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Shaefi S, Pannu A, Mueller AL, Flynn B, Evans A, Jabaley CS, Mladinov D, Wall M, Siddiqui S, Douin DJ, Boone MD, Monteith E, Abalama V, Nunnally ME, Cobas M, Warner MA, Stevens RD. Nationwide Clinical Practice Patterns of Anesthesiology Critical Care Physicians: A Survey to Members of the Society of Critical Care Anesthesiologists. Anesth Analg 2023; 136:295-307. [PMID: 35950751 PMCID: PMC9840646 DOI: 10.1213/ane.0000000000006160] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Despite the growing contributions of critical care anesthesiologists to clinical practice, research, and administrative leadership of intensive care units (ICUs), relatively little is known about the subspecialty-specific clinical practice environment. An understanding of contemporary clinical practice is essential to recognize the opportunities and challenges facing critical care anesthesia, optimize staffing patterns, assess sustainability and satisfaction, and strategically plan for future activity, scope, and training. This study surveyed intensivists who are members of the Society of Critical Care Anesthesiologists (SOCCA) to evaluate practice patterns of critical care anesthesiologists, including compensation, types of ICUs covered, models of overnight ICU coverage, and relationships between these factors. We hypothesized that variability in compensation and practice patterns would be observed between individuals. METHODS Board-certified critical care anesthesiologists practicing in the United States were identified using the SOCCA membership distribution list and invited to take a voluntary online survey between May and June 2021. Multiple-choice questions with both single- and multiple-select options were used for answers with categorical data, and adaptive questioning was used to clarify stem-based responses. Respondents were asked to describe practice patterns at their respective institutions and provide information about their demographics, salaries, effort in ICUs, as well as other activities. RESULTS A total of 490 participants were invited to take this survey, and 157 (response rate 32%) surveys were completed and analyzed. The majority of respondents were White (73%), male (69%), and younger than 50 years of age (82%). The cardiothoracic/cardiovascular ICU was the most common practice setting, with 69.5% of respondents reporting time working in this unit. Significant variability was observed in ICU practice patterns. Respondents reported spending an equal proportion of their time in clinical practice in the operating rooms and ICUs (median, 40%; interquartile range [IQR], 20%-50%), whereas a smaller proportion-primarily those who completed their training before 2009-reported administrative or research activities. Female respondents reported salaries that were $36,739 less than male respondents; however, this difference was not statistically different, and after adjusting for age and practice type, these differences were less pronounced (-$27,479.79; 95% confidence interval [CI], -$57,232.61 to $2273.03; P = .07). CONCLUSIONS These survey data provide a current snapshot of anesthesiology critical care clinical practice patterns in the United States. Our findings may inform decision-making around the initiation and expansion of critical care services and optimal staffing patterns, as well as provide a basis for further work that focuses on intensivist satisfaction and burnout.
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Affiliation(s)
- Shahzad Shaefi
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Ameeka Pannu
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Ariel L. Mueller
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Brigid Flynn
- Department of Anesthesiology, University of Kansas Medical Center, Kansas City, KS
| | | | - Craig S. Jabaley
- Division of Critical Care Medicine, Department of Anesthesiology, Emory University, Atlanta, GA
| | - Domagoj Mladinov
- Department of Anesthesiology and Perioperative Medicine, University of Alabama Hospital, Birmingham, AL
| | - Michael Wall
- Department of Anesthesiology, University of Minnesota Medical Center, Minneapolis, MN
| | - Shahla Siddiqui
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - David J. Douin
- Department of Anesthesiology, University of Colorado School of Medicine, Aurora, CO
| | - M. Dustin Boone
- Department of Anesthesiology, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Erika Monteith
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Vivian Abalama
- International Anesthesia Research Society (IARS), Society of Critical Care Anesthesiologists (SOCCA), San Francisco, CA
| | - Mark E. Nunnally
- Department of Anesthesiology, Perioperative Care and Pain Medicine, New York University Langone Health, New York, NY
| | - Miguel Cobas
- Department of Anesthesiology, Perioperative Medicine and Pain Management, University of Miami Jackson Memorial Hospital, Miami, FL
| | - Matthew A. Warner
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Robert D Stevens
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
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Sleep and Work in ICU Physicians During a Randomized Trial of Nighttime Intensivist Staffing. Crit Care Med 2020; 47:894-902. [PMID: 30985450 DOI: 10.1097/ccm.0000000000003773] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
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.
