Effect of Around the Clock Intensivist Coverage on Intensive Care Unit (ICU) Outcomes

June 16, 2010 updated by: University of Manitoba

The Effect of Alternative Attending Physician Staffing Models on Outcomes for Intensive Care Unit Patients, Families, and Health Care Workers

Intensive Care Units (ICU) are an important, but troubled, part of modern health care systems. While it seems likely that both the technical and structural elements of ICU care are important determinants of relevant ICU outcomes, little is known about how the structure of ICU care affects outcomes. One element of potential importance is the way that ICU physicians (intensivists) organize themselves to provide ICU care, particularly at night. The dominant, historical ("standard") model of intensivist staffing involves an intensivist who is present during daytime hours, but then takes "call" at night from home. But, in recent years there has been widespread concern about whether patients experience adverse events or worse outcomes related to a lesser level of expertise and care readily available at night in hospitals. Only two studies, both from single ICUs, and both using simple before vs. after study designs, have conducted interventional studies directly comparing a "standard" intensivist staffing model with a "24-7" model of nighttime intensivist coverage via shift work, i.e. with the daytime intensivist giving way at the late afternoon to a nightshift intensivist who remained in the hospital and covered the ICU until morning. Those two studies found contradictory effects of the intervention. But despite the absence of clear data indicating a benefit to ICU patients associated with having intensivists remain in the hospital overnight, there has been a major movement around the world towards ICU staffing models utilizing shift work to ensure such coverage. The potential impact of such a change in staffing paradigm is large, with possible effects on all the other major stakeholders involved in ICU care: families, nurses, and house officers. Both benefits and detriments are possible.

On the one hand, moving to a shift work model from a model in which a single intensivist becomes overworked and sleep-deprived as a result of being responsible for care both day and night, has the potential to reduce the sleep deprivation, job distress, and burnout prevalent among intensivists with standard staffing models. But, it would also require more intensivists, a serious challenge given the worsening intensivist manpower shortage. Also, there are many detrimental effects of shift work on humans, including negative effects on motor function, cognition, sleep, job satisfaction, mood, errors, and cardiovascular health. Shift work is the most common reason that Emergency Medicine physicians give for leaving that field. The physical availability of an intensivist around-the-clock might also influence the problems mentioned of family dissatisfaction with communication in ICUs, and poor communication/ teamwork with physicians often perceived by ICU nurses. In ICUs of teaching hospitals, where relatively inexperienced house officers typically remain in the ICU overnight, the nighttime presence of an attending physician might influence residents' perceptions of domains such as teaching, and clinical autonomy.

This purpose of this study is to rigorously compare the effects of two different intensivist staffing models, specifically the current standard model, and a 24-7 staffing model enabled via shift work. This study will be conducted in two ICUs, one academic with house officers who remain in ICU overnight (the Medical ICU at Health Sciences Center), and one in a community hospital which currently lacks overnight, in-ICU physicians (the Victoria General Hospital).

This study is designed to improve upon both prior studies. To obviate the problems with using historical controls inherent in those before-vs-after study designs, our study will alternate the two staffing models (e.g. A-B-A-B). Also, the investigators will rigorously assess the effect of 24 hour intensivist presence on all major stakeholders, i.e. patients, families, intensivists, nurses, and house officers.

Study Overview

Status

Status

Indicates the current recruitment status or the expanded access status.
Completed

Conditions

Conditions

The disease, disorder, syndrome, illness, or injury that is being studied. On ClinicalTrials.gov, conditions may also include other health-related issues, such as lifespan, quality of life, and health risks.

Intervention / Treatment

Intervention / Treatment

A process or action that is the focus of a clinical study. Interventions include drugs, medical devices, procedures, vaccines, and other products that are either investigational or already available. Interventions can also include noninvasive approaches, such as education or modifying diet and exercise.

Detailed Description

Design & Procedures - General Procedures

The investigators will directly compare 2 distinct models of intensivist coverage in the 2 participating ICUs in Winnipeg:

A) The standard model: A single intensivist staffs an ICU for 7 days. He/she will is present during daytime hours, and takes call from home afterwards. This is the current staffing paradigm in both participating ICUs.

