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Intensive care unit models: Do you
want them to be open or closed?
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A critical review
Debashish Chowdhury, Ashish K Duggal
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Website:
www.neurologyindia.com

DOI: Abstract:
10.4103/0028-3886.198205
Intensive care is a specialized branch of medicine dealing with the diagnosis, management, and follow up of
PMID: critically ill or critically injured patients. It requires input from other branches of medicine on various issues.
xxxx 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.
Key Words:
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.

O ver the past few years, there has been

Department of
Neurology, GB Pant
Institute of Post
Graduate Medical
Education and
Research, New Delhi,
India
Address for
correspondence:
Dr. 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
E‑mail:
debashishchowdhury@
hotmail.com
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.
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Brief History of Critical Care Medicine
and Intensive Care Unit
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
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.

© 2017 Neurology India, Neurological Society of India | Published by Wolters Kluwer - Medknow 39
 Chowdhury and Duggal: Open or closed ICU models
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
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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
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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
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
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
40
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.
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
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 Chowdhury and Duggal: Open or closed ICU models

Table 1: Comparative features of different formats of ICUs

Feature Open Closed Semi closed Advantage/Disadvantage
Primary Yes No Yes More satisfaction to the attendants of the
physicians patient. In addition, the primary physician
manage cases is well versed with the details and nuances
of patient’s medical history. This may be of
particular importance in surgical ICUs where
a better postoperative surgical care can be
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provided by the surgeon

Presence of May or may not be Always Always The presence of an intensivist as an ICU
ICU director present director means better evidence based
and intensivist management, effective utilization of
resources and more satisfaction among
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the nursing staff in a closed model.

Lack of a team leader may also result in
indecisiveness on the part of junior and
nursing staff
Physician Less likely May be present May be present, more Conflict among the intensivist and primary
conflict likely than a closed model physician or surgeon is more likely in closed
or semi closed ICU
Manpower Less More Moderate Shortage of trained intensivists implies that
requirement most hospitals cannot manage ICUs on a
closed basis. Closed ICUs are more useful
in large teaching hospitals while open ICUs
are more cost effective in small hospitals
Efficiency and Probably less efficient More efficient utilization More efficient utilization Use of evidence based medicine and
length of stay utilization of resources of resources and reduced of resources and reduced standard protocols result in a more efficient
and longer length of stay length of stay and mortality length of stay and mortality utilization of resources in a closed and
semi‑closed model
Satisfaction of More Less More The involvement of the primary physician
the relatives in patient care makes the relatives more
comfortable because the intensivist usually
does not have a pre‑existing relationship
with patients and their families

Table 2: Specialized neurophysiological monitoring in Neuro‑ICU

Parameter Methods Utility
Cerebral Blood Flow (CBF) Transcranial Doppler (TCD) Helpful during monitoring of brain trauma, subarachnoid hemorrhage
Monitoring ultrasonography (SAH) and neurosurgical procedures
Laser Doppler flowmetry (LDF)
Thermal diffusion (TD)
Cerebral Oxygen Monitoring Transcranial cerebral Helpful during monitoring of cardiac surgery and carotid
oximetry utilizing near infrared endarterectomy
spectroscopy (NIRS)
Jugular Bulb Oximetry By placing a fiberoptic oximeter Very useful for providing a global estimate of cerebral oxygenation in some
retrogradely into the jugular bulb conditions like head trauma or diffuse cerebral edema
Brain Tissue Oxygen Tension By using a small flexible Used in patients undergoing cerebrovascular surgery particularly for
microcatheter (<0.5 mm in diameter) monitoring during temporary vessel occlusion
that is inserted usually into the frontal
white matter and fixed onto a special
bolt
Intracerebral Microdialysis By using a microdialysis system To measure glucose, lactate and pyruvate concentrations (reflecting
carbohydrate metabolism), glutamate concentration (reflecting cell injury)
and glycerol concentration (reflecting cell membrane
breakdown)
Continuous EEG Useful to detect non‑convulsive status epilepticus, quantitative extraction
Electroencephalography of time‑frequency of seizures
(EEG) Monitoring Provides data for detecting delayed cerebral ischemia due to vasospasm
in patients with SAH. Useful for monitoring patients presenting with acute
ischemic stroke by using the Brain Symmetry Index (BSI)
Somatosensory Evoked EMG It is used to test the integrity of the central nervous system
Potentials (SSEP), The absence of cortical responses to bilateral median nerve stimulation
Electromyography (EMG), predicts a very grave prognosis especially in brain trauma
Motor Evoked Potential (MEP)

