with low to moderate acuity: one was a 10-bed ICU in an academic tertiary referral .... Thorens JB, Kaelin RM, Jolliet P, Chevrolet JC. Influence of the ... F, Chevret S, Schlemmer B, Azoulay E. Burnout syndrome in critical care nursing staff.
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AMERICAN JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINE
VOL 185
2012
Is the Doctor In? Views on the Deployment of Intensivists from Both Sides of the Atlantic Organization of care in our ICUs is a crucial issue for all involved. The patients are very sick, experience high mortality and morbidity, and thus are extremely vulnerable. Families are distressed and often struggling to process a great deal of information and may be asked to make substituted judgments for loved ones. The caregivers work under extreme pressure with varying forms of psychological stress, at risk for burnout and for conflict within the team (1–3). Of concern, high intensity in level of care is related to medical errors (4). Finally, there is not only a high emotional cost to the participants, but a high economic cost to health care systems as well. The importance of optimizing the organization of health care providers seems self-evident, but the means of optimization are unclear. A number of investigators have reported that outcomes are dependent, among other factors, on the type of structure (better in closed rather than open models), on the experience with procedures such as mechanical ventilation (5), and on staffing levels (6–8). A recent multicenter trial compared two intensivist staffing schedules—a continuous daily coverage schedule in 2-week rotations with a weekday coverage schedule with weekend cross-coverage. Results showed less physician burnout in the latter model and no changes in patient outcomes (9). This finding is consistent with observational studies linking burnout to staffing structure (2, 10, 11). In this issue of the Journal (pp. 738–743), Garland and coworkers (12) report a study comparing the effects of standard staffing (one intensivist staffing the ICU for 7 d, present during the day and taking calls from home at night) versus shiftwork staffing (one intensivist staffing the 7 day shifts and two different intensivists staffing the night shifts, thus providing 24/7 in-house intensivist presence) on several outcomes: intensivist burnout, family satisfaction, nurse and housestaff perceptions, resource use, and patient mortality and length of stay. This pilot study was performed with a prospective 32-week alternating crossover design and was conducted in two relatively small ICUs in Canada caring for patients with low to moderate acuity: one was a 10-bed ICU in an academic tertiary referral hospital and the other a 6-bed medical–surgical ICU in a community hospital. The primary endpoint of the study—risk of burnout for the physician measured by survey instrument—was significantly lower in the shiftwork model. Under this model, however, nurses reported a significantly higher role conflict score. Measures of patient outcome and family satisfaction were not different between the models. This study is important because it is original in its design (the crossover design avoiding the time effect confounding of prior before–after trials) and because the data are novel in suggesting that this 24/7 staffing model is more beneficial to physicians than to patients, whose outcomes were not different. This study has, however, a number of limitations. First and foremost, this is a pilot study and the number of patients (501) and families (119) studied relatively small with primarily short-term outcome measures. Patients also had a low acuity of illness, with only a moderate volume of admissions during the study period. The physician sample was 92% male, raising issues about generalizability to other care settings. Prior studies have shown disparate results in terms of burnout and gender (2, 3). We also do not know if the beneficial effects on burnout persist in the long term, and no data are provided regarding the relationship (if any) between salaries and burnout. One can argue that observed effects may be time dependent and that thresholds (workload, salaries, etc.) may exist below or above which changes in outcomes are not so apparent.
