Abstract
Critical illness does not keep to regular, daytime business hours; we must provide
high-quality care and support for intensive care unit (ICU) patients 24 hours per
day, 7 days per week. Whether this mandates the presence of similar numbers and types
of personnel throughout all hours of the day, however, has been the subject of much
debate and substantial research. In this article, we review the available literature
on the consequences of having three groups of care providers at a patient's bedside
overnight: physicians, visitors, and nurses. Though few of the studies on this topic
are randomized and prospective, several themes have emerged from the existing data.
First, there is dramatic variation in practice between and within countries. Second,
the weight of evidence does not indicate that patient outcomes are improved by having
an intensivist present overnight in ICUs that are staffed by intensivists during the
daytime hours. Third, although visitation is highly restricted in many ICUs—out of
concerns for disruption of care and a negative physiological or psychological impact
on patients—the available data suggest that patients and their families generally
benefit from open visitation policies. And finally, although there is little debate
that nurses are (and should be) available in the ICU 24/7, existing data do not provide
much of a consensus about the details. Uncertainties include whether outcomes are
better when each nurse is assigned only one patient (or, more generally, the optimal
patient:nurse ratio), who these nurses should be (e.g., registered nurses vs. other
personnel), and what their roles should entail (e.g., managing ventilators). As such,
we cannot yet identify the optimal overnight nurse staffing strategy. What is clear
is that the critical care community needs more and better data to further define these
aspects of the relationship between ICU structure and ICU outcomes.
Keywords
critical care - intensive care unit - optimal staffing - outcomes - intensivists -
ICU telemedicine
