title: The Association Between Daytime Intensivist Physician Staffing and Mortality in the Context of Other ICU Organizational Practices: A Multicenter Cohort Study.
abstract: OBJECTIVE
  Daytime intensivist physician staffing is associated with improved outcomes in the ICU. However, it is unclear whether this association persists in the era of interprofessional, protocol-directed critical care. We sought to reexamine the association between daytime intensivist physician staffing and ICU mortality and determine if interprofessional rounding and protocols for mechanical ventilation in part mediate this relationship.
  
  
  METHODS
  Retrospective cohort study of ICUs in the Acute Physiology and Chronic Health Evaluation clinical information system from 2009 to 2010.
  
  
  METHODS
  Forty-nine ICUs in 25 U.S. hospitals.
  
  
  METHODS
  Adults (17 yr and older) admitted to a study ICU.
  
  
  METHODS
  None.
  
  
  RESULTS
  We defined high-intensity daytime intensivist staffing as either a mandatory consult or closed ICU model; interprofessional rounds as rounds that included a respiratory therapist, pharmacist, physician and nurse; and protocol use as having protocols for liberation from mechanical ventilation and lung protective mechanical ventilation. Using multivariable logistic regression, we estimated the independent effect of daytime intensivist physician staffing on in-hospital mortality controlling for interprofessional rounds and protocols for mechanical ventilation, as well as other patient and hospital characteristics. Twenty-seven ICUs (55%) reported high-intensity daytime physician staffing, 42 ICUs (85%) reported daily interprofessional rounds, and 31 (63%) reported having protocols for mechanical ventilation. There was no association between daytime intensivist physician staffing and in-hospital mortality (adjusted odds ratio, 0.86; 95% CI, 0.65-1.14). After adjusting for interprofessional rounds and protocols for mechanical ventilation, the effect of daytime intensivist physician staffing remained nonsignificant (adjusted odds ratio, 0.90; 95% CI, 0.70-1.17).
  
  
  CONCLUSIONS
  High-intensity daytime physician staffing in the ICU was not significantly associated with lower mortality in a modern cohort. This association was not affected by interprofessional rounds or protocols for mechanical ventilation.
authors: 1Department of Systems, Populations and Leadership, University of Michigan School of Nursing, Ann Arbor, MI. 2Clinical Research Investigation and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA. 3Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA. 4Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA.
authors: Deena Kelly
authors: DK
authors: Costa
authors: David J
authors: DJ
authors: Wallace
authors: Jeremy M
authors: JM
authors: Kahn
mesh_terms: D018806:APACHE; D000328:Adult; D000368:Aged; D015331:Cohort Studies; D016001:Confidence Intervals; D003422:Critical Care / Q000458:organization & administration; D016638:Critical Illness / Q000401:mortality* / Q000628:therapy; D005260:Female; D015600:Glasgow Coma Scale; D017052:Hospital Mortality / Q000639:trends*; D006801:Humans; D007362:Intensive Care Units / Q000458:organization & administration; D008297:Male; D008875:Middle Aged; D016017:Odds Ratio; D009936:Organizational Innovation; D017063:Outcome Assessment, Health Care; D010561:Personnel Staffing and Scheduling / Q000458:organization & administration*; D012189:Retrospective Studies; D018570:Risk Assessment; D013997:Time Factors; D014481:United States; D000078329:Workforce; D055815:Young Adult