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

Weak Correlation Between Perceived and Measured Intensive Care Unit Nursing Workload: An Observational Study

BACKGROUND

Efficient management of nursing workload in the intensive care unit (ICU) is essential for patient safety, care quality, and nurse well-being. Current ICU-specific workload assessment scores lack comprehensive coverage of nursing activities and perceived workload.

PURPOSE

The purpose of this study was to assess the correlation between ICU nurses' perceived workload and the Nine Equivalents of Nursing Manpower Use Score (NEMS).

METHODS

In a 45-bed adult ICU at a tertiary academic hospital, nurses' perceived shift workload (measured with an 11-point Likert scale) was correlated with the NEMS, calculated manually and electronically.

RESULTS

The study included 1734 observations. The perceived workload was recorded for 77.6% of observations. A weak positive correlation was found between perceived and objectively measured workload.

CONCLUSION

Findings indicate a need to consider the multifaceted nature of nursing activities and individual workload perceptions in the ICU.

Impact of burnout and professional fulfillment on intent to leave among pediatric physicians: The findings of a quality improvement initiative

BACKGROUND AND OBJECTIVES

Physician burnout is rampant, and physician retention is increasingly hard. It is unclear how burnout impacts intent to leave an organization. We sought to determine how physician burnout and professional fulfillment impact pediatric physicians' intent to leave (ITL) an organization.

DESIGN AND METHODS

We performed 120, 1:1 semi-structured interviews of our pediatric faculty and used the themes therefrom to develop a Likert-scale based, 22-question battery of their current work experience. We created a faculty climate survey by combining those questions with a standardized instrument that assesses burnout and professional fulfillment. We surveyed pediatric and pediatric-affiliated (e.g. pediatric surgery, pediatric psychiatry, etc.) physicians between November 2 and December 9, 2022. We used standard statistical methods to analyze the data. An alpha-level of 0.05 was used to determine significance.

RESULTS

A total of 142 respondents completed the survey, 129 (91%) were Department of Pediatrics faculty. Burnout was present in 41% (58/142) of respondents, whereas 30% (42/142) were professionally fulfilled. There was an inverse relationship between professional fulfillment and ITL, p < 0.001 for the trend. Among those who were not professionally fulfilled, the odds ratio of ITL in the next three years was 3.826 [95% CI 1.575-9.291], p = 0.003. There was a direct relationship between burnout and ITL, p < 0.001 for the trend.

CONCLUSIONS

Among pediatric physicians, professional fulfillment is strongly, inversely related with ITL in the next three years. Similarly, burnout is directly related with ITL. These data suggest a lack of professional fulfillment and high burnout are strong predictors of pediatric physician turnover.

The importance of creating the right conditions for group intervision sessions among medical residents- a qualitative study

BACKGROUND

The burnout rates among residents urge for adequate interventions to improve resilience and prevent burnout. Peer reflection, also called group intervision sessions, is a potentially successful intervention to increase the resilience of young doctors. We aimed to gain insight into the perceived added value of intervision sessions and the prerequisite conditions to achieve this, according to residents and intervisors. Our insights might be of help to those who think of implementing intervision sessions in their institution.

METHODS

An explorative, qualitative study was performed using focus groups and semi-structured interviews with both residents (n = 8) and intervisors (n = 6) who participated in intervision sessions in a university medical center in the Netherlands. The topic list included the perceived added value of intervision sessions and factors contributing to that. The interviews were transcribed verbatim and coded using NVivo. Thematic analysis was subsequently performed.

RESULTS

According to residents and intervisors, intervision sessions contributed to personal and professional identity development; improving collegiality; and preventing burn-out. Whether these added values were experienced, depended on: (1) choices made during preparation (intervisor choice, organizational prerequisites, group composition, workload); (2) conditions of the intervision sessions (safety, depth, role of intervisor, group dynamics, pre-existent development); and (3) the hospital climate.

CONCLUSIONS

Intervision sessions are perceived to be of added value to the identity development of medical residents and to prevent becoming burned out. This article gives insight in conditions necessary to reach the added value of intervision sessions. Optimizing preparation, meeting prerequisite conditions, and establishing a stimulating hospital climate are regarded as key to achieve this.

A Mindfulness-Based Intervention for Acute Care Nursing Staff: A Pilot Study

Purpose:The purpose of this study was to determine if a mindfulness-based smartphone application, used for 5 minutes a day for 30 days, could address burnout among acute care nursing staff. Methods: A pretest-posttest design with a midpoint evaluation was utilized. The sample included 31 nursing staff from cardiovascular acute care units. The Copenhagen Burnout Inventory, Cognitive and Affective Mindfulness Scale-Revised, Perceived Stress Scale, and Brief Resilience Scale were used to measure the impact of the intervention on participants. Findings: In a repeated measures analysis, there were no statistically significant changes in scores on the Brief Resilience Scale across the three timeframes (F = 0.64, df = 1.42, p = .49). There were significant reductions over time for perceived stress (F = 10.56, df = 1.74, p = .002) and personal burnout (F = 11.8, df = 1.10, p = .007), and increased scores on mindfulness (F = 4.76, df = 1.57, p = .039). Conclusions: The utilization of a mindfulness-based smartphone application may promote the health and well-being of cardiovascular nurses in acute care units. Mindfulness-based smartphone apps should be considered as a method of self-care, along with other holistic approaches to improve well-being.

A Survey of Burnout Among Neurocritical Care Practitioners

BACKGROUND

Burnout is a growing problem among medical professionals, reaching a crisis proportion. It is defined by emotional exhaustion, cynicism, and career dissatisfaction and is triggered by a mismatch between the values of the person and the demands of the workplace. Burnout has not previously been examined thoroughly in the Neurocritical Care Society (NCS). The purpose of this study is to assess the prevalence, contributing factors, and potential interventions to reduce burnout within the NCS.

METHODS

A cross-sectional study of burnout was conducted using a survey distributed to members of the NCS. The electronic survey included personal and professional characteristic questions and the Maslach Burnout Inventory Human Services Survey for Medical Personnel (MBI). This validated measure assesses for emotional exhaustion (EE), depersonalization (DP), and personal achievement (PA). These subscales are scored as high, moderate, or low. Burnout (MBI) was defined as a high score in either EE or DP or a low score in PA. A Likert scale (0-6) was added to the MBI (which contained 22 questions) to provide summary data for the frequencies of each particular feeling. Categorical variables were compared using χ2 tests, and continuous variables were compared using t-tests.

RESULTS

A total of 82% (204 of 248) of participants completed the entire questionnaire; 61% (124 of 204) were burned out by MBI criteria. A high score in EE was present in 46% (94 of 204), a high score in DP was present in 42% (85 of 204), and a low score in PA was present in 29% (60 of 204). The variables feeling burned out now, feeling burned out in the past, not having an effective/responsive supervisor, thinking about leaving one's job due to burnout, and leaving one's job due to burnout were significantly associated with burnout (MBI) (p < 0.05). Burnout (MBI) was also higher among respondents early in practice (currently training/post training 0-5 years) than among respondents post training 21 or more years. In addition, insufficient support staff contributed to burnout, whereas improved workplace autonomy was the most protective factor.

CONCLUSIONS

Our study is the first to characterize burnout among a cross-section of physicians, pharmacists, nurses, and other practitioners in the NCS. A call to action and a genuine commitment by the hospital, organizational, local, and federal governmental leaders and society as a whole is essential to advocate for interventions to ameliorate burnout and care for our health care professionals.

Risk and prediction of job burnout in responding nurses to public health emergencies

BACKGROUND

In public health emergencies, nurses are vulnerable to adverse reactions, especially job burnout. It is critical to identify nurses at risk of burnout early and implement interventions as early as possible.

METHODS

A cross-sectional survey of the hospitals in Xiangyang City was conducted in January, 2023 using stratified cluster sampling. Anonymized data were collected from 1584 working nurses. The Impact of Events Scale-Revised (IES-R) and the Chinese version of the Maslach Burnout Inventory-General Survey (MBI-GS) were used to evaluate the post-traumatic stress disorder (PTSD) and burnout of nurses in public health emergencies. Logistic regression analysis was established to screen for risk factors of burnout, and a nomogram was developed to predict the risk of burnout. A calibration curve and the area under the receiver operating characteristic (ROC) curve were used to validate the nomogram internally.

