The effect of a tiered staffing model on outcomes for patients with ARDS during the COVID pandemic

ABSTRACT

INTRODUCTION: Our hospital experienced a surge in ICU capacity during the COVID-19 pandemic and adopted a tiered provider staffing model. We hypothesized that ICUs staffed with a tiered model would result in similar patient outcomes as ICUs staffed with a traditional intensivist model. METHODS: The study was conducted at a tertiary care center with 52 ICU beds staffed with a 24/7 intensivist coverage model. During the pandemic, ICU capacity was doubled and ICUs with COVID-19 patients were staffed by either an intensivist or by a non-intensivist under the direction of an intensivist using a tiered system. We included adult ICU patients with ARDS and suspected or confirmed COVID-19 between March and May of 2020. We collected demographics, COVID-19 and ARDS treatments, and outcomes of interest in traditionally staffed ICUs vs. ICUs staffed with a tiered model. The primary outcome was inpatient mortality. All outcomes were censored at day 28. We used Student's t-test, Wilcoxon Rank-Sum, Fisher's Exact, and Chi-Square for statistical analysis. RESULTS: A total of 138 patients were included 66 admitted to traditionally staffed ICUs and 52 to tiered staffing ICUs. The mean age was 67±12.1 years, 63% were male, and the mean SOFA score on admission was 7.5±2.9. Baseline characteristics were similar between groups. More patients in the tiered staffing ICUs received convalescent plasma (14 vs 3%, p=0.05) and azithromycin (41 vs 23%, p=0.05). There was no difference in other COVID-19 treatments, including corticosteroids, tocilizumab, and hydroxychloroquine. ARDS treatments were similar in traditionally staffed ICUs vs tiered staffing model ICUs, including daily median tidal volumes (6.2 vs. 6.2mL/kg, p=0.95), median daily fluid balance (159 vs. 92mL, 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). Successful extubation rates were similar between groups (36 vs. 40%, p=0.71). We also found no difference in ventilator-free, ICU-free, vasopressor-free, and dialysis-free days between groups. CONCLUSIONS: Patient outcomes were similar using a traditional vs. a tiered ICU staffing model during a pandemic. Our analysis is limited by its observational nature and confounded by other healthcare team staffing models.