Published online Aug 4, 2015. doi: 10.5492/wjccm.v4.i3.240
Peer-review started: December 21, 2014
First decision: February 7, 2015
Revised: March 12, 2015
Accepted: April 27, 2015
Article in press: April 29, 2015
Published online: August 4, 2015
Processing time: 240 Days and 2.9 Hours
In the last two decennia, the mixed population general intensive care unit (ICU) with a “closed format” setting has gained in favour compared to the specialized critical care units with an “open format” setting. However, there are still questions whether surgical patients benefit from a general mixed ICU. Trauma is a significant cause of morbidity and mortality throughout the world. Major or severe trauma requiring immediate surgical intervention and/or intensive care treatment. The role and type of the ICU has received very little attention in the literature when analyzing outcomes from critical injuries. Severely injured patients require the years of experience in complex trauma care that only a surgery/trauma ICU can provide. Should a trauma center have the capability of a separate specialized ICU for trauma patients (“closed format”) next to its standard general mixed ICU
Core tip: Trauma is a significant cause of morbidity and mortality throughout the world. Major or severe trauma requires immediate surgical intervention and/or intensive care treatment. Severely injured patients require the years of experience in complex trauma care that only a surgery/ trauma intensive care unit can provide.
- Citation: Timmers TK, Verhofstad MH, Leenen LP. Intensive care organisation: Should there be a separate intensive care unit for critically injured patients? World J Crit Care Med 2015; 4(3): 240-243
- URL: https://www.wjgnet.com/2220-3141/full/v4/i3/240.htm
- DOI: https://dx.doi.org/10.5492/wjccm.v4.i3.240
The contribution of organizational structure - in a wide variety of settings - for the delivery of critical care to patients has been the topic of study since the mid-1980s[1-9]. The preponderance of evidence recommends that intensivist-directed patient management is related to a reduced length of intensive care unit (ICU) stay, reduced hospital length of stay, and most likely decreased mortality. In the last two decennia, the mixed population general ICU with a “closed format” setting has gained in favour compared to the specialized critical care units with an “open format” setting, especially in Europe[8-15]. Therefore, critical care physicians have taken responsibility for the treatment of critically ill patients, and more and more specialized units are embedded in the intensive care department. These units are subsequently transformed into overall general units with a mixed population of different diseases. Although there seems to be more positive results towards the general mixed ICU within a “closed format” setting in the literature[4,6-8,10,16-23], there are still questions whether surgical patients benefit from a general mixed ICU. The only evidence accessible on this field comes from the neurosurgical intensive care; Intracerebral hemorrhage patients treated in a specialized neuroscience ICU had lower mortality, length of stay, and cost than those treated in a general ICU[24,25]; and from the burn intensive care[26-29]. Does this mean that we have to reorganise all specialized surgical units, even if those units are already working in accordance with the “closed format” setting Several authors state that we should not reform all of our specialized surgical ICUs[30-33].
