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Yarnell CJ, Jewell LM, Astell A, Pinto R, Devine LA, Detsky ME, Downar J, Ilan R, Rawal S, Wong N, You JJ, Fowler RA. Observational study of agreement between attending and trainee physicians on the surprise question: "Would you be surprised if this patient died in the next 12 months?". PLoS One 2021; 16:e0247571. [PMID: 33630939 PMCID: PMC7906409 DOI: 10.1371/journal.pone.0247571] [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] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 02/10/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Optimal end-of-life care requires identifying patients that are near the end of life. The extent to which attending physicians and trainee physicians agree on the prognoses of their patients is unknown. We investigated agreement between attending and trainee physician on the surprise question: "Would you be surprised if this patient died in the next 12 months?", a question intended to assess mortality risk and unmet palliative care needs. METHODS This was a multicentre prospective cohort study of general internal medicine patients at 7 tertiary academic hospitals in Ontario, Canada. General internal medicine attending and senior trainee physician dyads were asked the surprise question for each of the patients for whom they were responsible. Surprise question response agreement was quantified by Cohen's kappa using Bayesian multilevel modeling to account for clustering by physician dyad. Mortality was recorded at 12 months. RESULTS Surprise question responses encompassed 546 patients from 30 attending-trainee physician dyads on academic general internal medicine teams at 7 tertiary academic hospitals in Ontario, Canada. Patients had median age 75 years (IQR 60-85), 260 (48%) were female, and 138 (25%) were dependent for some or all activities of daily living. Trainee and attending physician responses agreed in 406 (75%) patients with adjusted Cohen's kappa of 0.54 (95% credible interval 0.41 to 0.66). Vital status was confirmed for 417 (76%) patients of whom 160 (38% of 417) had died. Using a response of "No" to predict 12-month mortality had positive likelihood ratios of 1.84 (95% CrI 1.55 to 2.22, trainee physicians) and 1.51 (95% CrI 1.30 to 1.72, attending physicians), and negative likelihood ratios of 0.31 (95% CrI 0.17 to 0.48, trainee physicians) and 0.25 (95% CrI 0.10 to 0.46, attending physicians). CONCLUSION Trainee and attending physician responses to the surprise question agreed in 54% of cases after correcting for chance agreement. Physicians had similar discriminative accuracy; both groups had better accuracy predicting which patients would survive as opposed to which patients would die. Different opinions of a patient's prognosis may contribute to confusion for patients and missed opportunities for engagement with palliative care services.
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Affiliation(s)
- Christopher J. Yarnell
- Institute of Health Management, Policy, and Evaluation, University of Toronto, Toronto, Canada
- Department of Medicine, Sinai Health System, Toronto, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Laura M. Jewell
- Memorial University of Newfoundland, Discipline of Family Medicine, Happy Valley-Goose Bay, Canada
| | - Alex Astell
- University of Manitoba Faculty of Medicine, Section of Critical Care Medicine, Manitoba, Canada
| | - Ruxandra Pinto
- Sunnybrook Health Sciences Centre Department of Critical Care, Toronto, Canada
| | - Luke A. Devine
- Department of Medicine, Sinai Health System, Toronto, Canada
- University of Toronto Temerty Faculty of Medicine, Division of General Internal Medicine, Toronto, Canada
| | - Michael E. Detsky
- Department of Medicine, Sinai Health System, Toronto, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - James Downar
- The Ottawa Hospital, Ottawa, Canada
- University of Ottawa Faculty of Medicine, Division of Palliative Care, Ottawa, Canada
| | - Roy Ilan
- Department of Critical Care Medicine, Rambam Health Care Campus, Technion, Israel Institute of Technology, Haifa, Israel
| | - Shail Rawal
- University of Toronto Temerty Faculty of Medicine, Division of General Internal Medicine, Toronto, Canada
