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1.  Critical care capacity in Canada: results of a national cross-sectional study 
Critical Care  2015;19(1):133.
Introduction
Intensive Care Units (ICUs) provide life-supporting treatment; however, resources are limited, so demand may exceed supply in the event of pandemics, environmental disasters, or in the context of an aging population. We hypothesized that comprehensive national data on ICU resources would permit a better understanding of regional differences in system capacity.
Methods
After the 2009–2010 Influenza A (H1N1) pandemic, the Canadian Critical Care Trials Group surveyed all acute care hospitals in Canada to assess ICU capacity. Using a structured survey tool administered to physicians, respiratory therapists and nurses, we determined the number of ICU beds, ventilators, and the ability to provide specialized support for respiratory failure.
Results
We identified 286 hospitals with 3170 ICU beds and 4982 mechanical ventilators for critically ill patients. Twenty-two hospitals had an ICU that routinely cared for children; 15 had dedicated pediatric ICUs. Per 100,000 population, there was substantial variability in provincial capacity, with a mean of 0.9 hospitals with ICUs (provincial range 0.4-2.8), 10 ICU beds capable of providing mechanical ventilation (provincial range 6–19), and 15 invasive mechanical ventilators (provincial range 10–24). There was only moderate correlation between ventilation capacity and population size (coefficient of determination (R2) = 0.771).
Conclusion
ICU resources vary widely across Canadian provinces, and during times of increased demand, may result in geographic differences in the ability to care for critically ill patients. These results highlight the need to evolve inter-jurisdictional resource sharing during periods of substantial increase in demand, and provide background data for the development of appropriate critical care capacity benchmarks.
Electronic supplementary material
The online version of this article (doi:10.1186/s13054-015-0852-6) contains supplementary material, which is available to authorized users.
doi:10.1186/s13054-015-0852-6
PMCID: PMC4426537  PMID: 25888116
2.  Patient safety, resident well-being and continuity of care with different resident duty schedules in the intensive care unit: a randomized trial 
Background:
Shorter resident duty periods are increasingly mandated to improve patient safety and physician well-being. However, increases in continuity-related errors may counteract the purported benefits of reducing fatigue. We evaluated the effects of 3 resident schedules in the intensive care unit (ICU) on patient safety, resident well-being and continuity of care.
Methods:
Residents in 2 university-affiliated ICUs were randomly assigned (in 2-month rotation-blocks from January to June 2009) to in-house overnight schedules of 24, 16 or 12 hours. The primary patient outcome was adverse events. The primary resident outcome was sleepiness, measured by the 7-point Stanford Sleepiness Scale. Secondary outcomes were patient deaths, preventable adverse events, and residents’ physical symptoms and burnout. Continuity of care and perceptions of ICU staff were also assessed.
Results:
We evaluated 47 (96%) of 49 residents, all 971 admissions, 5894 patient-days and 452 staff surveys. We found no effect of schedule (24-, 16- or 12-h shifts) on adverse events (81.3, 76.3 and 78.2 events per 1000 patient-days, respectively; p = 0.7) or on residents’ sleepiness in the daytime (mean rating 2.33, 2.61 and 2.30, respectively; p = 0.3) or at night (mean rating 3.06, 2.73 and 2.42, respectively; p = 0.2). Seven of 8 preventable adverse events occurred with the 12-hour schedule (p = 0.1). Mortality rates were similar for the 3 schedules. Residents’ somatic symptoms were more severe and more frequent with the 24-hour schedule (p = 0.04); however, burnout was similar across the groups. ICU staff rated residents’ knowledge and decision-making worst with the 16-hour schedule.
Interpretation:
Our findings do not support the purported advantages of shorter duty schedules. They also highlight the trade-offs between residents’ symptoms and multiple secondary measures of patient safety. Further delineation of this emerging signal is required before widespread system change. Trial registration: ClinicalTrials.gov, no. NCT00679809.
doi:10.1503/cmaj.140752
PMCID: PMC4361104  PMID: 25667258
3.  Percutaneous dilatational tracheostomy: mostly safe, but do benefits outweigh risks? 
Critical Care  2014;18(2):117.
Percutaneous dilatational tracheostomies have become one of the most frequently performed surgical procedures in the ICU, and are believed to offer a variety of advantages over open tracheostomies, including increased convenience. Recent publications have established that the risk of fatal complications related to the procedure is low. However, clinicians must still weigh these risks against expected but largely unproven benefits. More research is needed to establish the indications for the procedure, including the optimal patient selection and timing during a course of mechanical ventilation. Such studies should also seek to improve our ability to accurately identify which patients will require prolonged mechanical ventilation, and to quantify the potential benefits of tracheostomy compared with prolonged translaryngeal intubation.
doi:10.1186/cc13761
PMCID: PMC4057159  PMID: 25029438
4.  Variation of Arterial and Central Venous Catheter Use in United States Intensive Care Units 
Anesthesiology  2014;120(3):650-664.
