Page 53 - Hall et al (2015) Principles of Critical Care-McGraw-Hill

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

Both the aforementioned 2001 consensus group and an RT profes- staffing paradigms in most ICUs are not the result of thoughtful design
sional organization have stated that every ICU should have dedicated RT based on such quantitative analysis, we cannot assume that our current
support. 4,145 California mandates that ICUs have one RT for every four paradigms are optimal.
ventilators in use. Such statements and mandates do not, however, As discussed, this large question is complicated by the likelihood that
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provide guidance on how these can be accomplished in the face of a optimal ICU staffing is not “one size fits all.” Rather, what works best
shortage of such practitioners. 146 may depend on ICU type, size, case mix, and other features of baseline
An older survey of US ICUs found that almost half had dedicated structure. We must recognize that the definition of “optimal” includes
RTs. Studies assessing RTs in relation to patient outcomes in ICUs consideration of outcomes not only for patients, but also for the HCWs
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mainly address their role in achieving timely liberation from invasive and society. Accordingly, we need much more and higher quality research
mechanical ventilation. As all of these studies included RTs function- assessing how to best staff ICUs. As with any other kind of research, we
ing within the framework of protocols, this literature cannot distin- will need numerous studies from multiple sites to begin developing a
guish between effects of the protocols versus the RTs themselves. Most consistent and integrated understanding of this complex topic. 156
of these used some form of the protocol popularized by Ely et al,
147
who demonstrated that it could be implemented semiautonomously
by RTs. Three randomized, controlled studies, with a total of 809
148
patients, compared protocolized liberation efforts by RTs and/or nurses
with nonprotocolized physician-directed efforts. Two of them 149,150 KEY REFERENCES
found that patients managed under protocols spent substantially less • Angus D, Shorr A, White A, et al. Critical care delivery in
time on mechanical ventilation, while the third reported that the the United States: distribution of services and compliance
RT-driven protocol did not lead to improved ventilator time, reintuba- with Leapfrog recommendations. Crit Care Med. 2006;34(4):
tion rate, or other outcomes. Another study in a cardiovascular sur- 1016-1024.
151
gery ICU, using a less rigorous before versus after study design, found
that the RT-driven protocolized care reduced the average ventilator • Embriaco N, Azoulay E, Barrau K, et al. High level of burnout in
time, but only by an average of 2 hours. 152 intensivists: prevalence and associated factors. Am J Respir Crit
Care Med. Apr 1, 2007;175(7):686-692.
• Gajic O, Afessa B, Hanson AC, et al. Effect of 24-hour mandatory
SUMMARY AND CONCLUSIONS versus on-demand critical care specialist presence on quality of
We have reviewed a substantial literature pertaining to ICU staffing care and family and provider satisfaction in the intensive care unit
by various types of HCWs. Generally, it is a smorgasbord of disjointed of a teaching hospital. Crit Care Med. 2008;36(1):36-44.
observations that does not provide a coherent view of how best to staff • Gershengorn HB, Wunsch H, Wahab R, et al. Impact of non-
ICUs, and suffers from numerous shortcomings. Most are single center physician staffing on outcomes in a medical ICU. Chest. June
studies, with problematic study designs. Most studies come from large, 2011;139(6):1347-1353.
academic ICUs, rather than the community ICUs of more modest size, • Kim MM, Barnato AE, Angus DC, Fleisher LF, Kahn JM. The
where most critically ill patients receive care. 16,37 Most have limited effect of multidisciplinary care teams on intensive care unit mor-
themselves to evaluating only short-term clinical outcomes for patients, tality. Arch Intern Med. 2010;170(4):369-376.
ignoring other outcomes relevant to the many other stakeholders in ICU
care. Large heterogeneity of focus and design within individual topics • Landrigan C, Rothschild J, Cronin J, et al. Effect of reducing
3
hinders generalization and the ability to draw firm conclusions. Most interns’ work hours on serious medical errors in intensive care
studies focus on a single type of ICU worker, disregarding the important units. N Engl J Med. 2004;351(18):1838-1848.
interactions between them. 153,154 And there are concerns about publica- • Levy MM, Rapoport J, Lemeshow S, Chalfin DB, Phillips G,
tion bias against negative studies. 155 Danis M. Association between critical care physician management
The two areas with the most data relating to patient outcomes are the and patient mortality in the intensive care unit. Ann Intern Med.
intensity of intensivist involvement in care, and the PNR. Despite calls Jun 3, 2008;148(11):801-809.
for all ICUs to function as closed-model units with intensivists as the • MacLaren R, Bond CA, Martin SJ, Fike D. Clinical and
primary physician of record, evidence supporting this view is contra- economic outcomes of involving pharmacists in the direct care of
47
dictory. 10,12 Likewise, the weight of current evidence does not strongly critically ill patients with infections. Crit Care Med. 2008;36(12):
support the need for around-the-clock intensivist presence. 34-36,38 Even 3184-3189.
if it turns out that that closed-model ICUs produce better outcomes, it
is a multifaceted intervention, and we do not know which specific ele- • Valentin A, Ferdinande P; ESICM Working Group on Quality
ments of that organizational paradigm are responsible for improvement. Improvement. Recommendations on basic requirements for inten-
Likewise, the data do not supply a consistent answer to the question of sive care units: structural and organizational aspects. Intensive
whether ICUs would obtain better outcomes if they added nurses to Care Med. 2011;37:1575-1587.
reduce their PNRs. • Wagner J, Gabler NB, Ratcliffe SJ, Brown SE, Strom BL, Halpern
Although we do not yet know how best to staff our ICUs, we do know SD. Outcomes among patients discharged from busy intensive care
that the landscape of ICU staffing will continue to change under the units. Ann Intern Med. 2013;159(7):447-455.
stresses of nurse and intensivist shortages, and increasingly severe work- • Wallace DJ, Angus DC, Barnato AE, Kramer AA, Kahn JM.
hour limitations for physician trainees. Increasing use in ICUs of physician Nighttime intensivist staffing and mortality in critically ill patients.
extenders, nurse extenders, innovative staffing models, and technologies N Engl J Med. 2012;366:2093-2101.
such as telemedicine will occur simply to cope with these realities.
In the face of such changes, it is more important than ever to know
how staffing affects outcomes. At the current time we do not know
and are forced to guess or hope that how we are staffing our ICUs is
not unnecessarily harming the patients. In the absence of quantitative REFERENCES
evaluation, we should not assume that changes in ICU processes and
functions such as staffing are not causing such harm. Since current Complete references available online at www.mhprofessional.com/hall
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