Keywords

Introduction

The Italian Hospital, as the institution at the source of health care delivery, has been operating under crisis conditions for a long time because of an increasing demand for health care from a rapidly and constantly changing population. In Italy, child birth survival has increased threefold [1], infantile mortality has fallen to 4.3 per 1,000 live births while the general population has basically aged [2]. It is estimated that the ageing index will double before 2050 and thus future public health expenditure will be more and more subordinate to long-time care [3]. In today’s Italy, health care is universally provided under the law to all Italian citizens and the state, in various guises, sustains the bulk of the expenditure [4]. The last decades have witnessed the development of a private health care sector, although state as well as insurance contributions still account for most of the expense. The Italian health system is characterised by marked regional differences. Italian economic growth has never been uniform and the gap between the wealthiest northern and central regions and the less affluent southern ones has never been bridged. Regional socio-economic disparities have caused wide differences in the quality and efficiency of health services in this country, especially in the south where a high percentage of low-income families mostly live [5]. In the course of time, the evolution of the health care system has been marked by various attempts at reform [6] in the face of ever more stringent budgetary limits on the one hand, and an ever increasing process of decentralisation on the other. This devolution is ongoing and could lead to the creation of as many diverse local health systems as there are regions in the country [7].

Forty years ago, the concept of health care rationing was not widely perceived or mentioned. During the last 15 years, health care costs have become a major focus of public policy. While looking for ways of controlling costs, an awareness of economic trade-offs in the health care decision process has increased. Allocating resources to one branch of the service has meant leaving less available for other services. Allocating resources to one patient means that fewer resources will be available for others. Rationing has thus gained more visibility among the public and has now become explicit at all levels of the health care system. Moreover, in many intensive care units rationing still remains a taboo issue—thoroughly carried out but insufficiently discussed.

Physicians’ responsibility in carrying out the rationalisation of health care expenditure still meets with considerable resistance of a cultural nature. Doctors are wont to have a direct personal relationship with their patients and thus feel culturally alien with intervention costing which, compared to the life and health of the patient, is felt to be not commensurable. Thus, physicians may take a moral stand against considerations of cost in medical acts for the benefit of the health of all who trust themselves to their care [8–10].

Italy, too, has adopted a management cost reducing strategy for hospital-based facilities and has begun to introduce cutbacks in hospital bed capacity. Such a reduction should have slashed inappropriate admissions, made inter-hospital care more efficient and effective, as well as facilitated early discharge procedures. This strategy, however, has not been well accepted politically because of the strong dissatisfaction it causes among health care users and because it endangers the survival of local politicians. Moreover, the planning of alternative facilities and medical services, even with a reduced inter-hospital bed capacity, does not necessarily translate into an overall reduction in health care spending [11].

Despite the fact that emergency and intensive care facilities have always been considered beyond the reach of such a reductionist rationale, there has been a covert attempt at reducing the overall number of critical beds indiscriminately, since a controlled and targeted cutback is up against the vested interests of small-size hospitals.

Critical wards, whether providing specialist care or not, have always represented a show-piece for any hospital without, however, actually taking into account their utility within the context in which they operate, the efficiency of their role in specialist care delivery to critical patients and the results they achieve.

Italian intensivists as a profession belong to different sub-specialties of medicine and have now come to realise that intensive care unit beds are a limited and expensive type of resource [12, 13]. The shortage of beds is an everyday issue in many an intensive care unit [14, 15] and the allocation of beds is viewed as one of the most crucial aspects of the Italian health care system [16].

The National Health Care Plan and Intensive Care

The 1998 National Health Care Plan, and subsequent Regional Plans, recommended a ratio of three critical beds to one hundred hospital beds. These estimates, however, not only fail to reflect the existing actual Italian situation but they do not even taken into account the impossibility of new bed increments at zero cost. Delays in the application of the law and a lack of transparency about its purpose have resulted in the creation of intensive care units with a much reduced number of beds with the result that, on the one hand, shortages in critical patient care have not been made up and, on the other, that health care spending has actually increased.

There are marked differences in Italian health care regarding the number of beds each Region deems necessary to ensure intensive care to all its citizens. In 2005, a poll carried out by the Italian Association of Hospital-Based Anaesthesiologists and Intensive Care Specialists (AAROI) revealed that Italy has 3,814 beds available in intensive care units, which represented 50% of needs as assessed by international standards [17]. This investigation confirmed, moreover, the existence of notable differences between the various Regions as well as the existence of intensive care units with a scarce number of beds—in general two—which, in small hospitals situated in marginal areas, did not justify their own existence and actual utility.

