The NMJI

INTENSIVE CARE IN AUSTRALIA AND NEW ZEALAND: PAST, PRESENT AND FUTURE
The ascent of intensive care medicine from a subspecialty to a discipline in its own right in just over 25 years represents a marvellous achievement. Although the events resulting from the polio epidemic in Scandinavia in the 1950s are the original forerunners of modern-day intensive care, Australia and New Zealand were among the first countries to recognize the importance of developing it as a specialty.1 These two countries now also have one of the best developed systems for training in and practising intensive care medicine. The establishment of a common medical faculty to oversee specialist training programmes in both countries has fostered a similar style of intensive care practice in the two nations. This review examines the development of intensive care as a specialty in Australia and New Zealand and discusses some exciting changes taking place with regard to training and research.

Development of the training programme
The origins of the early intensive care units (ICUs) in Australia date back to the 1960s. To begin with, the ICUs were concentrated in the larger metropolitan cities. The early ‘intensivists’ came from a background of anaesthesia or internal medicine or both.

Prior to 2001, two streams of training in intensive care medicine were available in Australia and New Zealand.2 The Faculty of Anaesthetists of the Royal Australasian College of Surgeons (RACS) commenced a training programme in intensive care in 1976. Successful diplomates were awarded the FFARACS (Fellowship of the Faculty of Anaesthetists, Royal Australasian College of Surgeons), endorsed in intensive care. The formation of the Australian and New Zealand College of Anaesthetists (ANZCA) in 19923 and establishment of the Faculty of Intensive Care in 1993 by College Council led to a change in the diploma awarded from FFARACS to FFICANZCA (Fellow of the Faculty of Intensive Care, ANZCA). A diploma in paediatric intensive care was set up in 1997.

The Royal Australasian College of Physicians also established an independent training programme in intensive care. This involved 3 years of basic physician training, the written and clinical examinations in internal medicine, and 3 years of advanced training, comprising 2 core years in intensive care and 1 elective year.

Australian and New Zealand Intensive Care Society (ANZICS)
The ANZICS was formed in 1975.4 The Society’s aims are to represent the professional interests of the specialty, encourage training and research in intensive care, and develop standards of professional practice. It also provides expert advice to governmental and other bodies on matters pertaining to intensive care and maintains liaison with the nursing profession, and other organizations and international bodies involved in intensive care. The Society achieves these aims through a number of standing committees. The ANZICS has also been holding an Annual Scientific Meeting since 1976. In 2001, the World Congress of Intensive Care was held under the auspices of the ANZICS in Sydney. It is affiliated with the World Federation of Societies of Intensive and Critical Care Medicine.

Australasian Academy of Critical Care Medicine (AACCM)
The AACCM is an incorporated body established for the advancement of education and research in Australasian Critical Care Medicine.5 The Academy runs two courses in intensive care annually, one each in Adelaide and Brisbane. The Academy also publishes a quarterly scientific journal Critical Care and Resuscitation, which is now listed in the National Library of Medicine, Australia.

Clinical intensive care
There are nearly 200 ICUs across Australia and New Zealand treating approximately 100 000 patients each year. The majority of units contribute to a central database called the ANZICS Adult Patient Database.6 The database has recently compiled the statistics for Australia and New Zealand. The mean APACHE II score is 15.1 and the mean length of stay in the ICU is 43 hours. The overall unadjusted mortality is 13.9%. For further information on the demographics, distribution of ICUs and workforce issues, the reader is referred to the database.6

Australia and New Zealand are also unique in their set-up of intensive care services across the country. The majority of the population lives in the major metropolitan cities. Much of the inland area is sparsely populated. While limited intensive care services are available in rural and remote regions, there is a well- established aeromedical retrieval system allowing transfer of these patients to the major metropolitan cities.

Research in intensive care
Funded research jobs in intensive care are few and far between. Nevertheless, an increasing number of well-conducted basic and clinical research trials in intensive care originating from Australia and New Zealand are being published. This is largely due to the enthusiasm of clinicians who devote a substantial part of their own time to research. In the past 5 years, 2 organizations have contributed immensely to the successful conduct of clinical research.

ANZICS Clinical Trials Group (CTG). The CTG was formed at the ANZICS Annual Scientific Meeting in Sydney in 1994.7 The Group’s stated objectives are to conduct high-quality, large-scale randomized controlled trials (RCTs) in intensive care, and provide a discussion forum that allows members to present research ideas and obtain feedback from others interested in clinical research. It also encourages smaller ICUs to join in research efforts.

The CTG has been highly successful, attracting funding and generating publications in high impact journals.8–10 The Group’s most ambitious project to date—The SAFE Study—a 7000 patient RCT comparing albumin and saline for intravascular volume resuscitation has recently been completed. The results are eagerly awaited.

ANZIC Foundation. The Foundation was set up with the primary aims of raising funds for and promoting research in 3 key areas: lung injury, brain injury and sepsis.4 The Foundation has been highly successful as a fund-raiser and, to date, has been able to fund a number of clinical and basic science trials in these target areas.

Critical care education
In 1996, a Joint Specialist Advisory Committee for Intensive Care (JSAC-IC) was formed following considerable discussion between the Faculty of Intensive Care and the Royal Australasian College of Physicians. The aim of the JSAC-IC was to develop a single training programme for the specialty. This came to fruition in 2001, with the formation of the Joint Faculty of Intensive Care Medicine (JFICM).
The JFICM performs a number of important roles: it oversees intensive care training, conducts and administers the examination, performs accreditation of ICUs, publishes policy documents and training manuals, and organizes the intensive care component of the Annual Scientific Meeting of the ANZCA.

Current training programme
The training programme in intensive care has recently been revised. The total duration of training is 6 years, of which the first 3 years represent basic training and the latter three advanced training. The 6 years are divided into 1 year each of general hospital appointments, general medicine and anaesthesia, 2 years of intensive care and a 1 year elective period spent in intensive care or anaesthesia or medicine or research.
To be eligible for admission to the Fellowship of the JFICM, trainees must pass or be exempt from the ANZCA Primary Examination, pass the Faculty Fellowship Examination, complete a formal project and supervised training. Further details on the training programme are available on the College website.3

The future
Australia has recently been plagued by a number of crises hitting the medical community in general and those in intensive care in particular. These include disheartened doctors suffering from heavy workloads, bed shortages and medical indemnity woes. Despite this, the overall balance sheet looks favourable in terms of progress in training, clinical practice and research. We look forward to the future with hope, anticipation and confidence.