Using an artificial intelligence tool can be as accurate as human assessors in level one screening for a systematic review

BACKGROUND

Artificial intelligence (AI) offers a promising solution to expedite various phases of the systematic review process such as screening.

OBJECTIVE

We aimed to assess the accuracy of an AI tool in identifying eligible references for a systematic review compared to identification by human assessors.

METHODS

For the case study (a systematic review of knowledge translation interventions), we used a diagnostic accuracy design and independently assessed for eligibility a set of articles (n = 300) using human raters and the AI system DistillerAI (Evidence Partners, Ottawa, Canada). We analysed a series of 64 possible confidence levels for the AI's decisions and calculated several standard parameters of diagnostic accuracy for each.

RESULTS

When set to a lower AI confidence threshold of 0.1 or greater and an upper threshold of 0.9 or lower, DistillerAI made article selection decisions very similarly to human assessors. Within this range, DistillerAI made a decision on the majority of articles (93-100%), with a sensitivity of 1.0 and specificity ranging from 0.9 to 1.0.

CONCLUSION

DistillerAI appears to be accurate in its assessment of articles in a case study of 300 articles. Further experimentation with DistillerAI will establish its performance among other subject areas.

Association Between Surgeon/Anesthesiologist Sex Discordance and 1-year Mortality Among Adults Undergoing Noncardiac Surgery: A Population-based Retrospective Cohort Study

OBJECTIVE

To investigate the association between surgeon-anesthesiologist sex discordance and patient mortality after noncardiac surgery.

BACKGROUND

Evidence suggests different practice patterns exist among female and male physicians. However, the influence of physician sex on team-based practices in the operating room and subsequent patient outcomes remains unclear in the context of noncardiac surgery.

METHODS

We conducted a population-based, retrospective cohort study of adult Ontario residents who underwent index, inpatient noncardiac surgery between January 2007 and December 2017. The primary exposure was physician sex discordance (ie, the surgeon and anesthesiologist were of the opposite sex). The primary outcome was 1-year mortality. The association between physician sex discordance and patient outcomes was modeled using multivariable Cox proportional hazard regression with adjustment for relevant physician, patient, and hospital characteristics.

RESULTS

Of 541,209 patients, 158,084 (29.2%) were treated by sex-discordant physician teams. Physician sex discordance was associated with a lower rate of mortality at 1 year [5.2% vs. 5.7%; adjusted HR: 0.95 (0.91-0.99)]. Patients treated by teams composed of female surgeons and male anesthesiologists were more likely to be alive at 1 year than those treated by all-male physician teams [adjusted HR: 0.90 (0.81-0.99)].

CONCLUSIONS

Noncardiac surgery patients had a lower likelihood of 1-year mortality when treated by sex-discordant surgeon-anesthesiologist teams. The likelihood of mortality was further reduced if the surgeon was female. Further research is needed to explore the underlying mechanisms of these observations and design strategies to diversify operating room teams to optimize performance and patient outcomes.

Efficacy of searching in biomedical databases beyond MEDLINE in identifying randomised controlled trials on hyperbaric oxygen treatment

Introduction

Literature searches are routinely used by researchers for conducting systematic reviews as well as by healthcare providers, and sometimes patients, to quickly guide their clinical decisions. Using more than one database is generally recommended but may not always be necessary for some fields. This study aimed to determine the added value of searching additional databases beyond MEDLINE when conducting a literature search of hyperbaric oxygen treatment (HBOT) randomised controlled trials (RCTs).

Methods

This study consisted of two phases: a scoping review of all RCTs in the field of HBOT, followed by a a statistical analysis of sensitivity, precision, 'number needed to read' (NNR) and 'number unique' included by individual biomedical databases. MEDLINE, Embase, Cochrane Central Register of Control Trials (CENTRAL), and Cumulated Index to Nursing and Allied Health Literature (CINAHL) were searched without date or language restrictions up to December 31, 2022. Screening and data extraction were conducted in duplicate by pairs of independent reviewers. RCTs were included if they involved human subjects and HBOT was offered either on its own or in combination with other treatments.

Results

Out of 5,840 different citations identified, 367 were included for analysis. CENTRAL was the most sensitive (87.2%) and had the most unique references (7.1%). MEDLINE had the highest precision (23.8%) and optimal NNR (four). Among included references, 14.2% were unique to a single database.

Conclusions

Systematic reviews of RCTs in HBOT should always utilise multiple databases, which at minimum include MEDLINE, Embase, CENTRAL and CINAHL.

Changes in liver biochemistry and tacrolimus levels following the introduction of elexacaftor/tezacaftor/ivacaftor in patients with cystic fibrosis and liver transplant

INTRODUCTION

Elevated liver function tests (LFTs) are reported in individuals with cystic fibrosis (CF) starting elexacaftor/tezacaftor/ivacaftor (ETI). We report our experience with ETI in CF liver transplant patients.

