Retrospective Study of the Addition of Nighttime Intensivist Staffing to Daytime Intensivist Staffing in 49 Intensive Care Units Participating in the APACHE Clinical Information System from 2009-2010 (NEJM, 2012) [MEDLINE]: data were adjusted for case mix, severity of illness, and daytime intensivist staffing
In ICU’s with Low-Intensity Daytime Intensivist Staffing (Generally Open ICU’s), the Addition of Nighttime Intensivist Staffing Decreased Mortality Rates
In ICU’s with High-Intensity Daytime Intensivist Staffing, the Addition of Nighttime Intensivist Staffing Had No Mortality Benefit
Problems with the Study: study did not examine the iatrogenic complication rates, ICU cost, or ICU length of stay
Randomized Trial of ICU Staffing in an Academic Medical ICU (with Resident/Fellow Coverage) in the University of Pennsylvania Health System (NEJM, 2013) [MEDLINE]: n = 1598
Addition of Nighttime Intensivist Staffing to Daytime Intensivist Staffing on the Night of Patient’s Admission Did Not Improve ICU Length of Stay or ICU Mortality Rate
United States Critical Illness and Injury Trials Group Critical Illness Outcomes Study Intensivist Survey (Crit Care Med, 2014) [MEDLINE]: n = 69 ICU’s
Daily Plan of Care Review and Lower Bed/Nurse Ratio (Decreased to 1.5/1) were Both Associated with Decreased Annual ICU Mortality
24-Hour Intensivist Staffing and Closed ICU Status Had No Impact on Annual ICU Mortality
Clinical Efficacy-ICU Fellow Staffing
Observational Cohort Study in Academic Hospital Examining the Effect of Fellow Coverage Patterns (Am J Respir Crit Care Med 2014) [MEDLINE]
Patient Exposure to Cross-Covering Fellows was Associated with a Decrease in ICU Mortality, Increased Number of Nighttime Decisions, Increased Fentanyl Use, and Increased Transfusions, as Compared to Exposure to the Same Fellow Who Provided Daytime Coverage
Clinical Efficacy-Closed ICU Status
United States Critical Illness and Injury Trials Group Critical Illness Outcomes Study Intensivist Survey (Crit Care Med, 2014) [MEDLINE]: n = 69 ICU’s
Daily Plan of Care Review and Lower Bed/Nurse Ratio were Both Associated with Decreased Annual ICU Mortality
24-Hour Intensivist Staffing and Closed ICU Status Had No Impact on Annual ICU Mortality
Clinical Efficacy-Daily Plan of Care Review
United States Critical Illness and Injury Trials Group Critical Illness Outcomes Study Intensivist Survey (Crit Care Med, 2014) [MEDLINE]: n = 69 ICU’s
Daily Plan of Care Review and Lower Bed/Nurse Ratio were Both Associated with Decreased Annual ICU Mortality
24-Hour Intensivist Staffing and Closed ICU Status Had No Impact on Annual ICU Mortality
Clinical Efficacy-ICU Protocols
United States Critical Illness and Injury Trials Group Critical Illness Outcomes Study of ICU Protocols (Crit Care Med, 2015) [MEDLINE]
Median Number of Protocols Per ICU was 19
There was No Association Between the Number of Protocols and ICU Mortality Rate, Length of Stay, Use of Mechanical Ventilation, Use of Vasopressors, or Use of Continuous Sedation
Protocol Compliance with Mechanical Ventilation Protocols was Moderate and Did Not Differ Between Hospitals with High vs Low Numbers of Protocols
Clinical Efficacy-Bundles
Study of the Impact of a Bundle in the Prevention of Ventilator-Associated Pneumonia (Crit Care Med, 2011) [MEDLINE]
Implementation of a Ventilator-Associated Pneumonia Prevention Bundle Decreased the Rate of Ventilator-Associated Pneumonia: this occurred despite the bundle not achieving 95% for all of the elements
Clinical Efficacy-Telemedicine
Study of the Financial Impact of Telemedicine on ICU Care (Chest, 2017) [MEDLINE]
ICU Telemedicine Increased Case Volume, Increased Revenue Relative to Direct Costs, and Decreased Length of Stay
Clinical Efficacy-Intensive Care Unit to Intensive Care Unit Transfers
Swedish Observational Study of Impact of Intensive Care Unit to Intensive Care Unit Transfers (Ann Intensive Care, 2022) [MEDLINE]
Primary and secondary end-points were survival to 30 days and 180 days after discharge from the first ICU
Data from 75 ICUs in the Swedish Intensive Care Register, a nationwide intensive care register, were used for analysis (89% of all Swedish ICUs), covering local community hospitals, district general hospitals and tertiary care hospitals
We included adult patients (16 years or older) admitted to ICU and subsequently discharged by transfer to another ICU
Only the first admission was used
