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Bérubé M, Bradley N, O'Donnell M, Stelfox HT, Garraway N, Vasiliadis HM, Turcotte V, Perreault M, Menear M, Archambault L, Haagsma J, Provencher H, Genest C, Gagnon MA, Bourque L, Lapierre A, Khalfi A, Panenka W. Clinical practice guideline recommendations to improve the mental health of adult trauma patients: protocol for a systematic review. BMJ Open 2024; 14:e079205. [PMID: 38531562 DOI: 10.1136/bmjopen-2023-079205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/28/2024] Open
Abstract
INTRODUCTION Mental disorders are common in adult patients with traumatic injuries. To limit the burden of poor psychological well-being in this population, recognised authorities have issued recommendations through clinical practice guidelines (CPGs). However, the uptake of evidence-based recommendations to improve the mental health of trauma patients has been low until recently. This may be explained by the complexity of optimising mental health practices and interpretating CGPs scope and quality. Our aim is to systematically review CPG mental health recommendations in the context of trauma care and appraise their quality. METHODS AND ANALYSIS We will identify CPG through a search strategy applied to Medline, Embase, CINAHL, PsycINFO and Web of Science databases, as well as guidelines repositories and websites of trauma associations. We will target CPGs on adult and acute trauma populations including at least one recommendation on any prevention, screening, assessment, intervention, patient and family engagement, referral or follow-up procedure related to mental health endorsed by recognised organisations in high-income countries. No language limitations will be applied, and we will limit the search to the last 15 years. Pairs of reviewers will independently screen titles, abstracts, full texts, and carry out data extraction and quality assessment of CPGs using the Appraisal of Guidelines Research and Evaluation (AGREE) II. We will synthesise the evidence on recommendations for CPGs rated as moderate or high quality using a matrix based on the Grading of Recommendations Assessment, Development and Evaluation quality of evidence, strength of recommendation, health and social determinants and whether recommendations were made using a population-based approach. ETHICS AND DISSEMINATION Ethics approval is not required, as we will conduct secondary analysis of published data. The results will be disseminated in a peer-reviewed journal, at international and national scientific meetings. Accessible summary will be distributed to interested parties through professional, healthcare quality and persons with lived experience associations. PROSPERO REGISTRATION NUMBER: (ID454728).
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Affiliation(s)
- Mélanie Bérubé
- Population Health and Optimal Practices Research Unit Research Unit (Trauma-Emergency-Critical Care Medicine), CHU de Québec-Université Laval Research Centre, Québec, Quebec, Canada
- Faculty of Nursing, Université Laval, Québec City, Quebec, Canada
| | - Nori Bradley
- University of Alberta Hospital, Edmonton, Alberta, Canada
| | - Meaghan O'Donnell
- Department of Psychiatry, The University of Melbourne Faculty of Medicine Dentistry and Health Sciences, Melbourne, Victoria, Australia
| | - Henry Thomas Stelfox
- Department of Critical Care Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Naisan Garraway
- Vancouver General Hospital, Vancouver, British Columbia, Canada
| | | | - Valerie Turcotte
- Department of Social and Preventive Medicine, Université Laval, Québec City, Quebec, Canada
| | - Michel Perreault
- Institut universitaire en santé mentale Douglas, Montréal, Quebec, Canada
| | - Matthew Menear
- Department of Family Medicine and Emergency Medicine, Université Laval, Québec City, Quebec, Canada
| | - Léonie Archambault
- Institut universitaire en santé mentale Douglas, Montréal, Quebec, Canada
| | - Juanita Haagsma
- Faculty of Public Health, Erasmus MC, Rotterdam, The Netherlands
| | | | - Christine Genest
- Faculté des sciences infirmières, Université de Montréal, Montréal, Quebec, Canada
- Centre de recherche de l'Institut universitaire en santé mentale de Montréal, Montréal, Quebec, Canada
| | - Marc-Aurèle Gagnon
- Population Health and Optimal Practices Research Unit Research Unit (Trauma-Emergency-Critical Care Medicine), CHU de Québec-Université Laval Research Centre, Québec, Quebec, Canada
| | - Laurence Bourque
- Population Health and Optimal Practices Research Unit Research Unit (Trauma-Emergency-Critical Care Medicine), CHU de Québec-Université Laval Research Centre, Québec, Quebec, Canada
| | - Alexandra Lapierre
- Population Health and Optimal Practices Research Unit Research Unit (Trauma-Emergency-Critical Care Medicine), CHU de Québec-Université Laval Research Centre, Québec, Quebec, Canada
| | - Amal Khalfi
- Faculty of Nursing, Université Laval, Québec City, Quebec, Canada
| | - William Panenka
- Department of Psychiatry, The University of British Columbia, Vancouver, British Columbia, Canada
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Sauro KM, O'Rielly CM, Kersen J, Soo A, Bagshaw SM, Stelfox HT. Critical illness among patients experiencing homelessness: a retrospective cohort study. Crit Care 2023; 27:477. [PMID: 38053149 PMCID: PMC10699027 DOI: 10.1186/s13054-023-04753-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 11/20/2023] [Indexed: 12/07/2023] Open
Abstract
PURPOSE To understand the epidemiology and healthcare use of critically ill patients experiencing homelessness compared to critically ill patients with stable housing. METHODS This retrospective population-based cohort study included adults admitted to any ICU in Alberta, Canada, for a 3-year period. Administrative and clinical data from the hospital, ICU and emergency department were used to examine healthcare resource use (processes of care, ICU and hospital length of stay, hospital readmission and emergency room visits). Regression was used to quantify differences in healthcare use by housing status. RESULTS 2.3% (n = 1086) of patients admitted to the ICU were experiencing homelessness; these patients were younger, more commonly admitted for medical reasons and had fewer comorbidities compared to those with stable housing. Processes of care in the ICU were mostly similar, but healthcare use after ICU was different; patients experiencing homelessness who survived their index hospitalization were more than twice as likely to have a visit to the emergency department (OR = 2.3 times, 95% CI 2.0-2.6, < 0.001) or be readmitted to hospital (OR = 2.1, 95% CI 1.8-2.4, p < 0.001) within 30 days, and stayed 10.1 days longer in hospital (95% CI 8.6-11.6, p < 0.001), compared with those who have stable housing. CONCLUSIONS Patients experiencing homelessness have different characteristics at ICU admission and have similar processes of care in ICU, but their subsequent use of healthcare resources was higher than patients with stable housing. These findings can inform strategies to prepare patients experiencing homelessness for discharge from the ICU to reduce healthcare resource use after critical illness.
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Affiliation(s)
- K M Sauro
- Departments of Community Health Sciences, Surgery and Oncology, O'Brien Institute for Public Health and Arnie Charbonneau Cancer Institute, Cumming School of Medicine, University of Calgary, 3280 Hospital Dr. NW, Room 3D41, Calgary, AB, T2N 4Z6, Canada.
| | | | - J Kersen
- Department of Community Health Sciences and O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - A Soo
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - S M Bagshaw
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, and Alberta Health Services, Edmonton, AB, Canada
- Critical Care Strategic Clinical Network, Alberta Health Services, Alberta, Canada
| | - H T Stelfox
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, and Alberta Health Services, Edmonton, AB, Canada
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Maratta C, Hutchison K, Nicoll J, Bagshaw SM, Granton J, Kirpalani H, Stelfox HT, Ferguson N, Cook D, Parshuram CS, Moore GP. Overnight staffing in Canadian neonatal and pediatric intensive care units. Front Pediatr 2023; 11:1271730. [PMID: 38027260 PMCID: PMC10646373 DOI: 10.3389/fped.2023.1271730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 10/03/2023] [Indexed: 12/01/2023] Open
Abstract
Aim Infants and children who require specialized medical attention are admitted to neonatal and pediatric intensive care units (ICUs) for continuous and closely supervised care. Overnight in-house physician coverage is frequently considered the ideal staffing model. It remains unclear how often this is achieved in both pediatric and neonatal ICUs in Canada. The aim of this study is to describe overnight in-house physician staffing in Canadian pediatric and level-3 neonatal ICUs (NICUs) in the pre-COVID-19 era. Methods A national cross-sectional survey was conducted in 34 NICUs and 19 pediatric ICUs (PICUs). ICU directors or their delegates completed a 29-question survey describing overnight staffing by resident physicians, fellow physicians, nurse practitioners, and attending physicians. A comparative analysis was conducted between ICUs with and without in-house physicians. Results We obtained responses from all 34 NICUs and 19 PICUs included in this study. A total of 44 ICUs (83%) with in-house overnight physician coverage provided advanced technologies, such as extracorporeal life support, and included all ICUs that catered to patients with cardiac, transplant, or trauma conditions. Residents provided the majority of overnight coverage, followed by the Critical Care Medicine fellows. An attending physician was in-house overnight in eight (15%) out of the 53 ICUs, seven of which were NICUs. Residents participating in rotations in the ICU would often have rotation durations of less than 6 weeks and were often responsible for providing care during shifts lasting 20-24 h. Conclusion Most PICUs and level-3 NICUs in Canada have a dedicated in-house physician overnight. These physicians are mainly residents or fellows, but a notable variation exists in this arrangement. The potential effects on patient outcomes, resident learning, and physician satisfaction remain unclear and warrant further investigation.
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Affiliation(s)
- Christina Maratta
- Inter-Departmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Department of Critical Care Medicine, Hospital for Sick Children, Toronto, ON, Canada
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Child Health and Evaluative Sciences, SickKids Research Institute, Toronto, ON, Canada
| | - Kristen Hutchison
- Centre for Safety Research, Sick Kids Research Institute, Toronto, ON, Canada
| | - Jessica Nicoll
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Centre for Safety Research, Sick Kids Research Institute, Toronto, ON, Canada
| | - Sean M. Bagshaw
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - John Granton
- Inter-Departmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Haresh Kirpalani
- Department of Paediatrics, University of Pennsylvania, Philadelphia, PA, United States
| | - Henry Thomas Stelfox
- Department of Critical Care Medicine and O’Brien Institute for Public Health, University of Calgary & Alberta Health Services, Calgary, AB, Canada
| | - Niall Ferguson
- Inter-Departmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Department of Medicine and Physiology, University of Toronto, Toronto, ON, Canada
| | - Deborah Cook
- Department of Medicine and Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, ON, Canada
- Division of Critical Care Medicine, McMaster University, Hamilton, ON, Canada
| | - Christopher S. Parshuram
- Inter-Departmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Department of Critical Care Medicine, Hospital for Sick Children, Toronto, ON, Canada
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Child Health and Evaluative Sciences, SickKids Research Institute, Toronto, ON, Canada
- Centre for Safety Research, Sick Kids Research Institute, Toronto, ON, Canada
| | - Gregory P. Moore
- Division of Neonatology, Children’s Hospital of Eastern Ontario, Ottawa, ON, Canada
- Division of Newborn Care, The Ottawa Hospital, Ottawa, ON, Canada
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
- Clinical Research Unit, Research Institute, Children’s Hospital of Eastern Ontario, Ottawa, ON, Canada
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Moore L, Bérubé M, Belcaid A, Turgeon AF, Taljaard M, Fowler R, Yanchar N, Mercier É, Paquet J, Stelfox HT, Archambault P, Berthelot S, Guertin JR, Haas B, Ivers N, Grimshaw J, Lapierre A, Ouyang Y, Sykes M, Witteman H, Lessard-Bonaventure P, Gabbe B, Lauzier F. Evaluating the effectiveness of a multifaceted intervention to reduce low-value care in adults hospitalized following trauma: a protocol for a pragmatic cluster randomized controlled trial. Implement Sci 2023; 18:27. [PMID: 37420284 DOI: 10.1186/s13012-023-01279-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 05/28/2023] [Indexed: 07/09/2023] Open
Abstract
BACKGROUND While simple Audit & Feedback (A&F) has shown modest effectiveness in reducing low-value care, there is a knowledge gap on the effectiveness of multifaceted interventions to support de-implementation efforts. Given the need to make rapid decisions in a context of multiple diagnostic and therapeutic options, trauma is a high-risk setting for low-value care. Furthermore, trauma systems are a favorable setting for de-implementation interventions as they have quality improvement teams with medical leadership, routinely collected clinical data, and performance-linked to accreditation. We aim to evaluate the effectiveness of a multifaceted intervention for reducing low-value clinical practices in acute adult trauma care. METHODS We will conduct a pragmatic cluster randomized controlled trial (cRCT) embedded in a Canadian provincial quality assurance program. Level I-III trauma centers (n = 30) will be randomized (1:1) to receive simple A&F (control) or a multifaceted intervention (intervention). The intervention, developed using extensive background work and UK Medical Research Council guidelines, includes an A&F report, educational meetings, and facilitation visits. The primary outcome will be the use of low-value initial diagnostic imaging, assessed at the patient level using routinely collected trauma registry data. Secondary outcomes will be low-value specialist consultation, low-value repeat imaging after a patient transfer, unintended consequences, determinants for successful implementation, and incremental cost-effectiveness ratios. DISCUSSION On completion of the cRCT, if the intervention is effective and cost-effective, the multifaceted intervention will be integrated into trauma systems across Canada. Medium and long-term benefits may include a reduction in adverse events for patients and an increase in resource availability. The proposed intervention targets a problem identified by stakeholders, is based on extensive background work, was developed using a partnership approach, is low-cost, and is linked to accreditation. There will be no attrition, identification, or recruitment bias as the intervention is mandatory in line with trauma center designation requirements, and all outcomes will be assessed with routinely collected data. However, investigators cannot be blinded to group allocation and there is a possibility of contamination bias that will be minimized by conducting intervention refinement only with participants in the intervention arm. TRIAL REGISTRATION This protocol has been registered on ClinicalTrials.gov (February 24, 2023, # NCT05744154 ).
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Affiliation(s)
- Lynne Moore
- Department of Social and Preventive Medicine, Université Laval, 1050 Av. de La Médecine, Québec, Qc, Canada
- Population Health and Optimal Health Practices Research Unit, Centre de Recherche du CHU de Québec (Hôpital de L'Enfant-Jésus), Université Laval, 1050 Av. de La Médecine, Québec, Qc, Canada
| | - Mélanie Bérubé
- Population Health and Optimal Health Practices Research Unit, Centre de Recherche du CHU de Québec (Hôpital de L'Enfant-Jésus), Université Laval, 1050 Av. de La Médecine, Québec, Qc, Canada
- Faculty of Nursing, Université Laval, 1050 Av. de La Médecine, Québec, Qc, Canada
| | - Amina Belcaid
- Institut national d'excellence en santé et services sociaux, Bd Laurier, Québec, Qc, 2535, Canada
| | - Alexis F Turgeon
- Population Health and Optimal Health Practices Research Unit, Centre de Recherche du CHU de Québec (Hôpital de L'Enfant-Jésus), Université Laval, 1050 Av. de La Médecine, Québec, Qc, Canada
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, 1050 Av. de La Médecine, Québec, Qc, Canada
| | - Monica Taljaard
- Ottawa Hospital Research Institute, 725 Parkdale Ave, Ottawa, On, Canada
| | - Robert Fowler
- Sunnybrook Research Institute, 2075 Bayview Avenue, Toronto, On, Canada
| | - Natalie Yanchar
- Department of Surgery, University of Calgary, 3280 Hospital Dr. NW, Calgary, Ab, Canada
| | - Éric Mercier
- Population Health and Optimal Health Practices Research Unit, Centre de Recherche du CHU de Québec (Hôpital de L'Enfant-Jésus), Université Laval, 1050 Av. de La Médecine, Québec, Qc, Canada
| | - Jérôme Paquet
- Department of Surgery, Université Laval, 1050 Av. de La Médecine, Québec, Qc, Canada
| | - Henry Thomas Stelfox
- Department of Critical Care Medicine, Medicine and Community Health Sciences, O'Brien Institute for Public Health, University of Calgary, 3280 Hospital Dr. NW, Calgary, Al, Canada
| | - Patrick Archambault
- Population Health and Optimal Health Practices Research Unit, Centre de Recherche du CHU de Québec (Hôpital de L'Enfant-Jésus), Université Laval, 1050 Av. de La Médecine, Québec, Qc, Canada
| | - Simon Berthelot
- Population Health and Optimal Health Practices Research Unit, Centre de Recherche du CHU de Québec (Hôpital de L'Enfant-Jésus), Université Laval, 1050 Av. de La Médecine, Québec, Qc, Canada
| | - Jason R Guertin
- Population Health and Optimal Health Practices Research Unit, Centre de Recherche du CHU de Québec (Hôpital de L'Enfant-Jésus), Université Laval, 1050 Av. de La Médecine, Québec, Qc, Canada
| | - Barbara Haas
- Department of Surgery, University of Toronto, 149 College St, Toronto, On, Canada
| | - Noah Ivers
- Department of Family and Community Medicine and Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College St 4Th Floor, Toronto, On, Canada
| | - Jeremy Grimshaw
- Ottawa Hospital Research Institute, 725 Parkdale Ave, Ottawa, On, Canada
| | - Alexandra Lapierre
- Faculty of Nursing, Université de Montréal, Chem. de La Côte-Sainte-Catherine, Montréal, Qc, 2375, Canada
| | - Yongdong Ouyang
- Ottawa Hospital Research Institute, 725 Parkdale Ave, Ottawa, On, Canada
| | - Michael Sykes
- Department of Nursing, Midwifery, and Health, Northumbria University, Ellison PI, Newcastle, UK
| | - Holly Witteman
- Department of Family and Emergency Medicine, Université Laval, 1050 Av. de La Médecine, Québec, Qc, Canada
| | - Paule Lessard-Bonaventure
- Department of Surgery, Division of Neurosurgery, Université Laval, 1050 Av. de La Médecine, Québec, Canada
| | - Belinda Gabbe
- School of Public Health and Preventive Medicine, Monash University, 553 St. Kilda Rd, Melbourne, Victoria, VIC 3004, Australia
| | - François Lauzier
- Population Health and Optimal Health Practices Research Unit, Centre de Recherche du CHU de Québec (Hôpital de L'Enfant-Jésus), Université Laval, 1050 Av. de La Médecine, Québec, Qc, Canada
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, 1050 Av. de La Médecine, Québec, Qc, Canada
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Moss SJ, Racine N, Ahmed S, Birnie K, Cherak MS, Curran JA, Halperin D, Halperin SA, Harley M, Hu J, Leppan L, Nickel A, Russell K, Solis M, Smith S, Soo A, Stelfox M, Tutelman PR, Stelfox HT, Fiest KM, Parsons Leigh J. Codesigning a user-centred digital psychoeducational tool for youth mental well-being with families in Canada: study protocol for a sequential exploratory mixed methods study. BMJ Open 2023; 13:e072533. [PMID: 37369410 PMCID: PMC10410808 DOI: 10.1136/bmjopen-2023-072533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 06/05/2023] [Indexed: 06/29/2023] Open
Abstract
INTRODUCTION On 11 March 2020, WHO declared the novel coronavirus (COVID-19) disease a global pandemic. Governments globally implemented physical distancing measures and closure of public institutions that resulted in varying implications to youth mental well-being (eg, social isolation, reduced extracurricular activities). These impacts may have detrimental short-term and long-term effects on youth mental well-being; care for youth with mental health disorders was already overstretched, underfunded and fragmented before the pandemic and youth are not often considered in mental health initiatives. There is a pressing need to partner with youth and families to target and improve youth mental well-being prior to the onset of a mental health disorder, as well as to conduct research on youth mental well-being needs related to pandemic recovery. Here we present a protocol for partnering with youth and families to codesign a user-centred digital tool for youth mental well-being. METHODS AND ANALYSIS We will conduct a national research study to develop a catalogue of recommendations specific to supporting youth mental well-being, and a digital tool to support youth mental well-being through three phases of work: (1) expert consultation on data related to supporting youth mental well-being existing within our Pandemic Preparedness Research Program; (2) codesign of an innovative digital tool for youth mental well-being; and (3) assessment of the tool's usability and acceptability. ETHICS AND DISSEMINATION This study has been approved by the Dalhousie Research Ethics Board (2023-6538) and the Conjoint Health Research Ethics Board (23-0039). This study will complement ongoing foundational research in youth conducted by our team that involves partnering with youth and families to understand the unique implications of the pandemic on this population.
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Affiliation(s)
| | - Nicole Racine
- School of Psychology, University of Ottawa, Ottawa, Ontario, Canada
| | - Sofia Ahmed
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Kathryn Birnie
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Michal S Cherak
- Faculty of Health, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Janet A Curran
- Faculty of Health, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Donna Halperin
- School of Nursing, St Francis Xavier University, Antigonish, Nova Scotia, Canada
| | - Scott A Halperin
- Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Micaela Harley
- Faculty of Health, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Jia Hu
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Laura Leppan
- Faculty of Health, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Angie Nickel
- Faculty of Health, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Kristine Russell
- Faculty of Health, Dalhousie University, Halifax, Nova Scotia, Canada
| | - May Solis
- Faculty of Health, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Stacie Smith
- Faculty of Health, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Andrea Soo
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Maia Stelfox
- Faculty of Health, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Perri R Tutelman
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | | | - Kirsten M Fiest
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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Ho C, Ocampo W, Southern DA, Sola D, Baylis B, Conly JM, Hogan DB, Kaufman J, Stelfox HT, Ghali WA. Effect of a Continuous Bedside Pressure Mapping System for Reducing Interface Pressures: A Randomized Clinical Trial. JAMA Netw Open 2023; 6:e2316480. [PMID: 37266939 DOI: 10.1001/jamanetworkopen.2023.16480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/03/2023] Open
Abstract
Importance Continuous bedside pressure mapping (CBPM) technology can assist in detecting skin areas with excessive interface pressure and inform efficient patient repositioning to prevent the development of pressure injuries (PI). Objective To evaluate the efficacy of CBPM technology in reducing interface pressure and the incidence of PIs. Design, Setting, and Participants This parallel, 2-group randomized clinical trial was performed at a tertiary acute care center. The study started to enroll participants in December 2014 and was completed in May 2018. Participants included adults partially or completely dependent for bed mobility. Statistical analysis was performed from September 2018 to December 2022. Intervention Nursing staff using visual feedback from CBPM technology for 72 hours. Main Outcomes and Measures Absolute number of sensing points with pressure readings greater than 40 mm Hg, mean interface pressure across all sensing points under a patient's body, proportion of participants who had pressure readings greater than 40 mm Hg, and pressure-related skin and soft tissue changes. Results There were 678 patients recruited. After attrition, 260 allocated to the control group (151 [58.1%] male; mean [SD] age, 61.9 [18.5] years) and 247 in the intervention group (147 [59.5%] male; mean [SD] age, 63.6 [18.1] years) were included in analyses. The absolute number of sensing points with pressures greater than 40 mm Hg were 11 033 in the control group vs 9314 in the intervention group (P = .16). The mean (SD) interface pressure was 6.80 (1.63) mm Hg in the control group vs 6.62 (1.51) mm Hg in the intervention group (P = .18). The proportion of participants who had pressure readings greater than 40 mm Hg was 99.6% in both the control and intervention groups. Conclusions and Relevance In this randomized clinical trial to evaluate the efficacy of CBPM technology in the reduction of interface pressure and the incidence of PIs in a tertiary acute care center, no statistically significant benefit was seen for any of the primary outcomes. These results suggest that longer duration of monitoring and adequately powered studies where CBPM feedback is integrated into a multifaceted intervention to prevent PI are needed. Trial Registration ClinicalTrials.gov Identifier: NCT02325388.
