Critical care capacity in Canada: results of a national cross-sectional study

Barriers to Access to Cardiac Surgery: Canadian Situation and Global Context

Cardiovascular disease is the leading cause of morbidity and mortality worldwide. Cardiovascular care spans primary, secondary, and tertiary prevention and care, whereby tertiary care is particularly prone to disparities in care. Challenges in access to care especially affect low- and middle-income countries (LMICs), however, multiple barriers also exist and persist across high-income countries. Canada is lauded for its universal health coverage but is faced with health care system challenges and substantial geographic barriers. Canada possesses 203 active cardiac surgeons, or 5.02 per million population, ranging from 3.70 per million in Newfoundland and Labrador to 7.48 in Nova Scotia. As such, Canada possesses fewer cardiac surgeons per million population than the average among high-income countries (7.15 per million), albeit more than the global average (1.64 per million) and far higher than the low-income country average (0.04 per million). In Canada, adult cardiac surgeons are active across 32 cardiac centres, representing 0.79 cardiac centres per million population, which is just above the global average (0.73 per million). In addition to centre and workforce variations, barriers to care exist in the form of waiting times, sociodemographic characteristics, insufficient virtual care infrastructure and electronic health record interoperability, and health care governance fragmentation. Meanwhile, Canada has highly favourable surgical outcomes, well established postacute cardiac care infrastructure, considerable spending on health, robust health administrative data, and effective health technology assessment agencies, which provides a foundation for continued improvements in care. In this narrative review, we describe successes and challenges surrounding access to cardiac surgery in Canada and globally.

Wastewater-based surveillance as a tool for public health action: SARS-CoV-2 and beyond

Wastewater-based surveillance (WBS) has undergone dramatic advancement in the context of the coronavirus disease 2019 (COVID-19) pandemic. The power and potential of this platform technology were rapidly realized when it became evident that not only did WBS-measured SARS-CoV-2 RNA correlate strongly with COVID-19 clinical disease within monitored populations but also, in fact, it functioned as a leading indicator. Teams from across the globe rapidly innovated novel approaches by which wastewater could be collected from diverse sewersheds ranging from wastewater treatment plants (enabling community-level surveillance) to more granular locations including individual neighborhoods and high-risk buildings such as long-term care facilities (LTCF). Efficient processes enabled SARS-CoV-2 RNA extraction and concentration from the highly dilute wastewater matrix. Molecular and genomic tools to identify, quantify, and characterize SARS-CoV-2 and its various variants were adapted from clinical programs and applied to these mixed environmental systems. Novel data-sharing tools allowed this information to be mobilized and made immediately available to public health and government decision-makers and even the public, enabling evidence-informed decision-making based on local disease dynamics. WBS has since been recognized as a tool of transformative potential, providing near-real-time cost-effective, objective, comprehensive, and inclusive data on the changing prevalence of measured analytes across space and time in populations. However, as a consequence of rapid innovation from hundreds of teams simultaneously, tremendous heterogeneity currently exists in the SARS-CoV-2 WBS literature. This manuscript provides a state-of-the-art review of WBS as established with SARS-CoV-2 and details the current work underway expanding its scope to other infectious disease targets.

Modelling the potential increase in eligible participants in clinical trials with inclusion of community intensive care unit patients in Alberta, Canada: a decision tree analysis

PURPOSE

Critical care research in Canada is conducted primarily in academically affiliated intensive care units (ICUs) with established research infrastructure. Efforts are made to engage community hospital ICUs in research, although the impacts of their inclusion in clinical research have never been explicitly quantified. We therefore sought to determine the number of additional eligible patients that could be recruited into critical care trials and the change in time to study completion if community ICUs were included in clinical research.

METHODS

We conducted a decision tree analysis using 2018 Alberta Health Services data. Patient demographics and clinical characteristics for all ICU patients were compared against eligibility criteria from ten landmark, randomized, multicentre critical care trials. Individual patients from academic and community ICUs were assessed for eligibility in each of the ten studies, and decision tree analysis models were built based on prior inclusion and exclusion criteria from those trials.

RESULTS

The number of potentially eligible patients for the ten trials ranged from 2,082 to 10,157. Potentially eligible participants from community ICUs accounted for 40.0% of total potentially eligible participants. The recruitment of community ICU patients in trials would have increased potential enrolment by an average of 64.0%. The inclusion of community ICU patients was predicted to decrease time to trial completion by a mean of 14 months (43% reduction).

CONCLUSION

Inclusion of community ICU patients in critical care research trials has the potential to substantially increase enrolment and decrease time to trial completion.

Injury outcomes across Canadian trauma systems: a historical cohort study

PURPOSE

Most North American trauma systems have designated trauma centres (TCs) including level I (ultraspecialized high-volume metropolitan centres), level II (specialized medium-volume urban centres), and/or level III (semirural or rural centres). Trauma system configuration varies across provinces and it is unclear how these differences influence patient distributions and outcomes. We aimed to compare patient case mix, case volumes, and risk-adjusted outcomes of adults with major trauma admitted to designated level I, II, and III TCs across Canadian trauma systems.

METHODS

In a national historical cohort study, we extracted data from Canadian provincial trauma registries on major trauma patients treated between 2013 and 2018 in all designated level I, II, or III TCs in British Columbia, Alberta, Quebec, and Nova Scotia; level I and II TCs in New Brunswick; and four TCs in Ontario. We used multilevel generalized linear models to compare mortality and intensive care unit (ICU) admission and competitive risk models for hospital and ICU length of stay (LOS). Ontario could not be included in outcome comparisons because there were no population-based data from this province.

RESULTS

The study sample comprised 50,959 patients. Patient distributions in level I and II TCs were similar across provinces but we observed significant differences in case mix and volumes for level III TCs. There was low variation in risk-adjusted mortality and LOS across provinces and TCs but interprovincial and intercentre variation in risk-adjusted ICU admission was high.

CONCLUSIONS

Our results suggest that differences in the functional role of TCs according to their designation level across provinces leads to significant variations in the distribution of patients, case volumes, resource use, and clinical outcomes. These results highlight opportunities to improve Canadian trauma care and underline the need for standardized population-based injury data to support national quality improvement efforts.

Current census of oncology critical care medicine in China

OBJECTIVE

The purposes of this survey were to show the current situation of oncology critical care medicine in China by questionnaire, to understand the resource distribution of oncology critical care medicine and to analyze and evaluate the existing resources and reserve capacity of oncology critical care medicine in China.

METHODS

We conducted the survey mainly in the form of an online questionnaire. The Committee of Cancer Critical Care Medicine of the Chinese Anticancer Association (CACA) initiated the survey on 1 November 2017, and 36 member hospitals nationwide participated in the survey. The questionnaire included 10 items: investigator information, hospital information, general information of oncology critical care department, staffing of oncology critical care department, management in oncology critical care department, technical skills in oncology critical care department, patient source in oncology critical care department, equipment configuration in oncology critical care department, special skills in oncology critical care department and summary of the information.

RESULTS

The survey results included information from 28 member units, all of which were tertiary hospitals, distributed in 20 provinces and 4 direct-controlled municipalities. The results are as follows. (i) The total ratio of beds in the oncology critical care department to hospital beds was 1.06%, and the average number of beds in the oncology critical care department was 16.36. (ii) The ratio of physicians in the oncology critical care department to beds was ∼0.62:1, and the ratio of nurses to beds was ∼1.98:1. (iii) According to the census of the population and gross domestic product (GDP) of different regions conducted by the State Statistics Bureau in 2017, the ratio of beds in the oncology critical care department for tumor patients to the population was 4.55 beds per 10 million people, and the ratio of beds in the oncology critical care department to GDP was 8.00 beds per RMB 100 billion, on average. (iv) According to the requirements of the guidelines for the development and management of critical care medicine in China, the facilities in departments of oncology critical care medicine meet the requirements, and the technical skills of medical staff are competent.

CONCLUSION

The development of oncology critical care in China is becoming better, but there is still a certain gap compared with the intensive care unit standards in China and the average level of the nationwide. The development of oncology critical care medicine is urgent.

A Delphi Survey of Canadian Respiratory Therapists' Practice Statements on Pediatric Mechanical Ventilation

BACKGROUND

Pediatric mechanical ventilation practice guidelines are not well established; therefore, the European Society for Paediatric and Neonatal Intensive Care (ESPNIC) developed consensus recommendations on pediatric mechanical ventilation management in 2017. However, the guideline's applicability in different health care settings is unknown. This study aimed to determine the consensus on pediatric mechanical ventilation practices from Canadian respiratory therapists' (RTs) perspectives and consensually validate aspects of the ESPNIC guideline.