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Allen M, Gawad N, Park L, Raîche I. The Educational Role of Autonomy in Medical Training: A Scoping Review. J Surg Res 2019; 240:1-16. [DOI: 10.1016/j.jss.2019.02.034] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2018] [Revised: 01/30/2019] [Accepted: 02/22/2019] [Indexed: 12/18/2022]
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Finn KM, Metlay JP, Chang Y, Nagarur A, Yang S, Landrigan CP, Iyasere C. Effect of Increased Inpatient Attending Physician Supervision on Medical Errors, Patient Safety, and Resident Education: A Randomized Clinical Trial. JAMA Intern Med 2018; 178:952-959. [PMID: 29868877 PMCID: PMC6145715 DOI: 10.1001/jamainternmed.2018.1244] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE While the relationship between resident work hours and patient safety has been extensively studied, little research has evaluated the role of attending physician supervision on patient safety. OBJECTIVE To determine the effect of increased attending physician supervision on an inpatient resident general medical service on patient safety and educational outcomes. DESIGN, SETTING, AND PARTICIPANTS This 9-month randomized clinical trial performed on an inpatient general medical service of a large academic medical center used a crossover design. Participants were clinical teaching attending physicians and residents in an internal medicine residency program. INTERVENTIONS Twenty-two faculty provided either (1) increased direct supervision in which attending physicians joined work rounds on previously admitted patients or (2) standard supervision in which attending physicians were available but did not join work rounds. Each faculty member participated in both arms in random order. MAIN OUTCOMES AND MEASURES The primary safety outcome was rate of medical errors. Resident education was evaluated via a time-motion study to assess resident participation on rounds and via surveys to measure resident and attending physician educational ratings. RESULTS Of the 22 attending physicians, 8 (36%) were women, with 15 (68%) having more than 5 years of experience. A total of 1259 patients (5772 patient-days) were included in the analysis. The medical error rate was not significantly different between standard vs increased supervision (107.6; 95% CI, 85.8-133.7 vs 91.1; 95% CI, 76.9-104.0 per 1000 patient-days; P = .21). Time-motion analysis of 161 work rounds found no difference in mean length of time spent discussing established patients in the 2 models (202; 95% CI, 192-212 vs 202; 95% CI, 189-215 minutes; P = .99). Interns spoke less when an attending physician joined rounds (64; 95% CI, 60-68 vs 55; 95% CI, 49-60 minutes; P = .008). In surveys, interns reported feeling less efficient (41 [55%] vs 68 [73%]; P = .02) and less autonomous (53 [72%] vs 86 [91%]; P = .001) with an attending physician present and residents felt less autonomous (11 [58%] vs 30 [97%]; P < .001). Conversely, attending physicians rated the quality of care higher when they participated on work rounds (20 [100%] vs 16 [80%]; P = .04). CONCLUSIONS AND RELEVANCE Increased direct attending physician supervision did not significantly reduce the medical error rate. In designing morning work rounds, residency programs should reconsider their balance of patient safety, learning needs, and resident autonomy. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03318198.
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Affiliation(s)
- Kathleen M Finn
- Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston
| | - Joshua P Metlay
- Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston
| | - Yuchiao Chang
- Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston
| | - Amulya Nagarur
- Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston
| | - Shaun Yang
- Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston
| | - Christopher P Landrigan
- Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, Massachusetts.,Division of Sleep and Circadian Disorders, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Christiana Iyasere
- Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston
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Tanios MA, Teres D, Park H, Beltran A, Sehgal A, Leo JD. The Impact of Implementing an Intensivist Model With Nighttime In-Hospital Nocturnist and Effect on ICU Outcomes. J Intensive Care Med 2018; 35:461-467. [PMID: 29458294 DOI: 10.1177/0885066618758246] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Various intensivist staffing models have been suggested, but the long-term sustainability and outcomes vary and may not be sustained. We examined the impact of implementing a high-intensity intensivist coverage model with a nighttime in-house nocturnist (non-intensivist) and its effect on intensive care unit (ICU) outcomes. METHODS We obtained historical control baseline data from 2007 to 2011 and compared the same data from 2011 to 2015. The Acute Physiological and Chronic Health Evaluation outcomes system was utilized to collect clinical, physiological, and outcome data on all adult patients in the medical ICU and to provide severity-adjusted outcome predictions. The model consists of a mandatory in-house daytime intensivist service that leads multidisciplinary rounds, and an in-house nighttime coverage is provided by nocturnist (nonintensivists) with current procedural skills in airways management, vascular access, and commitment to supervise house staff as needed. The intensivist continues to be available remotely at nighttime for house staff and consultation with the nocturnist. A backup intensivist is available for surge management. RESULTS First year yielded improved throughput (2428 patients/year to 2627 then 2724 at fifth year). Case mix stable at 53.7 versus 55.2. The ICU length of stay decreased from 4.7 days (predicted 4.25 days) to 3.8 days (4.15) in first year; second year: 3.63 days (4.29 days); third year: 3.24 days (4.37), fourth year: 3.34 days (4.45), and fifth year: 3.61 days (4.42). Intensive care unit <24 hours readmission remained at 1%; >24 hours increased from 4% to 6%. Low-risk monitoring admissions remained at an average 17% (benchmark 17.18%). Intensive care unit mortality improved with standardized mortality ration averaging at 0.84. Resident satisfaction surveys improved. CONCLUSIONS Implementing an intensivist service with nighttime nocturnist staffing in a high-intensity large teaching hospital is feasible and improved ICU outcomes in a sustained manner that persisted after the initial implementation phase. The model resulted in reduced and sustained observed-to-predicted length of ICU stay.