Background
Arterial (AC) and central venous catheterization (CVC) are common in intensive care units (ICUs). Few data describe which patients receive these devices and whether variability in practice exists.
Methods
We conducted an observational cohort study of adult ICU admissions during 2001–2008 using Project IMPACT to determine whether AC and CVC use is consistent across United States ICUs. We examined trends over time and patients more (mechanically ventilated or on vasopressors) or less (predicted risk of hospital mortality ≤2%) likely to receive either catheter.
Results
Our cohort included 334,123 patients across 122 hospitals and 168 ICUs. Unadjusted AC usage rates remained constant (36.9% (2001) versus 36.4% (2008); P = 0.212) while CVC use increased (from 33.4% (2001) to 43.8% (2008), P < 0.001 comparing 2001 and 2008); adjusted AC usage rates were constant from 2004 (35.2%) to 2008 (36.4%, P = 0.43 for trend). Surgical ICUs used both catheters most often (unadjusted rates, ACs: 56.0% of patients vs. 22.4% in medical and 32.6% in combined units, P < 0.001; CVCs: 46.9% vs. 32.5% and 36.4%, P < 0.001). There was wide variability in AC use across ICUs in patients receiving mechanical ventilation (median (interquartile range): 49.2% (29.9%, 72.3%); adjusted Median Odds-Ratio (AMOR) 2.56), vasopressors (51.7% (30.8%,76.2%); AMOR 2.64), and with predicted mortality ≤2% (31.7% (19.5, 49.3%); AMOR 1.94). There was less variability in CVC use (mechanical ventilation: 63.4% (54.9%, 72.9%), AMOR 1.69; vasopressors: 71.4% (59.5%, 85.7%), AMOR 1.93; predicted mortality ≤2%: 18.7% (11.9%, 27.3%), AMOR 1.90).
Conclusions
Both ACs and CVCs are common in ICU patients. There is more variation in use of ACs than CVCs.
doi:10.1097/ALN.0000000000000008
PMCID: PMC4145875  PMID: 24424071
5.  Implementation and Evaluation of a Wiki Involving Multiple Stakeholders Including Patients in the Promotion of Best Practices in Trauma Care: The WikiTrauma Interrupted Time Series Protocol 
JMIR Research Protocols  2015;4(1):e21.
Background
Trauma is the most common cause of mortality among people between the ages of 1 and 45 years, costing Canadians 19.8 billion dollars a year (2004 data), yet half of all patients with major traumatic injuries do not receive evidence-based care, and significant regional variation in the quality of care across Canada exists. Accordingly, our goal is to lead a research project in which stakeholders themselves will adapt evidence-based trauma care knowledge tools to their own varied institutional contexts and cultures. We will do this by developing and assessing the combined impact of WikiTrauma, a free collaborative database of clinical decision support tools, and Wiki101, a training course teaching participants how to use WikiTrauma. WikiTrauma has the potential to ensure that all stakeholders (eg, patients, clinicians, and decision makers) can all contribute to, and benefit from, evidence-based clinical knowledge about trauma care that is tailored to their own needs and clinical setting.
Objective
Our main objective will be to study the combined effect of WikiTrauma and Wiki101 on the quality of care in four trauma centers in Quebec.
Methods
First, we will pilot-test the wiki with potential users to create a version ready to test in practice. A rapid, iterative prototyping process with 15 health professionals from nonparticipating centers will allow us to identify and resolve usability issues prior to finalizing the definitive version for the interrupted time series. Second, we will conduct an interrupted time series to measure the impact of our combined intervention on the quality of care in four trauma centers that will be selected—one level I, one level II, and two level III centers. Participants will be health care professionals working in the selected trauma centers. Also, five patient representatives will be recruited to participate in the creation of knowledge tools destined for their use (eg, handouts). All participants will be invited to complete the Wiki101 training and then use, and contribute to, WikiTrauma for 12 months. The primary outcome will be the change over time of a validated, composite, performance indicator score based on 15 process performance indicators found in the Quebec Trauma Registry.
Results
This project was funded in November 2014 by the Canadian Medical Protective Association. We expect to start this trial in early 2015 and preliminary results should be available in June 2016. Two trauma centers have already agreed to participate and two more will be recruited in the next months.
Conclusions
We expect that this study will add important and unique evidence about the effectiveness, safety, and cost savings of using collaborative platforms to adapt knowledge implementation tools across jurisdictions.
doi:10.2196/resprot.4024
PMCID: PMC4376233  PMID: 25699546
interrupted time series; wiki; quality improvement; knowledge translation; trauma care; stakeholder engagement; adapting knowledge tools
6.  Critical care trainees’ career goals and needs: A Canadian survey 
Designing an effective training program requires information regarding the needs, capability and aspirations of its users. Prompted by the low career satisfaction levels shown by critical care medicine (CCM) clinicians in a previous survey, and a lack of data regarding the career goals of CCM trainees in Canadian training programs, this survey-based study, which had an exemplary response rate of 85%, examined career expectations, and the barriers and enablers to career goals among individuals from adult and pediatric CCM programs across Canada.
