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)
Disclosure Slide I have no conflicts of interest to declare.
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
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
What we know about 24/7 ICUs Patient Outcomes Patient/Family Experience Clinician Experience
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 7,380 504 167,425 135,220 7,380 2,891 2,428 49,844 18,857 Hospital Mortality (OR, 95% CI) 0.2 1 2 5 favors "off-hours" favors control Bad OK??? * Holidays (not weekends) considered ** Saturday compared with Wednesday *** Weekend/weekday overnights considered together
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, 2010. Campbell L et al, Physiother Can, 2012. Angus DC et al, CCM, 2006.
PATIENT OUTCOMES Does More Staffing on Off-hours Help? Onsite Overnight Intensivist Telemedicine Coverage Kerlin MP et al, AJRCCM, 2016. Chen J et al, JICM, 2017.
PATIENT OUTCOMES Maybe Up-Staffing Expedites ICU Care? no D in ICU LOS overnight extubation ICU LOS Kerlin MP et al, AJRCCM, 2016. Chen J et al, JICM, 2017. Gershengorn HB et al, JAMA-IM, 2016.
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 2016. Gershengorn HB et al, JAMA-IM 2016.
What we know about 24/7 ICUs Patient Outcomes Patient/Family Experience Clinician Experience
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, 2016. Rabiee A et al, CCM, 2016. Parker AM et al, CCM, 2015. van Beusekon I et al, CC, 2016.
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, 2012. Gajic O et al, CM, 2008.
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.
What we know about 24/7 ICUs Patient Outcomes Patient/Family Experience Clinician Experience
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, 2016. Bhatt M et al, CCM, 2017. Embriaco N et al, AJRCCM, 2007.
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, 2011. Garland A et al, AJRCCM, 2012.
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, 2012. Stanton ES et al, AJCC, 2017.
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
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
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