The effect of white coats and gender on medical students' perceptions of physicians

BACKGROUND

Despite the fact that medical schools spend a considerable effort to rate clinical instructors, there is limited evidence regarding the effect of physical characteristics on instructor ratings. White coats have been shown to alter patients' perceptions of physicians although it has not been determined if preceptors who wear white coats are rated differently than their colleagues.

METHODS

Second year medical students were administered a questionnaire with four clinical scenarios depicting medical errors accompanied by a picture of a physician of different sexes and ethnicities. The packages were randomized so that the physicians depicted either had or did not have a white coat.

RESULTS

White coats did not alter the perception of physicians' ratings by medical students although sex and ethnicity/case were associated with the perception of trustworthiness, physician management, competence, professionalism and the perception of medical error.

CONCLUSIONS

Physical characteristics may alter students' ratings of physicians.

A Scoping Review of Frailty and Acute Care in Middle-Aged and Older Individuals with Recommendations for Future Research

There is general agreement that frailty is a state of heightened vulnerability to stressors arising from impairments in multiple systems leading to declines in homeostatic reserve and resiliency, but unresolved issues persist about its detection, underlying pathophysiology, and relationship with aging, disability, and multimorbidity. A particularly challenging area is the relationship between frailty and hospitalization. Based on the deliberations of a 2014 Canadian expert consultation meeting and a scoping review of the relevant literature between 2005 and 2015, this discussion paper presents a review of the current state of knowledge on frailty in the acute care setting, including its prevalence and ability to both predict the occurrence and outcomes of hospitalization. The examination of the available evidence highlighted a number of specific clinical and research topics requiring additional study. We conclude with a series of consensus recommendations regarding future research priorities in this important area.

Development of the major trauma case review tool

Background

As many as half of all patients with major traumatic injuries do not receive the recommended care, with variance in preventable mortality reported across the globe. This variance highlights the need for a comprehensive process for monitoring and reviewing patient care, central to which is a consistent peer-review process that includes trauma system safety and human factors. There is no published, evidence-informed standardised tool that considers these factors for use in adult or paediatric trauma case peer-review. The aim of this research was to develop and validate a trauma case review tool to facilitate clinical review of paediatric trauma patient care in extracting information to facilitate monitoring, inform change and enable loop closure.

Methods

Development of the trauma case review tool was multi-faceted, beginning with a review of the trauma audit tool literature. Data were extracted from the literature to inform iterative tool development using a consensus approach. Inter-rater agreement was assessed for both the pilot and finalised versions of the tool.

Results

The final trauma case review tool contained ten sections, including patient factors (such as pre-existing conditions), presenting problem, a timeline of events, factors contributing to the care delivery problem (including equipment, work environment, staff action, organizational factors), positive aspects of care and the outcome of panel discussion. After refinement, the inter-rater reliability of the human factors and outcome components of the tool improved with an average 86% agreement between raters.

Discussion

This research developed an evidence-informed tool for use in paediatric trauma case review that considers both system safety and human factors to facilitate clinical review of trauma patient care.

Conclusions

This tool can be used to identify opportunities for improvement in trauma care and guide quality assurance activities. Validation is required in the adult population.

Electronic supplementary material

The online version of this article (doi:10.1186/s13049-017-0353-5) contains supplementary material, which is available to authorized users.

Developing a framework to guide the de-adoption of low-value clinical practices in acute care medicine: a study protocol

BACKGROUND

Healthcare systems have difficulty incorporating scientific evidence into clinical practice, especially when science suggests that existing clinical practices are of low-value (e.g. ineffective or harmful to patients). While a number of lists outlining low-value practices in acute care medicine currently exist, less is known about how best to initiate and sustain the removal of low-value clinical practices (i.e. de-adoption). This study will develop a comprehensive list of barriers and facilitators to the de-adoption of low-value clinical practices in acute care facilities to inform the development of a framework to guide the de-adoption process.

METHODS

The proposed project is a multi-stage mixed methods study to develop a framework to guide the de-adoption of low-value clinical practices in acute care medicine that will be tested in a representative sample of acute care settings in Alberta, Canada. Specifically, we will: 1) conduct a systematic review of the de-adoption literature to identify published barriers and facilitators to the de-adoption of low-value clinical practices in acute care medicine and any associated interventions proposed (Phase one); 2) conduct focus groups with acute care stakeholders to identify important themes not published in the literature and obtain a comprehensive appreciation of stakeholder perspectives (Phase two); 3) extend the generalizability of focus group findings by conducting individual stakeholder surveys with a representative sample of acute care providers throughout the province to determine which barriers and facilitators identified in Phases one and two are most relevant in their clinical setting (Phase three). Identified barriers and facilitators will be catalogued and integrated with targeted interventions in a framework to guide the process of de-adoption in each of four targeted areas of acute care medicine (Emergency Medicine, Cardiovascular Health and Stroke, Surgery and Critical Care Medicine). Analyses will be descriptive using a combination of qualitative and quantitative analyses.

