In-House Attending and Extubation in Congenital Heart Surgery
In-House Attending and Extubation in Congenital Heart Surgery
Objectives: Many cardiac ICUs have instituted 24/7 attending physician in-house coverage, which theoretically may allow for more expeditious weaning from ventilation and extubation. We aimed to determine whether this staffing strategy impacts rates of nighttime extubation and duration of mechanical ventilation.
Design: National data were obtained from the Virtual PICU System database for all patients admitted to the cardiac ICU following congenital heart surgery in 2011 who required postoperative mechanical ventilation. Contemporaneous data from our local institution were collected in addition to the Virtual PICU System data. The combined dataset (n = 2,429) was divided based on the type of nighttime staffing model in order to compare rates of nighttime extubation and duration of mechanical ventilation between units that used an in-house attending staffing strategy and those that employed nighttime residents, fellows, or midlevel providers only.
Measurements and Main Results: Institutions that currently use 24/7 in-house attending coverage did not demonstrate statistically significant differences in rates of nighttime extubation or the duration of mechanical ventilation in comparison to units without in-house attendings. Younger patients cared for in non-in-house attending units were more likely to require reintubation.
Conclusions: Pediatric patients who have undergone congenital heart surgery can be safely and effectively extubated without the routine presence of an attending physician. The utilization of nighttime in-house attending coverage does not appear to have significant benefits on the rate of nighttime extubation and may not reduce the duration of mechanical ventilation in units that already use in-house residents, fellows, or other midlevel providers.
Children and adults admitted to ICUs during the weekend or at night have an increased risk for morbidity and mortality. It has been suggested that this association is directly related to differences in staffing patterns that occur during these times. In light of these controversial findings, there has been a great deal of interest in instituting 24/7 in-house attending level staffing in pediatric, adult, and cardiac ICUs (CICUs). The added experience and expertise of an in-house attending might confer a number of benefits including a reduction in the total duration of mechanical ventilation by allowing continued weaning and extubation during the nighttime hours. In fact, a recent retrospective single-center experience was published that did demonstrate a statistically significant reduction in the duration of mechanical ventilation in a PICU following institution of in-house attending coverage.
Given the association of prolonged mechanical ventilation following congenital heart surgery with adverse outcomes, there is obvious appeal in any strategy that results in decreased duration of mechanical ventilation. Additionally, reductions in the length of mechanical ventilation are likely to result in decreased resource utilization and shortened hospital length of stay (LOS), which has been related to long-term improvements in cognitive outcome in some studies.
We therefore sought to determine whether 24/7 in-house attending staffing models are associated with 1) increased rates of nighttime extubation and 2) reduced length of postoperative mechanical ventilatory support. Our current staffing model uses in-house CICU attendings from 07:00 to 17:00 on most days. During the off hours, pediatric cardiology fellows (with a minimum of 4 yr of postgraduate education) and midlevel caregivers provide in-house coverage, with attendings available from home. We hypothesized that this model is associated with similar rates of nighttime extubation and length of ventilatory support as 24/7 in-house attending staffing models.
Abstract and Introduction
Abstract
Objectives: Many cardiac ICUs have instituted 24/7 attending physician in-house coverage, which theoretically may allow for more expeditious weaning from ventilation and extubation. We aimed to determine whether this staffing strategy impacts rates of nighttime extubation and duration of mechanical ventilation.
Design: National data were obtained from the Virtual PICU System database for all patients admitted to the cardiac ICU following congenital heart surgery in 2011 who required postoperative mechanical ventilation. Contemporaneous data from our local institution were collected in addition to the Virtual PICU System data. The combined dataset (n = 2,429) was divided based on the type of nighttime staffing model in order to compare rates of nighttime extubation and duration of mechanical ventilation between units that used an in-house attending staffing strategy and those that employed nighttime residents, fellows, or midlevel providers only.
Measurements and Main Results: Institutions that currently use 24/7 in-house attending coverage did not demonstrate statistically significant differences in rates of nighttime extubation or the duration of mechanical ventilation in comparison to units without in-house attendings. Younger patients cared for in non-in-house attending units were more likely to require reintubation.
Conclusions: Pediatric patients who have undergone congenital heart surgery can be safely and effectively extubated without the routine presence of an attending physician. The utilization of nighttime in-house attending coverage does not appear to have significant benefits on the rate of nighttime extubation and may not reduce the duration of mechanical ventilation in units that already use in-house residents, fellows, or other midlevel providers.
Introduction
Children and adults admitted to ICUs during the weekend or at night have an increased risk for morbidity and mortality. It has been suggested that this association is directly related to differences in staffing patterns that occur during these times. In light of these controversial findings, there has been a great deal of interest in instituting 24/7 in-house attending level staffing in pediatric, adult, and cardiac ICUs (CICUs). The added experience and expertise of an in-house attending might confer a number of benefits including a reduction in the total duration of mechanical ventilation by allowing continued weaning and extubation during the nighttime hours. In fact, a recent retrospective single-center experience was published that did demonstrate a statistically significant reduction in the duration of mechanical ventilation in a PICU following institution of in-house attending coverage.
Given the association of prolonged mechanical ventilation following congenital heart surgery with adverse outcomes, there is obvious appeal in any strategy that results in decreased duration of mechanical ventilation. Additionally, reductions in the length of mechanical ventilation are likely to result in decreased resource utilization and shortened hospital length of stay (LOS), which has been related to long-term improvements in cognitive outcome in some studies.
We therefore sought to determine whether 24/7 in-house attending staffing models are associated with 1) increased rates of nighttime extubation and 2) reduced length of postoperative mechanical ventilatory support. Our current staffing model uses in-house CICU attendings from 07:00 to 17:00 on most days. During the off hours, pediatric cardiology fellows (with a minimum of 4 yr of postgraduate education) and midlevel caregivers provide in-house coverage, with attendings available from home. We hypothesized that this model is associated with similar rates of nighttime extubation and length of ventilatory support as 24/7 in-house attending staffing models.
Source...