Critical Care Unit Capacity in Canada: Have we failed to ... Care Unit Capacity in Canada: Have we failed to advocate adequately? Noel Gibney MB FRCP(C) Division of Critical Care Medicine

Division of Critical Care Medicine

Critical Care Unit Capacity in Canada:

Have we failed to advocate adequately?

Noel Gibney MB FRCP(C)


Disclosures

None


• Adequate critical care unit beds necessary to

provide adequate capacity to manage:

• Day to day admissions

• Seasonal surges

• Pandemics

• Disasters

• Inadequate capacity = critical care strain

• Excess capacity = waste

Critical Care Capacity


0%

10%

20%

30%

40%

50%

60%

IA 2-12 hrs 12-16 hrs >24 hrs

Mort

alit

y


Impact of ICU night discharge on outcomes

Author Country % Night discharges OR mortality

Beck U.K. 26% 1.87

Goldfrad U.K. 6% 1.33

Priestap Canada 10.1% 1.22

Tobin Australia 5.9% 1.63

Laupland Canada 21% 1.20


“For hospitalized patients, the number of ICU beds available at

the time of sudden clinical deterioration affects processes of

care.

As the number of available ICU beds decreases, patients are

less likely to be admitted to the ICU and are more likely to have

their goals of care changed…..”

Arch Int Med 2012;172:167-172


• 10 ICUs in Western France. Consecutive patients referred for

ICU admission for the first time over a 3-month period were

assessed for eligibility.

• During the study period, the mean number of days when the

unit was full per ICU was 48.5%.

• 193 patients refused ICU admission because the unit was full,

65 were never admitted to an ICU and the remaining 128

(66%) were admitted later on


Impact of refused ICU admission

Robert R et al. Am J Respir Crit Care Med Vol 185, Iss. 10, pp 1081–1087


Design: Observational study using NY State Inpatient Database

(2005–2007)

Setting: 159 NY State acute care hospitals.

Patients: 15,994 adult (≥18) hospital admissions with a primary

diagnosis of diabetic ketoacidosis

Results: Use of intensive care for diabetic ketoacidosis patients

varied widely across hospitals (adjusted range: 2.1% to 87.7%), but

was not associated with hospital length of stay or mortality.

Crit Care Med 2012; 40: 2009–2015


Setting: Administrative data for Alberta and four counties of western

Massachusetts 1990 to 1991. Detailed data on consecutive ICU

admissions from two Alberta hospitals, one western Massachusetts

hospital, and 24 other U.S. hospitals for 3 months in 1991 were used.

Results: ICU use and hospital mortality rates were compared for

50,030 hospital admissions.

• ICU days per million population were two to three times higher in

western Massachusetts than Alberta.

• The hospital mortality rate in western Massachusetts was similar

to, or higher than, the mortality rate in Alberta.

• In Alberta, a much higher proportion of ICU patients received

mechanical ventilation.

A comparison of intensive care unit utilization in Alberta and

western MassachusettsRapoport, John PhD; Teres, Daniel MD FCCM; Barnett, Robert MBBS;

Jacobs, Philip PhD; Shustack, Alan MD; Lemeshow, Stanley PhD; Norris,

Colleen MN; Hamilton, Stewart MD Crit Care Med 1995;23;1336-1346


To estimate the need for adult critical-care beds for a

population of 500 000 in the UK served by five hospitals.

Lancet 2000; 355: 595–98

ICU beds/100,000 pop HDU beds/100,000 pop

Available 5.8 11.2

To meet needs 95% 7.8 13.8

To meet needs 99% 8.6 15.0


Health Expenditure as share of GDP OECD 2010



• Governmental administrative database:• ICU and ICU beds are whatever the agency providing the information

says they are.

• Registry:• U.K.

