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The Impact of an Intensivist-Model ICU on Trauma-Related Mortality

Nathens, Avery B. MD, MPH, PhD*; Rivara, Frederick P. MD, MPH*; MacKenzie, Ellen J. PhD†; Maier, Ronald V. MD*; Wang, Jin PhD*; Egleston, Brian PhD‡; Scharfstein, Daniel O. ScD‡; Jurkovich, Gregory J. MD*

doi: 10.1097/01.sla.0000239005.26353.49
Original Articles and Discussions

Objective: To evaluate the effect of an intensivist-model of critical care delivery on the risk of death following injury.

Summary Background Data: An intensivist-model of ICU care is associated with improved outcomes and less resource utilization in mixed medical and surgical ICUs. The process of trauma center verification assures a relatively high standard of care and quality assurance; thus, it is unclear what the effect of a specific model of ICU care delivery might have on trauma-related mortality.

Methods: Using data from a large multicenter (68 centers) prospective cohort study, we evaluated the relationship between the model of ICU care (open vs. intensivist-model) and in-hospital mortality following severe injury. An intensivist-model was defined as an ICU where critically ill trauma patients were either on a distinct ICU service (led by an intensivist) or were comanaged with an intensivist (a physician board-certified in critical care).

Results: After adjusting for differences in baseline characteristics, the relative risk of death in intensivist-model ICUs was 0.78 (0.58–1.04) compared with an open ICU model. The effect was greatest in the elderly [RR, 0.55 (0.39–0.77)], in units led by surgical intensivists [RR, 0.67 (0.50–0.90)], and in designated trauma centers 0.64 (0.46–0.88).

Conclusions: Care in an intensivist-model ICU is associated with a large reduction in in-hospital mortality following trauma, particularly in elderly patients who might have limited physiologic reserve and extensive comorbidity. That the effect is greatest in trauma centers and in units led by surgical intensivists suggests the importance of content expertise in the care of the critically injured. Injured patients are best cared for using an intensivist-model of dedicated critical care delivery, a criterion that should be considered in the verification of trauma centers.

We report the mortality benefit among trauma patients cared for in an intensivist model ICU compared with an open unit. This model of critical care delivery was associated with a 45% reduction in mortality among the elderly (age ≥55 years), with no apparent benefit in the young.

From the *Department of Surgery, University of Washington & Harborview Injury Prevention and Research Center, Seattle, WA; †Johns Hopkins Bloomberg School of Public Health, Center for Injury Research and Policy, Baltimore, MD; and ‡Department of Biostatistics, Johns Hopkins University, Baltimore, MD.

Funded by Grant No. R49/CCR316840 from the National Center for Injury Prevention and Control of the Centers for Disease Control and Prevention and Grant No. R01/AG20361 from the National Institute on Aging of the National Institutes of Health.

Reprints will not be available from the authors.

Correspondence: Avery B. Nathens, MD, PhD, MPH, 325 9th Avenue, Box 359796, Seattle, WA 98104. E-mail: anathens@u.washington.edu.

© 2006 Lippincott Williams & Wilkins, Inc.