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Scientific Letter
DOI: 10.1016/j.medine.2019.10.007
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Available online 6 March 2020
Intensive Care Medicine and pre-hospital care: Is the integration the key to success? Integra Project
Medicina Intensiva y Medicina Extrahospitalaria: ¿la integración supone la clave del éxito? Proyecto Integra
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P. Burgueño Laguíaa,
Corresponding author
paula.burgue@gmail.com

Corresponding author.
, E. Argudob, F. Enríquez Corralesc, V. González Barrutiad, M. Sánchez-Satorrae, M. Morales-Codinae, on behalf of Grupo de Organización Planificación y Gestión de la SEMICYUC en el Área de Trabajo de Transporte Crítico
a Medicina Intensiva, Hospital Universitario 12 Octubre, Madrid, Spain
b Medicina Intensiva, Hospital Universitario Vall d’Hebron, Barcelona, Spain
c Servicio de Urgencias y Emergencias 112 de Castilla-La Mancha, SESCAM, Toledo, Spain
d Medicina Intensiva, Servicio de Emergencias Sanitarias de Castilla y León, Sacyl, Burgos, Spain
e Servicio de Medicina Intensiva, Hospital Universitari Germans Trias i Pujol, Barcelona, Spain
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Tables (2)
Table 1. Data obtained from the surveys.
Table 2. Data on secondary transfers obtained from the surveys conducted among specialists.
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To the Editor,

The change of paradigm toward an Intensive Care Medicine (ICM) open to early care and follow-up of the critically ill patient requires integrating different levels of healthcare. Also, it benefits from the participation of intensivists trough different ways of multi-professional and multidisciplinary collaboration.1–3 This model should not be exclusive of the hospital setting only. Complexity and technicity in the out-of-hospital setting is on the rise in pre-hospital care and secondary transfers as well as in the early activation processes from this setting. On the other hand, the introduction of special teams for inter-hospital transfers of critically ill patients has become more widely accepted and they have been perfectly sized to meet the needs and complexity of these patients.4–10

The possible role of the intensivist in this setting has not been explored in our country yet. This study was designed to know the big picture on the actual situation of critically ill patients in the out-of-hospital setting and the intensivists’ opinions and interest.

The Scientific Committee of the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC) gave its consent and e-mailed 3 surveys to its members. Surveys were sent to assistant or resident intensivists. In the case of resident tutors, they received another form with more specific questions on the training of their residents. Surveys were opened from March 1 through June 1, 2018. Questions were distributed in different blocks: characteristics of the sample and questions on the working space, training, and opinion. Participation was voluntary and the anonymity of participation was guaranteed. Data were handled and treated with confidentiality.

One hundred and thirty four surveys were obtained from medical specialist (40% of all respondents had already worked in pre-hospital care (PHC); 48% had a permanent job, 25% were interim professionals, and 21% temporal employees), 67 from residents (61% over the last 2 years of their residency), and 12 from tutors.

Data are shown in Table 1. Professionally, pre-hospital care is seen as a professional option for intensivists and it is something that interests them. Most assistant intensivists would like to work in both units if that was possible (64%) being professional motivation the main reason (36%). Working flexibility and the integration of this professional area within ICM services is seen as something positive by 75% of all specialists. On the other hand, there are working issues when it comes to recognizing the specialty of ICM in the PHC setting in some regions, which may condition access to these jobs. Also, respondents say that the time spent working in PHC is not recognized by most ICM job placement programs.

Table 1.

Data obtained from the surveys.

Work
Do you see PHC as a professional option?  F: 63% yes  R: 87% yes     
If possible, would you accept a job in both units?  F: 64% yes  R: 93% yes     
Out on professional grounds only?  F: 36% yes       
How is ICM recognized in your AC PHC job placement programs (compared to FCM)?  Lower32%  Same19%  Higher8%  I don’t know40% 
Is time worked in PHC recognized by intensivist units?  No47%  Yes17%    I don’t know35% 
Integrative elements among different healthcare levels
Do you do group clinical sessions in your unit?  None in 5 years65%  Occasionally in 5 years19%  <3/year12%  >3/year4% 
Do the PHC units have access to electronic health records in your AC/province?  Yes30%  No47%     
Training
Is it part of the residents training?  No: 75% R 
Have you been trained in triage and catastrophes during your residency?  Not yet: 82% R 
Do you think training should improve in this area?  Yes: 87% F and 67% T 
Do you care for air transfers?  Yes: 55% R 
Do you think ICM is an added value to air medicalized rescues?  Yes: 80% F 

AC, autonomous community; F, answer from an assistant intensivist; FCM, family and community medicine; ICM, intensive care medicine; PHC, pre-hospital care; R: answer from a resident intensivist; T, answer from a tutor.

