Question 26

College Answer

‘Closed’ ICUs are those managed by dedicated staff intensivists. Potential benefits include: 

a) Being physically present allows for early identification and intervention when problems occur in order to help prevent disaster.
b) An intensivist's knowledge of relevant protocols and evidence-based practice will likely benefit patients.
c) Third, intensivists coordinate communication and collaboration with the patient, family members, other ICU clinicians and medical specialists to provide optimum and informed care.
d) Finally, the intensivists in the ICU manager to standardize processes of care, triage patients, effect timely discharges, and evaluate performance.

Published evidence

Intensivists staffing is associated with reduced length of ICU and hospital stay. Daily rounds by an ICU physician were associated with a 3-fold reduction in hospital mortality among abdominal aortic surgery patients, and reduced hospital length of stay and postoperative complications after esophageal resection. In addition, a recent review of ICU team models found that when intensivists actively managed all ICU patients, a further improvement in survival occurred. An estimated 162 000 lives could be saved annually if intensivists staffed all nonrural adult ICUs (data from USA).

However the term closed ICU implies a non collaborative, non inclusive approach, whilst in reality it is a team effort.

Open ICUs

Several specialists involved consult, Physicians feel less excluded.
No single point of responsibility, patient coordination and communication, responsibility for bed management not clearly spelt out.

Discussion

There is a good discussion of this in LITFL.

In summary:

• An "Open" ICU is one where specialty teams have full admitting rights and where an intensivist is merely "consulting".
• A "Closed" ICU is one where the intensivist is the admitting medical officer and the specialty teams collaborate with ICU staff.
• A "High intensity" staffing model is one which involves either a closed ICU, or a "mandatory consult" situation where the specialty teams might still have admitting privileges to the ICU but every patient must be seen by an intensivist (hence "mandatory").

• Most ICUs worldwide are closed.
• The open vs closed debate is an American thing
• In America, half of ICUs dont have any intensivist coverage
  • In context, this means that even large units would not meet with the CICM accreditation criteria, and would be ineligible to accept trainees for the ICU training program.

Advantages of a "closed" ICU

• A "high intensity" model is associated with decreased mortality and ICU length of stay.
• However, at least in the United States a "closed" model does not seem to be associated with any mortality benefit independently of a "high intensity" model (According to a 2008 study by Levy et al as well as a subsequent meta-analysis by the same author). Essentially, it does not matter who the admitting specialist is, so long as the patients have mandatory daily intensivist involvement.
• An intensivist does not need to be on site for the whole 24 hours provided they are seeing every patient daily (a "high intensity" model).
• Focused critical care skills into a critical care environment
• Better coordination of critical care services
• A more cohesive treatment strategy, with better leadership
• More efficient use of resources (some patients do not need admission to ICU, and intensivists are better at triaging these cases)

Pronovost, Peter J., et al. "Physician staffing patterns and clinical outcomes in critically ill patients: a systematic review." Jama 288.17 (2002): 2151-2162.

Levy, Mitchell M., et al. "Association between critical care physician management and patient mortality in the intensive care unit." Annals of internal medicine 148.11 (2008): 801-809.

Wilcox, M. Elizabeth, et al. "Do Intensivist Staffing Patterns Influence Hospital Mortality Following ICU Admission? A Systematic Review and Meta-Analyses*." Critical care medicine 41.10 (2013): 2253-2274.

Wallace, David J., et al. "Nighttime intensivist staffing and mortality among critically ill patients." New England Journal of Medicine 366.22 (2012): 2093-2101.

Checkley, William, et al. "Structure, process, and annual ICU mortality across 69 centers: United States critical illness and injury trials group critical illness outcomes study*." Critical care medicine 42.2 (2014): 344-356.

Capanni, Francesca, and William Checkley. "Differences in Hospital Mortality by ICU Staffing Models: You Cannot Always Get What You Want, but Sometimes You Get What You Need*." Critical care medicine 41.10 (2013): 2433-2434.