Researchers at the University of Chicago took advantage of an institutional change, from an open to a closed ICU model, to study the merits of these two organizational strategies In their previous open system, patients were admitted to the 10-bed medical ICU and cared for by their primary physician, while daily recommendations for management were made by a critical care team. In the closed format, the critical care team assumed primary responsibility for all patients admitted to the ICU. All orders were written by the ICU team housestaff. When a patient was ready to transfer from the ICU, they were transferred back to the original ward service.
A two-month period in each format was compared, allowing evaluation of 124 and 121 patients in each period, respectively. The APACHE II scoring system was used to measure severity of illness and to predict mortality. Duration of mechanical ventilation, use of face mask ventilation, use of CPR, details of vascular catheter use, and both ICU and hospital length of stay were noted. Resource use was evaluated by collecting charge data for laboratory, pharmacy, radiology, and the total hospitalization, and by comparing the use of certain indicator tests and drugs. Other variables studied were the length of time required to accomplish patient transfer out of the ICU, interruptions during formal teaching rounds, and perceptions of patients, families, physicians, and nurses.
The patients in the closed ICU were older (59 vs 53 years) and more severely ill (APACHE II 20.6 vs 15.4) than those in the open ICU, although sepsis, hemorrhagic shock/hypovolemia, and gastrointestinal bleeding were the most common primary diagnoses in both study periods. In the closed ICU, the ratio of actual (31.4%) to predicted mortality (40.1%) was 0.78, while in the open ICU, the ratio of actual (22.6%) to predicted mortality (25.2%) was 0.90. There were no differences in duration of mechanical ventilation, use of CPR, length of stay for survivors in the ICU or hospital, or in the comparison of mean charges per patient per unit per day for lab, x-ray, and pharmacy resources between the two periods. There were significant increases in the use of sedatives and neuromuscular blockers in the closed ICU. More patients received arterial, central venous, and pulmonary artery catheters in the closed ICU, and they were used for a longer average duration. Occupancy of the MICU was higher during the closed period (95%) than the open period (76%). The amount of time to accomplish patient transfer from the ICU once the ward was notified was decreased by 40 minutes (from 280 minutes) in the closed ICU.
Formal ICU teaching rounds were interrupted for patient care issues much more frequently in the closed ICU. Total minutes of formal teaching was significantly less in the closed (659 minutes) than in the open (1231 minutes) system. Although not all patients or families were able to be interviewed, more than 67% in both groups agreed with decisions made about the patient while in the ICU. More than 20% of both patients and families in both groups wished to be more involved in decision making. More families in the closed ICU format reported that it was very easy to find a doctor to talk to; however, more than 60% in both groups reported that the nurse was the person most likely to answer questions and address concerns. Patients in both groups reported a need for greater emotional support. The care in the closed ICU format was rated as excellent more often by patients and families than in the open ICU (52.1% vs 44.2%)
Continuity of care was rated as poor by the house staff and attendings more often in the closed ICU (0% vs 23.8%). In the closed ICU format, house staff more often reported needing more independence in decision making (41% vs 5%) and rated learning opportunities as poor (23% vs 2%); however, more (43% vs 24%) were more comfortable managing ICU patients after a rotation in the closed vs. the open system. Nurses were more likely to say that they were confident (41% vs 7%) in the clinical judgment of the primary physician in the closed system compared with the open system. (Carson SS, et al. JAMA 1996;276:322-328.)
COMMENT BY DOREEN M. ANARDI, RN
In a 1991 nationwide survey of hospitals registered with the American Hospital Association, 22% of those responding used a closed ICU system. Larger hospitals, more specialized units, and medical school affiliation were more often associated with closed ICUs. The debate goes on about which format is preferable. These researchers describe a unique before and after scenario, that despite a brief two-month comparison, has compelling findingsimproved mortality in an already well-functioning ICU. Although the study population was older and more severely ill, there was not an increase in resource use in the closed ICU period.
An interesting finding in both systems is that more than 20% of the patients and families wished to be more involved in the decision making surrounding their care. Practitioners may be underestimating patients’ abilities to participate in their care in this clinical setting. It is encouraging that the families had easier access to the physician in charge of their family member during the closed period.
The effect of ICU organizational structure on physician education is an interesting one. Although the house staff gave lower ratings to the components of learning in the closed ICU system, they reported greater confidence in their management abilities after their rotation through the closed system. It isn’t surprising that the nurses reported greater confidence with the closed system; consistency of approach, ease of access to decision making care givers are important to the bedside deliverers and evaluators of care. The increased use of sedatives and arterial catheters during the closed ICU period may indicate greater attention to patient comfort.
This is a complex issue, and this study raises many fascinating questions. How to decide which format is best for an individual institution depends on the resources available, the people involved, and the desired outcomes. This study outlines some good points to evaluate in dealing with this important and politically sensitive issue in physician practice patterns and institutional organization.
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