DISCUSSION

There is a growing body of literature suggesting that the de-adoption of ineffective or harmful practices from patient care is integral to the delivery of high quality care and healthcare sustainability. The framework developed in this study will map barriers and facilitators to de-adoption to the most appropriate interventions, allowing stakeholders to effectively initiate, execute and sustain this process in an evidence-based manner.

A retrospective cohort study of the relationship between quality indicator measurement and patient outcomes in adult trauma centers in the United States

BACKGROUND

Improving care is a key strategy for reducing the burden of injuries, but it is unknown whether the use of quality indicators (QI) is associated with patient outcomes. We sought to evaluate the association between the use of QIs by trauma centers and outcomes in adult injury patients.

METHODS

We identified consecutive adult patients (n=223,015) admitted to 233 verified trauma centers January 1, 2007 to December 31, 2010 that contributed data to the National Trauma Data Bank and participated in a survey of QI practices. Generalized Linear Mixed Models were employed to evaluate the association between the intensity (number of QIs) and nature (report cards, internal and external benchmarking) of QI use and survival to hospital discharge, adjusting for patient and hospital characteristics.

RESULTS

There were no significant differences in the odds of survival to trauma center discharge according to the number of QIs measured (quartiles; odds ratio{OR} [95% confidence interval{CI}] 1.00 vs. 1.08 [0.90-1.31] vs. 1.00 [0.82-1.22] vs. 1.21 [0.99-1.49]), or whether centers used reports cards (OR 1.07, 95%CI 0.94-1.23), internal (OR 1.06, 95%CI 0.89-1.26) or external (OR 1.09, 95%CI 0.92-1.31) benchmarking. The duration (geometric mean) of mechanical ventilation (4.0days), ICU stay (4.6days), hospital stay (7.7days) and proportion of patients with a complication (13.6%) did not significantly differ according to the intensity or nature of QI use.

CONCLUSIONS

The intensity and nature of the QIs used by trauma centers was not associated with outcomes of patient care. Alternative quality improvement strategies may be needed.

Outcomes of elderly critically ill medical and surgical patients: a multicentre cohort study

PURPOSE

Very elderly (over 80 yr of age) critically ill patients admitted to medical-surgical intensive care units (ICUs) have a high incidence of mortality, prolonged hospital length of stay, and dependent living conditions should they survive. The primary purpose of this study is to describe the outcomes and differences in outcomes between very elderly medical patients and their surgical counterparts admitted to Canadian ICUs, thereby informing decision-making for clinicians and substitute decision-makers.

METHODS

This was a prospective multicentre cohort study of very elderly medical and surgical patients admitted to 22 Canadian academic and non-academic ICUs. Outcome measures included ICU length of stay and mortality, hospital length of stay and mortality, and disposition following hospital discharge.

RESULTS

There were 1,671 patients evaluated in this study. Patient demographics included a mean age of 84.5 yr, baseline Acute Physiology and Chronic Health Evaluation (APACHE) II score of 22.4, baseline Sequential Organ Failure Assessment (SOFA) score of 5.3, overall ICU mortality of 21.8%, and overall hospital mortality of 35.0%. Medical patient median ICU length of stay was 4.1 days, hospital length of stay was 16.2 days, ICU mortality was 26.5%, and hospital mortality was 41.5%. Surgical patient median ICU length of stay was 3.8 days, hospital length of stay was 20.1 days, ICU mortality was 18.7%, and hospital mortality was 31.6%. Only 45.0% of medical patients and 41.6% of surgical emergency patients were able to return home to live.

CONCLUSIONS

In this large sample of critically ill medical and surgical patients, the admission SOFA score and hospital lengths of stay were not different between the two groups, but medical patients had longer ICU lengths of stay and higher ICU and hospital mortality than surgical patients.