METHODS

A 3-round modified electronic Delphi survey was conducted; contents were guided by ESPNIC. Participants were RTs with at least 5 years of experience working in standalone pediatric ICUs or units with dedicated pediatric intensive care beds across Canada. Round 1 collected open-text feedback, and subsequent rounds gathered feedback using a 6-point Likert scale. Consensus was defined as ≥ 75% agreement; if consensus was unmet, statements were revised for re-ranking in the subsequent round.

RESULTS

Fifty-two RTs from 14 different pediatric facilities participated in at least one of the 3 rounds. Rounds 1, 2, and 3 had a response rate of 80%, 93%, and 96%, respectively. A total of 59 practice statements achieved consensus by the end of round 3, categorized into 10 sections: (1) noninvasive ventilation and high-flow oxygen therapy, (2) tidal volume and inspiratory pressures, (3) breathing frequency and inspiratory times, (4) PEEP and F_IO2 , (5) advanced modes of ventilation, (6) weaning, (7) physiological targets, (8) monitoring, (9) general, and (10) equipment adjuncts. Cumulative text feedback guided the formation of the clinical remarks to supplement these practice statements.

CONCLUSIONS

This was the first study to survey RTs for their perspectives on the general practice of pediatric mechanical ventilation management in Canada, generally aligning with the ESPNIC guideline. These practice statements considered information from health organizations and institutes, supplemented with clinical remarks. Future studies are necessary to verify and understand these practices' effectiveness.

Variation in the risk of death due to COVID-19: An international multicenter cohort study of hospitalized adults

BACKGROUND

There is wide variation in mortality among patients hospitalized with COVID-19. Whether this is related to patient or hospital factors is unknown.

OBJECTIVE

To compare the risk of mortality for patients hospitalized with COVID-19 and to determine whether the majority of that variation was explained by differences in patient characteristics across sites.

DESIGN, SETTING, AND PARTICIPANTS

An international multicenter cohort study of hospitalized adults with laboratory-confirmed COVID-19 enrolled from 10 hospitals in Ontario, Canada and 8 hospitals in Copenhagen, Denmark between January 1, 2020 and November 11, 2020.

MAIN OUTCOMES AND MEASURES

Inpatient mortality. We used a multivariable multilevel regression model to compare the in-hospital mortality risk across hospitals and quantify the variation attributable to patient-level factors.

RESULTS

There were 1364 adults hospitalized with COVID-19 in Ontario (n = 1149) and in Denmark (n = 215). In Ontario, the absolute risk of in-hospital mortality ranged from 12.0% to 39.8% across hospitals. Ninety-eight percent of the variation in mortality in Ontario was explained by differences in the characteristics of the patients. In Denmark, the absolute risk of inpatients ranged from 13.8% to 20.6%. One hundred percent of the variation in mortality in Denmark was explained by differences in the characteristics of the inpatients.

CONCLUSION

There was wide variation in inpatient COVID-19 mortality across hospitals, which was largely explained by patient-level factors, such as age and severity of presenting illness. However, hospital-level factors that could have affected care, including resource availability and capacity, were not taken into account. These findings highlight potential limitations in comparing crude mortality rates across hospitals for the purposes of reporting on the quality of care.

Estimated Cost-effectiveness of Subcutaneous Insulin Aspart in the Management of Mild Diabetic Ketoacidosis Among Children

IMPORTANCE

Intravenous (IV) insulin infusion is the standard of care for treating diabetic ketoacidosis (DKA) worldwide. Subcutaneous (SC) insulin aspart could decrease the use of health care resources.

OBJECTIVE

To compare the cost-effectiveness of mild uncomplicated DKA management with SC insulin aspart vs IV insulin infusion among pediatric patients from the perspective of a public health care payer using clinical data.

DESIGN, SETTING, AND PARTICIPANTS

This economic evaluation included children aged 2 to 14 years presenting to the emergency department of a single academic medical center with mild DKA between January 1, 2015, and March 15, 2020. The medical records for DKA treatment course and its associated hospitalization costs were reviewed. Data were analyzed from January 1, 2015, to March 15, 2020.

EXPOSURES

Subcutaneous insulin aspart vs IV regular insulin infusion.

MAIN OUTCOMES AND MEASURES

The incremental cost-effectiveness ratio (US dollars per hour), duration of DKA treatment, and length of hospital stay.

RESULTS

A total of 129 children with mild DKA episodes (mean [SD] age, 9.9 [3.1] years; 72 girls [55.8%]) were enrolled in the study. Seventy children received SC insulin aspart and 59 received IV regular insulin. Overall, the length of hospital stay in the SC insulin group was reduced (mean, 16.9 [95% CI, -31.0 to -2.9] hours) compared with the IV insulin group (P = .005). The mean (SD) cost of hospitalization in the SC insulin group (US $1071.99 [US $523.89]) was less than that in the IV insulin group (US $1648.90 [US $788.03]; P = .001). The incremental cost-effectiveness ratio was -34.08 (95% CI, -25.97 to -129.82) USD/h. The use of SC insulin aspart was associated with a lower likelihood of prolonged hospital stay (β = -17.22 [95% CI, -32.41 to -2.04]; P = .03) than IV regular insulin when controlling for age and sex.

CONCLUSION AND RELEVANCE

Findings of this economic evaluation suggest that SC insulin aspart is dominant vs IV regular insulin in the management of mild uncomplicated DKA in children.

Critical care practices in the world: Results of the global intensive care unit need assessment survey 2020

BACKGROUND

There is variability in intensive care unit (ICU) resources and staffing worldwide. This may reflect variation in practice and outcomes across all health systems.

AIM

To improve research and quality improvement measures administrative leaders can create long-term strategies by understanding the nature of ICU practices on a global scale.

METHODS

The Global ICU Needs Assessment Research Group was formed on the basis of diversified skill sets. We aimed to survey sites regarding ICU type, availability of staffing, and adherence to critical care protocols. An international survey ‘Global ICU Needs Assessment’ was created using Google Forms, and this was distributed from February 17^th, 2020 till September 23^rd, 2020. The survey was shared with ICU providers in 34 countries. Various approaches to motivating healthcare providers were implemented in securing submissions, including use of emails, phone calls, social media applications, and WhatsApp™. By completing this survey, providers gave their consent for research purposes. This study was deemed eligible for category-2 Institutional Review Board exempt status.

RESULTS

There were a total 121 adult/adult-pediatrics ICU responses from 34 countries in 76 cities. A majority of the ICUs were mixed medical-surgical [92 (76%)]. 108 (89%) were adult-only ICUs. Total 36 respondents (29.8%) were 31-40 years of age, with 79 (65%) male and 41 (35%) female participants. 89 were consultants (74%). A total of 71 (59%) respondents reported having a 24-h in-house intensivist. A total of 87 (72%) ICUs were reported to have either a 2:1 or ≥ 2:1 patient/nurse ratio. About 44% of the ICUs were open and 76% were mixed type (medical-surgical). Protocols followed regularly by the ICUs included sepsis care (82%), ventilator-associated pneumonia (79%); nutrition (76%), deep vein thrombosis prophylaxis (84%), stress ulcer prophylaxis (84%), and glycemic control (89%).

CONCLUSION

Based on the findings of this international, multi-dimensional, needs-assessment survey, there is a need for increased recruitment and staffing in critical care facilities, along with improved patient-to-nurse ratios. Future research is warranted in this field with focus on implementing appropriate health standards, protocols and resources for optimal efficiency in critical care worldwide.

Development of a repeated-measures predictive model and clinical risk score for mortality in ventilated COVID-19 patients

PURPOSE

The COVID-19 pandemic has caused intensive care units (ICUs) to reach capacities requiring triage. A tool to predict mortality risk in ventilated patients with COVID-19 could inform decision-making and resource allocation, and allow population-level comparisons across institutions.

METHODS

This retrospective cohort study included all mechanically ventilated adults with COVID-19 admitted to three tertiary care ICUs in Toronto, Ontario, between 1 March 2020 and 15 December 2020. Generalized estimating equations were used to identify variables predictive of mortality. The primary outcome was the probability of death at three-day intervals from the time of ICU admission (day 0), with risk re-calculation every three days to day 15; the final risk calculation estimated the probability of death at day 15 and beyond. A numerical algorithm was developed from the final model coefficients.

RESULTS

One hundred twenty-seven patients were eligible for inclusion. Median ICU length of stay was 26.9 (interquartile range, 15.4-52.0) days. Overall mortality was 42%. From day 0 to 15, the variables age, temperature, lactate level, ventilation tidal volume, and vasopressor use significantly predicted mortality. Our final clinical risk score had an area under the receiver-operating characteristics curve of 0.9 (95% confidence interval [CI], 0.8 to 0.9). For every ten-point increase in risk score, the relative increase in the odds of death was approximately 4, with an odds ratio of 4.1 (95% CI, 2.9 to 5.9).

CONCLUSION

Our dynamic prediction tool for mortality in ventilated patients with COVID-19 has excellent diagnostic properties. Notwithstanding, external validation is required before widespread implementation.