BACKGROUND:
For training programs to meet the needs of trainees, an understanding of their career goals and expectations is required.
OBJECTIVES:
Canadian critical care medicine (CCM) trainees were surveyed to understand their career goals in terms of clinical work, research, teaching, administration and management; and to identify their perceptions regarding the support they need to achieve their goals.
METHODS:
The online survey was sent to all trainees registered in a Canadian adult or pediatric CCM program. It documented the participants’ demographics; their career expectations; the perceived barriers and enablers to achieve their career goals; and their perceptions relating to their chances of developing a career in different areas.
RESULTS:
A response rate of 85% (66 of 78) was obtained. The majority expected to work in an academic centre. Only approximately one-third (31%) estimated their chances of obtaining a position in CCM as >75%. The majority planned to devote 25% to 75% of their time performing clinical work and <25% in education, research or administration. The trainees perceived that there were limited employment opportunities. Networking and having specialized expertise were mentioned as being facilitators for obtaining employment. They expressed a need for more protected time, resources and mentorship for nonclinical tasks during training.
CONCLUSION:
CCM trainees perceived having only limited support to help them to achieve their career goals and anticipate difficulties in obtaining successful employment. They identified several gaps that could be addressed by training programs, including more mentoring in the areas of research, education and administration.
PMCID: PMC4128527  PMID: 24724149
Career; Critical care; Education; Needs assessment; Survey; Training
7.  Intracranial Pressure Monitoring in Severe Traumatic Brain Injury: Results from the American College of Surgeons Trauma Quality Improvement Program 
Journal of Neurotrauma  2013;30(20):1737-1746.
Abstract
Although existing guidelines support the utilization of intracranial pressure (ICP) monitoring in patients with traumatic brain injury (TBI), the evidence suggesting benefit is limited. To evaluate the impact on outcome, we determined the relationship between ICP monitoring and mortality in centers participating in the American College of Surgeons Trauma Quality Improvement Program (TQIP). Data on 10,628 adults with severe TBI were derived from 155 TQIP centers over 2009–2011. Random-intercept multilevel modeling was used to evaluate the association between ICP monitoring and mortality after adjusting for important confounders. We evaluated this relationship at the patient level and at the institutional level. Overall mortality (n=3769) was 35%. Only 1874 (17.6%) patients underwent ICP monitoring, with a mortality of 32%. The adjusted odds ratio (OR) for mortality was 0.44 [95% confidence interval (CI), 0.31–0.63], when comparing patients with ICP monitoring to those without. It is plausible that patients receiving ICP monitoring were selected because of an anticipated favorable outcome. To overcome this limitation, we stratified hospitals into quartiles based on ICP monitoring utilization. Hospitals with higher rates of ICP monitoring use were associated with lower mortality: The adjusted OR of death was 0.52 (95% CI, 0.35–0.78) in the quartile of hospitals with highest use, compared to the lowest. ICP monitoring utilization rates explained only 9.9% of variation in mortality across centers. Results were comparable irrespective of the method of case-mix adjustment. In this observational study, ICP monitoring utilization was associated with lower mortality. However, variability in ICP monitoring rates contributed only modestly to variability in institutional mortality rates. Identifying other institutional practices that impact on mortality is an important area for future research.
doi:10.1089/neu.2012.2802
PMCID: PMC3796332  PMID: 23731257
head injury; intracranial pressure; multilevel analysis; traumatic brain injury
8.  Validity of Physician Billing Claims to Identify Deceased Organ Donors in Large Healthcare Databases 
PLoS ONE  2013;8(8):e70825.
Objective
We evaluated the validity of physician billing claims to identify deceased organ donors in large provincial healthcare databases.
Methods
We conducted a population-based retrospective validation study of all deceased donors in Ontario, Canada from 2006 to 2011 (n = 988). We included all registered deaths during the same period (n = 458,074). Our main outcome measures included sensitivity, specificity, positive predictive value, and negative predictive value of various algorithms consisting of physician billing claims to identify deceased organ donors and organ-specific donors compared to a reference standard of medical chart abstraction.
Results
The best performing algorithm consisted of any one of 10 different physician billing claims. This algorithm had a sensitivity of 75.4% (95% CI: 72.6% to 78.0%) and a positive predictive value of 77.4% (95% CI: 74.7% to 80.0%) for the identification of deceased organ donors. As expected, specificity and negative predictive value were near 100%. The number of organ donors identified by the algorithm each year was similar to the expected value, and this included the pre-validation period (1991 to 2005). Algorithms to identify organ–specific donors performed poorly (e.g. sensitivity ranged from 0% for small intestine to 67% for heart; positive predictive values ranged from 0% for small intestine to 37% for heart).
