From the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, University of California Davis; and the VA Northern California Health Care System, Mather, CA.
CORRESPONDENCE TO: Narin Sriratanaviriyakul, MD, Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, University of California Davis, 4150 V St, Ste 3400, Sacramento, CA 95817; e-mail: firstname.lastname@example.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.
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We read with great interest the article in a recent issue of CHEST (April 2015) by Kerlin et al,1 who retrospectively reported the outcomes of patients admitted to ICUs with nighttime staffing with an attending intensivist. The study showed no significant difference in mortality when compared with ICUs without nighttime attending intensivist staffing. Their results are consistent with their previous single-center randomized trial2 and other studies.3,4
As the authors have already discussed in the limitations of the study, although mortality is an important outcome, it may not capture many other roles of an intensivist. More than providing artificial organ or life supports, intensivist physicians also help patients and families establish goals of care with either primary intention of cure or focus on comfort. Once the goals of care are established, intensivist physicians may help establish and provide nosocomial end-of-life care. Mortality rate alone does not reflect the overall quality of care, as some deaths are perhaps expected as a result of maximizing comfort rather than curative care after thoughtful discussions with patients and families.
Furthermore, in this article, Kerlin et al1 observed a counterintuitive finding that the absence of nighttime physicians (of any kind) is associated with lower mortality. The authors attempted to explain this finding that the staffing models may be associated with differences in end-of-life care. This was supported by another finding that the ICUs without nighttime physician staffing were also less likely to have new limitations on life support established at night.
Another important role of the intensivist that often gets overlooked is managing ICU triage. Hence, the inclusion criteria of this study may lead to selection bias, as it included only subjects admitted to ICUs but not all subjects who were screened and triaged to different levels of care. If patients of lower acuity were triaged away from the ICU, the ICU mortality would likely be increased in the remaining sicker ICU patient population.
In our opinion, the use of mortality outcome may not be an appropriate sole indicator of quality of care for all critically ill patients. Thus, it is premature to conclude that the presence of nighttime intensivists is not of clinical benefit in ICUs, as stated by Kerlin et al.1 Future studies should address the quality of care by assessing clinical outcomes and compliance to therapeutic bundles of specific diseases, such as sepsis and ARDS.
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