Preliminary Design and Development of a Mechanical Ventilator Using Industrial Automation Components for Rapid Deployment During the COVID-19 Pandemic

The novel coronavirus disease 2019 (COVID-19) created a shortage of mechanical ventilators in the healthcare sector, resulting in rationed distribution, ethical dilemmas, and high mortalities. This technical report outlines the design and product outcome of a mechanical ventilator based on readily available off-the-shelf components, minimizing the dependence on manufacturing facilities. The ventilator was designed to operate in both hospitals and remote locations, having the ability to operate off various gas pressures and low voltage supplies. Due to the COVID-19 restrictions, the challenges of developing a device in an online setting with minimal manufacturing assistance were explored. Within a 10-day period, the team designed, prototyped, and conducted preliminary feasibility testing on the mechanical ventilator. The proposed design was not intended to replace, or be used as a medically approved ventilator, but demonstrates the ability to exploit off-the-shelf components to enable fast development and assembly. 

COVID-19 pandemic: the impact on Canada’s intensive care units

The COVID-19 pandemic has exposed the precarious demand-capacity balance in Canadian hospitals, including critical care where there is an urgent need for trained health care professionals to dramatically increase ICU capacity.

The impact of the pandemic on ICUs varied significantly across the country with provinces that implemented public health measures later and relaxed them sooner being impacted more severely. Pediatric ICUs routinely admitted adult patients. Non-ICU areas were converted to ICUs and staff were redeployed from other essential service areas. Faced with a lack of critical care capacity, triage plans for ICU admission were developed and nearly implemented in some provinces.

Twenty eight percent of patients in Canadian ICUs who required mechanical ventilation died. Surviving patients have required prolonged ICU admission, hospitalization and extensive ongoing rehabilitation. Family members of patients were not permitted to visit, resulting in additional psychological stresses to patients, families, and healthcare teams. ICU professionals also experienced extreme psychological stresses from caring for such large numbers of critically ill patients, often in sub-standard conditions. This resulted in large numbers of health workers leaving their professions.

This pandemic is not yet over, and it is likely that new pandemics will follow. A review and recommendations for the future are provided.

Overview of Canada's Answer to the COVID-19 Pandemic's First Wave (January-April 2020)

Canada is a federal state of almost 38 million inhabitants distributed over ten provinces and three territories, each with their own power regarding health. This case study describes the health infrastructures’ situation before the COVID-19 outbreak and their adaptations to face the expected cases, the available epidemiologic data for the beginning of the first wave (January–April 2020), and the public health and economic measures taken to control the pandemic both at the federal level and breaking down by province and territory. Canadian health infrastructures offered on average 12.9 intensive care units beds per 100,000 (occupancy rate ~90% before the outbreak), unevenly distributed across provinces and territories. Canada implemented public health measures, such as social distancing, when hospitalization and death rates due to the pandemic were still lower than in other countries; each province and territory adapted and implemented specific measures. Cumulated cases and deaths substantially increased from mid-March 2020, reaching 65 cases and 2 deaths per 100,000 on April 12, with strong differences across provinces and territories. Canada has been affected by the COVID-19 pandemic’s first wave with a generally slower dynamic than in the USA or in the European Union at the same period. This suggests that implementation of public health measures when health indicators were still low may have been efficient in Canada; yet the long-term care sector faced many challenges in some provinces, which drove a large part of the pandemic indicators.

An environmental scan of visitation policies in Canadian intensive care units during the first wave of the COVID-19 pandemic

Purpose

In response to the rapid spread of SARS-CoV-2, hospitals in Canada enacted temporary visitor restrictions to limit the spread of COVID-19 and preserve personal protective equipment supplies. This study describes the extent, variation, and fluctuation of Canadian adult intensive care unit (ICU) visitation policies before and during the first wave of the COVID-19 pandemic.

Methods

We conducted an environmental scan of Canadian hospital visitation policies throughout the first wave of the pandemic. We conducted a two-phased study analyzing both quantitative and qualitative data.

Results

We collected 257 documents with reference to visitation policies (preCOVID, 101 [39%]; midCOVID, 71 [28%]; and lateCOVID, 85 [33%]). Of these 257 documents, 38 (15%) were ICU-specific and 70 (27%) referenced the ICU. Most policies during the midCOVID/lateCOVID pandemic period allowed no visitors with specific exceptions (e.g., end-of-life). Framework analysis revealed five overarching themes: 1) reasons for restricted visitation policies; 2) visitation policies and expectations; 3) exceptions to visitation policy; 4) patient and family-centred care; and 5) communication and transparency.

Conclusions

During the first wave of the COVID-19 pandemic, most Canadian hospitals had public-facing visitor restriction policies with specific exception categories, most commonly for patients at end-of-life, patients requiring assistance, or COVID-19 positive patients (varying from not allowed to case-by-case). Further studies are needed to understand the consistency with which visitation policies were operationalized and how they may have impacted patient- and family-centred care.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12630-021-02049-4.

Health disparities of critically ill children according to poverty: the Korean population-based retrospective cohort study

Background

There is a lack of nationwide studies on critically ill patients’ health disparity under the National Health Insurance (NHI) system. We evaluated health disparities in intensive care unit (ICU) admission, outcomes, and readmission in impoverished children.

Methods

We conducted a retrospective cohort study using a national database from the Korean NHI and Medical Aid Program (MAP). MAP supports the population whose household income is lower than 40% of the median Korean household income. We defined poverty as being a MAP beneficiary and compared the poverty and non-poverty groups. Patients between 28 days and 18 years old who were admitted to the ICU were included. Hospital mortality and readmission were analyzed with adjustment for patient characteristics, hospital type, and management procedures.

Results

Out of 17,893 patients, 1153 (6.4%) patients were in poverty. The age-standardized ICU admission rate was higher in the poverty group (126.9 vs. 80.2 per 100,000 person-years). There was more age-standardized mortality in the poverty group (11.8 vs. 4.3 per 100,000 person-years). Patients in the poverty group did not have a statistically different risk of adjusted in-hospital mortality to those in the non-poverty group (odds ratio: 1.15, confidence interval [CI]: 0.84–1.55) but had a higher readmission rate (hazard ratio 1.25, CI 1.09–1.42).

Conclusion

Under the NHI system, the disparity in pediatric critical care outcomes according to poverty is not definite, but the healthcare disparity in pre- and post-hospital care is a concern. Further studies are required to improve pre- and post-hospital healthcare quality of impoverished children.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-11324-4.

In-House, Overnight Physician Staffing: A Cross-Sectional Survey of Canadian Adult ICUs

OBJECTIVES

Overnight physician staffing in the ICU has been recommended by the Society of Critical Care Medicine and the Leapfrog Consortium. We conducted a survey to review practice in the current era and to compare this with results from a 2006 survey.

DESIGN

Cross-sectional survey.

SETTING

Canadian adult ICUs.

PARTICIPANTS

ICU directors.

INTERVENTIONS

None.

MEASUREMENT AND MAIN RESULTS

A 29-question survey was sent to ICU directors describing overnight staffing by residents, fellows, nurse practitioners, and staff physicians, as well as duty duration, clinical responsibilities, and unit characteristics. We established contact with 122 ICU directors, of whom 107 (88%) responded. Of the 107 units, 60 (56%) had overnight in-house physicians. Compared with ICUs without overnight in-house physician coverage, ICUs with in-house physicians were in larger hospitals (p < 0.0001), had more beds (p < 0.0001), had more ventilated patients (p < 0.0001), and had more admissions (p < 0.0001). Overnight in-house physicians were first year residents (R1) in 20 of 60 (33%), second to fifth year residents (R2-R5) in 46 of 60 (77%), and Critical Care Medicine trainees in 19 of 60 (32%). Advanced practice nurses provided overnight coverage in four of 107 ICUs (4%). The most senior in-house physician was a staff physician in 12 of 60 ICUs (20%), a Critical Care Medicine trainee in 14 of 60 (23%), and a resident (R2-R5) in 20 of 60 (33%). The duration of overnight duty was on average 20-24 hours in 22 of 46 units (48%) with R2-R5 residents and 14 of 19 units (74%) covered by Critical Care Medicine trainees.

CONCLUSIONS

Variability of in-house overnight physician presence in Canadian adult ICUs is linked to therapeutic complexity and unit characteristics and has not changed significantly over the decade since our 2006 survey. Additional evidence about patient and resident outcomes would better inform decisions to revise physician scheduling in Canadian ICUs.

Critical Care Bed Capacity in Asian Countries and Regions

OBJECTIVE

To assess the number of adult critical care beds in Asian countries and regions in relation to population size.

DESIGN

Cross-sectional observational study.

SETTING

Twenty-three Asian countries and regions, covering 92.1% of the continent's population.

PARTICIPANTS

Ten low-income and lower-middle-income economies, five upper-middle-income economies, and eight high-income economies according to the World Bank classification.

