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Admon AJ, Cohen-Mekelburg S, Opatrny M, Lee KT, Law AC, Gershengorn HB, Valley TS, Prescott HC, Wiktor MJ, Neeluru J, Cooke CR, Weissman GE. Two Weeks Versus One Week of Maximal Patient-Intensivist Continuity for Adult Medical Intensive Care Patients: A Two-Center Target Trial Emulation. Crit Care Med 2024; 52:1323-1332. [PMID: 38713002 PMCID: PMC11326999 DOI: 10.1097/ccm.0000000000006322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/08/2024]
Abstract
OBJECTIVES To compare outcomes for 2 weeks vs. 1 week of maximal patient-intensivist continuity in the ICU. DESIGN Retrospective cohort study. SETTING Two U.S. urban, teaching, medical ICUs where intensivists were scheduled for 2-week service blocks: site A was in the Midwest and site B was in the Northeast. PATIENTS Patients 18 years old or older admitted to a study ICU between March 1, 2017, and February 28, 2020. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We applied target trial emulation to compare admission during an intensivist's first week (as a proxy for 2 wk of maximal continuity) vs. admission during their second week (as a proxy for 1 wk of maximal continuity). Outcomes included hospital mortality, ICU length of stay, and, for mechanically ventilated patients, duration of ventilation. Exploratory outcomes included imaging, echocardiogram, and consultation orders. We used inverse probability weighting to adjust for baseline differences and random-effects meta-analysis to calculate overall effect estimates. Among 2571 patients, 1254 were admitted during an intensivist's first week and 1317 were admitted during a second week. At sites A and B, hospital mortality rates were 25.8% and 24.2%, median ICU length of stay were 4 and 2 days, and median mechanical ventilation durations were 3 and 3 days, respectively. There were no differences in adjusted mortality (odds ratio [OR], 1.01 [95% CI, 0.96-1.06]) or ICU length of stay (-0.25 d [-0.82 d to +0.32 d]) for 2 weeks vs. 1 week of maximal continuity. Among mechanically ventilated patients, there were no differences in adjusted mortality (OR, 1.00 [0.87-1.16]), ICU length of stay (+0.06 d [-0.78 d to +0.91 d]), or duration of mechanical ventilation (+0.37 d [-0.46 d to +1.21 d]) for 2 weeks vs. 1 week of maximal continuity. CONCLUSIONS Two weeks of maximal patient-intensivist continuity was not associated with differences in clinical outcomes compared with 1 week in two medical ICUs.
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Affiliation(s)
- Andrew J Admon
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI
- Department of Epidemiology, University of Michigan School of Public Health, University of Michigan, Ann Arbor, MI
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI
- Pulmonary Service, Medicine Service, LTC Charles S. Kettles VA Medical Center, Ann Arbor, MI
| | - Shirley Cohen-Mekelburg
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI
- Division of Gastroenterology, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI
- Gastroenterology Service, Medicine Service, LTC Charles S. Kettles VA Medical Center, Ann Arbor, MI
| | - Megan Opatrny
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI
| | - Kathleen T Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI
| | - Anica C Law
- Pulmonary Center, Department of Medicine, Boston University School of Medicine, Boston, MA
- Richard A and Susan F Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, MA
| | - Hayley B Gershengorn
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL
- Division of Critical Care Medicine, Department of Medicine, Albert Einstein College of Medicine, Bronx, NY
| | - Thomas S Valley
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI
- Pulmonary Service, Medicine Service, LTC Charles S. Kettles VA Medical Center, Ann Arbor, MI
| | - Hallie C Prescott
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI
- Pulmonary Service, Medicine Service, LTC Charles S. Kettles VA Medical Center, Ann Arbor, MI
| | - Michael J Wiktor
- Quality Analytics Division, Quality Department, Michigan Medicine, Ann Arbor, MI
| | - Jayashree Neeluru
- Quality Analytics Division, Quality Department, Michigan Medicine, Ann Arbor, MI
| | - Colin R Cooke
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI
- Pulmonary Service, Medicine Service, LTC Charles S. Kettles VA Medical Center, Ann Arbor, MI
| | - Gary E Weissman
- Pulmonary, Allergy, and Critical Care Division, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
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Pilcher DV, Hensman T, Bihari S, Bailey M, McClure J, Nicholls M, Chavan S, Secombe P, Rosenow M, Huckson S, Litton E. Measuring the Impact of ICU Strain on Mortality, After-Hours Discharge, Discharge Delay, Interhospital Transfer, and Readmission in Australia With the Activity Index. Crit Care Med 2023; 51:1623-1637. [PMID: 37486188 PMCID: PMC10645102 DOI: 10.1097/ccm.0000000000005985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/25/2023]
Abstract
