Nighttime intensivist presence has ‘selective’ effect on ICU mortality
MedWire News: Nighttime availability of an intensivist is associated with reduced mortality in patients in the intensive care unit (ICU), but only in units that adopt a low-intensity staffing approach during the daytime, say researchers.
Jeremy Kahn (University of Pittsburgh School of Medicine, Pennsylvania, USA) and team say that their multicenter findings "reconcile" the conflicting results of two previous single-center studies: one was conducted in a low-intensity and the other in a high-intensity unit.
The study of Kahn et al included data from the Acute Physiology and Chronic Health Evaluation (APACHE) database on 65,752 patients admitted to 49 ICUs in 25 hospitals.
Overall ICU unadjusted mortality rates were 12.8% and 13.4% among units with (n=12) and without (n=37) nighttime intensivist staffing, respectively. There was also no mortality difference after accounting for multiple patient and hospital variables; however, a significant interaction with the daytime staffing model emerged.
In all, 22 ICUs had a low-intensity daytime staffing model, such that consultation with an intensivist was not mandatory. Among these units, the presence of a nighttime intensivist reduced patients' mortality risk by 38%.
The other ICUs had a high-intensity daytime model, with mandatory intensivist consultation. The presence of a nighttime intensivist did not reduce mortality in these units, report the researchers in The New England Journal of Medicine.
The associations were also apparent in a verification cohort of patients admitted to hospitals in Pennsylvania, USA. The 17% mortality risk reduction seen in low-intensity ICUs with nighttime intensivist cover was smaller than that seen in the APACHE cohort, which the team attributes to the reduced level of patient detail in the Pennsylvanian database, which "incompletely captured the increased severity of illness in ICUs with nighttime staffing."
In an editorial, Victoria Campbell (Nambour General Hospital, Queensland, Australia) says: "Regardless of the reason, the reduction in mortality is apparent, and low-intensity ICUs without a nighttime intensivist should consider a change in the staffing model to increase the involvement of intensivists in patient care.
"The results of this study provide support for the option of adding a nighttime intensivist as an alternative to adopting a high-intensity model in which the availability of an intensivist and financial and local political factors may be a barrier."
By Eleanor McDermid