A Closer Look at Critical Care Worldwide

2014 - 1 February – Critical Care in Underserved Areas
Ruth Kleinpell, PhD, RN, ACNP, FCCM
Ruth Kleinpell, PhD, RN, ACNP, FCCM, offers up a report from the 11th Congress of the World Federation of Societies of Intensive and Critical Care Medicine.


Engaging the global community to address health disparities for the critically ill and injured is essential to promoting optimal patient outcomes. The World Health Organization estimates more than 50 countries face critical shortages of healthcare workers, adding to a total global deficit of more than 2 million physicians, nurses, midwives and other healthcare workers. As critical care is one of the fastest growing hospital specialties, addressing these issues in underserved areas becomes crucial. 

The 11th Congress of the World Federation of Societies of Intensive and Critical Care Medicine, held last Fall in Durban, South Africa, offered several sessions on the international practice of critical care. The Congress, which was attended by more than 2,000 practitioners from around the world, presented more than 350 lectures and symposia to a multiprofessional audience. More than 500 nurses attended, representing 34% of the attendees, while physicians represented 52%, and allied health professionals represented 10%. 

The World Federation of Critical Care Nurses (WFCCN; www.wfccn.org), an international organization representing 500,000 nurses explored issues impacting the underserved during the 11th Congress of the World Federation of Societies of Intensive and Critical Care Medicine. WFCCN collaborated on several sessions  focused on the international practice of critical care. 

Despite differences in intensive care unit (ICU) capacity and technologies for critical care management, nurses from both developed and developing countries reported a focus on promoting best practices. Several common themes emerged, including staffing, education, and workload issues such as nurse-to-patient ratios. Quality metrics, such as infection prevention, early recognition of sepsis, and strategies for mobilization were shared, while similar global concerns emerged. 

Nurse representatives reported on specific initiatives being implemented in various countries. In Argentina, 24-hour family presence has been instituted, an ICU liaison nurse service was initiated, accredited specializations in critical care are now available at the university level, and hospitals are supporting training in critical care and emergency care. A shortage of nurses was reported.

Representatives from Peru indicated that infection prevention measures have been implemented against catheter-associated bloodstream infection. Strategies to prevent pneumonia are being instituted; however, nurses reported difficulty in obtaining chlorhexidine for oral hygiene. While ICU visiting hours are more open, family presence during invasive procedures and cardiopulmonary resuscitation is not accepted. 

In the United Kingdom, patients are mobilized much earlier in their ICU stay, visiting is less restricted, and palliative care in the ICU is widespread.  

Protocols for sedation and analgesia management have been instituted in Dubai, along with therapeutic hypothermia for post-cardiac arrest and brain injury. A bowel protocol has been implemented, reducing the rate of constipation by 55%.

In Sweden, prevention of ventilator-associated conditions and pneumonia (VAC/VAP) is being targeted with the use of guidelines. The national health authority has chosen several focus areas as quality indicators, including the prevention of patient falls, urinary catheter infections, postoperative wound infections, and intravenous catheter infections. 

The use of Safer Health Care Now Bundles (www.saferhealthcarenow.ca) is being advocated in Canada. Nurse-driven protocols, such as hand-washing audits, have been implemented since the severe acute respiratory syndrome crisis. Visiting hours are typically open in most ICUs with family-centered care, and an effort on reducing medication errors in the ICU is ongoing.

In Turkey, bundle care has been implemented, including a catheter-related infection prevention bundle and VAP bundle. While open family visitation is more widely promoted, family presence during invasive procedures and cardiopulmonary resuscitation is not practiced.

Bundles to improve patient care against VAP and infections also are being used in Iceland. Nursing representatives reported increased follow-up care for patients after ICU transfer. Open visitation is practiced in most units, and monthly interdisciplinary quality meetings are used to review adverse events and communication during handovers.

Early recognition of sepsis is being promoted in Belize, yet nurses cannot administer the first dose of antibiotics as this must be done by a physician.

In Greece, limited ICU visiting hours remain common-place and only physicians are able to provide patient status reports to families.

Open ICU visitation is practiced in New Zealand, and infection prevention measures are ongoing. Nurse staffing in the ICU is an issue, with more beds available than can be staffed.

The topics discussed at the meetings reflect the results of a recent WFCCN international survey on the most important issues facing critical care nursing across 65 countries. Priority areas that were identified included staffing levels, working conditions, access to quality educational programs, wages, formal practice guidelines/competencies and team work. Other factors of importance to the survey respondents were extended/advanced practice, relationship with physicians, formal credentialing process, and use of technologies. 

Less affluent countries identified a need for education and training and improved access to the Internet and other supportive infrastructures. Although staffing levels, wages and working conditions were major issues for over half of the countries, access to education and practice guidelines ranked as higher priorities.

Although addressing country-specific issues related to the provision of critical care is important, engaging the global critical care community to overcome barriers to quality patient care becomes paramount. Focusing on workforce issues, education and training, as well as promoting access to resources such as practice guidelines and best practice recommendations, will help to ensure that health disparities for the critically ill are addressed worldwide.