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Drs. Azocar and Lisbon are affiliated with the Department of Anesthesia and Critical Care, Beth Israel Deaconess Medical Center, and with Harvard Medical School.
Correspondence to: Alan Lisbon, MD, FCCP, Chief, Division of Critical Care, Department of Anesthesia and Critical Care, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA 02215; e-mail: alisbon{at}caregroup.harvard.edu
By the middle of the last century, new therapeutic modalities in both medicine and surgery allowed patients who would have otherwise died to survive their diseases. These patients often needed more intense care than that provided on the wards of hospitals. In various medical centers, specialized units opened to care for these critically ill patients. The close monitoring of physiologic variables was possible with advances in technology, and the ratio of nurses to patients was increased. Critical care medicine was born.
Controversy exists regarding who should take responsibility for the care of the critically ill patients. Traditionally, in the United States, the attending physician with the aid of consultants (ie, intensivists and other specialists) have managed critically ill patients.1 In a large analysis published in 1992,2 only 22% of the ICUs in the United States were considered "closed" (ie, only the unit staff could write orders).
The arguments against ICUs being run by intensivists include the following: the relative youth of the specialty; the different training backgrounds and certification systems (eg, internists, surgeons, anesthesiologists, and pediatricians); and conflicts regarding patient management, reimbursement for care while the patient is in the ICU, and elevated costs in the ICUs.3 Unfortunately, most of the resistance comes from fellow health-care practitioners, who simply disagree that the trained, practiced, and committed critical care physician is the best physician to treat critically ill patients.4 5
Despite furious opposition by some,5 there is clear evidence that ICUs in which a physician or a team of physicians provides 24-h coverage have better clinical outcomes, better resource utilization, and enhanced teaching for housestaff, nurses, and associate health-care workers than those ICUs that do not.
An emerging body of data recently has arisen showing the benefits of having intensivists run ICUs. Much of this data has been collected in institutions that move from an open system to a system in which an intensivist provides coverage 24 h a day. This change has allowed the unique opportunity to compare the two systems during similar time periods, eliminating technologic or therapeutic variability.
Many of the studies were performed in medical ICUs. Brown and Sullivan6 reported a 52% reduction in mortality when comparing patients with equivalent APACHE (acute physiology and chronic health evaluation) II scores in 2 consecutive years. The primary attending physician treated the first group (mortality rate, 27.8%), and the second group was cared for by an intensivist in cooperation with the primary physician (mortality rate, 13.4%).6 Similar results were achieved in a study7 looking at the impact of critical care staffing on patients with septic shock. Despite similar APACHE scores, mortality was significantly lower after the introduction of physicians with critical care training. The authors also noted a decrease in nonsurvivors’ charges from 62 to 49%, probably reflecting a better resource utilization in hopelessly ill patients.
Carlson et al8 reported results after a change from an open ICU, in which the primary care physician was in charge of the patient and the intensivist acted as consultant, to a closed ICU, in which critical care physicians directed the patient care. Despite higher APACHE II scores in the group treated in the closed system, improvement in clinical outcome was demonstrated by a lower ratio of actual to predicted mortalities. Although the housestaff indicated that they were busier in the closed system, they had higher levels of comfort in managing critically ill patients. Nurses, who provide most of the care for these patients, had a higher level of confidence in the intensivists when compared with the primary care physicians.
The introduction of a full-time director of critical care in a medical ICU of a community teaching hospital also resulted in a decrease in the overall mortality rate (from 20.9 to 14.9%).9 In this study, a detailed analysis of patients with pneumonia showed a reduction in the mortality rate from 46 to 31%. From an educational standpoint, residents improved their scores in the critical care in-training examination after the addition of the intensivist. Other studies10 11 have demonstrated reductions in the number of days patients require ventilators and in the length of stays in the ICU without compromising survival. Such reductions have substantial economic impact in terms of ICU and hospital costs.
