La Réanimation en Europe

La Réanimation en Europe - la même chose partout?- Jean-Daniel Chiche, MD PhD MICU & Dept of Host-Pathogen Interaction Hôpial Cochin & Institut Cochin, Paris-F

How could this be?

How could this be?

Always a good reason to differ

Is Intensive Care the Same Over Europe? Organisation of intensive care services Delivery of intensive care Patterns of care Outcome Processes of care Intensive care training Intensive care research

How many ICU beds in EU? (/100,000 inhab) 60,000 ICU beds 3% of acute care beds Germany 29.2 Norway 8.1 Belgium 17.5 France 7.4 Austria 15.1 Netherlands 6.4 Italy 12.5 UK 5.9 Switzerland 11.1 Sweden 5.9 Spain 9.7 Portugal 4.0 0 10 20 30 0 10 20 30

Numbers of ITU beds / 100,000 Population 30 25 20 15 10 5 0

Percentage of ITU beds / acute care beds 5.0 4.0 3.0 2.0 1.0 0.0

Europe: requirement for MV? Vincent et al., Intensive Care Med 1997

Is there an intensivist in the ICU? Hospital size 1 12 7 30 14 55 9 50 20 2 Small Medium Full-time Intensivist Consultant Intensivist Consultant Specialist Single Physician Other 4 Unit Type 19 13 47 17 17 46 33 3 General ICU MICU 37 4 5 14 40 19 36 34 10 2 4 14 21 18 45 13 52 21 14 Large Largest SICU Specialty Angus et al. JAMA 2000

Europe: intensivist present 24/7? Vincent et al., Intensive Care Med 1997

Intensivist model (closed ICUs) reduce mortality & ICU length of stay

Worldwide differences in ICU settings ICU beds Open vs. Closed ICUs Full-time presence of ICU physician Shifts vs «on-call» care patterns Staffing MDs Nurses ++, aid-nurses Physotherapists, respiratory therapists Pharmarcists, hospitalists, psychologists, Working-time directives

Intensive Care Medicine as a Specialty Intensive care medicine is about the combination of high-intensity hands-on care with the rational use of modern technology. It s the human resources of the ICU team, their organization and distribution, and how we apply technology consistently, NOT the genius of individuals or the treatment magic bullet that leads to efficient and effective ICU 1 1. Knaus et al. Ann Intern Med 1986

Types of Specialists practicing ICM N 20,000 Intensive Care Medicine 25% Anaesthesia 52% Cardiology 7% Internal medicine 9% General surgery 1% Neurosurgery 1% Neurology 1% Pulmonology 3% Cardiac Surgery 1%

Most Positive Factors Intellectual stimulation Treating acutely ill patients Application of complex physiology Procedure orientated Dealing with end-of-life issues Most Negative factors Lack of leisure time Stress among faculty Treating chronically ill patients Inconsistent with my personality Dealing with complex ethical issues

The Perfect Storm Increasing demand with static supply

The solution: train more intensive care specialists Fewer, but bigger units

What is a specialty? The Group Government engages with A College governing training and entry to the specialty An accreditation / revalidation process An examination / diploma A quality control framework A fee structure Research

The Road Map to Recognition of ICM

Competency Based Training in Intensive Care Medicine in Europe (& Elsewhere) Covers 42 countries across Europe and also Chile, Costa Rica, Indonesia, India, Hong Kong, USA

41 countries: n = 38 Formal adult ICM training in 36 (95%) 54 different training programmes Variations in structure, duration & format CBT in UK, Canada Ownership 55% supraspeciality (multidisciplinary access with common programme) 30% anaesthesia only 15% multiple subspeciality

Austria Belgium Bulgaria Czech Republic Estonia France Germany Greece Hungary Ireland Italy Latvia Lithuania Netherlands Poland Portugal Slovakia Slovenia Spain Switzerland United Kingdom Minimum duration of training (months) 90 80 70 60 50 40 30 20 10 0