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 Chowdhury and Duggal: Open or closed ICU models

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
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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.

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
Evidence in the Medical Literature: Should Intensive
required to assume a primary care role for patients in the ICU, Care Units always Function on a Closed Basis?
coordinating both neurological and medical management.
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Further, in NICUs, certain highly specialized monitoring may Several studies have attempted to identify the consequences of
be required [Table 2]. The neurointensitivist should not only these different ICU staffing patterns on patient care.[14‑20] These
be well‑versed in the standard ICU protocols, but also in the are summarized in Table 3. A critical analysis of these studies
specialized neuro‑critical monitoring and interventions, as is presented below.

Table 3: Summary of the studies comparing open and closed ICU formats
Authors Study setting Study year ICU type Controls Intensivist Outcome
intervention
Reynolds et al.[14] Tertiary 1982-1984 Medical Historical Closed Mortality Relative Risk Reduction
care, urban, 23%
teaching
hospital
Multz et al.[15] Teaching 1992-1993 Medical Historical and Closed Mortality Relative Risk Reduction
hospitals concurrent Retrospective: 19%
Prospective: 26%
Carson et al.[16] Teaching 1995-1996 Surgical Historical Closed Mortality Relative Risk Reduction:
hospital 58%
Hanson et al.[17] Teaching 1999 Surgical Concurrent Closed vs open Reduced length of stay in ICU
hospital and fewer complications in closed
model
Pollack et al.[18] Teaching 1989-1992 Paediatrics Historical Closed vs open Mortality Relative Risk Reduction
hospital by 25%
Dimick et al.[19] Multiple ICUs: 1994-1998 Surgical Cross sectional Mixed ICUs In‑hospital mortality rate was
Patients 1.5% in closed model versus
with hepatic 7.8% in open ICUs
resection
Manthous et al.[20] Community 1992-1994 Medical Historical Open vs closed Mortality reduction by 29% after
teaching conversion to closed model
hospital
Pronovost Systematic 2002 All types Historical and Low‑intensity Pooled estimate across all
et al.[21] review concurrent (open) vs or high studies=61%
intensity (closed)
Levy et al.[24] 100 ICUs in 2008 All types Cross‑sectional ‑ Standardized mortality ratio in
USA closed ICU was 1.09 vs 0.91 in
open ICUs
Kim et al.[25] 169 ICUs in 2010 All types Concurrent ‑ Lower odds of death were in
Pennsylvania closed ICU (OR 0.78) vs OR of
0.88 in open ICUs
van der Sluis Netherlands 1996-1998 General Historical Open vs closed Significant decrease in
et al.[26] (open format) and trauma mortality (25.7% vs 15.8%,
and 2003-2005 surgery P-value=0.001) and hospital
(closed format) stay (21 vs 17 days,
P-value=0.03)
Sakr et al.[27] 2015 All types Observational-1 day Open (82.9%) vs Availability
point prevalence closed (17.1%) of an in‑house intensivist 24 h/d
study in May 2007 was associated with
a trend toward a reduced risk of
in‑hospital death but ICU format
did not influence the adjusted risk
of in‑hospital death

42 Neurology India | January-February 2017 | Vol 65 | Issue 1

 Chowdhury and Duggal: Open or closed ICU models
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
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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
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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
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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
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
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
43
 Chowdhury and Duggal: Open or closed ICU models
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
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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
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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?
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
44
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
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.
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