D ATA D R I V E N . P O L I C Y F O C U S E D LDI ResearchBRIEF Research to Improve the Nation’s Health System 2017 . No. 7 STRUCTURAL, NURSING, AND PHYSICIAN CHARACTERISTICS AND 30-DAY MORTALITY FOR PATIENTS UNDERGOING CARDIAC SURGERY IN PENNSYLVANIA Meghan Lane-Fall, Tara S. Ramaswamy, Sydney E. Brown, Xu He, Jacob T. Gutsche, Lee A. Fleisher, Mark D. Neuman Critical Care Medicine, June 2017 KEYFINDINGS Cardiac surgery ICUs vary greatly in structure, care practices, and clinician staffing, but none of these organizational factors is consistently associated with patient mortality in the 30 days following surgery. In this study of 43 Pennsylvania hospitals and nearly 30,000 patients, there was no relationship between mortality and presence of daytime or nighttime intensivists, nurse ICU experience, or presence of interns or residents. THE QUESTION SELECTED CHARACTERISTICS OF Some ICU organizational practices, such as clinician staffing and available PENNSYLVANIA CARDIAC SURGERY ICUs specialists, have been associated with patient outcomes. From a fairly limited Structural Attributes Number (Percent) evidence base, payers and other stakeholders have set standards about how ICU dedicated to cardiac surgery 16 (37%) many and what kinds of providers are required to care for critically ill patients. Protocols: But few studies have been conducted in surgical ICUs; the question of how Low tidal volume ventilation for acute lung injury 18 (43) organizational features affect mortality in surgical ICUs remains an open one. Sedation management 33 (77) Cardiac surgery provides an opportunity to investigate the association further, Therapeutic hypothermia after cardiac arrest 37 (86) because almost all patients are admitted to an ICU after surgery, their care is Liberation from mechanical ventilation 36 (84) protocol-driven, and many of the surgeries are elective. This study describes Checklist for central line insertion 41 (98) the variability in how cardiac ICUs are structured and organized, and analyzes Respiratory therapists participate in daily rounds 26 (61) whether some features are associated with better patient outcomes in patients Pharmacists participate in daily rounds 23 (54) undergoing coronary artery bypass grafting (CABG) or valve procedures. Presence of nurse practitioners or physician assistants 37 (86) Telemedicine access 12 (29) Nursing attributes THE FINDINGS > /3 weekday nurses with 2+ years ICU experience 2 25 (61) Forty-three of 57 hospitals in Pennsylvania, representing 29,499 cardiac surgical Nurses allowed to work 16-hour shift 29 (69) patients, responded to the authors’ questionnaires. ICUs differed greatly in > /3 weekday nurses with BSN degree 2 11 (27) their structure and staffing, as shown in the table. After adjusting for patient Physician attributes characteristics, none of these attributes was associated with 30-day mortality in Presence of daytime intensivist 21 (54) the entire cohort of patients. Presence of attending at night 25 (60) Presence of nighttime intensivist 8 (19) Hospital has teaching affiliation 27 (63) Presence of interns or residents in ICU 8 (19) Presence of fellows in ICU 7 (16) COLONIAL PENN CENTER | 3641 LOCUST WALK | PHILADELPHIA, PA 19104-6218 | LDI.UPENN.EDU | P: 215-898-5611 | F: 215-898-0229 | @PENNLDI ResearchBRIEF LDI To explore whether patient acuity might exist alongside staffing that affect ICU patient among all patients and explored difference in influence the relationship between facility outcomes. Alternative study designs, such as outcomes between emergent and nonemergent characteristics and mortality, the authors qualitative or mixed methods approaches, may procedures. separately analyzed patients admitted electively help explain what these factors may be. and urgently. Among patients admitted Additionally, further research should follow electively, the presence of a nighttime intensivist up on the possibility that organizational was associated with decreased mortality, and practices have a different effect on patients Lane-Fall, M., Ramaswamy, T.S., Brown, S.E., the presence of a nighttime non-intensivist admitted electively than on those admitted He, X., Gutsche, J.T., Fleisher, L.A., Neuman, physician and presence of interns or residents emergently. The authors posit that mortality was associated with increased mortality. Among M.D. (2017), Structural, Nursing, and Physician in urgently admitted patients might be driven Characteristics and 30-Day Mortality for patients who were urgently admitted, less more by patient acuity than ICU staffing, which nurse experience was associated with increased Patients Undergoing Cardiac Surgery in would explain the associations they found in mortality. Pennsylvania. Critical Care Medicine. doi: electively-admitted patients only. If this finding 10.1097/CCM.0000000000002578 holds true in further research, it has implications THE IMPLICATIONS for care networks and efforts to regionalize specialty care. Hospitals in Pennsylvania have organized their cardiac ICUs in a variety of ways to meet the ABOUT LDI needs of post-surgical patients. For example, THE STUDY many ICUs have nurse practitioners or physician The authors conducted a retrospective cohort Since 1967, the Leonard Davis Institute assistants, but some also utilize residents and study of all ICUs in Pennsylvania that care for of Health Economics (LDI) has been the fellows. These clinicians have overlapping adult postoperative cardiac patients, and 43 of leading university institute dedicated to data- scopes of practice in many institutions, and 57 hospitals responded. From September 2012- driven, policy-focused research that improves further research is needed to understand May 2013 they surveyed facilities about use of our nation’s health and health care. Originally the roles that they play in a given setting. common ICU protocols, access to resources to founded to bridge the gap between scholars Furthermore, while these staffing decisions have support ICU care, and staffing characteristics in business (Wharton) and medicine at the an unclear effect on patient outcomes, they do (nurses, advanced practice providers, respiratory University of Pennsylvania, LDI now connects have different cost profiles. More research on therapists, pharmacists, and physicians). They all of Penn’s schools and the Children’s the cost-effectiveness of staffing models may linked facility survey responses to discharge Hospital of Philadelphia through its more be useful to inform best choices on staffing and data on patients treated in responding hospitals, than 250 Senior Fellows. resource use. information on hospital characteristics from the LDI Research Briefs are produced by Although some data suggest that ICU staffing American Hospital Association, and vital status LDI’s policy team. For more information decisions affect patient outcomes, most studies information from the Pennsylvania Department please contact Janet Weiner at focus on either medical or mixed medical- of Health. The study included 29,499 cardiac weinerja@mail.med.upenn.edu. surgical ICUs, with an underrepresentation surgical patients. of ICUs focusing on surgical care. This study They examined associations between ICU adds to the growing evidence base that finds organizational characteristics and mortality in no association between ICU staffing and the 30 days after cardiac surgery, adjusting for outcomes, suggesting that other factors may severity of illness. They measured these effects LEAD AUTHOR DR. MEGHAN LANE-FALL Meghan Lane-Fall, MD, MSHP is an Assistant Professor of Anesthesiology and Critical Care at the University of Pennsylvania. Her current research focuses on the impact of teamwork and communication on health care quality in the perioperative and critical care settings. Dr. Lane-Fall has expertise in the use of mixed methods to answer health services research questions related to surgical care and critical illness. She uses qualitative research techniques to study handoffs and team dynamics and both primary and secondary data sets to model relationships between intensive care unit staffing schemes, clinical predictors, and outcomes in patients receiving critical care. Dr. Lane-Fall received her MD from Yale University School of Medicine in 2006 and an MSHP from the University of Pennsylvania in 2013.