American Surgical Association
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The Impact of an Intensivist Model ICU on Trauma-Related Mortality
Avery B. Nathens, MD MPH*, Frederick P. Rivara, MD MPH*, Ellen J. MacKenzie, PhD*, Daniel Scharfstein, MD*, Ronald V. Maier, MD, Jin Wang, PhD*, Gregory J. Jurkovich, MD
University of Washington, Seattle, WA, University of Washington, Seattle, WA

The “Closed” ICU Improves Survival Following Severe Injury
Objective: The closed (intensivist) model of ICU care has not been widely adopted in US trauma centers (TC), likely due to the absence of evidence supporting this approach in trauma care and a shortage of surgeon intensivists. To better inform best practices, we determined the effect of the process of critical care delivery on trauma-related mortality.
Methods: We used data derived from the National Study for Cost & Outcomes in Trauma Care (NEJM, In press), a prospective study of 14,489 adult trauma patients (AIS>3) admitted to 18 Level 1 and 51 high volume non-designated centers across the US. Analyses were limited to 6,790 patients admitted to an ICU. ICU’s were classified as “closed” if patients were on a distinct ICU service or co-managed with an intensivist. Propensity analysis was used to adjust for differences in case mix and TC status. Data are presented as relative risk (RR) for in-hospital mortality.
Results: Only 38 (55.1%) centers had closed ICU’s. Crude mortality was lower (p<0.0001) in closed vs open ICU’s (table). With risk adjustment, the RR for death among all ages favored closed ICU’s [0.78 (0.58-1.04)]. There was marked benefit in the elderly.
Sample sizeMortalityAdjusted RR (95% CI) for death
Open (n=1,553)13.9 (%)11
Closed (n=5, 237)10.1 (%)1.08 (0.78-1.49)0.55 (0.39-0.77)

Conclusion: Closed ICU’s offer substantial mortality benefit, an effect most evident in the elderly. We postulate that this model provides closer attention to management of coexistent diseases in a population with little physiologic reserve. Adoption of a closed model of critical care delivery should be considered as part of TC verification criteria.

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