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 »  Brief History of...
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 »  Types of Intensi...
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 »  Critical Care Wi...
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 »  Evidence in the ...
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Table of Contents    
REVIEW ARTICLE
Year : 2017  |  Volume : 65  |  Issue : 1  |  Page : 39-45

Intensive care unit models: Do you want them to be open or closed? A critical review


Department of Neurology, GB Pant Institute of Post Graduate Medical Education and Research, New Delhi, India

Date of Web Publication12-Jan-2017

Correspondence Address:
Debashish Chowdhury
Department of Neurology, Room No 508, Academic Block, GB Pant Institute of Post Graduate Medical Education and Research, JN Nehru Marg, New Delhi - 110 002
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.198205

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 » Abstract 

Intensive care is a specialized branch of medicine dealing with the diagnosis, management, and follow up of critically ill or critically injured patients. It requires input from other branches of medicine on various issues. A critical care specialist has expertise in managing such patients round the clock. Based on his freedom to take decisions in the intensive care unit (ICU), different types of ICUs – open, closed, or semi-closed – have been defined. There is no doubt that all critical patients should be evaluated by an intensivist. Therefore, it is argued that a closed ICU model would be the ideal model. However, this may not always be feasible and other models may be more useful in resource-limited countries. In this review, we compare the different formats of ICU functioning and their suitability in different hospitals.


Keywords: Closed ICU, hospital stay, intensive care unit, mortality, open ICU, semi-closed ICU
Key Messages:

  • Neurocritical care is a highly-specialized field but there is a paucity of neurocritical care specialists
  • A closed ICU mode headed by an intensivist may be ideal but not cost - effective especially in a country like India
  • A semi-closed ICU with appropriate well-written protocols and a good nurse-patient ratio could be the solution to the reduction in mortality rates and the reduction in the duration of hospital stay so that the ICUs are utilized in a cost - effective manner.


How to cite this article:
Chowdhury D, Duggal AK. Intensive care unit models: Do you want them to be open or closed? A critical review. Neurol India 2017;65:39-45

How to cite this URL:
Chowdhury D, Duggal AK. Intensive care unit models: Do you want them to be open or closed? A critical review. Neurol India [serial online] 2017 [cited 2017 Mar 30];65:39-45. Available from: http://www.neurologyindia.com/text.asp?2017/65/1/39/198205


Over the past few years, there has been a tremendous advancement in the knowledge, technology, and skills required to treat critically ill patients. An intensive care unit (ICU)[1] is a highly specified and sophisticated area of the hospital, which is specifically designed, staffed, located, furnished, equipped, and dedicated to the management of critically ill patients with serious injuries or complications. The emergence of critical care as a distinct speciality and an increase in the number of doctors being trained in critical care medicine has resulted in a change in the staffing and organizational model of ICU. This has also started a tug-of-war between physicians and intensivists over the care of ICU patients. In the present article, we discuss the pros and cons of various organizational structures of ICUs.


 » Brief History of Critical Care Medicine and Intensive Care Unit Top


Early beginning

Perhaps the earliest use of critical care protocol to treat patients was made by Florence Nightingale during the Crimean War in the 1850s.[2] She triaged wounded soldiers depending on the severity of their injuries and monitored the sickest soldiers more regularly. This resulted in a sharp decline in the mortality rate. In 1926, the pioneer neurosurgeon, Walter Dandy, established the world's first hospital ICU in Boston with just 3 beds.[3] The field of critical care medicine then took a giant leap in the 1950s during the poliomyelitis outbreak in Denmark.[4] Bjorn Ibsen, an anesthetist, suggested that the polio afflicted patients could be supported through their illness by inserting a tracheostomy tube, manually clearing their secretions, and ventilating them with an oxygen/nitrogen mixer using positive pressure, which resulted in a reduction in mortality from polio from 80% to 25%.[5] Ibsen went on to open the first ICU in 1953, which was replicated around the world, and the branch of critical care medicine was established. In 1958, Dr Max Harry Weil and Dr Hebert Shubin opened a 4-bedded shock ward in Los Angeles County – University of Southern California Medical Center, Los Angeles, USA, to improve the recognition and treatment of serious complications in critically ill patients.[6]

Indian scenario

The first ICU in India was actually a coronary care unit, started in 1968 at the King Edward VII Memorial Hospital, Mumbai, followed by another one at the Breach Candy Hospital.[7] Since then, intensive care has grown into a specialty in its own right.