- University Health Network, General Internal Medicine, Toronto, Canada
| | - Natalie Wong
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
- University of Toronto Temerty Faculty of Medicine, Division of General Internal Medicine, Toronto, Canada
- Departments of General Internal Medicine and Critical Care Medicine, St Michael’s Hospital, Toronto, Canada
| | - John J. You
- Division of General Internal and Hospitalist Medicine, Department of Medicine, Trillium Health Partners, Mississauga, Ontario, Canada
| | - Rob A. Fowler
- Institute of Health Management, Policy, and Evaluation, University of Toronto, Toronto, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
- Sunnybrook Health Sciences Centre Department of Critical Care, Toronto, Canada
- Institute for Clinical Evaluative Sciences, Toronto, Canada
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Mody P, Pandey A, Slutsky AS, Segar MW, Kiss A, Dorian P, Parsons J, Scales DC, Rac VE, Cheskes S, Bierman AS, Abramson BL, Gray S, Fowler RA, Dainty KN, Idris AH, Morrison L. Gender-Based Differences in Outcomes Among Resuscitated Patients With Out-of-Hospital Cardiac Arrest. Circulation 2020; 143:641-649. [PMID: 33317326 DOI: 10.1161/circulationaha.120.050427] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [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: 01/14/2023]
Abstract
BACKGROUND Studies examining gender-based differences in outcomes of patients experiencing out-of-hospital cardiac arrest have demonstrated that, despite a higher likelihood of return of spontaneous circulation, women do not have higher survival. METHODS Patients successfully resuscitated from out-of-hospital cardiac arrest enrolled in the CCC trial (Trial of Continuous or Interrupted Chest Compressions during CPR) were included. Hierarchical multivariable logistic regression models were constructed to evaluate the association between gender and survival after adjustment for age, gender, cardiac arrest rhythm, witnessed status, bystander cardiopulmonary resuscitation, episode location, epinephrine dose, emergency medical services response time, and duration of resuscitation. Do not resuscitate (DNR) and withdrawal of life-sustaining therapy (WLST) order status were used to assess whether differences in postresuscitation outcomes were modified by baseline prognosis. The analysis was replicated among ALPS trial (Amiodarone, Lidocaine, or Placebo in Out-of-Hospital Cardiac Arrest) participants. RESULTS Among 4875 successfully resuscitated patients, 1825 (37.4%) were women and 3050 (62.6%) were men. Women were older (67.5 versus 65.3 years), received less bystander cardiopulmonary resuscitation (49.1% versus 54.9%), and had a lower proportion of cardiac arrests that were witnessed (55.1% versus 64.5%) or had shockable rhythm (24.3% versus 44.6%, P<0.001 for all). A significantly higher proportion of women received DNR orders (35.7% versus 32.1%, P=0.009) and had WLST (32.8% versus 29.8%, P=0.03). Discharge survival was significantly lower in women (22.5% versus 36.3%, P<0.001; adjusted odds ratio, 0.78 [95% CI, 0.66-0.93]; P=0.005). The association between gender and survival to discharge was modified by DNR and WLST order status such that women had significantly reduced survival to discharge among patients who were not designated DNR (31.3% versus 49.9%, P=0.005; adjusted odds ratio, 0.74 [95% CI, 0.60-0.91]) or did not have WLST (32.3% versus 50.7%, P=0.002; adjusted odds ratio, 0.73 [95% CI, 0.60-0.89]). In contrast, no gender difference in survival was noted among patients receiving a DNR order (6.7% versus 7.4%, P=0.90) or had WLST (2.8% versus 2.4%, P=0.93). Consistent patterns of association between gender and postresuscitation outcomes were observed in the secondary cohort. CONCLUSIONS Among patients resuscitated after experiencing out-of-hospital cardiac arrest, discharge survival was significantly lower in women than in men, especially among patients considered to have a favorable prognosis.
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Affiliation(s)
- Purav Mody
- Division of Cardiology, Department of Internal Medicine (P.M., A.P., M.W.S.), University of Texas Southwestern Medical Center, Dallas.,VA North Texas Health System, Dallas (P.M.)