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Affiliation(s)
- Chester Ho
- Division of Physical Medicine & Rehabilitation, Department of Medicine, Faculty of Medicine & Dentistry, University of Alberta and Alberta Health Services Neurosciences, Rehabilitation & Vision Strategic Clinical Network, Edmonton, Alberta, Canada
- W21C Research and Innovation Centre, O'Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada
| | - Wrechelle Ocampo
- W21C Research and Innovation Centre, O'Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada
| | - Danielle A Southern
- O'Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada
| | - Darlene Sola
- W21C Research and Innovation Centre, O'Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada
| | - Barry Baylis
- Department of Medicine, Cumming School of Medicine, University of Calgary, and Alberta Health Services, Calgary, Alberta, Canada
- W21C Research and Innovation Centre, O'Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada
- O'Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada
| | - John M Conly
- Department of Medicine, Cumming School of Medicine, University of Calgary, and Alberta Health Services, Calgary, Alberta, Canada
- W21C Research and Innovation Centre, O'Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada
- O'Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada
- Synder Institute for Chronic Diseases, Cumming School of Medicine, University of Calgary and Alberta Health Services, Calgary, Alberta, Canada
| | - David B Hogan
- Department of Medicine, Cumming School of Medicine, University of Calgary, and Alberta Health Services, Calgary, Alberta, Canada
- W21C Research and Innovation Centre, O'Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada
- O'Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada
| | - Jaime Kaufman
- W21C Research and Innovation Centre, O'Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada
| | - Henry Thomas Stelfox
- Department of Medicine, Cumming School of Medicine, University of Calgary, and Alberta Health Services, Calgary, Alberta, Canada
- W21C Research and Innovation Centre, O'Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada
- O'Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada
- Departments of Critical Care Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- Department of Critical Care Medicine, Alberta Health Services, Calgary, Alberta, Canada
| | - William A Ghali
- Department of Medicine, Cumming School of Medicine, University of Calgary, and Alberta Health Services, Calgary, Alberta, Canada
- W21C Research and Innovation Centre, O'Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada
- O'Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada
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Shahid A, Johnstone C, Sept BG, Kupsch S, Soo A, Fiest KM, Stelfox HT. Family coaching during Spontaneous Awakening Trials and Spontaneous Breathing Trials (FamCAB): pilot study protocol. BMJ Open 2023; 13:e068770. [PMID: 36806132 PMCID: PMC9943692 DOI: 10.1136/bmjopen-2022-068770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/22/2023] Open
Abstract
INTRODUCTION Many patients in the intensive care unit (ICU) require weaning from deep sedation (Spontaneous Awakening Trials, SATs) and mechanical ventilation (Spontaneous Breathing Trials, SBTs) in their journey to recovery. These procedures can be distressing for patients and their families. The presence of family members as 'coaches' during SATs/SBTs could provide patients with reassurance, reduce stress for patients and families and potentially improve procedural success rates. METHODS AND ANALYSIS This study will be executed in two phases:Development of a coaching module: a working group including patient partners (i.e., former ICU patients or family members of former ICU patients), researchers, and ICU clinicians will develop an educational module on family coaching during SATs/SBTs (FamCAB). This module will provide families of critically ill patients basic information about SATs/SBTs as well as coaching guidance.Pilot testing: family members of ICU patients will complete the FamCAB module and provide information on: (1) demographics, (2) anxiety and (3) satisfaction with care in the ICU. Family members will then coach the patient through the next clinically indicated SATs and/or SBTs. Information around duration of time and success rates of SATs and/or SBTs (ability to conduct a complete assessment) alongside feedback will be collected. ICU clinical staff (including physicians and nurses) will be asked for feedback on practicality and perceived benefits or drawbacks of family coaching during these procedures. Feasibility and acceptability of family coaching in SATs/SBTs will be determined. DISCUSSION The results of this work will inform whether a larger study to explore family coaching during SATs/SBTs is warranted. ETHICS AND DISSEMINATION This study has received ethical approval from the University of Calgary Conjoint Health Research Ethics Board. Results from this pilot study will be made available via peer-reviewed journals and presented at critical care conferences on completion.
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Affiliation(s)
- Anmol Shahid
- Department of Critical Care Medicine, University of Calgary & Alberta Health Services, Calgary, Alberta, Canada
| | - Corson Johnstone
- Department of Critical Care Medicine, University of Calgary & Alberta Health Services, Calgary, Alberta, Canada
| | - Bonnie G Sept
- Department of Critical Care Medicine, University of Calgary & Alberta Health Services, Calgary, Alberta, Canada
| | - Shelly Kupsch
- Department of Critical Care Medicine, University of Calgary & Alberta Health Services, Calgary, Alberta, Canada
| | - Andrea Soo
- Department of Critical Care Medicine, University of Calgary & Alberta Health Services, Calgary, Alberta, Canada
| | - Kirsten M Fiest
- Department of Critical Care Medicine, University of Calgary & Alberta Health Services, Calgary, Alberta, Canada
- Department of Psychiatry, Hotchkiss Brain Institute, and Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Henry Thomas Stelfox
- Department of Critical Care Medicine, University of Calgary & Alberta Health Services, Calgary, Alberta, Canada
- O'Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada
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Moore L, Bérubé M, Tardif PA, Lauzier F, Turgeon A, Cameron P, Champion H, Yanchar N, Lecky F, Kortbeek J, Evans D, Mercier É, Archambault P, Lamontagne F, Gabbe B, Paquet J, Razek T, Belcaid A, Berthelot S, Malo C, Lang E, Stelfox HT. Validation of Quality Indicators Targeting Low-Value Trauma Care. JAMA Surg 2022; 157:2796291. [PMID: 36103195 PMCID: PMC9475433 DOI: 10.1001/jamasurg.2022.3912] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 06/18/2022] [Indexed: 09/16/2023]
Abstract
Importance Reducing low-value care has the potential to improve patient experiences and outcomes and free up health care resources. Sixteen quality indicators were recently developed targeting reductions in low-value trauma care based on a synthesis of the best available evidence, expert consensus, and patient preferences. Objective To assess the validity of quality indicators on low-value trauma care using trauma registry data. Design, Setting, and Participants Data from an inclusive Canadian provincial trauma system were used in this analysis. Included were all admissions for injury to any of the 57 provincial adult trauma centers between April 1, 2013, and March 31, 2020. Metrics for quality indicators were developed iteratively with clinical experts. Main Outcomes and Measures Validity was assessed using a priori criteria based on 5 parameters: frequency (incidence and case volume), discrimination (interhospital variation), construct validity (correlation with quality indicators on high-value care), predictive validity (correlation with quality indicators on risk-adjusted outcomes), and forecasting (correlation over time). Results The study sample included 136 783 patient admissions (mean [SD] age, 63 [22] years; 68 428 men [50%]). Metrics were developed for 12 of the 16 quality indicators. Six quality indicators showed moderate or high validity on all measurable parameters: initial head, cervical spine, or whole-body computed tomography for low-risk patients; posttransfer repeated computed tomography; neurosurgical consultation for mild complicated traumatic brain injury; and spine service consultation for isolated thoracolumbar process fractures. Red blood cell transfusion in low-risk patients had low frequency but had moderate or high validity on all other parameters. Five quality indicators had low validity on at least 2 parameters: repeated head CT and intensive care unit admission for mild complicated traumatic brain injury, hospital admission for minor blunt abdominal trauma, orthosis for thoracolumbar burst fractures, and surgical exploration in penetrating neck injury without hard signs. Conclusions and Relevance This cohort study shows the feasibility of assessing low-value trauma care using routinely collected data. It provided data on quality indicators properties that can be used to decide which quality indicators are most appropriate in a given system. Results suggest that 6 quality indicators have moderate to high validity. Their implementation now needs to be tested.
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Affiliation(s)
- Lynne Moore
- Department of Social and Preventative Medicine, Université Laval, Québec City, Québec, Canada
- Population Health and Optimal Health Practices Research Unit, Trauma–Emergency–Critical Care Medicine, Centre de Recherche du CHU de Québec, Hôpital de l’Enfant-Jésus, Université Laval, Québec City, Québec, Canada
| | - Mélanie Bérubé
- Department of Social and Preventative Medicine, Université Laval, Québec City, Québec, Canada
- Population Health and Optimal Health Practices Research Unit, Trauma–Emergency–Critical Care Medicine, Centre de Recherche du CHU de Québec, Hôpital de l’Enfant-Jésus, Université Laval, Québec City, Québec, Canada
- Faculty of Nursing, Université Laval, Québec City, Québec, Canada
| | - Pier-Alexandre Tardif
- Population Health and Optimal Health Practices Research Unit, Trauma–Emergency–Critical Care Medicine, Centre de Recherche du CHU de Québec, Hôpital de l’Enfant-Jésus, Université Laval, Québec City, Québec, Canada
| | - François Lauzier
- Department of Social and Preventative Medicine, Université Laval, Québec City, Québec, Canada
- Population Health and Optimal Health Practices Research Unit, Trauma–Emergency–Critical Care Medicine, Centre de Recherche du CHU de Québec, Hôpital de l’Enfant-Jésus, Université Laval, Québec City, Québec, Canada
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, Québec City, Québec, Canada
| | - Alexis Turgeon
- Department of Social and Preventative Medicine, Université Laval, Québec City, Québec, Canada
- Population Health and Optimal Health Practices Research Unit, Trauma–Emergency–Critical Care Medicine, Centre de Recherche du CHU de Québec, Hôpital de l’Enfant-Jésus, Université Laval, Québec City, Québec, Canada
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, Québec City, Québec, Canada
| | - Peter Cameron
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Howard Champion
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Natalie Yanchar
- Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Fiona Lecky
- School of Health and Related Research, University of Sheffield, Sheffield, United Kingdom
- Trauma Audit and Research Network, Salford, United Kingdom
| | - John Kortbeek
- Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | - David Evans
- Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Éric Mercier
- Population Health and Optimal Health Practices Research Unit, Trauma–Emergency–Critical Care Medicine, Centre de Recherche du CHU de Québec, Hôpital de l’Enfant-Jésus, Université Laval, Québec City, Québec, Canada
| | - Patrick Archambault
- Population Health and Optimal Health Practices Research Unit, Transfert des Connaissances et Évaluation des Technologies et Modes d’Intervention en Santé, Centre de Recherche du CHU de Québec, Hôpital St François d’Assise, Université Laval, Québec City, Québec, Canada
| | - François Lamontagne
- Department of Medicine, Université de Sherbrooke, Sherbrooke, Québec, Canada
| | - Belinda Gabbe
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Jérôme Paquet
- Department of Surgery, Division of Neurosurgery, Université Laval, Québec City, Québec, Canada
| | - Tarek Razek
- Department of Trauma Surgery, Montreal General Hospital, McGill University Health Center, Montreal, Québec, Canada
| | - Amina Belcaid
- Institut National d’Excellence en Santé et Services Sociaux, Québec City, Québec, Canada
| | - Simon Berthelot
- Population Health and Optimal Health Practices Research Unit, Trauma–Emergency–Critical Care Medicine, Centre de Recherche du CHU de Québec, Hôpital de l’Enfant-Jésus, Université Laval, Québec City, Québec, Canada
| | - Christian Malo
- Département de Médicine Familiale et de Médicine d’urgence, Faculté de Médecine, Université Laval, Québec City, Québec, Canada
| | - Eddy Lang
- University of Calgary, Calgary, Alberta, Canada
| | - Henry Thomas Stelfox
- Department of Critical Care Medicine, O’Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada
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Moore L, Guertin JR, Tardif PA, Ivers NM, Hoch J, Conombo B, Antony J, Stelfox HT, Berthelot S, Archambault P, Turgeon A, Gandhi R, Grimshaw JM. Economic evaluations of audit and feedback interventions: a systematic review. BMJ Qual Saf 2022; 31:754-767. [PMID: 35750494 DOI: 10.1136/bmjqs-2022-014727] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 05/15/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND The effectiveness of audit and feedback (A&F) interventions to improve compliance to healthcare guidelines is supported by randomised controlled trials (RCTs) and meta-analyses of RCTs. However, there is currently a knowledge gap on their cost-effectiveness. OBJECTIVE We aimed to assess whether A&F interventions targeting improvements in compliance to recommended care are economically favourable. METHODS We conducted a systematic review including experimental, observational and simulation-based economic evaluation studies of A&F interventions targeting healthcare providers. Comparators were a 'do nothing' strategy, or any other intervention not involving A&F or involving a subset of A&F intervention components. We searched MEDLINE, CINAHL, CENTRAL, Econlit, EMBASE, Health Technology Assessment Database, MEDLINE, NHS Economic Evaluation Database, ABI/INFORM, Web of Science, ProQuest and websites of healthcare quality associations to December 2021. Outcomes were incremental cost-effectiveness ratios, incremental cost-utility ratios, incremental net benefit and incremental cost-benefit ratios. Pairs of reviewers independently selected eligible studies and extracted relevant data. Reporting quality was evaluated using CHEERS (Consolidated Health Economic Evaluation Reporting Standards). Results were synthesised using permutation matrices for all studies and predefined subgroups. RESULTS Of 13 221 unique citations, 35 studies met our inclusion criteria. The A&F intervention was dominant (ie, at least as effective with lower cost) in 7 studies, potentially cost-effective in 26 and was dominated (ie, the same or less effectiveness and higher costs) in 2 studies. A&F interventions were more likely to be economically favourable in studies based on health outcomes rather than compliance to recommended practice, considering medical costs in addition to intervention costs, published since 2010, and with high reporting quality. DISCUSSION Results suggest that A&F interventions may have a high potential to be cost-effective. However, as is common in systematic reviews of economic evaluations, publication bias could have led to an overestimation of their economic value.
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Affiliation(s)
- Lynne Moore
- Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, CHU de Québec-Université Laval, Quebec, Quebec, Canada
| | - Jason Robert Guertin
- Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, CHU de Québec-Université Laval, Quebec, Quebec, Canada
| | - Pier-Alexandre Tardif
- Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, CHU de Québec-Université Laval, Quebec, Quebec, Canada
| | - Noah Michael Ivers
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Jeffrey Hoch
- Department of Public Health Sciences, University of California San Francisco, San Francisco, California, USA
| | - Blanchard Conombo
- Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, CHU de Québec-Université Laval, Quebec, Quebec, Canada
| | - Jesmin Antony
- Women's College Hospital Institute for Health System Solutions and Virtual Care, Toronto, Ontario, Canada
| | | | - Simon Berthelot
- Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, CHU de Québec-Université Laval, Quebec, Quebec, Canada
| | - Patrick Archambault
- Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, CHU de Québec-Université Laval, Quebec, Quebec, Canada
| | - Alexis Turgeon
- Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, CHU de Québec-Université Laval, Quebec, Quebec, Canada
| | - Rohit Gandhi
- Department of Pediatric Neurology, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - J M Grimshaw
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
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10
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Moore L, Freire G, Ben Abdeljelil A, Berube M, Tardif PA, Gnanvi E, Stelfox HT, Beaudin M, Carsen S, Stang A, Beno S, Weiss M, Labrosse M, Zemek R, Gagnon IJ, Beaulieu E, Berthelot S, Klassen T, Turgeon AF, Lauzier F, Pike I, Macpherson A, Gabbe BJ, Yanchar N. Clinical practice guideline recommendations for pediatric injury care: protocol for a systematic review. BMJ Open 2022; 12:e060054. [PMID: 35477878 PMCID: PMC9047816 DOI: 10.1136/bmjopen-2021-060054] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION Evidence suggests the presence of deficiencies in the quality of care provided to up to half of all paediatric trauma patients in Canada, the USA and Australia. Lack of adherence to evidence-based recommendations may be driven by lack of knowledge of clinical practice guidelines (CPGs), heterogeneity in recommendations or concerns about their quality. We aim to systematically review CPG recommendations for paediatric injury care and appraise their quality. METHODS AND ANALYSIS We will identify CPG recommendations through a comprehensive search strategy including Medical Literature Analysis and Retrieval System Online, Excerpta Medica dataBASE, Cochrane library, Web of Science, ClinicalTrials and websites of organisations publishing recommendations on paediatric injury care. We will consider CPGs including at least one recommendation targeting paediatric injury populations on any diagnostic or therapeutic intervention from the acute phase of care with any comparator developed in high-income countries in the last 15 years (January 2007 to a maximum of 6 months prior to submission). Pairs of reviewers will independently screen titles, abstracts and full text of eligible articles, extract data and evaluate the quality of CPGs and their recommendations using Appraisal of Guidelines Research and Evaluation (AGREE) II and AGREE Recommendations Excellence instruments, respectively. We will synthesise evidence on recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) Evidence-to-Decision framework and present results within a recommendations matrix. ETHICS AND DISSEMINATION Ethics approval is not a requirement as this study is based on available published data. The results of this systematic review will be published in a peer-reviewed journal, presented at international scientific meetings and distributed to healthcare providers. PROSPERO REGISTRATION NUMBER International Prospective Register of Systematic Reviews (CRD42021226934).
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Affiliation(s)
- Lynne Moore
- Department of Social and Preventive Medicine, Faculté de médecine, Université Laval, Quebec City, Quebec, Canada
- Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, Centre de Recherche du CHU de Québec (Hôpital de l'Enfant-Jésus), Université Laval, Québec City, Québec, Canada
| | - Gabrielle Freire
- Division of Emergency Medicine, Department of Paediatrics, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Anis Ben Abdeljelil
- Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, Centre de Recherche du CHU de Québec (Hôpital de l'Enfant-Jésus), Université Laval, Québec City, Québec, Canada
| | - Melanie Berube
- Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, Centre de Recherche du CHU de Québec (Hôpital de l'Enfant-Jésus), Université Laval, Québec City, Québec, Canada
- Faculty of Nursing, Université Laval, Quebec City, Quebec, Canada
| | - Pier-Alexandre Tardif
- Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, Centre de Recherche du CHU de Québec (Hôpital de l'Enfant-Jésus), Université Laval, Québec City, Québec, Canada
| | - Eunice Gnanvi
- Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, Centre de Recherche du CHU de Québec (Hôpital de l'Enfant-Jésus), Université Laval, Québec City, Québec, Canada
| | - Henry Thomas Stelfox
- Departments of Critical Care Medicine, Medicine and Community Health Sciences, O'Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada
| | - Marianne Beaudin
- Sainte-Justine Hospital, Department of Paediatric Surgery, Université de Montréal, Montreal, Quebec, Canada
| | - Sasha Carsen
- Division of Orthopaedic Surgery, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Antonia Stang
- Pediatrics, Emergency Medicine, and Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Suzanne Beno
- Division of Emergency Medicine, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Matthew Weiss
- Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, Centre de Recherche du CHU de Québec (Hôpital de l'Enfant-Jésus), Université Laval, Québec City, Québec, Canada
- Transplant Québec, Montréal, Québec, Canada
| | - Melanie Labrosse
- Department of Pediatrics, Division of Emergency Medicine, CHU Sainte-Justine, Université de Montréal, Montreal, Quebec, Canada
| | - Roger Zemek
- Department of Pediatrics, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Isabelle J Gagnon
- Division of Pediatric Emergency Medicine, McGill University Health Centre, Montreal Children's Hospital, Montreal, Quebec, Canada
| | - Emilie Beaulieu
- Department of Pediatrics, Université Laval, Québec City, Québec, Canada
| | - Simon Berthelot
- Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, Centre de Recherche du CHU de Québec (Hôpital de l'Enfant-Jésus), Université Laval, Québec City, Québec, Canada
| | - Terry Klassen
- George & Fay Yee Centre for Health Care Innovation, Children's Hospital Research Institute of Manitoba, Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Alexis F Turgeon
- Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, Centre de Recherche du CHU de Québec (Hôpital de l'Enfant-Jésus), Université Laval, Québec City, Québec, Canada
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Faculté de médecine, Université Laval, Quebec City, Québec, Canada
| | - François Lauzier
- Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, Centre de Recherche du CHU de Québec (Hôpital de l'Enfant-Jésus), Université Laval, Québec City, Québec, Canada
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Faculté de médecine, Université Laval, Quebec City, Québec, Canada
| | - Ian Pike
- Department of Pediatrics, BC Injury Research and Prevention Unit, The University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Belinda J Gabbe
- School of Public Health and Preventive Medicine, Monash University, Clayton, Victoria, Australia
| | - Natalie Yanchar
- Department of Surgery, University of Calgary, Calgary, Alberta, Canada
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11
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Moore L, Bérubé M, Tardif PA, Lauzier F, Turgeon A, Cameron P, Champion H, Yanchar N, Lecky F, Kortbeek J, Evans D, Mercier É, Archambault P, Lamontagne F, Gabbe B, Paquet J, Razek T, Stelfox HT. Quality Indicators Targeting Low-Value Clinical Practices in Trauma Care. JAMA Surg 2022; 157:507-514. [PMID: 35476055 PMCID: PMC9047751 DOI: 10.1001/jamasurg.2022.0812] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Importance The use of quality indicators has been shown to improve injury care processes and outcomes. However, trauma quality indicators proposed to date exclusively target the underuse of recommended practices. Initiatives such as Choosing Wisely publish lists of practices to be questioned, but few apply to trauma care, and most have not successfully been translated to quality indicators. Objective To develop a set of evidence and patient-informed, consensus-based quality indicators targeting reductions in low-value clinical practices in acute, in-hospital trauma care. Design, Setting, and Participants This 2-round Research and Development/University of California at Los Angeles (RAND/UCLA) consensus study, conducted from April 20 to June 9, 2021, comprised an online questionnaire and a virtual workshop led by 2 independent moderators. Two panels of international experts from Canada, Australia, the US, and the UK, and local stakeholders from Québec, Canada, represented key clinical expertise involved in trauma care and included 3 patient partners. Main Outcomes and Measures Panelists were asked to rate 50 practices on a 7-point Likert scale according to 4 quality indicator criteria: importance, supporting evidence, actionability, and measurability. Results Of 49 eligible experts approached, 46 (94%; 18 experts [39%] aged ≥50 years; 37 men [80%]) completed at least 1 round and 36 (73%) completed both rounds. Eleven quality indicators were selected overall, 2 more were selected by the international panel and a further 3 by the local stakeholder panel. Selected indicators targeted low-value clinical practices in the following aspects of trauma care: (1) initial diagnostic imaging (head, cervical spine, ankle, and pelvis), (2) repeated diagnostic imaging (posttransfer computed tomography [CT] and repeated head CT), (3) consultation (neurosurgical and spine), (4) surgery (penetrating neck injury), (5) blood product administration, (6) medication (antibiotic prophylaxis and late seizure prophylaxis), (7) trauma service admission (blunt abdominal trauma), (8) intensive care unit admission (mild complicated traumatic brain injury), and (9) routine blood work (minor orthopedic surgery). Conclusions and Relevance In this consensus study, a set of consensus-based quality indicators were developed that were informed by the best available evidence and patient priorities, targeting low-value trauma care. Selected indicators represented a trauma-specific list of practices, the use of which should be questioned. Trauma quality programs in high-income countries may use these study results as a basis to select context-specific quality indicators to measure and reduce low-value care.
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Affiliation(s)
- Lynne Moore
- Department of Social and Preventative Medicine, Université Laval, Québec City, Québec, Canada.,Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, Centre de Recherche du CHU de Québec (Hôpital de l'Enfant-Jésus), Université Laval, Québec City, Québec, Canada
| | - Mélanie Bérubé
- Department of Social and Preventative Medicine, Université Laval, Québec City, Québec, Canada.,Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, Centre de Recherche du CHU de Québec (Hôpital de l'Enfant-Jésus), Université Laval, Québec City, Québec, Canada.,Faculty of Nursing, Université Laval, Québec City, Québec, Canada
| | - Pier-Alexandre Tardif
- Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, Centre de Recherche du CHU de Québec (Hôpital de l'Enfant-Jésus), Université Laval, Québec City, Québec, Canada
| | - François Lauzier
- Department of Social and Preventative Medicine, Université Laval, Québec City, Québec, Canada.,Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, Centre de Recherche du CHU de Québec (Hôpital de l'Enfant-Jésus), Université Laval, Québec City, Québec, Canada.,Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Université Laval, Québec City, Québec, Canada
| | - Alexis Turgeon
- Department of Social and Preventative Medicine, Université Laval, Québec City, Québec, Canada.,Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, Centre de Recherche du CHU de Québec (Hôpital de l'Enfant-Jésus), Université Laval, Québec City, Québec, Canada.,Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Université Laval, Québec City, Québec, Canada
| | - Peter Cameron
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Howard Champion
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Natalie Yanchar
- Department of Surgery, University of Calgary, Calgary, Canada
| | - Fiona Lecky
- School of Health and Related Research, University of Sheffield, Sheffield, United Kingdom.,Trauma Audit and Research Network, Salford, United Kingdom
| | - John Kortbeek
- Department of Surgery, University of Calgary, Calgary, Canada
| | - David Evans
- Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Éric Mercier
- Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, Centre de Recherche du CHU de Québec (Hôpital de l'Enfant-Jésus), Université Laval, Québec City, Québec, Canada
| | - Patrick Archambault
- Population Health and Optimal Health Practices Research Unit, Transfert des Connaissances et Évaluation des Technologies et Modes d'Intervention en Santé, Centre de Recherche du CHU de Québec - Université Laval (Hôpital St François d'Assise), Université Laval, Québec City, Québec, Canada
| | - François Lamontagne
- Department of Medicine, Université de Sherbrooke, Sherbrooke, Québec, Canada
| | - Belinda Gabbe
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Jérôme Paquet
- Division of Neurosurgery, Department of Surgery, Université Laval, Québec, Québec, Canada
| | - Tarek Razek
- Department of Trauma Surgery, Montreal General Hospital, McGill University Health Center, Montreal, Canada
| | - Henry Thomas Stelfox
- Departments of Critical Care Medicine, Medicine and Community Health Sciences, O'Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada
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Roberts DJ, Sypes EE, Nagpal SK, Niven D, Mamas M, McIsaac DI, van Walraven C, Shorr R, Graham ID, Stelfox HT, Grimshaw J. Evidence for overuse of cardiovascular healthcare services in high-income countries: protocol for a systematic review and meta-analysis. BMJ Open 2022; 12:e053920. [PMID: 35393307 PMCID: PMC8991042 DOI: 10.1136/bmjopen-2021-053920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Overuse of cardiovascular healthcare services, defined as the provision of low-value (ineffective, harmful, cost-ineffective) tests, medications and procedures, may be common and associated with increased patient harm and health system inefficiencies and costs. We seek to systematically review the evidence for overuse of different cardiovascular healthcare services in high-income countries. METHODS AND ANALYSIS We will search MEDLINE, EMBASE and Evidence-Based Medicine Reviews from 2010 onwards. Two investigators will independently review titles and abstracts and full-text studies. We will include published English-language studies conducted in high-income countries that enrolled adults (mean/median age ≥18 years) and reported the incidence or prevalence of overuse of cardiovascular tests, medications or procedures; adjusted risk factors for overuse; or adjusted associations between overuse and outcomes (reported estimates of morbidity, mortality, costs or lengths of hospital stay). Acceptable methods of defining low-value care will include literature review and multidisciplinary iterative panel processes, healthcare services with reproducible evidence of a lack of benefit or harm, or clinical practice guideline or Choosing Wisely recommendations. Two investigators will independently extract data and evaluate study risk of bias in duplicate. We will calculate summary estimates of the incidence and prevalence of overuse of different cardiovascular healthcare services across studies unstratified and stratified by country; method of defining low-value care; the percentage of included females, different races, and those with low and high socioeconomic status or cardiovascular risk; and study risks of bias using random-effects models. We will also calculate pooled estimates of adjusted risk factors for overuse and adjusted associations between overuse and outcomes overall and stratified by country using random-effects models. We will use the Grading of Recommendations, Assessment, Development and Evaluation to determine certainty in estimates. ETHICS AND DISSEMINATION No ethics approval is required for this study as it deals with published data. Results will be presented at meetings and published in a peer-reviewed journal. PROSPERO REGISTRATION NUMBER CRD42021257490.
