icu

The ICU From the Surgical Perspective

　　Pamela A. Lipsett, MD,[8] of Johns Hopkins Medical Institutions, Baltimore, Maryland, reviewed the organizational structure of the ICU from the surgical perspective. ICUs consume 30% of hospital costs, yet they comprise approximately 10% of inpatient beds. Most hospitals have a 10- to 12-bed ICU. Outcomes may be influenced by several variables, among which are severity of illness, surgical experience, and hospital organization, and specifically ICU physician and nurse staffing. Critical care is a relatively new subspecialty and its precise role has been gradually elucidated. Traditionally, patients in ICUs were cared for by their admitting physicians; thus, the term "open ICU" originated. This model was an extension of the ward where the admitting physician and the consultants were taking care of their own patients and were writing orders. As an extension of the "ward" model, there was only part-time medical coverage. As the pathophysiology and the needs of the critical illness were better understood, the need for a dedicated and specially trained physician arose, giving birth to the concept of the "closed" ICU. In this setting, only the intensivist directing the ICU takes care of the patient and gives orders. This model was not widely accepted and studies have been undertaken to examine its significance.
　　In the study by Ghorra and associates,[9] an open and a closed model were compared. The study took place at a surgical ICU of a large tertiary care hospital. The ICU was changed from an open unit to a closed one for 6 months. A total of 274 patients (125 in the open-unit period, 149 in the closed-unit period) were studied and the two 6-month periods were compared. The results favored the closed model. Mortality (14.4% vs 6.04%, P = .012), overall complication rate (55.84% vs 44.14%, P = .002), and acute renal failure (12.8% vs 2.67%, P = .001) all decreased in the closed unit.
In another study on the same topic, patients (n = 2987) undergoing abdominal aortic surgery were examined regarding their outcome by Pronovost and coworkers.[6] There was a great variation in inhospital mortality, and by multivariate analysis, the lack of an ICU physician was associated with a 3-fold increase in inhospital mortality (odds ratio [OR],[10] 3.0; 95% confidence interval [CI],[10] 1.9-4.9). Additionally, the following complications occurred more frequently when an ICU physician was not available: cardiac arrest (OR, 2.9; 95% CI, 1.2-7.0), acute renal failure (OR, 2.2; 95% CI, 1.3-3.9), septicemia (OR, 1.8; 95% CI, 1.2-2.6), platelet transfusion (OR, 6.4; 95% CI, 3.2-12.4), and reintubation (OR, 2.0; 95% CI, 1.0-4.1). Three other factors significantly associated with increased resource use were an ICU nurse-patient ratio higher than 1:2, not having monthly review of morbidity and mortality, and extubating patients in the operating room.
　　In the study by Dimick and colleagues,[11] 366 patients who underwent esophageal resection were retrospectively examined. The variable was the presence or not of an ICU physician in daily rounds. The study found that the absence of an ICU physician led to a 73% increase in hospital length of stay (7 days; 95% CI, 1-15; P = .012) and a 61% increase in total hospital cost ($8839; 95% CI, $1674-$19,192; P = .013). Respiratory failure, renal failure, aspiration, and reintubation were all associated with the lack of an ICU physician.
　　Young and coworkers[12] studied the reported reductions in mortality as a result of the presence of intensivists (reported ranging from 15% to 60%) and devised a formula to calculate the number of lives saved as a result of an intensivist's presence in the ICU. Based on the lower estimate of the decrease in mortality (15%), they calculated that the presence of intensivists would save approximately 53,850 lives each year in the United States. Another recent review of the literature found that high-intensity ICU physician staffing is associated with reduced mortality and hospital length of stay for both the ICU and the hospital.[13]
　　The shortage of intensivists is also recognized. Telemedicine is proposed as an alternative. Remote care by an intensivist may be alternatively used and was also shown to decrease mortality and complications.[14]
　　Dr. Lipsett concluded that costs, complications, and length of stay might all be reduced by the addition of a dedicated intensivist to the hospital staff. An open question is if a 24-hour model is better than the working-hours model.