The Impact of COVID-19 on the Clinical Practices, Working Environment, and Social Life of Intensivists in Non-COVID ICU

Study Design

This observational cross-sectional study was conducted during the late second COVID-19 wave in our country, i.e., July 2021 to September 2021 after an institutional ethical committee approval (IEC Code 2021-144-IP-EXP-39).

Survey Content

The writing group finalized the 16 questions for the online survey with an expected completion time of approximately 5 minutes. The questionnaire began with an introduction section stating details of the study and consent for participation. The initial 10 questions were related to the work and social profile of responding intensivists. It was followed by six questions (three closed with subheadings and three open) to assess the impact of COVID-19 on the changes in clinical practices, working environment, and social/personal life.

The survey questionnaire collected data over four broad categories, viz.

• Working sector, age of intensivists, clinical experience, comorbidities, working status of spouse, and dependent family members.

• Changes in the usual clinical practices in non-COVID ICU due to the impact of the pandemic.

• Changes in the working environment in the non-COVID ICU due to the impact of the pandemic.

• Impact of the pandemic on the social/personal life of the intensivists.

For the last three sections, intensivists were asked to compare pandemic conditions (mid-March 2020 through the date of doing the survey) to prepandemic conditions (pre-mid-March 2020).

The surveyweb link (link: https://forms.gle/ifnvVEmSZpRFr 6ay5) was distributed via e-mail and social media platforms to intensivists of both government and private sectors in India to collect real-time data soliciting their participation. Individual opinions (anonymous data) were collected automatically after the completion of the survey.

Sample Size

The sample size was estimated based on the assumption that 50% of the intensivists were satisfied with the current clinical and social aspects. The margin of error was assumed as 10 from the true proportion with 95% confidence; the given formula calculates the sample size.

• n = (zα_/2)²p (1 − p)/d²

• i.e., = (1.960)² 0.50(1 − 0.50)/(0.10)² = 97

As simple random sampling was not done, adjusting for a design effect of 1.5, the sample size to provide adequate power was calculated to be 97 × 1.5 = 145.5 ~ 150.

Statistical Analysis

The collected data were processed and cleaned for data analysis using Excel and R software. Descriptive statistics of the demographic, clinical, environmental, and social/personal life of the intensivists were calculated. Categorical data were presented in proportion, and continuous data were in median (Quartile 1, Quartile 3). Chi-square statistics were used for categorical data to find the association between several factors. Text data collected from open-ended questions were also analyzed and presented. The crude odds ratio was computed with 95% confidence intervals (CIs). Since it is a cross-sectional questionnaire based study, hence the significant level is increased to 10%. Thus, p-value of <0.10 was considered statistically significant to see the association of the independent variables with outcomes.

Changes in Usual Clinical Practice

Clinical practice changes during COVID-19 were assessed on six parameters such as clinical round duration and frequency, history evaluation, patient examination, airway maneuver, and invasive intervention by self and any changes in duty hours in the non-COVID ICUs.

Intensivists reported more than 40–50% decrease in clinical practice parameters like self-history evaluation, clinical round duration and frequency, airway maneuver, patient examination, and invasive intervention. Intensivists stated that ICU duty hours were increased by 23% (Fig. 1).

Intensivists reported that invasive interventions were decreased significantly in the private sector as compared to the government sector (p = 0.07). Intensivists without comorbidities performed significantly fewer patient examinations by self (p = 0.03). Less experienced intensivists (<12 years) performed significantly fewer invasive interventions than experienced (p = 0.07) (Table 2).

Changes in Working Environment

We assessed changes in the working environment during COVID-19 using five parameters: cooperation by authority, HCWs and colleague’s, burnout at the workplace and leaves.

Intensivists reported that burnout at the workplace was increased (42%) and leaves decreased by 65%. Cooperation among colleagues was better than cooperation received from authority (heads and administration) and HCWs (staff, ward boys, technician, etc.) (Fig. 1).

Intensivists reported that leaves were significantly decreased in the private sector as compared to the government sector (p = 0.06). Intensivists reported that HCW cooperation decreased significantly with less experienced intensivists (<12 years) (p = 0.05) (Table 2).

Changes in Intensivists’ Social/Personal Life

Fear of spreading infection to family, family time, physical exercise, and relaxation time felt isolated or not, and respect from patients were the parameters we assessed for reporting changes in social/personal life during the pandemic.

According to the Likert scale, three parameters such as family time, physical exercise, and relaxation time displayed a decrease in more than 40% responses. Intensivists felt isolated in more than 40% of responses. Intensivists had increased fear of spreading the infection to their own family in 56% of the responses. Whereas patients’ respect toward doctors increased by 33% according to intensivists (Fig. 1).

While comparing among working sectors, the intensivists reported that family time was substantially decreased with intensivists working in the private sector as compared to the government sector (p = 0.06) and with less experienced intensivists (p = 0.06). Intensivists responded that fear of infection to the family was significantly increased in working compared to the not working status of spouse (p = 0.004) (Table 2).

