ICU Characteristics in Michigan

Survey Development

The survey for this study was developed based on expert opinion and on previous work by the research team (A.D.A., P.J.P., S.A.F.). The survey was pilot tested in a small group of non‐Michigan hospitals and found to be understandable and readable. The survey was then revised and disseminated to all hospitals participating in the Keystone ICU project. Construct validity was determined by review of literature and discussion with the research team (A.D.A., P.J.P., S.A.F., R.C.H.). Content validity was determined by the pilot test, which included interviews with the individuals who pilot‐tested the survey. The survey sought to describe the organization of ICU physician services (including both intensivist and nonintensivist). A copy of the survey is available upon request.

Survey Protocol

Surveys were sent by e‐mail to the official nurse and/or physician project leader at each site in July 2005 from contact information provided by MHA. Another copy of the survey was emailed to ICUs that did not respond to the initial survey after 3 months and, if needed, a third survey was sent at 6 months with a follow‐up telephone call by 1 of the investigators (R.C.H.). The completed surveys were returned to MHA for compilation and analysis. The research project was reviewed by the University of Michigan Institutional Review Board and determined to be exempt from ongoing IRB review per federal exemption category 45 CFR 46.101.(b). The funder was not involved in the design of the study, collection, analysis, and interpretation of the data, or the decision to approve publication of the finished manuscript.

Statistical Analysis

Survey respondents were first characterized using simple univariable and bivariable methods. When appropriate, groups were compared based on chi‐square, Mann‐Whitney U test, or t test. Additionally, a series of multivariable analyses was performed, which sought to understand structural factors associated with the presence of higher‐intensity models, as well as use of hospitalists or intensivists. Results of the multivariate analysis are reported as odds ratios (ORs) and 95% confidence intervals (CIs). The critical region was defined as an alpha of 0.05. Statistical analysis was performed using SAS (version 9.1; SAS Institute, Inc., Cary, NC).

Response Rate

Ninety‐seven responses were received, including at least 1 response from every Keystone ICU hospital located in Michigan. Because our goal was to describe the organization of ICU physician services in non‐Federal hospitals, 1 Michigan VA hospital was eliminated from further consideration. Four hospitals with more than 1 ICU, which delivered care identically in all of their ICUs, provided 1 response and were counted as 1 site. As a result, 96 survey responses representing 115 ICUs in 72 Michigan hospitals were each counted as 1 site in the analysis. This included responses from ICUs not included in earlier analyses, which joined Keystone ICU after earlier work had been underway.15

Baseline Demographics

The mean (standard deviation [SD]) hospital size represented in the survey was 280 (22) beds, with a median of 249 (range, 40‐1031) beds. The mean size (SD) of the ICU was 13.3 (7.0) beds, median 12 beds, range 4 to 42 beds. There were 16 ICUs dedicated exclusively to the care of medicine patients, 14 dedicated surgical units, 8 dedicated cardiac ICUs, and 3 dedicated Neuro ICUs. The remainder had a mixed patient population. Seventy‐one ICUs (74%) cared for medical patients, 69 (72%) cared for surgical patients, 64 (67%) cared for cardiac patients, and 52 (53%) cared for neurological patients.

ICU Staffing Models

To better understand the role of intensivists in critical care delivery in Michigan, we examined differences in sites where patients are managed as closed sites exclusively by intensivists (closed ICU sites) in comparison to ICUs that had multiple attending specialties (open ICU sites). In addition, ICU sites where intensivists made most clinical decisionsa circumstance likely reflecting a high‐intensity staffing model of care5were compared with ICUs sites where decision‐making was made by nonintensivists or was shared (Table 1). Twenty‐four of 96 (25%) ICU sites were closed, and only intensivists served as the attending of record. Hospitals with closed ICUs or in which intensivists made most clinical decisions were larger and had larger ICUs than sites with open ICUs or with nonintensivist decision‐making (P < 0.05). These 24 closed sites represented 17 of 72 hospitals (24%), with the remainder of hospitals (76%) not having closed ICUs. Intensivists participated in rounds in 43 of 72 sites (60%) that were not closed. House officer participation in the care of ICU patients was not related to the presence or absence of intensivists (2 = 0.04; P = 0.847), although the average size of hospitals with house officers was larger than those without house officers (P < 0.0001).

