[HSF] ICU Management Systems

[Jbflegejr at aol.com]

Michael,  
I had the opportunity to work as a visiting surgeon in Umea, Sweden for three 
months in 2001-2002 and participated in a system of care from which we could 
derive some ideas. Umea has a tertiary care university medical center. The 
heart center had cardiac surgeons, cardiologists, cardiac anesthesiologists, and 
support staffs in a single administrative unit which was headed by Torkel 
Aberg, the chief of cardiac surgery. About 1000 cardiac operations, all adult, 
were done annually and the case mix was similar to ours as to age, diabetes, COPD 
and other comorbities. Hospital mortality ranged from 1% to 2% since 
inception of the unit in 1988. They have a CT surgical training program. There were 
seven or eight attending surgeons which included a visiting surgeon or two. 
Physicians in Sweden, trainees and attendings, have observed a mandated 40 hour 
work week for thirty years. 
The surgeons and anesthesiologists provided the postoperative care until 
discharge. The surgeons rotated beween operative duties and postoperative care 
every two weeks or so. When a surgeon was on operative duty, that is all that he 
did, ordinarily a case or two each day. When he was on postoperative care with 
the anesthesiologists he also was responsible for consultations and made the 
decisions for operation or not. The operating surgeon reviewed the patient 
assigned to him for operation the evening before and made the final decision 
before proceeding. The operating surgeon was finished at the end of the day and if 
his operation was not finished, the on-call surgeon took over. Imagine my 
surprise as I was well along with operation for aortic dissection when the on 
call surgeon tapped me on the shoulder and informed me that it was 5 o’clock and 
I was finished for the day. 
The on-call team composed of surgeons and anesthesiologists took care of the 
patients at night and weekends including take-backs for bleeding, emergencies, 
etc. 
I characterised this as a corporate system and it provided as good care as I 
have seen. It depended on a staff that had equivalent capability and trusted 
one another and on  highly standardized policies and procedures. It functioned 
well despite the rather stringent work hour constraints. 
I am sure that those of you who read this will put forward plenty of reasons 
why such a system could never work in the USA such as the doctors won’t accept 
it, the patients won’t accept it, the system for payment won’t work, the 
surgeon cannot have all of his individual preferences, etc. 
In my view, the way we work now does not work very well and as those of us 
who grew up awhile ago when ideals and expectations were considerably different 
drift from the scene the way we work now will be untenable. I firmly believe 
that within a short time work hour constraints will apply to all physicians and 
will be considerably more stringent than now. How are the patients, which 
will likely include me, going to receive good care unless we drastically change 
the way we work?  John Flege



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