The evolving role of intensive care in health care and society

Despite the evolving needs of patients and changing societal expectations, Australasian intensive care continues to provide a world leading service to patients and the broader society

With Melbourne hosting the 2019 World Congress of Intensive Care, it is timely to reflect on the nature of the speciality and consider its role within health care. The intensive care unit (ICU) can be a daunting place. For patients, families and even non‐intensive care clinicians, the complex and technically advanced environment can feel intimidating. The ICU represents a microcosm of the broader acute health care system, where the challenges of patient‐centred care, treatment, communication and resource management are encountered in a more impactful setting. The reach of intensive care is wide; current estimates from the Australian and New Zealand Intensive Care Society Centre for Outcome and Resource Evaluation suggest that Australians and New Zealanders have a 50% lifetime chance of requiring admission to an ICU.1 Intensive care interacts with every other element of acute care, serving the needs of patients, specialist units, hospitals and broader society. In its more recent history, intensive care has evolved to encompass more than just a single geographic location; it is an organised system of care that ensures delivery of timely and expert treatment to critically ill patients, increasingly extending this capability beyond the walls of the ICU itself and into many other settings.

Intensive care is a relatively young discipline, with the ICU evolving from post‐operative recovery areas and high acuity specialty wards. As technology and systems advanced, ICUs became established across major hospitals to group together the sickest patients where they could be managed by specialised teams. The ability to provide complex treatments such as mechanical ventilation over extended periods revolutionised the management of patients with severe organ failure, providing the possibility of recovery for many who would otherwise die of overwhelming illness. Demand for ICU support continues to increase in Australia (Box 1), likely driven by two main factors. First, advances in treatments across virtually all medical and surgical specialties offer new opportunities to extend life2 but cannot be delivered without a period of intensive care. Second, expectations of patients, families and clinicians are changing,3 such that complex, invasive and costly interventions needing ICU support are undertaken more often, even in very old people4 and those with advanced frailty.5,6 As a result, what was once considered “the end of the line” has shifted considerably over time. Given that these drivers of demand are likely to persist, the number of patients requiring admission to ICUs in our region is predicted to increase further.7 Notable changes in ICU practice over the past 20 years include an 8% increase in non‐elective admissions (now 60% of the total), a 32% decline in mechanically ventilated patients (now only 32% of the total), and a 46% increase in non‐ventilated medical patient admissions (now 29% of all admissions). Patient age has increased slightly (median age is now 65 years), while the burden of comorbidities and illness severity have not changed substantially.1 Current Australian ICU admission diagnoses are summarised in Box 2.

ICUs also play a pivotal role in organ donation. Almost all solid organ donation opportunities arise from within ICUs and are unique situations in that a single ICU admission can result in multiple ICU survivors. The success of educational efforts combined with increasing community support has resulted in much higher donation activity in ICUs over recent years.8

The apparent benefit of intensive care to individual patients has expanded its scope and demand, leading to ICUs becoming larger and more numerous. Since 2000, the total number of funded adult ICU beds across Australia and New Zealand has increased by nearly 13%, with the greatest growth occurring in large units based at major metropolitan hospitals.1 As part of this expansion there has been a reduction in small, low acuity units, mostly because many have graduated to become larger units that provide the full complement of ICU interventions. Additionally, mega‐units (major ICUs with more than 40 beds divided into multiple smaller pods supporting a range of highly specialised services) are now well established in all major cities.9 Across Australia, there are now 183 ICUs with 2219 beds (inclusive of paediatric and private units). With about 8.9 ICU beds per 100 000 population, Australia remains close to the median of published rankings for comparable regions.10 New Zealand's population is served by fewer beds, with 5.1 per 100 000. The regional distribution of ICU beds and associated admissions are summarised in Box 3.

The role of intensive care has evolved considerably over recent decades, with its key principles of clinical management now being utilised to identify and treat deteriorating patients in ward areas.11 Recognition of the long term sequelae of critical illness has led to outreach services and proposals for intensive care follow‐up clinics.12 In turn, these initiatives have led to modifications of intensive care practice that attempt to optimise the recovery of survivors and to minimise the long term physical, emotional and psychological burden on them and their families. This growth in demand has resulted in an increase in the workload of the intensive care specialist, and the expanded scope of practice has challenged training, educational processes, resources and standards.13,14

The intensive care medical workforce is also expanding. Most specialists working in ICUs across Australia and New Zealand are Fellows of the College of Intensive Care Medicine (CICM). The number of CICM Fellows has increased by 72% over the past ten years (Box 4), with about half of intensive care specialists now having a primary medical degree from overseas. Non‐CICM medical specialists (often anaesthetists and emergency physicians) continue to provide valuable service, especially to rural and regional ICUs. Considerable gender disparity persists in the intensive care medical workforce, with women comprising just over one‐third of advanced trainees and one‐fifth of specialist positions.15 While gender balance is slowly improving, strategies to enhance the recruitment and retention of women are required. In response, the Australian and New Zealand Intensive Care Society and the CICM have developed policies directed to prioritising gender equity.16

