Maintaining quality of care 24/7 in a nontrauma surgical intensive care unit.
BACKGROUND
Most surgical critical care literature reflects practices at trauma centers and tertiary hospitals. Surgical critical care needs and practices may be quite different at nontrauma center teaching hospitals. As acute care surgery develops as a component of surgical critical care and trauma, the opportunities and challenges of the nontrauma centers should be considered.


METHODS
In 2001, a new surgical critical care service was created for an 800-bed urban teaching hospital with a 12-bed surgical intensive care unit (SICU). Consults, daily rounds, daily notes, and adherence to best practices were standardized over the next 9 years for a team of postgraduate year-1 and -2 surgical residents, physician assistants and surgical intensivists. The Fundamentals of Critical Care Support course was given as basic introduction, and published guidelines for ventilators, hemodynamics, cardiac, infections, and nutrition management were implemented. A "beyond FCCS" curriculum was repeated every resident rotation. A 12-bed stepdown unit was developed for the more stable patients, mostly run by SICU physician assistants with SICU attending coverage. The first 5 years, night coverage was by the daytime intensivist from home. The last 4 years, night coverage was in-unit surgical intensivists or cardiac surgeons.


RESULTS
Data for 13,020 patients drawn from 152,154 operations over 9 years is reported. Surgery grew 89% to 24,000 cases/year in 2010. Half the patients were general, gastrointestinal oncology, or vascular surgery. Ninety-two percent were perioperative. The 8% nonoperative patients were mostly gastrointestinal bleeding, abdominal pain, or pancreatitis. In the first year, annual SICU mortality decreased from an average of 4.5% the 5 previous years to 1.96% (2002) and remained 1.75% (2003), 2.1% (2004), 1.9% (2005), 1.5% (2006), 1.5% (2007), 2.2% (2008), 2.4% (2009), and 2.1% (2010).


CONCLUSIONS
Annual mortality immediately improved at a busy nontrauma hospital with rapid, structured consultation by the SICU team, comprehensive daily rounds guided by critical care best practices, and daytime in-unit surgical intensivists. Low mortality was maintained over 9 years as surgery volume nearly doubled but did not improve further with 24/7 in-unit coverage by surgical intensivists and cardiac surgeons. The process of care in an SICU may be more important than 24 hour a day, 7 days a week intensivists.


METHODS
Therapeutic study, level II.
Department of Surgery, Beth Israel Medical Center, New York, NY, USA. mmcmille@chpnet.org
Marvin Allan
MA
McMillen
Nathan
N
Boucher
David
D
Keith
David Scott
DS
Gould
Asaf
A
Gave
Darryl
D
Hoffman
D003422:Critical Care / Q000458:organization & administration / Q000592:standards* / Q000706:statistics & numerical data; D003953:Diagnosis-Related Groups / Q000706:statistics & numerical data; D006746:Hospital Bed Capacity, 500 and over; D017052:Hospital Mortality; D006784:Hospitals, Teaching / Q000592:standards; D006801:Humans; D009519:New York City; D011787:Quality of Health Care / Q000592:standards / Q000706:statistics & numerical data