Intensivist physician staffing and the process of care in academic medical centres

BACKGROUND: Although intensivist physician staffing is associated with improved outcomes in critical care, little is known about the mechanism leading to this observation. OBJECTIVE: To determine the relationship between intensivist staffing and select process-based quality indicators in the intensive care unit. RESEARCH DESIGN: Retrospective cohort study in 29 academic hospitals participating in the University HealthSystem Consortium Mechanically Ventilated Patient Bundle Benchmarking Project. PATIENTS: 861 adult patients receiving prolonged mechanical ventilation in an intensive care unit. RESULTS: Patient-level information on physician staffing and process-of-care quality indicators were collected on day 4 of mechanical ventilation. By day 4, 668 patients received care under a high intensity staffing model (primary intensivist care or mandatory consult) and 193 patients received care under a low intensity staffing model (optional consultation or no intensivist). Among eligible patients, those receiving care under a high intensity staffing model were more likely to receive prophylaxis for deep vein thrombosis (risk ratio 1.08, 95% CI 1.00 to 1.17), stress ulcer prophylaxis (risk ratio 1.10, 95% CI 1.03 to 1.18), a spontaneous breathing trial (risk ratio 1.37, 95% CI 0.97 to 1.94), interruption of sedation (risk ratio 1.64, 95% CI 1.13 to 2.38) and intensive insulin treatment (risk ratio 1.40, 95% CI 1.18 to 1.79) on day 4 of mechanical ventilation. Models accounting for clustering by hospital produced similar estimates of the staffing effect, except for prophylaxis against thrombosis and stress ulcers. CONCLUSIONS: High intensity physician staffing is associated with increased use of evidence-based quality indicators in patients receiving mechanical ventilation.