Intensive Care Medicine in Portugal: Responding to Changes

The economic crisis in Portugal has forced the Government to impose major budget cuts in the National Health Service, and although the level of care for critically ill patients until now has remained adequate, intensive care medicine in the country is feeling limitations.

Overview

Since the first intensive care unit (ICU) to be established in Portugal was opened in Coimbra in the sixties, intensive care medicine has become a speciality of growing importance in the treatment of patients admitted to hospital, providing fundamental support to critically ill sepsis sufferers, patients admitted to the emergency room, and those admitted for a major operation or transplant surgery. The next critical care units to be introduced were in Lisbon and Oporto, predominantly in major teaching hospitals, and in the following decades ICUs were created in almost every Portuguese hospital.

In 2001, thirty years after the creation of the first ICU, there were 413 intensive care beds in 50 polyvalent ICUs (Direcção Geral Saúde, 2001). At the present time (September, 2012), there are 52 polyvalent ICUs and two ECMO centres in Portugal, providing a total of 451 intensive care beds (1.75% of all acute care beds). Unfortunately, ICU resources are not equally distributed throughout the country; most of the beds are in hospitals on the country’s coastline, with the highest concentration of resources in main urban areas such as Lisbon and Oporto, and the lowest in Azores.

Despite the increase in intensive care beds seen in the last decade, compared with other countries in Europe, Portugal still has the lowest ratio of beds per 100,000 inhabitants, standing at 4.2:100,000. Due to this low ratio, the number of ICU admissions per 100,000 inhabitants is low, while patients that are admitted are of high severity. As a consequence, in 2011, the mean simplified acute physiology score (SAPS II) in the ICUs that entered data to the HELICS database was 43.4. This implies high resource use, with patients staying in the ICU for a mean length of 10.5 days, and 63.4% of patients being mechanically ventilated (3.1% non invasively) in the first three days of intensive care. ICU case mix is dominated by medical patients (58.1%) and about 80% of all patients are infected on admission.

ICU Staffing

In Portugal, as in other countries, there has been a growing shortage of intensivists, despite efforts in training new specialists. Since the economic downfall, governmental budget constraints have been reflected primarily in the recruitment of new specialists, for renewal of ICUs teams. There are currently 202 intensivists in Portugal, a number that is not sufficient to ensure 24-hour coverage in all ICU’s. This has led to hospital managers recruiting non-specialised physicians to guarantee coverage. Only 59% of ICU doctors are intensive care certified, and the highest percentage of these work in northern Portugal.

Not only is there an insufficient supply of staff, but the workforce is also becoming old, with a mean age of 49.41 +/-7.39 years. This means that even using all its impending capacity, Portugal will be facing a shortage of intensivists, unless things change. With this stark reality in mind, measures are currently being taken to increase the capacity of ICUs in the main Portuguese hospitals.

Training in Intensive Care Medicine

Nowadays, intensive care medicine is a twoyear subspeciality. Entry into an intensive care medicine training programme is possible following successful completion of a primary speciality, namely anesthesia, internal medicine, pulmonology, cardiology or general surgery. The curriculum, defined by the National Board of Intensive Care Medicine, part of the Portuguese Medical Association, is based on the Competency-Based Training programme in Intensive Care Medicine for Europe (CoBaTrICE)—a programme from the European Society of Intensive Care Medicine (ESICM), which has extended towards harmonising intensive care medicine worldwide. Trainees are strongly encouraged to take the European Diploma in Intensive Care Medicine (EDIC) before taking the Portuguese final approval in intensive medicine exam (Ordem dos Médicos, 2006).

Over the years, SPCI has strived to make intensive care medicine a primary speciality with five-year training and multidisciplinary pathways in a competency-based programme. The society and the Portuguese Medical Association are working together for this to become a reality in the near future.

Educational Activities

The Portuguese Society for Intensive Care promotes training and professional development, and executes several courses, such as Fundamental Critical Care Support (FCCS), Fundamental Disaster Management (FDM) and ESICM’s Advanced Training Courses in Intensive Care (ATCIC) module on bronchoscopy. During a regular year, SPCI organises two to three courses that are integrated into national conferences. Students on these courses are not only undertaking medical training in intensive care, but also in other specialities, so that they may integrate critical care medicine into their primary speciality. This training is critical for physicians who regularly work in the emergency room.

Currently, SPCI organises two of the main intensive care meetings in Portugal: the National Congress, usually held in May, and a joint meeting with another Portuguese medical society, this year with the Portuguese Society of Pulmonology. Pulmão e Doente Crítico will be held in Oporto from 7–8 November. Other important meetings include Infection and Sepsis in Oporto, the Critically Ill meeting held in Lisbon in January, the Spring Meeting, and the Artificial Ventilation Update meeting (JAVA), which both take place in Oporto.

These meetings have been very important in helping physicians to recognise critically ill patients on their admission to the emergency department, so that they can be treated promptly. They also played a part in raising awareness of the Surviving Sepsis Campaign guidelines, prompting their adoption in Portuguese hospitals, as well as in educating physicians on how septic patients can be recognised early after admission. Finally, they prompted hospital managers to implement sepsis bundles outside of ICUs.

The Portuguese Society for Intensive Care has a strong relationship with the Brazilian Intensive Care Society (AMIB). Besides joint meetings between them, they share the same official journal: Brazilian Journal of Intensive Care. Soon, they will begin joint prospective studies, involving a large number of Portuguese and Brazilian ICU’s. SPCI is also involved in promoting education and training in African countries where Portuguese is spoken, organising courses on disaster management and preparedness, trauma, and care of the critically ill.

The joint work of SPCI, the Portuguese Medical Association and Portuguese intensivists has been fundamental in defining intensive care medicine as a fundamental speciality in hospital care.