Competence-Based Education & Training Knowledge + skills + attitude = COMPETENCE

Competence? Competency-based training? Defines what a practitioner can do, in terms of knowledge, skills, attitudes & behaviours Workplace-based assessment of training outcomes Curriculum determined by competencies, not by examination or duration of training Competency-based training focuses attention on the physician solely as craftsman / technician What distinguishes the craftsman from the professional? Attitudes, behaviours & ethics Self-regulation & life-long learning

COMPETENCY-BASED TRAINING IN INTENSIVE CARE MEDICINE IN EUROPE Phase 1: 2003-2006 CURRICULUM Competencies Final set of 102 Syllabus Knowledge, skills & attitudes for each competence Educational Resources Learning & teaching Assessment Descriptors of how competencies are assessed in workplace

169 competencies presented online for comment Expertise simplified to knwoledge, supervised & independent practice 102 competence statements grouped into 12 domains

COMPETENCY-BASED TRAINING IN INTENSIVE CARE MEDICINE IN EUROPE Phase 1: 2003-2006 CURRICULUM Competencies Final set of 102 Syllabus Knowledge, skills & attitudes for each competence Educational Resources Learning & teaching Phase 2: 2008-2010 Propose programme standards grouped within 4 domains Programmes Training centres (ICUs) Selection of trainees Trainers profiles & support Guidance on methods of assessment www.cobatrice.org e-portfolio http://prototype.cobafolio.cobatrice.org Assessment Descriptors of how competencies are assessed in workplace

Assessment Workplace based (WBA) DOPS minicex Multi-source feedback (MSF) Summative formative Examination Oral Case discussion Simulation.. Written Certificate EDIC National diploma E-portfolio (logbook) The ICM specialist Training Formal Lectures / Seminars Practical Informal Clinical practice Reading Disussing Lectures, seminars & courses ACLS, ATLS, PALS, Basic assessment & support in intensive care (BASIC) Advanced trainings courses in intensive care (ATCIC) Postgraduate courses MSc course Websites, podcasts, flash-conferences Educational material PACT

Austria Belgium Bulgaria Czech Republic Estonia France Germany Greece Hungary Ireland Italy Latvia Lithuania Netherlands Poland Portugal Slovakia Slovenia Spain Switzerland United Kingdom Countries that Recognize ICM as Particular Competence 90 80 70 60 50 40 30 20 10 0 and as a Primary Specialty

Development of ICM as Primary Specialty in the UK 1992 Formation of Joint Advisory Committee for ICM by Royal Colleges (JACIT). 1996 Formation of Intercollegiate Board for Training of ICM (ICBTICM). 1999 ICM included in specialist register as joint CCT with base specialty. 2001 Competency based training program launched. 2010 Creation of Faculty of ICM. 2011 Agreement of Primary CCT in ICM

Primary CCT in the UK ICM Program Year 1-2 Year 3 Year 4 Year 5 Year 6 Year 7 Core training Medicine / anaesthesia/ ICM/ EM ICM Complementary specialty Specialist ICM Paeds/ Neuro / Cardiac ICM ICM

Models of Governance Boards after primary boards 20% director control Open units Medical & surgical units Primary critical care training Specialist diploma 100% directors Closed or semiclosed units Combined units

Criticisms: ICM is considered to be too complex to be covered by one medical speciality alone. as ICM is extremely demanding physically and mentally..physicians who will have to leave ICM after some years due to burnout

What is essential today Attract young physicians to intensive care medicine! Improve the ICU environment Bigger units Better working conditions Dedicated time for life-long learning, research, Convey the right message ICM is a great specialty You can be an intensivist your whole life There are (and will be) reasonnably well-paid job opportunities Quality of patient care is compatible with quality of life for care givers Raise awareness on ICM as a specialty and improve the profile of intensivists

the ICU specialist