Clinical review: Critical care medicine in mainland China

Critical care medicine began in mainland China in the early 1980s. After almost 30 years of effort, it has been recognized as a specialty very recently. However, limited data suggest that critical care resources, especially ICU beds, are inadequate compared with those of developed countries. National critical care societies work together to set up good practice standards, and to improve academic levels with scientific meetings, education programs, and training courses. Critical care research in mainland China is beginning to evolve, with great potential for improvement.


History of critical care medicine in mainland China
Although advanced life support techniques, especially positive pressure ventilation, inspired the development of critical care medicine in Europe and North America in the 1950s, critical care medicine is still one of the newest disciplines of clinical medicine in mainland China.
As in many other countries, critical care was initially practiced in a variety of postoperative recovery rooms and/or an isolation area within the general ward. It is well recognized that the fi rst ICU in mainland China was set up in the Peking Union Medical College Hospital in 1982, in the form of a surgical ICU with only one bed [4,5]. Two years later, it became the fi rst Department of Critical Care Medicine in mainland China, with a seven-bed general ICU in the Peking Union Medical College Hospital, chaired by Dr Dechang Chen, the well-recognized founding father of critical care medicine in mainland China.
In November 1989, the Ministry of Health issued the Regulation of Hospital Accreditation and Management, which required the establishment of an ICU as a prerequisite for accreditation as a tertiary hospital [4,5]. Many ICUs were set up in hospitals all over China following the release of this document. Many physicians (including general surgeons, internists, emergency physicians, and anesthesiologists) were sent to other hospitals for critical care training, either abroad or domestically, before returning to practice as intensivists [4,5].

Development of critical care medicine as a specialty in mainland China
In mainland China, physicians of other relevant specialties were the fi rst to be assigned to work in ICUs because of their familiarity with the necessary techniques (anesthesiologists), disease entities (surgeons and internists), and required urgency of treatment (emergency physicians). However, after years of hard work, the important role of intensivists, as a coordinator during patient evaluation and treatment, has gradually been recognized and respected by other specialties. Junior physicians interested in critical care training can choose to be intensivists after they fi nish 3 or 4 years of fellowship training in surgery or internal medicine. However, the traditional specialties often still assume responsibility for or 'ownership' of patients, as well as have a desire to treat critically ill patients, as refl ected by the fact that the proposal for setting up a critical care society under the Chinese Medical Association (CMA) was rejected in 1996.
Public healthcare crises in China since 2003 have provided intensivists with an opportunity to demonstrate their knowledge and skills. Epidemics of severe acute respiratory syndrome (SARS) in 2003, of Streptococcus suis in 2005, and of avian infl uenza, as well as the Wenchuan Earthquake in 2008, caused extreme anxiety in the public due to the vulnerability of the general population, the high communicability of the diseases, and the high case fatality rate. Th erefore, intensivists were often convened by the government to be involved in crisis management very early [6]. Th eir ability to coordinate, cooperate, and communicate with regard to both patient management and policy-making was well demonstrated during daily work, and recognised by the general public and healthcare authorities. As a result, critical care medicine was offi cially recognized as a specialty of clinical medicine in 2009 [7].

