Influence of residency training on multiple attempts at endotracheal intubation.

PURPOSE: Endotracheal intubation (ETI) of critically ill patients is a high-risk procedure that is commonly performed by resident physicians. Multiple attempts (>/=2) at intubation have previously been shown to be associated with severe complications. Our goal was to determine the association between year of training, type of residency, and multiple attempts at ETI. METHODS: This was a cohort study of 191 critically ill patients requiring urgent intubation at two tertiary care teaching hospitals in Vancouver, Canada. Multivariable logistic regression was used to model the association between postgraduate year (PGY) of training and multiple attempts at ETI. RESULTS: The majority of ETIs were performed for respiratory failure (68.6%) from the hours of 07:00-19:00 (60.7%). Expert supervision was present for 78.5% of the intubations. Multiple attempts at ETI were required in 62%, 48%, and 34% of patients whose initial attempt was performed by PGY-1, PGY-2, and PGY-3 non-anesthesiology residents, respectively. Anesthesiology residents required multiple attempts at ETI in 15% of patients, regardless of the year of training. The multivariable model showed that both higher year of training (risk ratio [RR] 0.74; 95% confidence interval [CI] 0.54-0.93; P < 0.01) and residency training in anesthesiology (RR 0.52; 95% CI 0.20-1.0; P = 0.05) were independently associated with a decreased risk of multiple intubation attempts. Finally, intubations performed at night were associated with an increased risk of multiple intubation attempts (RR 1.3; 95% CI 1.0-1.4; P = 0.03). CONCLUSION: Year of training, type of residency, and time of day were significantly associated with multiple tracheal intubation attempts in the critical care setting.

Effect of ambient workload in the intensive care unit on mortality and time to discharge alive.

The purpose of this study was to determine the relationship between ambient workload and outcomes of patients in the intensive care unit (ICU). Measures of workload evaluated for each patient on each day of ICU admission were the number of new admissions, ICU census, "code blue" patients not admitted and Acute Physiology and Chronic Health Evaluation (APACHE) II scores and Multiple Organ Dysfunction Scores (MODSs) for admitted patients. Patients were defined as the patient at risk (the "index" patient) and the other patients in the ICU at the same time (the "non-index" patients). Logistic regression (for hospital mortality) and Cox proportional hazards regression (for time to discharge alive) were used to investigate the association between workload and outcomes. In total, 1,705 patients were included. Higher MODSs of non-index patients on the last day of the ICU admission were associated with lower mortality (odds ratio [OR] 0.82 per MODS point, 95% CI 0.72-0.94). A higher number of code blues during the ICU stay was associated with higher mortality (OR 1.18 per event, 95% CI 1.01-1.37). A higher ICU census and MODS of the non-index patients on the day of ICU admission were associated with a shorter time to discharge alive (hazard rate [HR] 1.03 per patient, 95% CI: 1.01-1.06, and 1.07 per MODS point, 95% CI:1.01-1.15, respectively).The association between measures of ambient workload in the ICU and patient outcomes is variable.Future resource planning and studies of patient safety would benefit from a prospective analysis of these factors to define workload limits and tolerances.

The impact of housestaff fatigue on occupational and patient safety.

Extended-duration work shifts (i.e., greater than 24 hours) for housestaff are a long-standing tradition. However, the resultant sleep deprivation and fatigue caused by these extreme work schedules pose potential threats to both physician and patient safety. We believe it is critical to understand the potential adverse consequences of housestaff fatigue to optimize shift schedules and reduce risks to both staff and patients.