The Value of 24/7 In-House ICU Staffing 24/7 Intensivist in the ICU

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Staffing of high-volume, high-intensity ICUs with 24 × 7 intensivist coverage facilitates the system changes, which allow ICU teams to provide 24 × 7 critical care and results in improved outcomes, shorter hospital stays, and overall cost savings. Opposition of 24 × 7 ICU staffing is primarily based upon the absence of clinical trials demonstrating improved patient outcomes, primarily mortality, coupled with the impracticality and cost of the addition of 24 × 7 intensivist coverage to all ICUs. These arguments are flawed. We will not argue that 24 × 7 in-house intensivist coverage needs to demonstrate mortality improvement as a prerequisite for implementation, nor is it necessary in the vast majority of ICUs, which are low-volume, low-acuity ICUs staffed by primarily by hospitalists with on-demand intensivist consultation or e-ICU coverage. However, there is no doubt that in high-acuity, high-volume centers, 24 × 7 intensivists staffing improves patient outcomes, reduces costs of care sufficiently to offset the additional staff, and is a pragmatic solution to control the ever-increasing need for ICU beds; staffed inefficiently by ever-increasing daytime-only intensivists (1–4).
Two models of intensivist presence in the ICU benefit from clarification. The ‘‘on-demand’’ model involves intensivists providing critical care during the day and responding, “on-demand,” to questions from fellows and residents during the night. On the other hand, the 24 × 7 model allows for the systematic delivery of 24 × 7 critical care through continuous supervision and treatment by an in-house critical care specialist. The ‘‘on demand’’ model, delivered from home or from an in-house intensivist, is the most used scheduling option deployed in the absence of a 24 × 7 model. The American College of Critical Care Medicine and Leapfrog group advocate continuous 24 × 7 intensivist and fundamental critical care support–certified physicians presence (5). The application of these recommendations across all ICUs fails to recognize the high degree of workload variability for intensivist across ICUs (6–8). It should be acknowledged that “ICU” does not correlate directly with a standard set of resources or staffing. Therefore, the benefits of 24 × 7 intensivists staffing should not be extrapolated to low-volume, low-acuity ICUs. And yet, this implication has been leveraged to distract from the evidence that nocturnal intensivists, deployed in high-volume, high-acuity ICUs provide clear benefit. Although much has been written about this topic, we believe that too much attention and analysis have been devoted to the “presence” of an intensivist at night and too little attention has been focused on the “system changes,” which accompany mature nighttime staffing models and allow ICU teams to provide the same degree of attention and service during the night as is expected during the day.
Those who oppose the benefits of 24 × 7 staffing are anxious to draw our attention to the randomized trial by Kerlin et al (9), which showed no difference in ICU length of stay (LOS), in hospital mortality, and the number of readmissions between two models. The random alternating week deployment of nighttime coverage prevented systematic practice changes essential to the success of any 24 × 7 in-house model. We conclude this trial effectively demonstrated that changing the location of where the intensivist sleeps does not change patient care. On-demand staffing from the in-house sleep room is not necessarily a different intervention than on-demand staffing from home. The integration of processes which continually progress patient’s care is integral to the success of nocturnal staffing models. Processes, which the presence of a nocturnal intensivist leads, include scheduled nighttime rounding, off-hours extubation, goals of care discussions, and initiation of comfort care. When these processes are integrated in a mature 24 × 7 coverage model, several themes emerge, including decreased length of ICU and total hospital stay (10), improved processes of care and staff satisfaction, and decreased ICU complication rate (1).
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