Nighttime Intensivist Coverage May Not Benefit All ICUs
By Betty Tran, MD, MS
Assistant Professor of Medicine, Pulmonary and Critical Care Medicine, Rush University Medical Center
Dr. Tran reports no financial relationships relevant to this field of study. This article originally appeared in the July 2012 issue of Critical Care Alert. It was edited by David J. Pierson, MD, and peer reviewed by William Thompson, MD. Dr. Pierson is Professor Emeritus, Pulmonary and Critical Care Medicine, University of Washington, Seattle, and Dr. Thompson is Associate Professor of Medicine, University of Washington, Seattle. Drs. Pierson and Thompson report no financial relationships relevant to this field of study.
Synopsis: This retrospective, multicenter study found that nighttime intensivist staffing is associated with lower patient mortality only in ICUs that lack mandatory daytime intensivist staffing.
Source: Wallace DJ, et al. Nighttime intensivist staffing and mortality among critically ill patients. N Engl J Med 2012;366:2093-3101.
Supporters of 24-hour intensivist staffing in the ICU cite potential benefits to the patient as a result of more timely and accurate diagnostic evaluation, consistent provision of complex treatment, and overall higher quality, safer care. Previous studies, however, have reported conflicting results with regard to patient outcomes in ICUs with nighttime intensivist staffing. This study by Wallace and colleagues sought to examine the relationship between nighttime intensivist staffing and mortality in patients admitted to the ICU.
The authors conducted a retrospective study using data obtained for 65,752 patients admitted to 49 ICUs in 25 hospitals (74% of all surveyed sites) participating in the Acute Physiology and Chronic Health Evaluation (APACHE) clinical outcomes database from 2009 through 2010. The hospitals were diverse with regard to academic status, geographic location, and number of ICU beds, and there were no significant differences between hospitals participating in the study and those that did not. Of the 49 ICUs that participated, 12 had nighttime intensivist staffing, contributing data for 14,424 admits (22%), and 37 had no nighttime intensivist for 51,328 admits (78%). There were no significant differences between patients admitted to ICUs with or without nighttime intensivists.
Nighttime intensivist staffing was associated with a reduction in risk-adjusted in-hospital mortality only in ICUs with low intensity (i.e., optional consultation) daytime intensivist coverage (odds ratio [OR] 0.62, P = 0.04). In ICUs with high intensity (i.e., mandatory consultation or primary care by an intensivist) daytime intensivist staffing, there was no additional mortality benefit associated with an in-hospital nighttime intensivist (OR 1.08, P = 0.78). These results were supported by sensitivity analyses in subgroup populations most likely to benefit from in-house nighttime intensivist staffing: patients receiving active treatment on admit, undergoing mechanical ventilation, admitted at night, with the highest acute physiology scores, and admitted with sepsis. Similar results were also found in a separate verification cohort using data from the Pennsylvania Health Care Cost Containment Council (PHC4). An additional finding was that when the definition of nighttime intensivist staffing was modified to include a resident physician, nighttime staffing was associated with lower mortality in all ICUs, although the addition of a nighttime intensivist to an ICU already staffed by residents offered no extra benefit in outcomes.
Commentary
As more hospitals contemplate moving toward 24-hour intensivist staffing, the potential benefits of such efforts will need to be weighed against the inherent costs and requisite expansion of the intensivist workforce necessary to build such programs. Crucial to this decision is the need for solid data supporting better outcomes in patients admitted to ICUs with nighttime intensivist staffing compared to other ICU models.
This study has important implications for addressing this dilemma. The findings suggest that ICUs already staffed by an intensivist either as a consultant or as the primary person responsible for the patient’s care or that have resident physician nighttime coverage do not benefit from the addition of a nighttime intensivist in the hospital in terms of reducing patient mortality. On the other hand, ICUs in which daytime intensivist input is merely optional may benefit from nighttime intensivist staffing. This latter observation is not surprising, as mandatory intensivist staffing in the ICU is associated with lower ICU and hospital mortality.1
Overall, the findings of this study argue against widespread implementation of 24-hour intensivist staffing as standard of care. Specific to academic teaching hospitals, there is added concern for loss of resident and fellow physician autonomy when a 24-hour intensivist is present. There are, however, other potential benefits to nighttime intensivist staffing. These include reduced intensivist burnout, increased allied health staff satisfaction, reduced patient ICU length of stay, and fewer procedural complications. Further studies on all these outcomes are warranted. In the meantime, individual ICUs will need to define carefully the anticipated benefits they hope to derive from 24-hour intensivist coverage and at what costs prior to expanding their staffing.
Reference.
1. Pronovost PJ, et al. Physician staffing patterns and clinical outcomes in critically ill patients: A systematic review. JAMA 2002;288:2151-2162.
This retrospective, multicenter study found that nighttime intensivist staffing is associated with lower patient mortality only in ICUs that lack mandatory daytime intensivist staffing.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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