Rapid growth

Today, the ICUs comprise up to 10% of all hospital beds and consume as much as 25–30% of hospital resources.[8] In India, critical care beds account for 5–8% of the total bed strength in large public teaching hospitals.[7]


 » Changes in Organizational Structure of Intensive Care Units Top


There has been a debate on the role of “intensivists” in the management of critically ill patients and their impact on patient outcomes. Many of the initial critical care units were staffed by physicians whose primary specialties were anesthesiology or internal medicine.[6] Over the past few years, critical care medicine has become a full subspecialty and can no longer be regarded just as a part of anaesthesia, medicine, surgery, or any other speciality. The understanding of physiology in critically ill patients and evidence-based practice is essential in the management of ICU patients. In the ICU, the 9 physiological systems that are monitored include the cardiovascular, central nervous, endocrine, gastrointestinal/nutrition, hematology, microbiology/sepsis, periphery/skin, renal/metabolic, and respiratory systems. An intensivist is usually a physican trained to do this and has undergone primary training in medicine, surgery, anesthesiology, or pediatrics followed by 2–3 years of critical care medicine training.[9] In India, according to the Indian Society of Critical Care Medicine (ISCCM),[10] an intensivist should have a postgraduate qualification in internal medicine, anesthesia, pulmonary medicine, or surgery and either an additional qualification in intensive care, or at least an year training in a reputed ICU abroad.


 » Types of Intensive Care Unit Models Top


Based on the extent of involvement and supervision by critical care physicians, ICUs function on 6 different models.

Open intensive care unit model

This is an ICU in which patients are admitted under the care of an internist, family physician, surgeon, or any other primary attending physician, with the intensivists being available to provide their expertise via elective consultation.[9] Intensivists may play a de facto primary role in the management of some patients, but only within the discretion of the admitting physician, and have no overreaching authority over patient care. The patient's primary physician determines the need for ICU admission and discharge. Although the primary physician may have less expertise in critical care medicine, it is argued that his long relationship with the patient may provide improved patient care and a greater satisfaction. However, the downside is greater variability in practice patterns. Single-organ specialists may not be aware of the overall management plan, resulting in potentially unnecessary or conflicting orders and increased expenses.

Closed intensive care unit model

In a closed model ICU, all patients admitted to the ICU are cared for by an intensivist-led team that is responsible for making clinical decisions.[11] The admissions and discharges are controlled by an on-site ICU physician in most closed ICU models. Because most ICU patients have similar problems, regardless of the reason for their critical illness, it is believed that management by a team of specially qualified intensive care physicians and nurses provides patients with better care and is associated with improved outcomes with a more efficient use of ICU resources.

Intensivist co-management

This involves an open ICU model in which all patients receive mandatory consultation from an intensivist.[11] The internist, family physician, or surgeon remains a co-attending-of-record with the intensivists collaborating in the management of all ICU patients.

Hybrid or transitional intensive care unit or semi-closed intensive care unit model

Hybrid/transitional/semi-closed ICU is one in which critical care team provides direct patient care in collaboration with other 'privileged' physicians, who are also allowed to write orders.[12] In this model, the primary treating physicians are not a part of the ICU team, but remain actively involved in their patients' care. Many surgical and cardiothoracic ICUs maintain this model.

Multiple consultant model

Multiple consultant model is one where multiple specialists are involved in the patient's care (a pulmonologist or intensivist might be consulted for ventilator management, but no one is designated specifically as the consultant intensivist). In some cases, the intensivist may act as the team leader and coordinate between all consultants, providing an integrated approach to the patient and family.[13]

Mixed intensive care unit models

In practice, the above mentioned models overlap to a considerable extent. The level of involvement of the intensivist may vary from daily rounds by an intensivist to the presence of a full-time intensivist in the ICU. [Table 1] highlights the advantages and disadvantages of various ICU models. Because this article primarily caters to neurosurgeons and neurologists, a brief mention may be made regarding the neuro-ICUs.
Table 1: Comparative features of different formats of ICUs

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The neurosciences intensive care unit

