Intensive Care of Anaesthesia: Recommendations of the Intensive Care Section of the Spanish Society of Anaesthesiology

Monedero, P.; Paz-Martín, D.; Cardona-Pereto, J.; Barturen, F.; Fernández-Quero, L.; Aguilera-Celorrio, L.; Canet, J.; Gómez-Herreras, J.I.; Peyró, R.; Sánchez, C.; Valía, J.C.
doi:10.1016/j.redare.2016.12.004
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">European guidelines for specialized training in anaesthesiology are drawn up by the European Board of Anaesthesiology &#40;EBA UEMS&#41; through its Standing Committee on Education and Professional Development&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">1</span></a> In these guidelines&#44; which are approved by the UEMS Council&#44; intensive care is defined as a core competency in the field of anaesthesiology&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">2</span></a> Unlike other specific competencies&#44; &#8220;Medical and perioperative care of critically ill patients&#47;General Intensive Care&#8221; is considered one of the general core competency domains that should be achieved by anaesthesiologist in Europe&#46; The &#8220;European Standards of Postgraduate Medical Specialist Training&#8221; in their &#8220;Training Requirements for the Specialty of Anaesthesiology&#44; Pain and Intensive Care Medicine&#8221; establish a minimum training time of 5 years to reach the competencies required to become a specialist in anaesthesiology&#44; of which up to 1 year can be specifically focussed on Intensive Care Medicine training&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Unlike most European countries&#44; anaesthesiologists in Spain receive just 4 years of training&#44; which is insufficient to fully acquire the competencies required by the specialty&#46; Constant&#44; though unheeded&#44; demands to increase the training period to 5 years prompted the former National Anaesthesiology Committee &#40;CNEA&#44; in its Spanish acronym&#41; to petition for the speciality to be included in medical residency training programme in order to extend training time and provide more training in intensive care medicine&#46;<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">4&#44;5</span></a> The current core residency curriculum has given the CNEA&#44; for the first time in its history&#44; the opportunity to develop a specific specialty training programme based on competencies described by the EBA UEMS<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">2</span></a> and the Competency Based Training Programme in Intensive Care Medicine for Europe&#44; or Cobatrice&#44;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">6</span></a> curricula&#44; albeit at the expense of extending the training period&#46; Although intensive care in Spain is not recognized as a multidisciplinary competency&#44; as it is in Europe&#44;<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">7&#8211;9</span></a> it must become as much part of the specialty of anaesthesiology as it is in cardiology&#46; In a recent editorial&#44; the Spanish Society of Cardiology defined its official position regarding the care of acute and critically ill cardiac patients in Spain&#44;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">10</span></a> stating that &#8220;the care of patients with acute&#44; critical cardiovascular disease is an essential part of the specialty of cardiology&#8221;&#44; proposing the creation of critical and acute cardiovascular care units attended and led by cardiologists&#46; As an interim&#44; short-term measure&#44; the Society calls for the creation of intermediate cardiac care units&#44; and highlights the need to &#8220;come to an understanding with intensive care unit managers to create organizational models that would enable intensivists and cardiologists to share the care of patients with acute heart disease&#8221;&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">The Intensive Care Section of the Spanish Society of Anaesthesiology&#44; following the recent elections to the board&#44;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">11</span></a> has evaluated the situation in Spain and proposed measures to improve critical care provided by specialists in Anaesthesiology&#46; The recommendations of the Intensive Care Section of the Spanish Society of Anaesthesiology include measures consistent with the speciality&#39;s intrinsic commitment to intensive care&#44; and the use of appropriate terms that accurately described the reality of the situation &#40;see <a class="elsevierStyleCrossRef" href="#sec0010">Appendix</a>&#41;&#46; The aim of these recommendations is to raise awareness among all anaesthesiologists of the need to&#58; 1&#41; accept intensive care as an essential part of our specialty&#59; 2&#41; ensure the availability of excellence training in intensive care&#44; particularly for residents who are the future of our specialty&#44; and 3&#41; improve the care provided to critically ill patients through research and the implementation of the quality standards recommended by the Ministry of Health&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The