EDITORIAL

How and How Much Can the Organization ofCritical Care Services Influence Patient Outcome?

Jesse Hall, MD

Hall JD. How and how much can the organization of critical nal care system. The exploration of these points iscare services influence patient outcome? J Intensive Care Med

essentially the answer to our second question—1999;14:251–253.where future research should be directed.

Hanson and Aranda offer a number of potentialIn this issue of the Journal, Hanson and Aranda [1] mechanisms to explain how intensivists impact out-provide a review of the literature concerning the come, but these are essentially speculations. Theimpact of intensivists and intensive care unit (ICU) surveyed literature simply does not tease out theorganization on patient outcomes. Their survey of myriad changes that occur with intensivist involve-19 peer-reviewed studies is a thorough compilation ment in critical care. Does administrative changeof those English-language publications which em- and protocol implementation make a difference?ployed before-and-after analysis, multicenter sever- Some recent studies have suggested that protocolsity of illness databases, or side-by-side comparisons may enhance outcomes and, of interest, protocolsof differently run ICUs to determine whether the that tend to bypass the physician (at least for day-presence of intensivists or ICU teams influence to-day judgments) may be most beneficial for cer-mortality, resource utilization, or cost. Their reading tain end points, such as shortening time to libera-of this literature is that there is a remarkably consis- tion from mechanical ventilation [3]. Protocols maytent finding of benefit associated with intensivist also best implement strategies that are known toinvolvement in critical care services. In exploration be of global benefit to critically ill patients, suchof the mechanisms for this, they cite a small sample as prophylaxis against thromboembolic disease orof a much larger literature to identify some of the institution of enteral nutrition. Does the provisionpotential influences upon outcomes from critical of intensivist involvement in the critical care teamillness, including payer status, cost-reduction proto- provide a higher level of integration of physicianscols, complication rates, triage, and education pro- with other care providers and hence improved out-grams. come? This intriguing possibility, almost a topic for

Upon reading this review, a number of questions medical anthropology and not well approached bycome to mind: 1) Are the broad conclusions correct? the methodologies of these studies, is suggested2) How can we best use this body of knowledge but hardly proved by a number of investigationsto direct future studies? and 3) Are there implica- reviewed here.tions for the present practice of critical care? Do intensivists reduce complications that lead

Regarding the first point, the major conclusion to morbidity and mortality? Certain complications,of the authors that ‘‘the preponderance of the data such as acquisition of nosocomial infection, areindicate that intensivists and intensive care teams known to dramatically alter outcome for the criti-have a beneficial impact on the outcomes and eco- cally ill [4] and several of the studies reviewed bynomics of intensive care’’ appears justified. While Hanson and Aranda demonstrated reduced compli-I have previously cautioned [2] that this literature cation rates with intensivist-directed managementsuffers from a possible reporting bias and lack of [5,6]. Not all studies, however, observed such reduc-ideal randomized prospective trials, the consistency tions in complication rates, our own included [7].of findings over time, study design, and care envi- To this point, it is likely that the ability of investiga-ronments support this basic conclusion. Less clear tors to prospectively define and identify all signifi-is how such benefit accrues, and, more importantly, cant complications is inadequate.what the impact of these ‘‘critical care outcomes’’ Is the benefit of intensive care reorganizationis when placed in the perspective of the longitudi- largely one of ‘‘being there’’—providing more phy-

sicians who are more available to the critically illpatient and with less competition from other clinical

From the University of Chicago, Chicago, IL.responsibilities? The majority of the studies re-

Address correspondence to Dr Hall, University of Chicago, MCviewed here were conducted in teaching hospitals,6026, Chicago, IL 60630, or e-mail: jhall@medicine.bsd.uchica-

go.edu. and the reorganization of critical care most often

Copyright q 1999 Blackwell Science, Inc. 251

252 Journal of Intensive Care Medicine Vol 14 No 6 November/December 1999

involved attending, fellow, and resident physician ment a shift of care from ‘‘cure to comfort’’ whenappropriate.deployment to the ICU. If greater presence is essen-

tial to derive improved outcome, the implications Thus the answer to our second question is thatthere is a great deal to do. This is not surprising,for nonteaching hospitals, intensivist manpower

requirements, and reimbursement requirements since productive and valuable investigations suchas those reviewed by Hanson and Aranda lead towould be obvious and enormous. Thus investiga-

tion of approaches which derive the greatest benefit many more questions than answers. The challengeto the next generation of research is to frame ques-from the wisest deployment of our human re-

sources is urgently needed. tions wisely and investigate the delivery of criticalcare before models are adopted for reasons notHow much benefit is actually quantitated by

these studies? The end points employed in the ma- driven by understanding the process of care. Inmy own view, these questions largely concern thejority of these investigations—ICU and hospital

mortality, ICU and hospital length of stay, estimated mechanisms of benefit of organizations of criticalcare services and their impact over the full life ofcost or number of diagnostic tests and consulta-

tions—are crude and do not help us understand the patient and the entire health care system. Thiswork has already begun for certain disease pro-the outcomes we are witnessing in the broader

context of patients’ lives and the entire health care cesses such as the acute respiratory distress syn-drome [10] but needs to be expanded broadly tosystem. As an extreme example, imagine that inten-

sivists help to transform the use of a given ICU, with recipients of care in medical, surgical, and mixedICUs. Preliminary studies of this type are beginningtriage of many patients requiring only monitoring to

other hospital environments. They then direct their to appear in our literature [11] and may well beforthcoming from countries or health care systemscare toward a large population of patients with

complex critical illness but some opportunity for that afford analysis of long-term outcomes. A natu-ral ‘‘laboratory’’ for such longitudinal studies is thesurvival. Their excellent care results in a population

of patients stabilized and then requiring a more large health care system, which often offers a varietyof different health care delivery models (includinggradual recovery from multisystem organ failure.