The pediatric literature also has provided similar evidence. Pollack et al12 reported a higher illness-adjusted ICU mortality rate in the preintensivist period. Lower intensity admissions and admissions for "monitoring" decreased, indicating a better utilization of the ICU technology and personnel. Pediatric ICUs in which a pediatric critical care program was present were generally associated with a better risk-adjusted mortality rate than those units without such fellowships.13
The most recent data come from surgical ICUs (SICUs). Ghorra et al14 found that the conversion of an SICU from a closed to an open format resulted in a lower mortality rate (14.4% vs 6.04%, respectively). The authors also noted a decrease in the incidence of acute renal failure (12.8% vs 2.6%, respectively) and in the number of consults (0.6 vs 0.4, respectively, per patient). A decrease in the number of subspecialty consults also was noted in a study by Popovich et al,15 suggesting that intensivists are capable of treating most problems affecting SICU patients.16 A recent article17 suggests that the management of acute renal failure by intensivists is as safe and efficient as it is when nephrologists are consulted. In another study, the absence of an ICU physician in the care of patients undergoing abdominal aortic surgery was associated with a threefold increase in in-hospital mortality. A significantly increased risk of cardiac arrest, renal failure, septicemia, platelet transfusion, and reintubation also was noted.18
Hanson et al1 compared two cohorts of patients admitted to an SICU during the same period of time. The study cohort was cared for by an on-site critical care team that was supervised by an intensivist. The control cohort was cared for by a team with patient-care responsibilities in multiple sites that was supervised by a general surgeon. Despite the fact that the study cohort group had higher APACHE II scores, they spent less time in the SICU, used fewer resources, had fewer complications, and had lower total hospital charges. As the APACHE score worsened, the differences became more significant.
The reason for these findings seems obvious. Critically ill patients are prone to rapid and dramatic changes in status. These changes necessitate constant monitoring, and immediate and appropriate therapy. In an open system, a physician with no formal training in critical care medicine, who may also have clinic, ward, and operating room responsibilities, takes care of the patient. When management problems are noted, sometimes with significant delays, they often are referred to a consultant.16 When a 24-h intensivist is present, the problems are detected and treated in a more efficient and timely fashion. Structured morning bedside rounds allow the planning of strategic decisions for the day, and evening rounds allow a review of the data and the results of the plan. A more standard and scientifically based education program can be provided to the housestaff, nurses, and other caregivers who participate in the care of these patients. The development of protocols for care and more efficient bed control helps to minimize costs. The intensivist also may facilitate decisions regarding the futility of care and the withholding/withdrawing of care.
It can be argued that as intensivists, our opinion is biased toward having critical care physicians manage all ICUs. However, we are not alone in our plea. A group of corporations (including Delta Airlines, General Motors, AT&T, IBM, Xerox, etc) has created a consortium called the Leapfrog Group. This consortium focuses on developing new cost-effective health-benefit policies. Among their recommendations is a health-care specification that requires a high-intensity physician-staffing model. The Leapfrog Group wants ICUs to be staffed with doctors who have credentials in critical care medicine.19 20
Our specialty has grown strong and large thanks to a large body of literature that has been produced in both the basic science and clinical arenas. This knowledge allows us to have a unique understanding of the disease processes that affect our patients and to apply an evidence-based approach in our daily practice. We do not wish to eliminate primary care physicians from the care of their patients. Their input and long-term relationship with the patient and family are very important in care. However, when a ship encounters a bad storm, a captain versed in navigating through difficult waters should be in charge. While in the ICU, the patient deserves a physician trained in critical care medicine.
References
This article has been cited by other articles:
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  L. A. Hoffman, M. B. Happ, C. Scharfenberg, D. DiVirgilio-Thomas, and F. J. Tasota Perceptions of Physicians, Nurses, and Respiratory Therapists About the Role of Acute Care Nurse Practitioners Am. J. Crit. Care., November 1, 2004; 13(6): 480 - 488. [Abstract] [Full Text] [PDF]
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 P. E. Marik and M. Weinman Captain of the Ship Chest, April 1, 2002; 121(4): 1382 - 1382. [Full Text] [PDF]
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