RESULTS

This study showed that only 3.7% of nurses were completely free of PTSD during a public health emergency. We found that PTSD varied by age, marital status, procreation status, length of service, employee status, and whether working in the ICU. The nurses aged 30 ~ 40 years old, single, married without children, non-regular employees, worked for less than three years or worked in the ICU had higher levels of PTSD. Regarding the prevalence of burnout, 27.4%, 48.5%, and 18.6% of nurses had a high level of emotional exhaustion (EE), depersonalization (DP), and diminished personal accomplishment (PA), respectively. There, 31.1% of nurses had more than two types of job burnout. The number of night shifts, the type of hospital, marital status, and the severity of PTSD were all associated with higher rates of exhaustion among nurses. As a graphical representation of the model, a nomogram was created and demonstrated excellent calibration and discrimination in both sets (AUC = 0.787).

CONCLUSIONS

This study confirmed the PTSD and burnout are common problems for in-service nurses during public health emergencies and screened out the high-risk groups of job burnout. It is necessary to pay more attention nurses who are single and working in general hospitals with many night shifts, especially nurses with severe PTSD. Hospitals can set up nurses' personal health records to give timely warnings to nurses with health problems, and carry out support interventions to relieve occupational stress.

Provider moral distress in caring for tracheostomy and ventilator dependent children: A single institution cross-sectional evaluation

OBJECTIVE

To determine levels of moral distress in a pediatric unit caring for patients with tracheostomy/ventilator dependence.

HYPOTHESIS

Moral distress will be significant in a dedicated pediatric trach/vent unit.

METHODS

The Moral Distress Survey-Revised (MDS-R) is a 21-question survey measuring moral distress in pediatrics. The MDS-R was anonymously distributed to medical degree/doctor of osteopathy (MD/DOs), advanced practice practitioners (APPs), registered nurses (RNs), and respiratory therapists (RTs) in a unit caring for tracheostomy/ventilator dependent patients. Descriptive statistics, bivariate and multivariate analysis were performed.

RESULTS

Response rate was 48% (61/127). Mean MDS-R score was 83 (range 43-119), which is comparable to reported levels in the pediatric intensive care unit (ICU). APPs had the highest median rate of moral distress (112, interquartile range [IQR], 72-138), while MD/DOs had the lowest median score (49, IQR, 43-77). RNs and RTs had MDS-R scores between these two groups (medians of 91 and 84, respectively).

CONCLUSIONS

Moral distress levels in a unit caring for long term tracheostomy and ventilator dependent patients are high, comparable to levels in pediatric ICUs. APPs. APPs had higher levels of distress compared to other groups. This may be attributable to the constant stressors of being the primary provider for complex patients, especially in a high-volume inpatient setting.

The prevalence of burnout among pulmonologists or respiratory therapists pre- and post-COVID-19: a systematic review and meta-analysis

OBJECTIVES

The coronavirus disease-19 (COVID-19) increased the already heavy workload in the pulmonary and respiratory departments, which therefore possibly increased the prevalence of burnout among pulmonologists or respiratory therapists. We aimed to compare the differences in burnout among pulmonologists or respiratory therapists pre- and post-COVID-19 by doing a systematic review with meta-analysis.

METHODS

We searched pulmonologist, or pulmonary, or respiratory, and burnout up to 29 January 2023 in six databases. We included studies investigating pulmonologists or respiratory therapists and reporting the prevalence of burnout among them. The risk of bias was assessed by a tool for prevalence studies. The overall prevalence of burnout was pooled.

RESULTS

A total of 2859 records were identified and 16 studies were included in the final analysis. The included studies reported 3610 responding individuals and 2336 burnouts. The pooled prevalence of burnout was 61.7% (95% confidence interval (CI), 48.6-73.2%; I² = 96.3%). The pooled prevalence of burnout during COVID-19 was significantly higher than it was prior to the outbreak (68.4% vs. 41.6%, p = .01). The result of the meta-regression revealed that COVID-19 coverage was significantly associated with the prevalence of burnout (p = .04).

CONCLUSIONS

Burnout was widely prevalent among pulmonologists or respiratory therapists and increasingly perceived during COVID-19. Therefore, interventions were needed to reduce burnout in this specialty.KEY MESSASGESThe coronavirus disease-19 increased the already heavy workload in the pulmonary and respiratory departments.Burnout was widely prevalent among pulmonologists or respiratory therapists and increasingly perceived during COVID-19.

Implementation of a Consensus-Driven Quality Improvement Protocol to Decrease Length of Stay after Elective Carotid Endarterectomy

BACKGROUND

National guidelines stipulate that postoperative length-of-stay (LOS) after elective carotid endarterectomy (CEA) should not exceed 1 day on average, yet perioperative care coordination gaps may limit the ability for institutions to achieve this goal. Internal review determined that increased LOS after CEA at our institution was frequently attributable to urinary retention or postoperative hypertension. We designed and implemented a quality improvement (QI) protocol aiming to better our institutional performance in postoperative LOS after CEA, consisting of 2 Plan-Do-Study-Act (PDSA) cycles.

METHODS

In the first PDSA cycle, a division-wide standardized protocol was developed by which antihypertensive medications were managed preoperatively and through postoperative day (POD) 1. This protocol included dedicated patient outreach with instructions for at-home antihypertensive management through the morning of POD 0. Second, alpha-1-blockade was administered to all male patients preoperatively. All patients receiving an elective CEA performed at our institution by vascular surgeons were included in the protocol. The primary outcome measure was defined percent failure of the LOS >1 day metric, with raw LOS as a secondary outcome measure. Process measures included adherence to the antihypertensive medication protocol and adherence to preoperative alpha-1 blockade. Balance measures included documented intraoperative hypotension and 30-day readmission. Fisher's exact test was used to evaluate relationships between preintervention and postintervention cohorts and the outcome measure. Wilcoxon rank-sum tests were used to evaluate relationships between cohorts and total LOS.

RESULTS

Baseline performance on the LOS >1 day metric after elective CEA was 58.3% in the 8 months prior to intervention, across 48 patients. Both PDSA interventions were implemented simultaneously. In the 12 months after intervention, 64 patients met protocol inclusion criteria, including 19 symptomatic patients (29.7%). Process measure success for preoperative antihypertensive regimen adherence was 89.8%. For males not chronically prescribed alpha-1 blockade preoperatively, process measure success for adherence to preoperative alpha-1 blockade was 78.8%. The intraoperative hypotension balance measure occurred in 1 patient (1.6%). Performance on the LOS >1 day outcome measure was improved to 32.8% (P = 0.01). Performance on the raw LOS outcome measure was similar between the preintervention cohort (median 2 days, interquartile range [IQR] 1-2) and postintervention cohort (median 1 day, IQR 1-2, P = 0.07). Performance on the 30-day readmission balance measure was similar between preintervention (6.3%) and postintervention cohorts (9.4%, P = 0.73).

CONCLUSIONS

The consensus-driven development and implementation of a QI protocol to reduce postoperative LOS after CEA showed promising results in our institution, with approximately 40% improvement in the primary outcome measure. Wider efforts to improve LOS after CEA should include a focus on minimization of postoperative hypertension and urinary retention.

Flow-Sizing Critical Care Resources

OBJECTIVES

To describe the factors affecting critical care capacity and how critical care organizations (CCOs) within academic centers in the U.S. flow-size critical care resources under normal operations, strain, and surge conditions.

DATA SOURCES

PubMed, federal agency and American Hospital Association reports, and previous CCO survey results were reviewed.

STUDY SELECTION

Studies and reports of critical care bed capacity and utilization within CCOs and in the United States were selected.

DATA EXTRACTION

The Academic Leaders in the Critical Care Medicine Task Force established regular conference calls to reach a consensus on the approach of CCOs to "flow-sizing" critical care services.

DATA SYNTHESIS

The approach of CCOs to "flow-sizing" critical care is outlined. The vertical (relation to institutional resources, e.g., space allocation, equipment, personnel redistribution) and horizontal (interdepartmental, e.g., emergency department, operating room, inpatient floors) integration of critical care delivery (ICUs, rapid response) for healthcare organizations and the methods by which CCOs flow-size critical care during normal operations, strain, and surge conditions are described. The advantages, barriers, and recommendations for the rapid and efficient scaling of critical care operations via a CCO structure are explained. Comprehensive guidance and resources for the development of "flow-sizing" capability by a CCO within a healthcare organization are provided.