Trauma has been called the unnoticed epidemic and the unheeded disease of modern society. Trauma every year impacts hundreds of thousands of individuals and cost billions of dollars in direct financial loss[34]. Trauma care has improved over the past 20 years, largely from improvements in trauma systems, assessment, triage, resuscitation, emergency and intensive care[34]. Trauma is a significant cause of morbidity and mortality throughout the world. Major or severe trauma requires immediate surgical intervention and/or intensive care treatment. Over one quarter of trauma patients are cared for in an ICU during their hospital admission in the United States[33,35]. Modern trauma care has become highly specialized, especially for the critically ill patient with multiple-system injuries[36]. The care provided in this setting plays a major role in ensuring survival following injury and might significantly influence functional outcome[33]. Nevertheless, the function and structure of the ICU has received very little awareness in the literature when examining outcomes from critical injuries[36]. The American College of Surgeons Committee on Trauma, whose criteria is used for the verification of trauma centers, recommends that the surgeon presuming first responsibility for the care of the injured patient should maintain that responsibility all through the acute care phase of hospitalization, including the ICU[37]. Nathens et al[30] have concluded that closed ICUs with a surgeon intensivist had the best outcome in the care of the critically injured trauma patient compared with the non-surgeon intensivists. Park et al[32] suggested that improved clinical outcomes, lower costs and reduced length of stay are directly related to a separate closed trauma unit. And the most recent study of Duane et al[36] concludes that severely injured patients require the years of experience in complex trauma care that only a surgery/trauma ICU can organise. These patients air a number of exceptional challenges for the ICU physician including the need for ongoing resuscitation, drive of resuscitation endpoints, and treatment of early post-resuscitation complications. How well these are addressed may have critical implications for long-term outcome and survival[38]. Timing in treatment (especially re-operations in the first 48 h) of the critically injured patient is of great importance; and who is better to understand these circumstances than the surgeon intensivist (with experience in trauma surgery) In a perfect world, should a trauma center have the capability of a separate specialized ICU for trauma patients (“closed format”) next to its standard general mixed ICU Critically injured patients requiring admission to the ICU often have multi-system injuries that require technically advanced medicine including resuscitation from shock. The ICU care of the trauma patient differ from that of other intensive care patients in many ways, one of the most important being the need to continuously combine operative and non-operative treatment. Though, development in the care of the injured has been made, death due to uncontrolled bleeding, severe head injury, or the development of multiple organ dysfunction syndrome remains all too common in this patient population. Additionally, due to the potential nature of the injuries, the problem not seldom arises that the optimum therapy for one injury or organ system, such as preoperative permissive hypotension in actively bleeding patients, may result in suboptimal or even harmful therapy in the existence of an other injury (such as traumatic brain injury)[39]. In addition, trauma leads to a state of relative immunosuppression with decreased humoral and cell mediated immunity[40-45].
Trauma surgery critical care teams often consult multiple specialists to provide the complex care necessary to treat the most severely injured. It is true that this kind of advanced medicine is indeed available at each Level I trauma center general ICU. However, would the experience of highly trained personnel (trauma nurses, senior surgical residents, trauma fellows) contribute even more to a better patient outcome With this kind of highly trained and experience personnel the possibility exists to perform small operations on the unit itself without having to wait and transport the critically injured patient to an operation theatre. Complex, high skilled nursing interventions such as volume replacement, correction of coagulopathy and hypothermia, invasive monitoring and the management of “damage-control” conditions demand understanding and experience that are not able to be gauged. These skills are obtained on a daily basis in Trauma ICUs where there is an excess of “hands-on” learning possibility. The development of such skills is critical for optimal results in life-threatening blunt and penetrating trauma. An identical care is hard to attain even from staff that is experienced and exceptional in their non-surgical fields[36]. Even in our own intensive care patient organisation (concerning surgical patients and the critically injured patients on outcome), a difference in the dimensions of crude ICU outcome (short-term mortality/length of ICU stay and ICU readmission) was seen after the reorganization to a general ICU[46]. Should there not be an organised survey among different trauma centers to analyse the critically injured patient outcome. This should give critical care physicians and surgeons specialized in trauma insight in the question whether patient outcome could gain from separate trauma units or give us the conclusive information whether we should continue combining all specialized care units together.
