Geo-economic variations in structure and organization of intensive care units: the ISOREA survey

Little is known on critical care services globally. This study aimed to describe ICU resources and organization across countries and assess variability by income group, between countries, and within countries.

Participating centers provided structured data on hospital and ICU characteristics via electronic case report form (January 2018 to July 2020). Questionnaire included 237 items covering general characteristics (2 topics) and ICU resources and organization (18 topics). We computed standardized functional domain scores (ISOREA score), classified ICUs using Marshall criteria, and readiness for essential emergency and critical care using a modified Schell score.

A total of 1,426 ICUs from five continents were recruited, and 1,225 were analyzed, from high-income countries (HICs, 58%), upper-middle-income (20%), and low/lower-middle-income countries (LLMICs, 22%). Most ICUs were in referral centers (90%) and large urban areas (80%). Most variables (93%) were significantly associated with income group, Most variables (93%) were significantly associated with income group, with 88% showing higher levels in HICs and lower levels in LLMICs. Six domains showed major disparities: extracorporeal support, respiratory support, emergency access to interventional radiology and surgery, neurology and trauma care, patient file and general monitoring, and cardiovascular and hemodynamic monitoring. According to the Marshall classification, 79% of ICUs in HICs were classified as level III, whereas 55% of ICUs in LLMICs were classified as level I. Domains with higher ISOREA scores varied primarily between countries, whereas lower-performing domains exhibited greater variability across ICUs within the same country. Adjustment for income group reduced, but did not eliminate, country-level clustering.

Substantial disparities exist in ICU resources and organization across income groups, countries, and ICUs. ICU capacities appeared multidimensional, extending beyond resource limitations.