To facilitate the opening of intensive care beds in crisis situations in the future, solutions exist: training all nursing students in this specialty, better recognition of caregivers, increase in the number of internships … At the moment, despite the difficulties accentuated by the covid epidemic, the public authorities continue to turn a deaf ear, regrets Nicolas de Prost, doctor at Henri-Mondor hospital and spokesperson for the national professional council for intensive care .
The number of patients hospitalized in intensive care for Covid exceeded 6,000 on Monday. The peak of contaminations seems to have passed, what about the seriously ill? What do you anticipate for the next few weeks?
The tension remains very high in the intensive care units and, while schools have reopened their doors this week and the relaxation of a number of measures is announced in the coming days, resuscitators are worried about the dynamics epidemic. A decline seems to have started a fortnight ago but this has not yet resulted in a significant decrease in the number of hospitalized patients, whether it is the total number of patients (30,596 on April 26) or especially the number. of patients treated in intensive care for the most severe forms of Covid-19 (6,001 on the same date). On the contrary, we have in fact observed for ten days a plateau, whether globally in France, or locally in Ile-de-France, where the incidence rate remains high, above 400/100 000 inhabitants. We therefore call for continued efforts while respecting barrier gestures, even if the temptation is great, with the arrival of fine weather, to release them!
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This very important third wave has once again shown how difficult it is to increase the number of places in intensive care in an acute crisis situation. So no lessons have been learned from the first wave?
Since the start of the pandemic, no new permanent resuscitation bed has been opened. Not one ! France usually has around 5,000 intensive care beds, and to keep up with the increase in needs linked to covid, all the additional capacities have been created on an ephemeral basis, by deprogramming in other services, to free up doctors and patients. nurses. Surgeons have calculated that to accommodate 8 patients in intensive care for a month, 150 to 200 procedures had to be deprogrammed. It’s enormous. The assessment of the consequences in terms of public health of these postponed operations remains to be carried out, but they promise to be catastrophic.
However, at the same time, when it came to determining the number of future doctors trained in resuscitation from the next academic year, nothing has changed. Usually, we have 72 residents in intensive care intensive care medicine every year, and in 2020, just after the first wave, this number was increased to … 74, when it is estimated that 150 should be trained per year. Likewise, the issue of recognizing the specificity of the intensive care nurse profession is not moving forward. It is incomprehensible, even though the crisis has shown how important the needs are.
Excluding the covid epidemic, were the services already saturated to the point of justifying increasing the number of places on a permanent basis?
The resuscitation capacity in France was already very limited before the Covid crisis. On average, the occupancy rate was 88%, while 80% should not be exceeded. We must always be able to accommodate patients in critical condition. For example, in a ten-bed ward, two should be permanently free, to receive the patient who has just had a cardiac arrest on the public highway, or the one who suddenly worsens after an operation. Of course, this 88% rate is an average. There are great regional and seasonal disparities. Thus, Brittany and the Pays de la Loire are particularly under-provided in resuscitation places, and it is fortunate that the epidemic was less severe there. Every winter, during influenza epidemics, all of our services are under severe stress.
It was the backdrop before the epidemic. But if nothing changes, the situation will continue to deteriorate as the population ages. We are already seeing that the ratio between the number of French people over 60 and the number of intensive care beds has deteriorated, as the Court of Auditors showed very clearly in its last report. An additional difficulty, our services are also experiencing a very high turnover of nursing staff, 20% on average per year, and sometimes up to 30%. Do you realize the impact on the day-to-day operation of the units? It is time for the public authorities to take stock of the situation.
What are your proposals?
The sinews of war are nurses. In our services, one nurse is needed for 2.5 patients. A regulatory text imposes it, so it is impossible to open beds, whether it is ephemeral or perennial, without having the available staff. However, since 2009, there is no longer a compulsory practical training course in intensive care during nursing training. It is a huge concern. Regularly, we have to call on staff from other services, as we have seen exacerbated with this crisis. It would therefore be essential that they all have a training base that includes resuscitation. Moreover, such an internship could make some people want to join our services.
Then we have to ask ourselves how to get them to stay. It is a question which it is high time to consider. Resuscitation nursing staff have great technical skills. They take care of patients on artificial ventilation, on dialysis, on circulatory assistance. They are also called upon to manage the psychological distress of relatives because in these services we have 20 to 30% of deaths. However, all these skills are neither recognized nor valued. Hence the professional exhaustion and the turnover that we are seeing.
“Discussions with the ministry are not progressing, unfortunately”
To develop these skills, we must offer career prospects. We could create an intensive care nurse qualification, in the same way that there are operating room nurses or nurse anesthetists. This could involve the creation of a master’s degree, which would be very rewarding, and financial recognition. If this allows nurses to stay a little longer in our services – 5 or 10 years instead of 3 years on average today – we will automatically have more staff available. This is essential, while the epidemic has further accentuated professional burnout, and we can fear an acceleration in turnover.
What about the doctors? France has no shortage of anesthesiologists, and they have also mobilized a lot to take care of patients with covid …
There are actually two training courses to access intensive care: intensive medicine, intensive care and anesthesia-intensive care. The needs for anesthetists are very important, and France is training many of these professionals – 473 interns last year for example. The problem is that in this sector, there is no regulation between the future exercise of anesthesiologist or resuscitator. In the end, the vast majority of doctors will choose anesthesia rather than resuscitation. So indeed, they can intervene during crises like the one we are going through. But that implies massive deprogramming, with all their deleterious consequences. And we must not forget, even if it is a subject that we do not know how to quantify very well, that we only do well what we do regularly. It is hard to imagine a surgeon who has not practiced for five or ten years having to go back to operating on patients. It’s a bit the same for resuscitation.
This is why we are asking for a rebalancing between the two sectors. The two courses have different content. Medical resuscitation is really the discipline specializing in the management of organ failures linked to serious medical problems or infectious pathologies. It is incomprehensible that we do not increase a little the number of positions related to this discipline. Especially since a significant proportion of professionals currently in post are already in the second part of their career. We have to prepare for the future. But for the moment, discussions with the ministry are not progressing, unfortunately.
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