5/31/2013

1

24/7 Attending Intensivist Staffing Improves Care of the Critically Ill

John H. Turnbull, M.D. Assistant Professor of Anesthesia Division of Critical Care Medicine

University of California—San Francisco

• All acute care admission in Ontario, Canada (1988-1997)

• Compared weekend vs. weekday in-hospital

mortality among patients with – Ruptured AAA – Acute epiglottitis – PE

Bell et al. NEJM 2001; 345: 663.

5/31/2013

2

Potential Benefits of 24/7 Intensivist Staffing

• Earlier establishment of treatment plans

• More timely resuscitation of unstable patients

• More consistent provision of complex care

• More consistent decision making at all hours of the day

• Retrospective review of 34 ICUs using the APACHE clinical information system; 2004-2006

• Primary outcome—in-hospital mortality

• Classified ICUs as – High intensity—mandatory consult or primary svc

– Low intensity—optional consultation of ICU svc

Findings…

• Overall, nighttime staffing without mortality benefit

• In low intensity ICUs, nighttime staffing associated with a reduction of risk-adjusted in-hospital mortality (OR 0.62, p=0.04)

• Limitations regarding study design 1. Retrospective analysis of database elements

2. Unclear on staffing responsibility during nighttime hours

5/31/2013

3

• 1 year randomized trial in academic MICU

• Assigned blocks of 7 consecutive nights to the control (no in-house intensivist) or intervention (in-house intensivist; night-float concept) strategies

• Patients categorized according to staffing on day of admission

• Primary outcome—ICU LOS

Findings…

• No difference in ICU or hospital LOS, mortality, ICU readmission or disposition on discharge

• Initial concerns regarding study design 1. Delivery of care may change as frequently as

weekly

2. No continuity of nighttime intensivist

3. Only required to evaluate new patients or patients who deteriorated

5/31/2013

4

24/7 Intensivist Presence Improves Delivery of Quality, Value-Based Care

• Decreasing hospital LOS • Improving adherence to clinical guidelines and processes of

care

• Reducing resource utilization

• Improving quality of life outcomes in long-term survivors • Improving provider satisfaction and GME education

Implementation of 24/7 Intensivist Staffing—MGH SICU

• Retrospective review of a pre- and post-implementation of 24/7 attending coverage

– 20 bed “closed model” SICU

– 24/7 fellow coverage throughout study

• Attending expectations

– Round twice nightly with housestaff and nursing

– No other obligations

Van der Wilden GM, et al. Implementation of 24/7 intensivist presence in the SICU: Effect on processes of care. J Trauma Acute Care Surg. 2013. 74

Comparison of Patient Cohorts Year 1 and Year 2

Parameter

Year 1 n = 1,408

Year 2 n = 1,421

p

Age, mean (+ SD), yr 60.8 (+ 18.1) 60.3 (+ 17.9) 0.45

Male, n (%) 824 (58.5) 824 (58) 0.77

Total patients ventilated, n (%) 782 (55.5) 777 (54.7) 0.65

APACHE II, mean (+ SD) 12.3 (+ 6.7) 11.2 (+ 6.2) 0.032

Trauma patients, n (%) 174 (12.4) 176 (12.4) 0.98

Secondary Outcomes

Outcomes Year 1 Year 2 P

Blood products, mean (+ SD)

284.2 (+ 47.9) 215.5 (+ 65.6) 0.006

Total PRBC, mean (+ SD)

158.5 (+ 23.1) 118.7 (+ 27.5) 0.0006

Total FFP, mean (+ SD)

87.2 (+ 23.5) 61.1 (+ 27.6) 0.016

CT scan rate, per patient

1.37 1.19 <0.0001

Attending presence decreased resource utilization and interventions with a risk for harm

5/31/2013

5

Initiation of 24/7 Coverage— Mayo MICU

• Prospective evaluation of initiation of 24/7 attending intensivist coverage

• 2 year study period

• No other major practice model interventions during study period

Gajic O, et al. Effect of 24-hour mandatory versus on-demand critical care specialist presence on quality of care and family and provider satifsication in the ICU of a teaching hospital. Critical Care Medicine. 2008. 36

Study Timeline

Baseline characteristics ICU Outcomes

Outcome Pre Post p

ICU LOS, median days 1.7 1.6 0.025

Hospital LOS, median days 6.7 5.9 0.022

ICU readmission, % 9.2 7.6 0.061

• Adjusted mean hospital LOS decreased by 1.4 days (95% CI -0.3 to -2.5 days)

