Open versus Closed ICUs

Intensive care units come in weird flavors. The patients admitted to a medical-surgical unit can be pretty diverse. Some are post-operative from large liver resections or bypass procedures or neurosurgery. Some are COPD exacerbations or heart failure or metastatic cancer. The diversity and breadth of cases can be overwhelming, and it's compounded by the fact that every patient is sick. The best doctor for each patient might be different. Shouldn't surgeons handle the post-operative patients? Shouldn't medicine handle the heart attacks?

ICUs have struggled with this dilemma since they were developed. In an "open" ICU, when a patient is transferred into the unit, he has two primary teams that write orders: the team that transferred him up and the ICU team. Thus, a patient who has a valve replacement can have medications prescribed by both the cardiothoracic surgeons and the intensivist. At the other end of the spectrum, a "closed" ICU means that when a patient is transferred to the unit, all the care and responsibility for that patient is transferred to the intensivist. When the patient leaves, then the care and responsibility is transferred back. In this model, if the intensivist needs help from the surgeon or cardiologist, he consults them for recommendations. The strength of this model is that there is less room for confusion or miscommunication between multiple providers.

The truth is most ICUs are some hybrid or combination of these two. Here at the Palo Alto VA, medical patients are exclusively handled by the ICU (thus a "closed model"); we write the admission orders, decide the plan, and have the clinical responsibility for the patient. Surgical patients are "comanaged"; both the surgical and the intensivist teams write orders, and ideally, we communicate so that we do this in sync.

Unfortunately, this doesn't always happen. We don't round in conjunction with the surgeons and the plan they decide occasionally conflicts with the plan we decide. Sometimes when patients are complex and haven't been fully deciphered, we run into the problem of too many cooks in the kitchen. This is not uncommon in medicine; I've had many patients in which consulting services disagree. However, it can sometimes make life in the ICU difficult.

I actually prefer the system we had in the surgical unit at San Francisco General Hospital. There, patients are comanaged as well, but the boundaries are clearly delineated; the intensivist makes the plan with regards to the ventilator, sedation, and access. For everything else, they are a consulting service. If we write an order to start aspirin, we have to be cleared by the primary surgical team to do so. This has its complications as well; the ICU team is at the bedside 24/7 and when an emergency happens, we may have to start medications that are out of our scope before we can get approval from the primary service. However, the clarity of each team's responsibilities helped define each patient's goals for the day.

In the end, I'm not sure how best to organize an ICU. Somehow, we must encompass a multidisciplinary group of specialists to care for these complex patients. But we also must designate roles, whether a single primary caregiver or a well-delineated team approach to prevent us from stepping on each other's toes.