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Intensive care medicine as a separate specialty will impact on the availability of services, training of pulmonary physicians, and the content of respiratory medicine journals such as Thorax.
In the 1990s a series of well publicised cases, in which critically ill patients were moved large distances in order to gain access to intensive care facilities, led to the recognition that the provision of intensive care services in the UK was characterised by unacceptable variations in organisation and delivery, quantity, funding, and effectiveness. It was appreciated that the ad hoc development of the discipline of intensive care medicine—following its origins in the polio epidemics of the 1950s—was responsible in part for this unhappy state of affairs. However, it was also apparent that there had been years of relative underfunding of intensive care units (ICUs) in the UK compared with other developed societies. The provision of ICU beds in the UK has historically been one of the smallest in the industrialised world. Only 2.6% of hospital beds were designated for intensive care before 2001 compared with averages of 3.3% and 5–7% in Europe and North America, respectively.1 Furthermore, in the UK the practice of intensive care medicine was led principally by clinicians with anaesthesia as their base speciality, who were being asked increasingly to provide multiple services across numerous hospital departments ranging from pain relief to supporting day case, high throughput surgery. Many of these issues were recognised in the Audit Commission report of 1999.2
By the end of the last decade, many pressure groups and professional bodies within the medical and allied professions—most notably the Intensive Care Society—together with central government recognised that a new multidisciplinary approach to the delivery of critical care services across acute hospitals was desirable. Consequently, in April 1999 the Department of Health appointed a review body tasked with developing a framework for the future organisation and delivery of critical care. The group published its report, “Comprehensive Critical Care”, in 2000.3 It acknowledged that many of the difficulties faced were both organisational and structural. A number of seminal recommendations emerged, the principal one being that a new approach based upon severity of illness should be used to determine the delivery of service in accordance with the individual needs of the patient, rather than their physical location (table 1⇓). It was agreed that the provision of comprehensive critical care should be defined by a systemically planned and delivered service integrated into a hospital-wide approach, extending beyond the physical boundaries of the intensive care and high dependency units. Networks were to be established between NHS trusts, working to common standards and protocols within geographically defined regions. It was recognised that a planned approach to workforce development was needed, balancing the skill mix between medical, nursing, and allied health professionals such that the most appropriate mix of skills could be brought to bear on specific clinical problems. Finally, the service was to incorporate a culture based on data collection, thereby promoting evidence based clinical care.
Two other relevant reports have since focused attention on the standards of care delivered to acutely ill patients within medical wards. The first was commissioned by the Royal College of Physicians4 following the publication of data indicating that the care of severely ill medical inpatients in the UK is frequently suboptimal, implicating poor recognition of the severity of illness by junior clinical staff, a lack of senior medical input, and the slow or inappropriate application of therapeutic interventions. Indeed, one investigation of the quality of medical management prior to ICU admission found it to be unsatisfactory in 54% of cases.5,6 Mortality in this group was significantly higher than in those managed appropriately in the pre-ICU phase (48% v 25%). Even more disturbingly, studies of events leading to “unexpected” in-hospital cardiac arrest have indicated that many patients have evidence of marked physiological deterioration clearly recorded before the event without appropriate action being taken.7,8 A key requirement for the increased provision of non-invasive ventilatory (NIV) support services was identified in the report, together with a number of other points relating particularly to the identification of acutely ill patients and the inadequacies of training junior clinical staff.
The second report, by the National Confidential Enquiry into Perioperative Deaths (NCEPOD), has commissioned an investigation of the care of medical patients requiring or developing level 3 dependency. Although the results are still awaited, they are likely to reinforce the impression that suboptimal management of medical inpatients in UK hospitals is not uncommon.
What has been the impact of these reports on the availability of facilities for patients with increased dependency?
More specifically, are there implications for respiratory physicians?
How should a journal such as Thorax recognise the importance of these developments?
IMPACT ON AVAILABILITY OF FACILITIES
ICU capacity in the winter of 2000 underwent a marked expansion in England with an increase of approximately 22% in total bed numbers catering for patients with what is now termed level 2 and level 3 dependency. Level 2 bed numbers increased by approximately 50% and level 3 beds by 8%. This is clearly good news for the critically ill, but issues relating to improved organisation and staffing remain to be addressed. Nevertheless, the Department of Health has recognised the deficiencies in the training of junior medical staff by recommending that all trainees, whatever their intended speciality, should be exposed to a period of training in intensive care medicine.9
Thoracic medicine has a key part to play in the delivery of a comprehensive critical care service within all acute trusts. This was recognised implicitly in the report of the Royal College of Physicians Working Group and developed further by the NHS Modernisation Agency subgroup emanating from the expert group producing “Comprehensive Critical Care”.10 Their recently published report suggested that an NIV service should be established in each acute trust, on the grounds that selected groups of patients with acute respiratory insufficiency have been shown to benefit from this intervention.11 Equally importantly, it may be more suited to patients’ needs and can reduce the complication rate attributable to endotracheal intubation. The development of such a service would not only facilitate the movement of patients from level 3 to level 2 dependency, but would also afford a more palatable and dignified means of providing respiratory support to those who have little hope of being successfully weaned from mechanical ventilation owing to the chronicity and/or terminal nature of their pulmonary disease. It was also recognised that NIV should be provided in specialist centres for patients with delayed weaning and for those likely to require long term and domiciliary ventilatory support.
