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Change in the provision of out-of-hours consultant cover improves case-mix adjusted mortality in a district general (university-affiliated) hospital intensive care unit

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Introduction

In the United Kingdom the national recommendations [1] for intensive care units (ICUs) include the 24-h availability of consultants with a sessional commitment to intensive care (intensivists). In practice this has not been possible outside the larger teaching hospitals, and normal practice in other hospitals has been for the consultant anaesthetist to provide cover for the ICU out of routine hours. Following introduction of 24-h intensivist cover in our hospital we wished to assess whether there was an improvement in mortality standardised for case-mix using the APACHE 2 prognostic calculation[2] (SMR).

Methods

The 465 patients admitted to ICU in the 18 months following introduction of 24-h intensivist cover (Intensivist) were compared with the 387 patients admitted to ICU in the 18 months immediately preceding the change (Non-Specialist) in a historically controlled study. APACHE 2 scores, calculated risk of death, age, ICU lengths of stay and hospital length of stay (survivors) were collected from the ICU database, and SMRs were calculated for each group. Patients who were under 16 years of age or who stayed in ICU<8 h (Intensivist: 49; Non-Specialist: 59) were excluded. Demographic data was assessed using ANOVA and SMR by Poisson distribution.

Results

There was a significant improvement in SMR in the intensivist group (P<0.01). The APACHE 2 scores in the patients in the intensivist group were significantly lower (P<0.05) (Table).

Conclusions

Within the methodological restrictions of the historical control design this study supports the introduction of 24-h intensivist cover in all intensive care units. The use of SMR as the primary end-point ensures a meaningful comparison of the groups despite the lower APACHE 2 scores in the intensivist group.

Table

References

  1. 1.

    Standards for Intensive Care Units. Intensive Care Society; London. 1997

  2. 2.

    Rowan KM, Kerr JH, Major E, McPherson K, Short A, Vessey MP: . BMJ . 1993, 307: 972-

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Blunt, M., Burchett, K. Change in the provision of out-of-hours consultant cover improves case-mix adjusted mortality in a district general (university-affiliated) hospital intensive care unit. Crit Care 4, P230 (2000). https://doi.org/10.1186/cc949

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Keywords

  • Intensive Care Unit
  • Methodological Restriction
  • Historical Control
  • Hospital Length
  • Meaningful Comparison