Rui Moreno MD, PhD
Unidade de Cuidados Intensivos Polivalente (UCIP) Hospital de
St. António dos Capuchos Centro Hospitalar d Lisboa (Zona Central) Lisbon, Portugal
The first intensive care units (ICUs) in Portugal were created in the late 1950s in Coimbra (Rui Carrington da Costa) and Oporto (Armando Pinheiro). Lisbon, the capital of the country, just introduced the first mixed medico-surgical ICU in 1979, although some spaces dedicated to the care of trauma and surgical patients existed there before. In recent years, ICU has undergone significant change in Portugal.
In the last 15 years, Portuguese intensive care medicine (ICM) has been subjected to two movements that changed the way the country provides assistance to the critically ill patient. First, in the early 1990s, several new ICUs were created throughout the country, allowing all districts of the country to have mixed ICUs – a privilege, up to that date, reserved for the large cities. Second, in 1997, the National Medical Board accepted the creation of the sub-specialty of intensive care medicine. In our national model, to be recognized as an intensive care sub-specialist, doctors have to have a primary specialty (internal medicine, anesthesia, surgery, etc.) and then go through two years of full clinical training in intensive care medicine with a final examination. This model is still far away from completion.
Over time, several specialties have been involved in the process of creating the ICM sub-specialty in Portugal, with most intensivists coming from anaesthesiology and internal medicine, as well as some from pneumology. The lack of a standardized, wellknown and well-respected program for education and training in ICM until recently pushed a significant number of Portuguese doctors to stand for the European Diploma in Intensive Care Medicine. Portugal has had a significant number of specialists recognized by the European Society of Intensive Care Medicine (ESICM) since 1990. To date, Portugal has not developed a specialty or subspeciality in critical care nursing.
According to the latest available data, Portugal has 52 ICUs in 41 hospitals, corresponding to around 394 staffed beds (440 installed beds). These numbers correspond to 3.9 mixed adult ICU beds per 100,000 inhabitants, but the beds are poorly distributed. For example, Alentejo has only around 2.8 beds per 100,000 inhabitants, and Algarve has 3.8 beds per 100,000 inhabitants during most of the year, but only 1.5 beds per 100,000 when the population reaches more than one million in the summer. Intensive care coverage is not available in all island areas (see table 1).
The Portugal Intensive Care Society, founded in 1975, is one of the oldest in Europe. The Society,with around 1,000 members, is a mixed society, with equivalent numbers of nurses and medical doctors. It holds mixed congresses, courses and other post-graduate activities. Portugal has always been active internationally, particularly with Spain and Brazil. The Society was a founding member of the World Federation of Societies of Intensive & Critical Care Medicine and of the Pan-American and Iberian Federation of Intensive Care Medicine,
whose Congress we hosted in 1995. Lisbon has been also selected to host the 2008 Meeting of the European Society of Intensive Care Medicine.
In a country facing a poor economic situation, intensive care medicine is currently subjected to pressure to increase productivity and decrease costs. The government’s lack of definition for what an ICU is and who can practice intensive caremedicine threaten the development of our speciality. Also, the lack of emphasis on basic and clinical research, with most Portuguese hospitals (even university-affiliated) dedicating almost all their time and resources to a heavy clinical burden, prevents further developments in our field. However, the number of Portuguese intensivists taking post-graduate courses and fellowships abroad is increasing, as is the number and quality of published manuscripts.
Portugal, with a strong culture of intensive care medicine based on quality of care, where almost all ICUs have already adopted a closed model, our dedicated professionals will face up to the challenge of integrating research and teaching in this process in the coming years. The SPCI will certainly serve an important role by providing information and training to members, by creating spaces for the exchange of ideas and experiences and by starting and sustaining collaborations. This is our challenge.