Full-Time Cardiac Intensive Care Unit Staffing by Heart Failure Specialists and its Association with Mortality Rates

https://doi.org/10.1016/j.cardfail.2021.09.013Get rights and content

Highlights

  • •

    Patients admitted to cardiac intensive care units (CICUs) have complex multiorgan dysfunction.

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    There is a shortage of dual-certified critical care cardiologists; therefore, new CICU models are needed.

  • •

    A closed CICU model staffed by a heart failure specialist is associated with lower mortality in CICUs.

ABSTRACT

Background

Cardiac intensive care units (CICUs) serve medically complex patients with multiorgan dysfunction. Whether a CICU that is staffed full time by heart failure (HF) specialists is associated with decreased mortality is unclear.

Methods and Results

A retrospective review of consecutive CICU admissions from January 1, 2012, to December 31, 2016, was performed. In January 2014, the CICU changed from an open unit staffed by any cardiologist to a closed unit managed by HF specialists. Patients’ baseline characteristics were determined, and a multivariate regression analysis was performed to ascertain mortality rates in the CICU. Baseline severity of illness was higher in the closed/HF specialist CICU model (P< 0.001). Death occurred in 101 of 1185 patients admitted to the CICU (8.5%) in the open-unit model and in 139 of 2163 patients (6.4%) admitted to the closed/HF specialist model (absolute risk reduction 2.1%, 95% confidence interval [CI] 0.1–4.0%; P = 0.01). The transition from an open to a closed/HF specialist model was associated with a lower overall CICU mortality rate (odds ratio [OR] 0.63; 95% CI 0.43–0.93). Prespecified interaction with a mechanical circulatory support device and unit model showed that treatment with such a device was associated with lower mortality rates in the closed/HF specialist model of a CICU (OR 0.6; 95% CI 0.18–0.78; P for interaction <0.01).

Conclusion

Transition to a closed unit model staffed by a dedicated HF specialist is associated with lower CICU mortality rates.

Graphical Abstract

Visual take-home. Transition from an open cardiac intensive care unit (CICU) to a closed/heart failure (HF)-staffed CICU. An open CICU was staffed by any cardiologist who supervised a house staff team composed of interns, residents and a cardiology fellow. The patient's primary cardiologist was ultimately responsible for the treatment plan. The CICU was transitioned to a closed-unit staffed by an HF-trained cardiologist. The house staff team was unchanged, but the HF cardiologist was responsible for and managed all of the patients in the CICU. Transition to a closed/HF-specialist CICU model was associated with lower CICU mortality rates, lower adjusted CICU mortality, and lower mortality rates of patients treated with mechanical circulatory support devices.

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Section snippets

Methods

This was a retrospective cohort study design that covered the period of January 1, 2012, to December 31, 2016. During this study period, 3353 patients were admitted to the CICU at Montefiore Medical Center (Bronx, NY); 382 patients were eliminated from the study because they had no history of cardiovascular disease and were admitted to the CICU as “MICU overflow.” The remaining 2971 patients representing 3348 admissions were divided into an open-unit group (1085 patients with 1185 admissions)

Results

During the study period, 2971 patients were admitted to the CICU and met study criteria (Table 1): 1085 patients had 1185 admissions during the open-unit model of management, and 1886 patients had 2163 admissions during the closed/HF specialist CICU model. Of the patients, 62% were male . Hypertension, diabetes, chronic kidney disease, atrial fibrillation, and histories of stroke were common in both groups. During hospitalization, 21% of patients required mechanical ventilation, 24% of patients

Discussion

This study compared mortality rates in an open-unit CICU model to those in a closed CICU model staffed by dedicated HF specialists. Our principal findings are the following: (1) a closed/HF specialist CICU model is associated with lower CICU mortality rates compared to an open-unit CICU model; (2) length of stay in the CICU was similar for the closed/HF specialist model; and (3) a closed/HF specialist CICU model is associated with lower CICU mortality for sicker patients (ie, those with

Conclusion

Admission to a closed-unit model CICU staffed by a HF cardiologist is associated with lower CICU mortality rates. Having a HF cardiologist staff a closed CICU model may be another appropriate strategy for caring for critically ill cardiac patients.

Disclosures

Ulrich P. Jorde is a consultant for Abbott. All other authors have no disclosures to report.

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    These authors contributed equally to the study.

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