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      The effect of a tiered provider staffing model on patient outcomes during the coronavirus disease 2019 pandemic: A single-center observational study

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          Abstract

          Background:

          During the coronavirus disease 2019 (COVID-19) pandemic, our hospital experienced a large influx of critically ill patients with acute respiratory failure. In order to increase intensive care unit (ICU) surge capacity, we adopted a “tiered model” for ICU provider staffing where multiple ICUs were staffed by noncritical care providers under the direction of an intensivist. We hypothesized that ICUs staffed with a tiered model would result in similar patient outcomes as ICU staffed with a traditional intensivist model.

          Methods:

          We performed a single-center, observational study in seven ICUs at a tertiary care center. We included consecutive adults admitted to the ICU with acute respiratory distress syndrome (ARDS) due to COVID-19 infection. We collected baseline demographics, treatments, and outcomes of interest in traditionally staffed ICUs versus ICUs staffed with a tiered model. The primary outcome was inpatient mortality. All outcomes were censored at day 28.

          Results:

          We included a total of 138 patients in our study: 66 patients were admitted to traditionally staffed ICUs and 52 were admitted to tiered staffing ICUs. Baseline characteristics were similar between groups. ARDS treatments were similar in traditionally staffed ICUs versus tiered staffing model ICUs, including daily mean tidal volume (6.2 mL/kg vs. 6.2 mL/kg, P = 0.95), median daily fluid balance (159 mL vs. 92 mL, P = 0.54), and use of prone ventilation (58% vs. 65%, P = 0.45). There was no difference in inpatient mortality between groups (50% vs. 42%, P = 0.46). We also found no difference in ventilator-free, ICU-free, vasopressor-free, and dialysis-free days between groups.

          Conclusions:

          Our results suggest that patient outcomes are similar in ICUs with traditional staffing models when compared to ICUs with a tiered staffing mode during a pandemic.

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          Most cited references12

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          Baseline Characteristics and Outcomes of 1591 Patients Infected With SARS-CoV-2 Admitted to ICUs of the Lombardy Region, Italy

          In December 2019, a novel coronavirus (severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2]) emerged in China and has spread globally, creating a pandemic. Information about the clinical characteristics of infected patients who require intensive care is limited.
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            Acute respiratory distress syndrome: the Berlin Definition.

            The acute respiratory distress syndrome (ARDS) was defined in 1994 by the American-European Consensus Conference (AECC); since then, issues regarding the reliability and validity of this definition have emerged. Using a consensus process, a panel of experts convened in 2011 (an initiative of the European Society of Intensive Care Medicine endorsed by the American Thoracic Society and the Society of Critical Care Medicine) developed the Berlin Definition, focusing on feasibility, reliability, validity, and objective evaluation of its performance. A draft definition proposed 3 mutually exclusive categories of ARDS based on degree of hypoxemia: mild (200 mm Hg < PaO2/FIO2 ≤ 300 mm Hg), moderate (100 mm Hg < PaO2/FIO2 ≤ 200 mm Hg), and severe (PaO2/FIO2 ≤ 100 mm Hg) and 4 ancillary variables for severe ARDS: radiographic severity, respiratory system compliance (≤40 mL/cm H2O), positive end-expiratory pressure (≥10 cm H2O), and corrected expired volume per minute (≥10 L/min). The draft Berlin Definition was empirically evaluated using patient-level meta-analysis of 4188 patients with ARDS from 4 multicenter clinical data sets and 269 patients with ARDS from 3 single-center data sets containing physiologic information. The 4 ancillary variables did not contribute to the predictive validity of severe ARDS for mortality and were removed from the definition. Using the Berlin Definition, stages of mild, moderate, and severe ARDS were associated with increased mortality (27%; 95% CI, 24%-30%; 32%; 95% CI, 29%-34%; and 45%; 95% CI, 42%-48%, respectively; P < .001) and increased median duration of mechanical ventilation in survivors (5 days; interquartile [IQR], 2-11; 7 days; IQR, 4-14; and 9 days; IQR, 5-17, respectively; P < .001). Compared with the AECC definition, the final Berlin Definition had better predictive validity for mortality, with an area under the receiver operating curve of 0.577 (95% CI, 0.561-0.593) vs 0.536 (95% CI, 0.520-0.553; P < .001). This updated and revised Berlin Definition for ARDS addresses a number of the limitations of the AECC definition. The approach of combining consensus discussions with empirical evaluation may serve as a model to create more accurate, evidence-based, critical illness syndrome definitions and to better inform clinical care, research, and health services planning.
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              Epidemiology, Patterns of Care, and Mortality for Patients With Acute Respiratory Distress Syndrome in Intensive Care Units in 50 Countries.

              Limited information exists about the epidemiology, recognition, management, and outcomes of patients with the acute respiratory distress syndrome (ARDS).
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                Author and article information

                Journal
                Int J Crit Illn Inj Sci
                Int J Crit Illn Inj Sci
                IJCIIS
                International Journal of Critical Illness and Injury Science
                Wolters Kluwer - Medknow (India )
                2229-5151
                2231-5004
                Jul-Sep 2021
                25 September 2021
                : 11
                : 3
                : 156-160
                Affiliations
                [1]Division of Pulmonary and Critical Care Medicine, Lahey Hospital and Medical Center, Burlington, MA, USA
                Author notes
                Address for correspondence: Dr. James Dargin, Division of Pulmonary and Critical Care Medicine, Lahey Hospital and Medical Center, 41 Mall Road, Burlington, MA 01805, USA. E-mail: james.m.dargin@ 123456lahey.org
                Article
                IJCIIS-11-156
                10.4103/ijciis.ijciis_37_21
                8547674
                34760662
                867dead8-22d7-4074-bdcc-b4e8dc6f1a93
                Copyright: © 2021 International Journal of Critical Illness and Injury Science

                This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.

                History
                : 01 May 2021
                : 20 May 2021
                Categories
                Original Article

                Emergency medicine & Trauma
                covid-19,intensive care units,personnel staffing and scheduling

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