With little evidence to guide them, many hospital intensive care units (ICUs) have been employing critical care physicians at night with the notion it would improve patients’ outcomes. However, new results from a one-year randomized trial from researchers at Penn Medicine involving nearly 1,600 patients admitted to the Hospital of the University Pennsylvania (HUP) Medical ICU suggest otherwise: Having a nighttime intensivist had no clear benefit on length of stay or mortality for these patients, not even patients admitted at night or those with the most critical illnesses at the time of admission.
The research was presented at the American Thoracic Society International Conference in Philadelphia May 20 by senior study author Scott D. Halpern, MD, PhD, assistant professor of Medicine, Epidemiology, and Medical Ethics and Health Policy, and published online the same day in the New England Journal of Medicine.
The findings raise a pertinent question in today's financially-conscious healthcare setting: Why invest financial resources to staff a nighttime intensivist if it’s not improving patient outcomes?
“This is an important finding that affects a lot of stakeholders,” said first author Meeta Prasad Kerlin, MD, MSCE, an assistant professor of Medicine in the division of Pulmonary, Allergy and Critical Care at the Perelman School of Medicine at the University of Pennsylvania. “Staffing an intensivist at night is probably quite costly, because the total billing will likely be at a higher rate, which could trickle down to the insurance provider or patient. There’s also the operating cost associated with staffing that impacts hospitals.”
“Based on these results, if an academic hospital’s primary goal is to improve patient outcomes, then I don’t think having an attending physician physically there overnight in a medical ICU is necessary,” she added. “In fairness, this study doesn't tell us what might happen with nighttime intensivists in ICUs that aren't like Penn's.”
Today, one third of academic hospitals in the U.S. and three quarters in Europe staff a nighttime physician in the ICU, despite a lack of clear evidence demonstrating its effectiveness. Previous studies on the topic lacked experimental designs and produced mixed results.
The medical ICU at HUP is a closed system, also called “high-intensity,” where patients are cared for by designated intensivists during the day, as opposed to “low-intensity” systems, where patients are not routinely cared for by intensivists during the day. A multicenter study published last year found that among ICUs with low-intensity daytime staffing, those employing nighttime intensivist staffing had lower-risk adjusted mortality compared to those without it. However, this larger multicenter study in NEJM, also presented at this year’s conference by Dr. Kerlin, refutes this finding, demonstrating no clear benefit with nighttime intensivist staffing in any type of ICU.
Click here to view the full release.