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Affiliation(s)
- Derek J Roberts
- Division of Vascular and Endovascular Surgery, Department of Surgery, The Ottawa Hospital and University of Ottawa, Ottawa, Ontario, Canada
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Emma E Sypes
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Sudhir K Nagpal
- Division of Vascular and Endovascular Surgery, Department of Surgery, The Ottawa Hospital and University of Ottawa, Ottawa, Ontario, Canada
| | - Daniel Niven
- Department of Critical Care Medicine, University of Calgary, Calgary, Alberta, Canada
| | | | - Daniel I McIsaac
- Anesthesiology and Pain Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Carl van Walraven
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Medicine, The Ottawa Hospital and University of Ottawa, Ottawa, Ontario, Canada
| | - Risa Shorr
- Learning Services, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Ian D Graham
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Henry Thomas Stelfox
- Department of Critical Care Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Jeremy Grimshaw
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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13
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Mele BS, Holroyd-Leduc JM, Harasym P, Dumanski SM, Fiest K, Graham ID, Nerenberg K, Norris C, Parsons Leigh J, Pilote L, Pruden H, Raparelli V, Rabi D, Ruzycki SM, Somayaji R, Stelfox HT, Ahmed SB. Healthcare workers' perception of gender and work roles during the COVID-19 pandemic: a mixed-methods study. BMJ Open 2021; 11:e056434. [PMID: 35139035 PMCID: PMC8718936 DOI: 10.1136/bmjopen-2021-056434] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
OBJECTIVES A high functioning healthcare workforce is a key priority during the COVID-19 pandemic. We sought to determine how work and mental health for healthcare workers changed during the COVID-19 pandemic in a universal healthcare system, stratified by gender factors. DESIGN A mixed-methods study was employed. Phase 1 was an anonymous, internet-based survey (7 May-15 July 2020). Phase 2 was semistructured interviews offered to all respondents upon survey completion to describe how experiences may have differed by gender identity, roles and relations. SETTING National universal healthcare system (Canada). PARTICIPANTS 2058 Canadian healthcare worker survey respondents (87% women, 11% men, 1% transgender or Two-Spirit), including 783 health professionals, 673 allied health professionals, 557 health support staff. Of the 63 unique healthcare worker types reported, registered nurses (11.5%), physicians (9.9%) and pharmacists (4.5%) were most common. Forty-six healthcare workers were interviewed. MAIN OUTCOME MEASURES Reported pandemic-induced changes to occupational leadership roles and responsibilities, household and caregiving responsibilities, and anxiety levels by gender identity. RESULTS Men (19.8%) were more likely to hold pandemic leadership roles compared with women (13.4%). Women (57.5%) were more likely to report increased domestic responsibilities than men (45%). Women and those with dependents under the age of 10 years reported the greatest levels of anxiety during the pandemic. Interviews with healthcare workers further revealed a perceived imbalance in leadership opportunities based on gender identity, a lack of workplace supports disproportionately affecting women and an increase in domestic responsibilities influenced by gender roles. CONCLUSIONS The COVID-19 pandemic response has important gendered effects on the healthcare workforce. Healthcare workers are central to effective pandemic control, highlighting an urgent need for a gender-transformative pandemic response strategy.
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Affiliation(s)
- Bria Scriven Mele
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Jayna M Holroyd-Leduc
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Hotchkiss Brain Institute, Calgary, Alberta, Canada
| | - Patricia Harasym
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Sandra M Dumanski
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Libin Cardiovascular Institute, Calgary, Alberta, Canada
| | - Kirsten Fiest
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- O'Brien Institute of Public Health, Calgary, Alberta, Canada
| | - Ian D Graham
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Kara Nerenberg
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Libin Cardiovascular Institute, Calgary, Alberta, Canada
| | - Colleen Norris
- Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada
| | | | - Louise Pilote
- Faculty of Medicine, McGill University, Montreal, Québec, Canada
| | - Harlan Pruden
- Faculty of Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Valeria Raparelli
- Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy
- University Center for Studies on Gender Medicine, University of Ferrara, Ferrara, Italy
| | - Doreen Rabi
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Libin Cardiovascular Institute, Calgary, Alberta, Canada
- O'Brien Institute of Public Health, Calgary, Alberta, Canada
| | - Shannon M Ruzycki
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- O'Brien Institute of Public Health, Calgary, Alberta, Canada
| | - Ranjani Somayaji
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- O'Brien Institute of Public Health, Calgary, Alberta, Canada
| | - Henry Thomas Stelfox
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- O'Brien Institute of Public Health, Calgary, Alberta, Canada
| | - Sofia B Ahmed
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Libin Cardiovascular Institute, Calgary, Alberta, Canada
- O'Brien Institute of Public Health, Calgary, Alberta, Canada
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14
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Berthelot S, Breton M, Guertin JR, Archambault PM, Berger Pelletier E, Blouin D, Borgundvaag B, Duhoux A, Harvey Labbé L, Laberge M, Lachapelle P, Lapointe-Shaw L, Layani G, Lefebvre G, Mallet M, Matthews D, McBrien K, McLeod S, Mercier E, Messier A, Moore L, Morris J, Morris K, Ovens H, Pageau P, Paquette JS, Perry J, Schull M, Simon M, Simonyan D, Stelfox HT, Talbot D, Vaillancourt S. A Value-Based Comparison of the Management of Ambulatory Respiratory Diseases in Walk-in Clinics, Primary Care Practices, and Emergency Departments: Protocol for a Multicenter Prospective Cohort Study. JMIR Res Protoc 2021; 10:e25619. [PMID: 33616548 PMCID: PMC7939947 DOI: 10.2196/25619] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 12/15/2020] [Accepted: 12/18/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND In Canada, 30%-60% of patients presenting to emergency departments are ambulatory. This category has been labeled as a source of emergency department overuse. Acting on the presumption that primary care practices and walk-in clinics offer equivalent care at a lower cost, governments have invested massively in improving access to these alternative settings in the hope that patients would present there instead when possible, thereby reducing the load on emergency departments. Data in support of this approach remain scarce and equivocal. OBJECTIVE The aim of this study is to compare the value of care received in emergency departments, walk-in clinics, and primary care practices by ambulatory patients with upper respiratory tract infection, sinusitis, otitis media, tonsillitis, pharyngitis, bronchitis, influenza-like illness, pneumonia, acute asthma, or acute exacerbation of chronic obstructive pulmonary disease. METHODS A multicenter prospective cohort study will be performed in Ontario and Québec. In phase 1, a time-driven activity-based costing method will be applied at each of the 15 study sites. This method uses time as a cost driver to allocate direct costs (eg, medication), consumable expenditures (eg, needles), overhead costs (eg, building maintenance), and physician charges to patient care. Thus, the cost of a care episode will be proportional to the time spent receiving the care. At the end of this phase, a list of care process costs will be generated and used to calculate the cost of each consultation during phase 2, in which a prospective cohort of patients will be monitored to compare the care received in each setting. Patients aged 18 years and older, ambulatory throughout the care episode, and discharged to home with one of the aforementioned targeted diagnoses will be considered. The estimated sample size is 1485 patients. The 3 types of care settings will be compared on the basis of primary outcomes in terms of the proportion of return visits to any site 3 and 7 days after the initial visit and the mean cost of care. The secondary outcomes measured will include scores on patient-reported outcome and experience measures and mean costs borne wholly by patients. We will use multilevel generalized linear models to compare the care settings and an overlap weights approach to adjust for confounding factors related to age, sex, gender, ethnicity, comorbidities, registration with a family physician, socioeconomic status, and severity of illness. RESULTS Phase 1 will begin in 2021 and phase 2, in 2023. The results will be available in 2025. CONCLUSIONS The end point of our program will be for deciders, patients, and care providers to be able to determine the most appropriate care setting for the management of ambulatory emergency respiratory conditions, based on the quality and cost of care associated with each alternative. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) PRR1-10.2196/25619.
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Affiliation(s)
- Simon Berthelot
- Axe Santé des populations et Pratiques optimales en santé, Centre de recherche du CHU de Québec-Université Laval, Québec, QC, Canada
- Department of Family and Emergency Medicine, Université Laval, Québec, QC, Canada
| | - Mylaine Breton
- Department of Community Health sciences, Université de Sherbrooke, Campus de Longueuil, Longueuil, QC, Canada
- Centre de recherche Charles-Le Moyne - Saguenay-Lac-Saint-Jean sur les innovations en santé, Longueuil, QC, Canada
| | - Jason Robert Guertin
- Axe Santé des populations et Pratiques optimales en santé, Centre de recherche du CHU de Québec-Université Laval, Québec, QC, Canada
- Department of Social and Preventive Medicine, Université Laval, Québec, QC, Canada
| | - Patrick Michel Archambault
- Axe Santé des populations et Pratiques optimales en santé, Centre de recherche du CHU de Québec-Université Laval, Québec, QC, Canada
- Department of Family and Emergency Medicine, Université Laval, Québec, QC, Canada
- VITAM - Centre de recherche en santé durable, Québec, QC, Canada
- Centre de recherche du Centre intégré de santé et de services sociaux de Chaudière-Appalaches, Lévis, QC, Canada
| | - Elyse Berger Pelletier
- Ministère de la santé et des services sociaux, Gouvernement du Québec, Québec, QC, Canada
| | - Danielle Blouin
- Department of Emergency Medicine, Queen's University, Kingston, ON, Canada
| | - Bjug Borgundvaag
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
- Schwartz/Reisman Emergency Medicine Institute, Sinai Health System, Toronto, ON, Canada
| | - Arnaud Duhoux
- Faculty of Nursing, Université de Montréal, Montréal, QC, Canada
| | - Laurie Harvey Labbé
- Axe Santé des populations et Pratiques optimales en santé, Centre de recherche du CHU de Québec-Université Laval, Québec, QC, Canada
| | - Maude Laberge
- Operations and Decision Systems Department, Faculty of Administrative Sciences, Université Laval, Québec, QC, Canada
| | - Philippe Lachapelle
- Axe Santé des populations et Pratiques optimales en santé, Centre de recherche du CHU de Québec-Université Laval, Québec, QC, Canada
| | | | - Géraldine Layani
- Department of Family and Emergency Medicine, Université de Montréal, Montréal, QC, Canada
| | - Gabrielle Lefebvre
- Axe Santé des populations et Pratiques optimales en santé, Centre de recherche du CHU de Québec-Université Laval, Québec, QC, Canada
| | - Myriam Mallet
- Axe Santé des populations et Pratiques optimales en santé, Centre de recherche du CHU de Québec-Université Laval, Québec, QC, Canada
| | - Deborah Matthews
- Ministry of Health and Long Term Care, Government of Ontario, Toronto, ON, Canada
| | - Kerry McBrien
- Departments of Family Medicine and Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Shelley McLeod
- Schwartz/Reisman Emergency Medicine Institute, Sinai Health System, Toronto, ON, Canada
- Division of Emergency Medicine, Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Eric Mercier
- Department of Family and Emergency Medicine, Université Laval, Québec, QC, Canada
| | - Alexandre Messier
- Department of Family and Emergency Medicine, Université de Montréal, Montréal, QC, Canada
| | - Lynne Moore
- Axe Santé des populations et Pratiques optimales en santé, Centre de recherche du CHU de Québec-Université Laval, Québec, QC, Canada
- Department of Social and Preventive Medicine, Université Laval, Québec, QC, Canada
| | - Judy Morris
- Department of Family and Emergency Medicine, Université de Montréal, Montréal, QC, Canada
- Hôpital du Sacré-Coeur-de-Montréal, Centre intégré universitaire de santé et de services sociaux du Nord-de-l'Île-de Montréal, Montréal, QC, Canada
| | - Kathleen Morris
- Canadian Institute for Health Information, Ottawa, ON, Canada
| | - Howard Ovens
- Schwartz/Reisman Emergency Medicine Institute, Sinai Health System, Toronto, ON, Canada
| | - Paul Pageau
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Jean-Sébastien Paquette
- Department of Family and Emergency Medicine, Université Laval, Québec, QC, Canada
- VITAM - Centre de recherche en santé durable, Québec, QC, Canada
- Laboratoire ARIMED, GMF-U de Saint-Charles-Borromée, Québec, QC, Canada
| | - Jeffrey Perry
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Michael Schull
- Department of Emergency Medicine, Sunnybrook Research Institute, University of Toronto, Toronto, ON, Canada
| | - Mathieu Simon
- Institut universitaire de cardiologie et de pneumologie de Québec, Québec, QC, Canada
| | - David Simonyan
- Axe Santé des populations et Pratiques optimales en santé, Centre de recherche du CHU de Québec-Université Laval, Québec, QC, Canada
| | - Henry Thomas Stelfox
- Department of Critical Care Medicine, Medicine and Community Health Sciences, O'Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada
| | - Denis Talbot
- Department of Social and Preventive Medicine, Université Laval, Québec, QC, Canada
| | - Samuel Vaillancourt
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- Department of Emergency Medicine, St Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
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15
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Conombo B, Guertin JR, Tardif PA, Farhat I, Moore T, Bouderba S, Soltana K, Archambault P, Berthelot S, Lauzier F, Turgeon AF, Stelfox HT, Chasse M, Hoch J, Moore L. Economic evaluation of intrahospital clinical practices in injury care: protocol for a 10-year systematic review. BMJ Open 2020; 10:e034472. [PMID: 32665383 PMCID: PMC7365427 DOI: 10.1136/bmjopen-2019-034472] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Revised: 04/14/2020] [Accepted: 05/28/2020] [Indexed: 12/03/2022] Open
Abstract
INTRODUCTION Underuse of high-value clinical practices and overuse of low-value practices are major sources of inefficiencies in modern healthcare systems. Injuries are second only to cardiovascular disease in terms of acute care costs but data on the economic impact of clinical practices for injury admissions are lacking. This study aims to summarise evidence on the economic value of intrahospital clinical practices for injury care. METHODS AND ANALYSIS We will perform a systematic review to identify research articles in economic evaluation of intrahospital clinical practices in acute injury care. We will search MEDLINE and databases such as Embase, Web of Science, NHS Economic Evaluation Database, Cochrane CENTRAL, BIOSIS and CINAHL for randomised or non-randomised controlled trials and observational studies using a combination of keywords and controlled vocabulary. We will consider the following outcomes relative to economic evaluations: incremental cost-effectiveness ratio, incremental cost-utility ratio, incremental net health benefit, incremental net monetary benefit (iNMB) and incremental cost-benefit ratio. Pairs of independent reviewers will evaluate studies that meet eligibility criteria and extract data from included articles using an electronic data extraction form. All outcomes will be converted into iNMB. We will report iNMB for practices classified by type of practice (hospitalisation, consultation, diagnostic, therapeutic-surgical, therapeutic-drugs, therapeutic-other). Results obtained with a ceiling ratio of $50 000 per quality-adjusted life year gained for identified clinical practices will be summarised by charting forest plots. In line with Cochrane recommendations for systematic reviews of economic evaluations, meta-analyses will not be conducted. ETHICS AND DISSEMINATION Ethics approval is not required as original data will not be collected. This study will summarise existing evidence on the economic value of clinical practices in injury care. Results will be used to advance knowledge on value-based care for injury admissions and will be disseminated through a peer-reviewed article, international scientific meetings and clinical and healthcare quality associations.
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Affiliation(s)
- Blanchard Conombo
- Department of Social and Preventive Medicine, Laval University, Quebec City, Quebec, Canada
- Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, Centre de Recherche du CHU de Québec (Hôpital de l'Enfant-Jésus), Laval University, Quebec City, Quebec, Canada
| | - Jason Robert Guertin
- Department of Social and Preventive Medicine, Laval University, Quebec City, Quebec, Canada
| | - Pier-Alexandre Tardif
- Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, Centre de Recherche du CHU de Québec (Hôpital de l'Enfant-Jésus), Laval University, Quebec City, Quebec, Canada
| | - Imen Farhat
- Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, Centre de Recherche du CHU de Québec (Hôpital de l'Enfant-Jésus), Laval University, Quebec City, Quebec, Canada
| | - Thomas Moore
- Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, Centre de Recherche du CHU de Québec (Hôpital de l'Enfant-Jésus), Laval University, Quebec City, Quebec, Canada
| | - Samy Bouderba
- Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, Centre de Recherche du CHU de Québec (Hôpital de l'Enfant-Jésus), Laval University, Quebec City, Quebec, Canada
| | - Kahina Soltana
- Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, Centre de Recherche du CHU de Québec (Hôpital de l'Enfant-Jésus), Laval University, Quebec City, Quebec, Canada
| | - Patrick Archambault
- Department of Family Medicine and Emergency Medicine, Laval University, Quebec City, Quebec, Canada
| | - Simon Berthelot
- Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, Centre de Recherche du CHU de Québec (Hôpital de l'Enfant-Jésus), Laval University, Quebec City, Quebec, Canada
- Department of Family Medicine and Emergency Medicine, Laval University, Quebec City, Quebec, Canada
| | - François Lauzier
- Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, Centre de Recherche du CHU de Québec (Hôpital de l'Enfant-Jésus), Laval University, Quebec City, Quebec, Canada
- Department of Anesthesia and Critical Care Medicine, Laval University, Quebec City, Quebec, Canada
| | - Alexis F Turgeon
- Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, Centre de Recherche du CHU de Québec (Hôpital de l'Enfant-Jésus), Laval University, Quebec City, Quebec, Canada
- Department of Anesthesia and Critical Care Medicine, Laval University, Quebec City, Quebec, Canada
| | | | - Michaël Chasse
- Department of Medicine, University of Montreal, Montreal, Quebec, Canada
| | - Jeffrey Hoch
- Department of Public Health Sciences, University of California, Sacramento, California, USA
| | - Lynne Moore
- Department of Social and Preventive Medicine, Laval University, Quebec City, Quebec, Canada
- Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, Centre de Recherche du CHU de Québec (Hôpital de l'Enfant-Jésus), Laval University, Quebec City, Quebec, Canada
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16
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Parsons Leigh J, de Grood C, Ahmed S, Bosma K, Burns KEA, Fowler R, Fox-Robichaud A, Mehta S, Mele T, Straus SE, Zepeda N, Kemp L, Fiest K, Stelfox HT. Improving gender equity in critical care medicine: a protocol to establish priorities and strategies for implementation. BMJ Open 2020; 10:e037090. [PMID: 32532779 PMCID: PMC7295422 DOI: 10.1136/bmjopen-2020-037090] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION While the number of women entering medical school now equals or surpasses the number of men, gender equity in medicine has not been achieved. Women continue to be under-represented in leadership roles (eg, deans, medical chairs) and senior faculty positions. In addition, women do not enter medical specialties as often as men, which can have important implications for work environment, reimbursement and the delivery of patient care. Compared with other medical specialties (eg, anaesthesiology, dermatology, etc), critical care medicine is a medical specialty with some of the lowest representation of women. While strategies to improve gender equity in critical care medicine exist in the published literature, efforts to comprehensively synthesise, prioritise and implement solutions have been limited.The objective of this programme of work is to establish priorities for the development and implementation of key strategies to improve the outcomes, well-being and experiences of women in critical care in Canada. METHODS AND ANALYSIS Three phases encompass this programme of work. In phase I, we will catalogue published strategies focused on improving gender inequity across medical specialties through a scoping review. In phase II, we will conduct a modified Delphi consensus process with decision-makers, physicians and researchers to identify key strategies (identified in phase I and proposed by participants in phase II) for improving gender inequity in the specialty of critical care medicine. Finally, in phase III, we will conduct a 1-day stakeholder meeting that engages participants from phase II to build capacity for the development and implementation of top ranked strategies. Data analyses from this programme of work will be both quantitative and qualitative. ETHICS AND DISSEMINATION The proposed programme of work is a foundational step towards establishing targeted strategies to improve gender inequity in the medical specialty of critical care medicine. Strategies will be prioritised by stakeholders, mapped to preidentified drivers of gender equity in the specialty and be scalable to institutional needs. A final report of our results including the list of top prioritised strategies and implementation objectives will be disseminated to panel participants, critical care leadership teams and major critical care societies who are partners in this work, around the country to facilitate uptake at the local level.The University of Calgary Conjoint Health Research Ethics Board has approved this study (REB16-0890).
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Affiliation(s)
- Jeanna Parsons Leigh
- School of Health Administration, Dalhousie University, Halifax, Nova Scotia, Canada
- Department of Critical Care Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Chloe de Grood
- Department of Critical Care Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Sofia Ahmed
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Karen Bosma
- Division of Critical Care Medicine, London Health Sciences Centre, London, Ontario, Canada
- Department of Medicine, Western University Schulich School of Medicine and Dentistry, London, Ontario, Canada
| | - Karen E A Burns
- Critical Care, St. Michael's Hospital, Toronto, Ontario, Canada
- Interdepartmental Division of Critical Care Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Robert Fowler
- Interdepartmental Division of Critical Care Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Alison Fox-Robichaud
- Department of Medicine, Division of Critical Care Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Sangeeta Mehta
- Interdepartmental Division of Critical Care Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Tina Mele
- Division of Critical Care Medicine, London Health Sciences Centre, London, Ontario, Canada
- Department of Medicine, Western University, London, Ontario, Canada
| | - Sharon E Straus
- Interdepartmental Division of Critical Care Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Nubia Zepeda
- Department of Critical Care Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Laryssa Kemp
- Department of Critical Care Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Kirsten Fiest
- Departments of Critical Care Medicine, Department of Psychiatry & Hotchkiss Brain Institute and Department of Community Health Sciences, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
- O'Brien Institute for Public Health, Calgary, Alberta, Canada
| | - Henry Thomas Stelfox
- O'Brien Institute for Public Health, Calgary, Alberta, Canada
- Department of Critical Care Medicine, Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
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17
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Jackson Chornenki N, Liaw P, Bagshaw S, Burns K, Dodek P, English S, Fan E, Ferrari N, Fowler R, Fox-Robichaud A, Garland A, Green R, Hebert P, Kho M, Martin C, Maslove D, McDonald E, Menon K, Murthy S, Muscedere J, Scales D, Stelfox HT, Wang HT, Weiss M. Data initiatives supporting critical care research and quality improvement in Canada: an environmental scan and narrative review. Can J Anaesth 2020; 67:475-484. [PMID: 31970619 DOI: 10.1007/s12630-020-01571-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Revised: 11/11/2019] [Accepted: 12/04/2019] [Indexed: 10/25/2022] Open
Abstract
PURPOSE Collection and analysis of health data are crucial to achieving high-quality clinical care, research, and quality improvement. This review explores existing hospital, regional, provincial and national data platforms in Canada to identify gaps and barriers, and recommend improvements for data science. SOURCE The Canadian Critical Care Trials Group and the Canadian Critical Care Translational Biology Group undertook an environmental survey using list-identified names and keywords in PubMed and the grey literature, from the Canadian context. Findings were grouped into sections, corresponding to geography, purpose, and patient sub-group initiatives, using a narrative qualitative approach. Emerging themes, impressions, and recommendations towards improving data initiatives were generated. PRINCIPAL FINDINGS In Canada, the Canadian Institute for Health Information Discharge Abstract Database contains high-level clinical data on every adult and child discharged from acute care facilities; however, it does not contain data from Quebec, critical care-specific severity of illness risk-adjustment scores, physiologic data, or data pertaining to medication use. Provincially mandated critical care platforms in four provinces contain more granular data, and can be used to risk adjust and link to within-province data sets; however, no inter-provincial collaborative mechanism exists. There is very limited infrastructure to collect and link biological samples from critically ill patients nationally. Comprehensive international clinical data sets may inform future Canadian initiatives. CONCLUSION Clinical and biological data collection among critically ill patients in Canada is not sufficiently coordinated, and lags behind other jurisdictions. An integrated and inclusive critical care data platform is a key clinical and scientific priority in Canada.
