ICU Physician Staffing What Else Do We Need to Know? Craig M. Lilly, MD, FCCP Worcester, MA

In this issue of CHEST (see page 951), Kerlin and colleagues1 provide another layer of evidence that 24/7 intensivist staffing is not associated with significant mortality or length-of-stay benefits. The observation that high-intensity critical care specialist involvement is associated with lower mortality and costs for adults with severe illness and injuries2 led to the hypothesis that 24/7 on-site intensivist staffing would result in better outcomes than daytime-only on-site staffing.3,4 The role of 24/7 intensivist staffing models for improving outcomes is an important issue in an era when the supply of critical care specialists is insufficient to meet the demands of an aging population.5 Concentrating specialists in ICUs that provide 24/7 staffing is expensive for institutions that can retain enough intensivists and reduces access to specialist care for other ICUs who must compete for a smaller pool of qualified specialists. This study by Kerlin and colleagues1 is consistent with most other studies, including a randomized trial of 24/7 staffing6 and an 8-week crossover Canadian study,7 and with a prior smaller observational study from this group.8 The consistency of the major findings of these studies moves the field beyond examining the veracity of associations of outcomes with 24/7 intensivist staffing models to a focus on what critical care specialists do that improves outcomes for their patients. New hypotheses are required to explain the apparent incongruity of studies

AFFILIATIONS: From the Department of Medicine, University of Massachusetts Medical School. FINANCIAL/NONFINANCIAL DISCLOSURES: The author has reported to CHEST that no potential conflicts of interest exist with any companies/ organizations whose products or services may be discussed in this article. CORRESPONDENCE TO: Craig M. Lilly, MD, FCCP, Department of Medicine, University of Massachusetts Medical School, UMass Memorial Medical Center, 281 Lincoln St, Worcester, MA 01605; e-mail: [email protected] © 2015 AMERICAN COLLEGE OF CHEST PHYSICIANS. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details. DOI: 10.1378/chest.14-2661


indicating that 24/7 intensivist staffing is not associated with length-of-stay or mortality benefits with studies that find that high-intensity critical care staffing impacts these outcomes. One hypothesis is that high-intensity staffing models serve as a surrogate marker for ICUs that have processes, procedures, and protocols that are effective enough for delivering the details of high-quality critical care such that off-hours intensivist intervention is so rarely required that differences in outcomes are difficult to detect. In this paradigm, progress depends on methods for selecting the right protocols for each patient and building teams that deliver this care with high fidelity. Critical care specialists play a key role for protocol and procedure development and for monitoring patient selection. The creation of accurate methods for identifying effective protocols and efficient ways to share and deliver them hold great promise for advancing the field. Another hypothesis for the failure of 24/7 intensivist models is that key interventions like source control for infections, renal replacement therapy, and interventional procedures may not be available after hours, such that off-hours recognition by a specialist does not impact outcomes. A third hypothesis is that implementation of a 24/7 ICU physician staffing model does not reliably change key behaviors and consequently does not change outcomes. It is possible that the addition of 24/7 intensivist interventions in which specialists are continuously active and working to verify primary source information, reviewing key imaging studies, are evaluating patients with evolving physiologic instability, and are present at the time of initial intake to confirm key clinical findings would have greater impact on outcomes than interventions where staff sleeping on-site rather than off-site are awakened to answer phone calls when subordinate clinicians choose to call them. In this scenario, progress depends on increasing timely intensivist engagement in key activities and the effectiveness of supporting health information technologies. Addressing these new hypotheses will require a new generation of critical care databases that include case-level metrics of clinical activity, researchers to analyze them, and a focus on process, outcomes, and quality from those who fund research.


References 1. Kerlin MP, Harhay MO, Kahn JM, Halpern SD. Nighttime intensivist staffing, mortality, and limits on life support: a retrospective cohort study. Chest. 2015;147(4):951-958. 2. Pronovost PJ, Angus DC, Dorman T, Robinson KA, Dremsizov TT, Young TL. Physician staffing patterns and clinical outcomes in critically ill patients: a systematic review. JAMA. 2002;288(17): 2151-2162. 3. Rubenfeld GD, Angus DC. Are intensivists safe? Ann Intern Med. 2008;148(11):877-879. 4. Burnham EL, Moss M, Geraci MW. The case for 24/7 in-house intensivist coverage. Am J Respir Crit Care Med. 2010;181(11): 1159-1160. 5. Angus DC, Kelley MA, Schmitz RJ, White A, Popovich J Jr ; Committee on Manpower for Pulmonary and Critical Care Societies (COMPACCS). Caring for the critically ill patient. Current and projected workforce requirements for care of the critically ill and patients with pulmonary disease: can we meet the requirements of an aging population? JAMA. 2000;284(21):2762-2770. 6. Kerlin MP, Small DS, Cooney E, et al. A randomized trial of nighttime physician staffing in an intensive care unit. N Engl J Med. 2013; 368(23):2201-2209. 7. Garland A, Roberts D, Graff L. Twenty-four-hour intensivist presence: a pilot study of effects on intensive care unit patients, families, doctors, and nurses. Am J Respir Crit Care Med. 2012;185(7):738-743. 8. Kerlin MP, Halpern SD. Nighttime physician staffing in an intensive care unit. N Engl J Med. 2013;369(11):1075.

