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CRITICAL CARE IN EUROPE

Jean-Louis Vincent, MD, PhD, Lambert Thijs, MD, PhD, and Vladimir Cerny, MD

Critical care in Europe, as elsewhere, is progressing rapidly and to complement progress in science and technology, the need for efficient, well-organized, and effective areas in which to care for the critically ill, and act on the latest advances, has never been greater. Across Europe, as communication between countries improves and expands, we seek to knit together individual units into an interactive network of intensive care units of similar structure, method, and training requirements. This will enable us, by combining the best aspects from each country, to create a better system and better transfer of research and clinical infor- mation that can only benefit the intensivist and his or her patient. This article briefly looks at the history of intensive care in Europe, then summarizes the present situation, and finally looks at the bright possibil- ities for the future.

HISTORICAL BACKGROUND

The concept of the modern intensive care unit in Europe was born as long ago as 1852, when Florence Nightingale realized the importance of keeping those patients needing particular attention together in one place for special nursing. One hundred years later, in 1952, an unusually severe poliomyelitis epidemic struck Copenhagen, Denmark, involving hundreds of paralyzed patients with respiratory difficulties. A new therapeutic approach using early tracheostomy, manual ventilation, and extensive physiotherapy under blood gas control was a ~ p l i e d . ~ A great

From the Department of Intensive Care, Erasme University Hospital, Free University of Brussels, Brussels, Belgium 0-LV); the Department of Intensive Care, Academic Hospi- tal W, Amsterdam, The Netherlands (LT); and the Department of Anesthesia and Critical Care Medicine, Charles University, Hradec Kralove, Czech Republic (VC)

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number of patients had to be ventilated for prolonged periods, but the overall survival rate approached 60%. From this successful experience developments of great importance emerged: construction of mechanical ventilators, humidifiers, monitoring equipment, and equipment for blood gas measurement. The year 1952 can therefore be considered to be the birth date of intensive care medicine in Europe.

Because it was recognized that patients with other forms of respira- tory disease could benefit from treatments used in the Copenhagen polio epidemic, several European countries developed intensive care units (ICU). These primarily provided respiratory support to patients with chronic respiratory failure secondary to neurologic disease, and consid- erable experience was thus gained in the management of patients requir- ing mechanical ventilation. ICUs as we know them today grew from such units, and from experience in postoperative patients in whom similar techniques were increasingly applied. These units were charac- terized by a higher nurse-to-patient ratio and easy access to monitoring and ventilatory equipment. Technology was not brought to patients in the hospital, but severely ill patients were increasingly admitted to specially designed areas with high technologic capabilities.

Such areas initially often consisted of just one or two beds set apart from the main ward by a screen or curtains, with patient care still very much the concern of the admitting doctor. With surgical and medical advances increasing numbers of patients needed such attention, and areas of the hospital were set apart for this specific purpose. Some hospitals kept separate areas for different patient categories, whereas others, often the smaller hospitals, just had a single unit, each patient being admitted under a different consultant who was then responsible for his or her care. Confusion sometimes reigned because no one doctor was in charge of the unit and one patient could therefore receive "umbrella" care from three or four consultants each covering his or her own field but often with little specific intensive care training, thus lacking a holistic approach. Patients were labeled as surgical, cardiac, medical, and so forth, rather than as intensive care and treatment empha- sis altered according to which specialty and which consultant they were under. As further progress in this field was made it became apparent that it would be more efficient to group these patients together, because patients requiring intensive care generally exhibited similar problems regardless of the initial reason for admission. Patients would therefore receive more effective care if treated by specially trained doctors with overall responsibility for decision making, acting in close collaboration with doctors from all other specialties. This is thus the current situation, a mixture of the older specialty and the more modern combined ICUs.

PRESENT SITUATION

Western Europe

Through the European Society of Intensive Care Medicine (ESICM) we know that there are between 3000 and 4000 ICUs in Western Europe.

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Although there have been some steps toward uniformity, many differ- ences remain between countries and in particular there is quite a north- south divide, with the United Kingdom falling more with the Southern European countries. The European Prevalence of Infection in Intensive Care (EPIC) study recently carried out a 1-day prevalence study of infections in about one third (n= 1417) of these units and gained much valuable information about the structure of units across Europe.I3 Fur- ther information can be drawn from an ethical questionnaire sent to members of the ESICM in 1989,'O from the simplified acute physiology score (SAPS 11) study in which 110 European ICUs participated: and from a recent survey among 199 European ICUs assessing quality stan- dards (unpublished data). These studies do not cover all the European centers, but certain general statements on the current situation seem warranted. The EPIC study, being the largest, is our main source of information.