Interpretation
Primary data abstraction to identify deceased organ donors should be used whenever possible, particularly for the detection of organ-specific donations. The limitations of physician billing claims should be considered whenever they are used.
doi:10.1371/journal.pone.0070825
PMCID: PMC3743842  PMID: 23967114
9.  Predictive score for estimating cancer after venous thromboembolism: a cohort study 
BMC Cancer  2013;13:352.
Background
Venous thromboembolism (VTE) has been associated with a higher risk of developing malignancy and mortality, and patients with VTE may therefore benefit from increased surveillance. We aimed to construct a clinical predictive score that could classify patients with VTE according to their risk for developing these outcomes.
Methods
Observational cohort study using an existing clinical registry in a tertiary academic teaching hospital in Buenos Aires, Argentina. 1264 adult patients greater than 17 years of age presented new VTE between June 2006 and December 2011 and were included in the registry. We excluded patients with previous or incident cancer, those who died during the first month, and those with less than one year of follow up (< 5%). 540 patients were included. Primary outcome was new cancer diagnosis during one year of follow-up, secondary composite outcome was any new cancer diagnosis or death. The score was developed using a multivariable logistic regression model to predict cancer or death.
Results
During follow-up, one-quarter (26.4%) of patients developed cancer (9.2%) or died (23.7%). Patients with the primary outcome had more comorbidities, were more likely to have previous thromboembolism and less likely to have recent surgery. The final score developed for predicting cancer alone included previous episode of VTE, recent surgery and comorbidity (Charlson comorbidity score), [AUC of 0.75 (95% CI 0.66-0.84) and 0.79 (95% CI 0.63-0.95) in the derivation and validation cohorts, respectively]. The version of this score developed to predict cancer or death included age, albumin level, comorbidity, previous episode of VTE, and recent surgery [AUC = 0.72 (95% CI 0.66-0.78) and 0.71 (95% CI 0.63-0.79) in the derivation and validation cohorts, respectively].
Conclusions
A simple clinical predictive score accurately estimates patients’ risk of developing cancer or death following newly diagnosed VTE. This tool could be used to help reassure low risk patients, or to identify high-risk patients that might benefit from closer surveillance and additional investigations.
Trial registration
ClinicalTrials.gov: NCT01372514.
doi:10.1186/1471-2407-13-352
PMCID: PMC3723428  PMID: 23875619
Venous thromboembolism; Thromboembolism; Cancer; Pulmonary embolism
10.  Economics of ICU Organization and Management 
Critical care clinics  2011;28(1):25-v.
doi:10.1016/j.ccc.2011.09.004
PMCID: PMC3665001  PMID: 22123097
Critical Care; Intensive Care Unit; Length of Stay; Staffing; Organization; Economics
11.  Organ donation after death in Ontario: a population-based cohort study 
Background:
Shortfalls in deceased organ donation lead to shortages of solid organs available for transplantation. We assessed rates of deceased organ donation and compared hospitals that had clinical services for transplant recipients (transplant hospitals) to those that did not (general hospitals).
Methods:
We conducted a population-based cohort analysis involving patients who died from traumatic brain injury, subarachnoid hemorrhage, intracerebral hemorrhage or other catastrophic neurologic conditions in Ontario, Canada, between Apr. 1, 1994, and Mar. 31, 2011. We distinguished between acute care hospitals with and without transplant services. The primary outcome was actual organ donation determined through the physician database for organ procurement procedures.
Results:
Overall, 87 129 patients died from catastrophic neurologic conditions during the study period, of whom 1930 became actual donors. Our primary analysis excluded patients from small hospitals, reducing the total to 79 746 patients, of whom 1898 became actual donors. Patients who died in transplant hospitals had a distribution of demographic characteristics similar to that of patients who died in other large general hospitals. Transplant hospitals had an actual donor rate per 100 deaths that was about 4 times the donor rate at large general hospitals (5.0 v. 1.4, p < 0.001). The relative reduction in donations at general hospitals was accentuated among older patients, persisted among patients who were the most eligible candidates and amounted to about 121 fewer actual donors per year (adjusted odds ratio 0.58, 95% confidence interval 0.36–0.92). Hospital volumes were only weakly correlated with actual organ donation rates.
Interpretation:
Optimizing organ donation requires greater attention to large general hospitals. These hospitals account for most of the potential donors and missed opportunities for deceased organ donation.
doi:10.1503/cmaj.122047
PMCID: PMC3652962  PMID: 23549970
12.  Variation in use of intensive care for adults with diabetic ketoacidosis* 
Critical care medicine  2012;40(7):2009-2015.