A Mixed-methods Study to Assess Interrater Reliability and Nurse Perception of the Braden Scale in a Tertiary Acute Care Setting

Research regarding the reliability of the Braden Scale and nurses' perspectives on the instrument for predicting pressure ulcer (PU) risk in acute care settings is limited. A mixed-methods study was conducted in a tertiary acute care facility to examine interrater reliability (IRR) of the Braden Scale and its subscales, and a qualitative survey using semi-structured interviews was conducted among nurses caring for patients in acute care units to gain nurse perspective regarding scale usability. Data were extracted from a previous retrospective, randomized, controlled trial involving adult patients with compromised mobility receiving care in a tertiary acute care hospital in Canada. One-way, intraclass correlation coefficients (ICCs) were calculated on item and total scores, and kappa statistics were used to determine reliability of categorizing patients on their risk. Interview results were categorized by common themes. Reliability was assessed on 64 patients, where nurses and research staff independently assessed enrolled participants at baseline and after 72 hours using the Braden Scale as it appeared on an electronic medical record. IRR for the total score was high (ICC = 0.807). The friction and shear item had the lowest reliability (ICC = 0.266). Reliability of categorizing patients' level of risk had moderate agreement (κ = 0.408). Three (3) major and 12 subthemes emerged from the 14 nurse interviews; nurses were aware of the scale's purpose but were uncertain of its effectiveness, some items were difficult to rate, and questions were raised as to whether using the scale enhanced patient care. Aspects identified by nurses to enhance usability included: 1) changes to the electronic version (incorporating the scale into daily assessment documents with readily available item descriptions), 2) additional training, and 3) easily available resource material to improve reliability and usability of scale. These findings need to be considered when using the Braden Scale in clinical practice. Further study of the value of the total Braden Scale and its subscales is warranted.

Family participation in intensive care unit rounds: Comparing family and provider perspectives

PURPOSE

To describe and compare intensive care unit (ICU) patient family member and provider experiences, preferences, and perceptions of family participation in ICU rounds.

METHODS

Cross-sectional survey of ICU family members and providers of patients admitted to 4 medical-surgical ICUs from September 2014 to March 2015.

MEASUREMENTS AND MAIN RESULTS

Surveys were completed by 63 (62%) family members and 258 (43%) providers. Provider respondents included physicians (9%), nurses (56%), respiratory therapists (24%), and other ICU team members (11%). Although 38% of providers estimated only moderate family member interest in participating in rounds, 97% of family members expressed high interest. Family members and providers reported listening (95% vs 96%; P=.594) and sharing information about the patient (82% vs 82%; P=.995) as appropriate roles for family members during rounds, but differed in their perceptions on asking questions (75% vs 86%; P=.043) and participating in decision making (36% vs 59%; P=.003). Compared with family members, providers were more likely to perceive family participation in rounds to cause family stress (7% vs 22%; P=.020) and confusion (0% vs 28%; P<.001).

CONCLUSION

Family members and providers share some perspectives on family participation in ICU rounds although other perspectives are discordant, with implications for communication strategies and collaborative decision making.

Pathogens and antimicrobial susceptibility profiles in critically ill patients with bloodstream infections: a descriptive study

BACKGROUND

Surveillance of antimicrobial resistance is vital to guiding empirical treatment of infections. Collating and reporting routine data on clinical isolate testing may offer more timely information about resistance patterns than traditional surveillance network methods.

METHODS

Using routine microbiology testing data collected from the Bacteremia Antibiotic Length Actually Needed for Clinical Effectiveness retrospective cohort study, we conducted a descriptive secondary analysis among critically ill patients in whom bloodstream infections had been diagnosed in 14 intensive care units (ICUs) in Canada. The participating sites were located within tertiary care teaching hospitals and represented 6 provinces and 10 cities. More than 80% of the study population was accrued from 2011-2013. We assessed the epidemiologic features of the infections and corresponding antimicrobial susceptibility profiles. Susceptibility testing was done according to Clinical Laboratory Standards Institute guidelines at accredited laboratories.

RESULTS

A total of 1416 pathogens were isolated from 1202 patients. The most common organisms were Escherichia coli (217 isolates [15.3%]), Staphylococcus aureus (175 [12.4%]), coagulase-negative staphylococci (117 [8.3%]), Klebsiella pneumoniae (86 [6.1%]) and Streptococcus pneumoniae (85 [6.0%]). The contribution of individual pathogens varied by site. For 13 ICUs, gram-negative susceptibility rates were high for carbapenems (95.4%), tobramycin (91.2%) and piperacillin-tazobactam (90.0%); however, the proportion of specimens susceptible to these agents ranged from 75.0%-100%, 66.7%-100% and 75.0%-100%, respectively, across sites. Fewer gram-negative bacteria were susceptible to fluoroquinolones (84.5% [range 64.1%-97.2%]). A total of 145 patients (12.1%) had infections caused by highly resistant microorganisms, with significant intersite variation (range 2.6%-24.0%, χ2 = 57.50, p < 0.001).