P- Reviewer: Gurjar M, Juneja D, Vugt A S- Editor: Tian YL L- Editor: A E- Editor: Wu HL
1. | Li TC, Phillips MC, Shaw L, Cook EF, Natanson C, Goldman L. On-site physician staffing in a community hospital intensive care unit. Impact on test and procedure use and on patient outcome. JAMA. 1984;252:2023-2027. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 19] [Cited by in F6Publishing: 19] [Article Influence: 0.5] [Reference Citation Analysis (0)] |
2. | Brown JJ, Sullivan G. Effect on ICU mortality of a full-time critical care specialist. Chest. 1989;96:127-129. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 153] [Cited by in F6Publishing: 154] [Article Influence: 4.4] [Reference Citation Analysis (0)] |
3. | Pronovost PJ, Jenckes MW, Dorman T, Garrett E, Breslow MJ, Rosenfeld BA, Lipsett PA, Bass E. Organizational characteristics of intensive care units related to outcomes of abdominal aortic surgery. JAMA. 1999;281:1310-1317. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 523] [Cited by in F6Publishing: 538] [Article Influence: 21.5] [Reference Citation Analysis (0)] |
4. | Ghorra S, Reinert SE, Cioffi W, Buczko G, Simms HH. Analysis of the effect of conversion from open to closed surgical intensive care unit. Ann Surg. 1999;229:163-171. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 134] [Cited by in F6Publishing: 143] [Article Influence: 5.7] [Reference Citation Analysis (0)] |
5. | Hanson CW, Deutschman CS, Anderson HL, Reilly PM, Behringer EC, Schwab CW, Price J. Effects of an organized critical care service on outcomes and resource utilization: a cohort study. Crit Care Med. 1999;27:270-274. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 188] [Cited by in F6Publishing: 154] [Article Influence: 6.2] [Reference Citation Analysis (0)] |
6. | Manthous CA, Amoateng-Adjepong Y, al-Kharrat T, Jacob B, Alnuaimat HM, Chatila W, Hall JB. Effects of a medical intensivist on patient care in a community teaching hospital. Mayo Clin Proc. 1997;72:391-399. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 96] [Cited by in F6Publishing: 95] [Article Influence: 3.5] [Reference Citation Analysis (0)] |
7. | Reynolds HN, Haupt MT, Thill-Baharozian MC, Carlson RW. Impact of critical care physician staffing on patients with septic shock in a university hospital medical intensive care unit. JAMA. 1988;260:3446-3450. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 179] [Cited by in F6Publishing: 175] [Article Influence: 4.9] [Reference Citation Analysis (0)] |
8. | Multz AS, Chalfin DB, Samson IM, Dantzker DR, Fein AM, Steinberg HN, Niederman MS, Scharf SM. A “closed” medical intensive care unit (MICU) improves resource utilization when compared with an “open” MICU. Am J Respir Crit Care Med. 1998;157:1468-1473. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 180] [Cited by in F6Publishing: 189] [Article Influence: 7.3] [Reference Citation Analysis (0)] |
9. | Topeli A, Laghi F, Tobin MJ. Effect of closed unit policy and appointing an intensivist in a developing country. Crit Care Med. 2005;33:299-306. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 36] [Cited by in F6Publishing: 39] [Article Influence: 2.1] [Reference Citation Analysis (0)] |
10. | Pronovost PJ, Angus DC, Dorman T, Robinson KA, Dremsizov TT, Young TL. Physician staffing patterns and clinical outcomes in critically ill patients: a systematic review. JAMA. 2002;288:2151-2162. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 1104] [Cited by in F6Publishing: 1019] [Article Influence: 46.3] [Reference Citation Analysis (0)] |
11. | Groeger JS, Strosberg MA, Halpern NA, Raphaely RC, Kaye WE, Guntupalli KK, Bertram DL, Greenbaum DM, Clemmer TP, Gallagher TJ. Descriptive analysis of critical care units in the United States. Crit Care Med. 1992;20:846-863. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 131] [Cited by in F6Publishing: 136] [Article Influence: 4.3] [Reference Citation Analysis (0)] |
12. | Schmitz R, Lantin M, White A. Future Workforce Needs in Pulmonary and Critical Care Medicine. Cambridge, Mass: Abt Associates 1999; . [Cited in This Article: ] |
13. | Audit Commission. Critical to Success: The Place of Efficient and Effective Critical Care Services Within the Acute Hospital. London, England: Audit Commission 1999; . [Cited in This Article: ] |
