Page 48 - Hall et al (2015) Principles of Critical Care-McGraw-Hill

CHAPTER 3: Intensive Care Unit Staffing 17

TELEMEDICINE Several authors have addressed work-hour limits that have been
increasingly placed on house officers in many countries. This is of great
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Telemedicine involves having ICU clinicians, who may be physicians consequence since teaching ICUs have historically relied on house staff
and/or nurses, remotely provide real-time care. This may be nighttime for patient care services, especially overnight. A consequence of these
only, or both days and nights. Remote clinicians have electronic access to limits is changes in house staff scheduling that reduces continuity of
a data stream typically including telemetry, diagnostic tests, information care. Also, teaching hospitals have attempted to fill the gaps by increased
from devices such as ventilators, and if they exist, an electronic medical use of hospitalists and nonphysician providers. While a detailed study
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record and computer order entry. In some systems, software continu- in two ICUs found that reduced working hours resulted in a lower rate
51
ously analyzes the data for early identification of worrisome trends. The of serious errors by first-year residents, 67,68 a large study of 104 ICUs was
eClinicians in these eICUs can see patients via video cameras, and talk unable to detect a change in severity-adjusted mortality attributable to
to HCWs in the ICU via telephone or intercom; they may even have a the work rule limits implemented in the United States in 2003. 69
robotic presence in the ICU. The remote physicians may or may not
52
have order writing authority. Several hundred hospitals in the United
States have implemented ICU telemedicine. The psychosocial aspects ICU STAFFING BY NONPHYSICIAN
53
of working in an eICU environment are substantially different than PROVIDERS AS PHYSICIAN EXTENDERS
bedside work. 54 Nonphysician providers, mainly nurse practitioners (NPs) and phy-
A number of studies, most commonly assessing the VISICU system, sician assistants (PAs), are increasingly involved in the care of ICU
have evaluated how introduction of eICU care influenced mortality, LOS, patients. 17,70,71 While different by way of background and training
costs, and complications 55-58 ; these individual studies have had contradic- (Table 3-1), these two classes of providers have been used, sometimes
tory results. A recent meta-analysis of 13 studies including 35 ICUs and interchangeably, in the ICU setting in a variety of ways. In some aca-
over 41,000 patients identified the limitations of this literature: all had demic ICUs, NPs and/or PAs have been integrated into house staff–
53
(a) simple before versus after study designs, (b) modest study quality, based ICU teams 72-74 ; in others, they have been used to staff entirely
(c) large heterogeneity in baseline ICU structures and eICU implemen- separate ICUs. 75,76 Alternatively, NPs have been employed on specialty-
tation, and (d) potential for bias by virtue of vendor involvement or based (eg, heart failure, trauma, 78,79 transplantation ) teams, which
77
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support for many of these studies. With these problems in mind, the assist in the care of some ICU patients. Finally, NPs have been added in
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meta-analysis indicated that eICU implementation led to lower ICU novel roles as overseers/outcomes managers and to provide unit-based
mortality (OR = 0.80, p = 0.02) and ICU LOS (difference 1.3 days, p = care in previously open-model ICUs. 81-83
0.01), without concomitant changes in hospital mortality or LOS.
Studies assessing the impact of NPs and/or PAs are shown in
Table 3-2. Patient morbidity, mortality, and quality of care have been
HOSPITALISTS seen to improve with the addition of NPs in novel roles in the ICU. With
Hospitalists are attending physicians who specialize in the care of hos- an NP acting as overseer/outcomes manager, hospital mortality, hos-
pitalized patients. Many US hospitals now have hospitalists involved pital and ICU LOS, duration of mechanical ventilation, complications
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with ICU care. Two studies have assessed outcomes related to these (including skin breakdown and urinary tract infections), and costs were
17
nonintensivists caring for ICU patients. An observational study com-
pared outcomes in two adult medical ICUs, one staffed by intensivists
and the other by hospitalists supported by an intensivist-led consultation
service. After adjustment for large differences in case mix, there were TABLE 3-1 Differences Between Nurse Practitioners and Physician Assistants
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no significant differences in hospital mortality (OR = 0.80, p = 0.22), as ICU Providers
ICU mortality (OR = 0.80, p = 0.41), or ICU LOS (mean difference
−0.3 days, p = 0.32). In a before versus after study in an intensivist-led Nurse Practitioners Physician Assistants
pediatric ICU, Tenner et al compared outcomes when night coverage Education/Background
was provided by residents versus hospitalists. After adjusting for major
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differences in case mix, nocturnal care by hospitalists was associated Prerequisite education Bachelor of nursing science College-level course-
with lower ICU mortality (OR = 0.36, p = 0.01) and ICU LOS (mean degree and licensure as a regis- work
difference −21 hours, p = 0.01). tered professional nurse (RN)
Degree conferred Masters or doctorate Bachelor or masters
HOUSE OFFICERS Duration of program 18 months to 5 years 26 months
Historically, house officers have been a vital part of ICU workforces, func- Specialty focus in critical care Yes No
tioning under supervision as an extension of attending physicians. A small Board certification required Varies by state Yes
and disjointed literature has addressed how house officers, that is, resi- to practice
dents and critical care subspecialty fellows influence outcomes in ICUs. Previous ICU experience Usually critical care nursing Varies, but usually none
A study of the impact of ICU fellows evaluated outcomes in two
academic, closed-model, medical-surgical ICUs. These units had ICU Practice Issues
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fellows about half the time, though they always had a full complement of Practice agreements required State regulated—most do not Supervisory agree-
less senior house staff. Results indicate no differences on mortality rates require physician collaboration ments with a physician
or LOS related to the presence of ICU fellows. or supervision required
Two studies evaluated outcomes in relation to the level of training of Prescriptive privileges State regulated—NPs have Yes
ICU residents. The first reported on 2274 patients in two open-model prescriptive privileges in most
ICUs in Taiwan that were covered by a single surgical resident. In an states
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unadjusted analysis, hospital mortality of patients cared for by first-year
residents was significantly higher than those cared for by more advanced Procedural skills Taught as part of most ACNP Learned on job
residents (25 vs 18%, p = 0.002). In a study of 5415 children admitted to programs
16 pediatric ICUs, mortality was higher in patients cared for by first- and Writing orders Yes Yes
second-year than third-year residents, and was also higher earlier in the Reproduced with permission from Gershengorn HB, Johnson MP, Factor P. The use of nonphysician pro-
educational year for each resident level. 65 viders in adult intensive care units. Am J Respir Crit Care Med. March 15, 2012;185(6):600-605.

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