INTERPRETATION

We assessed the epidemiologic features of bloodstream infections in a geographically diverse cohort of critically ill Canadian patients using routine pathogen and susceptibility data extracted from readily available microbiology testing databases. Expanding data sharing across more ICUs, with serial measurement and prompt reporting, could provide much-needed guidance for empiric treatment for patients as well as system-wide prevention methods to limit antimicrobial resistance.

Les considérations éthiques relatives à la désadoption d'aspects inefficaces ou nuisibles des soins de santé

La désadoption désigne l'abandon d'une pratique médicale ou d'un service de santé inefficace ou nuisible après une période d'adoption. Tandis que les dépenses croissantes en matière de santé menacent de paralyser les sociétés qui les financent, le fait de faciliter la désadoption peut faire partie intégrante de systèmes de santé durables qui prodiguent des soins de qualité. Le présent article explore des enjeux éthiques qui se rapportent à la désadoption, y compris les principes sous-jacents de bénéficience, de non-maléficience, de justice et d'autonomie.

Ethical considerations in the de-adoption of ineffective or harmful aspects of healthcare

De-adoption refers to the discontinuance of a medical practice or health service found to be ineffective or harmful following a previous period of adoption. As growing healthcare budgets threaten to cripple the societies that fund them, facilitating de-adoption may be integral to sustainable healthcare systems that provide high-quality care. This article explores ethical issues pertinent to de-adoption including the underpinnings of beneficence, non-maleficence, justice, and autonomy.

Patient and Family Member-Led Research in the Intensive Care Unit: A Novel Approach to Patient-Centered Research

Introduction

Engaging patients and family members as partners in research increases the relevance of study results and enhances patient-centered care; how to best engage patients and families in research is unknown.

Methods

We tested a novel research approach that engages and trains patients and family members as researchers to see if we could understand and describe the experiences of patients admitted to the intensive care unit (ICU) and their families. Former patients and family members conducted focus groups and interviews with patients (n = 11) and families of surviving (n = 14) and deceased (n = 7) patients from 13 ICUs in Alberta Canada, and analyzed data using conventional content analysis. Separate blinded qualitative researchers conducted an independent analysis.

Results

Participants described three phases in the patient/family “ICU journey”; admission to ICU, daily care in ICU, and post-ICU experience. Admission to ICU was characterized by family shock and disorientation with families needing the presence and support of a provider. Participants described five important elements of daily care: honoring the patient’s voice, the need to know, decision-making, medical care, and culture in ICU. The post-ICU experience was characterized by the challenges of the transition from ICU to a hospital ward and long-term effects of critical illness. These “ICU journey” experiences were described as integral to appropriate interactions with the care team and comfort and trust in the ICU, which were perceived as essential for a community of caring. Participants provided suggestions for improvement: 1) provide a dedicated family navigator, 2) increase provider awareness of the fragility of family trust, 3) improve provider communication skills, 4) improve the transition from ICU to hospital ward, and 5) inform patients about the long-term effects of critical illness. Analyses by independent qualitative researchers identified similar themes.

Conclusions

Patient and family member-led research is feasible and can identify opportunities for improving care.

Protocol to describe the analysis of text-based communication in medical records for patients discharged from intensive care to hospital ward

INTRODUCTION

Effective communication during hospital transitions of patient care is fundamental to ensuring patient safety and continuity of quality care. This study will describe text-based communication included in patient medical records before, during and after patient transfer from the intensive care unit (ICU) to a hospital ward (n=10 days) by documenting (1) the structure and focus of physician progress notes within and between medical specialties, (2) the organisation of subjective and objective information, including the location and accessibility of patient data and whether/how this changes during the hospital stay and (3) missing, illegible and erroneous information.

METHODS

This study is part of a larger mixed methods prospective observational study of ICU to hospital ward transfer practices in 10 ICUs across Canada. Medical records will be collected and photocopied for each consenting patient for a period of up to 10 consecutive days, including the final 2 days in the ICU, the day of transfer and the first 7 days on the ward (n=10 days). Textual analysis of medical record data will be completed by 2 independent reviewers to describe communication between stakeholders involved in ICU transfer.

ETHICS AND DISSEMINATION

Research ethics board approval has been obtained at all study sites, including the coordinating study centre (which covers 4 Calgary-based sites; UofC REB 13-0021) and 6 additional study sites (UofA Pro00050646; UBC PHC Hi4-01667; Sunnybrook 336-2014; QCH 20140345-01H; Sherbrooke 14-172; Laval 2015-2171). Findings from this study will inform the development of an evidence-based tool that will be used to systematically analyse the series of notes in a patient's medical record.

