I appreciate the opportunity to talk to you today about staffing models and unique programs to support work-life balance for pharmacists. My name is Tricia Parker. I am the Assistant Chief and Clinical Director of Inpatient Clinical Services at UC Davis Health and UC Davis Children's Hospital. It is entirely too easy to back yourself into a corner when it comes to scheduling practices if you're operating a schedule that's just entirely too lean. Your schedule really needs to start with the end in mind. You need to know how many pharmacists full-time equivalents are needed to assure optimal delivery of care for your critically ill and injured patients. What is optimal? I'll be referencing the position paper on critical care pharmacy services, the 2020 update that was published in the American Journal of Health System Pharmacists by Lett and colleagues. This paper summarizes the work of a joint task force comprised of the Society of Critical Care Medicine, the American College of Clinical Pharmacy Critical Care Practice and Research Network, and the American Society of Health System Pharmacists. The recommendations from this task force should serve as a guidepost to creating a best practice model for critical care pharmacy services. Within that model, you'll be able to prevent pharmacist burnout and allow for the opportunity to alleviate work-life conflict. Robert McLaren and colleagues set out to characterize critical care pharmacy services across the United States by surveying ICU pharmacist practitioners. The 2021 publication represented 493 intensive care units, and they saw that nearly 30% of the respondents are still not providing direct ICU pharmacist services. They also found that many institutions were still not participating in seven-day-a-week interprofessional rounding activities. So what does the ideal pharmacist FTE support in the ICU look like? From the position paper on critical care pharmacy services, it was described as decentralized clinical pharmacy services in the ICU should include routine and consistent patient care coverage inclusive of day, evening, and weekend coverage. This grid is a representation of our institution's services. Much like many of yours, we have a medical ICU, surgical ICU, burn ICU, neurosurgical ICU, cardiothoracic ICU, and a critical care PM shift coverage. These services are offered seven days a week. In this seven-day-a-week model, that would equate to 336 hours of support per week, which is equivalent to 8.4 FTEs. When we're talking about decentralized clinical pharmacy services, we're largely talking about direct patient care activities. In 2011, Dr. Degger described this as the pharmacist's observation of the patient and their contributions to the selection, modification, and monitoring of patient-specific drug therapy through collaborative practice with an interprofessional team. In our previous example, we determined that 8.4 FTEs were needed to provide these activities in a seven-day-a-week model, including an evening shift. This does not account for time off equivalents. We need to take into consideration the average vacation use, paid holiday time, professional leave, and any use of sick leave. This takes our 8.4 FTE need and converts that to nearly 10 FTEs needed when we take into consideration the time off needed for staff. But we don't stop there. What about quality improvement, research and scholarship, training and education? Where do these activities fit in? In McLaren's study, it was reported that the median patient-to-pharmacist ratio was 17 to 1. We know that direct clinical pharmacy services involve a variety of activities, including time spent on interprofessional rounds, order processing and verification activities, providing drug information to your teams and to patients' families, obtaining medication histories, providing medication reconciliation, assessing adverse drug events, evaluating, monitoring, and managing drug therapies, responding to all resuscitation emergencies, and documentation in the medical record in the form of progress notes, handoffs, and I-vents. In an 8-hour shift at a ratio of 17 to 1, that would allow about 25 minutes per patient with a one-minute transition between patients. We all know that any one of these activities could bog you down for much longer than that. Referencing back to the position paper on critical care pharmacy services, what are the expectations for quality improvement for the critical care pharmacist? It's described in the paper as implementing and maintaining policies and procedures, developing and implementing drug therapy protocols, guidelines, and order sets, and following through with an evaluation of the impact of those. It's leading or serving on committees, identifying and evaluating drug cost minimization opportunities and implementing cost containment measures, participating in the continuous readiness for ICU or hospital accreditations, and addressing any identified deficiencies that come up along the way, among many others. Research and scholarship expectations are described as having active involvement in the research process, including multi-center research, developing study proposals, screening patients for enrollment, enrolling patients into studies, analyzing the data, and publishing the results. Additional contributions to the medical literature are expected through case reports, letters to the editor, and being a peer reviewer for journals. There's also expectations that the pharmacist will disseminate results at professional meetings. And of course, there's a heavy lift with training and education. Precepting pharmacy students, residents, and fellows are essential. Advising on learner projects, such as research, med use evaluations, drug monographs, and grand rounds are needed. We expect the critical care pharmacist to educate other health professionals, students, and trainees as well, and provide interprofessional education, such as medical grand rounds. We expect active participation in interdisciplinary simulation activities, and we expect them to be certified in ACLS, PALS, and ENLS, and support that through an instructor status. So when are the pharmacists expected to complete these activities? In a study by Smith and colleagues in 2021, it was found that approximately 60% of critical care pharmacists experience burnout. This burnout was more common in pharmacists who are involved in performing quality improvement, research, and precepting activities. It was also found to be more common in pharmacists