title: An intensivist-directed intensive care unit improves clinical outcomes in a combat zone.
abstract: OBJECTIVE
  Intensivist-directed intensive care units (ICUs) have been shown to improve clinical outcomes. Numerous barriers exist that limit hospitals adopting this practice. We sought to show this staffing model can be implemented in an austere environment with limited resources resulting in improved outcomes.
  
  
  METHODS
  We conducted a retrospective observational cohort study of consecutive adult patients admitted to the ICU between March 2004 and January 2007.
  
  
  METHODS
  This study was conducted in an ICU in a U.S. Army Combat Support Hospital deployed to Afghanistan.
  
  
  METHODS
  North Atlantic Trade Organization members (U.S. military service members, American civilian contractors, members of the North Atlantic Trade Organization Coalition International Security Assistance Force), members of the Afghanistan National Army and National Police, and local Afghani nationals were included in the study. Both traumatic injuries and medical illnesses were treated.
  
  
  METHODS
  During the observation period, the ICU was converted from an open model to an intensivist-directed model.
  
  
  RESULTS
  Outcomes compared between the two models included ICU and hospital mortality, duration of mechanical ventilation, and ventilator-associated pneumonia rates. During the observation period, there were 2740 admissions, 965 of which were initially admitted to the ICU. We found significant reductions in ICU mortality (6.6% vs. 4.0%, p < 0.001), duration of mechanical ventilation (4.7 +/- 3.9 days vs. 3.1 +/- 2.7 days, p < 0.001), and rates of ventilator-associated pneumonia (42.5% vs. 8.0%; p < 0.001).
  
  
  CONCLUSIONS
  Transition to an intensivist-directed ICU in an Army Combat Support Hospital improved outcomes among ICU patients. This study demonstrates the feasibility of using this model in an austere, combat environment.
authors.affiliation: Pulmonary and Critical Care Medicine, Walter Reed Army Medical Center, Washington, DC, USA. christopher.lettieri@us.army.mil
authors.forename: Christopher J
authors.initials: CJ
authors.lastname: Lettieri
authors.forename: Anita A
authors.initials: AA
authors.lastname: Shah
authors.forename: David L
authors.initials: DL
authors.lastname: Greenburg
mesh_terms: D000328:Adult; D015331:Cohort Studies; D003422:Critical Care / Q000592:standards*; D005260:Female; D006801:Humans; D007362:Intensive Care Units / Q000592:standards*; D008297:Male; D008889:Military Personnel; D053717:Pneumonia, Ventilator-Associated / Q000453:epidemiology; D012121:Respiration, Artificial; D012189:Retrospective Studies; D016896:Treatment Outcome; D014481:United States