Yonsei Med J.  2013 Mar;54(2):432-436. 10.3349/ymj.2013.54.2.432.

Feasibility and Early Outcomes of Intensivist-Led Critical Care after Major Trauma in the Korean ICU

• Kim KD
• Lee JW
• Park HK

• KMID: 1503907
• DOI: http://doi.org/10.3349/ymj.2013.54.2.432

Abstract

PURPOSE
Substantial evidence supports the benefits of an intensivist model of critical care delivery. However, currently, this mode of critical care delivery has not been widely adopted in Korea. We hypothesized that intensivist-led critical care is feasible and would improve ICU mortality after major trauma.
MATERIALS AND METHODS
A trauma registry from May 2009 to April 2011 was reviewed retrospectively. We evaluated the relationship between modes of ICU care (open vs. intensivist) and in-hospital mortality following severe injury [Injury Severity Score (ISS) >15]. An intensivist-model was defined as ICU care delivered by a board-certified physician who had no other clinical responsibilities outside the ICU and who is primarily available to the critically ill or injured patients. ISS and Revised Trauma Score were used as measure of injury severity. The Trauma and Injury Severity Score methodology was used to calculate each individual patient's probability of survival.
RESULTS
Of the 251 patients, 57 patients were treated by an intensivist [intensivist group (IG)] while 194 patients were not [non-intensivist group (NIG)]. The ISS of IG was significantly higher than that for NIG (26.5 vs. 22.3, p=0.023). The hospital mortality rate for IG was significantly lower than that for NIG (15.8% and 27.8%, p<0.001).
CONCLUSION
The intensivist model of critical care is feasible, and there is room for improvement in the care of major trauma patients. Although trauma systems take time to mature, future studies are needed to evaluate the best model of critical care delivery for severely injured patients in Korea.

Keyword

Intensive care; trauma system; outcome; injury; TRISS

MeSH Terms

Adult
Aged
Critical Care/*methods
Female
Hospital Mortality
Humans
Intensive Care/*methods
*Intensive Care Units
Male
Middle Aged
Models, Theoretical
Postoperative Care/methods
*Specialization
Trauma Centers

Figure

• 

  Fig. 1 Mortality outcomes. observed mortality rate of the intensivist group was significantly lower than that of the non-intensivist group. IG, intensivist group; NIG, nonintensivist group; Ps, probability of survival by TRISS; TRISS, Trauma and Injury Severity Score.

Reference

1. American College of Surgeons. National Trauma Databank. 2004.

2. Haupt MT, Bekes CE, Brilli RJ, Carl LC, Gray AW, Jastremski MS, et al. Guidelines on critical care services and personnel: recommendations based on a system of categorization of three levels of care. Crit Care Med. 2003. 31:2677–2683.

3. Brilli RJ, Spevetz A, Branson RD, Campbell GM, Cohen H, Dasta JF, et al. Critical care delivery in the intensive care unit: defining clinical roles and the best practice model. Crit Care Med. 2001. 29:2007–2019.

4. 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. 288:2151–2162.

5. Nathens AB, Rivara FP, MacKenzie EJ, Maier RV, Wang J, Egleston B, et al. The impact of an intensivist-model ICU on trauma-related mortality. Ann Surg. 2006. 244:545–554.

6. Lee CC, Im M, Suh GJ. Time for change: the state of emergency medical services in South Korea. Yonsei Med J. 2006. 47:587–588.

7. The Leapfrog group. ICU physician staffing fact sheet. Accessed on 2012 Feb 28. Available at: http://leapfroggroup.org/media/file/LeapfrogICU_Physician_Staffing_Fact_Sheet.pdf.

8. Champion HR, Sacco WJ, Copes WS, Gann DS, Gennarelli TA, Flanagan ME. A revision of the Trauma Score. J Trauma. 1989. 29:623–629.

9. American College of Surgeons. Reference Guide of Suggested Classification. Accessed on 2011 June 21. Available at: http://www.facts.org/trauma/vrc1.pdf.

10. Hanson CW 3rd, Deutschman CS, Anderson HL 3rd, 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. 27:270–274.

11. Pronovost PJ, Holzmueller CG, Clattenburg L, Berenholtz S, Martinez EA, Paz JR, et al. Team care: beyond open and closed intensive care units. Curr Opin Crit Care. 2006. 12:604–608.

12. Stelfox HT, Straus SE, Nathens A, Bobranska-Artiuch B. Evidence for quality indicators to evaluate adult trauma care: a systematic review. Crit Care Med. 2011. 39:846–859.

13. DuBose JJ, Inaba K, Shiflett A, Trankiem C, Teixeira PG, Salim A, et al. Measurable outcomes of quality improvement in the trauma intensive care unit: the impact of a daily quality rounding checklist. J Trauma. 2008. 64:22–27.

14. Pestaña D, Espinosa E, Sangüesa-Molina JR, Ramos R, Pérez-Fernández E, Duque M, et al. Compliance with a sepsis bundle and its effect on intensive care unit mortality in surgical septic shock patients. J Trauma. 2010. 69:1282–1287.

15. Lee JW, Hwang JJ, Kim KD, Choi JH. Blunt cardiac and pericardial rupture without cardiac herniation: a diagnostic challenge. ANZ J Surg. 2011. 81:489–490.

16. 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.

17. Tinkoff G, Esposito TJ, Reed J, Kilgo P, Fildes J, Pasquale M, et al. American Association for the Surgery of Trauma Organ Injury Scale I: spleen, liver, and kidney, validation based on the National Trauma Data Bank. J Am Coll Surg. 2008. 207:646–655.

18. Dossett LA, Redhage LA, Sawyer RG, May AK. Revisiting the validity of APACHE II in the trauma ICU: improved risk stratification in critically injured adults. Injury. 2009. 40:993–998.