The Experts below are selected from a list of 2025 Experts worldwide ranked by ideXlab platform
Jeremy M Kahn - One of the best experts on this subject based on the ideXlab platform.
-
icu staffing feature phenotypes and their relationship with patients outcomes an unsupervised machine learning analysis
Intensive Care Medicine, 2019Co-Authors: Fernando G Zampieri, Jeremy M Kahn, Jorge I F Salluh, Luciano Cesar Pontes Azevedo, Lucas Petri Damiani, Lunna Perdigao Borges, William N Viana, Roberto Germano Costa, Thiago Domingos Correa, Dieter E S ArayaAbstract:To study whether ICU staffing features are associated with improved hospital mortality, ICU length of stay (LOS) and duration of mechanical ventilation (MV) using cluster analysis directed by machine learning. The following variables were included in the analysis: average bed to nurse, physiotherapist and physician ratios, presence of 24/7 board-certified Intensivists and dedicated pharmacists in the ICU, and nurse and physiotherapist autonomy scores. Clusters were defined using the partition around medoids method. We assessed the association between clusters and hospital mortality using logistic regression and with ICU LOS and MV duration using competing risk regression. Analysis included data from 129,680 patients admitted to 93 ICUs (2014–2015). Three clusters were identified. The features distinguishing between the clusters were: the presence of board-certified Intensivists in the ICU 24/7 (present in Cluster 3), dedicated pharmacists (present in Clusters 2 and 3) and the extent of nurse autonomy (which increased from Clusters 1 to 3). The patients in Cluster 3 exhibited the best outcomes, with lower adjusted hospital mortality [odds ratio 0.92 (95% confidence interval (CI), 0.87–0.98)], shorter ICU LOS [subhazard ratio (SHR) for patients surviving to ICU discharge 1.24 (95% CI 1.22–1.26)] and shorter durations of MV [SHR for undergoing extubation 1.61(95% CI 1.54–1.69)]. Cluster 1 had the worst outcomes. Patients treated in ICUs combining 24/7 expert Intensivist coverage, a dedicated pharmacist and nurses with greater autonomy had the best outcomes. All of these features represent achievable targets that should be considered by policy makers with an interest in promoting equal and optimal ICU care.
-
an official american thoracic society systematic review the effect of nighttime Intensivist staffing on mortality and length of stay among intensive care unit patients
American Journal of Respiratory and Critical Care Medicine, 2017Co-Authors: Meeta Prasad Kerlin, Jeremy M Kahn, Scott D Halpern, Elizabeth M Wilcox, Deena Kelly Costa, Neill K J Adhikari, Louise Rose, Cassandra J Bellamy, Hayley B Gershengorn, Meghan B LanefallAbstract:Background: Studies of nighttime Intensivist staffing have yielded mixed results.Goals: To review the association of nighttime Intensivist staffing with outcomes of intensive care unit (ICU) patients.Methods: We searched five databases (2000–2016) for studies comparing in-hospital nighttime Intensivist staffing with other nighttime staffing models in adult ICUs and reporting mortality or length of stay. We abstracted data on staffing models, outcomes, and study characteristics and assessed study quality, using standardized tools. Meta-analyses used random effects models.Results: Eighteen studies met inclusion criteria: one randomized controlled trial and 17 observational studies. Overall methodologic quality was high. Studies included academic hospitals (n = 10), community hospitals (n = 2), or both (n = 6). Baseline clinician staffing included residents (n = 9), fellows (n = 4), and nurse practitioners or physician assistants (n = 2). Studies included both general and specialty ICUs and were geographical...
-
the association between daytime Intensivist physician staffing and mortality in the context of other icu organizational practices a multicenter cohort study
Critical Care Medicine, 2015Co-Authors: Deena Kelly Costa, David J Wallace, Jeremy M KahnAbstract:Objective Daytime Intensivist physician staffing is associated with improved outcomes in the intensive care unit (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.
