2 AJTCCM VOL. 31 NO. 1 2025
EDITORIAL
e COVID-19 pandemic exposed the strengths and vulnerabilities of
healthcare systems worldwide, intensifying the debate over open and
closed intensive care unit (ICU) models. ese models have profound
implications for patient outcomes, resource utilisation and system
eciency. In times of crisis, achieving a balance between high-quality
care, resource optimisation and equitable access is of paramount
importance. Central to this debate are ethical considerations of
equity, justice and resource allocation. Ultimately, the challenge lies
in determining which model most eectively treats the maximum
number of patients without compromising quality of care – a decision
fundamentally dictated by the availability of trained personnel, cost-
eectiveness, and prioritisation of patient outcomes.
e closed ICU model, led by intensivists who oversee all aspects
of care, provides centralised, expert-driven management. is model
adheres to the ethical principle of utility – maximising survival
outcomes by prioritising the limited resources for those most likely
to benet.
Current evidence strongly supports the superiority of closed
ICUs, citing intensivist expertise, proactive infection control, and
efficient resource utilisation. Sharayah et al.[1] reported a 19.3%
reduction in central line-associated bloodstream infections along
with the elimination of catheter-associated urinary tract infections
and ventilator-associated pneumonias aer transitioning to a closed
ICU. Van der Sluijs et al.,[2] in a narrative review, documented
a36-61% cost reduction in closed ICUs. A comprehensive meta-
analysis by Vahedian-Azimi etal.,[3] encompassing 444 042 patients,
revealed signicantly higher ICU mortality (relative risk (RR) 1.16;
95% confidence interval (CI) 1.07-1.27; p<0.001) and hospital
mortality (RR 1.12; 95% CI 1.03-1.22; p=0.010) and longer ICU stays
(standardised mean dierence 0.43; 95% CI 0.01-0.85; p=0.040) in
open ICUs, ndings reinforced by recent systematic reviews and meta-
analysis.[4,5]
e promise of improved mortality and length of stay paints a
compelling picture. However, the true impact of ICU models is far
from straightforward. Conicting results, signicant heterogeneity
within the meta-analyses, and variability in study designs, patient
populations and resources reveal just how complex this issue is.
Patient and family satisfaction, long-term recovery and quality of life
remain underexplored and inconclusive – important considerations
when assessing overall ICU performance.
Importantly, most of the available evidence stems from the USA,
where advanced technology and specialised care prevail. For low-
and middle-income countries (LMICs) the relevance of this evidence
is questionable, overshadowed by the harsh realities of limited
infrastructure and workforce constraints.
Interestingly, closed ICUs reveal unexpected vulnerabilities during
periods of extreme strain. Studies report a rise in risk-adjusted
mortality in closed ICUs compared with their open counterparts,[6]
and a concerning decline in adherence to prophylaxis guidelines.[7]
While biases, including bias by indication, undoubtedly inuence
these ndings, they reveal the burden of centralised responsibility and
the stark reality of intensivist burnout, emphasising that even the most
robust systems have breaking points.
In reality, the widespread implementation of closed ICUs is
not feasible in resource-poor settings. The significant shortage
of intensivists renders round-the-clock intensivist coverage an
aspirational goal rather than a practical reality. e higher stang and
resource demands pose substantial nancial and logistical challenges,
especially for public hospitals and smaller facilities. is reliance on
specialised personnel and infrastructure risks limiting access to care,
potentially excluding vulnerable patients who may benet from life-
saving interventions.
Open ICUs, where general physicians manage care with ad hoc input
from intensivists, oer exibility and scalability, enabling hospitals to
rapidly expand critical care capacity. is model prioritises equity
– ensuring broader access to critical care while leveraging existing
resources.
However, the decentralised structure and less standardised
framework of open ICUs have inherent limitations. e absence of
intensivist-led management can lead to inconsistent application of
evidence-based protocols, fragmented communication and conicting
treatment decisions, particularly in complex cases. Additionally,
challenges in infection control, compounded by overcrowding and
infrastructural limitations, heighten the risk of nosocomial infections,
a signicant concern during periods of increased demand. Currently,
evidence supporting open ICUs is less robust than that supporting
the closed model, potentially reecting the settings in which they are
more commonly implemented. Moreover, existing literature primarily
focuses on transitions from an open ICU to a closed ICU model, with
little to no attention given to the reverse transition.
e retrospective study by Gwala etal.[8] in this issue of AJTCCM
makes an important contribution to the limited literature from LMICs,
oering timely insights into the feasibility of the open ICU model as a
practical solution during periods of overwhelming demand.
