The variability of critical care bed numbers in Europe - Intensive Care Medicine

The need for critical care capacity worldwide is increasing [1]. This has been described in the USA, where it is recognized that future provision of critical care is unlikely to be able to meet the estimated demands [2]. This potential shortfall has also been described in other countries, such as Norway, as a result of changes in population demographics [3]. Similar patterns are being described in many other countries, although most have been unable to accurately quantify the problem. The future increase in demand is due to a number of factors that include significant changes in the size and age of the population, together with increasing prevalence of relevant comorbidities and changing perceptions as to what critical care can offer [4, 5].

The identification of mechanisms to prevent this mismatch developing needs to take place with some urgency. Several factors have to be taken into account, all of which interact with each other at a variety of levels. Unless admission and referral practices change, the increased future demand can only be met by an increase in total capacity [2, 6]. Without an increase in capacity there will need to be rationing or triaging of available resource to ensure that patients who are most likely to benefit can receive the care they need [7]. Although part of this change may be met by increased provision of outreach and intermediate care [8], there will also need to be an increase in the number of critical care beds and hence also an increase in the numbers of appropriately skilled healthcare professionals to care for the increased number of patients.

To plan for these changes there is a need to better understand the current situation of critical care bed availability [4, 9–11]. Although several countries publish the numbers of beds provided, little is known about how this varies between countries even within a confined geographical region such as Europe. This study therefore aims to identify the total numbers of critical care beds for each country in Europe and to adjust the bed numbers to the population in order to illustrate the differences in resource provided for this group of patients.

This was an observational study assessing the numbers of adult critical care beds in each country in Europe between July 2010 and July 2011. For the purposes of this study critical care includes intensive care (ICU) and intermediate care beds (IMCU). To be included in this study, the bed had to be open, staffed and fulfil any relevant national criteria, where available. The following were excluded from the data collection: private healthcare providers, neonatal and paediatric intensive care beds, coronary care, stroke and pure renal units. The numbers of beds in each country were obtained by assessing data from reliable governmental sources (websites and contacts), national societies with a declared interest in intensive care medicine, national training boards, faculties or colleges and national registries where appropriate. Data obtained were then cross-referenced with the national council representative for the European Society of Intensive Care Medicine (ESICM) and other personal contacts with knowledge of their country, in order to provide face validity for the numbers obtained. In countries where, following this approach, data were still not forthcoming, personal contacts were used and numbers were estimated according to a local sample assessment.

Data describing the total population of each country were identified from a series of publicly available databases. These included the European Commission database (Eurostat) (ec.europa.eu/Eurostat), the World Health Organization (WHO) regional office for Europe, the Central Intelligence Agency (CIA) World Factbook (https://www.cia.gov/library/publications/the-world-factbook/) and the Organisation for Economic Co-operation and Development (OECD). Data were analysed using Graphpad Prism (version 5.1a) and are presented as numbers with a percentage. Linear regression analysis was performed in order to assess likely associations. A p value of less than 0.05 was taken to be significant.

In many countries, readily accessible data with regards to the provision of critical care bed numbers were not available. In some countries, for instance the UK, there were governmental census data. In other countries, data were available through national societies (for instance, Germany). In others no data were found, and local clinicians had to count the beds themselves (Portugal). There were marked differences in how critical care services were set up between countries, with some having separate intermediate and intensive care (Table ESM 1), whilst others manage both flexibly within single services. Some countries also included higher levels of care in acute general wards, for instance the Czech Republic.

We identified a total of 2,068,892 acute care hospital beds in Europe, with marked differences in total numbers of beds and also in the numbers of beds corrected per 100,000 of population between countries (Table 1). On average there were 409 acute care beds per 100,000 head of population. A total of 73,585 critical care beds were identified in Europe. This equates to an average of 11.5 beds per 100,000 head of population for Europe as a whole. The country with the highest number of beds was Germany (23,890), and the country with the least number of beds was Andorra (6). When the total numbers of beds per country were corrected for the size of the population, the differences were less marked although still present (Table 2). Germany still remained the country with the highest number of beds (29.2/100,000), whereas Portugal had the lowest (4.2/100,000) (Fig. 1).

Numbers of critical care beds corrected for size of population (per 100,000 inhabitants) for European countries

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The total numbers of critical care beds per country corrected for population size were positively correlated to population size (r ² = 0.69, p < 0.0001) but only weakly related to the country’s gross domestic product (GDP) (in millions of US dollars) (r ² = 0.16, p = 0.05), the proportion of GDP expended on healthcare (r ² < 0.0001, p = 0.91) (Fig. 2) or the proportion of elderly patients in the population (r ² = 0.04, p = 0.31).

