the problem of disproportionate critical care
TRANSCRIPT
Francesca RubulottaMD, PhD, FRCA,FFICM,
Chair of the Division of Professional Development of the ESICM
UEMS/EACCME Governance board EBICM member
Centre for Perioperative Medicine & Critical Care Research
Imperial College Healthcare NHS Trust
The Problem of Disproportionate Critical Care
Dublin 2016
Disclosure
• No Conflict of Interests
• Background
• Appropriateness of care in ICU
• Future studies
• Conclusions
• Background
• Appropriateness of care in ICU
• Future studies
• Conclusions
Definition: care which is perceived by health care providers as disproportionate in relation to the expected prognosis in terms of survival or quality of life.
‘Disproportionate care’
Clinicians who perceive the care they provide as inappropriate experience moral distress and are at risk for burnout.
Do we provide Disproportionate care?
ESICM executive commitee meeting 10Bruxelles 15-16/ 11 /2011
The number of published studies related to burnout, conflicts, moral distress is dramatically increasing.
The Evidence
The evidence …Did you ever experience a day like this…
ESICM executive commitee meeting 12Bruxelles 15-16/ 11 /2011
Does it have an impact?
• Stress, conflicts and burnout are proven to impair communication among the ICU staff
• There is evidence suggesting that the burnout leads to low performance and concentration.
Workplace-related stress & absenteeism:
a European priority
Scale & Costs of absenteeism• EU: The European Foundation for the
Improvement of Living and Working Survey, 2004, 2009 and 2013 :
– The 29% of workers believe that their work affects their health.• Depression 38%
– Matrix (2013), the cost to Europe of work-related depression was estimated to be 617 billion /year (absenteeism €272 b)
Scale & Costs of absenteeism
• UK’s estimated cost of stress, depression and anxiety (the Health and Safety executive 2010/11)–3,6 billion pounds/year –1 in 3 employees has interpersonal conflict at work (the Chartered Institute of Personnel and Development, 2015)
Scale & Costs of absenteeism
• USA: 54% stress-related (Harris et al., Elkin & Rosch)–500 billion dollars/yr,
• Canada: cost of work-related stress in Canada –CA$11 billion.
• Australia estimated the costs absenteeism due to work-related stress (Econtech 2008)
–$14.81 billion /year ???
Scale & Costs of absenteeism
• Italy:
Job VS profession concept!
Only 14% MILLENNIUM employees are engaged in their job
(Gallup 2016, American research-based, global performance-management
consulting company)
DOCTORS VS EMPLOYEES
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The Current Concept of
Work-life balanceCraig Carr
P Gruber, et al. ATCIC:Management in Intensive Care
Ideal work-life balance
Does having a successful, demanding, time consuming career necessarily result in deterioration of your private life?
Work-life conflictsWork-life enrichments
Shankar and Batnagar (2010)
• Is your workplace productive?86% of employees worldwide are not engaged. Many companies are experiencing a crisis of engagement and aren't aware of it.
• COMPANIES WITH HIGHLY ENGAGED WORKFORCES OUTPERFORM THEIR PEERS BY 147%
• Background
• Appropriateness of care in ICU
• Future studies
• Conclusions
26
ESICM Studies CONFLICUS: Azoulay E, Am J Respir
Crit Care Med. 2009
APPROPRICUS Piers R, Benoit D et al. JAMA 2011
DISPROPRICUS Benoit D et al 2013-2015
Single-day cross-sectional study
The APPROPRICUS STUDY APPROPRIATENESS of CARE in the ICU’s
Definition of ‘inappropriate care’ in this study
a specific patient-care situation in which the provider acts in a manner
contrary to his/her personal and professional beliefs
~ Definition of ‘Moral Distress’
occurs when the healthcare providerfeels certain of the ethical course of action but is constrained from taking that action
Aim / Research questions
– What is the prevalence of the perception of inappropriate care among ICU healthcare providers (nurses and physicians)?
– Which are the patient-related situations evoking this perception?
– Which are the factors associated with it?
