retrieval teams in moving critically ill patients between specialist units may also be relevant.9 Finally, long term follow up of the critically ill as outpatients following discharge from hospital may identify problems of chronic ill health that require active management and physical/mental rehabilitation.10

FUTURE DEVELOPMENT OF INTENSIVE CARE MEDICINE

The changing requirements and increased need for provision of intensive care were recognised in the UK in the late 1990s by the Department of Health which commissioned the report entitled “Comprehensive Critical Care” produced by an expert group to provide a blue print for the future development of intensive care within the NHS.11 A central tenet of the report is the idea that the service should extend to the provision of critical care throughout the hospital, and not merely to patients located within the traditional confines of the ICU. To this end, the adoption of a new classification of illness severity based on dependency rather than location was recommended. Traditionally, the critically ill were defined according to their need for intensive care (delivered at a ratio of one nurse to one patient) and those requiring high dependency care (delivered at a ratio of one nurse to two or more patients). The new classification is based on the severity of the patient's illness and on the level of care needed (table 1). The report therefore represents a “whole systems” approach encompassing the provision of care, both before and after the acute episode within an integrated system.

Table 1

Proposed classification of critical illness11

How should the respiratory physician react to these changes? Firstly, we hope this series will increase awareness of the range of clinical problems likely to be encountered in the ICU. Secondly, we suggest that an attachment in intensive care medicine for all respiratory trainees is increasingly necessary. Indeed, specialty recognition and the increased availability of training opportunities should encourage some trainees from respiratory medicine to seek a certificate of completion of specialist training (CCST) combined with intensive care medicine. Thirdly, we suggest that changes in the organisational and administrative structure of intensive care services heralded by the publication of “Comprehensive Critical Care” are likely to impact most heavily on respiratory physicians. For example, respiratory support services using non-invasive ventilation are particularly attractive in providing both “step up” (from the general wards) and “step down” (from the ICU) facilities. In the USA, respiratory physicians have for a long time been the major providers of critical care. In the UK, given appropriate resources and training, the pulmonary physician is ideally suited to become an integral and vital component of the critical care service within all NHS trusts.

REFERENCES

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    BMJ Publishing Group Ltd and British Thoracic Society