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Inicio Revista Española de Anestesiología y Reanimación (English Edition) Description of Intensive Care and Intermediate Care resources managed by Anaesth...
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Vol. 71. Issue 2.
Pages 76-89 (February 2024)
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375
Vol. 71. Issue 2.
Pages 76-89 (February 2024)
Special article
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Description of Intensive Care and Intermediate Care resources managed by Anaesthesiology Departments in Spain and their adaptation capacity during the COVID-19 pandemic
Descripción de los recursos en Cuidados Intensivos y Cuidados Intermedios gestionados por Anestesiología y Reanimación en España y su capacidad de adaptación durante la pandemia de la COVID-19
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G. Tamayo Medela,
Corresponding author
, F. Ramasco Ruedab, C. Ferrando Ortolác,d, R. González de Castroe, R. Ferrandis Comesf,g, C. Pastorinih, R. Méndez Hernándezb, J. García Fernándezi, the Grupo de REGISTRO UCI SCI SEDAR
a Hospital Universitario Cruces, ISS BioCruces, Bizkaia, Spain
b Hospital Universitario de la Princesa, Madrid, Spain
c Hospital Clínic, Institut d'Investigació August Pi i Sunyer, Barcelona, Spain
d CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
e Hospital Universitario de León, León, Spain
f Hospital Universitari i Politècnic La Fe, Valencia, Spain
g Facultad de Medicina, Universidad de Valencia, Valencia, Spain
h Fundación PETHEMA, Madrid, Spain
i Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain
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Figures (2)
Tables (7)
Table 1. Hospitals included in the study and percentage of participation by autonomous community.
Table 2. Hospitals with ICU-A included in the study.
Table 3. ICU-A beds included in the study.
Table 4. Hospitals with ICU-A during the COVID-19 pandemic included in the study.
Table 5. ICU-A beds during the COVID-19 pandemic included in the study.
Table 6. Ratio ICU-A beds per nurse.
Table 7. Intensive care mechanical ventilators included in the study.
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Additional material (7)
Abstract
Introduction

It is essential to understand the strategic importance of intensive care resources in the sustainable organisation of healthcare systems. Our objective has been to identify the intensive and intermediate care beds managed by Anaesthesiology and Resuscitation Services (A-ICU and A-IMCU) in Spain, their human and technical resources, and the changes made to these resources during the COVID-19 pandemic.

Material and methods

Prospective observational study performed between December 2020 and July 2021 to register the number and characteristics of A-ICU and A-IMCU beds in hospitals listed in the catalogue published by the Spanish Ministry of Health.

Results

Data were obtained from 313 hospitals (98% of all hospitals with more than 500 beds, 70% of all hospitals with more than 100 beds). One hundred and forty seven of these hospitals had an A-ICU with a total of 1702 beds. This capacity increased to 2107 (124%) during the COVID-19 pandemic. Three hundred and eight hospitals had an A-IMCU with a total of 3470 beds, 52.9% (2089) of which provided long-term care. The hospitals had 1900 ventilators, at a ratio of 1.07 respirators per A-ICU; 1559 anaesthesiologists dedicated more than 40% of their working time to intensive care. The nurse-to-bed ratio in A-ICUs was 2.8.

Discussion

A large proportion of fully-equipped ICU and IMCU beds in Spanish hospitals are managed by the anaesthesiology service. A-ICU and A-IMCUs have shown an extraordinary capacity to adapt their resources to meet the increased demand for intensive care during the COVID-19 pandemic.

Keywords:
ICU
ICU-A
PACU
Resources
COVID-19
Anaesthesiology
Resumen
Introducción

Los recursos de cuidados intensivos tienen valor estratégico y es necesario conocerlos para una planificación sanitaria sostenible. El objetivo es identificar las camas de cuidados intensivos e intermedios gestionadas por Servicios de Anestesiología y Reanimación (UCI-A y UCIM-A) en España, así como los recursos humanos y técnicos relacionados, y su variación durante la pandemia COVID-19.

Material y métodos

Estudio nacional observacional prospectivo de diciembre de 2020 a julio de 2021. Se recogieron datos relativos al número y características de las camas de UCI-A y UCIM-A en hospitales del catálogo Nacional de Hospitales del Ministerio de Sanidad.