-
the myth of the workforce crisis why the united states does not need more Intensivist physicians
American Journal of Respiratory and Critical Care Medicine, 2015Co-Authors: Jeremy M Kahn, Gordon D RubenfeldAbstract:Intensivist physician staffing is associated with lower mortality in the intensive care unit (ICU), yet many ICUs are not staffed by trained Intensivists. This gap has led to a number of proposals intended to increase the Intensivist supply in the United States. In this perspective we argue that such efforts would be both ineffective and ill-advised. Because many ICU patients are not critically ill, workforce models that base demand projections on ICU admission rather than true critical illness substantially overstate the workforce gap. Even in the presence of a workforce gap, training new Intensivists would not place them in hospitals where they are needed most, would not mitigate the shortage of nonphysician critical care providers, and would require a unrealistic increase in spending on physician training. In addition, efforts to train more Intensivists require us to prioritize intensive care over other specialties that are also in short supply, without clear justification for why Intensivists are more important. Rather than continuing an unwarranted push to increase the Intensivist supply, we suggest alternative workforce policies that emphasize novel interprofessional care models (to improve ICU quality in the absence of Intensivists) combined with limitations on the future growth of ICU beds (to reduce demand through implicit rationing of care). These policies offer opportunities to reduce the mismatch between critical care supply and demand without an unnecessary expansion of the Intensivist supply.
-
nighttime Intensivist staffing and the timing of death among icu decedents a retrospective cohort study
Critical Care, 2013Co-Authors: Lora A Reineck, Amber E Barnato, David J Wallace, Jeremy M KahnAbstract:Intensive care units (ICUs) are increasingly adopting 24-hour Intensivist physician staffing. Although nighttime Intensivist staffing does not consistently reduce mortality, it may affect other outcomes such as the quality of end-of-life care. We conducted a retrospective cohort study of ICU decedents using the 2009–2010 Acute Physiology and Chronic Health Evaluation clinical information system linked to a survey of ICU staffing practices. We restricted the analysis to ICUs with high-intensity daytime staffing, in which the addition of nighttime staffing does not influence mortality. We used multivariable regression to assess the relationship between nighttime Intensivist staffing and two separate outcomes potentially related to the quality of end-of-life care: time from ICU admission to death and death at night. Of 30,456 patients admitted to 27 high-intensity daytime staffed ICUs, 3,553 died in the hospital within 30 days. After adjustment for potential confounders, admission to an ICU with nighttime Intensivist staffing was associated with a shorter duration between ICU admission and death (adjusted difference: –2.5 days, 95% CI -3.5 to -1.5, p-value < 0.001) and a decreased odds of nighttime death (adjusted odds ratio: 0.75, 95% CI 0.60 to 0.94, p-value 0.011) compared to admission to an ICU without nighttime Intensivist staffing. Among ICU decedents, nighttime Intensivist staffing is associated with reduced time between ICU admission and death and reduced odds of nighttime death.
Scott D Halpern - One of the best experts on this subject based on the ideXlab platform.
-
sleep and work in icu physicians during a randomized trial of nighttime Intensivist staffing
Critical Care Medicine, 2019Co-Authors: Rita N Bakhru, Scott D Halpern, Meeta Prasad Kerlin, Mathias Basner, John Hansenflaschen, Ilene M Rosen, David F Dinges, William D SchweickertAbstract:OBJECTIVES To compare sleep, work hours, and behavioral alertness in faculty and fellows during a randomized trial of nighttime in-hospital Intensivist staffing compared with a standard daytime Intensivist model. DESIGN Prospective observational study. SETTING Medical ICU of a tertiary care academic medical center during a randomized controlled trial of in-hospital nighttime Intensivist staffing. PATIENTS Twenty faculty and 13 fellows assigned to rotations in the medical ICU during 2012. INTERVENTIONS As part of the parent study, there was weekly randomization of staffing model, stratified by 2-week faculty rotation. During the standard staffing model, there were in-hospital residents, with a fellow and faculty member available at nighttime by phone. In the intervention, there were in-hospital residents with an in-hospital nighttime Intensivist. Fellows and faculty completed diaries detailing their sleep, work, and well-being; wore actigraphs; and performed psychomotor vigilance testing daily. MEASUREMENTS AND MAIN RESULTS Daily sleep time (mean hours [SD]) was increased for fellows and faculty in the intervention versus control (6.7 [0.3] vs 6.0 [0.2]; p < 0.001 and 6.7 [0.1] vs 6.4 [0.2]; p < 0.001, respectively). In-hospital work duration did not differ between the models for fellows or faculty. Total hours of work done at home was different for both fellows and faculty (0.1 [< 0.1] intervention vs 1.0 [0.1] control; p < 0.001 and 0.2 [< 0.1] intervention vs 0.6 [0.1] control; p < 0.001, respectively). Psychomotor vigilance testing did not demonstrate any differences. Measures of well-being including physical exhaustion and alertness were improved in faculty and fellows in the intervention staffing model. CONCLUSIONS Although no differences were measured in patient outcomes between the two staffing models, in-hospital nighttime Intensivist staffing was associated with small increases in total sleep duration for faculty and fellows, reductions in total work hours for fellows only, and improvements in subjective well-being for both groups. Staffing models should consider how work duration, sleep, and well-being may impact burnout and sustainability.