14. | Ferdinande P. Recommendations on minimal requirements for Intensive Care Departments. Members of the Task Force of the European Society of Intensive Care Medicine. Intensive Care Med. 1997;23:226-232. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 83] [Cited by in F6Publishing: 89] [Article Influence: 3.3] [Reference Citation Analysis (0)] |
15. | Cole L, Bellomo R, Silvester W, Reeves JH. A prospective, multicenter study of the epidemiology, management, and outcome of severe acute renal failure in a “closed” ICU system. Am J Respir Crit Care Med. 2000;162:191-196. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 134] [Cited by in F6Publishing: 142] [Article Influence: 5.9] [Reference Citation Analysis (0)] |
16. | Parrillo JE. A silver anniversary for the Society of Critical Care Medicine--visions of the past and future: the presidential address from the 24th Educational and Scientific Symposium of the Society of Critical Care Medicine. Crit Care Med. 1995;23:607-612. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 9] [Cited by in F6Publishing: 11] [Article Influence: 0.4] [Reference Citation Analysis (0)] |
17. | Flaatten H. Effects of a major structural change to the intensive care unit on the quality and outcome after intensive care. Qual Saf Health Care. 2005;14:270-272. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 11] [Cited by in F6Publishing: 13] [Article Influence: 0.7] [Reference Citation Analysis (0)] |
18. | Fuchs RJ, Berenholtz SM, Dorman T. Do intensivists in ICU improve outcome. Best Pract Res Clin Anaesthesiol. 2005;19:125-135. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 20] [Cited by in F6Publishing: 10] [Article Influence: 0.5] [Reference Citation Analysis (0)] |
19. | Pronovost PJ, Dang D, Dorman T, Lipsett PA, Garrett E, Jenckes M, Bass EB. Intensive care unit nurse staffing and the risk for complications after abdominal aortic surgery. Eff Clin Pract. 2001;4:199-206. [PubMed] [Cited in This Article: ] |
20. | Leapfrog Group. ICU Physician Staffing Factsheet. Washington, DC: Leapfrog Group 2004; . [Cited in This Article: ] |
21. | Vincent JL. Need for intensivists in intensive-care units. Lancet. 2000;356:695-696. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 49] [Cited by in F6Publishing: 54] [Article Influence: 2.3] [Reference Citation Analysis (0)] |
22. | Chittawatanarat K, Pamorsinlapathum T. The impact of closed ICU model on mortality in general surgical intensive care unit. J Med Assoc Thai. 2009;92:1627-1634. [PubMed] [Cited in This Article: ] |
23. | Young MP, Birkmeyer JD. Potential reduction in mortality rates using an intensivist model to manage intensive care units. Eff Clin Pract. 2000;3:284-289. [PubMed] [Cited in This Article: ] |
24. | Mirski MA, Chang CW, Cowan R. Impact of a neuroscience intensive care unit on neurosurgical patient outcomes and cost of care: evidence-based support for an intensivist-directed specialty ICU model of care. J Neurosurg Anesthesiol. 2001;13:83-92. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 190] [Cited by in F6Publishing: 202] [Article Influence: 8.8] [Reference Citation Analysis (0)] |
25. | Diringer MN, Edwards DF. Admission to a neurologic/neurosurgical intensive care unit is associated with reduced mortality rate after intracerebral hemorrhage. Crit Care Med. 2001;29:635-640. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 419] [Cited by in F6Publishing: 445] [Article Influence: 19.3] [Reference Citation Analysis (0)] |
26. | Karyoute SM, Badran DH. Analysis of 100 patients with thermal injury treated in a new burn unit in Amman, Jordan. Burns Incl Therm Inj. 1989;15:23-26. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 4] [Cited by in F6Publishing: 5] [Article Influence: 0.1] [Reference Citation Analysis (0)] |
27. | Herndon DN, Spies M. Modern burn care. Semin Pediatr Surg. 2001;10:28-31. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 41] [Cited by in F6Publishing: 47] [Article Influence: 2.0] [Reference Citation Analysis (0)] |
28. | Fagan SP, Bilodeau ML, Goverman J. Burn intensive care. Surg Clin North Am. 2014;94:765-779. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 22] [Cited by in F6Publishing: 23] [Article Influence: 2.3] [Reference Citation Analysis (0)] |
