Workforce, Workload, and Burnout Among Intensivists and Advanced Practice Providers: A Narrative Review

Unmasking the Truth of Health Care Workers’ Well-being During the COVID-19 Pandemic

Background

Burnout is a well-documented multifactorial phenomenon that affects up to 47% of intensive care unit staff at some point in their career. The literature highlights increased rates of anxiety, depression, and posttraumatic stress disorder among staff as a result of the COVID-19 pandemic.

Local Problem

Following the second and, at the time of writing, largest surge of the COVID-19 pandemic, concern for staff ’s mental health prompted a hospital-wide study to assess depression, anxiety, posttraumatic stress disorder, and alcohol misuse and to determine the use and effectiveness of employee resources.

Methods

Through REDCap, 212 intensive care unit employees were surveyed with validated screening tools for depression, anxiety, posttraumatic stress disorder, and alcohol misuse. The use and perceived effectiveness of hospital initiatives were assessed.

Results

A total of 212 surveys were evaluated. Among respondents, 54% experienced mild anxiety, more than 50% screened positive for mild depression, and 37% screened positive for posttraumatic stress disorder. Most employees (74.5%) were aware of at least 1 resource; 37% knew of the COVID-19 newsletter, one of the top resources highlighted in the survey. Perceived effectiveness of resources ranged from 0.9% (disaster helpline) to 82.5% (prayers, readings, and the on-call chaplain—all “somewhat helpful”). The results correlate with the progressive trend of increased mental health concerns among intensive care unit employees. Survey results prompted an expansion of hospital resources.

Conclusions

COVID-19 has brought unique mental health challenges and stressors to intensive care unit staff. By adapting and expanding resources, hospitals can improve staff resiliency and mitigate some mental health concerns with the aim of decreasing the overall psychological impact of the pandemic.

Productivity Tracking: A Survey of Critical Care Pharmacist Practices and Satisfaction

Introduction: The position paper on critical care pharmacy services describes two tiers of responsibilities: essential and desirable activities. Activities are categorized into five domains: patient care, quality improvement, research and scholarship, training and education, and professional development. Documentation of these activities can be important for justifying pharmacist positions, comparing pharmacy practice models, conducting performance evaluations, and tracking individual workload; however, limited recommendations are provided for standardized productivity tracking, and national practices remain largely uncharacterized. Objectives: The purpose of this survey was to describe documentation practices of critical care pharmacist activities. Methods: A cross-sectional survey was distributed via email to 1694 members of the ACCP critical care practice research network. The survey asked respondents to describe the methods used to document productivity as it relates to the 5 domains. Results: Seventy-nine (4.7%) critical care pharmacists from 63 institutions completed the survey. Intervention documentation was used for position justification and annual reviews among 54.4% and 44.1% of pharmacists, respectively. Pharmacists were routinely expected to perform additional responsibilities beyond patient care that contribute to overall productivity, but the percentage of institutions that track these activities as a measure of pharmacist productivity was relatively low: quality improvement (46%), research/scholarship (29%), training/education (38%), and professional development (27%). Documentation of these additional responsibilities and activities was primarily used for annual evaluations, but the majority of respondents answered that no standardized method for tracking activities existed. In multivariate regression, dedicated ICU pharmacists was a significant predictor for increased satisfaction (Exp(ß) 4.498, 95% CI 1.054-19.187, P = .042). Conclusion: Practice variation exists in how and for what intent critical care pharmacists track productivity. Further evaluation and standardization of productivity tracking may aid in position justification and practice model evaluation for dedicated ICU pharmacists in today's value-based era.

Burnout among Respiratory Therapists and Perception of Leadership: A Cross Sectional Survey Over Eight Intensive Care Units

Background

Burnout syndrome (BOS) is a job-related stress disorder featured by three main cardinal manifestations: emotional exhaustion (EE), reduced personal accomplishment (PA), and depersonalization (DP).

Aim

We aimed to report the prevalence of burnout and the impact of leadership and work condition on the burnout among respiratory therapists (RT) are front-line practitioners in many critical settings.

Methods

We surveyed RT in eight intensive care units (ICU) at five tertiary hospitals, under one medical corporation, using three instruments: the Maslach Burnout Inventory Human Services Survey for Medical Personnel, Condition of Work Effectiveness Questionnaire (CWEQ), and Leadership behaviours scale. We used a group of other health care practitioners (ie, physicians and nurses) as the control group.

Results

Of a sampling frame of 1222 ICU practitioners, 445 (36.4%) responded with completed surveys. Eighty-four (17.3%) and 361 (82.7%) participants were in the RT and the control group, respectively. The overall burnout score was significantly lower in the RT group (53.6% vs. 67%, p = 0.02). The EE and DP scores were significantly lower in the RT group [(26.2% vs. 37.7, p = 0.048) and (9.5% vs. 19.9%, p = 0.025), respectively], but the PA score did not show significant difference between the groups. A significant negative relationship was found between CWEQ score and both EE and DP scores (rs = −0. 0.557, p < 0.001) and (rs = −0.372, p < 0.001), respectively, while a significant positive correlation was found between CWEQ and the PA score (rs = 0.225, p < 0.042). A significant negative relationship was found between the leadership attitude and EE scores (rs = −0.414, p < 0.001).

Conclusion

The results of this study suggest a high burnout rate among RT. The reported rate was significantly correlated to work conditions and leadership behaviours. Organizational efforts should be directed to combating burnout through the identification and adequate management of the key precipitating factors.

ClinicalTrials.gov Identifier:

NCT04620005

The Different Challenges in Being an Adult Versus a Pediatric Intensivist

There is little current research comparing stress, burnout, and resilience in pediatric and adult intensive care practitioners. This article analyzes data derived from a 2018 qualitative study of burnout and resilience among ICU providers to explore differences that may exist between the pediatric and adult domains of practice.

Compromised Integrity, Burnout, and Intent to Leave the Job in Critical Care Nurses and Physicians

To describe relationships between compromised integrity (CI), burnout, and intent-to-leave (ITL) practice in critical care (CC) and noncritical care (non-CC) nurses and physicians.

DESIGN

CC nurses (RNs) and physicians (MDs) from the American Medical Association Coping with COVID survey were matched by gender, race, years in practice, and role with non-CC clinicians to determine likelihood of ITL in relation to burnout and CI.

SETTING

U.S. Healthcare organizations; July-December 2020.

SUBJECTS

One hundred sixty-five CC RNs and 148 CC MDs (n = 313) matched with 165 non-CC RNs and 148 non-CC MDs from 83 healthcare organizations.

