Organized Staffing Directed by Intensivists Improves Outcomes for Critically Ill Patients

In a White Paper in this issue of the American Journal of Transplantation, Ranjan et al., who represent the views of the American Society of Transplant Surgeons (ASTS), opine against implementation of the ‘closed’ intensive care unit (ICU) model for the care of critically ill abdominal organ transplant patients (1). These authors argue that physicians with subspecialty training in intensive care medicine and transplant surgeons have different notions about the best ways to manage clinical problems in critically ill patients. Moreover, these authors imply that outcomes for transplant patients will suffer, if ‘general intensivists’ are permitted to direct the care of critically ill transplant patients, even if the care is carried out in close collaboration with the primary surgical service.

In support of this position, the White Paper's authors cite only one reference, namely a recent article by Levy and colleagues, who carried out a retrospective analysis of a large, prospectively collected database of critically ill patients and found that the likelihood of hospital mortality is higher for patients managed by critical care physicians as compared to patients not managed by intensivists (2). While the results reported by Levy et al. are certainly thought provoking, they hardly can be considered definitive, especially since the findings probably were influenced by important methodological issues (e.g. inadequate case-matching due to the presence of key unmeasured parameters). Moreover, the evidence in support of the alternative hypothesis—that mortality is lower when critically ill patients are managed in a closed ICU staffed by intensivists—is both extensive and consistent, irrespective of the patient population under investigation or the study design employed (3). In the context of the present discussion, it is especially noteworthy that several well-done studies have documented that outcome is significantly improved when surgical (trauma, aortic aneurysmorrhaphy, esophagectomy or general surgical) patients are managed, using an intensivist led critical care staffing model rather than an ‘open ICU’ model (4–7).

During their training, most abdominal transplant surgeons receive excellent mentoring with regard to the management of many common ‘ICU-type’ problems, such as acute lung injury, acute renal insufficiency, cardiogenic shock and severe sepsis. However, advanced surgical training in abdominal (i.e. hepatic, renal, pancreatic and intestinal) transplantation probably does not uniformly provide adequate experience with a number of procedures, which are commonly performed by intensivists, such as fiberoptic bronchoscopy, (transesophageal and/or transthoracic) echocardiography, thoracic ultrasonography and percutaneous tracheostomy. Furthermore, as they advance in their careers, most transplant surgeons spend increasing amounts of time in the operating room, seeing outpatients in the clinic setting, doing administrative work or running a research laboratory. Necessarily, therefore, practicing transplant surgeons often spend less time providing ‘hands-on’ care in the ICU than they did during their training years. On this basis alone, one must suppose that their familiarity with the constantly expanding and changing critical care literature eventually has to suffer. More important, however, is the idea that ICU patients are best managed on a minute-to-minute basis by an experienced, appropriately trained clinician, who is present at the bedside and available to conduct a physical examination, and interpret and integrate a steady stream of radiographic, biochemical and hemodynamic data.

The foregoing notwithstanding, it seems self-evident that transplant surgeons must be closely and continually involved in the care of their critically ill patients. Some decisions, such as those, regarding the need for and timing of operation or reoperation, can be made only by the attending surgeon. Other decisions, such as those regarding the design and adjustment of the immunosuppressive drug regimen or the need for complex diagnostic or therapeutic radiographic procedures, also are best made by the attending surgeon. Thus, the care model should be a collaborative one, which involves both the intensivist (often with subspecialty expertise in abdominal organ transplantation) and the transplant surgeon. This collaboration should be based on mutual trust and respect, and should put the safety of patients ahead of any and all concerns about turf or control.

As a former Speaker of the United States House of Representatives, Thomas ‘Tip’ O’Neill, once pointed out in a different context, ‘all politics is local’. Accordingly, it is important to recognize that the specific circumstances at different hospitals can lead to a variety of successful transplant ICU team structures, all of which are well adapted to the interests, skills and competing time commitments of the surgeons and intensivists involved. One size does not, and should not, fit all.

Disclosure

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