situation with regard to Intensive Anaesthesia Care in Spain varies greatly&#44; as shown in the analysis published by the previous CNEA&#46;<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">12&#44;13</span></a> Particularly striking is the existence of teaching hospitals with no Intensive Anaesthesia Care Units&#46; This prevents future anaesthetists from acquiring a fully comprehensive understanding of the specialty and acquiring the intensive care competencies they will need to put into practice both in the operating room and other settings&#46; In addition to its key role in defining the curriculum and duration of training in anaesthesia&#44; the CNEA can also shape the future of the specialty by changing the way anaesthesia teaching units are accredited&#46; Since the development of the core curriculum involves re-accreditation of teaching units&#44; we ask the CNEA to demand compliance with current accreditation requirements that include&#44; in addition to a post-anaesthesia care unit &#40;PACU&#41;&#44; a &#8220;recovery unit with 1 bed for every 1&#46;5 operating rooms&#44;&#8221; which &#8220;will be attended round the clock&#44;&#8221; and where intensive care is given to &#8220;high-risk or unstable patients or those at high risk of presenting complications&#8221;&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">14</span></a> The fact that the availability of an Intensive Anaesthesia Care unit is a pre-requisite for accreditation as a teaching hospital should compel managers to approve requests for setting up such units&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">All anaesthesiologists need to show their commitment to the specialty by working towards developing intensive care competencies in their own hospital&#46; Today&#44; thanks to the Royal Decree regulating the Specialised Care Register&#44;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">15</span></a> recovery units have been recognized as intensive care units&#44; provided they contain permanent beds and are subject to admission formalities&#46; All anaesthesia services should request that their permanent beds be subject to specific admission formalities in order to be classified as &#8220;intensive care units&#8221;&#46; Any units that are not recognized as such should advise the hospital management of the potential negative impact this could have on the case mix index &#40;CMI&#41; and on funding&#59; failing to properly encode the type of care given&#44; the procedures in place and their complexity would reduce the hospital&#39;s weight in the database used to obtain diagnostic-related groups &#40;DRG&#41;&#46; Formally admitting patients to the Intensive Anaesthesia Care unit in hospitals in which these beds are not considered part of the Intensive Care Unit would increase the centre&#39;s average weighting in terms of DRG&#44; and with it the CMI&#44; thus making the hospital eligible for additional funding&#46; Hospital admission services and coding departments play a pivotal in obtaining official recognition of beds in the Intensive Anaesthesia Care and the proper classification of the different levels of intensive care provided&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The steps needed to allocate beds to an Intensive Anaesthesia Care unit will vary&#44; depending on the characteristics of each unit&#46; Services in which only a PACU is available will first have to ensure the unit is open round the clock and has the appropriate number of medical and nursing staff on hand&#46; This is will make it possible to provide night-time mechanical ventilation to certain surgery patients&#44; and thus justify the creation of specific admission formalities to these special care beds&#46; Long-term mechanical ventilation is one of the criteria used in Europe to define an intensive care unit&#46;<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">16&#44;17</span></a> Once they have obtained recognition&#44; intensive anaesthesia care units should then expand their portfolio of services to include support for critically patients ill with multiple organ failure&#44; thus eliminating admission restrictions due to time constraints or organ failure&#46; This objective can only be achieved with ongoing efforts to improve training and quality of care&#44; in accordance with the guidelines recommended by the Spanish National Health System Quality Agency&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">18</span></a> In addition&#44; partnership agreements should also be reached with surgery services in order to create synergies&#44; develop preoperative enhanced recovery after surgery &#40;ERAS&#41; programmes&#44; and avoid surgical cancellations&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Making the required investment to train anaesthesia residents in intensive care medicine is essential if we are to change the future of our specialty&#46; The 6-month rotation in intensive care required by current guidelines<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">19</span></a> does not give residents the skills needed to work without