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EmergencyCare·PerioperativeCare·CriticalCare·PerinatalCare·Home Care Becauseyoucare Preparing for Disaster

Ascriticalcarespecialists,weareaccustomed to combating life-threatening illness and injuryon a E di t o r i a l dailybasis.Our staff must bevigilantand must beprepared torespond rapidlytoanydeteriora- tion in apatient’scondition,asthatpatient’slife connectionswiththe departments,hospitals maydepend on immediatemedicalintervention. and agenciesthatmightprovecrucialpartners Every day,around the world,criticalcaredoctors in atime of crisis. and nursessavethousandsof lives. Thisissueof ICU Management focuseson dis- But whathappenswhen thousandsof livesare astermanagement,in ordertoshareinsights that put in peril all atonce,in one location? Thissum- mayhelp criticalcaremanagers strengthen their meralone,anumberof disastersituationsrocked disasterpreparedness programs.Inthisissue, the world –atrain bombing in India, atsunami in Drs.Faltlhauserand Thomassharetheirexpertise Indonesia, tropicalstormsin Chinaand armed on careand transport,including the recentex- warfareinthe Middle East,among others.Natural pansion of aeromedicalevacuation operations and man-made disasters alikecanwreckhavoc tonaturaldisastersituations.Dr.Maegele then wheretheystrike,leaving death,destruction, gives anoverviewof the specialconsiderations illness and injuryin theirwake.Trauma, shock, affecting patients who wereevacuated toEurope infectious disease–inthe spaceofafew following the 2004tsunami disaster.Finally, moments,adisastermayproducemoreimmi- Dr.Farmer highlights specificaspects of disaster nentlylife-threatening medicalsituationsthanthe preparedness thathospitaland criticalcareman- average hospitalwould encounterundernormal agers should take intoconsideration well before circumstancesin weeksoreven months. disasterstrikes.Eachofthesearticlesoffers a uniqueand helpfulperspectiveoncoping with When ahurricane,terrorist attackorotherdisas- very differentdisasterresponsesituations. terhits,criticalcarespecialists arecalled on more thanevertopracticetheirlife-saving services.But Disasters forceus tomake tough medicalman- the overwhelming numberof victims,along with agementdecisionsand enterintocollaborative the manylogisticaland infrastructureproblems relationshipsthatmightnotexist during regular produced byadisastersituation,posesignificant ICU operations.Inordertoaccomplishthiseffec- challengestodelivering timely,quality critical tively,wemust beorganized and develop plans care. Disasterresponserequiresphenomenal in advancetomanage worst-casescenarios. coordination of medicalresources,space,priori- Preparedness isthe keytosuccessfuldisaster tiesand personnel –bothwithin amedicalunit response. Ihope thatthe articlesin thisissue and across affected medicalfacilities.This,in turn, of ICU Management offerideasthathelp requirescriticalcaremanagers toplaninadvance, improveyour unit’sdisasterresponseplans. Jean-LouisVincent establishdisasterresponsestrategiesand forge Mayyouneverhavetousethem. Head,Departmentof IntensiveCare,Erasme HospitalFree University of Letters tothe Editor&Requests forReferencesCited in ICU Management Brussels,Belgium [email protected] www.icu-management.org1

Table of Contents Volume 6-Issue3-Autumn 2006

EDITORIAL Preparing forDisasterJ.-L.Vincent 1

NEWS AND INNOVATIONS 4

COVER STORY: PREPARING FOR DISASTER Strategicaeromedicalevacuation in naturaldisasters: A.Faltlhauser,A.Thomas 6 Newtasksformilitary aeromedicalevacuation systems

Tertiary intensivecaretovictimsrepatriated toEurope M.Maegele 10 ICU Management is afterthe 2004tsunami disaster the OfficialManagement and PracticeJournalof The evolving role of criticalcaremedicine in disastermedicalresponse J.C.Farmer 14 the InternationalSymposium on IntensiveCareand MATRIX FEATURES EmergencyMedicine and Tightglycemiccontrol during criticalillness:Overcoming the obstacles S.Nasraway 15 waspreviouslypublished asHospitalCriticalCare. Benefits of aseparateairwayemergencyresponseteamB.Smith,S.Afifi, 17 M.Ault,L.Morris Editor-in-chief Prof. Jean-LouisVincent PRODUCT COMPARISON:TRANSPORTVENTILATORS Belgium Transport ventilators ECRI Europe 21 Editorialboard Prof. Antonio Artigas MANAGEMENT Spain Useofseverity scoresin clinicalpracticeM.Capuzzo 26 Dr.RichardBeale Motivating staff R.Pauldine,T.Dorman 29 United Kingdom Dr.Todd Dorman Evidence-based design supportsevidence-based United States medicine in the ICU D.K.Hamilton 31 Prof. HansKristianFlaatten Norway VIEWS &INTERVIEWS Prof. Luciano Gattinoni Inside the ESAwithSirPeterSimpson A.Heggestad 32 Italy Prof. Armand Girbes EU FOCUS Netherlands Institution Series:EuropeanCourtof Auditors I.Raath 34 Dr.Claude Martin France COUNTRYFOCUS: PORTUGAL Prof. KonradReinhart Anoverviewof the healthcaresystem in PortugalA.L.Jardim 37 Germany Intensivecaremedicine in PortugalR.Moreno 39 Prof. JukkaTakala Switzerland Intensivecaremedicine and emergencymedicine in PortugalR.Matos 40 Intensivecaretraining in PortugalT.Fevereiro,L.Amado 43 Correspondents Prof. David Edbrooke Sepsisand organfailureinPortugalI.Miranda 44 United Kingdom Dr.Anders Larsson CONGRESS PREVIEWS Denmark SCCM’sannualCongress:Improving patientcareSCCM 46 Prof. Esko Ruokonen Finland AGENDA 48 Prof. RetoStocker Switzerland Dr.PatriciaWegermann Letters tothe Editor&Requests forReferencesCited in ICU Management Germany [email protected]

www.icu-management.org3 N e w s

NeWwsorld PRNewswirepress release,the Triage MeterPro the useofthe AutoPulse. The studyanalyzed WHO findsmost countriesfall short combinesBiosite's rapid,easy-to-usetechnology out-of-hospitalcardiac arrest casesbetween of ensuring asafe blood supply withamoreconvenientuserinterface. January 2001and March2005and evaluated www.who.int databeforeand afterRAA paramedicsbegan The Triage MeterProisaportable,rapid testing using the AutoPulse. World Blood DonorDaywasJune 14,2006.To platformdesigned toprovide rapid,quantitative markthe occasion,the World Health orqualitativeresults forimmunoassays using The AutoPulseisdesigned tohelp improveblood Organization (WHO)released anannouncement urine,whole-blood orplasmaand featurescom- flowtothe heart and brain during sudden car- stating thatthe world ismaking slowprogress prehensivebuilt-in quality control capabilities. diac arrest bydelivering continuous,uninterrupt- towardsthe goalof100%unpaid,voluntary blood The Triage MeterPro's user-friendlyfeaturesare ed chest compressions.* donation. According tothe WHO, regular,volun- expected tomake testing even easiertoperform, tary donors aredesirable,astheyareless likely while maintaining the high quality and perfor- According toits MedicalDirectorJoseph P. tolie about theirhealthstatus and maybemore mancestandardsof the existing Triage Meter Ornato,MD, RAA isthe first EMS agencyin the likelytokeep themselveshealthy.Nevertheless, platform. According toBiosite,enhancements to U.S.tohaveshownthatsignificantlymore manycountriesstill fall short of ensuring the the Triage MeterProinclude analphanumeric patients cansurviveand bedischarged from the safety and the sustainability of blood supplies. keypad,75percentlargerdisplay,backlighting hospitalwithuseofthe AutoPulse. Most developing countriesstill depend on paid and fasterprinting. The Triage Meters also donors orfamilymembers; however,some have feature"Test Select™,"enabling healthcare *Clinicaldataavailable upon request. made progress byapplying stricterprinciples providers tocustomizetest menus based on within theirAIDS prevention programs. physicianpreferenceorpatientpresentation when using Triage Test Panelswithmultiple ana- AWHO surveyshowed 56of 124countriespar- lytes.Thisallows customers tousethe same ticipating in the surveysawanincreasein multi-analyteTriage Panel but choosewhich unpaid voluntary donation. The remaining 68 assays torunatthe time of testing. haveeithermade no progress orhaveseen a decline in the numberof unpaid,voluntary Biosite's announcementassuresthatcurrent donors.Ofthe 124countries,49 havereached and futureTriage tests will continuetobecom- 100%unpaid voluntary blood donation. patible withthe Triage MeterProand the Triage TeleflexMedicalexpands Furthermore,the numberof donationsper1,000 MeterPlus.The Triage MeterProisnowavailable respiratory offering population remainsabout 15 timesgreaterin in the United Statesand will launchinternation- www.teleflex.com high-income thaninlow-income countries, allyin the second half of 2006. despitethe increased need forsustained,safe blood suppliesin developing countries. TeleflexMedicalrecentlyissued apress release announcing the launchofaninnovativeinterface Recentstudynotesautomated CPR device The WHO introduced the 100%unpaid,voluntary fornon-invasiveventilation (NIV),designed to helping savelivesin one U.S.community blood donation policyin 1997.World Blood Donor www.zoll.com help patients breathe easier.According tothe Day,celebrated annuallyon June 14,wasestab- press release,the Nasal-AireII CriticalCare lished atthe 58thWorld HealthAssemblyin May The AutoPulse ® ,aportable devicethatis patientinterfaceisasingle patientuse,dispos- 2005bythe WHO's 192MemberStates,tourge strapped around the chest and doescardiopul- able deviceintended foruseinthe hospitaland all countriesin the world tothank blood donors, monary resuscitation (CPR)compressionsauto- othercriticalcaresettingsforthe administration promotevoluntary,unpaid blood donationsand matically,hashelped savelivesin one U.S.com- ensuresafe suppliesof blood forall. of non-invasiveventilation. The newdevice munity. comeswithaunique,patented nosepiecethat sealson the inside of the nose,ratherthanbeing Astudy,appearing in the Journalofthe compressed against it.According toTeleflex,this AmericanMedicalAssociation (JAMA),* tracked design renders obsoletethe bulkyheadgear News AutoPulse ® usage bythe Richmond Ambulance Industry required toachieveasealwithtraditionalNIV Authority (RAA),based in the stateofVirginia. Biosite ® Incorporated introducesTriage® The studyfound that,when compared tomanual- patientinterfaces,eliminating pressureonthe MeterPro™ CPR patients,AutoPulsepatients showed higher faceand bridge of the nose. Thispatient-friendly www.biosite.com ratesof the following: devicealsoallows the usertoconverse,eat, -Returnofspontaneous circulation (34.5% vs.20.2%); drink and wearglasseswhile receiving therapy, Biosite ® Incorporated recentlyunveiled its third- -Survivaltohospitaladmission (20.9% vs.11.1%);and actionswhichareoften hindered byotherNIV generation testing platform,the Triage® -Survivaltohospitaldischarge (9.7%vs.2.9%). maskoptions.Nasal-Aireisaregistered trade- MeterPro™atthe AmericanAssociation for markofInnomed Technologies,Inc. ClinicalChemistry (AACC)2006 AnnualMeeting The studycompared 499 manualCPR casesand in Chicago,Illinois,USA.According toaBiosite 284 casesusing automated CPR, whichinvolved

4 ICU Management3-2006

COVER STORY: PREPARING FOR DISASTER

Strategicaeromedicalevacuation in naturaldisasters: Newtasksformilitary aeromedical evacuation systems

MedEvac hasevolved intoaversitile and usefulmedicaltool fordisasterresponse.

History patients,each. The AE Units of the Luftwaffe-the PriortoWorld WarII, Germanyhadlittle experience “ Sanitaetsflugbereitschaften”-made anoutstand- in aeromedicalevacuation (AE)ofsickand wound- ing contribution tomilitary medicalcareinevacuat- ed patients.The need foraspecialised AE organi- ing thissignificantnumberof casualtiesunderthe sation wasrecognised,organised and used exten- humanitariansymbol of the Red Cross.Thiswas sivelyon all fronts during World WarII.Nearly2.5 the birthofthe modernAE systems. million casualtiesweretransported byregular troop carriers and 11 specialised AE Units,which The modernsystem concentrated on the intensivecareairtransport of Nowadays,almost all continuouslyavailable AE the seriouslywounded,especiallythosewith systemsoperating around the world arestill run brain,eye,jaw,thoracicand abdominalinjuries,or bymilitary institutions.The worldwide military LtCdr.A.Faltlhauser, withgunshotfractures.The AE Units were engagements of Westerncountries–forexample, MD, DEAA equipped withJunkers Ju-52s,whichcould carry the NATO partnercountries–make AE systems Col. A.Thomas,MD upto12litterpatients,plus 3to5ambulatory inevitable. Therefore,the GermanAirForce-

Departmentfor Anaesthesiology,Intensive CareMedicine,Emergency InteriorStretcherConfiguration Medicine,Prehospital Airbus A-310“MedEvac” Ambulanceand Helicopter Service(Head:Col. A. Thomas,MD) BundeswehrCentral HospitalKoblenz,Germany (Head:BrigGen. C.Veit,MD)

LitterKitSection

IntermediateCareSection

ICU Section (see diagram,right)

Figure1:OnboardwithStratAirMedevac 6 ICU Management3-2006 togetherwiththe MedicalService-created a aircraftelectricand oxygen supplysystemsfora StrategicAeromedicalEvacuation System minimumofsixhours.Even emergencysurgical (StratAirMedevac). The primary goalofthisAE sys- proceduresarepossible. All PTUsareconnected tem istoprovide high standardmedicalcarefor toacentralmonitoring unitforsurveillanceand Bundeswehrsoldiers.Itwassetuptoconduct documentation purposes. long-range evacuation operationsforsoldiers in criticalmedicalcondition,transporting them from This“flying ICU”isoperated byamedicalcrew deployments likeAfghanistanbacktoGermany. consisting of:aSeniorMedicalOfficer“Flight StratAirMedevac employs avariety of aircrafts, Surgeon,”serving asorganising “MedicalDirector;” suchasthe CL-601Challengerjet,the C-160 anEmergencyCareSpecialist Nurse“Crew Transall turboprop aircraftand,most importantfor Chief;”aMedicalEquipmentTechnician;two long-range StratAirMedevac, the Airbus A310(see Anaesthesiologyand intensivecaremedicine figure1). Specialists; twoEmergencyCarePhysicians; an ICU CareSpecialist Nurse;sixEmergencyCare OnboardaStratAirMedevac flight Specialist Nurses; fiveEmergencyCareAssistant The multi-role AE aircarrieristhe logisticbasisof Nurses; and sixMedicalStaff Soldiers.The aflying intensivecareunitforatotalof44recum- MedicalDirector,assisted bythe MedicalCrew bantpatients.Itissubdivided intoalitterkitsection Chief,isresponsible forcoordination and organisa- for28patients,anintermediatecaresection for10 tion. Asanexperienced flightsurgeon,he isthe patients and 6patienttransport units (PTU)meeting link between the flightcrewand the medicalteam. level 1traumaICU standards(see figure1). The Togetherwithone of the Anaesthesiology litterkitsection hasbasicmonitoring capabilities Specialists,he takesresponsibility forpre-flight (3-lead ECG, NIBP and pulseoxymetry),aswell patienttriage and positioning in the aircraft,aswell asalimited numberof emergencyrespirators asforpatientloading and unloading. (DraegerOxylog 2000). Moving suchalarge numberof severelyinjured All sixPTUsareequallyequipped and standardised patients involveschallenging behind-the-scene (see figure2). Theyprovide full ICU careand moni- logistics.Adequatepatientcollection,staging and toring and areable tofunction independentfrom loading facilitieson-scene areessential(e.g. patients havetobe moved intothe airplane withahigh lifter through the cargo door). Sufficientenergy and oxygen supplydur- ing long flights and dis- tinctplanning of patient movementafterarrival atthe destination air- port areotherkey issuesin setting upan AE operation. Finally, thishighlysophisticat ed tool forindividualised patienttransport needs adequateairport infra- structure,aslanding is onlypossible atairports withlong enough,con- creterunways.Ifthere isno fixed building Figure2:MedicalEquipment,PTU available forpatient www.icu-management.org7 COVER STORY: PREPARING FOR DISASTER

handover,the consequencesof patienttransfer in patientselection and emergencymedicalcarein outside of clinicalconditions–often in extreme cli- Thaihospitalspriortothe repatriation flight.Inthis maticsurroundingsand undermassivepublicand situation,based on afunctionalinfrastructurein mediainterest –haveanenormous impacton AE the home country,the “MedEvac-Airbus”wasthe staff’sworkperformance. Therefore,advance perfecttool notonlyforreturning Western access todetailed medicalinformation about all Europeantourists totheirhomes,but alsoto patients tobetransported isextremelyhelpfulto relievethe Thaimedicalsystem from anover- the AE crew.Aside from certain infectious dis- whelming numberof patients in avery short peri- eases(e.g.hemorrhagicfever),thereisalmost no od of time. contraindication forStratAirMedevac transport. StratAirMedevac evacuation maybecontraindicat- Conclusion ed forconditionssuchasuntreated intracranialair, The mission of aStratAirMedevac in naturaldisas- uncontrolled bleeding and massiveARDS,depend- ters istwofold. Inthe initialphasefollowing anat- ing on the localsituation,drugsupply,surgical uraldisaster,anoperation isprimarilyfocused on capacity onboardand flighttime. bringing material,personnel and expertisetothe affected area.Even if thisisnotthe primary goalof Newtasksforthe “MedEvac-Airbus” anAE operation,basicmedicalaid forthe suffering Although AE beganprimarilyasamilitary function, and searchand rescueactivitieson-sitearethe moreand moregovernmentaland privateorgani- most crucialtasks.Inthe second phase,afterini- tialstabilisation of the localsituation, aneatlyplanned AE operation isan option,torelievethe localmedical system from difficultand resource- consuming patients.AE withahighly sophisticated system asthe “MedEvac-Airbus”onlymakessense foruseinrepatriating foreign citizens, becauseoflimited airtransportation capacitiesin areaswithdestroyed infrastructure. Ongoing globalisation spreadsWesternEuropeancitizens overthe whole world. Therefore,the legaland commercialinterests of reinsurancecompaniesand govern- Figure3:Left:Typicaltransport situation in earlyphaseafterdisasterAE mentalauthoritiesforevacuation of Right:Unloading and patientdistribution after3rdtsunami flight theircitizensorcustomers aftermajor incidents make the futurecivil useof AE systemsamoreand morelikely sations,suchastravel agencyreinsurancecompa- scenario. 4 nies,arerequesting the “MedEvac-Airbus”to repatriatetheircustomers from disasterareas. Priortothe 2005Southeast Asiantsunami disas- ter,the “MedEvac-Airbus”wasused forrepatriat- ing casualtiesfrom bombattacks(e.g.Karachi, Pakistan,2002 and Djerba, Tunisia, 2002)and majoraccidents (bus crashinPuebla, Mexico, 2004). Withthe 2005tsunami disaster,the “MedEvac-Airbus”took on anewrole,responding tonaturaldisasters.

