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Critical Care Medicine:
doi: 10.1097/CCM.0b013e318292313a
Feature Articles

Do Intensivist Staffing Patterns Influence Hospital Mortality Following ICU Admission? A Systematic Review and Meta-Analyses*

Wilcox, M. Elizabeth MD, MSc1; Chong, Christopher A. K. Y. MD2,3; Niven, Daniel J. MD, MSc4; Rubenfeld, Gordon D. MD, MSc5; Rowan, Kathryn M. DPhil6; Wunsch, Hannah MD, MSc7,8; Fan, Eddy MD1

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Abstract

Objective:

To determine the effect of different intensivist staffing models on clinical outcomes for critically ill patients.

Data Sources:

A sensitive search of electronic databases and hand-search of major critical care journals and conference proceedings was completed in October 2012.

Study Selection:

Comparative observational studies examining intensivist staffing patterns and reporting hospital or ICU mortality were included.

Data Extraction:

Of 16,774 citations, 52 studies met the inclusion criteria. We used random-effects meta-analytic models unadjusted for case-mix or cluster effects and quantified between-study heterogeneity using I2. Study quality was assessed using the Newcastle-Ottawa Score for cohort studies.

Data Synthesis:

High-intensity staffing (i.e., transfer of care to an intensivist-led team or mandatory consultation of an intensivist), compared to low-intensity staffing, was associated with lower hospital mortality (risk ratio, 0.83; 95% CI, 0.70–0.99) and ICU mortality (pooled risk ratio, 0.81; 95% CI, 0.68–0.96). Significant reductions in hospital and ICU length of stay were seen (–0.17 d, 95% CI, –0.31 to –0.03 d and –0.38 d, 95% CI, –0.55 to –0.20 d, respectively). Within high-intensity staffing models, 24-hour in-hospital intensivist coverage, compared to daytime only coverage, did not improved hospital or ICU mortality (risk ratio, 0.97; 95% CI, 0.89–1.1 and risk ratio, 0.88; 95% CI, 0.70–1.1). The benefit of high-intensity staffing was concentrated in surgical (risk ratio, 0.84; 95% CI, 0.44–1.6) and combined medical-surgical (risk ratio, 0.76; 95% CI, 0.66–0.83) ICUs, as compared to medical (risk ratio, 1.1; 95% CI, 0.83–1.5) ICUs. The effect on hospital mortality varied throughout different decades; pooled risk ratios were 0.74 (95% CI, 0.63–0.87) from 1980 to 1989, 0.96 (95% CI, 0.69–1.3) from 1990 to 1999, 0.70 (95% CI, 0.54–0.90) from 2000 to 2009, and 1.2 (95% CI, 0.84–1.8) from 2010 to 2012. These findings were similar for ICU mortality.

Conclusions:

High-intensity staffing is associated with reduced ICU and hospital mortality. Within a high-intensity model, 24-hour in-hospital intensivist coverage did not reduce hospital, or ICU, mortality. Benefits seen in mortality were dependent on the type of ICU and decade of publication.

Copyright © 2013 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins

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