Daily Multidisciplinary ICU Rounds Improve Patient Outcomes
Abstract & Commentary
By David J. Pierson, MD, Editor, Professor, Pulmonary and Critical Care Medicine, Harborview Medical Center, University of Washington, Seattle, is Editor for Critical Care Alert.
Synopsis: In this large retrospective cohort study of more than 100,000 patients in 112 hospitals, after correction for illness severity and other factors, daily rounds by a multidisciplinary care team were associated with lower mortality in the ICU, regardless of whether an intensivist model of physician staffing was in use.
Source: Kim MM, et al. The effect of multidisciplinary care teams on intensive care unit mortality. Arch Intern Med 2010;170:369-376.
Kim and associates conducted a population-based, retrospective cohort study of medical patients admitted to acute care hospitals throughout the state of Pennsylvania between July 2004 and June 2006. They linked a statewide hospital organizational survey with hospital discharge data, and used multivariate logistic regression to look for independent relationships between daily multidisciplinary ICU rounds and 30-day patient mortality. They used data from each hospital's ICU that treated the largest number of adult, noncardiac, nonsurgical patients, and thus excluded pediatric ICUs and patients with primary cardiac, neurological, or surgical diagnoses. ICUs were classified according to whether physician staffing was by primary intensivist management, mandatory intensivist consultation, optional intensivist consultation, or absence of any intensivist. Whether a given hospital had multidisciplinary ICU rounds was determined by a yes or no answer to the question, "Does the ICU have daily multidisciplinary ICU rounds consisting of the physician, nurse, and other health care professionals (e.g., social worker, respiratory therapist, pharmacist)?" Based on the responses, hospitals were classified into four categories: 1) low-intensity staffing without multidisciplinary care teams; 2) low-intensity staffing with multidisciplinary care teams; 3) high-intensity staffing with multidisciplinary care teams; and 4) high-intensity staffing without multidisciplinary care teams.
Altogether, 471,112 patients were admitted to ICUs in 169 Pennsylvania hospitals during the study period. Kim et al excluded 55 hospitals (135,923 patients) that did not provide complete survey data, and also, because of their small number, the two hospitals (7699 patients) in category 4 above (high-intensity staffing but no multidisciplinary care teams). Further exclusion of patients with nonmedical diagnoses left 107,324 patients in 112 hospitals as the study cohort. Of these, 54 hospitals (48%) were in category 1, 36 (32%) were in category 2, and 22 (20%) were in category 3.
There was considerable heterogeneity among the hospitals, with those in category 3 (high-intensity staffing with multidisciplinary care teams) tending to be larger, teaching hospitals caring for sicker patients with more comorbidities. Accordingly, unadjusted in-hospital mortality was highest (16.4%) in those hospitals. However, after adjusting for patient and hospital characteristics, multidisciplinary care was associated with significant reductions in the odds of death (odds ratio [OR], 0.84; 95% confidence interval [CI], 0.76-0.93; P = 0.001). Stratified by intensivist physician staffing, the lowest odds of death were in high-intensity units with multidisciplinary care teams (OR, 0.78; 95% CI, 0.68-0.89; P < 0.001), followed by ICUs with low-intensity staffing and multidisciplinary care teams (OR, 0.88; 95% CI, 0.79-0.97; P = 0.01), as compared to low-intensity hospitals without multidisciplinary care teams. These findings persisted with examination of different patient subgroups, including those with sepsis, the requirement for mechanical ventilation, and the greatest severity of illness.
Numerous studies have shown that the presence of trained intensivists is associated with improved ICU outcomes, including mortality. This study shows that this benefit is at least in part due to multidisciplinary ICU teams in units where this model of patient care is present. That is, for medical ICU patients, all other factors being equal (e.g., primary diagnosis, severity of acute illness, and comorbidities), the likelihood of survival is better if they are managed in a unit in which the physician rounds daily with the nurse and others such as a clinical pharmacist, respiratory therapist, and/or social worker.
As the authors point out, the reasons for this association are uncertain. However, there are a number of likely explanations. Multidisciplinary rounds may reduce practice variation among individual physicians, facilitate management according to accepted best practices, and foster the implementation of evidence-based treatments (such as lung-protective ventilation for acute lung injury), the use of checklists (such as for central line insertion), and the use of protocols (such as for sedation and ventilator weaning). Pharmacist participation in rounds reduces medication errors and other drug-related adverse events. And rounding together on a daily basis undoubtedly improves communication among the different members of the ICU team.
Although the continuous presence of a trained intensivist is accepted as an ideal for ICU care, fewer than half of all units in the United States currently have such staffing. The present study demonstrates that, regardless of whether the high-intensity intensivist staffing model is in effect, daily multidisciplinary care rounds are associated with better patient outcomes. It thus suggests that implementing multidisciplinary ICU care could reduce mortality in units that do not currently use it.