MEASUREMENTS AND MAIN RESULTS

Burnout was measured with a single, validated question that mainly reflects emotional exhaustion (EE), and CI was determined by asking if respondents worried about doing things that compromised their integrity moderately or to a great extent. ITL included those moderately, likely, or definitely, intending to leave. Burnout correlated strongly with CI (tetrachoric r = 0.704 [0.606-0.803]; P < 0.001). Of 626 subjects, 59% experienced burnout, 24% CI, and 33% ITL. CC RNs experienced burnout more often (76%) than non-CC RNs (62%; P < 0.01) and CC MDs (51%; P < 0.001). CI was more frequent in CC RNs (44%) than non-CC RNs (23%) and CC MDs (16%; P < 0.001). In multivariate regressions, CC clinicians experiencing burnout had 50% greater odds of ITL than non-CC clinicians experiencing burnout; odds of ITL were substantially higher (odds ratio, 2.8-3.2) in those with CI regardless of location or burnout. In the ICU, those feeling valued by their organization had one-third the odds of ITL.

CONCLUSIONS

Burnout (EE) is high (>50%) among CC RNs and MDs, which may result in losses of CC clinicians while demand rises. Preventing CI independent of burnout may reduce turnover in all settings and especially in ICUs. Feeling valued may promote staff retention.

Quantifying Occupational Stress in Intensive Care Unit Nurses: An Applied Naturalistic Study of Correlations Among Stress, Heart Rate, Electrodermal Activity, and Skin Temperature

OBJECTIVE

To identify physiological correlates to stress in intensive care unit nurses.

BACKGROUND

Most research on stress correlates are done in laboratory environments; naturalistic investigation of stress remains a general gap.

METHOD

Electrodermal activity, heart rate, and skin temperatures were recorded continuously for 12-hr nursing shifts (23 participants) using a wrist-worn wearable technology (Empatica E4).

RESULTS

Positive correlations included stress and heart rate (ρ = .35, p < .001), stress and skin temperature (ρ = .49, p < .05), and heart rate and skin temperatures (ρ = .54, p = .0008).

DISCUSSION

The presence and direction of some correlations found in this study differ from those anticipated from prior literature, illustrating the importance of complementing laboratory research with naturalistic studies. Further work is warranted to recognize nursing activities associated with a high level of stress and the underlying reasons associated with changes in physiological responses.

APPLICATION

Heart rate and skin temperature may be used for real-time detection of stress, but more work is needed to validate such surrogate measures.

The Rapid Implementation of Ad Hoc Tele-Critical Care Respiratory Therapy (eRT) Service in the Wake of the COVID-19 Surge

A 24/7 telemedicine respiratory therapist (eRT) service was set up as part of the established University of Pennsylvania teleICU (PENN E-LERT^®) service during the COVID-19 pandemic, serving five hospitals and 320 critical care beds to deliver effective remote care in lieu of a unit-based RT. The eRT interventions were components of an evidence-based care bundle and included ventilator liberation protocols, low tidal volume protocols, tube patency, and an extubation checklist. In addition, the proactive rounding of patients, including ventilator checks, was included. A standardized data collection sheet was used to facilitate the review of medical records, direct audio–visual inspection, or direct interactions with staff. In May 2020, a total of 1548 interventions took place, 93.86% of which were coded as “routine” based on established workflows, 4.71% as “urgent”, 0.26% “emergent”, and 1.17% were missing descriptors. Based on the number of coded interventions, we tracked the number of COVID-19 patients in the system. The average intervention took 6.1 ± 3.79 min. In 16% of all the interactions, no communication with the bedside team took place. The eRT connected with the in-house respiratory therapist (RT) in 66.6% of all the interventions, followed by house staff (9.8%), advanced practice providers (APP; 2.8%), and RN (2.6%). Most of the interaction took place over the telephone (88%), secure text message (16%), or audio-video telemedicine ICU platform (1.7%). A total of 5115 minutes were spent on tasks that a bedside clinician would have otherwise executed, reducing their exposure to COVID-19. The eRT service was instrumental in several emergent and urgent critical interventions. This study shows that an eRT service can support the bedside RT providers, effectively monitor best practice bundles, and carry out patient–ventilator assessments. It was effective in certain emergent situations and reduced the exposure of RTs to COVID-19. We plan to continue the service as part of an integrated RT service and hope to provide a framework for developing similar services in other facilities.

Investigating the cognitive capacity constraints of an ICU care team using a systems engineering approach

Background

ICU operational conditions may contribute to cognitive overload and negatively impact on clinical decision making. We aimed to develop a quantitative model to investigate the association between the operational conditions and the quantity of medication orders as a measurable indicator of the multidisciplinary care team’s cognitive capacity.

Methods

The temporal data of patients at one medical ICU (MICU) of Mayo Clinic in Rochester, MN between February 2016 to March 2018 was used. This dataset includes a total of 4822 unique patients admitted to the MICU and a total of 6240 MICU admissions. Guided by the Systems Engineering Initiative for Patient Safety model, quantifiable measures attainable from electronic medical records were identified and a conceptual framework of distributed cognition in ICU was developed. Univariate piecewise Poisson regression models were built to investigate the relationship between system-level workload indicators, including patient census and patient characteristics (severity of illness, new admission, and mortality risk) and the quantity of medication orders, as the output of the care team’s decision making.

Results

Comparing the coefficients of different line segments obtained from the regression models using a generalized F-test, we identified that, when the ICU was more than 50% occupied (patient census > 18), the number of medication orders per patient per hour was significantly reduced (average = 0.74; standard deviation (SD) = 0.56 vs. average = 0.65; SD = 0.48; p < 0.001). The reduction was more pronounced (average = 0.81; SD = 0.59 vs. average = 0.63; SD = 0.47; p < 0.001), and the breakpoint shifted to a lower patient census (16 patients) when at a higher presence of severely-ill patients requiring invasive mechanical ventilation during their stay, which might be encountered in an ICU treating patients with COVID-19.

Conclusions

Our model suggests that ICU operational factors, such as admission rates and patient severity of illness may impact the critical care team’s cognitive function and result in changes in the production of medication orders. The results of this analysis heighten the importance of increasing situational awareness of the care team to detect and react to changing circumstances in the ICU that may contribute to cognitive overload.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12871-021-01548-7.