| | - Ambarish Pandey
- Division of Cardiology, Department of Internal Medicine (P.M., A.P., M.W.S.), University of Texas Southwestern Medical Center, Dallas
| | - Arthur S Slutsky
- Keenan Research Center for Biomedical Science at the Li Ka Shing Knowledge Institute, St. Michael's Hospital, Departments of Medicine, Surgery, and Biomedical Engineering, Interdepartmental Division of Critical Care (A.S.S.), University of Toronto, Ontario, Canada
| | - Matthew W Segar
- Division of Cardiology, Department of Internal Medicine (P.M., A.P., M.W.S.), University of Texas Southwestern Medical Center, Dallas
| | - Alex Kiss
- Evaluative Clinical Sciences, Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Institute for Health Policy and Management (A.K.), University of Toronto, Ontario, Canada
| | - Paul Dorian
- Division of Cardiology, St Michael's Hospital, Division of Cardiology, Department of Medicine, Faculty of Medicine, Institute of Medical Sciences (P.D.), University of Toronto, Ontario, Canada
| | - Janet Parsons
- Applied Health Research Centre at the Li Ka Shing Knowledge Institute, St Michael's Hospital, Department of Physical Therapy and the Rehabilitation Sciences Institute (J.P.), University of Toronto, Ontario, Canada
| | - Damon C Scales
- Sunnybrook Health Sciences Center, Interdepartmental Division of Critical Care Medicine, Faculty of Medicine, Institute for Health Policy and Management (D.C.S.), University of Toronto, Ontario, Canada
| | - Valeria E Rac
- Ted Rogers Centre for Heart Research and Peter Munk Cardiac Centre and Toronto General Hospital Research Institute, Toronto Health Economics and Technology Assessment (THETA) Collaborative, Institute of Health Policy, Management and Evaluation (V.E.R.), University of Toronto, Ontario, Canada
| | - Sheldon Cheskes
- Sunnybrook Centre for Prehospital Medicine, Division of Emergency Medicine, Department of Family and Community Medicine (S.C.), University of Toronto, Ontario, Canada
| | - Arlene S Bierman
- Centre for Practice Improvement, Agency for Healthcare Research and Quality, Rockville, MD (A.S.B.)
| | - Beth L Abramson
- Division of Cardiology, St Michael's Hospital, Division of Cardiology, Department of Medicine, Faculty of Medicine (B.L.A.), University of Toronto, Ontario, Canada
| | - Sara Gray
- Emergency Medicine and Critical Care, St Michael's Hospital, Division of Emergency Medicine, Department of Medicine, Interdepartmental Division of Critical Care, Faculty of Medicine (S.G.), University of Toronto, Ontario, Canada
| | - Rob A Fowler
- Sunnybrook Health Sciences Center, Interdepartmental Division of Critical Care Medicine, Faculty of Medicine, Institute for Health Policy and Management (R.A.F.), University of Toronto, Ontario, Canada
| | - Katie N Dainty
- North York General Hospital, Institute for Health Policy and Management (K.N.D.), University of Toronto, Ontario, Canada
| | - Ahamed H Idris
- Department of Emergency Medicine (A.H.I.), University of Texas Southwestern Medical Center, Dallas
| | - Laurie Morrison
- Rescu at the Li Ka Shing Knowledge Institute, Emergency Medicine, St. Michael's Hospital, Division of Emergency Medicine, Department of Medicine, Faculty of Medicine, Institute for Health Policy and Management (L.M.), University of Toronto, Ontario, Canada
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Wunsch H, Hill AD, Fu L, Fowler RA, Wang HT, Gomes T, Fan E, Juurlink DN, Pinto R, Wijeysundera DN, Scales DC. New Opioid Use after Invasive Mechanical Ventilation and Hospital Discharge. Am J Respir Crit Care Med 2020; 202:568-575. [PMID: 32348694 DOI: 10.1164/rccm.201912-2503oc] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Rationale: Patients who receive invasive mechanical ventilation (IMV) are usually exposed to opioids as part of their sedation regimen. The rates of posthospital prescribing of opioids are unknown.Objectives: To determine the frequency of persistent posthospital opioid use among patients who received IMV.Methods: We assessed opioid-naive adults who were admitted to an ICU, received IMV, and survived at least 7 days after hospital discharge in Ontario, Canada over a 26-month period (February, 2013 through March, 2015). The primary outcome was new, persistent opioid use during the year after discharge. We assessed factors associated with persistent use by multivariable logistic regression. Patients receiving IMV were also compared with matched hospitalized patients who did not receive intensive care (non-ICU).Measurements and Main Results: Among 25,085 opioid-naive patients on IMV, 5,007 (20.0%; 95% confidence interval [CI], 19.5-20.5) filled a prescription for opioids in the 7 days after hospital discharge. During the next year, 648 (2.6%; 95% CI, 2.4-2.8) of the IMV cohort met criteria for new, persistent opioid use. The patient characteristic most strongly associated with persistent use in the IMV cohort was being a surgical (vs. medical) patient (adjusted odds ratio, 3.29; 95% CI, 2.72-3.97). The rate of persistent use was slightly higher than for matched non-ICU patients (2.6% vs. 1.5%; adjusted odds ratio, 1.37 [95% CI, 1.19-1.58]).Conclusions: A total of 20% of IMV patients received a prescription for opioids after hospital discharge, and 2.6% met criteria for persistent use, an average of 300 new persistent users per year in a population of 14 million. Receipt of surgery was the factor most strongly associated with persistent use.