Objective
Intensive care unit (ICU) beds are limited, yet few guidelines exist for triage of patients to the ICU, especially patients at low-risk for mortality. The frequency with which low-risk patients are admitted to ICUs in different hospitals is unknown. Our objective was to assess variation in use of intensive care for patients with diabetic ketoacidosis (DKA), a common condition with a low-risk of mortality.
Design
Observational study using the New York State Inpatient Database (2005-2007).
Setting
159 New York State acute care hospitals.
Patients
15,994 adult (≥18) hospital admissions with a primary diagnosis of DKA (ICD-9-CM 250.1x).
Interventions
None.
Measurements and Main Results
We calculated reliability- and risk-adjusted ICU utilization, hospital length of stay (LOS), and mortality. We identified hospital-level factors associated with increased likelihood of ICU admission after controlling for patient characteristics using multilevel mixed-effects logistic regression analyses; we assessed the amount of residual variation in ICU utilization using the intra-class correlation coefficient. Use of intensive care for DKA patients varied widely across hospitals (adjusted range: 2.1% to 87.7%), but was not associated with hospital LOS or mortality. After multilevel adjustment, hospitals with a high volume of DKA admissions admitted DKA patients to the ICU less often (OR 0.40, p=0.002, highest quintile compared to lowest) whereas hospitals with higher rates of ICU utilization for all non-DKA inpatients admitted DKA patients to the ICU more frequently (OR 1.31, p=0.001, for each additional ten percent increase). In the multi-level model, more than half (58%) of the variation in ICU admission practice attributable to hospitals remained unexplained.
Conclusions
We observed variation across hospitals in use of intensive care for DKA patients that was not associated with differences in hospital LOS or mortality. Institutional practice patterns appear to impact admission decisions and represent a potential target for reduction of resource utilization in higher use institutions.
doi:10.1097/CCM.0b013e31824e9eae
PMCID: PMC3561634  PMID: 22564962
Diabetic Ketoacidosis; Delivery of Health Care; Physician’s Practice Patterns
13.  Statin therapy in critical illness: an international survey of intensive care physicians’ opinions, attitudes and practice 
Background
Pleotropic effects of statins on inflammation are hypothesised to attenuate the severity of and possibly prevent the occurrence of the host inflammatory response to pathogen and infection-related acute organ failure. We conducted an international survey of intensive care physicians in Australia, New Zealand (ANZ) and United Kingdom (UK). The aims of the survey were to assess the current prescribing practice patterns, attitudes towards prescribing statin therapy in critically ill patients and opinions on the need for an interventional trial of statin therapy in critically ill patients.
Methods
Survey questions were developed through an iterative process. An expert group reviewed the resulting 26 items for face and content validity and clarity. The questions were further refined following pilot testing by ICU physicians from Australia, Canada and the UK. We used the online Smart SurveyTM software to administer the survey.
Results
Of 239 respondents (62 from ANZ and 177 from UK) 58% worked in teaching hospitals; most (78.2%) practised in ‘closed’ units with a mixed medical and surgical case mix (71.0%). The most frequently prescribed statins were simvastatin (77.6%) in the UK and atorvastatin (66.1%) in ANZ. The main reasons cited to explain the choice of statin were preadmission prescription and pharmacy availability. Most respondents reported never starting statins to prevent (65.3%) or treat (89.1%) organ dysfunction. Only a minority (10%) disagreed with a statement that the risks of major side effects of statins when prescribed in critically ill patients were low. The majority (84.5%) of respondents strongly agreed that a clinical trial of statins for prevention is needed. More than half (56.5%) favoured rates of organ failure as the primary outcome for such a trial, while a minority (40.6%) favoured mortality.
Conclusions
Despite differences in type of statins prescribed, critical care physicians in the UK and ANZ reported similar prescription practices. Respondents from both communities agreed that a trial is needed to test whether statins can prevent the onset of new organ failure in patients with sepsis.
doi:10.1186/1472-6904-12-13
PMCID: PMC3416708  PMID: 22742644
Survey; Statin; Sepsis; Critical care; Clinical trials
14.  Routine chest x-rays in intensive care units: a systematic review and meta-analysis 
Critical Care  2012;16(2):R68.
Introduction
Chest x-rays (CXRs) are the most frequent radiological tests performed in the intensive care unit (ICU). However, the utility of performing daily routine CXRs is unclear.
Methods
We searched Medline and Embase (1948 to March 2011) for randomized and quasi-randomized controlled trials (RCTs) and before-after observational studies comparing a strategy of routine CXRs to a more restrictive approach with CXRs performed to investigate clinical changes among critically ill adults or children. In duplicate, we extracted data on the CXR strategy, study quality and clinical outcomes (ICU and hospital mortality; duration of mechanical ventilation and ICU and hospital stay).