Influence of Mutual Support on Burnout among Intensive Care Unit Healthcare Professionals

Introduction

Burnout among healthcare professionals in intensive care units (ICUs) is a serious issue that leads to early retirement and medication errors. Their gender, lower years of experience, and lower education have been reported as risk factors. Simultaneously, mutual support—commonly referred to as “back-up behavior,” in which staff members support each other—is critical for team performance. However, little is known about the influence of mutual support among ICU healthcare professionals on burnout. The U.S. Agency for Healthcare Research and Quality refers to mutual support as the involvement of team members in: assisting one another, providing and receiving feedback, and exerting assertive and advocacy behaviors when patient safety is threatened.

Objective

This study aimed to verify the hypothesis that lower mutual support among ICU healthcare professionals is associated with increased probability of burnout.

Methods

A web-based survey was conducted from March 4 to 20, 2021. All ICU healthcare professionals in Japan were included. An invitation was sent via the mailing list of the Japanese Society of Intensive Care Medicine and asked to mail to local communities and social network services. We measured burnout severity using the Maslach Burnout-Human Services Survey and mutual support using the TeamSTEPPS Teamwork Perceptions Questionnaire, as well as occupational background. The cutoff value for burnout was predefined and conducted logistic regression.

Results

We received 335 responses, all of which were analyzed. The majority of respondents were nurses (58.5%), followed by physicians (18.5%) and clinical engineers (10.1%). The burnout group scored significantly lower on mutual support than the non-burnout group. After adjusting for covariates in a logistic regression, low mutual support was an independent factor predicting a high probability of burnout.

Conclusions

This study suggests that it is important to focus on mutual support among ICU healthcare professionals to reduce the frequency of burnout.

The Impact of COVID-19: Nurses Occupational Stress and Strategies to Manage It

OBJECTIVE

The aim of this study was to explore the occupational stress perception of nurses and how they manage it during the COVID-19 pandemic.

BACKGROUND

The management of occupational stress is a key factor in promoting nurses' well-being.

METHODS

A descriptive cross-sectional study was conducted.

RESULTS

The top occupational stressors from the nurses' perspectives (N = 236) as measured by using an updated version of the Nursing Stress Scale (NSS) included wearing a face mask at all times in the hospital, unpredictable staffing and scheduling, not enough staff to adequately cover the unit, feeling helpless in the case a patient fails to improve, and being assigned to a COVID-19 patient. The mean stress score was 31.87. The updated NSS Cronbach's α was 0.92, and the interclass interclass correlation coefficient was 0.914.

CONCLUSION

Nurse administrators are in a strategic position to develop interventions (eg, open door policy, meetings, and employee assistance programs) to assist nurses in effectively managing stress.

Admission criteria in critically ill COVID-19 patients: A physiology-based approach

Introduction

The COVID-19 pandemic required careful management of intensive care unit (ICU) admissions, to reduce ICU overload while facing limitations in resources. We implemented a standardized, physiology-based, ICU admission criteria and analyzed the mortality rate of patients refused from the ICU.

Materials and methods

In this retrospective observational study, COVID-19 patients proposed for ICU admission were consecutively analyzed; Do-Not-Resuscitate patients were excluded. Patients presenting an oxygen peripheral saturation (SpO₂) lower than 85% and/or dyspnea and/or mental confusion resulted eligible for ICU admission; patients not presenting these criteria remained in the ward with an intensive monitoring protocol. Primary outcome was both groups’ survival rate. Secondary outcome was a sub analysis correlating SpO₂ cutoff with ICU admission.

Results

From March 2020 to January 2021, 1623 patients were admitted to our Center; 208 DNR patients were excluded; 97 patients were evaluated. The ICU-admitted group (n = 63) mortality rate resulted 15.9% at 28 days and 27% at 40 days; the ICU-refused group (n = 34) mortality rate resulted 0% at both intervals (p < 0.001). With a SpO₂ cut-off of 85%, a significant correlation was found (p = 0.009), but with a 92% a cut-off there was no correlation with ICU admission (p = 0.26). A similar correlation was also found with dyspnea (p = 0.0002).

Conclusion

In COVID-19 patients, standardized ICU admission criteria appeared to safely reduce ICU overload. In the absence of dyspnea and/or confusion, a SpO₂ cutoff up to 85% for ICU admission was not burdened by negative outcomes. In a pandemic context, the SpO₂ cutoff of 92%, as a threshold for ICU admission, needs critical re-evaluation.

Healthcare workers' structured daily reflection on patient safety, workload and work environment in intensive care. A descriptive retrospective study

OBJECTIVES

To describe the results of use of structured daily reflection assessments among healthcare workers at an intensive care unit over the course of one year.

METHODS

In this descriptive retrospective study, data were analysed both quantitatively and qualitatively. The data encompassed 1095 work shifts, evaluated by healthcare workers at an intensive care unit using a structured daily reflection instrument. The areas evaluated were patient safety, workload and work environment, and free-text comments were possible.

FINDINGS

The results showed that 36% (n = 395) of work shifts, most of them daytime shifts (44%; n = 161), were affected. Workload was the area that affected most work shifts (29%; n = 309). Missed nursing care, complex care and inaccurate communication impacted patient safety, while patient care, multitasking and working conditions affected workload. Work environment was impacted by organisational factors, environment, lack of control and moral stress.

CONCLUSION

Using daily reflection among healthcare workers in the intensive care unit illuminated areas that affect patient safety, workload, and work environment. The importance of communication and collaboration and how they can impact patient safety, workload, and the work environment were highlighted by the team.

Advanced Practice Provider-inclusive Staffing Models and Patient Outcomes in Pediatric Critical Care

BACKGROUND

Pediatric intensive care units (PICUs) are increasingly staffed with advanced practice providers (APPs), supplementing traditional physician staffing models.

OBJECTIVES

We evaluate the effect of APP-inclusive staffing models on clinical outcomes and resource utilization in US PICUs.

RESEARCH DESIGN

Retrospective cohort study of children admitted to PICUs in 9 states in 2016 using the Healthcare Cost and Utilization Project's State Inpatient Databases. PICU staffing models were assessed using a contemporaneous staffing survey. We used multivariate regression to examine associations between staffing models with and without APPs and outcomes.

MEASURES

The primary outcome was in-hospital mortality. Secondary outcomes included odds of hospital acquired conditions and ICU and hospital lengths of stay.

RESULTS

The sample included 38,788 children in 40 PICUs. Patients admitted to PICUs with APP-inclusive staffing were younger (6.1±5.9 vs. 7.1±6.2 y) and more likely to have complex chronic conditions (64% vs. 43%) and organ failure on admission (25% vs. 22%), compared with patients in PICUs with physician-only staffing. There was no difference in mortality between PICU types [adjusted odds ratio (AOR): 1.23, 95% confidence interval (CI): 0.83-1.81, P=0.30]. Patients in PICUs with APP-inclusive staffing had lower odds of central line-associated blood stream infections (AOR: 0.76, 95% CI: 0.59-0.98, P=0.03) and catheter-associated urinary tract infections (AOR: 0.73, 95% CI: 0.61-0.86, P<0.001). There were no differences in lengths of stay.

