Daniel M. Keller, PhD

May 30, 2013

PHILADELPHIA, Pennsylvania — Let the intensivist attendings and fellows go home. Their presence at night in a tertiary care intensive care unit (ICU) does not have any measurable benefit on patient outcomes, a randomized controlled trial shows.

One third of academic medical centers have implemented nighttime staffing with intensivists, but outcomes studies using before-and-after or crossover designs have produced mixed results.

"We wanted to understand whether or not this is a good thing to do," said Meeta Kerlin, MD, from the University of Pennsylvania in Philadelphia.

Dr. Kerlin presented the study results here at the American Thoracic Society 2013 International Conference. They were published online May 20 in the New England Journal of Medicine to coincide with the presentation.

The researchers compared 2 staffing models in their 24-bed ICU: a traditional model in which attendings and fellows were in the hospital during the day and on call at night (control nights), and a model in which intensivists were in the hospital during the day and overnight (staffed nights).

The ICU was randomized in 7-day blocks to control nights or staffed nights. Resident trainee and nurse staffing remained constant on all shifts.

The primary outcome was length of stay in the ICU, which Dr. Kerlin said is a "very patient-centered outcome" and relevant to cost.

 
There was no difference whether a patient was admitted on a night that had an intensivist in the hospital or not.
 

The study was conducted over 166 nights. Of the 1598 patients involved, 820 were in the staffed group and 778 were in the control group.

The groups were well matched for sex (about 55% male), age (median, 60 years), Acute Physiology and Chronic Health Evaluation (APACHE) III score (median, 67), interventions during ICU admission, source of admission, and proportion of nighttime admissions (about 60%).

"Essentially, there was no difference whether a patient was admitted on a night that had an intensivist in the hospital or not," Dr. Kerlin said.

There was no difference in secondary outcomes between staffed and control nights, including length of hospital stay (9.0 vs 8.8 days; hazard ratio, 0.91; 95% confidence interval, 0.81 - 1.03).

The interaction between severity of illness by APACHE III quartile and staffing had no effect on length of stay (= .29), nor did the interaction between severity of illness and experience level of the residents (= .30).

There were more calls to the on-call intensivist attendings and fellows on control nights than on staffed nights (2 vs ≤1; P  < .01), and they needed to return to the hospital more often on control nights (20 vs 1;< .01).

The implication is that residents and experienced staff nurses can generally handle whatever comes up at night. "As long as they have access by phone to expert advice, they can manage things," Dr. Kerlin noted.

The staffing models might affect resident education. Residents reported that they had sufficient autonomy when intensivists were on duty at night, but having them there made the residents feel more supported in their decisions. They also felt that the quality of their educational experience was better on nights when an intensivist was present.

In light of the fact that many hospitals are putting on intensivists at night, this comparison "does change things, and is really important," said Greg Martin, MD, from Emory University and Grady Memorial Hospital in Atlanta, Georgia, who was not involved with the study.

However, he cautioned that the study was done in a "relatively prestigious, high-quality training program. It's academic, it's a specific ICU and, obviously, they were well trained and well staffed already," making this a high-performing ICU at baseline. "That's probably the setting where you're less likely to find a benefit of having nocturnal staffing," he told Medscape Medical News.

Dr. Martin noted that it must have been a difficult study to do. Even though staffing at night was randomized, many patients overlapped staffing periods. However, there was no difference between patients who were in the ICU 100% with or without nighttime intensivist coverage.

This study received no commercial funding Dr. Kerlin and Dr. Martin have disclosed no relevant financial relationships.

N Engl J Med. Published online May 20, 2013. Abstract

American Thoracic Society (ATS) 2013 International Conference: Abstract A5243. Presented May 20, 2013.

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