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


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



      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).


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

      Graphical Abstract

      Key Words

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        • Julian DG.
        The history of coronary care units.
        Br Heart J. 1987; 57: 497-502
        • Braunwald E.
        Evolution of the management of acute myocardial infarction: a 20th century saga.
        Lancet. 1998; 352: 1771-1774
        • Katz JN
        • Turer AT
        • Becker RC.
        Cardiology and the critical care crisis: a perspective.
        J Am Coll Cardiol. 2007; 49: 1279-1282
        • Katz JN
        • Shah BR
        • Volz EM
        • Horton JR
        • Shaw LK
        • Newby LK
        • et al.
        Evolution of the coronary care unit: clinical characteristics and temporal trends in healthcare delivery and outcomes.
        Crit Care Med. 2010; 38: 375-381
        • Morrow DA
        • Fang JC
        • Fintel DJ
        • Granger CB
        • Katz JN
        • Kushner FG
        • et al.
        Evolution of critical care cardiology: transformation of the cardiovascular intensive care unit and the emerging need for new medical staffing and training models: a scientific statement from the American Heart Association.
        Circulation. 2012; 126: 1408-1428
        • Sinha SS
        • Sjoding MW
        • Sukul D
        • Prescott HC
        • Iwashyna TJ
        • Gurm HS
        • et al.
        Changes in primary noncardiac diagnoses over time among elderly cardiac intensive care unit patients in the United States.
        Circ Cardiovasc Qual Outcomes. 2017; 10e003616
        • Miller PE
        • Thomas A
        • Breen TJ
        • Chouairi F
        • Kunitomo Y
        • Aslam F
        • et al.
        Prevalence of noncardiac multimorbidity in patients admitted to two cardiac intensive care units and their association with mortality.
        Am J Med. 2021; 134: 653-661
        • Quinn T
        • Weston C
        • Birkhead J
        • Walker L
        • Norris R
        • Group MS.
        Redefining the coronary care unit: an observational study of patients admitted to hospital in England and Wales in 2003.
        QJM. 2005; 98: 797-802
        • Carson SS
        • Stocking C
        • Podsadecki T
        • Christenson J
        • Pohlman A
        • MacRae S
        • et al.
        Effects of organizational change in the medical intensive care unit of a teaching hospital: a comparison of “open” and “closed” formats.
        JAMA. 1996; 276: 322-328
        • Pronovost PJ
        • Angus DC
        • Dorman T
        • Robinson KA
        • Dremsizov TT
        • Young TL.
        Physician staffing patterns and clinical outcomes in critically ill patients: a systematic review.
        JAMA. 2002; 288: 2151-2162
        • Wilcox ME
        • Chong CA
        • Niven DJ
        • Rubenfeld GD
        • Rowan KM
        • Wunsch H
        • et al.
        Do intensivist staffing patterns influence hospital mortality following ICU admission? A systematic review and meta-analyses.
        Crit Care Med. 2013; 41: 2253-2274
        • El-Kersh K
        • Guardiola J
        • Cavallazzi R
        • Wiemken TL
        • Roman J
        • Saad M.
        Open and closed models of intensive care unit have different influences on infectious complications in a tertiary care center: a retrospective data analysis.
        Am J Infect Control. 2016; 44: 1744-1746
        • O'Malley RG
        • Olenchock B
        • Bohula-May E
        • Barnett C
        • Fintel DJ
        • Granger CB
        • et al.
        Organization and staffing practices in US cardiac intensive care units: a survey on behalf of the American Heart Association Writing Group on the Evolution of Critical Care Cardiology.
        Eur Heart J Acute Cardiovasc Care. 2013; 2: 3-8
        • Na SJ
        • Chung CR
        • Jeon K
        • Park CM
        • Suh GY
        • Ahn JH
        • et al.
        Association between presence of a cardiac intensivist and mortality in an adult cardiac care unit.
        J Am Coll Cardiol. 2016; 68: 2637-2648
        • Miller PE
        • Thomas A
        • Kunitomo Y
        • Aslam F
        • Canavan ME
        • et al.
        Transition from an open to closed staffing model in the cardiac intensive care unit improves clinical outcomes.
        J Am Heart Assoc. 2021; : ;10e:01818
        • Fanari Z
        • Barekatain A
        • Kerzner R
        • Hammami S
        • Weintraub WS
        • Maheshwari V.
        Impact of a multidisciplinary team approach including an intensivist on the outcomes of critically ill patients in the cardiac care unit.
        Mayo Clin Proc. 2016; 91: 1727-1734
        • Kapoor K
        • Verceles AC
        • Netzer G
        • Chaudhry A
        • Bolgiano M
        • Devabhakthuni S
        • et al.
        A collaborative cardiologist-intensivist management model improves cardiac intensive care unit outcomes.
        J Am Coll Cardiol. 2017; 70: 1422-1423
        • Chang SY
        • Multz AS
        • Hall JB.
        Critical care organization.
        Crit Care Clin. 2005; 21 (viii): 43-53
        • Katz JN
        • Minder M
        • Olenchock B
        • Price S
        • Goldfarb M
        • Washam JB
        • et al.
        The genesis, maturation, and future of critical care cardiology.
        J Am Coll Cardiol. 2016; 68: 67-79
        • Brusca SB
        • Barnett C
        • Barnhart BJ
        • Weng W
        • Morrow DA
        • Soble JS
        • et al.
        Role of critical care medicine training in the cardiovascular intensive care unit: survey responses from dual certified critical care cardiologists.
        J Am Heart Assoc. 2019; 8e011721
        • Blumenthal DM
        • Mikhael B
        • Lawler PR
        • Yeh RW
        • Metlay JP
        • Dudzinski DM.
        Personal and professional characteristics of U.S. dual-boarded critical care cardiologists in 2015.
        Crit Care Med. 2017; 45: e1292-e12e6
        • Knaus WA
        • Wagner DP
        • Zimmerman JE
        APACHE II: a severity of disease classification system.
        Crit Care Med. 1985; 13: 818-823
        • Gall Le
        • LS JR
        • Saulnier F.
        A new Simplified Acute Physiology Score (SAPS II) based on a European/North American multicenter study.
        JAMA. 1993; 270: 2957-2963
        • Fuster V.
        The (r)evolution of the CICU: better for the patient, better for education.
        J Am Coll Cardiol. 2018; 72: 2269-2271
      1. American Board of Internal Medicine. Candidates Certified–All Candidates. Available at: Accessed September 17, 2021.

