A Penn State College of Medicine vice dean who also works as a clinical psychiatrist shares his perspectives on medical staff burnout.

The stakes are high for physicians when it comes to burnout—it is estimated that a doctor commits suicide every day. Research indicates that nearly half of physicians nationwide are experiencing burnout symptoms. A study published in October 2018 found burnout increases the odds of physician involvement in patient safety incidents, unprofessionalism, and lower patient satisfaction.

"Organizations should be moving forward in a systemized way on burnout. We know enough to recognize that burnout is corrosive. It's time to act," says Dan Shapiro, PhD, vice dean for faculty and administrative affairs at Penn State College of Medicine in Hershey, Pennsylvania.

Shapiro and several colleagues recently published a journal article about a five-tier hierarchy that they developed to help healthcare administrators prioritize interventions that address medical staff burnout. He has been involved in initiatives to ease burnout among Penn State Health's clinicians and nurses for nearly two years.

HealthLeaders recently spoke with Shapiro to get his perspective on efforts to address medical staff burnout. Following is a lightly edited transcript of that conversation.

HealthLeaders: Why are you interested in the topic of staff burnout in the medical setting?

Shapiro: I'm a clinical psychologist, and I saw my first physician as a patient in 1995.

I started noticing patterns. Physicians would come much later to treatment than other people—I realized that we had acculturated them to deny their own needs.

One of the first things we do with medical students is introduce them to the cadaver. What's happening in their heads and their hearts is, "Oh my god! Oh my god!" But they learn not to show emotion and to be professional. They hide what is going on inside of them. They learn to put their forehead down and grind it out in the service of their patients. We need doctors and nurses who can do that, but that means they look for help way later than the average person.

I was recruited to be a chair at Penn State's medical school and became a vice dean. That's when I became interested in efficient ways of measuring and impacting the pervasive burnout problem among my colleagues—both the physicians and the nurses.

HL: A recent article in JAMA Psychiatry warns of the danger associated with confusing medical staff burnout with major depressive disorder. How have these varying diagnoses played out in your psychiatric practice?

Shapiro: I have data because we are using depression screening inventories along with burnout inventories, and the ratio is about 5-to-1. I have five burned out folks to at least one who screens positively for depression. And in all the work that I do, I also look for suicidal ideation.

The reason we use the burnout hierarchy is that it prioritizes interventions for administrators, and the first level is this exact topic—"Do you have an adequate mental health safety net? Do you know the percentage of your folks who have screened positive for major depression, suicidal ideation, and binge drinking or other substance use?"

When a physician, a nurse, or another health professional filling out our surveys indicates they have had any suicidal ideation, the first thing that pops up is a list of resources. Then, if there has been more than one episode of suicidal ideation in the past year, we break confidentiality and personally reach out to the patient.

HL: How does the five-tier hierarchy that you helped develop aid healthcare leaders in prioritizing burnout interventions?

Shapiro: The hierarchy is based on Maslow's Hierarchy, so it has some inherent logic for administrators. One of the issues they face is that there are more than 80 factors that have been associated with burnout. That's overwhelming.

I compare a physician who is showing signs of burnout to a pilot who sees a warning light that an engine has failed. The pilot has a systematic way of responding to the warning light: checking the speed and heading; determining how much time there is to make a decision; finding out whether there is fuel, air, and spark getting to the engine; and contacting air traffic control.

The advantage of having a prioritized hierarchy for burnout is it starts with interventions that make a major difference such as physiological basics and mental health basics. For physiological basics, you determine whether staff members are eating, sleeping, and hydrating. The percentage of healthcare professionals who are dehydrated at any given time can be more than 40%. We know that dehydration impacts cognition and mood.

HL: For senior healthcare administrators, what are the primary elements of their role in addressing burnout?

Shapiro: First, you must assess the problem, preferably with brief surveys that the physicians will fill out. Then, you need to start systematically addressing a prioritized plan. Our hierarchy produces a dashboard that has ratings on each of the five levels.