Historically, the first neurosciences intensive care unit (NICU) was opened in John Hopkins Hospital in 1932 by Dandy. NICUs may admit both neurological and neurosurgical patients, but some have remained largely neurosurgical or have specifically catered to neuro-trauma patients. The most common diagnosis at admisson include are stroke, head injury, brain tumor, post-hypoxic encephalopathy, neuromuscular respiratory failure, status epilepticus, various neurological infections, and admission for immediate postoperative observation. NICUs can also be open, closed, or semi-closed, as discussed previously. The increasing use of intravenous thrombolysis and endovascular interventions for stroke implies that more and more stroke patients are being treated in the NICU. The advent of closed NICUs required the arrival of another new subspecialist – the neurointensitivist – who was required to assume a primary care role for patients in the ICU, coordinating both neurological and medical management. Further, in NICUs, certain highly specialized monitoring may be required [Table 2]. The neurointensitivist should not only be well-versed in the standard ICU protocols, but also in the specialized neuro-critical monitoring and interventions, as detailed in [Table 2]. All this requires a good knowledge of the interface between the brain and other organ systems in the face of a critical illness. However, neurointensitivists are an extremely rare breed, and currently in USA, there are only 45 centres that have one. In India, to the best of our knowledge, there is no dedicated fellowships in neurocritical care, although there are post- doctoral courses offered in neuroanesthesia.
Table 2: Specialized neurophysiological monitoring in Neuro-ICU

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 » Evidence in the Medical Literature: Should Intensive Care Units always Function on a Closed Basis? Top


Several studies have attempted to identify the consequences of these different ICU staffing patterns on patient care.[14],[15],[16],[17],[18],[19],[20] These are summarized in [Table 3]. A critical analysis of these studies is presented below.
Table 3: Summary of the studies comparing open and closed ICU formats

Click here to view


In a systemic review Pronovost et al., concluded that high-intensity staffing (mandatory intensivist consultation or a closed ICU) was associated with a lower ICU mortality rate in 93% of studies with a reduced length of stay in the ICU.[21] It is generally agreed that intensivists can better manage critically ill patients because of a better understanding and management of ICU pathology, better use of evidence-based medicine, increased usage of protocols, and better ventilation management. As a result, various bodies have recommended that all patients in adult or pediatric general medical and/or surgical ICUs and NICUs should be managed or co-managed by an intensivist.[22] There are, however, some problems with the definitiveness of the statement that ICUs should always function on a closed basis.[23] First is the level of evidence. Most studies have used historical controls or before–after study designs and are limited to specific ICUs (for example, medical or surgical) in 1 or 2 centers. It is difficult to compare the outcome of ICUs in two time periods as advances in medicine over a time period could be responsible for better outcome in the closed ICU model. Further, cross-sectional studies are well-known for confounding factors due to variations in the illness severity.[9] However, randomized controlled trials (RCTs) are difficult to perform in this scenario because of obvious logistic problems. Levy et al.,[24] compared the hospital mortality between patients cared entirely by critical care physicians and those cared entirely by non-critical care physicians and concluded that odds for in-hospital mortality were higher for patients managed by critical care physicians. This study, thus, casts doubt on an established recommendation. Interestingly, among the 123 ICUs included in the study, only 23 ICUs were functioning on a closed basis.

On the contrary, Kim et al.,[25] found that the lowest odds of death within 30 days were in ICUs that had high-intensity physician staffing and multidisciplinary care teams. Similarly, in a study published in 2011, mortality decreased from 25.7% to 15.8% in high risk surgical patients when the format of ICU was changed from open to closed.[26] However, a recent 2015 international multicenter observational study showed different results. Based on post hoc analysis of data from the the Extended Prevalence of Infection in the ICU Study (EPIC II) study, which was an international 1-day point prevalence study of all patients admitted in over 1265 ICUs in 75 countries, the authors found that a high nurse: patient ratio was independently associated with a lower risk of in-hospital death. In addition, availability of an in-house intensivist 24 hours a day was associated with a trend toward a reduced risk of in-hospital death. However, the ICU format (open vs. closed) did not influence the adjusted risk of in-hospital death.[27] Thus, there is an uncertainty regarding the contention that closed ICU models have lower mortality and in-hospital stay rates. However, the authors postulated that most of the ICUs in this study were of the closed type and the relatively small number of open ICUs may not have been sufficient to demonstrate possible differences in outcome according to the ICU format. The conflicting results and the lack of randomized control trials imply that the last word on this subject is yet to be stated.

