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Staffing intensive care units with critical care physicians may improve clinical outcomes
EVIDENCE -BASED HE ALTHCARE MANAGEMENT
Staffing intensive care units with critical care physicians may improve clinical outcomes Abstracted from: Pronovost P, Angus D, DormanTet al. Physician staffing patterns and clinical outcomes in critically ill patients. JAMA 2002; 288: 2151^2162.
BACKGROUND Considerable resources are spent caring for people in intensive care units (ICUs). The organisation and sta⁄ng of ICUs varies considerably. The e¡ect of these sta⁄ng variations on patient outcomes remains unclear. It has been suggested that ICUs sta¡ed with critical care physicians (intensivists) may have improved clinical outcomes. Having physicians with skills to treat critically ill patients available may reduce morbidity and mortality. OBJECTIVE To assess the relationship between physician sta⁄ng and patient outcomes in intensive care units. METHOD Systematic review with meta-analysis. SEARCH STRATEGY The authors searched MEDLINE, EMBASE, HealthSTAR, Health Services Research Projects in Progress, the Cochrane Library and abstract proceedings from intensive care national scienti¢c meetings through 2001. There were no language restrictions. INCLUSION/EXCLUSION CRITERIA Randomised trials and controlled observational studies of critically ill adults or children were eligible if they assessed ICU attending physician sta⁄ng strategies and outcomes. Twenty-six observational studies were included, one of which included two comparisons of
1462-9410/03/$ - see front matter & 2003 Published by Elsevier Science Ltd. doi:10.1016/S1462-9410(03)00032-9
alternative sta⁄ng strategies. Twenty studies focused on a single ICU. The authors categorised ICU physician sta⁄ng as ‘low intensity’ (no intensivist or elective intensivist consultation) or ‘high intensity’ (mandatory intensivist consultation or closed ICU ^ all care directed by intensivist). OUTCOMES Hospital and ICU mortality; length of hospital stay. MAIN RESULTS Compared with low intensity sta⁄ng, high intensity sta⁄ng was associated with lower hospital mortality (pooled relative risk 0.71, 95% CI 0.62 to 0.82), lower ICU mortality (pooled relative risk 0.61, 95% CI 0.50 to 0.75) and reduced hospital and ICU stays. AUTHORS’ CONCLUSIONS Sta⁄ng intensive care units with critical care specialists may reduce mortality and hospital stay compared with low intensity physician sta⁄ng. Sources offunding: Notspeci¢ed. Correspondence to: DAngus, CRISMALaboratory, Department of Critical Care Medicine, University of Pittsburgh, USA. Email: [email protected] Abstract provided by Bazian Ltd, London
Evidence-based Healthcare (2003) 7, 63^ 64
63
Commentary Relevance Intensive care units (ICUs) evolved nearly 50 years ago as way of improving quality of care by centralising specialised interventions and personnel for critically ill patients.1 By the late 1960s, nearly all hospitals in the United States had at least one ICU.2 ICUs provide life sustaining treatments and monitoring that require highly trained personnel. Assessing the optimal staff|ng structure of physicians, nurses and support staff in the ICU is a complex task. Fiscal variables must be considered alongside patient, provider and institutional factors. It may be diff|cult to make evidencebased decisions in these scenarios. The data from this article may be useful to help inform the development process. Pronovost and colleagues conclude that higher intensity ICUs provide better and more eff|cient care, evidenced by improved mortality and reduced hospital stay, respectively. The limits of this type of analysis are well described in the manuscript, so will not be discussed here. Rather, the focus will be on how to interpret these f|ndings to improve care for patients. It may be valid to assume that higher intensity care in the ICU promotes improved outcomes. The acuity of illness is high in the ICU and changes in patient condition can occur minute by minute. Having more highly trained specialists may facilitate quality care. A signif|cant body of literature supports the volume ^ outcome relationship.3 That is, the more you do, the better you are. This has been suggested in multiple surgical areas, but also applies to other areas of specialised care such as the ICU. The degree of specialisation may also improve outcomes in special care situations, as has been found in comparisons of drug therapy provided by specialists and generalists in acute myocardial infarction.4 The use of ‘hospitalists’ in general medicine services follows the same argument, with improved outcomes of care.5^7 Pronovost’s systematic review of ICU structure supports the argument that higher intensity ICU care improves outcomes and efficiencies of care. Implications So how does one apply these f|ndings to patient care? Mandating that all ICUs be staffed at all hours by board certif|ed specialists is impractical and likely a waste of resources. Instead specialist and generalist hospitals and physicians need to partner to maximise the eff|ciency of care in ICUs. This partnership needs to include nursing and other support staff that provide care in the ICU. Each institution needs to decide whether a closed ICU or mandatory critical care consultation would f|t the local practice structure. Since this review did not differentiate between the two, the evidence would support either. One structure of care will not f|t