Multivariate analysis determined that the presence of hospitalists serving as attending physicians was strongly associated with an open ICU (OR = 12.2; 95%CI = 2.5‐60.2), as was the absence of intensivists at the site (OR = 12.2; 95%CI = 1.4‐105.8), while ICU and hospital size were not associated. When the analyses were limited to hospitals with intensivists (n = 69), decision‐making by intensivists was not associated with ICU or hospital size (OR = 1.0; 95%CI = 1.0‐1.0); or whether hospitalists acted as attendings (OR = 0.7; 95%CI = 0.2‐2.0).

Board Certification and ICU Administration

Only 18 sites (20%) acknowledged that 100% of their ICU attending physicians were board‐certified in critical care, with nearly two‐thirds of sites having fewer than 50% critical‐care board‐certified attending physicians (Table 1). The medical director of the ICU met for an administrative meeting with the ICU team of nurses, respiratory therapists, and other personnel on a regular (ie, at least quarterly) basis at 77 sites (80%) and held regular morbidity and mortality sessions to discuss ICU care with other physicians who work in the ICU at 43 sites (45%). The majority of sites (n = 67; 70%) provided salary support for the ICU medical director.

Critical‐care board‐certification was more common at sites with closed ICUs and at sites where decision‐making was performed by intensivists (P < 0.001). However, board‐certification was not uniform in closed ICUs (100% certification = 46%, >50% certification = 67%) or in ICUs where intensivists made most decisions (100% certification = 39%, >50% certification = 75%).

Hospitals in which hospitalists served as attending physicians were less likely to have 50% or greater critical‐care board‐certification in their ICU (OR = 0.13; 95%CI = 0.03‐0.50). ICU size, hospital size, and years in practice were not associated with critical‐care board‐certification. Hospital size, ICU size, and the presence of intensivists or hospitalists were not associated with whether the medical director receives support from the hospital.

Physician Extenders

Nineteen sites (20%) reported the utilization of advanced practice nurses; 15 sites (16%) reported use of physician assistants; and 7 sites (7%) reported use of both advance practice nurses and physician assistants to provide intensive care. Physician extenders were not more likely to work in closed ICUs (10/24) than in open ICUs (14/72) (2 = 3.63; P = 0.57).

Of the 27 sites reporting use of advanced practice nurses or physician assistants, the role of physician extenders was described as being similar to physicians in 8 sites (30%), somewhat autonomous but with limitations in 18 (67%), and in a role closer to a ward clerk or assistant in 1 site (4%). The activities of physician extenders included writing orders at 24 of these 27 sites (89%); writing progress notes at 25 sites (92%); communicating with consultants at 24 (89%) and with primary care physicians at 22 sites (82%); and coordinating discharge plans at 20 sites (74%). Physician extenders rounded alone at 16 sites (33%).

Clinical Activities

Intensivists participated in daily rounds at most sites (n = 67; 70%). Nonintensivists served as attending of record in 72 (75%) sites. Nonintensivist physicians participating in daily patient rounds were: surgeons (n = 66; 68% of sites), primary care physicians (n = 61; 64%), nonpulmonary internal medicine specialists (n = 53; 55%), cardiologists (n = 58; 60%), non‐critical‐care pulmonologists (n = 39; 41%), and hospitalists (n = 36; 38%). Intensivists were the primary decision‐makers at 30 sites (31%), nonintensivists at 34 (35%), and decision making was shared at 31 (32%).

At more than one‐half of sites, decisions regarding mechanical ventilation, the use of sedatives or paralytics, and the choice of vasopressor agents were made by intensivists, with other decisionssuch as the decision to call consultants, choice of antibiotics, or family meetingsshared between intensivists and nonintensivists more than 40% of the time (Table 2). During regular working hours, invasive procedures were performed by multiple clinicians, including house officers, intensivists, surgeons, and anesthesiologists and were not the province of any particular type of clinician (Table 3).

Regardless of the staffing model employed, the majority of sites (88%) provided care on a call‐based, rather than shift‐based system. Nighttime admissions and cross‐coverage issues were handled by house officers at more than one‐third of sites, with nonintensivist house physicians performing these tasks at 15% of sites (Table 4). Intensivists managed cross‐coverage issues by telephone at 29% of sites, and saw new admissions in person after hours at 8% of sites. Intensivists did not deliver care in scheduled shifts at any of these sites.

