Nighttime intensivist staffing and mortality

Dr. Chang

Wallace DJ, Angus DC et al. Nighttime intensivist staffing and mortality among critically ill patients. NEJM 366; 2093: 2012.

Summary: 

There has been an increasingly hot debate regarding the degree to which nighttime intensivists are associated with improvements in the quality of ICU care. Proponents suggest nighttime intensivists provide earlier establishment of treatment plans, more timely resuscitation of unstable patients, and more consistent decision-making all hours of the day. Opponents feel intensivists at night contribute to a high cost of hospitals' investments and that most judgment is based on lack of concrete evidence. Two prior studies showed: benefit of nighttime staffing involved in ICU care with low-intensity daytime staffing (Lancet, 2000); and no reduction for in-hospital mortality after adding night intensivists to already high-intensity staffing.

In brief, the study in this article was conducted over 2009-2010 and designed surveys were sent out to clinical coordinators at sites that utilize the APACHE scoring system. The primary outcome variable was in-hospital mortality (excluded patient discharged to hospice care). Multiple statistical analyses were performed, which included multivariate models to assess a relationship between nighttime intensivist staffing and in-hospital mortality. Adjustments were made for daytime intensivist staffing, illness severity, and case mix. Results were based on 65,752 (66% of total ICU admission) admitted to 49 ICUs in 25 hospitals:

- LOW-intensity daytime staffing: nighttime staffing associated with reduction in risk-adjusted in-hospital mortality (P=0.04)

- HIGH-intensity daytime staffing: no benefit with respect to risk-adjusted in-hospital mortality (P=0.78)

The discussion suggests that nighttime intensivists are more accessible to nursing staff and other providers, which ultimately aims to reduce medical errors. This is especially applicable in the setting of sepsis where studies have shown that rapid assessment improves outcomes. Limitations discussed included: lack of a random sample, definition of ‘nighttime’ broad in that it did not measure individualized clinical behavior, and that it did not evaluate increasing role of ICU telemedicine. In concluded that a general endorsement of 24-hour intensivist coverage is premature.