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Affiliation(s)
| | | | | | | | - Peter Dodek
- University of British Columbia, Vancouver, BC, Canada
| | | | - Eddy Fan
- University of Toronto, Toronto, ON, Canada
| | - Nicolay Ferrari
- Centre hospitalier de l'Université de Montréal, Montreal, QC, Canada
| | - Robert Fowler
- University of Toronto, Toronto, ON, Canada.
- Interdepartmental Division of Critical Care Medicine, Sunnybrook Hospital, University of Toronto, 2075 Bayview Avenue, Room D478, Toronto, ON, M4N 3M5, Canada.
| | | | | | | | - Paul Hebert
- Centre hospitalier de l'Université de Montréal, Montreal, QC, Canada
| | | | | | | | | | | | | | | | | | | | | | - Matthew Weiss
- Centre hospitalier universitaire de Québec, Quebec City, QC, Canada
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Sauro KM, Soo A, Kramer A, Couillard P, Kromm J, Zygun D, Niven DJ, Bagshaw SM, Stelfox HT. Venous Thromboembolism Prophylaxis in Neurocritical Care Patients: Are Current Practices, Best Practices? Neurocrit Care 2020; 30:355-363. [PMID: 30276615 DOI: 10.1007/s12028-018-0614-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND/OBJECTIVES Venous thromboembolism (VTE) is a leading cause of preventable, in-hospital deaths; critically ill patients have a higher risk. Effective and efficient strategies to prevent VTE exist; however, neurocritical care patients present unique challenges due to competing risk of bleeding. The objective of this study was to examine current VTE prophylaxis practices among neurocritical care patients, concordance with guideline-recommended care, and the association with clinical outcomes. METHODS This retrospective cohort study of patients admitted to ten adult, medical-surgical and neurological intensive care units (ICUs) in nine hospitals between 2014 and 2017 using administrative and clinical data. Neurocritical care patients were classified based on the primary admission diagnosis. Concordance with guideline-recommended care was evaluated using recommendations from recent guidelines. RESULTS 20.0% of 23,191 patients were classified as neurocritical care. Among neurocritical care patients, pharmacological VTE prophylaxis was administered on 60.9% of all ICU days, mechanical VTE prophylaxis on 46.9%, and no VTE prophylaxis on 12.2% of all ICU days. Type of VTE prophylaxis was associated with sex, neurological diagnosis, and invasive neurological monitoring. Fifty-six percentage of ICU days were guideline concordant but concordance varied by recommendation (range 6-100%) and by type of VTE prophylaxis recommended (p = 0.05); among patients where guidelines recommended use of pharmacologic prophylaxis, care was concordant 26.6% of ICU days, whereas for mechanical prophylaxis it was concordant 80.5% of ICU days. There was an overall improvement in guideline concordance on 2.3% of ICU days after the publication of the Society of Neurocritical Care guideline (p = 0.005). CONCLUSIONS Neurocritical care patients commonly receive mechanical VTE prophylaxis despite guidelines recommending the use of pharmacological VTE prophylaxis. Our findings suggest uncertainty around best VTE prophylaxis practices for neurocritical care patients remains.
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Affiliation(s)
- K M Sauro
- Department of Critical Care Medicine, University of Calgary, Calgary, AB, Canada.
- Department of Community Health Science, O'Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada.
| | - A Soo
- Department of Critical Care Medicine, University of Calgary, Calgary, AB, Canada
| | - A Kramer
- Department of Critical Care Medicine, University of Calgary, Calgary, AB, Canada
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - P Couillard
- Department of Critical Care Medicine, University of Calgary, Calgary, AB, Canada
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - J Kromm
- Department of Critical Care Medicine, University of Calgary, Calgary, AB, Canada
| | - D Zygun
- Department of Critical Care Medicine, School of Public Health, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - D J Niven
- Department of Critical Care Medicine, University of Calgary, Calgary, AB, Canada
- Department of Community Health Science, O'Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada
| | - S M Bagshaw
- Department of Critical Care Medicine, School of Public Health, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - H T Stelfox
- Department of Critical Care Medicine, University of Calgary, Calgary, AB, Canada
- Department of Community Health Science, O'Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada
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Parsons Leigh J, Petersen J, de Grood C, Whalen-Browne L, Niven D, Stelfox HT. 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. BMJ Open 2019; 9:e033333. [PMID: 31848173 PMCID: PMC6937030 DOI: 10.1136/bmjopen-2019-033333] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
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.
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Affiliation(s)
- Jeanna Parsons Leigh
- Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
- Department of Critical Care Medicine, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Jennie Petersen
- Department of Critical Care Medicine, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Chloe de Grood
- Department of Community Health Sciences, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Liam Whalen-Browne
- Department of Critical Care Medicine, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Daniel Niven
- Department of Critical Care Medicine, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Henry Thomas Stelfox
- Department of Critical Care Medicine, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
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Sauro K, Ghali WA, Stelfox HT. Measuring safety of healthcare: an exercise in futility? BMJ Qual Saf 2019; 29:341-344. [PMID: 31796577 DOI: 10.1136/bmjqs-2019-009824] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Revised: 11/18/2019] [Accepted: 11/21/2019] [Indexed: 01/29/2023]
Affiliation(s)
- Khara Sauro
- Departments of Community Health Sciences, Surgery & Oncology, the O'Brien Institute for Public Health & the Arnie Charbonneau Cancer Institute, University of Calgary, Calgary, Alberta, Canada
| | - William A Ghali
- Departments of Community Health Sciences & Medicine, and the O'Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada
| | - Henry Thomas Stelfox
- Departments of Critical Care Medicine & Community Health Sciences, and the O'Brien Institute for Public Health, Universty of Calgary, Calgary, Alberta, Canada
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Tardif PA, Moore L, Lauzier F, Farhat I, Archambault P, Lamontagne F, Chassé M, Stelfox HT, Gabbe BJ, Lecky F, Kortbeek J, Lessard-Bonaventure P, Truchon C, Turgeon AF. Low-value clinical practices in adult traumatic brain injury: an umbrella review protocol. BMJ Open 2019; 9:e031747. [PMID: 31601599 PMCID: PMC6797405 DOI: 10.1136/bmjopen-2019-031747] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
INTRODUCTION Traumatic brain injury (TBI) leads to 50 000 deaths, 85 000 disabilities and costs $60 billion each year in the USA. Despite numerous interventions and treatment options, the outcomes of TBI have improved little over the last three decades. In a previous scoping review and expert consultation survey, we identified 13 potentially low-value clinical practices in acute TBI. The objective of this umbrella review is to synthesise the evidence on potentially low-value clinical practices in the care of acute TBI. METHODS AND ANALYSIS Using umbrella review methodology, we will search Cochrane Central Register of Controlled Trials, Embase, Epistemonikos, International Prospective Register of Systematic Reviews (PROSPERO) and PubMed to identify systematic reviews evaluating the effect of potential intrahospital low-value practices using tailored population, intervention, comparator, outcome and study design questions based on the results of a previous scoping review. We will present data on the methodological quality of these reviews (Assessing the Methodological Quality of Systematic Reviews-2), reported effect sizes and strength of evidence (Grading of Recommendations, Assessment, Development and Evaluation). ETHICS AND DISSEMINATION Ethics approval is not required as original data will not be collected. Knowledge users from five healthcare quality organisations and clinical associations are involved in the design and conduct of the study. Results will be disseminated in a peer-reviewed journal, at international scientific meetings and to clinical, healthcare quality and patient-partner associations. This work will support the development of metrics to measure the use of low-value practices, inform policy makers on potential targets for deimplementation and in the long term reduce the use of low-value clinical practices in acute TBI care. PROSPERO REGISTRATION NUMBER CRD42019132428.
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Affiliation(s)
- Pier-Alexandre Tardif
- Population Health and Optimal Health Practices Unit, Trauma-Emergency-Critical Care Medicine, Centre de Recherche du CHU de Québec-Université Laval (Hôpital de l'Enfant-Jésus), Université Laval, Montreal, Quebec, Canada
| | - Lynne Moore
- Population Health and Optimal Health Practices Unit, Trauma-Emergency-Critical Care Medicine, Centre de Recherche du CHU de Québec-Université Laval (Hôpital de l'Enfant-Jésus), Université Laval, Montreal, Quebec, Canada
- Department of Social and Preventative Medicine, Université Laval, Montreal, Quebec, Canada
| | - François Lauzier
- Population Health and Optimal Health Practices Unit, Trauma-Emergency-Critical Care Medicine, Centre de Recherche du CHU de Québec-Université Laval (Hôpital de l'Enfant-Jésus), Université Laval, Montreal, Quebec, Canada
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Université Laval, Quebec City, Quebec, Canada
| | - Imen Farhat
- Population Health and Optimal Health Practices Unit, Trauma-Emergency-Critical Care Medicine, Centre de Recherche du CHU de Québec-Université Laval (Hôpital de l'Enfant-Jésus), Université Laval, Montreal, Quebec, Canada
- Department of Social and Preventative Medicine, Université Laval, Montreal, Quebec, Canada
| | - Patrick Archambault
- Population Health and Optimal Health Practices Unit, Trauma-Emergency-Critical Care Medicine, Centre de Recherche du CHU de Québec-Université Laval (Hôpital de l'Enfant-Jésus), Université Laval, Montreal, Quebec, Canada
- Département de médecine familiale et médecine d'urgence, Université Laval, Québec, QC, Canada
| | - Francois Lamontagne
- Department of Medicine, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Michael Chassé
- Department of Medicine, Université de Montréal, Montreal, Quebec, Canada
| | - Henry Thomas Stelfox
- Departments of Critical Care Medicine, Medicine and Community Health Sciences, O'Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada
| | - Belinda J Gabbe
- Monash University School of Public Health and Preventive Medicine, Melbourne, Victoria, Australia
- Farr Institute, Swansea University Medical School, Swansea University, Swansea, UK
| | - Fiona Lecky
- School of Health and Related Research, The University of Sheffield, Sheffield, UK
| | - John Kortbeek
- Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Paule Lessard-Bonaventure
- Population Health and Optimal Health Practices Unit, Trauma-Emergency-Critical Care Medicine, Centre de Recherche du CHU de Québec-Université Laval (Hôpital de l'Enfant-Jésus), Université Laval, Montreal, Quebec, Canada
- Department of Surgery, Division of Neurosurgery, Université Laval, Quebec City, Quebec, Canada
| | - Catherine Truchon
- Institut national d'excellence en santé et en services sociaux du Québec, Quebec City, Quebec, Canada
| | - Alexis F Turgeon
- Population Health and Optimal Health Practices Unit, Trauma-Emergency-Critical Care Medicine, Centre de Recherche du CHU de Québec-Université Laval (Hôpital de l'Enfant-Jésus), Université Laval, Montreal, Quebec, Canada
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Université Laval, Quebec City, Quebec, Canada
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Mador B, Fuselli P, Choudhary D, Bokhari F, Tanenbaum B, Tze N, Wong TH, Grant I, Sahi S, Tanenbaum B, Figueira S, Knight H, Grant I, Beno S, Moore L, Macpherson A, Laverty C, Watson I, Watson I, Laverty C, Bérubé M, Cowan S, Homer K, Bouderba S, Soltana K, Fransblow L, Fransblow L, Bérubé M, Gonthier C, Bryson A, Bokhari F, Rados A, Courval V, Masales C, Trust MD, Hogan J, Warriner Z, Lalande A, Chung D, Tanenbaun B, Kuper T, Mckee J, Bratu I, Makish A, Versolatto A, Ramagnano S, Mehrnoush V, Kang D, Moore L, Schellenberg M, LeBreton M, Javidan AP, Schwartz G, Doucet J, Cunningham A, Clarke R, Paradis T, Beamish I, Hilsden R, Raizman I, Green R, Green R, Green R, Esmail R, Moon J(J, Cheng V, Brisson A, Beno S, Heck C, Koeck E, Schneider P, Bal C, Ko YM(D, Martinez M, Kim D, Tierney J, Emigh B, Lie J, Tierney J, MacLean A, Milton L, Bradley N, Kim M, White J, Harris I, Tekian A, Babul S, Cowle S, Turcotte K, Dhillon R, Chadha K, Fu CY, Bajan F, Welsh S, Kaminsky M, Dennis A, Starr F, Butler C, Messer T, Poulakidas S, Ramagnano S, Grushka J, Beckett A, Filteau C, Larocque J, Nadkarni N, Chua WC, Loo L, Ang ASH, Iau PTC, Goo JTT, Chan KC, Adam TN, Seow DCC, Ng YS, Malhotra R, Chan AWM, Matchar DB, Van Nguyen H, Ong MEH, Lampron J, Bougie A, Brown C, Patel A, Edwards L, Spitz K, Ramagnano S, Lampron J, Nucete M, Lindsey S, Lampron J, Figueira S, Matar M, Michael D, Rosenfield D, Harvey G, Jessa K, Tardif PA, Mercier E, Berthelot S, Lecky F, Cameron P, Archambault P, Tien H, Beckett A, Nathens A, Luz LTD, Benjamin S, Chisholm A, Benjamin S, Chisholm A, Tien H, Beckett A, Nathens A, Luz LTD, Pasquotti T, Klassen B, Brisson A, Tze N, Fawcett V, Tsang B, Kabaroff A, Verhoeff K, Turner S, Kim M, Widder S, Fung C, Widder S, Kim M, Moore L, Lecky F, Lawrence T, Soltana K, Mansour T, Moore L, Bouderba S, Turgeon A, Krouchev R, Mercier E, Friedman D, Souranis A, Slapcoff L, Friedman D, Fakir MB, Turcotte V, Valiquette MP, Bernard F, Giroux M, Côté MÈ, Gagné A, Dollé S, Gélinas C, Belcaïd A, Truchon C, Moore L, Clément J, Pelletier LP, Ivkov V, Gamble K, Constable L, Haegert J, Bajani F, Fu CY, Welsh S, Kaminsky M, Dennis A, Starr F, Messer T, Butler C, Tatebe L, Poulakidas S, Thauvette D, Engels P, Klassen B, Coates A, De Silva S, Schellenberg M, Biswas S, Inaba K, Cheng V, Warriner Z, Love B, Demetriades D, Schellenberg M, Inaba K, Trust MD, Love B, Cheng V, Strumwasser A, Demetriades D, Joos E, Dawe P, Hameed M, Evans D, Garraway N, Gawaziuk J, Cristall N, Logsetty S, Ramagnano S, Federman N, Murphy P, Parry N, Leeper R, McBeth P, Wachs J, Hamilton D, Ball C, Gillman L, Kirkpatrick A, Dulai S, Falconer C, McLachlin M, Armstrong A, Parry N, Vogt K, Shi Q, Coates A, Engels P, Rice T, Nathens A, Naidu D, Brubacher J, Chan H, Erdelyi S, Kubasiak J, Bokhari F, Kaminsky M, Lauzier F, Tardif PA, Lamontagne F, Chassé M, Stelfox HT, Kortbeek J, Lessard-Bonaventure P, Truchon C, Turgeon A, Cheng V, Inaba K, Foran C, Warriner Z, Trust MD, Clark D, Demetriades D, Levesque K, Lampron J, Nathens A, Tien H, Luz LTD, Jing R, McFarlan A, Liu M, Sander B, Fowler R, Rizoli S, Ferrada P, Murthi S, Nirula R, Edwards S, Cantrell E, Han J, Haase D, Singleton A, Birkas Y, Casola G, Coimbra R, Condron M, Schreiber M, Azarow K, Hamilton N, Long W, Maxwell B, Jafri M, Whitman L, Wilson H, Wong H, Grushka J, Razek T, Fata P, Deckelbaum D, Kawaja K, Beckett A, Razek T, Deckelbaum D, Grushka J, Fata P, Beckett A, Lund M, Leeper R, Conn LG, Strauss R, Haas B, Beckett A, Nathens A, Tien H, Callum J, Luz LTD, Higgins S, Coles J, Erdogan M, Coles J, Higgins S, Erdogan M, Erdogan M, Kureshi N, Fenerty L, Thibault-Halman G, Walling S, Clarke DB, Vis C, Nosworthy S, Razek T, Boulanger N, Deckelbaum D, Grushka J, Fata P, Beckett A, Khwaja K, Schellenberg M, Inaba K, Warriner Z, Trust MD, Matsushima K, Lam L, Demetriades D, Lakha N, Wong H, McLauchlin L, Ashe CS, Logie SA, Lenton-Brym T, Rosenfield D, McDowall D, Wales P, Principi T, Mis J, Kaminsky M, Bokhari F, Rahbar E, Cotton B, Bryan P, MacGillivray S, Thompson G, Wishart I, Hameed M, Joos E, Evans D, Garraway N, Dawe P, Wild J, Widom K, Torres D, Blansfield J, Shabahang M, Dove J, Fluck M, Hameed M, Roux L, Nicol A, Schulenberg L, Fredericks C, Messer T, Starr F, Dennis A, Bokhari F, Kaminsky M, Teixeira P, Coopwood B, Aydelotte J, Cardenas T, Ali S, Brown C, Dawe P, Fredericks C, Matta LD, Messer T, Starr F, Dennis A, Kaminsky M, Bokhari F, Jiang HY, Yoon J, Kim M, Widder S, Hameed M, Wray C, Agarwal A, Harvin J. 2019 Trauma Association of Canada Annual Scientific Meeting Abstracts. Can J Surg 2019; 62:S3-S35. [PMID: 31091053 DOI: 10.1503/cjs.008619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Sauro K, Bagshaw SM, Niven D, Soo A, Brundin-Mather R, Parsons Leigh J, Cook DJ, Stelfox HT. Barriers and facilitators to adopting high value practices and de-adopting low value practices in Canadian intensive care units: a multimethod study. BMJ Open 2019; 9:e024159. [PMID: 30878979 PMCID: PMC6429967 DOI: 10.1136/bmjopen-2018-024159] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVE To compare and contrast illustrative examples of the adoption of high value practices and the de-adoption of low value practices. DESIGN (1) Retrospective, population-based audit of low molecular weight heparin (LMWH) for venous thromboembolism (VTE) prophylaxis (high value practice) and albumin for fluid resuscitation (low value practice) and (2) cross-sectional survey of healthcare providers. SETTING Data were collected from nine adult medical-surgical intensive care units (ICUs) in two large Canadian cities. Patients are managed in these ICUs by a group of multiprofessional and multidisciplinary healthcare providers. PARTICIPANTS Participants included 6946 ICU admissions and 309 healthcare providers from the same ICUs. MAIN OUTCOME MEASURES (1) The use of LMWH for VTE prophylaxis (per cent ICU days) and albumin for fluid resuscitation (per cent of patients); and (2) provider knowledge of evidence underpinning these practices, and barriers and facilitators to adopt and de-adopt these practices. RESULTS LMWH was administered on 38.7% of ICU days, and 20.0% of patients received albumin.Most participants had knowledge of evidence underpinning VTE prophylaxis and fluid resuscitation (59.1% and 84.2%, respectively). Providers perceived these practices to be followed. The most commonly reported barrier to adoption was insufficient knowledge/understanding (32.8%), and to de-adoption was clinical leader preferences (33.2%). On-site education was the most commonly identified facilitator for adoption and de-adoption (67.8% and 68.6%, respectively). CONCLUSIONS Despite knowledge of and self-reported adherence to best practices, the audit demonstrated opportunity to improve. Provider-reported barriers and facilitators to adoption and de-adoption are broadly similar.
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Affiliation(s)
- Khara Sauro
- Department of Critical Care Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Sean M Bagshaw
- Department of Critical Care Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Daniel Niven
- Department of Critical Care Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Andrea Soo
- Department of Critical Care Medicine, University of Calgary, Calgary, Alberta, Canada
| | | | - Jeanna Parsons Leigh
- Department of Critical Care Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Deborah J Cook
- Department of Medicine, McMaster University, Hamilton, Canada
| | - Henry Thomas Stelfox
- Department of Critical Care Medicine, University of Calgary, Calgary, Alberta, Canada
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Papathanassoglou EDE, Skrobik Y, Hegadoren K, Thompson P, Stelfox HT, Norris C, Rose L, Bagshaw SM, Meier M, LoCicero C, Ashmore R, Sparrow Brulotte T, Hassan I, Park T, Kutsogiannis DJ. Relaxation for Critically ill Patient Outcomes and Stress-coping Enhancement (REPOSE): a protocol for a pilot randomised trial of an integrative intervention to improve critically ill patients' delirium and related outcomes. BMJ Open 2019; 9:e023961. [PMID: 30782719 PMCID: PMC6340454 DOI: 10.1136/bmjopen-2018-023961] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
INTRODUCTION Delirium is a common complication of critical illness, associated with negative patient outcomes. Preventive or therapeutic interventions are mostly ineffective. Although relaxation-inducing approaches may benefit critically ill patients, no well-designed studies target delirium prevention as a primary outcome. The objective of this study is to assess feasibility and treatment effect estimates of a multimodal integrative intervention incorporating relaxation, guided imagery and moderate pressure touch massage for prevention of critical illness delirium and for related outcomes. METHODS AND ANALYSIS Randomised, controlled, single-blinded trial with two parallel groups (1:1 allocation: intervention and standard care) and stratified randomisation (age (18-64 years and ≥65 years) and presence of trauma) with blocking, involving 104 patients with Intensive Care Delirium Screening Checklist (ICDSC): 0-3 recruited from two academic intensive care units (ICUs). Intervention group participants receive the intervention in addition to standard care for up to five consecutive days (or until transfer/discharge); control group participants receive standard care and a sham intervention. We will assess predefined feasibility outcomes, that is, recruitment rates and protocol adherence. The primary clinical outcome is incidence of delirium (ICDSC ≥4). Secondary outcomes include pain scores, inflammatory biomarkers, heart rate variability, stress and quality of life (6 weeks and 4 months) post-ICU discharge. Feasibility measures will be analysed descriptively, and outcomes will be analysed longitudinally. Estimates of effects will be calculated. ETHICS AND DISSEMINATION The study has received approval from the Human Research Ethics Board, University of Alberta. Results will inform the design of a future multicentre trial. TRIAL REGISTRATION NUMBER NCT02905812; Pre-results.
