24 hour Intensivist Presence – desirable? Maybe. Efficient, Economic and Effective – Unlikely

Few issues have been more controversial in the past 20 years than the implementation of the intensivist model. Fundamentally this involves delegation of primary responsibility for critically ill patients to a narrow group of clinicians, whose primary training may be in an entirely different specialty. Hence, surgical patients may be managed by internists, and medical patients may be managed by anesthetists. I like to think of intensivists as coordinators of patient care, experts at resuscitation, who pay meticulous attention to detail and careful users of resources. As a result, each organ system does not have it’s own consultant, and medicines, interventions and tests are reduced, saving the institution a lot of money and resources.

Whether or not intensivists improve patient outcomes, versus primary medical or surgical teams rounding on patients, remains controversial. I have written about this in detail elsewhere (here subscription needed).  To summarize: daily rounds by an intensive care specialist improve outcomes in high risk surgical patients; intensive care teams (multidisciplinary) improve outcomes, as does the presence of a ICU medical director who sets standards. An article in Annals of Internal Medicine (conducted by well known intensivists) found that, in a study of >100,000 patients, critically ill patients managed by intensivists had worse outcomes (here). Patients managed by critical care physicians were sicker, had more procedures, and had higher hospital mortality rates than those managed by other physicians. I have always found this article confusing – for example in the non-intensivist model there were hospitals that had critical care fellows but no intensivist! The assumption that leads to the headline (“intensivists kill patients”), is that SAPS II is a good predictor of mortality and that adjustments based on SAPS II can separate out patients. If SAPS is not so good, then adjustments for severity of illness are meaningless. Also, there were significantly more patients transferred from other hospitals and more patients ventilated on admission in the CCM (intensivist) model. This suggests lead time bias: patients with similar severity of illness scores on admission to ICU that have been pre-resuscitated or transferred have worse outcomes.

The Irish government clearly believe in the intensivist model, as they seem to think that having us present in the ICU 24/7 will improve outcomes and save lots of money. In today’s Irish Times:

For the first time, consultants in areas such as emergency medicine, intensive care, neonatology and obstetrics will be rostered on a 24-hour basis, working eight-hour shifts. Dr Reilly has said the proposals could save up €200 million.” (article here). I don’t know how the geniuses in the Department of Health have come up with this number, but it is complete fiction. In addition, for a Hospital to provide 24 hour consultant in house cover for ICU, I calculate that this would require approx €1 million a year in direct salary costs (5 FTEs to cover around the clock plus 2 or 3 more to cover their daytime assignments – remember the EWTD applies to consultants as well). This may appear insignificant compared with the staggering savings that they are anticipating – but there is no systematic proof that over investigation (where available and it is not) at night, and over treatment (with what?) at night and bad decision making, by registrars, is costing the health system a fortune. In fact – there is not a single study published anywhere ever that shows that having a consultant intensivist present for patient resuscitation improves outcomes. Outcome improvement has been demonstrated in scenarios where patients have received timely fluids and antibiotics, and subsequent care with ventilator strategy, sedation and mobilization. Has anyone ever studied the 24 hour intensivist model? Yes they have….

A study in the Lancet in 2000 suggested that 24 hour availability of intensivists (the current model in ALL Irish level 3 ICUS) significantly improved outcomes (here). A group from Saudi Arabia claimed the 24/7 staffing led to similar mortality out of hours as within weekday hours (here) proving – well nothing. A nice pro-con debate on this topic can be read in Critical Care (here). A passionate plea for 24/7 coverage can be read in the “blue journal” (here). A core discussion point is that patients that are admitted out of hours (9-5 Monday to Friday) appear more likely to die. This assumes that worse outcomes are due to lack of consultant staffing in the ICU rather than confounders like: patient was getting sick, but no GP available, no elective surgery admitted out of hours, fewer investigations (radiology) available out of hours, patients on wards not being seen by primary care team out of hours etc. In other words, it may be the health system rather than the absence of continuous critical care consultant staffing that is at fault. A study from Paris suggested that out of hours admission patients did better! (here). A US study suggested no difference (here). Indeed, even in July changeover season, mortality is not greater (here). Moreover, papers that claim cost savings tend to massage their data (here).

In the NEJM in May 2012, a group from Pittsburgh looked at night time physician (intensivist) staffing in ICU versus outcomes in North America (article here). What the study showed, in a nutshell, was if the hospital had an intensivist and a critical care team during the day, having a consultant present, on site, at night made no difference to outcomes (our current model in Ireland). However, in hospitals where there was no critical care team during the day (low intensity staffing), having an intenisivist at night improved outcomes [I am still trying to figure out what kind of ICU would pay a consultant at night but not during the day – perhaps they were covered by Tele-ICU]. Also, having any doctor dedicated to the ICU at night (a resident) improved outcomes – very much our model in Ireland.

So, before we are forced to embrace 24/7 cover perhaps it is worth questioning why and for what benefit. I am not suggesting that there should not be 24/7 anesthesia, EM  or obstetrics (where you would anticipate fewer lawsuits, I presume) coverage, I am just relaying the best current evidence, which is that expending 5 FTEs worth of staff to cover 24/7 in adult ICU is not supported by best available evidence.

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