Effect of Intensive Care Unit Organizational Model and Structure on Outcomes in Patients with Acute Lung Injury

Rationale: Prior studies supported an association between intensive care unit (ICU) organizational model or staffing patterns and out-come in critically ill patients. Objectives: To examine the association of closed versus openmodels with patient mortality across adult ICUs in King County (WA). Methods: Cohort study of patients with acute lung injury (ALI). Measurements and Main Results: ICU structure, organization, and patient care practices were assessed using self-administered mail questionnairescompletedbythemedicaldirectorandnursemanager. We defined closed ICUs as units that required patient transfer to ormandatory patient comanagement by an intensivist andopen ICUs as those relying on other organizational models. Outcomes were obtained from the King County Lung Injury Project, a population-based cohort of patients with ALI. The main endpoint was hospital mortality. Of 24 eligible ICUs, 13 ICUs were designated closed and 11 open. Complete survey datawere available for 23 (96%) ICUs. Higher physician and nurse availability was reported in closed versus open ICUs. A total of 684 of 1,075 (63%) of patientswith ALI were cared for inclosedICUs.Afteradjusting forpotential confounders,patientswith ALI cared for in closed ICUs had reduced hospital mortality (adjusted odds ratio, 0.68; 95 % confidence interval, 0.53, 0.89; P 5 0.004). Consultationbyapulmonologist inopen ICUswasnot associatedwith improved mortality (adjusted odds ratio, 0.94; 95 % confidence in-terval, 0.74, 1.20; P 5 0.62). These findings were robust for varying assumptions about the study population definition. Conclusions: Patients with ALI cared for in a closed-model ICU have reduced mortality. These data support recommendations to imple-ment structured intensive care in the United States