Enhanced nighttime and continuous critical care physician coverage in adult intensive care units: A systematic review and meta-analysis.
Abstract
Background
The incremental benefit of extending attending-level critical-care coverage into nighttime hours remains uncertain, especially in ICUs with established daytime intensivist leadership.
Objective
To estimate the incremental effect of strict physical/on-site nighttime or continuous attending-level critical-care physician coverage and evaluate clinically distinct staffing strategies separately.
Methods
We conducted an updated review using PubMed/MEDLINE surveillance and citation tracking through August 9, 2026. Interventions were classified as physical/on-site coverage, continuous non-resident specialist availability, remote/tele-ICU or multicomponent programs, and enhanced-versus-enhanced models. Random-effects meta-analyses used risk ratios (RRs) for compatible binary outcomes and mean differences (MDs) for continuous outcomes. Risk of bias and certainty were assessed with RoB 2/ROBINS-I and GRADE.
Results
Twenty-two reports were retained. Four strict physical/on-site studies (13,276 patients) contributed to the primary hospital-mortality analysis, which showed no significant reduction in mortality (RR 0.92, 95% confidence interval [CI] 0.67-1.28; I2 = 61.7%). A sensitivity analysis additionally including one study of continuous non-resident specialist availability yielded a similar result (RR 0.87, 95% CI 0.66-1.14; I2 = 68%). ICU mortality (RR 0.93, 95% CI 0.70-1.23), ICU length of stay (MD 0.42 days, 95% CI -0.98 to 1.83), and hospital length of stay (MD -0.31 days, 95% CI -1.73 to 1.11) did not differ significantly. Certainty was very low for all pooled outcomes.
Conclusions
Evidence is sparse and heterogeneous. Strict on-site coverage did not significantly reduce hospital mortality (RR 0.92, 95% CI 0.67-1.28), and available studies cannot reliably isolate added benefit beyond existing ICU support. This does not question the importance of specialist critical-care expertise.