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Affiliation(s)
- Maged A Tanios
- Intensive Care Unit, Long Beach Memorial Hospital, Long Beach, CA, USA.,David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.,Pulmonary Division, Long Beach Memorial Hospital, Long Beach, CA, USA
| | - Daniel Teres
- Department of Public Health and Community Medicine, Tufts School of Medicine, Boston, MA, USA
| | - Hyunsoon Park
- Intensive Care Unit, Long Beach Memorial Hospital, Long Beach, CA, USA
| | - Antonio Beltran
- Intensive Care Unit, Long Beach Memorial Hospital, Long Beach, CA, USA.,Pulmonary Division, Long Beach Memorial Hospital, Long Beach, CA, USA
| | - Arunpal Sehgal
- Intensive Care Unit, Long Beach Memorial Hospital, Long Beach, CA, USA.,Pulmonary Division, Long Beach Memorial Hospital, Long Beach, CA, USA
| | - James D Leo
- MemorialCare Health System, Fountain Valley, CA, USA
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Kerlin MP, Adhikari NKJ, Rose L, Wilcox ME, Bellamy CJ, Costa DK, Gershengorn HB, Halpern SD, Kahn JM, Lane-Fall MB, Wallace DJ, Weiss CH, Wunsch H, Cooke CR. An Official American Thoracic Society Systematic Review: The Effect of Nighttime Intensivist Staffing on Mortality and Length of Stay among Intensive Care Unit Patients. Am J Respir Crit Care Med 2017; 195:383-393. [PMID: 28145766 DOI: 10.1164/rccm.201611-2250st] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
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 geographically diverse. Meta-analysis (one randomized controlled trial; three nonrandomized studies with exposure limited to nighttime intensivist staffing with adjusted estimates of effect) demonstrated no association with mortality (odds ratio, 0.99; 95% confidence interval, 0.75-1.29). Secondary analyses including studies without risk adjustment, with a composite exposure of organizational factors, stratified by intensity of daytime staffing and by ICU type, yielded similar results. Minimal or no differences were observed in ICU and hospital length of stay and several other secondary outcomes. CONCLUSIONS Notwithstanding limitations of the predominantly observational evidence, our systematic review and meta-analysis suggests nighttime intensivist staffing is not associated with reduced ICU patient mortality. Other outcomes and alternative staffing models should be evaluated to further guide staffing decisions.
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7
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Singman EL, Srikumaran D, Green L, Tian J, McDonnell P. Supervision and autonomy of ophthalmology residents in the outpatient Clinic in the United States: a survey of ACGME-accredited programs. BMC MEDICAL EDUCATION 2017; 17:105. [PMID: 28651531 PMCID: PMC5485577 DOI: 10.1186/s12909-017-0941-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Accepted: 06/13/2017] [Indexed: 06/09/2023]
Abstract
BACKGROUND The development and demonstration of incremental trainee autonomy is required by the ACGME. However, there is scant published research concerning autonomy of ophthalmology residents in the outpatient clinic setting. This study explored the landscape of resident ophthalmology outpatient clinics in the United States. METHODS A link to an online survey using the QualtricsTM platform was emailed to the program directors of all 115 ACGME-accredited ophthalmology programs in the United States. Survey questions explored whether resident training programs hosted a continuity clinic where residents would see their own patients, and if so, the degree of faculty supervision provided therein. Metrics such as size of the resident program, number of faculty and clinic setting were also recorded. Correlations between the degree of faculty supervision and other metrics were explored. RESULTS The response rate was 94%; 69% of respondents indicated that their trainees hosted continuity clinics. Of those programs, 30% required a faculty member to see each patient treated by a resident, while 42% expected the faculty member to at least discuss (if not see) each patient. All programs expected some degree of faculty interaction based upon circumstances such as the level of training of the resident or complexity of the clinical situation. 67% of programs that tracked the contribution of the clinic to resident surgical caseloads reported that these clinics provided more than half of the resident surgical volumes. More ¾ of resident clinics were located in urban settings. The degree of faculty supervision did not correlate to any of the other metrics evaluated. CONCLUSIONS The majority of ophthalmology resident training programs in the United States host a continuity clinic located in an urban environment where residents follow their own patients. Furthermore, most of these clinics require supervising faculty to review both the patients seen and the medical documentation created by the resident encounters. The different degrees of faculty supervision outlined by this survey might provide a useful guide presuming they can be correlated with validated metrics of educational quality. Finally, this study could provide an adjunctive resource to current international efforts to standardize ophthalmic residency education.
