The Allocation of Intensivists’ Rounding Time under Conditions of Intensive Care Unit Capacity Strain

With rising demand for critical care, intensivists' time must increasingly be divided among patients (1)(2)(3)(4)(5)(6).Recent studies suggest that increased strain at intensive care unit (ICU) admission leads to higher mortality in closed ICUs (7) and that increased strain at discharge leads to increases in ICU readmissions (8).These relationships between strain and outcomes could be mediated by strain-induced changes in the time intensivists devote to patients during patient care rounds (7-9).We therefore examined how the allocation of intensivists' time during rounds changes at times of low versus high ICU strain and whether intensivists preferentially allocate time away from certain patient groups as strain increases.Some results have been previously reported in the form of an abstract (10). MethodsWe conducted a prospective study of patient care rounds in the 24-bed medical ICU of the Hospital of the University of Pennsylvania in 2012.Time spent performing various rounding activities was recorded in real time by trained data collectors, using a tablet computer.Methods for assessing interrater reliability can be found in the online supplement.Data collection was randomly assigned to one of two intensivist-led medical ICU teams each day and was not performed on weekends.Variables describing patient characteristics, staffing, and ICU strain were obtained from the electronic medical record and as part of a separate clinical trial (11).Our analysis focused on "cognitive rounding time" (time spent on the patient's assessment and plan) and on total rounding time (presentation of events and data, assessment and plan, and teaching related to that patient).Three validated strain variables (5) were considered: team census ("census"), representing the number of patients rounded on by the observed team each day; number of new admissions ("admissions") since the end of rounds the previous day; and average severity of illness ("acuity") of patients on the team, using Acute Physiology and Chronic Health Evaluation III (APACHE III) scores ( 12).We constructed explanatory linear mixed-effects models for cognitive and total rounding time for each patient-day.Patients were treated as random clusters, cumulative days hospitalized in the ICU were included as a random slope and as a linear term, and attending was treated as an indicator variable (13).Patient race Definition of abbreviations: ICU = intensive care unit; IQR = interquartile range.*Within 2 calendar days of ICU discharge.† Within 90 days of hospital admission.