Resource Use in 'Open' and 'Closed' Intensive Care Units
ABSTRACT & COMMENTARY
Synopsis: Patient care is more efficient with a closed ICU, with the same or reduced mortality and a lower length of stay.
Source: Multz AS, et al. Am J Respir Crit Care Med 1998;157:1468-1473.
There are few prospective studies of the effect on outcome of critically ill patients and resource use in which intensivist staff direct critical care services and the care of all patients. Multz and colleagues carried out a prospective trial of two units in two large hospitals serving similar populations in the same geographic area. One is an "open" medical intensive care unit (MICU), in which critical care consultation on admitted patients is optional and intensivists do not perform preadmission evaluation. The other one is a "closed" MICU in which the attending intensivist is the physician of record for all MICU patients and a mandatory critical care consultation is required to screen all prospective admissions. In addition, because the closed MICU in which this prospective trial was conducted had previously operated as an open unit, Multz et al also report a retrospective analysis comparing outcomes before and after unit closure. During this retrospective study, no changes in care policy of any kind were introduced apart from unit closure.
Data collected included patients' demographics, diagnosis, insurance status, source of admission, calculation of the Mortality Probability Model score upon admission to the MICU (MPM0), ultimate outcome, length of stay (LOS), total hospital LOS, and number of days of mechanical ventilation. A total of 280 patients were evaluated in both units over almost four months of prospective investigation, and a total of 306 patients were evaluated for the retrospective study.
For both the prospective and retrospective cohorts, ICU closure was associated with lower hospital and ICU LOS, although there were no significant differences in age, primary diagnostic categories, insurance status, and MPM0 between open and closed units in either the retrospective or the prospective analysis. The number of days of mechanical ventilation was also lower in the closed than in the open ICU in both cohorts. (See Tables 1 and 2.) Moreover, although patient mortality was not influenced by ICU organization when each cohort was examined separately, when all the data were pooled, mortality was most closely correlated with mechanical ventilation, MPM0 score, and ICU organization. Thus, Multz et al conclude that MICU patients may be treated more efficiently in a closed ICU system.
Table 1
Prospective study
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| ICU LOS |
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| Hospital LOS |
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| Days on MV |
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Table 2
Retrospective analysis
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| ICU LOS |
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| Hospital LOS |
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| Days on MV |
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COMMENT BY FRANCISCO BAIGORRI, MD, PhD
Caring for patients with life-threatening illness is a most demanding job, requiring unremitting hard work and the skilled use of high technology equipment, and involving life and death dramas literally every day.1 In addition, the ICU is an employer of a large nursing staff and the purchaser of sophisticated and costly equipment; it has a large pharmacy budget, and it is a constant drain on laboratory resources. It seems obvious that the responsibility for patient care in these circumstances should fall on competent professionals with specific training and dedication.
Studies such as this one by Multz et al support that assumption. Moreover, in the near future, other factors may favor a closed organization of ICUs. For example, in an interesting essay on "Critical Care in the 21st Century" in a previous issue of Critical Care Alert,2 Rubenfeld pointed out that most ICUs in the United States will likely become closed as the financial incentives for caring for one's own patients in the ICU wane. Perhaps the absence of such financial incentives in my country (Spain), with a public health system, was one of the factors that favored the development of most ICUs as closed ICUs, run by intensive care specialists fully committed to critical care.
However, we must not forget that critical care is part of a continuum of progressive patient care, and decisions as to delivery of this component of care involve other health care professionals and managers, patients, and their relatives. The professionals responsible for the closed units must share their knowledge and interact with these speakers in order to achieve the best use of the resources available according to the needs of each patient. As Rubenfeld also pointed out in his analysis,2 we should think in terms of a continuity of acute care. The EURICUS-I, a study that explored the effect of organization and management on the effectiveness and efficiency of ICUs in EU countries, also highlighted the importance of progressive patient care for improving cost-effectiveness.1
COMMENT BY MARK T. GLADWIN, MD
As mentioned above, a number of retrospective studies have described improved efficiency and survival with closed ICU systems. While most of these studies report the experience of single institutions, Pollack and associates collected consecutive case series in 16 pediatric intensive care units (PICU).3 Analysis of risk-adjusted mortality revealed that the presence of a pediatric intensivist improved the probability of patient survival (relative odds of dying, 0.65). Interestingly, Green recently studied the effect of pediatric critical care fellowship training programs on mortality in these 16 PICUs,4 and found that ICUs with these training programs had a lower risk-adjusted mortality as well (odds of dying, 0.59).
These findings make sense to the practicing intensivist. It is intuitively obvious that when a highly trained physician is frequently at the bedside, decisions about diagnostics, therapeutics, and perhaps more importantly, weaning and withdrawal of therapies, are expedited. Multz et al determined that in a closed unit, LOS and days of mechanical ventilation were reduced. Furthermore, the primary determinant of LOS was days on mechanical ventilation. The presence of an intensivist may have contributed to a reduction in ventilator days by an increase in proactive weaning. Weaning from mechanical ventilation is similarly expedited by the development of weaning protocols that daily test the ability of a ventilated patient to breathe spontaneously. The conclusion is obvious: critically ill patients need attention and "micro-management;" investment in this process will likely prove cost-effective for hospitals.
The fact that the closed ICU structure was associated with an observed decrease in non-ICU LOS for both the retrospective and prospective studies (16 vs 21 days and 13 vs 22 days, respectively) is concerning. While Multz et al point out that this was not significant, the trend is robust. This suggests that other factors, besides a closed system, may have contributed to the observed decreases in LOS.
While these studies support the concept of a closed unit, further work is necessary to clarify what factors contribute to this efficiency. Is there a critical patient-to-intensivist ratio above which efficiency is lost and mortality rises? How will the institution of protocols for weaning, antibiotic use, and management of common diseases influence these outcomes? Will the addition of these protocols be synergistic with an intensivist or will they make the intensivist obsolete? And, finally, will the findings of Multz et al be supported by larger prospective trials in adult ICUs?
References
1. Reis Miranda D, Ryan DW, Schaufeli WB, Fidler V, eds. Organization and Management of Intensive Care. A Prospective Study in 12 European Countries. Berlin; Springer, 1998.
2. Rubenfeld GD. Crit Care Alert 1998;5:94-96.
3. Pollack MM, et al. JAMA 1994;272:941-946.
4. Green TP. Crit Care Med 1997;25:1621-1622.
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