Resultados

Se obtuvieron datos de 313 hospitales (98% del total de más de 500 camas, 70% del total de más de 100 camas). En 147 de ellos se registraron UCI-A, con un total de 1.702 camas que se incrementaron hasta 2.107 (124%) durante la pandemia COVID-19. En 308 hospitales se registraron UCIM-A, con un total de 3.470 camas de las cuales el 52,9% (2.089) prestaban atención continuada. Se registraron 1.900 respiradores con un ratio de 1,07 respiradores por cama de UCI-A. 1559 anestesiólogos tenían una dedicación superior al 40% a los cuidados intensivos. El ratio de camas de UCI-A por cada profesional de enfermería fue de 2,8.

Discusión

Los Servicios de Anestesiología gestionan un elevado número de camas UCI y UCIM en España, con una dotación adecuada de recursos. Han demostrado una gran capacidad de adaptación en situaciones de crisis dando respuesta al aumento de la demanda de cuidados intensivos durante la pandemia COVID-19.

Palabras clave:
UCI
UCI-A
URPA
Recursos
COVID-19
Anestesiología
Full Text
Introduction

References to specific care areas for critically ill hospitalised patients date back to the 19th century.1 However, the invasive mechanical ventilation unit created in 1952 in Copenhagen by the Danish anaesthesiologist Bjørn Ibsen during the polio epidemic is generally considered the origin of intensive care units (ICU) in Europe.2 Since then and up to the present day, ICUs have become an essential component of hospital care, constituting a link in the chain of care in an increasing number of processes, many of them surgical.3 Added to this is an increase in the expectations of healthcare professionals and users about the outcomes that intensive care can provide.4–6

Yet, there is little data on the actual availability of ICU beds in the national and international literature.7–10 In many European countries there are no official censuses, ICUs managed by different departments or services affiliated to the different Scientific Societies coexist, and most studies do not stratify data according to care level, including intermediate care units (IMCUs). It is therefore difficult to obtain reliable data and to interpret the published results. This lack of information prevents adequate planning, and any unexpected increase in demand for ICU beds can quickly overwhelm and exceed available resources, as occurred during the COVID-19 pandemic. Having the maximum information on available human and technical resources, as well as their adaptive capacity, enables contingency plans to be made with the capacity to multiply the number of available ICU beds, as was necessary in many regions during the first waves of the COVID-19 pandemic.11–15

The primary objective of the present study is to identify the number of ICU and IMCU beds managed by anaesthesiology and resuscitation services (ICU-A, IMCU-A) in Spain and their associated human (medical and nursing) and material (number of ventilators) resources. The secondary objective is to describe the variations during the first waves of the COVID-19 pandemic.

Material and methods

National, observational, descriptive, prospective study from December 2020 to July 2021.

We identified hospitals included in the Spanish National Catalogue of Hospitals of the Ministry of Health (CNHMS)16 that met the criteria for having an anaesthesiology and resuscitation department (ARD) according to the purpose and class of centre with which they were registered in 2020. The definitions of ICU-A and IMCU-A beds were established according to the level of care and in accordance with the standards and recommendations of the Ministry of Health,17 and the recommendations of the European Society of Intensive Care Medicine,18 the World Federation of Societies of Intensive and Critical Care Medicine,19 and the European Union of Medical Specialists 20:

ICU bed (care level II and III): effective bed, with the necessary material and human resources to provide continuous monitoring and organ support (24 h a day, every day of the year).

IMCU bed (care level I): bed with a dedicated monitoring system for patients at risk of deterioration of their condition but who do not require organ support, available continuously or non-continuously.

A form and user manual were designed for prospective online data collection, which included 68 variables relating to the identification of each hospital centre, as well as the number and characteristics of ICU-A and IMCU-A inpatient beds (Appendix A). Data were collected regarding structural resources present prior to February 2020 and their maximum variation in any of the waves of the COVID-19 pandemic recorded through July 2021. The activity of anaesthesiology physicians in ICUs or IMCUs managed by other hospital services was not recorded.

At least one researcher responsible for data collection in each hospital and in each autonomous community was selected from among professionals with proven experience linked to the regional anaesthesiology and resuscitation societies and to the Intensive Care Section of the Spanish Society of Anaesthesiology, Resuscitation, and Pain Therapy (SCI-SEDAR). Once the data collection process was completed, the hospital and regional investigators conducted a peer review, and a process of cleaning, homogenisation, purification, and subsequent structuring by the authors in charge of the statistical analysis. Hospitals with incomplete or inconsistent data were not included in the analysis.

