Physician burnout in pediatric critical care medicine.

OBJECTIVES: To determine the prevalence of, and factors associated with, burnout among pediatric intensivists across a variety of practice settings. DESIGN: A population-based survey, using a mailed questionnaire that included a previously validated Burnout Scale. SETTING: Private and academic pediatric critical care practices. PARTICIPANTS: Respondents from among all members of the Pediatric Section of the Society of Critical Care Medicine and all physicians certified in pediatric critical care medicine by the American Board of Pediatrics. MEASUREMENTS AND MAIN RESULTS: The questionnaire consisted of demographic items, variables noted in the literature as being associated with burnout (e.g., the individual's perception of how others valued their work, and the use of preventive measures such as regular exercise to relieve stress), and a validated Burnout Scale. The questionnaire also included questions pertaining to past training, practice of other primary specialties or subspecialties, practice settings, admission responsibilities, actual and preferred practice activities, total work effort, academic activities, and causes of stress at work. The Burnout Scale of Pines and Aronson is a self-diagnosis instrument, consisting of 21 questions using a 7-point frequency scale. The total Burnout Score represents an average of the scores for the individual components. Scores of < or = 3 in our study were classified as "not burned out." Scores of > 3 and < or = 4 were classified as "at risk." Scores of > 4 were classified as "burned out." A total of 883 questionnaires were mailed; 474 (56%) were respondent returns and 35 questionnaires could not be delivered. Primary analyses focused on the 389 respondent attending physicians presently practicing pediatric critical care medicine at the time of the survey. The average Burnout Score of these attending physicians was 3.1 +/- 0.8; 36% were classified as being at risk for burnout, and 14% were classified as burned out. There was no association between burnout status and the following work conditions: having fellows; having protected time for research and publications; frequency of being called at home; frequency of returning to the hospital when called at home; or call schedule. Respondents classified as burned out were significantly more likely than respondents who were classified as not burned out to feel that their work was not valued by others. Burned out respondents were less likely than respondents who were not burned out to give the following description: feeling very successful; feeling that their peers viewed them as very successful; feeling satisfied in their professional life; and routinely exercising or having some other outside interest. CONCLUSIONS: We found that a high degree of burnout exists in pediatric critical care medicine, with 50% of pediatric intensivists at risk or burned out. Overall, there was no association between Burnout Scores and training, practice specialties, or practice settings, nor was there an association with aspects of practice that are physically taxing. However, perceptions about the value of their work and feelings of success and satisfaction were highly associated with those respondents classified as burned out. Routine exercise (a strategy used by some for stress reduction) was associated with lower Burnout Scores. Further studies are necessary to evaluate the trends that we have reported and to identify causal factors.

Limitations and withdrawals of medical intervention in pediatric critical care.

OBJECTIVE: To investigate the use and implementation in pediatric intensive care units (PICUs) of three levels of restriction of medical intervention: do not resuscitate (DNR), additional limitations of medical interventions beyond DNR, and withdrawal of care. DESIGN: Consecutive patients admitted between December 1989 and January 1992. SETTING: A total of 16 PICUs randomly selected to represent variability in size, teaching status, and presence or absence of a pediatric intensivist and unit coordination. MAIN OUTCOME MEASURES: Profiles of children undergoing restrictions of medical interventions including the influence of chronic disease, the justifications for restrictions, and description of implementation practices. PATIENTS: All pediatric admissions undergoing restrictions (n = 119) drawn from 5415 consecutive PICU admissions. RESULTS: A total of 94 (79%) of the restriction patients died during the PICU course, representing 38% of all deaths. A total of 73 restrictions (61%) resulted from acute disease, most involving the central nervous system or respiratory system. Restrictions were evenly divided between DNR (39%), additional limitations of medical intervention beyond DNR (27%), and withdrawals of medical intervention (34%). Survival decreased with increasing levels of restriction from 35% of DNR patients to 9% of patients with additional limitations and 2% of withdrawal patients. Imminent death was cited as the justification for restrictions in 70% of cases, no relational potential was cited in 22%, and excessive burden was cited in 8%. CONCLUSIONS: Restrictions of medical intervention were used in all PICUs surveyed. Although severe chronic disease was common among restriction patients, acute disease was the predominant event precipitating placement of restrictions. Imminent death, not quality of life or excessive burden, was the most common justification.

Impact of quality-of-care factors on pediatric intensive care unit mortality.

OBJECTIVE: To determine the importance of the following care factors previously associated with hospital quality on survival from pediatric intensive care: size of the intensive care unit (ICU), medical school teaching status of the hospital housing the ICU, specialist status (pediatric intensivist), and unit coordination. DESIGN: After a national survey, consecutive case series were collected at 16 sites randomly selected to represent unique combinations of quality-of-care factors. SETTING: Pediatric ICUs. PATIENTS: Consecutive admissions to each site. MAIN OUTCOME MEASURE: Patient mortality adjusted for physiologic status, diagnosis, and other mortality risk factors. RESULTS: There were 5415 pediatric ICU admissions and 248 ICU deaths. The ICUs differed significantly with respect to descriptive variables, including mortality (range, 2.2% to 16.4%). Analysis of risk-adjusted mortality indicated that the hospital teaching status and the presence of a pediatric intensivist were significantly associated with a patient's chance of survival. The probability of patient survival after hospitalization in an ICU located in a teaching hospital was decreased (relative odds of dying, 1.79; 95% confidence interval [CI], 1.23 to 2.61; P = .002). In contrast, the probability of patient survival after hospitalization in an ICU with a pediatric intensivist was improved (relative odds of dying, 0.65; 95% CI, 0.44 to 0.95; P = .027). Post hoc analysis indicated that the higher severity-adjusted mortality in teaching hospitals may be explained by the presence of residents caring for ICU patients. CONCLUSION: Characteristics indicative of the best overall hospital quality may not be associated, or may be negatively associated, with quality of care in specialized care areas, including the pediatric ICU.

Outcomes of children in a persistent vegetative state.

OBJECTIVE: To determine the long-term outcomes and resource utilization of children discharged home in a vegetative state following neurologic injury. DESIGN: A case series. SETTING: Patients' homes. PATIENTS: Twenty children discharged from acute and chronic care hospitals with a diagnosis and discharge examination consistent with the vegetative state. INTERVENTIONS: Home care delivered, in part, by registered nurses. MEASUREMENTS: Assessed outcomes included survival/death, mental status, functional status, costs, and personnel requirements and technologies used for home care. A mailed questionnaire and telephone follow-up were used to assess patients awareness and caretaker satisfaction with home care. RESULTS: Children were followed in the vegetative state for 4.5 +/- 2.9 yrs. Six children died at home and two children died after rehospitalization. Twelve children survived at home, all for > 1 yr; eight children survived for > 3 yrs. Most patients were stable after the first year of home care. Twelve of 13 caretakers felt their child had some minimal awareness (e.g., voice recognition), although all children remained totally dependent. Costs of care averaged > $90,000/yr per patient. Care included 10 to 12 hrs/day of professional nursing care, and extensive time investments by other personnel, including public school personnel. CONCLUSIONS: The long-term outcome for children discharged from the hospital in a persistent vegetative state was poor. Forty percent of the patients died and, at best, children showed only minimal awareness after an average of 4.5 yrs. Care costs were > $90,000/yr per patient.