The Case for Telemedicine-Enhanced Nighttime Staffing in a Neuro-ICU.

Importance: This study compares the health outcomes and healthcare utilization of two staffing models for specialized neuro-ICU (NICU): a 24/7 intensive staffing (IS) model and a daytime 12-hour intensivist model with 12-hour nocturnal telemedicine-enhanced (TE) coverage. The IS model was studied from July 2016 to June 2017. The TE model was studied during the implementation period from July 2017 to June 2018.

Objectives: To compare the health outcomes and healthcare utilization of two staffing models for a specialized NICU.

Design: Retrospective cohort study.

Setting and participants: NICU with 24 beds in a 1200-bed urban, quaternary care, academic hospital in Northeast Ohio. Participants were critically ill patients with primary neurologic injuries admitted to the NICU between July 2016 and June 2018.

Main outcomes and measures: Multivariable logistic, and negative binomial regression analysis compared the following outcomes: mortality, ICU length of stay (LOS), hospital LOS, and ventilator days. Demographics and patient characteristics, including Acute Physiology and Chronic Health Evaluation scores, were used in model adjustments.

Results: Three thousand seventy-three patients were studied: n equals to 1542 IS (average age 61 yr [sd 17], 49% female, 73% White race) and n equals to 1531 TE (average age 62 yr (sd 17), 49% female, 70% White race). The TE model required less staff than IS model (5 vs. 9 staff intensivists), respectively. Compared with IS, the TE cohort had similar demographics and clinical indications, although the groups differed on the distribution of the body systems necessitating ICU admission. TE model was protective of ICU mortality compared with IS model (odds ratio = 0.59; 95% CI, 0.43-0.82; p = 0.002). However, TE was associated with a 10% increase in ICU LOS (incident rate ratio [IRR] = 1.10; 95% CI, 1.03-1.18; p = 0.006) and a 13% increase in total LOS (IRR = 1.13; 95% CI, 1.06-1.20; p < 0.001). There was no difference in ventilator days between groups.

Conclusions and relevance: The availability of critical care staff is not keeping pace with demand, especially in specialized ICUs, including NICU. The TE model required fewer staff with similar clinical outcomes. This is a preliminary study highlighting that alternate specialized ICU staffing models could require fewer labor requirements while still maintaining quality of care. Further research is required to assess the true impact of LOS differences and examine the impact of these models on physician burnout and retention. This new understanding would provide additional guidance on ICU staffing options and telemedicine costs to hospitals, ensuring efficient and effective resource allocation as ICU demands continue to increase.