Dani Hackner

Do faculty intensivists have better outcomes when caring for patients directly in a closed ICU versus consulting in an open ICU

Abstract Background:Intensivists have been associated with decreased mortality in several studies, but in one major study, centers with intensivist-staffed units reported increased mortality compared with controls. We hypothesized that a closed unit, in which a unit-based intensivist directly provides and coordinates care on all cases, has improved mortality and utilization compared with an open unit, in which individual attendings and consultants provide care, while intensivists serve as supervising consultants. Methods: We undertook the retrospective study of outcomes in 2 intensive care units (ICUs)—a traditional open unit managed by faculty intensivists and a second closed unit overseen by the same faculty intensivists who coordinated the care on all patients in a large community hospital. Primary Outcome: In-hospital mortality. Secondary Outcomes: Hospital length of stay (LOS), ICU LOS, and relative costs of hospitalization. Results: From January 2006 to December 2007, we identified 2602 consecutive admissions to the 2 medical ICUs. Of all patients admitted to the closed and open units, 19.2% and 24.7%, respectively, did not survive (P < 0.001, adjusted for severity). Median hospital LOS was 10 days for the closed unit and 12 days for the open unit (P < 0.001). Median ICU LOS was 2.2 days for the closed unit and 2.4 days for the open unit (P = NS). The unadjusted cost index for the open unit was 1.11 relative to the closed unit (1.0) (P < 0.001). However, after adjusting for disease severity, cost differences were not significantly different. Conclusions: We observed significant reductions in mortality and hospital LOS for patients initially admitted to a closed ICU versus an open unit. We did not observe a significant difference in ICU LOS or total cost after adjustment for severity.

Critical Conversations When the Bedside Clinician Calls for Clinical Ethics

VignetteBackground: Sharon is a 56-year-old woman who has been complaining of bloating and discomfort for years. While descending steps from her hillside home, she recently fell and fractured her pelvis. A CT of the pelvis revealed a large ovarian mass with smaller masses in the peritoneum, and studies of the chest and upper abdomen revealed masses in the liver and lung. A recent biopsy confirmed poorly differentiated cells. She was diagnosed with metastatic ovarian carcinoma and managed conservatively for the pelvic fracture. Until last month Sharon ran a preschool, but she has been homebound for weeks.Presentation: Now, a month after the fracture, Sharon has developed increasing shortness of breath and has been admitted to the hospital with fever and pulmonary infiltrates bilaterally. She appears weak and delirious and has a raspy cough and signs on examination of extensive lung consolidation. She has lost a substantial amount of weight since last month. She is receiving high-flow oxygen 100% in the ICU...

A Primer: Staffing the ICU for Performance, Part 2—Refining the Process With Staff

In this the second part of a 2-part ICU staffing series, we enjoin the reader to enter the multidisciplinary discussion over the broad issue of ICU staffing. Part 1 (vol. 1 no. 2, March 2010) empha...

Clinical Ethics in the ICU: A Case of Attempted Suicide

Vignette: A 57-year-old man was brought into the emergency department by paramedics for altered mental status. He was noted to be in his usual state of health the morning of the event when he became confused, vomited, and was observed to fall on the floor without trauma to the head. His baseline health was notable for diabetes mellitus, schizoaffective disorder, history of one prior hospitalization in 2009 for lithium toxicity, hyperlipidemia, and genital herpes. The patient’s wife, at bedside, denied that he used tobacco, alcohol, or street drugs. Living with him in the community, his wife indicated that the patient had a progressive brain disease and possibly early dementia, but she denied any impairment of activities of daily living.The spouse brought to the hospital a signed living will requesting no extraordinary measures in case of a coma with little hope of recovery. His “living will” also specified that he would refuse mechanical ventilation or tube feeding even for reversible conditions. The pati...

A Primer Staffing the ICU for Performance

In this 2-part article, we hope to join the reader in the broader discussion over ICU staffing. From the perspective of the clinician, we provide references to central concepts and landmark studies identifying organizational elements linked to patient outcomes. From the perspective of the unit management, we provide access to the literature on clinician interaction and organizational ethics. From the human resources (HR) literature, we provide relevant principles, standard practices, and concerns that should alert clinicians to seek HR and risk management consultation. In Part 1, we introduce many of the concepts relevant to staffing, hiring, and orienting teams toward performance. In Part 2, we explore management and business models as well as unit operations in relation to staff interests and concerns. The primer encourages managers and directors as well as clinicians and support staff to take a mindful stroll through each others’ concerns and published literature.

Critical Conversations Prolonged Mechanical Ventilation

Case:Mrs. Smith is an 85-year-old woman with longstanding chronic kidney disease (NKF Stage 5, <15 mL per 1.73 m2) who has been on hemodialysis for the past year. She is admitted to the intensive care unit from the community with acute respiratory distress syndrome. Her comorbidities include diabetes and hypertension (JNC7 Hypertension, Stage 2). The patient receives empiric treatment for health-care-associated pneumonia but remains ventilator dependent and on a high FIO2 after 2 weeks. The patient is off vasopressors.