The Impact of Implementing an Intensivist Model With Nighttime In-Hospital Nocturnist and Effect on ICU Outcomes

Abstract

Background:

Various intensivist staffing models have been suggested, but the long-term sustainability and outcomes vary and may not be sustained. We examined the impact of implementing a high-intensity intensivist coverage model with a nighttime in-house nocturnist (non-intensivist) and its effect on intensive care unit (ICU) outcomes.

Methods:

We obtained historical control baseline data from 2007 to 2011 and compared the same data from 2011 to 2015. The Acute Physiological and Chronic Health Evaluation outcomes system was utilized to collect clinical, physiological, and outcome data on all adult patients in the medical ICU and to provide severity-adjusted outcome predictions. The model consists of a mandatory in-house daytime intensivist service that leads multidisciplinary rounds, and an in-house nighttime coverage is provided by nocturnist (nonintensivists) with current procedural skills in airways management, vascular access, and commitment to supervise house staff as needed. The intensivist continues to be available remotely at nighttime for house staff and consultation with the nocturnist. A backup intensivist is available for surge management.

Results:

First year yielded improved throughput (2428 patients/year to 2627 then 2724 at fifth year). Case mix stable at 53.7 versus 55.2. The ICU length of stay decreased from 4.7 days (predicted 4.25 days) to 3.8 days (4.15) in first year; second year: 3.63 days (4.29 days); third year: 3.24 days (4.37), fourth year: 3.34 days (4.45), and fifth year: 3.61 days (4.42). Intensive care unit <24 hours readmission remained at 1%; >24 hours increased from 4% to 6%. Low-risk monitoring admissions remained at an average 17% (benchmark 17.18%). Intensive care unit mortality improved with standardized mortality ration averaging at 0.84. Resident satisfaction surveys improved.

Conclusions:

Implementing an intensivist service with nighttime nocturnist staffing in a high-intensity large teaching hospital is feasible and improved ICU outcomes in a sustained manner that persisted after the initial implementation phase. The model resulted in reduced and sustained observed-to-predicted length of ICU stay.

Keywords

intensivist nocturnist intensive care unit ICU hospital mortality intensivist staffing length of stay

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References

Pronovost

Angus

Dorman

Robinson

Dremsizov

Young

. Physician staffing patterns and clinical outcomes in critically ill patients: a systematic review. JAMA. 2002;288(17):2151–2162.

Wilcox

Chong

Niven

, et al. Do intensivist staffing patterns influence hospital mortality following ICU admission? A systematic review and meta-analyses. Crit Care Med. 2013;41(10):2253–2274.

Burnham

Moss

Geraci

. The case for 24/7 in-house intensivist coverage. Am J Respir Crit Care Med. 2010;181(11):1159–1160.

Davidson

. POINT: does the United States need more intensivist physicians? Yes. Chest. 2016;149(3):621–625.

Kerlin

Adhikari

Rose

, et al. An official American Thoracic Society Systematic Review: the effect of nighttime intensivist staffing on mortality and length of stay among intensive care unit patients. Am J Respir Crit Care Med. 2017;195(3):383–393.

Love

Maarouf

Olis

Obeidy

. 101: the model matters: intensivist model has large mortality/cost benefits vs consultative ccm ICU care. Crit Care Med. 2016;44(12 suppl 1):103.

Rubenfeld

. COUNTERPOINT: does the united states need more intensivist physicians? No. Chest. 2016;149(3):625–628.

Buchman

Coopersmith

Meissen

, et al. Innovative interdisciplinary strategies to address the intensivist shortage. Crit Care Med. 2017;45(2):298–304.

Degaspari

. An alternative approach to 24/7 ICU coverage. can tele-ICU monitoring fill the intensivist shortage? Healthc Inform. 2012;29(7):38–39.

10.

Halpern

Pastores

Oropello

Kvetan

. Critical care medicine in the United States: addressing the intensivist shortage and image of the specialty. Crit Care Med. 2013;41(12):2754–2761.

11.

Siegal

Dressler

Dichter

Gorman

Lipsett

. Training a hospitalist workforce to address the intensivist shortage in American hospitals: a position paper from the Society of Hospital Medicine and the Society of Critical Care Medicine. Crit Care Med. 2012;40(6):1952–1956.

12.

Kerlin

Halpern

. Twenty-four-hour intensivist staffing in teaching hospitals: tensions between safety today and safety tomorrow. Chest. 2012;141(5):1315–1320.

13.

Wallace

Angus

Barnato

Kramer

Kahn

. Nighttime intensivist staffing and mortality among critically ill patients. N Engl J Med. 2012;366(22):2093–2101.

14.

Kerlin

Small

Cooney

, et al. A randomized trial of nighttime physician staffing in an intensive care unit. N Engl J Med. 2013;368(23):2201–2209.

15.

Singer

Kohlwes

Bent

Zimmerman

Eisner

. The impact of a “low-intensity” versus “high-intensity” medical intensive care unit on patient outcomes in critically ill veterans. J Intensive Care Med. 2010;25(4):233–239.

