Intensive care units: specialized or multidisciplinary?
The very first intensive care units (ICUs), introduced towards the end of the 19th century, consisted of a few beds reserved for the sickest patients and put together in one area of the general hospital ward so that the patients could be watched more closely. Patients continued to be treated by their admitting physician with consultation by other specialists as dictated by the course of their disease. Later, separate rooms were created to gather together the special monitoring and organ support equipment and specially trained nursing and medical staff considered necessary for the optimal management of critically ill patients.
Over the years, especially in larger hospitals and more commonly in the United States than in other countries, subspecialty ICUs have developed, catering for specific groups of patients, such as those with neurological, respiratory, cardiac, surgical, trauma diagnoses. This division of intensive care into subspecialties reflects a general trend across medicine towards the creation of increasingly specialized subspecialties. In the United States, one third of all ICUs are now (sub)specialty units. But is there any evidence that such units provide better care than general, multidisciplinary ICUs catering for all critically ill patients regardless of diagnosis?
by Prof. Jean-Louis Vincent
Benefits of subspecialty ICUs
Proponents of specialized ICUs suggest that patient outcomes can be improved in such units because they are managed by staff with increased expertise and training in the particular field of diagnosis. Such units are thus able to provide more focused, relevant care. However, although highly trained in their particular specialty, staff in such units may be less experienced in diagnosing and managing other systemic complications of critical illness. There is relatively little data available comparing the benefits of specialty versus general ICUs. In one study, patients with intracerebral hemorrhage had improved survival rates when admitted to a specialized neurosurgical ICU compared to a general ICU [1]. However, in another analysis, admission to a diagnosis-appropriate specialty ICU was associated with no survival benefit compared to admission to a general ICU for a selection of common diagnoses, including acute coronary syndrome, ischemic stroke, intracranial hemorrhage, abdominal surgery, and coronary-artery bypass graft surgery [2]. Interestingly, admission to a diagnosis-inappropriate specialty ICU, e.g., a renal patient admitted to a neurosurgical ICU because the renal ICU was full, was associated with increased mortality rates [2]. Performing such comparative studies is, however, fraught with difficulty, largely because there is no set definition of a
