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Ryan Rivosecchi, PharmD, BCCCP
It is Monday morning in the cardiothoracic intensive care unit (ICU), and the clinical pharmacist arrives in the unit at around 6:30 a.m. to prepare for 8:00 a.m. rounds. With a full unit (20 beds), this leaves the pharmacist a mere 4.5 minutes per patient to review new medication orders, laboratory results, culture data, and several other details before rounds begin. The medical issues of these 20 patients comprise extracorporeal membrane oxygenation (ECMO), left ventricular assist devices, and both heart and lung transplants. At 7:45 a.m., the fourth-year pharmacy student enters the ICU to review patients before rounds. The code alarm sounds at 8:30 a.m., indicating ventricular fibrillation, with inability to achieve return of spontaneous circulation, and the patient dies at 9:15 a.m. The phone rings at 10:30 a.m.—the pharmacy has run out of milrinone because of a national back order, and the pharmacist needs to discuss alternative options with the cardiac surgery team. Rounds conclude right at 12:00 p.m., which leaves just enough time to stop by the cafeteria and quickly eat lunch while preparing for multidisciplinary lung transplant rounds, which start at 1:00 p.m. The pharmacist returns to the unit after rounds to find the pharmacy student waiting in the unit to ask additional questions about what happened during critical care rounds. The pharmacist is finally able to catch up on e-mail at 2:30 p.m. The clinical manager has requested that all cost savings initiatives be submitted by end of business on Wednesday. The pharmacist pauses for a moment and sighs, “This is going to be another long week.”
The Monday described is from personal experience, but substitute ECMO for acute respiratory distress syndrome, pharmacy student for resident, lung transplant rounds for pharmacy and therapeutics presentation, and cost savings initiatives for acute decompensated liver failure lecture, and most critical care clinical pharmacists are able to share a similar narrative. These types of days experienced by the critical care pharmacy professional and subsequent feelings of physiologic stress and exhaustion may lead to burnout syndrome (BOS).
BOS has been defined by Maslach et al as “a prolonged response to chronic emotional and interpersonal stressors on the job.”1,2 The consequences of BOS are psychological and physical, including exhaustion, insomnia, job turnover, lower morale, and decline in quality of service.3,4 BOS has been described in critical care physicians, nurses, and physician assistants (PAs).5–8 It has been described within the pharmacy profession; however, there has been no study evaluating BOS in critical care pharmacists.9–11 Jones et al studied BOS in clinical pharmacists of all subspecialties and found that it occurred at a rate of 61.2% and was driven by high levels of emotional exhaustion.11 This was quite similar to the rate of severe burnout of critical care PAs (55.6%) and physicians (45%).5,7 Bhatt et al found that, among critical care PAs, those caring for more patients per shift were more likely to experience BOS.7
The Society of Critical Care Medicine considers the critical care pharmacist an essential team member.12 The recent publication by Bhatt et al demonstrates that the pharmacist was almost always present in nearly 75% of critical care teams.7 The number of critical care residency training positions has nearly doubled in the previous six years, and the American College of Clinical Pharmacy recently created a board certification in critical care pharmacy.13 In 2006, nearly 40% of ICUs nationally were without critical care pharmacy services.14 As the volume, cost of critical care services, and focus on cost containment strategies provided nationally continue to rise, the expansion of critical care pharmacy services seems inevitable.13
Several factors may contribute to the likelihood of critical care pharmacist burnout: lack of off-hours and vacation coverage, shortage of off-service time, and patient volume. First, there is a lack of critical care-trained pharmacists for both off-hour coverage and scheduled time off service, creating the feeling that the pharmacist is never truly away from the unit. To some degree, this is unique to the pharmacist member of the multidisciplinary team. Nurses often work shifts, and physicians rotate coverage as well as on- and off-service time. Second, as pharmacists’ roles expand beyond patient care (including policy development, committee involvement, clinical research, and teaching), the amount of allotted off-service time has not increased in parallel. Last, an informal survey of large academic medical centers determined that the average critical care pharmacist is responsible for approximately 15 to 20 patients. This number may be even larger in nonacademic and community hospital settings. Bhatt et al found that there is a direct correlation between patient volume and risk of BOS.7
The profession of critical care pharmacy likely exhibits high rates of BOS. Research efforts should focus on the identification of BOS risk factors. Strategies should then be developed to combat BOS specific to critical care pharmacy.
1. Maslach C, Schaufeli WB, Leiter MP. Job burnout. Annu Rev Psychol. 2001;52:397-422.
2. Maslach C, Jackson SE, Leiter, MP. Maslach Burnout Inventory Manual. 3rd ed. Palo Alto, CA: Consulting Psychologists Press; 1996.
3. Maslach C, Jackson SE. The measurement of experienced burnout. J Organizational Behav. 1981 Apr;2:99-113.
4. Bell RB, Davison M, Sefcik D. A first survey. Measuring burnout in emergency medicine physician assistants. JAAPA. 2002;15(3):40-42, 45-48, 51-52 passim.
5. Embriaco N, Azoulay E, Barrau K, et al. High level of burnout in intensivists: prevalence and associated factors. Am J Respir Crit Care Med. 2007 Apr 1;175(7):686-692.
6. Embriaco N, Papazian L, Kentish-Barnes N, Pochard F, Azoulay E. Burnout syndrome among critical care healthcare workers. Curr Opin Crit Care. 2007 Oct;13(5):482-488.
7. Bhatt M, Lizano D, Carlese A, Kvetan V, Gershengorn HB. Severe burnout is common among critical care physician assistants. Crit Care Med. 2017 Nov;45(11):1900-1906.
8. Poncet MC, Toullic P, Papazian L, et al. Burnout syndrome in critical care nursing staff. Am J Respir Crit Care Med. 2007 Apr 1;175(7):698-704.
9. El-Ibiary SY, Yam L, Lee KC. Assessment of burnout and associated risk factors among pharmacy practice faculty in the United States. Am J Pharm Educ. 2017 May;81(4):75.
10. Higuchi Y, Inagaki M, Koyama T, et al. A cross-sectional study of psychological distress, burnout, and the associated risk factors in hospital pharmacists in Japan. BMC Public Health. 2016 Jul 8;16:534.
11. Jones GM, Roe NA, Louden L, Tubbs CR. Factors associated with burnout among US hospital clinical pharmacy practitioners: results of a nationwide pilot survey. Hosp Pharm. 2017 Dec;52(11):742-751.
12. Haupt MT, Bekes CE, Brilli RJ, et al; Task Force of the American College of Critical Care Medicine, Society of Critical Care Medicine. Guidelines on critical care services and personnel: recommendations based on a system of categorization of three levels of care. Crit Care Med. 2003 Nov;31(11):2677-2683.
13. Benedict N, Hess MM. History and future of critical care pharmacy practice. Am J Health Syst Pharm. 2015 Dec 1;72(23):2101-2105.
14. Maclaren R, Devlin JW, Martin SJ, Dasta JF, Rudis MI, Bond CA. Critical care pharmacy services in United States hospitals. Ann Pharmacother. 2006 Apr;40(4):612-618.