We have read the editorial by Worner et al,1 describing the position of the Spanish Society of Cardiology concerning the care of patients with acute and critical heart disease. We would like to convey our perplexity with regard to certain aspects of the editorial and express a few considerations.
We agree with the authors that the care of critically ill cardiac patients is increasingly complex and poses a major challenge. However, it does not seem logical, as the authors propose, that the treatment of the entire disease process by a single department during the patient's hospital stay would guarantee better continuity of care and be safer and more efficient. On the contrary, process management shifts from the classical vertical management, with a specialized, compartmental, service-oriented organization, to horizontal, integral and multidisciplinary management, focused on the patient, rather than the interests of certain specialties or their professionals.
We also share the view that ensuring excellent care of acutely ill cardiac patients during the critical phase is essential and has a strong impact on the final outcome. To achieve this, it is indispensable that the patients, particularly those with other organ dysfunctions in addition to their cardiac condition, be attended by professionals with specific, well-defined competence and the necessary training. The authors themselves admit that these aptitudes are not acquired during specialized cardiology training. Intensivists, in contrast, do have the specific training to assume these responsibilities, as recognized in the intensive care training program and demonstrated by the long experience of the departments of intensive care medicine in Spain.
Competence can be gained through training,2,3 but we must be aware of the time and resources necessary to achieve it without risking patient safety or the sustainability of the health system. For this reason, the proposal concerning the accreditation of all cardiologists in the treatment of critically ill patients does not appear to be appropriate. The model in which the care of these patients is carried out by intensivists, with the collaboration of many other specialties, has been shown to be effective, safe, and efficient.4
The authors cite data from a study5 that attempts to relate organizational aspects of coronary care units under the responsibility of cardiology departments with a lower risk-adjusted mortality in acute myocardial infarction. This study has substantial biases and clear methodological errors. The conditions of patients attended exclusively by members of cardiology departments were less serious and complex, and the overall mortality rate was lower. To make them comparable, adjustment variables were utilized with data from the 1990s and based on the minimum data set. Both approaches are questionable, one because it is old-fashioned and the other because of its imprecision, as the minimum data is not appropriate for the activity of intensive care departments.
Seeking collaboration with intensive care and other specialties only to achieve the strategic objectives of a single specialty neither strengthens nor favors trust and collaboration among specialties that should always work as a team to provide the best possible health care to each patient. Teamwork encompasses complementary competencies, all of them indispensable, and all the members of the team contribute equally to the process, which should be headed by the member or members who can provide the care most needed by a patient at any given time. The idea that the care of complex critically ill patients can be carried out without specialists in intensive care medicine, when technology and scientific evidence demand extraordinary professional training, is rash, to put it mildly, no matter how great the impetus of the heads of some departments or however favorable the situations that make it possible.
Meticulous clinical investigation of critically ill cardiac patients should indicate which organizational models are optimal, most efficient, and of the highest quality. The professionals, specialties, and scientific societies should be at the service of these aims, putting aside other interests, and pursuing the best health care that scientific evidence and the available resources can offer at all times.