CONCLUSIONS

We identified and summarized the fundamental principles affecting critical care capacity. The taskforce highlighted the advantages of the CCO governance model to achieve rapid and cost-effective "flow-sizing" of critical care services and provide recommendations and resources to facilitate this capability. The relevance of a comprehensive approach to "flow-sizing" has become particularly relevant in the wake of the latest COVID-19 pandemic. In light of the growing risks of another extreme epidemic, planning for adequate capacity to confront the next critical care crisis is urgent.

The Intensive Care Unit Bundle Board: A Novel Real-Time Data Visualization Tool to Improve Maintenance Care for Invasive Catheters

BACKGROUND

Critically ill patients are at greater risk of healthcare-associated infections (HAIs). The use of maintenance bundles helps to reduce this risk but also generates a rapid accumulation of complex data that is difficult to aggregate and subsequently act upon.

OBJECTIVES

We hypothesized that a digital display summarizing nursing documentation of invasive catheters (including central venous access devices, arterial catheters, and urinary catheters) would improve invasive device maintenance care and documentation. Our secondary objectives were to see if this summary would reduce the duration of problematic conditions, that is, characteristics associated with increased risk of infection.

METHODS

We developed and implemented a data visualization tool called the "Bundle Board" to display nursing observations on invasive devices. The intervention was studied in a 28-bed medical intensive care unit (MICU). The Bundle Board was piloted for 6 weeks in June 2022 and followed by a comparison phase, where one MICU had Bundle Board access and another MICU at the same center did not. We retrospectively applied tile color coding logic to prior nursing documentation from 2021 until the pilot phase to facilitate comparison pre- and post-Bundle Board release.

RESULTS

After adjusting for time, other quality improvement efforts, and nursing shift, multiple linear regression demonstrated a statistically significant improvement in the completion of catheter care and documentation during the pilot phase (p < 0.0001) and comparison phase (p = 0.002). The median duration of documented problematic conditions was significantly reduced during the pilot phase (p < 0.0001) and in the MICU with the Bundle Board (comparison phase, p = 0.027).

CONCLUSION

We successfully developed a data visualization tool that changed ICU provider behavior, resulting in increased completion and documentation of maintenance care and reduced duration of problematic conditions for invasive catheters in MICU patients.

Descriptive Comparison of Two Models of Tele-Critical Care Delivery in a Large Multi-Hospital Health Care System

Introduction: The Society of Critical Care Medicine Tele-Critical Care (TCC) Committee has identified the need for rigorous comparative research of different TCC delivery models to support the development of best practices for staffing, application, and approaches to workflow. Our objective was to describe and compare outcomes between two TCC delivery models, TCC with 24/7 Bedside Intensivist (BI) compared with TCC with Private Daytime Attending Intensivist (PI) in relation to intensive care unit (ICU) and hospital mortality, ICU and hospital length of stay (LOS), cost, and complications across the spectrum of routine ICU standards of care. Methods: Observational cohort study at large health care system in 12 ICUs and included patients, ≥18, with Acute Physiology and Chronic Health Evaluation (APACHE) IVa scores and predictions (October 2016-June 2019). Results: Of the 19,519 ICU patients, 71.7% (n = 13,993) received TCC with 24/7 BI while 28.3% (n = 5,526) received TCC with PI. ICU and Hospital mortality (4.8% vs. 3.1%, p < 0.0001; 12.6% vs. 8.1%, p < 0.001); and ICU and Hospital LOS (3.2 vs. 2.4 days, p < 0.001; 9.8 vs. 7.2 days, p < 0.001) were significantly higher among 24/7 BI compared with PI. The APACHE observed/expected ratios (odds ratio [OR]; 95% confidence interval [CI]) for ICU mortality (0.62; 0.58-0.67) vs. (0.53; 0.46-0.61) and Hospital mortality (0.95; 0.57-1.48) vs. (0.77; 0.70-0.84) were significantly different for 24/7 BI compared with PI. Multivariate mixed models that adjusted for confounders demonstrated significantly greater odds of (OR; 95% CI) ICU mortality (1.58; 1.28-1.93), Hospital mortality (1.52; 1.33-1.73), complications (1.55; 1.18-2.04), ICU LOS [3.14 vs. 2.59 (1.25; 1.19-1.51)], and Hospital LOS [9.05 vs. 7.31 (1.23; 1.21-1.25)] among 24/7 BI when compared with PI. Sensitivity analyses adjusting for ICU admission within 24 h of hospital admission, receiving active ICU treatments, nighttime admission, sepsis, and highest third acute physiology score indicated significantly higher odds for 24/7 BI compared with PI. Conclusion: Our comparison demonstrated that TCC delivery model with PI provided high-quality care with significant positive effects on outcomes. This suggests that TCC delivery models have broad-ranging applicability and benefits in routine critical care, thus necessitating progressive research in this direction.

Outcomes in Patients Perceived as Receiving Excessive Care by ICU Physicians and Nurses: Differences Between Patients < 75 and ≥ 75 Years of Age?

BACKGROUND

The benefit of the ICU for older patients is often debated. There is little knowledge on subjective impressions of excessive care in ICU nurses and physicians combined with objective patient data in real-life cases.

RESEARCH QUESTION

Is there a difference in treatment limitation decisions and 1-year outcomes in patients < 75 and ≥ 75 years of age, with and without concordant perceptions of excessive care by two or more ICU nurses and physicians?

STUDY DESIGN AND METHODS

This was a reanalysis of the prospective observational DISPROPRICUS study, performed in 56 ICUs. Nurses and physicians completed a daily questionnaire about the appropriateness of care for each of their patients during a 28-day period in 2014. We compared the cumulative incidence of patients with concordant perceptions of excessive care, treatment limitation decisions, and the proportion of patients attaining the combined end point (death, poor quality of life, or not being at home) at 1 year across age groups via Cox regression with propensity score weighting and Fisher exact tests.

RESULTS

Of 1,641 patients, 405 (25%) were ≥ 75 years of age. The cumulative incidence of concordant perceptions of excessive care was higher in older patients (13.6% vs 8.5%; P < .001). In patients with concordant perceptions of excessive care, we found no difference between age groups in risk of death (1-year mortality, 83% in both groups; P > .99; hazard ratio [HR] after weighting, 1.11; 95% CI, 0.74-1.65), treatment limitation decisions (33% vs 31%; HR after weighting, 1.11; 95% CI, 0.69-2.17), and reaching the combined end point at 1 year (90% vs 93%; P = .546). In patients without concordant perceptions of excessive care, we found a difference in risk of death (1-year mortality, 41% vs 30%; P < .001; HR after weighting, 1.38; 95% CI, 1.11-1.73) and treatment limitation decisions (11% vs 5%; P < .001; HR, 2.11; 95% CI, 1.37-3.27); however, treatment limitation decisions were mostly documented prior to ICU admission. The risk of reaching the combined end point was higher in the older adults (61.6% vs 52.8%; P < .001).

INTERPRETATION

Although the incidence of perceptions of excessive care is slightly higher in older patients, there is no difference in treatment limitation decisions and 1-year outcomes between older and younger patients once patients are identified by concordant perceptions of excessive care. Additionally, in patients without concordant perceptions, the outcomes are worse in the older adults, pleading against ageism in ICU nurses and physicians.

Critical care nursing policy, practice, and research priorities: An international cross-sectional study

PURPOSE

To examine the status of critical care nursing internationally, assess the impact of the COVID-19 pandemic, and identify research priorities by surveying professional critical care nursing organizations (CCNOs) worldwide.

DESIGN

A descriptive survey methodology was used. This study is the sixth worldwide quadrennial review to assess international critical care nursing needs and provide evidence to inform critical care nursing policy, practice and research priorities globally.

METHODS

The sixth World Federation of Critical Care Nurses survey of CCNOs was emailed to potential participants from countries with CCNOs or known critical care nurse leaders. Data were collected online using Survey Monkey™. Responses were entered into SPSS version 28 software (IBM Corp.) and analyzed by geographical region and national wealth group.

