The Impact of Implementing an Intensivist Model With Nighttime In-Hospital Nocturnist and Effect on ICU Outcomes

Tanios, Maged; Teres, Daniel; Park, Hyunsoon; Beltran, Antonio; Sehgal, Arunpal; Leo, James

doi:10.1177/0885066618758246

Cited by 7 publications

(7 citation statements)

References 36 publications

(47 reference statements)

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“…This lead to the suggestion that 24 × 7 intensivist staffing models may not be an effective use of intensivist resources in units with high-intensity staffing models (16,17). Interestingly, however, in another recent study, implementation of nighttime coverage with in-house nonintensivist ("nocturnist") physicians in a unit with a high-intensity staffing model did result in significant decreases in ICU length of stay (18). Independent of the coverage model employed to meet 24 × 7 demands in the ICU, intensivist-led multidisciplinary team models of ICU care are associated with decreased mortality risk for critically ill and injured patients (1,19).…”

Section: Intensivist-led Care In the Icumentioning

confidence: 99%

The Society of Critical Care Medicine at 50 Years: Interprofessional Practice in Critical Care: Looking Back and Forging Ahead

Kleinpell

Grabenkort

Boyle

et al. 2021

Critical Care Medicine

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Interprofessional practice in the ICU has been embraced as a standard of care since the early origins of the Society of Critical Care Medicine (SCCM) (1, 2). This focus has been instrumental in improving the care and outcomes of patients with life-threatening illness and injuries utilizing teams of critical care professionals (2). The ICU team is typically comprised of physicians, bedside nurses, nurse practitioners (NPs), physician assistants, clinical pharmacists, respiratory therapists (RTs), dieticians, physical/occupational therapists, case management and social work, dietician/nutritionists, spiritual support, as well as clinicians-in-training, among others. In the interprofessional team model, members of the ICU team communicate, collaborate, consult, and capitalize on the individual expertise of each team member (3). As highlighted by Dr. Max Harry Weil, the first president of SCCM, the ICU team is committed to bringing orderliness and expertise to the management of the critically ill patient (2). The coronavirus disease 2019 (COVID-19) pandemic and news reports of patients in the ICU during the pandemic served to raise the awareness of the general public of ICU care. More than ever, the importance of team-led care in the ICU became evident during the ongoing pandemic. In this article, part of a series on the 50th anniversary of SCCM in Critical Care Medicine, we review key aspects of interprofessional practice in critical care.Efforts to advance interprofessional team-based care in the ICU are essential for improving patient outcomes and ICU team performance (4). Evidencebased best practice for effective interprofessional team care has identified the importance of multidisciplinary rounds that include ICU patients and family members in the care discussions and decision-making, and uses communication strategies that foster inclusive and supportive behaviors to enhance interprofessional collaboration in the ICU (5). A review by the American College of Critical Care Medicine (ACCM) Task Force on Models of Critical Care highlighted the importance of multidisciplinary ICU rounds in reducing mortality independent of the care team structure (1). Additionally, optimal interprofessional team performance also appears contingent upon open communication, conflict resolution, cooperation, coordination, and coaching between individual team members (Table 1) (6). The frequent changing of individual ICU team members due to rotations and different schedules from day to day has been identified as a potential challenge in ICU team performance (7, 8). However, ICU professionals function cohesively as a team, sharing their

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Section: Intensivist-led Care In the Icumentioning

confidence: 99%

The Society of Critical Care Medicine at 50 Years: Interprofessional Practice in Critical Care: Looking Back and Forging Ahead

Kleinpell

Grabenkort

Boyle

et al. 2021

Critical Care Medicine

View full text Add to dashboard Cite

show abstract

“…Analyses of patient-to-provider ratios have shown mixed results with some demonstrating a deleterious mortality effect of higher ratios (6, 7) but others suggesting no association (8). Mandatory involvement of trained intensivists in ICU patient care, often referred to as a "closed" ICU model, has been associated with improved patient outcomes in multiple studies at single academic medical centers (9)(10)(11)(12)(13)(14)(15); however, large cohort studies of multiple academic and community-based ICUs have not been able to replicate this finding (16,17). One factor contributing to this inconsistency could be differences of effects between academic and community sites.…”

mentioning

confidence: 99%

Patient Outcomes and Unit Composition With Transition to a High-Intensity ICU Staffing Model: A Before-and-After Study

