Critical Care Models
Intensive care units may be managed as “open” or “closed” units. In an “open” unit, the patient’s primary medical practitioner (e.g. surgeon, physician, obstetrician) is primarily responsible for the decision to admit the patient to ICU and for the patient’s ongoing management in the ICU. In a “closed” unit, the ICU is run by an intensive care doctor (or team of doctors) who makes the decis
Intensive care units may be managed as “open” or “closed” units.
In an “open” unit, the patient’s primary medical practitioner (e.g. surgeon, physician, obstetrician) is primarily responsible for the decision to admit the patient to ICU and for the patient’s ongoing management in the ICU.
In a “closed” unit, the ICU is run by an intensive care doctor (or team of doctors) who makes the decision on which patients to admit to ICU and is primarily responsible for the patient’s care while in ICU. Input may be sought from other doctors (including the primary referring physician) but the ICU doctor remains primarily responsible for treatment decisions relevant to ICU care and ensures that decisions made by members of the multidisciplinary team are consistent with the overall goals of care for the particular patient.
Intensive care doctors may be “intensivists” or “non-intensivists”.
An intensivist is a medical practitioner with a recognised specialist qualification in critical care medicine. In South Africa, an intensivist is a specialist who has completed subspecialist training in critical care in the form of a certificate in critical care and is registered as a subspecialist in critical care with the Health Professions Council of South Africa (HPCSA).
Non-intensivists refer to other medical practitioners who do not have a formal specialist qualification in critical care medicine. This may include specialists from other disciplines who have received formal critical care training as part of their specialist training but may also include practitioners with no formal intensive care training.
Hybrid models also exist. There are numerous possible permutations. These include open models with optional intensivist consultation and open models with mandatory intensivist consultation. They also include “semi-closed” models where some beds in an ICU are “closed” beds and some beds are “open” beds or where the ICU operates as a closed unit during certain hours but (usually due to staffing constraints) functions as an open unit at other times.
As intensive care has become increasingly specialised, the limitations of open ICUs and part-time intensive care doctors have become apparent. Evidence suggests that closed ICUs and treatment directed by intensivists leads to improved clinical outcomes, administrative functioning, and resource utilisation.
A closed, intensivist-managed ICU is thus optimal. In addition, this ICU should have 24-hour on-site non-intensivist medical staff whose only clinical duties are to ICU. Intensivists whose only clinical duties are to ICU should be on site during the day and should provide after-hours offsite support to the resident doctors telephonically and be available to attend on site if required. This optimal model is often not possible due to inadequate numbers of trained intensivists, lack of career-pathing or administrative support for non-intensivist doctors dedicated to ICU, and concerns about funding models and the perceived cost of this model. Cost savings from this model may be significant though, and include reduced inappropriate resource utilisation, reduced costs from consultation from other specialties, reduced costs from a lower incidence of nosocomial infections, among others (6-17).
Intensive care units may also be “multidisciplinary” or “specialised” units. Specialised units may include trauma, coronary care, cardiothoracic, neurosurgical, surgical, burns, pulmonary, transplant and numerous other units. In general, there is little evidence to support the use of specialised over multidisciplinary units or vice versa. Paediatric intensive care units are the exception, and dedicated paediatric units are preferable to multidisciplinary combined paediatric and adult units.
Critical Care Society of Southern Africa Guidelines for the Provision of Critical Care Services in South Africa - Critical Care Society of Southern Africa - Version 1: July 2022