Inthe aftermathofthe tsunami,atotalofthree Photographs,in part,have Airbus flights wereconducted oversixdays,carry- been generouslyprovided ing atotalof123 severelyinjured (ISS >25inmore by: than30%) Europeancitizensbackhome. Although Prof.A.LechleuthnerMD, Figure4:CivilianStratAirMedevac operation 2002-2006 LtCol. S.SchaeferDiplMed, laterStratAirMedevac flights focused purelyon LtCol. G.HölldoblerMD, transport of severelyinjured citizens,the medical Referencesforthisarticle areavailable upon request at Maj. V.Mengel MD. crewmembers of the first flightwerealsoinvolved [email protected]

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Tertiary intensivecare tovictimsrepatriated toEurope afterthe 2004tsunami disaster

Individualsevacuated followingthe 2004tsunami disastersustainedtraumaticinjuries tothe head,chest and limbsthatwerecontaminated withhighlyresistantbacteria. Transferred patients from disasterareasshould beisolated until theirmicrobialflora areidentified,astheymayintroducenewand unusualpathogensintoanintensive careunit(ICU). Aggressivedebridement,togetherwithvacuum-assisted closurefor the interim,broadantimicrobialcoverage and psychoemotionalintervention,were cornerstonesof the successfulmanagementof the evacuated tsunami victims. Introduction MarcMaegele,M.D. OnDecember26,2004,agiantearthquake the CMMC forfurthersurgicaland ICU treatment. Departmentof Traumaand shockedSoutheast Asia, triggering deadlyflood Nodeathswerereported en route. OrthopedicSurgery waves(tsunami) across the IndianOcean. More IntensiveCareUnitof the than310,000 people werereported deadand mil- Majorproblem:Contaminated woundsand Departmentof Traumaand lionsleftdestitute. Shortlythereafter,European OrthopedicSurgery uncommon respiratory infections (Director:Prof. Dr.Bertil governments repatriated the most severelyinjured The predominantpatternofinjuryin the tsunami Bouillon,M.D.) tourists using MedicalEvacuation (“MedEvac”) victimsconsisted of multiple large-scale,soft-tis- Cologne-Merheim Medical aircrafts.Upon arrivalinEurope,patients were suewounds(range:2x3 cm–60x60 cm) in the Center(CMMC) distributed tovarious medicalcenters.One cohort lowerextremities(88%),upperextremities(29%) University of of severelyinjured patients wasadmitted tothe and head(18%) (see figure1,page 12). Additional Witten/Herdecke Cologne-Merheim MedicalCenter(CMMC)in injuriesincluded thoracictraumawithhemopneu- E-Mail:Marc.Maegele Germanyforfurthersurgicaland intensivecare mothoraxand serialribfractures(41%) and periph- @t-online.de unit(ICU)treatment(Maegele etal. 2005; eralbone fractures(47%),bothopen and closed. Maegele etal. 2006). Amajorproblem associated withwound manage- Triage and AirTransfer mentin thesepatients wassignificantcontamina- Following the tsunami,Europeangovernments tion. Microbiologicalassessmentidentified not quicklyorganized airlifts toevacuateinjured citi- onlyavariety of common isolates(Pseudomonas zensfrom the disasterarea.Theirstrategywasto 54%,Enterobacteriae36%,Aeromonasspp. evacuatepatients withminorinjuriesfirst,simulta- 27%),but alsouncommon isolates,whichwere neouslyproviding capacity tocareformoresevere- often multi-resistant(multi-resistantAcinetobacter lyinjured and hospitalized patients,who were and ESBL-positiveE.coli,18%each). The process unable toreachthe airport forevacuation. of near-drowning in seawaterinvolvesthe aspira- Following the establishmentof first-aid and collect- tion of immersion fluids,aswell asmarine debris, ing points atevacuation airports,“scout”teams intothe respiratory tract,thus providing intrapul- wereformed tosearchforinjured tourists.Initial monary inoculation of bacteriaand inducing pneu- surveys along the coasts quicklyindicated that monitisand pneumonia.All our patients showed onlydeadbodiesremained atand nearthe radiologicaland clinicalsignsof pneumonitisupon seashore,and thus the ongoing searchfocused arrival,and respiratory tractspecimenscontained a primarilyon localhospitalsin whichvictimshad high rateofmulti-resistantAcinetobacterspecies, received first-aid and treatmentfocusing on basic aswell asmethicillin-resistantStaphylococcus stabilizationofcardio-respiratory functions,wound aureus (MRSA),Aeromonashydrophilia, Pseudo- managementand infection control. monasspeciesand Candidaalbicans.Table 1on page 25summarizescausativepathogensand Upon triage atthe collecting point,patients with locationsfrom whichtheyhadbeen identified. minorinjurieswereairlifted viaregularorambu- lanceaircraft.Criticallyill patients wereevacuated Wound managementfocused on aggressiveand byAirbus A310MRTMedEvac aircraftfollowing repetitivedebridement,including removalofdevi- stabilizationofvitalfunctions(Zylka-Mehnhorn talized tissues.Intwocases,amputationswere 2005). Within ashort time,approximately2,500 inevitable. Between initialwound surgery and uninjured tourists and tourists withminorinjuries, delayed secondary closure,withorwithout skin aswell as300 moreseverelyinjured tourists from grafting,woundswereprotected using VAC® various countries,wereevacuated. Upon arrival therapy(VacuumAssisted Closure ® /V.A.C. afterthe 15-hour MedEvac flightfrom Phuketto Vakuumquellen,KCI Therapie Geräte,Höchstadt, the Cologne,Germany,military airport,one cohort Germany)(Argentaand Morykwas1997; Joseph of severelyinjured patients wastakendirectlyto etal. 2000;Mullneretal. 1997).

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Our initialchoiceofanti-infectivetherapywasa Upon arrivalinGermany,psychologicalcareforthe combination of apotentquinolone withclin- evacueeswascontinued directlyatthe airport by damycin.Thisstrategyiscommonlyfollowed in our disasterintervention teamsand emergencypas- facility forinfection of unknownorigin and general- tors,coordinated by Nachsorge,Opfer-und lycorrespondstothe guidelinesof the Paul-Ehrlich Angehörigenhilfe (NOAH),aspecialdivision of the Society forChemotherapy(Bodmanand Vogel FederalOfficeforCivil Protection and Disaster 2001). Thisapproachcovered majorpathogensthat Management( Bundesamtfür Bevölkerungsschutz could initiallybeexpected in our incoming patients und Katastophenhilfe ,orBKK). Thissupport net- (Lim 2005). Anti-infectivemanagementwas workalsointroduced telephone hotlines,assem- immediatelyadopted according toincoming bled (togetherwithairline companies)passenger results from microbiologyand resistancepatterns lists of the less severelyinjured patients who were (see table 1,page 25). evacuated on regularflights and distributed educa- tionalpamphlets on typicalclinicalsignsof post- Psychoemotionalaftermath traumaticstress syndrome toeacharriving victim, The full impactof the tidalwaveonthe mental indicating when toconsultprofessionalsupport. healthofsurvivors isstill unknown(Miller2005). In Upon federalrequest,the Departmentof February 2005,the World HealthOrganization Psychotraumaof the University of Heidelberg (WHO)estimated thatupto50%ofthe fivemillion assembled acomprehensivelist of 400 qualified people affected bythe tsunami would experience psychotherapists offering immediatesupport moderatetoseverepsychologicaldistress. nationwide when needed. Thesematerialsare Approximately5-10%would develop morepersist- intended tobepreserved orfurtherdeveloped for entproblems,e.g.depression,posttraumatic futuredisasters,and the foundation of anation- stress disorder(PTSD)orotheranxiety disorders wide and independentInstituteforPsychotrauma unlikelytoresolvewithout intervention. isbeing discussed (Bühring 2005). Psycho- therapeuticsupport forpatients and relatives Among all patients and relativesthatweretreated treated in the Cologne-Merheim MedicalCenter in our facility,clinicalsymptomsof posttraumatic wasprovided bythe department´spsychothera- psychologicalstress peuticintervention team,consisting of three responsewere qualified and experienced psychotraumatologists, noted. All patients available 24/7 upon request. treated in our hospi- talhadsuffered loss Summary /Conclusion of atleast one rela- Apatternofsevere,large-scale,soft-tissuedamage tive,and twomoth- including high-level contamination wascommon to ers of our cohort all tsunami victimsevacuated toour medicalfacili- lost bothoftheir ty.Microbiologicalassessmentidentified common children. Major aquaticpathogens,but alsoanunusuallyhigh rate complaints included of multi-resistantstrainsthatmayspreadeasily nightmares,emo- among patients treated in localhospitals.Strictiso- tionaldetachment, lation and broadmicrobiologicalassessmentis sleep difficulties, recommended forinfection control in patients flashbacks,head- arriving from thoseareas.Foroptimumtreatment, Figure1:Large scale softtissuewundsand vacuumsealing achesand intrusive tightcollaboration between surgeons,intensivists thoughts based upon and microbiologists ismandatory.Inaddition,care individualexperi- forthe physicalneedsof disastervictimsneedsto encesduring the disaster.Psychoemotionalrespon- bebalanced withcareforthe patients’emotional sesfurthercomprised distress about injuriessus- needs.Thus,anetworkofpsychologicalsupport is tained,dissociation,optical,acousticaland olfactory anessentialcomponentin disastermanagement. intrusionsand,in some cases,agitation. Using thisholistic, body-and-mind approachto criticalcare,our hospitalwassuccessfulintreating Tocoverthe psychoemotionaltraumaassociated the severelyinjured tsunami victims,preventing withthe disaster,non-governmentalorganizations the spreadofunusualmicrobesthroughout our (NGOs)and theirlocalpartners undertook efforts hospitaland setting the stage forour patients’ toassureinitialpsychologicalsupport alreadyat long-termhealing process following one of the the scene of the tsunami,in particularforchildren biggest naturaldisasters of our time. who,in part,suffered the loss of bothparents. + continued on p. 25

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COVER STORY: PREPARING FOR DISASTER

The evolving role of criticalcaremedicine in disastermedicalresponse Disasters areoften unexpected and cancausesignificantstrain on criticalcare resources.Dr.Farmerdiscusseskeyconsiderationsin criticalcaredisasterplanning.

Overview importantly,non-criticalcare,hospitalpersonnel Wehavetraditionallyfocused on the pre-hospital must betaughtalimited (defined) ICU skill set. caresetting asthe primary building blockofour 2.Portable criticalcare –Alarge-scale disaster disastermedicalresponsesystems.Weassume responsemayrequirethe provision of high-level thatthe hospitalwill “bethere,”will receivecasu- criticalcareinunanticipated locales(non-hospital, J.ChristopherFarmer, altieson short-notice,will rapidlyescalateemer- non-ICU). Wemust develop civil responsesystems M.D. gencycarecapabilitiesand will reliablymeetthe of portable criticalcareforuseduring large disas- Professorof Medicine and unexpected demandsimposed on the system. ters.United Statesmilitary experienceswith“far Consultantin CriticalCare Unfortunately,thisnotion isbothshort-sighted and forward” criticalcare,including the U.S.AirForce Medicine dangerous. CriticalCareAeromedicalTransport Teams(CCATT) MayoClinic Most hospitalsarechronicallyunder-funded,and program,offerausefulperspectiveforthe devel- Rochester,MN manystruggle just tomeetdaily,routine care opmentof civil-response,portable criticalcarepro- 507-255-3275 requirements.Inaddition,and aswehaveseen grams.CCATT hasalreadydealtwithmanyof the [email protected] time and time again,during amajordisaster,the challengesthatwemust overcome in ordertocare need forcriticalcareexpansion becomesuniversal. forpatients who requirecarebeyond the hospital, The hospitalbecomesanover-sized intensivecare and its applicability should befurtherexplored. unit(ICU),bothforpre-existing patients and disas- 3.Augmented on-sitecarecapabilities –Ofall tervictims.Unfortunately,most hospitalslackthe the medicaldeviceand supplyissuesthatweface, necessary clinicaltraining programs,sufficientper- the biggest conundrumismechanicalventilators. sonnel and the necessary equipment/supplystock- Inour alreadybusy criticalcareunits,anoutbreak pilestomeetthesedemands. of pandemicinfluenzaoravianinfluenzawould Furthermore,weassume thatthe hospitalstruc- quicklyoutstrip available respiratory careresources turewill physically“bethere” and will beusable (machinesand personnel). Moreover,the recent during adisaster.Whatif the building itself is SARS outbreakharshlyreminded us of the person- rendered unusable? Whatif itispartiallyunder alhealthriskstoICU personnel caring forafflicted water?Whatif acommunicable diseasedrastically patients withrespiratory failure,furthercomplicat- reducesthe available personnel pool needed to ing careprocesses.Manyquestionsremain unan- careforpatients?Manyhospitalsdo nothave swered. Wherewill additionalventilators come reality-based,executable plansforthesepotential from? Who will payforthem? Whatlevel of scenarios. machine sophistication ismandatory?Who will operatethesedevices? Framing the issuesin ordertoformulate 4. The impactof chroniccriticalillness –We necessary solutions haveasignificantlyincreasing population of ICU Letusenumeratethe issuesthatwemust address patients forwhom our therapeuticendpointisnot in ordertoassurethathospitalsare“on-line”and the elimination of criticalillness,but ratherestab- capable of meeting the criticalcaredemands lishing asustainable equilibriumwithacutedis- when amajordisasteroccurs: ease. Thesepatients requireaccess toregularand 1. Education and training –Education and train- frequentcare. Wheredothesepatients go forcare ing arerelativelylow-cost,high-yield interventions during adisaster?Thisproblem isnotdealtwithin thattangiblyenhancedisastermedicalresponse anymeaningfulwaybyexisting disasterresponse atevery level. However,currentdisastermedical plans.The onlyworkable solution involvesthe geo- education programsforhospitalpersonnel arenot graphicalmovementof thesepatients toother coordinated in scope and contentand do notade- localesin orderto“offload” the disastersite quatelyaddress the needsof criticalcareperson- responsesystem. Again,thiswill requirethe exis- nel. Educationalinitiativesmust:a)heighten disas- tenceofaportable criticalcareresponsecapability. terresponseawareness; b)measurablyenhance 5. Improved interoperability –Cooperation skill sets; c)define and teachindividualrolesand among hospitalsduring day-to-dayoperationsis responsibilities; d) teachalternatecommunication nil. Financiallyand otherwise,itlargelyremainsa methodsforuseduring adisaster; e) include self- facility-by-facility struggle fordailysurvival. preservation training;and,f) introducethe concept Therefore,the expectation thatduring adisaster, of howtoworktogetherduring mayhem. Most + continued on p. 25

14 ICU Management3-2006 MATRIX FEATURES

Tightglycemiccontrol during criticalillness: Overcoming the obstacles

Salientliteratureisreviewed describing the benefits and concernsof tightglycemiccon- trol in criticallyill patients.Hypoglycemiaand otherpitfallswithimplementation of an intensiveinsulin protocol arediscussed.

Criticallyill patients frequentlydevelop hyper- United StatesVeteransAffairs ICU Stakeholder glycemia.Until recently,therehavebeen few MedicalCenters database Anaesthesiology scientificreasonsput forthforcorrecting this investigation (announced atthe Cardiology hyperglycemia. June 2006 AmericanDiabetes Pharmacy Association annualmeeting) Internalmedicine Despitevery little exploratory investigation topre- mayhaveput the entireissue cede it,Vanden Berghe and colleaguesboldly torest.Towit,thisstudyof Microbiology embarkedupon the Leuven study:alarge prospec- 216,775criticallyill patients Nephrology tive,randomized,surgicalintensivecareunit,con- from 177 mixed ICUsdemon- Respiratory trolled trialtesting the hypothesisthatstricteug- strated thateachincremental ... lycemiccontrol using intensiveinsulin infusions increaseinblood glucose could increasesurvivaland reducemorbidity in a above6.1 mmol/Lincreased mortality.Survival criticalcarepopulation (Vanden Berghe etal. withnormoglycemiaincreased in medicaland in 2001). Theystudied 1,548 surgicalpatients (62% septicpatients,notjust in patients withcardiovas- post cardiac surgery),withthe aim of maintaining cularorsurgicaldiseases(FalcigliaAmerican ablood glucoserange between 80-110mg/dL(4.4 DiabetesAssociation,June 2006). -6.1 mmol/L). Theyobserved a42%reduction in riskofdeathand in various morbidities,particular- Managementof hyperglycemiahasbecome atop lyin the prolonged staygroupofpatients.Other priority in the careofcriticallyill patients,withthe comparativestudiesfollowed,in cardiac surgery JointCommission on Accreditation of Healthcare (Finneyetal. 2003; Lazaretal. 2004),trauma(Grey Organization,the InstituteofHealthcare and Perdrizet2004),mixed medical-surgical Improvement,the AmericanDiabetesAssociation (Krinsley2004) and alarge medicalICU population and The VolunteerHospitalAssociation all strongly (Vanden Berghe etal. 2006),reproducing the advocating forits implementation. same signalinapproximately5,000 combined patients,i.e.,thathyperglycemicmanagement The chief obstaclestoimplementation of rigorous, decreasesmortality and morbidity. tightglycemiccontrol aretwofold:nursing“push- back” and fearof hypoglycemia.Pushbackoccurs Asingle,large Germanstudy(VISEP),asyet becauseintensiveinsulin treatmentrequires unpublished,failed toshowbenefitwithintensive frequent,often hourly,blood glucosemonitoring; insulin in 537 patients withseveresepsis thispracticeisinherentlylaborintensive,placing StanleyA.Nasraway,Jr., (Brunkhorst etal. 2005). However,the experimen- significantdemandson the bedside nurse. MD, FCCM taldesign failed toexclude confounding variables Protocolizing euglycemicmanagementisameans DirectorSurgicalIntense bynotcontrolling forconventionalaspects of sep- of insuring standardized care,reducing variability CareUnits siscare(antibiotics,resuscitation,mechanicalven- and increasing the likelihood of hitting the target ProfessorSurgicalMedicine tilation). Becausethe studywasstopped prema- blood glucoserange in the earliest time possible. and Anesthesia turelyduetopotentialbut unrealized harmfrom Even withprotocolization,studieshaveshownthat Departmentof Surgery Tufts-NewEngland Medical hypoglycemia, itisnotsurprising thatno conclu- dailyfluctuationsin blood glucosearecommon Center siveobservationsrelated tobenefitcould be and significant(Finneyetal. 2003; Zimmerman Washington St., made. etal. 2004). Boston,MA02111 Snasraway@ Large multi-nationalstudiesongoing in Europe Hypoglycemia, defined asablood glucose<40-60 tufts-nemc.org (GLUControl) and in Australia/NewZealand and mg/dL[2.2-3.3mmol/L], isnowrecognized to Financialdisclosure: Canada(NICE-SUGAR)togetherwill targetsome befrequent(see figure1)and often severe SantraMedicalCorporation, 8,000 patients and should elucidatethe actualben- (Vriesendorpetal. 2006; Kanji etal. 2004). Fewif Investigator efits of intensiveinsulin. However,results of a anyirreversible consequencesof hypoglycemia www.icu-management.org15 MATRIX FEATURES

havebeen published in the setting of intensive insulin,but suchconsequencessimplymayhave been unobserved orunreported. Renalfailure, becauseitlengthensthe duration of action of insulin,and the unadjusted discontinuation of nutrition/feedingswithout adecreaseinconcomi- tantinsulin administration arethe twomost com- mon riskfactors associated withhypoglycemia. Additionally,recentevidencesuggests that “fingerstick” capillary blood tested bybedside glucometermaybefrequentlyinaccurate,particu- larlyin the hypoglycemicrange during whichthe trueblood glucoseisactuallyunderestimated (Kanji etal. 2005).

