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Respiratory Care |

Physician Staffing Models Impact the Timing of Decisions to Limit Life Support in the ICU

Michael Wilson*, MD; Ramez Samirat, MD; Murat Yilmaz, MD; Ognjen Gajic, MD; Vivek Iyer, MD
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Mayo Clinic, Rochester, MN


Chest. 2012;142(4_MeetingAbstracts):933A. doi:10.1378/chest.1389700
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Abstract

SESSION TYPE: Hot Topics in Respiratory & Critical Care

PRESENTED ON: Tuesday, October 23, 2012 at 04:30 PM - 05:45 PM

PURPOSE: A growing ICU trend is the implementation of 24 hour in-house staff intensivist coverage models. The impact of these staffing changes on the quality of end-of-life care and decision making is unclear. Our purpose was to measure the impact of 24 hour in-house staff intensivist coverage on 1) the quality of end of life care measures and 2) the timing of end-of-life decision making in a tertiary level medical ICU.

METHODS: Single center retrospective cohort study of all ICU related deaths that occurred 6 months before and after the implementation of mandatory 24 hour staff intensivist coverage in a medical ICU on January 3, 2006. Prior to the staffing change, the ICU was staffed by in house residents and fellows with a staff intensivist present in house during the day and on home call at night. The staffing change resulted 24 hour in-house staff intensivist coverage.

RESULTS: Eighty five deaths occurred in the 6 months prior to the staffing change and 65 deaths after. Decisions to limit life support were made in 70% of study subjects. After the staffing intervention: time from ICU admission to decision for withdrawal of mechanical ventilation was shortened by 2 days (p=.03), time to decision for change to do-not-resuscitate code status was shortened by 2 days (p=.03), time to initiation of comfort care orders was shortened by 1 day (p=.01) and time to family conference was shortened by 2 days (p=.09). Time to decision for withdrawal/withholding of life support was also shortened by 1 day (p=.08), and time to death was shortened by 2 days (p=.08 ). Other quality measures such as increased family presence around time of death (p=.01), and decreased intubations against patient wishes (from 3 to 0, p=.12) also improved in the period after the staffing change.

CONCLUSIONS: The implementation of mandatory 24 hour ICU in-house staff intensivist coverage was associated with quicker decision making across of a number of end-of-life domains. Positive trends were noted in quality of end-of-life care as reflected in family presence at time of death and decreased intubations against patient wishes.

CLINICAL IMPLICATIONS: Delivering appropriate and timely end-of-life care is an often overlooked quality measure. Physician staffing models influence decision making and quality of care at the end of life. Further studies are needed to better define the impact of staffing models on the delivery of end-of-life care.

DISCLOSURE: The following authors have nothing to disclose: Michael Wilson, Ramez Samirat, Murat Yilmaz, Ognjen Gajic, Vivek Iyer

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Mayo Clinic, Rochester, MN

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