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A Systematic Review

Peter J. Pronovost, MD, PhD; Derek C. Angus, MB, ChB, MPH; Todd Dorman, MD; Karen A. Robinson, MSc; Tony T. Dremsizov, MBA; Tammy L. Young

JAMA. 2002;288:2151-2162.

Context  Intensive care unit (ICU) physician staffing varies widely, and its association with patient outcomes remains unclear.

Objective  To evaluate the association between ICU physician staffing and patient outcomes.

Data Sources  We searched MEDLINE (January 1, 1965, through September 30, 2001) for the following medical subject heading (MeSH) terms: intensive care units, ICU, health resources/utilization, hospitalization, medical staff, hospital organization and administration, personnel staffing and scheduling, length of stay, and LOS. We also used the following text words: staffing, intensivist, critical, care, and specialist. To identify observational studies, we added the MeSH terms case-control study and retrospective study. Although we searched for non–English-language citations, we reviewed only English-language articles. We also searched EMBASE, HealthStar (Health Services, Technology, Administration, and Research), and HSRPROJ (Health Services Research Projects in Progress) via Internet Grateful Med and The Cochrane Library and hand searched abstract proceedings from intensive care national scientific meetings (January 1, 1994, through December 31, 2001).

Study Selection  We selected randomized and observational controlled trials of critically ill adults or children. Studies examined ICU attending physician staffing strategies and the outcomes of hospital and ICU mortality and length of stay (LOS). Studies were selected and critiqued by 2 reviewers. We reviewed 2590 abstracts and identified 26 relevant observational studies (of which 1 included 2 comparisons), resulting in 27 comparisons of alternative staffing strategies. Twenty studies focused on a single ICU.

Data Synthesis  We grouped ICU physician staffing into low-intensity (no intensivist or elective intensivist consultation) or high-intensity (mandatory intensivist consultation or closed ICU [all care directed by intensivist]) groups. High-intensity staffing was associated with lower hospital mortality in 16 of 17 studies (94%) and with a pooled estimate of the relative risk for hospital mortality of 0.71 (95% confidence interval [CI], 0.62-0.82). High-intensity staffing was associated with a lower ICU mortality in 14 of 15 studies (93%) and with a pooled estimate of the relative risk for ICU mortality of 0.61 (95% CI, 0.50-0.75). High-intensity staffing reduced hospital LOS in 10 of 13 studies and reduced ICU LOS in 14 of 18 studies without case-mix adjustment. High-intensity staffing was associated with reduced hospital LOS in 2 of 4 studies and ICU LOS in both studies that adjusted for case mix. No study found increased LOS with high-intensity staffing after case-mix adjustment.

Conclusions  High-intensity vs low-intensity ICU physician staffing is associated with reduced hospital and ICU mortality and hospital and ICU LOS.

Author Affiliations: Departments of Anesthesiology and Critical Care Medicine (Drs Pronovost and Dorman), Surgery (Drs Pronovost and Dorman), Medicine (Dr Dorman), Health Policy and Management (Dr Pronovost), and Epidemiology, Bloomberg School of Public Health (Ms Robinson), Johns Hopkins University, Baltimore, Md; and the Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Laboratory, Department of Critical Care Medicine (Dr Angus, Mr Dremsizov, and Ms Young), and Department of Health Policy and Management, Graduate School of Public Health (Dr Angus), University of Pittsburgh, Pittsburgh, Pa.

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