CONCLUSIONS

Despite being younger and sicker, children admitted to PICUs with APP-inclusive staffing had no increased odds of mortality and lower odds of some hospital acquired conditions compared with those in PICUs with physician-only staffing. Further research can inform APP integration strategies which optimize outcomes.

Regionalization of Critical Care in the United States: Current State and Proposed Framework From the Academic Leaders in Critical Care Medicine Task Force of the Society of the Critical Care Medicine

OBJECTIVES

The Society of Critical Care Medicine convened its Academic Leaders in Critical Care Medicine taskforce on February 22, 2016, during the 45th Critical Care Congress to develop a series of consensus papers with toolkits for advancing critical care organizations in North America. The goal of this article is to propose a framework based on the expert opinions of critical care organization leaders and their responses to a survey, for current and future critical care organizations, and their leadership in the health system to design and implement successful regionalization for critical care in their regions.

DATA SOURCES AND STUDY SELECTION

Members of the workgroup convened monthly via teleconference with the following objectives: to 1) develop and analyze a regionalization survey tool for 23 identified critical care organizations in the United States, 2) assemble relevant medical literature accessed using Medline search, 3) use a consensus of expert opinions to propose the framework, and 4) create groups to write the subsections and assemble the final product.

DATA EXTRACTION AND SYNTHESIS

The most prevalent challenges for regionalization in critical care organizations remain a lack of a strong central authority to regulate and manage the system as well as a lack of necessary infrastructure, as described more than a decade ago. We provide a framework and outline a nontechnical approach that the health system and their critical care medicine leadership can adopt after considering their own structure, complexity, business operations, culture, and the relationships among their individual hospitals. Transforming the current state of regionalization into a coordinated, accountable system requires a critical assessment of administrative and clinical challenges and barriers. Systems thinking, business planning and control, and essential infrastructure development are critical for assisting critical care organizations.

CONCLUSIONS

Under the value-based paradigm, the goals are operational efficiency and patient outcomes. Health systems that can align strategy and operations to assist the referral hospitals with implementing regionalization will be better positioned to regionalize critical care effectively.

Creating a Blueprint of Well-Being in Oncology: An Approach for Addressing Burnout From ASCO's Clinician Well-Being Taskforce

Optimizing the well-being of the oncology clinician has never been more important. Well-being is a critical priority for the cancer organization because burnout adversely impacts the quality of care, patient satisfaction, the workforce, and overall practice success. To date, 45% of U.S. ASCO member medical oncologists report experiencing burnout symptoms of emotional exhaustion and depersonalization. As the COVID-19 pandemic remains widespread with periods of outbreaks, recovery, and response with substantial personal and professional consequences for the clinician, it is imperative that the oncologist, team, and organization gain direct access to resources addressing burnout. In response, the Clinician Well-Being Task Force was created to improve the quality, safety, and value of cancer care by enhancing oncology clinician well-being and practice sustainability. Well-being is an integrative concept that characterizes quality of life and encompasses an individual's work- and personal health-related environmental, organizational, and psychosocial factors. These resources can be useful for the cancer organization to develop a well-being blueprint: a detailed start plan with recognized strategies and interventions targeting all oncology stakeholders to support a culture of community in oncology.

Cross-cultural adaptation of the SCORE survey and evaluation of the impact of Real-Time Random Safety Audits in organizational culture: A multicenter study

OBJECTIVE

To establish a cross-cultural adaptation of the Safety, Communication, Operational Reliability, and Engagement (SCORE) survey and to use this instrument to evaluate the impact of a safety intervention.

DESIGN

Cross-cultural adaptation and before-and-after evaluation study.

SETTING

5 ICU.

PARTICIPANTS

Medical residents, attending physicians, and nurses at those ICU.

INTERVENTIONS

Adaptation of the SCORE survey to Spanish culture. The adapted survey was used to assess all safety-culture-related domains before and one-year after implementing the use of a safety tool, Real-Time Random Safety Audits (in Spanish: Análisis Aleatorios de Seguridad en Tiempo Real, AASTRE).

MAIN OUTCOME MEASURE

Adaptabiliy of the Spanish version of SCORE survey in the ICU setting and evaluation of the effect of AASTRE on their domains.

RESULTS

The cross-cultural adaptation was adequate. Post-AASTRE survey scores [mean (standard deviation, SD)] were significantly better in the domains learning environment [50.55 (SD 20.62) vs 60.76 (SD 23.66), p<.0001], perception of local leadership [47.98 (SD 23.57) vs 62.82 (SD 27.46), p<.0001], teamwork climate [51.19 (SD 18.55) vs 55.89 (SD 20.25), p=.031], safety climate [45.07 (SD 17.60) vs 50.36 (SD 19.65), p=.01], participation decision making [3 (SD 0.82) vs 3.65 (SD 0.87), p<.0001] and advancement in the organization [3.21 (SD 0.77) vs 4.04 (SD 0.77), p<.0001]. However, post-AASTRE scores were significantly worse in the domains workload and burnout climate.

CONCLUSIONS

The cross-cultural adaptation of the SCORE survey into Spanish is a useful tool for ICUs. The application of the AASTRE is associated with improvements in six SCORE domains, including the safety climate.

Workforce, Workload, and Burnout in Critical Care Organizations: Survey Results and Research Agenda

OBJECTIVES

This report provides analyses and perspective of a survey of critical care workforce, workload, and burnout among the intensivists and advanced practice providers of established U.S. and Canadian critical care organizations and provides a research agenda.

DESIGN

A 97-item electronic survey questionnaire was distributed to the leaders of 27 qualifying organizations.

SETTING

United States and Canada.

PARTICIPANTS

Leaders of critical care organizations in the United States and Canada.

INTERVENTIONS

None.

DATA SYNTHESIS AND MAIN RESULTS

We received 23 responses (85%). The critical care organization survey recorded substantial variability of most organizational aspects that were not restricted by the critical care organization definition or regulatory mandates. The most common physician staffing model was a combination of full-time and part-time intensivists. Approximately 80% of critical care organizations had dedicated advanced practice providers that staffed some or all their ICUs. Full-time intensivists worked a median of 168 days (range 42-192 d) in the ICU (168 shifts = 24 7-d wk). The median shift duration was 12 hours (range, 7-14 hr), and the median number of consecutive shifts allowed was 7 hours (range 7-14 hr). More than half of critical care organizations reported having burnout prevention programs targeted to ICU physicians, advanced practice providers, and nurses.