5/31/2013

6

Comparison of Processes of Care

Pre Post p

Ventilator Bundle n = 97 (356 days n = 191 (963 days)

Stress ulcer prophylaxis, n (%) 349 (98) 961 (100) 0.002

VTE prophylaxis, n (%) 323 (91) 906 (94) 0.038

Sepsis resuscitation n = 45 n = 84

Adherence to severe sepsis guidelines, n (%)

32 (71) 69 (82) 0.153

ALI/ARDS n = 61 (109 days) n = 127 (311 days)

Adherence to low Tv ventilation, n (%)

79 (72) 251 (81) 0.077

Cumulative # of omission of processes of care

84 (24)

149 (16)

0.002

Comparison of ICU complications

Complication Pre 356 days (n= 97)

Post 963 days (n = 191)

p

DVT, n (%) 5 (1.4) 14 (1.5) 0.98

PE 3 (0.8) 3 (0.3) 0.213

Bleeding 8 (2.2) 8 (0.8) 0.047

VAP 9 (2.5) 18 (1.9) 0.449

Reintubation 13 (3.6) 21 (2.2) 0.147

Cumulative ICU complication rate

38 (11) 64 (7) 0.023

Staff Surveys

• Survey of attending intensivists, allied health staff and physicians in training

• Staff satisfaction and perceptions about patient safety, education, organization and function improved

• No difference in educational value of training physicians between models

• New model optimal for patient pare (38% vs 78% p< 0.001)

• 24/7 intensivist presence – Decreases hospital LOS when adjusted for severity of

illness

– Improves processes of care

– Decreases ICU complication rate

– Improves staff satisfaction

– Appears to not interfere with educational goals of physician trainees

5/31/2013

7

Quality of Life Follow-up

Reriani M, et al. Effect of 24-hour mandatory vs on-demand critical care specialist presence on long-term survival and quality of life. J Critical Care. 2012. 27.

Differences Between Baseline and 6 Month Follow-up of QoL Measures

SF-36 scale Pre 24/7 Within-patient score

difference

Post 24/7 Within-patient score

difference

p

Physical functioning 4 + 10 7 + 18 0.34

Role limitations, physical 3 + 12 11 + 13 0.01

Bodily pain 6 + 12 10 + 13 0.12

General health perception 2 + 11 3 + 13 0.54

Vitality 3 + 11 10 + 12 0.01

Social functioning 10 + 12 11 + 17 0.63

Role limitations, emotional 10 + 14 7 + 14 0.50

Mental health 7 + 13 8 + 13 0.82

Mental component 10 + 13 9 + 14 0.77

Physical component 2 + 11 8 + 14 0.03

Economic Impact

• Follow-up from Mayo study

• Cost analysis based on reimbursements from Medicare part A (UB revenue codes) and Medicare part B (CPT4 codes)

• Corrected for inflation, cost-to-charge indices and

proxied Medicare reimbursement rates

• Cost from ICU admission to hospital discharge

Banerjee R, et al. Economic Implications of nighttime attending intensivist coverage in a MICU. Critical Care Medicine. 2011. 39.

Total Cost Estimates

Pre Mean (SD) Post Mean (SD) p

All admissions

APACHE III Q1 $15,819 (26,656) $14,632 (24,632) 0.550

APACHE III Q2 $29,732 (40,719) $26,857 (40,486) 0.086

APACHE III Q3 $33,105 (43,209) $32,131 (35,663) 0.688

APACHE III Q4 $50,033 (70,924) $41,053 (47,431) 0.026

Total $32,834 (50,372) $28,473 (39,078) 0.004

All night admissions $29,935 (52,129) $25,384 (36,384) 0.007

5/31/2013

8

Economic Impact to CC Division

• MGH and Mayo required approximately approximately 2 additional FTEs

• Per MGH study, nocturnal intensivists supervised and billed all procedures and completion of billable critical care note (99291)

Year 1 Year 2

FTE 3.46 5.47

RVU 22,323 36,543

RVU/FTE 6,452 6,681

3.5% increase in RVU/FTE

• 24/7 attending intensivist presence

– Improves quality of life in long-term ICU survivors

– May increase revenue for critical care division while providing value-based, quality care that reduces overall costs

5/31/2013

9

In Summary

• No evidence that 24/7 intensivist improves mortality

• Multiple studies demonstrate 24/7 coverage – Decreases hospital LOS – Decreases ICU complication rate – Improves processes of care – Decreases utilization of resources and costs – Improves quality of life in survivors – Likely limited impact on educational objectives

Con: 24/7 Intensivist

Susan S. Yoo, M.D.

