American Society of Transplant Surgeons’ White Paper: Impact of Closed ICUs on Transplant Patients’ Care

The American Society of Transplant Surgeons (ASTS) recognizes that the critical care of the transplant patients, both in the pretransplant and posttransplant phase, is one of the most important components of the transplant recipient's care, impacting the suitability of the potential transplant candidate and then subsequently posttransplant morbidity, mortality as well as allograft survival. By virtue of having pretransplant end-organ failure, an extensive surgical procedure and unique postoperative management issues due to the new allograft and postoperative immunosuppression, the transplant patients must receive specialized critical care both in and out of the intensive care unit (ICU) by professionals well versed in these aspects of their care. The ASTS is also aware of the considerable debate and discussion regarding the utility of various ICU models in care of critically ill patients (1,2). The society is especially concerned about the recent initiative taken by institutions and regulators to promulgate the closed ICU model, where the ICUs are run under the exclusive authority of the intensivists while at the discretion of the intensivists, the primary service takes a consultative role in the management of their patients. It is a matter of concern that in the closed ICU model, the transplant team, that is ultimately responsible for the patient as well as the precious allograft and also possesses the skills and knowledge of these complex patients, is expected to assume a secondary role in the patient management team. We recognize that between general intensivists and transplant surgeons there exists a different approach to management of critical care situations such as fluid/ electrolytes, hemodynamics, sepsis and complications/ interactions of immunosuppressive mediations, and this conflicting approach to patient management has historically resulted in frustration for the transplant teams. The membership of the society has expressed concerns based on these historical observations especially since there has been continual improvement in transplant care and outcomes over the previous decade (3). We believe that these concerns need to be examined further and any major change in transplant patients’ critical care management should only be driven by well-designed studies and data analyses documenting outcome concerns necessitating a change. Therefore, it is the position of ASTS that transplant centers operate with a collaborative ICU model (as compared to a closed model) to ensure highest quality care to the transplant patient with the transplant team retaining the primary leadership role in the management of these patients.

ICUs comprise approximately 10% of acute care beds and account for >4 million ICU admissions annually (1). Given that there are a total of approximately 25 000 solid organ transplants annually (4), transplant patients consist of a very small fraction of the current ICU population. The physician providing care for the transplant patient in the ICU must be well versed not only in the standard ICU management but also in the management of end-organ failure, the unique pathophysiology of the end-stage-organ failure of that particular organ, understand the complexity of the transplant and related surgical procedures and immunosuppressive medications including the complex drug interactions and complications of these medications. Currently ICU care is being provided in many transplant centers by the transplant team under the leadership of transplant surgeon with experience in critical care management of transplant patients, in many cases with intensivists’ collaboration. It is the position of the ASTS that this critical care management model should continue in a collaborative fashion unless specific outcome concerns are identified for transplant patients’ ICU care in this model.

While the primary focus is the provision of quality care and reducing morbidity and mortality, other issues such as credentialing/ training of intensivists, current and projected lack of adequate numbers of trained surgical intensivists in various ICU models are also relevant and merit consideration (5).

The view that there is an improvement in the quality of care when the ICU care is provided only by the intensivists (6,7) is not universally accepted. Indeed, in the largest population registry study yet reported, patients managed exclusively by ‘critical care physicians’ had worse outcomes when compared with patients managed with their primary teams even after this was standardized with disease severity scores (8). The provision of perioperative care is a fundamental responsibility of surgeons who understand complex anatomy as well as the impact of the procedures they perform on the individual patient's physiology. The ASTS agrees with the concerns expressed by other surgeons that the loss of continuity of care of surgical patients is a vital issue of concern in closed units (9); this is especially true for the complex perioperative care of transplant patients.

Often dictated by the patient volume, most abdominal transplant surgeons, and abdominal transplant surgeons in training (Transplant Fellows), receive a concentrated experience in the care of transplant patients including their ICU care. The structure of a transplant fellowship requires fellows to spend considerable time learning the management of end-organ failure and ICU care of the posttransplant recipient. According to the ASTS guidelines, the transplant fellow must gain concentrated experience dedicated to caring exclusively for transplant patients over a 2 years’ period. Therefore the experience gained by the transplant surgeons in training includes ICU experience in both postoperative and preoperative care of transplant patients including management of end-organ failure (10). In contrast, since transplant patients comprise a very small fraction of the ICU population, the ‘general’ intensivist is unlikely to get a large or concentrated experience in the care of transplant patients. Considering the fact that existing manpower shortage of intensivists is projected to get even worse (5), the ASTS is concerned about the care of the transplant patients in the suggested ‘closed ICUs’ that are understaffed with personnel who have less than optimal training for this specialized patient population. This manpower shortage will get compounded further as the transplant surgeons in training will not achieve the previously expected level of experience and expertise in critical care management of transplant patients in the closed ICU model.

Conclusion

The optimum model of care for the transplant patients in the ICU is when the care is rendered by a physician who has extensive training and experience in

The ASTS proposes that by virtue of their training and experience with this specific patient population, currently in many transplant centers the ICU-experienced transplant surgeons function as the appropriate ‘intensivist’ for the transplant patients. Any proposed change from this model should only be driven by objective outcome concerns and data analyses.

Disclosure

The authors of this manuscript have no conflicts of interest to disclose as described by the American Journal of Transplantation.