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Intensive Care Med ; 45(11): 1599-1607, 2019 11.
Article in English | MEDLINE | ID: mdl-31595349

ABSTRACT

PURPOSE: To study whether ICU staffing features are associated with improved hospital mortality, ICU length of stay (LOS) and duration of mechanical ventilation (MV) using cluster analysis directed by machine learning. METHODS: The following variables were included in the analysis: average bed to nurse, physiotherapist and physician ratios, presence of 24/7 board-certified intensivists and dedicated pharmacists in the ICU, and nurse and physiotherapist autonomy scores. Clusters were defined using the partition around medoids method. We assessed the association between clusters and hospital mortality using logistic regression and with ICU LOS and MV duration using competing risk regression. RESULTS: Analysis included data from 129,680 patients admitted to 93 ICUs (2014-2015). Three clusters were identified. The features distinguishing between the clusters were: the presence of board-certified intensivists in the ICU 24/7 (present in Cluster 3), dedicated pharmacists (present in Clusters 2 and 3) and the extent of nurse autonomy (which increased from Clusters 1 to 3). The patients in Cluster 3 exhibited the best outcomes, with lower adjusted hospital mortality [odds ratio 0.92 (95% confidence interval (CI), 0.87-0.98)], shorter ICU LOS [subhazard ratio (SHR) for patients surviving to ICU discharge 1.24 (95% CI 1.22-1.26)] and shorter durations of MV [SHR for undergoing extubation 1.61(95% CI 1.54-1.69)]. Cluster 1 had the worst outcomes. CONCLUSION: Patients treated in ICUs combining 24/7 expert intensivist coverage, a dedicated pharmacist and nurses with greater autonomy had the best outcomes. All of these features represent achievable targets that should be considered by policy makers with an interest in promoting equal and optimal ICU care.


Subject(s)
Hospital Mortality/trends , Personnel Staffing and Scheduling/standards , Unsupervised Machine Learning/trends , Brazil , Cluster Analysis , Hospital Bed Capacity/statistics & numerical data , Humans , Intensive Care Units/organization & administration , Intensive Care Units/statistics & numerical data , Length of Stay/statistics & numerical data , Length of Stay/trends , Logistic Models , Nurses/statistics & numerical data , Nurses/supply & distribution , Odds Ratio , Organ Dysfunction Scores , Personnel Staffing and Scheduling/classification , Personnel Staffing and Scheduling/statistics & numerical data , Physical Therapists/statistics & numerical data , Physical Therapists/supply & distribution , Physicians/statistics & numerical data , Physicians/supply & distribution , Retrospective Studies , Time Factors
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