The data were analysed using Microsoft® Excel 16® and IBM® SPSS 28®. Although the data were analysed for each participating hospital, to simplify publication, the values were grouped at the national and autonomous community levels, in the form of absolute values and/or proportions and expressing the distribution of the different means by the minimum and maximum values.

ResultsParticipation in the registry (Sample)

A total of 575 CNHMS hospitals were identified that met the criteria for having an ARD, encompassing a total of 126,299 inpatient beds in 293 public, 280 private, and 2 Ministry of Defence facilities (Appendix B).

Valid data were obtained from 313 hospitals (54% of the total), 204 (65%) public centres, 107 (34%) private, and 2 from the Ministry of Defence, with a total of 97,708 hospital beds (77% of the total). This included 98% of hospitals with more than 500 beds, 70% with more than 100 beds, and 28% with fewer than 100 beds. Participation was heterogeneous among the different autonomous communities (Table 1) (Appendix B).

Table 1.

Hospitals included in the study and percentage of participation by autonomous community.

Autonomous community  Public  Public  Public  Total Public hospitals  Private  Private  Private  Total private hospitals  M. of defence  Total M. of defence hospitals  Total hospitals  Hospital beds  % Participation 
  Hospital ≦ 100 beds  Hospital >100–≦500 beds  Hospital >500 beds    Hospital ≦100 beds  Hospital >100–≦500 beds  Hospital >500 beds    Hospital >100–≦500 beds         
Andalusia  19  34    12      46  11,618  38.02 
Aragón  10    16  3670  84.21 
Asturias, Principado de        15  3104  75 
Balearic Islands            1841  31.58 
Canarias          3962  28.13 
Cantabria                1355  60 
Castilla-La Mancha              3253  34.62 
Castilla y León          15  5171  46.88 
Catalonia  17  24  23  34      58  17,218  67.44 
Ceuta                     
Comunitat Valenciana    18  25          28  10,285  84.85 
Extremadura    11          15  2496  75 
Galicia  12      19  8619  59.38 
Madrid, Comunidad de  14  25  13  39  14,250  54.93 
Melilla                  168  100 
Murcia, Región de        12  3420  57.14 
Navarra, Comunidad Foral de          1589  66.67 
Basque Country  11        15  5035  55.56 
Rioja, La            654  100 
National total  23  120  61  204  40  62  5  107  2  2  313  97,708  54.43 
UCI-A pre-pandemic

A total of 147 hospitals were recorded with an ICU-A, of which 112 (76%) were public (54 of them with more than 500 beds), 34 (23%) were private (3 with more than 500 beds), and 1 (0.7%) was a Ministry of Defence hospital with fewer than 500 beds (Table 2).

Table 2.

Hospitals with ICU-A included in the study.

AC  Public  Public  Public  Total Public  Private  Private  Private  Total Private  M. of defence  Total M. of defence hospitals  Total hospitals 
  Hospital ≦100 beds  Hospital >100–≦500 beds  Hospital >500 beds    Hospital ≦100 beds  Hospital >100–≦500 beds  Hospital >500 beds    Hospital >100–≦500 beds     
Andalusia    13          15 
Aragón               
Asturias, Principado de               
Balearic Islands                 
Canarias           
Cantabria               
Castilla-La Mancha             
Castilla y León           
Catalonia  14  12      26 
Comunitat Valenciana    12          15 
Extremadura           
Galicia  10      14 
Madrid, Comunidad de  14  21 
Melilla                 
Murcia, Región de             
Navarra, Comunidad Foral de             
Basque Country           
Rioja, La                 
National total  6  52  54  112  12  19  3  34  1  1  147 

A total of 1702 ICU-A beds were recorded, of which 1441 (84.7%) were in public hospitals (1026 in hospitals with more than 500 beds), 256 (15%) in private hospitals (43 of them in hospitals with more than 500 beds), and 5 (0.3%) in the Ministry of Defence hospital (Table 3).

Table 3.

ICU-A beds included in the study.

