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1 The 24/7 ICU H AYLEY B. G ERSHENGORN, MD FCCM U NIVERSITY OF M IAMI M ILLER S CHOOL OF M EDICINE (FLORIDA, USA) A LBERT E INSTEIN COLLEGE OF M EDICINE (N EW YORK, U SA)
2 Disclosure Slide I have no conflicts of interest to declare.
3 What is a 24/7 ICU? An ICU that functions the SAME regardless of time of day/week. Potential Time Periods 1. Daytime vs Overnight ICU staffing Access to other services 2. Weekends vs Weekdays ICU staffing Access to other services 3. Rounds vs non-rounding times New admissions 4. Visiting vs Non-Visiting Hours Family Presence
4 Why Move to a 24/7 ICU? Improve Patient Outcomes Improve Patient/Family Experience Improve Clinician Experience Timeliness of critical care interventions matters Delayed arrival to ICU affects outcomes Non-ICU commitments limit ability to visit at set times Having families present may help with delirium prevention/treatment Burnout is common in ICU providers Alterations in scheduling may help balance work and non-work time
5 What we know about 24/7 ICUs Patient Outcomes Patient/Family Experience Clinician Experience
6 PATIENT OUTCOMES Timing of ICU Admission Matters Weekends Cavallazzi et al, 2010 (meta-analysis) Laupland et al, 2011 (mulltiple centers, France) Abella et al, 2014* (single center, Spain) Zajic P et al, 2017** (multicenter, Austria) Overnight Cavallazzi et al, 2010 (meta-analysis) Laupland et al, 2011 (mulltiple centers, France) Ju et al, 2013 (single center, China) Brunot et al, 2016*** (single (single center, center, France) France) Rounds Afessa et al, 2009 (single center, US) de Souza et al, 2012 (mutiple centers, Canada) 180,600 7, , ,220 7,380 2,891 2,428 49,844 18,857 Hospital Mortality (OR, 95% CI) favors "off-hours" favors control Bad OK??? * Holidays (not weekends) considered ** Saturday compared with Wednesday *** Weekend/weekday overnights considered together
7 Hospitals PATIENT OUTCOMES Maybe ICU Staffing is (Partly) to Blame? Physical Therapists Canada: 69% of community hospitals 97% of tertiary care hospitals 23.3 FTEs M-F vs 2.9 S/S Doctors 8% Onsite in U.S. ICUs 5% another physician attending 22% 5% 7% 15% 3% 7%? Respiratory therapists? Clinical Pharmacists? Other Allied Health Providers day night day night weekday weekend Ottensmeyer CA et al, Physiother Can, Campbell L et al, Physiother Can, Angus DC et al, CCM, 2006.
8 PATIENT OUTCOMES Does More Staffing on Off-hours Help? Onsite Overnight Intensivist Telemedicine Coverage Kerlin MP et al, AJRCCM, Chen J et al, JICM, 2017.
9 PATIENT OUTCOMES Maybe Up-Staffing Expedites ICU Care? no D in ICU LOS overnight extubation ICU LOS Kerlin MP et al, AJRCCM, Chen J et al, JICM, Gershengorn HB et al, JAMA-IM, 2016.
10 PATIENT OUTCOMES Does Expediting Care Help Patients? Hospital Mortality seen with: 1. Overnight ICU discharge 2. Overnight extubation Overnight extubation Overnight discharge ICU LOS ICU occupancy mortality admission delays Yang S et al, Crit Care Gershengorn HB et al, JAMA-IM 2016.
11 What we know about 24/7 ICUs Patient Outcomes Patient/Family Experience Clinician Experience
12 PATIENT/FAMILY EXPERIENCE Negative Patient & Family Experiences Short-term Pain Agitation/delirium Long-term Anxiety (32-40%) Depression (29-34%) PTSD (25-44%) Confusion Miscommunication Helplessness Anxiety (15-24%) Depression (5-36%) PTSD (35-57%) Nikayin S et al, Gen Hosp Psych, Rabiee A et al, CCM, Parker AM et al, CCM, van Beusekon I et al, CC, 2016.
13 PATIENT/FAMILY EXPERIENCE Non-Impact of 24-hr Intensivist Staffing 32 week crossover study in 2 ICUs Pre-/post-study in 1 ICU Garland A et al, AJRCCM, Gajic O et al, CM, 2008.
14 PATIENT/FAMILY EXPERIENCE Impact of Unrestricted (24h) Visiting Hours 1 mixed population ICU Family Satisfaction (n=41 pre-, 140 post-) satisfaction with amount of care satisfaction with waiting room no D in other measures to 8pm Patients Satisfaction (n=12) 100% said flexible visiting hrs are a good idea no patients wanted fewer visits (2 wanted more) Mitchell ML & Aitken LM, Aust Crit Care, 2017.
15 What we know about 24/7 ICUs Patient Outcomes Patient/Family Experience Clinician Experience
16 CLINICIAN EXPERIENCE ICU Clinicians Experience Burnout 25-33% severe burnout 86% have 1 of 3 symptoms 45% severe burnout 71% in 1 PICU 56% severe burnout Moss M et al, AJRCCM, Bhatt M et al, CCM, Embriaco N et al, AJRCCM, 2007.
17 CLINICIAN EXPERIENCE Up-Staffing Impacts Physician Well-Being Having additional weekend coverage (no overnight coverage) burnout work-life balance job distress Having overnight coverage burnout work-life balance role overload Ali NA et al, AJRCCM, Garland A et al, AJRCCM, 2012.
18 CLINICIAN EXPERIENCE Up-Staffing Impacts Nurse Well-Being Bedside Nurses (n=13) Reporting Positive Impact of Nighttime Intensivist 85% 85% 69% 77% 100% 92% 100% Garland A et al, AJRCCM, Stanton ES et al, AJCC, 2017.
19 Summary The 24/7 ICU: 1. Has not been shown to impact patient outcomes Maybe for some patient subgroups? 2. Improves patient/family satisfaction Open visiting hours 3. Improves physician satisfaction;? impact on nursing
20 Barriers to Enacting the 24/7 ICU Data supporting benefit to patient outcomes is lacking Many practices/outcomes not yet studied Studying changes consistent with a 24/7 model is challenging Non-RCT based trial designs Resources are limited Change-avoidance behavior Financially prohibitive to hire additional staff Is this the right use of $? Demand for ICU clinicians outpaces supply Hesitance to round with families present Concerns about intervening on off-hours when hospital less well staffed
21 Should We Embrace the 24/7 ICU? In an ideal world (unlimited resources), yes. Our priority is patient outcomes Need study up-staffing off-hours in select patient subgroups Need use caution expanding daytime practices to overnight For now, $ should be spent on practices known to positively impact patient outcomes Should embrace non-costly changes Unrestricted visiting hours Changes in schedules which improve satisfaction without requiring additional staff
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