To compound matters even further, there are in Italy a polymorphic variety of intensive care units which, in some instances, hardly qualify as emergency care facilities (although they are allotted specific resources for this purpose) and which should be classified under the heading of sub-intensive therapy, given the type of admissions and treatments they provide. Any attempt at making clear which type of patients they admit, the specificity of the care they provide or the appropriateness of in-patient care has invariably met with failure, as does any bid which had come up against the counter-claims of these varied health care operators who, with local politicians, have a vested interest in upholding the status quo at all costs in order to ensure their survival. To plot thickens even further when one considers that, up to the present day, there has only been one system of Anaesthesiology and Intensive Care Specialist Schools to cover the whole theoretical and practical basis of the intensive care curriculum. This could have induced to think that all areas of intensive care could have been managed and carried out by the professional figures who had been graduates of these schools. In actual fact, the picture is somewhat chequered as it falls to the various heart surgeons, neurosurgeons, paediatricians, neonatologists, lung specialists, etc.—who sometimes lack an actual cultural background and specific training—to manage on their own, or with the help of an “on-call” consultant intensive care anaesthesiologist/resuscitation specialist, an intensive therapy which requires professionalism of the most expert kind.

Last but not least, the government will have to choose where it wants to go, what to do and what services to offer citizens in matters of health care, within the public or private sector, or a mixture of the two. For the time being, the only firm point is the continuing requirement on members of the public in need of care to incur the expense of additional charges on medical services in order to shore up the national health care spending, thereby levying a larger amount of “ad hoc” tax than what would derive from fixed fiscal revenue apportionment.

Critical and Intensive Care Departments in Italy

General intensive care is usually under the management of anaesthesiologists and intensivists and caters to both general medicine and surgery patients. It often deals with multiple trauma cases and sometimes accepts paediatric patients above 3–5 years of age.

Intensive care in cardiosurgery is mainly managed by cardiosurgeons who may collaborate with anaesthesiologists trained in resuscitation techniques as cases demand. It admits acute and sub-acute cardiosurgery cases.

Intensive care in neurosurgery is managed either by neurosurgeons working collaboratively with anaesthesiologists trained in resuscitation techniques as cases demand or by the anaesthesiologists themselves. It admits acute and sub-acute neurosurgery cases as well as general cranial trauma cases uncomplicated by multiple injuries.

Intensive care in cardiology is managed by cardiologists who rarely avail themselves of consults from anaesthesiologists trained in resuscitation techniques. It admits acute cardiology patients.

Trauma centres are managed by specialists with various cultural backgrounds and, in particular, by emergency care physicians, neurosurgeons and anaesthesiologists with resuscitation training. They manage patients with multiple trauma. The number of trauma centres is currently limited in Italy and where they exist they are distributed among the major cities. Their area of operation is not clearly defined.

Intensive care in neonatology is managed by paediatricians with training in neonatology. Only three centres (Turin, Genoa and Novara) are under the direct management of anaesthesia-resuscitation specialists with neonatal expertise. They operate within their respective neonatal pathology divisions and mainly deal with the management of the premature infant, either because of intensive care requirements or because only supportive care is required.

Intensive care in paediatrics is managed mainly by anaesthesiologists with resuscitation training and experience in paediatrics as well as, in some instances [2, 3] paediatricians with resuscitation expertise. It caters to all paediatric patients and may care for newborn children as well as adolescents over 14 years of age.

Sub-intensive care is ill-defined and the presence of intermediate care on the national territory is thus difficult to tally. The most frequently found units include:

  1. 1.

    Post-surgery recovery rooms.

  2. 2.

    Cardiosurgical intermediate care.

  3. 3.

    Neurosurgery intermediate care.

  4. 4.

    Sub-intensive therapy pneumology unit.

  5. 5.

    Sub-intensive unit for long-stay patients.

Optimistic Horizon Forecast for the Near Future

What we may expect to happen in the next 10 years in order to improve the care of the truly critical patient, utilise existing resources appropriately and reduce overall management costs is difficult to forecast since it is conditional on several internal as well as external factors, e.g. political, which lay outside the sphere of the health care institution itself. On the other hand, the rationalising of health care expenditure, meaning the best exploitation and the correct limitation of available resources for intensive care, has become indispensable and legitimate from both a legal and ethical point of view, although limitations of themselves are still insufficient to reach these goals.

The most useful course of action is to act on the unjustified expectations, bordering on miracle-working, which the public entertains regarding the efficacy of medicine—and of intensive care in particular—by providing accurate information on the inevitability of death and the persistence of serious disease which remain without a cure.

Moreover, acting on the physician’s culture is necessary, with particular emphasis on the actual possibilities of treatment in intensive care and on the risks incurred by patients because of inappropriate admission. The intensive care unit admission allows the survival of patients who may not otherwise do so but this can also expose patients to risks of complications linked to the very treatments applied, such as ventilation-associated pneumonia or ventilation-induced lung injury. Furthermore, it may let patients with severe disabilities, later requiring prolonged rehabilitative therapy, to survive and usher the prolongation of a terminal state attended by ethically unacceptable suffering on the part of the patients and their family [18–22].