Autonomous community  Public  Public  Public  Total public  Private  Private  Private  Total private  M. of defence  Total M. of defence  Total beds UCI-AR  Ratio ICU-AR beds/% hospital beds (1) 
  Hospital ≦100 beds  Hospital >100–≦500 beds  Hospital >500 beds    Hospital ≦100 beds  Hospital >100–≦500 beds  Hospital >500 beds    Hospital >100–≦500 beds       
Andalusia    60  107  167    21    21      188  3.52 
Aragón    10  10  20              20  3.32 
Asturias, Principado de    20  27  47              47  2.84 
Balearic Islands      12  12              12  1.43 
Canarias    43  47          49  1.67 
Cantabria    16  22              22  1.86 
Castilla-La Mancha  53  59              59  2.11 
Castilla y León    74  78          85  2.82 
Catalonia  61  97  159  73  16  94      253  2.84 
Comunitat Valenciana    39  155  194    34    34      228  3.58 
Extremadura  45    52          60  8.65 
Galicia  37  133  175  17  28      203  4.30 
Madrid, Comunidad de  41  186  231  17  20  10  47  283  3.58 
Melilla                  1.79 
Murcia, Región de  29  31  66              66  3.48 
Navarra, Comunidad Foral de      10  10    12    12      22  2.95 
Basque Country    27  65  92          95  3.71 
Rioja, La                  1.34 
National total  25  390  1026  1441  50  163  43  256  5  5  1702  3.48 

(1) Mean ratios of effective ICU-A beds per 100 hospital beds.

A total of 98 of the ICU-As were defined as surgical (66.7%), and 49 as multipurpose (33.3%). Of these, 99 (67.3%) were designated resuscitation units, 20 (13.6%) critical care units, and 16 (10.9%) intensive care units, the remaining 12 (8.2%) were recorded under another denomination (Fig. 1).

Figure 1.

Distribution of ICU-A and IMCU-A names.

(0.1MB).
UCI-A during the COVID-19 pandemic

A total of 201 hospitals with an ICU-A were recorded, of which 146 were public (72.6%, 57 with more than 500 beds), 54 private (26.9%, 5 with more than 500 beds), and 1 belonging to the Ministry of Defence (.5%). A total of 3809 ICU-A beds were recorded, of which 3265 were in public hospitals (2137 in hospitals with more than 500 beds), 534 in private hospitals (71 in hospitals with more than 500 beds), and 10 in the Ministry of Defence hospital (Table 4).

Table 4.

Hospitals with ICU-A during the COVID-19 pandemic included in the study.

Autonomous community  Public  Public  Public  Total Public  Private  Private  Private  Total private  M. of defence  Total M. of defence  Total hospitals  % Variation 
  Hospital ≦100 beds  Hospital >100–≦500 beds  Hospital >500 beds    Hospital ≦100 beds  Hospital >100–≦500 beds  Hospital >500 beds    Hospital >100–≦500 beds       
Andalusia    11  19          23  +53.33 
Aragón            +200.00 
Asturias, Principado de                +50.00 
Balearic Islands                  0.00 
Canarias                −16.67 
Cantabria                  −50.00 
Castilla-La Mancha              +33.33 
Castilla y León            10  +25.00 
Catalonia  13  19  19  27      46  +76.92 
Comunitat Valenciana    12  19          22  +46.67 
Extremadura              −42.86 
Galicia  11      16  +14.29 
Madrid, Comunidad de  11  21  31  +47.62 
Melilla                  0.00 
Murcia, Región de          +12.50 
Navarra, Comunidad Foral de            +50.00 
Basque Country              0.00 
Rioja, La                  0.00 
National total  7  82  57  146  13  36  5  54  1  1  201  +36.73 

This represented an overall increase of 36% of the hospitals managing an ICU-A, with an increase of 30% in public hospitals (5% in hospitals with more than 500 beds), and 58% in private hospitals. The number of ICU-A beds increased by 2107 beds (124%), 126% in public hospitals (108% in those with more than 500 beds), 108% in private hospitals, and 100% in the Ministry of Defence hospital (Table 5).

Table 5.

ICU-A beds during the COVID-19 pandemic included in the study.

