Correspondence
Primary care – The unrecognized member of the intensive care team
Journal of the Intensive Care Society 2015, Vol. 16(4) 361–362 ! The Intensive Care Society 2015 Reprints and permissions: sagepub.co.uk/ journalsPermissions.nav DOI: 10.1177/1751143715580584 jics.sagepub.com
Zudin A Puthucheary1,2
I have been working at National University Hospital Singapore for a year now on a busy intensive care unit (ICU), much like others in the UK in which I’ve worked. This week there is someone pre-liver transplant, someone for consideration of ECMO (extracorporeal membrane oxygenation) and the usual gamut of critical care staples – severe pneumonias, pancreatitis and acute renal failure. My senior resident is stuck in the emergency department intubating a sick patient, while 80-odd patients wait for a hospital bed to appear for their admission. I’m considering sending someone home from ICU, as there hasn’t and won’t be an in-patient bed for her in the near future. The department has diverse interests in teaching, research and clinical service, and camaraderie is evident among the consultant body. In patient mix and system pressures, this could be the UK. Other aspects are very different – the physiotherapists have mobilized a ventilated patient outside (32 and sunny, as opposed to a British January), there is no sign of a desultory sandwich for lunch (instead a buffet meal prior to the medical grand round) and my juniors have been through an aspirational trans-thoracic echocardiogram program,1 ensuring that I have regular excellent bedside assessments for my sick patients. All in all, it’s a great place to be an intensive care physician. Singapore has been consistently cited as a model of healthcare economics, with 4% of gross domestic product invested in healthcare.2 Secondary care is recognized to be world class, and there is a voracious interest in continued advancement, tying in international experience with local research addressing certain aspects of disease unique to their racial mix. However, I am acutely aware of the absence of organized general practice in this system. Primary care remains fractured. There are 18 polyclinics (subsidized) and 1400 private primary healthcare clinics in Singapore.2 As a result of shared financial responsibility (fees can be subsidized up to 80% depending on means testing), patients shop around for what they perceive to be the best primary care doctors, with long-term plans difficult to develop. Costs of drugs interfere with compliance. Defaulting to follow-up seems to be the norm, either due to costs or as a result of difficulties with integrating personal health needs into everyday life.
Leading causes of morbidity are the major non-communicable diseases: cancer, coronary heart disease, diabetes and hypertension. Long-term management of such chronic diseases is taxing even for the best systems. The lack of continuum of healthcare provision3 leads to a high level of preventable end organ damage.4 Ischaemic heart disease and chronic renal failure are common secondary to hypertension or diabetes.3–5 My remark regarding the relative youth of long-term dialysis patients with triple-vessel disease was met with the international medical language of one-upmanship – ‘‘40? Do you know how many 30 year-olds I see?’’ Teaching on the airway management of severe asthma had to be modified – near fatal asthma with community arrests is common.6 Sadly the majority that make it to our unit recover with beta agonists and steroids – there is no need for high-level care, merely compliance and access to healthcare. This preponderance of established chronic disease impacts on critical care both directly and indirectly. In the acutely unstable patient, hypertensive heart disease contributes to mortality,7 acute renal failure (pre-disposed to by chronic organ failure8) has a high mortality rate, and chronic lung disease may lead to prolonged ventilator weaning.9 ICU survival is only the first stage: chronic disease states are associated with a decline in functional capacity and a higher level of institutionalization.10 Many in critical care focus on survival and subsequent functional disability.11 Yet, it seems increasingly clear that without good long-term chronic disease management – for which the general practice team is essential – critical care will see an increasing number of patients with preventable chronic organ failure, at a younger age. Not only will they be younger but also from areas of social deprivation – those who already 1 Division of Respiratory and Critical Care Medicine, University Medicine Cluster, National University Health Systems, Singapore 2 Institute of Health and Human Performance, University College London, London, UK
Corresponding author: Zudin A Puthucheary, Division of Respiratory and Critical Care Medicine, National University Health System, 1 E, Kent Ridge Road, 119228 Singapore. Email: [email protected]
362 are likely to do worse from critical illness12 and who, from contraction of primary care services in the United Kingdom, will now have limited access to general practice. The link between the quality of primary care and the use of tertiary centre ICU beds may seem tenuous. But this is not so: they are tightly connected across the continuum of healthcare provision. In reality, decreasing the quality of chronic disease management impacts directly on demand for acute services but is masked by the lag-time for end organ failure development. Every hypertension clinic that closes will directly impact on the local critical care service, but it may take a decade for this to be realized. Singapore has chosen to aggressively address this gap in healthcare provision via their Agency for Integrated Care. In the United Kingdom, as primary care services contract, no coherent plan exists for management of chronic multi-system disease in the community – a clear failing of understanding of the interdependence of acute and chronic services. The primary care physician remains one of the core members of the ICU, a fact that needs to be increasingly acknowledged and supported. References 1. See KC, et al. Basic critical care echocardiography by pulmonary fellows: learning trajectory and prognostic impact using a minimally resourced training model*. Crit Care Med 2014; 42: 2169–2177.
