Integrated critical care: an approach to specialist cover for critical care in the rural setting

To the Editor: Hore and colleagues argue for “integrated critical care” as a solution to the problem of providing intensive-care cover for patients in rural and non-tertiary metropolitan hospitals.1 They claim that such an approach is required uniquely in these hospitals, whereas in tertiary centres “subspecialists would be involved in each phase of the management process”.

That this occurs is undisputed; however, it is far from the optimal model of care.2 Over the past 3 decades, the management of critically ill patients has evolved to require its own specialty. Other than in the traditional critical-care disciplines of anaesthesia and emergency medicine, training in critical care is not a significant component of specialty training programs. Within tertiary hospitals, therefore, the requirement that critically ill patients be cared for by specialists trained in critical-care medicine (and not a “committee” of subspecialty experts) is no less important than in the rural setting. There is consequently little difference between the skills and experience required of tertiary and rural critical-care specialists, and the continuum of critical care is the same in both settings.

The recent creation of the Joint Faculty of Intensive Care Medicine by the Royal Australasian College of Physicians (RACP) and the Australian and New Zealand College of Anaesthetists (ANZCA) has enabled many of the past artificial barriers to effective critical-care training and accreditation in Australasia to be broken down. It is now possible to enter intensive-care training from varied training programs, including those of the Australasian College for Emergency Medicine, the RACP and the ANZCA. Completion of training is recognised by successfully passing a broad-based critical-care examination.

The argument that training could and should include rural practice is well made. However, any comprehensive critical-care training will inevitably require some high-volume experience only available within a tertiary institution.

That there are differences in emphasis in the workload of our rural colleagues should be recognised. However, our job is essentially the same. There is no need for a separate specialty, but there is a need to ensure provision of high quality critical-care services to all patients into the future.