Measuring intensive care unit performance after sustainable growth rate reform: An example with the National Quality Forum metrics

BACKGROUND

Performance measurement is essential for quality improvement and is inevitable in the shift to value-based payment. The National Quality Forum is an important clearinghouse for national performance measures in health care in the United States.

AIM

We reviewed the National Quality Forum library of performance measures to highlight measures that are relevant to critical care medicine, and we describe gaps and opportunities for the future of performance measurement in critical care medicine.

CONCLUSION

Crafting performance measures that address core aspects of critical care will be challenging, as current outcome and performance measures have problems with validity. Future quality measures will likely focus on interdisciplinary measures across the continuum of patient care.

Opinions of Practicing Surgeons on the Appropriateness of Published Indications for Use of Damage Control Surgery in Trauma Patients: An International Cross-Sectional Survey

BACKGROUND

Variation in use of damage control (DC) surgery across trauma centers may be partially driven by surgeon uncertainty as to when it is appropriately indicated. We sought to determine opinions of practicing surgeons on the appropriateness of published indications for trauma DC surgery.

STUDY DESIGN

We asked 384 trauma centers in the United States, Canada, and Australasia to nominate 1 to 3 surgeons at their center to participate in a survey about DC surgery. We then asked nominated surgeons their opinions on the appropriateness (benefit-to-harm ratio) of 43 literature-derived indications for use of DC surgery in adult civilian trauma patients.

RESULTS

In total, 232 (64.8%) trauma centers nominated 366 surgeons, of whom 201 (56.0%) responded. Respondents rated 15 (78.9%) preoperative and 23 (95.8%) intraoperative indications to be appropriate. Indications respondents agreed had the greatest expected benefit included a temperature <34°C, arterial pH <7.2, and laboratory-confirmed (international normalized ratio/prothrombin time and/or partial thromboplastin time >1.5 times normal) or clinically observed coagulopathy in the pre- or intraoperative setting; administration of >10 units of packed red blood cells; requirement for a resuscitative thoracotomy in the emergency department; and identification of a juxtahepatic venous injury or devascularized or destroyed pancreas, duodenum, or pancreaticoduodenal complex during operation. Ratings were consistent across subgroups of surgeons with different training, experience, and practice settings.

CONCLUSIONS

We identified 38 indications that practicing surgeons agreed appropriately justified the use of DC surgery. Until further studies become available, these indications constitute a consensus opinion that can be used to guide practice in the current era of changing trauma resuscitation practices.

A clinical prediction tool for hospital mortality in critically ill elderly patients

BACKGROUND

Very elderly (80 years of age and above) critically ill patients admitted to medical intensive care units (ICUs) have a high incidence of mortality, prolonged hospital length of stay, and living in a dependent state should they survive.

OBJECTIVE

The objective was to develop a clinical prediction tool for hospital mortality to improve future end-of-life decision making for very elderly patients who are admitted to Canadian ICUs.

DESIGN

This was a prospective, multicenter cohort study.

SETTING

Data from 1033 very elderly medical patients admitted to 22 Canadian academic and nonacademic ICUs were analyzed.

INTERVENTIONS

A univariate analysis of selected predictors to ascertain prognostic power was performed, followed by multivariable logistic regression to derive the final prediction tool.

MAIN RESULTS

We included 1033 elderly patients in the analyses. Mean age was 84.6±3.5 years, 55% were male, mean Acute Physiology and Chronic Health Evaluation II score was 23.1±7.9, Sequential Organ Failure Assessment score was 5.3±3.4, median ICU length of stay was 4.1 (interquartile range, 6.2) days, median hospital length of stay was 16.2 (interquartile range, 25.0) days, and ICU mortality and all-cause hospital mortality were 27% and 41%, respectively. Important predictors of hospital mortality at the time of ICU admission include age (85-90 years of age had an odds ratio of hospital mortality of 1.63 [1.04-2.56]; >90 years of age had an odds ratio of hospital mortality of 2.64 [1.27-5.48]), serum creatinine (120-300 had an odds ratio of hospital mortality of 1.57 [1.01-2.44]; >300 had an odds ratio of hospital mortality of 5.29 [2.43-11.51]), Glasgow Coma Scale (13-14 had an odds ratio of hospital mortality of 2.09 [1.09-3.98]; 8-12 had an odds ratio of hospital mortality of 2.31 [1.34-3.97]; 4-7 had an odds ratio of hospital mortality of 5.75 [3.02-10.95]; 3 had an odds ratio of hospital mortality of 8.97 [3.70-21.74]), and serum pH (<7.15 had an odds ratio of hospital mortality of 2.44 [1.07-5.60]).

