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The Relationship Between In-House Attending Coverage and Nighttime Extubation Following Congenital Heart Surgery*

Iannucci, Glen J. MD1,2; Oster, Matthew E. MD, MPH1,2; Chanani, Nikhil K. MD1,2; Gillespie, Scott E. MS3; McCracken, Courtney E. PhD3; Kanter, Kirk R. MD4; Mahle, William T. MD1,2

Pediatric Critical Care Medicine: March 2014 - Volume 15 - Issue 3 - p 258–263
doi: 10.1097/PCC.0000000000000068
Quality and Safety

Objectives: Many cardiac ICUs have instituted 24/7 attending physician in-house coverage, which theoretically may allow for more expeditious weaning from ventilation and extubation. We aimed to determine whether this staffing strategy impacts rates of nighttime extubation and duration of mechanical ventilation.

Design: National data were obtained from the Virtual PICU System database for all patients admitted to the cardiac ICU following congenital heart surgery in 2011 who required postoperative mechanical ventilation. Contemporaneous data from our local institution were collected in addition to the Virtual PICU System data. The combined dataset (n = 2,429) was divided based on the type of nighttime staffing model in order to compare rates of nighttime extubation and duration of mechanical ventilation between units that used an in-house attending staffing strategy and those that employed nighttime residents, fellows, or midlevel providers only.

Measurements and Main Results: Institutions that currently use 24/7 in-house attending coverage did not demonstrate statistically significant differences in rates of nighttime extubation or the duration of mechanical ventilation in comparison to units without in-house attendings. Younger patients cared for in non-in-house attending units were more likely to require reintubation.

Conclusions: Pediatric patients who have undergone congenital heart surgery can be safely and effectively extubated without the routine presence of an attending physician. The utilization of nighttime in-house attending coverage does not appear to have significant benefits on the rate of nighttime extubation and may not reduce the duration of mechanical ventilation in units that already use in-house residents, fellows, or other midlevel providers.

Supplemental Digital Content is available in the text.

1Sibley Heart Center, Children’s Healthcare of Atlanta, Emory University, Atlanta, GA.

2Department of Pediatric Cardiology, Emory University, Atlanta, GA.

3Department of Pediatrics, Emory University, Atlanta, GA.

4Department of Cardiothoracic Surgery, Emory University, Atlanta, GA.

* See also p. 276.

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 (

The authors have disclosed that they do not have any potential conflicts of interest.

Address requests for reprints to: William T. Mahle, MD, Children’s Healthcare of Atlanta, Emory University School of Medicine, 1405 Clifton Road, NE, Atlanta, GA 30322–1062. E-mail

©2014The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies