Hayley B. Gershengorn

Impact of Nonphysician Staffing on Outcomes in a Medical ICU

BACKGROUND As the number of ICU beds and demand for intensivists increase, alternative solutions are needed to provide coverage for critically ill patients. The impact of different staffing models on the outcomes of patients in the medical ICU (MICU) remains unknown. In our study, we compare outcomes of nonphysician provider-based teams to those of medical house staff-based teams in the MICU. METHODS We conducted a retrospective review of 590 daytime (7:00 am-7:00 pm) admissions to two MICUs at one hospital. In one MICU staffed by nurse practitioners and physician assistants (MICU-NP/PA) there were nonphysicians (nurse practitioners and physicians assistants) during the day (7:00 am-7:00 pm) with attending physician coverage overnight. In the other MICU, there were medicine residents (MICU-RES) (24 h/d). The outcomes investigated were hospital mortality, length of stay (LOS) (ICU, hospital), and posthospital discharge destination. RESULTS Three hundred two patients were admitted to the MICU-NP/PA and 288 to the MICU-RES. Mortality probability model III (MPM(0)-III) predicted mortality was similar (P = .14). There was no significant difference in hospital mortality (32.1% for MICU-NP/PA vs 32.3% for MICU-RES, P = .96), MICU LOS (4.22 ± 2.51 days for MICU-NP/PA vs 4.44 ± 3.10 days for MICU-RES, P = .59), or hospital LOS (14.01 ± 2.92 days for MICU-NP/PA vs 13.74 ± 2.94 days for MICU-RES, P = .86). Discharge to a skilled care facility (vs home) was similar (37.1% for MICU-NP/PA vs 32.5% for MICU-RES, P = .34). After multivariate adjustment, MICU staffing type was not associated with hospital mortality (P = .26), MICU LOS (P = .29), hospital LOS (P = .19), or posthospital discharge destination (P = .90). CONCLUSIONS Staffing models including daytime use of nonphysician providers appear to be a safe and effective alternative to the traditional house staff-based team in a high-acuity, adult ICU.

Variation in use of intensive care for adults with diabetic ketoacidosis

Objective:Intensive care unit beds are limited, yet few guidelines exist for triage of patients to the intensive care unit, especially patients at low risk for mortality. The frequency with which low-risk patients are admitted to intensive care units in different hospitals is unknown. Our objective was to assess variation in the use of intensive care for patients with diabetic ketoacidosis, a common condition with a low risk of mortality. Design:Observational study using the New York State In-patient Database (2005–2007). Setting:One hundred fifty-nine New York State acute care hospitals. Patients:Fifteen thousand nine hundred ninety-four adult (≥18) hospital admissions with a primary diagnosis of diabetic ketoacidosis (International Classification of Diseases, Ninth Revision, Clinical Modification 250.1x). Interventions:None. Measurements and Main Results:We calculated reliability- and risk-adjusted intensive care unit utilization, hospital length of stay, and mortality. We identified hospital-level factors associated with increased likelihood of intensive care unit admission after controlling patient characteristics using multilevel, mixed-effects logistic regression analyses; we assessed the amount of residual variation in intensive care unit utilization using the intraclass correlation coefficient. Use of intensive care for diabetic ketoacidosis patients varied widely across hospitals (adjusted range: 2.1% to 87.7%), but was not associated with hospital length of stay or mortality. After multilevel adjustment, hospitals with a high volume of diabetic ketoacidosis admissions admitted diabetic ketoacidosis patients to the intensive care unit less often (odds ratio 0.40, p = .002, highest quintile compared to lowest), whereas hospitals with higher rates of intensive care unit utilization for all nondiabetic ketoacidosis in-patients admitted diabetic ketoacidosis patients to the intensive care unit more frequently (odds ratio 1.31, p = .001, for each additional 10% increase). In the multilevel model, more than half (58%) of the variation in the intensive care unit admission practice attributable to hospitals remained unexplained. Conclusions:We observed variations across hospitals in the use of intensive care for diabetic ketoacidosis patients that was not associated with differences in-hospital length of stay or mortality. Institutional practice patterns appear to impact admission decisions and represent a potential target for reduction of resource utilization in higher use institutions.

