The Association of Workload and Outcomes in the Pediatric Cardiac ICU*

Abstract

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 provider (fellows, nurse practitioners, physician assistants) workload and outcomes. We hypothesize frontline provider workload, measured by bed occupancy and staffing, is associated with poor outcomes and unnecessary testing. DESIGN:A retrospective single-center, time-stamped orders, ordering provider identifiers, and patient data were collected. Regression was performed to study the influence of occupancy on orders, length of stay, and mortality, controlling for age, weight, admission type, Society of Thoracic Surgery-European Association for Cardio-Thoracic Surgery Congenital Heart Surgery Mortality score, diagnosis, number of surgeries, orders, provider staffing, attending experience, and time fixed effects. SETTING: Twenty-seven bed tertiary cardiac ICU in a free-standing children's hospital.PATIENTS: Patients (0-18 yr) admitted to the pediatric cardiac ICU, January 2018 to December 2019. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS:There were 16,500 imaging and 73,113 laboratory orders among 1,468 patient admissions. Median age 6 months (12 d to 5 yr), weight 6.2 kg (3.7-16.2 kg); 840 (57.2%) surgical and 628 (42.8%) medical patients. ICU teams consisted of 16 attendings and 31 frontline providers. Mortality 4.4%, median stay 5 days (2-11 d), and median bed occupancy 89% (78-93%). Every 10% increase in bed occupancy had 7.2% increase in imaging orders per patient (p < 0.01), 3% longer laboratory turn-around time (p = 0.015), and 3 additional days (p < 0.01). Higher staffing (> 3 providers) was associated with 6% less imaging (p = 0.03) and 3% less laboratory orders (p = 0.04). The number of "busy days" (bed occupancy > 89%) was associated with longer stays (p < 0.01), and increased mortality (p < 0.01). CONCLUSIONS:Increased bed occupancy and lower staffing were associated with increased mortality, length of stay, imaging orders, and laboratory turn-around time. The data demonstrate performance of the cardiac ICU system is exacerbated during high occupancy and low staffing.

Training needs assessment for practicing pediatric critical care nurses in Malawi to inform the development of a specialized master’s education pathway: a cohort study

“…While almost 100% of nurses feel comfortable asking a colleague, supervisor, or medical doctor a question about their patient’s care, this still has great implications for the nurse’s ability to dedicate quality time to individual patients, provide thorough education, and quickly recognize clinical deterioration [ 28 ]. High patient workload in pediatric critical care settings is associated with long hospital stays and poor health outcomes for patients, and for nurses, increased medical errors and burn out [ 28 – 30 ].…”

Association Between Critical Events in the PICU and Outcomes in Neighboring Patients

“…Few studies have explored the association between nonpatient factors and outcomes in pediatric patients. Increased provider workload has been shown to adversely affect patient outcomes in multiple settings ( 6 , 7 , 12 ). For example, in the study by Tubbs-Cooley et al ( 6 ), neonatal ICU nurses with higher workloads had a higher likelihood of reporting missed care for their patients.…”

“…For example, in the study by Tubbs-Cooley et al ( 6 ), neonatal ICU nurses with higher workloads had a higher likelihood of reporting missed care for their patients. Another study by Fundora et al ( 7 ) concluded that PICU patients who were admitted when the unit had a higher occupancy rate and decreased staffing were found to have a higher mortality and longer length of stay. However, these studies did not consider the impact of critical events on patient outcomes.…”

Invited Commentary: An Ounce of Prevention Is Worth a Pound of Cure: Advancing the Search for Modifiable Factors Associated With Cardiac Arrest

“…Recently, several studies have been undertaken to show that critical care unit organization and personnel factors, ICU workload, and prevention bundles of care have been shown to affect outcomes in children with heart disease. [12][13][14] Although possibly modifiable, the factors reported in these studies shed light on previously ignored variables related to the human enterprise of complex critical care.…”