One- or two-week Patient-intensivist Continuity of Care in the ICU?

The optimal duration of intensivist service blocks in ICUs is still debated. Shorter blocks, while reducing physician burnout and providing fresh perspectives on treatment, result in more frequent changes in intensivists, which may negatively impact clinical outcomes due to increased turnover.

Existing studies on physician block lengths are difficult to apply to ICUs because of differences in patient acuity. ICU-focused research has primarily examined the effects of night or weekend coverage, often overlooking the potential impact of information loss when an intensivist leaves the care team after a block.

To better understand this issue, a study compared one versus two weeks of patient-intensivist continuity in hospitals where two-week blocks are standard. The analysis focused on outcomes for patients admitted during the first week (allowing up to two weeks of continuous care) versus those admitted in the second week (receiving one week of continuous care). This comparison offers insights into how continuity of care affects patient outcomes while controlling for variations related to the day of admission [1].

As an intensivist, what is your preferred duration for patient-intensivist continuity in the ICU to optimize patient care and outcomes?

• 0%One-week duration
• 0%Two-week duration
• 0%No preference

Key Findings

The results of the study revealed no significant differences in adjusted hospital mortality between the two groups, nor were there significant differences in ICU length of stay. Additionally, for patients requiring mechanical ventilation, the study found no differences in adjusted mortality, ICU length of stay, or the duration of mechanical ventilation. These findings suggest that extending intensivist continuity from one to two weeks may not have a substantial impact on key clinical outcomes for adult medical ICU patients.

Potential Benefits of Continuity

Although the primary study did not demonstrate significant outcome differences, other potential benefits of continuity of care in ICUs should not be overlooked. Continuity of care may enhance communication with patients and their families, leading to better understanding and satisfaction with the care provided.

Prolonged continuity also allows intensivists to more effectively detect and address evolving clinical issues, potentially preventing complications. Furthermore, consistent care by the same intensivist might contribute to more efficient resource utilization and improved care coordination, leading to a more streamlined ICU operation.

Considerations for Intensivists

Several factors must be considered when evaluating intensivist staffing models. Extended shifts and prolonged continuity can contribute to physician burnout, potentially affecting both the quality of care and the well-being of healthcare providers. Additionally, extended intensivist continuity may impact the educational experience and autonomy of trainees, who benefit from exposure to diverse clinical approaches and decision-making processes. The choice between 24/7 in-house coverage and other staffing models can also influence patient outcomes and intensivists' work-life balance. Finding a model that effectively balances these considerations is essential.

Caveats and Limitations

It is important to note that the primary study was observational, which limits the ability to draw causal inferences from the findings. The results may not be generalizable to all ICU types or patient populations, and other factors beyond the duration of continuity may play a significant role in determining outcomes. More research is needed to explore the nuances of intensivist continuity and its impact on different patient populations and ICU settings.

Conclusion

While current evidence does not strongly support extending intensivist continuity from one to two weeks for adult medical ICU patients in terms of clinical outcomes, continuity of care remains a vital aspect of ICU staffing models. Achieving a balance between patient outcomes, resource utilization, and provider well-being is crucial, and further research may be necessary to identify the most effective approaches. As intensivist staffing models continue to evolve, the importance of both continuity and adaptability in ICU care will remain central to optimizing patient outcomes.

Reference

1. Admon, Andrew J. MD, MPH, MS1,2,3,4; Cohen-Mekelburg, Shirley MD, MS3,5,6; Opatrny, Megan MD7; Lee, Kathleen T. MPH1; Law, Anica C. MD, MS8,9; Gershengorn, Hayley B. MD10,11; Valley, Thomas S. MD, MSc1,3,4; Prescott, Hallie C. MD, MSc1,3,4; Wiktor, Michael J. PhD, MS12; Neeluru, Jayashree MS12; Cooke, Colin R. MD, MSc, MS1,4; Weissman, Gary E. MD, MSHP13,14,15,16.Two Weeks Versus One Week of Maximal Patient-Intensivist Continuity for Adult Medical Intensive Care Patients: A Two-Center Target Trial Emulation*. Critical Care Medicine 52(9):p 1323-1332, September 2024 [Link]