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Nighttime Physician Staffing in an Intensive Care Unit To the Editor: In their randomized trial, Kerlin et al. (June 6 issue)1 found that the availability of on-site intensivists during the night in intensive care units (ICUs) did not improve patient outcomes as compared with supervision by off-site intensivists. Family satisfaction is considered to be an important indicator of quality of care.2-5 Although an overall consistently high level of family satisfaction has been reported across European ICUs,2,3 studies of Australian and Canadian ICUs have highlighted the frequency of physician interactions with families as an area to further improve family satisfaction.4,5 It would be of interest to examine the influence of nighttime staffing of senior physicians on both staff morale and family satisfaction. Jonathan C. Li, M.B., B.S. Yuyi You, M.B., B.S. Stuart L. Graham, M.B., B.S., Ph.D. Macquarie University Sydney, NSW, Australia
[email protected] No potential conflict of interest relevant to this letter was reported. 1. Kerlin MP, Small DS, Cooney E, et al. A randomized trial of
nighttime physician staffing in an intensive care unit. N Engl J Med 2013;368:2201-9. 2. Stricker KH, Kimberger O, Schmidlin K, Zwahlen M, Mohr U, Rothen HU. Family satisfaction in the intensive care unit: what makes the difference? Intensive Care Med 2009;35:2051-9.
this week’s letters 1074 Nighttime Physician Staffing in an Intensive Care Unit 1075 Inhaled Adrenaline in Acute Bronchiolitis 1077 Antithrombotic Therapy and Invasive Procedures 1080 PML in Patients Treated for Psoriasis
3. Schwarzkopf D, Behrend S, Skupin H, et al. Family satisfac-
tion in the intensive care unit: a quantitative and qualitative analysis. Intensive Care Med 2013;39:1071-9. 4. Heyland DK, Rocker GM, Dodek PM, et al. Family satisfaction with care in the intensive care unit: results of a multiple center study. Crit Care Med 2002;30:1413-8. 5. Sundararajan K, Sullivan TR, Chapman M. Determinants of family satisfaction in the intensive care unit. Anaesth Intensive Care 2012;40:159-65. DOI: 10.1056/NEJMc1308523
To the Editor: Kerlin et al. conclude that inhospital intensivist staffing at night did not improve patient outcomes in an academic medical ICU. However, in the intervention group, I think there is a discrepancy between the inclusion of patients for the calculation of the secondary-outcome data and the physical presence of a nighttime intensivist. According to the study methods, the staffing with in-hospital intensivists was from 7 p.m. to 7 a.m. In the secondary-outcome calculation, the nighttime admissions were those between 5 p.m. and 4:59 a.m. The secondary outcomes of patients admitted between 5 p.m. and 6:59 p.m. during the intervention period may not reflect nighttime staffing. Also, in the intervention group, the omission of patients who were admitted between 5 a.m. and 6:59 a.m. during the intervention period may have affected the secondary-outcome data on patients who were admitted at night. Hence, extra caution must be taken in interpreting these secondary-outcome data and the influence of in-hospital nighttime intensivist staffing during the intervention period. Manova David, M.D. Mayo Clinic Health System Eau Claire, WI
[email protected] No potential conflict of interest relevant to this letter was reported. DOI: 10.1056/NEJMc1308523
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correspondence
To the Editor: Kerlin and colleagues report no significant effect of in-hospital nighttime intensivists on patient outcomes. The authors suggest that the findings might be explained by the high quality of care provided by well-trained residents with telephone access to attending physicians. Given that resident training hours are limited,1 did the telephone interactions preclude an important training opportunity? The presence of nighttime attending physicians allows increased contact between residents and attending physicians. It also improves the educational experience, as noted in this study and others.2 In future studies evaluating the role of in-hospital nighttime attending physicians, the role of resident education should be considered. Kumaran Shanmugarajah, M.R.C.S. Imperial College London London, United Kingdom
[email protected]
Maria Lucia Madariaga, M.D. Massachusetts General Hospital Boston, MA
Sebastian Michel, M.D. Ludwig-Maximilians-Universität Munich, Germany No potential conflict of interest relevant to this letter was reported. 1. Steinbrook R. The debate over residents’ work hours. N Engl
J Med 2002;347:1296-302. 2. Haber LA, Lau CY, Sharpe BA, Arora VM, Farnan JM, Ranji SR. Effects of increased overnight supervision on resident education, decision-making, and autonomy. J Hosp Med 2012;7:606-10. DOI: 10.1056/NEJMc1308523
outcome, although it was not measured in this study. As noted in the Discussion section of our article, future studies of intensivist staffing should consider measuring family and nurse satisfaction. In response to David’s point: we defined nighttime admissions as admissions of patients who arrived in the medical ICU between 5 p.m. and 4:59 a.m., since these patients were routinely examined completely by the nighttime intensivists when they were present, rather than the daytime team. Although the findings were not included in the article, we conducted a sensitivity analysis using David’s definition of nighttime admissions and found results identical to those that we reported. We also agree with the comment by Shanmugarajah and colleagues regarding the possible opportunity for education during nighttime hours with the presence of a nighttime intensivist. We believe there are uncertain benefits of autonomy versus supervised instruction for trainees and long-term implications for the intensivist workforce1 that warrant further study to inform policies on nighttime staffing. Meeta Prasad Kerlin, M.D., M.S.C.E. Scott D. Halpern, M.D., Ph.D. Perelman School of Medicine at the University of Pennsylvania Philadelphia, PA
[email protected] Since publication of their article, the authors report no further potential conflict of interest. 1. Kerlin MP, Halpern SD. Twenty-four-hour intensivist staff-
The Authors Reply: We agree with Li and colleagues that family satisfaction is an important
ing in teaching hospitals: tensions between safety today and safety tomorrow. Chest 2012;141:1315-20.
DOI: 10.1056/NEJMc1308523
Inhaled Adrenaline in Acute Bronchiolitis To the Editor: Skjerven and colleagues (June 13 issue)1 reported that inhaled racemic adrenaline is not more effective than inhaled saline in infants with acute bronchiolitis. Inhaled therapies are used frequently to treat children with bronchiolitis,2 despite the lack of evidence from clinical trials and recommendations against their use.3 The American Academy of Pediatrics recommendations for bronchiolitis state, “A carefully monitored trial of α-adrenergic or β-adrenergic medication is an option. Inhaled bronchodilators should be continued only if there is a document-
ed positive clinical response to the trial using an objective means of evaluation.”3 We wonder whether the authors could identify a subgroup of infants who had a better initial clinical response to adrenaline (e.g., improvement in the overall clinical score of >2) and whether these participants had better clinical outcomes than did the overall population studied. Ricardo G. Branco, M.D., Ph.D. Addenbrooke’s Hospital Cambridge, United Kingdom
[email protected]
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