Logistics of closed intensive care unit

The second issue is that of logistics. To provide services for a single ICU with 24 X 7 coverage, five full-time equivalent (FTE) intensivists are required.[28] In the United States, in the 2011–2012 academic year, 1957 trainees were enrolled in the adult critical care medicine fellowships (surgery, anesthesia, medical critical care, and pulmonary/critical care), which is grossly inadequate.[29] The situation is worse in India with a much larger population when compared to USA with a total of 13 DM critical care and 17 FNB critical care seats annually.[30] It is impossible to provide a comprehensive critical care management in our country with such a small number of critical care specialists, and thus it is impossible to follow the closed model in most of the places, although the Indian Society of Critical Care Medicine (ISCCM) discourages adoption or continuance of open ICUs.[1]

In the USA, a survey conducted by the task force of the Society of Critical Care Medicine in 2007 revealed that intensivists provided clinical care in 60% of surveyed ICUs, with an average of 12.7 staff members identified by the ICU director as intensivists.[13] This implies that, even in a resource-rich setting, almost half of the ICU patients could not be treated by intensivists. Hence, a 24 hour-a-day coverage by an intensivist is a feat that is unrealistic for most hospitals due to perceived costs and the scarcity of intensivists. To the best of our knowledge and literature search, no such data is available from our country, although it is likely that the situation could only be worse. Most of the ICUs in India are, therefore, handled by anesthetists, physicians, or pediatricians. Even within an institute, different models are at work in different ICUs. In our institute, which is a tertiary care super-speciality teaching hospital, there are 7 ICUs which work on different models (1 closed, 3 semi-closed, and 3 open).


 » Burnout Syndrome in Intensive Care Unit Staff Top


Burnout is a psychological term for the experience of long-term exhaustion and diminished interest (depersonalization or cynicism), usually in the work context.[31] Burnout syndrome (BOS) was identified in the early 1970s in human service professionals, most notably in healthcare workers.[31] The most well-studied measurement of burnout in the literature is the Maslach Burnout Inventory (MBI),[32] which is a 22-item questionnaire that has a high reliability and validity. Higher levels of severe BOS are found in oncologists, anesthesiologists, physicians caring for patients with AIDS, and physicians working in emergency departments. Based on the most recent studies, severe burnout syndrome is present in approximately 50% of critical care physicians, and in one-third of critical care nurses.[33] Burnout ultimately leads to unsatisfactory patient care and higher attrition rates resulting in depletion of an already scarce workforce.


 » Critical Care Without Walls Top


In a closed ICU model, the primary clinical duties of the intensivists consist of caring for patients in the ICU with no outpatient responsibilities. This concept of a truly 'closed' critical care area has been challenged in recent years to enable access for patients outside the unit to intensive care processes and personnel. 'Critical care without walls' is the theory applied to this idea, whereby intensivists and critical care nurses offer their help and expertise to those who are acutely unwell in the ward.[34] In the existing setting of mismatch between the intensivist supply and demand, this concept appears too ambitious, However, a new development has occurred, at least in the West. Here the growing intensivist shortage has coincided with the appearance of hospitalists,[35] (physicians who focus on the care of hospitalized medical patients) on the healthcare landscape. Eighty-five percent of practicing hospitalists are internists, who have historically been well trained to manage acutely ill hospitalized patients. With their consistent presence in the hospital (many programs provide 24 × 7 in-house coverage), hospitalists see patients several times a day, if necessary, and can respond to their acute needs in real time. Enhancing hospitalists' skills to provide critical care services by providing them with limited, competency-based critical care training can go a long way in reducing the shortage of intensivists. Taniguchi and Okajima compared the open versus semi-closed ICUs and found that mortality of ICU patients was 9.9% in the open group and 6.6% in the semi-closed group (P = 0.05). The average length of hospital stay was 4.9 days in the open group and 4.8 days in the semi-closed group.[38]


 » Protocol Driven Semi-closed Intensive Care Unit: Is This the Answer? Top


It is clear that both open and closed ICU models have their own advantages and disadvantages. A closed ICU system may be ideal, but is probably not feasible at present, and with an ageing population and increasing requirement of intensivists, probably not achievable in the near future. With the continued rising costs of healthcare and the persistent short supply of intensivists, the semi-closed ICU model may make more sense to hospitals because the primary physician, under the guidance of the intensivist, can also help manage the patient when the intensivist is not immediately available. Further, protocol-driven care has been shown to be very effective in improving various aspects of patient care in the ICU setting. Brook et al.,[36] demonstrated that nursing-implemented sedation protocols not only deliver optimal sedation but can also decrease a patient's duration on mechanical ventilation. Similar protocols for management of anemia, acute respiratory distress syndrome/acute lung injury (ARDS/ALI), and weaning off from mechanical ventilation can be implemented by residents or nursing staff, and thus positively influence the patient outcome in semi-closed units. Leape et al.,[37] showed that ICUs can reduce the rate of preventable adverse drug events by 66% in the presence of a clinical pharmacist.