CONCLUSION

We identified high-risk characteristics for hospital mortality in the elderly population and developed a Risk Scale that may be used to inform discussions regarding goals of care in the future. Further study is warranted to validate the Risk Scale in other settings and evaluate its impact on clinical decision making.

The Effect of Inadequate Initial Empiric Antimicrobial Treatment on Mortality in Critically Ill Patients with Bloodstream Infections: A Multi-Centre Retrospective Cohort Study

Hospital mortality rates are elevated in critically ill patients with bloodstream infections. Given that mortality may be even higher if appropriate treatment is delayed, we sought to determine the effect of inadequate initial empiric treatment on mortality in these patients. A retrospective cohort study was conducted across 13 intensive care units in Canada. We defined inadequate initial empiric treatment as not receiving at least one dose of an antimicrobial to which the causative pathogen(s) was susceptible within one day of initial blood culture. We evaluated the association between inadequate initial treatment and hospital mortality using a random effects multivariable logistic regression model. Among 1,190 patients (1,097 had bacteremia and 93 had candidemia), 476 (40%) died and 266 (22%) received inadequate initial treatment. Candidemic patients more often had inadequate initial empiric therapy (64.5% versus 18.8%), as well as longer delays to final culture results (4 vs 3 days) and appropriate therapy (2 vs 0 days). After adjustment, there was no detectable association between inadequate initial treatment and mortality among bacteremic patients (Odds Ratio (OR): 1.02, 95% Confidence Interval (CI) 0.70-1.48); however, candidemic patients receiving inadequate treatment had nearly three times the odds of death (OR: 2.89, 95% CI: 1.05-7.99). Inadequate initial empiric antimicrobial treatment was not associated with increased mortality in bacteremic patients, but was an important risk factor in the subgroup of candidemic patients. Further research is warranted to improve early diagnostic and risk prediction methods in candidemic patients.

Financial Relationships between Organizations That Produce Clinical Practice Guidelines and the Biomedical Industry: A Cross-Sectional Study

BACKGROUND

Financial relationships between organizations that produce clinical practice guidelines and biomedical companies are vulnerable to conflicts of interest. We sought to determine whether organizations that produce clinical practice guidelines have financial relationships with biomedical companies and whether there are associations between organizations' conflict of interest policies and recommendations and disclosures provided in guidelines.

METHODS AND FINDINGS

We conducted a cross-sectional survey and review of websites of 95 national/international medical organizations that produced 290 clinical practice guidelines published on the National Guideline Clearinghouse website from January 1 to December 31, 2012. Survey responses were available for 68% (65/95) of organizations (167/290 guidelines, 58%), and websites were reviewed for 100% (95/95) of organizations (290/290 guidelines, 100%). In all, 63% (60/95) of organizations producing clinical practice guidelines reported receiving funds from a biomedical company; 80% (76/95) of organizations reported having a policy for managing conflicts of interest. Disclosure statements (disclosing presence or absence of financial relationships with biomedical companies) were available in 65% (188/290) of clinical practice guidelines for direct funding sources to produce the guideline, 51% (147/290) for financial relationships of the guideline committee members, and 1% (4/290) for financial relationships of the organizations producing the guidelines. Among all guidelines, 6% (18/290) disclosed direct funding by biomedical companies, 40% (117/290) disclosed financial relationships between committee members and biomedical companies (38% of guideline committee members, 773/2,043), and 1% (4/290) disclosed financial relationships between the organizations producing the guidelines and biomedical companies. In the survey responses, 60 organizations reported the procedures that they included in their conflict of interest policies (158 guidelines): guidelines produced by organizations reporting more comprehensive conflict of interest policies (per additional procedure, range 5-17) included fewer positive (rate ratio [RR] 0.91, 95% CI 0.86-0.95) and more negative (RR 1.32, 95% CI 1.09-1.60) recommendations regarding patented biomedical products. The clinical practice guidelines produced by organizations reporting more comprehensive conflict of interest policies were also more likely to include disclosure statements for direct funding sources (odds ratio [OR] 1.31, 95% CI 1.10-1.56) and financial relationships of guideline committee members (OR 1.36, 95% CI 1.09-1.79), but not financial relationships of the organizations (0 disclosures). Limitations of the study include the use of the National Guideline Clearinghouse as the single source of clinical practice guidelines and the self-report of survey responses and organizations' website postings.

