There has been an ongoing debate about the effect of 24/7 intensivist coverage in critical care units in both adult and pediatric hospitals.(10) Numerous studies have been done in the PICU and pediatric cardiac ICUs to evaluate the effect of this on patient outcomes and house staff education.(7, 11) However there is a paucity of such investigations in the NICU and the published data is not very reliable. In our study we received responses from 123 fellows and early career neonatologist from 1041 subjects. Since some early career neonatologists had completed training more than 5 years ago, they were not eligible to take the survey and hence, our response rate of 11.8% is not accurate. We chose to compare the results of the IH group with the non-IH group, in which we combined the responses from HC and mixed model groups. Since, the mixed models were primarily home coverage and only did IH coverage in specific situations, we believe these groups were better placed together. This also allowed us to better perceive the opinion about IH coverage from respondents that only worked in that model vs. those that did not. The results from our survey suggest that most respondents perceive that concerns about patient care and safety have led to an increase in IH coverage. There are conflicting feelings regarding the benefits of IH coverage on fellow education, however more participants in the IH coverage model perceived it to be better for fellow education than participants in non-IH models.
In a previous study done to evaluate patient volume, staffing and workload in relation to risk adjusted outcomes; the UK Neonatal Staffing Study Group reported less nosocomial infections and quantitatively less death or brain damage with less neonatal consultant coverage.(5) In this study, the authors defined neonatal consultant coverage as pediatricians with more than 50% of their clinical sessions committed to neonatal care. In another study done in Canadian NICUs the investigators showed that units with in-house faculty or fellow coverage had lower nocturnal mortality rates relative to units with coverage by residents or other personnel.(12) Despite this unclear data, there is a vast majority of academic centers with fellows in training that are adapting the IH attending coverage model.
In a large observational study done using a virtual Pediatrics System Database, Gupta et al demonstrated that 24/7 IH attending coverage in the PICU is associated with improved overall patient care and survival after cardiac arrest compared with ICU’s with HC model.(4) In a national survey of pediatric intensivists, pediatric critical care fellows and residents evaluating the perception of 24/7 IH attending on house staff education, only 50% of intensivists and 67% of house staff felt that house staff was well prepared for independent practice after training in an IH model of attending coverage. In this survey respondents currently working in IH models had a more favorable perceptions of the effects of IH coverage on house staff autonomy (P < .0001), supervision (P < .0001), and preparation for independent practice (P < .0001) when compared with those training in HC models.(7) Similarly, in our survey respondents at institutions with IH coverage felt strongly that IH coverage was beneficial for fellows’ education when compared to respondents from institutions with HC and mixed model. This may be due to the respondent’s familiarity with their model or that centers with IH model may have found ways to adapt to this changed model of attending coverage and utilize attending presence for improving the fellows educational experience. This may also suggest that there is a biased perception amongst respondents from institutions with HC model about the deleterious effects of IH coverage on fellows’ education.
The current guidelines of increased supervision requirement by ACGME (13) and recommendation of the society of Critical Care Medicine to have an intensivist led care of patients in the ICU have led to more institutes moving towards increased attending in house presence.(14) This increased attending presence in the NICU could provide an opportunity to improve fellows’ education. Another suggestion would be to encourage fellows to have a plan of action ready prior to consulting attendings and attendings could utilize this opportunity to convert the bedside clinical situation into a teachable moment.
There is a delicate balance between supervision and autonomy. In our survey, only 10 respondents felt that they did not have autonomy in their NICU. The fellows that felt lack of autonomy in their NICU were more likely to be training in centers with IH attending coverage. 83.7% of our respondents noted attending preference and 39.8% noted attending’s age as factors influencing the level of autonomy, they get in their NICU. In a commentary about increased attending presence in the NICU, Jobe and Martin remarked, “Younger attending physicians may be less comfortable in allowing physicians-in-training to make decisions, manage patients, and develop independence. Residents then become scribes for the clinical team rather than active participants, and fellows defer to attending physicians rather than making and defending decisions.”(6)
Fellowship programs have come up with different strategies to help provide fellows autonomy in the presence of IH attending. The most frequent strategies on how their program promoted fellows autonomy, involved: encouraging nurses to call the fellows first and encouraging fellows to make their own plan before calling the attending. Another suggestion could be for the attending to not be physically present in the unit during call. This would decrease the chances of the nurses approaching the attending with concerns directly and allowing them to be available promptly when the fellow needs help. In interest of patient safety, the ACGME recommends that fellowship program should have a checklist that provides fellows with guidelines for circumstances and events in which fellows must communicate with their supervising faculty(9). Only 30.9% of our respondents acknowledged having such a checklist. A better use of this tool may also help with addressing the issue of patient safety and balancing autonomy.
Although our study provides interesting and enlightening data, it is limited by the survey design and route of distribution. Since the TECaN list serve does not have a separate list for current fellows and early career neonatologists, we are unable to provide a response rate for current fellows who took this survey. Another limitation is the low response rate of the survey and may affect the validity of the results. The study also suffers from reporting bias since it is a self-reported survey and our ability to interpret the data. In addition this study only provides data about the perception of the respondents to change in attending coverage model. It does not objectively determine its effect on fellow competence, patient care and patient outcomes. However, it helps identify the major areas of concern with the perception of IH attending coverage in the NICU and can help guide programs to better address these concerns and implement measures to improve fellows’ educational experience. Based on the results from this survey a qualitative follow up study could be done, focusing on the fellows in HC model and analyze why they feel that attending presence would not be beneficial.