Effect of closed unit policy and appointing an intensivist in a developing country

Abstract

Objective: We hypothesized that a dual strategy--instituting a closed intensive care unit (ICU) policy and simultaneously appointing an intensivist--would improve patient outcome in a university hospital of a developing country and that the benefit would increase over time.

Design: Data were prospectively collected over 5 months before the policy change (open policy) and over an initial 6 mos (early closed policy) and subsequent 12 mos (late closed policy) after the policy change.

Setting: The study was conducted at a medical ICU of a university hospital in Turkey.

Patients: Two hundred patients were recruited during open policy, 149 during early closed policy, and 210 during late closed policy.

Measurements and results: Instituting a closed policy and simultaneously appointing a critical care specialist was associated with the admission of sicker patients and more frequent use of invasive procedures. Compared with open policy, patients were approximately 4.5 times more likely to survive their hospital stay during early closed policy (p < .001) and approximately five times more likely during late closed policy (p < .0001). Among patients receiving mechanical ventilation, hospital mortality was lower during the early (57%) and late closed periods (59%) than during open period (91%; p < .01). In multivariate analysis, open policy, mechanical ventilation, central venous catheterization, sepsis, and higher Acute Physiology and Chronic Health Evaluation II score each independently predicted mortality. The change in policy resulted in the admission of progressively sicker patients over time and increased the use of mechanical ventilation and central venous catheters.

Conclusion: A dual strategy of closed policy and simultaneously appointing an intensivist fostered admission of sicker patients and improved the survival of patients requiring admission to an ICU of a developing country.