Just like the patient safety movement, which started in the late 1990s, it's going to take us a while to address burnout and make real traction. So, we need to have realistic expectations. We also need to be prioritized in how we approach interventions. Engagement surveys can result in thousands of action plans at a health system, and our approach is the exact opposite. We want to pick a few interventions for each healthcare professional group, resource those interventions, have accountability, put action teams together from across several disciplines, and make substantive progress.

HL: What has Penn State done to address burnout?

Shapiro: The No. 1 thing that came out of our assessment was people feeling disrespected by the bureaucracy. So, we created a bureaucracy reduction team. We have systematically reduced the amount of email and automatic trainings. We're letting some people test out of compliance programs. We're thinking through nitty gritty details such as who can send an email to everyone in our organization, who can call a program mandatory, and which policies ought to be mandatory. 

Second, we recruited and hired a physician mental health professional with a PhD, and we established a wellness office. Third, we are working to optimize the EMR. Fourth, we are looking at compensation.

Fifth, we are actively recruiting leaders with greater emotional intelligence. Our chair candidates now must go through a simulation, where they interact with a mock disgruntled faculty member. We want leaders who can help faculty navigate the common challenges they face.

We are in the first iteration of our responses to burnout. We are viewing this as a long-term process.

HL: What data are you collecting?

We want to see a 2.5% reduction in burnout.

It's hard for me to believe that we are wasting anybody's time. If you are instituting better security in your emergency department, where 85% of your nurses have been assaulted in the past year, it's hard to think you are wasting your time regardless of the ultimate burnout score. There are a lot of interventions like that. Getting food and water to all the nurses in the ICUs just seems valid.

I'm very interested in what our turnover numbers are going to be. Some of these interventions are going to help health systems and hospitals to keep workers in greater percentages. The turnover rate among nurses is very high—young nurses leave about 16% to 17% of the time over the course of a year. That's enormously high. If you can keep half of that number, the intellectual firepower you are retaining is significant.

I'm interested in the perception of staff about the safety of their organization. We are looking at patient satisfaction data—there's a pretty strong relationship between staff burnout and your patient satisfaction scores.

Dan Shapiro can be reached via email at drdanshaps@gmail.com.

More emergency departments are helping to manage the care of medically complex older adults.

Among older adults, frequent utilizers of the emergency department tend to have multiple comorbidities, pain-related diagnoses, and injury-related visits, new research found.

Older adults are associated with high ED costs and resource consumption. Compared to other patients, older adults use the ED at higher rates, have long ED stays, and need more medical interventions during their visit.

The new research published in Annals of Emergency Medicine found that frequent geriatric utilizers of the ED accounted for an out-sized portion of visits. While frequent geriatric utilizers represented 5.7% of the patients in the study, they accounted for 21.2% of all ED visits.

"Although the ED is often portrayed as a significant and costly portion of [healthcare] spending, much of this is attributed to the increasing trend of community-based providers relying on EDs to evaluate patients with complex disease who were previously admitted to the hospital, as evidenced by an increase in high-intensity ED visits. As a result, the ED's role in delivering care for a large proportion of the population is expanding, especially for older and sicker patients," the researchers wrote.

There were three primary predictors of frequent geriatric ED utilization:

1. Multiple comorbidities: Patients over 65 with three or more comorbidities had the highest odds of frequent ED use (odds ratio 7.2).

2. Pain: The second most likely factor for frequent geriatric ED utilization was primary diagnosis of pain (5.5 odds ratio).

3. Injury: The geriatric ED frequency odds ratio for an injury-related visit was 3.8.

"Geriatric frequent users are likely to have comorbid conditions and be treated for conditions related to pain and injuries. These findings provide evidence to guide future interventions to address these needs that could potentially decrease

frequent ED use among geriatric patients," the researchers wrote.

Managing frequent geriatric ED users
 

Among geriatric patients, identifying factors that can lead to frequent ED visits and providing supportive services are crucial to improving care and lowering costs, the lead author of the Annals of Emergency Medicine research told HealthLeaders.

