Are Intensive Care Units Effective

Does intensive care work and does the way in which it is provided affect patients' outcomes? A higher rate of attributable mortality has been documented in patients who are refused intensive care, particularly on an emergency basis.1 Clinical outcome is improved by the conversion of so-called "open" ICU to closed facilities in which patient management is directed primarily by intensive care specialists.2 3 Superior organisational practices emphasising strong medical and nursing leadership can also improve outcome.4 The emergence of intermediate care, high dependency, or step down facilities has attempted to fill the growing gap between the level of care that may be provided in the ICU and that in the general wards. Worryingly, the time at which patients are discharged from ICU in the UK has a demonstrable effect on their outcome.5 Early identification of patients at risk of death—both before admission and after discharge from the

ICU—may decrease mortality.6 Patients can be identified who have a low risk of mortality and who are likely to benefit from a brief period of more intensive supervision and care.7 Designated teams that are equipped to transfer critically ill patients between specialist units have a crucial role to play in ensuring that patient care and the use of resources are optimized.8 Finally, long term follow up of the critically ill as outpatients following discharge from hospital may identify problems of chronic ill health that require active management and rehabilitation.9

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