The evidence: is 24-hour intensivist coverage beneficial? Richard H. Savel, MD, FCCM Associate Professor of Clinical Medicine & Neurology Albert Einstein College of Medicine New York, NY
Talk Overview • Evidence for benefit of 24/7 • Potential downsides of 24/7 • Conclusions
Conflicts of interest • Nothing to disclose
24/7 intensivist coverage • Better patient care (presumably) • Few hospitals have 24/7 (10-20%) • Why?
24/7: What are the questions? • What is the data? • Is it cost-effective? • Are there any downsides?
What does the data show? Is 24/7 intensivist coverage effective?
Night/weekend admissions • Increased mortality of acutely ill patients admitted on nights, weekends, and holidays • Partially attributed to lower staffing levels Bell et al. NEJM 2001; 345: 663.
Bell et al. • Analyzed all acute care admissions from emergency departments in Ontario, Canada, between 1988 and 1997 (3,789,917 admissions). Bell et al. NEJM 2001; 345: 663.
Bell et al. cont. • compared weekend vs. weekday in-hospital mortality among patients with three pre-specified diseases: • ruptured abdominal aortic aneurysm (5454 admissions), • acute epiglottitis (1139) • pulmonary embolism(11,686) • Also compared weekend vs. weekday in-hospital mortality among patients with three control diseases: • Myocardial infarction (160,220) • intracerebral hemorrhage(10,987) • acute hip fracture (59,670) Bell et al. NEJM 2001; 345: 663.
Bell et al, cont. • as well as for the 100 conditions that were the most common causes of death (accounting for 1,820,885 admissions). Bell et al. NEJM 2001; 345: 663.
Bell et al., conclusions • Certain causes of admission seemed to be associated with higher risk of death if admitted on weekend • 23 out of the top 100 reasons for death had a higher likelihood of death if admitted on weekend • Reasons unclear
Night/weekend admissions: • Larger “weekend” effect shown in major teaching hospitals • Even after adjustment for severity of illness Barnett et al. Med Care 2002;40:530 Cram et al. Am J Med 2004; 117: 151. Uusaro et al. Intensive Care Med 2003; 29: 2144.
Correlation with day of admission and ICU outcome? Med Care 2002;40:530
Barnett et al. Med Care 2002 • 156,000 patients (1991-97, Ohio) • 9% higher mortality if admitted on weekend. • But also Fri and Mon • Even authors state in discussion not to over interpret study. • Concern for unmeasured severity of illness, or selection bias, rather than quality of care.
In California… Am J Med 2004; 117: 151
…as well as in Finland. Intensive Care Med 2003; 29: 2144.
Outcome: attending vs. fellow/resident • Evidence to suggest improved outcome with attendings • Decreased resource utilization with attendings • Exaggerated “weekend” effect with fellows Higgins et al. CCM 2003; 31: 45 Ensminger et al. Chest 2004; 126:1292 Cram et al. Am J Med 2001; 117: 151
Both long ward stays before ICU admission and lack of full-time ICU physician involvement in care increase the probability of long ICU stays. These latter two factors are potentially modifiable and deserve prospective study. CCM 2003; 31: 45
Higgins study: • Presence of Critical Care fellow: • Independent risk factor for increased: • Weighted hospital days (OR 1.3) • ICU LOS (OR 1.5) • “Lack of full-time ICU physician involvement increased the probability of prolonged ICU stay.” Higgins et al. CCM 2003; 31: 45
Yet not all data clear Chest 2004; 126:1292
Ensminger 2004 • Mayo Clinic • Attending present during day • By phone at night, present as needed Chest 2004; 126:1292
Ensminger 2004 • In that study of 29,000 admissions • Being admitted to the ICU at night or on weekenddid not increase mortality • Except in surgical ICU (OR 1.23) Chest 2004; 126:1292
Wunsch 2004 • Another important study with no differences found with regard to mortality of weekend admissions • After appropriate adjustment for severity of illness
It appears that patients admitted during nights/weekends may do worse than those admitted during regular hours. (an argument for 24/7 coverage) Some data that being cared for by trainees may not be so great. What about data that presence of intensivists helps?
and Continuous on-site intensivists • A few recent studies formally exploring the relationship between: • Hixson, Arabi, Luyt, Gajic Presence of 24/7 intensivists Outcome
Benefits of 24/7 • Conclusions: • Using multivariate logistic regression to control for important clinical differences, they found that: • weekend admission • evening admission • had NO significant independent effect on mortality risk • Findings are consistent with previous work demonstrating the benefit of intensive care units staffed 24 hrs/day, 7-days/wk by in-house, board-certified intensivists. Pediatr Crit Care Med 2005; 6:523–530
Benefits of 24/7 • Arabi 06 • In an intensive care unit staffed by onsite certified intensivists 24/7, we found no compromise in the care of patients admitted during weekends and weeknights. • These findings suggest that such coverage helps in ensuring • consistency of care and therefore represents a potentially improved • model for intensive care unit practice. Crit Care Med 2006;34:605–611
Arabi CCM 2006 • All emergency admissions from March 1 1999 to Feb 28, 2003 Crit Care Med 2006;34:605–611
Benefits of 24/7 • Conclusions: • Admission during off hours is common. • Off-hours admissions were not associated with higher mortality and might even be associated with a lower death rate. Crit Care Med 2007; 35: 3-11
34% day Luyt CCM 2007
Benefits of 24/7 Crit Care Med 2008; 36:36–44
Gajic 2008 • Conclusions: • The introduction of continuous (24-hr) on-site presence by a staff academic critical care specialist was associated with • improved processes of care and staff satisfaction • decreased intensive care unit complication rate and hospital length of stay. Crit Care Med 2008; 36:36–44
Recent data in the cardiac surgery ICU…
Kumar et al. 2009 in CSICU • By adding 24/7 intensivists: • Decreased likelihood of receiving blood • 30.2% v. 42.3% (p<0.05) • Less likely to arrive in ICU intubated • 43.7% v. 66.5% • Median ICU LOS decreased by 1 day • No change in ICU readmissions or mortality Ann Thoracic Surg 2009; 88: 1153-61
So can we make sense of it all? • How about a summary slide?
Why so confusing? Significant heterogeneity in: • How nights and weekends are defined • Night and weekend staffing • Adjustment for severity of illness *Inherent limitations in study design*