Basic Unit Structure. The majority (74.4%) of units classify their case load as mixed surgical and medical, although there are still considerable numbers of units maintaining separate patient populations, with 9.2% of units termed surgical, 8.7% medical, and 7.7% specialist.

Unit Size. Unit size varies considerably, with 25% of units having more than 10 beds, 57% between 6 and 10, and still 18% have less than six beds. The United Kingdom had the highest proportion of small units, with 48% having less than six beds. The size of a unit is important because smaller units are not cost-effective, with little room for flexibil- ity, whereas larger units may be more effectively managed if divided into smaller subunits. The ESICM recommends that at least six beds are needed to have a manageable unit.ll

Bed Occupancy. On the day of the EPIC study13 bed occupancy averaged 78.5%, being the highest in Belgium with 94%. Thirty-seven percent of units have less than seven admissions per week, 37% have 8 to 14,15% have 15 to 21, and 11% of units have more than 21 admissions weekly. In replies to the ethical questionnairelo by 239 members of ESICM, 57% of responders said that bed availability commonly limited patient admission to the ICU. Bed availability is greatest in Scandinavia and The Netherlands but considerably lower in Italy and the United Kingdom, and this is partly related to the longer length of stay of ICU patients and to the higher proportion of smaller units in these latter countries. Less than 15% of patients stay longer than 21 days in Sweden, whereas in Italy the figure is greater than 35% (Fig. 1).

Staffing. Seventy-two percent of ICUs have a committed 24-hour doctor and 67.2% have an ICU director. Italy and Spain have the highest number of ICUs with a full-time doctor, whereas The Netherlands and Finland have the lowest. The presence of an ICU director is most com- mon in Greece and Spain, whereas in the United Kingdom and Ireland less than 30% of units have one. The most common primary specialty of the medical director in Europe is anesthesiology (unpublished data) which is in sharp contrast to the United States, where the majority have medicine as their primary ~pecialty.~ A recent survey of intensive care

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Figure 1. Geographical variations in the length of ICU stay. The countries are listed from north to south, and the United Kingdom is placed at the extreme right. (Data from Vincent JL, Bihari D, Suter PM, et al: The prevalence of nosocomial infection in intensive care units in Europe. Results of the EPIC study. JAMA 274:639-644, 1995.)

doctors in Western Europe showed that the primary specialty of 55% of respondents was anesthesiology, 23% internal medicine, 10% pediatrics, 2% surgery, and 9% other (unpublished data). The primary specialty varies according to the particular country: for example, in Sweden and Italy almost every ICU doctor has an anesthesiology background, whereas in Portugal and Greece the majority have internal medicine as their primary specialty. In Belgium, Holland, and France there is a much broader mixture of primary specialties. Almost 90% of the units report that ICU staff have full responsibility for patient care. The nurse-to- patient ratio is somewhat higher in the Northern countries than in the Southern countries, whereas for the number of specialists per bed the reverse is reported, and for numbers of residents and fellows there is no clear trend across Europe (unpublished data).

Patient Demography. In the SAPS study5 21% of patients were unscheduled surgical patients, 32% scheduled surgical patients, and 47% medical patients. In the EPIC studyI3 32% had undergone elective sur- gery, 23% emergency surgery, and 13% had been admitted with multiple trauma. Despite these apparent overall similarities, there are differences between the various countries, which may be related to the type of unit and local policies, but also to other conditions, such as marked differ- ences in the incidence of road accidents in the various European coun- t r ie~ . '~

In the EPIC study 62.3% of ICU patients were male, with a mean age of 51 years. The mean age of female admissions was 61 years. Thirty percent of patients were over 70 years of age. Sixty-three percent of

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patients were being mechanically ventilated, 78% had some form of intravenous catheter in situ, and 75% had a urinary catheter. Both the need for mechanical ventilation and for tracheostomy was greater in the South and in the United Kingdom which, together with longer patient stay and lower bed availability, suggest that these countries see larger numbers of sicker patients than the North of Europe. This is supported by the APACHE I1 scores, with more than 15% of patients having scores greater than 20 in Italy, Greece, Portugal, and the United Kingdom, whereas in Germany and Sweden the figure was less than 7.5% (Fig. 2).

Use of Severity of Illness Scores and Protocols. Slightly more than half of European ICUs seem to have written admission protocols. Protocols for procedures were used in almost 90% of units, treatment protocols in 839'0, and prevention protocols in 78% in a recent limited survey (unpublished data). Severity of illness scores were used in 74%, the APACHE I1 score being the most frequently applied, closely followed by the SAPS score (unpublished data).