• Level 1 ward bed

• Level 2 high dependency unit-no ventilation

• Level 3 intensive care unit-ventilation and one other organ support

• Survey• Ontario/British Columbia/Alberta

• Level 2 –support single failed organ system, no invasive ventilation

• Level 3 intensive care unit-invasive ventilation and multiple organ

support

Definition of ICU/Definition of ICU Bed


ICU Beds/100,000 Population

<19.9

20-29.9

30-39.9

>40

Carr B et al JAMA 2010:303;1371-1372

ICU beds/100,000 pop 0.01% 0.02% 0.03% 0.04% 0.05%

28 0 16.7 58.8 90.9 97.4

Hospital Referral Regions Exceeding Critical Care Capacity

by % of Population Experiencing Sudden Critical Illness


European ICU Capacity

Rhodes et al. Intensive Care Med 2012;38:1647–1653



What about Provinces?0 10 20 30 40

GermanyUnited States

BelgiumCroatia

CANADA?FranceSpain

ONTARIOAustralia

CANADA ?United Kingdom

NetherlandsSouth Africa (Private)

ALBERTABRITISH COLUMBIA

New Zealand

Beds/100,000 population


Critical care beds vs health expenditure as % GDP

Alberta

Canada



Alberta

Canada


Critical care beds vs health expenditure as % GDP


Critical care beds vs acute care beds

Canada

Alberta/BC

Ontario

Critical care

beds / 1

00,0

00 p

opula

tion

Acute care beds / 100,000 population


Alberta

Wunsch H et al, Crit Care Med, 2008; 36: 2787-2793

Critical care beds vs. acute care hospital beds

Canada


AB


Health care spending per capita vs ICU beds

BC

CanadaON


AB


BC

CanadaON

Although Canada spends slightly more per

capita on health, it trails many countries in ICU

bed capacity


Canada 1867


Constitution Act, 1867,

Provinces responsible for establishing, maintaining and

managing hospitals, asylums, charities and charitable institutions

Federal government was given jurisdiction over marine hospitals

and quarantine.

Confederation 1867


Principles

• Public Administration

• Comprehensiveness,

• Universality and

• Portability

• Accessibility

• Medically Necessary

• Sustainability

Canada Health Act 1984


• Hospital Boards

• Local Health Integrated Networks (LHINs)

• Regional Health Authorities

• Provincial Health Authorities

• Provincial Health Ministries

• Canada Health

• Public Health Agency of Canada

Governance of Health Systems across Canada


Canadian Provinces – E.U. Member StatesIndividual Health Systems with Federal Oversight Legislation


• Collects, analyzes and publishes data and information in a

standardized way.

• Vision: Better data. Better decisions. Healthier Canadians.

• Mandate: To lead the development and maintenance of

comprehensive and integrated health information that

enables sound policy and effective health system

management that improve health and health care.

• Values: Respect, integrity, collaboration, excellence,

innovation


• All active treatment hospitals in Canada

• Self reported by hospitals

• Acute care and specialty staffed beds in use

• Intensive Care

• Obstetrics

• Pediatrics

• Psychiatry

• Rehabilitation

• Completely inaccurate for Intensive Care

CIHI CMDB Acute Care Hospital Databasehttp://www.cihi.ca/CIHI-ext-portal/xls/internet/quickstats_cmdb_2012_01_en



• Medical Intensive Care Nursing Unit

• Surgical Intensive Care Nursing Unit

• Trauma Intensive Care Nursing Unit

• Combined Medical/Surgical Intensive Care Nursing Unit

• Burn Intensive Care Nursing Unit

• Cardiac Surgery Intensive Care Nursing Unit

• Coronary Intensive Care Nursing Unit

• Neonatal Intensive Care Nursing Unit

• Neurosurgery Intensive Care Nursing Unit

• Pediatric Intensive Care Nursing Unit

• Respirology Intensive Care Nursing Unit



• Medical Intensive Care Nursing Unit

• Surgical Intensive Care Nursing Unit

• Trauma Intensive Care Nursing Unit

• Combined Medical/Surgical Intensive Care Nursing Unit

• Burn Intensive Care Nursing Unit

• Cardiac Surgery Intensive Care Nursing Unit

• Coronary Intensive Care Nursing Unit

• Neonatal Intensive Care Nursing Unit

• Neurosurgery Intensive Care Nursing Unit

• Pediatric Intensive Care Nursing Unit

• Respirology Intensive Care Nursing Unit



Ontario Critical Care Strategy




Alberta Provincial H1N1 Bed Utilization, Non-ICU versus ICU:Suspected and Confirmed Cases as of 07:00 hr on Tuesdays and Fridays

