Mechanical ventilation in medical departments: a necessary evil, or a blessing in bad disguise?

In most countries there is a mismatch between demand for intensive care unit (ICU) beds and ICU bed availability. Because of a policy of low ICU-bed reimbursement this mismatch is much more profound in Israel, which arguably has the lowest number of ICU beds/1000 population of OECD countries. Increasing demand for mechanical ventilation has led to an ever-rising presence of ventilated patients in medical departments, which may reach up to 15% or more of medical beds, especially during winter months, posing serious challenges such as: delivery of adequate treatment, guaranteeing patient safety, nosocomial infections, emergence and spread of resistant organisms, dissatisfaction among family members and medical and nursing staff, as well as enormous direct and indirect expenses. This paper assumes that no change in ICU reimbursement will occur in the near future. We, therefore, describe a number of policy issues that should ideally be addressed together in order to cope realistically with the increase in mechanically ventilated patients in medical departments. First, all medical departments should operate a 5-bed augmented care room with one dedicated nurse per shift. Medical residents should receive a mandatory 3-month ICU rotation in their first year of residency, and attending physicians should receive adequate training in mechanical ventilation and vasopressor support, point-of-care ultrasound and central venous catheterization. Second, family physicians should be required to discuss and fill relevant forms with advance directives for elderly and/or chronically ill patients. Third, rules for terminal extubation should be established, even if only applied infrequently. Finally, co-payment should be considered for families of patients demanding all possible medical treatment in spite of contrary medical advice, considering these patients’ terminal status. Implementation of these recommendations will require policy decision making in the Ministry of Health, Scientific Council of the Israeli Medical Association, the professional societies (for internal medicine and family practice) and finally by the leadership of individual hospitals.