during the past 50 years , caring for the critically ill has become an increasingly complex task . new insights into pathophysiology , expensive therapeutic agents , and the proliferation of new technologies for physiologic monitoring contribute to making care of the critically ill patient a nuanced and demanding effort . thus , the need for an intensivist , trained in the management of critically ill patients , in the icu has become more evident . in fact , management by intensivists has become a quality indicator for many icus , especially high - intensity icus . numerous small , prospective cohort studies have demonstrated the beneficial effect of intensivists on outcomes in the critically ill [ 3 - 5 ] . consequently , some clinicians have advanced the argument that a night - time intensivist is an essential ingredient for safe , high - quality care for critically ill patients [ 6 - 8 ] . in response , many institutions have hired full - time intensivists for both day and night coverage in the icu . although the belief has also generated debate in the literature , no robust studies that supported either position had been published until recently . now two studies have been conducted that make a compelling argument for redirecting funding of night - time intensivists to areas of greater need in health care . significant messages for the field are conveyed in the article by wallace and colleagues , a retrospective cohort trial evaluating the presence of night - time intensivists in low- and high - intensity units . in high - intensity icus , consults or management by critical care physicians are mandated for all admitted patients ; in low - intensity icus , consultations by critical care physicians are not mandated . in this large database that involved 49 icus and more than 65,000 patients , high - intensity daytime staffing was not associated with decreased mortality , and no benefit of night - time intensivists could be found in high - intensity icus . this suggests that in icus where care is managed by intensivists during the day , a night shift by intensivists does not seem to improve care further . during the night the second study , a randomized controlled trial published by kerlin and colleagues , evaluated the effect of night - time intensivists on length of stay , mortality , and other outcomes . the message from this study is much clearer : this was a negative trial . in this methodologically rigorous trial , there was no difference in outcomes between the intensivist and control group , which consisted of in - house resident coverage at night with availability by telephone of fellows and intensivists . it is important to recognize that this randomized trial was conducted in a single - center , large academic , high - intensity university icu in the us , with a full complement of house staff and critical care trainees and can not be generalized to smaller , non - teaching , or low - intensity environments . therefore , both studies are consistent - addition of night - time intensivists to a high - intensity icu does not make a difference in mortality or length of stay . when critically ill patients are managed by intensivists during the day , there is no added benefit to patient outcomes with the presence of an intensivist on - site at night . in both studies , intensivists and/or fellows were on - call and available at night for management to maintain the consistency of care plans developed during daytime hours . although the article by wallace and colleagues   suggests that in low - intensity environments outcomes are improved when care is directed by intensivists at night , the widespread drive to add night - time intensivist coverage based on an assumption of better outcomes may have been premature . according to these articles , there is no evidence to support this assertion . in both of the recent articles , the authors suggest that other , unmeasured outcomes - such as better end - of - life care , improved compliance with quality measures , and better educational opportunities for house staff and nursing staff - may be improved with the presence of night - time intensivists . in part , this is supported by two recent articles by reinick and colleagues   and almeida and colleagues . however , we have to question whether this is an attempt to keep alive the belief that night - time intensivists do make a difference , and we must question whether the expense is justified by these potential outcomes . these two robust studies clearly suggest that night - time intensivists do not improve mortality in icus managed by intensivists during the day . perhaps it is time to stop trying to prove that a single intensivist in the unit at night has an effect on mortality . the value of a single intensivist may be more subtle , but just as important : as the leader of a team they create a safer environment that is more patient / family - centric , and that is more consistent with best practices . that value foretells considerable implications for many icus globally . given the reality of spiraling costs in health care , this might be one area in which cost savings can be realized without sacrificing the quality of care our patients receive . it is time we embraced the results of these trials as reflecting the need for daytime intensivists - who apply the appropriate standard of care in order to maintain high - quality care - and to redirect the resources proposed for night - time intensivists elsewhere .
during the past 50 years , caring for the critically ill has become increasingly complex and the need for an intensivist has become more evident . 
 management by intensivists has become a quality indicator for many icus . 
 numerous small studies have demonstrated the beneficial effect of intensivists on outcomes in the critically ill , and some clinicians have advanced the argument that a night - time intensivist is essential for the care of critically ill patients . in response , many institutions have hired full - time intensivists for both day and night coverage in the icu . 
 two recent studies have been conducted that make a compelling argument for redirecting funding of night - time intensivists to areas of greater need in health care . in a retrospective analysis of a large database that involved more than 65,000 patients , no benefit of night - time intensivists could be found in icus where care is managed by intensivists during the day . only in icus 
 where management by intensivists is not mandated could a beneficial impact on mortality be found . 
 the second study , a randomized controlled trial , evaluated the effect of night - time intensivists on length of stay , mortality , and other outcomes and was a negative trial . in this methodologically rigorous trial 
 , there was no difference in outcomes between the intensivist and control group , which consisted of in - house resident coverage at night with availability by telephone of fellows and intensivists . 
 these two robust studies clearly suggest that night - time intensivists do not improve mortality in icus managed by intensivists during the day . 
 though possibly beneficial in low - intensity environments , the widespread drive to add night - time intensivist coverage may have been premature .