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Staffing the unit – more questions than answers?

UK staffing survey tableA number of articles in the last few months have focused on staffing structure in the ICU.

Previously we’ve seen that ‘high intensity staffing‘  (a dedicated ICU team, or at least the obligatory consultation by one) reduces mortality, in the USA. However night-time intensivists don’t seem to do the same unless there’s a ‘low intensity’ daytime staffing model. Cross-covering fellows may even improve outcome, perhaps through a ‘second opinion’ effect, as suggested in a single centre study.

Now in England, after the recent core standards (ICS and ESICM), a national survey suggests neither consultants’ working pattern nor clinical experience affect mortality (adjusted). Grade of covering night doctor again appeared not to correlate with outcome. The suggestion that intensivist involvement in handover is associated with mortality can almost certainly be ignored as chance (given the small proportion where there is no involvement). Particularly as cardiac arrest in the preceding 24 hours seemed not to make a difference!

Telemedicine  has also shown promising results across the Atlantic in a recent meta-analysis.

Perhaps a bigger issue is staff at the bedside. Isn’t it likely that nursing staffing ratios and continuity affect clinical measures? And how do critical care practitioners and trainees fit into these results?

In any case, aren’t mortality statistics a blunt tool for this analysis? Clinically, longer term outcome measures, readmission rates and other quality indicators may be better. The organisational and meta-outcomes such as staffing moral, staff retention, patient and family satisfaction, and the trainees experience may be better still.