Currently, developing countries have had to choose not to invest out of all proportion in intensive medicine, being aware that they would have allowed a smaller number of patients to survive than if an equivalent economic investment had been diverted towards providing basic medical care (e.g. vaccinations, prevention, etc.) to a wider segment of their population.

The main problems against which intensive care units have to struggle on a daily basis can be summarised thus:

  • The definition of the requirements for beds for the hospital needs and within its catchment area (in the absence of effective regional planning).

  • The number of available beds and possibly available beds of immediate activation according to ISO resource management, unavailable because of the operational rigidity of health care personnel.

  • The appropriateness of admission and the clear definition of treatable patient categories.

  • Difficulties with the discharge of chronic patients for the lack of adequate facilities to care for them.

  • The need to deal with pandemic emergencies, especially those of a respiratory nature.

It is thus foreseeable that in the next 10 years, with the progression of a continuing long-term trend, there will be a necessity to act on different levels to attempt a cost reduction in order to rationalise existing resources and improve the performance of intensive care.

Action at Institution Level

  1. 1.

    It is necessary to actually distinguish between first-, second- and third-level hospitals in relation to the type of care they can deliver without their personnel feeling frustrated for being assigned to the lower tiers. What should be aimed at is the final outcome of the treatments applied and the patients’ satisfaction with the care provided.

    Adequate resources will have to be allotted to each level of the intensity of care (I, II or III) by carrying out expense reviews and by reducing squandering. Waste can be reduced by monitoring departmental performance, the type of patients admitted and expected outcomes, which must include fatality following long-term hospital stay or prolonged rehabilitative care because of iatrogenic issues deriving from treatment received.

  2. 2.

    Only intensive care units with at least six beds should remain operative and those units with few beds (2–4) should be closed, especially if allocated to small-size hospitals on the outskirts, or outside cities.

  3. 3.

    Among the benefits accruing from such closures are: improved quality of care, as small-size unit personnel acquire experience on a number of pathologies insufficient to increase their expertise and manual skills, and an economy of scales, deriving, e.g. from inferior acquisition costs of large quantities of consumables in comparison to small-size purchases.

  4. 4.

    Patient-centred care with the more severe cases admitted to specialist care units, which necessitate devolving to Regions the responsibility of intensive care medicine, taking into account the number of inhabitants, the ease of access to the facilities, etc. An example to emulate is the centralisation of at-risk pregnancies in a limited number of highly qualified centres. This has allowed not only the reduction of both maternal and neonatal mortality. It has also markedly reduced the management costs of this type of medical condition. The centralisation process has been made possible by the implementation of emergency services and of both road and airborne transportation of at-risk patients.

  5. 5.

    The creation of intermediate facilities (intermediate care units, step-down units, transitional care units, etc.), which provide less intensive care, but of a level consistent with the patients to be treated. Intermediate care reduces hospital costs by decreasing staffing to coincide with the needs of the patients. Since personnel costs may comprise up to 80% of total ICU expenses, the savings afforded by staff reduction (dealing with patients with an illness of intermediate severity) can be substantial. Intermediate care units reduce costs, ICU length of stay and do not impact negatively on patient outcomes [23].

  6. 6.

    Expansion of long-stay patient facilities in order to find the correct placing for patients once their hospital career (especially following intensive care) is terminated. It is important to be aware of the fact that many intensive-care patients require long rehabilitation periods and that some may be remain with seriously invalidating disabilities [24–28].

Action at Management Level

  1. 1.

    Awareness of what should be understood by intensive care, how many beds should be attributed to the unit, what type of care the unit must provide and what type of patients should be admitted to it. There should be the utmost clarity in stating the mission of the intensive care unit and well-defined protocols should be applied to patient admission, taking into account the possibility of the certainty of the diagnosis. As long as a reasonable doubt—or an uncertainty—remains about the irreversibility of the clinical condition, it is appropriate to initiate or continue intensive care. Conversely, if there is a reasonable certainty regarding the irreversibility of the diagnosis, it is also appropriate not to initiate or to suspend intensive measures so as not to unduly prolong the process of dying [29, 30].

    This is not an easy duty to perform, and recent studies in the United States have shown that most academic MICUs do not strictly apply ICU admission and restriction guidelines, as recommended by the Society of Critical Care Medicine and by the American Thoracic Society [31].

    Over-treatment is ethically reprehensible and unanimously condemned, since it determines an inappropriate use of health care means, is uselessly painful to the patient by causing physical and mental injuries and fails to respect the patient’s dignity in death. Excessive care is also morally wrong in that it further increases the suffering of family members, care-givers frustration and generates an unfair distribution of resources by detracting them from other patients [32].

