Division of Critical Care Medicine
Critical Care Unit Capacity in Canada:
Have we failed to advocate adequately?
Noel Gibney MB FRCP(C)
Disclosures
None
Division of Critical Care Medicine
Critical Care Capacity
• Adequate critical care unit beds necessary to
provide adequate capacity to manage:
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Day to day admissions
Seasonal surges
Pandemics
Disasters
• Inadequate capacity = critical care strain
• Excess capacity = waste
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60%
Mortality
50%
40%
30%
20%
10%
0%
IA
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2-12 hrs
12-16 hrs
>24 hrs
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
Division of Critical Care Medicine
Arch Int Med 2012;172:167-172
“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…..”
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10 ICUs in Western France. Consecutive patients referred for
ICU admission for the first time over a 3-month period were
assessed for eligibility.
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During the study period, the mean number of days when the
unit was full per ICU was 48.5%.
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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
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Impact of refused ICU admission
Robert R et al. Am J Respir Crit Care Med Vol 185, Iss. 10, pp 1081–1087
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Crit Care Med 2012; 40: 2009–2015
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.
Division of Critical Care Medicine
A comparison of intensive care unit utilization in Alberta and
western Massachusetts
Rapoport, 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
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.
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Lancet 2000; 355: 595–98
To estimate the need for adult critical-care beds for a
population of 500 000 in the UK served by five hospitals.
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
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Health Expenditure as share of GDP OECD 2010
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Definition of ICU/Definition of ICU Bed
• 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
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ICU Beds/100,000 Population
<19.9
20-29.9
30-39.9
>40
Hospital Referral Regions Exceeding Critical Care Capacity
by % of Population Experiencing Sudden Critical Illness
ICU beds/100,000 pop
0.01%
0.02%
0.03%
0.04%
0.05%
28
0
16.7
58.8
Carr B et al JAMA 2010:303;1371-1372
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90.9
97.4
European ICU Capacity
Rhodes et al. Intensive Care Med 2012;38:1647–1653
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What about Provinces?
0
10
20
Germany
United States
Belgium
Croatia
CANADA?
France
Spain
ONTARIO
Australia
CANADA ?
United Kingdom
Netherlands
South Africa (Private)
ALBERTA
BRITISH COLUMBIA
New Zealand
Beds/100,000 population
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30
40
Critical care beds vs health expenditure as % GDP
Canada
Alberta
Rhodes et al. Intensive Care Med 2012;38:1647–1653
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Critical care beds vs health expenditure as % GDP
Canada
Alberta
Rhodes et al. Intensive Care Med 2012;38:1647–1653
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Critical care beds / 100,000 population
Critical care beds vs acute care beds
Canada
Ontario
Alberta/BC
Acute care beds / 100,000 population
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Critical care beds vs. acute care hospital beds
Canada
Alberta
Wunsch H et al, Crit Care Med, 2008; 36: 2787-2793
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Health care spending per capita vs ICU beds
AB
BC
ON
Canada
Wunsch H et al, Crit Care Med, 2008; 36: 2787-2793
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Although Canada spends slightly more per
capita onABhealth, it trails many countries in ICU
Canada bed capacity
ON
BC
Wunsch H et al, Crit Care Med, 2008; 36: 2787-2793
Division of Critical Care Medicine
Canada 1867
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Confederation 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.
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Canada Health Act 1984
Principles
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Public Administration
Comprehensiveness,
Universality and
Portability
Accessibility
Medically Necessary
Sustainability
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Governance of Health Systems across Canada
• Hospital Boards
• Local Health Integrated Networks (LHINs)
• Regional Health Authorities
• Provincial Health Authorities
• Provincial Health Ministries
• Canada Health
• Public Health Agency of Canada
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Canadian Provinces – E.U. Member States
Individual Health Systems with Federal Oversight Legislation
Division of Critical Care Medicine
• 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
Division of Critical Care Medicine
CIHI CMDB Acute Care Hospital Database
http://www.cihi.ca/CIHI-ext-portal/xls/internet/quickstats_cmdb_2012_01_en
• All active treatment hospitals in Canada
• Self reported by hospitals
• Acute care and specialty staffed beds in use
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Intensive Care
Obstetrics
Pediatrics
Psychiatry
Rehabilitation
• Completely inaccurate for Intensive Care
Division of Critical Care Medicine
CIHI CMDB Acute Care Hospital Database
http://www.cihi.ca/CIHI-ext-portal/xls/internet/quickstats_cmdb_2012_01_en
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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
Division of Critical Care Medicine
CIHI CMDB Acute Care Hospital Database
http://www.cihi.ca/CIHI-ext-portal/xls/internet/quickstats_cmdb_2012_01_en
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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
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Division of Critical Care Medicine
Ontario Critical Care Strategy
Division of Critical Care Medicine
Division of Critical Care Medicine
Division of Critical Care Medicine
Alberta Provincial H1N1 Bed Utilization, Non-ICU versus ICU:
Suspected and Confirmed Cases as of 07:00 hr on Tuesdays and Fridays
Hospitalized Cases - Non-ICU
Hospitalized Cases – ICU
400
350
300
250
200
150
100
50
Jan-15
Jan-12
Jan-08
Jan-05
Dec-29
Dec-22
Division of Critical Care Medicine
Dec-18
Number of adult ICU beds ~ 170
Staffed/Funded Beds ~ 120
Usual number of ventilated ICU patients ~100
Peak number of ventilated ICU patients ~ 170
Peak number of H1N1 ICU patients ~ 120
Dec-15
Date (2009 - 2010)
Dec-11
Dec-08
Dec-04
Dec-01
Nov-27
Nov-24
Nov-20
Nov-13
Nov-10
Nov-06
Oct-30
Nov-03
Oct-27
Oct-23
Oct-20
Oct-16
Oct-13
Oct-09
Oct-06
Oct-02
Sep-29
Sep-25
Sep-22
Sep-18
Sep-15
Sep-11
Sep-08
Sep-04
Sep-01
Aug-28
Aug-25
Aug-21
Aug-18
Aug-14
Aug-11
Aug-07
Jul-31
Jul-28
Jul-24
Jul-21
Jul-17
Jul-14
Jul-10
Jul-07
Jul-03
Jun-30
Aug-04
0
***Nov-17
Number of Cases
450
Canadian Critical Care Society
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.
Division of Critical Care Medicine
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'
Division of Critical Care Medicine
You can’t manage if you don’t measure
0
10
20
Germany
United States
Belgium
Croatia
CANADA?
France
Spain
ONTARIO
Australia
CANADA ?
United Kingdom
Netherlands
South Africa (Private)
ALBERTA
BRITISH COLUMBIA
New Zealand
Beds/100,000 population
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30
40
Conclusions
• 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
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Similar to ICNARC, ANZICS
• We need the Canadian Critical Care Society to take lead
in concert with Canadian Critical Care Trials Group and
CIHI
Division of Critical Care Medicine
Thank you for
your attention!
Division of Critical Care Medicine