Economic implications of nighttime attending intensivist coverage in a medical intensive care unit*

Abstract

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.

Evolution of Critical Care Cardiology: Transformation of the Cardiovascular Intensive Care Unit and the Emerging Need for New Medical Staffing and Training Models

“…91,92 Although nocturnal intensivist coverage has been associated with shorter hospital length of stay and lower overall cost for the sickest patients, this may not necessarily be the case for less severely ill patients. 93 Some experts have argued that 24/7 (24 hours per day, 7 days per week) intensivist staffing itself does not reduce mortality or length of stay. 71 A number of factors could account for the differences in mortality rates seen when times of ICU admission are compared, such as differences in illness severity for patients admitted at night and general system issues such as lower levels of medical, nursing, and administrative staffing during off hours.…”

Are Attendings Different?. Intensivists Explain Their Handoff Ideals, Perceptions, and Practices

“…Similarly, these norms may not apply to attending physicians who are not intensivists practicing in multidisciplinary ICUs. Indeed, two-thirds of ICU care in the United States is delivered by nonintensivists (26), and it will be important to examine their handoff practices going forward. Second, although we did ask about ICU team structure, we did not gather detailed information about team dynamics, making it difficult to describe how attending handoffs might be impacted by the presence and experience of others, such as residents, fellows, or advanced practitioners.…”

Full-Time ICU Staff in the Intensive Care Unit: Does It Improve the Outcome?

“…Several studies suggest that an around-the-clock intensivist improves ICU outcomes with respect to decreased morbidity and mortality [4][5][6][7][8]. However, this around-the-clock intensivist model is expensive due to the shortage of intensivists [9][10][11], although it has been shown to be better for the intensivist with respect to decreasing 'burnout' [12].…”