CONCLUSIONS

The variability of current approaches suggests that systematic comparative analyses could identify best organizational practices. The research agenda for the study of critical care organizations should include studies that provide insights regarding the effects of the integrative structure of critical care organizations on outcomes at the levels of our patients, our workforce, our work practices, and sustainability.

Standardized Work Rounds Enhance Teaming, Comprehensiveness, Shared Mental Model Development, and Achievement Rate of End-of-Shift Goals

OBJECTIVES

To determine the impact of standardized PICU work rounds on the frequency of ideal teaming behaviors, rounds comprehensiveness, shared mental model index development, and rate of completed end-of-shift goals.

DESIGN

A single-center, pre-post, prospective cohort study.

SETTING

A 259-bed, quaternary, pediatric referral center.

PATIENTS

Children 0-18 years old from November 2018 to January 2020.

INTERVENTIONS

Standardized, bedside, nurse-led PICU work rounds, emphasizing ideal teaming behaviors using a collaboratively developed rounding script and quality/safety checklist.

MEASUREMENTS AND MAIN RESULTS

Study data were collected by direct observation and immediate postrounds participant questionnaire data. Primary outcomes were frequency of observed ideal teaming behaviors, rounds comprehensiveness, efficiency (rounds content divided by duration), shared mental model index (congruence among rounds participants regarding key healthcare data and planning), rounds face validity, and achievement rate of rounds-established, end-of-shift goals. During study, 154 encounters were observed (50 preintervention, 52 after Plan-Do-Study-Act cycle 1, and 52 after Plan-Do-Study-Act cycle 2). We observed improvements in overall shared mental model index (24-87%), rounds comprehensiveness (72-98%), and ideal teaming behaviors (including closed-loop communication: 82-100%; responsibility delegation: 74-100%; interdependence behaviors: 26-98%, all p < 0.01) by the end of study. Nursing presentations accounted for 3.6 ± 1.5 minutes of rounds and rounds duration was unchanged postintervention (11 ± 5 min preintervention and 11 ± 4 min after Plan-Do-Study-Act cycle 2, p > 0.99). Face validity, assessed using questionnaire data from 953 participants, revealed positive attitudes regarding efficiency, clarity, and participant self-value. Greatest enhancements in self-value were noted among advanced practice providers and respiratory therapists. On exploratory modeling, we noted associations between ideal teaming behaviors, rounds comprehensiveness, and shared mental model index. Similarly, we noted a positive association between the shared mental model index and the rate of achieved rounds-established, end-of-shift goals (odds ratio, 8.9; 95% CI, 1.7-46; p < 0.01).

CONCLUSIONS

Standardization of PICU work rounds may encourage ideal teaming behaviors, enhance rounds comprehensiveness, strengthen the congruence of participant shared mental model, and affect the rate of achieved goals established during rounds without compromising workplace efficiency.

Adequacy of workforce - are there enough critical care doctors in the US-post COVID?

PURPOSE OF REVIEW

The ICU is a complex ecosystem in which intensive care physicians, advanced practice providers (APPs), pharmacists, and respiratory therapists work in concert to take care of critically ill patients. The SARS COV2 pandemic highlighted weaknesses in the American healthcare system. This article explores the ability of American healthcare to adapt to this challenge.

RECENT FINDINGS

With the COVID-19 pandemic, intensivists, and ventilators have been identified as the most critical components leading to shortages in ICU capacity. Anesthesiologists play a unique role in being able to provide 'flex capacity' with critical care staffing, space, and equipment (post-anesthesia care units, operating rooms, and ventilators). With the advent of APPs, intensive care physician staffing ratios may potentially be increased to cover patients safely in a physician-led team model. Tele-medicine expands this further and can allow hospital coordination for optimizing ICU bed use.

SUMMARY

Although intensivists have been able to take care of the increased ICU caseload during the COVID-19 pandemic through recruiting other specialties, the question of what is the appropriate staffing model for the future is yet to be elucidated. Creating stronger multidisciplinary care teams that have the capacity to flex up critical care capacity may be the most prudent longer-term solution.

Harnessing implementation science to optimize harm prevention in critically ill children: A pilot study of bedside nurse CLABSI bundle performance in the pediatric intensive care unit

OBJECTIVE

Central-line associated bloodstream infection (CLABSI) is associated with increased mortality, morbidity, and cost in hospitalized children. An evidence-based bundle of care can decrease CLABSI, but bundle compliance is imperfect. We explored factors impacting bundle performance in the pediatric intensive care unit (PICU) by bedside nurses.

METHODS

Single-center cross-sectional electronic survey of PICU bedside nurses in an academic tertiary care center; using the COM-B (capability, opportunity, motivation) and TDF (theoretical domains framework) behavioral models to explore CLABSI bundle performance and identify barriers to compliance.

RESULTS

We analyzed 160 completed surveys from 226 nurses (71% response rate). CLABSI knowledge was strong (capability). However, challenges related to opportunity were identified: 71% reported that patient care requirements impact bundle completion; 32% described the bundle as stressful; and CLABSI was viewed as the most difficult of all bundles. Seventy-five percent reported being highly impacted by physician attitude toward the CLABSI bundle (motivation).

CONCLUSIONS

PICU nurses are knowledgeable and motivated to prevent CLABSI, but face challenges from competing clinical tasks, limited resources, and complex family interactions. Physician engagement was specifically noted to impact nurse motivation to complete the bundle. Interventions that address these challenges may improve bundle performance and prevent CLABSI in critically ill children.

Rapid Cycle Deliberate Practice to Facilitate "Nano" In Situ Simulation: An Interprofessional Approach to Just-in-Time Training

BACKGROUND

Simulation is increasingly used to identify latent threats to patient safety, such as delays in recognition and management of time-sensitive conditions. The Rapid Cycle Deliberate Practice teaching method may facilitate "nano" (brief) in situ simulation training in a critical care setting to improve multidisciplinary team performance of time-sensitive clinical tasks.

OBJECTIVE

To determine whether nano-in situ simulation training with Rapid Cycle Deliberate Practice can improve pediatric intensive care unit team proficiency in identifying and managing postoperative shock in a pediatric cardiac patient.

METHODS

A quality improvement educational project was conducted involving nano-in situ simulation sessions in a combined pediatric and pediatric cardiac intensive care unit. The Rapid Cycle Deliberate Practice method was used with an expert-driven checklist for 30-minute simulation scenarios.