Results
Nine studies (39,358 CXRs; 9,611 patients) were included in the meta-analysis. Three trials (N = 870) of moderate to good quality provided information on the safety of a restrictive routine CXR strategy; only one trial systematically assessed for missed findings. Pooled data from trials showed no evidence of effect of a restrictive approach on ICU mortality (risk ratio [RR] 1.04, 95% confidence interval [CI] 0.84 to 1.28, P = 0.72; two trials, N = 776), hospital mortality (RR 0.98, 95% CI 0.68 to 1.41, P = 0.91; two trials, N = 259), ICU length of stay (weighted mean difference [WMD] -0.86 days, 95% CI -2.38 to 0.66 days, P = 0.27; three trials, N = 870), hospital length of stay (WMD -2.50 days, 95% CI -6.62 to 1.61 days, P = 0.23; two trials, N = 259), or duration of mechanical ventilation (WMD -0.30 days, 95% CI -1.48 to 0.89 days, P = 0.62; three trials, N = 705). Adding data from six observational studies, one of which systematically screened for missed findings, gave similar results.
Conclusions
This meta-analysis did not detect any harm associated with a restrictive chest radiograph strategy. However, confidence intervals were wide and harm was not rigorously assessed. Therefore, the safety of abandoning routine CXRs in patients admitted to the ICU remains uncertain.
doi:10.1186/cc11321
PMCID: PMC3681397  PMID: 22541022
15.  Emergency department length of stay for patients requiring mechanical ventilation: a prospective observational study 
Background
Recommendations for acceptable emergency department (ED) length of stay (LOS) vary internationally with ≤ 8 h generally considered acceptable. Protracted ED LOS may place critically ill patients requiring mechanical ventilation at increased risk of adverse events as most EDs are not resourced for longitudinal delivery of critical care. Our objective was to quantify the ED LOS for mechanically ventilated patients (invasive and/or non-invasive ventilation [NIV]) and to explore patient and system level predictors of prolonged ED LOS. Additionally, we aimed to describe delivery and monitoring of ventilation in the ED.
Methods
Prospective observational study of ED LOS for all patients receiving mechanical ventilation at four metropolitan EDs in Toronto, Canada over two six-month periods in 2009 and 2010.
Results
We identified 618 mechanically ventilated patients which represented 0.5% (95% CI 0.4%–0.5%) of all ED visits. Of these, 484 (78.3%) received invasive ventilation, 118 (19.1%) received NIV; 16 received both during the ED stay. Median Kaplan-Meier estimated duration of ED stay for all patients was 6.4 h (IQR 2.8–14.6). Patients with trauma diagnoses had a shorter median (IQR) LOS, 2.5 h (1.3–5.1), compared to ventilated patients with non-trauma diagnoses, 8.5 h (3.3–14.0) (p <0.001). Patients requiring NIV had a longer ED stay (16.6 h, 8.2–27.9) compared to those receiving invasive ventilation exclusively (4.6 h, 2.2–11.1) and patients receiving both (15.4 h, 6.4–32.6) (p <0.001). Longer ED LOS was associated with ED site and lower priority triage scores. Shorter ED LOS was associated with intubation at another ED prior to transfer.
Conclusions
While patients requiring mechanical ventilation represent a small proportion of overall ED visits these critically ill patients frequently experienced prolonged ED stay especially those treated with NIV, assigned lower priority triage scores at ED presentation, and non-trauma patients.
doi:10.1186/1757-7241-20-30
PMCID: PMC3466156  PMID: 22494785
Mechanical ventilation; Emergency department; Non-invasive ventilation, critical illness; Acute respiratory failure
16.  Ultrasound-guided tracheostomy - not for the many, but perhaps the few... or the one 
Critical Care  2011;15(2):147.
Percutaneous tracheostomy has become a routine procedure in most intensive care units, and point of care ultrasound is becoming used with greater frequency to augment diagnosis and therapy for critically ill patients. The case series from Rajajee and colleagues incorporates 'real-time' ultrasound in an effort to improve the safety of percutaneous tracheostomy. While their report does not prove that ultrasound should be used prior to or during all percutaneous tracheostomies, it does reinforce several important safety considerations concerning the anatomy of the neck, and in particular the potential to encounter bleeding complications during these procedures.
doi:10.1186/cc10106
PMCID: PMC3219364  PMID: 21489326
19.  Mortality associated with withdrawal of life-sustaining therapy for patients with severe traumatic brain injury: a Canadian multicentre cohort study 
Background:
Severe traumatic brain injury often leads to death from withdrawal of life-sustaining therapy, although prognosis is difficult to determine.
Methods:
To evaluate variation in mortality following the withdrawal of life-sustaining therapy and hospital mortality in patients with critical illness and severe traumatic brain injury, we conducted a two-year multicentre retrospective cohort study in six Canadian level-one trauma centres. The effect of centre on hospital mortality and withdrawal of life-sustaining therapy was evaluated using multivariable logistic regression adjusted for baseline patient-level covariates (sex, age, pupillary reactivity and score on the Glasgow coma scale).