050

100150200250300350400450

Jun

-30

Jul-0

3

Jul-0

7

Jul-1

0

Jul-1

4

Jul-1

7

Jul-2

1

Jul-2

4

Jul-2

8

Jul-3

1

Au

g-04

Au

g-07

Au

g-11

Au

g-14

Au

g-18

Au

g-21

Au

g-25

Au

g-28

Sep-0

1

Sep-0

4

Sep-0

8

Sep-1

1

Sep-1

5

Sep-1

8

Sep-2

2

Sep-2

5

Sep-2

9

Oct-0

2

Oct-0

6

Oct-0

9

Oct-1

3

Oct-1

6

Oct-2

0

Oct-2

3

Oct-2

7

Oct-3

0

No

v-03

No

v-06

No

v-10

No

v-13

***N

ov-17

No

v-20

No

v-24

No

v-27

Dec-0

1

Dec-0

4

Dec-0

8

Dec-1

1

Dec-1

5

Dec-1

8

Dec-2

2

Dec-2

9

Jan-0

5

Jan-0

8

Jan-1

2

Jan-1

5

Date (2009 - 2010)

Nu

mb

er

of

Cas

es

Hospitalized Cases - Non-ICU

Hospitalized Cases – ICU

Number of adult ICU beds ~ 170Staffed/Funded Beds ~ 120Usual number of ventilated ICU patients ~100Peak number of ventilated ICU patients ~ 170Peak number of H1N1 ICU patients ~ 120


Our mission is to promote and enhance Critical Care

Medicine in Canada.

We espouse the philosophy of collaborative

multidisciplinary practice to promote research, education

and patient care in Critical Care Medicine.

To that end, our Society is involved in Critical Care

Medicine education in association with the Royal College

of Physicians and Surgeons of Canada, and in CCM

research with the Canadian Critical Care Trials Group.

Canadian Critical Care Society


The Australian and New Zealand Intensive Care Society is the

leading advocate on all intensive care related matters.

ANZICS leads the world in intensive care research through its

Clinical Trials Group and patient databases, including the Adult

Patient Database, the Paediatric Intensive Care Registry and

Critical Care Resources.

The Society is devoted to all aspects of intensive care medical

practice through ongoing professional education, the provision of

leadership in medical settings, clinical research and analysis of

critical care resources.

Our Vision'Advocate for Intensive Care throughout Australia and New Zealand'


You can’t manage if you don’t measure0 10 20 30 40

GermanyUnited States

BelgiumCroatia

CANADA?FranceSpain

ONTARIOAustralia

CANADA ?United Kingdom

NetherlandsSouth Africa (Private)

ALBERTABRITISH COLUMBIA

New Zealand

Beds/100,000 population


• We have done a poor job of advocating for critical care

capacity in Canada

• We have little usable data

• The existing data is not accurate

• However, it seems we have less Critical Care capacity

than many similar countries

• A Canadian Critical Care Registry is required

• Similar to ICNARC, ANZICS

• We need the Canadian Critical Care Society to take lead

in concert with Canadian Critical Care Trials Group and

CIHI

Conclusions


Thank you for

your attention!

Documents

Critical Care Unit Capacity in Canada: Have we failed to ... Care Unit Capacity in Canada: Have we failed to advocate adequately? Noel Gibney MB FRCP(C) Division of Critical Care Medicine