A Chicken in Every Pot—A Pediatric Intensivist in Every Unit/All the Time?* Alice D. Ackerman, MD, MBA, FCCM Carilion Clinic Children’s Hospital Roanoke, VA


o you work in a unit that has 24-hours-a-day, ­7-days-a-week coverage by a pediatric intensivist? Is that good or bad? Are intensivists who work in such units more likely to suffer from “burnout?” These are just some of the questions posed by Rehder et al (1) in a survey that formed the basis of their article in this issue of Pediatric Critical Care Medicine. This article is important for a number of reasons. First, Rehder et al (1) studied a phenomenon that is becoming increasingly popular (2) in our PICUs but without much evidence to support its popularity. Second, they attempted to identify perceptions not only of faculty in different coverage models but also of trainees at both the resident and fellow levels. Finally, they used a validated burnout score (3) to judge whether or not coverage model was related to physician burnout. Interestingly, they found that most of the queried physicians favored the coverage format present in their own institution, and they found that faculty physicians working in an in-house unit were less likely to report negative effects of their schedule on their personal lives or career progression than those working in a home-call situation were likely to believe would come from the need for 24 × 7 intensivist presence. In addition, the only factor clearly associated with increased risk for burnout was the actual number of nights per month (on average) the respondent spent in the unit. Respondents perceived that care in the PICU was safer and better for patient care but not necessarily more efficient with in-house coverage. So, perhaps, we can use these data to infer that all PICUs should have intensivists present all day (and night) every day. Clearly, we cannot. Despite the growing trend in the belief that

*See also p. 97. Key Words: burnout; patient safety; pediatric critical care; physician staffing; workforce Dr. Ackerman received royalties from Lippincott (editor of Rogers’ Textbook of Pediatric Intensive Care) and received support for travel from the American Academy of Pediatrics and from the Association of Medical School Pediatric Department Chairs. Copyright © 2014 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies DOI: 10.1097/PCC.0000000000000060



physical presence of intensivists leads to improved outcomes, the data are spotty and in some cases c­ontradictory (4–8). With a total of 2,120 board-certified pediatric intensivists in the United States (American Board of Pediatrics ­website-workforce page, accessed October 12, 2013), and at least 257 PICUs in the United States (2), it is clear that there are not enough pediatric intensivists to provide in-house coverage 24 × 7. Would it be “just as good” to substitute pediatric hospitalists, a group for which there is not (yet) board certification? What about advanced practice nurses? At the same time as we look at these questions, we must also be looking at how we evaluate the impact of specific staff presence differently now as opposed to the early days—before universal adoption of electronic health records, patient care guidelines, and widespread availability of bedside databases and medical diagnostic and treatment decision support information. A landmark article by Pollack et al (9) in 1988 established the benefit of having a pediatric intensivist in a unit. Would we find the same thing today? What are the specific patient or unit needs that the board-certified (or equivalent) pediatric intensivist meets that cannot be met in any other way? Although clearly this article does not attempt to address this topic, I believe that the article does help us to think about it. We must be careful to not become so comfortable with the familiar (preferring to work under the call structure each of us currently works in) that we are close-minded to the alternatives. When we ask questions, we need to be asking questions that will take us into the next era of provision of medical care. We need to leverage technology and new methods of communication and education in ways that we have not yet contemplated on a wide scale. The long-term success of the progress we have made in pediatric critical care will only come if we appropriately marry the new knowledge we gain daily, with new methods in which to apply it and deploy our most limited resource— the people at the bedsides. Would it be better to look at the competencies of a bedside provider than their training or board certification? Or should board certification take into account only their competencies and not depend so much on their training? I am asking these questions, not because I find any fault with the authors for conducting their survey in the way they did. In fact, their data move our physician-staffing conversation along and may provide important information for those trying to develop new in-house or blended coverage models. Clearly, these data show that in an attempt to conserve costs, February 2014 • Volume 15 • Number 2


we cannot just have physicians work more and more shifts in the hospital, as that is the situation correlated with the highest degree of burnout. However, it should not be interpreted as necessarily describing an optimal future state. That future state has to be something we as a society can afford, can sustain, and that can provide optimal outcomes for our patients, their families, and appropriate support for all the staff who work there. Although the preliminary results of a study using the virtual PICU systems database of outcomes related to type of coverage (10) showed no impact on mortality rates, we may have to become smarter about the questions we ask. Change in mortality rate for many PICUs will be difficult to show, unless the baseline risk-adjusted rate for a particular unit is higher than average. And just because the intensivist may be “in-house” does not mean that he or she is physically present in the PICU. We learn from Rehder et al that perceived intensity of coverage may vary between individual intensivists within the same PICU. We likely have to start standardizing expectations. Looking for units that have policies or guidelines determining when the intensivist (home-call or in-house) is present and actively involved in patient care. We must look at the training and expectations of the nurses, mid-level practitioners, fellows, and residents.