Proper

Wacker

Shaker

et al. 2023

Critical Care Explorations

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IMPORTANCE: Provider staffing models for ICUs are generally based on pragmatic necessities and historical norms at individual institutions. A better understanding of the role that provider staffing models play in determining patient outcomes and optimizing use of ICU resources is needed. OBJECTIVES: To explore the impact of transitioning from a low- to high-intensity intensivist staffing model on patient outcomes and unit composition. DESIGN, SETTING, AND PARTICIPANTS: This was a prospective observational before-and-after study of adult ICU patients admitted to a single community hospital ICU before (October 2016–May 2017) and after (June 2017–November 2017) the transition to a high-intensity ICU staffing model. MAIN OUTCOMES AND MEASURES: The primary outcome was 30-day all-cause mortality. Secondary outcomes included in-hospital mortality, ICU length of stay (LOS), and unit composition characteristics including type (e.g., medical, surgical) and purpose (ICU-specific intervention vs close monitoring only) of admission. RESULTS: For the primary outcome, 1,219 subjects were included (779 low-intensity, 440 high-intensity). In multivariable analysis, the transition to a high-intensity staffing model was not associated with a decrease in 30-day (odds ratio [OR], 0.90; 95% CI, 0.61–1.34; p = 0.62) or in-hospital (OR, 0.89; 95% CI, 0.57–1.38; p = 0.60) mortality, nor ICU LOS. However, the proportion of patients admitted to the ICU without an ICU-specific need did decrease under the high-intensity staffing model (27.2% low-intensity to 17.5% high-intensity; p < 0.001). CONCLUSIONS AND RELEVANCE: Multivariable analysis showed no association between transition to a high-intensity ICU staffing model and mortality or LOS outcomes; however, the proportion of patients admitted without an ICU-specific need decreased under the high-intensity model. Further research is needed to determine whether a high-intensity staffing model may lead to more efficient ICU bed usage.

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confidence: 99%

“…9 Several single-centre surveys from the US suggest that nocturnist programs improve perceived quality of care, increase resident satisfaction with overnight supervision and may enhance efficiency. 3,7 However, studies have not shown reductions in hospital length of stay or rates of mortality or hospital readmission. 2 Canadian teaching hospitals have been slow to implement nocturnists.…”

mentioning

confidence: 99%

Impact of an internal medicine nocturnist service on care of patients with cancer at a large Canadian teaching hospital: a quality-improvement study

Dunbar-Yaffe¹,

Wu²,

Oza³

et al. 2021

cmajo

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N octurnists (overnight hospitalists) have been widely implemented in teaching hospitals in the United States in an effort to meet Accreditation Council for Graduate Medical Education workload standards, 1 improve overnight supervision and enhance the quality of patient care. [2][3][4][5][6][7][8] Recent data indicate that about 50% of US teaching hospitals have nocturnists. 9 Several single-centre surveys from the US suggest that nocturnist programs improve perceived quality of care, increase resident satisfaction with overnight supervision and may enhance efficiency. 3,7 However, studies have not shown reductions in hospital length of stay or rates of mortality or hospital readmission. 2 Canadian teaching hospitals have been slow to implement nocturnists. 10 Nocturnal coverage is typically provided by firstyear residents from multiple disciplines, with staff available by telephone. Nocturnists are rare, and typically all admissions are performed by residents, without caps on volumes of existing patients or new admissions. Moreover, many Canadian teaching hospitals rely on teams of residents to cover all admitted medical patients, with no caps on the number of patients per resident. In contrast, in US hospitals, first-year internal medicine residents can manage a maximum of 10 patients. 1 Limits on Canadian resident work hours are determined at the provincial level rather than nationally, as in the US. Only Quebec has stipulated a maximum shift length (16 h), with most provinces still allowing 24-hour shifts. In Europe, resident work hours are restricted to 48-hour work weeks, and 13-hour shift limits are common. 11

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The Impact of Implementing an Intensivist Model With Nighttime In-Hospital Nocturnist and Effect on ICU Outcomes

Cited by 7 publications

References 36 publications

The Society of Critical Care Medicine at 50 Years: Interprofessional Practice in Critical Care: Looking Back and Forging Ahead

The Society of Critical Care Medicine at 50 Years: Interprofessional Practice in Critical Care: Looking Back and Forging Ahead

Patient Outcomes and Unit Composition With Transition to a High-Intensity ICU Staffing Model: A Before-and-After Study

Impact of an internal medicine nocturnist service on care of patients with cancer at a large Canadian teaching hospital: a quality-improvement study

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