Looking tothe Future Manyquestionsremain tobeanswered. Whatis the properblood glucosethreshold thatmust be maintained? Itmaywell bethatdifferenttypesof patients requiredifferentthresholdsof blood glu- cosetoachieveabenefit.Howcanintensive insulin therapybeprovided in the least laborious, nurse-intensivefashion? Therewill havetobe improvements in bedside blood glucosemonitor- ing.The holygrail of devicetechnologyundoubted- lywill bethe ability tocontinuouslymonitorpatient blood glucoseconcentrations,perhapsusing fiberopticorinfrared technology(Krinsleyetal. 2005). Continuous monitoring will provide multiple benefits:first,itwill permitsmoother,timelier adjustments in insulin infusionstomorequickly achievethe blood glucoseendpoint; and second,it will provide earlywarning tocaregivers about incip- ienthypoglycemia.Thislatterconcernhasbeen a flashpointof debateinintensivecareunits thatare balancing stricteuglycemiaagainst safety con- cernsforthe patient.Continuous monitoring will bepivotalnotonlyin measuring absoluteblood glucosevalues,but moreimportantlyin signaling emerging trendsovertime. 4

Leuven SICU,2001;n=765 16.7%

Zimmerman,2004;n=168 4.0%

Kanji,2004;n=50 6.9%

Vriesendorp,2006; n=2,272 18.7%

Leuven MICU,2006; n=595 7.6%

VISEP,2006; n 260 18.0% ˜ 051015 20 %Hypoglycemia, < 40mg/dL Figure1:Hypoglycemiain studies

16 Benefits of aseparate airwayemergency responseteam

Dr.Afifi and colleaguesexplain howestablishing adedicated hospital-based airwayemergencyresponseteamresulted in the reduction of cardiac arrest calls,efficientuseofavailable resourcesand minimized disruption in routine patientcare. Theyalsodescribethe method of process improvementused byanactive,multidisciplinary team. ICU Stakeholder Anaesthesiology Cardiology forpatients thatinitially Background Pharmacy NorthwesternMemorialHospitalisanationally experienced adocumented Internalmedicine recognized,744-bed academicmedicalcenter airwaycomplication priorto located in Chicago,Illinois,USA.Itisthe primary theircardiac arrest (see fig- Microbiology teaching hospitalforNorthwesternUniversity’s ure1,page 19). Upon review Nephrology FeinbergSchool of Medicine. The cardiac arrest of thisdata, the CPR Respiratory teamhasbeen NorthwesternMemorialHospital’s Committee theorized that ... traditionalstandardforemergencyresponseinthe the patientpopulation expe- eventof sudden cardiac arrest orpatientunrespon- riencing respiratory failure siveness.The cardiac arrest teamisamultidiscipli- priortocardiac arrest maynothaveprogressed to nary teamofhealthcareprofessionalsconsisting of anactualcardiac arrest if earliermedicalinterven- physiciansfrom medicine,surgery,anesthesiolo- tion byspecialized clinicianswasavailable totreat BrianL.Smith, gy,nursing services,pharmacyand respiratory and augmentrespiratory efforts.Thus,the CPR RCP,R.R.T. Administrative/Clinical care. Members of the cardiac arrest teamarecon- Committee embarkedonaquality improvement Director,Respiratory Care currentlypaged torespond toacardiac arrest by projecttobetterrespond tothesepatients. NorthwesternMemorial the hospitaloperator,onceanautomated arrest Hospital,Departmentof Anesthesiology call button,located in anyinpatientoroutpatient Process improvement-DMAIC NorthwesternUniversity clinicalarea, hasbeen activated. AtNorthwesternMemorialHospital,quality FeinbergSchool of Medicine improvementprojects utilizeaprocess improve- [email protected] Quality monitoring and datacollection menttechniquereferred toas“DMAIC Process Sherif Afifi, Quality monitoring and arrest dataarereviewed on Improvement.” DMAIC isanacronymthatstands MD, FCCM, FCCP amonthlybasisbythe Cardio-Pulmonary forDefine,Measure,Analyze,Improveand Chief,Division of Critical CareMedicine, Resuscitation (CPR)Committee. The CPR Control. DMAIC isastep-by-step approachto NorthwesternMemorial Committee isamultidisciplinary committee com- process improvement.The goalofDMAIC process Hospital prised of representativesfrom bothclinicaldepart- improvementistoreducethe defects orinefficien- AssociateProfessorof Anesthesiology ments and non-clinicalsupport departments.The ciesassociated withaprocess,delivermeasurable NorthwesternUniversity CPR Committee isunderthe medicaldirection of improvements and maintain theseimprovements FeinbergSchool of Medicine the Departmentof Anesthesiologyand ischaired overtime. DMAIC isavery simple wayforany [email protected] byacriticalcareanesthesiologist,who isresponsi- grouptoorganizetheirefforts toimproveacompli- Michael Ault,MD ble forcoordinating the quality monitoring process, cated process. AssistantProfessor datacollection and emergencyresponseopera- of Anesthesiology tionswithin the hospital. The CPR Committee reg- Define NorthwesternUniversity FeinbergSchool of Medicine ularlyreviews anysentinel events from the previ- The first phaseisDefine. Inthe Define phase,the [email protected] ous month,aswell asthe volume of cardiac objectiveistodetermine and define the problem arrests,the location of eacharrest and the proba- thatneedstobesolved. The problem discovered LindaL.Morris, Ph.D.,APN, CCNS ble causelinked toeachcardiac arrest (asdeter- through the CPR Committee’scardiac arrest data ClinicalNurseSpecialist, mined bythe medicalteamattending the arrest analysiswas:the numberof cardiac arrest team Respiratory Care and documented in the arrest summary). callswasincreasing in patientpopulationsthat NorthwesternMemorial Hospital, werenotprimary cardiac patients.The CPR AssistantProfessorof Cardiac arrest datareview Committee suspected thatthisincreasewasattri- ClinicalAnesthesiology Sequentialreviews of the cardiac arrest databy butable topatients thatdeveloped airwaycompli- NorthwesternUniversity FeinbergSchool of Medicine the CPR Committee revealed thatasignificant cations,which,overtime,progressed intocardiac [email protected] numberof cardiac arrest teamcallswereactivated stress and eventualcardiac arrest. www.icu-management.org 17 8 6 85 0 22

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Measure thesisthatthe implementation of the AERTdid During the Measurephase,astrategyisestab- reducethe numberof emergencycallsforthe lished todetermine howtomeasurethe process muchlargercardiac arrest team. Infact,following and collectthe datathatisrequired toanalyzeper- implementation of the AERT, the ratio of emer- formance. The cardiac arrest teamnursecollected gencycallstothe AERTtothoseofthe cardiac dataon every cardiac arrest call todetermine the arrest teamunderwentagradual,but complete, numberof cardiac arrest callsand the rootcause reversal. (see figure2). The CPR Committee did foreach. Thisdatawasthen submitted monthlyto notnoteasignificantincreaseinthe numberof the CPR Committee fortheirreview. totalcalls,whichincluded bothcardiac arrest and emergencyairwaycalls.However,the cardiac Analyze arrest teamcallsdecreased bymorethanhalf, The thirdphaseisAnalyze. Inthisphase,the data whereas,overaperiod of 24months,therewasa isdrilled downtothe rootcausesof performance 35% increaseinthe numberof AERTcalls. variation.Thisisthe most analyticaland statistically Continued monitoring of emergencyresponse intensivephase. Datacanoften bedisplayed using teamdataiscriticalformaintaining the improve- agraph formattovisuallycomparetrendsand ments thatweregained withthe implementation highlightvariation. The dataobtained from this of the AERT.The CPR Committee expects to projectindicated that,in alarge numberof cardiac observeacontinued trend of agreaternumberof arrest calls,the patienthadaprimary airwayrespi- AERTcallscompared tocardiac arrest calls. ratory component,whichwasdetermined tobe the rootcauseforthe cardiac arrest.Inthese Conclusion cases,the cardiac arrest wasaconsequenceof The implementation of adedicated,hospital-based respiratory failure. airwayemergencyresponseteamreduced the numberof emergencycallsforcardiac arrest.The Improve airwayemergencyresponseteamminimized the Inthe Improvephase,the goalistogeneratealter- disruption in routine patientcarecompared tothe nativestothe currentprocess,assess the risk cardiac arrest team,whichrequiresalarge number associated witheachalternative,selectthe best of clinicalstaff responders tobepulled awayfrom alternativeand pilotthe solution. The CPR theirprimary clinicalareas. 4 Committee responded tothe findingsbyestablish- ing anadditionalemergencyresponseteamcalled the AirwayEmergencyResponseTeam(AERT). The AERTwould beactivated foranypatientwho required emergentendotrachealintubation orany otheremergencyairwayassistance. The AERT waschartered toprovide earlyintervention forthe prevention of cardiac arrest in airwaypatients.The AERT, consisting of ananesthesiologist,anurse and arespiratory therapist,wasless labor-inten- sivethanthe cardiac arrest team,whichdeploys a largergroupofmedicaland support personnel. Screening parameters foractivating the airway teamwereput in placetoensurethatthe appropri- ateteamwascalled torespond toemergencies. Ahospital-wide educationalinitiativewasestab- Figure1 lished toeducatethe clinicalstaff about the AERT. Ongoing dataisaccumulating tohelp the CPR Committee monitorthe AERT’ssuccess in reach- ing its goalsof reducing the numberof cardiac arrest callsovertime,minimizing disruption torou- tine clinicaloperationsand increasing efficiencyby utilizing aspecialized airwaymanagementteam thatrequiresfewerpersonnel thanthe cardiac arrest team.

Control The finalphaseisControl. Inthe control phase,the intention istoerror-proof the newprocess and to usetoolstomonitorthe process.The datacollected post-AERTimplementation supported the hypo- Figure2 www.icu-management.org 19 PRODUCT COMPARISON: TRANSPORTVENTILATORS HealthcareProductComparison System ECRI RECOMMENDED SPECIFICATIONS1 MODEL BASIC TRANSPORT VENTILATOR Transport Ventilators WHERE MARKETED FDACLEARANCE CE MARK (MDD) PATIENT TYPE Adult,pediatric, infant,neonatal ECRI isatotallyindependent CONTROLS Pressurelevel,cmH O 0-50 nonprofitresearchagencydes- 2 Pressureramp ignated asaCollaborating Tidalvolume,mL 100-2,000 Centreofthe World Health Breathrate,br/min 0-50 Organization (WHO). Such Insptime,sec 0-2 organizationsareappointed tocontributetoWHO’spub- PEEP,cmH 2 O 0-20 Pressuresupport lichealthmission byproviding specialized knowledge, FiO 2 ,% 21-90 expertise,and support in the healthfield tothe WHO I:E 1:1to1:3 and its membernations.ECRI iswidelyrecognized as Triggermechanism Floworpressure one of the world’sleading independentorganizations Panel lock Yes committed toadvancing the quality of healthcarewith OPERATING MODES Assist/control over240employeesglobally. Volume breaths Yes ECRI Europe Pressurebreaths Yes WeltechCentreRidgeway ECRI’sfocus ismedicaldevicetechnology,healthcare SIMV WelwynGarden City riskand quality managementand healthtechnology Volume breaths Optional Herts AL72AA, assessment.Itprovidesinformation servicesand techni- Pressurebreaths Yes Pressuresupport Yes United Kingdom calassistancetomorethan5,000 hospitals,healthcare Spontaneous/CPAP Tel. +44 (0)1707 871511 organizations,ministriesof health,governmentand Pressuresupport Yes Fax.+44 (0)1707 393138 planning agencies,voluntary sectororganizationsand Apnea-backupvent Yes [email protected] accrediting agenciesworldwide. Its databases(over30), Other www.ecri.org.uk publications,information servicesand technicalassistance servicessetthe standardforthe healthcarecommunity.

All of ECRI’sproducts and servicesareavailable through the EuropeanOffice,addressing the specialrequire- MONITORED PARAMETERSPEEP Yes ments of Europe and the UK.Utilizing some of the PEEP PIP Yes world’slargest healthrelated databases,help,support MAP Yes and guidancecanbegiven toour Europeanclients ata Exhaled tidalvolume Optional locallevel. Exhaled minutevolume Optional Other ECRI ispleased toprovide readers of ICU Management withsample information on products fortransport venti- PATIENT ALARMS O 2 Yes lators,designed foruseincriticalcarefrom its FiO 2 HealthcareProductComparison System (HPCS). The Lo/hi minutevolume Optional HPCS reports contain extensiveinformation about the Lowinsppressure Yes technology,its purpose,its principlesof operation,stage High pressure Yes Loss of PEEP Optional of developmentspecifications,reported problemsand Apnea Optional recommended specifications. InverseI:E Optional High continuous Yes pressure/occlusion High resprate Optional EQUIPMENT ALARMS Gas-supplyfailure Yes Powerfailure Yes Ventinoperative Yes The dataareextracted from ECRI’s Lowbattery Yes 2004databaseand haveadditionally Footnotesused in pages20to23 Self-diagnostic Yes been reviewed and updated bythe 1. Theserecommendatonsarethe opinionsof ECRI's Other respectivemanufacturers.Publication technologyexperts.ECRI assumesno liability fordecisions of all submitted dataisnotpossible: made based on thisdata. MRI COMPATIBLE Preferred forfurtherinformation pleasecontact 2.EP version only. POWER Standard [email protected]. 3.B10without alarmsisFDA approved.

20 ICU Management3-2006 Oxylog 1000 Oxylog 2000 Oxylog 3000 Savina Evita4edition

Worldwide Worldwide Worldwide Worldwide Worldwide Yes Yes 510(k) pending Yes Yes Yes Yes Yes Yes Yes Notspecified Notspecified Notspecified Adult,paediatric Adult,paediatric, neonatal

25-55 20 -60 0-55 0-99 0-80 Notapplicable Notapplicable Yes yes yes Minutevolume setting 100 -1500 50-2000 50-2000 3-2,000 withNeoFlow 4-54 5-40 2-60 2-80 0-150 Depending on setfrequency Depending on setfrequencyand I:E ratio 0.2-10 0.2-10 0.1-30 0-20 0-15 0-20 0-35 0-35 Notspecified Notspecified 0-35abovePEEP 0-70 0-80 60 or100% 60 or100% 40-100 21-100 21-100 1:1.5 1:3to2:1 1:4to3:1 1:150to150:1 1:300 to300:1 Notapplicable Flow Flow Flow(pressure) Flow(pressure) No No No Yes Yes

Yes Yes Yes Yes,AutoFlow Yes,AutoFlow Notspecified Notspecified Notspecified Yes Yes

Notspecified Yes Yes Yes Yes Notspecified Pressurelimited Yes Yes Yes Notspecified Notspecified Yes Yes Yes

Notspecified CPAP,no pressuresupport Yes Yes Yes Notspecified (CMV only) Notspecified Yes Yes Yes Notspecified Notspecified PCV+,noninvasivedelivery possible PCV+,AutoFlow,nCPAP,all modes PCV+,AutoFlow,MMV,bilevel / forCPAP and PCV+ havenoninvasive(NIV)delivery APRV,automatic-tubecompensation option (all patientranges)including nCPAP, all modeshavenoninvasive(NIV) delivery option,optionalindependent lung ventilation

Notspecified Yes Yes Yes Yes Yes Yes Yes Yes Yes Notspecified Yes Yes Yes Yes Notspecified Yes Yes Yes Yes Notspecified Yes Yes Yes Yes

Respiratory rate,inspiratory time, Sponteneous respiratory rate, MV spont,MVleak,FiO 2 ,RR, Tinsp, MV spont,MVleak,FiO 2 ,RR, Tinsp, CPAP pressurelevel, sponteneous minutevolume, I:E, R, C, Temp. Texp,I:E, CO2 ,R,C,Temp.

expiratory tidalvolume plateaupressure,FiO 2

Notspecified Notspecified Yes Yes Yes Notspecified Notspecified Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Notspecified Notspecified Yes Yes Yes Notapplicable,CMV ventilation Yes Yes Yes Yes Notspecified Notspecified Notspecified Notspecified Yes Yes Yes Yes Yes Yes

Notspecified Notspecified Yes Yes Yes

Yes Yes Yes Yes Yes Yes,100%pneumatic Yes Yes Yes Yes Notapplicable,100%pneumatic Yes Yes Yes Yes Yes,lowpressuresupply,no battery needed Yes Yes Yes Yes Notspecified Yes Yes Yes Yes Acousticand visualalarms Acousticand visualalarms Leakage,flowsensor Exhalation valve,flowsensor Exhalation valve,flowsensor insertion,leakage insertion,leakage No No No No No

www.icu-management.org 21 HealthcareProductComparison System ECRI RECOMMENDED 1 PULMONETIC SYSTEMS SPECIFICATIONS MAQUET MODEL BASIC TRANSPORT EvitaXL Servo-I LTV800 VENTILATOR WHERE MARKETED Worldwide Worldwide Worldwide FDACLEARANCE Yes Yes Yes CE MARK (MDD) Yes Yes Yes PATIENT TYPE Adult,pediatric, infant,neonatal Adult,paediatric, neonatal Adult,pediatric, neonates Adult,pediatric CONTROLS

Pressurelevel,cmH 2 O 0-50 0-95 0-120; Infant0-80 No Pressureramp yes Notspecified Notspecified Tidalvolume,mL 100-2,000 3-2,000 withNeoFlow 100-4,000; infant2-350 50-2,000 Breathrate,br/min 0-50 0-300 0-150 0-80 Insptime,sec 0-2 0.1-30 0.1-5 0.3-9.9

PEEP,cmH 2 O 0-20 0-50 0-50 0-20 Pressuresupport 0-95 Yes No

FiO 2 ,% 21-90 21-100 21-100 No I:E 1:1to1:3 1:300 to300:1 1:10to4:1 1:4to4:1 Triggermechanism Floworpressure Flow(pressure) Pressure,flow Pressure Panel lock Yes Yes Yes Yes OPERATING MODES Assist/control Volume breaths Yes Yes,AutoFlow Yes Yes Pressurebreaths Yes Yes Yes No SIMV Volume breaths Optional Yes Yes Yes Pressurebreaths Yes Yes Yes No Pressuresupport Yes Yes Yes No Spontaneous/CPAP Pressuresupport Yes Yes Yes No Apnea-backupvent Yes Yes Yes Yes Other SmartCare(knowledge based weaning Pressure-regulated volume control; None specified system),PCV+,AutoFlow,MMV,bilevel / NIV;Volume Support; Bi-Vent; APRV,automatic-tubecompensation (all Automode,NasalCPAP patientranges)including nCPAP,all modes havenoninvasive(NIV)delivery option, optionalindependentlung ventilation

MONITORED PARAMETERSPEEP Yes Yes 0-99 cmH 2 O PEEP Yes

PIP Yes Yes Yes 0-120 cmH 2 O MAP Yes Yes Yes 0-99 cmH 2 O Exhaled tidalvolume Optional Yes Yes No Exhaled minutevolume Optional Yes Yes No

Other MV spont,MVleak,FiO 2 ,RR, Tinsp, Texp,I:E, CO2 ,R,C,Temp.

