Page 47 - Hall et al (2015) Principles of Critical Care-McGraw-Hill

16 PART 1: An Overview of the Approach to and Organization of Critical Care

best is the same in ICU and non-ICU settings, we will restrict ourselves day. Some have also pointed to data showing that care is worse at night;
to data derived from ICUs, and generally from adult ICUs. Although the however, that literature is contradictory, with some studies showing such
major focus will be on clinically relevant outcomes for patients, where an effect 19-25 and others not. 26-32 Others have called for 24/7 intensivist
available we will also include considerations of other outcomes that are presence by suggesting that it will provide better end-of-life care, and
important to HCWs and society, such as job satisfaction and costs. As benefit trainees and nurses. 15
3
highlighted below, this literature has numerous limitations, and at the Despite abundant opinions, there are sparse data on this topic, most
current time does not supply much guidance on how best to staff ICUs. of which were observational, or used before versus after designs that
suffer from the pitfalls of historical controls. Blunt et al, reported that
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INTENSIVISTS the standardized hospital mortality ratio after changing to the 24/7 staff-
ing model among 824 patients in a single ICU in the United Kingdom
Many investigators have tried to address whether ICU patients have bet- declined from 1.11 to 0.81. For 4388 patients in a medical ICU in the
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ter outcomes if there are intensivists (attending physician specialists in United States such a change was not associated with improved ICU sur-
critical care medicine) involved in their care, or if they receive a higher vival (10.2 vs 10.4%, p = 0.83), hospital survival (17% vs 19%, p = 0.33),
“dose” of intensivist care. This literature is difficult to interpret and apply or family satisfaction, though it was associated with some improvements
because determining whether intensivist involvement produces better in ICU-acquired complications, processes of care, and reduced intensiv-
outcomes would require all physicians to round in a similar controlled ist burnout. Of note, in this latter situation, the standard ICU staffing
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fashion, and for there to be no other differences in ICU administration, model had ICU fellows present overnight. In the only interventional
team composition or function. No such experiments have been done. study, which did not use historical controls, Garland et al utilized an
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■ OPEN VERSUS CLOSED ICUS, AND RELATED TOPICS alternating crossover study design in two closed-model, intensivist-run
ICUs, one academic and one in a community hospital without house
Most of these studies relate to “open” versus “closed” ICU structures. staff. Inclusion of the community ICU is valuable because it is more
Usually, an open ICU has patients cared for by multiple generalists with comparable to the majority of ICUs than are the large, academic units,
or without assistance of intensivists, while in a closed ICU the attending which are the subject of most ICU research. 16,37 In this study, 24/7
physician of record for all the patients is a single intensivist. Open ICUs intensivist presence did not produce better patient outcomes or family
are more common in the United States and some other countries, satisfaction in either ICU. The main effect of the shiftwork model was
4-6
while closed ICUs are the rule in other areas. However, this delinea- on the intensivists, for whom it was associated with lower job and life
7,8
tion does not adequately define the intensivist staffing model, as there stresses. In the largest study to date, Wallace et al performed a retrospec-
are countless variations and intermediate models for both types. tive, cross-sectional analysis of 49 ICUs participating in the APACHE
6,9
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Furthermore, there are often a host of other differences between open database project. Their sophisticated analysis indicated that nocturnal
and closed ICUs, making it difficult to say that any benefits of closed- intensivist presence was associated with lower hospital mortality in ICUs
model ICUs are due to the involvement of intensivists; for example, with low-intensity involvement of intensivists in daytime care (OR =
closed ICUs are more common in larger, academic hospitals that typi- 0.62, p = 0.04), but not in those with high-intensity daytime intensivist
cally have residents and ICU fellows working in them. 4,6 involvement (OR = 1.08, p = 0.78).
More than 30 studies have compared outcomes in open versus closed These observations highlight the fact that the impact of 24/7 intensiv-
ICUs. Most of these have been from single ICUs, and most used before ist coverage may depend on ICU type, and preexisting staffing. Also,
versus after study design that in all cases changed from open to closed it is important to note that 24/7 staffing requires more intensivists, a
units. These have yielded mixed results. In a systematic review and serious challenge given the worsening intensivist shortage. 39,40 While no
meta-analysis of 27 studies involving 27,000 patients, Pronovost et al complete analysis of costs has been done, Banerjee et al reported that
tried to make sense of the organizational diversity of ICUs by dividing around-the-clock intensivist staffing led to lower direct costs, but only
intensivist involvement into high versus low “intensity.” High intensity for the sickest patients. 41
10
by an intensivist was mandatory. They found that high-intensity inten- ■ INTENSIVIST WORKLOAD
comprised both closed-model ICUs and open ICUs where consultation
sivist involvement was associated with lower ICU and hospital mortality Workload is related to staffing, and there has been concern about
(unadjusted, pooled risk ratios of 0.61 and 0.71, respectively) and also intensivists’ workload. This concern derives from data showing that job
shorter ICU and hospital length of stay (LOS). An economic evaluation burnout among intensivists is not rare, 42-44 and that trainees’ perception
based on these findings indicated that costs would be lower with high- of high workload discourages them from going into this subspecialty.
45
intensity intensivist involvement. In contrast, Levy et al performed a Though there has been great attention to reducing the workload of
11
cross-sectional study using the Project IMPACT database, including physician trainees, little attention has been paid to the consequences for
101,000 patients in 123 ICUs. Adjusting for severity of illness, they ana- attending physicians. 46
12
lyzed hospital mortality according to whether or not patients were under Although the European Society of Intensive Care Medicine has stated
the care of an intensivist, without distinguishing whether the intensivist that the optimal size of an ICU is 8 to 12 beds, little is known about
47
acted as the primary attending physician or a consultant. They reported the workload intensivists should have in order to improve outcomes for
that patients with intensivists involved in their care had higher hospital patients, and for themselves. In a preliminary study, we found no clear
mortality (odds ratio [OR] 1.42, p <.001). The accompanying editorial relationship between job burnout and self-reported workload. Dara et
44
speculated about possible reasons for the disparity between Pronovost’s al sought to assess patient outcomes in relation to intensivist workload.
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and Levy’s studies. 13 They studied 2492 patients in a medical ICU over 18 months, during sub-
■ AROUND-THE-CLOCK INTENSIVIST PRESENCE stantial changes in ICU size and team composition, such that the ratio of
beds per intensivist varied from 7.5 to 15. The results suggested that ICU
A growing movement around the world has intensivists physically LOS was longer when the ratio was 15, while hospital LOS and mortality
present around-the-clock (24/7), usually effected via shiftwork where rates were not different. An observational study with many methodologic
different intensivists are present during days and nights. Some have limitations suggested better patient outcomes when ICU doctors worked
opined that 24/7 intensivist staffing is the ideal. 14,15 Such staffing exists 12 hours rather than 8-hour shifts. In a cluster randomized study in five
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in a minority of North American ICUs, 4,16-18 but is common in some medical ICUs, Ali et al studied the effect of weekend cross-coverage for
50
European countries. 8 intensivists doing half-month rotations. This form of weekend respite
The main rationale for 24/7 intensivist presence is reasonable, that to reduce workload had no detrimental effects on mortality or LOS, but
at night critically ill patients need as much expert care as during the produced less burnout and job distress for the intensivists.

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