B) The 24-7 in-house coverage model: 24-7 in-hospital coverage by an intensivist is enabled by splitting each 24 hour period into two shifts. There will, as in the standard model, be a single intensivist covering the ICU during the day shifts for one week. The day shift will run 8 am to 5:30 pm on weekdays, and 8 am to 3 pm on Saturday and Sunday. The night shift intensivist will arrive and take over at 5:30 pm on weekdays, and 3 pm on weekends and remain in the hospital until 8 am. Call rooms will be provided to allow the night shift intensivist to sleep, if the workload permits.

The interventional part of the study will last 32 weeks, comprising 4 blocks of 8 weeks each. It will run from October 2008 until June 2009. During each 8 week block, each ICU will be staffed under model A or B. Thus we will alternate the models: A-B-A-B in one ICU, and B-A-B-A in the other. This alternating design obviates the problem with historical controls; any nonrandom difference between the two staffing models should be seen to come and go in this design.

A variety of outcomes will be compared between the two intensivist staffing models. The primary outcome, which is the one for which the sample size analysis was performed, is the intensivists' burnout scores.

In order to avoid contamination between the staffing models, patients (and family participants) whose ICU stay is long enough to include time under both models will be excluded from analysis. Also excluded will be patients who are directly transferred from one ICU in Winnipeg to another. For patients who are admitted more than once to a participating ICU during the study, only the initial ICU admission will be included in the analysis.

The intensivists rotate on a weekly basis, and they will be provided questionnaires at the end of each week of ICU service. ICU nurses will be surveyed at the end of each 8 week block of a given staffing model. House officers in the ICU at HSC rotate on a 4 week basis, and they will be provided questionnaires at the end of their final week of their ICU rotations.

Even though the study design makes it likely (apart from the possibility of seasonal differences over the 32 weeks of the study) that participants' characteristics will be balanced between the two staffing models, this is not a randomized study and our primary analysis will use regression modeling to adjust for baseline characteristics of subjects. The investigators will use ordinary least squares or quantile regression for continuous variables, and logistic regression for binary variables. This approach permits assessment for differential effects between the two sites by including: (i) an indicator variable representing the separate sites, and (ii) interaction terms between that indicator variable and other covariates. A relevant aspect of the analysis is that outcomes for the intensivists, nurses and house officers derive from questionnaires, and that a single individual could complete the questionnaire more than once. Regression using General Estimating Equation methodology will therefore be used to account for correlation of responses within subjects.

Design & Procedures - Specific Aims Specific Aim#1: To compare clinical outcomes for ICU patients cared for under the two intensivist staffing models.

• The Department of Medicine has long maintained a comprehensive clinical database of all patients admitted to Winnipeg ICUs. It contains information about patients' demographics, illness type and severity, comorbid conditions, and ICU and hospital course, including the outcomes for this study. The investigators will obtain a deidentified data file containing this information for patients admitted to the participating ICUs during the study period.

Specific Aim#2: To compare family satisfaction with ICU care under the two intensivist staffing models.

• On each day for each of the participating ICUs, the investigators will attempt to recruit the next-of-kin of one newly admitted patient. The investigators will use a 2 stage consent process for these participants. The investigators will use the Family Satisfaction Survey - ICU 24 for assessing family satisfaction with care. This well-validated tool has two subscales, and has been extensively used in Canadian ICUs.

Specific Aim#3: To compare the work-related personal/emotional burden for intensivists working under the two intensivist staffing models.

• The intensivists will be asked to complete multiple questionnaires. Before starting, and after concluding the intervention, all Winnipeg intensivists will be surveyed. After each one week rotation, the intensivists who worked that week in the participating ICUs will be surveyed. A single consent provided before beginning the study intervention will ask the intensivists to consent for all the questionnaire that they will receive. The initial survey establishes background information, and asks for their opinions and preferences relating to the two different intensivist staffing models. The concluding survey repeats those questions. The weekly questionnaires contain the items for the 5 scales that will be analyzed; four of those scales are validated. The fifth scale, Role Conflict, aims to assess an interaction that only occurs in the shift work staffing model, i.e. the interface between 2 intensivists doing shift-work. The investigators were unable to find any scale that addresses this sort of issue, and thus created the items ourselves.