INTERVENTIONS

Data closest to 2017 on critical care beds, including ICU and intermediate care unit beds, were obtained through multiple means, including government sources, national critical care societies, colleges, or registries, personal contacts, and extrapolation of data.

MEASUREMENTS AND MAIN RESULTS

Cumulatively, there were 3.6 critical care beds per 100,000 population. The median number of critical care beds per 100,000 population per country and region was significantly lower in low- and lower-middle-income economies (2.3; interquartile range, 1.4-2.7) than in upper-middle-income economies (4.6; interquartile range, 3.5-15.9) and high-income economies (12.3; interquartile range, 8.1-20.8) (p = 0.001), with a large variation even across countries and regions of the same World Bank income classification. This number was independently predicted by the World Bank income classification on multivariable analysis, and significantly correlated with the number of acute hospital beds per 100,000 population (r = 0.19; p = 0.047), the universal health coverage service coverage index (r = 0.35; p = 0.003), and the Human Development Index (r = 0.40; p = 0.001) on univariable analysis.

CONCLUSIONS

Critical care bed capacity varies widely across Asia and is significantly lower in low- and lower-middle-income than in upper-middle-income and high-income countries and regions.

A qualitative study of physician perceptions and experiences of caring for critically ill patients in the context of resource strain during the first wave of the COVID-19 pandemic

Background

The COVID-19 pandemic has led to global shortages in the resources required to care for critically ill patients and to protect frontline healthcare providers. This study investigated physicians’ perceptions and experiences of caring for critically ill patients in the context of actual or anticipated resource strain during the COVID-19 pandemic, and explored implications for the healthcare workforce and the delivery of patient care.

Methods

We recruited a diverse sample of critical care physicians from 13 Canadian Universities with adult critical care training programs. We conducted semi-structured telephone interviews between March 25–June 25, 2020 and used qualitative thematic analysis to derive primary themes and subthemes.

Results

Fifteen participants (eight female, seven male; median age = 40) from 14 different intensive care units described three overarching themes related to physicians’ perceptions and experiences of caring for critically ill patients during the pandemic: 1) Conditions contributing to resource strain (e.g., continuously evolving pandemic conditions); 2) Implications of resource strain on critical care physicians personally (e.g., safety concerns) and professionally (e.g. practice change); and 3) Enablers of resource sufficiency (e.g., adequate human resources).

Conclusions

The COVID-19 pandemic has required health systems and healthcare providers to continuously adapt to rapidly evolving circumstances. Participants’ uncertainty about whether their unit’s planning and resources would be sufficient to ensure the delivery of high quality patient care throughout the pandemic, coupled with fear and anxiety over personal and familial transmission, indicate the need for a unified systemic pandemic response plan for future infectious disease outbreaks.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06393-5.

An analysis of the policy responses to the COVID-19 pandemic in France, Belgium, and Canada

OBJECTIVES

This paper presents an overview and comparative analysis of the epidemiological situation and the policy responses in France, Belgium, and Canada during the early stages of the 2020 Covid-19 pandemic (Feb.-Aug. 2020). These three countries are compared because they represent a spectrum of different governance structures while also being OECD nations that are similar in many other respects.

METHODS

A rapid review of primary data from the three countries was conducted. Data was collected from official government documents whenever possible, supplemented by information from international databases and local media reports. The data was then analysed to identify common patterns as well as significant divergences across the three countries, especially in the areas of health policy and technology use.

RESULTS

France, Belgium and Canada faced differing epidemiological situations during the Covid-19 pandemic, and the wide variety of policy actions taken appears to be linked to existing governance and healthcare structures. The varying degrees of federalism and regional autonomy across the three countries highlight the different constraints faced by national policy-makers within different governance models.

CONCLUSIONS

The actions taken by all three countries appear to have been largely dictated by existing health system capacity, with increasing federalism associated with more fragmented strategies and less coordination across jurisdictions. However, the implications of certain policies related to economic resilience and health system capacity cannot yet be fully evaluated and may even prove to have net negative impacts into the future.

How the high acuity unit changes mortality in the intensive care unit: a retrospective before-and-after study

PURPOSE

High acuity units (HAU) are hospital units that provide patients with more acute care and closer monitoring than a general hospital ward but are not as resource intensive as an intensive care unit (ICU). Nevertheless, the impact of opening a HAU on ICU patient outcomes remains poorly defined. We investigated how the creation of a HAU impacted patient outcomes in the ICU.

METHODS

This historical cohort study compared ICU patient in-hospital mortality, ICU length of stay (LOS), and hospital LOS before and after the creation of a HAU in a tertiary-care hospital with a medical/surgical ICU between 1 January 2013 and 31 December 2017.

RESULTS

Data from 4,380 patients (984 in the pre-HAU group and 3,396 in the post-HAU group) were analyzed. In this cohort of ICU patients, 360 (37%) died in the pre-HAU group before the creation of a HAU, and 1,074 (32%) died in the post-HAU group after the creation of a HAU. The creation of a HAU was associated with lower relative risk of in-hospital mortality (adjusted risk ratio, 0.80; 95% confidence interval [CI], 0.72 to 0.89; P < 0.001). The creation of a HAU was also associated with reduced ICU and hospital LOS with a 12% increase in the rate of ICU discharge (adjusted sub-distribution hazard ratio [SHR], 1.12; 95% CI, 1.02 to 1.23; P = 0.02) and a 26% increase in the rate of hospital discharge (adjusted SHR, 1.26; 95% CI, 1.14 to 1.39; P < 0.001), when accounting for the competing risk of death.

CONCLUSIONS

These data support the hypothesis that the creation of a HAU may be associated with reduced in-hospital mortality, ICU LOS, and hospital LOS for ICU patients.

Capacity of intensive care units in Ghana

Purpose

To document the equipment, resource and bed capacity of Intensive Care Units (ICUs) in the Republic of Ghana.

Materials and methods

Cross-sectional observational study of all operating ICUs in Ghana. Sixteen operating ICUs in 9 hospitals were identified and surveyed (13 adult and 3 pediatric ICUs).

Results

There were a total of 113 adult and 36 pediatric ICU beds for a population of 30 million, (0.5 ICU beds per 100,000 people). The median number of staffed ICU beds and ventilators were 5 (IQR 4–6), and 4 (IQR 3–5) respectively. There were 2 pediatric and 6 adult intensivists practicing in the country. About half of the ICUs (56%) were staffed solely by non-intensivist providers. While there is adequate nursing support and availability of essential critical care medications, the current financing model for critical care delivery creates a significant barrier for most patients.

Conclusion

Ghana has a significant shortage of critical care beds that are inequitably distributed across the country and a shortfall of intensivists to staff ICUs. A holistic approach that focuses on the key bottlenecks to quality improvement would be required to improve the capacity and quality of critical care delivery.

•

There were a total of 113 adult and 36 pediatric critical care beds for a population of 30 million people in Ghana.

•

In February 2020, Ghana had a total Critical Care bed capacity of 0.5 ICU beds per 100,000 people.

•

There were 16 operational ICUs across 9 institutions, of which 13 were adult and 3 were pediatric ICUs.

•

There were 8 intensivists (5 on loan from the Cuban Government) in the whole country.

Association between intensive care unit occupancy at discharge, afterhours discharges, and clinical outcomes: a historical cohort study

PURPOSE

There is a paucity of evidence evaluating whether intensive care unit (ICU) discharge occupancy is associated with clinical outcomes. It is unknown whether increased discharge occupancy leads to greater afterhours discharges and downstream consequences. We explore the association between ICU discharge occupancy and afterhours discharges, 72-hr readmission, and 30-day mortality.

METHODS

This single-centre, historical cohort study included all patients discharged from the Vancouver General Hospital ICU between 5 April 2010 and 13 September 2017. Data were obtained from the British Columbia Critical Care Database. Occupancy was defined as the number of ICU bed hours utilized divided by the available bed hours for that day. Any discharge between 22:00 and 6:59 was considered afterhours. Logistic regression models adjusting for important covariates were constructed.

RESULTS

We included 8,862 ICU discharges representing 7,288 individual patients. There were 1,180 (13.3%) afterhours discharges, 408 (4.6%) 72-hr readmissions, and 574 (6.5%) 30-day post-discharge deaths. Greater discharge occupancy was associated with afterhours discharges (per 10% increase: adjusted odds ratio [aOR], 1.12; 95% confidence interval [CI], 1.03 to 1.20; P = 0.005). Discharge occupancy was not associated with 72-hr readmission (per 10% increase: aOR, 0.97; 95% CI, 0.87 to 1.09; P = 0.62) or 30-day mortality (per 10% increase: aOR, 1.05; 95% CI, 0.95 to 1.16; P = 0.32). Afterhours discharge was not associated with 72-hr readmission (aOR, 1.15; 95% CI, 0.86 to 1.54; P = 0.34) or 30-day mortality (aOR, 1.05; 95% CI, 0.82 to 1.36; P = 0.69).