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Affiliation(s)
- Hannah Wunsch
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Sunnybrook Research Institute, Toronto, Ontario, Canada.,ICES, Toronto, Ontario, Canada.,Interdepartmental Division of Critical Care Medicine.,Department of Anesthesia
| | - Andrea D Hill
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Sunnybrook Research Institute, Toronto, Ontario, Canada
| | | | - Rob A Fowler
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Sunnybrook Research Institute, Toronto, Ontario, Canada.,ICES, Toronto, Ontario, Canada.,Interdepartmental Division of Critical Care Medicine.,Department of Medicine, and
| | - Han Ting Wang
- Critical Care Division, Department of Medicine, Maisonneuve-Rosemont Hospital affiliated with the University of Montreal, Montreal, Quebec, Canada; and
| | - Tara Gomes
- ICES, Toronto, Ontario, Canada.,Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada.,Li Ka Shing Knowledge Institute and
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine.,Department of Medicine, and
| | - David N Juurlink
- Sunnybrook Research Institute, Toronto, Ontario, Canada.,ICES, Toronto, Ontario, Canada.,Department of Medicine, and
| | - Ruxandra Pinto
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Duminda N Wijeysundera
- ICES, Toronto, Ontario, Canada.,Department of Anesthesia.,Li Ka Shing Knowledge Institute and.,Department of Anesthesia, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Damon C Scales
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Sunnybrook Research Institute, Toronto, Ontario, Canada.,ICES, Toronto, Ontario, Canada.,Interdepartmental Division of Critical Care Medicine.,Department of Medicine, and
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Martin CM, Lam M, Allen B, Richard L, Lau V, Ball IM, Wunsch H, Fowler RA, Scales DC. Determinants of Direct Discharge Home From Critical Care Units: A Population-Based Cohort Analysis. Crit Care Med 2020; 48:475-483. [PMID: 32205593 DOI: 10.1097/ccm.0000000000004178] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [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] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To describe trends and patient and system factors associated with direct discharge from critical care to home in a large health system. DESIGN Population-based cohort study of direct discharge to home rates annually over 10 years. We used a multivariable, multilevel random-effects regression model to analyze current factors associated with direct discharge home in a subcohort from the most recent 2 years. SETTING One hundred seventy-four ICUs in 101 hospitals in Ontario. PATIENTS All patients discharged from an ICU between April 1, 2007, and March 31, 2017. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Overall, 237,200 patients (21.1%) were discharged directly home from an ICU. The rate of direct discharge to home increased from 18.6% in 2007 to 23.1% in 2017 (annual increase of 1.02; 95% CI, 1.02-1.03). There were marked variations in rates of direct discharge to home across all critical care units. For medical and surgical units, the median odds ratio was 1.76 (95% CI, 1.59-1.92). In these units, direct discharge to home was associated with younger age (odds ratio, 0.36; 95% CI, 0.34-0.39 for age 80-105 vs age 18-39), fewer comorbidities (odds ratio, 1.74; 95% CI, 1.63-1.85 for Charlson comorbidity index of 0 vs 2), diagnoses of overdose/poisoning (odds ratio, 1.35; 95% CI, 1.23-1.47) and diabetic complications (odds ratio, 1.35; 95% CI, 1.2-1.51), and admission after a same-day procedure (odds ratio, 2.82; 95% CI, 2.46-3.23 compared with emergency department). ICU occupancy was inversely associated with direct discharge to home with an odds ratio of 0.88 (95% CI, 0.87-0.88) for each 10% increase. CONCLUSIONS High rates of direct discharge to home with evidence of significant practice variation combined with identifiable patient characteristics suggest that further evaluation of this increasingly common transition in care is warranted.