To expand capacity during the COVID-19 pandemic, an open ICU,
managed by base-discipline specialists with ad hoc intensivist support,
was integrated alongside the tertiary hospital’s traditional closed ICU
model. Triage and bed allocation were centralised under the closed
ICU team. Both units beneted from the expertise of experienced
ICU nurses, a notable contrast to many settings grappling with critical
shortages of such specialised personnel.
e authors compared the outcomes of 203 non-COVID patients
managed under the two ICU stang models: 77 patients in the open
ICU and 126 patients in the closed ICU. e ndings revealed no
signicant dierences in key outcomes, including in-hospital mortality
(16.9% in the open ICU v. 15.1% in the closed ICU; p=0.769), adverse
event incidence (45.5% v. 38.9%; p=0.357), and hospital length of stay
(median 4 days v. 3 days; p=0.635).
While the study provides much-needed perspectives for the
implementation of an open ICU model, several considerations aect
its generalisability. e study’s focus on a younger, healthier population
with low illness severity (median Acute Physiologic Assessment and
Intensive care unit models in pandemics and beyond: Striking the
balance between eciency, ethics and equity
AJTCCM VOL. 31 NO. 1 2025 3
EDITORIAL
Chronic Health Evaluation (APACHE II) score 7; predicted mortality
5-10%) is particularly noteworthy. With a median (IQR) age of 38
(26-53) years, over half of the participants having no comorbidities
(56%), and a substantial proportion not critically ill but admitted
primarily for intensive monitoring (36%; Society of Critical Care
Medicine (SCCM) score II), the ndings may not readily apply to
older, more complex ICU populations, particularly high-risk medical
patients. is limitation is underscored by the association of advancing
age and comorbidities with higher mortality in the open ICU (OR
1.034 and 4.58, respectively), absent in the closed model. Potential
biases in patient allocation, an inherent challenge during crises,
may explain these dierences. Notably, trauma patients, typically
considered high risk, were 2.4 times more likely to be admitted to
the closed ICU, while a greater proportion of SCCM III patients
(patients with a more guarded prognosis) were admitted to the open
ICU (20.8% v. 7.1%). Although Gwala etal.’s study provides support
for open ICUs, it serves as an important reminder to consider patient
populations, illness severity and contextual factors when assessing the
true impact of the ICU model in question.
Most studies have looked at the eect of medical management of
open or closed ICUs. In this study, experienced ICU nurses were
present in both the open and closed ICUs. e role of nurses may be an
important consideration. Transition from open to closed ICU models
has invariably imposed a new (intensivist-led) medical hierarchy on
an established intensive care nursing system. is change in structure
has usually been associated with better outcomes and increased
nursing satisfaction.[9,10] Skilled nursing is one of the most important
determinants of ICU outcome and may be more important than the
medical input, once appropriate protocols for general ICU care and
infection prevention and control have been established.
e urgent need for adaptable and exible critical care models
has never been clearer. Emerging hybrid approaches, combining
the strengths of open and closed systems and tailored to the unique
demands of individual settings, offer a pragmatic and balanced
solution particularly suited to pandemics and beyond. However, their
success hinges on strategic patient selection, and their ecacy in high-
acuity, diverse populations and LMICs remains uncertain – a glaring
research gap that demands immediate attention.
e COVID-19 pandemic starkly exposed the persistent inequities
in access to quality critical care. is crisis calls for decisive action.
Empowering healthcare providers through workforce training,
contextual research, innovative technology and telemedicine will
strengthen critical care delivery. Customising ICU models to meet the
distinct needs of various environments oers a sustainable solution.
Strengthening collaboration between physicians and intensivists,
supported by standardised local protocols, is essential to reinforce
critical care systems and ensure resilience. e goal is not simply
to prepare ICUs for future pandemics but to address longstanding
disparities that leave vulnerable communities underserved. The
reward of commitment is a future where critical care is a fundamental
right, not a privilege.
Usha Lalla
FCP (SA), Cert Critical Care (SA) Phys, Cert Pulmonology (SA)
Division of Pulmonology, Department of Medicine, Faculty of Medicine and
Health Sciences, Stellenbosch University and Tygerberg Hospital, Cape Town,
South Africa
usha@sun.ac.za
Richard Raine
MB ChB, MMed (Med), FCP (SA)
Division of Pulmonology, Department of Medicine, Faculty of Health
Sciences, University of Cape Town and Groote Schuur Hospital, Cape Town,
SouthAfrica
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