-
What’s behind the white coat: Potential mechanisms of physician-attributable variation in critical care
2019Co-Authors: Kuldeep N. Yadav, Nicole B Gabler, Scott D Halpern, Michael Josephs, Michael E. Detsky, Joanna L. HartAbstract:BackgroundCritical care intensity is known to vary across regions and centers, yet the mechanisms remain unidentified. Physician behaviors have been implicated in the variability of intensive care near the end of life, but physician characteristics that may underlie this association have not been determined.PurposeWe sought to identify behavioral attributes that vary among Intensivists to generate hypotheses for mechanisms of Intensivist-attributable variation in critical care delivery.MethodsWe administered a questionnaire to Intensivists who participated in a prior cohort study in which Intensivists made prognostic estimates. We evaluated the degree to which scores on six attribute measures varied across Intensivists. Measures were selected for their relevance to preference-sensitive critical care: a modified End-of-Life Preferences (EOLP) scale, Life Orientation Test–Revised (LOT-R), Jefferson Scale of Empathy (JSE), Physicians' Reactions to Uncertainty (PRU) scale, Collett-Lester Fear of Death (CLFOD) scale, and a test of omission bias. We conducted regression analyses assessing relationships between Intensivists’ attribute scores and their prognostic accuracy, as physicians’ prognostic accuracy may influence preference-sensitive decisions.Results20 of 25 eligible Intensivists (80%) completed the questionnaire. Intensivists’ scores on the EOLP, LOT-R, PRU, CLFOD, and omission bias measures varied considerably, while their responses on the JSE scale did not. There were no consistent associations between attribute scores and prognostic accuracy.ConclusionsIntensivists vary in feasibly measurable attributes relevant to preference-sensitive critical care delivery. These attributes represent candidates for future research aimed at identifying mechanisms of clinician-attributable variation in critical care and developing effective interventions to reduce undue variation.
-
an official american thoracic society systematic review the effect of nighttime Intensivist staffing on mortality and length of stay among intensive care unit patients
American Journal of Respiratory and Critical Care Medicine, 2017Co-Authors: Meeta Prasad Kerlin, Jeremy M Kahn, Scott D Halpern, Elizabeth M Wilcox, Deena Kelly Costa, Neill K J Adhikari, Louise Rose, Cassandra J Bellamy, Hayley B Gershengorn, Meghan B LanefallAbstract:Background: Studies of nighttime Intensivist staffing have yielded mixed results.Goals: To review the association of nighttime Intensivist staffing with outcomes of intensive care unit (ICU) patients.Methods: We searched five databases (2000–2016) for studies comparing in-hospital nighttime Intensivist staffing with other nighttime staffing models in adult ICUs and reporting mortality or length of stay. We abstracted data on staffing models, outcomes, and study characteristics and assessed study quality, using standardized tools. Meta-analyses used random effects models.Results: Eighteen studies met inclusion criteria: one randomized controlled trial and 17 observational studies. Overall methodologic quality was high. Studies included academic hospitals (n = 10), community hospitals (n = 2), or both (n = 6). Baseline clinician staffing included residents (n = 9), fellows (n = 4), and nurse practitioners or physician assistants (n = 2). Studies included both general and specialty ICUs and were geographical...
