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open ICU

Discussion in 'Internal Medicine and IM Subspecialties' started by Roadrunner, Jun 5, 2008.

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  2. RTrain

    RTrain National Merit Finalist 2+ Year Member

    Aug 18, 2007
    On first pass, it seems totally invalid. The way open ICU's work, in my experience, is that when the ER or a ward team feels that a patient needs ICU care, they make an "ICU consult." If the ICU resident thinks that a patient doesn't merit ICU care, they'll turn the patient down. At that point, the ward team (or hospitalist) is free to admit the patient to the ICU under their own care, without an intensivist. Of course, the ICU resident has a vested interest in keeping as many patients off his or her service as possible, so there's a high degree of motivation to block ICU transfers - only the very sickest patients make the cut. Patients who are intubated, on pressors, obvious multi-organ failure - they always got the nod, and they clearly have a higher mortality than a COPD'er who just needs a night on NIPPV.

    The article tried to control for this, but they mention right in the abstract that there could be unrecognized confounders of that nature that could invalidate the results. I think all that study does is confirm two obvious truths: 1) intensivists take care of sick patients, and 2) sick patients frequently die.
  3. orientedtoself

    orientedtoself resident 5+ Year Member

    Oct 14, 2005
    yes, but the results of this article challenge the standard belief that intensivists take better care of icu patients than general internists. sure, maybe they didn't control enough for the severity. but what if they did? why are the patients dying?
  4. Soundwave

    Soundwave Decepticon 2+ Year Member

    Aug 26, 2007
    because more is usually not better in medicine. the more procedures you get, the more complications you will have, the more things that they will find that need further work-up, it turns into a mess pretty easily. I didn't read that article carefully (no interest in these retrospective "controlled" papers), but I wouldn't be surprised if the intensivists were more aggressive about withdrawing support in patients. If you see a lot of ICU patients and know that 90% don't survie some condition, you are probably more likely to tell some family member to withdraw support then if you haven't just come off taking care of the last 9 of 10 patients that died with tht condition. I've noticed that, there is a lot of last patient biasesness in medicine where you assume your patient is going to do as poorly as your last patient did even when the evidence may not support it.
  5. elwademd

    elwademd 2+ Year Member

    Jun 24, 2007
    it seems that the study is just too broad, as there are likely way too many differences between icu's, and what is considered an "icu patient". my hospital is an open icu, and we see what i consider to be really sick patients. however, both my grandparents have been in the icu (in other hospitals), and i think i would have had either of my grandparents in a step down unit/dou or telemetry.

    some patients go to icu as a part of a protocol, eg. s/p spinal fusion, drug overdose regardless of drug ingested, dka, stemi s/p stent... those patients are likely to do well, and probably don't derive any benefit from having a full time intensivist on board. do these type of patients, as alluded to by rtrain, get refused, and then fall into the non-intensivist arm? i assume they do.

    on the other hand, the 90 year old nursing home patient who is demented, contracted, chronic indwelling foley with cough, dirty urine, bp of 70, o2 sat of 60% on non rebreather... we know an intensivist is likely to be involved, and we know the chance of mortality is high?

    also, as the authors of the article pointed out, they looked at in hospital mortality, not 30 day mortality. it'd be interesting to know what the 30 day mortality is/was.

    i'd be intersted to hear the view of any pulmonary/critical care medicine fellows or attendings we might have here on sdn on this article.
  6. HomerSD

    HomerSD 2+ Year Member

    Feb 4, 2008
    San Diego
    Interesting study, but clearly has some issues. The critical care cohort of patients was much sicker than the non-critical care physician group. They attempted to control for disease severity by stratifying for SAP and propensity scores, but it's not at all clear that this is sufficient to control completely for the higher acuity of the critical care cohort. The discussion goes into a number of other potential confounders, including lead time bias.

    I think the paper is best viewed as a discussion point about what ideal care is in the ICU (particularly with which protocols and procedures should be instituted), rather than as evidence that intensivist's are not needed with critical care patients.
  7. Hernandez

    Hernandez Paranoid and Crotchety... Physician 10+ Year Member

    That was my first thought as well, I'll read it more in-depth later.
  8. orientedtoself

    orientedtoself resident 5+ Year Member

    Oct 14, 2005
    i doubt there would be this kind of debate and skepticism if the study showed improved mortality with intensivists. i think we all believe that intensivists are better at taking care of icu patients. in the article they cited several articles that had shown improved mortality with intensivist care. we have closed icu's at most of the hospitals here. this article goes against something most of us believe, and it's harder to accept. however, i think it's important to recognize one's own biases and view the data objectively.
  9. Boz Bozeman

    Boz Bozeman

    Dec 4, 2007
    My take-home point from this article is that papers about critical care medicine are really difficult from a technical perpective. Honestly, I would have been shocked if this paper did show a statistical mortality benefit regarding the type of physician that cares for the critically ill, because, for all intents and purposes, no studies about critical care show a mortality benefit. If I recall correctly, the papers that led to the implementation of the "venilator bundle," like those for GI prophylaxis, raising the head of the bed, daily sedation vacations, etc, some of the papers that have influenced practice of ICU medicine the most in the past decade, did not show a mortality benefit. Mostly they showed decreased days on a ventilator and decreased days in the ICU. In addition to the points mentioned above, the numbers required to sufficiently power these studies and the marginal benefit of these maneuvers makes it really hard to do such a study well.
  10. elwademd

    elwademd 2+ Year Member

    Jun 24, 2007
    here's an interesting take on this article from dr. bob wachter:


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