FINDINGS

Ninety-nine national representative respondents participated in the survey (70.7% response rate). The most important issues identified were working conditions, teamwork, staffing levels, formal practice guidelines, wages, and access to quality education programs. The top five CCNO services that were of most importance were providing national conferences, local conferences, workshops and education forums, practice standards and guidelines, and professional representation. Important pandemic-related services and activities provided by CCNOs included addressing emotional and mental well-being of nurses, providing guidance related to nurse staffing/workforce needs, assisting to coordinate efforts to obtain personal protective equipment supplies, serving as a country liaison with the World Health Organization's COVID-19 response activities, and assisting in the development and implementation of policies regarding standards of care. The most important contributions expected from the World Federation of Critical Care Nurses were standards for professional practice, standards for clinical practice, website resources, professional representation, and providing online education and training materials. The top five research priority areas were: stress levels (inclusive of burnout, emotional exhaustion and compassion fatigue); critical care nursing shortage, skill mix and workforce planning; recruitment, retention, turnover, working conditions; critical care nursing education and patient outcomes; and adverse events, staffing levels, patient outcomes.

CONCLUSIONS

The results highlight priority areas for critical care nursing internationally. The COVID-19 pandemic impacted critical care nurses as direct care providers. As a result, addressing the ongoing needs of critical care nurses remains a priority area of focus. The results also highlight important policy and research priorities for critical care nursing globally. Results of this survey should be incorporated into strategic action plans at the national and international levels.

CLINICAL RELEVANCE

Issues of importance to critical care nurses including research and policy priorities during and following COVID-19 are now clarified through this survey. The impact and importance that COVID-19 has had on critical care nurses and their preferences and priorities are provided. Clear guidance to leaders and policy makers on where critical care nurses would like to see greater focus and attention to help strengthen the contribution of critical care nursing practice to the global healthcare agenda.

Digitalization in Urology-A Multimethod Study of the Relationships between Physicians' Technostress, Burnout, Work Engagement and Job Satisfaction

The potential influences of digitization on the mental health of personnel in the healthcare sector are increasingly coming into the scientific focus in the healthcare sector, especially in terms of the use of information and communication technologies. To date, there have been no German studies of the effects of technostress in healthcare. This cross-sectional study examined the relationships between technostress, burnout, work engagement, and job satisfaction among physicians in the field of urology. Data were collected via an online survey based on the job demands-resources model and the concept of technostress. The survey was sent to German urologists working in inpatient clinics. The participating physicians experienced moderate levels of technostress (M = 2.67, SD = 0.69). The results, based on a general linear model analysis, showed that technostress is significantly positively associated with burnout (β = 0.293; p < 0.001) and negatively associated with work engagement (β = -0.175; p < 0.001) and job satisfaction (β = -0.206; p < 0.001). This study also identified stress and strain factors associated with the use of ICT and assessed institutional support offers as coping mechanisms. The results of this study and its formulated practical implications can serve as a basis for discussing sustainable digitalization strategies in hospitals, taking into consideration technostress and its impact on physicians' burnout, work engagement and job satisfaction.

Determinants of Professional Fulfillment and Burnout Among Intensivists: A National Survey by the Society of Critical Care Anesthesiologists in 2022

BACKGROUND

Increased burnout and decreased professional fulfillment among intensive care physicians is partly due to intensive care unit (ICU) workload. Although the SARS-CoV-2 (COVID-19) pandemic increased ICU workload, it also may have increased feelings of personal fulfillment due to positive public perceptions of physicians caring for COVID patients. We surveyed critical care anesthesiologists to identify the effect of provider demographics, ICU workload, and COVID-19-related workload, on professional fulfillment and burnout.

METHODS

We performed an exploratory survey of 606 members of the Society of Critical Care Anesthesiologists (SOCCA) in January and February 2022. We used the Stanford Professional Fulfillment Index (PFI) to grade levels of professional fulfillment and markers of burnout (ie, work exhaustion and disengagement). Univariable and multivariable models were used to identify associations between provider demographics and practice characteristics and professional fulfillment and work exhaustion.

RESULTS

One hundred and seventy-five intensivists (29%) responded. A total of 65% were male and 49% were between 36 and 45 years old. The overall median PFI score-0 (none) to 24 (most professional fulfillment)-was 17 (IQR, 1-24), with a wide distribution of responses. In multivariable analysis, factors associated with higher professional fulfillment included age >45 years ( P =.004), ≤15 weeks full-time ICU coverage in 2020 ( P =.02), role as medical director ( P =.01), and nighttime home call with supervision of in-house ICU fellows ( P =.01).

CONCLUSIONS

Professional fulfillment and work exhaustion in this cross-sectional survey were associated with several demographic and practice characteristics but not COVID-19-related workload, suggesting that COVID-19 workload may not have either positive or negative perceptions on professional fulfillment.

Integrating a Virtual ICU with Cardiac and Cardiovascular ICUs: Managing the Needs of a Complex and High-Acuity Specialty ICU Cohort

A long-standing shortage of critical care intensivists and nurses, exacerbated by the coronavirus disease (COVID-19) pandemic, has led to an accelerated adoption of tele-critical care in the United States (US). Due to their complex and high-acuity nature, cardiac, cardiovascular, and cardiothoracic intensive care units (ICUs) have generally been limited in their ability to leverage tele-critical care resources. In early 2020, Houston Methodist Hospital (HMH) launched its tele-critical care program called Virtual ICU, or vICU, to improve its ICU staffing efficiency while providing high-quality, continuous access to in-person and virtual intensivists and critical care nurses. This article provides a roadmap with prescriptive specifications for planning, launching, and integrating vICU services within cardiac and cardiovascular ICUs-one of the first such integrations among the leading academic US hospitals. The success of integrating vICU depends upon the (1) recruitment of intensivists and RNs with expertise in managing cardiac and cardiovascular patients on the vICU staff as well as concerted efforts to promote mutual trust and confidence between in-person and virtual providers, (2) consultations with the bedside clinicians to secure their buy-in on the merits of vICU resources, and (3) collaborative approaches to improve workflow protocols and communications. Integration of vICU has resulted in the reduction of monthly night-call requirements for the in-person intensivists and an increase in work satisfaction. Data also show that support of the vICU is associated with a significant reduction in the rate of Code Blue events (denoting a situation where a patient requires immediate resuscitation, typically due to a cardiac or respiratory arrest). As the providers become more comfortable with the advances in artificial intelligence and big data-driven technology, the Cardiac ICU Cohort continues to improve methods to predict and track patient trends in the ICUs.

Factors contributing to healthcare professionals' adaptive capacity with hospital standardization: a scoping review

BACKGROUND

Certain factors contribute to healthcare professionals' adaptive capacities towards risks, challenges, and changes such as attitudes, stress, motivation, cognitive capacity, group norms, and teamwork. However, there is limited evidence as to factors that contribute to healthcare professionals' adaptive capacity towards hospital standardization. This scoping review aimed to identify and map the factors contributing to healthcare professionals' adaptive capacity with hospital standardization.

METHODS

Scoping review methodology was used. We searched six academic databases to September 2021 for peer-reviewed articles in English. We also reviewed grey literature sources and the reference lists of included studies. Quantitative and qualitative studies were included if they focused on factors influencing how healthcare professionals adapted towards hospital standardization such as guidelines, procedures, and strategies linked to clinical practice. Two researchers conducted a three-stage screening process and extracted data on study characteristics, hospital standardization practices and factors contributing to healthcare professionals' adaptive capacity. Study quality was not assessed.

RESULTS

A total of 57 studies were included. Factors contributing to healthcare professionals' adaptive capacity were identified in numerous standardization practices ranging from hand hygiene and personal protective equipment to clinical guidelines or protocols on for example asthma, pneumonia, antimicrobial prophylaxis, or cancer. The factors were grouped in eight categories: (1) psychological and emotional, (2) cognitive, (3) motivational, (4) knowledge and experience, (5) professional role, (6) risk management, (7) patient and family, and (8) work relationships. This combination of individual and group/social factors decided whether healthcare professionals complied with or adapted hospital standardization efforts. Contextual factors were identified related to guideline system, cultural norms, leadership support, physical environment, time, and workload.

CONCLUSION

The literature on healthcare professionals' adaptive capacity towards hospital standardization is varied and reflect different reasons for compliance or non-compliance to rules, guidelines, and protocols. The knowledge of individual and group/social factors and the role of contextual factors should be used by hospitals to improve standardization practices through educational efforts, individualised training and motivational support. The influence of patient and family factors on healthcare professionals' adaptive capacity should be investigated.

TRIAL REGISTRATION

Open Science Framework ( https://osf.io/ev7az ) https://doi.org/10.17605/OSF.IO/EV7AZ .