CONCLUSIONS

Greater ICU discharge occupancy was associated with a significant increase in afterhours discharges. Nevertheless, neither discharge occupancy nor afterhours discharge were associated with 72-hr readmission or 30-day mortality.

Early mortality in critical illness - A descriptive analysis of patients who died within 24 hours of ICU admission

PURPOSE

To describe patients who die within 24 h of ICU admission in order to better optimize care delivery.

METHODS

This was a retrospective cohort study of patients ≥18 years old admitted to 17 adult ICUs in Alberta, Canada from January 1, 2016 and June 30, 2017. Data were obtained from a provincial clinical information system and data repository. The primary outcome was incidence of ICU death within 24 h of admission. Secondary outcomes were patient and system factors associated with early death. Variables of interest were identified a priori and examined using multivariable logistic regression.

RESULTS

Of 19,556 patients admitted to ICU in an 18-month period, 3.3% died within 24 h, representing 29.8% of ICU deaths. Factors associated with early death were age (adjusted-OR 0.99, 95% CI, 0.9-1.0), acuity (adjusted-OR 1.3, 95% CI, 1.3-1.4), admission from the Emergency Department (ED; adjusted-OR 1.5, 95% CI, 1.1-1.9) and surgical (adjusted-OR 2.27, 95% CI, 1.4-3.6), neurologic (adjusted-OR 4.6, 95% CI, 3.1-6.9) or trauma diagnosis (adjusted-OR 6.1, 95% CI, 2.4-15.6).

CONCLUSION

Patients who die within 24 h constitute one third of ICU deaths. Age, acuity, admission from the ED and surgical, neurologic or trauma-related admission diagnosis correlate with early death.

Assessment of Costs of Avoidable Delays in Intensive Care Unit Discharge

IMPORTANCE

Delays in transfer for discharge-ready patients from the intensive care unit (ICU) are increasingly described and contribute to strained capacity.

OBJECTIVE

To describe the epidemiological features and health care costs attributable to potentially avoidable delays in ICU discharge in a large integrated health care system.

DESIGN, SETTING, AND PARTICIPANTS

This population-based cohort study was performed in 17 adult ICUs in Alberta, Canada, from June 19, 2012, to December 31, 2016. Participants were patients 15 years or older admitted to a study ICU during the study period. Data were analyzed from October 19, 2018, to May 20, 2020.

EXPOSURES

Avoidable time in the ICU, defined as the portion of total ICU patient-days accounted for by avoidable delay in ICU discharge (eg, waiting for a ward bed).

MAIN OUTCOMES AND MEASURES

The primary outcome was health care costs attributable to avoidable time in the ICU. Secondary outcomes were factors associated with avoidable time, in-hospital mortality, and measures of use of health care resources, including the number of hours in the ICU and the number of days of hospitalization. Multilevel mixed multivariable regression was used to assess associations between avoidable time and outcomes.

RESULTS

In total, 28 904 patients (mean [SD] age, 58.3 [16.8] years; 18 030 male [62.4%]) were included. Of these, 19 964 patients (69.1%) had avoidable time during their ICU admission. The median avoidable time per patient was 7.2 (interquartile range, 2.4-27.7) hours. In multivariable analysis, male sex (odds ratio [OR], 0.92; 95% CI, 0.87-0.98), comorbid hemiplegia or paraplegia (OR 1.47; 95% CI, 1.23-1.75), liver disease (OR 1.20; 95% CI, 1.04-1.37), admission Acute Physiology and Chronic Health Evaluation II score (OR, 1.03; 95% CI, 1.02-1.03), surgical status (OR, 0.90; 95% CI, 0.82-0.98), medium community hospital type (OR, 0.12; 95% CI, 0.04-0.32), and admission year (OR, 1.16; 95% CI, 1.13-1.19) were associated with avoidable time. The cumulative avoidable time was 19 373.9 days, with estimated attributable costs of CAD$34 323 522. Avoidable time accounted for 12.8% of total ICU bed-days and 6.4% of total ICU costs. Patients with avoidable time before ICU discharge showed higher unadjusted in-hospital mortality (1115 [5.6%] vs 392 [4.4%]; P < .001); however, in multivariable analysis, avoidable time was associated with reduced in-hospital mortality (adjusted hazard ratio, 0.74; 95% CI, 0.64-0.85). Results were similar in sensitivity analyses.

CONCLUSIONS AND RELEVANCE

In this study, potentially avoidable discharge delay occurred for most patients admitted to ICUs across a large integrated health system and translated into substantial associated health care costs.

COVID-19 and US Health Financing: Perils and Possibilities

While the COVID-19 pandemic presents every nation with challenges, the United States’ underfunded public health infrastructure, fragmented medical care system, and inadequate social protections impose particular impediments to mitigating and managing the outbreak. Years of inadequate funding of the nation’s federal, state, and local public health agencies, together with mismanagement by the Trump administration, hampered the early response to the epidemic. Meanwhile, barriers to care faced by uninsured and underinsured individuals in the United States could deter COVID-19 care and hamper containment efforts, and lead to adverse medical and financial outcomes for infected individuals and their families, particularly those from disadvantaged groups. While the United States has a relatively generous supply of Intensive Care Unit beds and most other health care infrastructure, such medical resources are often unevenly distributed or deployed, leaving some areas ill-prepared for a severe respiratory epidemic. These deficiencies and shortfalls have stimulated a debate about policy solutions. Recent legislation, for instance, expanded coverage for testing for COVID-19 for the uninsured and underinsured, and additional reforms have been proposed. However comprehensive health care reform – for example, via national health insurance – is needed to provide full protection to American families during the COVID-19 outbreak and in its aftermath.

Critical care practice in India: Results of the intensive care unit need assessment survey (ININ2018)

BACKGROUND

A diverse country like India may have variable intensive care units (ICUs) practices at state and city levels.

AIM

To gain insight into clinical services and processes of care in ICUs in India, this would help plan for potential educational and quality improvement interventions.

METHODS

The Indian ICU needs assessment research group of diverse-skilled individuals was formed. A pan- India survey "Indian National ICU Needs" assessment (ININ 2018-I) was designed on google forms and deployed from July 23^rd-August 25^th, 2018. The survey was sent to select distribution lists of ICU providers from all 29 states and 7 union territories (UTs). In addition to emails and phone calls, social medial applications-WhatsApp™, Facebook™ and LinkedIn™ were used to remind and motivate providers. By completing and submitting the survey, providers gave their consent for research purposes. This study was deemed eligible for category-2 Institutional Review Board exempt status.

RESULTS

There were total 134 adult/adult-pediatrics ICU responses from 24 (83% out of 29) states, and two (28% out of 7) UTs in 61 cities. They had median (IQR) 16 (10-25) beds and most, were mixed medical-surgical, 111(83%), with 108(81%) being adult-only ICUs. Representative responders were young, median (IQR), 38 (32-44) years age and majority, n = 108 (81%) were males. The consultants were, n = 101 (75%). A total of 77 (57%) reported to have 24 h in-house intensivist. A total of 68 (51%) ICUs reported to have either 2:1 or 2≥:1 patient:nurse ratio. More than 80% of the ICUs were open, and mixed type. Protocols followed regularly by the ICUs included sepsis care, ventilator- associated pneumonia (83% each); nutrition (82%), deep vein thrombosis prophylaxis (87%), stress ulcer prophylaxis (88%) and glycemic control (92%). Digital infrastructure was found to be poor, with only 46 % of the ICUs reporting high-speed internet availability.

CONCLUSION

In this large, national, semi-structured, need-assessment survey, the need for improved manpower including; in-house intensivists, and decreasing patient-to-nurse ratios was evident. Sepsis was the most common diagnosis and quality and research initiatives to decrease sepsis mortality and ICU length of stay could be prioritized. Additionally, subsequent surveys can focus on digital infrastructure for standardized care and efficient resource utilization and enhancing compliance with existing protocols.

Intensive care inequity in Rio de Janeiro: the effect of spatial distribution of health services on severe acute respiratory infection

OBJECTIVE

To analyze the distribution of adult intensive care units according to geographic region and health sector in Rio de Janeiro and to investigate severe acute respiratory infection mortality in the public sector and its association with critical care capacity in the public sector.

METHODS

We evaluated the variation in intensive care availability and severe acute respiratory infection mortality in the public sector across different areas of the city in 2014. We utilized databases from the National Registry of Health Establishments, the Brazilian Institute of Geography and Statistics, the National Mortality Information System and the Hospital Admission Information System.

