Published ahead of print on June 7, 2007, doi:10.1164/rccm.200701-165OC Am. J. Respir. Crit. Care Med., Volume 176, Number 7, October 2007, 685-690 A more recent version of this article appeared on October 1, 2007
Submitted on January 31, 2007 Effect of ICU Organizational Model and Structure on Outcomes in Patients with Acute Lung InjuryMiriam M Treggiari1*,1 Department of Anesthesiology, University of Washington, Seattle, WA, USA, 2 Department of Health Services, University of Washington, Seattle, WA, USA, 3 Department of Biostatistics, University of Washington, Seattle, WA, USA, 4 Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington, Seattle, WA, USA * To whom correspondence should be addressed. E-mail: treggmm{at}u.washington.edu.
Rationale: Prior studies supported an association between ICU organizational model or staffing patterns and outcome in critically ill patients. Objective: To examine the association of closed versus open models with patient mortality across adult ICUs in King County (WA). Methods: Cohort study of patients with acute lung injury (ALI). Measurements and Main Results: ICU structure, organization, and patient care practices were assessed using self-administered mail questionnaires completed by the medical director and nurse manager. We defined closed ICUs as units that required patient transfer to or mandatory patient comanagement by an intensivist and open ICUs as those relying on other organizational models. Outcomes were obtained from the King County Lung Injury Project, a population based cohort of ALI patients. The main endpoint was hospital mortality. Of 24 eligible ICUs, 13 ICUs were designated closed and 11 open. Complete survey data were available for 23 (96%) ICUs. Higher physician and nurse availability was reported in closed than open ICUs. 684/1,075 (63%) of ALI patients were cared for in closed ICUs. After adjusting for potential confounders, ALI patients cared for in closed ICUs had reduced hospital mortality (adjusted OR 0.68, 95%CI: 0.53,.89, P=0.004). Consultation by a pulmonologist in open ICUs was not associated with improved mortality (adjusted OR 0.94, 95%CI: 0.74, 1.20, P=0.62). These findings were robust for varying assumptions about the study population definition. Conclusions: ALI patients cared for in a closed model ICU have reduced mortality. These data support recommendations to implement structured intensive care in the United States. Key words: Intensive Care Unit, Intensivist, Outcome, Practice patterns, Leapfrog Group
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