Autonomous community  Public  Public  Public  Total public  Private  Private  Private  Total private  M. of defence  Total M. of defence  Total hospitals  % Variation 
  Hospital ≦100 beds  Hospital >100–≦500 beds  Hospital >500 beds    Hospital ≦100 beds  Hospital >100–≦500 beds  Hospital >500 beds    Hospital >100–≦500 beds       
Andalusia    121  203  324    28    28      352  +87.23 
Aragón    18  48  66          74  +270.00 
Asturias, Principado de    52  39  91              91  +93.62 
Balearic Islands      36  36              36  +200.00 
Canarias    14  63  77              77  +57.14 
Cantabria    16    16              16  −27.27 
Castilla-La Mancha  11  48  113  172              172  +191.53 
Castilla y León    23  154  177  10      10      187  +120.00 
Catalonia  187  233  421  62  170  44  276      697  +175.49 
Comunitat Valenciana    230  299  529    48    48      577  +153.07 
Extremadura    54    54          61  +1.67 
Galicia  39  191  235  17  30      265  +30.54 
Madrid, Comunidad de  22  186  487  695  32  60  10  102  10  10  807  +185.16 
Melilla                  −33.33 
Murcia, Región de  28  81  111          112  +69.70 
Navarra, Comunidad Foral de    12  16  28    24    24      52  +136.36 
Basque Country  48  143  200              200  +110.53 
Rioja, La      31  31              31  +342.86 
National total  50  1078  2137  3265  117  346  71  534  10  10  3809  +123.80 
IMCU-A

The same descriptive and comparative analysis was performed (before and during the pandemic) (Appendix C).

There were 308 hospitals with IMCU-A (202 public, 104 private, 2 of the Ministry of Defence), with a total of 3470 IMCU-A beds. Of these, 60% (2089 beds) provided 24/7 continuous care.

A total of 230 (74.7%) of the IMCU-A were designated as post anaesthesia recovery units (PACU), 57 (18.5%) as resuscitation units, and the remaining 21 (6.8%) were recorded under other names (Fig. 1).

During the COVID-19 pandemic, there was an overall decrease of 27% in the number of IMCU-A beds, with a relative increase of 3% in those providing continuous care.

Medical and nursing staffing

The 313 hospitals included in the study had 7774 doctors specialising in anaesthesiology and resuscitation. Of these, prior to the COVID-19 pandemic, 377 (4.9%) worked 100% of their working day in an ICU-A and 1182 (15.2%) at least 40% (Appendix D). No changes were recorded during the pandemic.

The national mean bed-to-doctor ratios during the regular working day were 4 (min. 3–max. 7) in ICU-A and 8 (3–10) in IMCU-A; and 8 (3–11) and 8 (3–17) respectively during hours of continuous care (Appendix E). During the COVID-19 pandemic, there was a decrease in mean ratios of 2.4% in ICU-A and 21.4% in IMCU-A during regular working hours; and 4% and 12.8% respectively during continuous care hours.

The national mean bed-to-nurse ratios were 3 (1–5) in ICU-A and 4 (3–6) in IMCU-A (Table 6 and Appendix F). During the pandemic, a reduction was recorded in the mean ratios of 7.3% in ICU-A and 18.7% in IMCU-A.

Table 6.

Ratio ICU-A beds per nurse.

Autonomous community  Public  Public  Mean Public  Private  Private  Mean Private  M. of defence  Mean M. of defence  Overall mean 
  Hospital ≦500 beds  Hospital >500 beds    Hospital ≦500 beds  Hospital >500 beds    Hospital ≦500 beds     
Andalusia  3.00  3.40  3.18  4.50    4.50      3.38 
Aragón  3.00  3.00  3.00            3.00 
Asturias, Principado de  5.00  2.50  4.38            4.38 
Balearic Islands    2.00  2.00            2.00 
Canarias  3.00  2.25  2.40  2.00    2.00      2.33 
Cantabria  2.00  2.00  2.00            2.00 
Castilla-La Mancha  1.33  2.00  1.67            1.67 
Castilla y León  9.00  2.40  3.50  3.00    3.00      3.38 
Catalonia  3.06  2.40  2.82  2.00  2.00  2.00      2.44 
Comunitat Valenciana  2.80  2.36  2.54  3.33    3.33      2.70 
Extremadura  5.00    5.00  4.00    4.00      4.71 
Galicia  3.38  2.50  2.85  2.67  3.00  2.75      2.82 
Madrid, Comunidad de  2.29  2.33  2.31  3.00  2.00  2.83  2.00  2.00  2.44 
Melilla  1.50    1.50            1.50 
Murcia, Región de  2.50  3.00  2.63            2.63 
Navarra, Comunidad Foral de    3.00  3.00  2.00    2.00      2.50 
Basque Country  2.63  2.67  2.64  3.00    3.00      2.69 
Rioja. La    3.00  3.00            3.00 
National mean  3.11  2.52  2.82  2.74  2.33  2.71  2.00  2.00  2.79 
Provision of intensive care ventilators