Results:
We randomly selected 720 patients with traumatic brain injury for our study. The overall hospital mortality among these patients was 228/720 (31.7%, 95% confidence interval [CI] 28.4%–35.2%) and ranged from 10.8% to 44.2% across centres (χ2 test for overall difference, p < 0.001). Most deaths (70.2% [160/228], 95% CI 63.9%–75.7%) were associated with withdrawal of life-sustaining therapy, ranging from 45.0% (18/40) to 86.8% (46/53) (χ2 test for overall difference, p < 0.001) across centres. Adjusted odd ratios (ORs) for the effect of centre on hospital mortality ranged from 0.61 to 1.55 (p < 0.001). The incidence of withdrawal of life-sustaining therapy varied by centre, with ORs ranging from 0.42 to 2.40 (p = 0.001). About one half of deaths that occurred following the withdrawal of life-sustaining therapies happened within the first three days of care.
Interpretation:
We observed significant variation in mortality across centres. This may be explained in part by regional variations in physician, family or community approaches to the withdrawal of life-sustaining therapy. Considering the high proportion of early deaths associated with the withdrawal of life-sustaining therapy and the limited accuracy of current prognostic indicators, caution should be used regarding early withdrawal of life-sustaining therapy following severe traumatic brain injury.
doi:10.1503/cmaj.101786
PMCID: PMC3185074  PMID: 21876014
20.  Corticosteroids for acute respiratory distress syndrome 
BMJ : British Medical Journal  2008;336(7651):969-970.
Avoid corticosteroids for prophylaxis; possibly use them for treatment
doi:10.1136/bmj.39553.408924.80
PMCID: PMC2364810  PMID: 18434378
22.  A knowledge translation collaborative to improve the use of therapeutic hypothermia in post-cardiac arrest patients: protocol for a stepped wedge randomized trial 
Background
Advances in resuscitation science have dramatically improved survival rates following cardiac arrest. However, about 60% of adults that regain spontaneous circulation die before leaving the hospital. Recently it has been shown that inducing hypothermia in cardiac arrest survivors immediately following their arrival in hospital can dramatically improve both overall survival and neurological outcomes. Despite the strong evidence for its efficacy and the apparent simplicity of this intervention, recent surveys show that therapeutic hypothermia is delivered inconsistently, incompletely, and often with delay.
Methods and design
This study will evaluate a multi-faceted knowledge translation strategy designed to increase the utilization rate of induced hypothermia in survivors of cardiac arrest across a network of 37 hospitals in Southwestern Ontario, Canada. The study is designed as a stepped wedge randomized trial lasting two years. Individual hospitals will be randomly assigned to four different wedges that will receive the active knowledge translation strategy according to a sequential rollout over a number of time periods. By the end of the study, all hospitals will have received the intervention. The primary aim is to measure the effectiveness of a multifaceted knowledge translation plan involving education, reminders, and audit-feedback for improving the use of induced hypothermia in survivors of cardiac arrest presenting to the emergency department. The primary outcome is the proportion of eligible OHCA patients that are cooled to a body temperature of 32 to 34°C within six hours of arrival in the hospital. Secondary outcomes will include process of care measures and clinical outcomes.
Discussion
Inducing hypothermia in cardiac arrest survivors immediately following their arrival to hospital has been shown to dramatically improve both overall survival and neurological outcomes. However, this lifesaving treatment is frequently not applied in practice. If this trial is positive, our results will have broad implications by showing that a knowledge translation strategy shared across a collaborative network of hospitals can increase the number of patients that receive this lifesaving intervention in a timely manner.
Trial Registration
ClinicalTrials.gov Trial Identifier: NCT00683683
doi:10.1186/1748-5908-6-4
PMCID: PMC3031244  PMID: 21235799
23.  Risk Factors for SARS Transmission from Patients Requiring Intubation: A Multicentre Investigation in Toronto, Canada 
PLoS ONE  2010;5(5):e10717.
Background
In the 2003 Toronto SARS outbreak, SARS-CoV was transmitted in hospitals despite adherence to infection control procedures. Considerable controversy resulted regarding which procedures and behaviours were associated with the greatest risk of SARS-CoV transmission.
Methods
A retrospective cohort study was conducted to identify risk factors for transmission of SARS-CoV during intubation from laboratory confirmed SARS patients to HCWs involved in their care. All SARS patients requiring intubation during the Toronto outbreak were identified. All HCWs who provided care to intubated SARS patients during treatment or transportation and who entered a patient room or had direct patient contact from 24 hours before to 4 hours after intubation were eligible for this study. Data was collected on patients by chart review and on HCWs by interviewer-administered questionnaire. Generalized estimating equation (GEE) logistic regression models and classification and regression trees (CART) were used to identify risk factors for SARS transmission.