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Affiliation(s)
- Eric L. Singman
- Wilmer Eye Institute General Eye Services Clinic, @ Johns Hopkins Hospital, Wilmer B-29, 600 N. Wolfe St, Baltimore, MD 21287 USA
| | - Divya Srikumaran
- Wilmer Eye Institute General Eye Services Clinic, @ Johns Hopkins Hospital, Wilmer B-29, 600 N. Wolfe St, Baltimore, MD 21287 USA
| | - Laura Green
- Ophthalmology Residency Program Director, Lifebridge Health Krieger Eye Institute, 2411 W. Belvedere Ave, Baltimore, MD 21215 USA
| | - Jing Tian
- Biostatistics Consulting Center, Johns Hopkins University Bloomberg School of Public Health, 615 N. Wolfe St, Room 3148, Baltimore, MD 21287 USA
| | - Peter McDonnell
- Wilmer Eye Institute, @ Johns Hopkins Hospital, Maumenee 727, 600 N. Wolfe St, Baltimore, MD 21287 USA
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Kerlin MP, Halpern SD. Nighttime physician staffing improves patient outcomes: no. Intensive Care Med 2016; 42:1469-71. [PMID: 27349238 DOI: 10.1007/s00134-016-4367-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Accepted: 04/20/2016] [Indexed: 11/25/2022]
Affiliation(s)
- Meeta Prasad Kerlin
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA. .,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.
| | - Scott D Halpern
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.,Fostering Improvement in End-of-Life Decision Science (FIELDS) Program, University of Pennsylvania, Philadelphia, PA, USA.,Department of Biostatistics and Epidemiology, Perelmany School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Kerlin MP, Halpern SD. Response. Chest 2015; 148:e67-e68. [PMID: 26238850 DOI: 10.1378/chest.15-1097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- Meeta Prasad Kerlin
- Pulmonary, Allergy, and Critical Care Division, Department of Medicine (Drs Kerlin and Halpern), University of Pennsylvania, Philadelphia, PA; Center for Clinical Epidemiology and Biostatistics (Drs Kerlin and Halpern), University of Pennsylvania, Philadelphia, PA; Department of Medical Ethics and Health Policy (Dr Halpern), University of Pennsylvania, Philadelphia, PA; Perelman School of Medicine, University of Pennsylvania and Leonard Davis Institute of Health Economics (Drs Kerlin and Halpern), University of Pennsylvania, Philadelphia, PA; P30 Roybal Center on Behavioral Economics and Health (Dr Halpern), University of Pennsylvania, Philadelphia, PA; Fostering Improvement in End-of-Life Decision Science (FIELDS) Program (Dr Halpern), University of Pennsylvania, Philadelphia, PA.
| | - Scott D Halpern
- Pulmonary, Allergy, and Critical Care Division, Department of Medicine (Drs Kerlin and Halpern), University of Pennsylvania, Philadelphia, PA; Center for Clinical Epidemiology and Biostatistics (Drs Kerlin and Halpern), University of Pennsylvania, Philadelphia, PA; Department of Medical Ethics and Health Policy (Dr Halpern), University of Pennsylvania, Philadelphia, PA; Perelman School of Medicine, University of Pennsylvania and Leonard Davis Institute of Health Economics (Drs Kerlin and Halpern), University of Pennsylvania, Philadelphia, PA; P30 Roybal Center on Behavioral Economics and Health (Dr Halpern), University of Pennsylvania, Philadelphia, PA; Fostering Improvement in End-of-Life Decision Science (FIELDS) Program (Dr Halpern), University of Pennsylvania, Philadelphia, PA
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Sun NZ, Maniatis T. Scheduling in the context of resident duty hour reform. BMC MEDICAL EDUCATION 2014; 14 Suppl 1:S18. [PMID: 25561221 PMCID: PMC4304277 DOI: 10.1186/1472-6920-14-s1-s18] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
Fuelled by concerns about resident health and patient safety, there is a general trend in many jurisdictions toward limiting the maximum duration of consecutive work to between 14 and 16 hours. The goal of this article is to assist institutions and residency programs to make a smooth transition from the previous 24- to 36-hour call system to this new model. We will first give an overview of the main types of coverage systems and their relative merits when considering various aspects of patient care and resident pedagogy. We will then suggest a practical step-by-step approach to designing, implementing, and monitoring a scheduling system centred on clinical and educational needs in the context of resident duty hour reform. The importance of understanding the impetus for change and of assessing the need for overall workflow restructuring will be explored throughout this process. Finally, as a practical example, we will describe a large, university-based teaching hospital network's transition from a traditional call-based system to a novel schedule that incorporates the new 16-hour duty limit.