64
Evidence-based Healthcare (2003) 7, 63^ 64
all hospitals. Using the APACHE methodology8 to risk-stratify those who require consultation may serve the same purpose, while allowing for an open ICU. Professional societies such as the AmericanThoracic Society, Society of Critical Care Medicine and National Association of Inpatient Physicians can promote‘best practices’ to their members and influence organisations to partner with physicians and nurses to improve ICU care. Future research could tease out the process and structural factors responsible for improvements in high intensity ICUs. Is it due to the improved availability of intensivists or their level of expertise? Perhaps by being more comfortable in the ICU environment and forming improved working relationships with other physicians, nursing and support staff, the intensivist is able to facilitate improved care. Research into organisational factors may provide greater insight. Peter J. Kaboli, MD, MS Division of General Internal Medicine University of Iowa Carver College of Medicine and Iowa City VA Medical Center Iowa City, USA Literature cited 1. Sirio CA, Knaus WA.Quality assessment and assurance in the intensive care unit. In: Sivak ED, HigginsTL, Seiver A (eds). The High Risk Patient: Management of the Critically Ill. Philadelphia: Williams & Wilkins,1995:1576 ^1586. 2. Strosberg MA, Teres D. Gatekeeping in the Intensive Care Unit. Chicago: Health Administration Press,1997. 3. Halm EA, Lee C, Chassin MR. Is volume related to outcome in health care? A systematic review and methodologic critique of the literature. Ann Intern Med 2002; 137: 511^520. 4. Ayanian JZ, Hauptman PJ, Guadagnoli E et al. Knowledge and practices of generalist and specialist physicians regarding drug therapy for acute myocardial infarction. N Engl J Med1994; 331: 1136^1142. 5. Meltzer D, Manning WG, Morrison J et al. Effects of physician experience on costs and outcomes on an academic general medicine service: results of a trial of hospitalists. Annals of Intern Med (online) 2002; 137: 866 ^ 874. 6. Auerbach AD, Wachter RM, Katz P et al. Implementation of a voluntary hospitalist service at a community teaching hospital: improved clinical eff|ciency and patient outcomes. Annals of Intern Med 2002; 137: 859^ 865. 7. Kaboli PJ, Barnett MJ, Wilson SR, Rosenthal GE.The impact of a new academic hospitalist service on length of stay and charges. J Gen Intern Med 2002; 17: 126. 8. Knaus WA, Wagner DP, Draper EA et al. The APACHE III prognostic system. Risk prediction of hospital mortality for critically ill hospitalized adults.Chest 1991; 100: 1619^1636.
Staffing intensive care units with critical care physicians may improve clinical outcomes Abstracted from: Pronovost P, Angus D, DormanTet al. Physician staffing patterns and clinical outcomes in critically ill patients. JAMA 2002; 288: 2151^2162.
BACKGROUND Considerable resources are spent caring for people in intensive care units (ICUs). The organisation and sta⁄ng of ICUs varies considerably. The e¡ect of these sta⁄ng variations on patient outcomes remains unclear. It has been suggested that ICUs sta¡ed with critical care physicians (intensivists) may have improved clinical outcomes. Having physicians with skills to treat critically ill patients available may reduce morbidity and mortality. OBJECTIVE To assess the relationship between physician sta⁄ng and patient outcomes in intensive care units. METHOD Systematic review with meta-analysis. SEARCH STRATEGY The authors searched MEDLINE, EMBASE, HealthSTAR, Health Services Research Projects in Progress, the Cochrane Library and abstract proceedings from intensive care national scienti¢c meetings through 2001. There were no language restrictions. INCLUSION/EXCLUSION CRITERIA Randomised trials and controlled observational studies of critically ill adults or children were eligible if they assessed ICU attending physician sta⁄ng strategies and outcomes. Twenty-six observational studies were included, one of which included two comparisons of
1462-9410/03/$ - see front matter & 2003 Published by Elsevier Science Ltd. doi:10.1016/S1462-9410(03)00032-9
alternative sta⁄ng strategies. Twenty studies focused on a single ICU. The authors categorised ICU physician sta⁄ng as ‘low intensity’ (no intensivist or elective intensivist consultation) or ‘high intensity’ (mandatory intensivist consultation or closed ICU ^ all care directed by intensivist). OUTCOMES Hospital and ICU mortality; length of hospital stay. MAIN RESULTS Compared with low intensity sta⁄ng, high intensity sta⁄ng was associated with lower hospital mortality (pooled relative risk 0.71, 95% CI 0.62 to 0.82), lower ICU mortality (pooled relative risk 0.61, 95% CI 0.50 to 0.75) and reduced hospital and ICU stays. AUTHORS’ CONCLUSIONS Sta⁄ng intensive care units with critical care specialists may reduce mortality and hospital stay compared with low intensity physician sta⁄ng. Sources offunding: Notspeci¢ed. Correspondence to: DAngus, CRISMALaboratory, Department of Critical Care Medicine, University of Pittsburgh, USA. Email: [email protected] Abstract provided by Bazian Ltd, London
Evidence-based Healthcare (2003) 7, 63^ 64
63