RESULTS

There is a wide range of intensive care unit beds per capita (from 4.0 intensive care unit beds per 100,000 people in public hospitals in the West Zone to 133.6 intensive care unit beds per 100,000 people in private hospitals in the Center Zone) in the city of Rio de Janeiro. The private sector accounts for almost 75% of the intensive care unit bed supply. The more developed areas of the city concentrate most of the intensive care unit services. Map-based spatial analysis shows a lack of intensive care unit beds in vast territorial extensions in the less developed regions of the city. There is an inverse correlation (r = -0.829; 95%CI -0.946 to -0.675) between public intensive care unit beds per capita in different health planning areas of the city and severe acute respiratory infection mortality in public hospitals.

CONCLUSION

Our results show a disproportionate intensive care unit bed provision across the city of Rio de Janeiro and the need for a rational distribution of intensive care.

Growth and Changing Characteristics of Pediatric Intensive Care 2001-2016

OBJECTIVES

We assessed the growth, distribution, and characteristics of pediatric intensive care in 2016.

DESIGN

Hospitals with PICUs were identified from prior surveys, databases, online searching, and clinician networking. A structured web-based survey was distributed in 2016 and compared with responses in a 2001 survey.

SETTING

PICUs were defined as a separate unit, specifically for the treatment of children with life-threatening conditions. PICU hospitals contained greater than or equal to 1 PICU.

SUBJECTS

Physician medical directors and nurse managers.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

PICU beds per pediatric population (< 18 yr), PICU bed distribution by state and region, and PICU characteristics and their relationship with PICU beds were measured. Between 2001 and 2016, the U.S. pediatric population grew 1.9% to greater than 73.6 million children, and PICU hospitals decreased 0.9% from 347 to 344 (58 closed, 55 opened). In contrast, PICU bed numbers increased 43% (4,135 to 5,908 beds); the median PICU beds per PICU hospital rose from 9 to 12 (interquartile range 8, 20 beds). PICU hospitals with greater than or equal to 15 beds in 2001 had significant bed growth by 2016, whereas PICU hospitals with less than 15 beds experienced little average growth. In 2016, there were eight PICU beds per 100,000 U.S. children (5.7 in 2001), with U.S. census region differences in bed availability (6.8 to 8.8 beds/100,000 children). Sixty-three PICU hospitals (18%) accounted for 47% of PICU beds. Specialized PICUs were available in 59 hospitals (17.2%), 48 were cardiac (129% growth). Academic affiliation, extracorporeal membrane oxygenation availability, and 24-hour in-hospital intensivist staffing increased with PICU beds per hospital.

CONCLUSIONS

U.S. PICU bed growth exceeded pediatric population growth over 15 years with a relatively small percentage of PICU hospitals containing almost half of all PICU beds. PICU bed availability is variable across U.S. states and regions, potentially influencing access to care and emergency preparedness.

Projecting demand for critical care beds during COVID-19 outbreaks in Canada

BACKGROUND

Increasing numbers of coronavirus disease 2019 (COVID-19) cases in Canada may create substantial demand for hospital admission and critical care. We evaluated the extent to which self-isolation of mildly ill people delays the peak of outbreaks and reduces the need for this care in each Canadian province.

METHODS

We developed a computational model and simulated scenarios for COVID-19 outbreaks within each province. Using estimates of COVID-19 characteristics, we projected the hospital and intensive care unit (ICU) bed requirements without self-isolation, assuming an average number of 2.5 secondary cases, and compared scenarios in which different proportions of mildly ill people practised self-isolation 24 hours after symptom onset.

RESULTS

Without self-isolation, the peak of outbreaks would occur in the first half of June, and an average of 569 ICU bed days per 10 000 population would be needed. When 20% of cases practised self-isolation, the peak was delayed by 2-4 weeks, and ICU bed requirement was reduced by 23.5% compared with no self-isolation. Increasing self-isolation to 40% reduced ICU use by 53.6% and delayed the peak of infection by an additional 2-4 weeks. Assuming current ICU bed occupancy rates above 80% and self-isolation of 40%, demand would still exceed available (unoccupied) ICU bed capacity.

INTERPRETATION

At the peak of COVID-19 outbreaks, the need for ICU beds will exceed the total number of ICU beds even with self-isolation at 40%. Our results show the coming challenge for the health care system in Canada and the potential role of self-isolation in reducing demand for hospital-based and ICU care.

Mapping structure, process and outcomes in the removal of low-value care practices in Canadian intensive care units: protocol for a mixed-methods exploratory study

INTRODUCTION

The challenge of implementing best evidence into clinical practice is a major problem in modern healthcare that can result in ineffective, inefficient and unsafe care. There is a growing body of literature which suggests that the removal or reduction of low-value care practices (ie, deadoption) is integral to the delivery of high-quality care and the sustainability of our healthcare system. However, currently very little is known about deadoption practices in Canada. We propose to map the current state of deadoption in Canadian intensive care units (ICUs). A key deliverable of this work will include development of an inventory of barriers, facilitators and potential implementation strategies for guiding the deadoption efforts.

METHODS AND ANALYSIS

We will use Canadian adult general systems ICUs as our laboratory of investigation and employ a two-phased sequential exploratory mixed-methods approach: (1) semi-structured interviews with critical care stakeholders to develop an understanding of the structure (ie, healthcare context), process (ie, actions and events in healthcare) and outcomes (ie, effects on health status, quality, knowledge or behaviour) of deadoption (phase I) and (2) surveys with a broader sample of critical care stakeholders to further identify important barriers and facilitators, as well as potential implementation strategies (phase II). Interview data will be analysed through qualitative content analysis and survey data will be analysed through quantitative analyses to identify top barriers and facilitators, as well as top rated strategies.

ETHICS AND DISSEMINATION

Ethical approval has been obtained through the University of Calgary Research Ethics Board (REB 17-2153). Participants involved will have the opportunity to provide feedback on the final written reports to support accurate representation of the data. The findings of this study will be disseminated through peer-reviewed publications and oral presentations with critical care stakeholders across Canada. Patient and family partners will receive an executive summary of the findings.

Variability in intensive care unit admission among pregnant and postpartum women in Canada: a nationwide population-based observational study

Background

Pregnancy-related critical illness results in approximately 300,000 deaths globally each year. The objective was to describe the variation in ICU admission and the contribution of patient- and hospital-based factors in ICU admission among acute care hospitals for pregnant and postpartum women in Canada.

Methods

A nationwide cohort study between 2004 and 2015, comprising all pregnant or postpartum women admitted to Canadian hospitals. The primary outcome was ICU admission. Secondary outcomes were severe maternal morbidity (a potentially life-threatening condition) and maternal death (during and within 6 weeks after pregnancy). The proportion of total variability in ICU admission rates due to the differences among hospitals was described using the median odds ratio from multi-level logistic regression models, adjusting for individual hospital clusters.

Results

There were 3,157,248 identifiable pregnancies among women admitted to 342 Canadian hospitals. The overall ICU admission rate was 3.2 per 1000 pregnancies. The rate of severe maternal morbidity was 15.8 per 1000 pregnancies, of which 10% of women were admitted to an ICU. The most common severe maternal morbidity events included postpartum hemorrhage (n = 16,364, 0.52%) and sepsis (n = 11,557, 0.37%). Of the 195 maternal deaths (6.2 per 100,000 pregnancies), only 130 (67%) were admitted to ICUs. Patients dying in hospital, without admission to ICU, included those with cardiovascular compromise, hemorrhage, and sepsis. For 2 pregnant women with similar characteristics at different hospitals, the average (median) odds of being admitted to ICU was 1.92 in 1 hospital compared to another. Hospitals admitting the fewest number of pregnant patients had the highest incidence of severe maternal morbidity and mortality. Patient-level factors associated with ICU admission were maternal comorbidity index (OR 1.88 per 1 unit increase, 95%CI 1.86–1.99), urban residence (OR 1.09, 95%CI 1.02–1.16), and residing at the lowest income quintile (OR 1.44, 95%CI 1.34–1.55).

Conclusions

Most women who experience severe maternal morbidity are not admitted to an ICU. There exists a wide hospital-level variability in ICU admission, with patients living in urban locations and patients of lowest income levels most likely to be admitted to ICU. Cardiovascular compromise, hemorrhage, and sepsis represent an opportunity for improved patient care and outcomes.

Preparing intensive care for the next pandemic influenza

Few viruses have shaped the course of human history more than influenza viruses. A century since the 1918-1919 Spanish influenza pandemic-the largest and deadliest influenza pandemic in recorded history-we have learned much about pandemic influenza and the origins of antigenic drift among influenza A viruses. Despite this knowledge, we remain largely underprepared for when the next major pandemic occurs.While emergency departments are likely to care for the first cases of pandemic influenza, intensive care units (ICUs) will certainly see the sickest and will likely have the most complex issues regarding resource allocation. Intensivists must therefore be prepared for the next pandemic influenza virus. Preparation requires multiple steps, including careful surveillance for new pandemics, a scalable response system to respond to surge capacity, vaccine production mechanisms, coordinated communication strategies, and stream-lined research plans for timely initiation during a pandemic. Conservative models of a large-scale influenza pandemic predict more than 170% utilization of ICU-level resources. When faced with pandemic influenza, ICUs must have a strategy for resource allocation as strain increases on the system.There are several current threats, including avian influenza A(H5N1) and A(H7N9) viruses. As humans continue to live in closer proximity to each other, travel more extensively, and interact with greater numbers of birds and livestock, the risk of emergence of the next pandemic influenza virus mounts. Now is the time to prepare and coordinate local, national, and global efforts.