Protocol driven discharge and weaning

The discharge and weaning criteria may differ in various ICUs. For example, in NICUs, for shifting patients to a step down care, besides the common requirement of stable metabolic, hemodynamic, and respiratory profiles and requirement of respiratory therapies (e.g., suction) every 4 hours or less, other considerations such as a stable neurological status for at least 24 hours and absence of seizures may be important. Similarly, airway and pulmonary management of the patient with neurological disease is associated with many challenges. The managing intensivist should be well versed with the patient's neurological condition and its pathogenesis. These will have huge implications for the management of the airway and respiratory status. Although specific guidelines have been developed for weaning and discontinuation of ventilatory support,[39] developing specific extubation criteria for the neurological patient has proven to be problematic. The patients' respiratory muscle strength and their ability to maintain oxygenation with decreasing ventilatory support have received maximum attention.[40],[41] The most consistent airway parameters associated with extubation success were the presence of a spontaneous cough and a required suctioning frequency of >2 hours.[42] For extubation, it is reasonable to incorporate the same pulmonary function tests that are used during intubation.

Thus, a protocol driven semi-closed ICU may be a solution for resource-limited countries like India.


 » Conclusion Top


Critical care medicine is one of the fastest growing specialities in medicine. There is no doubt that all critical patients should be evaluated by an intensivist, and possibly a closed ICU model is the ideal model. Still this is not achievable even in the near future in ICUs across India or even in a resource-rich country such as USA. What is more important is to reduce mortality and ICU stay in a cost effective manner. This can be achieved in semi-closed ICU with appropriate well-written protocols for various procedures. The recent post hoc analysis of the EPIC II study also shows that providing a better nurse-patient ratio and round-the-clock availability of an in-house intensivist goes a long way in reducing the mortality rates and hospital stay duration irrespective of the format of ICU. Finally, ICU management is a team effort. It is important to create an environment where opinions of all members of the team are respected with a common goal to reduce ICU-related mortality in a cost effective manner.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
 » References Top

1.
Rungta N, Govil D, Nainan S, Munjal M, Divatia J, Jani CK. ICU Planning and designing in India – Guidelines 2010 Guidelines Committee ISCCM. Available from: isccm.org/images/Section1.pdf. [Last accessed on 2015 Aug 10].  Back to cited text no. 1
    
2.
Munro CL. The “Lady With the Lamp'' illuminates critical care today. Am J Crit Care 2010;19:315-7.  Back to cited text no. 2
    
3.
Fox WL. Dandy of Johns Hopkins. 6th ed. Baltimore, Maryland: Williams and Wilkins; 1984.  Back to cited text no. 3
    
4.
West JB. The physiological challenges of the 1952 Copenhagen poliomyelitis epidemic and a renaissance in clinical respiratory physiology. J Appl Physiol 2005;99:424-32.  Back to cited text no. 4
    
5.
Wackers GL. Modern anaesthesiological principles for bulbar polio: Manual IPPR in the 1952 polio-epidemic in Copenhagen. Acta Anaesthesiol Scand 1994;38:420-31.  Back to cited text no. 5
    
6.
Vincent JL. Critical care - Where have we been and where are we going? Crit Care 2013;17(Suppl 1):S2.  Back to cited text no. 6
    
7.
Yeolekar ME, Mehta S. ICU care in India - status and challenges. JAPI 2008;56:221-2.  Back to cited text no. 7
    
8.
Halpern NA, Bettes L, Greenstein R. Federal and nationwide intensive care units and healthcare costs: 1986–1992. Crit Care Med 1994;22:2001-7.  Back to cited text no. 8
    
9.
Rothschild J. Closed intensive care units and other models of care for critically ill patients. In: Shojania KG, Duncan BW, McDonald KM, et al., editors. Making Health Care Safer: A Critical Analysis of Patient Safety Practices. Evidence Report/Technology Assessment No. 43. Rockville, MD: Agency for Healthcare Research and Quality; 2001. p. 413-22.  Back to cited text no. 9
    