Staffing in ICUs : Physicians and Alternative Staffing Models

The evidence regarding physician staffing of ICUs does not yet provide a consistent view of the best model to use. Most studies have significant limitations, and this subject is complicated by the fact that optimal ICU staffing may depend on ICU characteristics. The topic with the most data regarding patient outcomes is the intensity of intensivist involvement in care, particularly the value of closed- vs open-model ICUs; however, the evidence is inconsistent here as well. Even if closed-model ICUs produce better outcomes, we do not know which specific elements of that multifaceted organizational paradigm are responsible for improvement. Also, studies of around-the-clock intensivist presence have not consistently shown that it is associated with superior outcomes. Increasingly, nonphysician providers are playing innovative roles in the ICU, and care provided by teams including nurse practitioners or physician assistants appears to be safe and comparable to that provided by other staffing models. Although we do not know the best way to staff ICUs, the conditions of ICU physician coverage will continue to change under the stresses of shortages of intensivists and increasing duty hour limitations for trainees. Nonphysician providers, innovative physician staffing models, telemedicine, and other technologies will be increasingly used to cope with these realities. This evolution makes it more important than ever to study how staffing affects outcomes. Only quantitative evaluation can tell us whether one staffing model is better than another. Accordingly, we need more research from multiple sites to develop a consistent and integrated understanding of this complex topic.

Recent Advances in Chest MedicineStaffing in ICUs: Physicians and Alternative Staffing Models

The evidence regarding physician staffing of ICUs does not yet provide a consistent view of the best model to use. Most studies have significant limitations, and this subject is complicated by the fact that optimal ICU staffing may depend on ICU characteristics. The topic with the most data regarding patient outcomes is the intensity of intensivist involvement in care, particularly the value of closed- vs open-model ICUs; however, the evidence is inconsistent here as well. Even if closed-model ICUs produce better outcomes, we do not know which specific elements of that multifaceted organizational paradigm are responsible for improvement. Also, studies of around-the-clock intensivist presence have not consistently shown that it is associated with superior outcomes. Increasingly, nonphysician providers are playing innovative roles in the ICU, and care provided by teams including nurse practitioners or physician assistants appears to be safe and comparable to that provided by other staffing models. Although we do not know the best way to staff ICUs, the conditions of ICU physician coverage will continue to change under the stresses of shortages of intensivists and increasing duty hour limitations for trainees. Nonphysician providers, innovative physician staffing models, telemedicine, and other technologies will be increasingly used to cope with these realities. This evolution makes it more important than ever to study how staffing affects outcomes. Only quantitative evaluation can tell us whether one staffing model is better than another. Accordingly, we need more research from multiple sites to develop a consistent and integrated understanding of this complex topic.

Understanding Changes in Established Practice: Pulmonary Artery Catheter Use in Critically Iii Patients*

Objective:Multiple studies suggest that routine use of pulmonary artery catheters is not beneficial in critically ill patients. Little is known about the patterns of “uptake” of practice change that involves removal of a device previously considered standard of care, rather than adoption of a new technique or technology. Our objective was to assess recent pulmonary artery catheter use across ICUs and identify factors associated with high use. Design:Cohort study. Setting:U.S. ICUs in Project IMPACT. Patients:Adult ICU admissions from 2001 to 2008. Interventions:None. Measurements and Main Results:Trends in pulmonary artery catheter use from 2001 to 2008 were assessed. For 2006–2008, we compared pulmonary artery catheter use across ICUs. We assessed characteristics of ICUs and hospitals in the top quartile for in-ICU pulmonary artery catheter placement (vs the bottom quartile) using chi-square and t tests and factors associated with in-ICU pulmonary artery catheter insertion using multilevel mixed effects logistic regression. Total pulmonary artery catheter use decreased from 10.8% of patients (2001–2003) to 6.2% (2006–2008; p < 0.001); insertion of pulmonary artery catheters in ICU decreased from 4.2% to 2.2% (p < 0.001). In 2006–2008, ICUs in the top quartile for in-ICU pulmonary artery catheter insertion (3.4–25.0% of patients) were more often surgical (54.2% vs 21.7% in the lowest quartile, p = 0.070), teaching hospitals (54.2% vs 4.3%, p = 0.001), and had surgeon leadership (40.9% vs 13.0%, p = 0.067). After multivariable regression, surgical patients (p < 0.001) and all patients in surgical ICUs (p = 0.057) were more likely to have pulmonary artery catheters placed in ICU. Conclusions:Use of pulmonary artery catheters in ICU patients has declined but with significant variation across units. Removal of this technology has occurred most in nonsurgical ICUs and patients.

Association Between US Norepinephrine Shortage and Mortality Among Patients With Septic Shock

