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Simulation of a Novel Schedule for Intensivist Staffing to Improve Continuity of Patient Care and Reduce Physician Burnout

Geva, Alon MD, MPH1–3; Landrigan, Christopher P. MD, MPH4–6; van der Velden, Meredith G. MD1,3; Randolph, Adrienne G. MD, MSc1,3

doi: 10.1097/CCM.0000000000002319
Clinical Investigations

Objective: Despite widespread adoption of in-house call for ICU attendings, there is a paucity of research on optimal scheduling of intensivists to provide continuous on-site coverage. Overnight call duties have traditionally been added onto 7 days of continuous daytime clinical service. We designed an alternative ICU staffing model to increase continuity of attending physician care for patients while also decreasing interruptions to attendings’ nonclinical weeks.

Design: Computer-based simulation of a 1-year schedule.

Setting: A simulated ICU divided into two daytime teams each covered by a different attending and both covered by one overnight on-call attending.

Subjects: Simulated patients were randomly admitted on different service days to assess continuity of care.

Interventions: A “shared service schedule” was compared to a standard “7 days on schedule.” For the 7 days on schedule, an attending covered a team for 7 consecutive days and off-service attendings cross-covered each night. For the shared schedule, four attendings shared the majority of daytime and nighttime service for two teams over 2 weeks, with recovery periods built into the scheduled service time.

Measurements and Main Results: Continuity of care as measured by the Continuity of Attending Physician Index increased by 9% with the shared schedule. Annually, the shared service schedule was predicted to increase free weekends by 3.4 full weekends and 1.3 weekends with either Saturday or Sunday off. Full weeks without clinical obligations increased by 4 weeks. Mean time between clinical obligations increased by 5.8 days.

Conclusions: A shared service schedule is predicted to improve continuity of care while increasing free weekends and continuity of uninterrupted nonclinical weeks for attendings. Computer-based simulation allows assessment of benefits and tradeoffs of the alternative schedule without disturbing existing clinical systems.

1Division of Critical Care Medicine, Department of Anesthesiology, Perioperative, and Pain Medicine, Boston Children’s Hospital, Boston, MA.

2Computational Health Informatics Program, Boston Children’s Hospital, Boston, MA.

3Department of Anaesthesia, Harvard Medical School, Boston, MA.

4Division of General Pediatrics, Department of Medicine, Boston Children’s Hospital, Boston, MA.

5Division of Sleep Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, MA.

6Department of Pediatrics, Harvard Medical School, Boston, MA.

Supported, in part, by the Department of Anesthesiology, Perioperative, and Pain Medicine at Boston Children’s Hospital.

Dr. Geva was supported by grant from the National Institutes of Child Health and Human Development/National Institutes of Health (NIH) (T32HD040128), and received support for article research from the NIH. Dr. Landrigan has served as a paid consultant to Virgin Pulse to help develop a Sleep and Health Program. He has consulted with and holds equity in the I-PASS Institute, which seeks to train institutions in best handoff practices and aid in their implementation (i.e., to help develop a program to disseminate safer handoffs of care). In addition, he has received monetary awards, honoraria, and travel reimbursement from multiple academic and professional organizations for teaching and consulting on sleep deprivation, physician performance, handoffs, and safety, and he has served as an expert witness in cases regarding patient safety and sleep deprivation. The remaining authors have disclosed that they do not have any potential conflicts of interest.

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