Intensive care unit staffing and quality of care: challenges in times of an intensivist shortage - Critical Care Science (CCS)

Intensive care unit staffing and quality of care: challenges in times of an intensivist shortage |

Intensive care unit physician staffing models

The most widely studied ICU physician staffing models vary in the degree to which intensivists are involved in patient management. "High-intensity" ICUs are those where most patients are managed by a full-time or consulting intensivist, whereas "low-intensity" ICUs have either no intensivist involvement or offer elective intensivist consultations.^{( )} There have been no randomized clinical trials comparing high- and low-intensity ICUs, but there is strong observational evidence to suggest that high-intensity staffing is associated with reduced hospital and ICU mortality and length of stay.^{( )} This finding was consistent across medical and surgical patients, academic and community hospitals, and studies within and outside the United States. The predominant conclusion drawn from these data is that the expertise of intensivists in ICUs indeed matters. However, it is important to note that no study has evaluated exactly which elements of a high-intensity organizational model are responsible for improving patient outcomes. Given the current fiscal constraints on healthcare and the potential cost implications of hiring more intensivists, many ICUs may be unable to adopt a high-intensity staffing model. Indeed, a 2006 survey of 393 ICU directors in the United States revealed that half of ICUs were low intensity, 26% were high intensity, and the remainder had an intermediate intensivist presence.^{( )}

If some degree of exposure to intensivists is beneficial to patients, then would more exposure be even better? This notion, combined with international prioritization of patient safety, has led to proliferation of the nighttime intensivist staffing model, without a solid evidence base. The largest retrospective cohort study thus far found no mortality benefit from an intensivist presence at night in ICUs with high-intensity daytime staff, but did detect a significant reduction in mortality in those with low-intensity daytime staffing.^{( )} One high-intensity academic ICU conducted the only randomized clinical trial of nighttime intensivist staffing and similarly found that it conferred no mortality benefit compared with nighttime staffing by medical trainees with telephone access to an intensivist.^{( )} Thus, the available data suggest that an ICU with daytime intensivist staffing may not need nighttime intensivist staffing. Alternatively, perhaps any physician present overnight is as effective as an intensivist. Furthermore, the nighttime presence of an intensivist has potentially significant cost, educational, and team communication implications, the extent of which is not yet fully understood.

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