16.

Zimmerman

Kramer

McNair

Malila

. Acute Physiology and Chronic Health Evaluation (APACHE) IV: hospital mortality assessment for today’s critically ill patients. Crit Care Med. 2006;34(5):1297–1310.

17.

Zimmerman

Kramer

McNair

Malila

Shaffer

. Intensive care unit length of stay: benchmarking based on Acute Physiology and Chronic Health Evaluation (APACHE) IV. Crit Care Med. 2006;34(10):2517–2529.

18.

den Broeck

Kaulfuss

. Statistical estimation. In: den Broeck

Brestoff

, eds. Epidemiology: Principles and Practical Guidelines. London, New York: Springer; 2013:417.

19.

Higgins

Teres

Copes

Nathanson

Stark

Kramer

. Assessing contemporary intensive care unit outcome: an updated mortality probability admission model (MPM0-III). Crit Care Med. 2007;35(3):827–835.

20.

The APACHE (R) IV Equations Benchmarks for Mortality and Resource Use. Cerner Corporation. 2005;Version 1 0:29.

21.

Higgins

McGee

Steingrub

Rapoport

Lemeshow

Teres

. Early indicators of prolonged intensive care unit stay: impact of illness severity, physician staffing, and pre-intensive care unit length of stay. Crit Care Med. 2003;31(1):45–51.

22.

Arabi

Alshimemeri

Taher

. Weekend and weeknight admissions have the same outcome of weekday admissions to an intensive care unit with onsite intensivist coverage. Crit Care Med. 2006;34(3):605–611.

23.

Gajic

Afessa

Hanson

, et al. Effect of 24-hour mandatory versus on-demand critical care specialist presence on quality of care and family and provider satisfaction in the intensive care unit of a teaching hospital. Crit Care Med. 2008;36(1):36–44.

24.

Kumar

Singal

Manji

, et al. The benefits of 24/7 in-house intensivist coverage for prolonged-stay cardiac surgery patients. J Thorac Cardiovasc Surg. 2014;148(1):290–297.e296.

25.

Banerjee

Naessens

Seferian

, et al. Economic implications of nighttime attending intensivist coverage in a medical intensive care unit. Crit Care Med. 2011;39(6):1257–1262.

26.

Gershengorn

Johnson

Factor

. The use of nonphysician providers in adult intensive care units. Am J Respir Crit Care Med. 2012;185(6):600–605.

27.

Kleinpell

Ely

Grabenkort

. Nurse practitioners and physician assistants in the intensive care unit: an evidence-based review. Crit Care Med. 2008;36(10):2888–2897.

28.

Wise

Akopov

Williams

Jr Ido

Leeper

Jr Dressler

. Hospitalists and intensivists in the medical ICU: a prospective observational study comparing mortality and length of stay between two staffing models. J Hosp Med. 2012;7(3):183–189.

29.

Costa

Wallace

Kahn

. The association between daytime intensivist physician staffing and mortality in the context of other ICU organizational practices: a multicenter cohort study. Crit Care Med. 2015;43(11):2275–2282.

30.

Levy

Rapoport

Lemeshow

Chalfin

Phillips

Danis

. Association between critical care physician management and patient mortality in the intensive care unit. Ann Intern Med. 2008;148(11):801–809.

31.

Lane-Fall

Collard

Turnbull

Halpern

Shea

. ICU attending handoff practices: results from a national survey of academic intensivists. Crit Care Med. 2016;44(4):690–698.

32.

Weled

Adzhigirey

Hodgman

, et al. Critical care delivery: the importance of process of care and ICU structure to improved outcomes: an update from the American College of Critical Care Medicine Task Force on Models of Critical Care. Crit Care Med. 2015;43(7):1520–1525.

33.

Garland

Roberts

Graff

. Twenty-four-hour intensivist presence: a pilot study of effects on intensive care unit patients, families, doctors, and nurses. Am J Respir Crit Care Med. 2012;185(7):738–743.

34.

Engerstrom

Kramer

Nolin

, et al. Comparing time-fixed mortality prediction models and their effect on ICU performance metrics using the simplified acute physiology score 3. Crit Care Med. 2016;44(11):e1038–e1044.

35.

Kramer

Higgins

Zimmerman

. Comparing observed and predicted mortality among ICUs using different prognostic systems: why do performance assessments differ? Crit Care Med. 2015;43(2):261–269.

36.

Kim

Barnato

Angus

Fleisher

Kahn

. The effect of multidisciplinary care teams on intensive care unit mortality. Arch Intern Med. 2010;170(4):369–376.

37.

Barr

Fraser

Puntillo

, et al. Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med. 2013;41(1):263–306.

38.

Schmidt

Girard

Kress

, et al. Liberation from mechanical ventilation in critically ill adults: executive summary of an official American College of Chest Physicians/American Thoracic Society Clinical Practice Guideline. Chest. 2017;151(1):160–165.