title: Association of Intensive Care Unit Patient-to-Intensivist Ratios With Hospital Mortality.
abstract: The patient-to-intensivist ratio (PIR) across intensive care units (ICUs) is not standardized and the association of PIR with patient outcome is not well established. Understanding the impact of PIR on outcomes is necessary to optimize senior medical staffing and deliver high-quality care.
  
  
  
  To test the hypotheses that: (1) there is significant variation in the PIR across ICUs and (2) higher PIRs are associated with higher hospital mortality for ICU patients.
  
  
  
  Retrospective cohort analysis of patients (≥16 years) admitted to ICUs staffed by a single intensivist during daytime hours in the United Kingdom from 2010 to 2013.
  
  
  
  Patient-to-intensivist ratios, which we defined for each patient as the number of patients cared for by the intensivist each day averaged over the patient's stay.
  
  
  
  Using standard summary statistics, we evaluated PIR variation across ICUs. We used multivariable, mixed-effect, logistic regression analysis to evaluate the association between PIR and hospital mortality at ultimate discharge from acute hospital (primary outcome) and at ICU discharge.
  
  
  
  Among 49 686 adults in 94 ICUs, median age was 66 (interquartile range [IQR], 52-76) years, and 45.1% were women. The ultimate hospital mortality was 25.7%. The median PIR for patients was 8.5 (IQR, 6.9-10.8; full range, 1.0-23.5), and varied substantially among individual ICUs. The association between PIR and ultimate hospital mortality was U-shaped; there was a reduction in the odds of mortality associated with an increasing PIR up to 7.5 after which the odds of mortality increased again significantly (average patient mortality for lowest PIR, 22%; PIR of 7.5, 15%; highest PIR, 19%; P = .003). A similar U-shaped association was seen for PIR and mortality in the ICU (nadir of mortality at a PIR of 7.8, P < .001).
  
  
  
  PIR varied across UK ICUs. The optimal PIR in this cohort of UK ICU patients was 7.5, with significantly increased ICU and hospital mortality above and below this ratio. The number of patients cared for by 1 intensivist may impact patient outcomes.
authors.affiliation: Division of Critical Care Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York.
authors.forename: Hayley B
authors.initials: HB
authors.lastname: Gershengorn
authors.affiliation: Intensive Care National Audit & Research Centre, Napier House, London, United Kingdom.
authors.forename: David A
authors.initials: DA
authors.lastname: Harrison
authors.affiliation: Departments of Medicine and Community Health Sciences, University of Manitoba, Winnipeg, Canada.
authors.forename: Allan
authors.initials: A
authors.lastname: Garland
authors.affiliation: Interdepartmental Division of Critical Care Medicine, University of Toronto, University Health Network, Toronto, Ontario, Canada.
authors.forename: M Elizabeth
authors.initials: ME
authors.lastname: Wilcox
authors.affiliation: Intensive Care National Audit & Research Centre, Napier House, London, United Kingdom.
authors.forename: Kathryn M
authors.initials: KM
authors.lastname: Rowan
authors.affiliation: Interdepartmental Division of Critical Care Medicine, University of Toronto, Sunnybrook Health Sciences Center, Toronto, Ontario, Canada6Department of Anesthesiology, College of Physicians and Surgeons, Columbia University, New York, New York7Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York.
authors.forename: Hannah
authors.initials: H
authors.lastname: Wunsch
mesh_terms: D000368:Aged; D003422:Critical Care / Q000379:methods / Q000458:organization & administration / Q000706:statistics & numerical data; D016638:Critical Illness / Q000401:mortality / Q000628:therapy; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D007362:Intensive Care Units / Q000458:organization & administration / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D010043:Outcome and Process Assessment, Health Care; D010559:Personnel Management / Q000592:standards*; D010561:Personnel Staffing and Scheduling / Q000592:standards*; D011787:Quality of Health Care; D012189:Retrospective Studies; D006113:United Kingdom / Q000453:epidemiology