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. 2012 May 31;366(22):2093-101.
doi: 10.1056/NEJMsa1201918. Epub 2012 May 21.

Nighttime intensivist staffing and mortality among critically ill patients

David J Wallace  1 , Derek C Angus, Amber E Barnato, Andrew A Kramer, Jeremy M Kahn
Affiliations

Nighttime intensivist staffing and mortality among critically ill patients

David J Wallace et al. N Engl J Med. .

Erratum in

  • N Engl J Med. 2012 Aug 30;367(9):881

Abstract

Background: Hospitals are increasingly adopting 24-hour intensivist physician staffing as a strategy to improve intensive care unit (ICU) outcomes. However, the degree to which nighttime intensivists are associated with improvements in the quality of ICU care is unknown.

Methods: We conducted a retrospective cohort study involving ICUs that participated in the Acute Physiology and Chronic Health Evaluation (APACHE) clinical information system from 2009 through 2010, linking a survey of ICU staffing practices with patient-level outcomes data from adult ICU admissions. Multivariate models were used to assess the relationship between nighttime intensivist staffing and in-hospital mortality among ICU patients, with adjustment for daytime intensivist staffing, severity of illness, and case mix. We conducted a confirmatory analysis in a second, population-based cohort of hospitals in Pennsylvania from which less detailed data were available.

Results: The analysis with the use of the APACHE database included 65,752 patients admitted to 49 ICUs in 25 hospitals. In ICUs with low-intensity daytime staffing, nighttime intensivist staffing was associated with a reduction in risk-adjusted in-hospital mortality (adjusted odds ratio for death, 0.62; P=0.04). Among ICUs with high-intensity daytime staffing, nighttime intensivist staffing conferred no benefit with respect to risk-adjusted in-hospital mortality (odds ratio, 1.08; P=0.78). In the verification cohort, there was a similar relationship among daytime staffing, nighttime staffing, and in-hospital mortality. The interaction between nighttime staffing and daytime staffing was not significant (P=0.18), yet the direction of the findings were similar to those in the APACHE cohort.

Conclusions: The addition of nighttime intensivist staffing to a low-intensity daytime staffing model was associated with reduced mortality. However, a reduction in mortality was not seen in ICUs with high-intensity daytime staffing. (Funded by the National Heart, Lung, and Blood Institute.).

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Figures

Figure 1
Figure 1
Numbers of Patients, Intensive Care Units (ICUs), and Hospitals in the Study.
See this image and copyright information in PMC

Comment in

  • Intensive enough?
    Campbell V. Campbell V. N Engl J Med. 2012 May 31;366(22):2124-5. doi: 10.1056/NEJMe1203772. Epub 2012 May 21. N Engl J Med. 2012. PMID: 22612640 No abstract available.
  • Nighttime intensivist staffing.
    Raikhelkar J, Scurlock C, Kopec I. Raikhelkar J, et al. N Engl J Med. 2012 Sep 6;367(10):971; author reply 972. doi: 10.1056/NEJMc1207796. N Engl J Med. 2012. PMID: 22931273 No abstract available.
  • Nighttime intensivist staffing.
    Chao CM, Lai CC. Chao CM, et al. N Engl J Med. 2012 Sep 6;367(10):971; author reply 972. doi: 10.1056/NEJMc1207796. N Engl J Med. 2012. PMID: 22931274 No abstract available.
  • Nighttime intensivist staffing.
    Sareli A. Sareli A. N Engl J Med. 2012 Sep 6;367(10):971-2; author reply 972. doi: 10.1056/NEJMc1207796. N Engl J Med. 2012. PMID: 22931275 No abstract available.

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