Guidelines
Moss M, Good V, Gozal D, et al. A Critical Care Societies collaborative statement: burnout syndrome in critical care healthcare professionals. A call for action. Am J Resp Crit Care Med. 2016;194:106-13. A multi-society guideline statement on burnout syndrome (BOS) that describes the diagnostic criteria, prevalence, risk factors, and adverse effects of BOS. It also proposes some possible mitigation strategies that may be helpful for providers and their patients.
24 Hour Intensivist Staffing
Gajic O, Assefa B, Hanson AC, et al. Effect of 24-hour mandatory versus on-demand critical care specialist presence on quality of care and family and provider satisfaction in the intensive care unit of a teaching hospital. Crit Care Med. 2008; 36: 36-44. A single ICU cohort study assessing outcomes before and after the introduction of a 24 hour intensivist model in an academic center with existing resident and fellow staffing. They found adherence to evidence-based processes improved from a baseline of 76% up to 84% (p = .002), decreased length of stay, and improved staff satisfaction, but no difference in mortality. Concerns raised since publication include generalizability to non-academic settings, as well as long-term costs and risk of physician burnout with this staffing model.
Kerlin MP, Small DS, Cooney E, et al. A randomized trial of nighttime physician staffing in an intensive care unit. New Engl J Med. 2013; 368: 2201-2209. This was a single ICU, randomized, controlled study of 24 hour in-house intensivist coverage compared with standard day + home coverage over 1 year in an academic ICU. The authors found no difference in mortality, length of stay, ICU readmission, or discharge to home. They did not assess patient or provider satisfaction. This adds to the body of evidence that 24 hour intensivist staffing in resident-staffed ICUs has no effect on mortality, and is equivocal in its effect on LOS.
Tele-ICU
Thomas EJ, Lucke JF, Wueste L, et al. Association of telemedicine for remote monitoring of intensive care patients with mortality, complications, and length of stay. JAMA. 2009;302:2671–2678. A multi-center, before-after implementation trial on the effect of telemedicine on ICU outcomes of > 4000 patients in 6 ICUs. They utilized proprietary eICU technology and allowed providers to request varying degrees of tele-ICU support. In contrast to prior smaller studies they found no difference in mortality or length of stay. The “Opt In” model of support may have weakened efficacy of the intervention, and as with prior studies, the heterogeneity of the term “tele-ICU” complicates the comparison of trials.
Lilly CM, Cody S, Zhao H, et al. University of Massachusetts Memorial Critical Care Operations Group. Hospital mortality, length of stay, and preventable complications among critically ill patients before and after tele-ICU reengineering of critical care processes. JAMA. 2011;305: 2175-2183. A single center multi-ICU, pre- and post-intervention trial at an academic medical center. Their intervention included both physiologic monitoring, reviewing of daily goals, and auditing for best-practices use. Significant improvements in mortality (11.8% vs. 13.6%), and length of stay (9.8 d v 13.3d) were seen. All tele-ICU providers also worked in the physical ICUs, which may have improved provider buy-in. The complex, multifaceted intervention may not be generalizable to ICUs without similar resources.
PMID: 21576622
Checklists
Cavalcanti AB, Bozza FA, Machado FR, et al. Effect of a quality improvement intervention with daily round checklists, goal setting, and clinician prompting on mortality of critically ill patients: a randomized clinical trial. JAMA. 2016; 315:1480-90. A large cluster randomized study of usual care versus a QI process incorporating a checklist and daily goal setting in 118 ICUs with 6800 patient encounters. There was no effect on mortality. There was significant improvement in other measures such as limiting tidal volumes and sedation, but no change in several outcomes including CLABSI, CAUTI, and VAP. While prior studies had looked at pre- and post-intervention outcomes, this is the first study of checklists that was prospectively randomized.
Resident ICU Schedules
The following studies examined the effect of resident shift length on the occurrence of medical errors. The 2004 study determined interns made substantially more errors when they worked frequent shifts of 24 hours or more than when they worked shorter shifts. A new study in 2020 showed that more errors occurred in residents not working extended shifts of 24 hours or more. Residents working shorter shifts had an increased workload (defined as the mean number of ICU patients per resident), and no difference in errors was found between the two schedules once adjusted for workload.
Landrigan CP, Rothschild JM, Cronin JW, et al. Effect of reducing interns' work hours on serious medical errors in intensive care units. N Engl J Med. 2004; 351:1838-48.
Landrigan CP, Rahman SA, Sullivan JP, et al. ROSTERS study group. Effect of patient safety of a resident physician schedule without 24-hour shifts. N Engl J Med. 2020;382(26):2514-2523.
APP Integration
McCarthy C, O’Rourke NC, Madison JM. Integrating advanced practice providers into medical critical care teams. Chest. 2013; 143:847-50. This brief article provides a nice review of how best to approach the integration of advanced practice providers in the critical care setting with a focus on reimbursement, coding and billing.
