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Renad Abu-Sawwa, PharmD, BCPPS
Pediatric Critical Care Clinical Pharmacy Specialist; UF Health Shands Children’s Hospital
Clinical Assistant Professor; University of Florida, College of Pharmacy

Burnout. Delirium. Both terms have infiltrated their way into medical literature in recent years, especially in the realms of psychiatry and neurocritical care, respectively. It is not my intent to belabor either of these terms to oblivion but rather present a unique perspective with a juxtaposition of the two conditions–opening the door for the clinician to become the patient. It is my belief that the burnout epidemic facing fellow clinicians is analogous to delirium in our patients in the intensive care unit (ICU) in etiology, severity, and sequelae. It is a radical notion, but before dismissing it, I urge you to continue reading.

The brain-mind complex is a dynamic, plastic organ that adapts to its environment. If that environment changes, the brain-mind accommodates both physiologically and mentally.  What then, if that environment becomes a source of anxiety, discomfort, and/or stress? In trauma, the brain-mind’s ability to adapt may become impaired or its response may exacerbate the underlying injury–both biologically and psychologically. As many of us who work in neurology and psychiatry know, the two are fluid, thus leading to coining of the term neuropsychiatry.

According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-V), delirium is defined as an acute disturbance of all three of the following by an underlying medical condition: (1) attention (i.e., ability to sustain focus), (2) awareness (i.e., orientation to the environment), and (3) cognition (i.e., the mental action of acquiring knowledge and comprehension through thought, experience, and sensory stimulation) [1]. The ACTIVATE study further expands upon these diagnostic criteria with additional clinical manifestations including difficulty thinking clearly, inability to focus, changes in sleep, changes in mood/behavior, and hallucinations [2].

While burnout is not defined by DSM-V, in some countries it is a condition that justifies the use of sick leave. The three most agreed upon clinical manifestations of burnout include (1) a change in professional performance, (2) increased indifference or mental distance regarding one’s job, and (3) mental exhaustion [3]. The argument can be made that the above three symptoms of burnout could align with the criteria for delirium, specifically the attention disturbance, impaired awareness, and decreased cognition. Both conditions could be classified as neuropsychiatric and overlap with other conditions, making them at times difficult to distinguish. For example, many of the symptoms of delirium are also experienced by patients with psychosis and/or dementia. Similarly, there is growing evidence that extreme burnout can progress to manifest symptoms similar to anxiety and/or depression.

Based on the new 2022 Society of Critical Care Medicine "Clinical Practice Guidelines on Prevention and Management of Pain, Agitation, Neuromuscular Blockade, and Delirium in Critically Ill Pediatric Patients With Consideration of the ICU Environment and Early Mobility (SCCM PANDEM) guidelines, the emphasis on non-pharmacological therapy such as early mobility, family engagement and support, restoring sleep-wake cycles, and minimizing modifiable risk factors of delirium, have all been elucidated as measures to prevent or treat delirium in the ICU [4]. Many of these can also be beneficial in clinicians suffering from burnout, including exercise/physical activity, social support (e.g., from family, friends, and coworkers), adequate sleep, and minimizing modifiable risk factors of burnout (e.g. demands of understaffing, long work hours, time pressure, complex patients, lack of control/autonomy, and isolation/discrimination). Just as we recognize the risk of patients developing delirium based on their non-modifiable risk factors, it is important to be cognizant and proactive towards our colleagues who have non-modifiable risk factors that increase their risk of burnout (e.g., early career status, female gender, and being single). Just as family members experience distress witnessing their loved ones suffering from delirium during their ICU stay, it can be equally distressing for families and colleagues to witness clinicians experiencing burnout. Despite its high prevalence, known detrimental effects, and an increasing focus for quality improvement initiatives, delirium is often overlooked in the ICU or minimized as a normal part of a patients’ clinical course. Similarly, burnout amongst healthcare workers has continued to increase in recent years, and as a result it has become normalized as collateral damage. To add insult to injury, the trauma of being a clinician amidst the COVID-19 pandemic has left our “heroes” to fall by the hundreds due to emotional and physical exhaustion and the inability to cope or practice at peak performance.

Delirium is extremely costly on healthcare systems with longer ICU and hospital stays. Likewise, burnout is costly for institutions due to employee turnover. Thus, clinicians and administrative leaders need to reduce and manage delirium and/or burnout symptoms utilizing systemwide holistic initiatives. While being in the ICU and working in hospitals are both non-modifiable factors for our patients and clinicians, respectively, it is imperative that we address environmental factors in the ICU to prevent delirium in our patients, and likewise optimize the institutional culture and environment in healthcare settings to prevent and manage burnout in clinicians.  As we strive to take care of our critically ill patients and their families to prevent and manage delirium, it is also time for us to take care of ourselves and our colleagues.

There is consensus among clinicians that the foundation of delirium management should be preventative in nature, as it is difficult to treat once it has developed. I would make the same statement regarding clinician burnout, as it is often much more severe and difficult to manage by the time it is identified and clinicians have decided to seek help.

My call to action is that awareness alone is not enough. It is my hope that we as clinicians can approach our colleagues and each other with the same compassion and care that we offer our patients, and collectively join forces to create a culture in healthcare that puts both patients and clinicians at the center of its construct.  

References

1. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596
2. Fiest KM, Krewulak KD, Sept BG, Spence KL, Davidson JE, Ely EW, Soo A, Stelfox HT. A study protocol for a randomized controlled trial of family-partnered delirium prevention, detection, and management in critically ill adults: the ACTIVATE study. BMC Health Serv Res. 2020 May 24; 20(1): 453.10.1186/s12913-020-05281-8
3. Bianchi R, Schonfeld IS, Laurent E. Burnout-depression overlap: a review. Clin Psychol Rev. 2015 Mar;36:28-41. doi: 10.1016/j.cpr.2015.01.004. Epub 2015 Jan 17. PMID: 25638755.
4. Smith, H et al.2022 Society of Critical Care Medicine Clinical Practice Guidelines on Prevention and Management of Pain, Agitation, Neuromuscular Blockade, and Delirium in Critically Ill Pediatric Patients With Consideration of the ICU Environment and Early Mobility. Ped Crit Care Med 2022 Feb;23(2):e74-e110