Interestingly, the decreased burnout with the 24/7 intensivist presence was mainly driven by the group providing only daytime coverage (and thus not being called and not staying at night). Would this staffing model benefit the day worker at the cost of the night worker? In addition, it may be argued that the statistically significant change in the burnout scale bears a weak relationship with the change in individual well-being. Of particular importance is the finding of increased nurse perception of role conflict with the 24/7 coverage model. The role that nurses play in the ICU enterprise is fundamental and critical, and any reorganization benefiting physicians would need to be judged by its effects on nurses and other members of the ICU team. Joint assessment of symptom control by intensivists and nurses is an independent predictor of fewer conflicts (1, 4), and the quality of physician relationships with nurses is an independent factor associated with burnout (2). Azoulay and coworkers (1) showed that nurse– physician conflicts were common: 33% of those surveyed reported such conflicts. In the same study, staff working more than 40 hours per week, covering more than 15 ICU beds, active in end-of-life care, and working on a team with inadequate communication (no routine meetings) were at higher risk for perceived conflicts. Merlani and coworkers (3) also showed that team composition (a high proportion of female nurses) was associated with a decreased risk of burnout in ICU caregivers in Switzerland. Investigators have also noted that collaboration, communication, and personal familiarity with preferences within the ICU team are essential to patient outcomes, whether or not an intensivist is present around the clock (13). Accordingly, the finding of increased nurse perception of conflict is a danger signal that begs further understanding of the full impact of reorganization of physician coverage. Considerable worldwide variability exists in current ICU organization and utilization. In a cohort study performed in 275 ICUs using the SAPS 3 database, Rothen and colleagues (14) examined the variability in outcomes and resource use. Only interprofessional rounds, emergency department needs, and geographical region were independently associated with outcome, measured as standardized mortality rate. The number of physicians, including fulltime specialists, the availability of physicians, and the nurses per bed were not associated with outcomes. Wunsch and colleagues (15) analyzed a large series of ICU admissions in the United States and the United Kingdom (UK). In this retrospective cohort, the UK patients were more frequently ventilated within 24 hours after ICU admission (68% vs. 27%), were sicker (Acute Physiology and Chronic Health Evaluation II 20.5 vs. 15.3) and had higher hospital mortality (38% vs. 16%). The comparisons, however, were highly confounded by differences in case mix, hospital length of stay, and discharge practices. The European Society of Intensive Care Medicine has declared that safe and high-quality ICU care require optimal service delivered by skilled and trained specialists 24/7, although contentious issues are raised by this recommendation (16, 17). The 24/7 coverage is onerous in part because European legislation restricts the number of hours that a doctor may work to a maximum of 48 hours per week. On the other hand, the vast part of healthcare expenses in Europe are covered by national health systems and thus by public taxes. There are, however, marked differences with respect to structure of, access to, and demography of intensive care training programs between European countries (18–20). Patient populations also differ widely. A study performed in 1,417 West European ICUs and
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encompassing 17 countries (21) showed that South European countries and the UK tended to have less ICU beds and sicker patients as compared with Northern Europe. The presence of a committed 24/7 coverage was also variable, from a low of about 40% of ICUs in Norway, Finland, and the Netherlands, to a high of 90% or more in France, Italy, and Spain. The majority of ICUs (75%) had a mixed medical–surgical case mix, and 18% of ICUs had less than six beds. The requirements for mechanical ventilation were above 50% in all countries, with a maximum of near 80% in the UK. Fundamental reforms are being implemented in the UK (22) in terms of training (primary specialty or dual certification), infrastructure, and staffing, with the aim of improving patient care and retaining the ethos of a socially funded enterprise. Given this heterogeneity, perhaps the time is ripe to perform an international study comparing the common North American model (intensivist present during daytime and taking calls from home at night) with the common European model (24/7 intensivist presence). Certainly the study by Garland and colleagues (12) should be considered as part of a pilot literature identifying some signals to be tracked in larger studies to determine what is best for patients, families, and care providers as we consider these alternative organizations. Data support the notion that intensivists are good, but we do not know exactly why nor how to best deploy and titrate this group of providers. In addition, it is conceivable that large variability exists in what intensivists actually do when at work, both at day and night. An ideal goal would be to develop a long-term sustainable staffing model for ICU physicians, based on robust data, that produces better outcomes. Researchers in this field need to shed further light on these fundamental issues. Under the current high pressure of purchasers, administration, and hospital managers, physicians are increasingly strained to improve efficiency. Data from future studies could inform these decisions about resource allocation. More importantly, a proper understanding of organizational patterns and their consequences is necessary to meet our responsibilities as physicians to patients, families, and our colleagues who are part of the ICU team. Author disclosures are available with the text of this article at www.atsjournals.org.
Jordi Mancebo, M.D. Servei de Medicina Intensiva Hospital de St. Pau, Barcelona, Spain Jesse Hall, M.D. Section of Pulmonary and Critical Care Medicine University of Chicago Chicago, Illinois References 1. Azoulay E, Timsit JF, Sprung CL, Soares M, Rusinova´ K, Lafabrie A, Abizanda R, Svantesson M, Rubulotta F, Ricou B, et al. Prevalence and factors of intensive care unit conflicts: the conflicus study. Am J Respir Crit Care Med 2009;180:853–860. 2. Embriaco N, Azoulay E, Barrau K, Kentish N, Pochard F, Loundou A, Papazian L. High level of burnout in intensivists: prevalence and associated factors. Am J Respir Crit Care Med 2007;175:686–692.