PATIENT ALARMS O 2 Yes Yes Yes FiO 2 Yes Lo/hi minutevolume Optional Yes Yes No Lowinsppressure Yes Yes Yes Notspecified High pressure Yes Yes Yes Yes Loss of PEEP Optional Yes Yes Notspecified Apnea Optional Yes Yes Yes InverseI:E Optional Yes Yes Notspecified High continuous Yes Yes Yes No pressure/occlusion High resprate Optional Yes Yes Yes EQUIPMENT ALARMS Gas-supplyfailure Yes Yes Yes Yes Powerfailure Yes Yes Yes Yes Ventinoperative Yes Yes Yes Yes Lowbattery Yes Yes Yes Yes Self-diagnostic Yes Yes Yes Yes Other Exhalation valve,flowsensor Pre-UseCheckofall systems Disconnct/ senseline insertion,leakage MRI COMPATIBLE Preferred No Yes,withspecialagreement No POWER Standard 100/110/120/220/240,50/60 Hz Notspecified

22 ICU Management3-2006 PULMONETIC SYSTEMS VIASYSHEALTHCARE PNEUPAC PNEUPAC PNEUPAC

LTV900 :LTV 950:LTV 1000 AVIAN transPAC-2:TransPAC-2D ventiPACV200D babyPACB100

Worldwide Worldwide Worldwide Worldwide Worldwide Yes Yes No Yes No 3 Yes Yes Yes Yes Yes Adult,pediatric Pediatric, adult Adult,child Adult,child Neonatal,infant

1-99 0-100 Notspecified Notspecified 12-70 Notspecified NA Notspecified Notspecified Notspecified 50-2,000 50-2,000 20-960 50-3,000 0-330 0-80 0-150 8-40 7-60 10-120 0.3-9.9 0.1-3 0.6-2.9 0.5-3 0.25-2 0-20 ExternalPEEP valveonbreathing circuit NA Optional,0-20 0-20

1-60 cmH 2 O NA Notspecified Notspecified Notspecified NA :NA:21-100 Varies 45-100 45-100 21-100 1:4to4:1 Calculated,notsetparameter 0.1 :1.6 Infinitelyvariable Infinitelyvariable

Flow Pressure-2to-8cmH 2 O Notspecified Indemand mode Notspecified Yes NA Notspecified Notspecified Notspecified

Yes Yes No InCMV No Yes Yes No No No

Yes Yes No InCMV (SMMV) No Yes Yes No No ViaIMV/CPAP No:Yes:Yes No No No ViaCPAP

Yes Yes Notspecified Notspecified ViaCPAP Yes Yes Notspecified Notspecified Notspecified None specified None specified None specified Demand,CMV/demand IMV/CPAP,CPAP

0-99 cmH 2 O Yes Notspecified OnP200DEP version Onmanometer

0-120 cmH 2 O Yes Notspecified Viamanometer Onmanometer 0-99 cmH 2 O Yes Notspecified Viamanometer Onmanometer 0-4,000 mL No Notspecified Notspecified Notspecified 0-99.9 L No Notspecified Notspecified Notspecified

Yes Onaccessory blender Optional Notspecified Notspecified

Yes NA Notspecified Notspecified Notspecified

Notspecified Off,2-50cmH 2 O Notspecified Yes Yes Yes 1-100 20-80 Yes Yes Notspecified Yes Notspecified Visualonmanometer 2 Visualonmanometer Yes Yes Notspecified Notspecified Notspecified No Inverse Notspecified Notspecified Notspecified No NA Notspecified Yes Yes

Yes 30 sec Yes Notspecified Yes

Yes Onaccessory blender Notspecified Yes Yes Yes Yes Notspecified Yes Yes Yes Yes Notspecified Notspecified Notspecified Yes Yes Notspecified Yes Yes Yes NA Notspecified Onswitchon Onswitchon Disconnct/ senseline None specified None specified Normalfunction Normalfunction

No No Optional Yes Yes Notspecified 100-125/200-250VAC11-30 VDC, Pneumatic Pneumatic Pneumatic internalbattery www.icu-management.org 23

continued from p. 12 y c in y c in x ac in y c in z o bac ac in x ac in

Isolates t a z idim n c om L o ca t ion P eni c illin A mpi c illin A mpi / S u l ba M e z lo c illin P ipe r ac illin P ip / Ta O x ac illin C ef a lo t in C ef ur o x im C efo t a x im C ef C efepim I mipenem M e r openem G en t a mi c in T o b r a m y c in A mik O flo C ip r oflo C lind a m y c in F o s fom E ryt h r om R if a mpi c in Va T ei c opl a nin Acinetobacterbaumanii bc/rt/s/w RI RRR/IRRR RRRR Aeromonashydrophilia w RRI RR RRSRRI/SS ISI/S Aeromonasveronii w RRRRRRSSRRI RI Alcaligenesxylooxydans bc/rt/s RSSRSSSSRR R Bacillus species w RRR RRR SSI SSRSRSS Bacteroidescaccae bc/s/w Bacteroidesspecies* w Burkholderiacepacia rt RSSISI/SR SRRRSM Clostridiumsepticum bc/s Corynebacteriumstriatum w RR RI SR RRRRRSS Enterobacteraerogenes w RRSSS RRS SSSS Enterobactercloacae w RRSSS RRS SSSS Enterococcus faecalis bc/rt/s/w RSS RRR SR R/I/S RRR/SR/SSS Enterococcus faecium bc/rt/s/w RRR RRR RR RRRRR/ISS E.coli (ESBL +) bc/s/w RRRRR RRR SRSI Klebsiellapnemoniae rt RRRRR RRR SRIR Morganellamorganii w RRSSS RRSSSSSSS S Proteus mirabilis w SSSSS SSS SSSS Proteus vulgaris w RRRRR RRR SI IS Pseudomonasaeruginosa bc/s/w RRRI IRRRRI SSR/I/S RIS S.aureaus (MRSA) bc/rt/s/w RR RRR RR RRSRSSS Stenotrophomonasmaltophilia bc/rt/s/w RRRRRR/IR RRRRSI Legend bc -blood culture s-serum R-resistant S-sensitive Table 1:Pathogens,locationsand resistances rt -respiratory tract w-wound I-intermediatesensitivity

continued from p. 14

thingswill suddenlychange and hospitalswill surveillance,tracking,education,ongoing risk effectivelycooperatewitheachotherisunreason- assessmentand soforth. Istheresufficientover- able. Impromptu cooperation without aneffective laptomerge some of the planning,education and planforcoordination ensureslimited success at practiceofhospitalpatientsafety and some best.Theremust beanenforceable mandate aspects of disastermedicalresponse? Ithink that and support from governmentalauthoritiesfor the answeris“yes.” inter-hospitalcooperation and planning,before adisasteroccurs. Summary 6. Making available budgetary resourceswork - Wehavemuchtodo. Thisbrief essayoutlinesthe The cost of effectivedisasterplanning and disasterresponse-related problemsthathospital responseisenormous.Itisnotrealistictoexpect and criticalcareunits must solve. Fortunately, budget-constrained facilitiestoabsorbtheseaddi- therearepotentialsolutions.However,no single tionalcosts,and yet,relief from governments will solution iscomprehensivebyitself.Afunctional notfill the gap. Therefore,itseemsreasonable to solution setwill consist of a“patchwork” of these seek economiesof scale. Forexample,toincrease measures,adjusted and quilted according tolocal ICU surge capacity during adisaster,existing needs.Thiswill requiresome degree of central MedicalEmergencyTeams(MET)could,withlittle coordination bygovernmentalagencies,aswell as additionaltraining,provide ahighlyeffective the developmentof civil criticalcareresponse adjunctivecapability when criticalcareunits teams.Disasters will continuetooccur,hospitals arefull and additionalICU servicesarerequired. and criticalcareunits will respond,and the gener- Inaddition,patientsafety programsrequire alpopulaceexpects them tobeready. 4

www.icu-management.org25 MANAGEMENT

Useofseverity scoresin clinicalpractice

Severity scoresmaybeused totake asnapshotof apatient’s currentclinicalstatus ortomake afilm of the dynamicprocess of the patient’sclinicalcourseovertime.

Severity scorescanbedefined asaquantitative ICU patientpopulation foruseinICU performance approachtoprovide anobjectivemeasureofsever- analysisand comparison between ICUs(bench- ity of illness and,eventually,probability of survival marking). Forstudypurposes,APACHE II and forpatients admitted toanintensivecareunit SAPS II areused todescribepatientpopulation (ICU). Moreover,multipurposemodels,suitable for MauriziaCapuzzo,MD atthe time of ICU admission orpatientenrolment patients withdifferentillnesses,allowsome risk Departmentof Surgical, in astudy,asAPACHE II wasused in the Protein C Anaestheticand stratification of ICU patients.Therearetwomain Worldwide Evaluation in SevereSepsis RadiologicalSciences ways touseseverity scoresin clinicalpractice:as (PROWESS)study(Bernardetal. 2001). Section of Anaesthesiology staticordynamicmeasurementsystems. and IntensiveCare Recently,the largest prospectivemulticentre, University Hospital When used asstaticmeasurementsystems, multinationaldatabaseavailable atthe present of Ferrara, Italy severity scoresarecomputed atafixed pointin (Metnitz etal. 2005) hasdeveloped SAPS 3,which Italianrepresentativein time,sowecansaythattheytake a“photograph” iscalculated on admission (Moreno etal. 2005). the Council of European of the patient’smedicalstatus.The Acute The new,SAPS 3scoreiscomputed on datacol- Society of IntensiveCare PhysiologyAnd ChronicHealthEvaluation lected within one hour of ICU admission and con- Medicine (APACHE II)(Knaus etal. 1985) and the Simplified ceptuallydissociatesevaluation of the individual Deputy chairof the Section AcutePhysiologyScore(SAPS II)(LeGall etal. patientfrom the evaluation of ICU. on HealthServices 1993),whicharethe most widelyused static Researchand Outcome severity scores,arecomputed according tothe One significantlimitation of multipurposemodels [email protected] most deranged valuesof the variablesspecifically computed atafixed pointin time isthattheydo www.hsro-esicm.org defined foreachscore,whicharecollected during notgiveinformation about clinicalchangesduring the first 24hours afterICU admission. Inaddition anICU stay.Tomeasurechangesin the clinical toproviding asnapshotof apatient’sclinicalsitua- courseofthe ICU patientovertime,the patient’s tion,theseseverity scorescanbeused tocalcu- clinicalpictureneedstobecaptured daily,tomake latethe probability of hospitalmortality in agiven a“film” of the dynamicprocess of clinicalimprove- mentordeterioration. APACHE II and SAPS II could becomputed repeatedly,even daily,but their computation istime consuming.Therefore,other, simplerseverity scoreshavebeen proposed for System MODLOD SOFA repeated measurements. Respiratory PaO /FiO PaO /FiO PaO /FiO 2 2 2 2 2 2 Initially,dynamicseverity scoresonlyconsidered Ventilation Ventilation the presenceorabsenceoforgandysfunction RenalCreatinine Creatinine Creatinine orinfection daily(Fagon etal. 1993; Knaus etal. Diuresis 1985). Subsequently,however,severaldynamic Urea severity scores,suchasthe Multiple Organ Dysfunction (MOD)Score(Marshall etal. 1995), HepaticBilirubin Bilirubin the LogisticOrganDysfunction (LOD)System Prothrombin t.Bilirubin (LeGall etal. 1996)and the Sepsis-related Organ CardiovascularHR HR Amines FailureAssessment(SOFA),laternamed the MeanAP SystolicAPMeanAP SequentialOrganFailureAssessment(Vincentet CVP al. 1996; Vincentetal. 1998),havebeen published. All of thesescoresmeasurethe level of dysfunc- HaematologicalPlatelets Platelets Platelets tion in the same sixsystems(respiratory,renal, WBC hepatic, cardiovascular,haematologicaland central nervous)and havetobecomputed daily. C.N.S.GCS GCS GCS

N.ofvariables8128 Among thesedynamicseverity scores,SOFAis unique,especiallyin its assessmentof the cardio- Table 1:Variablesused in the dynamicseverity scoresconsidered, according tothe sixsystemsassessed. vascularsystem. The SOFAscoremeasuresthe

26 ICU Management3-2006

MANAGEMENT

severity of dysfunction according toarterialpres- Although bothstaticand dynamicseverity scores sureand/oruse,type and doseofvasoactive offerusefulimagesof apatient’sclinicalsituation, amines,whichmakesitusefulinassessing the theybothhavetheirlimitations.Despitethe physiologicderangementof the cardiovascularsys- widespreaduseofstaticseverity scoresin the tem in lightof the degree of therapeuticinterven- comparison of patientgroupsorICUs,theirusein tion. Thisis,possibly,the reason forthe wide- individualpatients remainsdifficult,if notimposs- spreaduseofSOFAscores,astestified bythe con- ible,asseverity scorescannotalways accurately tinuous increaseinthe numberof articlesincluding predictanindividualpatient’ssurvival(European SOFAscoressince2000. Consensus Conference1994). Dynamicseverity scoresdo notallowmedicalpersonnel toidentify The totalmaximumSOFAscoreand deltaSOFA newillnessesorclinicalcomplicationsattheir quantifythe degree of dysfunction/failurethat onset,astheyencompass onlythosedysfunctions appears during the ICU stayand the cumulative developed enough tobemeasured,and theycan- insultsuffered bythe patient(Moreno etal. 1999). notdetectchangesof valuesalreadyatthe top of Accordingly,the SOFAscoreonapatient’slast ICU the score(ceiling effect). daycanbeused asatool todescriberesidual dysfunctionsatICU discharge. Inaddition,Cabré Medicine hasbeen anart working tobecome asci- etal. recentlyproposed using SOFAscores, enceforcenturies.Severity scoresenhanceour according tominimum,maximumand trend over ability topaintaccurateimagesof apatient’smed- first fivedays in ICU,asadecision-making tool icalsituation. Atthe same time,theyofferaquan- (Cabréetal. 2005). titativetool thatwill help advancemedicine further downthe pathofscience. 4 Motivating staff Motivationalincentivesoften areequated tofinancialorothermaterialreward forperformance;howevermaterialrewardalone israrelyasufficientmotivating factorin achieving top performance. Long-termmotivation isconsiderably morecomplex.Inthisarticle,wewill reviewfactors thatfrequentlyinfluence individualperformanceand discuss techniquesthatareusefulincreating and sustaining amotivationalenvironmentforthe entireICU team.