  2. 2.

    Reduction in inappropriate admissions. Unfortunately, inappropriate ICU admissions are perceived as a frequent occurrence, mainly attributable to the difficulties inherent to the assessment of the appropriateness of the admission itself. Physicians are naturally aware that their decisions are based purely on medical necessity, but their decisions are also often influenced by extraneous factors such as pressure from their superiors or the referring physician, by the patient’s family or by the threat of litigation. The main perceived problems are of a clinical nature and the economical influences are poorly recognised, even if they are present [9].

  3. 3.

    More attention should be paid to the “do not resuscitate” order on patients’ forms, with special reference to terminal cases or patients who may reach the hospital in a deep coma or who suffer from injuries incompatible with survival. It is wise to always keep clearly in mind the intensive care mission: to maintain and support vital functions in patients with an elevated potential for recovery from acute illness.

  4. 4.

    To disconnect the patient from the means of support in cases of assessed brain death, as allowed under Italian law. In general, the procedure can be carried out without particular problems if the patient is eligible for organ donation, while greater reluctance should be exercised in other settings. Beds in intensive care are a precious commodity, and thus incorrectly admitting to, or keeping in the unit one patient may preclude another also in dire need from benefiting from the same right to treatment [33, 34].

  5. 5.

    To implement the indispensable requisites for high-grade and up-to-date intensive care, the following should be considered:

    • A specialist in intensive care medicine should be on duty at all times.

    • A nursing team should on duty at all times: one nurse for two patients on average and in relation to the level of the intensity of care.

    • A minimum of six beds should be available at all times with the possibility to add two or more.

    • The capability of dealing with an occasional increase in bed requirements in accordance with ISO resource management [35].

    • The possibility to assess cardiac output (e.g. in case of cardiac decompensation, sepsis, etc.).

    • The use of ultrasound for routine assessment, also in respiratory pathologies.

    • The availability of ultra-filtration systems, dialysis equipment, and in general of filtering devices.

    • A facilitated access to radiology (conventional, CAT, NMR, ultrasound) at all times.

    • The availability of laboratory findings and facilities and of the blood bank at all times.

    • The availability of beds equipped with ventilator, heart monitor and an adequate number of pumps.

    • A centralised monitoring and alarm control system.

    • Medical personnel adequate for the level of intensive care delivered to the individual patient.

Additional Action

  1. 1.

    Choosing as much as possible those treatments appropriate to the specific patient in order to avoid the onset of complications such as ventilation-induced lung injury, ventilation-associated lung injury and ventilation-associated pneumonia, even if these problems are often considered almost as if they belonged to the natural course of intensive care patient’s illness [36–38].

  2. 2.

    Minimising the use of invasive techniques of direct (intubation or mechanical respiration) or indirect (central catheter placement and in-dwelling for longer periods than necessary for therapy) treatments to the amount of time strictly necessary for diagnosis and acute phase treatment [39].

  3. 3.

    Bringing forward the initiation of the best possible treatment for the specific pathology, even if it could appear at first to be the more invasive course and for the specific patient, thus avoiding intolerable waiting times or inefficacious alternative interventions. Once the pathology is established and the patient’s clinical status reaches its acme (respiratory insufficiency becoming cardio-respiratory insufficiency, onset of multiple organ failure), it becomes necessary to resort to more invasive forms of treatment with subsequently increased iatrogenic risks [40].

  4. 4.

    Early disconnection of invasive means of support (e.g. in-dwelling tubes) and increased use of non-invasive means (e.g. non-invasive ventilatory support delivered through a mask following extubation).

  5. 5.

    Early but protected discharge from intensive care as the unit is a constant source of infection. The patient not in need of active monitoring of her vital functions should be transferred to an area with a lesser risk of infection within the shortest possible time.

Final Considerations

It is hardly imaginable to think that there may be no more resources available to dedicate to the care of the intensive care patient, regardless of considerations of age and acute pathology, in the near future. However, for want of extensive resources to dedicate to intensive care medicine, it is necessary to consider a model of such care in different terms with respect to the past. Physicians must continue to be the defenders of the patient’s health, but in this role they must take into account the resources they use and oversee their utilisation with circumspection. Furthermore, it is necessary to consider new operational models of intensive care in order to guarantee optimal resource utilisation by regrouping critical patients with different acute pathologies in large-size intensive care facilities where there will always be a need to ensure both isolation and the differentiation of their treatment. Some attempts are already in progress, for instance by incorporating acute neurosurgery patients into general intensive therapy units. The benefits that may accrue include: (1) improved resource use; (2) economy of scale; (3) greater expertise and improved treatment for patients with complex pathologies.