RESULTS

A total of 23 critical care providers participated. The proportion of time-sensitive tasks completed within 5 minutes increased significantly from before to after training (52% [13 of 25] vs 100% [25 of 25]; P ≤ .001). Using a 5-point Likert scale, with higher scores indicating higher levels, the participants reported high degrees of performance confidence (mean, 4.42; SD, 0.20) and satisfaction with the simulation experience (mean, 4.96; SD, 0.12).

CONCLUSION

The Rapid Cycle Deliberate Practice method was used to facilitate nano-in situ simulation training and identify areas requiring additional education to improve patient safety. In situ simulation can educate providers in a cost-effective and timely manner.

Prevalence of burnout among intensivists in mainland China: a nationwide cross-sectional survey

BACKGROUND

Burnout has gained increasing attention worldwide; however, there is a lack of relevant research in China. This study investigated the prevalence and factors associated with burnout in physicians of the intensive care unit (ICU) in mainland China.

METHODS

This cross-sectional multicenter study included critical care physicians from all provinces in mainland China (except Tibet). A self-administered survey questionnaire was conducted. It included three parts: demographic information, lifestyle and work information, and the Maslach Burnout Inventory. The levels of burnout were calculated. The factors independently associated with burnout were analyzed by logistic regression.

RESULTS

Finally, 1813 intensivists participated in the survey. The participation rate was 90.7%. The prevalence of burnout and severe burnout was 82.1% (1489/1813) and 38.8% (704/1813), respectively. According to the logistic regression analysis, "difficulty in making treatment decisions" was independently associated with burnout [OR = 1.365, CI (1.060, 1.757)]. "Higher number of children" [OR = 0.714, CI (0.519, 0.981)] and higher "income satisfaction" [OR = 0.771, CI (0.619, 0.959)] were independent protective factors against severe burnout.

CONCLUSIONS

The burnout rate in ICU physicians in China is high. Difficult treatment decisions, the number of children, and income satisfaction are independently associated with burnout rates among ICU physicians in China.

TRIAL REGISTRATION

Burnout syndrome of the Chinese personnel working in intensive care units: a survey in China, ChiCTR-EOC-17013044, registered October 19, 2017. http://www.chictr.org.cn/showproj.aspx?proj=22329 .

Association of Burnout With Depression and Anxiety in Critical Care Clinicians in Brazil

IMPORTANCE

It is unclear whether burnout, anxiety, and depression constitute the same or different constructs. Better understanding of these constructs is important for diagnosis and treatment for intensive care unit (ICU) clinicians.

OBJECTIVE

To determine the associations and distinctiveness of burnout, depression, and anxiety in a sample of ICU clinicians.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study used baseline data from the ICU Visits Study, a cluster-randomized crossover clinical trial conducted from April 2017 to July 2018 in 36 mixed public and private nonprofit ICUs in Brazil. ICU clinicians, including day-shift physicians, nurses, nurse technicians, and physiotherapists working in an ICU at least 20 hours per week, were enrolled. Data were analyzed from December 27, 2019, to October 10, 2020.

MAIN OUTCOMES AND MEASURES

The main outcome measures were burnout, depression, and anxiety measured with the Maslach Burnout Inventory (MBI; range, 0-6, with high scores indicating more burnout) and the Hospital Depression and Anxiety Scale (HADS; range, 0-3, with higher scores indicating more depression or anxiety). Internal consistencies were satisfactory.

RESULTS

The total sample included 715 ICU clinicians (median [interquartile range] age, 34.8 [30.2-39.3] years; 520 [72.7%] women), including 96 physicians (13.4%), 159 nurses (22.2%), 358 nurse technicians (50.1%), and 102 physiotherapists (14.3%). Clinicians reported low levels of emotional exhaustion (mean [SD] score, 1.84 [1.18]), depersonalization (mean [SD] score, 0.98 [1.03]), and personal accomplishment (mean [SD] score, 5.05 [0.87]) on the MBI, and similarly low levels of depression (mean [SD] score, 0.54 [0.40]) and anxiety (mean [SD] score, 0.70 [0.45]) on the HADS. Confirmatory factor analyses consistently showed improved fit separating latent burnout dimensions from depression and anxiety. An exploratory graph analysis combining gaussian graphical model with clustering algorithms for weighted networks suggested 3 clusters, with distinct burnout, anxiety, and depression clusters. This structure was confirmed using a bootstrap with 1000 random samples, in which the 3-cluster solution emerged in 625 samples (62.5%). Both latent variable loadings and network statistics suggested 3 key indicators (ie, feeling burned out from work, worrying thoughts, and reverse-scored reporting feeling cheerful) that can be used for short screening instruments.

CONCLUSIONS AND RELEVANCE

These findings suggest that burnout and clinical symptoms of depression and anxiety were empirically distinct in a large sample of ICU clinicians, highlighting the importance of screening for burnout and clinical symptoms to allow fast access to adequate support and treatment in health professionals at high risk of burnout.

Telemedicine in the ICU: Innovation in the Critical Care Process

Tele-ICU is a technology-based model designed to deliver effective critical care in the intensive care unit (ICU). The tele-ICU system has been developed to address the increasing demand for intensive care services and the shortage of intensivists. A finite number of intensivists from remote locations provide real-time services to multiple ICUs and assist in the treatment of critically ill patients. Risk prediction algorithms, smart alarm systems, and machine learning tools augment conventional coverage and can potentially improve the quality of care. Tele-ICU is associated with substantial improvements in mortality, reduced hospital and ICU length of stay, and decreased health care costs. Although multiple studies show improved outcomes following the implementation of tele-ICU, results are not consistent. Several factors, including the heterogeneity of tele-ICU infrastructure deployed in different facilities and the reluctance of health care workers to accept tele-ICU, could be associated with these varied results. Considerably high installation and ongoing operational costs might also be limiting the widespread utilization of this innovative service. While we believe that the implementation of tele-ICU offers potential advantages and makes critical care delivery more efficient, further research on the impact of this technology in critical care settings is warranted.

Benchmarking Critical Care Well-Being: Before and After the Coronavirus Disease 2019 Pandemic

Supplemental Digital Content is available in the text.

Objectives:

Examine well-being, measured as burnout and professional fulfillment, across critical care healthcare professionals, ICUs, and hospitals within a health system; examine the impact of the coronavirus disease 2019 pandemic.

