Respiratory Trials·org

Topic

ICU administration

Staffing, rapid response, triage, and end-of-life communication.

Staffing changes rarely deliver what they promise. Nighttime in-hospital intensivist cover did not improve outcomes in a randomised trial (Kerlin 2013), though an earlier before-and-after study found better processes and staff satisfaction (Gajic 2008). More surprising still, abolishing 24-hour resident shifts *increased* serious medical errors (ROSTERS) — the likely mechanism being that fewer hours per doctor means more handovers, and each handover loses information.

Checklists built their reputation on uncontrolled before-and-after data (Keystone ICU). Cluster-randomised against concurrent controls across 118 units, daily round checklists with goal setting and prompting did not reduce mortality (CHECKLIST-ICU).

Telemedicine works when it comes with authority and process change (Lilly 2011) and not as remote monitoring alone, where full treatment authority was delegated for only a third of patients (Thomas 2009). Pharmacist workload tracks with medication complexity, and higher workload is associated with less care delivered (MRC-ICU).

Overnight intensivist presence

Trial Year Therapy Effect Finding
Kerlin 2013 2013 Nighttime in-hospital intensivist Having an intensivist in the hospital overnight did not improve outcomes
Gajic 2008 before-and-after study 2008 Continuous on-site intensivist Continuous on-site intensivist presence improved processes of care and staff satisfaction

Telemedicine in intensive care

Trial Year Therapy Effect Finding
Lilly 2011 before-and-after study 2011 Tele-ICU Tele-ICU with process reengineering was associated with lower mortality and shorter stays
Thomas 2009 before-and-after study 2009 Remote ICU monitoring Remote ICU monitoring alone did not improve mortality or length of stay

Checklists and quality improvement

Trial Year Therapy Effect Finding
CHECKLIST-ICU 2016 Daily checklist with goal setting and prompting Daily checklists and clinician prompting did not reduce mortality

Doctors' working patterns

Trial Year Therapy Effect Finding
ROSTERS 2020 Schedule without extended shifts Abolishing 24-hour shifts increased serious medical errors rather than reducing them

Pharmacist staffing

Trial Year Therapy Effect Finding
MRC-ICU observational study 2022 Critical care pharmacist input Higher pharmacist workload was associated with less care delivered and worse outcomes

Key references

Guidelines, standards and reviews for this topic.