CONCLUSIONS

Financial relationships between organizations that produce clinical practice guidelines and biomedical companies are common and infrequently disclosed in guidelines. Our study highlights the need for an effective policy to manage organizational conflicts of interest and disclosure of financial relationships.

A scoping review on the conduct and reporting of scoping reviews

BACKGROUND

Scoping reviews are used to identify knowledge gaps, set research agendas, and identify implications for decision-making. The conduct and reporting of scoping reviews is inconsistent in the literature. We conducted a scoping review to identify: papers that utilized and/or described scoping review methods; guidelines for reporting scoping reviews; and studies that assessed the quality of reporting of scoping reviews.

METHODS

We searched nine electronic databases for published and unpublished literature scoping review papers, scoping review methodology, and reporting guidance for scoping reviews. Two independent reviewers screened citations for inclusion. Data abstraction was performed by one reviewer and verified by a second reviewer. Quantitative (e.g. frequencies of methods) and qualitative (i.e. content analysis of the methods) syntheses were conducted.

RESULTS

After searching 1525 citations and 874 full-text papers, 516 articles were included, of which 494 were scoping reviews. The 494 scoping reviews were disseminated between 1999 and 2014, with 45% published after 2012. Most of the scoping reviews were conducted in North America (53%) or Europe (38%), and reported a public source of funding (64%). The number of studies included in the scoping reviews ranged from 1 to 2600 (mean of 118). Using the Joanna Briggs Institute methodology guidance for scoping reviews, only 13% of the scoping reviews reported the use of a protocol, 36% used two reviewers for selecting citations for inclusion, 29% used two reviewers for full-text screening, 30% used two reviewers for data charting, and 43% used a pre-defined charting form. In most cases, the results of the scoping review were used to identify evidence gaps (85%), provide recommendations for future research (84%), or identify strengths and limitations (69%). We did not identify any guidelines for reporting scoping reviews or studies that assessed the quality of scoping review reporting.

CONCLUSION

The number of scoping reviews conducted per year has steadily increased since 2012. Scoping reviews are used to inform research agendas and identify implications for policy or practice. As such, improvements in reporting and conduct are imperative. Further research on scoping review methodology is warranted, and in particular, there is need for a guideline to standardize reporting.

What are emergency-sensitive conditions? A survey of Canadian emergency physicians and nurses

OBJECTIVE

In a previous study, we assembled a multidisciplinary Canadian panel and identified 37 International Classification of Diseases-10-Canada Diagnosis Groups (DGs) for which emergency department (ED) management may potentially reduce mortality (emergency-sensitive conditions). Before using these 37 DGs to calculate a hospital standardized mortality ratio (HSMR) specific to emergency care, we aimed to test their face validity with ED care providers.

METHODS

We conducted a self-administered web survey among Canadian emergency physicians and nurses between November 22 and December 31, 2012. All members (N=2,507) of the Canadian Association of Emergency Physicians and the National Emergency Nurses Association were surveyed. They were asked to agree or disagree (binary response) with the panel classification for each of the 37 DG emergency-sensitive conditions identified and provide free text responses to identify missing entities.

RESULTS

A total of 719 ED providers (719 of 2,507, 29%) completed the survey, of whom 470 were physicians (470 of 1,407, 33%) and 232 were nurses (232 of 1,100, 21%). Information on professional status was not provided for 17 respondents. Of 37 DGs, 32 (e.g., A41 sepsis) were rated by more than 80% of respondents to be emergency-sensitive conditions. The remaining five DGs (e.g., E11 type 2 diabetes mellitus) were rated by 68.5 to 79.7% of the respondents to be emergency-sensitive conditions. Respondents suggested an additional 31 emergency-sensitive diagnoses.

CONCLUSION

We identified 37 emergency-sensitive DGs that had high face validity with emergency physicians and nurses, which will enable the calculation of an ED-HSMR.

Critical care transition programs and the risk of readmission or death after discharge from ICU

PURPOSE

Critical care transition programs have been widely implemented to improve the safety of patient discharge from ICU, but have undergone limited evaluation. We sought to evaluate implementation of a critical care transition program on patient readmission to ICU (72 h) and mortality (14 days).

METHODS

Interrupted time series analysis of 32,234 consecutive adult patients discharged alive from medical-surgical ICUs in eight hospitals in two cities between January 1, 2002 and January 1, 2012. A multidisciplinary ICU provider team (physician, nurse, respiratory therapist) that serially evaluated each patient after ICU discharge was implemented in three hospitals in one city (study group), but not the five hospitals in the other city (control group). Temporal changes were examined using multivariable, segmented linear regression models.

