Newsletter March 2023: We do better! Did you know?

Gabriel M. Gurman, MD
Chief Editor

The first intensive care unit (ICU) appeared concomitantly on both continents, Europa and North America, at the end of the 6th decade of the last century. This was not a pure coincidence. The polio pandemic, which started in Scandinavia a couple of years earlier, obliged the medical administration all over the world to take measures to be prepared to treat future cases of acute respiratory failure, and very soon, those units started to admit almost any acute patient, whose life was in jeopardy.

But, from the organization’s point of view, further developments of ICUs took different ways.

All over the world, intensive care has become part of Anaesthesiology as a medical speciality. Still, in the USA and a few other countries, those domains separated, critical care becoming a subspecialty, not compulsory related to Anaesthesiology.

This was not the only difference which showed up during the following years.

In Europe, the ICUs were closed units where patient management was directly supervised by a full-time intensivist in charge of every detail of the patient’s treatment. In the USA, an open-unit model was developed in which every single decision regarding patient care was in the hands of the primary physician. For example, orders were prescribed by the surgeon for surgical cases, by the internal medicine physician in case of pneumonia, and by neurologists when the patient was in a coma after an acute cerebrovascular accident.

A survey done some 20 years ago in the USA (1), covering almost 400 ICUs, revealed that a full-time intensivist managed critical care for only 23% of the ICUs, an intensivist was consulted for 14%, and no intensivist was involved in the treatment of the rest. In only 29% of the ICUs, a full-time intensivist was available.

In contrast, a study published in 2012 (2) showed that the percentage of closed ICUs in Western Europe reached 89%.

From the psychological point of view, on an interhuman level, the primary physician is afraid of losing control over treatment once the patient is transferred to an ICU. Therefore, the primary physician considers themselves the only legitimate person in charge (and responsible!) for the patient care and refuses to share treatment responsibility with any other colleague.

Besides, a closed unit increases the cost of a treatment since it has to be staffed for 24-hour coverage.

Crippen, in 1997 asked a hypothetical question (3): “Picture your hospital emergency department with a physician on call from home. Is this a place that you would bring a sick person to be evaluated?”.

Faced with this reality, one can ask a simple question: which is the best organizational system, the closed or the open unit?

Some units tried to solve this dilemma by adding to an open ICU some specific help by getting remote consultation from an intensivist (4). For example, during 16 weeks, an intensivist was consulted by telemedicine to obtain clinical information and to communicate with the on-site ICU personnel. This intervention period was compared with two 6-week control periods the year before. During telemedicine communication, the severity-adjusted ICU mortality (compared with both baseline periods) decreased by 68%, the incidence of ICU complications by 44%, the length of stay in the ICU by 34%, and ICU costs by 33%.

Theoretically, there are no doubts that the unit in which there is a permanent presence and responsibility of a physician whose speciality is critical care could offer better treatment to any patient admitted to that unit.

One cannot forget the fact that what defines a closed ICU is the highest-intensity staffing ICU model, 24 hours a day, 365 days a year.

But besides this fact, e.g. the permanent coverage by a dedicated intensivist, the closed unit creates a unique atmosphere in which the team care, based on the multidisciplinary approach, could ensure better treatment for every complicated patient.

A morning round, with the participation of the intensivist in charge of the unit for that day, accompanied by critical care residents, the primary physician, but also by a pharmacist, a dietician, and a specialist in infectious disease, can offer the guarantee of the best treatment for each patient.

Objective studies strengthen all the above arguments about the superiority of the sealed unit.

Early in the 90s of the last century, Carson et al. (5) showed that nurses working in closed ICUs were more likely to feel confident in the clinical judgment of the attending physician than those in open ICUs.

At the beginning of this century, the Leapfrog Group ( an American consortium that purchases healthcare for their employees) created high-intensity model standards for some medical fields, including ICU staffing (6). However, one USA survey (7) indicated that 47% of ICUs surveyed had some intensivist coverage, but only 4% of intensive care units met Leapfrog high-intensity model standards.

In a study published in 2016, El Kersh et al. (8) compared open and closed ICUs in connection with infectious complications. They discovered that the closed ICU model was associated with a 52% reduction in ventilator-associated pneumonia rate (p = .038) and a 25% reduction in central line-associated bloodstream infection rate (p = .631). They concluded that “a closed ICU model allowed clinical leadership centralization that further facilitates standardized care delivery that translated into fewer infectious complications”.

Ogura et al. (9) studied almost 2,500 septic patients admitted in either an open or a closed ICU. Their results showed a significantly higher survival rate in a closed ICU and a substantially shorter ICU stay.

Finally, Parikh et al. (10) reported in 2012 that the change from an open to a closed ICU format was associated with shorter ICU stays and improved quality measures, including less ventilator-associated pneumonia and central vein access device infection.

I want to end this presentation with the results of an exciting study published in 1999 by Ghorra et al. (11).

The study was carried out at a surgical intensive care unit in a large tertiary care hospital, which was changed from an open team, where private attending physicians contributed and controlled the care of their patients, to a closed unit, where patients’ medical care was provided only by the critical care team. A retrospective review was undertaken over six consecutive months in each system, encompassing 274 patients (125 in the open-unit period, 149 in the closed-unit period). Morbidity and mortality were compared between the two periods, along with length-of-stay (LOS) and a number of other parameters.

Their conclusion is: “The change of our unit from an open to a closed system improved morbidity and mortality, irrespective of the severity of illness and interventions used. Our data support the use of a closed unit in an academic centre where the staffing of critical care physicians is adequate”.

Fortunately, here, on our continent, the dilemma between an open vs a closed ICU was solved from the beginning. In most of our units, the physicians in charge of patient care-24 hours a day- are specialists or residents in Anaesthesiology. An anaesthesiologist leads the clinical activity, but the routine of daily care is based on the multidisciplinary approach, in which the primary physician has a vital role, along with a specialist in various domains. Still, the 24-hour management is covered by people dedicated to our speciality.

Recently I found in my notebook a sentence taken from a famous manual of Critical Care written by Skilmann (12): “Units that do not provide 24-hour specialist physician coverage cannot be truly called intensive care units because intensive care also means intensive physician care”.

One cannot but agree with this statement, published almost half a century ago.

References:

1. Angus DC et al. JAMA 2000;284:2762
2. Sakr Y et al. Crit Care Med 2015;43:519
3. Crippen D. Cost and Quality 1997;3:38
4. Rosenfeld BA et al. Crit Care Med 2000;28:3925
5. Carson SS et al. JAMA 1996;276:322
6. Logani S, Green A, Gasperino J. Crit Care Res and Practice Volume 2011; Article ID 170814, 7 pages doi:10.1155/2011/170814
7. Hyzy RC  et al. J Hosp Med 2010;5:4
8. El Kersh K et al. AM J Infect Control 2016;44:1744
9. Ogura T et al, J Intens Care 2018;6:57
10. Parikh A et al. Crit Care Med 2012;40:2754
11. Ghorra S et al. Ann SUrg 1999;229:163
12. Skilmann JJ. Intensive Care, Little, Brown, 1975, pp 10

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