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Affiliation(s)
| | - Yoanna Skrobik
- Department of Medicine, Regroupement de Soins Critiques Respiratoires, FRQS, McGill University, Montreal, Quebec, Canada
| | | | - Patrica Thompson
- Critical Care Research Group, Royal Alexandra Hospital, Edmonton, AB, Canada
| | | | - Colleen Norris
- Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada
| | - Louise Rose
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- King's College London, London, UK
| | - Sean M Bagshaw
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
- General Systems ICU, University of Alberta Hospital, Edmonton, Alberta, Canada
| | - Michael Meier
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
- General Systems ICU, University of Alberta Hospital, Edmonton, Alberta, Canada
| | - Cheryl LoCicero
- Registered Massage Therapist (RMT), Certified Advanced Rolfer, Vancouver, Canada
| | - Rhonda Ashmore
- Registered Massage Therapist (RMT), PT, Hamilton, Ontario, Canada
| | | | - Imran Hassan
- EPICORE Centre, University of Alberta, Edmonton, Alberta, Canada
| | - Tanya Park
- Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada
| | - Demetrios J Kutsogiannis
- Critical Care Research Group, Royal Alexandra Hospital, Edmonton, AB, Canada
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
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de Grood C, Job McIntosh C, Boyd JM, Zjadewicz K, Parsons Leigh J, Stelfox HT. Identifying essential elements to include in Intensive Care Unit to hospital ward transfer summaries: A consensus methodology. J Crit Care 2018; 49:27-32. [PMID: 30343010 DOI: 10.1016/j.jcrc.2018.10.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Revised: 09/17/2018] [Accepted: 10/04/2018] [Indexed: 12/26/2022]
Abstract
PURPOSE Transitions of care from the intensive care unit (ICU) to a hospital ward are high risk and contingent on effective communication. We sought to identify essential information elements to be included in an ICU to hospital ward transfer summary tool, and describe tool functionality and composition perceived to be important. MATERIALS AND METHODS A panel of 13 clinicians representing ICU and hospital ward providers used a modified Delphi process to iteratively review and rate unique information elements identified from existing ICU transfer tools through three rounds of review (two remote and one in person). Qualitative content analysis was conducted on transcribed audio recordings of the workshop to characterize tool functionality and composition. RESULTS A total of 141 unique information elements were reviewed of which 63 were identified by panelists as essential. Qualitative content analyses of panelist discussions identified three themes related to how information elements should be considered when developing an ICU transfer summary tool: 1) Flexibility, 2) Usability, and 3) Accountability. CONCLUSION We identified 63 distinct information elements identified as essential for inclusion in an ICU transfer summary tool to facilitate communication between providers during the transition of patient care from the ICU to a hospital ward.
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Affiliation(s)
| | - Chloe de Grood
- Department of Community Health Sciences, TRW Building, 3(rd) Floor, University of Calgary, 3280 Hospital Drive NW, Calgary, Alberta T2N 4Z6, Canada
| | - Christiane Job McIntosh
- Cardiovascular Health and Stroke Strategic Clinical Network, Alberta Health Services, 10101 Southport Road SW, Calgary, Alberta T2W 3N2, Canada
| | - Jamie M Boyd
- Department of Community Health Sciences, TRW Building, 3(rd) Floor, University of Calgary, 3280 Hospital Drive NW, Calgary, Alberta T2N 4Z6, Canada
| | - Karolina Zjadewicz
- Alberta Health Services, Ground Floor, McCaig Tower, University of Calgary, 3134 Hospital Drive NW, Calgary, Alberta T2N 2T9, Canada
| | - Jeanna Parsons Leigh
- Department of Community Health Sciences, TRW Building, 3(rd) Floor, University of Calgary, 3280 Hospital Drive NW, Calgary, Alberta T2N 4Z6, Canada; Department of Critical Care Medicine, Ground Floor, McCaig Tower, University of Calgary, 3134 Hospital Drive NW, Calgary, Alberta T2N 2T9, Canada
| | - Henry Thomas Stelfox
- Department of Community Health Sciences, TRW Building, 3(rd) Floor, University of Calgary, 3280 Hospital Drive NW, Calgary, Alberta T2N 4Z6, Canada; Alberta Health Services, Ground Floor, McCaig Tower, University of Calgary, 3134 Hospital Drive NW, Calgary, Alberta T2N 2T9, Canada; Department of Critical Care Medicine, Ground Floor, McCaig Tower, University of Calgary, 3134 Hospital Drive NW, Calgary, Alberta T2N 2T9, Canada.
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Boyd JM, Roberts DJ, Parsons Leigh J, Stelfox HT. Administrator Perspectives on ICU-to-Ward Transfers and Content Contained in Existing Transfer Tools: a Cross-sectional Survey. J Gen Intern Med 2018; 33:1738-1745. [PMID: 30051330 PMCID: PMC6153252 DOI: 10.1007/s11606-018-4590-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Revised: 04/20/2018] [Accepted: 07/10/2018] [Indexed: 12/20/2022]
Abstract
BACKGROUND The transfer of critically ill patients from the intensive care unit (ICU) to hospital ward is challenging. Shortcomings in the delivery of care for patients transferred from the ICU have been associated with higher healthcare costs and poor satisfaction with care. Little is known about how hospital ward providers, who accept care of these patients, perceive current transfer practices nor which aspects of transfer they perceive as needing improvement. OBJECTIVE To compare ICU and ward administrator perspectives regarding ICU-to-ward transfer practices and evaluate the content of transfer tools. DESIGN Cross-sectional survey design. PARTICIPANTS We administered a survey to 128 medical and/or surgical ICU and 256 ward administrators to obtain institutional perspectives on ICU transfer practices. We performed qualitative content analysis on ICU transfer tools received from respondents. KEY RESULTS In total, 108 (77%) ICU and 160 (63%) ward administrators responded to the survey. The ICU attending physician was reported to be "primarily responsible" for the safety (93% vs. 91%; p = 0.515) of patient transfers. ICU administrators more commonly perceived discharge summaries to be routinely included in patient transfers than ward administrators (81% vs. 60%; p = 0.006). Both groups identified information provided to patients/families, patient/family participation during transfer, and ICU-ward collaboration as opportunities for improvement. A minority of hospitals used ICU-to-ward transfer tools (11%) of which most (n = 21 unique) were designed to communicate patient information between providers (71%) and comprised six categories of information: demographics, patient clinical course, corrective aids, mobility at discharge, review of systems, and documentation of transfer procedures. CONCLUSION ICU and ward administrators have similar perspectives of transfer practices and identified patient/family engagement and communication as priorities for improvement. Key information categories exist.
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Affiliation(s)
- Jamie M Boyd
- Departments of Critical Care Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Derek J Roberts
- Department of Surgery, University of Calgary and the Foothills Medical Centre, Calgary, Alberta, Canada
| | - Jeanna Parsons Leigh
- Departments of Critical Care Medicine, O'Brien Institute for Public Health, University of Calgary and Alberta Health Services, Calgary, Alberta, Canada
| | - Henry Thomas Stelfox
- Departments of Critical Care Medicine, Medicine and Community Health Sciences, O'Brien Institute for Public Health, University of Calgary and Alberta Health Services - Calgary Zone, Calgary, Alberta, Canada.
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Moore L, Champion H, Tardif PA, Kuimi BL, O'Reilly G, Leppaniemi A, Cameron P, Palmer CS, Abu-Zidan FM, Gabbe B, Gaarder C, Yanchar N, Stelfox HT, Coimbra R, Kortbeek J, Noonan VK, Gunning A, Gordon M, Khajanchi M, Porgo TV, Turgeon AF, Leenen L. Impact of Trauma System Structure on Injury Outcomes: A Systematic Review and Meta-Analysis. World J Surg 2018; 42:1327-1339. [PMID: 29071424 DOI: 10.1007/s00268-017-4292-0] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND The effectiveness of trauma systems in decreasing injury mortality and morbidity has been well demonstrated. However, little is known about which components contribute to their effectiveness. We aimed to systematically review the evidence of the impact of trauma system components on clinically important injury outcomes. METHODS We searched MEDLINE, EMBASE, Cochrane CENTRAL, and BIOSIS/Web of Knowledge, gray literature and trauma association Web sites to identify studies evaluating the association between at least one trauma system component and injury outcome. We calculated pooled effect estimates using inverse-variance random-effects models. We evaluated quality of evidence using GRADE criteria. RESULTS We screened 15,974 records, retaining 41 studies for qualitative synthesis and 19 for meta-analysis. Two recommended trauma system components were associated with reduced odds of mortality: inclusive design (odds ratio [OR] = 0.72 [0.65-0.80]) and helicopter transport (OR = 0.70 [0.55-0.88]). Pre-Hospital Advanced Trauma Life Support was associated with a significant reduction in hospital days (mean difference [MD] = 5.7 [4.4-7.0]) but a nonsignificant reduction in mortality (OR = 0.78 [0.44-1.39]). Population density of surgeons was associated with a nonsignificant decrease in mortality (MD = 0.58 [-0.22 to 1.39]). Trauma system maturity was associated with a significant reduction in mortality (OR = 0.76 [0.68-0.85]). Quality of evidence was low or very low for mortality and healthcare utilization. CONCLUSIONS This review offers low-quality evidence for the effectiveness of an inclusive design and trauma system maturity and very-low-quality evidence for helicopter transport in reducing injury mortality. Further research should evaluate other recommended components of trauma systems and non-fatal outcomes and explore the impact of system component interactions.
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Affiliation(s)
- Lynne Moore
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, Québec, QC, Canada. .,Axe Santé des Populations et Pratiques Optimales en Santé (Population Health and Optimal Health Practices Research Unit), Traumatologie - Urgence - Soins intensifs (Trauma - Emergency - Critical Care Medicine), CHU de Québec - Université Laval Research Center (Enfant-Jésus Hospital), Québec, QC, Canada.
| | - Howard Champion
- Department of Surgery, University of the Health Sciences, Annapolis, MD, USA
| | - Pier-Alexandre Tardif
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, Québec, QC, Canada.,Axe Santé des Populations et Pratiques Optimales en Santé (Population Health and Optimal Health Practices Research Unit), Traumatologie - Urgence - Soins intensifs (Trauma - Emergency - Critical Care Medicine), CHU de Québec - Université Laval Research Center (Enfant-Jésus Hospital), Québec, QC, Canada
| | - Brice-Lionel Kuimi
- Axe Santé des Populations et Pratiques Optimales en Santé (Population Health and Optimal Health Practices Research Unit), Traumatologie - Urgence - Soins intensifs (Trauma - Emergency - Critical Care Medicine), CHU de Québec - Université Laval Research Center (Enfant-Jésus Hospital), Québec, QC, Canada
| | - Gerard O'Reilly
- Emergency and Trauma Centre, The Alfred Hospital, Melbourne, Australia.,School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Ari Leppaniemi
- Abdominal Center, Helsinki University hospital, Helsinki, Finland
| | - Peter Cameron
- Emergency and Trauma Centre, The Alfred Hospital, Melbourne, Australia.,School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | | | - Fikri M Abu-Zidan
- Department of Surgery, College of Medicine and Health Sciences, United Arab Emirates University, Al-Ain, United Arab Emirates
| | - Belinda Gabbe
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Christine Gaarder
- Department of Traumatology, Oslo University Hospital Ulleval, Oslo, Norway
| | - Natalie Yanchar
- Department of Surgery, Dalhousie University, Halifax, NS, Canada
| | - Henry Thomas Stelfox
- Departments of Critical Care Medicine, Medicine and Community Health Sciences, O'Brien Institute for Public Health, University of Calgary, Calgary, Canada
| | - Raul Coimbra
- Division of Trauma, Surgical Critical Care, Burns, and Acute Care Surgery, University of California, San Diego Health System, San Diego, CA, USA
| | - John Kortbeek
- Department of Surgery, Division of General Surgery and Division of Critical Care, University of Calgary, Calgary, AB, Canada
| | | | - Amy Gunning
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Malcolm Gordon
- Department of Emergency Medicine, University of Glasgow, Glasgow, UK
| | | | - Teegwendé V Porgo
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, Québec, QC, Canada.,Axe Santé des Populations et Pratiques Optimales en Santé (Population Health and Optimal Health Practices Research Unit), Traumatologie - Urgence - Soins intensifs (Trauma - Emergency - Critical Care Medicine), CHU de Québec - Université Laval Research Center (Enfant-Jésus Hospital), Québec, QC, Canada
| | - Alexis F Turgeon
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, Québec, QC, Canada.,Axe Santé des Populations et Pratiques Optimales en Santé (Population Health and Optimal Health Practices Research Unit), Traumatologie - Urgence - Soins intensifs (Trauma - Emergency - Critical Care Medicine), CHU de Québec - Université Laval Research Center (Enfant-Jésus Hospital), Québec, QC, Canada
| | - Luke Leenen
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
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Soril LJJ, Noseworthy TW, Dowsett LE, Memedovich K, Holitzki HM, Lorenzetti DL, Stelfox HT, Zygun DA, Clement FM. Behaviour modification interventions to optimise red blood cell transfusion practices: a systematic review and meta-analysis. BMJ Open 2018; 8:e019912. [PMID: 29776919 PMCID: PMC5961610 DOI: 10.1136/bmjopen-2017-019912] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
OBJECTIVE To assess the impact of behaviour modification interventions to promote restrictive red blood cell (RBC) transfusion practices. DESIGN Systematic review and meta-analysis. SETTING, PARTICIPANTS, INTERVENTIONS Seven electronic databases were searched to January 2018. Published randomised controlled trials (RCTs) or non-randomised studies examining an intervention to modify healthcare providers' RBC transfusion practice in any healthcare setting were included. PRIMARY AND SECONDARY OUTCOMES The primary outcome was the proportion of patients transfused. Secondary outcomes included the proportion of inappropriate transfusions, RBC units transfused per patient, in-hospital mortality, length of stay (LOS), pretransfusion haemoglobin and healthcare costs. Meta-analysis was conducted using a random-effects model and meta-regression was performed in cases of heterogeneity. Publication bias was assessed by Begg's funnel plot. RESULTS Eighty-four low to moderate quality studies were included: 3 were RCTs and 81 were non-randomised studies. Thirty-one studies evaluated a single intervention, 44 examined a multimodal intervention. The comparator in all studies was standard of care or historical control. In 33 non-randomised studies, use of an intervention was associated with reduced odds of transfusion (OR 0.63 (95% CI 0.56 to 0.71)), odds of inappropriate transfusion (OR 0.46 (95% CI 0.36 to 0.59)), RBC units/patient weighted mean difference (WMD: -0.50 units (95% CI -0.85 to -0.16)), LOS (WMD: -1.14 days (95% CI -2.12 to -0.16)) and pretransfusion haemoglobin (-0.28 g/dL (95% CI -0.48 to -0.08)). There was no difference in odds of mortality (OR 0.90 (95% CI 0.80 to 1.02)). Protocol/algorithm and multimodal interventions were associated with the greatest decreases in the primary outcome. There was high heterogeneity among estimates and evidence for publication bias. CONCLUSIONS The literature examining the impact of interventions on RBC transfusions is extensive, although most studies are non-randomised. Despite this, pooled analysis of 33 studies revealed improvement in the primary outcome. Future work needs to shift from asking, 'does it work?' to 'what works best and at what cost?' PROSPERO REGISTRATION NUMBER CRD42015024757.
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Affiliation(s)
- Lesley J J Soril
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- O'Brien Institute for Public Health, The University of Calgary, Calgary, Alberta, Canada
| | - Thomas W Noseworthy
- O'Brien Institute for Public Health, The University of Calgary, Calgary, Alberta, Canada
| | - Laura E Dowsett
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- O'Brien Institute for Public Health, The University of Calgary, Calgary, Alberta, Canada
| | - Katherine Memedovich
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- O'Brien Institute for Public Health, The University of Calgary, Calgary, Alberta, Canada
| | - Hannah M Holitzki
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- O'Brien Institute for Public Health, The University of Calgary, Calgary, Alberta, Canada
| | - Diane L Lorenzetti
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- O'Brien Institute for Public Health, The University of Calgary, Calgary, Alberta, Canada
| | - Henry Thomas Stelfox
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- O'Brien Institute for Public Health, The University of Calgary, Calgary, Alberta, Canada
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Foothills Medical Centre, Calgary, Alberta, Canada
- Critical Care Strategic Clinical Network, Alberta Health Services, Edmonton, Alberta, Canada
| | - David A Zygun
- Critical Care Strategic Clinical Network, Alberta Health Services, Edmonton, Alberta, Canada
- Department of Critical Care Medicine, Alberta Health Services and Faculty of Medicine and Dentistry, University of Alberta, Calgary, Alberta, Canada
| | - Fiona M Clement
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- O'Brien Institute for Public Health, The University of Calgary, Calgary, Alberta, Canada
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Moore L, Evans D, Yanchar NL, Thakore J, Stelfox HT, Hameed M, Simons R, Kortbeek J, Clément J, Lauzier F, Turgeon AF. Canadian benchmarks for acute injury care. Can J Surg 2017; 60:380-387. [PMID: 28930046 DOI: 10.1503/cjs.002817] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Acute care injury outcomes vary substantially across Canadian provinces and trauma centres. Our aim was to develop Canadian benchmarks to monitor mortality and hospital length of stay (LOS) for injury admissions. METHODS Benchmarks were derived using data from the Canadian National Trauma Registry on patients with major trauma admitted to any level I or II trauma centre in Canada and from the following patient subgroups: isolated traumatic brain injury (TBI), isolated thoracoabdominal injury, multisystem blunt injury, age 65 years or older. We assessed predictive validity using measures of discrimination and calibration, and performed sensitivity analyses to assess the impact of replacing analytically complex methods (multiple imputation, shrinkage estimates and flexible modelling) with simple models that can be implemented locally. RESULTS The mortality risk adjustment model had excellent discrimination and calibration (area under the receiver operating characteristic curve 0.886, Hosmer-Lemeshow 36). The LOS risk-adjustment model predicted 29% of the variation in LOS. Overall, observed:expected ratios of mortality and mean LOS generated by an analytically simple model correlated strongly with those generated by analytically complex models (r > 0.95, κ on outliers > 0.90). CONCLUSION We propose Canadian benchmarks that can be used to monitor quality of care in Canadian trauma centres using Excel (see the appendices, available at canjsurg.ca). The program can be implemented using local trauma registries, providing that at least 100 patients are available for analysis.
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Affiliation(s)
- Lynne Moore
- From the Department of Social and Preventative Medicine, Université Laval, Québec, Que. (Moore); the Axe Santé des Populations et Pratiques Optimales en Santé, Traumatologie-Urgence-Soins intensifs, Centre de Recherche du CHU de Québec, Hôpital de l'Enfant-Jésus, Université Laval, Québec, Que. (Moore, Lauzier, Turgeon); the Department of Surgery, University of Calgary, Calgary, Alta. (Yanchar); the Department of Surgery, University of British Columbia, Vancouver, BC (Evans, Thakore, Hameed); the Department of Critical Care Medicine, Medicine and Community Health Sciences (Stelfox), O'Brien Institute for Public Health, University of Calgary, Calgary, Alta. (Stelfox); the Department of Surgery, Division of General Surgery and Division of Critical Care, University of Calgary, Calgary, Alta. (Kortbeek); the Institut national d'excellence en santé et en services sociaux, Québec, Que. (Clément); the Department of Surgery, Université Laval, Québec, Que. (Clément); and the Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, Québec, Que. (Lauzier, Turgeon)
| | - David Evans
- From the Department of Social and Preventative Medicine, Université Laval, Québec, Que. (Moore); the Axe Santé des Populations et Pratiques Optimales en Santé, Traumatologie-Urgence-Soins intensifs, Centre de Recherche du CHU de Québec, Hôpital de l'Enfant-Jésus, Université Laval, Québec, Que. (Moore, Lauzier, Turgeon); the Department of Surgery, University of Calgary, Calgary, Alta. (Yanchar); the Department of Surgery, University of British Columbia, Vancouver, BC (Evans, Thakore, Hameed); the Department of Critical Care Medicine, Medicine and Community Health Sciences (Stelfox), O'Brien Institute for Public Health, University of Calgary, Calgary, Alta. (Stelfox); the Department of Surgery, Division of General Surgery and Division of Critical Care, University of Calgary, Calgary, Alta. (Kortbeek); the Institut national d'excellence en santé et en services sociaux, Québec, Que. (Clément); the Department of Surgery, Université Laval, Québec, Que. (Clément); and the Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, Québec, Que. (Lauzier, Turgeon)
| | - Natalie L Yanchar
- From the Department of Social and Preventative Medicine, Université Laval, Québec, Que. (Moore); the Axe Santé des Populations et Pratiques Optimales en Santé, Traumatologie-Urgence-Soins intensifs, Centre de Recherche du CHU de Québec, Hôpital de l'Enfant-Jésus, Université Laval, Québec, Que. (Moore, Lauzier, Turgeon); the Department of Surgery, University of Calgary, Calgary, Alta. (Yanchar); the Department of Surgery, University of British Columbia, Vancouver, BC (Evans, Thakore, Hameed); the Department of Critical Care Medicine, Medicine and Community Health Sciences (Stelfox), O'Brien Institute for Public Health, University of Calgary, Calgary, Alta. (Stelfox); the Department of Surgery, Division of General Surgery and Division of Critical Care, University of Calgary, Calgary, Alta. (Kortbeek); the Institut national d'excellence en santé et en services sociaux, Québec, Que. (Clément); the Department of Surgery, Université Laval, Québec, Que. (Clément); and the Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, Québec, Que. (Lauzier, Turgeon)
| | - Jaimini Thakore
- From the Department of Social and Preventative Medicine, Université Laval, Québec, Que. (Moore); the Axe Santé des Populations et Pratiques Optimales en Santé, Traumatologie-Urgence-Soins intensifs, Centre de Recherche du CHU de Québec, Hôpital de l'Enfant-Jésus, Université Laval, Québec, Que. (Moore, Lauzier, Turgeon); the Department of Surgery, University of Calgary, Calgary, Alta. (Yanchar); the Department of Surgery, University of British Columbia, Vancouver, BC (Evans, Thakore, Hameed); the Department of Critical Care Medicine, Medicine and Community Health Sciences (Stelfox), O'Brien Institute for Public Health, University of Calgary, Calgary, Alta. (Stelfox); the Department of Surgery, Division of General Surgery and Division of Critical Care, University of Calgary, Calgary, Alta. (Kortbeek); the Institut national d'excellence en santé et en services sociaux, Québec, Que. (Clément); the Department of Surgery, Université Laval, Québec, Que. (Clément); and the Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, Québec, Que. (Lauzier, Turgeon)
| | - Henry Thomas Stelfox
- From the Department of Social and Preventative Medicine, Université Laval, Québec, Que. (Moore); the Axe Santé des Populations et Pratiques Optimales en Santé, Traumatologie-Urgence-Soins intensifs, Centre de Recherche du CHU de Québec, Hôpital de l'Enfant-Jésus, Université Laval, Québec, Que. (Moore, Lauzier, Turgeon); the Department of Surgery, University of Calgary, Calgary, Alta. (Yanchar); the Department of Surgery, University of British Columbia, Vancouver, BC (Evans, Thakore, Hameed); the Department of Critical Care Medicine, Medicine and Community Health Sciences (Stelfox), O'Brien Institute for Public Health, University of Calgary, Calgary, Alta. (Stelfox); the Department of Surgery, Division of General Surgery and Division of Critical Care, University of Calgary, Calgary, Alta. (Kortbeek); the Institut national d'excellence en santé et en services sociaux, Québec, Que. (Clément); the Department of Surgery, Université Laval, Québec, Que. (Clément); and the Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, Québec, Que. (Lauzier, Turgeon)
| | - Morad Hameed
- From the Department of Social and Preventative Medicine, Université Laval, Québec, Que. (Moore); the Axe Santé des Populations et Pratiques Optimales en Santé, Traumatologie-Urgence-Soins intensifs, Centre de Recherche du CHU de Québec, Hôpital de l'Enfant-Jésus, Université Laval, Québec, Que. (Moore, Lauzier, Turgeon); the Department of Surgery, University of Calgary, Calgary, Alta. (Yanchar); the Department of Surgery, University of British Columbia, Vancouver, BC (Evans, Thakore, Hameed); the Department of Critical Care Medicine, Medicine and Community Health Sciences (Stelfox), O'Brien Institute for Public Health, University of Calgary, Calgary, Alta. (Stelfox); the Department of Surgery, Division of General Surgery and Division of Critical Care, University of Calgary, Calgary, Alta. (Kortbeek); the Institut national d'excellence en santé et en services sociaux, Québec, Que. (Clément); the Department of Surgery, Université Laval, Québec, Que. (Clément); and the Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, Québec, Que. (Lauzier, Turgeon)
| | - Richard Simons
- From the Department of Social and Preventative Medicine, Université Laval, Québec, Que. (Moore); the Axe Santé des Populations et Pratiques Optimales en Santé, Traumatologie-Urgence-Soins intensifs, Centre de Recherche du CHU de Québec, Hôpital de l'Enfant-Jésus, Université Laval, Québec, Que. (Moore, Lauzier, Turgeon); the Department of Surgery, University of Calgary, Calgary, Alta. (Yanchar); the Department of Surgery, University of British Columbia, Vancouver, BC (Evans, Thakore, Hameed); the Department of Critical Care Medicine, Medicine and Community Health Sciences (Stelfox), O'Brien Institute for Public Health, University of Calgary, Calgary, Alta. (Stelfox); the Department of Surgery, Division of General Surgery and Division of Critical Care, University of Calgary, Calgary, Alta. (Kortbeek); the Institut national d'excellence en santé et en services sociaux, Québec, Que. (Clément); the Department of Surgery, Université Laval, Québec, Que. (Clément); and the Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, Québec, Que. (Lauzier, Turgeon)
| | - John Kortbeek
- From the Department of Social and Preventative Medicine, Université Laval, Québec, Que. (Moore); the Axe Santé des Populations et Pratiques Optimales en Santé, Traumatologie-Urgence-Soins intensifs, Centre de Recherche du CHU de Québec, Hôpital de l'Enfant-Jésus, Université Laval, Québec, Que. (Moore, Lauzier, Turgeon); the Department of Surgery, University of Calgary, Calgary, Alta. (Yanchar); the Department of Surgery, University of British Columbia, Vancouver, BC (Evans, Thakore, Hameed); the Department of Critical Care Medicine, Medicine and Community Health Sciences (Stelfox), O'Brien Institute for Public Health, University of Calgary, Calgary, Alta. (Stelfox); the Department of Surgery, Division of General Surgery and Division of Critical Care, University of Calgary, Calgary, Alta. (Kortbeek); the Institut national d'excellence en santé et en services sociaux, Québec, Que. (Clément); the Department of Surgery, Université Laval, Québec, Que. (Clément); and the Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, Québec, Que. (Lauzier, Turgeon)
| | - Julien Clément
- From the Department of Social and Preventative Medicine, Université Laval, Québec, Que. (Moore); the Axe Santé des Populations et Pratiques Optimales en Santé, Traumatologie-Urgence-Soins intensifs, Centre de Recherche du CHU de Québec, Hôpital de l'Enfant-Jésus, Université Laval, Québec, Que. (Moore, Lauzier, Turgeon); the Department of Surgery, University of Calgary, Calgary, Alta. (Yanchar); the Department of Surgery, University of British Columbia, Vancouver, BC (Evans, Thakore, Hameed); the Department of Critical Care Medicine, Medicine and Community Health Sciences (Stelfox), O'Brien Institute for Public Health, University of Calgary, Calgary, Alta. (Stelfox); the Department of Surgery, Division of General Surgery and Division of Critical Care, University of Calgary, Calgary, Alta. (Kortbeek); the Institut national d'excellence en santé et en services sociaux, Québec, Que. (Clément); the Department of Surgery, Université Laval, Québec, Que. (Clément); and the Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, Québec, Que. (Lauzier, Turgeon)
| | - François Lauzier
- From the Department of Social and Preventative Medicine, Université Laval, Québec, Que. (Moore); the Axe Santé des Populations et Pratiques Optimales en Santé, Traumatologie-Urgence-Soins intensifs, Centre de Recherche du CHU de Québec, Hôpital de l'Enfant-Jésus, Université Laval, Québec, Que. (Moore, Lauzier, Turgeon); the Department of Surgery, University of Calgary, Calgary, Alta. (Yanchar); the Department of Surgery, University of British Columbia, Vancouver, BC (Evans, Thakore, Hameed); the Department of Critical Care Medicine, Medicine and Community Health Sciences (Stelfox), O'Brien Institute for Public Health, University of Calgary, Calgary, Alta. (Stelfox); the Department of Surgery, Division of General Surgery and Division of Critical Care, University of Calgary, Calgary, Alta. (Kortbeek); the Institut national d'excellence en santé et en services sociaux, Québec, Que. (Clément); the Department of Surgery, Université Laval, Québec, Que. (Clément); and the Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, Québec, Que. (Lauzier, Turgeon)
| | - Alexis F Turgeon
- From the Department of Social and Preventative Medicine, Université Laval, Québec, Que. (Moore); the Axe Santé des Populations et Pratiques Optimales en Santé, Traumatologie-Urgence-Soins intensifs, Centre de Recherche du CHU de Québec, Hôpital de l'Enfant-Jésus, Université Laval, Québec, Que. (Moore, Lauzier, Turgeon); the Department of Surgery, University of Calgary, Calgary, Alta. (Yanchar); the Department of Surgery, University of British Columbia, Vancouver, BC (Evans, Thakore, Hameed); the Department of Critical Care Medicine, Medicine and Community Health Sciences (Stelfox), O'Brien Institute for Public Health, University of Calgary, Calgary, Alta. (Stelfox); the Department of Surgery, Division of General Surgery and Division of Critical Care, University of Calgary, Calgary, Alta. (Kortbeek); the Institut national d'excellence en santé et en services sociaux, Québec, Que. (Clément); the Department of Surgery, Université Laval, Québec, Que. (Clément); and the Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, Québec, Que. (Lauzier, Turgeon)
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Blanchard IE, Ahmad A, Tang KL, Ronksley PE, Lorenzetti D, Lazarenko G, Lang ES, Doig CJ, Stelfox HT. The effectiveness of prehospital hypertonic saline for hypotensive trauma patients: a systematic review and meta-analysis. BMC Emerg Med 2017; 17:35. [PMID: 29183276 PMCID: PMC5706402 DOI: 10.1186/s12873-017-0146-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Accepted: 11/15/2017] [Indexed: 12/04/2022] Open
Abstract
Background The optimal prehospital fluid for the treatment of hypotension is unknown. Hypertonic fluids may increase circulatory volume and mute the pro-inflammatory response of the body to injury and illness. The purpose of this systematic review is to determine whether in patients presenting with hypotension in the prehospital setting (population), the administration of hypertonic saline (intervention), compared to an isotonic fluid (control), improves survival to hospital discharge (outcome). Methods Searches were conducted in Medline, Embase, CINAHL, and CENTRAL from the date of database inception to November, 2016, and included all languages. Two reviewers independently selected randomized control trials of hypotensive human participants administered hypertonic saline in the prehospital setting. The comparison was isotonic fluid, which included normal saline, and near isotonic fluids such as Ringer’s Lactate. Assessment of study quality was done using the Cochrane Collaborations’ risk of bias tool and a fixed effect meta-analysis was conducted to determine the pooled relative risk of survival to hospital discharge. Secondary outcomes were reported for fluid requirements, multi-organ failure, adverse events, length of hospital stay, long term survival and disability. Results Of the 1160 non-duplicate citations screened, thirty-eight articles underwent full-text review, and five trials were included in the systematic review. All studies administered a fixed 250 ml dose of 7.5% hypertonic saline, except one that administered 300 ml. Two studies used normal saline, two Ringer’s Lactate, and one Ringer’s Acetate as control. Routine care co-interventions included isotonic fluids and colloids. Five studies were included in the meta-analysis (n = 1162 injured patients) with minimal statistical heterogeneity (I2 = 0%). The pooled relative risk of survival to hospital discharge with hypertonic saline was 1.02 times that of patients who received isotonic fluids (95% Confidence Interval: 0.95, 1.10). There were no consistent statistically significant differences in secondary outcomes. Conclusions There was no significant difference in important clinical outcomes for hypotensive injured patients administered hypertonic saline compared to isotonic fluid in the prehospital setting. Hypertonic saline cannot be recommended for use in prehospital clinical practice for the management of hypotensive injured patients based on the available data. PROSPERO registration # CRD42016053385.