Survey Development

The survey for this study was developed based on expert opinion and on previous work by the research team (A.D.A., P.J.P., S.A.F.). The survey was pilot tested in a small group of non‐Michigan hospitals and found to be understandable and readable. The survey was then revised and disseminated to all hospitals participating in the Keystone ICU project. Construct validity was determined by review of literature and discussion with the research team (A.D.A., P.J.P., S.A.F., R.C.H.). Content validity was determined by the pilot test, which included interviews with the individuals who pilot‐tested the survey. The survey sought to describe the organization of ICU physician services (including both intensivist and nonintensivist). A copy of the survey is available upon request.

Survey Protocol

Surveys were sent by e‐mail to the official nurse and/or physician project leader at each site in July 2005 from contact information provided by MHA. Another copy of the survey was emailed to ICUs that did not respond to the initial survey after 3 months and, if needed, a third survey was sent at 6 months with a follow‐up telephone call by 1 of the investigators (R.C.H.). The completed surveys were returned to MHA for compilation and analysis. The research project was reviewed by the University of Michigan Institutional Review Board and determined to be exempt from ongoing IRB review per federal exemption category 45 CFR 46.101.(b). The funder was not involved in the design of the study, collection, analysis, and interpretation of the data, or the decision to approve publication of the finished manuscript.

Statistical Analysis

Survey respondents were first characterized using simple univariable and bivariable methods. When appropriate, groups were compared based on chi‐square, Mann‐Whitney U test, or t test. Additionally, a series of multivariable analyses was performed, which sought to understand structural factors associated with the presence of higher‐intensity models, as well as use of hospitalists or intensivists. Results of the multivariate analysis are reported as odds ratios (ORs) and 95% confidence intervals (CIs). The critical region was defined as an alpha of 0.05. Statistical analysis was performed using SAS (version 9.1; SAS Institute, Inc., Cary, NC).

Response Rate

Ninety‐seven responses were received, including at least 1 response from every Keystone ICU hospital located in Michigan. Because our goal was to describe the organization of ICU physician services in non‐Federal hospitals, 1 Michigan VA hospital was eliminated from further consideration. Four hospitals with more than 1 ICU, which delivered care identically in all of their ICUs, provided 1 response and were counted as 1 site. As a result, 96 survey responses representing 115 ICUs in 72 Michigan hospitals were each counted as 1 site in the analysis. This included responses from ICUs not included in earlier analyses, which joined Keystone ICU after earlier work had been underway.15

Baseline Demographics

The mean (standard deviation [SD]) hospital size represented in the survey was 280 (22) beds, with a median of 249 (range, 40‐1031) beds. The mean size (SD) of the ICU was 13.3 (7.0) beds, median 12 beds, range 4 to 42 beds. There were 16 ICUs dedicated exclusively to the care of medicine patients, 14 dedicated surgical units, 8 dedicated cardiac ICUs, and 3 dedicated Neuro ICUs. The remainder had a mixed patient population. Seventy‐one ICUs (74%) cared for medical patients, 69 (72%) cared for surgical patients, 64 (67%) cared for cardiac patients, and 52 (53%) cared for neurological patients.

ICU Staffing Models

To better understand the role of intensivists in critical care delivery in Michigan, we examined differences in sites where patients are managed as closed sites exclusively by intensivists (closed ICU sites) in comparison to ICUs that had multiple attending specialties (open ICU sites). In addition, ICU sites where intensivists made most clinical decisionsa circumstance likely reflecting a high‐intensity staffing model of care5were compared with ICUs sites where decision‐making was made by nonintensivists or was shared (Table 1). Twenty‐four of 96 (25%) ICU sites were closed, and only intensivists served as the attending of record. Hospitals with closed ICUs or in which intensivists made most clinical decisions were larger and had larger ICUs than sites with open ICUs or with nonintensivist decision‐making (P < 0.05). These 24 closed sites represented 17 of 72 hospitals (24%), with the remainder of hospitals (76%) not having closed ICUs. Intensivists participated in rounds in 43 of 72 sites (60%) that were not closed. House officer participation in the care of ICU patients was not related to the presence or absence of intensivists (2 = 0.04; P = 0.847), although the average size of hospitals with house officers was larger than those without house officers (P < 0.0001).