Specific Aim#4: To compare ICU nurses' perceptions of working alongside the two intensivist staffing models.

• At the end of each 8 week block of the study, we will ask all nurses in the participating ICUs to complete a questionnaire. The questionnaire asks for background information, about the mix of shifts they worked over the prior 8 weeks, and includes items from 5 validated scales.

Specific Aim#5: To compare ICU house officers' perceptions of working under the two intensivist staffing models.

• At the end of each 4 week rotation of ICU house officers in the Medical ICU at HSC, we will ask them to complete a questionnaire. The questionnaire asks for background information, the number of previous ICU rotations they completed, and items from 4 scales. The Autonomy and Role Conflict scales are validated. The Clinical comfort and Education/learning scales have been previously used, but have not been formally validated.

Study Type

Study Type

Describes the nature of a clinical study. Study types include interventional studies (also called clinical trials), observational studies (including patient registries), and expanded access.
Observational

Enrollment (Actual)

Enrollment

The number of participants in a clinical study. The "anticipated" enrollment is the target number of participants that the researchers need for the study.
627

Contacts and Locations

This section provides the contact details for those conducting the study, and information on where this study is being conducted.

Study Locations

  • Canada
    • Manitoba
      • Winnipeg, Manitoba, Canada, R1A 1R9
        • Winnipeg Health Sciences Centre
      • Winnipeg, Manitoba, Canada, R3T 2E8
        • Victoria General Hospital

Participation Criteria

Researchers look for people who fit a certain description, called eligibility criteria. Some examples of these criteria are a person's general health condition or prior treatments.

Eligibility Criteria

Eligibility Criteria

The key requirements that people who want to participate in a clinical study must meet or the characteristics they must have. Eligibility criteria consist of both inclusion criteria (which are required for a person to participate in the study) and exclusion criteria (which prevent a person from participating). Types of eligibility criteria include whether a study accepts healthy volunteers, has age or age group requirements, or is limited by sex.

Ages Eligible for Study

17 years and older (Child, Adult, Older Adult)

Accepts Healthy Volunteers

No

Genders Eligible for Study

All

Sampling Method

Non-Probability Sample

Study Population

All patients admitted to the participating Intensive Care Units during the study period

Description

Inclusion Criteria:

  • ICU admission contained entirely within the period of a single intensivist staffing format during the study period.

Exclusion Criteria:

  • Repeat ICU admissions during the study period
  • ICU admissions that overlapped more than one intensivist staffing format during the study period

Study Plan

This section provides details of the study plan, including how the study is designed and what the study is measuring.

How is the study designed?

Design Details

  • Observational Models: Ecologic or Community
  • Time Perspectives: Prospective

Cohorts and Interventions

Group / Cohort

Group / Cohort

A group or subgroup of participants in an observational study that is assessed for biomedical or health outcomes.
Intervention / Treatment