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Affiliation(s)
- Claudio M Martin
- Division of Critical Care, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
- Lawson Health Research Institute, London, ON, Canada
| | | | | | | | - Vincent Lau
- Division of Critical Care, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Ian M Ball
- Division of Critical Care, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
- Lawson Health Research Institute, London, ON, Canada
- Department of Epidemiology and Biostatistics, Western University, London, ON, Canada
| | - Hannah Wunsch
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON, Canada
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- ICES, Toronto, ON, Canada
| | - Rob A Fowler
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON, Canada
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- ICES, Toronto, ON, Canada
| | - Damon C Scales
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON, Canada
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- ICES, Toronto, ON, Canada
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Abstract
PURPOSE To explore contemporary clincial case management of patients with Ebola virus disease. METHODS A narrative review from a clinical perspective of clinical features, diagnostic tests, treatments and outcomes of patients with Ebola virus disease. RESULTS Substantial advances have been made in the care of patients with Ebola virus disease (EVD), precipitated by the unprecedented extent of the 2014-2016 outbreak. There has been improved point-of-care diagnostics, improved characterization of the clinical course of EVD, improved patient-optimized standards of care, evaluation of effective anti-Ebola therapies, administration of effective vaccines, and development of innovative Ebola treatment units. A better understanding of the Ebola virus disease clinical syndrome has led to the appreciation of a central role for critical care clinicians-over 50% of patients have life-threatening complications, including hypotension, severe electrolyte imbalance, acute kidney injury, metabolic acidosis and respiratory failure. Accordingly, patients often require critical care interventions such as monitoring of vital signs, intravenous fluid resuscitation, intravenous vasoactive medications, frequent diagnostic laboratory testing, renal replacement therapy, oxygen and occasionally mechanical ventilation. CONCLUSION With advanced training and adherence to infection prevention and control practices, clinical interventions, including critical care, are feasible and safe to perform in critically ill patients. With specific anti-Ebola medications, most patients can survive Ebola virus infection.
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Affiliation(s)
- Peter Kiiza
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - S Mullin
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - K Teo
- Canadian Forces Health Services Group, Toronto, 10 Yukon Lane, North York, ON, M3K 0A1, Canada
| | - N K J Adhikari
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada.,Institute for Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - R A Fowler
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada. .,Institute for Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada. .,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada. .,, 2075 Bayview Avenue, Room D478, Toronto, ON, M4N 3M5, Canada.
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Loignon C, Nouvet E, Couturier F, Benhadj L, Adhikari NKJ, Murthy S, Fowler RA, Lamontagne F. Barriers to supportive care during the Ebola virus disease outbreak in West Africa: Results of a qualitative study. PLoS One 2018; 13:e0201091. [PMID: 30183718 PMCID: PMC6124726 DOI: 10.1371/journal.pone.0201091] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Accepted: 07/09/2018] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND During the 2013-2016 West Africa Ebola outbreak, supportive care was the only non-experimental treatment option for patients with Ebola virus disease (EVD). However, providing care that would otherwise be routine for most clinical settings in the context of a highly contagious and lethal pathogen is much more challenging. The objective of this study was to document and deepen understanding of barriers to provision of supportive care in Ebola treatment units (ETUs) as perceived by those involved in care delivery during the outbreak. METHODS This qualitative study consisted of 29 in-depth semi-structured interviews with stakeholders (decision-makers, physicians, nurses) involved in patient care delivery during the outbreak. Analysis consisted of interview debriefing and team-based transcript coding in NVivo10 software using thematic analysis. FINDINGS Participants emphasized three interconnected barriers to providing high-quality supportive care during the outbreak: 1) lack of material and human resources in ETUs; 2) ETU organizational structure limiting the provision of supportive clinical care; and 3) delayed and poorly coordinated policies limiting the effectiveness of global and national responses. Participants also noted the ethical complexities of defining and enacting best clinical practices in low-income countries. They noted tension between, on one hand, scaling up minimal care and investing in clinical care preparedness to a level sustainable in West Africa and, on the other, providing a higher level of supportive care, which in low-resource health systems would require important investments. CONCLUSION Our findings identified potentially modifiable barriers to the delivery of supportive care to patients with EVD in West Africa. Addressing these in the inter-outbreak period will be useful to improve patient care and outcomes during inevitable future outbreaks. Promoting community trust and engagement through long-term capacity building of the healthcare workforce and infrastructure would increase both health system resilience and ability to handle other outbreaks of emerging diseases.