Epidemiology of Anaphylaxis in Critically Ill Children in the United States and Canada

BACKGROUND

Anaphylaxis is a rapid-onset, multisystem, and potentially fatal hypersensitivity reaction with varied reports of prevalence, incidence, and mortality. There are limited cases reported of severe and/or fatal pediatric anaphylaxis.

OBJECTIVE

This study describes the largest cohort of intensive care unit pediatric anaphylaxis admissions with a comprehensive analysis of identified triggers, clinical and demographic information, and probability of death.

METHODS

We describe the epidemiology of pediatric anaphylaxis admissions to North American pediatric intensive care units (PICUs) that were prospectively enrolled in the Virtual Pediatric Systems database from 2010 to 2015. One hundred thirty-one PICUs in North America (United States and Canada) were queried for anaphylaxis International Classification of Diseases, Ninth Revision or International Classification of Diseases, Tenth Revision codes from the Virtual Pediatric Systems database from 2010 to 2015 in the United States and Canada. One thousand nine hundred eighty-nine patients younger than 18 years were identified out of 604,279 total number of patients admitted to a PICU in the database during this time frame.

RESULTS

The primary outcome was mortality, which was compared with patient and admission data using Fisher exact test. Secondary outcomes (intubation, length of stay, mortality risk scores, systolic blood pressure, and pupillary reflex) were analyzed using the Kruskal-Wallis test or Wilcoxon rank-sum test, as appropriate. One thousand nine hundred eighty-nine patients with an anaphylaxis International Classification of Diseases code were identified in the database. One percent of patients died because of critical anaphylaxis. Identified triggers for fatal cases were peanuts, milk, and blood products. Peanuts were the most common trigger. Children were mostly male when younger than 13 years, and mostly female when 13 years and older. Average length of stay was 2 days. There was a higher proportion of Asian patients younger than 2 years or when the trigger was food.

CONCLUSIONS

This is the largest study to describe pediatric critical anaphylaxis cases in North America and identifies food as the most common trigger. Death occurs in 1% of cases, with intubation occurring most commonly in the first hour. The risk for intensive care unit admission in children underscores the serious nature of anaphylaxis in this population.

Prognosis of patients with acute respiratory failure and prolonged intensive care unit stay

Background

Reasons for the prolonged critical care support include uncertainty of outcome, the complex dynamic created between physicians with care team members and the patient's family over a general unwillingness to surrender to unfavorable outcomes. The purpose of this study was to investigate outcomes and identify risk factors of patients with acute respiratory failure (ARF) who required a prolonged intensive care unit (ICU) stay (≥21 days). It may provide reference to screen patients who are suitable for hospice care.

Methods

The medical records of all ARF patients with a prolonged ICU stay were retrospectively reviewed. The primary outcome was in-hospital mortality.

Results

We identified 1,189 patients. Sepsis (n=896, 75.4%) was the most common cause of prolonged ICU stays, following by renal failure (n=232, 19.5%), and unstable hemodynamic status vasopressors or arrhythmia (n=208, 17.5%). Using multivariable logistic regression, we identified eight risk factors of death: age >75 years, ICU stay for more than 28 days, APACHE II score ≥25, unstable hemodynamic status, renal failure, hepatic failure, massive gastrointestinal tract bleeding, and using a fraction of inspired oxygen (FiO₂) ≥40%. The overall in-hospital mortality rate was 53.6% (n=637), and it up to 75.3% (216/287) for patients with at least three risk factors.

Conclusions

The outcome of patients with ARF who required prolonged ICU stay was poor. They had a high risk of in-hospital mortality. Palliative care should be considered as a reasonable option for the patients at high risk of death.

Experiences with a temporary synthetic skin substitute after decompressive craniectomy: a retrospective two-center analysis

BACKGROUND

Decompressive craniectomy is a commonly performed procedure. It reduces intracranial pressure, improves survival, and thus might have a positive impact on several neurosurgical diseases and emergencies. Sometimes primary skin closure is not possible due to cerebral herniation or extensive skin defects. In order to prevent further restriction of the underlying tissue, a temporary skin expansion might be necessary.

METHODS AND MATERIAL

We retrospectively reviewed patients in need for a temporary skin substitute because skin closure was not possible after craniectomy without violating brain tissue underneath in a time period of 6 years (2011-2016). With this study, we present initial experiences of Epigard (Biovision, Germany) as an artificial temporary skin replacement. We performed this analysis at two level-1 trauma centers (Trauma Center Murnau, Germany; University Hospital of St. Poelten, Austria). Demographic data, injury and surgical characteristics, and complication rates were analyzed via chart review. We identified nine patients within our study period. Six patients suffered from severe traumatic brain injury and developed pronounced cerebral herniation in the acute or subacute phase. Three patients presented with non-traumatic conditions (one atypical intracerebral hemorrhage and two patients with extensive destructive tumors invading the skull and scalp).

RESULTS

A total of 20 Epigard exchanges (range 1-4) were necessary before skin closure was possible. A CSF fistula due to a leaky Epigard at the interface to the skin was observed in two patients (22%). Additional complications were four wound infections, three CNS infections, and three patients developed a shunt dependency. Three patients died within the first month after injury.

CONCLUSIONS

Temporary skin closure with Epigard as a substitute is feasible for a variety of neurosurgical conditions. The high complication and mortality rate reflect the complexity of the encountered pathologies and need to be considered when counseling the patient and their families.

Association between strained ICU capacity and healthcare costs in Canada: A population-based cohort study

BACKGROUND

Intensive care is resource intensive, with costs representing a substantial quantity of total hospitalization costs. Strained ICU capacity compromises care quality and adversely impacts outcomes; however, the association between strain and healthcare costs has not been explored.

MATERIALS AND METHODS

Population-based cohort study performed in 17 adult ICUs in Alberta, Canada. Data were captured on hospitalizations, ambulatory care, physician services and drug dispenses occurring 1-year before and 1-year after index ICU admission. Strain was defined as occupancy ≥90%; with 21 additional definitions evaluated. Patients were categorized as strain and non-strain admissions. Costs attributable to strain, were calculated as difference-in-difference costs using propensity-score matching.

RESULTS

30,557 patients were included (strain: 11,830 [38.7%]; non-strain: 18,727 [61.3%]). At 1-year, strain admissions had adjusted-incremental per-patient cost of CA$9406 (95%CI, $5654-13,157) compared to non-strain admissions, due to hospitalization costs (CA$7930; 95%CI, $4553-11,307) and physician claims (CA$844; 95%CI, $430-1259). This equated to CA$111.3 million (95%CI, $66.9-155.6 million) in excess attributable costs. Strain portended longer hospitalization (3.3 days; 95%CI, 1.1-5.5); and more ambulatory visits (1.0; 95%CI, 0.1-2.0) and physician claims (9.5; 95%CI, 6.2-12.7). Incremental costs were robust across strain definitions.

CONCLUSIONS

Admissions to ICUs experiencing strain incur incremental costs, attributed to longer hospitalization and physician services.

Comparison of outcomes and costs between adult diabetic ketoacidosis patients admitted to the ICU and step-down unit

PURPOSE

There is wide variation in the utilization of Intensive Care Unit (ICU) beds for treatment and monitoring of adult patients with Diabetic Ketoacidosis (DKA). We sought to compare the outcomes and hospital costs of adult DKA patients admitted to ICUs as compared to those admitted to step-down units.

MATERIALS AND METHODS

We included consecutive adult patients from two hospitals with a diagnosis of DKA. Patients were either admitted to the ICU, or a step-down unit, which has a nurse-to-patient ratio of 2:1, but does not have capability for mechanical ventilation or administration of vasoactive agents. The primary outcome was in-hospital mortality.

RESULTS

We included 872 patients in the analysis. 71 (8.1%) were admitted to ICU, while 801 (91.9%) were admitted to a step-down unit. We found no difference in in-hospital mortality between patients admitted to the ICU and those admitted to the step-down unit (adjusted odds ratio [OR]: 1.14, 95% confidence interval [CI]: 0.87-2.64). Mean total hospital costs were significantly higher for patients admitted to the ICU ($20,428 vs. $6484, P < 0.001).

