By Kathryn Radigan, MD

Attending Physician, Division of Pulmonary and Critical Care, Stroger Hospital of Cook County, Chicago

Dr. Radigan reports no financial relationships relevant to this field of study.

SYNOPSIS: When overnight shifts were staffed by nighttime intensivists rather than residents with attending intensivists on call remotely, most nurses perceived improvements in clinical care, procedures, efficiency, communication, and job place comfort.

SOURCE: Stanton ES, et al. Nurses’ perceptions of in-hospital versus telephone availability of an intensivist at night in an intensive care unit. Am J Crit Care 2017;26:203-209.

Studies have shown that in-hospital management of critically ill patients does not change patient mortality rates in high-intensity ICUs. There is concern that outcomes such as mortality may be flawed and incomplete. To better understand the areas affected by nighttime intensivist staffing that have not been addressed, Stanton et al conducted a randomized clinical trial in a U.S. academic center. The trial included semi-structured interviews of 13 night-shift bedside nurses in the medical ICU toward the end of a previously published randomized trial of nighttime intensivist staffing that included randomization of attending presence in one-week blocks from 7 p.m. to 7 a.m.

Participation was voluntary, and nursing participants were compensated $50 for a 30-45 minute phone or in-person interview that included a script designed to elicit participants’ perceptions of employing an intensivist in the hospital at night. One trained investigator moderated interviews, and three investigators independently reviewed interview transcripts to identify key domains. A qualitative analysis was completed by using a grounded theory approach. Investigators found that in addition to the five themes that were purposefully discussed during the interview (efficiency, communication, job place comfort, quality of care, and procedures), participants also identified three additional themes, including supervision of trainees, experience, and system issues. Examples of system issues included making an additional physician available when resources are limited and timely transfer of patients in and out of the ICU. Most of the nurses who were interviewed thought that nighttime intensivists improved clinical care, procedures, efficiency, communication, and comfort in the job place. All nurses believed that system issues improved. Twelve out of the 13 nurses believed supervision of trainees improved.

Nurses, who are constantly present at the bedside and carry a more detailed perspective on patient care issues, perceived improvements in communication, efficiency, supervision, system issues, and experience with nighttime intensivist staffing. Since this study cannot provide concrete associations or quantifiable outcomes, further studies are needed to assess whether these improvements may lead to a change in patient outcomes and if there are other areas affected by nighttime staffing, including burnout rates, educational outcomes of residents, and family satisfaction.

COMMENTARY

Supporters of 24-hour intensivist staffing suggest that intensivist staffing at night may result in prompt establishment of treatment plans, rapid resuscitation of patients without delay, and adjustment of complex therapies more efficiently. Others have questioned the benefits of nighttime intensivists without data to support their presence, especially when factoring in cost.

In 2012, researchers showed that critically ill patients who were not cared for routinely by intensivists during the day experienced lower risk-adjusted mortality with the presence of in-hospital nighttime intensivists.1 This study sparked interest in whether there was a dose-adjusted response to the presence of nighttime intensivists in the setting of an ICU with established daytime intensivist staffing.

In 2013, Kerlin et al conducted a one-year randomized trial in an academic medical ICU examining the effects of nighttime staffing with in-hospital intensivists as compared with nighttime coverage by daytime intensivists who were available for consultation by telephone.2 There was no evidence that nighttime staffing had a significant effect on length of stay in the ICU or hospital, ICU or in-hospital mortality, readmission to the ICU, or the probability of discharge to home. These findings were consistent whether the patient was admitted at night regardless of the severity of illness or experience of the resident.

Although it is well described that in-person management by nighttime intensivists does not change patients’ mortality rates in the ICU, there are concerns that these traditional ICU outcomes are flawed. To elicit insights from the nursing perspective of nighttime staffing with attending intensivists vs. residents with attending intensivists on call, Stanton et al further investigated and revealed that all nurses appreciate improvements in communication, efficiency, supervision, system issues, and experience with nighttime intensivist staffing.

This study supports the theory that staffing by an intensivist at night produces benefits that are not captured by previous studies. It has been hypothesized that endpoints such as mortality are not as valuable when attempting to capture benefit in this scenario. For instance, the presence of an attending at night may lead to more prompt end-of-life discussions by a physician who inevitably has more expertise than a resident physician. Of course, addressing code status and altering goals of care would represent deaths that do not reflect poor delivery of care as a traditional mortality analysis would assume.

Other areas that may be affected by nighttime intensivist staffing include burnout rates of attending physicians, nurses, and trainees, along with educational outcomes of residents and family satisfaction. It also remains unclear how the intensity of the attending presence may affect patient outcomes.

It is clear that overnight attending physicians may vary drastically in their practice, with some involved with every patient plan of care while others may adhere to a philosophy of “call me if you have any trouble.” These different philosophies also may alter outcomes significantly. Although this study was not designed to provide concrete associations between nighttime intensivist staffing and quantifiable outcomes, nurses perceived improvements in communication, efficiency, supervision, system issues, and experience with nighttime intensivist staffing. More studies are necessary to assess whether these improvements lead to a change in patient outcome and if other areas, including burnout rates, educational outcomes of residents, and family satisfaction, are affected.

REFERENCES

  1. Wallace DJ, et al. Nighttime intensivist staffing and mortality among critically ill patients. N Engl J Med 2012;366:2093-2101.
  2. Kerlin MP, et al. A randomized trial of nighttime physician staffing in an intensive care unit. N Engl J Med 2013;368:2201-2209.