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Affiliation(s)
- Christine Loignon
- Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, Canada
| | - Elysée Nouvet
- School of Health Studies, University of Western Ontario, London, Canada
| | - François Couturier
- Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, Canada
| | - Lynda Benhadj
- Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, Canada
| | - Neill K. J. Adhikari
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Interdepartmental Division of Critical Care, University of Toronto, Toronto, Canada
| | - Srinivas Murthy
- Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - Rob A. Fowler
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Interdepartmental Division of Critical Care, University of Toronto, Toronto, Canada
| | - François Lamontagne
- Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, Canada
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El-Mor IM, Fowler RA, Platz GJ, Sutherland MW, Martin A. An Improved Detached-Leaf Assay for Phenotyping Net Blotch of Barley Caused by Pyrenophora teres. Plant Dis 2018; 102:760-763. [PMID: 30673396 DOI: 10.1094/pdis-07-17-0980-re] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Net blotch, caused by Pyrenophora teres, is a major barley (Hordeum vulgare) leaf disease worldwide. P. teres occurs as two forms-P. teres f. teres, and P. teres f. maculata-inducing net and spot-like symptoms, respectively. An intact-seedling assay, where entire seedlings are inoculated by spraying with a conidial suspension, is frequently used for phenotyping net blotch. However, this presents a biosecurity risk in the glasshouse when nonlocal isolates are being screened. Alternatively, a detached-leaf assay (DLA-droplet method) can be used in which leaf segments laid out in a covered tray are inoculated with droplets of a conidial suspension, confining the inoculum. However, using this method, net and spot form symptoms cannot be distinguished from each other. We have developed an improved DLA (DLA-spray method) in which detached whole leaves are sprayed with the inoculum to produce distinct lesions. We compare the results for the three phenotyping methods above using four isolates from both net and spot forms of the disease to inoculate a standard set of eight barley genotypes. Results indicate that the DLA-spray method is a functional, informative and rapid test that readily differentiates the two forms of the pathogen in a biosecure environment.
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Affiliation(s)
- I M El-Mor
- University of Southern Queensland, Centre for Crop Health, Toowoomba, 4350, QLD, Australia
| | - R A Fowler
- Queensland Department of Agriculture & Fisheries, Hermitage Research Facility, Warwick, 4370, QLD, Australia
| | - G J Platz
- Queensland Department of Agriculture & Fisheries, Hermitage Research Facility, Warwick, 4370, QLD, Australia
| | - M W Sutherland
- University of Southern Queensland, Centre for Crop Health, Toowoomba
| | - A Martin
- University of Southern Queensland, Centre for Crop Health, Toowoomba
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Brown KN, Leigh JP, Kamran H, Bagshaw SM, Fowler RA, Dodek PM, Turgeon AF, Forster AJ, Lamontagne F, Soo A, Stelfox HT. Transfers from intensive care unit to hospital ward: a multicentre textual analysis of physician progress notes. Crit Care 2018; 22:19. [PMID: 29374498 PMCID: PMC5787341 DOI: 10.1186/s13054-018-1941-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Accepted: 01/02/2018] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Little is known about documentation during transitions of patient care between clinical specialties. Therefore, we examined the focus, structure and purpose of physician progress notes for patients transferred from the intensive care unit (ICU) to hospital ward to identify opportunities to improve communication breaks. METHODS This was a prospective cohort study in ten Canadian hospitals. We analyzed physician progress notes for consenting adult patients transferred from a medical-surgical ICU to hospital ward. The number, length, legibility and content of notes was counted and compared across care settings using mixed-effects linear regression models accounting for clustering within hospitals. Qualitative content analyses were conducted on a stratified random sample of 32 patients. RESULTS A total of 447 patient medical records that included 7052 progress notes (mean 2.1 notes/patient/day 95% CI 1.9-2.3) were analyzed. Notes written by the ICU team were significantly longer than notes written by the ward team (mean lines of text 21 vs. 15, p < 0.001). There was a discrepancy between documentation of patient issues in the last ICU and first ward notes; mean agreement of patient issues was 42% [95% CI 31-53%]. Qualitative analyses identified eight themes related to focus (central point - e.g., problem list), structure (organization, - e.g., note-taking style), and purpose (intention - e.g., documentation of patient course) of the notes that varied across clinical specialties and physician seniority. CONCLUSIONS Important gaps and variations in written documentation during transitions of patient care between ICU and hospital ward physicians are common, and include discrepancies in documentation of patient information.