Journal of the Intensive Care Society 16(4) 2. Ministry of Health, Singapore, https://www.moh. gov.sg/content/moh_web/home/ (2014, accessed 20 March 2015). 3. Tan CC. National disease management plans for key chronic non-communicable diseases in Singapore. Ann Acad Med Singap 2002; 31: 415–418. 4. Dans A, et al. The rise of chronic non-communicable diseases in southeast Asia: time for action. Lancet 2011; 377: 680–689. 5. Cheah J. Chronic disease management: a Singapore perspective. BMJ 2001; 323: 990–993. 6. Lim TK, and Chay OM. Fatal asthma in Singapore. Ann Acad Med Singap 2012; 41: 187–188. 7. Landesberg G, et al. Diastolic dysfunction and mortality in severe sepsis and septic shock. Eur Heart J 2012; 33: 895–903. 8. Mehta RL, et al. Spectrum of acute renal failure in the intensive care unit: the PICARD experience. Kidney Int 2004; 66: 1613–1621. 9. Quinnell TG, et al. Prolonged invasive ventilation following acute ventilatory failure in COPD: weaning results, survival, and the role of noninvasive ventilation. Chest 2006; 129: 133–139. 10. Kahn JM, et al. Long-term acute care hospital utilization after critical illness. JAMA 2010; 303: 2253–2259. 11. Puthucheary ZA, and Hart N. Skeletal muscle mass and mortality – but what about functional outcome? Crit Care 2014; 18: 110. 12. Welch CA, et al. The association between deprivation and hospital mortality for admissions to critical care units in England. J Crit Care 2010; 25: 382–390.
Primary care – The unrecognized member of the intensive care team
Journal of the Intensive Care Society 2015, Vol. 16(4) 361–362 ! The Intensive Care Society 2015 Reprints and permissions: sagepub.co.uk/ journalsPermissions.nav DOI: 10.1177/1751143715580584 jics.sagepub.com
Zudin A Puthucheary1,2
I have been working at National University Hospital Singapore for a year now on a busy intensive care unit (ICU), much like others in the UK in which I’ve worked. This week there is someone pre-liver transplant, someone for consideration of ECMO (extracorporeal membrane oxygenation) and the usual gamut of critical care staples – severe pneumonias, pancreatitis and acute renal failure. My senior resident is stuck in the emergency department intubating a sick patient, while 80-odd patients wait for a hospital bed to appear for their admission. I’m considering sending someone home from ICU, as there hasn’t and won’t be an in-patient bed for her in the near future. The department has diverse interests in teaching, research and clinical service, and camaraderie is evident among the consultant body. In patient mix and system pressures, this could be the UK. Other aspects are very different – the physiotherapists have mobilized a ventilated patient outside (32 and sunny, as opposed to a British January), there is no sign of a desultory sandwich for lunch (instead a buffet meal prior to the medical grand round) and my juniors have been through an aspirational trans-thoracic echocardiogram program,1 ensuring that I have regular excellent bedside assessments for my sick patients. All in all, it’s a great place to be an intensive care physician. Singapore has been consistently cited as a model of healthcare economics, with 4% of gross domestic product invested in healthcare.2 Secondary care is recognized to be world class, and there is a voracious interest in continued advancement, tying in international experience with local research addressing certain aspects of disease unique to their racial mix. However, I am acutely aware of the absence of organized general practice in this system. Primary care remains fractured. There are 18 polyclinics (subsidized) and 1400 private primary healthcare clinics in Singapore.2 As a result of shared financial responsibility (fees can be subsidized up to 80% depending on means testing), patients shop around for what they perceive to be the best primary care doctors, with long-term plans difficult to develop. Costs of drugs interfere with compliance. Defaulting to follow-up seems to be the norm, either due to costs or as a result of difficulties with integrating personal health needs into everyday life.