OBJECTIVES ICU resource strain leads to adverse patient outcomes. Simple, well-validated measures of ICU strain are lacking. Our objective was to assess whether the "Activity index," an indicator developed during the COVID-19 pandemic, was a valid measure of ICU strain. DESIGN Retrospective national registry-based cohort study. SETTING One hundred seventy-five public and private hospitals in Australia (June 2020 through March 2022). SUBJECTS Two hundred seventy-seven thousand seven hundred thirty-seven adult ICU patients. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Data from the Australian and New Zealand Intensive Care Society Adult Patient Database were matched to the Critical Health Resources Information System. The mean daily Activity index of each ICU (census total of "patients with 1:1 nursing" + "invasive ventilation" + "renal replacement" + "extracorporeal membrane oxygenation" + "active COVID-19," divided by total staffed ICU beds) during the patient's stay in the ICU was calculated. Patients were categorized as being in the ICU during very quiet (Activity index < 0.1), quiet (0.1 to < 0.6), intermediate (0.6 to < 1.1), busy (1.1 to < 1.6), or very busy time-periods (≥ 1.6). The primary outcome was in-hospital mortality. Secondary outcomes included after-hours discharge from the ICU, readmission to the ICU, interhospital transfer to another ICU, and delay in discharge from the ICU. Median Activity index was 0.87 (interquartile range, 0.40-1.24). Nineteen thousand one hundred seventy-seven patients died (6.9%). In-hospital mortality ranged from 2.4% during very quiet to 10.9% during very busy time-periods. After adjusting for confounders, being in an ICU during time-periods with higher Activity indices, was associated with an increased risk of in-hospital mortality (odds ratio [OR], 1.49; 99% CI, 1.38-1.60), after-hours discharge (OR, 1.27; 99% CI, 1.21-1.34), readmission (OR, 1.18; 99% CI, 1.09-1.28), interhospital transfer (OR, 1.92; 99% CI, 1.72-2.15), and less delay in ICU discharge (OR, 0.58; 99% CI, 0.55-0.62): findings consistent with ICU strain. CONCLUSIONS The Activity index is a simple and valid measure that identifies ICUs in which increasing strain leads to progressively worse patient outcomes.
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Affiliation(s)
- David V Pilcher
- The Australian and New Zealand Intensive Care Society (ANZICS) Centre for Outcome and Resource Evaluation, Prahran, VIC, Australia
- Department of Intensive Care, Alfred Health, Commercial Road, Prahran, VIC, Australia
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- Department of Intensive Care, Guy's and St. Thomas' NHS Foundation Trust, London, United Kingdom
- College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
- Adult Retrieval Victoria, Ambulance Victoria, South Melbourne, VIC, Australia
- Department of Intensive Care, St. Vincent's Hospital, Darlinghurst, NSW, Australia
- Department of Intensive Care, Alice Springs Hospital, Alice Springs, NT, Australia
- Department of Intensive Care, Fiona Stanley Hospital, Murdoch, WA, Australia
| | - Tamishta Hensman
- The Australian and New Zealand Intensive Care Society (ANZICS) Centre for Outcome and Resource Evaluation, Prahran, VIC, Australia
- Department of Intensive Care, Guy's and St. Thomas' NHS Foundation Trust, London, United Kingdom
| | - Shailesh Bihari
- College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
| | - Michael Bailey
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Jason McClure
- Department of Intensive Care, Alfred Health, Commercial Road, Prahran, VIC, Australia
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- Adult Retrieval Victoria, Ambulance Victoria, South Melbourne, VIC, Australia
| | - Mark Nicholls
- The Australian and New Zealand Intensive Care Society (ANZICS) Centre for Outcome and Resource Evaluation, Prahran, VIC, Australia
- Department of Intensive Care, St. Vincent's Hospital, Darlinghurst, NSW, Australia
| | - Shaila Chavan
- The Australian and New Zealand Intensive Care Society (ANZICS) Centre for Outcome and Resource Evaluation, Prahran, VIC, Australia
| | - Paul Secombe
- The Australian and New Zealand Intensive Care Society (ANZICS) Centre for Outcome and Resource Evaluation, Prahran, VIC, Australia
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- Department of Intensive Care, Alice Springs Hospital, Alice Springs, NT, Australia
| | - Melissa Rosenow
- Adult Retrieval Victoria, Ambulance Victoria, South Melbourne, VIC, Australia
| | - Sue Huckson
- The Australian and New Zealand Intensive Care Society (ANZICS) Centre for Outcome and Resource Evaluation, Prahran, VIC, Australia
| | - Edward Litton
- The Australian and New Zealand Intensive Care Society (ANZICS) Centre for Outcome and Resource Evaluation, Prahran, VIC, Australia
- Department of Intensive Care, Fiona Stanley Hospital, Murdoch, WA, Australia
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Klick JC, Syed M, Leong R, Miranda H, Cotter EK. Health and Well-Being of Intensive Care Unit Physicians: How to Ensure the Longevity of a Critical Specialty. Anesthesiol Clin 2023; 41:303-316. [PMID: 36872006 PMCID: PMC9985495 DOI: 10.1016/j.anclin.2022.10.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2023]
Abstract
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.