1. Rehder KJ, Cheifetz IM, Markovitz BP, et  al; the Pediatric Acute Lung Injury and Sepsis Investigators Network: Survey of In-House Coverage by Pediatric Intensivists: Characterization of 24/7 In-Hospital Pediatric Critical Care Faculty Coverage. Pediatr Crit Care Med 2014; 15:97–104 2. Odetola FO, Clark SJ, Freed GL, et al: A national survey of pediatric critical care resources in the United States. Pediatrics 2005; 115:e382–e386 3. Maslach C, Schaufeli WB, Leiter MP: Job burnout. Annu Rev Psychol 2001; 52:397–422 4. Arabi Y, Alshimemeri A, Taher S: Weekend and weeknight admissions have the same outcome of weekday admissions to an intensive care unit with onsite intensivist coverage. Crit Care Med 2006; 34:605–611 5. Burnham EL, Moss M, Geraci MW: The case for 24/7 in-house intensivist coverage. Am J Respir Crit Care Med 2010; 181:1159–1160 6. Dultz LA, Pachter HL, Simon R: In-house trauma attendings: A new financial benefit for hospitals. J Trauma 2010; 68:1032–1037 7. Kumar K, Zarychanski R, Bell DD, et  al; Cardiovascular Health Research in Manitoba Investigator Group: Impact of 24-hour ­in-house intensivists on a dedicated cardiac surgery intensive care unit. Ann Thorac Surg 2009; 88:1153–1161 8. Pronovost PJ, Angus DC, Dorman T, et al: Physician staffing patterns and clinical outcomes in critically ill patients: A systematic review. JAMA 2002; 288:2151–2162 9. Pollack MM, Katz RW, Ruttimann UE, et al: Improving the outcome and efficiency of intensive care: The impact of an intensivist. Crit Care Med 1988; 16:11–17 10. Khandhar P, Kuhn A, Murkowski K, et al: Evaluation of PICU attending coverage model and patient mortality. Crit Care Med 2011; 39 (12 Suppl):484

Parental Perspectives of Donation After Circulatory Determination of Death in Children: Have We Really Investigated the Heart of the Matter?* Paul N. Bauer, MD Yong Y. Han, MD Department of Critical Care Medicine Children’s Mercy Hospital and Clinics; and Department of Pediatrics University of Missouri–Kansas City School of Medicine Kansas City, MO


ince its “reintroduction” in 1993 by physicians at the University of Pittsburgh as a means to increase the pool of transplantable solid organs (1), the practice of donation after circulatory determination of death (DCDD) has become

*See also p. 105. Key Words: circulatory determination of death; organ donation; parent The authors have disclosed that they do not have any potential conflicts of interest. Copyright © 2014 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies DOI: 10.1097/PCC.0000000000000052

Pediatric Critical Care Medicine

increasingly familiar in adult medicine and has also been gaining traction in pediatrics with annual organ procurements from children in the United States having risen 174% from 50 to 137 between the years 2001 and 2010 (2). This growing trend has been accompanied by cautious support of DCDD (or perhaps “uneasy acceptance”) by the pediatric healthcare community (3–5). At the heart of these anxious sentiments lies an undercurrent of controversy (6–8), with some Pediatric Critical Care Medicine physicians voicing strong ethical concerns over its current practice (9, 10). Additionally, only a fraction of the organs procured via pediatric DCDD to date have been transplanted into other children (2), potentially raising questions of equity in existing organ allocation policies. Remarkably absent from these discussions has been the input of family members (specifically parents), largely because their attitudes and opinions regarding pediatric DCDD have not been investigated. Understanding how parents perceive and experience pediatric DCDD is integral to providing optimal ­family-centered care as insight into parental views can better direct medical care according to the family’s convictions rather than the interests of organ procurement organizations. www.pccmjournal.org


all the time?*.

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