A total of 1900 intensive care ventilators managed by an ARD were recorded, 1804 in hospitals with an ICU-A. Mean ventilator to ICU-A bed ratios were 1.1 (0.5–1.6). During the pandemic, the mean ratios decreased by 47% [0.6 (0.1–2.1)] (Table 7). Non-intensive care-specific ventilators used in ICU-A during the pandemic were not recorded in this study.

Table 7.

Intensive care mechanical ventilators included in the study.

Autonomous community  Ventilators  Ventilators ICU-A (1)  Mean ratios ventilators/ICU-A beds (2)  Mean ratios ventilators/ICU-A beds C-19 (3) 
Andalusia  138  117  0.74  0.38 
Aragón  17  10  0.50  0.09 
Asturias. Principado de  68  62  1.38  1.16 
Balearic Islands  13  12  1.00  0.33 
Canarias  79  77  1.50  0.99 
Cantabria  32  25  1.35  0.69 
Castilla-La Mancha  82  71  1.62  0.40 
Castilla y León  112  106  1.11  0.51 
Catalonia  230  219  .89  0.34 
Comunitat Valenciana  299  295  1.23  0.41 
Extremadura  41  37  0.50  0.41 
Galicia  234  229  1.06  1.14 
Madrid. Comunidad de  302  296  1.01  0.30 
Melilla  0.67  1.00 
Murcia. Región de  87  86  1.41  2.14 
Navarra. Comunidad Foral de  31  29  1.34  0.57 
Basque Country  127  125  1.42  0.71 
Rioja. La  0.86  0.19 
National  1900  1804  1.07  0.56 

(1) Intensive care mechanical ventilators in hospitals with an ICU-A. (2) Mean ratios of mechanical ventilators to ICU-A beds. (3) Mean ratios of mechanical ventilators to ICU-A beds during the COVID-19 pandemic.

Discussion

Although this study cannot be considered an exhaustive national catalogue of intensive and intermediate care resources managed by an ARD, it does include a high proportion of those available in our country. We consider the study sample to be representative of hospitals with more than 100 beds, as well as those under public management.

Given that the data was collected using a form, and despite the fact that the variables were defined in a user manual, unintentional bias on the part of the recorders cannot be ruled out.

ICU-A beds

This study presents the first national registry of ICU-A beds. Previous publications offer us, from different perspectives, data on these units, although they are not comparable with each other for different reasons. A study published in Europe in 2012 recorded a provision of 11.5 ICU beds per 100,000 inhabitants, with approximately 2.8 ICU beds per 100 acute inpatient beds, with marked differences between different countries.9 A study published in Spain in 2013 recorded 5569 intensive care beds, of which 3336 were managed by intensive care services (ICS) and 2233 by other medical services, mostly surgical ICUs managed by an ARD.10 A previous study published in Spain in 2010 had identified 3498 ICU beds in teaching hospitals, 2043 managed by ICS, and 1455 by an ARD, and 1572 additional surgical intermediate care beds managed by an ARD.7 In the present register, a greater number of ICU-A beds were identified (1702), which could be explained by the growth that these units have experienced in the last 10 years and by possible selection biases of the hospitals surveyed in previous studies.

According to the data of the present study, most of the ICU-A beds (60%) belong to public hospitals with more than 500 beds and to surgical (66%), or multipurpose (33%) units, which means we can infer that a differentiating element of the ICU-A with respect to units managed by other services is that they provide care preferentially to surgical patients. In contrast, in a study published in 2015 on 138,999 patients admitted to Spanish ICUs, primarily multipurpose, the reason for admission was surgical in only 32% of cases.21 The ratio of 1.7 ICU-A beds per 100 inpatient beds at national level is below the mean value of 2.8 published in Europe,9 which puts into context the ratio of ICU-A beds to total ICU beds in Spain, estimated at between 3.6 and 5.5, according to different authors.9,10 However, in hospitals that have an ICU-A, the mean ratio of ICU-A beds per 100 inpatient beds reached a value of 3.4%, with a mean value per community of min. 1.3% and max. 8.6%. Therefore, we can state that, although not all hospitals have an ICU-A, and there is great geographic variability, those that do have an ICU-A have a considerable number of beds.

