Our study did not find an association between nighttime ICU discharge and hospital mortality. However, the ICU readmission rate was higher and the hospital length of stay longer in the nighttime transfer group.
Objective
Our objective was to assess the cost implications of changing the ICU staffing model from on-demand presence to mandatory 24 hour in-house critical care specialist presence.
Design
A pre-post comparison was undertaken among the prospectively assessed cohorts of patients admitted to our medical ICU one year before and after the change. Our data was stratified by APACHE III quartile and whether a patient was admitted during the day or at night. Costs were modeled using a generalized linear model with log-link and gamma distributed errors.
Setting
A large academic center in the Midwest.
Patients
All patients admitted to the adult medical ICU on or after January 1, 2005 and discharged on or before December 31, 2006. Patients receiving care under both staffing models were excluded.
Intervention
Changing the ICU staffing model from on-demand presence to mandatory 24 hour in-house critical care specialist presence.
Measurements
Total cost estimates of hospitalization were calculated for each patient starting from the day of ICU admission to day of hospital discharge.
Main Results
Adjusted mean total cost estimates were 61% lower in the post-period relative to the pre-period for patients admitted during night hours (7PM to 7AM) who were in the highest APACHE III quartile. No significant differences were seen at other severity levels. Unadjusted ICU length of stay fell in the post-period relative to the pre-period (3.5 vs. 4.8) with no change in non-ICU length of stay.
Conclusions
We find 24-hour ICU intensivist staffing reduces lengths of stay and cost estimates for the sickest patients admitted at night. The costs of introducing such a staffing model need to be weighed against the potential total savings generated for such patients in smaller ICUs, especially ones that predominantly care for lower acuity patients.
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