INTENSIV-News
Physician staffing patterns and clinical outcomes in critically ill patients: a systematic review.
Pronovost PJ, Angus DC, Dorman T, et al. JAMA 2002; 288:2151-62
Department of Critical Care Medicine, Johns Hopkins University, Baltimore, Md, USA.
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
SOURCE: 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.
Die alkoholische Händedesinfektion hat in Mitteleuropa eine lange Tradition. Alkohol wirkt sicher und schnell gegen die meisten im Krankenhaus relevanten Infektionserreger und die alkoholische Händedesinfektion ist überall durchführbar, unabhängig von Waschbecken und Wasserhähnen. In den angelsächsischen Ländern und in Frankreich sah das bisher anders aus: Das Händewaschen wurde eindeutig bevorzugt, man hatte vor allem Angst davor, dass die Haut durch die Anwendung von Alkohol leiden könnte. Die vorliegende randomisierte klinische Studie ist deshalb wichtig für die weitere Durchsetzung der alkoholischen Händedesinfektion in diesen Ländern:
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