Exposure was discharge to any other ICU (ICU-to-ICU transfer), whether in the same or in another hospital
Transfers were grouped into three predefined categories: clinical transfer, capacity transfer, and repatriation
We identified 15,588 transfers among 112,860 admissions (14.8%) and analysed 11,176 after excluding 4112 repeat transfer of the same individual and 300 with missing risk adjustment
The majority were clinical transfers (62.7%), followed by repatriations (21.5%) and capacity transfers (15.8%)
Unadjusted 30-day mortality was 25.0% among capacity transfers compared to 14.5% and 16.2% for clinical transfers and repatriations, respectively
Adjusted odds ratio (OR) for 30-day mortality were 1.25 (95% CI 1.06-1.49 p = 0.01) for capacity transfers and 1.17 (95% CI 1.02-1.36 p = 0.03) for clinical transfers using repatriation as reference
The differences remained 180 days post-discharge
Recommendations (American College of Critical Care Medicine Task Force on Models of Critical Care, 2015) (Crit Care Med, 2015) [MEDLINE]
Intensivist-Led, High-Performing, Multidisciplinary Team Dedicated to the Intensive Care Unit is an Integral Part of Effective Care Delivery
Process Improvement is the Backbone of Achieving High-Quality Intensive Care Unit Outcomes
Standardized Protocols Including Care Bundles and Order Sets to Facilitate Measurable Processes and Outcomes Should Be Used and Further Developed in the Intensive Care Unit Setting
Institutional Support for Comprehensive Quality Improvement Programs as well as Tele-ICU Programs Should Be Provided
Intensive Care Unit Bundles
xxxx
Critical care bundles and grouped orders with reminders have been found to be an effective strategy to improve patient outcomes
These measures have been associated with a decrease in central line duration and infection rate, a decrease in ventilator days, a decreased incidence of self-extubation, and a decreased incidence of VAP
References
General
Decreasing ventilator-associated pneumonia in a trauma ICU. J Trauma 2006;61:122 [MEDLINE]
Intensive care unit quality improvement: A how-to guide for the interdisciplinary team. Crit Care Med 2006;34:211 [MEDLINE]
Measurable outcomes of quality improvement in the trauma intensive care unit: The impact of a daily quality rounding checklist. J Trauma. 2008 Jan;64(1):22-7; discussion 27-9. doi: 10.1097/TA.0b013e318161b0c8 [MEDLINE]
Patient flow variability and unplanned readmissions to an intensive care unit. Crit Care Med 2009;37:2882-87 [MEDLINE]
Reducing ventilator-associated pneumonia in intensive care: impact of implementing a care bundle. Crit Care Med. 2011 Oct;39(10):2218-24. doi: 10.1097/CCM.0b013e3182227d52 [MEDLINE]
Nighttime intensivist staffing and mortality among critically ill patients. N Engl J Med 2012;366:2093-2101 [MEDLINE]
Intensive enough. N Engl J Med 2012;366:2124-2125 [MEDLINE]
Staffing in ICUs: physicians and alternative staffing models. – Chest. 2013 Jan;143(1):214-221. doi: 10.1378/chest.12-1531 [MEDLINE]
A randomized trial of nighttime physician staffing in an intensive care unit. N Engl J Med. 2013 Jun 6;368(23):2201-9. doi: 10.1056/NEJMoa1302854. Epub 2013 May 20 [MEDLINE]
Nighttime cross-coverage is associated with decreased intensive care unit mortality. Am J Respir Crit Care Med 2014;189(11):1395-1401 [MEDLINE]
Cross-coverage in the intensive care unit: More than meets the “I”? Am J Respir Crit Care Med 2014;189(11):1297-1298 [MEDLINE]
Structure, process, and annual ICU mortality across 69 centers: United States Critical Illness and Injury Trials Group Critical Illness Outcomes Study. Crit Care Med. 2014 Feb;42(2):344-56. doi: 10.1097/CCM.0b013e3182a275d7 [MEDLINE]
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;43:1520–1525 [MEDLINE]
Protocols and Hospital Mortality in Critically Ill Patients: The United States Critical Illness and Injury Trials Group Critical Illness Outcomes Study. Crit Care Med. 2015 Oct;43(10):2076-84. doi: 10.1097/CCM.0000000000001157 [MEDLINE]
ICU Telemedicine Program Financial Outcomes. Chest. 2017 Feb;151(2):286-297. doi: 10.1016/j.chest.2016.11.029. Epub 2016 Dec 6 [MEDLINE]
Intensive Care Unit to Intensive Care Unit Transfers
Intensive care unit to unit capacity transfers are associated with increased mortality: an observational cohort study on patient transfers in the Swedish Intensive Care Register. Ann Intensive Care. 2022 Apr 4;12(1):31. doi: 10.1186/s13613-022-01003-x [MEDLINE]
