Intensive Care Medicine

, Volume 38, Issue 10, pp 1647–1653

The variability of critical care bed numbers in Europe

Authors

    • Department of Intensive Care MedicineSt George’s Healthcare NHS Trust and University of London
  • P. Ferdinande
    • Surgical and Transplantation ICUUniversity Hospital Gasthuisberg
  • H. Flaatten
    • ICUHaukeland University Hospital
  • B. Guidet
    • Assistance Publique-Hôpitaux de Paris, Hôpital Saint-Antoine, service de réanimation médicale
    • Inserm, Unité de Recherche en Épidémiologie Systèmes d’Information et Modélisation (U707)
  • P. G. Metnitz
    • Department of Anesthesia and General Intensive CareAKH Wien, Medical University of Vienna
  • R. P. Moreno
    • Unidade de Cuidados Intensivos Polivalente, Hospital de St. António dos CapuchosCentro Hospitalar de Lisboa Central, E.P.E.
Original

DOI: 10.1007/s00134-012-2627-8

Cite this article as:
Rhodes, A., Ferdinande, P., Flaatten, H. et al. Intensive Care Med (2012) 38: 1647. doi:10.1007/s00134-012-2627-8

Abstract

Purpose

To quantify the numbers of critical care beds in Europe and to understand the differences in these numbers between countries when corrected for population size and gross domestic product.

Methods

Prospective data collection of critical care bed numbers for each country in Europe from July 2010 to July 2011. Sources were identified in each country that could provide data on numbers of critical care beds (intensive care and intermediate care). These data were then cross-referenced with data from international databases describing population size and age, gross domestic product (GDP), expenditure on healthcare and numbers of acute care beds.

Results

We identified 2,068,892 acute care beds and 73,585 (2.8 %) critical care beds. Due to the heterogeneous descriptions of these beds in the individual countries it was not possible to discriminate between intensive care and intermediate care in most cases. On average there were 11.5 critical care beds per 100,000 head of population, with marked differences between countries (Germany 29.2, Portugal 4.2). The numbers of critical care beds per country corrected for population size were positively correlated with GDP (r 2 = 0.16, p = 0.05), numbers of acute care beds corrected for population (r 2 = 0.12, p = 0.05) and the percentage of acute care beds designated as critical care (r 2 = 0.59, p < 0.0001). They were not correlated with the proportion of GDP expended on healthcare.

Conclusions

Critical care bed numbers vary considerably between countries in Europe. Better understanding of these numbers should facilitate improved planning for critical care capacity and utilization in the future.

Keywords

Intensive care Bed numbers Demand Supply

Introduction

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

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

To plan for these changes there is a need to better understand the current situation of critical care bed availability [4, 911]. Although several countries publish the numbers of beds provided, little is known about how this varies between countries even within a confined geographical region such as Europe. This study therefore aims to identify the total numbers of critical care beds for each country in Europe and to adjust the bed numbers to the population in order to illustrate the differences in resource provided for this group of patients.

Materials and methods

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

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

Results

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

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

Descriptors of population size, economic strength and health expenditure in European countries

 