Critical care resources and services
Th ere is no census on critical care resources in China, including the number of ICUs, intensivists, ICU nurses, and relevant facilities (for example, bedside monitors, artifi cial ventilators), because no national survey has ever been performed.
We performed computerized literature searches of the China Academic Journals Full-text Database of the China National Knowledge Infrastructure. We used the search terms 'intensive care unit' or 'intensive care' or 'critical care unit' and 'survey' , and found only eight relevant papers concerning critical care resources in mainland China [8][9][10][11][12][13][14][15] that were published within the past decade (Table 2). Unfortunately, none of these eight papers selected a representative sample of ICUs in China. Table 2 summarizes data from these eight papers [8][9][10][11][12][13][14][15], in addition to those of the China Critical Care Clinical Trial Group (CCCCTG) [16]. Based on the above data, we made a rough estimation that, in mainland China, ICU beds might account for 1.8% (interquartile range 1.3% to 2.1%) of total hospital beds [8][9][10][12][13][14][15][16]. In 2008, the Ministry of Health reported that there were a total of 2,882,862 beds in 19,712 hospitals in China [3]. Th erefore, we estimate that there were 51,891 (37,477 to 60,540) ICU beds in China in 2008, corresponding to 3.91 (2.82 to 4.56) ICU beds per 100,000 population, with 217 hospital beds per 100,000 population. Th is fi gure is comparable to that of the United Kingdom (3.5 ICU beds per 100,000 population), which was the lowest of eight countries in North America and Western Europe [17].
In addition, the ICU nurse-to-bed ratio ranged from 1.37 to 2.02 [8][9][10][11][12][13][14][15][16], corresponding to 71,091 to 104,820 ICU nurses in mainland China. According to limited data, there is no signifi cant diff erence in ICU beds and nurse-to-bed ratios between coastal areas and inland areas. Although there are usually more ICU beds in tertiary hospitals than local hospitals, there is no diff erence in nurse-to-bed ratio. Even few data are available for bedside monitors, mechanical ventilators, and dialysis machines, which preclude the possibility of making any estimation.
Th ere has been no large-scale observational study about case mix in Chinese ICUs, although some data are available. Among 443 patients receiving mechanical ventilation for more than 48 hours in 26 ICUs, mean age was 62.4 ± 19.5 years, and 298 (67.3%) were male [18]. Medical reasons accounted for 58.2% of all ICU admissions, followed by emergency surgery (22.8%), and elective surgery (19.0%) [18]. Data from the CCCCTG showed that, among 38,922 patients admitted to 24 ICUs in 2007 and 2008, about two-thirds (66.2 ± 23.0%) were treated with invasive mechanical ventilation, pulmonary artery catheters or arterial pulse contour analysis was used in 2.9 ± 3.6% of patients, and continuous renal replacement therapy was used in 12.2 ± 11.4% of patients [19]. Th e hospital mor tality rate was 13.1 ± 8.6% [19].

National critical care societies
As mentioned above, anesthesiologists, general surgeons, emergency physicians and pulmonologists are all involved in ICU management in mainland China. Th eir infl uence is well described by the presence of critical care sections Although the CMA refused to set up a critical care society in 1996, the fi rst national critical care society in mainland China was established in 1997, called the Chinese Society of Critical Care Medicine (CSCCM), and currently has about 500 members. Th e major objective of the CSCCM is to provide a multidisciplinary platform for promoting critical care medicine all over China, provide expert opinion to the government and other bodies, and encourage both national and international academic exchange.
Th e CSCCM organizes a 3-day biennial national conference, with attendees increasing from 200 in 1997 to more than 1,000 people in 2006, including physicians, nurses, and company representatives. In 2006, the CSCCM hosted the 14th International Congress of the Asia Pacifi c Association of Critical Care Medicine (APACCM) in Beijing. Th e scientifi c program included 16 plenary lectures, 130 lectures and workshops by 57 speakers from 19 countries. Th is was the fi rst time that an international conference on critical care medicine had ever been held in mainland China, a milestone demonstrating more involvement in the international community.
Since its establishment, the CSCCM has developed close relationships with multiple international profes sional societies, such as the Society of Critical Care Medicine (SCCM), the European Society of Intensive Care Medicine, the Société de Réanimation de Langue Française, the APACCM, and the World Federation of Societies of Intensive and Critical Care Medicine (WFSICCM). Right now, the CSCCM is the only member society representing mainland China in both the WFSICCM and APACCM.
Th e second national critical care society, the Chinese Society of Intensive Care Medicine, was established in 2005 under the CMA (CSICM-CMA). CSICM-CMA has been working actively to enact clinical practice guidelines, including nutritional support, mechanical ventilation, and sepsis management.
Th e third national critical care society, the Chinese Association of Critical Care Physicians (CACCP), was founded in July 2009. As an affi liation to the China Medical Doctors Association, the aim of the CACCP will include professional certifi cation of intensivists.
Th ese three societies have the common philosophy to cooperate with each other in the future because they share almost the same leadership.