Commentary Relevance Intensive care units (ICUs) evolved nearly 50 years ago as way of improving quality of care by centralising specialised interventions and personnel for critically ill patients.1 By the late 1960s, nearly all hospitals in the United States had at least one ICU.2 ICUs provide life sustaining treatments and monitoring that require highly trained personnel. Assessing the optimal staff|ng structure of physicians, nurses and support staff in the ICU is a complex task. Fiscal variables must be considered alongside patient, provider and institutional factors. It may be diff|cult to make evidencebased decisions in these scenarios. The data from this article may be useful to help inform the development process. Pronovost and colleagues conclude that higher intensity ICUs provide better and more eff|cient care, evidenced by improved mortality and reduced hospital stay, respectively. The limits of this type of analysis are well described in the manuscript, so will not be discussed here. Rather, the focus will be on how to interpret these f|ndings to improve care for patients. It may be valid to assume that higher intensity care in the ICU promotes improved outcomes. The acuity of illness is high in the ICU and changes in patient condition can occur minute by minute. Having more highly trained specialists may facilitate quality care. A signif|cant body of literature supports the volume ^ outcome relationship.3 That is, the more you do, the better you are. This has been suggested in multiple surgical areas, but also applies to other areas of specialised care such as the ICU. The degree of specialisation may also improve outcomes in special care situations, as has been found in comparisons of drug therapy provided by specialists and generalists in acute myocardial infarction.4 The use of ‘hospitalists’ in general medicine services follows the same argument, with improved outcomes of care.5^7 Pronovost’s systematic review of ICU structure supports the argument that higher intensity ICU care improves outcomes and efficiencies of care. Implications So how does one apply these f|ndings to patient care? Mandating that all ICUs be staffed at all hours by board certif|ed specialists is impractical and likely a waste of resources. Instead specialist and generalist hospitals and physicians need to partner to maximise the eff|ciency of care in ICUs. This partnership needs to include nursing and other support staff that provide care in the ICU. Each institution needs to decide whether a closed ICU or mandatory critical care consultation would f|t the local practice structure. Since this review did not differentiate between the two, the evidence would support either. One structure of care will not f|t
64
Evidence-based Healthcare (2003) 7, 63^ 64
all hospitals. Using the APACHE methodology8 to risk-stratify those who require consultation may serve the same purpose, while allowing for an open ICU. Professional societies such as the AmericanThoracic Society, Society of Critical Care Medicine and National Association of Inpatient Physicians can promote‘best practices’ to their members and influence organisations to partner with physicians and nurses to improve ICU care. Future research could tease out the process and structural factors responsible for improvements in high intensity ICUs. Is it due to the improved availability of intensivists or their level of expertise? Perhaps by being more comfortable in the ICU environment and forming improved working relationships with other physicians, nursing and support staff, the intensivist is able to facilitate improved care. Research into organisational factors may provide greater insight. Peter J. Kaboli, MD, MS Division of General Internal Medicine University of Iowa Carver College of Medicine and Iowa City VA Medical Center Iowa City, USA Literature cited 1. Sirio CA, Knaus WA.Quality assessment and assurance in the intensive care unit. In: Sivak ED, HigginsTL, Seiver A (eds). The High Risk Patient: Management of the Critically Ill. Philadelphia: Williams & Wilkins,1995:1576 ^1586. 2. Strosberg MA, Teres D. Gatekeeping in the Intensive Care Unit. Chicago: Health Administration Press,1997. 3. Halm EA, Lee C, Chassin MR. Is volume related to outcome in health care? A systematic review and methodologic critique of the literature. Ann Intern Med 2002; 137: 511^520. 4. Ayanian JZ, Hauptman PJ, Guadagnoli E et al. Knowledge and practices of generalist and specialist physicians regarding drug therapy for acute myocardial infarction. N Engl J Med1994; 331: 1136^1142. 5. Meltzer D, Manning WG, Morrison J et al. Effects of physician experience on costs and outcomes on an academic general medicine service: results of a trial of hospitalists. Annals of Intern Med (online) 2002; 137: 866 ^ 874. 6. Auerbach AD, Wachter RM, Katz P et al. Implementation of a voluntary hospitalist service at a community teaching hospital: improved clinical eff|ciency and patient outcomes. Annals of Intern Med 2002; 137: 859^ 865. 7. Kaboli PJ, Barnett MJ, Wilson SR, Rosenthal GE.The impact of a new academic hospitalist service on length of stay and charges. J Gen Intern Med 2002; 17: 126. 8. Knaus WA, Wagner DP, Draper EA et al. The APACHE III prognostic system. Risk prediction of hospital mortality for critically ill hospitalized adults.Chest 1991; 100: 1619^1636.