Open-ended Questions

There were three open-ended questions in the questionnaire; “How do you keep yourself motivated during COVID?”; “Your opinion on the impact of COVID on social environment/Family/Society?”; and “Your opinion on the impact of COVID on working environment and clinical practice?” R software was used with Tidytext, quanteda, quanteda, textplots, and topic models packages to analyze the text data.

Text Modeling for How You Keep Yourself Motivated

The text is dominated by a few common words like “Time,” “Music,” “Friends,” and “Exercise.” Terms used in the topic modeling suggest that meditation, watching web series, reading books, listening to music, and regular exercise/yoga are the usual methods to keep mentally fit and motivated during the pandemic. Spending time with family, reconnecting with friends, taking care of patients, and positive thinking keep them motivated (Fig. 2).

Text Modeling for an Opinion on the Impact of COVID on the Clinical Environment

The text is dominated by a few common words like “COVID,” “Fear,” “Touch,” and “Patients,” etc. The top terms of the topic modeling plot further gave an insight that there is a significant decrease in touching patients, burden, stress, and negative thoughts have increased (Fig. 3).

Text Modeling for an Opinion on the Impact of COVID on the Social Environment

The text is dominated by a few common words like “Family,” “Social,” “Bonding,” and “Mental,” etc. The top terms of the topic modeling plot further revealed that social life was also impacted due to decreased interaction among people. This pandemic taught us how to live simple. Fear has affected the mental strength. The economic loss has also been impactful (Fig. 4).

Changes in Usual Clinical Practice

Intensivists reported reduction in history evaluation, clinical round duration and frequency, patient examination, airway maneuver, and invasive intervention by themselves in the ICU. Hence, appropriate level of care and intervention in non-COVID ICUs were either delayed or deficient. Increased risk of exposure, either due to poor implementation or compliance of strict COVID-ICU protocols or improper triaging, may have led to the spread of COVID within these ICUs. Under these circumstances, self-preservation and family’s best-interest may have resulted in alteration of ICU practices.

Fewer interventions in the private sector may have been due to lesser number of non-COVID ICU patient admissions, as majority centers were COVID care. Furthermore, major interventions may already have been performed prior to transfer to non-COVID ICUs from COVID-ICUs. Less-experienced (<12 years) intensivists performed fewer interventions as they were overworked and cited exposure risk during close contact.

Several published articles report that HCWs struggled with longer duty hours in COVID-ICUs, higher workload, and rapidly changing environment.^7,8 Increase in duty hours in non-COVID ICUs in our study may have been due to limited trained manpower or additional responsibilities trusted upon them over and above their usual routine.

Changes in Working Environment

Leaves were decreased during the COVID-19 pandemic (more in private vs government sector) most probably due to scarcity of staff, which must be more in the private sector than the government sector.

Intensivists reported that HCWs cooperation decreased significantly specially with less experienced intensivists. Myths and miscommunication among lower level HCWs about COVID, heightened exposure risk due to greater, and longer contact exposure times with patients, poor pay, and higher risk could all be plausible explanations.

In our study, intensivists reporting burnout at the workplace (non-COVID ICU) increased considerably (42%) than during the pre-COVID times. Even in the pre-COVID era, severe burnout was reported in up to 45% of intensivists, affecting usual working conditions.⁹ In COVID times, several researchers have reported burnout among HCWs working in COVID set-up.^10–12 The institutional support system, newer challenges, individual stress level, cooperation among HCWs, and to some extent personal support systems are all directly related to this burnout. Probably a grievance redressal mechanism and better communication between the administrator and intensivists could have created more harmony in the working environment. Of course, better remuneration could have resulted in more cooperation at all ends.

Changes in Intensivists’ Social/Personal Life

Family time significantly decreased with intensivists working in the private sector and who were less experienced. This may have been due to higher work pressure in the private sector to perform at par with pre-COVID period and frontline activity of less experienced young intensivists. Furthermore, in the Government sector, balance was maintained between COVID and non-COVID duties with more structured off-duty periods.

Intensivists had increased fear of spreading the infection to dependents despite working inside the non-COVID ICUs. A false-sense of security and lowering of guard in non-COVID ICUs by other workers might be the cause for this. Fear of self-exposure and spreading the infection to one’s family played on the minds of intensivists, interfering in deliverance of ICU care at most centers. Stigma of acquiring and spreading infection might also be a factor to fear. One Indian study even reported that HCWs were forced to conceal their identities to save their families from social ostracization.⁸ These areas need further evaluation and clarifying guidelines in terms of professional obligations of intensivists in a pandemic situation vs professional rights.^13,14

Limitations

We penned a new and naive questionnaire that needs further validation. We could not include intensivists who were not well versed with modern communication gadgets. Intensivists had to recall pre-COVID conditions, so there may be recall bias working in our study.

During initiation of our study, we could have used the abbreviated Maslach burnout inventory for burnout measurement.¹⁵