Perspectives
Health services administration Anaesthetics
Volume 198 - Issue 6

Should hospitals have intensivist consultants in-house 24 hours a day? - Yes

Authors:  Sean L Kelly, Roger D Harris and Anthony R Burrell

Med J Aust 2013; 198 (6): 308. || doi: 10.5694/mja12.11578
Published online: 1 April 2013
An intensive care unit is only as good as the care and decision making provided at 2 am. What is needed is an environment that promotes optimal decision making 24 hours a day.
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Onsite intensivist support is needed to improve clinical decisions and safety

An intensive care unit (ICU) is only as good as the care and decision making provided at 2 am. If we believe that intensivists really make a difference to patient outcomes, surely extended hours of onsite intensivist cover are necessary? A patient-centred approach to staffing that takes into account the potential for human error is needed. Most Australian ICUs are staffed after-hours by registrars. Some are not vocational trainees. Experience and clinical skill is variable. Onsite intensivist support tends to be concentrated throughout the day, with the on-call specialists often required to be onsite for 12 hours or more and on-call overnight. Challenges exist in providing uniform levels of clinical expertise around the clock to ICU patients while maintaining a healthy and safe work routine for clinicians.

The ICU is a complex operating environment that requires high-risk decision making day and night. Early work on errors in the ICU emphasised adverse incidents; current research concentrates on diagnostic error. A recent systematic review of autopsy studies on ICU patients found an important incidence of critical misdiagnosis including vascular events and infections.1 Other missed diagnoses included pulmonary embolus, myocardial infarction, pneumonia and aspergillosis. Perhaps extended onsite intensivist cover would help reduce misdiagnoses?

Acute care hospital intensive care services are not only provided within increasingly large ICUs (30 plus beds are not uncommon), but many ICUs also provide rapid response to the wards. Night duty is associated with an increased risk of error because it coincides with the circadian nadir of medical staff and is associated with mild-to-moderate sleep deprivation. A study that examined sleep patterns in a tertiary Australasian ICU found that many registrars were sleep deprived while working on night duty (45% had woken before 16:00 and 48% had less than 5 hours’ sleep before shifts).2 It has been shown that even a modest sleep deficit can impair waking neurobehavioural functions.3

A recent study examined cognitive errors in the ICU and reviewed current research on dual process theory in relation to diagnostic error.4 In essence there are considered to be two types of clinical thinking: pattern recognition (intuitive thinking) and analytical thinking. An experienced clinician mainly uses intuitive thinking, and only uses analytical reasoning when encountering a new situation. Clinical reasoning is often influenced by cognitive bias. Many such biases have been described, including confirmation bias (selecting information to confirm the diagnosis), anchoring heuristic (relying on initial impression despite subsequent information) and framing effects (diagnostic information biased by inappropriate information).

It follows that intuitive thinking is where most cognitive error occurs. Individuals with sleep deprivation and task saturation are more likely to revert to intuitive thinking, which requires less effort than thinking analytically.

It can thus be argued that what is needed is an environment that promotes optimal decision making 24 hours a day. Specialists working extended days and on-call overnight to support junior onsite medical staff is not optimal. While all clinicians will be subject to the pressures of night duty outlined earlier, ICUs need a senior clinician who is awake and immediately available.

There have been arguments for and against intensivist staffing of ICU after-hours with no clear resolution.5 Those opposing 24-hour intensivist staffing have made arguments on the basis of no discernible difference in outcome, intensivist lifestyle and burnout, the need for registrars to have a degree of autonomy in their training, and cost. There are practical difficulties in moving to this system including night duty fatigue and clinical handover. Importantly, it requires a shift from continuity of care provided by individuals to one of system-based continuity. Market forces may eventually drive change towards 24-hour in-house specialist staffing. Increasing numbers of trained specialists and a limited pool of specialist positions has the potential to decrease the demand for intensive care training. Another problem is the smaller ICUs, where 24-hour specialist cover is impractical — although the remote telemedicine model with 24-hour intensivist supervision of multiple ICUs may be the answer here.

Hospitals have a duty to provide safe care. Ideally there should be a specialist awake and available to the ICU at all times. This is a major change in intensivist work practices. Evening shift rostering for intensivists may provide a transition to safer cover for ICUs as well as optimising clinician work routines. Most tertiary hospitals now have specialist anaesthetists and emergency physicians working evening shifts. It might be naive to think that intensive care, which is so closely affiliated to these acute care specialties, should be different.

Authors

  • Sean L Kelly BMed, FACEM1,2
  • Roger D Harris MB BS, FACEM, FCICM3,4
  • Anthony R Burrell MB BS, FANZCA, FCICM1,5
  • 1. Intensive Care Coordination and Monitoring Unit, Agency for Clinical Innovation, Sydney, NSW.
  • 2. Faculty of Health, University of Newcastle, Newcastle, NSW.
  • 3. Royal North Shore Hospital, Sydney, NSW.
  • 4. University of Sydney, Sydney, NSW.
  • 5. University of Technology, Sydney, NSW.

Correspondence: sean.kelly@aci.health.nsw.gov.au

Competing interests

No relevant disclosures.

References

Provenance: Commissioned; not externally peer reviewed.

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