UCI-A beds during the COVID-19 pandemic

During the early phases of the pandemic in Europe, increases in ICU bed capacity were recorded ranging from 15% in Denmark to 226% in Ireland, with values close to 100% in most of the countries for which data are available.12 The contingency plans implemented by ARDs during the COVID-19 pandemic in Spain made it possible to increase the number of hospitals with ICU-A by 36% and the number of beds by 124% (up to 2107), thus ensuring COVID and non-COVID critical patient care that would otherwise not have been possible. Added to this is the collaboration and support of numerous anaesthesiologists in units managed by intensive care and pneumology services, sometimes the majority in these units, which has not been included in this study.

However, the true success of this strategy should not only be evaluated based on the high number of ICU resources managed, but also on the excellent morbimortality results published by the Spanish ICU-A network.22–26

Much of the increase in ICU-A beds came from the reallocation of ICU-A beds, and the adaptation of operating theatres and other hospital areas. This demonstrates the enormous adaptive capacity that characterizes ARDs, based on their ability to reallocate quickly and efficiently human and material resources from surgical areas or intermediate care units in response to unexpected demand for intensive care. This capacity had already been documented in our recent history, and was what made it possible to provide adequate care to many of the victims of the attacks of March 11, 2004 in Madrid.27

IMCU-A beds

IMCU-A beds have fewer human and material resources, and therefore generate lower costs.28 As in the case of ICUs, there are both multipurpose IMCUs and specific IMCUs for certain processes or pathologies. The IMCU-As in the present study are mainly dedicated to providing post-anaesthesia, post-operative, or post-intervention care. Although there is no universal definition of IMCU, standards for post-anaesthesia care units (PACU) have been established in Europe.20 The Ministry of Health Surgical Block Standards and Recommendations recommend 1.5–2 post-anaesthesia care beds per operating theatre.29

ICU beds have been inconsistently included in previous studies on intensive care resources.7,9,10,30 The present study identified 3470 IMCU-A beds, of which 2089 (60%) provide continuous care, making them de facto level I ICU beds if they have the capacity to provide respiratory support.17–19 The SEDAR White Paper attempted to provide an approach to the organisation of this type of unit,31 but despite their importance in the healthcare system and the fact that they provide care to tens of thousands of patients annually, there is no other document in our country that defines the standards for this type of unit, sometimes of similar or greater complexity than others acknowledged in official documents.

IMCU-A during the COVID-19 pandemic

The number of IMCU-A beds decreased by 27% (−952 beds), with a relative increase (3%) in those providing continuous care. These data, which were associated with the increase in IMCU-A beds, show how contingency plans to increase ICU beds during the pandemic were made possible in large part through the reallocation of resources managed by an ARD usually dedicated to surgical processes.11,14,15 Similarly, it shows that many of the IMCU-As have the resources and flexibility to convert to level II or III ICUs when the situation requires it.

Medical staffing in ICU-A

The European Society of Intensive Care Medicine (ESICM) recognises that there is a multidisciplinary intensive care model in Europe, which can be accessed through both primary specialty programmes in intensive care medicine and other core specialties that include intensive care medicine competencies in their training programmes over a two-year period,32 anaesthesiology being the most widespread example. The Union of European Medical Specialists together with the European Society of Anaesthesiology and Intensive Care (ESAIC) have recently updated their anaesthesiology training programme,33 emphasising intensive care as a core competency of the specialty. In order to meet these European training standards, the Spanish National Specialties Commission has formally requested a new 5-year training programme for the specialty of anaesthesiology.34

The present study demonstrates that this model is a reality in Spain, where 1 in 5 anaesthesiologists perform at least 40% of their activity in an ICU.

There are no standards or recommendations on the ratio of ICU beds to medical staff, and the evidence on the influence of this factor on outcomes is difficult to interpret. 35 However, as the present study demonstrates, there being 7774 active anaesthesiology and resuscitation physicians shows an enormous potential of human resources that could be reassigned from surgical areas to ICU-A during the pandemic; when despite the increase in the number of beds (124%), the ratio of beds per doctor decreased, both during the regular working day and during continuous care (Fig. 2).

Figure 2.