Prevalence of burnout syndrome in Spanish radiologists

BACKGROUND AND AIMS

The primary objective was to analyze the prevalence and degree of professional burnout in radiologists in Spain. Secondary objectives were to identify possible factors that increase or decrease the risk of burnout to enable preventive and corrective measures, decrease the stress associated with this condition, and thereby increase radiologists' performance and satisfaction at work.

MATERIAL AND METHODS

This cross-sectional observational study used a voluntary, anonymous online survey of attending radiologists and residents through Google Forms®. The survey was structured into three sections: a qualitative assessment of the degree of professional burnout with the Maslach Burnout Inventory Human Services Survey (MBI-HSS), a series of sociodemographic and work-related questions, and a final section centered on possible causes of stress and improvements to the working environment. The results of the survey were analyzed statistically to determine which variables were associated with burnout syndrome as well as to identify possible risk factors and protective factors.

RESULTS

After disseminating the survey through social networks and email contacts, we received a total of 226 responses (175 from attending radiologists and 51 from residents; 52% men; mean age, 41 ± 11 years; age range, 25-68). The prevalence of the syndrome was 33%, without significant differences between attending radiologists and residents. No risk factors associated with burnout were identified. Teaching in the workplace was the only protective factor.

CONCLUSIONS

One-third of the respondents had burnout syndrome. Because the consequences of this syndrome can affect professionals' personal life and their ability to do their jobs, early detection and intervention should be prioritized.

Critical Care Pharmacists: A Focus on Horizons

Critical care pharmacy has evolved rapidly over the last 50 years to keep pace with the rapid technological and knowledge advances that have characterized critical care medicine. The modern-day critical care pharmacist is a highly trained individual well suited for the interprofessional team-based care that critical illness necessitates. Critical care pharmacists improve patient-centered outcomes and reduce health care costs through three domains: direct patient care, indirect patient care, and professional service. Optimizing workload of critical care pharmacists, similar to the professions of medicine and nursing, is a key next step for using evidence-based medicine to improve patient-centered outcomes.

Expanding access to difficult urinary catheter insertion services through a novel nurse practitioner-led team

BACKGROUND

Within the United States health care system, one of the most common procedures performed daily is urinary catheterization. Oftentimes, the urinary catheter is placed by nursing personnel without any difficulty. Although the procedure is usually simple and routine, there are instances in which placement can be problematic.

LOCAL PROBLEM

Urology is one of the smallest surgical subspecialties, with intermittent availability given active commitments in the operating room and clinic. This opened an opportunity for nurse practitioners (NPs) at an urban quaternary care hospital to further enhance their skill set in the care of these patients.

METHODS

Fifteen Rapid Response Team NPs were selected based on specific criteria. Their roles expanded to include consults for difficult urinary catheter insertions.

INTERVENTION

A 2-step training program was implemented for NPs to develop proficiency in inserting urinary catheters in patients with new or known urologic conditions.

RESULTS

Of the 391 catheter consults made to the NP group, 73 (18.7%) of them required urology follow-up.

CONCLUSION

This program can benefit patients by potentially reducing catheter-related complications and associated length of stay.

Intensivist physician-to-patient ratios and mortality in the intensive care unit

PURPOSE

A high daily census may hinder the ability of physicians to deliver quality care in the intensive care unit (ICU). We sought to determine the relationship between intensivist-to-patient ratios and mortality among ICU patients.

METHODS

We performed a retrospective cohort study of intensivist-to-patient ratios in 29 ICUs in 10 hospitals in the United States from 2018 to 2020. We used meta-data from progress notes in the electronic health record to determine an intensivist-specific caseload for each ICU day. We then fit a multivariable proportional hazards model with time-varying covariates to estimate the relationship between the daily intensivist-to-patient ratio and ICU mortality at 28 days.

RESULTS

The final analysis included 51,656 patients, 210,698 patient days, and 248 intensivist physicians. The average caseload per day was 11.8 (standard deviation: 5.7). There was no association between the intensivist-to-patient ratio and mortality (hazard ratio for each additional patient: 0.987, 95% confidence interval: 0.968-1.007, p = 0.2). This relationship persisted when we defined the ratio as caseload over the sample-wide average (hazard ratio: 0.907, 95% confidence interval: 0.763-1.077, p = 0.26) and cumulative days with a caseload over the sample-wide average (hazard ratio: 0.991, 95% confidence interval: 0.966-1.018, p = 0.52). The relationship was not modified by the presence of physicians-in-training, nurse practitioners, and physician assistants (p value for interaction term: 0.14).

CONCLUSIONS

Mortality for ICU patients appears resistant to high intensivist caseloads. These results may not generalize to ICUs organized differently than those in this sample, such as ICUs outside the United States.

Patient Enrollment Growth and Burnout in Primary Care at the Veterans Health Administration

BACKGROUND

Patient enrollment levels at Veterans Health Administration (VHA) facilities change based on Veteran demand for care, potentially affecting demands on staff. Effects on burnout in the primary care workforce associated with increases or decreases in enrollment are unknown.

OBJECTIVE

Estimate associations between patient enrollment and burnout.

DESIGN

In this serial cross-sectional study, VHA patient enrollment and workforce data from 2014 to 2018 were linked to burnout estimates for 138 VHA facilities. The VHA's annual All Employee Survey provided burnout estimates.

PARTICIPANTS

A total of 82,421 responses to the 2014-2018 All Employee Surveys by primary care providers (PCPs), including physicians, nurse practitioners, and physician assistants; nurses; clinical associates; and administrative clerks were included. Respondents identified as patient-aligned care team members.

MAIN MEASURES

Independent variables were (1) the ratio of enrollment to PCPs at VHA facilities and (2) the year-over-year change in enrollment per PCP. Burnout was measured as the annual proportion of staff at VHA facilities who reported emotional exhaustion and/or depersonalization. Each primary care role was analyzed independently.

KEY RESULTS

Overall enrollment decreased from 1553 enrollees per PCP in 2014 to 1442 enrollees per PCP in 2018 across VHA facilities. Forty-three facilities experienced increased enrollment (mean of 1524 enrollees/PCP in 2014 to 1668 in 2018) and 95 facilities experienced decreased enrollment (mean of 1566 enrollees/PCP in 2014 to 1339 in 2018). Burnout decreased for all primary care roles. PCP burnout was highest, decreasing from a facility-level mean of 51.7% in 2014 to 43.8% in 2018. Enrollment was not significantly associated with burnout for any role except nurses, for whom a 1% year-over-year increase in enrollment was associated with a 0.2 percentage point increase in burnout (95% CI: 0.1 to 0.3).

CONCLUSIONS

Studies assessing changes in organizational-level predictors are rare in burnout research. Patient enrollment predicted burnout only among nurses in primary care.

Professional Coaching as a Continuing Professional Development Intervention to Address the Physician Distress Epidemic

ABSTRACT

Physician distress and burnout are reaching epidemic proportions, threatening physicians' capacities to develop and maintain competencies in the face of the increasingly demanding and complex realities of medical practice in today's world. In this article, we suggest that coaching should be considered both a continuing professional development intervention as well as an integral part of a balanced and proactive solution to physician distress and burnout. Unlike other interventions, coaching is intended to help individuals gain clarity in their life, rather than to treat a mental health condition or to provide advice, support, guidance, or knowledge/skills. Certified coaches are trained to help individuals discover solutions to complex problems and facilitate decision-making about what is needed to build and maintain capacity and take action. Across many sectors, coaching has been shown to enhance performance and reduce vulnerability to distress and burnout, but it has yet to be systematically implemented in medicine. By empowering physicians to discover and implement solutions to challenges, regain control over their lives, and act according to their own values, coaching can position physicians to become leaders and advocates for system-level change, while simultaneously prioritizing their own well-being.

An Exploration of Critical Care Professionals' Strategies to Enhance Daily Implementation of the Assess, Prevent, and Manage Pain; Both Spontaneous Awakening and Breathing Trials; Choice of Analgesia and Sedation; Delirium Assess, Prevent, and Manage; Early Mobility and Exercise; and Family Engagement and Empowerment: A Group Concept Mapping Study

The goals of this exploratory study were to engage professionals from the Society for Critical Care Medicine ICU Liberation Collaborative ICUs to: 1) conceptualize strategies to enhance daily implementation of the Assess, prevent, and manage pain; Both spontaneous awakening and breathing trials; Choice of analgesia and sedation; Delirium assess, prevent, and manage; Early mobility and exercise; and Family engagement and empowerment (ABCDEF) bundle from different perspectives and 2) identify strategies to prioritize for implementation.