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Affiliation(s)
- I E Blanchard
- Alberta Health Services, Emergency Medical Services, Calgary, Alberta, Canada. .,University of Calgary, Cumming School of Medicine, Department of Critical Care, Calgary, Alberta, Canada. .,University of Calgary, Cumming School of Medicine, Department of Community Health Sciences, Calgary, Alberta, Canada.
| | - A Ahmad
- University of Calgary, Cumming School of Medicine, Department of Community Health Sciences, Calgary, Alberta, Canada
| | - K L Tang
- University of Calgary, Cumming School of Medicine, Department of Medicine, Calgary, Alberta, Canada
| | - P E Ronksley
- University of Calgary, Cumming School of Medicine, Department of Community Health Sciences, Calgary, Alberta, Canada
| | - D Lorenzetti
- University of Calgary, Cumming School of Medicine, Department of Community Health Sciences, Calgary, Alberta, Canada
| | - G Lazarenko
- Alberta Health Services, Emergency Medical Services, Calgary, Alberta, Canada
| | - E S Lang
- University of Calgary, Cumming School of Medicine, Department of Emergency Medicine, Calgary, Alberta, Canada
| | - C J Doig
- University of Calgary, Cumming School of Medicine, Department of Critical Care, Calgary, Alberta, Canada
| | - H T Stelfox
- University of Calgary, Cumming School of Medicine, Department of Critical Care, Calgary, Alberta, Canada.,University of Calgary, Cumming School of Medicine, Department of Community Health Sciences, Calgary, Alberta, Canada.,University of Calgary, Cumming School of Medicine, Department of Medicine, Calgary, Alberta, Canada.,O'Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada
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Moore L, Stelfox HT, Evans D, Hameed SM, Yanchar NL, Simons R, Kortbeek J, Bourgeois G, Clément J, Turgeon AF, Lauzier F. Trends in Injury Outcomes Across Canadian Trauma Systems. JAMA Surg 2017; 152:168-174. [PMID: 27829100 DOI: 10.1001/jamasurg.2016.4212] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance In response to the burden of injury, the structure of injury care has changed considerably across Canada in the past decade. However, little is known about how patient outcomes have evolved. Objective To evaluate trends in mortality, hospital length of stay, and unplanned readmission in Canadian trauma systems between 2006 and 2012. Design, Setting, and Participants A pan-Canadian retrospective cohort study was conducted among adults admitted for major injury to a Canadian level I or II trauma center between April 1, 2006, and March 31, 2012. Data analysis was conducted from April 15 to December 3, 2015. Exposures Trauma centers and systems. Main Outcomes and Measures Multilevel generalized linear models were used to evaluate trends in the risk-adjusted incidence of mortality and readmission and risk-adjusted mean length of stay. Trend analyses were conducted globally and by province. Results Among 78 807 patients (mean [SD] age, 50.7 [22.0] years; 22 540 women and 56 267 men) admitted for major injury during the study period, risk-adjusted mortality decreased from 12.1% (95% CI, 9%-16.1%) to 9.9% (95% CI, 7.4%-13.3%; P < .001) and mean length of hospital stay decreased from 11.6 (95% CI, 9.9-13.6) to 10.6 (95% CI, 9.1-12.5) days (P < .001). Statistically significant reductions in mortality were observed for Ontario (12% [95% CI, 10.7%-13.6%] to 8% [95% CI, 6.9%-9.2%]; P < .001), Alberta (12% [95% CI, 10%-14.3%] to 9.1% [95% CI, 7.7%-10.8%]; P = .02), and Manitoba (13% [95% CI, 9.1%-18.4%] to 11.1% [95% CI, 8.3%-14.7%]; P = .04). Risk-adjusted hospital stay decreased significantly in Québec (11.6 [95% CI, 11.1-12] to 9.1 [95% CI, 8.9-9.5] days; P < .001), British Columbia (12.5 [95% CI, 12-13.1] to 11.4 [10.9-11.9] days; P < .001), and Ontario (10.1 [95% CI, 9.8-10.4] to 9.8 [95% CI, 9.5-10.1] days; P < .001). No change in the incidence of readmission was observed. Conclusions and Relevance We observed an 18.2% relative decrease in risk-adjusted mortality in Canadian trauma centers during the study period, representing 248 additional lives saved in 2012 vs 2006. Risk-adjusted mean hospital stay decreased by 8.6%, representing nearly 10 000 hospital days saved. A better understanding of the structures and processes behind observed improvements is needed to further reduce the burden of injury in Canada.
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Affiliation(s)
- Lynne Moore
- Department of Social and Preventative Medicine, Université Laval, Québec City, Québec, Canada2Population Health and Optimal Health Practices Research Unit, Trauma, Emergency, and Critical Care Medicine, Centre de Recherche du Centre Hospitalier Universitaire de Québec Hôpital de l'Enfant-Jésus, Université Laval, Québec City, Québec, Canada
| | - Henry Thomas Stelfox
- Department of Critical Care Medicine, Medicine and Community Health Sciences, O'Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada
| | - David Evans
- Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Sayed Morad Hameed
- Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Natalie L Yanchar
- Department of Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Richard Simons
- Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - John Kortbeek
- Division of General Surgery, Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Gilles Bourgeois
- Institut National d'Excellence en Santé et en Services Sociaux, Québec, Québec City, Canada
| | - Julien Clément
- Department of Surgery, Université Laval, Québec, Québec City, Canada
| | - Alexis F Turgeon
- Population Health and Optimal Health Practices Research Unit, Trauma, Emergency, and Critical Care Medicine, Centre de Recherche du Centre Hospitalier Universitaire de Québec Hôpital de l'Enfant-Jésus, Université Laval, Québec City, Québec, Canada9Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Université Laval, Québec, Québec City, Canada
| | - François Lauzier
- Population Health and Optimal Health Practices Research Unit, Trauma, Emergency, and Critical Care Medicine, Centre de Recherche du Centre Hospitalier Universitaire de Québec Hôpital de l'Enfant-Jésus, Université Laval, Québec City, Québec, Canada9Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Université Laval, Québec, Québec City, Canada
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Moore L, Champion H, O’Reilly G, Leppaniemi A, Cameron P, Palmer C, Abu-Zidan FM, Gabbe B, Gaarder C, Yanchar N, Stelfox HT, Coimbra R, Kortbeek J, Noonan V, Gunning A, Leenan L, Gordon M, Khajanchi M, Shemilt M, Porgo V, Turgeon AF. Impact of trauma system structure on injury outcomes: a systematic review protocol. Syst Rev 2017; 6:12. [PMID: 28109306 PMCID: PMC5251247 DOI: 10.1186/s13643-017-0408-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Accepted: 01/06/2017] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Injury represents one of the greatest public health challenges of our time with over 5 million deaths and 100 million people temporarily or permanently disabled every year worldwide. The effectiveness of trauma systems in decreasing injury mortality and morbidity has been well demonstrated. However, the organisation of trauma care varies significantly across trauma systems and we know little about which components of trauma systems contribute to their effectiveness. The objective of the study described in this protocol is to systematically review evidence of the impact of trauma system components on clinically significant outcomes including mortality, function and disability, quality of life, and resource utilization. METHODS We will perform a systematic review of studies evaluating the association between at least one trauma system component (e.g. accreditation by a central agency, interfacility transfer agreements) and at least one injury outcome (e.g. mortality, disability, resource use). We will search MEDLINE, EMBASE, COCHRANE central, and BIOSIS/Web of Knowledge databases, thesis holdings, key injury organisation websites and conference proceedings for eligible studies. Pairs of independent reviewers will evaluate studies for eligibility and extract data from included articles. Methodological quality will be evaluated using elements of the ROBINS-I tool and the Cochrane risk of bias tool for non-randomized and randomized studies, respectively. Strength of evidence will be evaluated using the GRADE tool. DISCUSSION We expect to advance knowledge on the components of trauma systems that contribute to their effectiveness. This may lead to recommendations on trauma system structure that will help policy-makers make informed decisions as to where resources should be focused. The review may also lead to specific recommendations for future research efforts. SYSTEMATIC REVIEW REGISTRATION This protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO) on 28-06-2016. PROSPERO 2016:CRD42016041336 Available from http://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42016041336 .
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Affiliation(s)
- Lynne Moore
- Department of Social and Preventative Medicine, Université Laval, Québec, QC Canada
- Axe Santé des Populations et Pratiques Optimales en Santé (Population Health and Optimal Health Practices Research Unit), Traumatologie–Urgence-Soins intensifs (Trauma–Emergency–Critical Care Medicine), CHU de Québec–Université Laval Research Center (Enfant-Jésus Hospital), 1401, 18e rue, local H-012a, Québec, G1J 1Z4 Canada
| | | | - Gerard O’Reilly
- Emergency and Trauma Centre, The Alfred Hospital, Melbourne, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Ari Leppaniemi
- Department of Surgery, Helsinki University, Helsinki, Finland
| | - Peter Cameron
- Emergency and Trauma Centre, The Alfred Hospital, Monash University, Melbourne, Australia
| | - Cameron Palmer
- Trauma Service, Royal Children’s Hospital, Melbourne, Australia
| | - Fikri M. Abu-Zidan
- Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
| | - Belinda Gabbe
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Christine Gaarder
- Department of Traumatology, Oslo University Hospital Ulleval, Oslo, Norway
| | - Natalie Yanchar
- Department of Surgery, Dalhousie University, Halifax, Nova Scotia Canada
| | - Henry Thomas Stelfox
- Departments of Critical Care Medicine, Medicine and Community Health Sciences, O’Brien Institute for Public Health, University of Calgary, Calgary, Canada
| | - Raul Coimbra
- Division of Trauma, Surgical Critical Care, Burns, and Acute Care Surgery, University of California, San Diego Health System, San Diego, California USA
| | - John Kortbeek
- Department of Surgery, Division of General Surgery and Division of Critical Care, University of Calgary, Calgary, Alberta Canada
| | - Vanessa Noonan
- Rick Hansen Institute, Vancouver, BC Canada
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Amy Gunning
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Luke Leenan
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Malcolm Gordon
- Department of Emergency Medicine, University of Glasgow, Glasgow, UK
| | | | - Michèle Shemilt
- Axe Santé des Populations et Pratiques Optimales en Santé (Population Health and Optimal Health Practices Research Unit), Traumatologie–Urgence-Soins intensifs (Trauma–Emergency–Critical Care Medicine), CHU de Québec–Université Laval Research Center (Enfant-Jésus Hospital), 1401, 18e rue, local H-012a, Québec, G1J 1Z4 Canada
| | - Valérie Porgo
- Department of Social and Preventative Medicine, Université Laval, Québec, QC Canada
| | - Alexis F. Turgeon
- Department of Social and Preventative Medicine, Université Laval, Québec, QC Canada
| | - on behalf of the International Injury Care Improvement Initiative
- Department of Social and Preventative Medicine, Université Laval, Québec, QC Canada
- Axe Santé des Populations et Pratiques Optimales en Santé (Population Health and Optimal Health Practices Research Unit), Traumatologie–Urgence-Soins intensifs (Trauma–Emergency–Critical Care Medicine), CHU de Québec–Université Laval Research Center (Enfant-Jésus Hospital), 1401, 18e rue, local H-012a, Québec, G1J 1Z4 Canada
- U Health Sciences, Baltimore, Maryland USA
- Emergency and Trauma Centre, The Alfred Hospital, Melbourne, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Department of Surgery, Helsinki University, Helsinki, Finland
- Emergency and Trauma Centre, The Alfred Hospital, Monash University, Melbourne, Australia
- Trauma Service, Royal Children’s Hospital, Melbourne, Australia
- Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
- Department of Traumatology, Oslo University Hospital Ulleval, Oslo, Norway
- Department of Surgery, Dalhousie University, Halifax, Nova Scotia Canada
- Departments of Critical Care Medicine, Medicine and Community Health Sciences, O’Brien Institute for Public Health, University of Calgary, Calgary, Canada
- Division of Trauma, Surgical Critical Care, Burns, and Acute Care Surgery, University of California, San Diego Health System, San Diego, California USA
- Department of Surgery, Division of General Surgery and Division of Critical Care, University of Calgary, Calgary, Alberta Canada
- Rick Hansen Institute, Vancouver, BC Canada
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
- Department of Emergency Medicine, University of Glasgow, Glasgow, UK
- Seth G.S. Medical College and KEM Hospital, Mumbai, India
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Niven DJ, Gaudet JE, Laupland KB, Mrklas KJ, Roberts DJ, Stelfox HT. Accuracy of peripheral thermometers for estimating temperature: a systematic review and meta-analysis. Ann Intern Med 2015; 163:768-77. [PMID: 26571241 DOI: 10.7326/m15-1150] [Citation(s) in RCA: 135] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Body temperature is commonly used to screen patients for infectious diseases, establish diagnoses, monitor therapy, and guide management decisions. PURPOSE To determine the accuracy of peripheral thermometers for estimating core body temperature in adults and children. DATA SOURCES MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, and CINAHL Plus from inception to July 2015. STUDY SELECTION Prospective studies comparing the accuracy of peripheral (tympanic membrane, temporal artery, axillary, or oral) thermometers with central (pulmonary artery catheter, urinary bladder, esophageal, or rectal) thermometers. DATA EXTRACTION 2 reviewers extracted data on study characteristics, methods, and outcomes and assessed the quality of individual studies. DATA SYNTHESIS 75 studies (8682 patients) were included. Most studies were at high or unclear risk of patient selection bias (74%) or index test bias (67%). Compared with central thermometers, peripheral thermometers had pooled 95% limits of agreement (random-effects meta-analysis) outside the predefined clinically acceptable range (± 0.5 °C), especially among patients with fever (-1.44 °C to 1.46 °C for adults; -1.49 °C to 0.43 °C for children) and hypothermia (-2.07 °C to 1.90 °C for adults; no data for children). For detection of fever (bivariate random-effects meta-analysis), sensitivity was low (64% [95% CI, 55% to 72%]; I2 = 95.7%; P < 0.001) but specificity was high (96% [CI, 93% to 97%]; I2 = 96.3%; P < 0.001). Only 1 study reported sensitivity and specificity for the detection of hypothermia. LIMITATIONS High-quality data for some temperature measurement techniques are limited. Pooled data are associated with interstudy heterogeneity that is not fully explained by stratified and metaregression analyses. CONCLUSION Peripheral thermometers do not have clinically acceptable accuracy and should not be used when accurate measurement of body temperature will influence clinical decisions. PRIMARY FUNDING SOURCE None.
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Affiliation(s)
- Daniel J. Niven
- From Peter Lougheed Centre, Foothills Medical Centre, and University of Calgary, Calgary, Alberta; and Royal Inland Hospital, Kamloops, British Columbia, Canada
| | - Jonathan E. Gaudet
- From Peter Lougheed Centre, Foothills Medical Centre, and University of Calgary, Calgary, Alberta; and Royal Inland Hospital, Kamloops, British Columbia, Canada
| | - Kevin B. Laupland
- From Peter Lougheed Centre, Foothills Medical Centre, and University of Calgary, Calgary, Alberta; and Royal Inland Hospital, Kamloops, British Columbia, Canada
| | - Kelly J. Mrklas
- From Peter Lougheed Centre, Foothills Medical Centre, and University of Calgary, Calgary, Alberta; and Royal Inland Hospital, Kamloops, British Columbia, Canada
| | - Derek J. Roberts
- From Peter Lougheed Centre, Foothills Medical Centre, and University of Calgary, Calgary, Alberta; and Royal Inland Hospital, Kamloops, British Columbia, Canada
| | - Henry Thomas Stelfox
- From Peter Lougheed Centre, Foothills Medical Centre, and University of Calgary, Calgary, Alberta; and Royal Inland Hospital, Kamloops, British Columbia, Canada
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Niven DJ, Mrklas KJ, Holodinsky JK, Straus SE, Hemmelgarn BR, Jeffs LP, Stelfox HT. Towards understanding the de-adoption of low-value clinical practices: a scoping review. BMC Med 2015; 13:255. [PMID: 26444862 PMCID: PMC4596285 DOI: 10.1186/s12916-015-0488-z] [Citation(s) in RCA: 206] [Impact Index Per Article: 22.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Accepted: 09/15/2015] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Low-value clinical practices are common in healthcare, yet the optimal approach to de-adopting these practices is unknown. The objective of this study was to systematically review the literature on de-adoption, document current terminology and frameworks, map the literature to a proposed framework, identify gaps in our understanding of de-adoption, and identify opportunities for additional research. METHODS MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, the Cochrane Database of Systematic Reviews, the Cochrane Database of Abstracts and Reviews of Effects, and CINAHL Plus were searched from 1 January 1990 to 5 March 2014. Additional citations were identified from bibliographies of included citations, relevant websites, the PubMed 'related articles' function, and contacting experts in implementation science. English-language citations that referred to de-adoption of clinical practices in adults with medical, surgical, or psychiatric illnesses were included. Citation selection and data extraction were performed independently and in duplicate. RESULTS From 26,608 citations, 109 were included in the final review. Most citations (65%) were original research with the majority (59%) published since 2010. There were 43 unique terms referring to the process of de-adoption-the most frequently cited was "disinvest" (39% of citations). The focus of most citations was evaluating the outcomes of de-adoption (50%), followed by identifying low-value practices (47%), and/or facilitating de-adoption (40%). The prevalence of low-value practices ranged from 16% to 46%, with two studies each identifying more than 100 low-value practices. Most articles cited randomized clinical trials (41%) that demonstrate harm (73%) and/or lack of efficacy (63%) as the reason to de-adopt an existing clinical practice. Eleven citations described 13 frameworks to guide the de-adoption process, from which we developed a model for facilitating de-adoption. Active change interventions were associated with the greatest likelihood of de-adoption. CONCLUSIONS This review identified a large body of literature that describes current approaches and challenges to de-adoption of low-value clinical practices. Additional research is needed to determine an ideal strategy for identifying low-value practices, and facilitating and sustaining de-adoption. In the meantime, this study proposes a model that providers and decision-makers can use to guide efforts to de-adopt ineffective and harmful practices.