Introduction Understanding the factors thatmotivate The ability of ICU managers topositivelymoti- employeesisbased on understanding funda- vateteammembers hasvast potentialtoimpact mentalsof humannature. Existing dataappears the quality of caredelivered,the environmentof todemonstratethatitisnotreallypossible to careand individualteammembersatisfaction, directlymotivateanotherperson. Unfortunately, therebyinfluencing retention and recruitmentof itispossible tode-motivateanotherperson. It teammembers.Creating amotivationalenviron- isthereforeimportanttocreateworking condi- Todd Dorman, mentisanart thatrequiresmanagerialskill, tionsunderwhichanindividual’sinherentmoti- M.D.FCCM anunderstanding of factors thatareimportant vation cansurfaceand become explicitly JohnsHopkinsUniversity todifferentgroupsof professionalsaswell as expressed. School of Medicine individualteammembers and compelling Baltimore leadership. Ingeneral,the main forcebehind lasting moti- [email protected] vation (and avoiding de-motivation) involves Whymotivation matters meeting the psychologicalneedsof the indivi- Ronald Pauldine,M.D. The importanceofunderstanding the principles dual,ratherthanproviding materialrewards. JohnsHopkinsBayview of motivation forthe ICU teamisunderscored Factors thatcontributetoapositiveworkenvi- MedicalCenter Baltimore bythe influenceamotivated staff hason anum- ronmentinclude:capable leadership,decent berof issuesthatarecentraltorunning a physicalsurroundings,acceptanceofthe indi- [email protected] smoothand efficientICU.Thisisespeciallytrue vidualintothe team,individualrecognition asa in the context of today’shighlycompetitive, partneron the team,fairtreatment,jobsecu- resource-limited and workforce-depleted critical rity,knowledge and understanding of the effect careenvironment.Aswewill see,amotivated on one’sefforts in meeting the organizational staff should beahappy,satisfied and productive goals,knowledge and understanding of the staff.Ifthe motivationalneedsof the staff are organizationalpoliciesand procedures,recogni- met,retention and recruitmentarelikelytobe tion of specialeffort orachievement,respect enhanced. This,in turn,leadstosavingsin the regarding religious beliefsorculturaldiffer- cost and time associated withrecruitmentand ences,assurancethatall on the teamdotheir training,lost productivity while searching for fairshareand fairmonetary compensation replacements,lost productivity while training (McConnell 2005). The extenttowhichthese replacements and the problemsassociated with variableshaveimportanceand valuetoindivi- resolving staffing issueswhile searching for dualteammembers will vary considerably. newstaff. Therefore,understanding the valuesystem of individualteammembers canhelp the manager Whatreallymotivatesstaff? matchmotivating factors tothe individualto Incongruity between whatmanagers and optimizethe environmentforself-motivation employeesviewasmotivating factors hasbeen and achievement. well described. Inpast studies,managers fre- quentlycited factors suchaswagesand job Inordertoeffectivelymotivateindividualstaff security asthe keyinfluenceson theirstaff, members,one must considerthateachteam while employeesidentified factors suchas memberhasuniquemotivationaldrivers,values being appreciated and participating in meaning- and biases,aswell asadifferentperspectiveon fulworkasthe most significantissuestothem reasonable expectationsand returns(Nicholson (Thiedke2004). Thisprinciple seemstohold true 2003). Itisimportanttorecognizethatmotiva- forhealthcareworkers aswell,asmoney tionalfactors maydifferbetween groupssuch appears nottobethe primary issueinphysician asphysicians,nurses,respiratory therapists, turnoverand dissatisfaction in boththe United patientaidesand othersupport staff,and that Statesand United Kingdom (Pearson etal. the individualswithin eachgroupwill likely 2004;Weber2005). weightspecificfactors differently.While the www.icu-management.org 29 MANAGEMENT

temptation maybetotargetstrategiesatspe- fasterresponsestobehaviorwill havea cificgroups,the valueofunderstanding and strongereffecton behaviorin the future. Also knowing your employeesasindividualscannot bearin mind thatpositiveincentivesexert a beunderestimated. strongereffectthannegativeincentives,ordis- incentives.Finally,itiscriticaltoacknowledge Creating themotivating environment thatthe importanceofanyparticularmotivation- Itisevidentfrom the abovediscussion thatan alfactorissubjective,and reactionswill vary understanding of the factors thatmotivatespe- from one individualtoanother. cificgroupsand individualemployeesiscentral tohelping them meettheirmotivationalneeds, Specialconsiderations therebyhelping tomeetthe needsof the organ- The factisthatmost of your top people areself- ization. Itmaybedesirable forthe ICU manager motivated and arenotlikelytorespond toexter- toinitiatechangesin policies,procedures,work nalincentives,but will bemost likelymotivated environmentand leadership style withinput byaddressing the factors discussed above. Itis from the team,in ordertoaddress issuesthat the ability toengage the less motivated players affectmotivation and,indeed,issuescontribut- thatcreatesthe challenge and often provesto ing tode-motivation in the organization. belaborand time intensive. Sincechange comesfrom within,itisthe responsibility of the Thereareseveralfactors thatamanagermust managertounderstand the individualvaluesof considerwhen instituting acultureofmotiva- thesepotentialproblem employees(Nicholson tion in the ICU.Itisimportanttocreateanenvi- 2003). Whatmotivatesthem? Whatinterferes ronmentthatallows professionalstaff to withtheirmotivation? Areyou,astheirboss, achieveprofessionalsatisfaction and develop- part of the problem? Itisimportanttocommu- ment,including clinicaladvancement,teaching nicatedirectlyand tocarefullyconsiderthe orfaculty rank considerations,researchor arrayof possible outcomes.Rememberthatit opportunitiesforadministrativeand leadership maynotbepossible tomeetthe motivational duties.Formanyemployees,anorganizational needsand expectationsof everyone. culturethatallows them totake pride in the organization through amission and valuesthat Meanwhile,do notforgetthe needsof your arecentered on honestyand integrity will be most motivated teammembers.Obstaclesto important(Anonymous 2003). Forprofessional performancecancreateanenvironmentthatis staff in the ICU,asin otherareasof healthcare, de-motivating (Britt 2003). Make every attempt meaning isinherentlyobvious in the work. tosetyour people upforsuccess.Provide the However,itisimportanttocareforthoseatall necessary resourcesand sufficientroom for levelsof the organization and provide informa- your staff tobecreativeand take chanceswith- tion on howtheirworkmatters and contributes out negativeramifications.Setthe barhigh,but tothe end product(Shenkel and Gardner2004). haverealisticexpectations.Becarefultoensure Open,accurateand frequentcommunication thatthesehighlymotivated,valuable team contributestoanenvironmentwherethe members do notoverworkthemselves,in order efforts of the teamareclearlyvalued and feed- toavoid burnout.The effectiveleaderwill help backisprovided on howmembercontribution createanenvironmentthatrecognizesgood impacts the organization. Managers should con- workand rewardsexcellence. siderwhetherthe practicemodel and adminis- trativesupport forthe ICU teamcould bebetter Concluding thoughts aligned withemployee expectations.Fairness Creating the optimalmotivating environmentfor and equity in compensation between peers is the ICU teamisacomplextask,requiring a anotherareaof concern. Some issuesmaybe detailed understanding of the myriadoffactors beyond the immediatecontrol of the ICU man- thatspecificgroupsand individualsvalueand to ager,suchasfamilyissuesrelated togeograph- whichtheyrespond. While difficult,the effort iclocation orthe ability tofind satisfaction in will berewarded withamotivated,happystaff, the localcommunity (Weber2005). However, leading toincreased productivity,apositive understanding thesefactors maybebeneficial workenvironmentand improved recruitment tothe ICU managerwhen designing amotiva- and retention of ICU teammembers.Datafrom tionalworkenvironment. non-healthcaresettingsdemonstratesthat when staff motivation ishigh,outcomesare Severalprinciplesapplytoimplementing and enhanced,and thereisno reason tobelievethat evaluating the effort tocreateamotivational the same results would notbetrueinhealth- environment.Rememberthatreinforcementof care. Futureresearchshould aim toconfirmthis behaviorwill encourage repetition and that relationship. 4

30 ICU Management3-2006 Evidence-based design supports evidence-based medicine in the ICU

PeterPronovost,MD, of JohnsHopkins,lost his Design and the Robert Wood Johnson Foundation fathertoamedicalerrorwhile in medicalschool toproduceameta-analysisof the credible research and wenton toexperiencethe disturbing prevent- in thisarea(Ulrichetal. 2004). Theyfound more able loss of achild in hisintensivecareunit(ICU). than650rigorous studiesthatdealtwithpatient Josie King died of dehydration in one of the world’s and staff safety issues,the environment’simpact premieracademichospitals.Thishasmade Pro- on stress and the careenvironment’srelationship novost atireless and widelyrecognized crusader withclinicalquality. forevidence-based improvements in criticalcare (Miller2002). Itisdifficulttoimagine thatmaking Aninteresting and related example of application D.KirkHamilton, medicaldecisionson the basisof the best available in the field comestous from the NeuroICU at credible researchfindingswould notleadto Emory University in Atlanta.Dr.AlanSamuels,the B.Arch,MSOD, FAIA, improved outcomes.Thisconcepthasbeen unitdirector,found himself less thansatisfied with FACHA, spreading sincethe earlynineties. proposed plansforareplacementICU.He isanAssociateProfessor of Architectureand a approached Zimring atnearbyGeorgiaTechtoask Fellowof the Centerfor "Evidence-based medicine isthe conscientious, whethertherewasevidencerelating clinicalout- HealthSystems&Design explicitand judicious useofcurrentbest evidence comestodesign of criticalcareenvironments. atTexasA&M University in making decisionsabout the careofindividual Theyinvolved graduatestudents in astudywhich forwhichhecurrently patients." (Sackett etal. 1996) led toadesign charrette,orintensivedesign servesasInterim Director. session,withthe architects.Onthe basisof the Hisresearchareaisthe Asanarchitectspecialized in the design of medical evidencecollected,the ICU wasredesigned. relationship of evidence- environments,including criticalcare,Iproposethat Samuelsplanstostudyoutcomeswhen the based healthfacility design evidence-based design isanobvious analog to projectiscompleted and report hisresults.Ilook tomeasurable organiza- evidence-based medicine. Evidence-based design forwardtotheirpublication. tionalperformance. Hehas chaired the ICU Design isthe conscientious and judicious useofcurrent Committee of the Society best evidence,and its criticalinterpretation,to Moreserious researchrelating criticalcareenviron- forCriticalCareMedicine make significantdesign decisionsforeachunique ments and outcomesisneeded toanswerimpor- (SCCM)and currently project.Thesedesign decisionsshould bebased tantquestions.Inthe areaof safety,weneed bet- serveson the boardsof the on sound hypothesesrelated tomeasurable out- terresearchonthe environment’srole in spreading CenterforHealthDesign comes.Ihavepreviouslypublished adescription: orpreventing the spreadofinfection,aswell asthe (CHD)and the Coalition for efficacyand design of hand hygiene locations.We HealthEnvironments "Evidence-based designers make criticaldecisions, need toknowwhichdesignsareassociated with Research(CHER). Hamilton togetherwithaninformed client,on the basis reduced errorand injury.Weknowthatdaylight, isthe past presidentof of the best available information from credible artificiallighting,temperature,humidity,odorand boththe AmericanCollege of HealthcareArchitects researchand the evaluation of completed noiseall havephysiologicalimpacton the build- (ACHA)and the AIA projects." (Hamilton 2003) ing’soccupants,but weneed toknowmuchmore Academyof Architecture about howtheyimpactclinicaloutcomesin the forHealth. Healthcarefacility designsbased on the findingsof ICU.Sincecommunication isamajorissueinthe researcharedeveloped in anattempttocreate ICU,weneed design researchtodiscoverbetter environments thatimprovecarebyenhancing ways toencourage and enhanceit.Ifproductivity, patientsafety and being activelytherapeutic, performanceand alertness areissuesformanage- supportiveoffamilyinvolvement,efficientforstaff ment,then researchcanhelp identifyeffective performanceand restorativeforworkers under ways in whichthe physicalsetting canbedesigned stress.Thereisaclearcompatibility of common asanenablerof the workprocess,ratherthana themesbetween the design of healthcareenviron- barrier.The range of relevantstudiesisnearlyinfinite. ments based on researchand the practiceof evidence-based medicine in thosephysicalsettings. Clinicianswho subscribetothe tenets of evidence- based practiceincriticalcareshould become Thereisagrowing bodyof credible researchrelat- championsof collaboration witharchitects and ing the careenvironmenttoclinicaloutcomes. designers who arealsoworking in anevidence- Environmentalpsychologists RogerUlrich,PhD, of based model. Bothmust collaboratewithre- TexasA&M University and Craig Zimring,PhD, of searchers who cananswerkeyquestionsforthem. the GeorgiaTechnicalInstitute,togetherwiththeir Theyareeach,afterall,seeking the same thing. students,werefunded bythe CenterforHealth The synergisticresults will speakforthemselves. 4 www.icu-management.org 31 VIEWS AND INTERVIEWS

Insidethe ESAwith SirPeterSimpson SirPeterSimpson isthe 2006 -2007 Presidentof the EuropeanSociety of Anaesthesiology(ESA). InthisinterviewwithAmandaHeggestad,during Euroanaesthesia2006,SirPeterSimpson discusseshisexperienceswith the ESAsofar,aswell ashisgoalsforthe ESAgoing forward.

Canyoubrieflydescribehow Howdoesthe ESA support the ESA came tobe? criticalcaremedicine? The ESAformed when three existing European Criticalcareisamajorsubspecialty of anesthesiol- anesthesiologysocieties–the EuropeanAcademy ogy,and the ESAisvery supportiveofcriticalcare of Anaesthesiology,the Confederation of Euro- practitioners.Thereisaninexorable demand for peanNationalSocietiesof Anaesthesiologists,and criticalcareinrecentyears,and the publicoften the EuropeanSociety of Anaesthesiologists – equatescriticalcarewithquality care. The ESA merged intoaconsolidated organization. The ESA needstocontinuesupporting the placeand status draws on the strengthsof thesecomponentorgan- of criticalcaremedicine. Muchofour workalready izations,sothatwearenowable toofferquality focuseson criticalcare. Myhope isthatwewill be education,training and professionaldevelopment able tocatereven bettertothe needsof our mem- initiatives; animpressiveannualmeeting on anes- bercriticalcarespecialists going forward. thesiologyin Europe;ajournalcovering current anesthesiologyissues; and ameanstobring Whatprofessionalinterests led toyour togetherthe various Europeannationalanesthesi- involvementwiththe ESA? ologysocieties.Inaddition,weareparticularly Myclinicalinterests revolvearound anesthesiology proudofour Europeandiplomain anesthesiology, and perioperativecareforneurosurgery and inva- afirst step towardacoordinated,international siveneuroradiology.Iamalsoextremelyinterested standardinanesthesiology.Inuniting thesefor- in medicaltraining and workforceissues.Duein merlyindependentorganizationsand theirservic- part tomyinterest in the postgraduatetraining of es,the ESAprovidesacommon platformfor anesthesiologists,Iplayed akeyrole in establish- Europeanstodiscuss anesthesiologyeducation, ing the EuropeanDiplomaof Anaesthesiologyand managementand practice. IntensiveCarein1984,and Icontinued tosupport thisinitiativeasChairmanofthe Examination Howwould youdescribethe ESA’srole Committee until thisyear.Ihavealsobeen heavily in anesthesiology? involved in the RoyalCollege of Anaesthetists’ The success of anyorganization liesin its rele- training activities.Inaddition,during mytime as vance. The ESApromoteshigh-quality and safe MedicalDirectorwiththe NationalHealthService, patientcarewithin the constraints of the Ideveloped amajorinterest in workforceissues, resourcesand laws of its membercountries.The including the causesof and potentialsolutionsfor ESA’sjobistosupport the developmentof quality poorperformanceinmedicalstaff.Iamexcited anesthesiologyin all countries,no matterwhat about the potentialimpactthatthe ESAwill have resourcesareavailable,and tofosterdialogue on all theseissuesduring mytermasPresident. between membercountriesabout best practices, optimaluseofresourcesand standardsof care. Howhasyour experienceas Our membercountrydelegates,training opportu- ESA Presidentbeen sofar? nities,and the Europeandiplomathatweoffer,in Sofar,mytermasESAPresidenthasbeen both particular,arekeytothisinternationalexchange. As very exciting and challenging.Thisposition the ESAconsiders expanding and diversifying our requiresawide range of skills,and Ihavedrawnon activitiesin the future,wewill need tomaintain a them all –from interpersonalcommunication skills clearfocus on our goalsasanorganization. toknowledge of governmentrelations.Most

32 ICU Management3-2006 importantly,asESAPresident,Imust bereadyto consolidated form. Wewill need todeliversome communicateinanopen and constructivewayon quickresults tomaintain the momentumbehind nearlyanyissue. Ihavetobeaccessible toany- our impacton patientcare,without forgetting our bodywho wishestospeakwithme,and Itryto longer-terminitiatives.Wewill alsoneed toremain make surethatIdo take the time tolisten toevery- accessible toour members and tothe public.Ifeel one who approachesme. Ieven respond toall of thatweareoff toagreatstart. mye-mailspersonally.Itisvery importanttometo maintain open,personalcontactwithESAmem- Whatisyour best experienceasESA bers and the public. Presidentsofar? Mybest experiencehasbeen,undoubtedly,the Thissoundsvery demanding. Wheredoyou enthusiasmofeveryone involved in formation of a find the time? consolidated ESA.Everyone wants ittowork,and Sometimes,itisdifficulttobalanceprivatelifewith our members havebeen very generous withtheir the demandsof thispublicrole,but in the end,itis time in ordertomake ithappen. Ultimately,Iam mydutytotake everyone’sconcernsintoconsider- very pleased toknowthatthe ESAhassomething ation. When Icommitted toserveasESAPresi- thatpeople want. dent,Icommitted,within reason,tomaking myself available atall times.And,Ireallyenjoythe work. And,finally,whathasbeen your worst So,forthe termofmyPresidency,myESAduties experiencesofar? come first. During the merger,wehadtomake some tough decisionsabout the consolidated organization. This Whatareyour personalgoalsforthe ESA? wasparticularlydifficult,becausesome people When Iassumed myrole asESAPresident,Ipro- wereunhappywithcertain decisions,and Ido not duced astrategypapertoguide the ESAthrough liketosee people upset.Ialways aim forconsen- its transition toaconsolidated organization. Iam sus.Inthe end,though,everyone involved was keen totrytodevelop aEuropeanidentity foranes- willing toembracethe largergoalofaconsolidat- thesiology,without sacrificing nationalidentities. ed organization withcoordinated objectives. Weneed toestablishsome consistencyin stan- Thankstoeveryone’sinput and cooperation,Iam dardsand education,particularlygiven the mobility happytosayIbelievethatthe formation of the of healthcareworkers within the EuropeanUnion. ESAhasbeen acompletesuccess. 4 Iwould liketocoordinatemoreinthisareawith the EuropeanUnion of MedicalSpecialists.Inaddi- tion,weneed toencourage academicanesthesio- Dr.PeterSimpson’sCurrent logy.Anesthesiologyissometimesconsidered KeyAppointments: a“safe”serviceratherthanascience,and,asa • ConsultantAnaesthetist,NorthBristol NHS Trust result,thereisnotasmuchresearchactivity in our (FrenchayHospital) field asthereshould be. The ESAcanand should • President,EuropeanSociety of Anaesthesiology, take aleadinpromoting anesthesiologyresearch. Finally,Ialsohope toexpand and refine our com- 2006-2007 munication efforts –expand our professionalnet- • KnightBachelor,Queen’sBirthdayHonours List works,tailorour journaltoour readers’needs,and 2006,forServicestothe NHS increaseour mediainvolvementtoraisepublic • President,RoyalCollege of Anaesthetists, awareness of anesthesiology. 2003-2006 • DeputyChairman,PostgraduateMedical Whatarethe biggest challengesfacing Education and Training Board(PMETB) the ESA going forward? • Vice-Chairman,Specialist Training Authority (STA) The transition toaconsolidated organization with anelected boardwasadifficultprocess,but I • Past-Chairman,NationalConfidentialEnquiry into believeithasbeen agreatsuccess.One of the PatientOutcome and Death(NCEPOD) biggest challengeswewill faceinthe futureis • Past-ChairmanofExaminationsCommittee, keeping everyone on boardand maintaining EuropeanSociety of Anaesthesiology people’senthusiasmforthe ESAin its new, www.icu-management.org 33 EU FOCUS

European Courtof Auditors

The EuropeanCourtof Auditors (the Court)isthe externalauditinstitu- tion of the EuropeanUnion (EU)and acts asits “financialconscience”. Founded in 1977 in Luxembourg,the Courtisindependentfrom otherEU institutions.Its taskistokeep trackofEU funds,making surethatthe Commission managesthem properly.Based on the Court’sAnnual Report,the EuropeanParliamentgivesthe Commission finaldischarge IlzeRaath EditorEuropeanAffairs forthe execution of every annualbudget.