DESIGN

Mixed-methods group concept mapping over 8 months using an online method. Participants provided strategies in response to a prompt about what was needed for successful daily ABCDEF bundle implementation. Responses were summarized into a set of unique statements and then rated on a 5-point scale on degree of necessity (essential) and degree to which currently used.

SETTING

Sixty-eight academic, community, and federal ICUs.

PARTICIPANTS

A total of 121 ICU professionals consisting of frontline and leadership professionals.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

A final set of 76 strategies (reduced from 188 responses) were suggested: education (16 strategies), collaboration (15 strategies), processes and protocols (13 strategies), feedback (10 strategies), sedation/pain practices (nine strategies), education (eight strategies), and family (five strategies). Nine strategies were rated as very essential but infrequently used: adequate staffing, adequate mobility equipment, attention to (patient's) sleep, open discussion and collaborative problem solving, nonsedation methods to address ventilator dyssynchrony, specific expectations for night and day shifts, education of whole team on interdependent nature of the bundle, and effective sleep protocol.

CONCLUSIONS

In this concept mapping study, ICU professionals provided strategies that spanned a number of conceptual implementation clusters. Results can be used by ICU leaders for implementation planning to address context-specific interdisciplinary approaches to improve ABCDEF bundle implementation.

Health and Well-Being of Intensive Care Unit Physicians: How to Ensure the Longevity of a Critical Specialty

A second epidemic of burnout, fatigue, anxiety, and moral distress has emerged concurrently with the coronavirus disease 2019 (COVID-19) pandemic, and critical care physicians are especially affected. This article reviews the history of burnout in health care workers, presents the signs and symptoms, discusses the specific impact of the COVID-19 pandemic on intensive care unit caregivers, and attempts to identify potential strategies to combat the Great Resignation disproportionately affecting health care workers. The article also focuses on how the specialty can amplify the voices and highlight the leadership potential of underrepresented minorities, physicians with disabilities, and the aging physician population.

Nationwide Clinical Practice Patterns of Anesthesiology Critical Care Physicians: A Survey to Members of the Society of Critical Care Anesthesiologists

BACKGROUND

Despite the growing contributions of critical care anesthesiologists to clinical practice, research, and administrative leadership of intensive care units (ICUs), relatively little is known about the subspecialty-specific clinical practice environment. An understanding of contemporary clinical practice is essential to recognize the opportunities and challenges facing critical care anesthesia, optimize staffing patterns, assess sustainability and satisfaction, and strategically plan for future activity, scope, and training. This study surveyed intensivists who are members of the Society of Critical Care Anesthesiologists (SOCCA) to evaluate practice patterns of critical care anesthesiologists, including compensation, types of ICUs covered, models of overnight ICU coverage, and relationships between these factors. We hypothesized that variability in compensation and practice patterns would be observed between individuals.

METHODS

Board-certified critical care anesthesiologists practicing in the United States were identified using the SOCCA membership distribution list and invited to take a voluntary online survey between May and June 2021. Multiple-choice questions with both single- and multiple-select options were used for answers with categorical data, and adaptive questioning was used to clarify stem-based responses. Respondents were asked to describe practice patterns at their respective institutions and provide information about their demographics, salaries, effort in ICUs, as well as other activities.

RESULTS

A total of 490 participants were invited to take this survey, and 157 (response rate 32%) surveys were completed and analyzed. The majority of respondents were White (73%), male (69%), and younger than 50 years of age (82%). The cardiothoracic/cardiovascular ICU was the most common practice setting, with 69.5% of respondents reporting time working in this unit. Significant variability was observed in ICU practice patterns. Respondents reported spending an equal proportion of their time in clinical practice in the operating rooms and ICUs (median, 40%; interquartile range [IQR], 20%-50%), whereas a smaller proportion-primarily those who completed their training before 2009-reported administrative or research activities. Female respondents reported salaries that were $36,739 less than male respondents; however, this difference was not statistically different, and after adjusting for age and practice type, these differences were less pronounced (-$27,479.79; 95% confidence interval [CI], -$57,232.61 to $2273.03; P = .07).

CONCLUSIONS

These survey data provide a current snapshot of anesthesiology critical care clinical practice patterns in the United States. Our findings may inform decision-making around the initiation and expansion of critical care services and optimal staffing patterns, as well as provide a basis for further work that focuses on intensivist satisfaction and burnout.

The relationship between secondary traumatic stress and burnout in critical care nurses: The mediating effect of resilience

PURPOSE

To examine the mediating factor on the association of secondary traumatic stress and burnout among critical care nurses.

DESIGN

A correlational study.

METHODS

Data were collected from a convenience sampling of 147 nurses from two general hospitals who had six or more months of experience working in an intensive care unit. The collected data were analyzed through t-test, ANOVA, Scheffé test, Mann-Whitney test, Kruskal-Wallis test, Bonferroni correction, and Pearson's correlation coefficient using SPSS 25.0. The mediating effect of resilience was analyzed through the three-stage mediation effect test procedure using hierarchical regression analysis and the Sobel test.

RESULTS

Secondary traumatic stress had a statistically significant positive correlation with burnout (r = 0.45, p <.001), and a statistically significant negative correlation between burnout and resilience (r = -0.54, p <.001) was observed. Secondary traumatic stress was found to have a statistically significant effect on resilience, which was the mediating variable (β = -0.17, p =.042). Additionally, secondary traumatic stress had a statistically significant effect on burnout (β = 0.45, p <.001). The significance of the mediating effect of resilience on the relationship between secondary traumatic stress and burnout was investigated using the Sobel test, and the mediating effect of resilience was found to be statistically significant (Z = 1.98, p =.048).

CONCLUSION

Resilience was found to have a partial mediating effect in the relationship between critical care nurses' secondary traumatic stress and burnout. The study thus provides basic data on the importance of resilience in preventing burnout from secondary traumatic stress.

The Association of Professional Burnout and Turnover Intentions Among Intensive Care Units Physicians: A Cross-Sectional Study

Intensive Care Units (ICU) workers work in highly stressful conditions that make them prone to professional burnout, which can lead to high turnover rates. This study explores professional burnout levels among ICU workers in Kuwait general governmental hospitals (GGHs), their turnover intentions, and the correlation factors. A cross-sectional self-administered survey study was conducted. Professional burnout level was measured using the Copenhagen Burnout Inventory (CBI), while turnover intention was measured using the Turnover Intention Scale (TIS-6). Data were analyzed using STATA software, and descriptive, correlative, and comparative analyses were performed. Eighty-nine ICU physicians filled out the questionnaire. Most of the participants were males, married, non-Kuwaiti nationals, with 10 to 20 years of experience, and the mean age of respondents was 39.2. The total professional burnout score was high was 54.7 (17.6). There were high total average scores for the personal and work-related domains. Participants who were younger than 35 years of age and graduated before 5 to 10 years had higher levels of professional burnout compared to other groups. More than half of the sample expressed their intention to leave their current job as an ICU physician. However, no association was found between turnover intentions and levels of burnout. High levels of professional burnout of turnover intentions were seen among ICU physicians in Kuwait. Policies should be adopted to reduce and mitigate professional burnout among ICU physicians and increase their retention. Future research should further investigate professional burnout among ICU staff, the associated factors, and its relation to their turnover intention.

The nature and sources of the emotional distress felt by intensivists and the burdens that are carried: A qualitative study

BACKGROUND

Work in intensive care units is often traumatic and emotionally distressing, sometimes leading to growth but at other times to negative outcomes such as worker burnout and mental illness. The type and origin of distresses to intensivists has been poorly characterised in the literature. This evidence gap makes it difficult to develop tailored educational process or cultural interventions for all who work within the specialty.

OBJECTIVES

The aim of this study was to elicit the nature and sources of workplace emotional distress in an international sample of intensivists.

METHOD

Interviews were undertaken with experienced intensivists in Australia and Israel related to the basis of workplace distress. These were transcribed and qualitatively thematically analysed.

