ICU : an open and shut case?

Todd Fraser on 26-03-2011

This week's blog was suggested by Benjamin Moran, raising the intriguing issue of whether or not a closed ICU format, familiar to most intensivists in Australasia, improves patient outcomes. Certainly the concept has a solid theoretical basis, and anecdotes abound of improved outcomes related to intensivist-controlled units. However the evidence for this is not as solid as many of us would like to believe. Not all units function this way, and not all non-intensivists share the view - cardiothoracic or neurosurgical ICUs are a good example. So how strong is the evidence base for a closed format unit?

2 Comments

Got something to say?

Log in to your account

Forgotten your password?

samar pandhem wrote 03-27-2011 04:45:41 pm
That is true that non intensivists think that we delay the discharge and create unnecessary morbidity in the disguise of safety. I have never seen any surgeon(CT & neurosurgeon) giving credit to intensivists. Their argument Is we donot have any idea of what the surgical perspective is and what surgeons are trying to achieve. I am not aware of any specific study saying closed ICU is better. Should we aim to do one if we believe it is!

Benjamin Moran wrote 03-29-2011 01:58:32 pm
It is a truth universally acknowledged that a critically ill patient being treated by an intensivist must be in want of better outcomes. These improvements in outcome are supported in the literature, particularly with treatment of acute lung injury, intracerebral haemorrhage and AAA surgery. However, an article by Levy et al (2008) challenged the literature with a retrospective analysis of an ICU database, comparing the outcomes in critically ill patients managed by critical care physicians (i.e. a closed unit) to those managed by non-critical care physicians (open units). After adjusting for severity of illness scores and probability of referral to a critical care physician, those treated by intensivists were 40% more likely to die in hospital!

Although this is a retrospective, observational study, it does raise some interesting points. The first is the end-point of mortality. It is well known that intensivists are more likely to change the paradigm of care from active to palliative, making the goal of quality of life paramount. Methodological problems exist for studies where quality of life is the endpoint, but it is one of the main questions asked when a patient is admitted to ICU. Management plans are based on this notion.

Another interesting point is the external validity of studies from outside of Australian and New Zealand. Our baseline mortality rates seem to be lower than in the United States. This was seen in the RENAL trial and as the premise to the ARISE trial.