-
an observational study of decision making by medical Intensivists
Critical Care Medicine, 2015Co-Authors: Mary S Mckenzie, Catherine L Auriemma, Jennifer M Olenik, Elizabeth Cooney, Nicole B Gabler, Scott D HalpernAbstract:Objectives:The ICU is a place of frequent, high-stakes decision making. However, the number and types of decisions made by Intensivists have not been well characterized. We sought to describe Intensivist decision making and determine how the number and types of decisions are affected by patient, pro
-
twenty four hour Intensivist staffing in teaching hospitals tensions between safety today and safety tomorrow
Chest, 2012Co-Authors: Meeta Prasad Kerlin, Scott D HalpernAbstract:There is an inherent tension between the training needs of inexperienced clinicians and the safety of the patients for whom they are responsible. Our society has accepted this tension as a necessary trade-off to maintain a competent workforce of physicians year after year. However, recent trends in medical education have diminished resident autonomy in favor of the safety of current patients. One dramatic example is the rapid increase in the number of academic ICUs that provide coverage by attending physicians at all hours. The potential benefits of this staffing model have strong face validity: improved quality and efficiency from the constant involvement of experienced Intensivists, increased family and staff satisfaction from the immediate availability of attending physicians, and reduced burn-out among Intensivists from reduced on-call responsibilities. Thus, many hospitals have moved toward 24-h coverage by attending Intensivist physicians without evidence that these benefits actually accrue and perhaps without full consideration of possible unintended consequences. In this article, we discuss the potential benefits and risks of nocturnal Intensivist staffing, considering the needs of current and future patients. Furthermore, we suggest that there remains sufficient uncertainty about these benefits and risks that it is both necessary and ethical to study the effects in earnest.
Meeta Prasad Kerlin - One of the best experts on this subject based on the ideXlab platform.
-
sleep and work in icu physicians during a randomized trial of nighttime Intensivist staffing
Critical Care Medicine, 2019Co-Authors: Rita N Bakhru, Scott D Halpern, Meeta Prasad Kerlin, Mathias Basner, John Hansenflaschen, Ilene M Rosen, David F Dinges, William D SchweickertAbstract:OBJECTIVES To compare sleep, work hours, and behavioral alertness in faculty and fellows during a randomized trial of nighttime in-hospital Intensivist staffing compared with a standard daytime Intensivist model. DESIGN Prospective observational study. SETTING Medical ICU of a tertiary care academic medical center during a randomized controlled trial of in-hospital nighttime Intensivist staffing. PATIENTS Twenty faculty and 13 fellows assigned to rotations in the medical ICU during 2012. INTERVENTIONS As part of the parent study, there was weekly randomization of staffing model, stratified by 2-week faculty rotation. During the standard staffing model, there were in-hospital residents, with a fellow and faculty member available at nighttime by phone. In the intervention, there were in-hospital residents with an in-hospital nighttime Intensivist. Fellows and faculty completed diaries detailing their sleep, work, and well-being; wore actigraphs; and performed psychomotor vigilance testing daily. MEASUREMENTS AND MAIN RESULTS Daily sleep time (mean hours [SD]) was increased for fellows and faculty in the intervention versus control (6.7 [0.3] vs 6.0 [0.2]; p < 0.001 and 6.7 [0.1] vs 6.4 [0.2]; p < 0.001, respectively). In-hospital work duration did not differ between the models for fellows or faculty. Total hours of work done at home was different for both fellows and faculty (0.1 [< 0.1] intervention vs 1.0 [0.1] control; p < 0.001 and 0.2 [< 0.1] intervention vs 0.6 [0.1] control; p < 0.001, respectively). Psychomotor vigilance testing did not demonstrate any differences. Measures of well-being including physical exhaustion and alertness were improved in faculty and fellows in the intervention staffing model. CONCLUSIONS Although no differences were measured in patient outcomes between the two staffing models, in-hospital nighttime Intensivist staffing was associated with small increases in total sleep duration for faculty and fellows, reductions in total work hours for fellows only, and improvements in subjective well-being for both groups. Staffing models should consider how work duration, sleep, and well-being may impact burnout and sustainability.