Results
45 laboratory-confirmed intubated SARS patients were identified. Of the 697 HCWs involved in their care, 624 (90%) participated in the study. SARS-CoV was transmitted to 26 HCWs from 7 patients; 21 HCWs were infected by 3 patients. In multivariate GEE logistic regression models, presence in the room during fiberoptic intubation (OR = 2.79, p = .004) or ECG (OR = 3.52, p = .002), unprotected eye contact with secretions (OR = 7.34, p = .001), patient APACHE II score ≥20 (OR = 17.05, p = .009) and patient Pa02/Fi02 ratio ≤59 (OR = 8.65, p = .001) were associated with increased risk of transmission of SARS-CoV. In CART analyses, the four covariates which explained the greatest amount of variation in SARS-CoV transmission were covariates representing individual patients.
Conclusion
Close contact with the airway of severely ill patients and failure of infection control practices to prevent exposure to respiratory secretions were associated with transmission of SARS-CoV. Rates of transmission of SARS-CoV varied widely among patients.
doi:10.1371/journal.pone.0010717
PMCID: PMC2873403  PMID: 20502660
24.  Prophylactic anticoagulation to prevent venous thromboembolism in traumatic intracranial hemorrhage: a decision analysis 
Critical Care  2010;14(2):R72.
Introduction
Patients with intracranial hemorrhage due to traumatic brain injury are at high risk of developing venous thromboembolism including deep vein thrombosis (DVT) and pulmonary embolism (PE). Thus, there is a trade-off between the risks of progression of intracranial hemorrhage (ICH) versus reduction of DVT/PE with the use of prophylactic anticoagulation. Using decision analysis modeling techniques, we developed a model for examining this trade-off for trauma patients with documented ICH.
Methods
The decision node involved the choice to administer or to withhold low molecular weight heparin (LMWH) anticoagulation prophylaxis at 24 hours. Advantages of withholding therapy were decreased risk of ICH progression (death, disabling neurologic deficit, non-disabling neurologic deficit), and decreased risk of systemic bleeding complications (death, massive bleed). The associated disadvantage was greater risk of developing DVT/PE or death. Probabilities for each outcome were derived from natural history studies and randomized controlled trials when available. Utilities were obtained from accepted databases and previous studies.
Results
The expected value associated with withholding anticoagulation prophylaxis was similar (0.90) to that associated with the LMWH strategy (0.89). Only two threshold values were encountered in one-way sensitivity analyses. If the effectiveness of LMWH at preventing DVT exceeded 80% (range from literature 33% to 82%) our model favoured this therapy. Similarly, our model favoured use of LMWH if this therapy increased the risk of ICH progression by no more than 5% above the baseline risk.
Conclusions
Our model showed no clear advantage to providing or withholding anticoagulant prophylaxis for DVT/PE prevention at 24 hours after traumatic brain injury associated with ICH. Therefore randomized controlled trials are justifiable and needed to guide clinicians.
doi:10.1186/cc8980
PMCID: PMC2887195  PMID: 20406444
25.  The Use of Wireless E-Mail to Improve Healthcare Team Communication 
Objective
To assess the impact of using wireless e-mail for clinical communication in an intensive care unit (ICU).
Design
The authors implemented push wireless e-mail over a GSM cellular network in a 26-bed ICU during a 6-month study period. Daytime ICU staff (intensivists, nurses, respiratory therapists, pharmacists, clerical staff, and ICU leadership) used handheld devices (BlackBerry, Research in Motion, Waterloo, ON) without dedicated training. The authors recorded e-mail volume and used standard methods to develop a self-administered survey of ICU staff to measure wireless e-mail impact.
Measurements
The survey assessed perceived impact of wireless e-mail on communication, team relationships, staff satisfaction and patient care. Answers were recorded on a 7-point Likert scale; favorable responses were categorized as Likert responses 5, 6, and 7.
Results
Staff sent 5.2 (1.9) and received 8.9 (2.1) messages (mean [SD]) per day during 5 months of the 6-month study period; usage decreased after study completion. Most (106/125 [85%]) staff completed the questionnaire. The majority reported that wireless e-mail improved speed (92%) and reliability (92%) of communication, improved coordination of ICU team members (88%), reduced staff frustration (75%), and resulted in faster (90%) and safer (75%) patient care; Likert responses were significantly different from neutral (p < 0.001 for all). Staff infrequently (18%) reported negative effects on communication. There were no reports of radiofrequency interference with medical devices.
Conclusions
Interdisciplinary ICU staff perceived wireless e-mail to improve communication, team relationships, staff satisfaction, and patient care. Further research should address the impact of wireless e-mail on efficiency and timeliness of staff workflow and clinical outcomes.
doi:10.1197/jamia.M2299
PMCID: PMC2744721  PMID: 19567803

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