      2. Keningsberg B, Barnett CF. Cardiovascular intensive care training. July 31, 2018. Available at: Accessed July 15, 2020.

      3. Accreditation Council for Graduate Medical Education. Advanced heart failure and transplant cardiology (159). Available at: Accessed September 2, 2020.

        • Ratcliffe JA
        • Wilson E
        • Islam S
        • Platsman Z
        • Leou K
        • Williams G
        • et al.
        Mortality in the coronary care unit.
        Coron Artery Dis. 2014; 25: 60-65
        • Campanile A
        • Castellani C
        • Santucci A
        • Annunziata R
        • Tutarini C
        • Reccia MR
        • et al.
        Predictors of in-hospital and long-term mortality in unselected patients admitted to a modern coronary care unit.
        J Cardiovasc Med (Hagerstown). 2019; 20: 327-334
        • Holland EM
        • Moss TJ.
        Acute noncardiovascular illness in the cardiac intensive care unit.
        J Am Coll Cardiol. 2017; 69: 1999-2007
        • Massetti M
        • Tasle M
        • Le Page O
        • Deredec R
        • Babatasi G
        • Buklas D
        • et al.
        Back from irreversibility: extracorporeal life support for prolonged cardiac arrest.
        Ann Thorac Surg. 2005; 79 (discussion 83–4): 178—83
        • Thiele H
        • Zeymer U
        • Neumann FJ
        • Ferenc M
        • Olbrich HG
        • Hausleiter J
        • et al.
        Intraaortic balloon support for myocardial infarction with cardiogenic shock.
        N Engl J Med. 2012; 367: 1287-1296
        • Ouweneel DM
        • Eriksen E
        • Sjauw KD
        • van Dongen IM
        • Hirsch A
        • Packer EJ
        • et al.
        Percutaneous mechanical circulatory support versus intra-aortic balloon pump in cardiogenic shock after acute myocardial infarction.
        J Am Coll Cardiol. 2017; 69: 278-287
        • Shah M
        • Patnaik S
        • Patel B
        • Ram P
        • Garg L
        • Agarwal M
        • et al.
        Trends in mechanical circulatory support use and hospital mortality among patients with acute myocardial infarction and non-infarction related cardiogenic shock in the United States.
        Clin Res Cardiol. 2018; 107: 287-303