Closed for Business

There has been much focus recently on the ICU and with good reasons. It is the most expensive care we provide to patients and represents care rendered to the sickest of sick. These patients are the most complicated medically and caring for them is likewise also complicated. Taking care of ICU patients requires multiple health care providers coordinating care within a complex setting. It mixes advance technology, complex medical procedures, advance life support, state-of-the-art monitoring systems with good nursing and doctoring skills. All this needs to be coordinated well for an ICU to operate efficiently and effectively and make the most out of saving lives. However, despite all the technology, in the end, it is people who provide the care.  Critical care medicine is a complex system that requires a substantial human element. For such systems to work well, efficiency is of key importance along with systems that promote good communication.  Unfortunately, a lot of ICU care is neither.

There are basically two models current medical intensive care units operate under and these are based upon which physicians have direct care responsibilities. The open model ICU is set up so that any physician can admit patients to the ICU and care for them. A critical care physician may also be involved but the idea is that all the physicians involved co-manage the patient. This is how most of ICUs operate in the United States. The primary care physician, specialists (sometimes many of them) are all following the patient and ordering tests and procedures. If a critical care physician is involved, he or she will also be caring for the patient and ordering tests and procedures. In addition, ideally, the ICU physician will be coordinating all the care provided by all these other doctors. This may seem like a good system; all physicians co-managing the patient in a collaborative environment with each one bringing their own expertise and experience. Unfortunately, the reality of how this system operates is much less than ideal and, in fact, it is quite dysfunctional.

The closed model of how an ICU operates is based upon the critical care physician who may also be called an intensivist as the main care giver. Typically, this means that this physician is the one ordering tests and procedures. Other physicians can still see the patient but they are restricted from ordering tests and procedures and in some instances even kept from directly consulting other physicians. Primary care physicians and other consulting physicians are still involved but only are permitted render recommendations. It is ultimately up to the critical care physicians to follow through on the advice and recommendations of these other physicians. All other health care providers must work through the critical care specialist. Another important aspect of the closed system is that the critical care physician is in the ICU for a full work day (and longer if necessary). Typically, this physician has no other duties like seeing patients in the office, or going to other hospitals. This is protected time. It’s easy to see how this system may improve efficiency and it is this model that is advocated over the closed model in care for critically ill patients.  Unfortunately, only a minority of ICUs operate under this model.

There are several problems with the open system. One issue allows any physician to render treatment to a critically ill patient regardless of whether this physician is qualified or experienced in the care of such patients. Critical care medicine is a highly specialized field. Physicians who are specialist in critical care undergo years of training and acquire extensive experience. Relegating the care of such sick patients to health care professionals who neither have training nor experience in the care of the critically ill is questionable. If there happens to be a critical care specialist involved, he or she may also have other obligations beyond caring for patients in the ICU. Many critical care physicians are also lung and sleep specialists. They may have to see other patients in the hospital or in the office in addition to patients in the ICU. Like all the other physicians on board, they come to the ICU see their patients, write their notes and orders and then leave. One physician may write an order or procedure not known by the other physicians or many physicians may be writing orders that are redundant or in conflict with other orders. In the setting of high patient complexity, things get mixed up pretty quickly, with the right hands not knowing what the left hands are doing so to speak. Efficiency drops, patients end up getting tests and procedures that may not be necessary, much energy and time is squandered in clarifying and correcting orders, and patients can be exposed to otherwise avoidable risks in tests that may not be needed, and all in the end, jeopardizing care. In short, there is redundancy, inefficiency, and little coordination of care.

Another big problem with the open system is communication and continuity of care. Ideally, all these physicians involved should communicate with each other each day. This rarely happens to the level it should with each health care provider tending to their busy schedule and only seeing ICU patients on the fly. All these providers are also coming by at different times throughout the day. Critical care medicine can be fast paced with patients capable of deteriorating quickly. What one physician may see in the morning is not what another physician may see in the afternoon. Again, communication would help ameliorate this issue but physicians don’t talk to each other enough. There are too many cooks in the kitchen all at different times doing their own things and not talking to one another.

The closed model system has many advantages over the open model. It places the care of such sick patients directly under a physician with training and experience in dealing with the critically ill. It relegates most or all of order writing and procedures to this individual. The ICU physician’s duty is to be in the unit with no other outside obligations making it easier to coordinate care by other specialists. Restricting order writing, forces physicians to communicate with each other and especially with the critical care specialist. A physician may want to obtain a CT scan of the brain but the patient may not be stable enough for transfer to the scanner. The critical care physician can weigh in on the necessity of such testing and veto it until the patient is stable enough to be safely transported. If a patient deteriorates or is especially sick, there is someone there or readily accessible who has training and experience in treating critically ill patients.

There are many reasons why more ICUs are not closed. This is actually a very complicated issue. There is a shortage of critical care physicians for one. There are not enough to go around and staff ICUs under the closed model. Not all ICUs have enough sick patients to support an on-site dedicated critical care physician. A small community hospital with a four bed ICU is not enough to justify a closed system and hiring a dedicated specialist. The patients in that four bed unit are likely going to be not that sick compared to a larger health care system. Many physicians who are not trained nor have the expertise in critical care medicine may be against a closed model and perceive a loss of autonomy in giving up their ability to write orders when they have always been permitted to do so. These are some of the issues related to closing an ICU. Clearly, in those settings where there is a need along with the resources available to permit such staffing, the closed system is the way to go.






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