ICU Without Walls
Vladimir Kvetan, MD (Critical Care)
Professor of Clinical Medicine, Department of Medicine (Critical Care)
Professor, Department of Anesthesiology
Associate Professor, Department of Surgery
With an exploding population of elderly patients who need increasing amounts of critical care, hospitals across the United States have been challenged to expand intensive care unit (ICU) services. ICU beds, however, can cost up to four times a normal medical surgical bed.
Hospital intensive care units (ICUs) throughout the United States operate primarily under an "open" or "closed" model. In the open ICU, patients are often admitted without triage and cared for by their primary care physicians with varying levels of critical care input. The closed ICU has stricter administrative and triage controls. Incoming patients are evaluated for severity of condition and transferred to the care of an intensivist. Which model achieves more effective use of scarce resources is a subject of continual debate.
Rather than following one of the traditional ICU models, the Einstein-Montefiore Critical Care Medicine (CCM) Consult Services function as an "ICU Without Walls", with a rapid response team of critical care medicine specialists ("intensivists") available 24/7 to immediately treat the sickest patients whether they are in the emergency department, general medical surgical units, or intensive care units (ICUs) of Montefiore Medical Center and Weiler Hospital.
Montefiore's team of intensivists, many of them triple boarded, works directly with the administrative leadership of the hospital and has the collaboration of all departments and specialties.
The ICU Without Walls initiative has proven effective in a number of areas:
- Montefiore has reduced the mortality in its medical-surgical ICUs to under 8% over the past two decades.
- While the CCM Services receive more than 400 consult requests each month for critically ill patients, ICU beds (87 across the two campuses) represent only 8% of the total hospital beds. By expanding services without increasing the number of ICU beds, Montefiore's rapid response program has improved the quality of care while reducing lengths of stay and enabling the hospital to minimizes costs.
- Montefiore's Emergency Department (ED) patient population has doubled over the last decade, with over 250,000 visits annually. However, by treating and triaging these patients immediately, the CCM team frees up the ED staff to care for others, allowing the hospitals to manage unprecedented patient volumes without becoming overwhelmed.
- The CCM Service continuously treats the most severely ill post-operative neurosurgical, cardiothoracic, and general surgical patients following major surgery. Patients receive better care, sooner, freeing the OR more quickly for other patients.
- Montefiore has been singled out as providing exemplary critical care by several prominent, external organizations, including Solucient, the Alliance for Quality Health Care, and the Leapfrog Group. It has demonstrated excellent performance in external benchmarking studies such as the Dartmouth Atlas of Health Care.