Total size of population

Gross domestic product (GDP) ($millions)b

Gross domestic product (GDP) per inhabitant ($)b

Total expenditure on health as a % of GDPc

% of population over 65 years of agea

Andorra

84,082

2,893

34,407

7.7

13.0

Austria

8,404,252

377,382

44,904

8.6

18.2

Belgium

11,007,020

467,779

42,498

8.2

18.0

Bulgaria

7,504,868

47,702

6,356

4.4

18.2

Croatia

4,425,747

60,834

13,745

7.8

16.9

Cyprus

804,435

23,174

28,808

6.0

10.4

Czech Republic

10,532,770

192,030

18,232

6.9

16.3

Denmark

5,560,628

309,866

55,725

9.8

17.1

Estonia

1,340,194

19,253

14,366

5.3

17.7

Finland

5,375,276

239,177

44,496

6.8

17.8

France

65,075,310

2,562,742

39,381

9.2

16.8

Germany

81,748,892

3,286,451

40,202

8.9

20.6

Greece

11,329,618

305,415

26,957

5.8

19.6

Hungary

9,986,000

130,421

13,060

5.2

16.9

Iceland

318,452

12,594

39,548

7.9

12.7

Ireland

4,480,176

206,985

46,200

7.2

11.6

Italy

60,626,508

2,055,114

33,898

7.4

20.3

Latvia

2,229,641

24,013

10,770

8.1

16.9

Lithuania

3,244,601

36,370

11,209

7.8

16.5

Luxembourg

511,840

54,950

107,358

4.1

14.9

The Netherlands

16,654,979

780,668

46,873

5.5

15.6

Norway

4,920,305

412,990

83,936

8.1

16.0

Poland

38,200,037

469,401

12,288

5.3

13.7

Portugal

10,636,979

229,154

21,543

5.7

18.0

Romania

21,413,815

161,629

7,548

5.4

14.8

Slovakia

5,435,273

87,450

16,089

6.0

12.8

Slovenia

2,050,189

47,733

23,282

6.8

16.8

Spain

46,152,926

1,409,946

30,549

7.0

17.1

Sweden

9,415,570

458,725

48,720

8.2

19.7

Switzerland

7,866,500

527920

67,110

6.8

17.0

UK

62,435,709

2,250,209

36,040

8.2

16.5

aCIA World Factbook

bEurostat 2011

cOECD 2009 %GDP

Table 2

Data describing numbers of adult acute care, intermediate care and intensive care beds per European country

 

Acute care bedsa

Acute care beds/100,000 population

Intermediate care (IMCU) beds

Intensive care (ICU) beds

Critical care beds

ICU and IMCU beds/100,000 population

ICU beds as % of acute care beds

GDP ($million)/ICU beds

Andorra

188

224

 

 

6

7.1

3.2

482.2

Austria

48,446

635

569

1,264

1,833

21.8

3.4

205.9

Belgium

50,156

456

 

 

1,755

15.9

3.5

266.5

Bulgaria

57,460

766

 

 

913

12.2

1.6

52.2

Croatia

15,629

353

 

 

650

14.7

4.2

93.6

Cyprus

2,813

350

9

83

92

11.4

3.3

251.9

Czech Republic

91,068

865

 

 

1,227

11.6

1.3

156.5

Denmark

17,124

308

 

 

372

6.7

2.2

833.0

Estonia

5,096

380

72

124

196

14.6

3.8

98.2

Finland

12,442

231

28

301

329

6.1

2.6

727.0

France

232,821

358

3,471

4,069

7,540

11.6

3.2

339.9

Germany

469,791

575

 

 

23,890

29.2

5.1

137.6

Greece

44,411

392

30

650

680

6.0

1.5

449.1

Hungary

41,574

416

 

 

1,374

13.8

3.3

94.9

Iceland

1,169

367

 

 

29

9.1

2.5

434.3

Ireland

12,202

272

88

201

289

6.5

2.4

716.2

Italy

201,932

333

 

 

7,550

12.5

3.7

272.2

Latvia

11,833

531

 

 

217

9.7

1.8

110.7

Lithuania

17,061

526

 

 

502

15.5

2.9

72.5

Luxembourg

2,511

204

27

100

127

24.8

5.1

432.7

The Netherlands

56,085

337

 

 

1,065

6.4

1.9

733.0

Norway

13,639

277

 

 

395

8.0

2.9

1,045.5

Poland

156,662

410

 

 

2,635

6.9

1.7

178.1

Portugal

31,722

298

 

451 

451

4.2

1.4

508.1

Romania

108,611

507

2,574

2,000

4,574

21.4

4.2

35.3

Slovakia

32,560

599

 

 

500

9.2

1.5

174.9

Slovenia

7,656

373

 

 

131

6.4

1.7

364.4

Spain

124,194

269

 

 

4,479

9.7

3.6

314.8

Sweden

26,131

278

 

 

550

5.8

2.1

834.0

Switzerland

28,096

357

 

 

866

11.0

3.1

609.6

UK

147,809

237

1,737

2,377

4,114

6.6

2.8

547.0

aWorld Health Organization Regional Office for Europe (2009)

https://static-content.springer.com/image/art%3A10.1007%2Fs00134-012-2627-8/MediaObjects/134_2012_2627_Fig1_HTML.gif
Fig. 1

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

The total numbers of critical care beds per country corrected for population size were positively correlated to population size (r 2 = 0.69, p < 0.0001) but only weakly related to the country’s gross domestic product (GDP) (in millions of US dollars) (r 2 = 0.16, p = 0.05), the proportion of GDP expended on healthcare (r 2 < 0.0001, p = 0.91) (Fig. 2) or the proportion of elderly patients in the population (r 2 = 0.04, p = 0.31).
https://static-content.springer.com/image/art%3A10.1007%2Fs00134-012-2627-8/MediaObjects/134_2012_2627_Fig2_HTML.gif
Fig. 2

