Immediate Past President
On behalf of the UK
Intensive Care Society
Drs Ridley and Winter present the facts on intensive care in the UK.
Bearing in mind the problems with the definition of an intensive care unit and the existence of single specialty units, there are about 285 adult general intensive care units in the UK. These units serve a total population of 60 million. The latest figures from the UK Department of Health show that there were 3193 critical care beds in September 2005 (www.doh.gov.uk). These are divided between 1772 Level 3 (ICU) beds and 1422 Level 2 (HDU) beds. This provides a national distribution of one ICU bed per 34,000 population and one HDU bed per 42,000. However, there is wide geographical variation, with the distribution of ICU beds varying between 3 and 8 per 100,000 with fewer critical care resources in rural areas compared to large cities.
In 1998, the Audit Commission reported that the median size of an ICU in the UK was 5.3 beds. Since 2000, following additional government funding, the total number of critical care beds has increased to an average 11 ICU and/or HDU beds per unit.
The number of nursing staff on intensive care is one nurse per critically ill patient. This requires an establishment of between six to seven whole time equivalents per ICU bed (7.3 if UK statuary leave is accounted for). On the HDU, the nursing establishment is less with one nurse per two patients, as the perceived level of intervention is less on HDU. The size of the medical team on call during the day and night varies, but one medical team (i.e. one senior doctor plus a trainee) should be able to look after eight ICU patients. This level of staffing has been accepted and recommended by the Department of Health (2000). The importance of increasing the establishment of other healthcare professionals contributing to the care of the critically ill has just recently been formally recognised in the report of the Adult Critical Care Stakeholder forum, “Quality Critical Care: Beyond Comprehensive Critical Care” (2005: see page 54 for more information on this report).
Figures from the Intensive Care National Audit and Research Centre (ICNARC) suggest that the average age of patients admitted to critical care units in 2002 to 2003 was 60.1 years and most patients were admitted from the operating theatres (42%), the general ward (23%) or emergency departments (18%) (ICNARC 2004a). The commonest three reasons for admission were pneumonia (7.6%), aortic or iliac dissection or aneurysm (4.4%) and large bowel tumour (4.2%). In the UK, the mean APACHE score is 16.5 (ICNARC 2004b) and the ICU mortality approximately 20% with a further 9% of patients dying before leaving hospital (ICNARC 2004a).
The cost of UK critical care is difficult to establish as a percentage of a hospital budget, but results from the National Cost Block Study (Medical Economics and Research Centre Sheffield 2005) suggest that in 2002- 2003 the average daily cost of ICU was £1186, while combined ICU/HDU cost £1063 per day. Most UK ICUs run as closed units but the clinical and management responsibility for HDU patients is more likely to be shared on an open basis.
Although outreach services have been well developed and supported in the UK, with a variety of models, their full impact has been difficult to prove. While there are reports of beneficial improvements in the level of understanding of critical illness on the general ward (Ball et al. 2003), the hoped for reduction in mortality has not been reported (Hillman et al. 2005).
Clinical critical care research in the UK was until recently institution based. However, the UK Intensive Care Society (www.ics.ac.uk) has appointed a Director of Research and an Intensive Care Foundation to organise critical care research on a trials network as presently occurs in Canada, Australia and New Zealand. The first trial is examining the advantages (or otherwise) of early versus late tracheostomy.
In the UK, the education and training of doctors is undertaken by the Intercollegiate Board for Training in Intensive Care Medicine. The Board stipulates the competencies that trainees need to acquire and sets the standard for ICUs to be recognised as training centres. The Board also runs the UK diploma in intensive care medicine.