IMPLICATIONS FOR RESPIRATORY PHYSICIANS
Respiratory physicians have diagnostic and therapeutic skills particularly relevant to the care of the acutely ill. Thus, respiratory insufficiency represents the most common cause of deterioration for patients likely to require level 3 support, and acute respiratory illnesses represent the second most common reason for Accident & Emergency consultation in the UK. Furthermore, respiratory physicians already make an enormous contribution to the provision of acute emergency care to patients arriving in acute trusts via the unselected medical take. Thoracic physicians also possess skills that are complementary to those of intensivists with predominantly anaesthetic backgrounds. In particular, they have the experience and resources to provide the often prolonged inpatient care that ICU survivors require once they no longer need the services of critical care. In addition, they are well placed to provide longer term outpatient follow up to this group as recommended in “Comprehensive Critical Care”. Finally, respiratory physicians could participate in the care of patients requiring prolonged weaning on the model of North American intermediate care units.
The recognition by the Specialist Advisory Committee for Training in Respiratory Medicine that gaining competency in certain skills relevant to intensive care medicine forms a crucial part of the training programme of all specialist registrars is tacit recognition of the increasingly close ties between respiratory medicine and critical care. Indeed, the recognition that one year of training in intensive care medicine (incorporating experience in anaesthesia) can substitute for an equivalent period in general internal medicine/respiratory medicine has precluded the need to extend the overall period of training for those seeking recognition of their experience at intermediate level by the Intercollegiate Board for Training in intensive care medicine. Specialty recognition, involving the award of a dual or even triple (general internal medicine, respiratory, intensive care medicine) certificate of specialty training, is now available for those prepared to add a further year to their training programme.
In other countries (notably North America where the vast majority of intensive care facilities are staffed by individuals with training in pulmonary/critical care), intensive care and respiratory medicine have traditionally been closely linked. This pattern may be adopted increasingly across Europe following the publication of a report by the European Respiratory Society exploring the basis of this relationship.12 In summary, recognition that individuals with clinical experience gained in a variety of base specialties have a part to play in the delivery of newly designated critical care services should encourage the participation of respiratory physicians in this increasingly important activity. We would encourage some to become intensivists in their own right, but all should work within the multidisciplinary team to develop and expand the service within the spirit of “Comprehensive Critical Care”.
“The new editors of Thorax pledge to pay particular attention to submissions . . . from . . . acute care and intensive care medicine”
IMPLICATIONS FOR JOURNALS IN RESPIRATORY MEDICINE
So what are the implications of the closer links developing between respiratory medicine and intensive care medicine for journals such as Thorax? We suggest that they are several.
Firstly, many of the key advances in critical care that have emerged in recent years have been related to the investigation and management of patients with acute and chronic respiratory insufficiency. Indeed, the American Thoracic Society’s decision in the early 1990s to change the title of the American Review of Respiratory Disease to incorporate critical care medicine is tacit recognition of the growing and increasingly influential scientific base of intensive care medicine. Secondly, it seems reasonable that respiratory physicians should be educated in subjects relevant to the acutely ill patient, especially if up to 6 months of experience for all specialist registrars is to take place within the environs of a critical care service. Moreover, if an increasing burden of responsibility for the provision of acute care, at least for patients with respiratory insufficiency, is to be placed upon our specialty, then the publication of appropriate scientific advances and allied educational initiatives—both features of this publication over the years—should be encouraged. Thirdly, while Thorax remains the journal of the British Thoracic Society, by encouraging submissions from individuals practising within intensive care medicine with non-respiratory base specialties, the breadth, interest and circulation of the journal and its impact on clinical practice will be augmented. Fourthly, recognition that acute illness will represent an ever escalating burden upon the NHS should lead investigators and scientists to address the problems of the critically ill with ever increasing urgency. Indeed, we suggest that relevance of research to the needs of stakeholders—the patients we serve—will become an issue of increasing importance to the research councils and charitable bodies in deciding on the allocation of their scarce resources. Finally, and possibly most important of all, intensive care medicine is exciting and very broad based. Legitimate areas of investigation range from genetic predisposition to critical illness through the cellular aspects of the pathophysiology of the inflammatory response (manifest in sepsis, the systemic inflammatory response syndrome, and their sequelae) to complex economic and ethical issues.
We are privileged to report that the new editors of Thorax pledge to pay particular attention to submissions (scientific, clinical, and reviews) emerging from the fields of acute care and intensive care medicine. Not surprisingly, we applaud this initiative and hope that it leads to an expansion of the scientific and clinical base of a newly recognised specialty that will bring together multiple disciplines in a novel and exciting fashion.