Overview time on specificissuesorgiveanopinion atthe Established on 22 July1975by request of anEU institution. OtherimportantCourt the Treaty of Brussels,the Court reports include opinions,SpecificAnnualReports started operating asanexternal on EU bodies,and reports on subjects of particular Community auditbodyin interest. October1977.Sincethe signing of the Treaty of Maastricht,the Court hasbeen Court officials recognised asone of the fiveinstitutionsof the EuropeanCommunities. Members According tothe EuropeanCommunity Treaty,the Main role Court consists of one Memberfrom every The Court independentlyaudits the collection and MemberState. TheseMembers areappointed by spending of EU fundsbythe institutions,European the Council,afterconsultation withthe European DevelopmentFundsand otherEU agenciesand Parliamentbased on nominationsbyevery bodies.Furthermore,the Court investigates MemberState. Members of the Court arechosen whetherfinancialoperationshavebeen properly on the basisof having workedforanauditing insti- recorded,legallyand regularlyexecuted and man- tution in theircountryof origin ortheirspecific aged toensureefficiencyand transparency. qualifications.Theyworkfull-time forthe Court for asix-year,renewable term. The Court’srole,asexternalauditor,istoassess the financialmanagementof the EU’sbudgetasa The Members sitasacollege thatisthe main deci- whole. Inpractice,thismeansthatthe Court sion-making bodyof the Court.The annualwork examinesthe paperworkofanyorganisation han- programme sets out the tasksthatevery Member dling EU income orexpenditure. Anyirregularities isresponsible forimplementing.Specialised audit arereported tothe EuropeanParliamentand staff assists them. Forthe sake of efficiency, Council. The Court’sauditresponsibilitieshave “chambers”(withalimited numberof Members been extended toCommunity fundsmanaged by each) canbesetuptoadoptcertain typesof outside bodiesand bythe EuropeanInvestment reports oropinions. Bank. APresident,whom the Members electfrom One of the Court’smost importantfunctionsisto amongst theirnumber,headsthe Court.The assist the budgetary authority (European President’stermofofficeisthree years and is Parliamentand Council) byissuing anAnnual renewable. His/herrole isthatof primus inter Report on the previous financialyear.The content pares :first among equals.S/he hastochairCourt of thisreport plays animportantrole in the meetingsand ensurethatdecisionsareimple- Parliament’sdecision whetherornottoapprove mented and thatall the institution’sactivitiesare the Commission’shandling of the budget.If properlycarried out.Furthermore,the Presidentis approved,the Court sendsthe Council and responsible forthe legalserviceand the external Parliamentastatementof assurancethat relationsdepartment,regarding the discharge Europeantaxpayers’moneywasjudiciouslyspent. authority,otherEU institutionsand the supreme Beforethe EU’sfinancialregulationsareadopted, auditinstitutionsof the Memberand beneficiary the Court givesits opinion. Itmaycommentatany States.

34 ICU Management3-2006 Secretary-General expenditureofthe EU and 1. 6%ofthe totaladmin- The Secretary-General,the most seniorofficialin istrativeexpenditureofthe EU institutionsand the institution,isappointed bythe Court.His/her bodies.Atthe Court’sbehest,anexternalaudit dutiesinclude managing the Court’sstaff and firmaudits its financialstatements.Theseresults administration,suchasprofessionaltraining and arecommunicated tothe EuropeanParliamentand translation service(aunitforevery officiallan- the Council and published in the OfficialJournal guage) and the Court’ssecretariat. and on the Court’swebsite.

Humanresources Auditscope The entireCourt staff comprisesabout 760audi- The MaastrichtTreaty requiresthe Court toaudit tors,translators and administrativesupport.The the implementation of the generalbudgetof the Court employs nationalsfrom all the Member EU,the EuropeanDevelopmentFunds,aswell as Statestoensureabalanced spreadoflinguistic the financialstatements of the EU bodiesand and professionalskills.Staff come from awide agencies.The scope of audits rangesfrom financial range of backgrounds:from the publicand private statements todetailed examinationsof specific sectors,e.g.accountancypractice,internaland budgetary areasormanagementtopics.These externalaudit,lawand economics.The recruitment audittasksaredivided into: policyfollows the generalprinciplesand employ- • Recurrentaudittasks,whichhavetobedone mentconditionsof the EU institutions,and its every year,suchasthe financialstatements of the workforcecomprisesbothpermanentcivil ser- EU,the EuropeanDevelopmentFunds,and of all vants and staff on temporary contracts. otherbodiesand agenciessetupbythe EU;and • Selected audittasks.inwhichthe Court selects Internalorganisation budgetary areasormanagementtopicsof specific The Court operatesasacollegiatebodywithits interest fordetailed audit. Members adopting auditreports and opinionsby majority vote. Meetingsarenotopen tothe public. The Court worksindependentlyof nationalgovern- The Court draws upits ownrulesof procedure ments and otherEU institutions.The Court isfree governing its internaloperation,whicharethen todecide on topics,whatitwants toauditand submitted tothe Council forapproval. when itwants topresentits observationsand pub- licisefindings.The Court selects anumberof The auditors aredivided intoauditgroupsthatare sub-divided intovarious specialised units,which coverthe differentareasof the budget.The Court assignseachMembertoagroup,whichischaired Fraud&OLAF bya“Dean”.Members of the groupelectthe Dean from amongst theirnumberforarenewable,two- Every year,the Court reports on the manage- yearterm. The Dean’srole istoensurethe smooth mentof the budget,anyirregularitiesand sus- running of the groupand its divisionsin agreement pected fraud. The EuropeanCommission and withall the Members of thatgroup. the MemberStatesareprimarilyresponsible The AdministrativeCommittee,composed of forpreventing,detecting and investigating Members representing the auditgroups,takes errors and irregularities.The Court’staskisto careofadministrativematters requiring aformal assess howwell theyhavefulfilled theirduty, decision bythe Court.Since2004,the Court may then suggest improvements. adoptdocuments without discussion based on a two-thirddecision of the Members of anaudit grouporthe AdministrativeCommittee. When fraud,corruption oranyillegalactivity is identified,the matteriscommunicated tothe The Court alsoappoints anInternalAuditor,who reports tothe AuditCommittee (comprised of EuropeanAnti-FraudOffice(OLAF). OLAF, three Members of the Court and anexternal whichhasspecialindependentstatus,was expert). given responsibility forconducting detailed administrativeanti-fraudinvestigations,investi- The budget The Court isfinanced from the generalbudgetof gating prosecutionsin Memberand benefici- the EU.The budgetamounted toabout 95 million ary States,and recovering EU funds. eurosin 2004,representing 0.1% of the total www.icu-management.org 35 EU FOCUS

budgetary and managementtopicsevery year,but examining keysupporting documentation,physical doesnotauditevery budgetary areain depthevery inspection,orenquiry.Methodsforexamining and year.Asabasisforidentifying audittasks,the testing systemsand transactionsinclude various Court regularlyundertakesariskanalysisof the techniques,suchasstatisticalsampling.Insome entireauditfield,considering issuessuchas cases,externalexperts areengaged toprovide knownproblemsorweaknesses,financialsignifi- specialist knowledge. canceand findingsof previous audits.The Court ranksthesepotentialtasksbypriority based on Reporting the results of the riskanalysisand the need to Auditreports communicatethe results of the ensureabalanced coverage of the budgetary area. Court’sworktothe auditee (European Inaddition,specificconcernsof the European Commission orotherEU institution concerned), Parliament,the Council and the publicatlarge are the discharge authority and the generalpublic. alsoconsidered beforethe finalselection of audit Aftercompletion of the auditwork,the auditors tasksismade. drawupadraftauditreport (“the Court’sprelimi- nary observations”),whichcontainsauditobserva- The Court’sauditpoliciesarelargelybased on tionsand findings,conclusionson the auditobjec- INTOSAI Auditing Standardsand International tivesand recommendationsforimprovement. Standardson Auditing –issued bythe International Federation of Accountants –thathavebeen adapted The draftauditreport isexamined first bythe audit tosuitthe EU context.Underthe MaastrichtTreaty, groupand then submitted forapprovalbythe the Court hasrightof access toanyinformation it Court.The report isthen senttothe auditee in the requirestocarryout its tasks.The auditors do on- context of abilateraldiscussion procedure. The the-spotchecksatthe various EU institutionsat auditee checksthe report and sendsanofficial the premisesof bodiesorlegalpersonsmanaging reply–taking intoaccountthe reactionsof the fundson behalf of the EU,including all levelsof MemberStates–tothe Court.The Court either administration dealing withEU funds. maintainsits originalobservationsorchanges them tocorrectanyerrors orambiguities,depend- Auditprocedure ing on the reply.Finally,the auditee’sreplyispub- Every auditiscarried out in three main stages: lished withthe auditreport.Atthe end of the bilat- planning,testing and reporting. eraldiscussion procedure,the Court formally adopts the definitiveauditreport. Planning The Court’sworkprogramme isplanned on a Benefits forthe EU citizen multi-annualand annualbasis.The multi-annual Asthe Court of Auditors isthe finalconscienceof planentailsdefining and updating its strategy, the EU,itstandstoreason thatcitizensexpectto whereasthe annualplandetailsspecifictasksfor see and reapthe benefits of its existence. Both thatyear. politicalscrutinyand closemediaattention –espe- ciallytocasesof fraudormisuse–necessitatethe The auditors prepareanaudit-planning memoran- EuropeanCourt of Auditors’role asanexternal dumforevery auditundertaken. Thismemoran- auditorof the EuropeanUnion. Assuch,the Court dumsets out the auditscope,approachand audit plays avitalrole: objectives,aswell ashowthesearetobe • Bypublishing its reports,the Court helpspro- achieved in the most efficientand cost-effective motetransparencyand accountability in the man- way.The memorandumiscomplemented byan agementof EU funds; auditprogramme thatsets out the audittesting • Through its auditwork,the Court helpsensure needed in detail. The auditplanning memoranda thatEU fundsarecollected and used in accor- and auditprogrammesaresubmitted forapproval dancewiththe applicable rulesand regulations; tothe auditgroupresponsible forthattask. • Its auditobservationsand recommendations help managers of EU fundsimprovetheirperform- Testing anceand contributetowardsimproving sound Testing isdone toobtain sufficient,relevantand financialmanagement; and reliable auditevidencethatwill allowthe auditors • Its auditreports serveasabasisforthe demo- toreachconclusionson the auditobjectives. craticscrutinyof the utilisation of EU fundsbythe Teamsof twoorthree collectevidenceinaccor- EuropeanParliamentand the Council. dancewiththe auditprogramme within the EU Although notinfallible,the Court strivestouphold institutionsand Memberand beneficiary States. its mandatebyproviding the best possible service Auditevidencecanbeobtained in various ways: in anexpanding EuropeanUnion. 4

36 ICU Management3-2006 COUNTRYFOCUS

Anoverviewof the healthcare system in Portugal

Healthcareison every country’spoliticalagenda, especiallybecauseofthe need tofind solutionstothe continuing increaseincost while meeting the challenge,feltby every healthcaresystem,toguarantee moreand better healthcaretoits population. Inordertoexplain today’shealth- caresystem in Portugaland identifyopportunitiesfor restructuring,one must firstunderstand howthe system evolved and whatfactors haveimpacted its development.

HealthcareinPortugalduring Europe. Yetin tandem,therewasasignificantrise the eraof democraticconsolidation in healthcarespending,anincreaseinhuman (1974-1985) resourcesdeployed and anupswing in the indica- The implementation of the NationalHealthService tors foruseofhealthcareservices(OECD 2006). (NHS)in1979,whichguaranteed “universal,gen- eraland free”healthcare,islinked tothe democra- Latest developments in the evolution tization process in Portugal. Atthe time,twomain of the healthcaresystem (1995-2006) featurescharacterized the NHS: 1) Itwasfunded Particularlyafter2002,anumberof structural bythe Statebudgetand 2)Itintegrated anumber reformsweredeveloped and implemented,some of differenthealthservices.Within ashort time of whichwereinnovative. Some of the moreliber- from the creation of the NHS,healthcarecoverage alprinciplesfrom the previous period wereincor- of the Portuguesepopulation wentfrom 58% in porated (separating the funderfrom the provider), AnaLuisaJardim,MD 1974,to100 %in1980(Barrosand Simões1999). and providers werereorganized withaviewto ICU –H.Capuchos, decentralization and increased flexibility of man- Lisbon,Portugal HealthcareinPortugalfrom 1985-1995 agement.Some examplesof thisarethe corpora- [email protected] Atthe end of the 80s,debatearoseregarding tization of afewpublichospitals,and the creation healthcarereforminPortugaland anumberof of Integrated Centers of Responsibility in hospi- otherEuropeancountries.Withpublichealthcare tals,whichactasintermediatelevelsof administra- services’lackofefficiencyand the public’sdifficul- tion,and thirdgeneration healthcenters. ty in accessing theseservices,advocatesincreas- inglydefended introducing market-oriented and The OECD’sSeptember2004Report (Economic competition mechanismsintothe system of SurveyPortugal2004) made agloballypositive healthcareprovision. Herethe privatesectorwould assessmentof the reformunderwayand the legis- take amoreactiverole,while funding became lation thathadbeen passed. The keystrategyfor moreindividualized and the NHS became subject reformiscombined nationalhealthcarewherepub- tocorporatemanagement.Serious doubts were lic, privateand socialhealthcareproviders coexist cast on centralized healthcaresystems,suchas and areregulated byan“independentand thoseinthe United Kingdom and Southern autonomous regulatory entity”thatoversees Europe. issuesof equity,accessibility,quality and rights of users. In1990,the BasicLawforHealthwaspassed in Portugal,and then,in 1993,the NHS statutecame According tothe Ministryof Health(2004),74% of out.Bothweretoplayapivotalrole in thiscritical hospitalbedsbelong tothe publicnetwork,while newhealthcarestrategy.The most far-reaching leg- 23%belong tothe privatesector.79% of the pri- islativemeasurewasthe creation of Regional vatesectorbedsbelong tothe privatenon-profit HealthAdministrations(RHAs),whichcoordinate sectorand 21%tothe for-profitprivatesector hospitalsand healthcarecenters overwidespread (Ministryof Health2004). Itshould bestressed geographicareas.Alsoatthistime,Portugalunder- that,in 2001,the shareofPortugal’sGDP spenton wentits first experienceofprivatemanagementof healthcarewasalready9.3%-while the European apublichospital. average was9.0%(OECD 2006).

From 1974to1995,therewasoverall improvement Hospitalcare in healthindicators,and the countryprogressively Anewhospitalmanagementlawwaspassed for converged withthe average healthfiguresfor all hospitalsthatcalled forheightened management www.icu-management.org 37 COUNTRYFOCUS

responsibility,upgraded efficiency,effective Waiting lists forsurgery assessmentof professionalsand introduction of Tocombatlong waiting lists forsurgery,the health- financialincentives.Asaresult,34hospitalswere caresystem created aper-patientincentivepro- corporatized,with31,morethan1/3 of all public gram,laterreplaced bythe “Integrated System for hospitals,designated Public Managementof Patients Signed UpforSurgery,” CorporateEntities(PCEs). In whichmakesthe Statemoreaccountable toits addition,twoofthe largest citizenry.Italsogivescitizensgreaterfreedom by teaching hospitalshavealso guaranteeing thatusers of the healthcaresystem recentlybeen corporatized. This will undergo surgery within aclinicallyacceptable newlegalframeworkallows for time period. Currently,aftersixmonthson await- greateradministrativeautono- ing list forsurgery,patients haverecourseto myand financialaccountability undergo the procedureataprivatehospitalatthe in hospitalmanagement,while expenseofthe NHS.The average waiting period permitting greaterleewayin forsurgery in 2002 was5.5 years.In2004thiswas purchasing equipmentand significantlyreduced to8.7months.(Pereira2005). materialsand in hiring emplo- yees.PCE hospitalemployees Drugpolicy arecurrentlycovered byin indi- Portugalholdsfirst placeforexpenditureondrugs. vidualworkcontracts. The shareofthe GDP on pharmaceuticalsin 2000 was2.0%(OPSS 2001). However,certain meas- Other,non-corporatized public ureshavebeen takentoreducethistype of spend- hospitals(the PublicAdmin- ing.Forexample,the genericdrugmarkethas istrativeSectorhospitals,or expanded,withthe marketshareforgenericsbur- PAShospitals)areexpected to geoning from 0.34% in 2002 to9.66%in2004, followsuit,improving their although thisisstill lowerthanthe figuresforthe Figure1:GDP SharesSpenton HealthCare overall performancebyfollow- rest of Europe. (Pereira2005). in 2001(OECD 2006) ing the benchmarkssetbythe PCEs.Modernpartnership Funding of the NHS modelshavealsobeen adopt- Morethan95% of NHS funding comesout of the ed,in whichpublic-private Statebudget,withthe rest made upofrevenue partnerships(PPPs)ofthe from patientco-payments,subsystemsand insur- PrivateFinanceInitiativetype ance. Hospitalbudgets absorb53%ofNHS fund- havebeen setup. Thisinvolves ing and constitutethe largest shareofpublic the construction,financing and spending on healthcare. NHS healthcenters make operation of newpublicNHS up11% of economicresourcesallotted tohealth hospitalsbyprivateentities. while pharmaciesrepresent24% (Pereira2005).

Primary care Aphilosophyof paying hospitalsforeffective“pro- Legislation alreadypublished duction”ofacts and servicesrendered tousers opensthe waytothe reform hasbeen introduced,asopposed tothe former of primary healthcarebymeans scheme of provisionaltwelfthsof the Statebudget Figure2:Improvementin the Performance of neworganizationalmodels. based on previous budgethistories.Thus,greater of PCE Hospitals(Pereira2005) Specifically,heathcenters will emphasishasbeen placed on contractualization, berestructured intofamily involving agreements signed bythe paying/con- healthunits thatarefunc- tracting entity (the PortugueseStatethrough its tionallyand technicallyautonomous.Legislation Ministryof Health) and units providing healthcare alsoallows forthe managementof healthcenters (hospitals,healthcenters). byprivate,socialorpublicentitiesundercontract, withStatepayments forresults benefiting Conclusion the population. Apaymentscheme linked to All the structuralmeasuresaffecting the healthcare performancewasalsointroduced forgeneral system overthe last fewyears –namelychanges practitioners. in the legalstatusof hospitals(hospital-corpora- tion),the creation of public-privatepartnerships, Continuing care the reformofprimary healthcareand the promo- Anationalnetworkofcontinuing care,especially tion of genericpharmaceuticals–stand tobring aimed atthe elderly,the chronicallyill and people about effectivechangesin Portuguesehealthcare. undergoing lengthyrecoverieswasalsocreated. However,itisstill too earlytotell howfar-reaching Thisprojectisstill in its very earlystages. theirimpactwill be. 4

38 ICU Management3-2006 Intensivecaremedicine in Portugal The firstintensivecareunits (ICUs)inPortugalwerecreated in the late1950s in Coimbra(RuiCarrington daCosta)and Oporto(Armando Pinheiro). Lisbon, the capitalofthe country,just introduced the firstmixed medico-surgicalICU in 1979,although some spacesdedicated tothe careoftraumaand surgical patients existed therebefore. Inrecentyears,ICU hasundergone significant change in Portugal.

