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. 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. NEJM 2001; 345: 663.
23/100
dx
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
Am J Med 2004; 117: 151
Am J Med 2004; 117: 151
…as well as in Finland.
Intensive Care Med 2003; 29: 2144.
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
weekend did not increase mortality
• Except in surgical ICU (OR 1.23)
Chest 2004; 126:1292
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
So…
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?
Continuous on-site intensivists
• A few recent studies formally exploring
the relationship between:
Presence of 24/7 intensivists
and
• Hixson, Arabi, Luyt, Gajic
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, boardcertified 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
Crit Care Med 2006;34:605–611
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
Crit Care Med 2008; 36:36–44
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…
Ann Thoracic Surg 2009; 88: 1153-61
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*
What about cost?
Is it cost effective?
• Much increase in manpower
• Theoretically can increase billing, but usually
not enough to cover increased cost
• 5 FTE for one full time intensivist position
• Extra funding must be secured in most cases
Hendershot et al. J Trauma 2009; 67: 196-9
What are the downsides?
Downsides of 24/7 coverage (?)
• Unclear that it is necessary
for good outcomes
• Interfere with training (?)
• Burnout issues
24/7:Necessary?
• The data remain somewhat conflicted
• Some argue against the “shift work”
mentality
24/7: lifestyle issues
• Conclusions:
• Though the faculty said that going from day to
night shifts increased stress, when they
changed the schedule, they found no
difference in stress scores.
Acad Emerg Med. 2004 ;11:111-4.
24/7: Burnout issues
• Conclusions:
• Approximately one-half of the intensivists
presented a high level of burnout.
Organizational factors, but not factors
related to the patients, appeared to be
associated with burnout.
Am J Respir Crit Care Med. 2007;175(7):686-92
24/7: Burnout issues
Embriaco et al.
24/7: training issues
• Concerns that trainees might lack the
ability to act independently and make
decisions if attending always around
• Little data to support this, but an
interesting topic
24/7: alternatives
• Hospitalists
• Telemedicine
• Physician extenders
Hospitalists
• Conclusions:
• Improved survival with hospitalists, rather than
residents, providing after-hours care when an
intensivist is not in house suggests that the quality of
care of critically ill patients is improved when more
experienced physicians are providing bedside care.
Crit Care Med 2003; 31:847–852
Telemedicine
• Technology-enabled remote care can be used to
provide continuous ICU patient management and to
achieve improved clinical and economic outcomes.
• This intervention’s success suggests that remote
care programs may provide a means of improving
quality of care and reducing costs when on-site
intensivist coverage is not available.
Crit Care Med 2000; 28: 3925–3931
Physician extenders
Crit Care Med 2008; 36:2888 –2897
Kleinpell et al. 2008
Crit Care Med 2008; 36:2888 –2897
So, in conclusion…
Conclusions
• Having 24/7 coverage by in-house
attending intensivist:
– Makes intuitive sense that would be
associated with improved outcomes
– Data not completely clear
– Costly
– Multiple possible downsides
Conclusions
• Must do a careful analysis of the needs
of your particular institution
– (patient care, education, etc.)
• Must look carefully at financial
resources
• Conclusion for any particular institution
will need to be individualized
Thank you
• Vladimir Kvetan, MD, FCCM
• Division of CCM at
Montefiore/AECOM
Questions?
Contact information
• Richard H. Savel, MD, FCCM
• Email: rhsavel@gmail.com
• telephone: 718 744 7658