Training of critical care physicians, nurses and respiratory therapists
At present, there is no formal accredited critical care training program in China. Residents can choose critical care medicine as their specialty after graduation from medical school. Rotation in other departments, such as anesthesia or internal medicine, is not obligatory, and is organized according to institution and department requirements. On the other hand, residents may consider critical care medicine as a subspecialty after fi nishing a fellowship training program in internal medicine, anesthesia, general surgery, or emergency medicine.
ICU physicians can register as intensivists (for those working in general ICUs), or, alternatively, remain registered under their primary specialty of anesthesiology, internal medicine, general surgery or emergency medicine (for those working in specialized ICUs) [7].
In mainland China, most nursing education programs employ only a 3-year curriculum after senior high school. Although colleague education programs have become more and more popular, there is still a signifi cant demand for professional education for nurses. In 2003, the Beijing Nursing Association started to implement a critical care nurse certifi cation program, with around 150 trainees every year. Th e program is composed of 1 month of lectures and 1 month of clinical practice, followed by examination of knowledge and skills. Trainees are also required to fi nish a review before certifi cates are issued. In 2007, the China Nursing Association followed the same model in order to meet the need in other cities in mainland China.
Respiratory therapists are present in only a few ICUs. Sichuan University set up the fi rst program of respiratory therapy in a medical school in mainland China in 2002 [24].

Future development of critical care medicine in mainland China
Th e lack of a national accredited critical care training program is believed to be a major obstacle for improving professional education in China. Although access to state-of-the-art advances might be available during national and international conferences, basic knowledge and skills are inadequately, and sometimes incorrectly, taught in many hospitals. For the past 5 years, the CSCCM has dedicated itself to promoting professional education with regard to basic knowledge and skills in critical care medicine. Th e CSCCM successfully organizes a Fundamental Critical Care Support course, a Funda mental Disaster Management course, and a Multiprofessional Critical Care Review Course, with support from the SCCM. In 2007, the CSCCM endorsed the Basic Assessment and Support Intensive Care course, and promoted the course in mainland China. Nine provider courses have been organized until November 2009, with more than 220 participants. However, an advanced training program is still under development, and the number of trainees is very limited compared with the large number of intensivists in mainland China.
More over, a national board exam for critical care medicine is not yet available, which suggests that we do not have a minimum national standard for intensivists.
Critical care research in mainland China is in its infancy. Most study results are published in national medical journals in the Chinese language, while very few investigators succeed in publishing their studies in peerreviewed international medical journals. Possible reasons might include: inadequate training and experience in clinical research; inadequate staffi ng dedicated to research; inadequate funding for critical care research; and inadequate language profi ciency.
However, Chinese intensivists have become more actively involved in international multicenter studies during recent years. For example, a total of 1,135 patients in 57 ICUs in mainland China were enrolled in an observational study, accounting for 21% of patients and 14% of ICUs (S Finfer, unpublished data). Th is suggests a great potential for future improvement in clinical research in mainland China.
Considering the above limitations and potential improve ment, we do believe that Chinese intensivists may benefi t from academic exchange with the international medical community with regard to the following: development of a series of training programs fulfi lling international standards; development of a national board exam for critical care medicine; and conduction of multicenter trials compatible with good clinical practice.

Conclusion
Overall, critical care medicine in mainland China is still in a phase of development. After years of dedicated hard work, critical care medicine has been recognized as a specialty by the government and other specialties. However, due to scarce resources and limited experience, critical care training and clinical research are still underdeveloped, which also represents a great potential for future improvement.