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ICU Physician Staffing24/7 Intensivist Staffing: What Else Do We Need to Know? FREE TO VIEW

Craig M. Lilly, MD, FCCP
Author and Funding Information

From the Department of Medicine, University of Massachusetts Medical School.

CORRESPONDENCE TO: Craig M. Lilly, MD, FCCP, Department of Medicine, University of Massachusetts Medical School, UMass Memorial Medical Center, 281 Lincoln St, Worcester, MA 01605; e-mail: Craig.Lilly@umassmed.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. 2015;147(4):867-868. doi:10.1378/chest.14-2661
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In this issue of CHEST (see page 951), Kerlin and colleagues1 provide another layer of evidence that 24/7 intensivist staffing is not associated with significant mortality or length-of-stay benefits. The observation that high-intensity critical care specialist involvement is associated with lower mortality and costs for adults with severe illness and injuries2 led to the hypothesis that 24/7 on-site intensivist staffing would result in better outcomes than daytime-only on-site staffing.3,4 The role of 24/7 intensivist staffing models for improving outcomes is an important issue in an era when the supply of critical care specialists is insufficient to meet the demands of an aging population.5 Concentrating specialists in ICUs that provide 24/7 staffing is expensive for institutions that can retain enough intensivists and reduces access to specialist care for other ICUs who must compete for a smaller pool of qualified specialists.

This study by Kerlin and colleagues1 is consistent with most other studies, including a randomized trial of 24/7 staffing6 and an 8-week crossover Canadian study,7 and with a prior smaller observational study from this group.8 The consistency of the major findings of these studies moves the field beyond examining the veracity of associations of outcomes with 24/7 intensivist staffing models to a focus on what critical care specialists do that improves outcomes for their patients. New hypotheses are required to explain the apparent incongruity of studies indicating that 24/7 intensivist staffing is not associated with length-of-stay or mortality benefits with studies that find that high-intensity critical care staffing impacts these outcomes.

One hypothesis is that high-intensity staffing models serve as a surrogate marker for ICUs that have processes, procedures, and protocols that are effective enough for delivering the details of high-quality critical care such that off-hours intensivist intervention is so rarely required that differences in outcomes are difficult to detect. In this paradigm, progress depends on methods for selecting the right protocols for each patient and building teams that deliver this care with high fidelity. Critical care specialists play a key role for protocol and procedure development and for monitoring patient selection. The creation of accurate methods for identifying effective protocols and efficient ways to share and deliver them hold great promise for advancing the field. Another hypothesis for the failure of 24/7 intensivist models is that key interventions like source control for infections, renal replacement therapy, and interventional procedures may not be available after hours, such that off-hours recognition by a specialist does not impact outcomes.

A third hypothesis is that implementation of a 24/7 ICU physician staffing model does not reliably change key behaviors and consequently does not change outcomes. It is possible that the addition of 24/7 intensivist interventions in which specialists are continuously active and working to verify primary source information, reviewing key imaging studies, are evaluating patients with evolving physiologic instability, and are present at the time of initial intake to confirm key clinical findings would have greater impact on outcomes than interventions where staff sleeping on-site rather than off-site are awakened to answer phone calls when subordinate clinicians choose to call them. In this scenario, progress depends on increasing timely intensivist engagement in key activities and the effectiveness of supporting health information technologies. Addressing these new hypotheses will require a new generation of critical care databases that include case-level metrics of clinical activity, researchers to analyze them, and a focus on process, outcomes, and quality from those who fund research.

References

Kerlin MP, Harhay MO, Kahn JM, Halpern SD. Nighttime intensivist staffing, mortality, and limits on life support: a retrospective cohort study. Chest. 2015;147(4):951-958.
 
Pronovost PJ, Angus DC, Dorman T, Robinson KA, Dremsizov TT, Young TL. Physician staffing patterns and clinical outcomes in critically ill patients: a systematic review. JAMA. 2002;288(17):2151-2162. [CrossRef] [PubMed]
 
Rubenfeld GD, Angus DC. Are intensivists safe? Ann Intern Med. 2008;148(11):877-879. [CrossRef] [PubMed]
 
Burnham EL, Moss M, Geraci MW. The case for 24/7 in-house intensivist coverage. Am J Respir Crit Care Med. 2010;181(11):1159-1160. [CrossRef] [PubMed]
 
Angus DC, Kelley MA, Schmitz RJ, White A, Popovich J Jr; Committee on Manpower for Pulmonary and Critical Care Societies (COMPACCS). Caring for the critically ill patient. Current and projected workforce requirements for care of the critically ill and patients with pulmonary disease: can we meet the requirements of an aging population? JAMA. 2000;284(21):2762-2770. [CrossRef] [PubMed]
 
Kerlin MP, Small DS, Cooney E, et al. A randomized trial of nighttime physician staffing in an intensive care unit. N Engl J Med. 2013;368(23):2201-2209. [CrossRef] [PubMed]
 
Garland A, Roberts D, Graff L. Twenty-four-hour intensivist presence: a pilot study of effects on intensive care unit patients, families, doctors, and nurses. Am J Respir Crit Care Med. 2012;185(7):738-743. [CrossRef] [PubMed]
 
Kerlin MP, Halpern SD. Nighttime physician staffing in an intensive care unit. N Engl J Med. 2013;369(11):1075. [CrossRef] [PubMed]
 

Figures

Tables

References

Kerlin MP, Harhay MO, Kahn JM, Halpern SD. Nighttime intensivist staffing, mortality, and limits on life support: a retrospective cohort study. Chest. 2015;147(4):951-958.
 
Pronovost PJ, Angus DC, Dorman T, Robinson KA, Dremsizov TT, Young TL. Physician staffing patterns and clinical outcomes in critically ill patients: a systematic review. JAMA. 2002;288(17):2151-2162. [CrossRef] [PubMed]
 
Rubenfeld GD, Angus DC. Are intensivists safe? Ann Intern Med. 2008;148(11):877-879. [CrossRef] [PubMed]
 
Burnham EL, Moss M, Geraci MW. The case for 24/7 in-house intensivist coverage. Am J Respir Crit Care Med. 2010;181(11):1159-1160. [CrossRef] [PubMed]
 
Angus DC, Kelley MA, Schmitz RJ, White A, Popovich J Jr; Committee on Manpower for Pulmonary and Critical Care Societies (COMPACCS). Caring for the critically ill patient. Current and projected workforce requirements for care of the critically ill and patients with pulmonary disease: can we meet the requirements of an aging population? JAMA. 2000;284(21):2762-2770. [CrossRef] [PubMed]
 
Kerlin MP, Small DS, Cooney E, et al. A randomized trial of nighttime physician staffing in an intensive care unit. N Engl J Med. 2013;368(23):2201-2209. [CrossRef] [PubMed]
 
Garland A, Roberts D, Graff L. Twenty-four-hour intensivist presence: a pilot study of effects on intensive care unit patients, families, doctors, and nurses. Am J Respir Crit Care Med. 2012;185(7):738-743. [CrossRef] [PubMed]
 
Kerlin MP, Halpern SD. Nighttime physician staffing in an intensive care unit. N Engl J Med. 2013;369(11):1075. [CrossRef] [PubMed]
 
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