24/7 Attending Intensivist Staffing Improves Care of the Critically Ill

Transcription

1 24/7 Attending Intensivist Staffing Improves Care of the Critically Ill John H. Turnbull, M.D. Assistant Professor of Anesthesia Division of Critical Care Medicine University of California San Francisco All acute care admission in Ontario, Canada ( ) Compared weekend vs. weekday in-hospital mortality among patients with Ruptured AAA Acute epiglottitis PE Bell et al. NEJM 2001; 345:

2 Potential Benefits of 24/7 Intensivist Staffing Earlier establishment of treatment plans More timely resuscitation of unstable patients More consistent provision of complex care More consistent decision making at all hours of the day Retrospective review of 34 ICUs using the APACHE clinical information system; Primary outcome in-hospital mortality Classified ICUs as High intensity mandatory consult or primary svc Low intensity optional consultation of ICU svc Findings Overall, nighttime staffing without mortality benefit In low intensity ICUs, nighttime staffing associated with a reduction of risk-adjusted inhospital mortality (OR 0.62, p=0.04) Limitations regarding study design 1. Retrospective analysis of database elements 2. Unclear on staffing responsibility during nighttime hours 2

3 1 year randomized trial in academic MICU Assigned blocks of 7 consecutive nights to the control (no in-house intensivist) or intervention (in-house intensivist; night-float concept) strategies Patients categorized according to staffing on day of admission Primary outcome ICU LOS Findings No difference in ICU or hospital LOS, mortality, ICU readmission or disposition on discharge Initial concerns regarding study design 1. Delivery of care may change as frequently as weekly 2. No continuity of nighttime intensivist 3. Only required to evaluate new patients or patients who deteriorated 3

4 24/7 Intensivist Presence Improves Delivery of Quality, Value-Based Care Decreasing hospital LOS Improving adherence to clinical guidelines and processes of care Reducing resource utilization Improving quality of life outcomes in long-term survivors Improving provider satisfaction and GME education Implementation of 24/7 Intensivist Staffing MGH SICU Retrospective review of a pre- and postimplementation of 24/7 attending coverage 20 bed closed model SICU 24/7 fellow coverage throughout study Attending expectations Round twice nightly with housestaff and nursing No other obligations Van der Wilden GM, et al. Implementation of 24/7 intensivist presence in the SICU: Effect on processes of care. J Trauma Acute Care Surg Comparison of Patient Cohorts Year 1 and Year 2 Secondary Outcomes Outcomes Year 1 Year 2 P Parameter Year 1 n = 1,408 Year 2 n = 1,421 Age, mean (+ SD), yr 60.8 (+ 18.1) 60.3 (+ 17.9) 0.45 Male, n (%) 824 (58.5) 824 (58) 0.77 Total patients ventilated, n (%) 782 (55.5) 777 (54.7) 0.65 APACHE II, mean (+ SD) 12.3 (+ 6.7) 11.2 (+ 6.2) Trauma patients, n (%) 174 (12.4) 176 (12.4) 0.98 p Blood products, mean (+ SD) Total PRBC, mean (+ SD) Total FFP, mean (+ SD) CT scan rate, per patient (+ 47.9) (+ 65.6) (+ 23.1) (+ 27.5) (+ 23.5) 61.1 (+ 27.6) < Attending presence decreased resource utilization and interventions with a risk for harm 4

5 Initiation of 24/7 Coverage Mayo MICU Study Timeline Prospective evaluation of initiation of 24/7 attending intensivist coverage 2 year study period No other major practice model interventions during study period Gajic O, et al. Effect of 24-hour mandatory versus on-demand critical care specialist presence on quality of care and family and provider satifsication in the ICU of a teaching hospital. Critical Care Medicine Baseline characteristics ICU Outcomes Outcome Pre Post p ICU LOS, median days Hospital LOS, median days ICU readmission, % Adjusted mean hospital LOS decreased by 1.4 days (95% CI -0.3 to -2.5 days) 5

6 Comparison of Processes of Care Comparison of ICU complications Pre Post p Ventilator Bundle n = 97 (356 days n = 191 (963 days) Stress ulcer prophylaxis, n (%) 349 (98) 961 (100) VTE prophylaxis, n (%) 323 (91) 906 (94) Sepsis resuscitation n = 45 n = 84 Adherence to severe sepsis guidelines, n (%) 32 (71) 69 (82) ALI/ARDS n = 61 (109 days) n = 127 (311 days) Adherence to low Tv ventilation, n (%) 79 (72) 251 (81) Complication Pre 356 days (n= 97) Post 963 days (n = 191) p DVT, n (%) 5 (1.4) 14 (1.5) 0.98 PE 3 (0.8) 3 (0.3) Bleeding 8 (2.2) 8 (0.8) VAP 9 (2.5) 18 (1.9) Reintubation 13 (3.6) 21 (2.2) Cumulative ICU complication rate 38 (11) 64 (7) Cumulative # of omission of processes of care 84 (24) 149 (16) Staff Surveys Survey of attending intensivists, allied health staff and physicians in training Staff satisfaction and perceptions about patient safety, education, organization and function improved No difference in educational value of training physicians between models New model optimal for patient pare (38% vs 78% p< 0.001) 24/7 intensivist presence Decreases hospital LOS when adjusted for severity of illness Improves processes of care Decreases ICU complication rate Improves staff satisfaction Appears to not interfere with educational goals of physician trainees 6

