News Release

How will society handle the huge increase in demand for critical care services?

Peer-Reviewed Publication

The Lancet_DELETED

In the final paper of The Lancet Series on Critical Care, the future of intensive care services is assessed, with the authors saying that governments face major challenges in rationing care in the face of ever-increasing demand. Increasing productivity and prevention efforts, and assessing potential interventions with better-designed studies, will both help these efforts. The final paper is by Professor Jean-Louis Vincent, Erasme University Hospital, Brussels, Belgium, and Professor Mervyn Singer, University College London, UK.

The authors highlight the difficulties of using randomised controlled trials in ICUs, where large numbers are required to detect small differences in mortality. They say: "Paradoxically, the major contribution of randomised controlled trials in critical care settings has been the finding that overtreatment is often harmful. Excessive blood transfusion, targeting supranormal cardiac output and oxygen delivery values, high tidal volumes in mechanically ventilated patients, excessive calorie intake, and excess sedation have all been associated with worse outcomes. Use of more conservative or less invasive therapies often represents the best approach—eg, increased use of non-invasive mechanical ventilator techniques."

Improved outcomes for patients in critical care have been achieved with general improvements in the process of care rather than the use of specific therapeutic interventions. For example, good infection control and preventing joint contractures and bed sores. A full-time intensivist service is also highlighted as important for improvement of outcomes; as shown in a systematic review by Pronovost and colleagues, ICUs with high-intensity intensivist staffing (mandatory consultation or all care directed by intensivists) reduced hospital mortality rates by 29% in a meta-analysis of 17 studies.

The authors acknowledge that productivity might be gained through reductions in patient stay from early recognition and prevention of organ failure, and efficiencies might be improved through changes in staffing patterns and use of electronic supports. But they say: "Governments and society need to establish how much critical care they can afford, rather than simply placing an unreasonable responsibility on the intensivist to make decisions about rationing. Importantly too, there are huge predicted shortfalls in ICU staffing, presenting extra challenges for the organisation and function of the ICU. Telemedicine might assist small units that cannot provide 24-h specialist cover, and is likely to be used more often in ICUs of the future."

They add: "The increasing likelihood of pandemics and major natural and terrorist disasters could also place extreme demands on the adequate provision of critical care. Policies need to be in place to cope with an influx of large numbers of critically ill or injured patients, and the possible need to triage those likely to die."

Also discussed in this final paper is the need to better characterise patients for clinical trials to test critical care interventions, and a need to address the increasing infection rates related to aggressive surgical techniques, as well as concerns over increasing antibiotic resistance. Processes must also be developed to prevent organ failure occurring or further damage where it is already established. Techniques to promote recovery in failing organs must also be more intensively examined.

The authors conclude: "The ICU is playing an increasingly important part within the hospital, and ICU staff have a higher profile in hospital-wide acute care. Improvements in understanding the basic cellular mechanisms underlying critical illness, ICU management and structure, and critical care trial design, alongside continued advances in technology, diagnostic tests, and therapies, will help to create real progress in terms of patient outcomes."

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Professor Jean-Louis Vincent, Erasme University Hospital, Brussels, Belgium. T) +32.2.555.3380 E) jlvincen@ulb.ac.be

Professor Mervyn Singer, University College London, UK. E) m.singer@ucl.ac.uk

For full Series paper 3, see: http://press.thelancet.com/cc3.pdf

NOTE: THE ABOVE LINK IS FOR JOURNALISTS ONLY; IF YOU WISH TO PROVIDE A LINK TO THE FREE ABSTRACT OF THIS PAPER FOR YOUR READERS, PLEASE USE THE FOLLOWING, WHICH WILL GO LIVE AT THE TIME THE EMBARGO LIFTS: http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(10)60575-2/abstract


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