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Sleep and Work in ICU Physicians During a Randomized Trial of Nighttime Intensivist Staffing.

ABSTRACT: OBJECTIVES:To compare sleep, work hours, and behavioral alertness in faculty and fellows during a randomized trial of nighttime in-hospital intensivist staffing compared with a standard daytime intensivist model. DESIGN:Prospective observational study. SETTING:Medical ICU of a tertiary care academic medical center during a randomized controlled trial of in-hospital nighttime intensivist staffing. PATIENTS:Twenty faculty and 13 fellows assigned to rotations in the medical ICU during 2012. INTERVENTIONS:As part of the parent study, there was weekly randomization of staffing model, stratified by 2-week faculty rotation. During the standard staffing model, there were in-hospital residents, with a fellow and faculty member available at nighttime by phone. In the intervention, there were in-hospital residents with an in-hospital nighttime intensivist. Fellows and faculty completed diaries detailing their sleep, work, and well-being; wore actigraphs; and performed psychomotor vigilance testing daily. MEASUREMENTS AND MAIN RESULTS:Daily sleep time (mean hours [SD]) was increased for fellows and faculty in the intervention versus control (6.7 [0.3] vs 6.0 [0.2]; p < 0.001 and 6.7 [0.1] vs 6.4 [0.2]; p < 0.001, respectively). In-hospital work duration did not differ between the models for fellows or faculty. Total hours of work done at home was different for both fellows and faculty (0.1 [< 0.1] intervention vs 1.0 [0.1] control; p < 0.001 and 0.2 [< 0.1] intervention vs 0.6 [0.1] control; p < 0.001, respectively). Psychomotor vigilance testing did not demonstrate any differences. Measures of well-being including physical exhaustion and alertness were improved in faculty and fellows in the intervention staffing model. CONCLUSIONS:Although no differences were measured in patient outcomes between the two staffing models, in-hospital nighttime intensivist staffing was associated with small increases in total sleep duration for faculty and fellows, reductions in total work hours for fellows only, and improvements in subjective well-being for both groups. Staffing models should consider how work duration, sleep, and well-being may impact burnout and sustainability.

SUBMITTER: Bakhru RN

PROVIDER: S-EPMC6579612 | biostudies-literature | 2019 Jul

REPOSITORIES: biostudies-literature

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Sleep and Work in ICU Physicians During a Randomized Trial of Nighttime Intensivist Staffing.

Bakhru Rita N RN Basner Mathias M Kerlin Meeta Prasad MP Halpern Scott D SD Hansen-Flaschen John J Rosen Ilene M IM Dinges David F DF Schweickert William D WD

Critical care medicine 20190701 7

<h4>Objectives</h4>To compare sleep, work hours, and behavioral alertness in faculty and fellows during a randomized trial of nighttime in-hospital intensivist staffing compared with a standard daytime intensivist model.<h4>Design</h4>Prospective observational study.<h4>Setting</h4>Medical ICU of a tertiary care academic medical center during a randomized controlled trial of in-hospital nighttime intensivist staffing.<h4>Patients</h4>Twenty faculty and 13 fellows assigned to rotations in the med ...[more]

PMID: 30985450

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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.).

Project description:BackgroundIncreasing numbers of intensive care units (ICUs) are adopting the practice of nighttime intensivist staffing despite the lack of experimental evidence of its effectiveness.MethodsWe conducted a 1-year randomized trial in an academic medical ICU of the effects of nighttime staffing with in-hospital intensivists (intervention) as compared with nighttime coverage by daytime intensivists who were available for consultation by telephone (control). We randomly assigned blocks of 7 consecutive nights to the intervention or the control strategy. The primary outcome was patients' length of stay in the ICU. Secondary outcomes were patients' length of stay in the hospital, ICU and in-hospital mortality, discharge disposition, and rates of readmission to the ICU. For length-of-stay outcomes, we performed time-to-event analyses, with data censored at the time of a patient's death or transfer to another ICU.ResultsA total of 1598 patients were included in the analyses. The median Acute Physiology and Chronic Health Evaluation (APACHE) III score (in which scores range from 0 to 299, with higher scores indicating more severe illness) was 67 (interquartile range, 47 to 91), the median length of stay in the ICU was 52.7 hours (interquartile range, 29.0 to 113.4), and mortality in the ICU was 18%. Patients who were admitted on intervention days were exposed to nighttime intensivists on more nights than were patients admitted on control days (median, 100% of nights [interquartile range, 67 to 100] vs. median, 0% [interquartile range, 0 to 33]; P<0.001). Nonetheless, intensivist staffing on the night of admission did not have a significant effect on the length of stay in the ICU (rate ratio for the time to ICU discharge, 0.98; 95% confidence interval [CI], 0.88 to 1.09; P=0.72), ICU mortality (relative risk, 1.07; 95% CI, 0.90 to 1.28), or any other end point. Analyses restricted to patients who were admitted at night showed similar results, as did sensitivity analyses that used different definitions of exposure and outcome.ConclusionsIn an academic medical ICU in the United States, nighttime in-hospital intensivist staffing did not improve patient outcomes. (Funded by University of Pennsylvania Health System and others; ClinicalTrials.gov number, NCT01434823.).

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.