Ethical Issues. Despite limited bed availability, there are no wide- spread criteria for ICU admission. Many doctors admit patients with little hope of survival who probably gain least benefit at the highest cost. This raises all sorts of ethical questions relating to quality of life, patient rights, and ICU economics, but generally many doctors realize that the ICU is certainly not the most appropriate place to care for the terminally ill. Decisions regarding resuscitation, withholding therapy, and euthanasia are difficult for all and very subjective, with great varia- tions throughout Europe. The Netherlands officially has the most liberal

Apache Score > 20

Finland Sweden Netherlands Genany Switzerland Italy Ponugal UK Norway Denmark Belgurn Austria France Spa," Greece

Figure 2. Geographical variations in the APACHE II score of ICU patients. The countries are listed from north to south, and the United Kingdom is placed at the extreme right. (Data from Vincent JL, Bihari D, Suter PM, et al: The prevalence of nosocomial infection in intensive care units in Europe. Results of the EPIC study. JAMA 274:639-644, 1995.)

250 VINCENT et a1

views on euthanasia, but in replies to our ethical questionnaire 36% of respondents from all countries said they sometimes practice euthanasia, and doctors in The Netherlands were not significantly different in their practices to those of neighboring countries. Withdrawal of life support and euthanasia were less common in Spain, Portugal, and Italy and here such decisions were more commonly restricted to the medical staff without patient or family involvement.

Nosocomial Infection. ICU-acquired infection was reported in 20.6% of ICU patients with wide international variations: from 9.7% in Switzerland to 31.6% in Italy. 59.6% of resistant Staphylococcus aureus were resistant to methicillin, and again the highest prevalence of methi- cillin resistant staphylococcus aureus (MRSA) was in Italy, with 8 l % . I 3 The development of ICU-acquired infection is associated with higher mortality rates and it is interesting to ask why there are such different rates across Europe. ICU-acquired infection is related, among other factors, to length of stay and mechanical ventilation and we have already seen that the South has more mechanically ventilated patients and more patients staying longer than 21 days, so it is perhaps not so surprising that they have a greater prevalence of ICU infection.

Eastern Europe

We have little data available on the structure of ICUs in Eastern Europe. Some data have been collected in the Czech R e p ~ b l i c ~ , ~ and we can assume that this is fairly representative of the situation in other Eastern European countries. As in the rest of Europe, units are a mixture of specialized ICUs associated with different departments (e.g., neuro- surgery, pediatrics, burns, and combined medical-surgical units).

Unit Size. Unit size is similar to that across Western Europe, with 20% of units having more than 10 beds, 70% 5 to 10 beds, and 10% less than five beds.

Bed Occupancy. Sixty-five percent of units have less than seven admissions per week, 25% have 8 to 14, and 10% have 15 to 21. The average length of stay for ICU patients is 10.6 days.

Staffing. Eastern European countries compare favorably with the rest of Europe in terms of medical staffing. Ninety-nine percent of units have a committed 24-hour doctor and 75% of units have an ICU director. The majority of ICU doctors have anesthesiology as their primary spe- cialty.

In summary, differences remain in unit size, staffing, and structure throughout Europe. These are partly related to differences in patient demography and to local culture, and for these reasons some differences will always remain. Important differences also exist between Europe and the United States, where more units are often managed by the primary physician. It is, however, now well established that the level of care is superior when a properly trained intensivist is in charge.” One

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can use these variations between countries to identify those areas where one can best apply guidelines to enable more efficient unit operation.

SOCIETIES OF INTENSIVE CARE MEDICINE

In most European countries, national societies of intensive care medicine were founded relatively early as a forum for scientific and educational interaction between practitioners in the field (Fig. 3). These national societies had, and still have, little formal contact. In 1982, the ESICM was founded with the aim of stimulating (clinical) research and education at a European level. This society is not a federation of national societies but consists of individual members in all European countries. ESICM membership has grown rapidly over the years and is still rising, but its total membership is significantly less than the sum of all members of the national societies.

FUTURE AIMS

Over the past few years, the ESICM has formed several international task forces in an attempt to draw-up guidelines for training and struc- ture, which could be applied to ICUs throughout Europe. These recom- mendations include guidelines for training programs and aspects of design, protocols, and staffing, and aim to enable efficient management within, and easy interaction between, ICUs.', 8* ", l2

Design. An ICU should be a geographically separate area of the hospital with a minimum of six beds, providing adequate floor space for easy movement through the unit and around patients. Adequate supplies of oxygen, air, suction, electricity, and lighting must be ensured, along with back-up facilities in the event of supply failure. The minimum specialist equipment should include continuous cardiac monitoring, tem- porary cardiac pacing, ventilatory support, and pump-controlled fluid administration. Facilities for blood gas, hemoglobin, and electrolyte anal- ysis, and radiographic services must be readily available at all times. Each ICU must function 24 hours a day, 7 days a week.