Multivariate analysis determined that the presence of hospitalists serving as attending physicians was strongly associated with an open ICU (OR = 12.2; 95%CI = 2.5‐60.2), as was the absence of intensivists at the site (OR = 12.2; 95%CI = 1.4‐105.8), while ICU and hospital size were not associated. When the analyses were limited to hospitals with intensivists (n = 69), decision‐making by intensivists was not associated with ICU or hospital size (OR = 1.0; 95%CI = 1.0‐1.0); or whether hospitalists acted as attendings (OR = 0.7; 95%CI = 0.2‐2.0).

Board Certification and ICU Administration

Only 18 sites (20%) acknowledged that 100% of their ICU attending physicians were board‐certified in critical care, with nearly two‐thirds of sites having fewer than 50% critical‐care board‐certified attending physicians (Table 1). The medical director of the ICU met for an administrative meeting with the ICU team of nurses, respiratory therapists, and other personnel on a regular (ie, at least quarterly) basis at 77 sites (80%) and held regular morbidity and mortality sessions to discuss ICU care with other physicians who work in the ICU at 43 sites (45%). The majority of sites (n = 67; 70%) provided salary support for the ICU medical director.

Critical‐care board‐certification was more common at sites with closed ICUs and at sites where decision‐making was performed by intensivists (P < 0.001). However, board‐certification was not uniform in closed ICUs (100% certification = 46%, >50% certification = 67%) or in ICUs where intensivists made most decisions (100% certification = 39%, >50% certification = 75%).

Hospitals in which hospitalists served as attending physicians were less likely to have 50% or greater critical‐care board‐certification in their ICU (OR = 0.13; 95%CI = 0.03‐0.50). ICU size, hospital size, and years in practice were not associated with critical‐care board‐certification. Hospital size, ICU size, and the presence of intensivists or hospitalists were not associated with whether the medical director receives support from the hospital.

Physician Extenders

Nineteen sites (20%) reported the utilization of advanced practice nurses; 15 sites (16%) reported use of physician assistants; and 7 sites (7%) reported use of both advance practice nurses and physician assistants to provide intensive care. Physician extenders were not more likely to work in closed ICUs (10/24) than in open ICUs (14/72) (2 = 3.63; P = 0.57).

Of the 27 sites reporting use of advanced practice nurses or physician assistants, the role of physician extenders was described as being similar to physicians in 8 sites (30%), somewhat autonomous but with limitations in 18 (67%), and in a role closer to a ward clerk or assistant in 1 site (4%). The activities of physician extenders included writing orders at 24 of these 27 sites (89%); writing progress notes at 25 sites (92%); communicating with consultants at 24 (89%) and with primary care physicians at 22 sites (82%); and coordinating discharge plans at 20 sites (74%). Physician extenders rounded alone at 16 sites (33%).

Clinical Activities

Intensivists participated in daily rounds at most sites (n = 67; 70%). Nonintensivists served as attending of record in 72 (75%) sites. Nonintensivist physicians participating in daily patient rounds were: surgeons (n = 66; 68% of sites), primary care physicians (n = 61; 64%), nonpulmonary internal medicine specialists (n = 53; 55%), cardiologists (n = 58; 60%), non‐critical‐care pulmonologists (n = 39; 41%), and hospitalists (n = 36; 38%). Intensivists were the primary decision‐makers at 30 sites (31%), nonintensivists at 34 (35%), and decision making was shared at 31 (32%).

At more than one‐half of sites, decisions regarding mechanical ventilation, the use of sedatives or paralytics, and the choice of vasopressor agents were made by intensivists, with other decisionssuch as the decision to call consultants, choice of antibiotics, or family meetingsshared between intensivists and nonintensivists more than 40% of the time (Table 2). During regular working hours, invasive procedures were performed by multiple clinicians, including house officers, intensivists, surgeons, and anesthesiologists and were not the province of any particular type of clinician (Table 3).

Regardless of the staffing model employed, the majority of sites (88%) provided care on a call‐based, rather than shift‐based system. Nighttime admissions and cross‐coverage issues were handled by house officers at more than one‐third of sites, with nonintensivist house physicians performing these tasks at 15% of sites (Table 4). Intensivists managed cross‐coverage issues by telephone at 29% of sites, and saw new admissions in person after hours at 8% of sites. Intensivists did not deliver care in scheduled shifts at any of these sites.

