The practice of intensive care in Latin America: a survey of academic intensivists

We conducted a cross-sectional study of intensivists from 11 Latin American countries (Argentina, Bolivia, Brazil, Chile, Colombia, Ecuador, Guatemala, Mexico, Paraguay, Peru, and Uruguay). The Pontificia Universidad Católica de Chile was the only coordinating center. The local ethics committee (Comité de Etica Clínica de la Facultad de Medicina) waived the need for informed consent because survey participation was voluntary; thus, informed consent is assumed.

In May 2016, Latin American intensivists, identified from lists provided by national critical care medicine societies and networks, social networks, and personal contacts, were invited to participate in the survey. One week later, a web-based electronic questionnaire was submitted. Weekly reminders were emailed to nonrespondents from June through September 2016.

The survey was designed by a committee that incorporated questions regarding training, workload, competencies, continuing education, research activities, and experiential aspects. The construct was defined on the basis of studies that demonstrated links between individual characteristics of intensivists with clinical performance [7].

After a draft revision by a group of LIVEN investigators, some questions were reformulated, added, or deleted. Content validity was established by independent reviewers who determined whether each question captured the intended domain. After piloting the survey in 4 centers, the final version included 51 items under the following domains: organizational characteristics of the ICU, human resources, professional development, research participation, competencies and skills, satisfaction, and expectations.

We asked some questions about septic shock management because this condition integrates ICU workflow, resource availability, and diverse aspects of critical care provision. We considered that ICUs with appropriate conditions for septic shock care had availability of antibiotics, vasopressors, laboratory tests (arterial blood gases, serum lactate, general blood and biochemistry tests, blood and fluid cultures and microbiology identification), imaging resources, and the possibility to consult different specialists upon request (see full survey as Additional file 1: File S1).

We defined a long or short morning round on the basis of the duration being longer or shorter than 2 h, respectively. We defined a multidisciplinary round as one that, apart from the intensivists, included at least two other professionals (nurses, respiratory therapists, pharmacists, or other specialists).

We investigated the association between country-level factors and relevant outcomes, adjusting for individuals’ characteristics using multilevel multivariable logistic regression. A two-level model was fit with intensivist-level fixed effects at the first level and country-level fixed effects at the second level, as well as a country-specific random effect. Individual-level variables of interest included age, sex, years of experience (collinear with age), weekly working time (in hours), and type of ICU (public/private, academic/nonacademic). We selected variables for the multivariable model using forward and backward stepwise regression. We considered variables for the model if they were associated with outcome with a p value less than 0.20 in univariate analysis. Additionally, some variables were introduced to the model because of their clinical relevance, regardless of their p value. We performed subgroup analyses by stratifying intensivists according to their position in the ICU. To choose among the alternative models, we used the likelihood ratio test for testing on the boundary of the parameter space as a measure of the relative predictive ability of a statistical model for a given set of data. Two-tailed p values less than 0.05 were considered statistically significant. We conducted all statistical analyses with the use of Stata 14.2 software (StataCorp, College Station, TX. USA).

Of the 1380 surveys sent out, we received 735 responses by intensivists from 11 countries, yielding a global response rate of 53%. (See Fig. 1 for country representation.) Sixty percent of intensivists worked in ICUs located in public hospitals (Table 1, Additional file 2: Table S1A), with no statistically significant difference according to their position (Additional file 2: Table S1B). Sixty percent worked in two or more hospitals (Additional file 2: Table S1C, D), and 67% worked in academic hospitals (Table 1, Additional file 2: Table S1A), without any difference in the public/private status of their primary hospital (Additional file 2: Table S1D).

The surveyed workforce was composed predominantly of males (68%) and young adults (median age, 40 [35–48] years) (Table 1, Fig. 2a). Fifty-three percent of intensivists had less than 10 years of experience in the ICU, and 20% had more than 20 years (Table 1, Fig. 2b). Residents comprised a minority of the respondents (13%).

ICU training varied among countries, with three different formal academic programs of variable duration (2–4 years) and a work-based assessment of competences without specific duration (Table 1, Additional file 3: Figure S1).