RESULTS

After implementation of the program, there was an immediate non-significant decrease in the absolute proportion of patients readmitted to ICU in the study group (-0.4%, 95% CI -1.7 to +1.0%) and a non-significant increase in the absolute proportion of patients readmitted to ICU in the control group (+1.0%, 95% CI -0.3 to +2.2%). Subsequently, there were non-significant changes in the absolute proportion of patients readmitted to ICU in both the study (+0.1% per quarter; 95% CI, -0.1 to +0.2%) and control (-0.1 per quarter; 95% CI, -0.2 to +0.1%) groups over time. No significant changes were observed in mortality. The results were stable across patient subgroups.

CONCLUSIONS

Implementation of a critical care transition program was not associated with patient readmission to ICU or mortality.

Quality and performance measures of strain on intensive care capacity: a protocol for a systematic review

BACKGROUND

The matching of critical care service supply with demand is fundamental for the efficient delivery of advanced life support to patients in urgent need. Mismatch in this supply/demand relationship contributes to "intensive care unit (ICU) capacity strain," defined as a time-varying disruption in the ability of an ICU to provide well-timed and high-quality intensive care support to any and all patients who are or may become critically ill. ICU capacity strain leads to suboptimal quality of care and may directly contribute to heightened risk of adverse events, premature discharges, unplanned readmissions, and avoidable death. Unrelenting strain on ICU capacity contributes to inefficient health resource utilization and may negatively impact the satisfaction of patients, their families, and frontline providers. It is unknown how to optimally quantify the instantaneous and temporal "stress" an ICU experiences due to capacity strain.

METHODS

We will perform a systematic review to identify, appraise, and evaluate quality and performance measures of strain on ICU capacity and their association with relevant patient-centered, ICU-level, and health system-level outcomes. Electronic databases (i.e., MEDLINE, EMBASE, CINAHL, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Web of Science, and the Agency of Healthcare Research and Quality (AHRQ) - National Quality Measures Clearinghouse (NQMC)) will be searched for original studies of measures of ICU capacity strain. Selected gray literature sources will be searched. Search themes will focus on intensive care, quality, operations management, and capacity. Analysis will be primarily narrative. Each identified measure will be defined, characterized, and evaluated using the criteria proposed by the US Strategic Framework Board for a National Quality Measurement and Reporting System (i.e., importance, scientific acceptability, usability, feasibility).

DISCUSSION

Our systematic review will comprehensively identify, define, and evaluate quality and performance measures of ICU capacity strain. This is a necessary step towards understanding the impact of capacity strain on quality and performance in intensive care and to develop innovative interventions aimed to improve efficiency, avoid waste, and better anticipate impending capacity shortfalls.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42015017931.

Identifying low-value clinical practices in critical care medicine: protocol for a scoping review

INTRODUCTION

Reducing unnecessary, low-value clinical practice (ie, de-adoption) is key to improving value for money in healthcare, especially among patients admitted to intensive care units (ICUs) where resource consumption exceeds other medical and surgical populations. Research suggests that low-value clinical practices are common in medicine, however systematically and objectively identifying them is a widely cited barrier to de-adoption. We will conduct a scoping review to identify low-value clinical practices in adult critical care medicine that are candidates for de-adoption.

METHODS AND ANALYSIS

We will systematically search the literature to identify all randomised controlled trials or systematic reviews that focus on diagnostic or therapeutic interventions in adult patients admitted to medical, surgical or specialty ICUs, and are published in 3 general medical journals with the highest impact factor (New England Journal of Medicine, The Lancet, Journal of the American Medical Association). 2 investigators will independently screen abstracts and full-text articles against inclusion criteria, and extract data from included citations. Included citations will be classified according to whether or not they represent a repeat examination of the given research question (ie, replication research), and whether the results are similar or contradictory to the original study. Studies with contradictory results will determine clinical practices that are candidates for de-adoption.

ETHICS AND DISSEMINATION

Our scoping review will use robust methodology to systematically identify a list of clinical practices in adult critical care medicine with evidence supporting their de-adoption. In addition to adding to advancing the study of de-adoption, this review may also serve as the launching point for clinicians and researchers in critical care to begin reducing the number of low-value clinical practices. Dissemination of these results to relevant stakeholders will include tailored presentations at local, national and international meetings, and publication of a manuscript. Ethical approval is not required for this study.