Inthe last 15 years,Portugueseintensivecare doctors.Itholdsmixed congresses,coursesand RuiMoreno MD, PhD medicine (ICM)hasbeen subjected totwomove- otherpost-graduateactivities.Portugalhasalways Unidade de Cuidados ments thatchanged the waythe countryprovides been activeinternationally,particularlywithSpain IntensivosPolivalente assistancetothe criticallyill patient.First,in the and Brazil. The Society wasafounding memberof (UCIP) early1990s,severalnewICUswerecreated the World Federation of Societiesof Intensive& HospitaldeSt.António dosCapuchos throughout the country,allowing all districts of the CriticalCareMedicine and of the Pan-American CentroHospitalardLisboa countrytohavemixed ICUs–aprivilege,uptothat and IberianFederation of IntensiveCareMedicine, (ZonaCentral) date,reserved forthe large cities.Second,in 1997, whoseCongress wehosted in 1995. Lisbon has Lisbon,Portugal the NationalMedicalBoardaccepted the creation been alsoselected tohost the 2008Meeting of [email protected] of the sub-specialty of intensivecaremedicine. the EuropeanSociety of IntensiveCareMedicine. Inour nationalmodel,toberecognized asan intensivecaresub-specialist,doctors havetohave Inacountryfacing apooreconomicsituation, aprimary specialty (internalmedicine,anesthesia, intensivecaremedicine iscurrentlysubjected to surgery,etc.) and then go through twoyears of pressuretoincreaseproductivity and decrease full clinicaltraining in intensivecaremedicine with costs.The government’slackofdefinition forwhat afinalexamination. Thismodel isstill faraway anICU isand who canpracticeintensivecaremed- from completion. icine threaten the developmentof our speciality. Also,the lackofemphasison basicand clinical Overtime,severalspecialtieshavebeen involved research,withmost Portuguesehospitals(even in the process of creating the ICM sub-specialty in university-affiliated) dedicating almost all their Portugal,withmost intensivists coming from anes- time and resourcestoaheavy clinicalburden, thesiologyand internalmedicine,aswell assome prevents furtherdevelopments in our field. from pneumology.The lackofastandardized,well- However,the numberof Portugueseintensivists knownand well-respected programforeducation taking post-graduatecoursesand fellowships and training in ICM until recentlypushed asignifi- abroadisincreasing,asisthe numberand quality cantnumberof Portuguesedoctors tostand for of published manuscripts. the EuropeanDiplomain IntensiveCareMedicine. Portugalhashadasignificantnumberof specialists Portugal,withastrong cultureofintensivecare recognized bythe EuropeanSociety of Intensive medicine based on quality of care,wherealmost CareMedicine (ESICM)since1990.Todate, all ICUshavealreadyadopted aclosed model, Portugalhasnotdeveloped aspecialty orsub- our dedicated professionalswill faceuptothe speciality in criticalcarenursing. challenge of integrating researchand teaching in thisprocess in the coming years.The SPCI will According tothe latest available data, Portugalhas certainlyserveanimportantrole byproviding infor- 52ICUsin 41 hospitals,corresponding toaround mation and training tomembers,bycreating 394 staffed beds(440installed beds). Thesenum- spacesforthe exchange of ideasand experiences bers correspond to3.9 mixed adultICU bedsper and bystarting and sustaining collaborations.This 100,000 inhabitants,but the bedsarepoorlydis- isour challenge. 4 tributed. Forexample,Alentejo hasonlyaround 2.8 bedsper100,000 inhabitants,and Algarvehas3.8 Region HospitalsMixed ICUsInstalled bedsActivebedsInhabitants Activebeds/ bedsper100,000 inhabitants during most of the 100.000 inhabitants year,but only1. 5bedsper100,000 when the pop- North149 100 120 3236006 3,1 ulation reachesmorethanone million in the sum- Centre99748720023053,7 mer.Intensivecarecoverage isnotavailable in all Lisbon and Tagus River2115166 1793378967 4,9 island areas(see table 1). Alentejo 33 1313461637 2,8 Algarve22 15 15 3952083,8 The PortugalIntensiveCareSociety,founded in Azores221616241000 6,6 1975,isone of the oldest in Europe. The Society, Madeira11 1010263000 3,8 witharound 1,000 members,isamixed society, TOTAL 5241 394 4409978123 3,9 withequivalentnumbers of nursesand medical Table 1:Access tocareinPortugal www.icu-management.org 39 COUNTRYFOCUS

Intensivecaremedicine and emergency medicine in Portugal

One of the most remarkable aspects of the evolution of medicine in Portugalinthe last decade hasbeen the growing developmentand recognition of emergencymedicine.

Introduction Portugalhasalways provided healthcareservices CODU isthe primary coordinatorof emergency topatients who,duetothe high riskorserious- medicalservicesand receivesall requests for ness of theirclinicalsituation,haverequired an emergencyassistanceviathe call number112. Ricardo Matos,MD emergencyapproach. However,thisworkhas CODU isstaffed around the clockbydoctors and Unidade de Cuidados neverbeen asprofessional,asorganised,as centraloperators withspecifictraining toanswer IntensivosPolivalentes structured and,ultimately,aswidelyrecognised as the calls,performtriage and provide pre-emer- (UCIP) itistoday(Marquesand AlmeidaeSousa2004). gencycounselling.CODU candispatchvarious HospitaldeSantoAntónio Thisarticle highlights the most importantcontri- emergencyresponseresources,suchasthe INEM dosCapuchos buting factors in the riseofemergencymedicine and CODU Ambulances,the MedicalEmergency CentroHospitalarde in Portugal. and Reanimation Vehicles( ViaturasMédicasde Lisboa(ZonaCentral) EmergênciaeReanimação, orVMER),the Catas- Lisbon,Portugal Pre-hospitalmedicine trophe Intervention Vehicles( Viaturasde Inter- Ricardo.gmatos@ vençãoemCatástrofe ,orVIC)and the Medical mail.telepac.com The NationalInstituteofMedicalEmergency ( InstitutoNacionaldeEmergênciaMédica,or EmergencyHelicopters.Using its telecommun- INEM)wasfounded in 1981.Withthe approvalof icationscapabilities,CODU candispatchand anewlawin 2003 (PortugueseGovernment support theseemergencyresponseteams,then, Publishing Service2003a)and of anewinternalset based on clinicalinformation from the field, of regulationsin 2004(PortugueseGovernment preparethe appropriatehospitalforthe patient’s Publishing Service2004),INEM wasrestructured, reception. increasing bothits structureand resources.Its areasof action and coverage werealsoexpanded, The NationalFireand Civil Protection Service bringing INEM coverage tonearlyall national ( ServiçoNacionaldeBombeiroseProtecçãoCivil, territories. orSNBPC),subjecttothe InternalAffairs Minister, wascreated in 2003 (PortugueseGovernment IncontinentalPortugal,INEM isresponsible foran Publishing Service2003b). Its objectiveistopro- integrated medicalemergencysystem thatguar- tectand assist people and property,byguiding and anteesimmediateand appropriatehealthcarefor coordinating all the civil protection and emergency accidentcasualtiesand victimsof sudden illness. activities.SNBPC isresponsible forpreventing Among its manytasks,INEM providesinitialmed- collectiverisksfrom serious accidents orcatas- icalhelp atthe accidentsite,transportation of vic- trophesand minimising the impactof thesesitua- timstothe correcthospitaland inter-hospitalcom- tionswhen theyoccur.Italsocoordinatesthe munication services.Through its Europeanemer- activitiesof the fireservicesand lendstechnical gencycall number(112),INEM hasseveralmeans and financialsupport toactivitiesin all civil protec- torespond effectively,atanytime,tomedical tion fields,asappropriate. SNBPC promotes,sup- emergencysituations(PortugueseGovernment ports,and critiquesthe developmentof emer- Publishing Service1997). Inordertoprovide effi- gencyplansatthe nationallevel. Finally,SNBPC cientmedicalassistancetovictimsof sudden fosters emergencyand civil protection cooperation illness oraccident,wehavethe following emergency withnationaland internationalorganisations, services,appropriatefordifferenttypesof medical particularlywithin the EuropeanUnion and luso- emergencies:EmergencyPatientCoordination phone diaspora. Centres( Centrosde OrientaçãodeDoentes Urgentes ,orCODUs);the EmergencyPatient Hospitalmedicine Coordination CentreforSituationsOccurring at Portugalhasrecentlybuiltanumberof newhospi- Sea( CentrodeOrientaçãodeDoentesUrgentes tals,replacing severalold and less functional parasituaçõesocorridasno mar ,orCODU-Mar); buildingsand,atthe same time,ensuring better the Poison Information Centre(Centrode coverage of the nationalterritory.Inaddition, InformaçãoAntivenenos ,orCIAV);and the High Portugalhascreated newemergencyservices, RiskNeonatalTransport Subsystem ( Sub-sistema recognising emergencymedicine’sessentialrole de TransportedeRecém-Nascidosde AltoRisco ). within hospitals–afactnotalways acknowledged

40 ICU Management3-2006 in the past,particularlyin some centraland univer- Professionaltraining sity hospitals.Even now,manyhospitalsdo not Severalentitiesstand out fortheirworkinemer- haveasystem torespond tointernalemergencies, gencymedicaltraining in recentyears: and whereasystem isin place,itisrunonan exclusivelyvolunteerbasis. INEM’sMedicalEmergencyTraining Department , in responsetonumerous requests from the Particularlyduring the 1990s,Portugalbeganopen- population and in accordancewithits mission, ing moreintensivecareunits ( Unidadesde regularlyoffers coursestonon-professionalsand CuidadosIntensivos ,orICUs)(Direcção-Geralda professionalsalike,suchascourseson adultbasic Saúde 2003),duetothe broadening of indications lifesupport (BLS)forlaymen,paediatricBLS for forpatientadmission;betterand fasterintra-and laymen,BLS forhealthprofessionalsand basic extra-hospitalassistanceresources; and increased emergencytechniques(http://inem.min-saude.pt). requirementof intensivecaremedicine (withthe evolution of moreaggressivesurgicalormedical The PortugueseSociety of Surgery ( Sociedade therapeuticsin severalareas,likehaematology, Portuguesade Cirurgia ,orSPC)hasbeen offering oncologyand transplantation). Withthe introduc- Advanced TraumaLifeSupport® (ATLS)courses tion of additionalICUs,progressiveand better since1999,in collaboration withthe Committee on communication developed between ICUsand Traumaof the AmericanCollege of Surgeons otherhospitalareas,suchasintra-and extra-hospi- (www.atlsportugal.org/index.html). ATLS isapost- talemergencyservices,surgery rooms,intermedi- graduatemedicaltraining programme,whichaims atecareunits and departments facilitating fast- atimproving the quality of initialmedicalhelp for trackpatientadmission systems. the polytraumatised patient,trying toreducethe mortality and incapacity associated with“the 20th Finally,the HealthMinistrycreated the National century epidemic”- trauma. HospitalReferenceNetworkforEmergency ( Redesde ReferenciaçãoHospitalarNacionalpara The PortugueseSociety of IntensiveCare aUrgência/EmergênciaeparaosCuidadosInten- ( Sociedade Portuguesade CuidadosIntensivos ,or sivos )and promulgated suggestionsforthe devel- SPCI)offers aregularprogramme of courses,includ- opmentof intensivecareinthe frameworkofthe ing FundamentalCriticalCareSupport (FCCS)and NationalHealthService(Recomendaçõesparao Fundamentalsof DisasterManagement(FDM), desenvolvimentodosCuidadosIntensivosno quadro delivered bySPCI in partnership withthe American do ServiçoNacionaldeSaúde),thus creating the Society of CriticalCareMedicine (SCCM). FCCS is essentialconditionsforthe justification and plan- atwo-daycoursefornon-intensivists thatteaches ning of the financialand humanresources,ensur- the fundamentalprinciplesof the first 24hours of ing betternationalcoverage of emergencymedical medicalcareforthe criticalpatient.Thiscourse, services(Direcção-GeraldaSaúde 2003; Minis- offered atseverallocationsthroughout the country tério daSaúde 2004a;Ministério daSaúde 2004b). eachyear,hasbeen very successfulinPortugal, alreadyhaving trained hundredsof professional doctors and nurses.The same canbesaid about the FDM course,whichhas been offered since2004. Itisa one-daycourseondisaster medicine,whichhasmade possible aclosercoopera- tion between the various entitiesof emergency medicine,suchas SPCI, INEM and SNBPC.One of the

A most importantcontri- d v e butionsof SPCI todate r t i s wasthe developmentof m e n t the document“Guide- linesforthe transport of the criticallyill patients”,byan SPCI taskforcein1997 (www.spci.org/index2.html). www.icu-management.org 41 COUNTRYFOCUS EU FOCUS

The PortugueseResuscitation Council ( Conselho differentexperiencesin basictraining provided Portuguêsde Ressuscitação ,orCPR)focuseson byamultidisciplinary staff working togetherin coordination and promotion of initiativesrelated emergencymedicine. Regardless of Portugal’s toreanimation,normalisation of educationalpro- preferenceforaCompetenceoveraSpecialisa- grammestodevelop education and practiceof tion,the countryhasmade significantprogress cardio-respiratory reanimation techniques,in towardaclearcurriculumdefinition and the estab- accordancewiththe EuropeanResuscitation lishmentof excellenceservices,wherehigh quali- Council (ERC). Itwascreated in 1997and hasbeen ty technicaland scientifictraining canbedone. amemberof the EuropeanResuscitation School The OM will beresponsible foraccreditation and since1999. CPR hascertified seven schoolsof certification in our country. reanimation training in Portugal,whichregularly delivermanycoursesin basic, intermediateand The role of intensivecaremedicine advanced paediatricand adultlifesupport,aswell Intensivecaremedicine hasplayed animportant asautomaticexternaldefibrillation coursesand basic part in the developmentof emergencymedicine in oradvanced lifesupport coursesforinstructors. Portugal. Thereisobviouslyalotin common between the twodisciplines,whichsharethe com- Inaddition tothesekeytraining sources,the Fire mon goalofproviding medicalcaretoseverelyill or ServicesCorporations,PublicSecurity Corpora- injured patients and areoften onlydistinguishable tions,Schools,Societies( Corporaçõesde Bom- from one anotherin whereand when thiscarecan beiros,Corposde Segurança Pública, Escolas, beprovided. However,the contribution thatIdeem Sociedades )and the PortugueseTraumaSociety most importantisthe training of emergencymed- ( Sociedade Portuguesade Trauma )contributeto icine practitioners,whichoccurs mostlyin ICUs. emergencymedicaltraining activities.Portuguese ThisICU training often developsthe trainee’staste universitiesarealsoinvolved in emergencymed- foremergencymedicine,effectivelyrecruiting icaltraining,suchasOportoUniversity and its traineestothe vocation. Severalintensivists Faculty of Medicine,whichoffers aMasterDegree played animportantrole in the creation of the in EmergencyMedicine,and the Abel Salazar CompetenceinEmergencyMedicine,and their BiomedicalScienceInstitute,whichoffers a interest in the field continues.Manyintensivists MasterDegree in DisasterMedicine. arefirmlycommitted tocontributing tothe training of thosewho provide healthcaretocriticaloremer- Emergencymedicine accreditation gencypatients. In2002,the NationalExecutiveCouncil of the NationalMedicalBoard(Conselho Nacional InPortugal,the intensivist hasembraced the role Executivo,orCNE, daOrdem dosMédicos ,or of “olderbrother”tothe emergencymedicine OM)recognising the universaldevelopmentof practitioner.The intensivist arrived first,grewearli- emergencymedicine and its predictable and desir- er,contributed decisivelytothe emergencypracti- able nationalexpansion,created the Competence tioner’straining and will,Iamsure,continuetodo in MedicalEmergency(Ordem dosMédicos so. But nowtheywill worktogether,and theirwork 2002). Itestablished requisitetechnical-profession- will bemoreequitable,withmutualbenefits for alqualificationsfordoctors working in emergency thesecomplementary areasof medicine and for medicine. Atthe same time,itissued best practice theirpatients. 4 norms,aiming atimprovementof healthcareserv- ice. Based on thesenewstandards,severalspe- cialisations,suchassurgery,internalmedicine, RelevantWebsites anaesthesiologyand paediatrics,wereallowed • InstitutoNacionaldeEmergênciaMédica, toaccess thisCompetence,through adequate www.inem.min-saude.pt curriculumassessmentbyacommittee appointed • ServiçoNacionaldeBombeiroseProtecçãoCivil, bythe CNE. www.snbpc.pt • Sociedade Portuguesade Cirurgia, Although the EuropeanSociety forEmergency http://spcir.com Medicine (EuSEM)promotesthe creation of a • Sociedade Portuguesade CuidadosIntensivos, Specialisation in EmergencyMedicine (EuSEM www.spci.org/index.html 2002a,EuSEM2002b),specialisationisnotan • Conselho Portuguêsde Ressuscitação, option in Portugal. The PortugueseMedicalBoard www.cprportugal.net considered itpreferable totake advantage of the

42 ICU Management3-2006 Intensivecaretraining in Portugal Sincethe inceptionofthe firstPortugueseintensivecareunit(ICU)inthe latefifties,significant(but still insufficient)progress hasbeen made,with the installation of manyICUsand the training of staff,doctors and nurses forcriticalpatients’care.