Critical illness is often a frightening journey for patients and their families; the circumstances may be sudden, confronting and stressful. Patients may experience feelings of profound vulnerability, loss of autonomy, threats to personhood, and fear of dying.17 Intensive monitoring and intrusive interventions can be highly burdensome and even dehumanising in a way that is difficult to mitigate. In response, ICU clinicians prioritise effective communication. Rapidly establishing a relationship with patients and families based on trust and confidence is extremely important, especially when the outcome is uncertain. While much of the care may be delivered using an organ‐based approach, intensivists are cognisant of the absolute requirement to deal sensitively with the entire person rather than a mere collection of failing body systems. This whole‐of‐person approach is crucial for effective care and resonates strongly with patients and families.

The overall goals of intensive care are to identify patients with potentially reversible causes of critical illness and to provide both general organ support and disease specific interventions to reduce morbidity and prevent avoidable death. It is not always initially clear how much of a patient's illness is reversible. For some, the reality is that they have chronic irreversible organ failure that cannot be effectively treated. Others may have such an overwhelming acute illness that survival is not possible. Recognition of these realities requires time, information, consultation and good judgement. Intensive care clinicians must consider every situation carefully, especially when there is progressive deterioration despite extensive treatment. While predictive models are helpful for service planning and system design, they are much less appropriate for individual patients.18 Effective communication, consultation with colleagues, establishment of goals of care, consideration of all treatment options, and shared decision making are essential elements for ensuring that patient welfare remains the central tenet of management.19 However, intensive care is practised within a social context; resources are not unlimited, although the cost of providing all potentially beneficial treatment may well be effectively unlimited. While never losing sight of their fiducial responsibility to individual patients, intensive care specialists remain mindful of the cost of health care and of their ethical responsibility to practise in a non‐discriminatory manner. Social justice dictates that treatment can only be offered to an individual if it can be offered to all individuals with the same indication. Intensive care specialists therefore have a duty to contribute to public debate that determines the norms of medical practice as they evolve over time.

Australasian intensive care has a strong record of high performance.20 This may in part be attributable to its relatively small size; our intensive care community is cohesive and collaborative. These characteristics have enabled the development of a single specialist training pathway, a comprehensive benchmarking program and patient registry, and many authoritative guidelines that are bi‐national in nature and globally significant. Australasian intensive care research is prodigious and impactful,21 with more multicentre investigator‐initiated research undertaken than in other comparable regions.20 Most importantly, patient outcomes for Australasian intensive care rank among the best in the world and are improving. Even after accounting for increasing patient age, comorbidities and illness severity at the time of admission, the likelihood of dying in hospital after admission to an ICU in Australia and New Zealand has nearly halved over the past 20 years1 (Box 5). Single‐centre studies suggest that Australian ICU survivors live well compared with international cohorts.22 However, given that the proportion of survivors discharged to chronic care or rehabilitation facilities has doubled over this period (currently over 9%),1 it is essential that future research efforts link survival to other important outcomes such as physical function and psychological wellbeing.

Progressive advancement across these various domains of intensive care practice builds upon strong foundations, while also recognising where inequality exists23 and aiming to foster greater inclusivity and diversity. The fundamental motivators for intensive care specialists are the responsibility and privilege of caring for the sickest of patients in the health care system and their families. This urgent and inspiring challenge is an ever‐present driving force for all who work in intensive care medicine.

Box 1 – Admissions to Australian intensive care units (ICUs), 2009–20181

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Box 2 – Admissions to Australian intensive care units, by diagnostic group, 2016–20181

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Box 3 – Distribution of adult intensive care unit (ICU) beds and admissions across Australia and New Zealand

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Admission numbers: Australian and New Zealand Intensive Care Society Centre for Outcome and Resource Evaluation (ANZICS CORE) Adult Patient Database (viewed July 2019). Bed numbers: ANZICS CORE Adult Patient Database Critical Care Resources and Minimum Dataset surveys 2017–18 (note: bed numbers are for paediatric ICUs and general/adult ICUs). Population estimates at 30 June 2018 were 24 992 747 for Australia (http://stat.data.abs.gov.au/Index.aspx?DataSetCode=ERP_QUARTERLY#a) and 4 885 500 for New Zealand (http://nzdotstat.stats.govt.nz/wbos/Index.aspx?_ga=2.227011870.2048874141.1547617034-720109120.1547617034#).

Box 4 – Number of Fellows of the College of Intensive Care Medicine of Australia and New Zealand, 2010–2019

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Source: College of Intensive Care Medicine of Australia and New Zealand database (data extracted July 2019).

Box 5 – Deaths of patients admitted to Australasian intensive care units: risk‐adjusted odds ratios (95% CI), 1995–20181

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