who develop protocols, provide educational end services, actively participate in hospital committees, and implement policies and procedures. All of these are activities that we just described as being essential components of the critical care pharmacist's contribution to the care team. Critical care pharmacists should be provided protected time to facilitate education, administrative, research, and scholarly activities. This is supported in the position paper on critical care pharmacy services. As we continue to reflect on the ideal pharmacist FD support needs in the critical care units, we recognize that decentralized clinical pharmacy services are essential in a seven-day-a-week model. We also recognize the need for a critical care PM support shift. In a model that supports a medical ICU, surgical ICU, burn ICU, neurosurgical ICU, and cardiothoracic ICU, the needs equate to about 336 hours per week of support, which translates to 8.4 full-time equivalents. As we take those 8.4 full-time equivalent staff and we allow for time off equivalents to accommodate vacation requests, the use of holiday leave, professional leave, and sick leave, this factors in at about a 15% variance, which takes our 336 hours to 395 hours per week, or 9.88 FTEs. Taking this one step further to protect time for quality improvement, research and scholarship, and training and education, you should factor in anywhere between 10 and 20% of every pharmacist's productive time to devote to accomplish these activities. If a 10% of productive time need is used, 9.88 FTEs increase to 10.81. At 15%, that translates to 11.36 FTEs, and at 20%, that translates to nearly 12 full-time equivalent pharmacists need. It can be argued that not all pharmacists will need the 20% of productive time protected for these activities, but certainly your leads in your various intensive care units, as well as an RPD, would benefit from this time. So using our guidepost, the position paper on critical care pharmacy services, one might argue that days, evenings, and weekends are simply not enough. Best practice would describe a facility where medication-related consults are available 24-7 to all critically ill or injured patients, that a pharmacist certified in ACLS or PALS responds to all resuscitation events in the hospital 24-7. It would also be an expectation that a pharmacist responds to all resuscitation and time-dependent emergencies in the hospital, including cardiac arrest, rapid response, trauma response, hemorrhagic shock, sepsis response, and acute neurologic life support activations. But are we ready for that? I would argue that this should be our goal, to have 24-7 critical care pharmacy services at all major academic medical centers or institutions that are caring for critically ill or injured patients. So you have enough FTEs to do the work, or if not, you're working on bridging the gap. But you still need to build a schedule, and this is often challenging. We know that weekends and evenings are often dissatisfiers for employees, but they're essential in hospital practice. We know that women outnumber men in the profession of pharmacy, and they're more likely to have work-life conflicts. Women are also more likely to need or want to work part-time, and the average number of hours worked per week by pharmacists have decreased over time. This could be due in part to the demand for work-life balance, or the fact that Generation Xers, Millennials, and Baby Boomers are working later into their lives or are required to care for their elderly parents. Okay, so some scheduling considerations. One of the things that's currently under consideration at our institution is the concept of a compressed work week, or 10-hour shifts. This was a request that was brought forward by our emergency medicine and critical care pharmacists as an attempt to decrease pharmacists' burnout and to improve the efficiency for non-direct patient care activities. Instead of having an isolated day for quality improvement, research and scholarship, training and education, and administrative functions, spreading that time out over the course of a four-day work week by adding two additional hours allows for the flexibility to attend committee work and participate in longitudinal activities that support resident and student projects. However, although this is preferred by many, some may find this as a challenge and pose a work-life conflict. Considerations may be made to make this a remote option for the non-direct patient care activities for the following two hours or to flex that time into an off day. Other scheduling considerations that have been reported in the literature as a means to improve work-life balance or to minimize work-life conflict include the use of part-time positions or considering job sharing, the engagement of frontline team members in scheduling practices, providing advanced notice scheduling, so perhaps a quarterly schedule so staff can plan better, having creative approaches to work schedule patching. So what do you do when the schedule has been posted and changes need to be made? Or consideration of other creative scheduling such as a 7-on-7-off schedule, an 8-on-6-off schedule, or a 9-80 schedule where staff work nine days in a two-week period for a total of 80 hours. So are you ready for a change? It's important to engage your frontline clinicians in the proposal. It's essential to be transparent with other pharmacy leaders. You need to know your state labor laws and involve members of payroll, labor relations, and unions. Consider a pilot and require accountability for non-direct patient care time. You also must have a collapse plan when staffing challenges arise. There's always the unexpected leave of absence or unanticipated resignation. And how do you support your schedule otherwise? So in summary, pharmacists' work schedules often create work-life conflicts and contribute to burnout. Assuring adequate FTE support to account for time off and other variance factors is imperative to supporting a best practice model and mitigate burnout. Engaging your staff in scheduling practices and providing protected time for non-direct patient care activities is essential. And administrators need to be as adaptive and flexible as possible while assuring the staffing model meets the business need of the critical care service. Here are a list of my references, and thank you so much for your time.

staffing models

work-life balance

pharmacists

critical care units

pharmacist full-time equivalents (FTEs)