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Respite Staffing Decreases Intensivist Burnout
Abstract & Commentary
By Leslie A. Hoffman, RN, PhD, Department of Acute/Tertiary Care, School of Nursing, University of Pittsburgh. Dr. Hoffman reports no financial relationship to this field of study.
This article originally appeared in the September 2011 issue of Critical Care Alert. It was edited by David J. Pierson, MD, and was peer reviewed by William Thompson, MD. Dr. Pierson is Professor Emeritus, Pulmonary and Critical Care Medicine, University of Washington, Seattle, and Dr. Thompson is Associate Professor of Medicine, University of Washington, Seattle. Drs. Pierson and Thompson report no financial relationships relevant to this field of study.
Synopsis: Intensivists experienced significantly less burnout, work-home life imbalance, and job distress under an interrupted schedule vs a continuous (half-month) schedule. ICU length of stay and mortality were non-significantly higher under continuous scheduling.
Source: Ali NA, et al on behalf of the Midwest Critical Care Consortium. Continuity of care in intensive care units: A cluster-randomized trial of intensivist staffing. Am J Respir Crit Care Med 2011;Jun 30. [Epub ahead of print].
This study assessed the impact of two formats, intermittent scheduling (IS) or continuous scheduling (CS), on intensivist and patient outcomes. The study involved five medical ICUs in four academic-affiliated hospitals in the United States. The units were 12-15 bed, closed-model ICUs with care teams that included a board-certified intensivist, internal medicine residents, and ICU fellows. Intensivists were in the ICU or nearby during the day and took calls overnight from home, returning to the ICU at their discretion. Internal medicine residents were continuously present overnight. ICU fellows were present during the day and took home calls overnight. In the CS format, a single intensivist was responsible every day during a half-month rotation. In the IS, a single intensivist was responsible Mondays-Fridays for half the month and each weekend was cross-covered by a different intensivist from the same pool of partners. Weekend-covering intensivists could have non-ICU responsibilities during weekdays, but not during weekend ICU coverage. The ICUs were randomized to one of two sequences (CS-IS-CS or IS-CS-IS) over a 9-month period. Job burnout, job stress, and work-home life imbalance were measured using scales derived from the National Study of the Changing Workforce.
Forty-five intensivists and 1900 patients participated in the study. As expected, continuity of care was higher under CS; 72% of patients had a single intensivist care for them during their entire ICU stay under CS vs. 38% under IS (P < 0.0001). ICU and hospital length of stay (LOS) were nonsignificantly higher under CS (∆ ICU LOS 0.36 days, P = 0.20; ∆ hospital LOS 0.34 days, P = 0.71; ICU mortality, odds ratio 1.43, P = 0.12; hospital mortality, odds ratio 1.17, P = 0.41). Intensivists experienced significantly higher burnout, work-home life imbalance, and job distress working under CS.
Projections indicate a future imbalance in numbers of intensivists required to meet patient care needs vs. those prepared in this specialty. In addition, there is an ongoing debate whether ICUs should be staffed by intensivists around the clock (24/7) to ensure optimal patient care, a factor that would increase staffing needs. A further concern relates to Accreditation Council for Graduate Medical Education (ACGME) requirements that place stringent limits on coverage by house staff. Implementation of these regulations typically requires more frequent handoffs and, consequently, interruptions in the continuity of care, as well as more hours of care by an attending physician. Findings of this article are thus timely and provocative. Despite less continuity of care with weekend-end cross coverage, IS proved better for intensivists in regard to measures of job stress, burnout, and work-life balance and was not associated with worse outcomes for patients. As the authors note, this finding challenges conventional wisdom, but does not contradict existing knowledge. Research showing better outcomes with higher intensity of intensivist involvement has not examined the variable of continuity of care, and studies demonstrating problems related to handoffs a consequence of discontinuity of care have used subjective assessment of outcomes. Job burnout is known to predispose to more errors, as are factors that increase job stress (e.g., workload and work duration).
Additional rigorously designed studies are needed to clarify the best way to provide ICU care, including advantages and disadvantages of continuous vs interrupted intensivist staffing, incorporating acute care nurse practitioners into the care team, and use of telemedicine. The design of this study suggests it should be possible to implement designs testing these variables within the same institution by changing providers or provider schedules in a systematic manner and examining patient care outcomes.