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Intensive Care Unit Staffing and Failure to Rescue with Major Surgery

      Introduction: Every year thousands of patients undergoing major surgery experience adverse outcomes resulting in admission to an intensive care unit (ICU). Optimal management of these patients in the ICU through evidence based guidelines and processes of care may improve morbidity and mortality. However, the added value of certified intensivists in guiding this care remains debatable. Methods: Using 2006 Medicare data, we identified patients undergoing colectomy (n=49,327), pancreatectomy (n=2,748), and esophagectomy (n=2,242) at hospitals participating in the Leapfrog Group Hospital Quality and Safety Survey. A total of 1,044, 634, and 704 participating hospitals performed colectomy, pancreatectomy, and esophagectomy, respectively. We compared rates of major complications (pulmonary failure, pneumonia, myocardial infarction, deep venous thrombosis/pulmonary embolism, acute renal failure, hemorrhage, surgical site infection, and gastrointestinal bleeding), failure to rescue (death following a major complication), and 30-day in-hospital mortality between hospitals reporting adherence to the Leapfrog ICU physician staffing model and those who did not. Results: For colectomy, pancreatectomy, and esophagectomy, there were 51.9%, 35.6%, and 40.9%, who underwent surgery in a hospital with certified intensivists, respectively. Hospitals with the presence of a full-time intensivist had lower mortality rates for all three operations. Failure to rescue rates were lower in hospitals where an intensivist managed or co-managed all ICU patients who underwent pancreatectomy (15.7% vs. 26.5%; OR 2.11, 95% CI 1.43-3.12), and colectomy (24.4% vs. 26.1%; OR 1.10, 95% CI 1.01-1.19). For esophagectomy, there was a trend toward lower failure to rescue rates in hospitals with dedicated intensivists (19.7% vs. 21.3%; OR 1.04, 95% CI 0.73-1.50). Conclusions: Hospitals with the presence of full-time intensivists who manage or co-manage all ICU patients are associated with lower mortality and failure to rescue rates after high risk surgery. Efforts to implement an ICU staffing standard across the United States should continue to emphasize the potential improvements in patient safety.
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