Survey Development

The survey for this study was developed based on expert opinion and on previous work by the research team (A.D.A., P.J.P., S.A.F.). The survey was pilot tested in a small group of non‐Michigan hospitals and found to be understandable and readable. The survey was then revised and disseminated to all hospitals participating in the Keystone ICU project. Construct validity was determined by review of literature and discussion with the research team (A.D.A., P.J.P., S.A.F., R.C.H.). Content validity was determined by the pilot test, which included interviews with the individuals who pilot‐tested the survey. The survey sought to describe the organization of ICU physician services (including both intensivist and nonintensivist). A copy of the survey is available upon request.

Survey Protocol

Surveys were sent by e‐mail to the official nurse and/or physician project leader at each site in July 2005 from contact information provided by MHA. Another copy of the survey was emailed to ICUs that did not respond to the initial survey after 3 months and, if needed, a third survey was sent at 6 months with a follow‐up telephone call by 1 of the investigators (R.C.H.). The completed surveys were returned to MHA for compilation and analysis. The research project was reviewed by the University of Michigan Institutional Review Board and determined to be exempt from ongoing IRB review per federal exemption category 45 CFR 46.101.(b). The funder was not involved in the design of the study, collection, analysis, and interpretation of the data, or the decision to approve publication of the finished manuscript.

Statistical Analysis

Survey respondents were first characterized using simple univariable and bivariable methods. When appropriate, groups were compared based on chi‐square, Mann‐Whitney U test, or t test. Additionally, a series of multivariable analyses was performed, which sought to understand structural factors associated with the presence of higher‐intensity models, as well as use of hospitalists or intensivists. Results of the multivariate analysis are reported as odds ratios (ORs) and 95% confidence intervals (CIs). The critical region was defined as an alpha of 0.05. Statistical analysis was performed using SAS (version 9.1; SAS Institute, Inc., Cary, NC).

Response Rate

Ninety‐seven responses were received, including at least 1 response from every Keystone ICU hospital located in Michigan. Because our goal was to describe the organization of ICU physician services in non‐Federal hospitals, 1 Michigan VA hospital was eliminated from further consideration. Four hospitals with more than 1 ICU, which delivered care identically in all of their ICUs, provided 1 response and were counted as 1 site. As a result, 96 survey responses representing 115 ICUs in 72 Michigan hospitals were each counted as 1 site in the analysis. This included responses from ICUs not included in earlier analyses, which joined Keystone ICU after earlier work had been underway.15

Baseline Demographics

The mean (standard deviation [SD]) hospital size represented in the survey was 280 (22) beds, with a median of 249 (range, 40‐1031) beds. The mean size (SD) of the ICU was 13.3 (7.0) beds, median 12 beds, range 4 to 42 beds. There were 16 ICUs dedicated exclusively to the care of medicine patients, 14 dedicated surgical units, 8 dedicated cardiac ICUs, and 3 dedicated Neuro ICUs. The remainder had a mixed patient population. Seventy‐one ICUs (74%) cared for medical patients, 69 (72%) cared for surgical patients, 64 (67%) cared for cardiac patients, and 52 (53%) cared for neurological patients.

ICU Staffing Models

To better understand the role of intensivists in critical care delivery in Michigan, we examined differences in sites where patients are managed as closed sites exclusively by intensivists (closed ICU sites) in comparison to ICUs that had multiple attending specialties (open ICU sites). In addition, ICU sites where intensivists made most clinical decisionsa circumstance likely reflecting a high‐intensity staffing model of care5were compared with ICUs sites where decision‐making was made by nonintensivists or was shared (Table 1). Twenty‐four of 96 (25%) ICU sites were closed, and only intensivists served as the attending of record. Hospitals with closed ICUs or in which intensivists made most clinical decisions were larger and had larger ICUs than sites with open ICUs or with nonintensivist decision‐making (P < 0.05). These 24 closed sites represented 17 of 72 hospitals (24%), with the remainder of hospitals (76%) not having closed ICUs. Intensivists participated in rounds in 43 of 72 sites (60%) that were not closed. House officer participation in the care of ICU patients was not related to the presence or absence of intensivists (2 = 0.04; P = 0.847), although the average size of hospitals with house officers was larger than those without house officers (P < 0.0001).