Design:

To complement a longitudinal survey administered to medical critical care physicians at the end of an ICU rotation, which began in May 2018, we conducted a cross-sectional survey among critical care professionals across four hospitals in December 2018 to January 2019. We report the results of the cross-sectional survey and, to examine the impact of the coronavirus disease 2019 pandemic, the longitudinal survey results from July 2019 to May 2020.

Setting:

Academic medical center.

Subjects:

Four-hundred eighty-one critical care professionals, including 353 critical care nurses, 58 advanced practice providers, 57 physicians, and 13 pharmacists, participated in the cross-sectional survey; 15 medical critical care physicians participated in the longitudinal survey through the coronavirus disease 2019 pandemic.

Interventions:

None.

Measurements and Main Results:

Burnout was present in 50% of ICU clinicians, ranging from 42% for critical care physicians to 55% for advanced practice providers. Professional fulfillment was less common at 37%, with significant variability across provider (p = 0.04), with a low of 23% among critical care pharmacists and a high of 53% among physicians. Well-being varied significantly at the hospital and ICU level. Workload and job demand were identified as drivers of burnout and meaning in work, culture and values of work community, control and flexibility, and social support and community at work were each identified as drivers of well-being. Between July 2019 and March 2020, burnout and professional fulfillment were present in 35% (15/43) and 58% (25/43) of medical critical care physician responses, respectively. In comparison, during the coronavirus disease 2019 pandemic, burnout and professional fulfillment were present in 57% (12/21) and 38% (8/21), respectively.

Conclusions:

Burnout was common across roles, yet differed across ICUs and hospitals. Professional fulfillment varied by provider role. We identified potentially modifiable factors related to clinician well-being that can inform organizational strategies at the ICU and hospital level. Longitudinal studies, designed to assess the long-term impact of the coronavirus disease 2019 pandemic on the well-being of the critical care workforce, are urgently needed.

Impact of Geographical Cohorting in the ICU: An Academic Tertiary Care Center Experience

Supplemental Digital Content is available in the text.

ICU is a multifaceted organization where multiple teams care for critically ill patients. In the current era, collaboration between teams and efficient workflows form the backbone of value-based care. Geographical cohorting is a widespread model for hospitalist rounding, but its role in ICUs is unclear. This study evaluates the outcomes of geographical cohorting in a large ICU of an Academic Health Center.

Associations between job demands, job resources and patient-related burnout among physicians: results from a multicentre observational study

OBJECTIVES

To investigate associations of job demands and resources with patient-related burnout among physicians.

DESIGN

Multicentre observational study.

SETTING

Fifty medical departments at 14 (academic and non-academic) hospitals in the Netherlands.

PARTICIPANTS

Four hundred sixty-five physicians (71.6% response rate), comprising 385 (82.8%) medical specialists and 80 (17.2%) residents.

MAIN OUTCOME MEASURES

Job demands (workload and bureaucratic demands), job resources (participation in decision making, development opportunities, leader's inspiration, relationships with colleagues and patients)-measured with the validated Questionnaire of Experience and Evaluation of Work and Physician Worklife Survey-and patient-related burnout, measured using the validated Copenhagen Burnout Inventory.

RESULTS

Patient-related burnout was positively associated with workload (b=0.36; 95% CI, 0.25 to 0.48; p<0.001) and negatively associated with development opportunities (b=-0.18; 95% CI, -0.27 to -0.08; p<0.001) and relationships with patients (b=-0.12; 95% CI, -0.22 to -0.03; p=0.01). Relationships with patients moderated the association between bureaucratic demands and patient-related burnout (b=-0.15; 95% CI, -0.27 to -0.04; p=0.01).

CONCLUSIONS

Physicians with high workloads and few development opportunities reported higher levels of patient-related burnout. Those with positive patient relationships were less likely to experience patient-related burnout, even in the presence of excessive bureaucracy. Therefore, positive physician-patient relationships may be supported to reduce the likelihood of physicians' patient-related burnout. However, the specific support needed to effectively reduce patient-related burnout may vary per healthcare context and thus requires intensified research across healthcare systems and settings.

Discrete-Event Simulation Modeling of Critical Care Flow: New Hospital, Old Challenges

Supplemental Digital Content is available in the text.

Objectives:

As the demand for critical care beds rises each year, hospitals must be able to adapt. Delayed transfer of care reduces available critical care capacity and increases occupancy. The use of mathematic modeling within healthcare systems has the ability to aid planning of resources. Discrete-event simulation models can determine the optimal number of critical care beds required and simulate different what-if scenarios.

Design:

Complex discrete-event simulation model was developed using a warm-up period of 30 days and ran for 30 trials against a 2-year period with the mean calculated for the runs. A variety of different scenarios were investigated to determine the effects of increasing capacity, increasing demand, and reduction of proportion and length of delayed transfer of care out of the ICU.

Setting:

Combined data from two ICUs in United Kingdom.

Patients:

The model was developed using 1,728 patient records and was validated against an independent dataset of 2,650 patients.

Interventions:

None.

Measurements and Main Results:

During model validation, the average bed utilization and admittance rate were equal to the real-world data. In the what-if scenarios, we found that increasing bed numbers from 23 to 28 keeping the arrival rate stable reduces the average occupancy rate to 70%. We found that the projected 4% yearly increase in admissions could overwhelm even the 28-bedded unit, without change in the delayed transfer of care episodes. Reduction in the proportion of patients experiencing delayed transfer of care had the biggest effect on occupancy rates, time spent at full capacity, and average bed utilization.

Conclusions:

Using discrete-event simulation of commonly available baseline patient flow and patient care data produces reproducible models. Reducing the proportion of patients with delayed transfer of care had a greater effect in reducing occupancy levels than simply increasing bed numbers even when demand is increased.

Sustaining improvements in relational coordination following team training and practice change: A longitudinal analysis

BACKGROUND

Poor communication is a leading cause of errors in health care. Structured interprofessional bedside rounds are a promising model to improve communication.

PURPOSE

The aim of the study was to test if an intervention to improve communication and coordination in an inpatient heart failure care unit would result in lasting change.

METHODOLOGY/APPROACH

The relational coordination (RC) survey was administered to seven workgroups (i.e., nurses, physicians) at baseline (2015) and three subsequent years following the intervention (team training, leadership development workshops, and structured interprofessional bedside round implementation). Descriptive analysis and mixed-effects models were used to assess the impact of the intervention on improving RC.

RESULTS

During the study period (2015-2018), 344 participants completed the survey for an overall response rate of 53.5% (n = 643). Postintervention, the RC index significantly increased from 3.79 to 4.08 (p < .001) and remained significantly higher over 2 years, with an RC index of 4.12 and 4.04, respectively (p < .001). The range of RC scores between and within workgroups narrowed over time, with nonrotating workgroups showing the most improvements.