Intervention / Treatment

A process or action that is the focus of a clinical study. Interventions include drugs, medical devices, procedures, vaccines, and other products that are either investigational or already available. Interventions can also include noninvasive approaches, such as education or modifying diet and exercise.
Standard staffing model
All patients in participating ICUs during the blocks of time when a single intensivist staffs a participating ICU for a 7 day period. The intensivist will be present during daytime hours, and takes call from home afterwards.
Other: Alternative Intensivist staffing models
During the study period, each participating ICU alternated (ABAB or BABA) between two distinct intensivist staffing formats: (i) the standard staffing model, an intensivist is responsible for care in that ICU for the entire 7 days, being present during the daytime hours, and taking call from home at night, (ii) the 24-7 in-hospital, shiftwork model, enabled by splitting each 24 hour period into two shifts. There will, as in the standard model, be a single intensivist covering the ICU during the day shifts for one week. The day shift will run 8 am to 5:30 pm on weekdays, and 8 am to 3 pm on Saturday and Sunday. The night shift intensivist will arrive and take over at 5:30 pm on weekdays, and 3 pm on weekends and remain in the hospital until 8 am.
24-7 shiftwork staffing model
All patients in participating ICUs during the blocks of time when the 24-7 in-hospital intensivist coverage model is in place. This model is enabled by splitting each 24 hour period into two shifts. There will, as in the standard model, be a single intensivist covering the ICU during the day shifts for one week. The day shift will run 8 am to 5:30 pm on weekdays, and 8 am to 3 pm on Saturday and Sunday. The night shift intensivist will arrive and take over at 5:30 pm on weekdays, and 3 pm on weekends and remain in the hospital until 8 am. Call rooms will be provided to allow the night shift intensivist to sleep, if the workload permits.
Other: Alternative Intensivist staffing models
During the study period, each participating ICU alternated (ABAB or BABA) between two distinct intensivist staffing formats: (i) the standard staffing model, an intensivist is responsible for care in that ICU for the entire 7 days, being present during the daytime hours, and taking call from home at night, (ii) the 24-7 in-hospital, shiftwork model, enabled by splitting each 24 hour period into two shifts. There will, as in the standard model, be a single intensivist covering the ICU during the day shifts for one week. The day shift will run 8 am to 5:30 pm on weekdays, and 8 am to 3 pm on Saturday and Sunday. The night shift intensivist will arrive and take over at 5:30 pm on weekdays, and 3 pm on weekends and remain in the hospital until 8 am.

What is the study measuring?

Primary Outcome Measures

Primary Outcome Measures

In a clinical study's protocol, the planned outcome measure that is the most important for evaluating the effect of an intervention/treatment. Most clinical studies have one primary outcome measure, but some have more than one.
Outcome Measure
Measure Description
Time Frame
Emotional Exhaustion subscale of the Maslach Burnout Inventory, among intensivists
Time Frame: 1 week
Reference: Maslach, C., W. B. Schaufeli, and M. P. Leiter. 2001. Job Burnout. Annual Review of Psychology 52:397-422.
1 week

