Comparing Models of Staffing in the ICU on Patient and Nurse Outcomes
Intensive care units (ICUs) are specialized areas of the hospital that provide care for critically ill patients. ICUs require highly trained personnel, such as intensivists and ICU nurses, to implement effective processes and perform specialized procedures. However, ICU staffing is a complex and challenging issue, as it depends on multiple factors such as availability of trained personnel, patient acuity, size of ICU, and economic constraints. Therefore, different models of ICU staffing have been developed and implemented in various settings, with the aim of improving patient and nurse outcomes.
One of the main aspects of ICU staffing is the role of the intensivist, a physician who is specially trained in critical care medicine. The involvement of intensivists in the care of ICU patients has been shown to improve clinical outcomes and reduce costs [1]. However, there is no consensus on the optimal level and mode of intensivist involvement. Some of the common models of ICU staffing based on intensivist involvement are:
– Open ICU: In this model, the primary care physician retains responsibility for the patient’s care and can consult an intensivist if needed. The intensivist has no authority over the patient’s management and acts as an advisor.
– Closed ICU: In this model, the intensivist assumes full responsibility for the patient’s care and directs all aspects of management. The primary care physician transfers the patient to the intensivist and has no role in the decision-making process.
– High-intensity ICU: In this model, either a closed ICU or a mandatory intensivist consultation is implemented. The intensivist has a high degree of involvement and authority over the patient’s care.
– Low-intensity ICU: In this model, either an open ICU or an elective intensivist consultation is implemented. The intensivist has a low degree of involvement and authority over the patient’s care.
A systematic review and meta-analysis by Wilcox et al. [2] compared the effects of high-intensity versus low-intensity ICU staffing on patient mortality, length of stay (LOS), and costs. The review included 26 studies with a total of 1,371,364 patients. The results showed that high-intensity ICU staffing was associated with lower hospital mortality (odds ratio [OR] 0.84, 95% confidence interval [CI] 0.76–0.92), lower ICU mortality (OR 0.80, 95% CI 0.71–0.90), shorter hospital LOS (mean difference [MD] −1.19 days, 95% CI −1.77 to −0.61), shorter ICU LOS (MD −0.64 days, 95% CI −1.10 to −0.18), and lower hospital costs (MD −$3,926, 95% CI −$6,356 to −$1,496). The authors concluded that high-intensity ICU staffing improves patient outcomes and reduces costs.
Another aspect of ICU staffing is the role of advanced practice providers (APPs), such as nurse practitioners (NPs) and physician assistants (PAs). APPs are health professionals who have advanced education and training in a specific area of practice. APPs can work independently or collaboratively with physicians to provide care for ICU patients. Some of the benefits of APPs in the ICU are:
– Increased access to care: APPs can provide care for patients who otherwise would not have access to an intensivist or a specialist physician.
– Improved continuity of care: APPs can provide consistent care for patients throughout their stay in the ICU and beyond.
– Enhanced quality of care: APPs can provide evidence-based care for patients based on standardized protocols and guidelines.
– Reduced workload for physicians: APPs can perform tasks that would otherwise be done by physicians, such as history taking, physical examination, ordering tests, prescribing medications, performing procedures, and documenting care.
– Increased satisfaction for patients and staff: APPs can improve communication and collaboration among the health care team and enhance patient satisfaction and trust.
A systematic review by Kleinpell et al. [3] evaluated the impact of APPs on patient outcomes in the ICU. The review included 17 studies with a total of 12,718 patients. The results showed that APPs were associated with similar or improved outcomes compared to physician-only models in terms of mortality, LOS, complications, readmissions, quality indicators, and patient satisfaction. The authors concluded that APPs are effective providers of care for critically ill patients.
A third aspect of ICU staffing is the use of telemedicine, which is the delivery of health care services using information and communication technologies. Telemedicine can enable remote monitoring and consultation for ICU patients by connecting them with intensivists or specialists who are not physically present in the hospital. Some of the advantages of telemedicine in the ICU are:
– Improved access to care: Telemedicine can provide care for patients who are located in rural or underserved areas, where there is a shortage of intensivists or specialists.
– Improved quality of care: Telemedicine can provide timely and accurate diagnosis and treatment for patients, based on real-time data and expert opinion.
– Reduced costs: Telemedicine can reduce the need for patient transfer, travel, and staffing, which can save money for the health care system and the patients.
– Increased satisfaction for patients and staff: Telemedicine can improve communication and collaboration among the health care team and increase patient satisfaction and confidence.
A systematic review by Young et al. [4] assessed the impact of telemedicine on patient outcomes in the ICU. The review included 13 studies with a total of 41,596 patients. The results showed that telemedicine was associated with lower hospital mortality (OR 0.81, 95% CI 0.74–0.88), lower ICU mortality (OR 0.74, 95% CI 0.62–0.88), shorter hospital LOS (MD −1.26 days, 95% CI −2.44 to −0.08), and shorter ICU LOS (MD −1.30 days, 95% CI −2.17 to −0.43). The authors concluded that telemedicine improves patient outcomes in the ICU.
In conclusion, different models of ICU staffing have different effects on patient and nurse outcomes. High-intensity ICU staffing with intensivist involvement, APPs, and telemedicine are associated with improved outcomes compared to low-intensity ICU staffing, physician-only models, and no telemedicine. However, the optimal model of ICU staffing may depend on the local context, resources, and preferences of the stakeholders involved.
References
[1] Pronovost PJ, Angus DC, Dorman T, Robinson KA, Dremsizov TT, Young TL. Physician staffing patterns and clinical outcomes in critically ill patients: a systematic review. JAMA. 2002;288(17):2151–62.
[2] Wilcox ME, Chong CAKY, Niven DJ, Rubenfeld GD, Rowan KM, Wunsch H, et al. Do intensivist staffing patterns influence hospital mortality following ICU admission? A systematic review and meta-analyses. Crit Care Med. 2013;41(10):2253–74.
[3] Kleinpell RM, Ward NS, Kelso LA, Micek ST, Wessman BT, Williams MD. Provider to patient ratios for nurse practitioners and physician assistants in critical care units. Am J Crit Care. 2018;27(3):250–5.
[4] Young LB, Chan PS, Lu X, Nallamothu BK, Sasson C, Cram PM. Impact of telemedicine intensive care unit coverage on patient outcomes: a systematic review and meta-analysis. Arch Intern Med. 2011;171(6):498–506.