7 Quality of Life Follow-up Reriani M, et al. Effect of 24-hour mandatory vs on-demand critical care specialist presence on long-term survival and quality of life. J Critical Care Differences Between Baseline and 6 Month Follow-up of QoL Measures SF-36 scale Pre 24/7 Within-patient score difference Post 24/7 Within-patient score difference Physical functioning Role limitations, physical Bodily pain General health perception Vitality Social functioning Role limitations, emotional Mental health Mental component Physical component p Economic Impact Follow-up from Mayo study Cost analysis based on reimbursements from Medicare part A (UB revenue codes) and Medicare part B (CPT4 codes) Corrected for inflation, cost-to-charge indices and proxied Medicare reimbursement rates Total Cost Estimates Pre Mean (SD) Post Mean (SD) p All admissions APACHE III Q1 $15,819 (26,656) $14,632 (24,632) APACHE III Q2 $29,732 (40,719) $26,857 (40,486) APACHE III Q3 $33,105 (43,209) $32,131 (35,663) APACHE III Q4 $50,033 (70,924) $41,053 (47,431) Total $32,834 (50,372) $28,473 (39,078) All night admissions $29,935 (52,129) $25,384 (36,384) Cost from ICU admission to hospital discharge Banerjee R, et al. Economic Implications of nighttime attending intensivist coverage in a MICU. Critical Care Medicine

8 Economic Impact to CC Division MGH and Mayo required approximately approximately 2 additional FTEs Per MGH study, nocturnal intensivists supervised and billed all procedures and completion of billable critical care note (99291) Year 1 Year 2 FTE RVU 22,323 36,543 RVU/FTE 6,452 6, % increase in RVU/FTE 24/7 attending intensivist presence Improves quality of life in long-term ICU survivors May increase revenue for critical care division while providing value-based, quality care that reduces overall costs 8

9 In Summary No evidence that 24/7 intensivist improves mortality Multiple studies demonstrate 24/7 coverage Decreases hospital LOS Decreases ICU complication rate Improves processes of care Decreases utilization of resources and costs Improves quality of life in survivors Likely limited impact on educational objectives Con: 24/7 Intensivist Susan S. Yoo, M.D. Assistant Professor of Anesthesia Division of Critical Care Medicine University of California San Francisco/ San Francisco General Hospital 2003; 31(3): Conclusions: Nighttime admission to study ICU not associated with higher mortality or longer hospital or ICU stay compared to daytime admission Conclusion: Day of week and time of day of ICU admission were not associated with significant differences in hospital mortality after adjustment for case mix 9

10 2004; 126: ; 35(1) Conclusions: Admissions during off hours were not associated with higher mortality, and may be associated with a lower death rate Conclusions: Overall adjusted hospital mortality of weekend admissions to medical or multispecialty (but not SICU) not higher than weekday admissions. 2009, 3:8. Conclusions: Time or day of admission does not influence risk for in-hospital mortality in major trauma victims Night/Weekend Admissions No definitive evidence that patients admitted to ICUs during off-hours have worse outcomes. 2011; 146 (7): Conclusions: No demonstrable mortality difference among injured patients presenting on weeknights vs weekdays, and lower mortality on weekends vs weekdays 10

11 2012; 366:

12 Conclusions In low-intensity daytime staffing ICUs, nighttime intensivist coverage was associated with a mortality reduction (p<0.04) There was no reduction in mortality demonstrated for highintensity daytime staffing ICUs. Published online May 20,

13 Blanket application of 24-hour ICU attending coverage is premature No definitive evidence that weekend and night admissions to ICUs have worse outcomes No definitive evidence that 24-hour attending intensivist coverage improves patient outcomes Let s Talk Logistics Well-documented intensivist shortage Estimated that only 20-33% of critically ill patients are cared for by ICU trained physicians Implications for rural hospitals 13

14 Physician burnout higher than any other US worker Embriaco N, Papazian L, Kentish-Bares N, et al. Burnout syndrome among critical care healthcare workers. Curr Opin Crit Care 2007; 13: Shanafelt TD, Boone S, Litjen T, et al. Burnout and Satisfaction with work-life balance among US physicians relative to the general US population. Arch intern med 2012; 172 (18): Physician training Alternative Strategies Protocolization/bundles High-intensity ICU > Low-intensity ICU ICU nurse workforce Advanced level practitioners, hospitalist coverage Telemedicine Wallace DJ, Angus DC,.Barnato AE. Nighttime Intensivist Staffing and Mortality among Critically Ill Patients. NEJM 2012; 366 (22):

15 High-intensity staffing model JAMA 2002; 288(17): Conclusions: Lower hospital and ICU mortality and length of stay in high-intensity staffed ICUs Summary Conclusions There are consistently Crit Care Med 2010; 38 (7) demonstrated associations between increased RN Med Care 2007 Dec; 45(12): staffing in hospital wards or intensive care units and lower odds of hospital-related J Adv Nurs 2012; 68 (5): mortality and adverse events Teleintensivist Critical care research and practice Adv Level Practitioners/Hospitalists Crit Care Med 2008; 36(10): Blanket application of 24-hour ICU attending coverage is premature No definitive evidence that weekend and night admissions to ICUs have worse outcomes. No definitive evidence that 24-hour attending intensivist coverage improves patient outcomes. High costs, ICU physician shortages, expected worsened burnout, job satisfaction, impact on physician training are critically important factors. Factors that predict patient outcomes are multifold and not adequately addressed by only examining the physician-patient interface. Alternative strategies (telemedicine, nurse practitioners, transition to high-intensity ICUs, hospitalist coverage, etc) should be explored. 15