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

On average there are 2.8 critical care beds for every 100 acute care beds across Europe. This again hides a marked variation, however, with Germany and Luxembourg having the highest percentage at 5.1/100,000 and the Czech Republic the lowest (1.3/100,000) (Table 2). The numbers of critical care beds were correlated with the numbers of acute care beds corrected for population size (r 2 = 0.12, p = 0.05) (Fig. 3) and also the percentage of acute care beds as compared with critical care (r 2 = 0.59, p < 0.0001) (Figure ESM 1).
https://static-content.springer.com/image/art%3A10.1007%2Fs00134-012-2627-8/MediaObjects/134_2012_2627_Fig3_HTML.gif
Fig. 3

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

Discussion

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

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

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

An interesting question that arises from examination of this data is how the different countries cope with the widely differing levels of critical care capacity. Presumably, in a grossly homogeneous geographical and developed region such as Europe, one would expect that comparable numbers of patients would develop acute critical illness in the different countries. One would hence expect that the different levels of provision should have a major impact on practice and hence presumably outcomes [6, 1619]. Again comparing Portugal and Germany, it is impossible that Portugal is able to admit the same amount of patients to critical care as in Germany. The implication must therefore be that either patients in Portugal with need for critical care are unable to get it or that Germany overprovides intensive care for its population. Only further analysis of data that describe provision and practice of critical care in detail across countries will enable us to answer these questions. As a start, comparison of data from European countries with established national registries of intensive care could give more insight into such details. At present such registries are operative in England, Scotland, Norway, Finland and Sweden, The Netherlands, and Austria. With the exception of Austria, these are all countries with a relatively low number of ICU beds per population unit, as can be seen in Fig. 1.

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

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

Acknowledgments

ESICM: Claudia Arena and Giulia Evolvi, Andorra: Antoni Margarit, Austria: Philipp Metnitz, Austrian Center of Documentation and Quality Assurance in Intensive Care Medicine (ASDI), Belgium: Federal Government. Patrick Ferdinande and Eric Hoste, Bulgaria: National Center of Health Informatics-Public Health Statistics, Croatia: Ino Husedzinovich, president of the Croatian Society of Intensive Care Medicine, Czech Republic: Ivan Novak, scientific secretary of the Czech Society of Anesthesia and Intensive Care Medicine, Cyprus: Department of Medical and Public Health Service-Maria Psalti and Theodorus Kyprianou, Denmark: National Board of Health, Estonia: Indrek Rätsep, from the database of the Estonian Society of Anaesthesiologists, Finland: Ville Pettila-Finnish Society of Intensive Care Medicine, France: Agence technique de l’information hospitalière (ATIH), Germany: German Association of Anaesthesiology and Intensive Care, Greece: Apostolos Armaganidis, president of the Greek Society of Intensive Care Medicine, Hungary: Akos Csomos for the Hungary national health fund database, Iceland: Kari Hreinsson, president of the Icelandic Society of Anesthesiology and Intensive Care Medicine, Ireland: Patrick Seigne, The Prospectus Report (A Review of Adult Critical Care Services in Ireland, 2009), Italy: Ministry of Health, Latvia: Indulis Vagas (president of the National Society of Anesthesiology and Reanimation of Latvia), Lithuania: Jurate Sypilaite-Lithuanian Society of Intensive Care Medicine, Luxembourg: Max Martin, Malta: Carmel Abela, The Netherlands: Jozef Kesecioglu and Hans van der Spoel, Norway: Hans Flaatten, Poland: Krystof Kusza-Polish Ministry of Health, Portugal: Rui Moreno; Colégio de Medicina Intensiva da Ordem dos Médicos; Sociedade Portuguesa de Medicina Intensiva, Romania: National Center for Statistic of the Ministry of Health-Ioana Grigoras and Natalia Hagau, Slovakia: Jozef Firment Slovakian Society of Intensive Care Medicine, Slovenia: Slovenian Health Statistic Yearbook, Spain: Cristobal Leon Gil and the SEMICYUC and Cesar Aldecoa, Sweden: Goran Karlstrom, Switzerland: Hans Rothen, National coordinator, data from the Swiss Society of Intensive Care Medicine, UK: Department of Health (2010), Scottish Intensive Care Society, Linda Mulholland, Critical Care Networks of Wales and Northern Ireland.

Conflicts of interest

None.

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