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Affiliation(s)
- Daniel J Niven
- Department of Critical Care Medicine, University of Calgary, Calgary, Alberta, T1Y 6J4, Canada. .,Department of Community Health Sciences, University of Calgary, Calgary, Alberta, T2N 4Z6, Canada.
| | - Kelly J Mrklas
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, T2N 4Z6, Canada.
| | - Jessalyn K Holodinsky
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, T2N 4Z6, Canada.
| | - Sharon E Straus
- Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Ontario, M5B 1T8, Canada.
| | - Brenda R Hemmelgarn
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, T2N 4Z6, Canada. .,Department of Medicine, University of Calgary, Calgary, Alberta, T2N 4Z6, Canada.
| | - Lianne P Jeffs
- Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Ontario, M5B 1T8, Canada.
| | - Henry Thomas Stelfox
- Department of Critical Care Medicine, University of Calgary, Calgary, Alberta, T1Y 6J4, Canada. .,Department of Community Health Sciences, University of Calgary, Calgary, Alberta, T2N 4Z6, Canada. .,Department of Medicine, University of Calgary, Calgary, Alberta, T2N 4Z6, Canada.
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Roizblatt D, Eamer G, Roberts D, Ball C, Banfield J, Greene B, Veigas P, Moore L, Schellenberg M, Ali J, Ali J, Xiao J, Babul S, Goeres P, Babsail AM, Rice T, MacGillivray S, Addioui A, Tardif PA, Porgo TV, Matar M, Tze N, Rae R, Alali A, Da Luz LT, Vogt K, Da Luz LT, Murphy P, Ali J, Mador B, Muakkassa F, Faidim S, Kirkpatrick A, Kirkpatric A, Laviolette M, Taylor S, Engels P, Hossri S, Snider C, Kortbeek J, Green R, Green R, Green R, Snider C, Green R, Lee C, Green R, Driedger M, Clement J, Charan NKD, Sowers N, Neuhaus N, Hardy I, Younus M, Ibrahim-Zada I, Marrer AMP, Bailey K, Bennett S, Gillman L, Hossri S, Cyr K, Yanchar N, Hinton M, Bernal E, Chisholm A, Hogan A, Watson I, Hogan A, Hogan A, Hewitson L, Rouse C, Rouse C, Al-Thani H, Masson-Trottier M, Mydeen MF, Sne N, Peralta R, Bracco D, Bracco D, Bekdache O, Bracco D, Bracco D, Padim P, Omar M, Yazdani S, Hussein Z, Zargaran E, Fong D, Almaawali A, Tien H, Alshlwi S, Moffat B, Biswas S, Hassan ME, Biswas S, Biswas S, LaLande A, Al Rawahi A, Min A, Phelan B, Harrington J, Mucciaccio M, Alhinai F, Knight H, Young D, Alam A, Waggott M, McKee J, Al-Masrouri S, Al Hinai A, McKee J, Mckee J, Semprun C, Collins D, Kim D, Grenier T, Curtis S, Dufrsne P, Curtis S, Khan S, Curtis S, Appel J, Appel J, Stewart TC, Keenan A, Thakore J, Younus A, Marrero AMP, Mapiour D, Hamadani F, Nascimento B, McGowan M, Kokoski C, Logsetty S, Lawless B, McBeth P, Di Battista A, Rao J, Alhabboubi M, Neto JR, Alhabboubi M, Neto JR, Rao J, Neto JR, Menezes A, Gillard K, Almansoori K, Nash N, Babsail A, Alhabboubi M, Hamadani F, Benyayer D, Malo C, Deckelbaum D, Khwaja K, Beckett A, Razek T, Fata P, Bratu I, Craig J, Faris P, Ball C, Tiruta C, Xiao J, McBeath P, Kubes P, Doig C, Kirkpatrick A, Lampron J, Rizoli S, Callum J, Nascimento B, Da Luz LT, Lauzier F, Berthelot S, Stelfox HT, Kortbeek J, Simons R, Bourgeois G, Clement J, Stevens K, Mehmood A, Gautam S, Zafarm I, Sorvari A, Adam R, Ondiveeran H, Bedaysie H, Ali E, Sorvari A, Briggs S, Wilson C, Robertson HL, Roberts D, Kirkpatrick A, Zeiler F, Unger B, Gillman L, Alhadhrami B, Elhusseini M, Alhalbboubi M, Abdulla M, Chughtai T, Fata P, Khwaja K, Razek T, Beckett A, Sne N, Rice J, Reid S, Li J, Baillie F, Somers A, Robinson T, Boone A, Sandhu N, Wishart I, Saint-Vil D, Crevier L, Beaudinn M, Moore L, Moore L, Lavoie A, Nshimyumukiza L, Turgeon A, Bourgeois G, Lapointe J, Cisse B, Duplantie J, Tran A, Margie O, Yelle JD, Pagliarello G, Lampron J, Grenier T, Lampron J, Bakry H, Malla A, Faidi S, Coates A, Engels P, Neto AC, DaCosta LD, Inaba K, Rhind S, Nascimento B, Rizoli S, Moffat B, Leeper W, Charyk-Stewart T, Malthaner R, Gray D, Parry N, Pena CES, Tien H, Nathens A, Nascimento B, Parry N, Sothilingam N, Vogt K, Moffat B, Gray D, Batey B, Charyk-Stewart T, Sovari A, Henry S, Nascimento B, Rizoli S, Marley R, Salvator A, Yetmar Z, Horattas I, Erck D, Landry BA, Coates A, Patlas M, Tien H, LaPorta A, McKee J, Wright-Beatty H, Keillorn J, Brien S, Roberts D, Wong J, Beckett A, Mador B, Ball C, Louw D, McKee I, McKee J, Panebianco N, Parfitt RJ, Roberts D, Hamilton D, Sevcik B, Lampron J, Waggott M, Stelfox HT, Boyd J, Erdogan M, Widder S, Butler M, Kureshi N, Martin K, Green R, Fasanya C, Barrett N, Cyr K, Camorlinga P, Quigley S, Kureschi N, Erdogan M, Butler M, Kureshi N, Erdogan M, Butler M, Kureshi N, Erdogan M, Longsetty S, Jian D, Fergusson D, Turgeon A, McIntyre L, Kovacs G, Griesdale D, Butler M, McLeod S, Klingel M, Van Aarsen K, Franc J, Peddle M, Fergusson D, Turgeon A, McIntyre L, Kovacs G, Griesdale D, Butler M, Gupta A, Wells B, Dixon E, Ball C, Moore L, Rajaram K, Froese P, Erdogan M, Green R, Younus M, Torres D, Widom K, Leonard D, Baro S, Dove J, Blansfield J, Shabahang M, Timmons S, Wild J, McFaull S, Beaudin M, Saint-Vil D, Torres D, Widom K, Leonard D, Baro S, Dove J, Blansfield J, Shabahang M, Wild J, Friese R, Rhee P, Veercruysse G, Joseph B, Wang A, Coates A, Pelletier H, Calligan D, Amath A, Knight H, Lampron J, Brindley P, Paton-Gay D, Engels P, Park J, Widder S, Fasanya C, Snider C, Barrett N, Cheng A, Mikrogianakis A, Dhanani S, Bhanji F, Lalani A, Al-Harthi F, Mehta S, Wolf S, Arnoldo B, Kowalske K, Phelan H, Benjamin S, Hogan A, Woodford S, Watson I, Woodford S, Watson I, Hogan A, Woodford S, Chisholm A, Louis R, St. Pierre E, Louis R, Woodford S, Watson I, Atkinson P, Mekwan J, Verheul G, Lewis D, Hayre J, French J, Watson I, Benjamin S, Fraser J, Chisholm A, Sealy B, Erdogan M, Green R, Atkinson P, Hayre J, French J, Watson I, Benjamin S, Fraser J, Chisholm A, Sealy B, Erdogan M, Green R, Atkinson P, El-Menyar A, Consunji R, Zarour A, Abdulrahman H, Parchani A, Peralta R, Cyr CE, Arbour C, Gosselin N, Marcotte K, Johnson A, Rice T, Rice J, Passos E, Fan J, Baillie F, Jichici D, Healey A, Consunji R, El Menyar A, Shaltout H, Abdi H, Tarakieh H, Abdulrahman H, Parchani A, Zarour A, Al Thani H, Deckelbaum D, Grenier T, Razek T, Boniface R, Museru L, Lalande A, Deckelbaum D, Razek T, Deckelbaum D, Grenier T, Razek T, Marcoux J, Maleki M, Deckelbaum D, Razek T, Canestrini S, Tuma M, McFarlan A, Neto JR, Veigas P, Rizoli S, Belmont CCG, Moore L, Tardif PA, Dufresne P, Bonaventure PL, McFarlan A, Veigas P, Neto JR, Rizoli S, Lakha N, Simons R, Ramsey D, Hameed M, Nicol A, Spence R, Navsaria P, Lakha N, Hussein Z, Wong H, Martinez R, Shangguan E, Asselstine J, Nascimento B, Brenneman F, Alhadhrami B, Bracco D, Razek T, Grush J, Vogt K, Ahghari M, Parry N, MacDonald R, Gray D, Iqbal S, Fong N, Grushka J, Deckelbaum D, St-Laurent L, Eckert E, Razek T, Khwaja K, Boniface R, Munthali V, Bracco D, Deckelbaum D, Museru L, Razek T, Kirkpatrick A, Roberts D, Doig C, Alhinai F, Xiao J, Kortbeek J, Rizoli S, Perez A, Shek P, Grodecki R, Veigas P, Peng H, Fraser J, Pishe T, Middeton J, Chisholm A, Benjamin S, Watson I, Atkinson P, Stewart TC, Penney A, McLeod S, Klingel M, Van Aarsen K, Hedges C, Dukelow A, Bradford P, Levy D, Kirkpatrick A, Doig C, Roberts D, Xiao J, Al Rawahi A, Keenan A, Waggott M, Lally S, Xiao J, Rados A, Williams A, Vis C, Perlman R, Callum J, Nascimento B, Tien H, Keenan A, Knight H, Tien H, Wright-Beatty H, Keillor J, LaPorta A, Brien S, Roberts D, Ball C, Louw D, Kirkpatrick A, Garraway N, Smith T, Simons R, Hameed M, Ball C, Roberts D, Filips D, Kirkpatrick A, Mckee I, Bouclin M, Atkinson I, Roberts D, McKee I, Kirkpatrick A, Tien H, Alam A, Nathens A, Nascimento B, Kim G, Putnam B, de Virgilio C, Maciel J, Neville A, Bongard F, Bricker S, Plurad D, Tze N, Odenbach J, Grokiert R, Falconer C, Courchesne C, Campbell S, Newton A, Moore L, Clement J, Falconer C, Sevcik B, VanRiper L, Wilkes H, Hussein A, Newton A, Alisc E, Hoysted C, Landolt M, Parri N, Lytle M, Stanley R, Kharbanda A, Babl F, Kassam-Adams N, Fichter K, Rao J, Harris Y, Nahachewsky D, Rao J, Parry N, Batey B, Fleiszer T, Fraser DD, Klassen B, Waggott M, Briereley Y, McMillan J, Robinson S, Williams D, Wild J, Widder S, Qosa H, Khwaja K, Razek T, Perez A, Rizoli S, Trpcic S, Adhikari N, Lamontagne F, Cumyn A, Burns K, Scales D, Duffett M, Henry B, McFarlan A, Zakrison T, Young A, MacKinnon D, Dainty K, Denbok J, Mcgowan M, Blight A, Bakker A, Barratt L, Butorac E, Gaunt K, Gawaziuk J, Lim S, Chateau D, Khan S, Doupe M, Sareen J, Sekhon M, Hameed M, Schuurman N, Dodek P, Ayas N, Vu E, Griesdale D, Rhind S, Hassan S, Perez A, Topolovec-Vranic J, Da Luz LT, Kenjilnaba, Neto AC, Trpcic S, Da Costa LD, Baker A, Rizoli S, Appel J, Lyster K, Grushka J, Hassan ME, Baabsail A, Khwaja K, Deckelbaum D, Razek T, Fata P, Ahmed N, Rotstein O, Rizoli S, Gao ZH, Duong M, Deckelbaum D, Razek T, Shum-Tim D, Khwaja K, Rizoli S, Abreu E, Rotstein O, Appel J, Fichter K, Abreu E, Machado C, Neto MP, Godinho J, Bernardes A, Rizoli S, Fry N, Liang M, Khwaja K, Brenneman F, Bleszynski M, Buczkowski A, Parry N, Martindale R, Evans D, Fraser S, Stephens M, Rao J, Kirkpatrick A, Knowlton L, Hameed M, Almansorri D, Mutiso V, Saleh A, Hawes H, Hogan J, Kromm J, Menon M, Benns M. Trauma Association of Canada Annual Scientific Meeting, Westin Calgary Calgary, Alberta, Apr. 10–11, 2015Outcomes and opportunities for improvement in self-inflicted blunt and penetrating traumaAbdominal compartment syndrome in the childActive negative pressure peritoneal therapy after abbreviated laparotomy: The intraperitoneal vacuum randomized controlled trialUse of a novel combined RFA/saline energy instrument for arresting ongoing hemorrhage from solid organ injuriesHealth care costs of burn patients from homes without fire sprinklersPenetrating trauma in eastern Ontario: a descriptive analysisThresholds of rotational thrombelastometry (ROTEM) used for the diagnosis and management of bleeding trauma patients: a systematic reviewA quality indicator to measure hospital complications for injury admissionsThromboelastography (TEG) in the management of trauma: implications for the developing worldPotential role of the rural trauma team development course (RTTDC) in the United Arab Emirates (UAE)Applicability of the advanced disaster medical response (ADMR) course, Trinidad and TobagoInflammatory mediators in intra-abdominal sepsis or injury: a scoping reviewEvaluation of the online Concussion Awareness Training Toolkit (CATT) for parents, players and coachesUltrasound assessment of optic nerve sheath diameter (ONSD) in healthy volunteersThe benefits of epidural analgesia in flail chest injuriesMandatory reporting rates of injured alcohol-impaired drivers with suspected alcohol dependence in a level 1 Canadian trauma centre: a single institution’s experienceSimulation implementation in a new pediatric residency program in Haiti: trauma specificsManagement of skull fractures in children younger than 1 year of ageResource use in patients who have sustained a traumatic brain injury within an integrated Canadian trauma system: a multicentre cohort studyResource use intensity in a mature, integrated Canadian trauma system: a multicentre cohort studyRates and determinants of unplanned emergency department visits and readmissions within 30 days following discharge from the trauma service — the Ottawa Hospital experienceAlcohol — screening, brief intervention and referral to treatment (SBIRT): Is it readily available in Canadian trauma centres?Management of traumatic occult hemothorax: a survey among trauma providers in CanadaAn audit of venous thromboembolism prophylaxis: a quality assurance project at our level 1 trauma centreCatecholamines as outcome markers in traumatic brain injuryAre we missing the missed injury? The burden of traumatic missed injuries diagnosed after hospital dischargeThe use of fibrinogen concentrate in trauma: a descriptive systematic reviewVery early initiation of chemical venous thromboembolism prophylaxis after solid organ injury is safe: a call for a national prospective multicentre studyThe 2 student to 1 faculty (2:1) model of teaching the Advanced Trauma Operative Management (ATOM) courseTrauma transfusion in the elderlyCocaine and benzodiazepines are more predictive of an injury severity score greater than 15 compared to alcohol or tetrahydrocannabinol in trauma patients under 18 years oldAre we missing traumatic bowel and mesenteric injuries?The marriage of surgical simulation and telementoring for damage control surgical training of operational first-respondersAdding remote ultrasound control to remote just-in-time telementored trauma ultrasound: a pilot studyDescriptive analysis of morbidity and mortality associated with falls at a level 1trauma centreDevelopment of an ICU transition questionnaire: evaluating the transfer process from ICU, ward, and patient/family stakeholder perspectivesUse of IO devices in trauma: A survey of trauma practitioners in Canada, Australia and New ZealandTime to reversal of medication-induced coagulopathy in traumatic intracranial hemorrhageMeta-analysis of randomized control trials of hospital based violence interventions on repeat intentional injuryBlunt injury of a horseshoe kidney, case report and review of the literatureLegal consequences for alcohol-impaired drivers involved in motor vehicle collisions: a systematic reviewA characterization of major adult sport-related trauma in Nova Scotia, 2000–2013Is hockey the most dangerous pediatric sport? An evaluation of pediatric sport-related injuries treated in Nova ScotiaInterim results of a pilot randomized control trial of an ED-based violence intervention programPre-intubation resuscitation by Canadian physicians: results of a national surveyFirst-responder accuracy using SALT during mass-casualty incident simulationEmergent endotracheal intubation: medications and device choices by Canadian resuscitation physicians“Oh the weather outside is frightful”: Severe injury secondary to falls while installing residential Christmas lightsCan we speak the same language? Understanding Quebec’s inclusive trauma systemAn unusual segmental clavicle fracture treated with titanium elastic nailImpact of the age of stored blood on trauma patient mortality: a systematic reviewInterhospital transfer of traumatic brain injury: utilization of helicopter transportCheerleading injuries: a Canadian perspectivePre-hospital mode of transport in a rural trauma system: air versus groundAnalysis of 15 000 patient transfers to level 1 trauma centre: Injury severity does not matter — just drive, drive, drive!The effects of legislation on morbidity and mortality associated with all-terrain vehicle and motorcycle crashes in Puerto RicoAssessing how pediatric trauma patients are supported nutritionally at McMaster Children’s HospitalOutcomes of conservative versus operative management of stable penetrating abdominal traumaS.T.A.R.T.T. — Evolution of a true multidisciplinary trauma crisis resource management simulation courseDevelopment of criteria to identify traumatic brain injury patients NOT requiring intensive care unit monitoringAssigning costs to visits for injuries due to youth violence — the first step in a cost-effectiveness analysisThere’s no TRIK to it — development of the Trauma Resuscitation in Kids courseResilient despite childhood trauma experiencesA five-year, single-centre review of toxic epidermal necrolysis managementAll in the family: creating and implementing an inclusive provincial trauma registryLessons learned from a provincial trauma transfer systemThe NB Trauma Program: 5 years laterProvincial coordination of injury prevention: the New Brunswick (NB) experienceImproving access and uptake of trauma nursing core course (TNCC): a provincial approachULTRASIM: ultrasound in trauma simultation. Does the use of ultrasound during simulated trauma scenarios improve diagnostic abilities?Traumatic tale of 2 cities, part 1: Does being treated by different EMS affect outcomes in trauma patients destined for transport to level 1 trauma centres in Halifax and Saint John?Traumatic tale of 2 cities, part 2: Does being treated by different hospitals affect outcome in trauma patients destined for transport to Level 1trauma centres in Halifax and Saint John?Protective devices use in road traffic injuries in a developing countryFunctional and anatomical connectivity and communication impairments in moderate to severe traumatic brain injuryCaring and communicating in critical cases: Westlock trauma form, a resource for rural physiciansMonitoring of ocular nerve sheath in traumatic raised intracranial pressure (Moonstrip Study): a prospective blinded observational trialEstablishing an alcohol screening and brief intervention for trauma patients in a multicultural setting in the Middle East: challenges and opportunitiesThe poor compliance to seat belt use in Montréal: an 18 461 road user iPhone-based studyAn iPad-based data acquisition for core trauma registry data in 6 Tanzanian hospitals: 1 year and 13 462 patients later“The Triple-Q Algorithm”: a practical approach to the identification of liver topographyA pan-Canadian bicycle helmet use observational studyDoor to decompression: the new benchmark in trauma craniotomiesAre missed doses of pharmacological thromboprophylaxis a risk factor for thromboembolic complications?Complications following admission for traumatic brain injuryExcessive crystalloid infusion in the first 24 hours is not associated with increased complications or mortalitySBIRT: plant, tend, growReal time electronic injury surveillance in an African trauma centreSBIRT in concert: establishing a new initiativeReview of the current knowledge of the pathophysiology of acute traumatic coagulopathy: implications for current trauma resuscitation practicesFactors associated with primary fascial closure rates in patients undergoing damage control laparotomyFree intraperitoneal fluid on CT abdomen in blunt trauma: Is hospital admission necessary?The need for speed — the time cost of off-site helipadsEndovascular management of penetrating Zone III retroperitoneal injuries in selective patients: a case reportMeasured resting energy expenditure in patients with open abdomens: preliminary data of a prospective pilot studyTraumatic inferior gluteal artery pseudoaneurysm: case report and review of literaturePancreatico duodenectomy, SMA, SMV repair and delayed reconstruction following blunt abdominal trauma. A case report with discussion of trauma whipple and complex pancreatico duodenal injuriesA retrospective evaluation of the effect of the Trauma Team Training program in TanzaniaDoes procalcitonin measurement predict clinical outcomes in critically ill/injured adults managed with the open abdomen technique?In trauma, conventional ROTEM and TEG results are not interchangeable but are similar in clinical applicabilitySevere trauma in the province of New Brunswick: a descriptive epidemiological studyPartnering for success — a road safety strategy for London and regionEvaluation of a patient safety initiative of rapid removal of backboards in the emergency departmentActive negative pressure peritoneal therapy and C-reactive protein levels after abbreviated laparotomy for abdominal trauma or intra-abdominal sepsisA comparison of outcomes: Direct admissions vs. interhospital transfers April 2009–March 2014YEE HA or YEE OUCH! A 5-year review of large animal-related incidentsEarly goal-directed therapy for prevention of hypothermia-related transfusion, morbidity and mortality in severely injured trauma patientsImproving care of adolescent trauma patients admitted to adult trauma centres by fostering collaboration between adult and pediatric partnersExpediting operational damage control laparotomy closure: iTClam v. suturing during damage control surgical simulation trainingAre conventional coagulation tests inadequate in the assessment of acute traumatic coagulopathy?Predictors of long-term outcomes in patients admitted to emergency general surgery services: a systematic review of literatureUse of the iTClamp versus standard suturing techniques for securing chest tubes: A randomized cadaver studyiTClamp application for control of simulated massive upper extremity arterial hemorrhage by tactical policeAssessing performance in the trauma roomThe deadly need for methadone/opiate educationTrends in the management of major abdominal vascular injuries: 2000–2014Addressing high school seniors’ risky behaviours through a hospital-based and peer teaching outreach programScreening for risk of post-traumatic stress disorder after injury in acutely injured children: a systematic reviewThe impact of trauma centre designation levels on surgical delay, mortality and complications: a multicentre cohort studyHow many acutely injured children report subsequent stress symptoms?The frequency of coagulopathy and its significance in an emergency neurotrauma facilityPsychosocial care for injured children: The views of 2500 emergency department physicians and nurses from around the worldDevelopment of the Trauma Electronic Document (TED)Development of trauma team activation criteria for an urban trauma centreBrains and brawn: evaluation of a sports skills and concussion awareness campRegional trauma networks: a tale of 2 pilotsContinuous data quality improvement in a provincial trauma registryDoes the Rural Trauma Team Development Course shorten transfer time?Epidemiology of trauma in Puerto RicoCT scans facilitate early discharge of trauma patientsFeasibility of data collection in a conflict zone to assess the impact on emergency health care deliveryConsent for Emergency Research (CONfER): a national survey of Canadian research ethics board practicesMaking handover safer for our trauma patients through the lens of trauma team leadersChallenges and opportunities to improve trauma transitions of care from emergency to intensive care nursingPhysical disorder following major injury: a population-based studyToward an inclusive trauma system: regional trauma system development in OntarioTraumatic brain injury in British Columbia: current incidence, injury patterns and risk factorsAcute cytokine and chemokine profiles in brain-injured patients: relationship to sympathetic activation and outcomeMultidisciplinary trauma simulation training in a tertiary care centreNon-operative management of blunt splenic injuries: routine radiologic follow-up may reduce the time of activity restrictionModified triple layer peritoneal-aponeurotic transposition: a new strategy to close the open abdomenMesenchymal stem cells locate and differentiate to the trauma site in a blunt rat liver trauma model: preliminary resultsThree indications for the “open abdomen”, anatomical, logistical and physiological: How are they different?Development of an urban trauma centre using lean methodologyThe impact of standardized care in 191 patients with chest tube thoracostomyComplex abdominal wall reconstruction: recommendations from the Canadian Abdominal Wall Reconstruction GroupCompensatory behaviours and cognitions in persons with history of traumaDevelopment of the Kenyatta National Hospital — University of Alberta Orthopedic Trauma Assessment Tool: phase 1 resultsRisk-taking behaviour negatively affects outcome in burn patients. Can J Surg 2015. [DOI: 10.1503/cjs.003415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Roberts DJ, Leigh-Smith S, Faris PD, Ball CG, Robertson HL, Blackmore C, Dixon E, Kirkpatrick AW, Kortbeek JB, Stelfox HT. Clinical manifestations of tension pneumothorax: protocol for a systematic review and meta-analysis. Syst Rev 2014; 3:3. [PMID: 24387082 PMCID: PMC3880980 DOI: 10.1186/2046-4053-3-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2013] [Accepted: 12/23/2013] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Although health care providers utilize classically described signs and symptoms to diagnose tension pneumothorax, available literature sources differ in their descriptions of its clinical manifestations. Moreover, while the clinical manifestations of tension pneumothorax have been suggested to differ among subjects of varying respiratory status, it remains unknown if these differences are supported by clinical evidence. Thus, the primary objective of this study is to systematically describe and contrast the clinical manifestations of tension pneumothorax among patients receiving positive pressure ventilation versus those who are breathing unassisted. METHODS/DESIGN We will search electronic bibliographic databases (MEDLINE, PubMed, EMBASE, and the Cochrane Database of Systematic Reviews) and clinical trial registries from their first available date as well as personal files, identified review articles, and included article bibliographies. Two investigators will independently screen identified article titles and abstracts and select observational (cohort, case-control, and cross-sectional) studies and case reports and series that report original data on clinical manifestations of tension pneumothorax. These investigators will also independently assess risk of bias and extract data. Identified data on the clinical manifestations of tension pneumothorax will be stratified according to whether adult or pediatric study patients were receiving positive pressure ventilation or were breathing unassisted, as well as whether the two investigators independently agreed that the clinical condition of the study patient(s) aligned with a previously published tension pneumothorax working definition. These data will then be summarized using a formal narrative synthesis alongside a meta-analysis of observational studies and then case reports and series where possible. Pooled or combined estimates of the occurrence rate of clinical manifestations will be calculated using random effects models (for observational studies) and generalized estimating equations adjusted for reported potential confounding factors (for case reports and series). DISCUSSION This study will compile the world literature on tension pneumothorax and provide the first systematic description of the clinical manifestations of the disorder according to presenting patient respiratory status. It will also demonstrate a series of methods that may be used to address difficulties likely to be encountered during the conduct of a meta-analysis of data contained in published case reports and series. PROSPERO registration number: CRD42013005826.
