| BackgroundSevere sepsis is defined as acute organ dysfunction secondary to documented or suspected infection. It is one of the leading reasons for hospitalization. In developed countries such as United States and Australia, the annual incidence of severe sepsis ranged from50per100,000population to nearly350per100,000population, and increasing annually in incidence at a rate of1.5%-8.2%. In Taiwan, China, the age-standardized annual incidence rates increased by1.6-fold, from135per100,000in1997to217per100,000in2006. In elderly persons, the incidence of sepsis or septic shock and the related mortality rates are substantially higher than those in younger persons. Given the global aging population and the extension of life expectancy, the incidence of severe sepsis is expected to keep rising in the future.In ICU, approximate11%-27%patients had episodes of severe sepsis and20%-50%of them died. Given the associated organ dysfunctions and metabolic disorder with severe sepsis, it is reasonable an early recognition and intervention would be beneficial. Rivers and colleagues found that early goal-directed therapy (EGDT) provides significant benefits in patients with severe sepsis and septic shock, by reducing mortality from46.5%to30.5%. Thus, an effective and early intervention would improve the outcomes of patients with severe sepsis and septic shockIn fact, more than half ICU patients were admitted in off-hours in holiday, weekends and night shifts, there is no exception of patients with severe sepsis and septic shock. However, the resources of hospital and ICU at peak time are stretched to thin and some studies demonstrated that off-hours admission increased the mortality of critically ill patients. Interestingly, weekend and weeknight admissions have the same outcome of weekday admissions to an intensive care unit once the ICU staffed with intensivist. It is generally acknowledged that attending intensivists are more experienced and therefore would provide more appropriate and effective treatments for critically ill patients. On the other hand, patients and their families, even physicians outside ICU would prefer intensivists with higher experience to treat their patients. Nevertheless, staffing ICU with attending intensivitst during off-hours would increase the burdens of hospital and the whole health system. Moreover, too much off-hours shifts would aggravate the burnouts among ICU physicians. Although that24/7attending intensivitst coverage would improve outcome is an idea with intuitive appeal, few empirical study is available as to the effect of off-hours attending intensivitst coverage on the ICU patients with severe sepsis and septic shock. Thus, a prospectively observational cohort was designed to compare the treatment and outcomes of severe sepsis and septic shock among attending and fellow intensivitst coverage during off-hours in a tertiary academic hospital.Material and methodsThe study location is the only mixed ICU in the hospital with around1300beds. It is a closed ICU and staffed with attending intensivists and some fellows and residents at daytime. Residents are rotated at every five to six days interval for the night shifts, leaded by either attending or fellow intensivists. Consecutive patients met the preset criteria between April2010and December2012were enrolled in the study. The institutional review board of the hospital approved the study protocol and waived from the need for a consent form. The study was register in www.clinicaltrialecrf.org and the trial number is ChiCTR-OCH-12002496.All treatments were at the discretion of on-shift ICU physicians. The demographic data, baseline lab findings, treatments and ICU outcomes were recorded. The primary aim of the study was to compare the outcomes of off-hours ICU admitted patients with severe sepsis and septic shock with either attending or fellow intensivitst coverage. Second aims were to compare the treatment and other outcome indicators, such as ICU and hospital length of stay, incidence of acute respiratory distress syndrome and acute kidney injury, ICU cost and cost for antimicrobial treatments.Descriptive data were reported as either mean±SD, median (interquartile range) or number and percentage. With respect to the differences in ICU outcomes between two groups, categorical variables were compared using chi-square analysis. Continuous variables were compared using Independent Sample T test for normally distributed data and Mann-Whitney U test for non-normally distributed data. Power=1-β was calculated using PASS12.0. To identify potential correlation between off-hours attending intensivist coverage and ICU outcomes for patients with severe sepsis and septic shock, binary logistic regression analysis was performed using ICU mortality as the dependent variable and patient demographics, admission hours, clinical condition, co-morbidities, baseline lab findings, infection sources and APACHE II as the independent variables. The generalized estimating equation (GEE) regression model was used to account for the effect of clustering of patients among physicians, which may make their observations not independently. Odds ratios and their95%confidence intervals (95%CIs) were calculated. Statistical analysis was performed, using SPSS16.0(Chicago,I11, USA). Significance was defined as a P value<0.05.ResultsThere were260patients enrolled in the study. Of them,123patients were assigned to the treatment of attending intensivists, while137patients were treated by fellow intensivists. There were no significant differences in terms of patients’age, gender, source of admission, ICU admission hours, previous surgical procedure, co-morbidity, infection sites, percent of patients ventilated on ICU admission, APACHE II score and central venous oxygen saturation between the two groups.With respect to the treatment, the fluid intake, output volume, and preferred choice of vasopressor were similar. Attending intensivists were more likely to prescribe combined antimicrobial agents for the initial empirical therapy (52.8%vs38.7%, P=0.022). Approximate two thirds of intensivists of both groups chose carbapenems-based antimicrobial regimen. Specimens of vast majority of the patients were cultured before antimicrobial agents were administration. Interval between administration of antimicrobial agents and ICU admission were similar between two groups (3.3±1.5hours vs3.4±1.8hours,P=0.563). Compared to attending intensivists, fellow intensivists were more likely to use steroid in the treatment of severe sepsis and septic shock (9.8%vs21.9%,P=0.008).The incidences of acute respiratory distress syndrome and acute kidney injury between were similar. The median ventilation days (13.4vsl3.6days, P=0.111) and renal replacement days(3.0vs2.6days, P=0.880)were also similar. Median ICU length of stay (16.9vs15.7days, P=0.105) and hospital stay (27.0vs26.0days, P=0.168) were also similar. Moreover, the ICU cost and cost for antimicrobial treatment were also similar.By adjusting patients’age, gender, source of admission, ICU admission hours, previous procedure, co-morbidity, infected sites, ventilated on ICU admission, APACHE II score and initial empirical antimicrobial therapy, the regression analysis demonstrated that patients with COPD (OR:19.34,95%CI:2.57-145.72, P=0.004), prior tumor (OR.11.06,95%CI:1.82-67.11,P=0.009), and high APACHE II score (OR:1.29,95%CI:1.14-1.46, P<0.001) were the independent high risk for patients mortality. While off-hours attending intenvisits coverage provides no extra benefit (OR:1.16,95%CI:0.34-3.94,P=0.818) in terms of ICU mortality.ConclusionThe addition of off-hours attending intensivists coverage to a daytime attending staffing model was not associated with reduced mortality for patients with severe sepsis and septic shock. |
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