Leading causes of morbidity are the major non-communicable diseases: cancer, coronary heart disease, diabetes and hypertension. Long-term management of such chronic diseases is taxing even for the best systems. The lack of continuum of healthcare provision3 leads to a high level of preventable end organ damage.4 Ischaemic heart disease and chronic renal failure are common secondary to hypertension or diabetes.3–5 My remark regarding the relative youth of long-term dialysis patients with triple-vessel disease was met with the international medical language of one-upmanship – ‘‘40? Do you know how many 30 year-olds I see?’’ Teaching on the airway management of severe asthma had to be modified – near fatal asthma with community arrests is common.6 Sadly the majority that make it to our unit recover with beta agonists and steroids – there is no need for high-level care, merely compliance and access to healthcare. This preponderance of established chronic disease impacts on critical care both directly and indirectly. In the acutely unstable patient, hypertensive heart disease contributes to mortality,7 acute renal failure (pre-disposed to by chronic organ failure8) has a high mortality rate, and chronic lung disease may lead to prolonged ventilator weaning.9 ICU survival is only the first stage: chronic disease states are associated with a decline in functional capacity and a higher level of institutionalization.10 Many in critical care focus on survival and subsequent functional disability.11 Yet, it seems increasingly clear that without good long-term chronic disease management – for which the general practice team is essential – critical care will see an increasing number of patients with preventable chronic organ failure, at a younger age. Not only will they be younger but also from areas of social deprivation – those who already 1 Division of Respiratory and Critical Care Medicine, University Medicine Cluster, National University Health Systems, Singapore 2 Institute of Health and Human Performance, University College London, London, UK
Corresponding author: Zudin A Puthucheary, Division of Respiratory and Critical Care Medicine, National University Health System, 1 E, Kent Ridge Road, 119228 Singapore. Email: [email protected]
362 are likely to do worse from critical illness12 and who, from contraction of primary care services in the United Kingdom, will now have limited access to general practice. The link between the quality of primary care and the use of tertiary centre ICU beds may seem tenuous. But this is not so: they are tightly connected across the continuum of healthcare provision. In reality, decreasing the quality of chronic disease management impacts directly on demand for acute services but is masked by the lag-time for end organ failure development. Every hypertension clinic that closes will directly impact on the local critical care service, but it may take a decade for this to be realized. Singapore has chosen to aggressively address this gap in healthcare provision via their Agency for Integrated Care. In the United Kingdom, as primary care services contract, no coherent plan exists for management of chronic multi-system disease in the community – a clear failing of understanding of the interdependence of acute and chronic services. The primary care physician remains one of the core members of the ICU, a fact that needs to be increasingly acknowledged and supported. References 1. See KC, et al. Basic critical care echocardiography by pulmonary fellows: learning trajectory and prognostic impact using a minimally resourced training model*. Crit Care Med 2014; 42: 2169–2177.
Journal of the Intensive Care Society 16(4) 2. Ministry of Health, Singapore, https://www.moh. gov.sg/content/moh_web/home/ (2014, accessed 20 March 2015). 3. Tan CC. National disease management plans for key chronic non-communicable diseases in Singapore. Ann Acad Med Singap 2002; 31: 415–418. 4. Dans A, et al. The rise of chronic non-communicable diseases in southeast Asia: time for action. Lancet 2011; 377: 680–689. 5. Cheah J. Chronic disease management: a Singapore perspective. BMJ 2001; 323: 990–993. 6. Lim TK, and Chay OM. Fatal asthma in Singapore. Ann Acad Med Singap 2012; 41: 187–188. 7. Landesberg G, et al. Diastolic dysfunction and mortality in severe sepsis and septic shock. Eur Heart J 2012; 33: 895–903. 8. Mehta RL, et al. Spectrum of acute renal failure in the intensive care unit: the PICARD experience. Kidney Int 2004; 66: 1613–1621. 9. Quinnell TG, et al. Prolonged invasive ventilation following acute ventilatory failure in COPD: weaning results, survival, and the role of noninvasive ventilation. Chest 2006; 129: 133–139. 10. Kahn JM, et al. Long-term acute care hospital utilization after critical illness. JAMA 2010; 303: 2253–2259. 11. Puthucheary ZA, and Hart N. Skeletal muscle mass and mortality – but what about functional outcome? Crit Care 2014; 18: 110. 12. Welch CA, et al. The association between deprivation and hospital mortality for admissions to critical care units in England. J Crit Care 2010; 25: 382–390.