Importance Drug shortages in the United States are common, but their effect on patient care and outcomes has rarely been reported. Objective To assess changes to patient care and outcomes associated with a 2011 national shortage of norepinephrine, the first-line vasopressor for septic shock. Design, Setting, and Participants Retrospective cohort study of 26 US hospitals in the Premier Healthcare Database with a baseline rate of norepinephrine use of at least 60% for patients with septic shock. The cohort included adults with septic shock admitted to study hospitals between July 1, 2008, and June 30, 2013 (n = 27 835). Exposures Hospital-level norepinephrine shortage was defined as any quarterly (3-month) interval in 2011 during which the hospital rate of norepinephrine use decreased by more than 20% from baseline. Main Outcomes and Measures Use of alternative vasopressors was assessed and a multilevel mixed-effects logistic regression model was used to evaluate the association between admission to a hospital during a norepinephrine shortage quarter and in-hospital mortality. Results Among 27 835 patients (median age, 69 years [interquartile range, 57-79 years]; 47.0% women) with septic shock in 26 hospitals that demonstrated at least 1 quarter of norepinephrine shortage in 2011, norepinephrine use among cohort patients declined from 77.0% (95% CI, 76.2%-77.8%) of patients before the shortage to a low of 55.7% (95% CI, 52.0%-58.4%) in the second quarter of 2011; phenylephrine was the most frequently used alternative vasopressor during this time (baseline, 36.2% [95% CI, 35.3%-37.1%]; maximum, 54.4% [95% CI, 51.8%-57.2%]). Compared with hospital admission with septic shock during quarters of normal use, hospital admission during quarters of shortage was associated with an increased rate of in-hospital mortality (9283 of 25 874 patients [35.9%] vs 777 of 1961 patients [39.6%], respectively; absolute risk increase = 3.7% [95% CI, 1.5%-6.0%]; adjusted odds ratio = 1.15 [95% CI, 1.01-1.30]; P = .03). Conclusions and Relevance Among patients with septic shock in US hospitals affected by the 2011 norepinephrine shortage, the most commonly administered alternative vasopressor was phenylephrine. Patients admitted to these hospitals during times of shortage had higher in-hospital mortality.

Variation of Arterial and Central Venous Catheter Use in United States Intensive Care Units

Background:Arterial catheters (ACs) and central venous catheters (CVCs) are common in intensive care units (ICUs). Few data describe which patients receive these devices and whether variability in practice exists. Methods:The authors conducted an observational cohort study on adult patients admitted to ICU during 2001–2008 by using Project IMPACT to determine whether AC and CVC use is consistent across U.S. ICUs. The authors examined trends over time and patients more (mechanically ventilated or on vasopressors) or less (predicted risk of hospital mortality ⩽2%) likely to receive either catheter. Results:Our cohort included 334,123 patients across 122 hospitals and 168 ICUs. Unadjusted AC usage rates remained constant (36.9% [2001] vs. 36.4% [2008]; P = 0.212), whereas CVC use increased (from 33.4% [2001] to 43.8% [2008]; P < 0.001 comparing 2001 and 2008); adjusted AC usage rates were constant from 2004 (35.2%) to 2008 (36.4%; P = 0.43 for trend). Surgical ICUs used both catheters most often (unadjusted rates, ACs: 56.0% of patients vs. 22.4% in medical and 32.6% in combined units, P < 0.001; CVCs: 46.9% vs. 32.5% and 36.4%, P < 0.001). There was a wide variability in AC use across ICUs in patients receiving mechanical ventilation (median [interquartile range], 49.2% [29.9–72.3%]; adjusted median odds ratio [AMOR], 2.56), vasopressors (51.7% [30.8–76.2%]; AMOR, 2.64), and with predicted mortality of 2% or less (31.7% [19.5–49.3%]; AMOR, 1.94). There was less variability in CVC use (mechanical ventilation: 63.4% [54.9–72.9%], AMOR, 1.69; vasopressors: 71.4% (59.5–85.7%), AMOR, 1.93; predicted mortality of 2% or less: 18.7% (11.9–27.3%), AMOR, 1.90). Conclusions:Both ACs and CVCs are common in ICU patients. There is more variation in use of ACs than CVCs.

The surgical Apgar score is strongly associated with intensive care unit admission after high-risk intraabdominal surgery.

BACKGROUND: Understanding intensive care unit (ICU) triage decisions for high-risk surgical patients may ultimately facilitate resource allocation and improve outcomes. The surgical Apgar score (SAS) is a simple score that uses intraoperative information on hemodynamics and blood loss to predict postoperative morbidity and mortality, with lower scores associated with worse outcomes. We hypothesized that the SAS would be associated with the decision to admit a patient to the ICU postoperatively. METHODS: We performed a retrospective cohort study of adults undergoing major intraabdominal surgery from 2003 to 2010 at an academic medical center. We calculated the SAS (0–10) for each patient based on intraoperative heart rate, mean arterial blood pressure, and estimated blood loss. Using logistic regression, we assessed the association of the SAS with the decision to admit a patient directly to the ICU after surgery. RESULTS: The cohort consisted of 8501 patients, with 72.7% having an SAS of 7 to 10 and <5% an SAS of 0 to 4. A total of 8.7% of patients were transferred immediately to the ICU postoperatively. After multivariate adjustment, there was a strong association between the SAS and the decision to admit a patient to the ICU (adjusted odds ratio 14.41 [95% confidence interval {CI}, 6.88–30.19, P < 0.001] for SAS 0–2, 4.42 [95% CI, 3.19–6.13, P < 0.001] for SAS 3–4, and 2.60 [95% CI, 2.08–3.24, P < 0.001] for SAS 5–6 compared with SAS 7–8). CONCLUSIONS: The SAS is strongly associated with clinical decisions regarding immediate ICU admission after high-risk intraabdominal surgery. These results provide an initial step toward understanding whether intraoperative hemodynamics and blood loss influence ICU triage for postsurgical patients.