"EDs are increasingly playing a pivotal role in the care of these patients. EDs throughout the United States have started to develop and implement geriatric-specific policies and protocols. These include comprehensive health risk screening, consultations with specialists such as geriatricians and pharmacists while patients are in the ED, referrals to memory clinics and other specialty clinics when a need is identified, and redesigning patient care areas to meet the needs of older patients," said Edward Castillo, PhD, MPH, Department of Emergency Medicine, University of California, San Diego.

Designing health programs across the continuum of care can be effective in managing older patients who are frequent ER users, he said.

"Intervention programs across the continuum of care would allow providers more opportunities to implement prevention strategies or treatment plans that can help alleviate the need for frequent ED visits and hospitalizations in older patients," Castillo said.

Older patients often have complex medical conditions that require care after they leave the ED, he said. "Wraparound services in the primary care, ED, and post-ED setting that take into consideration the patients' and their caregiver's wellbeing are necessary to successfully manage these patients."

Approaches to repaying medical school debt include loan forgiveness programs, loan consolidation, living within a budget, and locum tenens opportunities.

Most physicians who graduated from medical school in 2015 or earlier are still carrying student loan debt, with one-third owing more than $250,000, a new survey found.

Medical school debt is believed to impact choice of specialty and to exert upward pressure on pricing for physician services. Annually, a new class of doctors graduates with student loans totaling $2.6 billion, with the median student debt per physician estimated at $194,000.

A new Weatherby Healthcare survey based on data collected from 500 practicing physicians nationwide who graduated from medical school at least four years ago found 65% of the doctors are still paying off student loans.

"Every physician has a unique situation, so it's important to carefully consider how the repayment strategy you choose will affect your future. Do your research, talk to colleagues who are further down the road in repaying their debts, and seek help from a loan repayment expert. Making the right choices for you early on can result in significant long-term savings," Weatherby President Bill Heller says.

The medical staffing company's survey generated several key data points:

• 34% of indebted survey respondents expected to take at least a decade to pay off their student loans
   
• Of the 35% of respondents who had paid off their student loans, 47% achieved the feat within two years of graduating medical school
   
• 60% of respondents said that purchasing a home had increased their debt load and slowed repayment of their student loans
   
• For repayment strategies, 66% were interested in loan forgiveness programs, 45% wanted to learn about loan consolidation and refinancing, 39% wanted to find out how to live within a budget, and 29% were interested in locum tenens opportunities

Comparing physician student debt to other college loans
 

Although physicians take on significantly more student loan debt than other college graduates, many can pay off their loans relatively quickly, Heller says.

"Like most professions, the amount of medical school debt can vary widely among physicians; based on which medical school they attend as well as their access to grants, scholarships, military benefits, and family support. Most physicians finish residency with more than $150,000 in student loans, and it's not uncommon for new doctors to have debt of $300,000 or more. Compare this to the general college graduate average of $29,800," he says.

As is the case for all college graduates, the time it takes physicians to pay off their student loans depends on several factors, including loan balance, specialty, work setting, pursuit of loan forgiveness, and repayment strategies, he says.

"According to a Wisconsin survey, the average time to pay off student loans for the general population of college graduates was 21.1 years. If a physician chooses to participate in an income-driven repayment plan, it can take 20 or even 25 years before they are debt free. However, it seems a minority choose this option. Of the physicians we surveyed who had already paid off their debt, 6% said it took more than 10 years to pay off their loan."

Hartford Hospital's ADAPT program has decreased length of stay and readmissions attributable to delirium.

Hartford Hospital has developed a comprehensive approach to addressing delirium in the hospital setting.

In-hospital delirium has been associated with several negative patient outcomes, including increased risk of death, increased risk of a prolonged or permanent cognitive impairment, increased readmissions, and increased risk of developing dementia after hospitalization.

"We know the more severe the delirium is and the longer it lasts, the worse the outcome," says Christine Waszynski, DNP, APRN, coordinator of inpatient geriatric services at Hartford Hospital, which is based in Hartford, Connecticut.

Patients who experience delirium during a hospitalization also can develop a form of post-traumatic stress disorder, she says.

