Hospitalist and Intensivist Experiences of the “Open” Intensive Care Unit Environment: a Qualitative Exploration

Abstract

Background: Most U.S. academic medical centers employ “closed” intensive care units (ICUs), where critically ill patients are admitted under the supervision of intensivists managing dedicated ICU teams. Some centers utilize a unique “open” ICU structure, where primary services longitudinally follow patients who become critically ill into the ICU with intensivist comanagement. The impact of open ICUs on patient care and education of trainees has not been well-characterized. Objective: The objective of this study is to characterize affordances and barriers to education and patient care, from the perspectives of hospitalists and intensivists teaching in the ICU. Design: We conducted semi-structured interviews with hospitalist and intensivist faculty at a large academic medical center with an open ICU structure. We coded deidentified interview transcripts to inductively analyze the data for themes and subthemes. Participants: We recruited hospitalist and intensivist faculty members who attend on teaching services in the open ICU system. Approach: Given the complexity of multiple teachers and learners in the ICU environment, we selected shared mental models as our primary theoretical lens through which we analyzed and interpreted our data. Key Results: We identified three main themes regarding education in the open ICU system: (1) communication challenges, (2) educational barriers and affordances, and (3) structural barriers and affordances. Hospitalists and intensivists agreed on some barriers and facilitators to education, such as continuity of care, yet they disagreed on others. Specifically, hospitalists and intensivists had a shared mental model regarding barriers to patient care and education in the open ICU structure, but had divergent opinions regarding the affordances of the structure, such as continuity and availability of ICU expertise. Conclusions: The open ICU environment presents facilitators and barriers to trainee education and patient care. Our findings can be leveraged to improve communication, education, and patient care on both hospitalist and ICU teams.