ContextIntensive care unit (ICU) physician staffing varies widely, and its
association with patient outcomes remains unclear.ObjectiveTo evaluate the association between ICU physician staffing and patient
outcomes.Data SourcesWe searched MEDLINE (January 1, 1965, through September 30, 2001) for
the following medical subject heading (MeSH) terms: intensive
care units, ICU, health resources/utilization, hospitalization, medical staff,
hospital organization and administration, personnel staffing and scheduling,
length of stay, and LOS. We also used the
following text words: staffing, intensivist, critical, care, and specialist. To identify observational
studies, we added the MeSH terms case-control study and retrospective study. Although we searched for non–English-language
citations, we reviewed only English-language articles. We also searched EMBASE,
HealthStar (Health Services, Technology, Administration, and Research), and
HSRPROJ (Health Services Research Projects in Progress) via Internet Grateful
Med and The Cochrane Library and hand searched abstract proceedings from intensive
care national scientific meetings (January 1, 1994, through December 31, 2001).Study SelectionWe selected randomized and observational controlled trials of critically
ill adults or children. Studies examined ICU attending physician staffing
strategies and the outcomes of hospital and ICU mortality and length of stay
(LOS). Studies were selected and critiqued by 2 reviewers. We reviewed 2590
abstracts and identified 26 relevant observational studies (of which 1 included
2 comparisons), resulting in 27 comparisons of alternative staffing strategies.
Twenty studies focused on a single ICU.Data SynthesisWe grouped ICU physician staffing into low-intensity (no intensivist
or elective intensivist consultation) or high-intensity (mandatory intensivist
consultation or closed ICU [all care directed by intensivist]) groups. High-intensity
staffing was associated with lower hospital mortality in 16 of 17 studies
(94%) and with a pooled estimate of the relative risk for hospital mortality
of 0.71 (95% confidence interval [CI], 0.62-0.82). High-intensity staffing
was associated with a lower ICU mortality in 14 of 15 studies (93%) and with
a pooled estimate of the relative risk for ICU mortality of 0.61 (95% CI,
0.50-0.75). High-intensity staffing reduced hospital LOS in 10 of 13 studies
and reduced ICU LOS in 14 of 18 studies without case-mix adjustment. High-intensity
staffing was associated with reduced hospital LOS in 2 of 4 studies and ICU
LOS in both studies that adjusted for case mix. No study found increased LOS
with high-intensity staffing after case-mix adjustment.ConclusionsHigh-intensity vs low-intensity ICU physician staffing is associated
with reduced hospital and ICU mortality and hospital and ICU LOS.

/pdf/physician-staffing-patterns-and-clinical-outcomes-in-5b3j8ptzj2.pdf

Physician Staffing Patterns and Clinical Outcomes in Critically Ill Patients: A Systematic Review

Physician Staffing Patterns and Clinical Outcomes in Critically Ill Patients

OBJECTIVES--To compare outcome between intensive care units in Britain and Ireland both before and after adjustment for case mix with the American APACHE II method and to validate the American APACHE II method in Britain and Ireland. DESIGN--Prospective, cohort study of consecutive admissions to intensive care units. SETTING--26 general intensive care units in Britain and Ireland. SUBJECTS--8796 admissions to the study intensive care units. MAIN OUTCOME MEASURE--Death or survival at discharge from intensive care unit and hospital. RESULTS--At discharge from both intensive care unit and hospital there was a greater than twofold variation in crude mortality between the 26 units. After adjustment for case mix, variations in mortality were still apparent. For four intensive care units the observed numbers of deaths were significantly different from the number predicted by the American APACHE II equation. The overall goodness of fit, or predictive ability, of the APACHE II equation for the British and Irish data was good, being only slightly inferior to that obtained when the equation was tested on the data from which it had been derived. When patients were grouped by various factors such as age and diagnosis, the equation did not adjust across the subgroups in a uniform manner. CONCLUSIONS--The American APACHE II equation did not fit the British and Irish data. Use of the American equation could be of advantage or disadvantage to individual intensive care units, depending on the mix of patients treated.

https://www.bmj.com/content/bmj/307/6910/977.full.pdf

Intensive Care Society's APACHE II study in Britain and Ireland--II: Outcome comparisons of intensive care units after adjustment for case mix by the American APACHE II method.

OBJECTIVES--To describe the extent of variation in the case mix of adult admissions to general intensive care units in Britain and Ireland and investigate the impact of such variation on outcome. DESIGN--Prospective, cohort study of consecutive admissions to intensive care units. SETTING--26 general intensive care units in Britain and Ireland. SUBJECTS--9099 admissions to the intensive care units studied. MAIN OUTCOME MEASURE--Death or survival at discharge before and after adjustment of case mix (age, history of chronic conditions, surgical status, diagnosis, and severity of illness) according to the APACHE II method. RESULTS--Important differences in case mix were found, with large variations between the units. Hospital mortality was significantly associated with most of the case mix factors investigated. CONCLUSIONS--Comparing crude death rates in hospital between intensive care units may be misleading indicators of performance. The collection of data on case mix needs to be standardised and differences in case mix adjusted for when comparing outcome between different intensive care units.

https://www.bmj.com/content/bmj/307/6910/972.full.pdf

Intensive Care Society's APACHE II study in Britain and Ireland--I: Variations in case mix of adult admissions to general intensive care units and impact on outcome.

This study tests whether an outreach educational program tailored to institutional specific patient care practices would improve the quality of care delivered to mechanically ventilated intensive care unit (ICU) patients in rural hospitals. The study was conducted as a randomized control trial using 20 rural Iowa hospitals as the unit of analysis. Twelve randomly selected hospitals received an outreach educational program. After review of the medical records of eligible patients, a multidisciplinary team of intensive care unit specialists from an academic medical center delivered an educational program with content specific to the findings and capacity of the hospital. The outcome measures included patient care processes, patient morbidity and mortality outcomes, and resource use. Results indicated that the outreach program significantly improved many patient care processes (lab work, nursing, dietary management, ventilator management, ventilator weaning). The program marginally reduced hospital ventilator days. Both total length of stay and ICU length of stay fell markedly in the intervention group (by an average of 3.2 and 2.1 d, respectively), while the control group fell only 0.6 and 0.3 d, respectively. However, these effects did not reach statistical significance. Unfortunately, the program had no detectable effects on the clinical outcomes of mortality or nosocomial events. We conclude that an outreach program of this type can effectively improve processes of care in rural ICUs. However, improving processes of care may not always translate into improvement of specific outcomes.

Outreach education to improve quality of rural ICU care. Results of a randomized trial.

Intensive care units (ICUs) exist in most acute care hospitals and account for between 5% and 10% of all hospital beds.1'2 There is, however, surprisingly little data concerning the appropriate use of ICU services and their effect on patient outcomes. This uncertainty is highlighted by the variation in intensive care practices among hospitals,3'4 Many studies examining the extent and causes of this variation were performed in tertiary care centers and may not be directly applicable to intensive care practices in community hospitals.'4 To characterize and better understand variation in intensive

Procaccini J

Papers

Variation in intensive care unit practices in two community hospitals.