Secondary Outcome Measures

Secondary Outcome Measures

In a clinical study's protocol, a planned outcome measure that is not as important as the primary outcome measure for evaluating the effect of an intervention but is still of interest. Most clinical studies have more than one secondary outcome measure.
Outcome Measure
Measure Description
Time Frame
Home-work imbalance, among intensivists
Time Frame: 1 week
Reference: Kopelman, R. E., J. H. Greenhaus, and T. F. Connolly. 1983. A Model of Work, Family, and Interrole Conflict: A Construct Validation Study. Organizational Behavior and Human Performance 32:198-215.
1 week
Role overload, among intensivists
Time Frame: 1 week
Reference: Bacharach, S. B., P. Bamberger, and S. C. Conley. 1990. Work Processes, Role Conflict, and Role Overload: The Case of Nurses and Engineers in the Public Sector. Work and Occupations 17(2):199-228.
1 week
Role ambiguity, among intensivists
Time Frame: 1 week
Reference: Peterson, M. F., P. B. Smith, A. Akande, and e. al. 1995. Role Conflict, Ambiguity, and Overload: A 21-Nation Study. Academy of Management Journal 38(2):429-452.
1 week
Role conflict, among intensivists
Time Frame: 1 week
A 3 item scale we developed for assessing conflict occurring at the interface between 2 intensivists doing shift-work, and thus caring for the same patients.
1 week
ICU mortality, among ICU patients
Time Frame: up to 32 weeks
Obtained from the Winnipeg ICU database.
up to 32 weeks
Hospital mortality, among ICU patients
Time Frame: up to 1 year
Obtained from the hospital charts of the two participating hospitals.
up to 1 year
ICU length of stay, among ICU patients
Time Frame: up to 32 weeks
Obtained from the Winnipeg ICU database.
up to 32 weeks
Hospital length of stay, among ICU patients
Time Frame: up to 1 year
Obtained from the hospital charts of the two participating hospitals.
up to 1 year
Satisfaction with care, among families of ICU patients
Time Frame: up to 32 weeks
Reference: Wall, R. J., R. A. Engelberg, L. Downey, D. K. Heyland, and J. R. Curtis. 2007. Refinement, scoring, and validation of the Family Satisfaction in the Intensive Care Unit (FS-ICU) survey. Critical Care Medicine 35(1):271-279.
up to 32 weeks
Satisfaction with decision-making, among families of ICU patients
Time Frame: up to 32 weeks
Reference: Wall, R. J., R. A. Engelberg, L. Downey, D. K. Heyland, and J. R. Curtis. 2007. Refinement, scoring, and validation of the Family Satisfaction in the Intensive Care Unit (FS-ICU) survey. Critical Care Medicine 35(1):271-279.
up to 32 weeks
Nurse-physician collaboration, as perceived by ICU nurses
Time Frame: 8 weeks
Reference: Baggs, J. G. 1994. Development of an instrument to measure collaboration and satisfaction about care decisions. Journal of Advanced Nursing 20(1):176-182.
8 weeks
Satisfaction with communications, as perceived by ICU nurses
Time Frame: 8 weeks
Reference: Shortell, S. M., D. M. Rousseau, R. R. Gillies, K. J. Devers, and T. L. Simons. 1991. Organizational assessment in intensive care units: Construct development, reliability, and validity of the ICU nurse-physician questionnaire. Medical Care 29(8):709-27.
8 weeks
Nurse-physician understanding, as perceived by ICU nurses
Time Frame: 8 weeks
Reference: Shortell, S. M., D. M. Rousseau, R. R. Gillies, K. J. Devers, and T. L. Simons. 1991. Organizational assessment in intensive care units: Construct development, reliability, and validity of the ICU nurse-physician questionnaire. Medical Care 29(8):709-27.
8 weeks
Shift Communication, as perceived by ICU nurses
Time Frame: 8 weeks
Reference: Shortell, S. M., D. M. Rousseau, R. R. Gillies, K. J. Devers, and T. L. Simons. 1991. Organizational assessment in intensive care units: Construct development, reliability, and validity of the ICU nurse-physician questionnaire. Medical Care 29(8):709-27.
8 weeks
Role conflict, as perceived by ICU nurses
Time Frame: 8 weeks
Reference: Peterson, M. F., P. B. Smith, A. Akande, and e. al. 1995. Role Conflict, Ambiguity, and Overload: A 21-Nation Study. Academy of Management Journal 38(2):429-452.
8 weeks
Autonomy, as perceived by ICU house officers
Time Frame: 4 weeks
Reference: Fields, D. L. 2002. Taking the Measure of Work; A Guide to Validated Scales for Organizational Research and Diagnosis. Sage Publications, Thousand Oaks
4 weeks
Role conflict, as perceived by ICU house officers
Time Frame: 4 weeks
Reference: Peterson, M. F., P. B. Smith, A. Akande, and e. al. 1995. Role Conflict, Ambiguity, and Overload: A 21-Nation Study. Academy of Management Journal 38(2):429-452.
4 weeks
Clinical comfort, as perceived by ICU house officers
Time Frame: 4 weeks
Reference: Carson, S. S., C. Stocking, R. Podsadecki, J. Christenson, A. Pohlman, S. MacRae, J. Jordan, H. Humphrey, M. Siegler, and J. Hall. 1996. Effects of organizational change in the medical intensive care unit of a teaching hospital. JAMA 276(4):322-328
4 weeks
Education/learning, as perceived by ICU house officers.
Time Frame: 4 weeks
Reference: Carson, S. S., C. Stocking, R. Podsadecki, J. Christenson, A. Pohlman, S. MacRae, J. Jordan, H. Humphrey, M. Siegler, and J. Hall. 1996. Effects of organizational change in the medical intensive care unit of a teaching hospital. JAMA 276(4):322-328
4 weeks

Collaborators and Investigators

This is where you will find people and organizations involved with this study.

