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The Association Between Daytime Intensivist Physician Staffing and Mortality in the Context of Other ICU Organizational Practices

A Multicenter Cohort Study*

Costa, Deena Kelly PhD, RN1; Wallace, David J. MD, MPH2,3; Kahn, Jeremy M. MD, MS2,4

doi: 10.1097/CCM.0000000000001259
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Objective: Daytime intensivist physician staffing is associated with improved outcomes in the ICU. However, it is unclear whether this association persists in the era of interprofessional, protocol-directed critical care. We sought to reexamine the association between daytime intensivist physician staffing and ICU mortality and determine if interprofessional rounding and protocols for mechanical ventilation in part mediate this relationship.

Design: Retrospective cohort study of ICUs in the Acute Physiology and Chronic Health Evaluation clinical information system from 2009 to 2010.

Setting: Forty-nine ICUs in 25 U.S. hospitals.

Patients: Adults (17 yr and older) admitted to a study ICU.

Interventions: None.

Measurements and Main Results: We defined high-intensity daytime intensivist staffing as either a mandatory consult or closed ICU model; interprofessional rounds as rounds that included a respiratory therapist, pharmacist, physician and nurse; and protocol use as having protocols for liberation from mechanical ventilation and lung protective mechanical ventilation. Using multivariable logistic regression, we estimated the independent effect of daytime intensivist physician staffing on in-hospital mortality controlling for interprofessional rounds and protocols for mechanical ventilation, as well as other patient and hospital characteristics. Twenty-seven ICUs (55%) reported high-intensity daytime physician staffing, 42 ICUs (85%) reported daily interprofessional rounds, and 31 (63%) reported having protocols for mechanical ventilation. There was no association between daytime intensivist physician staffing and in-hospital mortality (adjusted odds ratio, 0.86; 95% CI, 0.65–1.14). After adjusting for interprofessional rounds and protocols for mechanical ventilation, the effect of daytime intensivist physician staffing remained nonsignificant (adjusted odds ratio, 0.90; 95% CI, 0.70–1.17).

Conclusion: High-intensity daytime physician staffing in the ICU was not significantly associated with lower mortality in a modern cohort. This association was not affected by interprofessional rounds or protocols for mechanical ventilation.

1Department of Systems, Populations and Leadership, University of Michigan School of Nursing, Ann Arbor, MI.

2Clinical Research Investigation and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA.

3Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA.

4Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA.

* See also p. 2503.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/ccmjournal).

This work was presented at AcademyHealth conference June 8-10, 2014, where it received an inaugural award for “Best of Annual Research Meeting”.

Dr. Costa received support for article research from the National Institutes of Health (NIH) (NIH T32HL007820). Her institution received grant support from the NIH (T32 training grant to University of Pittsburgh [T32HL007820]). Dr. Wallace received support for article research from the NIH. His institution received grant support from the NIH (K12HL109068). Dr. Kahn consulted (in kind research support from Cerner Corporation), acknowledges funding from The Gordon and Betty Moore Foundation, and received support for article research from the NIH. His institution received grant support from the NIH (K23HL082650).

For information regarding this article, E-mail: kahnjm@upmc.edu

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