Patient-related situation: age, co-morbidities, …
Work characteristics•End of life decision involvement•Jobstrain •(demand, control, support)•Collaboration•Ethical climate
Personal characteristics•Demographic characteristics•Role: nurse - physician
Patient-related situation
Moral Distress(ACUTE stress)
Work characteristics
Personal characteristics
Perception ofInappropriate care
Burnout(CHRONIC stress)
↓ Quality of patient care
Method:
– Single-day cross-sectional study
– Self-report survey (paper)
May 11th 2010
Note: different shifts
Results:
–ICUs in 10 European countries –99 ICUs, 17 no IRB 82 Reported–ADULT patients (> 16 years old)–1691 Healthcare providers (HCPs)
• nurses (head nurses, nurses and nurse assistants)• physicians (junior and senior)
–Responders rate median 93%
Prevalence of perceived inappropriate care– 27% (439/1651*) of HCP found that care was
inappropriate for at least one of their patients
– How often do similar situations occur in you ICU? (63% often)
Prevalence of perceived inappropriate care– 27% (439/1651*) of HCP found that care was
inappropriate for at least one of their patients
To what extend are you confident that inappropriate care in this patient will be resolved in your ICU? (57% are not confident)
Jobleave
– 9% of respondents left previous jobs because of dissent with the way patient care was handled
– 31% of respondents had thoughts about leaving their current job
• 28% in respondents not indicating inappropriate care• 39% in respondents indicating inappropriate care(Chi-Square, p<0.001)
Gallup Daily tracking, • 32% of employees in the U.S. are engaged
• Worldwide, only 13% of employees working for an organization are engaged.
• 24% are "actively disengaged,"
Factors associated Hierarchical Multivariate Regression analysis
Healthcare providers reporting
•That nurses are not involved in the EOL decision-making
•Poor nurse physician collaboration
•Not having freedom how to do their work
•Perception of having to work very hard
Factors associated with the perception of inappropriate careHierarchical Multivariate Regression analysis
Conclusions
• 1 in 4 ICU healthcare providers perceived that at least one of their patients was getting inappropriate care on the day of the survey
• 63% stated that similar situations often occur
• 57% didn’t believe this would be resolved
Conclusions
• Providing ‘too much care’ is the most frequent situation evoking this perception of inappropriate care
• followed by the daily pressure of shortage of ICU beds.
(‘other patients would benefit more’)
Conclusions
Interventions aimed at improving the quality of the nurse-
physician collaboration are important
Conclusions
• Clinicians who perceive the care they provide as inappropriate experience moral distress and are at risk for burnout.
• This situation may jeopardize patient quality of care and increase staff turnover.
Mechanisms underlying inappropriate care in European ICUs: confronting views from
nurses, junior and senior physicians
Chest 2014, Aug;146(2):267-75
• Distress related to perceived inappropriate care was most common in nurses.
• Nurses associated a higher workload with a higher rate of perceived inappropriate care.
• Junior physicians had the lowest rates of distress related to perceived inappropriate care.
• Physicians more often ascribed inappropriate care to prognostic uncertainty and nurses to interpersonal factors
• Background
• Appropriateness of care in ICU
• Future studies
• Conclusions
The DISPROPRICUS STUDY
Disproportionate care in the ICU’s : a multicenter international longitudinal study
Supported by the Ethics section of ESICM. Grant : ECCRN clinical research award 2012.
Definition of ‘disproportionate care’
care which is perceived by health care providers as disproportionate in relation to the expected prognosis
in terms of expected survival or quality of life.
~ Definition of ‘Moral Distress’
occurs when the healthcare providerfeels certain of the ethical course of action but is constrained from taking that action
Currently 74 units in 61 hospitals in 12 countries
The DISPROPRICUS STUDY Milan Italy, ESICM 2016 [email protected] [email protected] .
Bruxelles 15-16/ 11 /2011 ESICM executive commitee meeting 58
ESICM SAID in ICU
Self-awareness and individual development in ICU
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“The project is addressed to nurses and doctors working in the ICU.
The idea is to allow doctors and nurses to have a personal development course and more self-awareness,
We all have the capacity to inspire and empower others…
But we must first be willing to devote ourselves to our personal growth and development as leaders.
Contrary to the opinion of many people, leaders are not born
Leaders are made, and they are made by effort and hard work.
Vince Lombardi, professional football coach
Authentic Leaders VS Managers “The story of your life is not your life. It is your story.”
In other words, it is your personal narrative that matters, not the mere facts of your lifeJohn Barth
• Background
• Appropriateness of care in ICU
• Future studies
• Conclusions
Conclusions• Conflicts and disproportional care reduce
quality of care in ICU
• Increasing awareness of the problem/s
• No interventions planned
Waterpolo picture
CIAOThank you