Sponsor

Sponsor

The organization or person who initiates the study and who has authority and control over the study.
University of Manitoba

Collaborators

Collaborators

An organization other than the sponsor that provides support for a clinical study. This support may include activities related to funding, design, implementation, data analysis, or reporting.
St. Boniface Hospital

Publications and helpful links

The person responsible for entering information about the study voluntarily provides these publications. These may be about anything related to the study.

General Publications

Study record dates

These dates track the progress of study record and summary results submissions to ClinicalTrials.gov. Study records and reported results are reviewed by the National Library of Medicine (NLM) to make sure they meet specific quality control standards before being posted on the public website.

Study Major Dates

Study Start

Study Start

The actual date on which the first participant was enrolled in a clinical study. The "anticipated" study start date is the date that the researchers think will be the study start date.
October 1, 2008

Primary Completion (Actual)

Primary Completion

The date on which the last participant in a clinical study was examined or received an intervention to collect final data for the primary outcome measure. Whether the clinical study ended according to the protocol or was terminated does not affect this date. For clinical studies with more than one primary outcome measure with different completion dates, this term refers to the date on which data collection is completed for all the primary outcome measures. The "anticipated" primary completion date is the date that the researchers think will be the primary completion date for the study.
June 1, 2009

Study Completion (Actual)

Study Completion

The date on which the last participant in a clinical study was examined or received an intervention/treatment to collect final data for the primary outcome measures, secondary outcome measures, and adverse events (that is, the last participant's last visit). The "anticipated" study completion date is the date that the researchers think will be the study completion date.
June 1, 2009

Study Registration Dates

First Submitted

First Submitted

The date on which the study sponsor or investigator first submitted a study record to ClinicalTrials.gov. There is typically a delay of a few days between the first submitted date and the record's availability on ClinicalTrials.gov (the first posted date).
June 16, 2010

First Submitted That Met QC Criteria

First Submitted That Met QC Criteria

The date on which the study sponsor or investigator first submits a study record that is consistent with National Library of Medicine (NLM) quality control (QC) review criteria. The sponsor or investigator may need to revise and submit a study record one or more times before NLM's QC review criteria are met. It is the responsibility of the sponsor or investigator to ensure that the study record is consistent with the NLM QC review criteria.
June 16, 2010

First Posted (Estimate)

First Posted

The date on which the study record was first available on ClinicalTrials.gov after National Library of Medicine (NLM) quality control (QC) review has concluded. There is typically a delay of a few days between the date the study sponsor or investigator submitted the study record and the first posted date.
June 17, 2010

Study Record Updates

Last Update Posted (Estimate)

Last Update Posted

The most recent date on which changes to a study record were made available on ClinicalTrials.gov. There may be a delay between when the changes were submitted to ClinicalTrials.gov by the study's sponsor or investigator (the last update submitted date) and the last update posted date.
June 17, 2010

Last Update Submitted That Met QC Criteria

Last Update Submitted That Met QC Criteria

The most recent date on which the study sponsor or investigator submitted changes to a study record that are consistent with National Library of Medicine (NLM) quality control (QC) review criteria. It is the responsibility of the sponsor or investigator to ensure that the study record is consistent with the NLM QC review criteria.
June 16, 2010

Last Verified

Last Verified

The most recent date on which the study sponsor or investigator confirmed the information about a clinical study on ClinicalTrials.gov as accurate and current. If a study with a recruitment status of recruiting; not yet recruiting; or active, not recruiting has not been confirmed within the past 2 years, the study's recruitment status is shown as unknown.
June 1, 2010

More Information

Terms related to this study

Keywords

Additional Relevant MeSH Terms

Other Study ID Numbers

Other Study ID Numbers

Identifiers or ID numbers other than the NCT number that are assigned to a clinical study by the study's sponsor, funders, or others. These numbers may include unique identifiers from other trial registries and National Institutes of Health grant numbers.
  • H2008:233

Drug and device information, study documents

Studies a U.S. FDA-regulated drug product

No

Studies a U.S. FDA-regulated device product

No

product manufactured in and exported from the U.S.

No

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