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Affiliation(s)
- Ning-Zi Sun
- Division of General Internal Medicine, McGill University Health Centre; Department of Medicine, McGill University, QC, Canada
| | - Thomas Maniatis
- Division of General Internal Medicine, McGill University Health Centre; Department of Medicine, McGill University, QC, Canada
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Affiliation(s)
- Jared Rubenstein
- Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
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12
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Biondi EA, Leonard MS, Nocera E, Chen R, Arora J, Alverson B. Tempering pediatric hospitalist supervision of residents improves admission process efficiency without decreasing quality of care. J Hosp Med 2014; 9:106-10. [PMID: 24382752 PMCID: PMC4103017 DOI: 10.1002/jhm.2138] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2013] [Revised: 10/30/2013] [Accepted: 12/02/2013] [Indexed: 11/06/2022]
Abstract
BACKGROUND Many academic pediatric hospital medicine (PHM) divisions have recently increased in-house supervision of residents, often providing 24/7 in-house attending coverage. Contrary to this trend, we removed mandated PHM attending input during the admission process. We present an evaluation of this process change. METHODS This cohort study compared outcomes between patients admitted to the PHM service before (July 1, 2011-September 30, 2011) and after (July 1, 2012-September 30, 2012) the process change. We evaluated time from admission request to inpatient orders, length of stay (LOS), frequency of change in antibiotic choice, and rapid response team (RRT) calls within 24 hours of admission. Data were obtained via chart abstraction and from administrative databases. Wilcoxon rank sum and Fisher exact tests were used for analysis. RESULTS We identified 182 and 210 admissions in the before and after cohorts, respectively. Median time between emergency department admission request and inpatient orders was significantly shorter after the change (123 vs 62 minutes, P < 0.001). We found no significant difference in LOS, the number of changes to initial resident antibiotic choice, standard of care, or RRTs called within the first 24 hours of admission. CONCLUSION Removing mandated attending input in decision making for PHM admissions significantly decreased time to inpatient resident admission orders without a change in measurable clinical outcomes.
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Affiliation(s)
- Eric A Biondi
- Division of Hospital Medicine, Department of Pediatrics, University of Rochester, Rochester, New York
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Affiliation(s)
- Ellen L Burnham
- University of Colorado Anschutz Medical Campus, Research Complex 2, 12700 E. 19th Ave, Aurora, CO 80045.
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14
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Fourrier F. La fin des nuits de garde en réanimation ? MEDECINE INTENSIVE REANIMATION 2013. [DOI: 10.1007/s13546-013-0712-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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15
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Kerlin MP, Halpern SD. Nighttime physician staffing in an intensive care unit. N Engl J Med 2013; 369:1075. [PMID: 24024847 DOI: 10.1056/nejmc1308523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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16
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Kerlin MP, Small DS, Cooney E, Fuchs BD, Bellini LM, Mikkelsen ME, Schweickert WD, Bakhru RN, Gabler NB, Harhay MO, Hansen-Flaschen J, Halpern SD. A randomized trial of nighttime physician staffing in an intensive care unit. N Engl J Med 2013; 368:2201-9. [PMID: 23688301 PMCID: PMC3732473 DOI: 10.1056/nejmoa1302854] [Citation(s) in RCA: 165] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Increasing numbers of intensive care units (ICUs) are adopting the practice of nighttime intensivist staffing despite the lack of experimental evidence of its effectiveness. 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.).
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Affiliation(s)
- Meeta Prasad Kerlin
- Pulmonary, Allergy, and Critical Care Division, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104-6021, USA
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Rawat N. Shifting the Focus of ICU Staffing Research to the Community. Chest 2012. [DOI: 10.1378/chest.12-1831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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