Intensivist physician staffing and the process of care in academic medical centres

Abstract

Although intensivist physician staffing is associated with improved outcomes in critical care, little is known about the mechanism leading to this observation. To determine the relationship between intensivist staffing and select process-based quality indicators in the intensive care unit. Retrospective cohort study in 29 academic hospitals participating in the University HealthSystem Consortium Mechanically Ventilated Patient Bundle Benchmarking Project. 861 adult patients receiving prolonged mechanical ventilation in an intensive care unit. Patient-level information on physician staffing and process-of-care quality indicators were collected on day 4 of mechanical ventilation. By day 4, 668 patients received care under a high intensity staffing model (primary intensivist care or mandatory consult) and 193 patients received care under a low intensity staffing model (optional consultation or no intensivist). Among eligible patients, those receiving care under a high intensity staffing model were more likely to receive prophylaxis for deep vein thrombosis (risk ratio 1.08, 95% CI 1.00 to 1.17), stress ulcer prophylaxis (risk ratio 1.10, 95% CI 1.03 to 1.18), a spontaneous breathing trial (risk ratio 1.37, 95% CI 0.97 to 1.94), interruption of sedation (risk ratio 1.64, 95% CI 1.13 to 2.38) and intensive insulin treatment (risk ratio 1.40, 95% CI 1.18 to 1.79) on day 4 of mechanical ventilation. Models accounting for clustering by hospital produced similar estimates of the staffing effect, except for prophylaxis against thrombosis and stress ulcers. High intensity physician staffing is associated with increased use of evidence-based quality indicators in patients receiving mechanical ventilation.