supervision&#46; These can only be obtained with additional training after the residency period&#44; as is required in practically all other specialty fields&#44; in which specific competencies and subspecialization after residency are required to quality as a specialist&#46; Services that do not have an Intensive Anaesthesia Care unit should arrange for their residents to be rotated in hospitals equipped with these specialist units in order to give trainees a better&#44; more comprehensive understanding of the speciality&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Finally&#44; as names express the nature of the realities they describe&#44; we must all undertake to use the correct terminology&#46; We must not permit some common terms&#44; such as intensivist or intensive care&#44; to unjustifiably become the exclusive prerogative of a primary specialty&#44; and so lose their multimodal identity&#46; Accordingly&#44; we include here a glossary &#40;see <a class="elsevierStyleCrossRef" href="#sec0010">Appendix</a>&#41; with definitions of the most common terms used in intensive care&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">In conclusion&#44; it is the responsibility of all anaesthesiologists to promote intensive care as a part of our specialist field&#44; using appropriate terminology and encouraging hospitals to improve quality of care by setting up Intensive Anaesthesia Care units and providing appropriate training&#46; The CNEA plays a key role in defining and developing our specialty&#44; particularly in the field of intensive care&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflict of interests</span><p id="par0050" class="elsevierStylePara elsevierViewall">The authors declare they have no conflicts of interest&#46;</p></span></span>"
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        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Monedero P&#44; Paz-Mart&#237;n D&#44; Cardona-Pereto J&#44; Barturen F&#44; Fern&#225;ndez-Quero L&#44; Aguilera-Celorrio L&#44; et al&#46; Cuidados Intensivos de Anestesia&#58; recomendaciones de la Secci&#243;n de Cuidados Intensivos de la Sociedad Espa&#241;ola de Anestesiolog&#237;a&#46; Rev Esp Anestesiol Reanim&#46; 2017&#59;64&#58;282&#8211;285&#46;</p>"
      ]
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        "etiqueta" => "&#9734;&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0010">This article is part of the Anaesthesiology and Resuscitation Continuing Medical Education Program&#46; An evaluation of the questions on this article can be made through the Internet by accessing the Education Section of the following web page&#58; <span class="elsevierStyleInterRef" id="intr0010" href="http://www.elsevier.es/redar">www&#46;elsevier&#46;es&#47;redar</span></p>"
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    "apendice" => array:1 [
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            "apendice" => "<p id="par0055" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">&#8728;</span><p id="par0060" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Anaesthesiology and Intensive Care&#58;</span> A primary specialty in Spain&#44;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">20</span></a> known in Europe as Anaesthesiology&#44; Pain and Intensive Care Medicine&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">2</span></a></p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">&#8728;</span><p id="par0065" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Anaesthesiologist or anaesthetist&#58;</span> Specialist in Anaesthesiology and Critical Care medicine&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">&#8728;</span><p id="par0070" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Intensive Care or Critical Care Medicine&#58;</span> Medical field specializing in the care of critically ill patients&#44;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">21</span></a> being a patient whose life is in danger due to presence or risk of organ failure requiring organ failure care and support&#44; and who must be monitored round the clock to enable timely intervention if his or her condition deteriorates&#46; In Europe&#44; intensive care competence is acquired in a multidisciplinary setting following primary specialization in anaesthesiology&#44; cardiology&#44; cardiovascular surgery&#44; general surgery&#44; internal medicine&#44; pulmonology&#44; neurosurgery&#59; in Spain&#44; it is also a primary specialty&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">&#8728;</span><p id="par0075" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Intensivist&#58;</span> Physician who has acquired competence in Intensive Care Medicine&#46; The term must not be used in an exclusive sense&#44; and should not be confused with a specialist in &#8220;Intensive Care Medicine&#8221;&#44; who should be called a &#8220;primary intensivist&#8221;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">&#8728;</span><p id="par0080" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Anaesthetist intensivist or intensivist anaesthetist&#58;</span> Specialist