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Affiliation(s)
- John C Klick
- Department of Anesthesiology, University of Vermont Medical Center, University of Vermont Larner College of Medicine, 111 Colchester Avenue, Burlington, VT 05401, USA
| | - Madiha Syed
- Department of Intensive Care & Resuscitation, Anesthesiology Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Mail Code G58, Cleveland, OH 44195, USA
| | - Ron Leong
- Thomas Jefferson University Hospital, Sidney Kimmel Medial College, 111 South 11th Street, Gibbon Building, Suite 8130, Philadelphia, PA 19107, USA
| | - Haley Miranda
- Department of Anesthesiology, Pain and Perioperative Medicine, University of Kansas Medical Center, 3901 Rainbow Boulevard, MS 1034, Kansas City, KS 66160, USA
| | - Elizabeth K Cotter
- Department of Anesthesiology, Pain and Perioperative Medicine, University of Kansas Medical Center, 3901 Rainbow Boulevard, MS 1034, Kansas City, KS 66160, USA.
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Vranas KC, Golden SE, Nugent S, Valley TS, Schutz A, Duggal A, Seitz KP, Chang SY, Slatore CG, Sullivan DR, Hough CL, Mathews KS. The Influence of the COVID-19 Pandemic on Intensivists' Well-Being: A Qualitative Study. Chest 2022; 162:331-345. [PMID: 35568205 PMCID: PMC9093195 DOI: 10.1016/j.chest.2022.05.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 04/05/2022] [Accepted: 05/04/2022] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND The COVID-19 pandemic has strained health care systems and has resulted in widespread critical care staffing shortages, negatively impacting the quality of care delivered. RESEARCH QUESTION How have hospitals' emergency responses to the pandemic influenced the well-being of frontline intensivists, and do any potential strategies exist to improve their well-being and to help preserve the critical care workforce? STUDY DESIGN AND METHODS We conducted semistructured interviews of intensivists at clusters of tertiary and community hospitals located in six regions across the United States between August and November 2020 using the "four S" framework of acute surge planning (ie, space, staff, stuff, and system) to organize the interview guide. We then used inductive thematic analysis to identify themes describing the influence of hospitals' emergency responses on intensivists' well-being. RESULTS Thirty-three intensivists from seven tertiary and six community hospitals participated. Intensivists reported experiencing substantial moral distress, particularly because of restricted visitor policies and their perceived negative impacts on patients, families, and staff. Intensivists also frequently reported burnout symptoms as a result of their experiences with patient death, exhaustion over the pandemic's duration, and perceived lack of support from colleagues and hospitals. We identified several potentially modifiable factors perceived to improve morale, including the proactive provision of mental health resources, establishment of formal backup schedules for physicians, and clear actions demonstrating that clinicians are valued by their institutions. INTERPRETATION Restrictive visitation policies contributed to moral distress as reported by intensivists, highlighting the need to reconsider the risks and benefits of these policies. We also identified several interventions as perceived by intensivists that may help to mitigate moral distress and to improve burnout as part of efforts to preserve the critical care workforce.
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Affiliation(s)
- Kelly C Vranas
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Oregon Health and Science University, Portland, OR; Division of Pulmonary and Critical Care, Oregon Health and Science University, Portland, OR; Palliative and Advanced Illness Research (PAIR) Center, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
| | - Sara E Golden
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Oregon Health and Science University, Portland, OR
| | - Shannon Nugent
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Oregon Health and Science University, Portland, OR; Department of Psychiatry, Oregon Health and Science University, Portland, OR
| | - Thomas S Valley
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI; Center for Bioethics and Social Sciences in Medicine, University of Michigan, Ann Arbor, MI
| | - Amanda Schutz
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Abhijit Duggal
- Department of Critical Care, Respiratory Institute, Cleveland Clinic, Cleveland, OH; Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH
| | - Kevin P Seitz
- Division of Pulmonary, Allergy, and Critical Care Medicine, Vanderbilt University, Nashville, TN
| | - Steven Y Chang
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, David Geffen School of Medicine at UCLA, Ronald Reagan-UCLA Medical Center, Los Angeles, CA
| | - Christopher G Slatore
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Oregon Health and Science University, Portland, OR; Division of Pulmonary and Critical Care, Oregon Health and Science University, Portland, OR
| | - Donald R Sullivan
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Oregon Health and Science University, Portland, OR; Division of Pulmonary and Critical Care, Oregon Health and Science University, Portland, OR; Knight Cancer Institute, Oregon Health and Science University, Portland, OR
| | - Catherine L Hough
- Division of Pulmonary and Critical Care, Oregon Health and Science University, Portland, OR
| | - Kusum S Mathews
- Division of Pulmonary, Critical Care, & Sleep Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY; Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
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Wunsch H. Getting out of the 1950s: rethinking old priorities for staffing in critical care. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:695. [PMID: 33317580 PMCID: PMC7734891 DOI: 10.1186/s13054-020-03426-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 12/04/2020] [Indexed: 11/10/2022]
Affiliation(s)
- Hannah Wunsch
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, 2075 Bayview Ave, Rm D108, Toronto, ON, ON, M5R 3B2, Canada. .,Department of Anesthesia and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada. .,Sunnybrook Research Institute, Toronto, ON, Canada. .,Department of Anesthesiology, Columbia University, New York, NY, USA.
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