Comparing mortality among adult, general intensive care units in England with varying intensivist cover patterns: a retrospective cohort study

Abstract

IntroductionResearch has demonstrated that intensivist-led care of the critically ill is associated with reduced intensive care unit (ICU) and hospital mortality. The objective of this study was to evaluate whether a relation exists between intensivist cover pattern (for example, number of days of continuous cover) and patient outcomes among adult general ICUs in England.MethodsWe conducted a retrospective cohort study by using data from a pooled case mix and outcome database of adult general critical care units participating in the Intensive Care National Audit & Research Centre (ICNARC) Case Mix Programme. Consecutive admissions to participating units for the years 2010 to 2011 were linked to a survey of intensivist cover practices. Our primary outcome of interest was mortality at ultimate discharge from acute-care hospital.ResultsThe analysis included 80,122 patients admitted to 130 ICUs in 128 hospitals. Multivariable logistic regression analysis was used to assess the relation between intensivist cover patterns (days of continuous cover, grade of physician staffing at nighttime, and frequency of daily handovers) and acute hospital mortality, adjusting for patient case mix. No relation was seen between days of continuous cover by a single intensivist or grade of physician staffing at nighttime and acute hospital mortality. Acute hospital mortality and ICU length of stay were not associated with intensivist characteristics, intensivist full-time equivalents per bed, or years of clinical experience. Intensivist participation in handover was associated with increased mortality (odds ratio, 1.27; 95% confidence interval, 1.04 to 1.55); however, only nine units reported no intensivist participation.ConclusionsWe found no relation between days of continuous cover by a single intensivist or grade of physician staffing at nighttime and patient outcomes in adult, general ICUs in England. Intensivist participation in handover was associated with increased mortality; further research to confirm or refute this finding is required.Electronic supplementary materialThe online version of this article (doi:10.1186/s13054-014-0491-3) contains supplementary material, which is available to authorized users.

Association between day and time of admission to critical care and acute hospital outcome for unplanned admissions to adult general critical care units: cohort study exploring the ‘weekend effect’

“…Previous research using the ICNARC CMP database found no association between patterns of senior intensivist staffing and mortality in the UK. 8 Other variables that are known to affect mortality among critically ill patients, including time of discharge to the ward, caseload, and level of training of the admitting physician, were beyond the scope of the present study.…”

“…7 Nonetheless, the number of doctors present on the critical care unit, availability of accredited intensivists, and accessibility of diagnostic and surgical services may vary at different times of day and at weekends compared with weekdays. 8 It is imperative to ascertain whether out-ofhours services are adequate to cover emergency care without any adverse impact on outcome for patients. As such, the effect of day and time of admission to the hospital or critical care unit on mortality has been the subject of recent scrutiny and controversy.…”

Toward the Ideal Ratio of Patients to Intensivists

“…This allows their work to be distinguished from prior work which used number of ICU beds to reflect ICU census 5 or the average full-time equivalent (FTE) of the intensivists at the ICU to reflect the number of intensivists caring for the patient. 6 Gershengorn and colleagues 4 provide an impressive number of alternative approaches to measuring individual physician workload in their sensitivity analyses, and find a consistent general pattern.…”

Intensive care medicine in smaller hospitals: here to stay

“…Importantly, many of these smaller units in the UK defied the political assumption that bigger is better and demonstrated outcomes that matched larger units, even with adjusted staffing structures. 9 A difference of opinion led to interesting discussions among the ICM community. In a nutshell, some believed smaller units should close and become stabilisation and transfer centres; others believed that onsite critical care expertise was an essential component of a safe hospital.…”