Abstract
IntroductionIntensive care units (ICUs) are increasingly adopting 24-hour intensivist physician staffing. Although nighttime intensivist staffing does not consistently reduce mortality, it may affect other outcomes such as the quality of end-of-life care.MethodsWe conducted a retrospective cohort study of ICU decedents using the 2009–2010 Acute Physiology and Chronic Health Evaluation clinical information system linked to a survey of ICU staffing practices. We restricted the analysis to ICUs with high-intensity daytime staffing, in which the addition of nighttime staffing does not influence mortality. We used multivariable regression to assess the relationship between nighttime intensivist staffing and two separate outcomes potentially related to the quality of end-of-life care: time from ICU admission to death and death at night.ResultsOf 30,456 patients admitted to 27 high-intensity daytime staffed ICUs, 3,553 died in the hospital within 30 days. After adjustment for potential confounders, admission to an ICU with nighttime intensivist staffing was associated with a shorter duration between ICU admission and death (adjusted difference: –2.5 days, 95% CI -3.5 to -1.5, p-value < 0.001) and a decreased odds of nighttime death (adjusted odds ratio: 0.75, 95% CI 0.60 to 0.94, p-value 0.011) compared to admission to an ICU without nighttime intensivist staffing.ConclusionsAmong ICU decedents, nighttime intensivist staffing is associated with reduced time between ICU admission and death and reduced odds of nighttime death.
Highlights
Intensive care units (ICUs) are increasingly adopting 24-hour intensivist physician staffing
Patients admitted to lowintensity ICUs, those who survived to hospital discharge, and decedents whose death occurred more than 30 days after ICU admission
We found that adjusted length of time from ICU admission to death was significantly shorter among decedents admitted to ICUs with nighttime intensivists compared with those without (Table 3)
Summary
Intensive care units (ICUs) are increasingly adopting 24-hour intensivist physician staffing. Nighttime intensivist staffing does not consistently reduce mortality, it may affect other outcomes such as the quality of end-of-life care. Intensivist physician staffing is associated with lower mortality and decreased length of stay in the ICU [1,2]. This observation has led to efforts to expand the intensivist physician staffing model [3], during the day and at night [4,5]. The quality of end-of-life care is an important patient-centered outcome and may be impacted by nighttime intensivist staffing through earlier and more frequent conversations between physicians and surrogate decision-makers regarding prognosis and goals of care [10]. Since intensive communication leads to earlier decisions regarding life-sustaining therapy withdrawal [11,12], increased communication through the addition of nighttime intensivists could result in earlier withdrawal of life-sustaining therapy and thereby alter the timing of death among ICU decedents
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