RESULTS

In 2018, 19 intensivists participated in the study. Several key themes emerged from data analysis, some relating to clinical work, such as catastrophic patient outcomes, and some relating to interpersonal and systems-level challenges. Navigating complex interpersonal dynamics with carers and staff, both within and outside the intensive care unit team, caused substantial emotional burden.

CONCLUSIONS

Many factors contribute to workplace stress for doctors in the intensive care setting. In elucidating common reactions to these stressors, we have attempted to normalise responses. We further note that the skill sets relevant to the many challenges identified are generally missing in medical training curricula. It may be prudent to consider their inclusion in the future.

COVID-19: Lessons Learned, Lessons Unlearned, Lessons for the Future

The COVID-19 pandemic has affected clinicians in many different ways. Clinicians have their own experiences and lessons that they have learned from their work in the pandemic. This article outlines a few lessons learned from the eyes of CHEST Critical Care Editorial Board members, namely practices which will be abandoned, novel practices to be adopted moving forward, and proposed changes to the health care system in general. In an attempt to start the discussion of how health care can grow from the pandemic, the editorial board members outline their thoughts on these lessons learned.

SWEAT ICU-An Observational Study of Physician Workload and the Association of Physician Outcomes in Academic ICUs

The optimal staffing model for physicians in the ICU is unknown. Patient-to-intensivist ratios may offer a simple measure of workload and be associated with patient mortality and physician burnout. To evaluate the association of physician workload, as measured by the patient-to-intensivist ratio, with physician burnout and patient mortality.

DESIGN

Cross-sectional observational study.

SETTING

Fourteen academic centers in the United States from August 2020 to July 2021.

SUBJECTS

We enrolled ICU physicians and collected data on adult ICU patients under the physician's care on the single physician-selected study day for each physician.

MEASUREMENTS and MAIN RESULTS

The primary exposure was workload (self-reported number of patients' physician was responsible for) modeled as high (>14 patients) and low (≤14 patients). The primary outcome was burnout, measured by the Well-Being Index. The secondary outcome measure was 28-day patient mortality. We calculated odds ratio for burnout and patient outcomes using a multivariable logistic regression model and a binomial mixed effects model, respectively. We enrolled 122 physicians from 62 ICUs. The median patient-to-intensivist ratio was 12 (interquartile range, 10-14), and the overall prevalence of burnout was 26.4% (n = 32). Intensivist workload was not independently associated with burnout (adjusted odds ratio, 0.74; 95% CI, 0.24-2.23). Of 1,322 patients, 679 (52%) were discharged alive from the hospital, 257 (19%) remained hospitalized, and 347 (26%) were deceased by day 28; 28-day outcomes were unknown for 39 of patients (3%). Intensivist workload was not independently associated with 28-day patient mortality (adjusted odds ratio, 1.33; 95% CI, 0.92-1.91).

CONCLUSIONS

In our cohort, approximately one in four physicians experienced burnout on the study day. There was no relationship be- tween workload as measured by patient-to-intensivist ratio and burnout. Factors other than the number of patients may be important drivers of burnout among ICU physicians.

Current State of Critical Care Nursing Worldwide: Current Training, Roles, Barriers, and Facilitators

This review provides insights on the current state of roles and responsibilities, on-the-job training, barriers, and facilitators of critical care nursing (CCN) practice. Some of the established roles and training of CCN were providing care for acutely ill patients, delivering expert and specialist care, working as a part of a multidisciplinary team, monitoring, and initiating timely treatment, and providing psychosocial support and advanced system treatment, especially in high-income countries. In low-resource settings, critical care nurses work as health care assistants, technical or ancillary staff, and clinical educators; manage medications; care for mechanically ventilated patients; and provide care to deteriorating patients.

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.

Analysis of workload generated in the two years following first consultation by each new cancer patient: studying the past to plan the future of cancer care

Introduction

Prevalence of cancer patients is dramatically increasing. We aimed at quantifying the oncology workload generated by each new cancer patient in the two years following first consultation.

Methods

In this record-based retrospective study, we retrieved data of all newly diagnosed patients treated at the Oncology Department of Udine Academic Hospital between 01.01.2012 and 31.12.2017. We calculated mean number and standard deviation of the activity type generated by each new cancer patient during the following 2 years.

Results

Seven thousand four hundred fifty-two cancer patients generated a total of 85,338 clinical episodes. The two-years mean number of oncology episodes generated was 11.31 (i.e., for every 1,000 new cancer patients, 11,310 oncology activities are generated overall in the following two-year lapse). Patients with advanced disease generated the highest workload (24.3; SD 18.8) with a statistically significant difference compared to adjuvant and follow-up patients (p < 0.001). The workload generated in the period 0–6 and 0–12 months was significantly higher than in the following months (p < 0.001) and it was also higher for patients initially designated to treatment (p < 0.001).

Conclusion

This is the first study reporting on the mean oncology workload generated during the 2 years following first consultation. Workload is the highest for patient with advanced disease, especially in the first months and in patients in active treatment. A detailed analysis of workloads in oncology is feasible and could be crucial for planning a sustainable framework for cancer care in the next future.

Instant Gratification and Overtreating to Be Safe: Perceptions of U.S. Intensive Care Unit Pharmacists and Residents on Antimicrobial Stewardship

Antimicrobial stewardship programs have been associated with numerous impacts on medical practice including reductions in costs, antimicrobial resistance, and adverse events. While antimicrobial stewardship is now considered an essential element of medical practice, the understandings of the value of antimicrobial stewardship among medical practitioners vary. Additionally, non-physician practitioners are regularly left out of antimicrobial stewardship interventions targeting antimicrobial decision-making. Here, we contribute the perspective from resident physicians and specialists in pharmacy regarding their involvement in antimicrobial prescribing. Notably, our semi-structured interviews with 10 residents and pharmacy specialists described their limited autonomy in the clinical setting. However, the participants regularly worked alongside primary antimicrobial decision-makers and described feeling pressure to overtreat to be safe. The clear rationales and motivations associated with antimicrobial prescribing have a noticeable impact on physicians in training and non-physician practitioners, and as such, we argue that antimicrobial stewardship interventions targeting primary antimicrobial decision-makers are missing an opportunity to address the breadth of antimicrobial prescribing culture. By looking at the perspectives and rationales of physicians in training and non-physician practitioners, we can see evidence that the act of antimicrobial prescribing is impacted by individuals on all levels of the hierarchies present in medical practice.

Mindfulness as an Antidote to Burnout for Nursing and Support Staff in an Oncological Intensive Care Unit: A Pilot Study

We set out to implement a pilot mindfulness-based intervention (MBI) to alleviate burnout, stress, anxiety, and depression in nursing and support staff of an oncological intensive care unit. We created an 8-week personalized yoga therapy MBI for nurses and patient care technicians in an oncological intensive care unit. Validated self-report scale tools were used to measure burnout, stress, anxiety, and depression in the intervention and control groups (Institutional Quality Improvement Registry no. 296, 2018). Changes in scores from baseline to postintervention were evaluated between groups. Forty-five staff, 21 in the control group and 24 in the intervention group, participated. Both groups at baseline had low prevalence of stress, anxiety, and depression (13% vs 36.8%, P = .11; 21.7% vs 52.6%, P = .17; 17.4% vs 26.3%, P = .48; respectively). Low rates of high emotional exhaustion, depersonalization, and low professional efficacy were observed for both groups (41.7% vs 35.0%, P = .65; 20.8% vs 15%, P = .71; 58.3% vs 50.0%, P = .58, respectively). Post-MBI, prevalence of depression, anxiety, stress, emotional exhaustion, and depersonalization remained low and similar between both groups. Notwithstanding, professional efficacy scores significantly improved in a between-group comparison (0.063 vs -0.25; P = .0336). We observed that burnout, stress, anxiety, and depression were remarkably low in our study relative to the literature. Implementation of the MBI faced many obstacles and had low compliance during participation. This presumably influenced results and should be addressed prior to any future intervention. Despite this, professional efficacy improved significantly.

TRIAL REGISTRATION

Approved by MD Anderson Cancer Center Quality Improvement Registry (no. 296, 2018).

