Abstract
RationaleHospitals are increasingly using critical care outreach teams (CCOTs) to respond to patients deteriorating outside intensive care units (ICUs). CCOT staffing is variable across hospitals and optimal team composition is unknown.ObjectivesTo assess whether adding a critical care medicine trained physician assistant (CCM-PA) to a critical care outreach team (CCOT) impacts clinical and process outcomes.MethodsWe performed a retrospective study of two cohorts—one with a CCM-PA added to the CCOT (intervention hospital) and one with no staffing change (control hospital)—at two facilities in the same system. All adults in the emergency department and hospital for whom CCOT consultation was requested from October 1, 2012-March 16, 2013 (pre-intervention) and January 5-March 31, 2014 (post-intervention) were included. We performed difference-in-differences analyses comparing pre- to post-intervention periods in the intervention versus control hospitals to assess the impact of adding the CCM-PA to the CCOT.Measurements and Main ResultsOur cohort consisted of 3,099 patients (control hospital: 792 pre- and 595 post-intervention; intervention hospital: 1114 pre- and 839 post-intervention). Intervention hospital patients tended to be younger, with fewer comorbidities, but with similar severity of acute illness. Across both periods, hospital mortality (p = 0.26) and hospital length of stay (p = 0.64) for the intervention vs control hospitals were similar, but time-to-transfer to the ICU was longer for the intervention hospital (13.3–17.0 vs 11.5–11.6 hours, p = 0.006). Using the difference-in-differences approach, we found a 19.2% reduction (95 confidence interval: 6.7%-31.6%, p = 0.002) in the time-to-transfer to the ICU associated with adding the CCM-PA to the CCOT; we found no difference in hospital mortality (p = 0.20) or length of stay (p = 0.52).ConclusionsAdding a CCM-PA to the CCOT was associated with a notable reduction in time-to-transfer to the ICU; hospital mortality and length of stay were not impacted.
Highlights
Critical illness can arise anywhere in the hospital, emergency department, or even prior to hospital arrival
P = 0.002) in the time-to-transfer to the intensive care units (ICUs) associated with adding the critical care medicine trained physician assistant (CCM-PA) to the critical care outreach teams (CCOTs); we found no difference in hospital mortality (p = 0.20) or length of stay (p = 0.52)
Adding a CCM-PA to the CCOT was associated with a notable reduction in time-to-transfer to the ICU; hospital mortality and length of stay were not impacted
Summary
Critical illness can arise anywhere in the hospital, emergency department, or even prior to hospital arrival. Critical illness is often optimally managed when treatment is initiated early.[1, 2] For these reasons, numerous quality groups advocate for rapid response/medical emergency teams (RR/METs) to attend quickly to patients experiencing clinical deterioration outside the intensive care unit (ICU).[3,4,5] While data on their impact is mixed,[6,7,8,9,10] these teams are increasingly common across U.S hospitals and internationally.[11]. Recommendations are that team composition be determined by each “institution’s resources and needs.”[5] Published literature suggests many models—including intensivists, hospitalists, housestaff, non-physician-providers and critical care nurses—are used.[12,13,14,15,16] How one team structure compares to another and the impact of including clinicians with different backgrounds is not well studied. In a single center study of RR/METs led by intensivists versus resident physicians, there was no difference in patients’ progression to cardiac arrest, need for ICU admission, or hospital mortality;[13] yet, still more work needs to be done to understand whether this is the “right” RR/MET structure or if other configurations may be more effective and/or just as effective, but with lower costs
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