SCCM Pod-445 The Association of Workload and Outcomes in the Pediatric Cardiac ICU

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Healthcare workload has emerged as an important metric associated with poor outcomes. To measure workload, studies have used bed occupancy as a surrogate. However, few studies have examined frontline clinician workload and outcomes. Host Elizabeth Mack, MD, MS, FCCM, is joined by Michael Fundora, MD, FAAP, to discuss if the hypothesized frontline clinician workload, measured by bed occupancy and staffing, is associated with poor outcomes and unnecessary testing (Fundora M.P., et al. Pedtr Crit Care Med. 2021 August; 22:683-691). Michael Fundora is a physician in the Division of Cardiology, Department of Pediatrics, Children’s Healthcare of Atlanta at Emory University School of Medicine in Atlanta, Georgia. This podcast is sponsored by Mölnlycke.

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Transcript:

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Dr. Mack: Hello and welcome to the Society of Critical Care Medicine’s iCritical Care Podcast. I’m your host, Dr. Elizabeth Mack. Today I’ll be speaking with Dr. Michael Fundora about the article, “The Association of Workload and Outcomes in the Pediatric Cardiac ICU,” published in Pediatric Critical Care Medicine. To access the full article, visit pccmjournal.org.
 
Dr. Fundora is a physician in the Division of Cardiology, Department of Pediatrics, Children’s Healthcare of Atlanta at Emory University School of Medicine in Atlanta, Georgia, USA. Welcome Dr. Fundora. Can you tell us a little bit about your hypothesis and design?
 
Dr. Fundora: We wanted to set out to understand the interaction of workload on patient outcomes and frontline provider behavior as measured by orders. When it comes down to it, workload is really difficult to isolate. When we were thinking through how to design this project, we decided to look at bed occupancy as a surrogate measure of workload.
 
We pulled all data on patients during a two-year period. This was a retrospective study. We looked at January 2018 to December 2019 and also pulled all ICU orders placed on all patients admitted to the unit. We also looked at who wrote those orders and their level of experience. We cross-referenced everyone who wrote orders with their shift schedules, just to make sure we had the cleanest data possible. Then we created a model and we were able to risk-adjust and control for the patient factors. We controlled for things like the day of the week and time of day. For the model, we took it a step further and wanted to make sure that sicker longer-stay patients weren’t confounding our analysis.
 
So we performed a robustness analysis where we confirmed the effects that we found by trying different things, such as removing outliers. We then did a cost analysis based on our findings and analyzed the resources that these patients would take up. This is what we described, especially in the discussion part of our paper.
 
Dr. Mack: Were there any findings that you were surprised to learn?
 
Dr. Fundora: I really didn’t expect to see an association between bed occupancy and mortality. As an intensivist, this is really the most frightening scenario. I think that we all really worry about missing something or a patient having a bad outcome when the ICU is busy. I know that, for example, I start walking around a lot more. I start getting a little bit nervous and I try to check up on things as much as possible because I worry that if anyone is distracted we might be missing something. And so I was pretty surprised to find that.
 
But at the same time I think we showed that this is not just a staffing problem. It’s not just when the staff is stretched thin. When we found that the turnaround time for the labs actually increased when the unit was busy or full, that was surprising to me because, in isolation, taking a few extra minutes to get the lab results back, maybe it’s not a huge deal or maybe it’s not clinically significant, but it started making me think of the wider environment that the ICU sits in—the hospital resources. How long does it take to get an x-ray? How long would it take for me to get a CT scan if there were an emergency? What happens to the capacity elsewhere in the hospital? So when we found that there was a longer turnaround time, it made me think a little bit deeper about the capacity of the ICU and realize that staff has a certain capacity, but there are also other resources that we need to pay attention to.
 
So I think staffing is a huge problem, don’t get me wrong. But I think that also, if we’re going to start thinking about how to tackle busy units that maybe could have negative impacts on patient outcomes, we need to think about staff. We also need to think about all these other resources—lab capacity, x-ray or radiology capacity, and where these other bottlenecks are, which may not be so obvious.
 