CONCLUSIONS

Adult DKA patients admitted to a step-down unit had comparable in-hospital mortality and lower hospital costs as compared to those admitted to the ICU.

Perspectives on strained intensive care unit capacity: A survey of critical care professionals

Background

Strained intensive care unit (ICU) capacity represents a supply-demand mismatch in ICU care. Limited data have explored health care worker (HCW) perceptions of strain.

Methods

Cross-sectional survey of HCW across 16 Alberta ICUs. A web-based questionnaire captured data on demographics, strain definition, and sources, impact and strategies for management.

Results

658 HCW responded (33%; 95%CI, 32–36%), of which 452 were nurses (69%), 128 allied health (19%), 45 physicians (7%) and 33 administrators (5%). Participants (agreed/strongly agreed: 94%) reported that strain was best defined as “a time-varying imbalance between the supply of available beds, staff and/or resources and the demand to provide high-quality care for patients who may become or who are critically ill”; while some recommended defining “high-quality care”, integrating “safety”, and families in the definition. Participants reported significant contributors to strain were: “inability to discharge ICU patients due to lack of available ward beds” (97%); “increases in the volume” (89%); and “acuity and complexity of patients requiring ICU support” (88%). Strain was perceived to “increase stress levels in health care providers” (98%); and “burnout in health care providers” (96%). The highest ranked strategies were: “have more consistent and better goals-of-care conversations with patients/families outside of ICU” (95%); and “increase non-acute care beds” (92%).

Interpretation

Strain is perceived as common. HCW believe precipitants represent a mix of patient-related and operational factors. Strain is thought to have negative implications for quality of care, HCW well-being and workplace environment. Most indicated strategies “outside” of ICU settings were priorities for managing strain.

Healthcare Provider Perceptions of Causes and Consequences of ICU Capacity Strain in a Large Publicly Funded Integrated Health Region: A Qualitative Study

OBJECTIVES

Discrepancy in the supply-demand relationship for critical care services precipitates a strain on ICU capacity. Strain can lead to suboptimal quality of care and burnout among providers and contribute to inefficient health resource utilization. We engaged interprofessional healthcare providers to explore their perceptions of the sources, impact, and strategies to manage capacity strain.

DESIGN

Qualitative study using a conventional thematic analysis.

SETTING

Nine ICUs across Alberta, Canada.

SUBJECTS

Nineteen focus groups (n = 122 participants).

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Participants' perspectives on strain on ICU capacity and its perceived impact on providers, families, and patient care were explored. Participants defined "capacity strain" as a discrepancy between the availability of ICU beds, providers, and ICU resources (supply) and the need to admit and provide care for critically ill patients (demand). Four interrelated themes of contributors to strain were characterized (each with subthemes): patient/family related, provider related, resource related, and health system related. Patient/family-related subthemes were "increasing patient complexity/acuity," along with patient-provider communication issues ("paucity of advance care planning and goals-of-care designation," "mismatches between patient/family and provider expectations," and "timeliness of end-of-life care planning"). Provider-related factor subthemes were nursing workforce related ("nurse attrition," "inexperienced workforce," "limited mentoring opportunities," and "high patient-to-nurse ratios") and physician related ("frequent turnover/handover" and "variations in care plan"). Resource-related subthemes were "reduced service capability after hours" and "physical bed shortages." Health system-related subthemes were "variable ICU utilization," "preferential "bed" priority for other services," and "high ward bed occupancy." Participants perceived that strain had negative implications for patients ("reduced quality and safety of care" and "disrupted opportunities for patient- and family-centered care"), providers ("increased workload," "moral distress," and "burnout"), and the health system ("unnecessary, excessive, and inefficient resource utilization").

CONCLUSIONS

Engagement with frontline critical care providers is essential for understanding their experiences and perspectives regarding strained capacity and for the development of sustainable strategies for improvement.

Time required to initiate outbreak and pandemic observational research

PURPOSE

Observational research focused upon emerging infectious diseases such as Ebola virus, Middle East respiratory syndrome, and Zika virus has been challenging to quickly initiate. We aimed to determine the duration of start-up procedures and barriers encountered for an observational study focused upon such infectious outbreaks.

MATERIALS AND METHODS

At 1 pediatric and 5 adult intensive care units, we measured durations from protocol receipt to a variety of outbreak research milestones, including research ethics board (REB) approval, data sharing agreement (DSA) execution, and patient study screening initiation.

RESULTS

The median (interquartile range) time from site receipt of the protocol to REB submission was 73 (30-126) days; to REB approval, 158 (42-188) days; to DSA completion, 276 (186-312) days; and to study screening initiation, 293 (269-391) days. The median time from REB submission to REB approval was 43 (13-85) days. The median time for all start-up procedures was 335 (188-335) days.

CONCLUSIONS

There is a lengthy start-up period required for outbreak-focused research. Completing DSAs was the most time-consuming step. A reactive approach to newly emerging threats such as Ebola virus, Middle East respiratory syndrome, and Zika virus will likely not allow sufficient time to initiate research before most outbreaks are advanced.

Do stable non-ST-segment elevation acute coronary syndromes require admission to coronary care units?

BACKGROUND

Clinical practice guidelines recommend admitting patients with stable non-ST-segment elevation acute coronary syndrome (NSTE ACS) to telemetry units, yet up to two-thirds of patients are admitted to higher-acuity critical care units (CCUs). The outcomes of patients with stable NSTE ACS initially admitted to a CCU vs a cardiology ward with telemetry have not been described.

METHODS

We used population-based data of 7,869 patients hospitalized with NSTE ACS admitted to hospitals in Alberta, Canada, between April 1, 2007, and March 31, 2013. We compared outcomes among patients initially admitted to a CCU (n=5,141) with those admitted to cardiology telemetry wards (n=2,728).

RESULTS

Patients admitted to cardiology telemetry wards were older (median 69 vs 65years, P<.001) and more likely to be female (37.2% vs 32.1%, P<.001) and have a prior myocardial infarction (14.3% vs 11.5%, P<.001) compared with patients admitted to a CCU. Patients admitted directly to cardiology telemetry wards had similar hospital stays (6.2 vs 5.7days, P=.29) and fewer cardiac procedures (40.3% vs 48.5%, P<.001) compared with patients initially admitted to CCUs. There were no differences in the frequency of in-hospital mortality (1.3% vs 1.2%, adjusted odds ratio [aOR] 1.57, 95% CI 0.98-2.52), cardiac arrest (0.7% vs 0.9%, aOR 1.37, 95% CI 0.94-2.00), 30-day all-cause mortality (1.6% vs 1.5%, aOR 1.50, 95% CI 0.82-2.75), or 30-day all-cause postdischarge readmission (10.6% vs 10.8%, aOR 1.07, 95% CI 0.90-1.28) between cardiology telemetry ward and CCU patients. Results were similar across low-, intermediate-, and high-risk Duke Jeopardy Scores, and in patients with non-ST-segment myocardial infarction or unstable angina.

CONCLUSIONS

There were no differences in clinical outcomes observed between patients with NSTE ACS initially admitted to a ward or a CCU. These findings suggest that stable NSTE ACS may be managed appropriately on telemetry wards and presents an opportunity to reduce hospital costs and critical care capacity strain.

Nontraumatic spinal cord injury at the neurological intensive care unit: spectrum, causes of admission and predictors of mortality

OBJECTIVE

Nontraumatic spinal cord injuries (NTSCIs) form a heterogeneous group of diseases, which may evolve into a life-threatening condition. We sought to characterize spectrum, causes of admission and predictors of death in patients with NTSCI treated at the neurological intensive care unit (NICU).

METHODS

We performed a retrospective observational analysis of NTSCI cases treated at a tertiary care center between 2001 and 2013. Among the 3937 NICU admissions were 93 patients with NTSCI (2.4%). Using multivariate logistic regression analysis, we examined predictors of mortality including demographics, etiology, reasons for admission and GCS/SAPS (Glasgow Coma Scale/Simplified Acute Physiology Score) scores.

RESULTS

Infectious and inflammatory/autoimmune causes made up 50% of the NTSCI cases. The most common reasons for NICU admission were rapidly progressing paresis (49.5%) and abundance of respiratory insufficiency (26.9%). The mortality rate was 22.6% and 2.5-fold higher than in the cohort of all other patients treated at the NICU. Respiratory insufficiency as the reason for NICU admission [odds ratio (OR) 4.97, 95% confidence interval (CI) 1.38-17.9; p < 0.01], high initial SAPS scores (OR 1.04; 95% CI 1.003-1.08; p = 0.04), and the development of acute kidney injury throughout the stay (OR 7.25, 1.9-27.5; p = 0.004) were independent risk factors for NICU death.

CONCLUSIONS

Patients with NTSCI account for a subset of patients admitted to the NICU and are at risk for adverse outcome. A better understanding of predisposing conditions and further knowledge of management of critically ill patients with NTSCI is mandatory.