-
an official american thoracic society systematic review the effect of nighttime Intensivist staffing on mortality and length of stay among intensive care unit patients
American Journal of Respiratory and Critical Care Medicine, 2017Co-Authors: Meeta Prasad Kerlin, Jeremy M Kahn, Scott D Halpern, Elizabeth M Wilcox, Deena Kelly Costa, Neill K J Adhikari, Louise Rose, Cassandra J Bellamy, Hayley B Gershengorn, Meghan B LanefallAbstract:Background: Studies of nighttime Intensivist staffing have yielded mixed results.Goals: To review the association of nighttime Intensivist staffing with outcomes of intensive care unit (ICU) patients.Methods: We searched five databases (2000–2016) for studies comparing in-hospital nighttime Intensivist staffing with other nighttime staffing models in adult ICUs and reporting mortality or length of stay. We abstracted data on staffing models, outcomes, and study characteristics and assessed study quality, using standardized tools. Meta-analyses used random effects models.Results: Eighteen studies met inclusion criteria: one randomized controlled trial and 17 observational studies. Overall methodologic quality was high. Studies included academic hospitals (n = 10), community hospitals (n = 2), or both (n = 6). Baseline clinician staffing included residents (n = 9), fellows (n = 4), and nurse practitioners or physician assistants (n = 2). Studies included both general and specialty ICUs and were geographical...
-
interrater reliability of surveillance for ventilator associated events and pneumonia
Infection Control and Hospital Epidemiology, 2017Co-Authors: Meeta Prasad Kerlin, William E Trick, Deverick J Anderson, Hilary M Babcock, Ebbing Lautenbach, Renaud Gueret, Michael KlompasAbstract:OBJECTIVE To compare interrater reliabilities for ventilator-associated event (VAE) surveillance, traditional ventilator-associated pneumonia (VAP) surveillance, and clinical diagnosis of VAP by Intensivists. DESIGN A retrospective study nested within a prospective multicenter quality improvement study. SETTING Intensive care units (ICUs) within 5 hospitals of the Centers for Disease Control and Prevention Epicenters. PATIENTS Patients who underwent mechanical ventilation. METHODS We selected 150 charts for review, including all VAEs and traditionally defined VAPs identified during the primary study and randomly selected charts of patients without VAEs or VAPs. Each chart was independently reviewed by 2 research assistants (RAs) for VAEs, 2 hospital infection preventionists (IPs) for traditionally defined VAP, and 2 Intensivists for any episodes of pulmonary deterioration. We calculated interrater agreement using κ estimates. RESULTS The 150 selected episodes spanned 2,500 ventilator days. In total, 93–96 VAEs were identified by RAs; 31–49 VAPs were identified by IPs, and 29–35 VAPs were diagnosed by Intensivists. Interrater reliability between RAs for VAEs was high (κ, 0.71; 95% CI, 0.59–0.81). Agreement between IPs using traditional VAP criteria was slight (κ, 0.12; 95% CI, −0.05–0.29). Agreement between Intensivists was slight regarding episodes of pulmonary deterioration (κ 0.22; 95% CI, 0.05–0.39) and was fair regarding whether episodes of deterioration were attributable to clinically defined VAP (κ, 0.34; 95% CI, 0.17–0.51). The clinical correlation between VAE surveillance and Intensivists’ clinical assessments was poor. CONCLUSIONS Prospective surveillance using VAE criteria is more reliable than traditional VAP surveillance and clinical VAP diagnosis; the correlation between VAEs and clinically recognized pulmonary deterioration is poor. Infect Control Hosp Epidemiol 2017;38:172–178
-
a randomized trial of nighttime physician staffing in an intensive care unit
Survey of Anesthesiology, 2014Co-Authors: Meeta Prasad Kerlin, Elizabeth Cooney, Nicole B Gabler, Dylan S Small, Barry D Fuchs, Lisa M Bellini, Mark E Mikkelsen, William D Schweickert, Rita N Bakhru, Michael O HarhayAbstract:Methods We conducted a 1-year randomized trial in an academic medical ICU of the effects of nighttime staffing with in-hospital Intensivists (intervention) as compared with nighttime coverage by daytime Intensivists who were available for consultation by telephone (control). We randomly assigned blocks of 7 consecutive nights to the intervention or the control strategy. The primary outcome was patients’ length of stay in the ICU. Secondary outcomes were patients’ length of stay in the hospital, ICU and in-hospital mortality, discharge disposition, and rates of readmission to the ICU. For length-of-stay outcomes, we performed time-to-event analyses, with data censored at the time of a patient’s death or transfer to another ICU. Results A total of 1598 patients were included in the analyses. The median Acute Physiology and Chronic Health Evaluation (APACHE) III score (in which scores range from 0 to 299, with higher scores indicating more severe illness) was 67 (interquartile range, 47 to 91), the median length of stay in the ICU was 52.7 hours (interquartile range, 29.0 to 113.4), and mortality in the ICU was 18%. Patients who were admitted on intervention days were exposed to nighttime Intensivists on more nights than were patients admitted on control days (median, 100% of nights [interquartile range, 67 to 100] vs. median, 0% [interquartile range, 0 to 33]; P<0.001). Nonetheless, Intensivist staffing on the night of admission did not have a significant effect on the length of stay in the ICU (rate ratio for the time to ICU discharge, 0.98; 95% confidence interval [CI], 0.88 to 1.09; P = 0.72), ICU mortality (relative risk, 1.07; 95% CI, 0.90 to 1.28), or any other end point. Analyses restricted to patients who were admitted at night showed similar results, as did sensitivity analyses that used different definitions of exposure and outcome. Conclusions In an academic medical ICU in the United States, nighttime in-hospital Intensivist staffing did not improve patient outcomes. (Funded by University of Pennsylvania Health System and others; ClinicalTrials.gov number, NCT01434823.)
