Jason P. Lott, Theodore J. Iwashyna, Jason D. Christie, David A. Asch, Andrew A. Kramer, and Jeremy M. Kahn Am J Respir Crit Care Med Vol 179. pp 676–683, 2009

 ICU organization  varies widely across hospitals  a wide range of diagnoses and procedures  ‘‘General’’ ICUs  “Specialty” ICUs - diagnosis-specific care for select populations of critically ill - improve outcomes by reducing diagnostic variability and focusing nursing expertise within a unit - lower levels of diagnostic diversity  decreased mortality

 The relationship between ICU specialization and patient outcomes  incompletely characterized  Understanding the impact of specialty ICUs on patient mortality  optimizing the allocation of limited hospital resources  Specialized critical care  increased administrative costs or efforts to standardize the organization and management of critical care

 To determine the association between specialty ICU care and hospital mortality and ICU length of stay in a diverse population of critically ill patients

 Retrospective cohort study using the Acute Physiology and Chronic Health Evaluation (APACHE) IV database  APACHE - a voluntary clinical information system that provides risk-adjusted outcome data to participating United States hospitals - contains detailed clinical, physiologic, and demographic information on all patients admitted to the ICU

 Specialty ICUs : surgical ICUs, medical ICUs, neurological ICUs, cardiothoracic surgery ICUs, and cardiac care units  different outcomes depending on whether or not they are in the right specialty ICU or another type of specialty ICU

 ‘‘ideal’’ specialty ICU - abdominal surgery  surgical ICU - acute myocardial infarction  cardiac care unit - cardiac surgery  cardiothoracic surgery ICU - intracranial hemorrhage  neurological ICU - ischemic stroke  neurological ICU - pneumonia  medical ICU.  Patients admitted to a specialty ICU that was not the ideal specialty ICU  a ‘‘non-ideal’’ specialty ICU  general ICU, ideal specialty ICU, and non-ideal specialty ICU.

 Primary outcome variables : in-hospital mortality and ICU length of stay  Potential confounders : age, gender, severity of illness (as measured by APACHE III score), admission source, pre-ICU length of stay, mechanical ventilation status on admission, teaching status of hospital, region of within the United Status (Northeast, Southeast, Midwest, or West), and annual diagnosis-specific volume (i.e., the average annual number of patients within each diagnostic category in each ICU)

 Admission to an ideal specialty ICU - not associated with improved risk-adjusted survival compared with admission to a general ICU  No consistent relationship between specialization and ICU length of stay  no survival or length of stay benefit compared with general ICUs for patients with the selected conditions

 Several reasons why specialization might fail to improve survival in the ICU - Critical illness syndromes(acute respiratory failure, acute lung injury, and sepsis)  common to all ICU patients - Critically ill patients with different underlying diagnoses  more alike  obviating the need for specialized care - Intensivist physicians, multidisciplinary care teams, protocolized care

 Important implications for the organization of critical services - Hospitals use different care models for critically ill patients  a single general ICU, several specialty ICUs, a combination of the two (e.g. a general ICU and a cardiac care unit)  costly, especially for smaller centers  particularly relevant for countries (the United Kingdom, Denmark) which are seeking to expand their ICU infrastructures to meet future demand for critical care services  The organization of critical care in certain developing world countries : optimal resource structuring and allocation for sustainable critical care delivery

 Other reasons that a hospital might want to create subspecialty ICUs independent of mortality  specialization might affect costs and resource utilization in ways unrelated to length of stay, Issues of convenience, control  duration of mechanical ventilation, cost, family satisfaction  to facilitate or enhance the education of residents and other hospital staff and to train critical care specialists

 Admission to a non-ideal specialty ICU (when patients need to board in other ICUs or if a hospital has a limited number of specialty ICUs)  significantly higher adjusted mortality  disco-ordination of care  Efforts to minimize admission to non-ideal ICUs  improved ICU survival

 Limitations 1.ICU level organizational factors(intensivist physician staffing, multidisciplinary care, nurse-to-patient ratios, critical care training program status or the availability of various residents)  factors of decreased mortality  more common in specialty ICUs 2. In-hospital mortality (rather than 28-day mortality)  less sensitive to variation in discharge practices between hospitals 3. not evaluate other patient-centered outcomes(functional status, quality of life) 4. our six diagnostic categories  significant diagnostic heterogeneity

 Ideal specialty ICU care appears to offer no survival benefit over general ICU care for select common diagnoses  Non-ideal specialty ICU care is associated with increased risk-adjusted mortality