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Sebastián UU, Ricardo AVA, Alvarez BC, Cubides A, Luna AF, Arroyo-Parejo M, Acuña CE, Quintero AV, Villareal OC, Pinillos OS, Vieda E, Bello M, Peña S, Dueñas-Castell C, Rodriguez GMV, Ranero JLM, López RLM, Olaya SG, Vergara JC, Tandazo A, Ospina JPS, Leyton Soto IM, Fowler RA, Marshall JC. Zika virus-induced neurological critical illness in Latin America: Severe Guillain-Barre Syndrome and encephalitis. J Crit Care 2017; 42:275-281. [PMID: 28806562 PMCID: PMC7127615 DOI: 10.1016/j.jcrc.2017.07.038] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2017] [Revised: 06/30/2017] [Accepted: 07/20/2017] [Indexed: 12/13/2022]
Abstract
Zika virus (ZIKAV) is classically described as causing minor symptoms in adult patients, however neurologic complications have been recognized. The recent outbreak in Central and South America has resulted in serious illness in some adult patients. We report adult patients in Latin America diagnosed with ZIKAV infection admitted to Intensive Care Units (ICUs). METHODS Multicenter, prospective case series of adult patients with laboratory diagnosis of ZIKAV in 16 ICUs in 8 countries. RESULTS Between December 1st 2015 and April 2nd 2016, 16 ICUs in 8 countries enrolled 49 critically ill patients with diagnosis of ZIKAV infection. We included 10 critically ill patients with ZIKAV infection, as diagnosed with RT-PCR, admitted to the ICU. Neurologic manifestations concordant with Guillain-Barre Syndrome (GBS) were present in all patients, although 2 evolved into an encephalitis-like picture. 2 cases died, one due to encephalitis, the other septic shock. CONCLUSIONS Differing from what was usually reported, ZIKAV infection can result in life-threatening neurologic illness in adults, including GBS and encephalitis. Collaborative reporting to identify severe illness from an emerging pathogen can provide valuable insights into disease epidemiology and clinical presentation, and inform public health authorities about acute care priorities.
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Affiliation(s)
- Ugarte Ubiergo Sebastián
- Critical Care Department, Clínica Indisa, Universidad Andrés Bello, Santiago de Chile, Chile; FEPIMCTI, Council WFSICCM, Chile
| | | | | | - Angela Cubides
- Universidad Santiago de Cali, Cali, Colombia; Universidad del Valle, Cali, Colombia
| | - Angélica F Luna
- General Critical Care Unit and Intermediate Care, Neiva, Colombia
| | - Max Arroyo-Parejo
- Hospital Privado Clínica Santa Sofía, Caracas, Venezuela; Hospital Vargas de Caracas, Caracas, Venezuela
| | | | | | - Orlando Ch Villareal
- Clínica Evaluamos, Córdoba, Colombia; Facultad de Medicina, Universidad del Sinú, Córdoba, Colombia
| | - Oscar S Pinillos
- Metabolic Disorders and Intensive Care Research Group, Cali, Colombia
| | - Elías Vieda
- Hospital Universitario del Valle, Cali, Colombia
| | - Manuel Bello
- Critical Care Department, Hospital Nacional San Rafael, San Salvador, El Salvador; Salvadorean Critical Care Association, El Salvador
| | - Susana Peña
- Ministry of Health, San Salvador, El Salvador
| | | | | | - Jorge L M Ranero
- Hospital General de Enfermedades, Instituto Guatemalteco de Seguridad Social, Guatemala City, Guatemala
| | | | - Sandra G Olaya
- Obstetric and Gynecologic Intensive Care Unit, Hospital San Jorge Pereira, Colombia
| | - José C Vergara
- Hospital Luis Vernaza, Holy Spirit University of Guayaquil Ecuador, Guayaquil, Ecuador; Universidad Espíritu Santo de Guayaquil, Ecuador
| | - Ana Tandazo
- Hospital Luis Vernaza, Holy Spirit University of Guayaquil Ecuador, Guayaquil, Ecuador; Universidad Espíritu Santo de Guayaquil, Ecuador
| | | | | | - R A Fowler
- Clinical Epidemiology, Sunnybrook Research Institute, Canada; Sunnybrook Health Sciences Centre, Canada; Department of Medicine and Interdepartmental Division of Critical Care Medicine, University of Toronto, Canada
| | - John C Marshall
- Surgery, University of Toronto, Canada; Michael Hospital, Toronto, Canada
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Baran B, Demanuele C, Vuper TC, Seicol B, Fowler RA, Correll D, Parr E, Callahan CE, Morgan A, Stickgold R, Manoach DS. 1113 THE EFFECTS OF ESZOPICLONE ON SLEEP SPINDLES AND MEMORY CONSOLIDATION IN SCHIZOPHRENIA: A DOUBLE-BLIND RANDOMIZED TRIAL. Sleep 2017. [DOI: 10.1093/sleepj/zsx050.1112] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Hill AD, Fowler RA, Pinto R, Herridge MS, Cuthbertson BH, Scales DC. Long-term outcomes and healthcare utilization following critical illness--a population-based study. Crit Care 2016; 20:76. [PMID: 27037030 PMCID: PMC4818427 DOI: 10.1186/s13054-016-1248-y] [Citation(s) in RCA: 125] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Accepted: 02/19/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND The purpose of this study was to examine hospital mortality, long-term mortality, and health service utilization among critically ill patients. We also determined whether these outcomes differed according to