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No benefit seen with nighttime in-house intensivist coverage

Clinical Question:
Does nighttime coverage by in-house attending intensivists reduce length of stay in the intensive care unit?

Bottom Line:
An intensive care unit (ICU) staffing model consisting of in-house attending intensivists in an academic medical center in which medical residents served as first-line care providers did not decrease ICU length of stay (LOS) or improve ICU and in-hospital mortality. This supports previous findings from observational studies that demonstrate that there may be little benefit to in-house nighttime intensivists in ICUs that have mandatory involvement of daytime intensivists. (LOE = 1b)

Reference:
Kerlin MP, Small DS, Cooney E, et al. A randomized trial of nighttime physician staffing in an intensive care unit. N Engl J Med 2013;368(23):2201-2209.  [PMID:23688301]

Study Design:
Randomized controlled trial (nonblinded)

Funding:
Other

Allocation:
Uncertain

Setting:
Inpatient (ICU only)

Synopsis:
All patients who were admitted to a medical ICU over the course of 1 year were enrolled into this study. Investigators randomly assigned 1-week blocks to an intervention staffing model or control model. The intervention model consisted of nighttime coverage by in-hospital attending physician intensivists; the control model consisted of nighttime coverage by daytime intensivists or fellows who were available by phone consultation only. The medical residents continued to be the first-line care providers at day and at night in each model. Patients in the ICU during both the intervention and control periods had similar characteristics, a median age of 60 years, and similar illness severity based on APACHE III scoring. Of note, 60% in each group were admitted during nighttime hours (defined as 5 PM to 5 AM). For the primary outcome of ICU LOS, there was no significant difference detected between the 2 groups. This finding remained when the analysis was restricted to patients admitted during nighttime hours. Additionally, prespecified subgroup analyses stratifying by either patient severity of illness or by the experience level of the medical residents did not affect LOS. Finally, hospital LOS and mortality were similar in the 2 groups. Of note, residents involved in this study were surveyed and the majority perceived improved quality of care with the nighttime intensivist staffing. However, less than half of the eligible residents actually responded to the survey.

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