ABSTRACT
We conducted this retrospective, cohort study to evaluate the quality of patient care and procedure use in the medical intensive care unit (MICU) following reorganisation and staffing by an intensivist. Consecutive admissions to an adult MICU in a university affiliated hospital during two 3-month periods, August to October 1993 (Period 1, n = 112) and January to March 1994 (Period 2, n = 127) were analysed.
In Period 1, the MICU was run under the open system in which patient care was provided by the individual attending physicians. In Period 2, a resident MICU team led by a trained intensivist took over the medical care from the primary physicians when the patients were admitted to the MICU. The intensivist also vetted MICU admissions and decided on MICU discharge. In addition, there was a resident respiratory therapist to attend to ventilatory care during office hours. After office hours, the care of the MICU was delegated to the on-call team on a rotational basis among the medical departments. This was the semi-closed ICU model. The patients in the two periods were similar with respect to age, sex, race, source of admission and APACHE II scores. There was improvement in the median ICU length of stay for survivors from 3 days in Period 1, to 2 days in Period 2 (P = 0.0114). The relative risk of ICU death in Period 1 compared to Period 2 was 1.23 (P = 0.286). There was no significant difference in the use of peritoneal dialysis (5.4% versus 6.3%) and mechanical ventilation (55.4% versus 49.6%). However, utilisation of intra-arterial lines and pulmonary artery catheters increased from 0% in both Periods 1 and 2 to 23.6% and 5.5%, respectively. Reorganisation of the MICU in Period 2 resulted in reduced length of MICU stay for survivors. Hence, we believe that coverage by a dedicated ICU team and active respiratory care by a respiratory therapist during office hours were beneficial for the care of the critically ill. There was also a noticeable increase in the use of invasive monitoring.Critical care is costly as it is labour intensive and involves expensive life support technology. In the United States, the intensive care units (ICUs) use about 15% of the total hospital cost or about 1% of the gross national product.
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