Project description:PurposeThe COVID-19 pandemic caused a massive healthcare crisis. To investigate what makes healthcare system resilient and physicians better at coping during a crisis situation, our study investigated the role risk exposure, such as working at COVID-19 entry points, sleep, and perceived work safety played in reducing negative psychological functioning at work, as well as their effects on adverse and potentially fatal incidences of compromised safety and medical errors.MethodsOur study included a representative sample of 1,189 physicians, from all 12 Slovenian regions and all medical occupations, as registered by the Medical Chamber of Slovenia. For the purposes of this study, a Questionnaire of Sleep and Psychological Functioning at Work was developed in the form of an online retrospective self-report. Additionally, our study included items assessing physicians perceived work safety and frequency of negative outcomes (compromised safety and medical errors) during the first month of the Covid-19 epidemic.ResultsPhysicians working at COVID-19 entry points were more likely to experience night awakening, slept less than 5 h per night, experience nightmares, and had lower levels of psychological functioning in comparison to other physicians. Both hypothesized models showed adequate fit. A higher score on the sleep scale (sleep quantity, sleep quality, and shorter sleep latency) has been shown to predict lower levels of negative psychological functioning at work and, indirectly, reduced incidences of compromised safety and medical errors. Contrary to our expectations, no significant direct effect of sleep on compromised safety and medical errors was found. When perceived work safety was added into the model, the model showed improved fit, with perceived work safety predicting better sleep, less negative psychological functioning at work, and less compromised safety.ConclusionSleep and safety both play an important role in reducing negative psychological functioning at work and, by doing so, decreasing the negative and potentially fatal incidents during the pandemic, such as compromised safety and medical errors. Further, research is needed to see how medical guidelines can be updated to ensure physicians sleep and that their safety is protected.

Project description:BackgroundA large body of research suggests that hospitals with intensive care units staffed by board-certified intensivists have lower mortality rates than those that do not.ObjectiveTo determine whether hospitals can reduce their mortality by adopting an intensivist staffing model.DesignRetrospective, longitudinal study using 2003-2010 Medicare data and the Leapfrog Group Hospital surveys.Setting and patientsIn total, 2,916,801 Medicare patients at 488 US hospitals.MeasurementsWe studied 30-day and in-hospital mortality among patients with several common medical and surgical conditions. We first compared risk-adjusted mortality rates of 3 groups of hospitals: those that were intensivist staffed throughout this time period, those that were not intensivist staffed, and those that transitioned to intensivist staffing somewhere during the period. We then examined rates of mortality improvement within each of the 3 groups and used difference-in-differences techniques to assess the independent effect of intensivist staffing among the subset of hospitals that transitioned.ResultsHospitals with intensivist staffing at the beginning of our study period had lower mortality rates than those without. However, hospitals that adopted intensivist staffing during the study period did not substantially improve their mortality rates. In our difference-in-differences analysis, there was no significant independent improvement in mortality after transitioning to intensivist staffing either overall [relative risk (RR), 0.96; 95% confidence interval (CI), 0.90-1.02] or in the medical (RR, 0.95; 95% CI, 0.89-1.02) or surgical populations (RR, 0.97; 95% CI, 0.84-1.10).LimitationsRisk adjustment was based on administrative data. Categorization of exposure was by survey response at the hospital level.ConclusionsAdoption of an intensivist staffing model was not associated with improved mortality in Medicare beneficiaries. These findings suggest that the lower mortality rates previously observed at hospitals with intensivist staffing may be attributable to other factors.

Project description:BackgroundHigh-quality leadership improves resuscitation for in-hospital cardiac arrest (IHCA), but experienced resuscitation leaders are unavailable in many settings.Research questionDoes real-time telemedical intensivist consultation improve resuscitation quality for IHCA?Study design and methodsIn this multicenter randomized controlled trial, standardized high-fidelity simulations of IHCA conducted between February 2017 and September 2018 on inpatient medicine and surgery units at seven hospitals were assigned randomly to consultation (intervention) or simulated observation (control) by a critical care physician via telemedicine. The primary outcome was the fraction of time without chest compressions (ie, no-flow fraction) during an approximately 4- to 6-min analysis window beginning with telemedicine activation. Secondary outcomes included other measures of chest compression quality, defibrillation and medication timing, resuscitation protocol adherence, nontechnical team performance, and participants' experience during resuscitation participation.ResultsNo-flow fraction did not differ between the 36 intervention group (0.22 ± 0.13) and the 35 control group (0.19 ± 0.10) resuscitation simulations included in the intention-to-treat analysis (P = .41). The etiology of the simulated cardiac arrest was identified more often during evaluable resuscitations supported by a telemedical intensivist consultant (22/32 [69%]) compared with control resuscitations (10/34 [29%]; P = .001), but other measures of resuscitation quality, resuscitation team performance, and participant experience did not differ between intervention groups. Problems with audio quality or the telemedicine connection affected 14 intervention group resuscitations (39%).InterpretationConsultation by a telemedical intensivist physician did not improve resuscitation quality during simulated ward-based IHCA.Trial registryClinicalTrials.gov; No.: NCT03000829; URL: www.Clinicaltrialsgov.

Dataset Information

Sleep and Work in ICU Physicians During a Randomized Trial of Nighttime Intensivist Staffing.

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Sleep and Work in ICU Physicians During a Randomized Trial of Nighttime Intensivist Staffing.

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