HONOLULU — Fewer than half of critically ill patients received a physical examination from their primary intensive care unit physicians each day, Canadian researchers have found.
Patients seen first during rounds, those with higher Sequential Organ Failure Assessment (SOFA) scores, and those not in isolation were more likely to be examined by their lead physicians during surreptitious line-of-sight observations of 195 patient/physician encounters, according to the findings of a study presented at the annual congress of the Society of Critical Care Medicine.
During multidisciplinary rounds, time spent at each ICU patient's bedside averaged 8 minutes, with progressively less time spent on each subsequent patient in the rounding order. Time spent at the bedside increased with higher SOFA scores and with the number of health professionals attending medical rounds.
Dr. Adel Al-Sarraf led the study at Sunnybrook Health Sciences Centre in Toronto, in which an impartial observer with critical care experience timed patient encounters and noted whether each ICU patient received a physical examination each day.
The busy academic medical center ICU had a mean 95.6% occupancy during the study, with a ratio of medical to surgical patients of 31:69. Nearly half of patients were mechanically ventilated, and 9% were in isolation. The mean Acute Physiology and Chronic Health Evaluation (APACHE) score for the study population was 19.6.
Lead physicians physically examined their patients in 87 of 195 daily encounters, or 46.5%.
The duration of the primary ICU physician's time at the bedside averaged 11 minutes, with 69 seconds spent on physical examination.
The first patient seen by the lead physician was 2.5 times more likely to receive a physical examination than was the last patient seen. Patients in isolation were almost four times less likely to be examined, while higher SOFA scores slightly but significantly increased the likelihood of an examination.
As clinical experience increased, the likelihood of a lead physician conducting a physical examination decreased, with fellows being most lax, said Dr. Al-Sarraf. During briefer multidisciplinary rounds, just 8% of patients were physically examined.
Each patient seen during multidisciplinary rounds was seen for a shorter time than the previous patient was. When more health care professionals attended rounds, time spent at a patient's bedside increased, as was also true with a higher SOFA score.
Dr. Al-Sarraf concluded that “patient, caregiver, and ICU organization factors significantly influence bedside clinical examination and assessment practices.”
During the discussion following his talk, Dr. Al-Sarraf acknowledged that the study did not include any measures that would determine whether physical examinations correlated with improved outcome. He said that this might be a fruitful avenue for future research, particularly because technology has taken physicians increasingly away from patients' bedsides.