Originally published in the April 2003 issue of Critical Connections,
Volume 2, Number 2.

When the medical ICU at Grady Memorial Hospital in Atlanta, Georgia, transitioned to the intensivist model, the success was so dramatic, those involved wondered why the change was not made sooner.

“In less than five years, Grady went from being a hospital in transition to being named one of the Solucient 100 Top HospitalsTM: ICU Benchmarks for Success in 2000,” says Robert Aranson, MD, a catalyst of the Grady transformation and a Society of Critical Care Medicine member.

In 1995, Grady Health System redesigned and reconstructed six adult ICUs as it transitioned from an open/consultative ICU model to the primary-care multidisciplinary intensivist model. Grady Health System is a 1,423-bed, safety net inner-city teaching hospital supported by both Emory University and Morehouse schools of medicine. Grady has approximately 35,000 admissions and 800,000 outpatient visits annually. Approximately 6,500 patients are treated in Grady’s ICUs; roughly equal to 18 percent of the patients flowing through the hospital.

Before the transition, Grady had an open ICU system consisting of 70 adult beds in various parts of the hospital. After the reconstruction, Grady doubled the number of critical and acute care beds to nearly 130. The vast majority of the new ICU beds were localized in the new wing of the hospital.

“Changing to the intensivist model vastly improved ICU outcomes. Patient care was greatly improved with fewer procedural complications, reduced time on mechanical ventilation, and shortened length of stay,” says Dr. Aranson, who is Grady’s former ICU medical director and who also served as the medical director of the respiratory care department, chair of the ethics committee, and founder and chair of the critical care committee.

Not only did Grady commit to an intensivist model for the ICUs, which includes critical care board certified directors and staff in every unit, but the hospital also created a multidisciplinary ICU team that includes medical and nursing directors as well as representatives from pharmacy, respiratory therapy and administration. This team is now responsible for the overall direction of the units. “The multidisciplinary approach is one of the most important predictors for improved quality, improved outcome and decreased length of stay,” says Michael Heisler, MD, MPH, director of the division of general internal medicine at Morehouse School of Medicine and chair of the ICU project team.

From July 2001 to July 2002 the length of stay in the Grady medical ICU dropped an additional half day, length of stay in the intermediate care unit dropped a day and a half, and length of stay in the telemetry service dropped another half day. “The concerted multidisciplinary effort of the intensivist model continues to generate measurable impact,” says Chad VanDenBerg, MPH, director of the Center for Clinical Effectiveness-Grady Health System.

Grady is one of the few public-funded urban trauma referral centers in the United States that is committed to the use of an objective outcomes assessment tool. Currently, APACHE III is being installed in all of the adult ICUs, stepdown and telemetry units, as a means of tracking severity, quality, outcomes and cost.

“Having been brought up in the culture of floor teams admitting to open-system ICUs and then having later been exposed to the intensivist system convinced me that the intensivist model is better—without question,” declares Dr. Aranson.

“Every hospital should move to the intensivist system or as close to it as possible,” Dr. Aranson recommends. He notes that teaching institutions are unique in that they have house staff and fellows to help to make the transition to an intensivist-modeled ICU.

Nurses and respiratory therapists find patient care easier under the intensivist model, according to Dr. Aranson. In the previously open unit, staff had to contact any number of physicians regarding patient care. “For example, in the open system, the nurse contacted the unit team for the ventilator while the floor team was contacted for potassium correction. With the intensivist system, one crew is at the helm, so nurses need not wait for a physician’s answers and direction,” explains Dr. Aranson.

When Grady’s medical ICU implemented the intensivist model, unit teams were created. Previously, the medical ICU had been open and resident teams from the floors admitted patients to the ICU. The ICU had a skeletal team that acted more as consultants than as primary caregivers.

“There were obvious problems with the formerly open system. The teams were often at odds on how to handle patients, and the floor teams wanted to keep as much control of the unit patients as they could. After the change, the unit and its staff worked much more smoothly and efficiently with the floor teams transferring patient care to the dedicated medical ICU team,” Dr. Aranson recalls.

“Things fell into place when we changed to the intensivist model. When a patient moved from the floor to the ICU, the floor team could follow the patient’s progress but could not write orders. All patient care fell under the aegis of the unit teams. However, the floor team was encouraged to follow the patient while in critical care. This helped streamline continuity of care when patients left the ICU and returned to the floor,” continues Dr. Aranson.

Split between two floors, the two original open medical ICUs each held eight patients in one room with curtained off beds. The new unit has reasonably sized individual rooms that can easily fit all necessary equipment including ventilators. “The new design made life easier for everyone who worked in the medical ICU,” says Dr. Aranson.

“Having an intensivist driven ICU is essential for providing better patient care at lower cost with better outcomes. The system is a good system, and I am very happy working in that system at Grady,” concludes Marc Moss, MD, codirector of Grady’s medical ICU.

Dr. Aranson left Grady Memorial Hospital three years ago to return to his native Maine, where he is a pulmonologist and intensivist at Mercy Hospital in Portland.

Editor's note: The Society is seeking similar success stories about implementing the multidisciplinary team model by its members. Because implementing the model is often a challenging task, sharing your experience may help other intensivists overcome similar obstacles to the ones you faced. Your experience will also help SCCM highlight the fact that the multidisciplinary team model can work in any setting and that the intensivist can work effectively with other healthcare providers.

These stories will be collected and published by SCCM as a resource to its members and other healthcare practitioners.