10.
Divatia JV, Baronia AK, Bhagwati A, Chawla R, Iyer S, Jani CK, et al. Critical care delivery in intensive care units in India: Defining the functions, roles and responsibilities of a consultant intensivist. Indian J Crit Care Med 2006;10:53-63.  Back to cited text no. 10
  Medknow Journal  
11.
Watson GA, Alarcon LH. Intensivists: Don't quit your day job…yet! Crit Care 2010;14:305.  Back to cited text no. 11
    
12.
Tinti MS, Haut ER, Horan AD, Sonnad S, Reilly PM, Schwab CW, et al. Transition to a semiclosed surgical intensive care unit (SICU) leads to improved resident job satisfaction: A prospective, longitudinal analysis. J Surg Educ 2009;66:25-30.  Back to cited text no. 12
    
13.
Brilli RJ. Critical care delivery in the intensive care unit: Defining clinical roles and the best practice model. Crit Care Med 2001;29:2007-19.  Back to cited text no. 13
    
14.
Reynolds NH, Haupt MT, Thill-Baharozian MC, Carlson RW. Impact of critical care physician staffing with septic shock in a university hospital medical intensive care unit. JAMA 1988;260:3446-50.  Back to cited text no. 14
    
15.
Multz AS, Chalfin DB, Samson IM, Dantzker DR, Fein AM, Steinberg HN, et al. A closed medical intensive care unit (MICU) improves resource utilization when compared with an open MICU. Am J Respir Crit Care Med 1998;157:1468-73.  Back to cited text no. 15
    
16.
Carson SS, Stocking C, Podsadecki T, Christenson J, Pohlman A, MacRae S, et al. Effects of organizational change in the medical intensive care unit of a teaching hospital: A comparison of “open” and “closed” formats. JAMA 1996;276:322-8.  Back to cited text no. 16
    
17.
Hanson CW, Deutschman CS, Anderson HL, Reilly PM, Behringer. EC, Schwab CW, et al. Effects of an organized critical care service on outcomes and resource utilization: A cohort study. Crit Care Med 1999;27:270-4.  Back to cited text no. 17
    
18.
Pollack MM, Katz RW, Ruttimann UE, Getson PR. Improving the outcome and efficiency of intensive care: The impact of an intensivist. Crit Care Med 1988;16:11-7.  Back to cited text no. 18
    
19.
Dimick JB, Pronovost PJ, Heitmiller RF, Lipsett PA. Intensive care unit physician staffing is associated with decreased length of stay, hospital cost, and complications after esophageal resection. Crit Care Med 2001;29:753-8.  Back to cited text no. 19
    
20.
Manthous CA, Amoateng-Adjepong Y, al-Kharrat T, Jacob B, Alnuaimat HM, Chatila W, et al. Effects of a medical intensivist on patient care in a community teaching hospital. Mayo Clin Proc 1997;72:391-9.  Back to cited text no. 20
    
21.
Pronovost PJ, Young T, Dorman T, Robinson K, Agnus DC. Association between ICU physician staffing and outcomes: A systematic review. Crit Care Med 1999;27:A43.  Back to cited text no. 21
    
22.
The Leapfrog Group Factsheet. ICU Physician Staffing (IPS). Available from: http://www.leapfroggroup.org/media/file/FactSheet_IPS.pdf. [Last accessed on 2015 Aug 10].  Back to cited text no. 22
    
23.
Pronovost PJ, Angus DC, Dorman T, Robinson KA, Dremsizov TT, Young TL. Physician staffing patterns and clinical outcomes in critically ill patients: A systematic review. JAMA 2002;288:2151-62.  Back to cited text no. 23
    
24.
Levy MM, Rapoport J, Lemeshow S, Chalfin DB, Phillips G, Danis M. Association between Critical Care Physician management and patient mortality in the Intensive Care Unit. Ann Intern Med 2008;148:801-9.  Back to cited text no. 24
    
25.
Kim MM, Barnato AE, Angus DC, Fleisher LA, Kahn JM. The effect of multidisciplinary care teams on intensive care unit mortality. Arch Intern Med 2010;170:369-76.  Back to cited text no. 25
    
