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Nighttime intensivist staffing, mortality, and limits on life support: a retrospective cohort study.

ABSTRACT:

Background

Evidence regarding nighttime physician staffing of ICUs is suboptimal. We aimed to determine how nighttime physician staffing models influence patient outcomes.

Methods

We performed a multicenter retrospective cohort study in a multicenter registry of US ICUs. The exposure variable was the ICU's nighttime physician staffing model. The primary outcome was hospital mortality. Secondary outcomes included new limitations on life support, ICU length of stay, hospital length of stay, and duration of mechanical ventilation. Daytime physician staffing was studied as a potential effect modifier.

Results

The study included 270,742 patients in 143 ICUs. Compared with nighttime staffing with an attending intensivist, nighttime staffing without an attending intensivist was not associated with hospital mortality (OR, 1.03; 95% CI, 0.92-1.15; P = .65). This relationship was not modified by daytime physician staffing (interaction P = .19). When nighttime staffing was subcategorized, neither attending nonintensivist nor physician trainee staffing was associated with hospital mortality compared with attending intensivist staffing. However, nighttime staffing without any physician was associated with reduced odds of hospital mortality (OR, 0.79; 95% CI, 0.68-0.91; P = .002) and new limitations on life support (OR, 0.83; 95% CI, 0.75-0.93; P = .001). Nighttime staffing was not associated with ICU or hospital length of stay. Nighttime staffing with an attending nonintensivist was associated with a slightly longer duration of mechanical ventilation (hazard ratio, 1.05; 95% CI, 1.02-1.09; P < .001).

Conclusions

We found little evidence that nighttime physician staffing models affect patient outcomes. ICUs without physicians at night may exhibit reduced hospital mortality that is possibly attributable to differences in end-of-life care practices.

SUBMITTER: Kerlin MP

PROVIDER: S-EPMC4388125 | biostudies-literature |

REPOSITORIES: biostudies-literature

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Project description:BackgroundHospitals are increasingly adopting 24-hour intensivist physician staffing as a strategy to improve intensive care unit (ICU) outcomes. However, the degree to which nighttime intensivists are associated with improvements in the quality of ICU care is unknown.MethodsWe conducted a retrospective cohort study involving ICUs that participated in the Acute Physiology and Chronic Health Evaluation (APACHE) clinical information system from 2009 through 2010, linking a survey of ICU staffing practices with patient-level outcomes data from adult ICU admissions. Multivariate models were used to assess the relationship between nighttime intensivist staffing and in-hospital mortality among ICU patients, with adjustment for daytime intensivist staffing, severity of illness, and case mix. We conducted a confirmatory analysis in a second, population-based cohort of hospitals in Pennsylvania from which less detailed data were available.ResultsThe analysis with the use of the APACHE database included 65,752 patients admitted to 49 ICUs in 25 hospitals. In ICUs with low-intensity daytime staffing, nighttime intensivist staffing was associated with a reduction in risk-adjusted in-hospital mortality (adjusted odds ratio for death, 0.62; P=0.04). Among ICUs with high-intensity daytime staffing, nighttime intensivist staffing conferred no benefit with respect to risk-adjusted in-hospital mortality (odds ratio, 1.08; P=0.78). In the verification cohort, there was a similar relationship among daytime staffing, nighttime staffing, and in-hospital mortality. The interaction between nighttime staffing and daytime staffing was not significant (P=0.18), yet the direction of the findings were similar to those in the APACHE cohort.ConclusionsThe addition of nighttime intensivist staffing to a low-intensity daytime staffing model was associated with reduced mortality. However, a reduction in mortality was not seen in ICUs with high-intensity daytime staffing. (Funded by the National Heart, Lung, and Blood Institute.).

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Project description:Daytime intensivist physician staffing is associated with improved outcomes in the ICU. However, it is unclear whether this association persists in the era of interprofessional, protocol-directed critical care. We sought to reexamine the association between daytime intensivist physician staffing and ICU mortality and determine if interprofessional rounding and protocols for mechanical ventilation in part mediate this relationship.Retrospective cohort study of ICUs in the Acute Physiology and Chronic Health Evaluation clinical information system from 2009 to 2010.Forty-nine ICUs in 25 U.S. hospitals.Adults (17 yr and older) admitted to a study ICU.None.We defined high-intensity daytime intensivist staffing as either a mandatory consult or closed ICU model; interprofessional rounds as rounds that included a respiratory therapist, pharmacist, physician and nurse; and protocol use as having protocols for liberation from mechanical ventilation and lung protective mechanical ventilation. Using multivariable logistic regression, we estimated the independent effect of daytime intensivist physician staffing on in-hospital mortality controlling for interprofessional rounds and protocols for mechanical ventilation, as well as other patient and hospital characteristics. Twenty-seven ICUs (55%) reported high-intensity daytime physician staffing, 42 ICUs (85%) reported daily interprofessional rounds, and 31 (63%) reported having protocols for mechanical ventilation. There was no association between daytime intensivist physician staffing and in-hospital mortality (adjusted odds ratio, 0.86; 95% CI, 0.65-1.14). After adjusting for interprofessional rounds and protocols for mechanical ventilation, the effect of daytime intensivist physician staffing remained nonsignificant (adjusted odds ratio, 0.90; 95% CI, 0.70-1.17).High-intensity daytime physician staffing in the ICU was not significantly associated with lower mortality in a modern cohort. This association was not affected by interprofessional rounds or protocols for mechanical ventilation.

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