-
twenty four hour Intensivist staffing in teaching hospitals tensions between safety today and safety tomorrow
Chest, 2012Co-Authors: Meeta Prasad Kerlin, Scott D HalpernAbstract:There is an inherent tension between the training needs of inexperienced clinicians and the safety of the patients for whom they are responsible. Our society has accepted this tension as a necessary trade-off to maintain a competent workforce of physicians year after year. However, recent trends in medical education have diminished resident autonomy in favor of the safety of current patients. One dramatic example is the rapid increase in the number of academic ICUs that provide coverage by attending physicians at all hours. The potential benefits of this staffing model have strong face validity: improved quality and efficiency from the constant involvement of experienced Intensivists, increased family and staff satisfaction from the immediate availability of attending physicians, and reduced burn-out among Intensivists from reduced on-call responsibilities. Thus, many hospitals have moved toward 24-h coverage by attending Intensivist physicians without evidence that these benefits actually accrue and perhaps without full consideration of possible unintended consequences. In this article, we discuss the potential benefits and risks of nocturnal Intensivist staffing, considering the needs of current and future patients. Furthermore, we suggest that there remains sufficient uncertainty about these benefits and risks that it is both necessary and ethical to study the effects in earnest.
Allan Garland - One of the best experts on this subject based on the ideXlab platform.
-
association of intensive care unit patient to Intensivist ratios with hospital mortality
JAMA Internal Medicine, 2017Co-Authors: Hayley B Gershengorn, Allan Garland, Elizabeth M Wilcox, David A Harrison, Kathryn M Rowan, Hannah WunschAbstract:Importance 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. Objective 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. Design, Setting, and Participants 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. Exposures 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. Main Outcomes and Measures 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. Finding 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 Conclusions and Relevance 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.
-
twenty four hour Intensivist presence a pilot study of effects on intensive care unit patients families doctors and nurses
American Journal of Respiratory and Critical Care Medicine, 2012Co-Authors: Allan Garland, Dan Roberts, Lesley GraffAbstract:Rationale: Around-the-clock Intensivist presence in intensive care units (ICUs) has been promoted as necessary to optimize outcomes. Little data have addressed how it affects the multiple stakeholders in such care.Objectives: To assess effects of around-the-clock Intensivist presence on Intensivists, patients, families, housestaff, and nurses.Methods: This 32-week, crossover pilot trial of two Intensivist staffing models, performed in two Canadian ICUs, alternated 8-week blocks of two staffing models: the standard model, where one Intensivist worked for 7 days, taking night call from home; and the shift work model, where one Intensivist worked 7 day shifts, while other Intensivists remained in the ICU at night.Measurements and Main Results: Surveys scaled from 0–100 points assessed outcomes for 24 Intensivists (primary outcome: burnout); 119 families (satisfaction); 74 nurses (satisfaction with collaboration and communications, role conflict); and 34 housestaff (autonomy, supervision, and learning opportu...