Protocols. Protocols for common activities must be established for each unit and the use of internationally recognized, regularly reviewed policies is recommended. Such protocols include advice on tracheal intubation and extubation, antimicrobial use and infection prevention, basic monitoring levels, and appropriate emergency drug treatments for a variety of conditions. Liaison between hospital specialties and the pharmacist is essential for the continuing institution of such policies.

Staffing. Levels of staffing by qualified medical, nursing, and sup- port personnel should be appropriate to the patients on the unit at any one time and must, therefore, be flexible. Good communication between staff members is essential to ensure efficient running of the unit. One very important factor is the availability of a committed doctor 24 hours

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a day. All too often a doctor's orders are given while passing through the unit perhaps en route to give anesthesia in the operating room, or even worse from the end of a telephone, without proper assessment of the patient. Each ICU should also be overseen by an ICU director, a specialist in intensive care who is responsible for patient admission and discharge policies, ICU administration, on-going education, and liaison between other departments and the public. His or her role is to combine all elements of the ICU to create a smoothly running unit."

The intensive care specialist must have completed training in a primary specialty, such as anesthesiology, internal medicine, surgery, or pediatrics, and then undergone a 2-year period of full-time training in intensive care medicine. This latter period must cover aspects across a wide range of specialties including both theoretical and practical knowl- edge, and may involve periods at several ICUs to obtain the necessary experience. Continuous supervision by full-time ICU staff is essential at all times of this training process.8, 11, l2

CONCLUSION

Critical care medicine is one of the fields in which we are making the most advances, both in terms of research and in patient care. The situation in Europe is changing as we communicate more and share beneficial information. Membership in European medical societies and attendance at international conferences facilitates this communication, and we are building an interactive system of European ICUs with certain areas of uniformity while allowing for individual countries' cultural and economic differences. By so doing we will create the most conducive environment for future research and for effective, efficient patient care.

References

1. Aitkenhead AR, Booij LH, Dhainaut JF, et al: International standards for safety in the

2. Brown JJ, Sullivan G: Effect on ICU mortality of a full-time critical care specialist.

3. Czech Health Statistics Yearbook, 1994. Prague, Cesky spisovatal, Praha, 1995, pp 85-88 4. Groeger JS, Strosberg MA, Halpern NA, et al: Descriptive analysis of critical care units

in the United States. Crit Care Med 20:846-863, 1992 5. Le Gall JR, Lemeshow S, Saulnier: A new simplified acute physiology score (SAPS 11)

based on a European/North American Multicenter study. JAMA 2702957-2963, 1993 6. Reynolds HN, Haupt MT, Thill-Baharozian MC, Carlson RW: Impact of critical care

physician staffing on patients with septic shock in a university hospital medical intensive care unit. JAMA 260:3446-3450, 1988

7. Secher 0 The polio epidemic in Copenhagen 1952. In Atkinson RS, Boulton TB (eds): The History of Anesthesia. International Congress and Symposium Series 134. London, Royal Society of Medicine Services, 1989, pp 425432

8. Thijs LG, Baltopoulos G, Bihari D, et al: Guidelines for a training program in intensive care medicine. Intensive Care Med 22166-172, 1996

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9. Trenkler S, Sevcik P: Intensive care in the Czech and Slovak Republics. Intensive Care World 9:180-181, 1992

10. Vincent J L European attitudes towards ethical problems in intensive care medicine: Results of an ethical questionnaire. Intensive Care Med 16:256-264, 1990

11. Vincent JL, Artigas A, Bihari D, et al: Guidelines for the utilization of intensive care units. Intensive Care Med 20163-164, 1994

12. Vincent JL, Baltopoulos G, Bihari D, et al: Guidelines for training in intensive care medicine. Intensive Care Med 2080-81, 1994

13. Vincent JL, Bihari D, Suter PM, et al: The prevalence of nosocomial infection in intensive care units in Europe. Results of the EPIC study. JAMA 274:639444, 1995

14. Yates DW: Trauma care in Europe 1995. In Goris RJA, Trentz 0 (eds): The Integrated Approach for Trauma Care. Update in Intensive Care and Emergency Medicine 22. Berlin, Springer Verlag, 1995, pp 1-12

Address reprint requests to

Jean-Louis Vincent, MD, PhD Department of Intensive Care

Erasme University Hospital Route de Lennik 808

8-1070 Brussels Belgium