26.
van der Sluis FJ, Slagt C, Liebman B, Beute J, Mulder JW, Engel AF. The impact of open versus closed format ICU admission practices on the outcome of high risk surgical patients: A cohort analysis. BMC Surg 2011;23:11-8.  Back to cited text no. 26
    
27.
Sakr Y, Moreira CL, Rhodes A, Ferguson ND, Kleinpell R, Pickkers P, et al. The impact of hospital and ICU organizational factors on outcome in critically ill patients: Results from the Extended Prevalence of Infection in Intensive Care study. Crit Care Med 2015;43:519-26.  Back to cited text no. 27
    
28.
Higgins TL, Steingrub JS. ICU Organization and Management. In: Irwin RS, Rippe JM, editors. Irwin and Rippe's Intensive Care Medicine, 7th Ed. USA: Lippincott Williams & Wilkins; 2011. p. 2143-52.  Back to cited text no. 28
    
29.
List of ACGME Accredited Programs and Sponsoring Institutions. Available from: http://www.acgme.org/adspublic. [Last accessed on 2015 Aug 10].  Back to cited text no. 29
    
30.
Ananthakrishnan N. Distribution of postgraduate medical seats in different disciplines: Is there rationality in decision-making? Natl Med J India 2011;24:365-7.  Back to cited text no. 30
    
31.
Embriaco N, Papazian L, Kentish-Barnes N, Pochard F, Azoulay E. Burnout syndrome among critical care healthcare workers. Curr Opin Crit Care 2007;13:482-8.  Back to cited text no. 31
    
32.
Maslach C, Schaufeli WB, Leiter MP. Job burnout. Annu Rev Psychol 2001;52:397-422.  Back to cited text no. 32
    
33.
Maslach C, Jackson S, Leiter MP. Maslach Burnout Inventory Manual. 3rd ed. Consulting Psychologists. Palo Alto, CA: Press Inc.; 1996.  Back to cited text no. 33
    
34.
Hillman K. Critical care without walls. Curr Opin Crit Care 2002;8:594-9.  Back to cited text no. 34
    
35.
Siegel EM, Dressler DD, Dichter JR, Gorman MJ, Lipsett PA. Training a hspital list workforce to address the intensivist shortage in American hospitals: A position paper from the Society of Hospital Medicine and the Society of Critical Care Medicine. J Hosp Med 2012;7:359-64.  Back to cited text no. 35
    
36.
Brook AD, Ahrens TS, Schaiff R, Prentice D, Sherman G, Shannon W, et al. Effect of a nursing-implemented sedation protocol on the duration of mechanical ventilation. Crit Care Med 1999;27:2609-15.  Back to cited text no. 36
    
37.
Leape LL, Cullen DJ, Clapp MD, Burdick E, Demonaco HJ, Erickson JI, et al. Pharmacist participation on physician rounds and adverse drug effects in the intensive care unit. JAMA 1999;281:267-70.  Back to cited text no. 37
    
38.
Taniguchi T, Okajima M. Effect of organizational structure of the ICU on the prognosis: Open format versus semi-closed format. Crit Care 2013;17(Suppl 2):517.  Back to cited text no. 38
    
39.
MacIntyre NR. Evidenced based guidelines for weaning and discontinuing ventilatory support: A collected task force facilitatedby the American College of Chest Physicians; the American Association of Respiratory Care; and the American College of Critical Care Medicine. Chest 2001;120(6 suppl):S375-95.  Back to cited text no. 39
    
40.
Esteban A, Alía I, Tobin MJ, Gil A, Gordo F, Vallverdú I, et al. Effect of spontaneous breathing trial duration on outcome of attempts to discontinue mechanical ventilation: The Spanish lung failure collaborative group. Am J Respir Crit Care Med 1999;159:512-8.  Back to cited text no. 40
    
41.
Vallverdu I, Calaf N, Subirana M, Net A, Benito S, Mancebo J. Clinical characteristics, respiratory functional parameters, and outcome of a two hour T- piece trial in patients weaning from mechanical ventilation. Am J Respir Crit Care Med 1998;158:1855-62.  Back to cited text no. 41
    
42.
Coplin WM, Pierson DJ, Cooley KD, Newell DW, Rubenfeld GD. Implications of extubation delay in brain injured patients meeting standard weaning criteria. Am J Respir Crit Care Med 2000;161:1530-6.  Back to cited text no. 42
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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