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Correspondence |

Shifting the Focus of ICU Staffing Research to the CommunityShifting the Focus of ICU Staffing Research FREE TO VIEW

Nishi Rawat, MD
Author and Funding Information

From the Johns Hopkins Community Physicians and Armstrong Institute for Patient Safety and Quality, The Johns Hopkins University.

Correspondence to: Nishi Rawat, MD, Johns Hopkins Community Physicians, 5755 Cedar Ln, Columbia, MD 21044; e-mail: nrawat1@jhmi.edu


Financial/nonfinancial disclosures: The author has reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2012;142(6):1695-1696. doi:10.1378/chest.12-1831
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To the Editor:

In an issue of CHEST (May 2012), I read with great interest the article on 24-h intensivist staffing in teaching hospitals by Kerlin and Halpern1 because it was published at the same time as a large retrospective study that did not reveal a mortality benefit with night intensivist staffing at high-intensity ICUs.2 Kerlin and Halpern1 make strong arguments in support of prospective randomized trials on the topic of ICU staffing. As well, I recently questioned the need for 24-h intensivist coverage on the basis of my anecdotal experience in the community setting.3

In the article, the authors focused on the risks and benefits of 24-h attending staff as these relate to medical education and the care of patients in an academic setting. They also briefly discussed the potential for the unintended consequences of decreased staffing and compromising care at regional hospitals, widening existing chasms of care. I emphasize that this is not a theoretical problem—it is real and ever growing in the community, where the shortage of trained intensivists is already painfully felt. For this reason, this topic should be examined in earnest, as advocated by the authors, and the focus should shift to the community setting. I believe that there is a pressing need to explore the value of night intensivists to community ICUs, more so than studying that of a night ICU attending physician working with trainees vs trainees alone to academic ICUs.

Most community hospitals in my metropolitan region have shifted from a 12- or 16-h workday to 24-h coverage. As Kerlin and Halpern1 mentioned, the benefits of this move seemingly have strong face validity and the support of observational studies. However, a significant consequence of this shift is that a small regional pool of community intensivists is now spread thin to cover nights. This, in turn, has led to lean and fractured day coverage and exacerbated a provider tug-of-war between facilities where full-time equivalent (FTE) and moonlighting physicians recruited to fill voids created by night staffing at one facility leave voids at another. For example, we recently recruited an FTE physician from one facility, leaving that facility, which had recently transitioned to 24-h coverage, more short staffed. A nearby hospital just transitioned to 24-h staffing and recruited one of our moonlighter physicians, necessitating our FTE physicians to work more nights. These voids are challenging to fill given the ongoing shortage of trained intensivists and may offset the purported benefits of 24-h coverage.

Nonacademic ICUs account for more than one-half of the ICUs in the United States.4 Despite this, most ICU staffing research to date has involved academic centers, leaving a paucity of evidence to guide community ICU staffing. Research on staffing in academia has focused on the question of whether 24-h attending physician coverage is necessary. This has little bearing on community ICUs because these typically are staffed with one intensivist, not a team of trainees led by an attending physician. The main question for community ICUs is whether the presence of a night intensivist is at all necessary if there is high-intensity staffing during the day. Alternatives to 24-h intensivist staffing include night intensivist phone coverage, remote video monitoring, physician extender coverage, expanded hospitalist coverage, or any combination of these. These alternatives need to be explored rigorously because the demand for trained intensivists continues to outstrip supply. If viable, these alternatives may help to alleviate the increasing staffing strain in the community.

References

Kerlin MP, Halpern SD. Twenty-four-hour intensivist staffing in teaching hospitals: tensions between safety today and safety tomorrow. Chest. 2012;141(5):1315-1320. [CrossRef] [PubMed]
 
Wallace DJ, Angus DC, Barnato AE, Kramer AA, Kahn JM. Nighttime intensivist staffing and mortality among critically ill patients. N Engl J Med. 2012;366(22):2093-2101. [CrossRef] [PubMed]
 
Rawat N. Intensive care unit staffing: an academic debate but a community crisis. Crit Care Med. 2012;40(3):1032. [CrossRef] [PubMed]
 
Angus DC, Shorr AF, White A, Dremsizov TT, Schmitz RJ, Kelley MA; Committee on Manpower for Pulmonary and Critical Care Societies (COMPACCS). Critical care delivery in the United States: distribution of services and compliance with Leapfrog recommendations. Crit Care Med. 2006;34(4):1016-1024. [CrossRef] [PubMed]
 

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References

Kerlin MP, Halpern SD. Twenty-four-hour intensivist staffing in teaching hospitals: tensions between safety today and safety tomorrow. Chest. 2012;141(5):1315-1320. [CrossRef] [PubMed]
 
Wallace DJ, Angus DC, Barnato AE, Kramer AA, Kahn JM. Nighttime intensivist staffing and mortality among critically ill patients. N Engl J Med. 2012;366(22):2093-2101. [CrossRef] [PubMed]
 
Rawat N. Intensive care unit staffing: an academic debate but a community crisis. Crit Care Med. 2012;40(3):1032. [CrossRef] [PubMed]
 
Angus DC, Shorr AF, White A, Dremsizov TT, Schmitz RJ, Kelley MA; Committee on Manpower for Pulmonary and Critical Care Societies (COMPACCS). Critical care delivery in the United States: distribution of services and compliance with Leapfrog recommendations. Crit Care Med. 2006;34(4):1016-1024. [CrossRef] [PubMed]
 
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