Not all ICUs need a specialist at night: study

Among hospital intensive care units (ICUs) with a daytime physician specially trained in critical care, adding a specialist to cover the night shift does not improve patients' survival, according to a new study.

Among hospitals with ICUs that don't have a dedicated critical care physician during the day, however, the presence of such a doctor at night was tied to a smaller likelihood that patients would die.

The results, published in the New England Journal of Medicine, counter an argument from some in the medical community that ICUs need round-the-clock intensivists - doctors who specialize in critical care.

"Our knee jerk reaction is to try to put intensivists in every ICU at all hours of the day, and that reaction is likely a misstep because it oversimplifies the issue," said Dr. Jeremy Kahn, senior author of the study and a professor at the University of Pittsburgh School of Medicine.

Most research has shown that having an intensivist in an ICU during the day improves the chances that patients will survive, said Kahn.

"There's been this movement to say, 'well, we need to be there at night too,'" said Dr. Allan Garland, a professor at the University of Manitoba in Winnipeg, Canada, who was not involved in the study. "But what there hasn't been is much data."

Data are important when it comes to staffing ICUs, considering there are not enough intensivists to go around and they are a much more expensive staff member than, say, a nurse.

Kahn said just half of all ICUs in the United States have access to a critical care specialist.

And several earlier studies on the impact of nighttime intensivists have had mixed results.

To try to get a clearer picture of how much they help patients survive, Kahn's group examined a larger group of ICUs.

They collected information from 49 ICUs across the U.S., covering more than 65,000 patients.

Twelve of the ICUs had an intensivist on staff at night, while the other 37 did not.

About 13 out of every 100 patients in the ICUs died within the hospital or went from the ICU to hospice care, regardless of whether there was an intensivist available at night or not.

But when the researchers divided the ICUs into two categories - those that had intensivists overseeing patient care during the day, and those that did not - Kahn's group got a different answer.

Among the 22 ICUs with no intensivist during the day, having one at night was tied to a 38 percent lower patient death rate than in ICUs without a day- or nighttime intensivist.

"The results of this large study seem to support previously observed associations between overall 'higher intensity staffing' and lower mortality," said Dr. Ognjen Gajic, a professor at the Mayo Clinic in Rochester, MN, who did not participate in this research.