Assistant Professor of Anesthesia

Division of Critical Care Medicine

University of California San Francisco/ San Francisco General Hospital

Conclusions: Nighttime admission to study ICU not associated

with higher mortality or longer hospital or ICU stay compared to

daytime admission

2003; 31(3): 858-863.

Conclusion: Day of week and time of day of ICU

admission were not associated with significant

differences in hospital mortality after adjustment for case

mix

5/31/2013

10

Conclusions: Overall adjusted hospital mortality of

weekend admissions to medical or multispecialty (but

not SICU) not higher than weekday admissions.

2004; 126:1292-1298

2007; 35(1) 3-11.

Conclusions: Admissions during “off” hours were not associated with

higher mortality, and may be associated with a lower death rate

Conclusions: Time or day of admission does not influence risk

for in-hospital mortality in major trauma victims

2009, 3:8.

Conclusions: No demonstrable mortality difference among

injured patients presenting on weeknights vs weekdays, and

lower mortality on weekends vs weekdays

2011; 146 (7): 810-817.

Night/Weekend Admissions

No definitive evidence that patients admitted to ICUs during

“off-hours” have worse outcomes.

5/31/2013

11

2012; 366:2093-2101.

5/31/2013

12

Conclusions In low-intensity daytime staffing ICUs, nighttime intensivist

coverage was associated with a mortality reduction (p<0.04)

There was no reduction in mortality demonstrated for high-

intensity daytime staffing ICUs.

Published online May 20, 2013

5/31/2013

13

Blanket application of 24-hour ICU

attending coverage is premature No definitive evidence that weekend and night admissions to

ICUs have worse outcomes

No definitive evidence that 24-hour attending intensivist

coverage improves patient outcomes

Let’s Talk Logistics Well-documented intensivist shortage

Estimated that only 20-33% of critically ill patients are cared

for by ICU trained physicians

Implications for rural hospitals

5/31/2013

14

Physician burnout higher than any other US

worker

Embriaco N, Papazian L, Kentish-Bares N, et al. Burnout syndrome among critical care healthcare

workers. Curr Opin Crit Care 2007; 13: 482-488.

Shanafelt TD, Boone S, Litjen T, et al. Burnout and Satisfaction with work-life balance among US

physicians relative to the general US population. Arch intern med 2012; 172 (18): 1377-1385.

Physician training

Wallace DJ, Angus DC,.Barnato AE. Nighttime Intensivist Staffing and Mortality among Critically Ill Patients.

NEJM 2012; 366 (22): 2093-2101.

Alternative Strategies Protocolization/bundles

High-intensity ICU > Low-intensity ICU

ICU nurse workforce

Advanced level practitioners, hospitalist coverage

Telemedicine

5/31/2013

15

High-intensity staffing model

JAMA 2002; 288(17): 2151-2162.

Conclusions: Lower hospital and ICU mortality and length

of stay in high-intensity staffed ICUs

Med Care 2007 Dec; 45(12):1195-204

Crit Care Med 2010; 38 (7) 1521-1528

J Adv Nurs 2012; 68 (5): 1073-81.

Summary Conclusions

There are consistently

demonstrated associations

between increased RN

staffing in hospital wards or

intensive care units and lower

odds of hospital-related

mortality and adverse events

Teleintensivist Critical care research and practice. 2012

Adv Level Practitioners/Hospitalists

Crit Care Med 2008; 36(10):2888-2897.

Blanket application of 24-hour ICU

attending coverage is premature No definitive evidence that weekend and night admissions to

ICUs have worse outcomes.

No definitive evidence that 24-hour attending intensivist coverage improves patient outcomes.

High costs, ICU physician shortages, expected worsened burnout, job satisfaction, impact on physician training are critically important factors.

Factors that predict patient outcomes are multifold and not adequately addressed by only examining the physician-patient interface.

Alternative strategies (telemedicine, nurse practitioners, transition to high-intensity ICUs, hospitalist coverage, etc) should be explored.