in &#8220;Anaesthesiology and Intensive Care&#8221; who has acquired competence in Intensive Care Medicine&#46;</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">&#8728;</span><p id="par0085" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Primary intensivist&#58;</span> Specialist in &#8220;Intensive Care Medicine&#8221;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">&#8728;</span><p id="par0090" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Intensive Care Medicine&#58;</span> See Intensive Care&#46;</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">&#8728;</span><p id="par0095" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Intensive Medicine&#58;</span> Primary specialty in Spain&#44;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">22</span></a> which is not recognized in Europe&#44; which provides non-specialist physicians with training in &#8220;Intensive Care Medicine&#8221;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">&#8728;</span><p id="par0100" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Anaesthetist&#58;</span> See Anaesthesiologist&#46;</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">&#8728;</span><p id="par0105" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Intensivist physician&#58;</span> See Intensivist&#46;</p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">&#8728;</span><p id="par0110" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Recovery room&#58;</span> See post anaesthesia care unit &#40;PACU&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">&#8728;</span><p id="par0115" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Critical Care Unit&#58;</span> Term to be withdrawn&#44; equivalent to &#8220;Anaesthesia Critical Care Unit&#8221;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">&#8728;</span><p id="par0120" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Intensive Care Unit&#58;</span> Specific hospital area staffed by health professionals providing multidisciplinary care&#44; which complies with certain functional&#44; structural and organizational requirements needed to guarantee the conditions of safety&#44; quality and efficiency required to aid in the recovery of patients who need respiratory support or basic respiratory support together with support for at least 2 organs or systems&#59; and all complex patients requiring support for multiple organ failure&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">18</span></a> They can be managed by primary intensivists &#40;Intensive Care Unit&#41; or by anaesthetist intensivists &#40;Intensive Anaesthesia Care Unit&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0070"><span class="elsevierStyleLabel">&#8728;</span><p id="par0125" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Intensive Anaesthesia Care Unit&#58;</span> &#8220;Intensive Care Unit&#8221; managed by intensivist anaesthesiologists&#46; This term should replace the confusing terms &#8220;Critical Care Unit&#8221; or &#8220;Recovery Unit&#8221;&#46; It can be abbreviated as IACU&#46;</p></li><li class="elsevierStyleListItem" id="lsti0075"><span class="elsevierStyleLabel">&#8728;</span><p id="par0130" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Intermediate Care Unit&#58;</span> Specific hospital area that treats patients requiring a higher level of a care than that given on the hospital ward&#44; but less than the Intensive Care Unit&#46; Patients requiring invasive mechanical ventilation or renal replacement therapy are usually excluded from these units&#46;</p></li><li class="elsevierStyleListItem" id="lsti0080"><span class="elsevierStyleLabel">&#8728;</span><p id="par0135" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Intensive Medicine Unit&#58;</span> &#8220;Intensive Care Unit&#8221; managed by primary intensivists&#46; They could be called &#8220;Intensive Medicine Intensive Care Units&#8221;&#44; or be abbreviated to IMU&#46;</p></li><li class="elsevierStyleListItem" id="lsti0085"><span class="elsevierStyleLabel">&#8728;</span><p id="par0140" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Recovery Unit&#58;</span> Term to be withdrawn&#44; equivalent to &#8220;Intensive Anaesthesia Care Unit&#8221;&#44; due to it being confused with emergency room resuscitation cubicles&#44; and due to their recognition as intensive care units in Royal Decree 69&#47;2015 of 6 February&#44; regulating the Specialised Care Register</p></li><li class="elsevierStyleListItem" id="lsti0090"><span class="elsevierStyleLabel">&#8728;</span><p id="par0145" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Post anaesthesia care unit &#40;PACU&#41;&#58;</span> Specific hospital area&#44; within the surgical suite&#44;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">23</span></a> where patients who have undergone an anaesthetic procedure that does not require a high level of care are treated and monitored&#46; The PACU is part of the intensive care unit&#46;</p></li></ul></p>"
            "etiqueta" => "Appendix"
            "titulo" => "Glossary"
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