"They have recurrent or unresolved issues related to their experience during a delirium episode. It can have an extremely negative impact on their life. They "remember" bad things that happened to them during their hospitalization and have to reconcile that it is really their perception of what happened—people really were not attacking them and aliens were not abducting them for testing."

In 2011, Hartford Hospital launched Actions for Delirium Assessment, Prevention, and Treatment. The ADAPT program has achieved impressive results. From 2013 to 2018, delirium-attributable days at the hospital decreased 40%. From 2012 to 2019, readmissions have fallen 14% for patients who experience delirium during a hospitalization.

The ADAPT program has three key components: screening, prevention, and treatment and management.

1. Screening for delirium
 

The ADAPT program features delirium screening in the inpatient and the emergency department settings.

For the inpatient setting, nurses screen all patients for delirium using the Confusion Assessment Method. When a patient is identified at high-risk for delirium, a care pathway is triggered, says Robert Dicks, MD, chief of geriatric medicine at Hartford Hospital.

"When a nurse identifies a patient who screens as abnormal, the clinicians are notified on the spot that they have a patient who is at high risk for delirium and they are engaged at that point. Then the preventive measures kick in," he says.

In the emergency department setting, nurses screen every patient over age 65 with a Single Question in Delirium (SQID) screening technique. These patients are asked whether they have been more confused lately. If a patient has a family member or someone else with them, that individual also is asked the question about the patient.

If the answer to the SQID question is "yes," a patient gets an intentional test—counting backward from 20 to one. "Attentional deficit is the key element of delirium. You must be inattentive to be delirious," Waszynski says.

2. Preventing delirium
 

Once a patient has been identified at high-risk for delirium, the ADAPT program calls for a range of preventive measures by clinicians, nurses, and hospital volunteers.

Clinicians focus on three kinds of preventive measures: avoiding administration of deliriogenic medications such as Ativan and fentanyl, avoiding the abrupt discontinuation of medications such as opioids and steroids, and avoiding several medical interventions when they are deemed unnecessary such as telemetry and urinary catheters.

Most nursing preventive measures are basic best practices such as moving the patient around, ensuring patients get as much uninterrupted sleep at night as possible, making sure patients have their sensory aids such as glasses, and providing assistance for eating and drinking.

Volunteers provide several preventive services to patients at high-risk for delirium, including socializing with patients, encouraging cognitive activities such as word searches, and assisting patients with walking.

Other preventive measures include an "all about me" poster placed in a patient's room. "It has basic information about patients such as what they like to be called, what they like to eat, the important people in their life, their dog's name, and what activities they enjoy," Waszynski says.

3. Treating and managing delirium
 

"When a nurse screens a patient as abnormal, it is an urgent situation," Dicks says.

The first step in treating delirium is determining the cause of the condition, he says. "It may be a drug-induced delirium. It may be a medication that was inappropriately stopped. It may be drug interactions. There's always the risk that infection and an abnormality in the blood can cause delirium. A new injury or stress can cause delirium. All of those factors are dealt with based on a systematic review."

Once clinicians feel secure that they have an explanation for delirium or the patient is responding in an expected way, there is a consult with one of three specialties—geriatrics, neurology, or psychiatry—for a second opinion. "Providers want to make sure that they are not dealing with something atypical, that there is not some other workup that is justified, and that the treatment they have approved is appropriate," Dicks says.

Clinicians apply best practices "across the board" related to treatment strategy, he says. "There are certain medications that we believe are more effective and better tolerated than other medications, and we guide clinicians to those medications in our protocol. When those medications are ineffective or contraindicated, we have second-line and third-line treatment strategies."

Cost-effectiveness of ADAPT
 

An Institute for Healthcare Improvement blog post highlights the cost-effectiveness of Hartford Hospital's ADAPT program.

Accounting for longer lengths of stay and higher costs of care per day, delirium adds more than $22,000 to an inpatient stay at Hartford Hospital. The total costs of the ADAPT program are about $50 per patient.

"From the Hartford Hospital data and analysis applied to it, one might reasonably conclude that even under the most conservative scenarios, ADAPT should at least break even and probably perform far better than that," the IHI blog post says.