Skip to main content

Higher Intensivist Staffing Levels Linked to Fewer ICU Deaths

 |  By cclark@healthleadersmedia.com  
   November 19, 2013

A meta-analysis into guidelines that call for "high-intensity staffing" models employing intensivists in the ICU reveals better patient outcomes, but not at night.

Staffing hospital intensive care units with more intensivists resulted in fewer in-hospital deaths and lower lengths of both hospital and ICU stays when compared with having fewer intensivists.

But no improvements in mortality or length of stay were seen with staffing the ICU with intensivists at night, an expensive and difficult task for most hospitals because such certified specialists are in extremely short supply across North America.

Those are the conclusion from a meta-analysis study by Toronto researchers who analyzed 52 observational cohorts in North America treated over more than 50 years, or about 331,222 patients. They wanted to determine if putting critical care specialists in charge of ICUs staffed around the clock resulted in better patient outcomes. The report was published in the October edition of the journal Critical Care Medicine.

The issue is a controversial one because current North American and European guidelines recommend that so called "high-intensity staffing models" in which intensivists take over the care of these patients, is the most suitable model for ICU care. Those guidelines also suggest that coverage should extend around the clock.

But those guidelines belie the reality of daily operations for most hospitals, which allow any physician to oversee patient care in the ICU, "and an intensivist may or may not be available for consultation."

The authors, led by M. Elizabeth Wilcox, MD, of the Division of Critical Care Medicine at the University of Toronto, said that if lower mortality and length of stay can be achieved with a high-intensity model that doesn't involve night time coverage, "we might achieve similar improvements while allowing sufficient time for workforce growth to meet current and future demands."

Robert Wachter, MD, UCSF Chief of the Division of Hospital Medicine and Chief of Medical Service, suggests that the meta-analysis may give a hint that a solution has to do with the ICU culture.

"One could argue that what you're seeing here by having an intensivist there all day long, even when the intensivist is not there to manage every single thing, there are practice patterns, the way people escalate care, their philosophy, and the way they approach quality improvement" that make the difference, without the expense of nighttime intensivist staffing, he said.

"When the staff sees something broken, do they just sort of find a work-around, or do they actually fix it and have confidence that when there's a system glitch, they report it to the appropriate people because then someone will look into it the next day," Wachter said.

The authors say that their analysis was somewhat hampered by some differences, which they describe as "the myriad of staffing patterns currently in practice," and other "confounding factors influencing care delivery, such as the presence of nonintensivist physician providers, type of bedside nursing care, specialty teams, regionalization of medical care, and a lack of standard definitions for ICU administration and management."

Tagged Under:


Get the latest on healthcare leadership in your inbox.