Reference as : Robbins RA, Singarajah CU. June 2011 Critical Club Journal Club. Southwest J Pulm Crit Care 2011;2:77-78. (Click here for PDF version )
This month’s Critical Care Journal club focused on two recent articles regarding nighttime coverage of the intensive care unit (ICU). Because of the commitment of Banner Good Samaritan to the electronic ICU (eICU), Dr. Raschke and his colleagues did not feel comfortable reviewing these articles. Therefore, Drs. Robbins and Singarajah are filling in for this month. Both practice at the Phoenix VA where nighttime coverage is neither by electronic nor on-site intensivists, but by second or third year medicine house officers with pulmonary/critical care fellow backup and medical attending physician backup.
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: 2175-83. (Click here for the abstract of the manuscript).
This article by Lilly et al. examined the effect of an adult eICU intervention on hospital mortality, length of stay, best practice adherence, and preventable complications from a compared to care performed by house officers at night during a preintervention period. The authors used a prospective stepped-wedge clinical practice study of 6290 adults admitted to any of 7 ICUs (3 medical, 3 surgical, and 1 mixed cardiovascular). The hospital mortality rate was 13.6% during the preintervention period compared with 11.8% during the eICU intervention period (p=0.005). The tele-ICU intervention period compared with the preintervention period was associated with higher rates of best clinical practice adherence for the prevention of deep vein thrombosis, prevention of stress ulcers, cardiovascular protection, prevention of ventilator-associated pneumonia and catheter-related bloodstream infection. Furthermore, use of the eICU shortened hospital length of stay (9.8 vs 13.3 days, p<0.001).
This article supports the use of eICU but has a number of caveats. First, the comparison was a before and after comparison which often favor the intervention. This may be due to other interventions which occurred concomitantly with the eICU implementation or the Hawthorne effect (observation alone tends to induce change). Second, the study was at a single institution and might not be applicable to other institutions. Third, the comparison was between eICU and night coverage with a house officer. It is not surprising that the outcomes might be better with a more experienced physician caring for the patient. The authors did not perform a comparison between an in-house physician intensivist and an eICU. Fourth, some details are missing. The educational level of the house officer is not stated. A first year house officer might not perform as well as sixth year senior pulmonary/critical care fellow. The number of patients being covered by the house officer or eICU physician is not stated. If the house officer was also covering floor patients or the eICU physician was covering only a few patients, this workload could make a difference. Clearly, large, multi-institutional, randomized, studies comparing the eICU with a beside intensivist are needed.
Economic implications of nighttime attending intensivist coverage in a medical intensive care unit. Crit Care Med 2011;39:1257–1262. (Click here for the abstract of the manuscript).
The article by Banerjee et al. assessed the cost implications of changing the intensive care unit staffing model from on-demand presence to mandatory 24 hour in-house critical care specialist presence. Like Lily’s study discussed above this was a pre-post comparison in a single academic center. Total cost estimates of hospitalization were calculated for each patient and adjusted mean total cost estimates were 61% lower after implementation of a 24 hour in-house critical care specialist for patients admitted during night hours (7 PM to 7 AM) who were in the highest Acute Physiology and Chronic Health Evaluation III quartile. The unadjusted intensive care unit length of stay fell in the post period relative to the pre period (3.5 vs. 4.8) with no change in non-intensive care unit length of stay on mortality.
Although virtually all the same criticisms of Lily’s study are also true in this study, both studies have the theme that care of the patient by the most experienced physician, whether in person or electronically, leads to improved outcomes. Future studies should address the various types of ICU coverage available – just house officers in internal medicine; house officers with critical care/pulmonary fellows; or either of the prior two with an in house attending. There are a variety of staffing models for attending coverage with critical care medicine attending physicians from internal medicine, surgery and anesthesiology available for coverage. Comparing in house coverage of a medical ICU by say surgery attending physicians as compared to medical attending physicians may be useful as well. One interpretation of the Bannerjee study is that it the change in model led to a more “efficient” way to achieve the same mortality. The eICU may be more of an administrative method to employ relatively limited resources (CCM attending physicians) more cost effectively, cost effectively that is, from the perspective of the payers and not necessarily for the physicians.
Several points remain unclear: does the physician need to be at bedside; or what staffing levels need to be present? For example, can one physician covering 200 patients electronically produce results as good as one physician covering 20 at the bedside? It is also unclear whether a physician monitoring all the patients is really necessary or can a physician extender such as a nurse practioner or physicians assistant monitor the patients electronically and have the physician become involved either electronically or in person when intervention is appropriate. Lastly, it should be pointed out that although the concept of electronic coverage has been applied to the intensive care unit because of potential staffing shortages, it may also be applied to other areas of the hospital. This includes not only physicians but also nursing and administration where it is unclear whether the presence of the nurse or administrator needs to be in the hospital or can be at a remote location.