As well understood by the experienced intensivist, within the ICUs) and the ability to determine theimpact of these services on other sectors of thethis ‘‘chronic critical care’’ often need not be con-

ducted in the ICU, particularly with the press of system and on patient outcome decades hence.Finally, how can we best answer our last ques-patients requiring this locale for care. Since ongoing

care for these patients is beyond the means of the tion? In reading this review one is encouraged thatthe role of the intensivists has justifiably grown, butroutine ward, transfer to a long-term acute care

(LTAC) setting is often effected. This system of care, that the precise way in which services should bestructured remains to be defined. This literaturedriven by reimbursement issues as well as care re-

quirements, has grown explosively in a period of parallels other research comparing differences be-tween specialty and subspecialty care [12], althoughtime overlapping with many of the studies reviewed

here. Short-term outcome from the perspective of often the impact of the intensivist is to shift the careof the critically ill patient from a broad group ofthe ICU or hospital may appear to be salutary, but

is incomplete without a further analysis of long- subspecialty consultants to a more consolidatedtreatment approach. It is likely that a variety ofterm outcome in the LTAC facility and beyond. Of

interest, one recent study of mechanically ventilated organizations of critical care services will be identi-fied that are necessary for the variety of health carepatients sent for LTAC reported a 50% mortality in

the LTAC hospital, with only 8% of patients fully environments present now and evolving in the fu-ture. The most confident recommendation for ourfunctional and living independently at 1 year [8].

Thus the success of critical care services as judged present practice is to provide an education to thetrainees of our specialty that confers the meansby admission hospital outcome may have signifi-

cant downsides in long-term follow-up studies. The to craft future studies and to critically appraise animportant and growing literature [13].studies reviewed here do not address how intensiv-

ists employ the array of care facilities available tothem. Of interest, other reports have demonstratedan awareness and implementation of withholding Referencesand withdrawing care from the hopelessly ill byintensivists that has grown over time [9]. It is con- 1. Hanson CW, Aranda M. Impact of intensivists and ICU teamsceivable that the reorganization of critical care on patient outcomes. J Intensive Care Med 1999;14:254–261

2. Hall JB. Advertisements for ourselves—let’s be cautious in-services by intensivists may more effectively imple-

Hall: Organization of Critical Care Services 253

terpreting outcomes studies of critical care services [edito- long-term acute care: an analysis of 133 mechanically venti-lated patients. Am J Resp Crit Care Med 1999;159:1568–1573rial]. Crit Care Med 1999;27:229–230

3. Ely EW, Bennett PA, Bowton DL, et al. Large scale implemen- 9. Prendergast TJ, Luce JM. Increasing incidence of withhold-tation of a respiratory therapist-driven protocol for ventilator ing and withdrawing of life support from the critically ill.weaning. Am J Resp Crit Care Med 1999;159:439–446 Am J Resp Crit Care Med 1997;155:15–20

4. Pittet D, Tarara D, Wenzel RP. Nosocomial bloodstream in- 10. Davidson TA, Caldwell ES, Curtis JR, et al. Reduced qualityfection in critically ill patients. Excess length of stay, extra of life in survivors of acute respiratory distress syndromecosts, and attributable mortality. JAMA 1994;271:1598–1601 compared with critically ill control patients. JAMA 1999; 281:

5. Pronovost P, Jenckes M, Dorman T, et al. Organizational 354–360characteristics of intensive care units related to outcomes 11. Short TG, Buckley TA, Rowbottom MY, et al. Long-termof abdominal aortic surgery. JAMA 1999;281:1310–1317 outcome and functional health status following intensive

6. Hanson CW, Deutschman CS, Anderson HL, et al. The effect care in Hong Kong. Crit Care Med 1999;27:51–57of an organized critical care service on outcomes and re- 12. Donohoe MT. Comparing generalist and specialty care dis-source utilization: a cohort study. Crit Care Med 1999;27: crepancies, deficiencies, and excesses. Arch Intern Med270–274 1998;158:1596–1608

7. Carson SS, Stocking C, Podsadecki T, et al. Effects of an 13. Curtis JR, Rubenfeld GD, Hudson LD. Training pulmonaryorganizational change in the medical intensive care unit and critical care physicians in outcomes research: shouldof a teaching hospital: comparison of ‘open’ and ‘closed’ we take the challenge? Am J Respir Crit Care Med 1998;157:formats. JAMA 1996;276:322–328 1012–1015

8. Carson SS, Bach PB, Brzozowski L, et al. Outcomes after