Nighttime physician staffing improves patient outcomes: we are not sure.

Abstract

The financial cost to implement dedicated nighttime senior physician staffing in intensive care units (ICUs) would not be inconsiderable to any healthcare system. Therefore, prior to embarking on such a financial outlay, there would need to be substantive evidence around two major areas: (1) evidence that there is a nighttime “problem” and (2) evidence that dedicated nighttime ICU senior physician staffing fixed/mitigated the nighttime “problem” and delivered benefits, including economic benefits, to offset the financial outlay. With respect to (1), while there is evidence that discharging patients from ICU at night can be harmful in some healthcare settings (with night used as a proxy either for premature ICU discharge and/or a period when staffing on the ward/floor is lower) [1], evidence of “harms” to patients who are admitted at night is conflicting [2] and for those who remain in the ICU overnight appears limited. Though not within the scope of this debate on patient outcomes, with respect to “harms” to family members, the evidence seems non-existent and with respect to “harms” to staff, there is some evidence that ICU physicians, working within a daytime-only model, may suffer cognitive fatigue and sleep deprivation and that this may impair performance. With regard to (2), while there is evidence that exposure to ICU physician staffing per se may improve patient outcomes (e.g. those treated in ICU physician-led or “closed” units) [3], the evidence that dedicated nighttime ICU senior physician staffing affords additional benefits to patients appears conflicting and limited. The pro debaters [4] consider the question of dedicated nighttime ICU senior physician staffing broadly— including not only the impact on patient outcomes (the scope of this debate) but also on daytime ICU physicians’ workload and the cumulative role of fatigue and sleep deprivation on performance and burnout. The pro debaters suggest that, from both personal experience and the existing literature, there is ample evidence that dedicated nighttime ICU senior physician staffing improves outcomes for patients and for staff and that the difficulty lies only in teasing out from the existing evidence when, where and how outcomes are improved—given the important role played by context. The con debaters [5] suggest that while the premise of dedicated nighttime ICU senior physician staffing appears intuitively one that would seem to improve patient outcomes, the evidence does not support this. However, they accept a need to consider not only the patient outcomes studied to date (predominantly mortality and length of stay) but also other outcomes for patients (e.g. quality of care including end-of-life care, quality of life, etc.), for family members/caregivers (e.g. family satisfaction) and for payers (e.g. staff satisfaction, cost savings) and agree that this evidence is far from substantive. The con debaters conclude that, given the absence of direct evidence of benefit of dedicated nighttime ICU senior physician staffing on the patient outcomes that have been studied, the costs of implementing it cannot be justified. While coming to different conclusions, both sides of the debate, pro and con, highlight the challenges posed by the methodological limitations and the issues of generalizability of the existing evidence base evaluating dedicated nighttime ICU senior physician staffing. With regard to methodological limitations, much of the existing evidence on dedicated nighttime ICU senior physician staffing comes from observational studies—both *Correspondence: bertrand.guidet@sat.aphp.fr 1 Service de Reanimation Medicale, Assistance Publique-Hopitaux de Paris, Hopital Saint-Antoine, 75012 Paris, France Full author information is available at the end of the article