29. | Snell JA, Loh NH, Mahambrey T, Shokrollahi K. Clinical review: the critical care management of the burn patient. Crit Care. 2013;17:241. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 56] [Cited by in F6Publishing: 65] [Article Influence: 5.9] [Reference Citation Analysis (0)] |
30. | Nathens AB, Rivara FP, MacKenzie EJ, Maier RV, Wang J, Egleston B, Scharfstein DO, Jurkovich GJ. The impact of an intensivist-model ICU on trauma-related mortality. Ann Surg. 2006;244:545-554. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 8] [Cited by in F6Publishing: 38] [Article Influence: 2.1] [Reference Citation Analysis (0)] |
31. | Lee JC, Rogers FB, Horst MA. Application of a trauma intensivist model to a Level II community hospital trauma program improves intensive care unit throughput. J Trauma. 2010;69:1147-1152; discussion 1152-1153. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 5] [Cited by in F6Publishing: 6] [Article Influence: 0.5] [Reference Citation Analysis (0)] |
32. | Park CA, McGwin G, Smith DR, May AK, Melton SM, Taylor AJ, Rue LW. Trauma-specific intensive care units can be cost effective and contribute to reduced hospital length of stay. Am Surg. 2001;67:665-670. [PubMed] [Cited in This Article: ] |
33. | Nathens AB, Maier RV, Jurkovich GJ, Monary D, Rivara FP, Mackenzie EJ. The delivery of critical care services in US trauma centers: is the standard being met. J Trauma. 2006;60:773-783; disucssion 783-784. [PubMed] [Cited in This Article: ] |
34. | Available from: http://emedicine.medscape.com/. [Cited in This Article: ] |
35. | American College of Surgeons. National Trauma Databank (Accessed November 2002). Available from: https://www.facs.org/quality programs/trauma/ntdb. [Cited in This Article: ] |
36. | Duane TM, Rao IR, Aboutanos MB, Wolfe LG, Malhotra AK. Are trauma patients better off in a trauma ICU. J Emerg Trauma Shock. 2008;1:74-77. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 10] [Cited by in F6Publishing: 14] [Article Influence: 1.1] [Reference Citation Analysis (0)] |
37. | American College of Surgeons Committee on Trauma. Resources for optimal care of the injured patient 1999. Chicago: American College of Surgeons 1998; . [Cited in This Article: ] |
38. | Shere-Wolfe RF, Galvagno SM, Grissom TE. Critical care considerations in the management of the trauma patient following initial resuscitation. Scand J Trauma Resusc Emerg Med. 2012;20:68. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 28] [Cited by in F6Publishing: 33] [Article Influence: 2.8] [Reference Citation Analysis (0)] |
39. | Deitch EA, Dayal SD. Intensive care unit management of the trauma patient. Crit Care Med. 2006;34:2294-2301. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 39] [Cited by in F6Publishing: 41] [Article Influence: 2.3] [Reference Citation Analysis (0)] |
40. | Mullick P, Talwar V, Pawar M. Factors influencing morbidity in ICU trauma admissions – A 3 year retrospective analysis. Indian J Anaesth. 2004;48:111-115. [Cited in This Article: ] |
41. | Stillwell M, Caplan ES. The septic multiple-trauma patient. Crit Care Clin. 1988;4:345-373. [PubMed] [Cited in This Article: ] |
42. | Morgan AS. Risk factors for infection in the trauma patient. J Natl Med Assoc. 1992;84:1019-1023. [PubMed] [Cited in This Article: ] |
43. | O’Mahony JB, Palder SB, Wood JJ, McIrvine A, Rodrick ML, Demling RH, Mannick JA. Depression of cellular immunity after multiple trauma in the absence of sepsis. J Trauma. 1984;24:869-875. [PubMed] [Cited in This Article: ] |
44. | Hietbrink F, Koenderman L, Rijkers G, Leenen L. Trauma: the role of the innate immune system. World J Emerg Surg. 2006;1:15. [PubMed] [Cited in This Article: ] |
45. | Hietbrink F, Koenderman L, Althuizen M, Pillay J, Kamp V, Leenen LP. Kinetics of the innate immune response after trauma: implications for the development of late onset sepsis. Shock. 2013;40:21-27. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 48] [Cited by in F6Publishing: 52] [Article Influence: 5.2] [Reference Citation Analysis (0)] |
46. | Timmers TK, Hulstaert PF, Leenen LP. Patient outcomes can be associated with organizational changes: a quality improvement case study. Crit Care Nurs Q. 2000;37:125-134. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 5] [Cited by in F6Publishing: 7] [Article Influence: 0.8] [Reference Citation Analysis (0)] |