The impact of an intensivist-model ICU on trauma-related mortality

High quality supportive care in an intensive care unit is a key factor impacting survival following severe injury and is second only to initial hemorrhage control in its importance. As a result, there is much to be gained by optimizing the critical care of the severely injured patient, a point not lost on those seeking careers in trauma who frequently seek advanced training in surgical critical care. The delivery of surgical critical care services currently falls into 2 broadly defined models. In one, the operating surgeon assumes primary responsibility for postoperative care, including the provision of critical care services. This approach is in keeping with the ethical standards of the American College of Surgeons under which surgeons are responsible for the postoperative care of their patients. In this context, the ICU is only a location where advanced monitoring and organ support are available. The surgeon continues with clinical responsibilities outside the intensive care unit while also caring for his/her critically ill patients. This organizational approach is typically referred to as an “open” intensive care unit.1,2 The second model is referred to as a closed ICU, or an intensivist-model of critical care delivery.2 In this construct, physicians certified in critical care by one of several specialty boards (Internal Medicine, Anesthesiology, or Surgery) assume responsibility for delivery of intensive care. It is assumed that the intensivist has no other clinical care responsibilities outside the ICU and is primarily available to the critically ill patient. If the intensivist is a surgeon, it is expected that he or she perform no other duties that limit their availability to the patients in the ICU (eg, operating room or clinic attendance). We have previously evaluated the principal organizational structure of critical care delivery in almost 300 trauma centers across the United States.3 In that sample, 77% of centers reported intensivist involvement in the care of the critically injured, either in the form of collaborative care or the transfer of care to an intensivist. Level II centers were less likely to adopt this approach, with almost 40% reporting that the operating or trauma surgeon was responsible for critical care delivery. Respondents from centers with open ICUs cited the potential for loss of continuity of care, lack of intensivists, and loss of autonomy as the most frequent reasons for not seeking the involvement of an intensivist. Reports from medical and surgical intensive care units have suggested improved outcomes in patients cared for in closed or intensivist-model ICUs compared with an open unit, with reductions in hospital mortality of 30% to 40%.4–7 As a result of these data, the Leapfrog Group, a coalition of more than 170 public and private U.S. organizations that provide healthcare benefits to more than 36 million persons, has made ICU physician staffing an important quality indicator for its beneficiaries.8 However, the American College of Surgeons Committee on Trauma (ACS COT) criteria used for the verification of trauma centers suggests that the surgeon assuming initial responsibility for the care of the injured patient should maintain that responsibility throughout the acute care phase of hospitalization, including the ICU.9 While this standard might be interpreted as in direct conflict with the quality standards put forth by the Leapfrog Group recommendations, there are no data supporting any particular approach for severely injured patients. We set out to fill this gap in knowledge using data derived from a large prospective cohort study of injured patients cared for in a wide variety of both trauma centers and nondesignated centers throughout the country. Our principal objective was to evaluate whether an intensivist model of critical care delivery offered a survival benefit compared with an open model of ICU care.