demographic and clinical characteristics. METHODS We conducted a retrospective cohort study of adults (age ≥ 18 years) who survived admission to an intensive care unit (ICU) in Ontario, Canada, between 1 April 2002 and 31 March 2012, excluding isolated admissions to step-down or intermediate ICUs, coronary care ICUs, or cardiac surgery ICUs. Adults (age ≥ 18 years) who survived an acute hospitalization that did not include an ICU stay formed the comparator group. The primary outcome was mortality following hospital discharge. Secondary outcomes were healthcare utilization, including emergency room admissions and hospital readmissions during follow-up. RESULTS Over the study interval, 500,124 patients were admitted to ICUs and 420,187 (84%) survived to hospital discharge. Median follow-up for survivors was 5.3 (interquartile range 2.5, 8.2) years. Patients admitted to an ICU were more likely to subsequently visit the emergency department, be readmitted to the hospital and ICU, receive home care support, require rehabilitation, and be admitted for long-term care. Those requiring more resources within the ICU required more resources after discharge. One-third of patients admitted to the ICU died during long-term follow-up, with overall probabilities of death of 11% and 29% at 1 year and 5 years, respectively. In the adjusted analysis, there was an increasing hazard of death with increasing age, reaching a hazard ratio of 18.08 (95 % confidence interval 16.60-19.68) for those ≥ 85 years of age compared with those aged 18-24 years. CONCLUSIONS Healthcare utilization after hospital discharge was higher among ICU patients, and also among those requiring more healthcare resources during their ICU admission, than among all hospitalized patients as a group. One-third of ICU patients died within the 5 years following discharge, and age was the most influential determinant of outcome. These findings should help target post-ICU discharge services for high-risk groups and better inform goals-of-care discussions for elderly critically ill patients.
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Affiliation(s)
- A D Hill
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada. .,Sunnybrook Research Institute, Toronto, ON, Canada.
| | - R A Fowler
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Sunnybrook Research Institute, Toronto, ON, Canada.,Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON, Canada
| | - R Pinto
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - M S Herridge
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON, Canada.,Toronto General Hospital/University Health Network, Toronto, ON, Canada
| | - B H Cuthbertson
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Sunnybrook Research Institute, Toronto, ON, Canada.,Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON, Canada
| | - D C Scales
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Sunnybrook Research Institute, Toronto, ON, Canada.,Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON, Canada
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Affiliation(s)
- R A Fowler
- The Toronto General Hospital, Toronto, Ontario, Canada
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Fowler RA, Nichols L, Letourneau BE, Castello P. Estimating the economic impact of an initiative to increase organ donation in a transplant center. Transplant Proc 1997; 29:3259-60. [PMID: 9414707 DOI: 10.1016/s0041-1345(97)00902-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- R A Fowler
- Partnership for Organ Donation, Boston, Massachusetts 02109-4901, USA
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McNamara P, Franz HG, Fowler RA, Evanisko MJ, Beasley CL. Medical record review as a measure of the effectiveness of organ procurement practices in the hospital. Jt Comm J Qual Improv 1997; 23:321-33. [PMID: 9234074 DOI: 10.1016/s1070-3241(16)30322-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Organ procurement efforts are central to the transplant sector of the health care system, yet procurement effectiveness is not routinely assessed. MRRs provide a solid foundation for identifying gaps in organ procurement performance, implementing and tracking the success of QI initiatives, and monitoring ongoing performance.
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Affiliation(s)
- P McNamara
- Partnership for Organ Donation, Boston, MA 02109, USA.
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Fowler RA, Meyskens FL. Tumor viruses and human cancer. II. DNA tumor viruses. Ariz Med 1978; 35:661-2, 666-7. [PMID: 214057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Fowler RA. Theatre ecortnrse. Nurs Mirror Midwives J 1970; 131:34. [PMID: 5202137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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Fowler RA. Dishwasher to clean surgical instruments. Nurs Mirror Midwives J 1970; 131:33. [PMID: 5201789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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