CONCLUSION

Findings indicate that positive changes as a result of the intervention have been sustained, despite high rates of turnover among all workgroups. Notably, positive change in RC was found to be more pronounced for nonrotating workgroups compared to team members who rotate within the hospital (i.e., pharmacists who rotate to other units every month).

PRACTICE IMPLICATIONS

This intervention holds promise for teams seeking best practice models of "high-reliability" care organization and delivery. Sustained changes from this intervention represent an important area of future practice-based research.

Physician Burnout: Achieving Wellness for Providers and Patients

Purpose of Review

This review summarizes the history and scope of physician burnout, and explores recent advances in its understanding. With a particular focus on physicians who have completed their training, it also explores the present and future of interventions designed to alleviate the symptoms and sequelae of burnout.

Recent Findings

Nearly 50 years since first described, burnout continues to remain a pervasive issue within anesthesia and medicine as a whole. Recent work has continued to outline risk factors and specialty-specific prevalence, and explore individual and institutional interventions to prevent and treat symptoms.

Summary

Burnout continues to impact all who work in healthcare, at all levels of training. This review highlights recent advances in our understanding of the scope, causes, and management of burnout. In light of the current COVID-19 pandemic, we hope that the national and international focus on preventing and remediating burnout will continue to expand and strengthen.

Nurse Practitioners and Physician Assistants in Acute and Critical Care: A Concise Review of the Literature and Data 2008-2018

OBJECTIVES

To provide a concise review of the literature and data pertaining to the use of nurse practitioners and physician assistants, collectively called advanced practice providers, in ICU and acute care settings.

DATA SOURCES

Detailed search strategy using the databases PubMed, Ovid MEDLINE, and the Cumulative Index of Nursing and Allied Health Literature for the time period from January 2008 to December 2018.

STUDY SELECTION

Studies addressing nurse practitioner, physician assistant, or advanced practice provider care in the ICU or acute care setting.

DATA EXTRACTION

Relevant studies were reviewed, and the following aspects of each study were identified, abstracted, and analyzed: study population, study design, study aims, methods, results, and relevant implications for critical care practice.

DATA SYNTHESIS

Five systematic reviews, four literature reviews, and 44 individual studies were identified, reviewed, and critiqued. Of the research studies, the majority were retrospective with others being observational, quasi-experimental, or quality improvement, along with two randomized control trials. Overall, the studies assessed a variety of effects of advanced practice provider care, including on length of stay, mortality, and quality-related metrics, with a majority demonstrating similar or improved patient care outcomes.

CONCLUSIONS

Over the past 10 years, the number of studies assessing the impact of advanced practice providers in acute and critical care settings continue to increase. Collectively, these studies identify the value of advanced practice providers in patient care management, continuity of care, improved quality and safety metrics, patient and staff satisfaction, and on new areas of focus including enhanced educational experience of residents and fellows.

Burnout and Joy in the Profession of Critical Care Medicine

This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency Medicine 2020. Other selected articles can be found online at https://www.biomedcentral.com/collections/annualupdate2020. Further information about the Annual Update in Intensive Care and Emergency Medicine is available from http://www.springer.com/series/8901.

Scales Used to Measure Job Stressors in Intensive Care Units: Are They Relevant and Reliable? A Systematic Review

Background: Many studies have been conducted in intensive care units (ICUs) to identify the stress factors involved in the health of professionals and the quality and safety of care. The objectives are to identify the psychometric scales used in these studies to measure stressors and to assess their relevance and validity/reliability. Methods: All peer-reviewed full-text articles published in English between 1997 and 2016 and focusing on an empirical quantitative study of job stressors were identified through searches on seven databases and editorial portals. Results: From the 102 studies analyzed, we identified 59 different scales: 17 "all settings scales" (16 validated scales), 20 "healthcare settings scales" (13 validated scales), and 22 "ICU settings scales" (two validated scales). All these scales used measured stressors from at least one of the following eight broad categories: High job demands, Problematic relationships with other professionals, Lack of control over work situations and career, Lack of organizational resources, Problematic situations with users and relatives, Dealing with ethical- and moral-related situations, Risk management issues, and Disadvantages in comparison to other occupational situations. The "all settings scales" and "healthcare settings scales," the most often validated, did not measure, or only slightly measured, the stressors most specific to ICUs. Where these were taken into account, the authors were forced to develop their own tools or modify existing scales without testing the validity of the tool used. Conclusions: This review highlights the lack of a tool that meets both the criteria of validity and relevance with regard to the specificity of work in ICUs. Future research must focus on developing reliable/valid tools covering all types of relevant stressors to ensure the quality of the studies carried out in this field.

Intensivists' Direct Management without Residents May Improve the Survival Rate Compared to High-Intensity Intensivist Staffing in Academic Intensive Care Units: Retrospective and Crossover Study Design

BACKGROUND

Medical staff members are concentrated in the intensive care unit (ICU), and medical residents are essentially needed to operate the ICU. However, the recent trend has been to restrict resident working hours. This restriction may lead to a shortage of ICU staff, and there is a chance that regional academic hospitals will face running ICUs without residents in the near future.

METHODS

We performed a retrospective observational study (intensivist crossover design) of medical patients who were transferred to two ICUs from general wards between September 2017 and February 2019 at one academic hospital. We compared the ICU outcomes according to the ICU type (ICU with resident management under high-intensity intensivist staffing vs. ICU with direct management by intensivists without residents).

RESULTS

Of 314 enrolled patients, 70 were primarily managed by residents, and 244 were directly managed by intensivists. The latter patients showed better ICU mortality (29.9% vs. 42.9%, P = 0.042), lower cardiopulmonary resuscitation (CPR) (10.2% vs. 21.4%, P = 0.013), lower continuous renal replacement therapy (CRRT) (24.2% vs. 40.0%, P = 0.009), and more advanced care planning decisions before death (87.3% vs. 66.7%, P = 0.013) than the former patients. The better ICU mortality (hazard ratio, 1.641; P = 0.035), lower CPR (odds ratio [OR], 2.891; P = 0.009), lower CRRT (OR, 2.602; P = 0.005), and more advanced care planning decisions before death (OR, 4.978; P = 0.007) were also associated with intensivist direct management in the multivariate cox and logistic regression analysis.

CONCLUSION

Intensivist direct management might be associated with better ICU outcomes than resident management under the supervision of an intensivist. Further large-scale prospective randomized trials are required to draw a definitive conclusion.