The changing world

With a projected increase in the world population from 7.2 billion currently to 9.6 billion by 2050, the population of the 49 least developed countries is expected to double from 900 million in 2013 to 1.8 billion [1]. As such, the number of patients who may need critical care will increase substantially, with a majority of these in resource-restricted settings. Coupled with an ageing global population, the complexity of the challenge will be enormous. Infectious diseases and trauma will continue to be main reasons for intensive care unit (ICU) admission, but natural as well as man-made disasters will occasionally place additional strain on critical care services, with the largest strain again in resource-restricted settings. Healthcare expenditures vary considerably from approximately US $9400 annually per capita in the USA to less than US $20 per capita in many African countries [2], and with limited financial resources, the strategic priority is given to public health programs and not to more expensive services such as critical care. Around the globe, what constitutes an ICU will continue to vary in terms of structure, processes and staffing, all of which often remain inadequate in resource-restricted settings [3]. However, the basic premise will remain the same: the outcome of critically ill patients will substantially be improved by the provision of essential critical care [4], and many aspects can and should be provided even if resources are low [5]. Moving towards better critical care globally will require a multifaceted approach to address not only patient and organizational challenges, but also those related to staffing, cultural and technological aspects, as well as quality and safety. Addressing these complex challenges will certainly require involvement not only at the local ICU level but also at the level of hospitals, national societies and governments. In Table 1, we present examples of where and how critical care could and should improve, with a focus on resource-restricted settings. Some of these cases are highlighted in the following text.

Table 1 Examples of where and how critical care could improve globally

Patient level challenges and solutions

Patient-level challenges to critical care in 2050, including increasing patient numbers and limited or no access to critical care, must be addressed by means other than merely increasing the number of beds per capita. Acute care services vary substantially across regions, and the variation is only partially attributable to differences in the gross domestic product [6]. Focus needs to be on early pre-ICU intervention and on better triage in order to reduce morbidity and the need for ICU admission. In addition, improving resource utilization and reducing waste will be equally essential. Finally, a strategy of appropriate end-of-life care that maintains patient integrity but avoids futile interventions needs to be introduced, especially in settings where clear standards do not yet exist.

ICU-level challenges and solutions

Lack of proper basic infrastructures, including equipment and supplies, and substandard infection control will continue to challenge critical care by 2050. Prioritization will vary depending on the setting. In some areas, availing of intravenous fluids and uninterrupted oxygen and electricity may provide the greatest return. For mechanically ventilated patients, simply improving limited or unsafe endotracheal suctioning will prove to be life saving. There is a clear need for setting-specific standards for what is minimally needed within an ICU to be adopted by hospitals and governments.

Challenges in staffing

In resource-restricted settings, critical care is not yet a well-developed specialty. Consequently, there is a great potential for incraasing the scope of training for physicians, nurses and other personnel. Training needs to focus on specific critical care skills, but it should also include basic management and organizational aspects, such as admission and discharge policies, multidisciplinary rounds, and proper documentation and handovers. Train-the-trainer approach will become increasingly important for sustainable training. In addition, resource-rich ICUs are increasingly committed to partner with resource-restricted ICUs for support and knowledge exchange. Several active examples include the initiatives by the World Health Organization, the Chinese University of Hong Kong, Médecins Sans Frontières, the National Intensive Care Surveillance (NICS) and our own academic groups.

Quality improvements

Wide variations in processes of care and outcomes exist among settings according to income level [7]. For example, mortality due to sepsis has decreased over the last decades to 20–40% in resource-rich settings, whereas mortality rates of up to 80% are still reported from resource-restricted regions [8]. This high mortality is attributed to late recognition of critical illness, poor translation of current knowledge [9] and poor ICU service structure. Low adherence to simple but effective evidence-based practices, such as low-tidal ventilation and the use of light sedation, is frequent in resource-restricted settings. A recent multicenter study demonstrated that implementing protocols in this setting is associated not only with lower mortality rates but also with an increased efficiency [10].

Clinical practice guidelines have been mainly based on evidence from resource-rich settings. Some of these recommendations, however, can be beyond the capability of resource-restricted ICUs and could even be dangerous, as is the case of aggressive fluid resuscitation (The FEAST trial) [11]. Treatment of infections should be setting-specific because resource-restricted countries have different pathogens, higher antibiotic resistance and less access to newer and expensive antimicrobials than resource-rich ones. An initiative from the Global Intensive Care-working group of the ‘European Society of Intensive Care Medicine’ has started to produce setting-specific recommendations [12], but this initiative is still hampered by absence of evidence for most recommendations used in resource-rich settings.

Safety initiatives

Avoidable adverse patient events are common in the ICUs [13]. The risk in resource-restricted settings is unknown but likely to be high. Therefore, a comprehensive approach for building safety into each system to prevent, reduce, report and analyze medical errors should be of great importance.

Technological challenges

Technology, such as telemedicine may play a significant role reducing the need for specialized staff [14]. Other measures, such as the use of remote application of checklists, are associated with improved adherence to best practices [15].

Conclusion

The journey toward excellent global critical care in 2050 is unlikely to be easy but is certainly going to be an exciting and interesting one. A comprehensive multifaceted approach is needed to improve the delivery of critical care globally, and such efforts are likely to translate to major improvement in patient outcome.