Guest Editorial: The Road to Pediatric Cardiac Intensive Care in the Netherlands

The Netherlands, also known as ‘Holland’ with its famous capital Amsterdam, is a small country in Western Europe which fits 231 times in the United States. It is however 12 times more densely populated compared to the USA (424 versus 34 inhabitants/km²) with 17.5 million inhabitants of whom 3.5 million are children. Nationwide, approximately 4 children are born with congenital heart disease every day. Within this small country there are 7 medical universities with associated pediatric hospitals and at the moment four of these provide congenital and pediatric cardiac surgery (Leiden, Rotterdam, Utrecht, and Groningen).

There are dedicated congenital heart surgeons in the Netherlands, but no dedicated pediatric cardiac intensive care units or cardiac intensivists. And postoperatively these children are therefore cared for in combined pediatric intensive care units (medical, surgical). This means that the professionals taking care of these children are all trained as general pediatric intensive care nurses and pediatric intensive care physicians. We do not have dedicated cardiac intensivists, but some have a more ‘cardiac-focus’ than others (for instance in Leiden where more than 60% of our patients are post-cardiac surgery). In the Netherlands it is not possible to be ‘double-boarded’, so one cannot be a pediatric cardiologist and a pediatric intensivist at the same time. We as intensivists therefore work very closely together with our cardiology colleagues when taking care of children with congenital heart disease. To become a pediatric intensivist in the Netherlands one first has to fully qualify as either a general pediatrician or as an anesthesiologist (5-6 year training following medical university). And then one can further subspecialize during an intensive care fellowship which lasts another 2.5-3 years. All intensive care fellows will do a rotation of 3-6 months in one of the four centers that provide cardiac surgery so that all pediatric intensivists receive some exposure during their training.

But, things may very well change. There currently are plans to further centralize congenital heart surgery to three or even only two centers (instead of the current four). Certainly, centralizing care and increasing exposure can be a good development for our patients, but choosing the right centers and organizing this transition well is proving to be challenging and requires careful planning and preparation. If not done carefully, there is a significant chance that the quality of care could actually temporarily decrease and not increase as would be the ultimate goal. Further centralization of congenital heart surgery will certainly have a significant impact on the organization of pediatric intensive care in the Netherlands and maybe we should start to consider establishing dedicated cardiac intensive care units which could eventually lead the way to a new official specialty for the Netherlands: the pediatric cardiac intensivist?

Peter P. Roeleveld, MD, PhD
Pediatric Intensivist, PICU Director
Leiden University Medical Center