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Affiliation(s)
- Derek J Roberts
- Department of Surgery, University of Calgary and the Foothills Medical Centre, 1403-29th Street NW, T2N 2T9, Calgary, Alberta, Canada.
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Holodinsky JK, Roberts DJ, Ball CG, Blaser AR, Starkopf J, Zygun DA, Stelfox HT, Malbrain ML, Jaeschke RC, Kirkpatrick AW. Risk factors for intra-abdominal hypertension and abdominal compartment syndrome among adult intensive care unit patients: a systematic review and meta-analysis. Crit Care 2013; 17:R249. [PMID: 24144138 PMCID: PMC4057241 DOI: 10.1186/cc13075] [Citation(s) in RCA: 126] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/10/2013] [Accepted: 09/25/2013] [Indexed: 02/08/2023]
Abstract
Introduction Although intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) are associated with substantial morbidity and mortality among critically ill adults, it remains unknown if prevention or treatment of these conditions improves patient outcomes. We sought to identify evidence-based risk factors for IAH and ACS in order to guide identification of the source population for future IAH/ACS treatment trials and to stratify patients into risk groups based on prognosis. Methods We searched electronic bibliographic databases (MEDLINE, EMBASE, PubMed, and the Cochrane Database from 1950 until January 21, 2013) and reference lists of included articles for observational studies reporting risk factors for IAH or ACS among adult ICU patients. Identified risk factors were summarized using formal narrative synthesis techniques alongside a random effects meta-analysis. Results Among 1,224 citations identified, 14 studies enrolling 2,500 patients were included. The 38 identified risk factors for IAH and 24 for ACS could be clustered into three themes and eight subthemes. Large volume crystalloid resuscitation, the respiratory status of the patient, and shock/hypotension were common risk factors for IAH and ACS that transcended across presenting patient populations. Risk factors with pooled evidence supporting an increased risk for IAH among mixed ICU patients included obesity (four studies; odds ratio (OR) 5.10; 95% confidence interval (CI), 1.92 to 13.58), sepsis (two studies; OR 2.38; 95% CI, 1.34 to 4.23), abdominal surgery (four studies; OR 1.93; 95% CI, 1.30 to 2.85), ileus (two studies; OR 2.05; 95% CI, 1.40 to 2.98), and large volume fluid resuscitation (two studies; OR 2.17; 95% CI, 1.30 to 3.63). Among trauma and surgical patients, large volume crystalloid resuscitation and markers of shock/hypotension and metabolic derangement/organ failure were risk factors for IAH and ACS while increased disease severity scores and elevated creatinine were risk factors for ACS in severe acute pancreatitis patients. Conclusions Although several IAH/ACS risk factors transcend across presenting patient diagnoses, some appear specific to the population under study. As our findings were somewhat limited by included study methodology, the risk factors reported in this study should be considered candidate risk factors until confirmed by a large prospective multi-centre observational study.
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Li P, Ali S, Tang C, Ghali WA, Stelfox HT. Review of computerized physician handoff tools for improving the quality of patient care. J Hosp Med 2013; 8:456-63. [PMID: 23169534 DOI: 10.1002/jhm.1988] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2012] [Revised: 08/27/2012] [Accepted: 09/19/2012] [Indexed: 11/10/2022]
Abstract
BACKGROUND Computerized physician handoff tools (CHTs) are designed to allow distributed access and synchronous archiving of patient information via Internet protocols. However, their impact on the quality of physician handoff, patient care, and physician work efficiency have not been extensively analyzed. METHODS We searched MEDLINE, PUBMED, EMBASE, CINAHL, the Cochrane database for systematic reviews, and the Cochrane central register for clinical trials, from January 1960 to December 2011. We selected all articles that reported randomized controlled trials, controlled clinical trials, controlled before-after studies, and quasi-experimental studies of the use of CHTs for physician handoff for hospitalized patients. Relevant studies were evaluated independently for their eligibility for inclusion by 2 individuals in a 2-stage process. RESULTS The literature search identified 1026 citations of which 6 satisfied the inclusion criteria. One study was a randomized controlled trial, whereas 5 were controlled before-after studies. Two studies showed that using CHTs reduced adverse events and missing patients. Three studies demonstrated improved overall quality of handoff after CHT implementation. One study suggested that CHTs could potentially enhance work efficiency and continuity of care during physician handoff. Conflicting impacts on consistency of handoff were found in 2 studies. CONCLUSIONS The evidence that CHTs improve physician handoff and quality of hospitalized patient care is limited. CHT may improve the efficiency of physician work, reduce adverse events, and increase the completeness of physician handoffs. However, further evaluation using rigorous study designs is needed.
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Affiliation(s)
- Pin Li
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada.
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Stelfox HT, Joshipura M, Chadbunchachai W, Ellawala RN, O'Reilly G, Nguyen TS, Gruen RL. Trauma quality improvement in low and middle income countries of the Asia-Pacific region: a mixed methods study. World J Surg 2012; 36:1978-92. [PMID: 22526038 DOI: 10.1007/s00268-012-1593-1] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Quality Improvement (QI) programs have been shown to be a valuable tool to strengthen care of severely injured patients, but little is known about them in low and middle income countries (LMIC). We sought to explore opportunities to improve trauma QI activities in LMIC, focusing on the Asia-Pacific region. METHODS We performed a mixed methods research study using both inductive thematic analysis of a meeting convened at the Royal Australasian College of Surgeons, Melbourne, Australia, November 21-22, 2010 and a pre-meeting survey to explore experiences with trauma QI activities in LMIC. Purposive sampling was employed to invite participants with demonstrated leadership in trauma care to provide diverse representation of organizations and countries within Asia-Pacific. RESULTS A total of 22 experts participated in the meeting and reported that trauma QI activities varied between countries and organizations: morbidity and mortality conferences (56 %), monitoring complications (31 %), preventable death studies (25 %), audit filters (19 %), and statistical methods for analyzing morbidity and mortality (6 %). Participants identified QI gaps to include paucity of reliable/valid injury data, lack of integrated trauma QI activities, absence of standards of care, lack of training in QI methods, and varying cultures of quality and safety. The group highlighted barriers to QI: limited engagement of leaders, organizational diversity, limited resources, heavy clinical workload, and medico-legal concerns. Participants proposed establishing the Asia-Pacific Trauma Quality Improvement Network (APTQIN) as a tool to facilitate training and dissemination of QI methods, injury data management, development of pilot QI projects, and advocacy for quality trauma care. CONCLUSIONS Our study provides the first description of trauma QI practices, gaps in existing practices, and barriers to QI in LMIC of the Asia-Pacific region. In this study we identified opportunities for addressing these challenges, and that work will be supported by APTQIN.
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Affiliation(s)
- Henry Thomas Stelfox
- Department of Critical Care Medicine, Medicine and Community Health Sciences, Institute for Public Health, University of Calgary, Teaching Research & Wellness Building, 3280 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada.
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Moore L, Stelfox HT, Turgeon AF. Complication rates as a trauma care performance indicator: a systematic review. Crit Care 2012; 16:R195. [PMID: 23072526 PMCID: PMC3682297 DOI: 10.1186/cc11680] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/20/2012] [Accepted: 09/14/2012] [Indexed: 12/14/2022]
Abstract
Introduction Information on complication rates is essential to trauma quality improvement efforts. However, it is unclear which complications are the most clinically relevant. The objective of this study was to evaluate whether there is consensus on the complications that should be used to evaluate the performance of acute care trauma hospitals. Methods We searched the Medline, EMBASE, Cochrane Central, CINAHL, BIOSIS, TRIP and ProQuest databases and included studies using at least one nonfatal outcome to evaluate the performance of acute care trauma hospitals. Data were extracted in duplicate using a piloted electronic data abstraction form. Consensus was considered to be reached if a specific complication was used in ≥ 70% of studies (strong recommendation) or in ≥ 50% of studies (weak recommendation). Results Of 14,521 citations identified, 22 were eligible for inclusion. We observed important heterogeneity in the complications used to evaluate trauma care. Seventy-nine specific complications were identified but none were used in ≥ 70% of studies and only three (pulmonary embolism, deep vein thrombosis, and pneumonia) were used in ≥ 50% of studies. Only one study provided evidence for the clinical relevance of complications used and only five studies (23%) were considered of high methodological quality. Conclusion Based on the results of this review, we can make a weak recommendation on three complications that should be used to evaluate acute care trauma hospitals; pulmonary embolism, deep vein thrombosis, and pneumonia. However, considering the observed disparity in definitions, the lack of clinical justification for the complications used, and the low methodological quality of studies, further research is needed to develop a valid and reliable performance indicator based on complications that can be used to improve the quality and efficiency of trauma care.
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Stelfox HT, Kushner B. Skin necrosis in patients with arterial catheters flushed with a solution containing heparin. Intensive Care Med 2012; 38:918-9. [PMID: 22358226 DOI: 10.1007/s00134-012-2511-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/23/2012] [Indexed: 11/26/2022]
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Abstract
Abstract
Background
Valid and reliable measures of trauma system performance are needed to guide improvement activities, benchmarking and public reporting, future investment and research. Traditional measures of in-hospital mortality fail to take into account prehospital and posthospital care, recovery after discharge, and the nature and costs of long-term disability.
Methods
Drawing on recent systematic reviews, an overview was conducted of existing and emerging trauma care performance indicators. Changes in the nature and purpose of indicators were assessed.
Results
Among a large number of existing, mostly locally developed performance indicators, only peer review of deaths has evidence of validity or reliability. The usefulness of the traditional performance measure of in-hospital mortality has been challenged. There is an emerging shift in focus from mortality to non-mortality outcomes, from hospital-based to long-term community-based outcome assessment, and from single measures of trauma centre performance to measures better suited to monitoring the performance of systems of care spanning the entire patient journey. As a result, a new generation of indicators is emerging that are both feasible and potentially more useful for commissioners and payers of population-based services.
Conclusion
A global endeavour is now under way to agree on a set of standardized performance indicators that are meaningful to patients, carers, clinicians, managers and service funders, are likely to contribute to desired outcomes, and are valid, reliable and have a strong evidence base.
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Affiliation(s)
- R L Gruen
- National Trauma Research Institute, The Alfred Hospital, Monash University, Melbourne, Victoria, Australia
- Department of Surgery, Monash University, Melbourne, Victoria, Australia
| | - B J Gabbe
- National Trauma Research Institute, The Alfred Hospital, Monash University, Melbourne, Victoria, Australia
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - H T Stelfox
- Department of Critical Care Medicine, Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - P A Cameron
- National Trauma Research Institute, The Alfred Hospital, Monash University, Melbourne, Victoria, Australia
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
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Li P, Stelfox HT, Ghali WA. A prospective observational study of physician handoff for intensive-care-unit-to-ward patient transfers. Am J Med 2011; 124:860-7. [PMID: 21854894 DOI: 10.1016/j.amjmed.2011.04.027] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2010] [Revised: 03/23/2011] [Accepted: 04/07/2011] [Indexed: 01/11/2023]
Abstract
BACKGROUND Poor physician handoff can be a major contributor to suboptimal care and medical errors occurring in the hospital. Physician handoffs for intensive care unit (ICU)-to-ward patient transfer may face more communication hurdles. However, few studies have focused on physician handoffs in patient transfers from the ICU to the inpatient ward. METHODS We performed a hospitalized patient-based observational study in an urban, university-affiliated tertiary care center to assess physician handoff practices for ICU-to-ward patient transfer. One hundred twelve adult patients were enrolled. The stakeholders (sending physicians, receiving physicians, and patients/families) were interviewed to evaluate the quality of communication during these transfers. Data collected included the presence and effectiveness of communication, continuity of care, and overall satisfaction. RESULTS During the initial stage of patient transfers, 15.6% of the consulted receiving physicians verbally communicated with sending physicians; 26% of receiving physicians received verbal communication from sending physicians when patient transfers occurred. Poor communication during patient transfer resulted in 13 medical errors and 2 patients being transiently "lost" to medical care. Overall, the levels of satisfaction with communication (scored on a 10-point scale) for sending physicians, receiving physicians, and patients were 7.9±1.1, 8.1±1.0, and 7.9±1.7, respectively. CONCLUSION The overall levels of satisfaction with communication during ICU-to-ward patient transfer were reasonably high among the stakeholders. However, clear opportunities to improve the quality of physician communication exist in several areas, with potential benefits to quality of care and patient safety.
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Affiliation(s)
- Pin Li
- Department of Medicine, University of Calgary, Alberta, Canada.
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Stelfox HT, Straus SE, Khandwala F, Conly J, Haslett J, Zwierzchowski S. An observational study of a wireless temporal artery bandage thermometer. Can J Anaesth 2010; 57:870-1. [PMID: 20552419 DOI: 10.1007/s12630-010-9343-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2010] [Accepted: 06/02/2010] [Indexed: 11/26/2022] Open
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Abstract
OBJECTIVES To systematically review the literature on quality indicators (QIs) for evaluating trauma care, identify QIs, map their definitions, and examine the evidence base in support of the QIs. DATA SOURCES We searched MEDLINE, EMBASE, CINAHL, Cochrane Database of Systematic Reviews, Cochrane Database of Abstracts of Reviews of Effects, and Cochrane Central Register of Controlled Trials from the earliest available date through January 14, 2009. To increase the sensitivity of the search, we also searched the grey literature and select journals by hand, reviewed reference lists to identify additional studies, and contacted experts in the field. STUDY SELECTION AND DATA EXTRACTION We selected all articles that identified or proposed 1 or more QIs to evaluate the quality of care delivered to patients with major traumatic injuries. Minimum inclusion criteria were a description of 1 or more QIs designed to evaluate patients with major traumatic injuries (defined as multisystem injuries resulting in hospitalization or death) and focused on prehospital care, hospital care, posthospital care, or secondary injury prevention. DATA SYNTHESIS The literature search identified 6869 citations. Review of abstracts led to the retrieval of 538 full-text articles for assessment, of which 192 articles were selected for review. Of these, 128 (66.7%) articles were original research, predominantly trauma database case series (57 [29.7%]) and cohort studies (55 [28.6%]), whereas 37 (19.3%) were narrative reviews and 8 (4.2%) were guidelines. A total of 1572 QIs in trauma care were identified and classified into 8 categories: non-American College of Surgeons Committee on Trauma (ACS-COT) audit filters (42.0%), ACS-COT audit filters (19.1%), patient safety indicators (13.2%), trauma center/system criteria (10.2%), indicators measuring or benchmarking outcomes of care (7.4%), peer review (5.5%), general audit measures (1.8%), and guideline availability or adherence (0.8%). Measures of prehospital and hospital processes (60.4%) and outcomes (22.8%) were the most common QIs identified. Posthospital and secondary injury prevention QIs accounted for less than 5% of QIs. CONCLUSIONS Many QIs for evaluating the quality of trauma care have been proposed, but the evidence to support these indicators is not strong. Practical recommendations to select QIs to measure the quality of trauma care will require systematic reviews of identified candidate indicators and empirical studies to fill the knowledge gaps for postacute QIs.
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Affiliation(s)
- Henry Thomas Stelfox
- Department of Critical Care Medicine, Foothills Medical Centre, University of Calgary, 1403-29 St. NW, Calgary, Alberta, Canada.
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Stelfox HT, Ahmed SB, Zygun D, Khandwala F, Laupland K. Characterization of intensive care unit acquired hyponatremia and hypernatremia following cardiac surgery. Can J Anaesth 2010; 57:650-8. [PMID: 20405264 DOI: 10.1007/s12630-010-9309-1] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2009] [Accepted: 03/29/2010] [Indexed: 10/19/2022] Open
Abstract
PURPOSE Although intensive care unit (ICU) acquired sodium disturbances are common in critically ill patients, few studies have examined sodium disturbances in patients following cardiac surgery. The objective of this study was to describe the epidemiology of ICU-acquired hyponatremia and hypernatremia in patients following cardiac surgery. METHODS We identified 6,727 adults (> or =18 yr) who were admitted consecutively to a regional cardiovascular intensive care unit (CVICU) from January 1, 2000 to December 31, 2006 and were documented as having normal serum sodium levels (133 to 145 mmol.L(-1)) during the first day of ICU admission. ICU-acquired hyponatremia and hypernatremia were defined as a change in serum sodium concentration to <133 mmol.L(-1) or >145 mmol.L(-1), respectively, following ICU day one. RESULTS A first episode of ICU-acquired hyponatremia and hypernatremia developed in 785 (12%) and 242 (4%) patients, respectively, (95% confidence interval [CI] 11-12% and 95% CI 3-4%, respectively), with a respective incidence density of 4.2 and 1.3 patients per 100 days of ICU admission (95% CI 4.0-4.5 and 95% CI 1.2-1.5). The incidence of ICU-acquired sodium disturbances varied according to the patients' demographic and clinical variables for both hyponatremia (age, diabetes, Acute Physiology and Chronic Health Evaluation [APACHE II] score, mechanical ventilation, length of ICU stay, serum glucose level, and serum potassium level) and hypernatremia (APACHE II score, mechanical ventilation, length of hospital stay prior to ICU admission, length of ICU stay, serum glucose level, and serum potassium level). Compared with patients with normal serum sodium levels, hospital mortality was increased in patients with ICU-acquired hyponatremia (1.6% vs 10%, respectively; P < 0.001) and ICU-acquired hypernatremia (1.6% vs 14%, respectively; P < 0.001). CONCLUSION ICU-acquired hyponatremia and hypernatremia are common complications in critically ill patients following cardiac surgery. They are associated with patient demographic and clinical characteristics and an increased risk of hospital mortality.
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Affiliation(s)
- Henry Thomas Stelfox
- Department of Critical Care Medicine, University of Calgary, Foothills Medical Centre, Canada.
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Stelfox HT, Hess DR, Schmidt UH. A North American survey of respiratory therapist and physician tracheostomy decannulation practices. Respir Care 2009; 54:1658-1664. [PMID: 19961631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
BACKGROUND Tracheostomy is a common surgical procedure performed on critically ill patients. However, little is known about how clinicians make decisions to decannulate patients, and whether similar decisions are made by respiratory therapists (RTs) and physicians. METHODS We performed a cross-sectional survey of RTs (n = 52) and physicians (n = 102) at 54 medical centers in North America, to characterize contemporary decannulation practices. RESULTS RTs and physicians rated ability to tolerate capping, secretions, cough effectiveness, and level of consciousness as the most important factors in the decannulation decision, with RTs placing greater emphasis on ability to tolerate capping and physicians on level of consciousness. In the clinical scenarios, RTs and physicians recommended decannulation with similar frequency (52% vs 55%, P = .54). Patients were most likely to be recommended for decannulation if they had a strong cough, scant thin secretions, required minimal supplemental oxygen, and were alert and interactive. In addition, RTs were more likely to recommend decannulation for patients who demonstrated an ability to tolerate tracheostomy tube capping for 72 hours and whose etiology of respiratory failure was chronic obstructive pulmonary disease. RTs preferred shorter time frames for defining decannulation failure than did physicians (median response 48 h vs 96 h, P = .02 for test of proportions). Both groups identified 2-5% (median response) as an acceptable rate of decannulation failure (P = .48 for test of proportions). CONCLUSIONS Important differences exist in the decannulation practices of North American RTs and physicians. Evidence-based tracheostomy guidelines are needed to facilitate the safe and effective management of patients with tracheostomies.
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Affiliation(s)
- Henry Thomas Stelfox
- Department of Critical Care Medicine, University of Calgary, Foothills Medical Centre EG23A, 1403 29 Street NW, Calgary, Alberta T2N 2T9 Canada.
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Chiasson TC, Manns BJ, Stelfox HT. An economic evaluation of venous thromboembolism prophylaxis strategies in critically ill trauma patients at risk of bleeding. PLoS Med 2009; 6:e1000098. [PMID: 19554085 PMCID: PMC2695771 DOI: 10.1371/journal.pmed.1000098] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2008] [Accepted: 05/14/2009] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Critically ill trauma patients with severe injuries are at high risk for venous thromboembolism (VTE) and bleeding simultaneously. Currently, the optimal VTE prophylaxis strategy is unknown for trauma patients with a contraindication to pharmacological prophylaxis because of a risk of bleeding. METHODS AND FINDINGS Using decision analysis, we estimated the cost effectiveness of three VTE prophylaxis strategies-pneumatic compression devices (PCDs) and expectant management alone, serial Doppler ultrasound (SDU) screening, and prophylactic insertion of a vena cava filter (VCF) -- in trauma patients admitted to an intensive care unit (ICU) with severe injuries who were believed to have a contraindication to pharmacological prophylaxis for up to two weeks because of a risk of major bleeding. Data on the probability of deep vein thrombosis (DVT) and pulmonary embolism (PE), and on the effectiveness of the prophylactic strategies, were taken from observational and randomized controlled studies. The probabilities of in-hospital death, ICU and hospital discharge rates, and resource use were taken from a population-based cohort of trauma patients with severe injuries (injury severity scores >12) admitted to the ICU of a regional trauma centre. The incidence of DVT at 12 weeks was similar for the PCD (14.9%) and SDU (15.0%) strategies, but higher for the VCF (25.7%) strategy. Conversely, the incidence of PE at 12 weeks was highest in the PCD strategy (2.9%), followed by the SDU (1.5%) and VCF (0.3%) strategies. Expected mortality and quality-adjusted life years were nearly identical for all three management strategies. Expected health care costs at 12 weeks were Can$55,831 for the PCD strategy, Can$55,334 for the SDU screening strategy, and Can$57,377 for the VCF strategy, with similar trends noted over a lifetime analysis. CONCLUSIONS The attributable mortality due to PE in trauma patients with severe injuries is low relative to other causes of mortality. Prophylactic placement of VCF in patients at high risk of VTE who cannot receive pharmacological prophylaxis is expensive and associated with an increased risk of DVT. Compared to the other strategies, SDU screening was associated with better clinical outcomes and lower costs.
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Affiliation(s)
- T. Carter Chiasson
- Department of Biomedical Sciences, University of Calgary, Calgary, Canada
| | - Braden J. Manns
- Departments of Medicine and Community Health Sciences, University of Calgary, Calgary, Canada
| | - Henry Thomas Stelfox
- Departments of Critical Care Medicine, Medicine and Community Health Sciences, University of Calgary, Calgary, Canada
- * E-mail:
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Affiliation(s)
- Eric Camiré
- Department of Critical Care Medicine, University of Calgary, Calgary, Alta
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