Dr. Mack: Yes, I think that’s really important. And this is something that we often like to not focus on or put to the side. Is there anything that you would consider to be your biggest takeaway from the study or anything in particular that you have changed as a result of your findings?
 
Dr. Fundora: I think the biggest takeaway from the study is that we saw that there was an association between bed occupancy as a surrogate for unit workload and patient outcomes. I think there are limitations to this study. It’s a retrospective study. Bed occupancy is a good surrogate for workload but it’s not perfect.
 
What this has triggered in my mind and many of us is that now we’re starting to pay attention to a lot of the components that go into ICU capacity. It’s not just the number of beds. It’s not just the number of providers. These are a huge part of it, but we need to start thinking about a holistic approach to ICU capacity.
 
This has launched a lot of other studies. I’m working with some other researchers and colleagues on how to measure different aspects of workload in real time, in a prospective way. So I think having the support coming from this study, building the support to do further research like that, is going to be crucial to really understanding the problem. At the same time, I think that, in the beginning, a lot has been published on workload in bedside nurses. There’s been a lot of great work in NICU nurses as well. I always believe that ICU is a team sport. The nurses are doing a ton of work, but we also need to look at the entire team.
 
We have to look at everything—the bedside nurses, even environmental services and how they turn over beds, and the support we get from them. Respiratory therapists have been a huge problem lately, especially with the surge of COVID, there have been a lot of travelers and things like that. There have been a lot of those kinds of challenges out there. We need to look at them, we need to look at frontline providers, we need to look at how to support our fellows who are in the frontline provider role, who don’t necessarily want to be intensivists or work in an ICU, if they’re cardiology fellows, for example. And then, of course, how we can support each other as physicians in the ICU.
 
Dr. Mack: I’m curious as to your thoughts on how these data fit in with the classic pediatric cardiac volume outcome relationship studies.
 
Dr. Fundora: In my experience, I think that, especially when it comes to cardiac surgery, there needs to be a critical threshold of volume. I think there is a minimal amount that needs to happen in a cardiac ICU to get to proficiency. I think that applies for everything, everybody from cardiac surgeons all the way down. The ICU people even need to know how to take care of these patients, preoperatively, postoperatively, if they come back for a medical admission, across the board.
 
I think there is a minimum volume that they need to achieve. As far as it goes with our paper, we also need to understand a little bit better that it’s not just about a volume outcome equation. I think we need to think more of capacity. The two terms, capacity and volume, seem kind of similar but they’re really not. If you break it down, it’s what I’m talking about in the sense that capacity is the amount that you can handle at any time. It’s not just volume in terms of taking up beds. Beds is a part of the calculation. It’s not just the amount of staffing, but staffing is part of the calculation. It’s really that whole holistic approach to thinking about how to manage an ICU.
 
That’s why I think that, when units go through bed expansions, for example, administrators and leadership really need to start thinking about all of the other components that go into it. It’s not just getting a few extra beds. It’s also about making sure that we have enough staff for them, enough bedside staff, respiratory therapists, the clinical support people who work throughout the hospital, the lab is going to be able to support the ICU, and radiology and everything else that we need to care for our patients.
 
We should be looking at this in terms of capacity. I think that those hospitals that are able to manage the capacity adequately and are able to think in these ways are going to have better outcomes because they never really get into that red zone where they’re maxed out and overwhelmed with the number of patients they have, which we showed is associated with bad outcomes. They’re always able to stay in that middle zone, which in our paper we say is around 80% capacity. If they’re able to stay in that sweet spot, I think that translates into better outcomes for their patients.
 
Dr. Mack: Finally, I’m curious as to your thoughts on the current situation, where we may be beyond the system’s capacity, looking past the individual institution, but exceeding the capacity of the system and most of us being in the red zone. Any thoughts or advice you have for us there?
 
