Overnight Intensivists Can Cut Mortality in Low-Intensity ICUs

SAN FRANCISCO – Overnight intensivist coverage reduces ICU mortality, but only in ICUs that don’t have robust intensivist coverage during the day, according to University of Pittsburgh researchers.

The team linked the outcomes of 65,752 ICU patients in the APACHE (Acute Physiologic and Chronic Health Evaluation) database from 2009-2010 to survey-assessed staffing practices at the 49 ICUs where they were treated.

In the 22 ICUs with low-intensity daytime staffing (meaning that intensivists weren’t routinely involved in patient care during the day and intensivist consults were only optional), having an intensivist present in the ICU at night – or at least immediately available to manage overnight ICU emergencies – was associated with a significant reduction in risk-adjusted, in-hospital mortality (odds ratio, 0.62; P = .04), the researchers said.

That wasn’t the case in the 27 ICUs with high-intensity daytime staffing, where intensivists had primary responsibility for patients during the day or intensivist consults were required for daytime admissions. Adding an overnight intensivist to expand that coverage to 24 hours did not significantly reduce risk-adjusted, in-hospital mortality (OR, 1.08; P = .78) (N. Engl. J. Med. 2012 May 21 [doi:10.1056/NEJMsa1201918]).

The critical care community – as well as hospitals, insurance providers, and legislators – have debated ICU staffing in the wake of studies showing that outcomes improve when intensivists manage ICU patients during the day (JAMA 2002;288:2151-62).

Among other questions on their minds was whether nighttime coverage would improve outcomes even more, senior author Dr. Jeremy Kahn, of the departments of critical care medicine and health policy at the University of Pittsburgh, said at the international conference of the American Thoracic Society.

"Our study indicates" that "ICUs with low-intensity daytime staffing, the most common staffing model in the United States, have better outcomes when intensivists are present at night. Nationally, two-thirds of ICUs have no intensivists at night, so expanding the role of intensivists in these ICUs could translate into improved health care quality," he said.

But ICUs with robust intensivist coverage during the day – and, frequently, resident coverage at night – do "not share the same benefit from nighttime intensivists. This shows that the movement to expand intensivist presence in these hospitals may be premature, especially since intensivists are in relatively short supply," Dr. Kahn said.

"Individual hospitals and ICUs will need to weigh the anticipated benefits of expanding intensivist nighttime coverage against those of other quality-improvement efforts in order to best serve their patients, staff, and community," he and his colleagues concluded in their report.

It’s unclear why overnight intensivists reduced mortality in ICUs where they did not have a robust daytime presence. Perhaps they ensured more timely resuscitation of unstable patients, quicker treatment initiations, and more efficient adjustments of complex therapies, the researchers said.

Dr. Kahn and Dr. Campbell reported no relevant disclosures.