COPD Undefeated! Mohsen Sadatsafavi, MD, PhD Don D. Sin, MD, FCCP Vancouver, BC, Canada

In 1968, the Phillip Morris Company launched a memorable campaign to sell its cigarettes, Virginia Slims, using a catchy slogan: “You’ve come a long way, baby,” which led to a massive increase in sales of cigarettes, especially among women, and launched the modern epidemic of COPD in the United States. Today, AFFILIATIONS: From the Division of Respiratory Medicine (Drs Sadatsafavi and Sin), University of British Columbia; and the Center for Clinical Epidemiology and Evaluation (Dr Sadatsafavi), and the James Hogg Research Centre (Dr Sin), St. Paul’s Hospital. FINANCIAL/NONFINANCIAL DISCLOSURES: The authors have reported to CHEST the following conflicts: Dr Sin has received honoraria for speaking engagements from drug companies including AstraZeneca, Merck & Co, Boehringer Ingelheim GmbH, Takeda Pharmaceutical Company Limited, and Grifols; has received investigator-initiated grants from AstraZeneca, Boehringer Ingelheim GmbH, and Grifols; and has sat on scientific advisory boards of Almirall and AstraZeneca. Dr Sadatsafavi reports no potential conflicts of interest with any companies/organizations whose productions or services may be discussed in this article. CORRESPONDENCE TO: Don D. Sin, MD, FCCP, Room 8446, St. Paul’s Hospital, Vancouver, BC, V6Z 1Y6, Canada; e-mail: [email protected] © 2015 AMERICAN COLLEGE OF CHEST PHYSICIANS. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details. DOI: 10.1378/chest.14-2979

868 Editorials

there are . 12.7 million Americans with COPD, and nearly 140,000 Americans succumb to this disease every year.1 Over the past 2 decades, there has been a concerted effort to find new therapeutic solutions to address the growing burden of COPD. How have we done? The study by Ford,2 published in this issue of CHEST (see page 989), reports on the COPD hospitalization rates over the previous 10 years in the United States. The results are largely disappointing and provide a sobering reminder that the epidemic of COPD is far from defeated.2 Using large and representative datasets of the US population, Ford determined the trends in hospitalization for COPD from 2001 to 2012 and emergency visits from 2006 to 2012. He found that these rates have increased by 20% to 30% during this time, and between 2002 and 2012, the inpatient charges for COPD have increased by an astonishing 125%. Readmissions were also stubbornly high at 21%, with most patients coming back to the hospital because of their poorly controlled COPD. The most discouraging news comes from the author’s clever juxtaposition of COPD numbers with similar figures for common cardiovascular disorders. The rates of hospitalization for these conditions have decreased significantly, with the most dramatic improvements observed in hospitalizations related to coronary artery disease and congestive heart failure, for which the ageadjusted rates have dropped by 70% and 40%, respectively, between 2001 and 2012. These striking reductions in cardiovascular hospitalizations likely reflect major improvements in therapeutics as well as primary and secondary preventions of disease and provide hope that with improved care and treatment of patients with COPD in the future, these hospitalization rates can also decrease. An inevitable concern with such types of data is to what extent the observed trends might have been affected by the evolution of sampling methods. During the study period, the number of participating states providing hospitalization data increased by 39%, and the entire survey experienced a major redesign in 2012. Another concern lies with the changes in diagnostic classification of COPD that might have occurred over the study period. Even subtle changes in physicians’ propensity for labeling a certain clinical event as COPD hospitalization vs another condition can easily affect population trends, a phenomenon commonly referred to as diagnostic exchange (or diagnostic drift).3 This is especially relevant for COPD, in which misdiagnosis can occur owing to its nonspecific symptoms and


147#4 CHEST APRIL 2015


ICU physician staffing: what else do we need to know?

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