Global Critical Care: Key Articles You Missed from Around the Globe

Many of us assume that health systems in high-income countries are adequately resourced to care for critically ill patients and that those in low- and middle-income countries are ill-equipped. However, the pandemic brought into rapid focus the fragility of even the most highly resourced practice settings. During COVID-19, hospitals in Los Angeles ran out of oxygen, the most essential of medications (asamonitor.pub/4aOy0YF). Further, disparities in outcomes from critical illness continue to occur across demographic groups and the rural-urban geographic spread – despite the well-resourced systems within the United States (Demographic Research 2021;45:1185-1218).

With increasing noncommunicable disease burdens such as obesity, diabetes, cardiovascular and cerebrovascular disease, liver and kidney diseases, and trauma, the critical illness burden is rising. Even the wealthiest country in the world is not immune to the strain critical illness places on a health care system. Although lack of training programs and scarcity of trained intensivists plague many countries, the U.S. is also experiencing a physician shortage, especially in rural settings (ATS Sch 2023;4:1-3). Expanded access to fellowship training in the U.S. and other high-income countries for foreign medical graduates is one solution. This could increase the number of critical care physicians for the hosting countries during training, while contributing a higher number of trained intensivists in the trainees’ countries of origin thereafter.

The U.S. is unique in its many pathways toward critical care medicine specialization. Fellowships often accept anesthesiologists, internal medicine, and emergency medicine physicians in addition to pulmonary and surgical programs. Simultaneously, there has been a rise in advanced practice providers advocating for their own independent billing and unsupervised practice. Conversely, in much of the world, anesthesiology is synonymous with critical care medicine. Anesthesiology training models in much of Europe include critical care as part of the core training program. As such, many resource-constrained countries follow this economical all-in-one training model. Unfortunately, there are far fewer trained intensivists in these settings, leaving training less robust than needed. In resource-constrained settings, such as Sub-Saharan Africa, the care of critically ill patients falls to anesthesia professionals, despite inadequate training in critical care medicine. It is here that scope of practice is relevant.

Although anesthesiologists are well trained in resuscitation and mechanical ventilation, care of the critically ill across the entire continuum, including discharge from ICU, requires more specialized training. As the calls to expand capacity and training in critical care medicine increase across underdeveloped health care systems, including the rural U.S., anesthesiologists must lead the way, lest others fill the gap. Anesthesiology physician-led critical care practice optimizes patient outcomes and strengthens our reputation as perioperative leaders. We must seize the opportunity to protect both our patients and our specialty.

Frugal innovation, green practices, resource utilization, cost-savings – these are areas in which the U.S. health care system desperately needs to improve. These are also areas in which resource-constrained countries are better (Crit Care 2011;15:302). Early identification and rapid response, as defined by the Essential Emergency and Critical Care Network, or EECCnetwork, are low-cost solutions that potentially decrease the need for advanced, ICU-level care. These prudent solutions also decrease postoperative mortality and increase pandemic preparedness (BMJ Glob Health 2021;6:e006585).

Movements toward single-use items driven by concerns for safety and infection control have drastically increased landfill waste and carbon output associated with production. The pandemic compacted these problems as contaminated plastics were refused from recycling (Int J Environ Res Public Health 2023;20:4310). This is in stark contrast to the sterilized cloth drapes, reusable sterilized equipment, and judicious use of supplies and pharmaceuticals common when resources are more limited.

The World Federation of Intensive and Critical Care serves as the central hub of critical care societies across the world. Additionally, committees on critical care medicine exist within many anesthesiology professional societies. The Society of Critical Care Anesthesiologists, the Society of Critical Care Medicine, and the World Federation of Societies of Anaesthesiologists may be the most recognizable to North American anesthesiologists. There is great potential for collaboration across professional societies, both in developing health care systems and those that are well-resourced. Global alignment is needed, but this is not a copy-paste scenario.

Societies must work together for culturally cognizant approaches, developing the best solutions for diverse patient populations and practice settings. Too often, solutions offered by high-income countries misalign with the needs of their resource-limited colleagues. One example is demonstrated by the countless short courses and guidelines on triage and resuscitation, while there are too few on fundamental care for the 90% of critically ill patients found outside of ICUs. And, there are virtually no courses or training opportunities appropriate for low-resource settings addressing the daily care of patients necessary for discharge out of intensive care or to reduce the post-ICU syndrome that often follows (Eur J Med Res 2023;28:322).

Embedding critical care training earlier into medical and nursing schools, including the care of patients outside the ICU, would have greater impact on the culture of recognizing and caring for life-threatening conditions using basic equipment and fundamental skills that should be universally available. Professional bodies should encourage and advocate vigorously for review of the curricula in earlier stages of training. This should occur even outside times of crisis.

Global critical care is facing significant challenges and changes. The importance of critical care is not just in ICUs, but everywhere a critically ill patient is found. Aging populations, diseases, conflicts, and uneven access to more advanced health care add to the pressure. Even in wealthy countries like the U.S., we have seen vulnerabilities during events like the pandemic. Anesthesiologists must lead critical care capacity efforts by expanding their training to provide better care and also by learning from resource-constrained countries about efficient and cost-effective ways to care for patients. Collaboration between health care organizations worldwide is essential to finding solutions that work for everyone. It is encouraging that global critical care is evolving and gaining greater priority, but we must work together to improve care for critically ill patients around the world.