0
Correspondence |

Another Meaningful End Point for Nighttime Intensivist CoverageShifting the Focus on House Staff Education FREE TO VIEW

Jason Rho, MD; Catherine Hompesch, MD; Timil Patel, MD
Author and Funding Information

From the Department of Pulmonary and Critical Care Medicine (Dr Rho) and the Department of Internal Medicine (Drs Hompesch and Patel), University of Texas Southwestern Medical Center.

CORRESPONDENCE TO: Jason Rho, MD, Department of Pulmonary and Critical Care Medicine, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390; e-mail: jason.rho@phhs.org


FINANCIAL/NONFINANCIAL DISCLOSURES: The authors have 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;148(2):e66. doi:10.1378/chest.15-0520
Text Size: A A A
Published online
To the Editor:

We read in earnest the retrospective study by Kerlin et al1 in the recent issue of CHEST (April 2015), which found that nighttime intensivist staffing is not associated with a reduction in ICU or hospital mortality rate and overall length of stay. This study, as the authors noted, supports the existing body of work, from a single-center randomized controlled trial, multicentered observational study, and meta-analysis, that shows this staffing model failing to improve upon patient-centered outcomes such as mortality rate and length of stay in high-intensity daytime staffed ICUs.1 Other clinical end points outside of patient-centered outcomes, such as reduced financial costs2 and reduced physician burnout,3 have also been examined.

As physicians in various stages of our medical training, we contend that the next most important question to address is to what degree nighttime intensivist presence impacts the education of residents and fellows. Survey data from two studies suggest that house staff perceive less autonomy when having 24-h supervision.3,4 Whether this translates into less overall competency and more overreliance on guidance that can affect trainees’ future medical practice and knowledge base has yet to be resolved. Identifying a causal relationship, if any, between nighttime intensivist coverage and house staff education may prove to be an arduous task. Nonetheless, surrogate end points, such as patient, family, and nursing evaluations of overnight house staff trained in these two different staffing models; procedural complication or failure rates of overnight house staff; or even simulation-based testing, may help clarify this murky relationship. Furthermore, the curtailed clinical exposure of house staff in the era of duty hour regulations more than ever necessitates verifiable assurance of high-quality training. Even in the single-centered randomized trial conducted at the University of Pennsylvania, residents were “expected to review all new admissions and critical events with a fellow, an intensivist, or both, in person or by telephone within 1 hour.”5 As more academic medical centers move toward adopting nighttime intensivist supervision, gone may be the days when house staff, yet not their patients, have to live, die, and learn with the decisions that they alone make. We call on future investigators and studies of 24-h intensivist coverage to include house staff education as a meaningful end point.

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. [CrossRef] [PubMed]
 
Banerjee R, Naessens JM, Seferian EG, et al. Economic implications of nighttime attending intensivist coverage in a medical intensive care unit. Crit Care Med. 2011;39(6):1257-1262. [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]
 
Diaz-Guzman E, Colbert CY, Mannino DM, Davenport DL, Arroliga AC. 24/7 in-house intensivist coverage and fellowship education: a cross-sectional survey of academic medical centers in the United States. Chest. 2012;141(4):959-966. [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]
 

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. [CrossRef] [PubMed]
 
Banerjee R, Naessens JM, Seferian EG, et al. Economic implications of nighttime attending intensivist coverage in a medical intensive care unit. Crit Care Med. 2011;39(6):1257-1262. [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]
 
Diaz-Guzman E, Colbert CY, Mannino DM, Davenport DL, Arroliga AC. 24/7 in-house intensivist coverage and fellowship education: a cross-sectional survey of academic medical centers in the United States. Chest. 2012;141(4):959-966. [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]
 
NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).

Some tools below are only available to our subscribers or users with an online account.

Related Content

Customize your page view by dragging & repositioning the boxes below.

Find Similar Articles
  • CHEST Journal
    Print ISSN: 0012-3692
    Online ISSN: 1931-3543