3. Merlani P, Verdon M, Businger A, Domenighetti G, Pargger H, Ricou B. Burnout in ICU caregivers: a multicenter study of factors associated to centers. Am J Respir Crit Care Med 2011;184:1140–1146. 4. Azoulay E, Mancebo J, Brochard L. Surviving the night in the ICU: who needs senior intensivists? Am J Respir Crit Care Med 2010;182:293–294. 5. Kahn JM, Goss CH, Heagerty PJ, Kramer AA, O’Brien CR, Rubenfeld GD. Hospital volume and the outcomes of mechanical ventilation. N Engl J Med 2006;355:41–50. 6. Banerjee R, Naessens JM, Seferian EG, Gajic O, Moriarty JP, Johnson MG, Meltzer DO. Economic implications of nighttime attending intensivist coverage in a medical intensive care unit. Crit Care Med 2011;39:1257–1262. 7. Needleman J, Buerhaus P, Pankratz VS, Leibson CL, Stevens SR, Harris M. Nurse staffing and inpatient hospital mortality. N Engl J Med 2011; 364:1037–1045. 8. Thorens JB, Kaelin RM, Jolliet P, Chevrolet JC. Influence of the quality of nursing on the duration of weaning from mechanical ventilation in patients with chronic obstructive pulmonary disease. Crit Care Med 1995;23:1807–1815. 9. Ali NA, Hammersley J, Hoffmann SP, O’Brien JM Jr, Phillips GS, Rashkin M, Warren E, Garland A; 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;184:803–808. 10. Azoulay E, Herridge M. Understanding ICU staff burnout: the show must go on. Am J Respir Crit Care Med 2011;184:1099–1100. 11. Poncet MC, Toullic P, Papazian L, Kentish-Barnes N, Timsit JF, Pochard F, Chevret S, Schlemmer B, Azoulay E. Burnout syndrome in critical care nursing staff. Am J Respir Crit Care Med 2007;175:698–704. 12. Garland A, Roberts D, Graff L. Twenty-four-hour intensivist presence: a pilot study of effects on intensive care unit patients, families, doctors and nurses. Am J Respir Crit Care Med 2012;185:738–743. 13. Lindell KO, Chlan LL, Hoffman LA. Nursing perspectives on 24/7 intensivist coverage. Am J Respir Crit Care Med 2010;182:1338–1340. 14. Rothen HU, Stricker K, Einfalt J, Bauer P, Metnitz PG, Moreno RP, Takala J. Variability in outcome and resource use in intensive care units. Intensive Care Med 2007;33:1329–1336. 15. Wunsch H, Angus DC, Harrison DA, Linde-Zwirble WT, Rowan KM. Comparison of medical admissions to intensive care units in the United States and UK. Am J Respir Crit Care Med 2011;183:1666–1673. 16. Rhodes A, Moreno RP, Chiche JD. ICU structures and organization: putting together all the pieces of a very complex puzzle. Intensive Care Med 2011;37:1569–1571. 17. Valentin A, Ferdinande P. Recommendations on basic requirements for intensive care units: structural and organizational aspects. Intensive Care Med 2011;37:1575–1587. 18. Rhodes A, Chiche JD, Moreno R. Improving the quality of training programs in intensive care: a view from the ESICM. Intensive Care Med 2011;37:377–379. 19. Rubulotta F, Moreno R, Rhodes A. Intensive care medicine: finding its way in the “European labyrinth.” Intensive Care Med 2011;37:1907– 1912. 20. The CoBaTrICE Collaboration. International standards for programmes of training in intensive care medicine in Europe. Intensive Care Med 2011;37:385–393. 21. Vincent JL, Suter P, Bihari D, Bruining H. Organization of intensive care units in Europe: lessons from the EPIC study. Intensive Care Med 1997;23:1181–1184. 22. Bion J, Evans T. The influence of health care reform on intensive care: a UK perspective. Am J Respir Crit Care Med 2011;184:1093–1094. Copyright ª 2012 by the American Thoracic Society DOI: 10.1164/rccm.201201-0149ED
Secondary Prevention of Idiopathic Pulmonary Fibrosis: Catching the Horse Still in the Barn The origins of idiopathic pulmonary fibrosis (IPF) have eluded us for decades. Basic science and translational approaches have provided much-needed insights into the biological pathways that
contribute to lung fibrosis, yet despite these advances, IPF remains an idiopathic disease. Perhaps our meager success is the result of a too-narrow focus on symptomatic, clinically advanced disease.