Impact of Pharmacists to Improve Patient Care in the Critically Ill: A Large Multicenter Analysis Using Meaningful Metrics With the Medication Regimen Complexity-ICU (MRC-ICU) Score

OBJECTIVES

Despite the established role of the critical care pharmacist on the ICU multiprofessional team, critical care pharmacist workloads are likely not optimized in the ICU. Medication regimen complexity (as measured by the Medication Regimen Complexity-ICU [MRC-ICU] scoring tool) has been proposed as a potential metric to optimize critical care pharmacist workload but has lacked robust external validation. The purpose of this study was to test the hypothesis that MRC-ICU is related to both patient outcomes and pharmacist interventions in a diverse ICU population.

DESIGN

This was a multicenter, observational cohort study.

SETTING

Twenty-eight ICUs in the United States.

PATIENTS

Adult ICU patients.

INTERVENTIONS

Critical care pharmacist interventions (quantity and type) on the medication regimens of critically ill patients over a 4-week period were prospectively captured. MRC-ICU and patient outcomes (i.e., mortality and length of stay [LOS]) were recorded retrospectively.

MEASUREMENTS AND MAIN RESULTS

A total of 3,908 patients at 28 centers were included. Following analysis of variance, MRC-ICU was significantly associated with mortality (odds ratio, 1.09; 95% CI, 1.08-1.11; p < 0.01), ICU LOS (β coefficient, 0.41; 95% CI, 00.37-0.45; p < 0.01), total pharmacist interventions (β coefficient, 0.07; 95% CI, 0.04-0.09; p < 0.01), and a composite intensity score of pharmacist interventions (β coefficient, 0.19; 95% CI, 0.11-0.28; p < 0.01). In multivariable regression analysis, increased patient: pharmacist ratio (indicating more patients per clinician) was significantly associated with increased ICU LOS (β coefficient, 0.02; 0.00-0.04; p = 0.02) and reduced quantity (β coefficient, -0.03; 95% CI, -0.04 to -0.02; p < 0.01) and intensity of interventions (β coefficient, -0.05; 95% CI, -0.09 to -0.01).

CONCLUSIONS

Increased medication regimen complexity, defined by the MRC-ICU, is associated with increased mortality, LOS, intervention quantity, and intervention intensity. Further, these results suggest that increased pharmacist workload is associated with decreased care provided and worsened patient outcomes, which warrants further exploration into staffing models and patient outcomes.

Supporting Professionals in Critical Care Medicine: Burnout, Resiliency, and System-Level Change

Burnout is occurring in epidemic proportions among intensive care unit physicians and other health-care professionals-accelerated by pandemic-driven stress. The impact of burnout is far-reaching, threatening the health of individual workers, the safety and quality of care our patients receive, and eroding the infrastructure of health care in general. Drivers of burnout include excessive quantity of work (nights, weekends, and acuity surges); excessive menial tasks; incivility, poor communication, and challenges to team success; and frequent moral distress and end-of-life issues. This article provides system-based practice and individual strategies to address these drivers and improve the well-being of our team and our patients.

Pilot of rapid implementation of the advanced practice provider in the workflow of an existing tele-critical care program

Incorporating the advanced practice provider (APP) in the delivery of tele critical care medicine (teleCCM) addresses the critical care provider shortage. However, the current literature lacks details of potential workflows, deployment difficulties and implementation outcomes while suggesting that expanding teleCCM service may be difficult. Here, we demonstrate the implementation of a telemedicine APP (eAPP) pilot service within an existing teleCCM program with the objective of determining the feasibility and ease of deployment. The goal is to augment an existing tele-ICU system with a balanced APP service to assess the feasibility and potential impact on the ICU performance in several hospitals affiliated within a large academic center. A REDCap survey was used to assess eAPP workflows, expediency of interventions, duration of tasks, and types of assignments within different service locations. Between 02/01/2021 and 08/31/2021, 204 interventions (across 133 12-h shift) were recorded by eAPP (n_routine = 109 (53.4%); n_urgent = 82 (40.2%); n_emergent = 13 (6.4%). The average task duration was 10.9 ± 6.22 min, but there was a significant difference based on the expediency of the task (F [2; 202] = 3.89; p < 0.022) and type of tasks (F [7; 220] = 6.69; p < 0.001). Furthermore, the eAPP task type and expediency varied depending upon the unit engaged and timeframe since implementation. The eAPP interventions were effectively communicated with bedside staff with only 0.5% of suggestions rejected. Only in 2% cases did the eAPP report distress. In summary, the eAPP can be rapidly deployed in existing teleCCM settings, providing adaptable and valuable care that addresses the specific needs of different ICUs while simultaneously enhancing the delivery of ICU care. Further studies are needed to quantify the input more robustly.

Teaching the pursuit of sustainable excellence

In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.

Deployment of Tele-ICU Respiratory Therapy and the Creation of an eRT Service Line

Penn Medicine launched a 24-7 telemedicine respiratory therapist (eRT) service as part of its tele–critical care medicine (tele-CCM) service serving seven hospitals and more than 320 critical care beds. Service line interventions were focused on protocolized evidence-based practices, safety, documentation compliance, and urgent emergent ad hoc clinical needs. Concomitantly, the eRTs were available to respond to urgent and emergent interventions on the basis of the clinical bedside situation. Their activity was triggered by Penn E-lert staff (serving the tele-ICUs), bedside staff, algorithmic trigger software, or the eRT’s own review of a patient’s clinical condition. A standardized data collection was deployed to gather information about the interventions. The value of the eRT service was defined in terms of estimated lives saved by implementing the standards of care earlier than the bedside staff would or acute respiratory distress syndrome (ARDS) algorithmic trigger and by intervening during emergent and urgent clinical request, improving care delivery, and complying with best clinical practices, and by the time freed for onsite staff to perform other duties. Between May 2020 and August 2021, eRTs registered 31,609 activities; 97.8% of interventions were related to the routine established workflows, while 1.9% were urgent and 0.3% emergent. In 51.2% of all eRT accomplished activities, no communication with other staff was needed. When communication did take place, eRTs connected with the bedside respiratory therapist in 36.7% of interactions, followed by house staff (7.2%), advanced practice providers (5.2%), and registered nurses (1.6%). The eRTs communicated via phone (81.4%), asynchronous text platform (16%), or tele-CCM software (1.4%). While prompted by staffing, safety, and logistics challenges during a Covid-19 surge, the resulting eRT service line has been well received and has become a part of the standard of care. Overall efficiency of respiratory care service delivery was increased as Penn retained staff and increased the flexibility of bedside therapists. Furthermore, the eRT service detected unfavorable practice patterns in ARDS treatment and intervened before the ARDS algorithmic trigger was activated or acted upon. Some of the tasks can be accomplished by the eRT in a shorter amount of time than it would take bedside staff. In addition, the remote staffing reduced personal protective equipment utilization. All of these gains translated into postpandemic time savings. Penn’s experience shows that the eRT care model can be transformed into a system-valued proposition and retained with sustained benefit beyond the pandemic surge.

Attitudes and Perceptions of Health Leaders for the Quality Enhancement of Workforce in Saudi Arabia

BACKGROUND AND AIM

Besides the unique exposure and experience of health leaders in facing challenges and overcoming them, and the relatively fewer articles relating to the perception of health leaders in workforce quality enhancement, health leadership plays a crucial role in redirecting the workforce, increasing job satisfaction, professional development, and burnout prevention. Thus, this study aimed to understand the current healthcare workforce quality and future expectations from the attitudes and perceptions of health leaders.

METHODS

A qualitative research was carried out using semi-structured interviews consisting of 24 different questions. Participants of the study were healthcare leaders from different backgrounds and governmental institutions. All interviews were recorded, transcribed, and then analyzed using thematic analysis via the N-Vivo program.

RESULTS

Eleven participants were involved in the study, with one female and ten males. A thematic analysis and N-Vivo program yielded 5 main themes: (1) workforce competency, (2) health transformation, (3) leadership, (4) workforce planning, and (5) healthcare quality, with 22 emerging sub-themes. Moreover, participants responded with different attitudes and perceptions.

CONCLUSION

Health leaders are satisfied with the current direction of workforce competency and planning, yet fragmentation of the system and poor accessibility may need further enhancement. Furthermore, misutilization of services and the uncertainty of the future and talent pool are potential barriers for capability building. Moreover, with the existing gap in the workforce, health leaders believe that privatization and corporatization may have a positive effect. Aside from that, Saudization with the current plan of having a minimum standard of accepting non-Saudis in certain areas might benefit in maintaining competition and enriching experience. However, catching up with further research in healthcare quality in Saudi Arabia is needed because of the ongoing health transformation.

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.