As a member of a study team, McGowan Institute for Regenerative Medicine affiliated faculty member Derek C. Angus, M.D., M.P.H., professor and the Dr. Mitchell P. Fink Chair in Critical Care Medicine, and director of CRISMA (Clinical Research, Investigation, and Systems Modeling of Acute Illnesses) Center at the University of Pittsburgh, reported that intensive care units (ICUs) that have no or limited access to critical care doctors during the day can improve patient outcomes by having the specialists, called intensivists, staff the unit at night. However, the researchers were unable to find any incremental benefit of nighttime staffing in ICUs that were robustly staffed with the specialists during the day. The findings were published in the New England Journal of Medicine.
Research has shown that daytime staffing with intensivists improves ICU patient outcomes, noted senior author Jeremy M. Kahn, M.D., associate professor, Department of Critical Care Medicine, Pitt School of Medicine. But fewer than half of all ICUs in the U.S. are manned by intensivists, while many large medical centers, particularly teaching hospitals such as UPMC, have adopted not only intensivist staffing but have extended it to a 24-hour intensivist staffing model.
"Intuition would suggest that round-the-clock attention from an expert trained in critical care medicine would be of even greater benefit to these very ill patients," Dr. Kahn said. "But until this project, no one had carefully examined whether that assumption would hold true. As it turns out, having some access to intensivists, who are in great demand, is the key to better outcomes. Round-the-clock intensivist staffing is only helpful in some ICUs."
The research team reviewed admission details between 2009 and 2010 from 34 community and academic hospitals that use the Acute Physiology and Chronic Health Evaluation clinical information system, a database that collects details of patient outcomes as well as ICU staffing primarily for internal quality control monitoring. The researchers sent follow-up surveys to those hospitals and received responses from 25, which included 49 ICUs and nearly 66,000 patient admissions.
Dr. Kahn and his colleagues found that patient mortality was lower in ICUs where an intensivist was available at night only if there was no intensivist heavily involved in care during the day. In ICUs where intensivists were on duty during the day, mortality was unaffected by the presence of intensivists at night.
"There is a huge opportunity to improve survival rates in some ICUs by bringing an intensivist on board at night," Dr. Kahn said. "However, there aren't enough of us to staff all the ICUs that need intensivists, so hospitals with a strong intensivist presence during the day – like most academic medical centers – should consider whether additional intensivist coverage is needed at night."
Abstract (Nighttime intensivist staffing and mortality among critically ill patients. David J. Wallace, M.D., M.P.H., Derek C. Angus, M.D., M.P.H., Amber E. Barnato, M.D., M.P.H., Andrew A. Kramer, Ph.D., and Jeremy M. Kahn, M.D. The New England Journal of Medicine; online May 21, 2012.)