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Original Research: Critical Care Medicine |

Nighttime Intensivist Staffing, Mortality, and Limits on Life SupportNighttime Intensivist Staffing and ICU Outcomes: A Retrospective Cohort Study

Meeta Prasad Kerlin, MD, MSCE; Michael O. Harhay, MPH; Jeremy M. Kahn, MD; Scott D. Halpern, MD, PhD
Author and Funding Information

From the Pulmonary, Allergy, and Critical Care Division, Department of Medicine (Drs Kerlin and Halpern), Center for Clinical Epidemiology and Biostatistics (Drs Kerlin and Halpern and Mr Harhay), and Department of Medical Ethics and Health Policy (Dr Halpern), Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Leonard Davis Institute of Health Economics (Drs Kerlin and Halpern and Mr Harhay), P30 Roybal Center on Behavioral Economics and Health (Dr Halpern), and Fostering Improvement in End-of-Life Decision Science (FIELDS) Program (Dr Halpern), University of Pennsylvania, Philadelphia, PA; and Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center (Dr Kahn), Department of Critical Care, University of Pittsburgh School of Medicine, Pittsburgh, PA.

CORRESPONDENCE TO: Meeta Prasad Kerlin, MD, MSCE, Pulmonary, Allergy, and Critical Care Division, Perelman School of Medicine, University of Pennsylvania, 3600 Spruce St, W Gates Bldg, Rm 05011, Philadelphia, PA 19104; e-mail: prasadm@uphs.upenn.edu


FOR EDITORIAL COMMENT SEE PAGE 867

Part of this article has been presented in abstract form at the American Thoracic Society 2013 International Congress, May 17-22, 2013, Philadelphia, PA.

FUNDING/SUPPORT: This project was supported in part by a grant from the National Heart, Lung, and Blood Institute [K08HL116771 to Dr Kerlin] and a grant from the Agency for Healthcare Research and Quality [K08HS018406 to Dr Halpern].

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


Chest. 2015;147(4):951-958. doi:10.1378/chest.14-0501
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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.

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