The median weekly workload was 60 (IQR, 47–70) h, mostly spent in the ICU (Additional file 4: Figure S2), without differences between academic and nonacademic centers (median 60 [IQR, 46–70] vs. 60 [IQR, 48–68] h; p = 0.7). The duration and characteristics of clinical rounds varied widely across countries, with differences between academic and nonacademic units (Fig. 3).

Fifty-two percent of intensivists worked daily and also did night shifts. Twenty-two percent worked only in day shifts, and 22% only in night shifts. The median number of night shifts was 1 (IQR, 1–2) per week. Younger intensivists did more night shifts per week (p < 0.001). According to position, staff intensivists performed the higher number of shifts per week (median, 2 [IQR, 1–3]), followed by residents (median, 2 [IQR, 1–2]) (p < 0.001). The number of beds covered per intensivist varied from 3 to 12 per night shift. Most ICUs (76%) had consultants available during night shifts. Overall, survey respondents considered themselves very competent to perform many common procedures. There were significant differences according to position, age, and years of experience in the ICU (Table 2).

Most intensivists (85%) reported adequate conditions to manage patients with septic shock. However, perception of satisfactory conditions was lower in ICUs located in public hospitals (OR, 0.36 [0.26–0.47]; p < 0.001) and in nonacademic ICUs (OR, 0.48 [0.35–0.65]; p < 0.001). The main reasons for dissatisfaction were attributed to insufficient technology (11%), laboratory support (5%), imaging resources (5%), and limited drug availability (5%). Lactate could be measured by 90% of intensivists, but at a variable time, depending on ICU type (Additional file 5: Table S2A). A computed tomographic (CT) scan was available within < 2 h in 54% of ICUs and within < 6 h in 81% of ICUs, with variations according to ICU type (Additional file 5: Table S2B). In all countries, ICUs located in private hospitals had significantly greater availability of CT scanners compared with ICUs belonging to the public health sector (68% vs 49% in < 2 h; OR, 3.13 [2.02–5.94]; p < 0.001).

The Internet was widely accessible (91%). Most Latin American intensivists used online resources to improve their scientific knowledge (96%). More than half of the intensivists surveyed (54%) read scientific studies regularly, daily, or two or three times per week (Table 2), whereas 32% read no more than one scientific study per month. These results were similar for academic and nonacademic ICUs (p = 0.6). Seventy-five percent of respondents had attended at least one scientific meeting in the past year, and 88% had taken a refresher course. Seventy-six percent reported having “some” or “much” institutional support, but 24% responded that they had “minimal” or “no support” from their hospitals to participate in these meetings. Financial and permission restrictions were the main reasons (Table 3).

Seventy percent of the respondents participated in research activities, mostly in academic settings (71%). Working in a nonacademic ICU and being a resident were associated with less probability of doing research (OR, 0.50 [0.36–0.73]; and OR, 0.36 [0.23–0.58], respectively; p < 0.001 for both). Conversely, being male was associated with higher probability of doing research (OR, 1.52 [1.08–2.15]; p = 0.017). Most of the funding came from intensivists’ respective institutions (39%) or was self-provided (19%), whereas 14% of intensivists declared no specific research funding. Research grants and pharmaceutical sponsorship were rarely available (9% and 7%, respectively). Most of the research was published in peer-reviewed journals (63%).

Environmental conditions (private restrooms, comfortable bedrooms for rest or sleep) during night shifts were reported as inappropriate in 62% of the respondents, especially by female intensivists (71% vs. 60%; p < 0.001). A minority of intensivists were satisfied with their personal income (19%). It was higher in male than in female physicians (22% vs 13%; OR, 1.84 [1.17–2.91]; p = 0.009). On the contrary, higher weekly workload (OR, 0.98 [0.97–0.99]; p = 0.017) and a higher number of night shifts (OR, 0.80 [0.67–0.96]; p = 0.007) were associated with lower income satisfaction. Overall, a minority of intensivists (27%) reported having considered quitting their job as intensivists, mostly in Argentina (41%) and Brazil (36%). Fifty-five percent on the Latin American intensivists intended to leave ICU practice before retirement.