title: Nighttime intensivist staffing and mortality among critically ill patients.
abstract: BACKGROUND
  Hospitals are increasingly adopting 24-hour intensivist physician staffing as a strategy to improve intensive care unit (ICU) outcomes. However, the degree to which nighttime intensivists are associated with improvements in the quality of ICU care is unknown.
  
  
  METHODS
  We conducted a retrospective cohort study involving ICUs that participated in the Acute Physiology and Chronic Health Evaluation (APACHE) clinical information system from 2009 through 2010, linking a survey of ICU staffing practices with patient-level outcomes data from adult ICU admissions. Multivariate models were used to assess the relationship between nighttime intensivist staffing and in-hospital mortality among ICU patients, with adjustment for daytime intensivist staffing, severity of illness, and case mix. We conducted a confirmatory analysis in a second, population-based cohort of hospitals in Pennsylvania from which less detailed data were available.
  
  
  RESULTS
  The analysis with the use of the APACHE database included 65,752 patients admitted to 49 ICUs in 25 hospitals. In ICUs with low-intensity daytime staffing, nighttime intensivist staffing was associated with a reduction in risk-adjusted in-hospital mortality (adjusted odds ratio for death, 0.62; P=0.04). Among ICUs with high-intensity daytime staffing, nighttime intensivist staffing conferred no benefit with respect to risk-adjusted in-hospital mortality (odds ratio, 1.08; P=0.78). In the verification cohort, there was a similar relationship among daytime staffing, nighttime staffing, and in-hospital mortality. The interaction between nighttime staffing and daytime staffing was not significant (P=0.18), yet the direction of the findings were similar to those in the APACHE cohort.
  
  
  CONCLUSIONS
  The addition of nighttime intensivist staffing to a low-intensity daytime staffing model was associated with reduced mortality. However, a reduction in mortality was not seen in ICUs with high-intensity daytime staffing. (Funded by the National Heart, Lung, and Blood Institute.).
authors.affiliation: Department of Critical Care Medicine, Clinical Research, Investigation, and Systems of Modeling of Acute Illness Center, University of Pittsburgh School of Medicine, Pittsburgh, PA 15261, USA.
authors.forename: David J
authors.initials: DJ
authors.lastname: Wallace
authors.forename: Derek C
authors.initials: DC
authors.lastname: Angus
authors.forename: Amber E
authors.initials: AE
authors.lastname: Barnato
authors.forename: Andrew A
authors.initials: AA
authors.lastname: Kramer
authors.forename: Jeremy M
authors.initials: JM
authors.lastname: Kahn
mesh_terms: D018806:APACHE; D000328:Adult; D000368:Aged; D016638:Critical Illness / Q000401:mortality* / Q000628:therapy; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D007362:Intensive Care Units; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D010561:Personnel Staffing and Scheduling; D012189:Retrospective Studies; D012306:Risk; D016896:Treatment Outcome; D000078329:Workforce