April 13, 1999
Patients undergoing high-risk surgery may be up to three times more likely to survive if their hospital's intensive care unit (ICU) is staffed by "intensivists," or physicians specially trained in critical care, according to a Johns Hopkins study of 46 Maryland hospitals. A national shortage of these specialists makes it imperative for patients and hospitals to pay attention to ICU staffing, the study's authors say.
Results of the study, published in the April 14 issue of the Journal of the American Medical Association, showed that overall mortality rates after repair of abdominal aortic aneurysms ranged from 0 percent to 66 percent in the hospitals studied. Having an intensivist in the ICU also resulted in an average 83 percent reduction in the number of days spent in that unit.
"Whenever possible, patients should make a point of asking how their hospitals' intensive care units are staffed before they schedule a high-risk procedure such as abdominal aneurysm repair," says Peter J. Pronovost, M.D., lead author of the study and assistant professor of anesthesiology and critical care medicine. "Daily rounds by an ICU specialist are as important as the experience of the surgeon, if not more so."
As a result of the intensivist shortage, he says, many hospitals put non-surgical patients together with post-surgical patients in a single ICU rather than having separate services for each. Because nurses and on-call physicians often tend to pay closer attention to the medical patients, post-operative patients may develop complications that easily could have been prevented or lessened had an intensivist been involved in their care from the start.
For the study, researchers analyzed hospital discharge data for 2,987 abdominal aortic aneurysm patients who were treated at 46 Maryland hospitals between 1994 and 1996, looking at mortality rates, hospital length of stay and the number of days spent in the ICU. People with abdominal aneurysm -- a dangerous ballooning of a major blood vessel -- routinely require ICU admission because of high post-operative morbidity and mortality. The authors also surveyed 39 ICU medical directors in the area about their ICU organization and staffing.
Not having daily rounds by an ICU physician was associated with an increased risk of cardiac arrest, kidney failure, serious infections, and a need for platelet transfusion and reintubation.
The study also found that:
- Patients were twice as likely to die if the hospital did not have a full-time ICU medical director or if less than half of the ICU attending physicians were certified in critical care.
- Hospital stays increased by an average of 10 percent if the hospital did not have a full-time ICU medical director.
- An ICU nurse-patient ratio of less than 1:2 during the day increased the length of time spent in the ICU by 49 percent.
The research was supported in part by Abbott Pharmaceuticals, Abbott Park, Ill.
The study's other authors were Mollie W. Jenckes, M.H.Sc.; Todd Dorman, M.D.; Elizabeth Garrett; Michael J. Breslow, M.D.; Brian A. Rosenfeld, M.D.; Pamela A. Lipsett, M.D.; and Eric Bass, M.D., M.P.H.
Relevant Web sites:
Johns Hopkins Department of Anesthesiology and Critical Care Medicine -- http://www.med.jhu.edu/anesthesiology/