Variation in the number of ICU-A and IMCU-A beds and staffing ratios before and during the COVID-19 pandemic. Showing an increase in ICU beds (bar diagrams), with constant or decreasing ratios of beds to medical and nursing staff (solid, dashed, and dotted lines).

(0.24MB).

These data reinforce the notion that it is essential that anaesthesiologists have training strategies that ensure the acquisition and maintenance of competencies in intensive care medicine throughout their professional career.

Nurse staffing in ICU-A

Nurse staffing has been used to determine the level of care in ICUs.18,19 A recent study published by intensive care nurses in Spain recorded a ratio of 2–3 ICU beds per nurse in 69% of the participating units, with variable ratios in 27% of the units.36 In the present study, an average of 2.7 ICU-A beds per nurse was recorded, demonstrating that nurse staffing does not differ in general terms between ICU-As and ICUs managed by other specialties in Spain. During the pandemic, despite the increase (124%) in the number of ICU-A beds, the ratio of beds per nurse improved, which has been noted by other authors.37 This data can be interpreted as an indicator of the success of contingency plans and the ability of ARDs to quickly and efficiently reallocate human resources from surgical areas or intermediate care units in response to an unexpected demand for intensive care (Fig. 2).

Provision of intensive care respirators

The ability to provide invasive mechanical ventilation is one of the requirements for defining an ICU bed.19 The recent pandemic has demonstrated that intensive care ventilators are a resource of great strategic value. In the present study, the number of ventilators exceeded the number of ICU-A beds, which can be considered an indicator of their adequate provision. However, the fact that the number of ICU-A beds increased 2.24-fold, together with the fact that the most frequent cause of admission was respiratory failure, led to an increase in the demand for ventilators that the market was unable to supply in the early phases of the pandemic. A large number of new ICU-A beds were equipped with other types of ventilators, mostly anaesthesia machines and transport ventilators or other ventilators not specific to intensive care. Although these types of ventilators have been shown to have suboptimal characteristics for the treatment of the most severe cases of respiratory distress,38,39 the survival results published by the Spanish ICU-A network in the COVID-19 pandemic were excellent.22–26

Overall view

It has recently been published that 70% of intensive care resources in Europe are managed by an ARD, reaching 100% in Scandinavian countries.40 The data of the present study demonstrate that Spanish ARDs manage numerous intensive care resources, ranging from IMCU or level I ICU, to ICU of the highest complexity. Royal Decree 69/2015, of February 6, regulating the Registry of Specialised Health Care Activity,41 recognises specific intensive care units, coronary units, large burn units, neonatal and paediatric intensive care units as ICUs as well as post-operative resuscitation units with a fixed number of beds and where administrative admissions take place. However, the term “resuscitation unit” used to identify the majority of ICU-As (67.34% in this study) has proven a non-specific term, as it is used interchangeably to identify IMCU-As in 18.5% of cases. The replacement of the term “resuscitation unit” with the term “anaesthesia intensive care unit” has been previously proposed by some authors.42

A strategic lesson learned from the pandemic is that multidisciplinary and coordinated models of intensive care are more efficient models that can provide sustainability from a human resource management perspective, and the versatility and flexibility needed to adapt ICUs to a changing demand for care.11–15 The results of this study show the inherent adaptive capacity of the ICU-A and IMCU-A, which made it possible to cope with an exceptional increase in the demand for intensive care during the COVID-19 pandemic.

This study highlights the need for the vision of anaesthesiology in the management of intensive care at regional and national level, the need to improve the administrative organisation of the IMCU-A, and the rationality of the fifth year of the specialty in our country.

Conclusions

The present study shows that the ARDs manage a high number of the ICU and IMCU beds available in Spain, and that they have an adequate amount of medical and nursing staff, as well as numerous essential strategic resources, such as intensive care ventilators. The ARDs have demonstrated a great capacity for readapting and reallocating resources to respond to changing needs in crisis situations such as the COVID-19 pandemic, with good results. However, given the constant variation over time of ICU and IMCU resources, and their strategic value, an official registry of ICUs and IMCUs in the different autonomous communities is advisable, which in turn would converge in a national and European census.

Funding

No funding was received for this study.

Conflicts of interest

The authors have no conflict of interest to declare.

Appendix A
Supplementary data

The following are Supplementary data to this article:

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The members of the Grupo de REGISTRO UCI SCI SEDAR are reflected in Appendix A.

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