Intensivists at night: putting resources in the right place

Mitchell M Levy

doi:10.1186/cc13060

Abstract

During the past 50 years, caring for the critically ill has become increasingly complex and the need for an intensivist has become more evident. Management by intensivists has become a quality indicator for many ICUs. Numerous small studies have demonstrated the beneficial effect of intensivists on outcomes in the critically ill, and some clinicians have advanced the argument that a night-time intensivist is essential for the care of critically ill patients. In response, many institutions have hired full-time intensivists for both day and night coverage in the ICU. Two recent studies have been conducted that make a compelling argument for redirecting funding of night-time intensivists to areas of greater need in health care. In a retrospective analysis of a large database that involved more than 65,000 patients, no benefit of night-time intensivists could be found in ICUs where care is managed by intensivists during the day. Only in ICUs where management by intensivists is not mandated could a beneficial impact on mortality be found. The second study, a randomized controlled trial, evaluated the effect of night-time intensivists on length of stay, mortality, and other outcomes and was a negative trial. In this methodologically rigorous trial, there was no difference in outcomes between the intensivist and control group, which consisted of in-house resident coverage at night with availability by telephone of fellows and intensivists. These two robust studies clearly suggest that night-time intensivists do not improve mortality in ICUs managed by intensivists during the day. Though possibly beneficial in low-intensity environments, the widespread drive to add night-time intensivist coverage may have been premature.

Highlights

During the past 50 years, caring for the critically ill has become an increasingly complex task
Expensive therapeutic agents, and the proliferation of new technologies for physiologic monitoring contribute to making care of the critically ill patient a nuanced and demanding effort
Some clinicians have advanced the argument that a night-time intensivist is an essential ingredient for safe, high-quality care for critically ill patients [6,7,8]

Summary

Introduction

During the past 50 years, caring for the critically ill has become an increasingly complex task. It is important to recognize that this randomized trial was conducted in a single-center, large academic, high-intensity university ICU in the US, with a full complement of house staff and critical care trainees and cannot be generalized to smaller, non-teaching, or low-intensity environments Both studies are consistent - addition of night-time intensivists to a high-intensity ICU does not make a difference in mortality or length of stay. The article by Wallace and colleagues [11] suggests that in low-intensity environments outcomes are improved when care is directed by intensivists at night, the widespread drive to add night-time intensivist coverage based on an assumption of better outcomes may have been premature According to these articles, there is no evidence to support this assertion. We have to question whether this is an attempt to keep alive the belief that night-time intensivists do make a difference, and we must question whether the expense is justified by these potential outcomes

Conclusions

Society of Critical Care Medicine Quality Indicators Committee