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KEY POINTS

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  • Most studies addressing staffing of ICUs have had significant limitations, and this literature does not yet provide a consistent view of the best model to use. This subject is complicated by the fact that optimal ICU staffing may depend on ICU characteristics.

  • Despite calls for all ICUs to function as closed-model units with intensivists as the primary physician of record, evidence supporting this view is contradictory. Likewise, studies of around-the-clock intensivist presence have not consistently shown that it is associated with superior outcomes.

  • The data do not supply a consistent answer to the question of whether ICUs would obtain better outcomes if they added nurses to reduce their patient:nurse ratios.

  • Increasingly, nonphysician providers are playing innovative roles in the ICU, and care provided by teams including nurse practitioners or physician assistants appears to be safe and comparable to that provided by other staffing models.

  • The conditions of ICU staffing will continue to change under the stresses of shortages of a variety of health care workers relevant to ICU care, and increasing duty hour limitations for physician trainees. Nonphysician providers, innovative staffing models, telemedicine, and other technologies will be increasingly used to cope with these realities.

  • Since only quantitative evaluation can tell us whether one staffing model is better than another, we need more research from multiple sites to develop a consistent and integrated understanding of this complex topic.

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INTRODUCTION

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Like all complex organizations, intensive care units (ICUs) have numerous variable elements of organization and structure, including how they are staffed. Outside of medicine, it is widely accepted that most of the opportunities to improve the performance of complex organizations derive from improving the structures and processes of which they consist. Within this systems-based concept, every aspect of what we do and how we do it is a candidate for study and change, including all aspects of ICU staffing.1 Though a variety of types of health care workers (HCWs) collaborate in caring for ICU patients,2 relatively little is known about the relationships between ICU staffing and outcomes. It is rare for staffing patterns to be the result of an evidence-based assessment of what works best; they usually reflect historical precedents, combined with practical necessities and growth by accretion.

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Staffing options can be framed as a number of questions, such as: Who does it?, How many of them are there to do it?, What do they do?, and How do they do it? These address the type, training, experience, and other characteristics of the HCWs; details of work schedules, including workload, duty hours, shiftwork, and coverage for nights and weekends; details of assigned tasks; and interfaces between different types of HCW. Not only is all of this highly complex and interacting, but the optimal staffing structure for a given ICU may well differ based on ICU type, size, case mix, and other differences of baseline structure.

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