The rapid evolution of technicaland scientific skillsin the managementof respiratory,cardiovas- knowledge in the areaof criticalcarebrought cular,neurological,renal,haematological,gastroin- about the need foranewspecialisation forthose testinal,obstetrics,burn,toxicsyndrome and working in intensivecare,regardless of theirprevi- infectious diseasecases.Theymust alsobeprofi- ous studies.Thisneed wasfirst recognised in 1989 cientin all the currentICU techniques.Afterthe byour NationalMedicalBoard(Ordem dos training period,candidatesundergo athree-part Médicos ,orOM),whichisin charge of medical exam,performed bymembers of the ICU staff, training.Thatyear,the OM implemented the Ciclo including curricular,theoreticaland practical de EstudosEspeciaisem MedicinaIntensiva ,or issues.Afterqualification,the OM certifiescandi- “SpecialStudiesCycle in IntensiveCareMedicine”, datesassub-specialists in intensivecaremedicine. atwo-yearperiod of training forthosedesiring to TeresaFevereiro,MD workincriticalcare. In2005,the OM recognised The intensivecaresub-specialty will replacethe LuisaAmado,MD intensivecareasasub-specialty and established Ciclo de EstudosEspeciaisem MeidcinaIntensiva Unidade de Cuidados newrequirements forqualification. in the future. Candidatesaresubjecttothe same IntensivosPolivalente specialty requirements and areadmitted tothe (UCIP) InPortugal,intensivecaremedicine istaughtonly training programme aftercurricularevaluation and HospitaldeSantoAntónio dosCapuchos atCoimbraUniversity,one of Portugal’ssixmedical aninterview.The two-yeartraining isdone in a CentroHospitalarde schools.Itisafour-monthcoursewiththeoretical C-Level ICU,on afull-time (42h/week) schedule. Lisboa, ZonaCentral and practicaltraining,included in the last yearof The ICU continuallyevaluatescandidateson their Lisbon,Portugal the usualmedicalstudies. proficiencyin the areasof criticalcaredescribed [email protected] above. Afterthe training period,if the candidate Intensivecaretraining isnowpart of the residency qualifieswithatleast 10out of 20 possible points curriculaof medicaland surgicalspecialties,its in the continuous evaluation,he orshe will under- duration ranging from three tonine monthsand,if go athree-part exam(curricular,theoreticaland desired bythe trainee,extended tothe maximum practical). Thisexamisadministered byaboardof of twelvemonths.Thisresidencymust becom- fiveintensivecaresub-specialists,three from pleted in aB-Level ICU.During thistraining period, otherICUs. the trainee must recognise,prioritise,and imple- mentaprocedureplanforevery type of critical InPortugal,therearenowabout 170 intensivecare medical,surgicalortraumapatient.Afterthe train- sub-specialists.The majority of them arelong-term ing period,all candidatesareevaluated in atheo- intensivecarepractitioners,from internalmedi- reticaland practicalexam,qualifying withatleast cine,pneumologyand anaesthesiology.Weexpect 10out of 20 possible points. thatthe coming years will bring manymoresub- specialists and greaterrecognition of the impor- The Ciclo de EstudosEspeciaisem Medicina tanceofthe specifictraining forthosetaking care Intensiva ,initiated in 1989,isatwo-yearperiod of of criticallyill patients. 4 training forthosewanting tospecialiseinintensive care. All candidatesmust haveprevi- ous specialisation in internalmedi- cine,generalsurgery,anaesthesi- ICU Level A-Level B-Level C-Level ologyorothermedicalorsurgical CaseMixx >10%medical,surgical,>15% medical,surgical, and urgent/ emergencyand urgent/emergencypatients specialities.Candidatesareaccepted patients (each),including coronary, toaprogramme in aB-orC-Level neurological,and traumapatients ICU aftercurricularevaluation. During Years of Activity x>2years >5years ActiveBedsx >6beds>8beds thistwo-yeartraining period,candi- Admissions/Yearx >150admissions>200 admissions datesworkonafull-time schedule Training x1intensivecarespecialist >5intensivecarespecialists in (42h/week) in the ICU,but candi- in charge of medicaltraining charge of medicaltraining datesmayalsostayforshort periods OtherRequirements Meets minimalcriteriathatMeets the abovecriteriaand Meets the abovecriteriaand must befulfilled byevery ICU,maytrain residents.offers atraining programme of time in otherICUs,focusing in based on areport of ICU and investigationalprojects. morespecificareas,liketrauma, statisticsand certified byMaytrain sub-specialists. neurological,coronary orburncare anindependentboard. *Thesecriteriaareperiodicallyrevised and audited. ICUs.Candidatesshould acquire Table 1:PortugueseICU Requirements,byLevel* www.icu-management.org 43 COUNTRYFOCUS

Sepsis and organfailure in Portugal

Sepsis,defined asthe host responsetoaninfectious process,is one of the most frequentdiagnosesin the intensivecareunit(ICU), and when associated withorgansystem dysfunction,remainsone of the most common causesof mortality in criticalcare.Thispaper reviews some of its characteristicsin PortugueseICUs.

Isabel Miranda, MD. Unidade de Cuidados APortugueseprospectiveand multicenterstudy IntensivosPolivalente(UCIP) sepsis(Vincentetal. 2006). ICU and hospitalmor- HospitaldeSt.António from 15 ICUs,including 701patients (58% of them tality of septicpatients washigh (32%and 38%, dosCapuchos of medicalwithmeanSAPS 38±41),showed that, respectively),aswasSAPS score(46,2±14,8). CentroHospitalarde Lisboa atadmission,34% of the patients wereinfected Inthisstudy,Portugalwasthe countrywiththe (ZonaCentral) (Moreno etal. 1999). ICU and hospitalmortality highest frequencyof sepsisand mortality. Lisbon,Portugal (20%and 30%,respectively),weresignificantly [email protected] related tosepsisand septicshock. Organdysfunc- The numberof patients included in thesestudiesis tion atICU admission,assessed bySOFAscore, lowand notrepresentativeofall PortugueseICU wassignificantlyassociated withinfection. There patients.Nevertheless,Albertietal. showed that, wasalsoacorrelation between SOFAscoreand in Portugal,the rateofinfection atICU admission mortality,sepsisand septicshockatadmission or and during ICU stayishigh,and the SOAP study during ICU stay.Atthe same time,therewerea observed ahigh rateofsepsis,severesepsisand numberof patients withhigh SOFAscores,but ICU and hospitalmortality in Portuguesepatients without SIRS, sepsisorsepticshockcriteria. (Albertietal. 2002; Vincentetal. 2006). Howcould weexplain theseresults?Mortality rateinseptic Recently,anotherprospectivemulticenterstudy patients isalmost double of thatof nonseptic about community-acquired sepsis(CAS)in patients,becausesepticpatients aregenerally Portugal,included2,643ICU patients from 17 moreill. However,thisisnotthe sole explanation, ICUs; 606 (23%) hadCAS, 41% of the CAS becauseassociation between sepsisprevalence patients hadseveresepsisand 48% hadseptic and mortality isstrongerthanbetween mortality shock(Carneiroetal. 2006). Microbiologicallydoc- and severity of diseasemeasured bySAPS II umented infection wasfound in 40%ofpatients. (Warren and Ferguson 2006). The SOAP study’s Septicpatients hadalongerICU stayand ahigher finding thatthereisanassociation between the mortality ratethanthe control group. The authors degree of organdysfunction and numberof failing concluded thattherearenowmorepatients admit- organsand mortality,alreadynoted byVincent ted withCASand moreseveresepsisand septic (Vincentetal. 1998),suggests thatorganfailure shock,compared toprevious,similarstudies. waselevated in the Portuguesepopulation,given the observed mortality in thesepatients. Therearealsoother,internationalepidemiological Differencesin case-mix,admission criteria, pre- studieswithPortuguesedataabout:incidenceof ICU and ICU resourceutilization,widespread infectionsand sepsis(Albertietal. 2002; Vincentet antibioticuseand subsequentimpacton multire- al. 2006),theirinfluenceonoutcome (Albertietal. sistantmicroorganismsmayalsoaccountforpoor 2003; Albertietal. 2005) and incidenceoforgan outcome in Portugal’ssepticpatients. dysfunction in ICU patients (Vincentetal. 1998). However,Portugalispoorlyrepresented in these InPortugal,therearefewstudieson the epidemi- studies,and datafrom some of thesestudiesis ologyof community,hospitaland ICU-acquired notpublished separatelyaccording tocountryof infection and organdysfunction in criticalcare origin. Nevertheless,wecansee in the Alberti patients.However,one cancarefullystatethat studythat,in 514patients from three Portuguese thereisahigh severity of infection,sepsisand centers withICU staylongerthan24hours,there organfailureinthiscountrythatcannotbe wasahigh rateofinfection on ICU admission (291 explained just bydifferencesin studyprotocolsand patients,57%) and ICU acquired infections(122 methodology.Furtherresearchisneeded tobetter patients,24%) (Albertietal. 2002). The SOAP identifythe factors thatcontributetothisphenom- study,whichincluded 69patients from 6 enon and totake action in ordertodecrease PortugueseICUs,shows that50patients (73%) mortality forsevereinfection and organfailure hadsepsisand that64% of them hadsevere in Portugal. 4

44 ICU Management3-2006

CONGRESSES

SCCM’sannualCongress: Improving patientcare 2007 Congress Co-chairs Elevateyour clinicalknowledgeduring the Society of CriticalCareMedicine’s (SCCM)36thCriticalCareCongress, February 17to21,2007,in Orlando,

Florida, USA. Simon Finfer,MD, MBBS, MRCP SeniorStaff Specialist in IntensiveCare RoyalNorthShoreHospitalofSydney Stayabreast of newdevelopments,obtain needed University of Sydney toolstohelp advanceyour knowledge and further Sydney,Australia your practiceofcriticalcareatthe Society of Plenary:ClinicalRole of Albumin in the CriticallyIll CriticalCareMedicine’s36thCriticalCare Daren K.Heyland,MD, MSc Congress.Regardless of your profession orrole in AssociateProfessorof Medicine the criticalcareteam,the Congress will offeryoua Kingston GeneralHospital well-rounded perspectiveonthe latest diagnosis Queen’sUniversity and treatmentof acutediseasesand conditions Kingston,Ontario,Canada Plenary:Pharmaco-Nutrition:ANewEmerging Paradigm common in the intensivecareunit(ICU)environ- ment. PatrickM.Kochanek,MD, FCCM Director,SafarCenterforResuscitation Research RichardJ.Brilli,MD, University of Pittsburgh MedicalCenter FCCM The Society’sfive-dayCongress offers numerous Pittsburgh,Pennsylvania, USA Professorof Pediatrics cutting-edge sessions,hands-on workshops, Plenary:EmergencyPreservation forResuscitation ClinicalDirector, informativesymposiaand exciting socialengage- (EPR):Beyond CPR PediatricICU ments.Participants canenrichtheirexperienceby Lucien L.Leape,MD CincinnatiChildren’s taking part in pre-Congress educationalsessions Departmentof HealthPolicyand Management HospitalMedicalCenter and postgraduatereviewcoursesheld on Friday, AdjunctProfessorof HealthPolicy Cincinnati,Ohio,USA February 16and/orSaturday,February 17.These HarvardSchool of PublicHealth Boston,Massachusetts,USA sessionsprovide acost-effective,convenient Stephen M.Pastores, Plenary:Problem Doctors: method toenhanceyour Congress educational IsThereaSystem–Level Solution MD, FCCM experience. Director, WilliamJ.Sibbald,MD, FCCM CriticalCareMedicine Physician-in-Chief Fellowship Programand Join seven internationallyknownleaders asthey Sunnybrook HealthSciencesCentre CriticalCareResearch presentengaging topicsthroughout the Plenary Professorof Medicine University of Toronto MemorialSloan-Kettering Sessions.Offered during unopposed timeframes, Toronto,Ontario,Canada CancerCenter,NewYork Plenary Sessionswill offerparticipants the oppor- Plenary:Learning From Others:Best Practices USA tunity tolisten tokeynoteaddressesthatpromote in Leadership From Leaders Outside Healthcare importanteducationaldevelopments (see table 1). Jeffery S.Vender,MD, FCCM Director,MedicalSurgicalICU Adistinguished faculty hasbeen assembled to DepartmentChairof Anesthesiology presentimportantsessionsconcerning topics Evanston Hospital suchascardiology,end of life,endocrinology,nutri- Professorof Anesthesiology tion,hematology,infectious diseases,neurology, NorthwesternUniversity Evanston,Illinois,USA sepsis,traumaand others.Participants will obtain Plenary:OrganizationalChange:The Process newperspectiveson the etiologyand manage- of Moving TodayIntoTomorrow mentof clinicalillnessestooptimizethe careand HectorR.Wong,MD outcomesof all criticallyill and injured patients. Director,Division of CriticalCareMedicine CincinnatiChildren’sHospitalMedicalCenter Discovereverything Orlando hastoofferduring Cincinnati,Ohio,USA the 36thCriticalCareCongress.Best knownasa Plenary:Genome-Level Expression Profiles of PediatricSepticShock familydestination withlovable characters and fan- tasticattractions,Orlando isalsoafun,exciting Table 1:KeynoteAddresses city foradults.The city offers manyactivities,from playing around of golf on achampionship course, Registernowtoelevateyour clinicalknowledge shopping atoutletmallsorenjoying afine-dining atthe largest multiprofessionalcriticalcareevent experience. Whateveryoudesire,Orlando canbe of the year. Become anSCCM memberand save asaffordable orasluxurious asyouchoose. upto$200offthe Congress registration fee.

46 ICU Management3-2006

Agenda ICU Management isthe OfficialManagementand PracticeJournalof the InternationalSymposiumonIntensiveCareand EmergencyMedicine.

EDITOR-IN CHIEF Jean-LouisVincent,Head,Departmentof IntensiveCare,Erasme Hospital, SEPTEMBER 2006 Free University of Brussels,[email protected] EDITORIAL BOARD 2-6EuropeanRespiratory Society 2006 AnnualCongress Prof. Antonio Artigas(Spain) [email protected] Munich,Germany Dr.RichardBeale (United Kingdom) [email protected] www.ersnet.org/ers/default.aspx?id=2078 Dr.Todd Dorman(United States)[email protected] th Prof. HansKristianFlaatten (Norway)[email protected] 24-27 19 AnnualCongress of the EuropeanSociety Prof. Luciano Gattinoni (Italy)[email protected] of IntensiveCareMedicine Prof. Armand Girbes(Netherlands)[email protected] Barcelona, Spain Dr.Claude Martin (France) [email protected] www.esicm.org Prof. KonradReinhart (Germany)[email protected] Prof. JukkaTakala(Switzerland) [email protected] OCTOBER 2006 NATIONAL CORRESPONDENTS 4-8 4 th EuropeanCongress on EmergencyMedicine Prof. David Edbrooke (United Kingdom) [email protected] DrAnders Larsson (Denmark) [email protected] Crete,Greece Prof. Esko Ruokonen (Finland) [email protected]. www.ecem2006.com Prof. RetoStocker(Switzerland) [email protected] 12-13Cours d'Echocardiographie-Doppleren soinsintensifsetréanimation Dr.PatriciaWegermann (Germany) Brussels,Belgium [email protected] www.intensive.org MANAGING EDITOR 12-15 31 st Australian&NewZealand AnnualScientificMeeting [email protected] on IntensiveCare SCIENTIFIC EDITOR Tasmania,Australia [email protected] www.anzics.com.au nd CONSULTING EDITOR 20-22 2 InternationalEmergencyMedicine Conferenceand Kirstie Edwards the 1 st InternationalAnesthesiologyand CriticalCareConference Pristina, Kosovo EDITORS [email protected] K.Ruocco,D.Sains,C.Hommez EUROPEAN AFFAIRS EDITORS NOVEMBER 2006 [email protected] 16-17Cours d'Echocardiographie-Doppleren soinsintensifsetréanimation [email protected] Brussels,Belgium [email protected] www.intensive.org EDITORIAL ASSISTANT [email protected] DECEMBER 2006 th GUEST AUTHORS 5-712 PostgraduateRefresherCourse S.Afifi,L.Amado,M.Ault,R.J.Brilli,M.Capuzzo,T.Dorman,A.Faltlhauser, Brussels,Belgium J.C.Farmer,T.Fevereiro,D.K.Hamilton,A.L.Jardim,M.Maegele,R.Matos, www.intensive.org I.Miranda, R.Moreno,L.Morris,S.Nasraway,S.M.Pastores,R.Pauldine, P.Simpson,B.Smith,A.Thomas,J.-L.Vincent FEBRUARY 2007 PUBLISHING HOUSE 5-9 15th WinterSymposiumonIntensiveCareMedicine EuromedicalCommunicationss.a. 28,ruedelaLoi,B-1040Brussels,Belgium Crans-Montana, Switzerland Tel +32 22868500 www.intensive.org Fax+32 22868508 18-2136th CriticalCareCongress of the SCCM E-mail [email protected] Orlando,USA Websitewww.icu-management.org www.sccm.org PUBLISHER [email protected] MARCH 2007 rd MEDIA CONTACT,MARKETING, ADVERTISING 22-243 World Congress AbdominalCompartmentSyndrome LukHaesebeyt [email protected] (WCACS2007) Antwerp,Belgium SUBSCRIPTION RATES One yearEurope 50Euros www.wcacs.org Overseas65Euros 27-30 27th AnnualInternationalSymposiumonIntensiveCare Twoyears Europe 85 Euros and EmergencyMedicine Overseas100 Euros Brussels,Belgium Note:Participants of the InternationalSymposiumonIntensive www.intensive.org Careand EmergencyMedicine receiveaone yearsubscription aspart of theirsymposiumfee. MAY2007 th ART DIRECTOR 22-2415 World Congress on Disasterand EmergencyMedicine Astrid Mentzik [email protected] Amsterdam,The Netherlands www.wcdem2007.org PRODUCTION AND PRINTING Imprimerie Centrale s.a.,Luxembourg JUNE 2007 Printrun:7,100 -ISSN =1377-7564 9-12Euroanaesthesia © ICU Management ispublished quarterly.The publisheristobenotified Munich,Germany of cancellationssixweeksbeforethe end of the subscription. The reproduc- tion of (parts of) articleswithout consentof the publisherisprohibited. The www.euroanesthesia.org publisherdoesnotacceptliability forunsolicited materials.The publisher retainsthe righttorepublishall contributionsand submitted materialviathe Internetand othermedia.

LEGAL DISCLAIMER The Publishers,Editor-in-Chief,EditorialBoard,Correspondents and Editors make every effort tosee thatno inaccurateormisleading data, opinion or statementappears in thispublication. All dataand opinionsappearing in the articlesand advertisements herein arethe sole responsibility of the contrib- utororadvertiserconcerned. Thereforethe publishers,Editor-in-chief, Letters tothe Editor&Requests EditorialBoard,Correspondents,Editors and theirrespectiveemployees forReferencesCited in ICU Management acceptno liability whatsoeverforthe consequencesof anysuchinaccurate ormisleading data, opinion orstatement. [email protected] REFERENCES Referencescited in thisjournalareprovided toEuromedical 48 Communicationsbythe authors and areavailable on request [email protected]. What’sone waytodramatically impactCriticalCare?

Achieve

1weaning00protocol compli% ance.

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EmergencyCare·PerioperativeCare·CriticalCare·PerinatalCare·Home Care Becauseyoucare Volume 6-Issue3-Autumn 2006 The OfficialManagementand PracticeJournal PPrrepepaarringing foforr DIDISASASTSTERER - 7 5 6 4 377

ISSN =1 PLUS: • TRANSPORTVENTILATORS • INTENSIVE CARE • GLYCAEMIC CONTROL IN PORTUGAL