-
continuity of care in intensive care units a cluster randomized trial of Intensivist staffing
American Journal of Respiratory and Critical Care Medicine, 2011Co-Authors: Naeem A Ali, Jeffrey Hammersley, Stephen Hoffmann, James M Obrien, Gary Phillips, Mitchell C Rashkin, Edward Warren, Allan GarlandAbstract:Rationale: Little is known about the consequences of Intensivists’ work schedules, or Intensivist continuity of care.Objectives: To assess the impact of weekend respite for Intensivists, with consequent reduction in continuity of care, on them and their patients.Methods: In five medical intensive care units (ICUs) in four academic hospitals we performed a prospective, cluster-randomized, alternating trial of two Intensivist staffing schedules. Daily coverage by a single Intensivist in half-month rotations (continuous schedule) was compared with weekday coverage by a single Intensivist, with weekend cross-coverage by colleagues (interrupted schedule). We studied consecutive patients admitted to study units, and the Intensivists working in four of the participating units.Measurements and Main Results: The primary patient outcome was ICU length of stay (LOS); we also assessed hospital LOS and mortality rates. The primary Intensivist outcome was physician burnout. Analysis was by multivariable regression. A t...
Caleb G Alexander - One of the best experts on this subject based on the ideXlab platform.
-
surgeon reported conflict with Intensivists about postoperative goals of care
Archives of Surgery, 2013Co-Authors: Terrah Paul J Olson, Karen J Brasel, Andrew J Redmann, Caleb G Alexander, Margaret L SchwarzeAbstract:Results: The adjusted response rate was 55.6%. Fortythree percent of surgeons reported sometimes or always experiencing conflict about postoperative goals of care with Intensivists, and 43% reported conflict with nurses. Younger surgeons reported higher rates of conflict than older surgeons with both Intensivists (57% vs 32%; P=.001) and nurses (48% vs 33%; P=.001). Surgeons practicing in closed intensive care units reported more frequent conflict than those practicing in open intensive care units (60% vs 41%; P=.005). On multivariate analysis, the odds of reporting conflict with Intensivists were 2.5 times higher for surgeons with fewer years of experience compared with their older colleagues (odds ratio, 2.5; 95% CI, 1.6-3.8) and 70% higher for reporting conflict with nurses (odds ratio, 1.7; 95% CI, 1.12.6). The odds of reporting conflict with Intensivists about goals of postoperative care were 40% lower for surgeons who primarily managed their intensive care unit patients than for those who worked in a closed unit (odds ratio, 0.60; 95% CI, 0.40-0.96).
-
surgeon reported conflict with Intensivists about postoperative goals of care
JAMA Surgery, 2013Co-Authors: Terrah Paul J Olson, Karen J Brasel, Andrew J Redmann, Caleb G Alexander, Margaret L SchwarzeAbstract:Objective To examine surgeons' experiences of conflict with Intensivists and nurses about goals of care for their postoperative patients. Design Cross-sectional incentivized US mail-based survey. Setting Private and academic surgical practices. Participants A total of 2100 vascular, neurologic, and cardiothoracic surgeons. Main Outcome Measures Surgeon-reported rates of conflict with Intensivists and nurses about goals of care for patients with poor postsurgical outcomes. Results The adjusted response rate was 55.6%. Forty-three percent of surgeons reported sometimes or always experiencing conflict about postoperative goals of care with Intensivists, and 43% reported conflict with nurses. Younger surgeons reported higher rates of conflict than older surgeons with both Intensivists (57% vs 32%; P = .001) and nurses (48% vs 33%; P = .001). Surgeons practicing in closed intensive care units reported more frequent conflict than those practicing in open intensive care units (60% vs 41%; P = .005). On multivariate analysis, the odds of reporting conflict with Intensivists were 2.5 times higher for surgeons with fewer years of experience compared with their older colleagues (odds ratio, 2.5; 95% CI, 1.6-3.8) and 70% higher for reporting conflict with nurses (odds ratio, 1.7; 95% CI, 1.1-2.6). The odds of reporting conflict with Intensivists about goals of postoperative care were 40% lower for surgeons who primarily managed their intensive care unit patients than for those who worked in a closed unit (odds ratio, 0.60; 95% CI, 0.40-0.96). Conclusions Surgeons regularly experience conflict with critical care clinicians about goals of care for patients with poor postoperative outcomes. Higher rates of conflict are associated with less experience and working in a closed intensive care unit.