Comparison of the numbers of critical care beds per 100,000 against the proportion of health expenditure as a percentage of gross domestic product (in millions of US dollars). Lines represent linear regression analysis together with 95 % confidence intervals around the line (r ² < 0.0001, p = 0.91)

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On average there are 2.8 critical care beds for every 100 acute care beds across Europe. This again hides a marked variation, however, with Germany and Luxembourg having the highest percentage at 5.1/100,000 and the Czech Republic the lowest (1.3/100,000) (Table 2). The numbers of critical care beds were correlated with the numbers of acute care beds corrected for population size (r ² = 0.12, p = 0.05) (Fig. 3) and also the percentage of acute care beds as compared with critical care (r ² = 0.59, p < 0.0001) (Figure ESM 1).

Linear regression analysis of the numbers of critical care beds corrected per 100,000 population against the numbers of acute care of beds corrected for population size. Data presented are the regression line together with the 95 % confidence intervals around it (r ² = 0.13, p = 0.05)

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In this work we found marked heterogeneity in the numbers of critical care beds between European countries, even when corrected for population size and age distribution, gross domestic product, expenditure on healthcare and numbers of total acute care beds. The differences in provision can be exemplified by the fact the Germany has 6.9 times the number of intensive care beds compared with Portugal per head of population.

The artificial split of critical care beds into either intermediate or intensive care varies widely across Europe despite the move to standardize descriptions across the region [12, 13]. This lack of a consistent definition reduces our ability to compare clinical practice and organizational models across borders and therefore will not help individual countries to build the case for additional capacity in future years. We believe that it would be beneficial to have a European standard definition of exactly what an intensive care bed is, which could then be implemented within the different countries. This definition could include factors related to the unit’s ability to address organ dysfunction/failure, availability of beds throughout the day and week, patient/nurse and patient/doctor ratios, severity of illness and the operative rather than the planned mean level of care of the ICU [14].

The overall number of critical care beds for Europe was 11.5/100,000 head of population. This is in marked contrast to the number for the USA, which Carr found to be 28/100,000 in 2010 [15]. The heterogeneity of the data between European countries is consistent with the findings reported by other groups. Wunsch and colleagues [9] presented similar data although only on a very limited number (six) of European countries in addition to a number of other non-European countries. The provision of intensive care beds that they found within the European region was very similar to the numbers presented in this study, despite their collection of data being from 2005, 5 years earlier.

An interesting question that arises from examination of this data is how the different countries cope with the widely differing levels of critical care capacity. Presumably, in a grossly homogeneous geographical and developed region such as Europe, one would expect that comparable numbers of patients would develop acute critical illness in the different countries. One would hence expect that the different levels of provision should have a major impact on practice and hence presumably outcomes [6, 16–19]. Again comparing Portugal and Germany, it is impossible that Portugal is able to admit the same amount of patients to critical care as in Germany. The implication must therefore be that either patients in Portugal with need for critical care are unable to get it or that Germany overprovides intensive care for its population. Only further analysis of data that describe provision and practice of critical care in detail across countries will enable us to answer these questions. As a start, comparison of data from European countries with established national registries of intensive care could give more insight into such details. At present such registries are operative in England, Scotland, Norway, Finland and Sweden, The Netherlands, and Austria. With the exception of Austria, these are all countries with a relatively low number of ICU beds per population unit, as can be seen in Fig. 1.

We have been able to demonstrate that there are still major differences within Europe regarding provision of critical care services. These differences are too large to be explained purely by differences in the characteristics of the populations and are inadequately explained by the economic strength of the country. In that respect, the three wealthiest countries in Europe [measured in GDP ($)/inhabitant]: Luxembourg (107,358), Norway (83,936), and Switzerland (67,110) have respectively 21, 8, and 11 ICU beds/100,000 population. It seems likely that the healthcare models present in each country have a major impact on the development and prioritization of this resource. This is likely to reflect a variety of factors that range from specialty status, bed and patient models and bed utilization (admission and discharge criteria) protocols. In addition, the staffing of other hospital wards may also play a major role. We restricted this study to the provision of beds through the public healthcare systems, excluding private providers. There may, therefore, be an underestimation of numbers in some countries due to the missing private sector.

More research is urgently needed to understand how the differing numbers of critical care beds impact on practice and ultimately on patient outcomes. If the need for these beds continues to grow, then the most effective and cost-efficient use of this level of care must be developed in order for most countries to be able to afford this level of provision of healthcare.

Authors

1. A. Rhodes

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2. P. Ferdinande

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3. H. Flaatten

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4. B. Guidet

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5. P. G. Metnitz

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6. R. P. Moreno

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