Physicians and residents alike agree that group clinical sessions with PHC services are rare (65% of respondents say they have never ever participated in these sessions over the last 5 years), still they are regarded as useful by 90% of specialists. The computerization of PHC services is also varied.

Regarding training, most residents say this area of knowledge is not part of their curriculum; 82% of them have never been trained in triage or catastrophes. Fifty percent of the tutors think that the new training plan may be insufficient to meet the minimum training needs in this field while 87% of the specialists and 67% of the tutors believe that it is necessary to provide more training in this area.

Regarding critical secondary transfers (Table 2) between intensive care units, most of these transfers are performed by the usual PHC services (61%). These transfers are only specialized regarding ECMO transfers (13%). Forty-two percent say they have organizational issues and lack of secondary transfer protocols including inter-hospital agreements, and minimum safety measures, and informed consent. Referring units are the ones that often have a transfer protocol available (30%). Most respondents think it would necessary to have specialized transfer teams available as part of a national structure to guarantee the flow of these critically ill patients among the different Spanish autonomous communities.

Table 2.

Data on secondary transfers obtained from the surveys conducted among specialists.

Secondary transfer
Are critical inter-hospital specialized transfers available among units in your AC?  No61%  Seldom20%  T-ECMO only13%  Yes5% 
Do you think this type of transfer is necessary?  Yes74%  Maybe21%  No4%   
Regarding secondary transfers, do you have a protocol that includes inter-hospital agreements, safety minimum requirements, informed consent?  No42%  Yes (referring ICU)30%  Yes (receiving ICU)17%  I don’t know11% 
ECMO transfer and referrals
Does your unit have ECMO available?  No 58%  Yes 34% 
Specify the type of ICU with ECMO-capabilities you are referring to:
Patient referring center, without an established T-ECMO    46% 
Patient referring center, T-ECMO is performed anarchically and sporadically by this or that unit    7% 
Patient referring center, T-ECMO is performed in an orderly fashion by our unit    9% 
ECMO reference center, we import and perform T-ECMO    13% 
ECMO reference center, T-ECMO is under discussion    9% 
Do you think T-ECMO is the sole responsibility of the ICM unit?    Yes61% 
Do you think you can perform T-ECMO?    No72% 

AC, autonomous community; ECMO, extracorporeal membrane oxygenation; ICM, intensive care medicine; ICU, intensive care unit; T-ECMO, transfer with extracorporeal membrane oxygenation.

Fifty-eight percent of respondents say they do not have ECMO-type extracorporeal support techniques available; 46% of respondents say they the referring center and are worried about the impossibility of transferring patients with ECMO. When an ECMO transfer is performed, it is carried out by the referring centers in only 16% of the cases, and by the reference center in 13% of the cases. Sixty-six percent of respondents think that ECMO and other extracorporeal support devices are being introduced without any type of territorial organization, thus promoting health inequalities. Sixty-one percent think that this type of transfers is the sole responsibility of the ICM unit, yet most (72%) agree that they have not been trained in these transfers.

This study has many limitations in its design, low participation, and probably selection biases. Even so, it shows the big picture with large areas with room for improvement. It can be said that there is professional interest on this issue among intensivists, and even more among residents, but not with the differences that physicians expect to see. ICM is seen as an added value in this setting yet training limitations and barriers among the different levels of healthcare can be a significant limiting factor. On the other hand, inter-hospital transfers, and especially ECMO transfers, seem to worry many health professionals who believe we still have availability issues to certain treatments and referral therapies among the different centers and organizational issues like lack of qualified personnel and, probably, lack of safety during the entire process.

This study discussed an innovative issue that has become very popular following the growing technical proficiency and complexity of the healthcare process in the management of critically ill patients focused on managing the internal process that runs in our country. That is why results cannot be extrapolated. More studies are needed to help us define the actual role of ICM in these stages of the healthcare process.

Acknowledgements

We wish to thank the Spanish Society of Intensive and Critical Care Medicine and Coronary Units for their help distributing the surveys nationwide.

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Please cite this article as: Burgueño Laguía P, Argudo E, Enríquez Corrales F, González Barrutia V, Sánchez-Satorra M, Morales-Codina M. Medicina Intensiva y Medicina Extrahospitalaria: ¿la integración supone la clave del éxito? Proyecto Integra. Med Intensiva. 2020. https://doi.org/10.1016/j.medin.2019.10.001

Copyright © 2019. Elsevier España, S.L.U. and SEMICYUC
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