Dr. Fundora: The first thing is that you need data. We all need data, right? It’s hard to make any decisions, it’s hard to even make the case just based on an anecdotal feeling. I know we all feel that, when our ICU is full or busy, it’s a dangerous situation, but I think that the most important thing is to try to find some data to back up your feeling. There are times where we can have a high census in the ICU, but it doesn’t really feel like things are out of control. I think a lot of people also feel that it only really takes one patient for things to feel completely out of control.
 
So I think that there is definitely a portion of this that we have to think about. Patient acuity has to be calculated into this as well. I think that, for those units that always feel that they’re in the red zone, looking at the different components of capacity—beds, staffing—these are things that need to be taken into account.
 
We’ve been talking a lot about the red zone for patients, but we also need to think a little bit about the red zone for ourselves too. We can’t go through weeks of service at a time and be completely spent by the end of it. That’s just not sustainable. We have to think about safety for ourselves too. So I would say that if there’s a unit that feels like they’re in the red zone all the time, bringing those concerns and also maybe some solutions to the leadership and, being very clear, showing that there is a cost to everything that we do. I think that would at least help and maybe go some way toward alleviating some of those situations.
 
Dr. Mack: Thank you so much. Is there anything else that we haven’t talked about that you’d like to share or just leave us some parting words?
 
Dr. Fundora: I want to thank all my coauthors. Dr. Mahle has been a great mentor to me, and I really appreciate the interest that everyone’s had in this paper. We hope to continue researching in this area and trying to clarify a lot of these things that we’ve been talking about today, in terms of capacity and when are units safe or not safe for patients. I think that, especially now, everyone has been talking about surges in children’s hospitals, we should try our best to pay attention to a lot of these issues in order to do our best, to take care of our patients, and have the best outcomes possible.
 
Dr. Mack: I just want to share our huge amount of gratitude to you and your colleagues and coauthors who did this work. It is incredibly relevant to what’s going on right now in our world and a really thoughtful contribution to the literature around both patient and clinician wellness. Thank you so much.
 
This concludes another edition of the iCritical Care Podcast. For the iCritical Care Podcast, I’m Dr. Elizabeth Mack.
 
Babies and children are not immune to pressure injuries. Mölnlycke® Z-Flo Fluidized Positioners put your youngest patients in the best position. Z-Flo is designed for conformational positioning across the continuum of care from developmental growth in NICU patients to pediatric pressure injury management. Z-Flo positioners conform and mold to every body, big or small. For more information visit molnlycke.us.
 
Elizabeth H. Mack MD, MS, FCCM, is a professor of pediatrics and chief of pediatric critical care at Medical University of South Carolina Children’s Health in Charleston, South Carolina, USA. Dr. Mack received her bachelor of science and medical degrees from the University of South Carolina. She completed her residency at University of South Carolina Palmetto Health and her fellowship at Cincinnati Children’s Hospital Medical Center. She also completed a master of science degree with a focus on epidemiology and biostatistics at the University of Cincinnati. Currently she serves as chair of the American Academy of Pediatrics Section of Critical Care and is past chair of SCCM’s Current Concepts in Pediatric Critical Care Course.
 
Join or renew your membership with SCCM, the only multiprofessional society dedicated exclusively to the advancement of critical care. Contact a customer service representative at +1 847 827-6888 or visit sccm.org/membership for more information. The iCritical Care podcast is the copyrighted material of SCCM and all rights are reserved. Statements of fact and opinion expressed in this podcast are those of authors and participants and do not imply an opinion or endorsement on the part of SCCM, its officers, volunteers, or members or that of the podcast commercial supporter.
 
Some episodes of the iCritical Care Podcast include a transcript of the episode’s audio. Although the transcription is largely accurate, in some cases it is incomplete or inaccurate due to inaudible passages or transcription errors and should not be treated as an authoritative record.

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