Association Between Arterial Catheter Use and Hospital Mortality in Intensive Care Units

IMPORTANCE Arterial catheters are used frequently in intensive care units (ICUs). Clinical effectiveness and adverse events associated with the use of the catheters have not been formally evaluated in clinical studies. OBJECTIVE To determine whether an association exists between arterial catheter use and hospital mortality in ICU patients. DESIGN, SETTING, AND PARTICIPANTS Propensity-matched cohort analysis of data in the Project IMPACT database, from 2001 to 2008. A total of 139 ICUs in the United States were included. Participants were ICU patients 18 years or older. EXPOSURE Arterial catheter use. MAIN OUTCOMES AND MEASURES Our main outcome was hospital mortality. We assessed a primary cohort of medical patients requiring mechanical ventilation and 9 secondary cohorts. We used propensity score-matched pairs as the primary analytic strategy. Sensitivity analyses included 4 alternative methods of comparison in the primary cohort: multivariate modeling without propensity adjustment, mixed-effects multivariate logistic regression without propensity adjustment, multivariate modeling with propensity adjustment, and stratification based on propensity quintiles. RESULTS Our primary cohort consisted of 60 975 patients; 24 126 of these patients (39.6%) had an arterial catheter in place during their ICU stay, and analyses were based on 13 603 propensity score-matched pairs. We found no association between arterial catheter use and hospital mortality in medical patients requiring mechanical ventilation in the primary analysis (odds ratio [OR], 0.98; 95% CI, 0.93-1.03; P = .40) or the 4 sensitivity analyses (P ≥ .58 for all). In 8 of 9 secondary cohorts we were unable to detect an association between arterial catheter use and hospital mortality. In the cohort of patients receiving vasopressors, arterial catheter use was associated with an increased odds of death (OR, 1.08; 95% CI, 1.02-1.14; P = .008). CONCLUSIONS AND RELEVANCE In this propensity-matched cohort analysis, arterial catheters were not associated with improvements in hospital mortality in medical ICU patients requiring mechanical ventilation. Given the costs and potential harms associated with invasive catheters, randomized clinical trials are needed to further evaluate the usefulness of these frequently used devices.

The effect of window rooms on critically ill patients with subarachnoid hemorrhage admitted to intensive care

IntroductionClinicians and specialty societies often emphasize the potential importance of natural light for quality care of critically ill patients, but few studies have examined patient outcomes associated with exposure to natural light. We hypothesized that receiving care in an intensive care unit (ICU) room with a window might improve outcomes for critically ill patients with acute brain injury.MethodsThis was a secondary analysis of a prospective cohort study. Seven ICU rooms had windows, and five ICU rooms did not. Admission to a room was based solely on availability.We analyzed data from 789 patients with subarachnoid hemorrhage (SAH) admitted to the neurological ICU at our hospital from August 1997 to April 2006. Patient information was recorded prospectively at the time of admission, and patients were followed up to 1 year to assess mortality and functional status, stratified by whether care was received in an ICU room with a window.ResultsOf 789 SAH patients, 455 (57.7%) received care in a window room and 334 (42.3%) received care in a nonwindow room. The two groups were balanced with regard to all patient and clinical characteristics. There was no statistical difference in modified Rankin Scale (mRS) score at hospital discharge, 3 months or 1 year (44.8% with mRS scores of 0 to 3 with window rooms at hospital discharge versus 47.2% with the same scores in nonwindow rooms at hospital discharge; adjusted odds ratio (aOR) 1.01, 95% confidence interval (95% CI) 0.67 to 1.50, P = 0.98; 62.7% versus 63.8% at 3 months, aOR 0.85, 95% CI 0.58 to 1.26, P = 0.42; 73.6% versus 72.5% at 1 year, aOR 0.78, 95% CI 0.51 to 1.19, P = 0.25). There were also no differences in any secondary outcomes, including length of mechanical ventilation, time until the patient was able to follow commands in the ICU, need for percutaneous gastrostomy tube or tracheotomy, ICU and hospital length of stay, and hospital, 3-month and 1-year mortality.ConclusionsThe presence of a window in an ICU room did not improve outcomes for critically ill patients with SAH admitted to the ICU. Further studies are needed to determine whether other groups of critically ill patients, particularly those without acute brain injury, derive benefit from natural light.