Multivariate analysis determined that the presence of hospitalists serving as attending physicians was strongly associated with an open ICU (OR = 12.2; 95%CI = 2.5‐60.2), as was the absence of intensivists at the site (OR = 12.2; 95%CI = 1.4‐105.8), while ICU and hospital size were not associated. When the analyses were limited to hospitals with intensivists (n = 69), decision‐making by intensivists was not associated with ICU or hospital size (OR = 1.0; 95%CI = 1.0‐1.0); or whether hospitalists acted as attendings (OR = 0.7; 95%CI = 0.2‐2.0).

Board Certification and ICU Administration

Only 18 sites (20%) acknowledged that 100% of their ICU attending physicians were board‐certified in critical care, with nearly two‐thirds of sites having fewer than 50% critical‐care board‐certified attending physicians (Table 1). The medical director of the ICU met for an administrative meeting with the ICU team of nurses, respiratory therapists, and other personnel on a regular (ie, at least quarterly) basis at 77 sites (80%) and held regular morbidity and mortality sessions to discuss ICU care with other physicians who work in the ICU at 43 sites (45%). The majority of sites (n = 67; 70%) provided salary support for the ICU medical director.

Critical‐care board‐certification was more common at sites with closed ICUs and at sites where decision‐making was performed by intensivists (P < 0.001). However, board‐certification was not uniform in closed ICUs (100% certification = 46%, >50% certification = 67%) or in ICUs where intensivists made most decisions (100% certification = 39%, >50% certification = 75%).

Hospitals in which hospitalists served as attending physicians were less likely to have 50% or greater critical‐care board‐certification in their ICU (OR = 0.13; 95%CI = 0.03‐0.50). ICU size, hospital size, and years in practice were not associated with critical‐care board‐certification. Hospital size, ICU size, and the presence of intensivists or hospitalists were not associated with whether the medical director receives support from the hospital.

Physician Extenders

Nineteen sites (20%) reported the utilization of advanced practice nurses; 15 sites (16%) reported use of physician assistants; and 7 sites (7%) reported use of both advance practice nurses and physician assistants to provide intensive care. Physician extenders were not more likely to work in closed ICUs (10/24) than in open ICUs (14/72) (2 = 3.63; P = 0.57).

Of the 27 sites reporting use of advanced practice nurses or physician assistants, the role of physician extenders was described as being similar to physicians in 8 sites (30%), somewhat autonomous but with limitations in 18 (67%), and in a role closer to a ward clerk or assistant in 1 site (4%). The activities of physician extenders included writing orders at 24 of these 27 sites (89%); writing progress notes at 25 sites (92%); communicating with consultants at 24 (89%) and with primary care physicians at 22 sites (82%); and coordinating discharge plans at 20 sites (74%). Physician extenders rounded alone at 16 sites (33%).

Clinical Activities

Intensivists participated in daily rounds at most sites (n = 67; 70%). Nonintensivists served as attending of record in 72 (75%) sites. Nonintensivist physicians participating in daily patient rounds were: surgeons (n = 66; 68% of sites), primary care physicians (n = 61; 64%), nonpulmonary internal medicine specialists (n = 53; 55%), cardiologists (n = 58; 60%), non‐critical‐care pulmonologists (n = 39; 41%), and hospitalists (n = 36; 38%). Intensivists were the primary decision‐makers at 30 sites (31%), nonintensivists at 34 (35%), and decision making was shared at 31 (32%).

At more than one‐half of sites, decisions regarding mechanical ventilation, the use of sedatives or paralytics, and the choice of vasopressor agents were made by intensivists, with other decisionssuch as the decision to call consultants, choice of antibiotics, or family meetingsshared between intensivists and nonintensivists more than 40% of the time (Table 2). During regular working hours, invasive procedures were performed by multiple clinicians, including house officers, intensivists, surgeons, and anesthesiologists and were not the province of any particular type of clinician (Table 3).

Regardless of the staffing model employed, the majority of sites (88%) provided care on a call‐based, rather than shift‐based system. Nighttime admissions and cross‐coverage issues were handled by house officers at more than one‐third of sites, with nonintensivist house physicians performing these tasks at 15% of sites (Table 4). Intensivists managed cross‐coverage issues by telephone at 29% of sites, and saw new admissions in person after hours at 8% of sites. Intensivists did not deliver care in scheduled shifts at any of these sites.