METHOD

All CF liver transplant patients under the care of the Leeds CF team were commenced on ETI. Liver biopsies were performed when ALT >3 times upper limit of normal with or without bilirubin elevation. Treatment was guided by transplant hepatology and CF teams. Clinical data including lung function, LFTs and tacrolimus levels were collected.

RESULTS

Four patients (3 male, 1 female) on tacrolimus were commenced on ETI. Median time post liver transplantation was 6.5 years. Three patients underwent liver biopsy. One biopsy was abnormal with immune-mediated liver injury, which responded to increased immunosuppression. Management of tacrolimus levels proved straightforward.

CONCLUSION

ETI therapy in CF post liver transplant recipients was encouraging. Normal liver biopsy provides re-assurance to continue treatment despite elevated LFTs.

Interventions to facilitate interprofessional collaboration in the operating theatre: A scoping review

BACKGROUND

Ineffective collaboration can increase adverse events in the operating theatre. When professionals work collaboratively, they are more likely to improve patient safety and outcomes.

AIM

To identify interprofessional collaboration interventions involving operating theatre teams and describe their effect on facilitating communication, teamwork, and safety.

METHODS

A scoping review of four databases. Results were analysed by identifying interventions and mapping their related outcomes.

RESULTS

Twenty studies evaluated single or multi-faceted interventions. Despite low-quality study designs (no randomised controlled trials), four interventions (eg: briefings, checklists, team training, debriefing) improved communication and teamwork, and enhanced safety outcomes. Only one study, using team training, reported that organisational level interventions (eg: Standard Operating Procedures, Lean quality improvement management system) improved teamwork and safety outcomes.

CONCLUSION

Several studies reported interventions enhanced interprofessional collaboration within operating theatre teams. Although findings were in favour of improved communication and teamwork, more rigorous research is required.

Barriers and enablers to and strategies for promoting domestic plasma donation throughout the world: Overarching protocol for three systematic reviews

INTRODUCTION

The growing demand for plasma protein products has caused concern in many countries who largely rely on importing plasma products produced from plasma collected in the United States and Europe. Optimizing recruitment and retention of a diversity of plasma donors is therefore important for supporting national donation systems that can reliably meet the most critical needs of health services. This series of three systematic reviews aims to synthesize the known barriers and enablers to source plasma donation from the qualitative and survey-based literature and identify which strategies that have shown to be effective in promoting increased intention to, and actual donation of, source plasma.

METHODS AND ANALYSIS

Primary studies involving source or convalescent plasma donation via plasmapheresis will be included. The search strategy will capture all potentially relevant studies to each of the three reviews, creating a database of plasma donation literature. Study designs will be subsequently identified in the screening process to facilitate analysis according to the unique inclusion criteria of each review (i.e., qualitative, survey, and experimental designs). The search will be conducted in the electronic databases SCOPUS, MEDLINE, EMBASE, PsycINFO, and CINAHL without date or language restrictions. Studies will be screened, and data will be extracted, in duplicate by two independent reviewers with disagreements resolved through consensus. Reviews 1 and 2 will draw on the Theoretical Domains Framework and Intersectionality, while Review 3 will be informed by Behaviour Change Intervention Ontologies. Directed content analysis and framework analysis (Review 1), and descriptive and inferential syntheses (Reviews 2 and 3), will be used, including meta-analyses if appropriate.

DISCUSSION

This series of related reviews will serve to provide a foundation of what is known from the published literature about barriers and enablers to, and strategies for promoting, plasma donation worldwide.

Effectiveness of interprofessional teamwork interventions for improving occupational well-being among perioperative healthcare providers: a systematic review

The occupational well-being of healthcare providers is crucial for safe and effective patient care, especially in the complex, high acuity operating room (OR) setting. There has been a recent proliferation of interventions to improve teamwork in the OR setting, but the impact of these interventions on clinician occupational well-being has yet to be systematically assessed. This systematic review aimed to summarize the impact of interprofessional teamwork interventions on occupational well-being among perioperative healthcare providers. We included all qualitative or quantitative peer-reviewed studies assessing a multidisciplinary teamwork intervention including members of at least two professions. We included seven studies which involved checklists (n = 2), simulation-based training (n = 2), and various teamwork development and training programs (n = 3). Five of the seven included studies reported no significant effect on job satisfaction, while one found a significant negative association between the intervention and job satisfaction (p < .0001), and another showed significant decrease in worker stress. Our findings highlight the gaps in our understanding of the impact of interprofessional teamwork interventions on healthcare worker well-being in the perioperative environment and the multi-level factors influencing OR teamwork, intervention implementation, and well-being across the different professions.

Analyzing interprofessional teamwork in the operating room: An exploratory observational study using conventional and alternative approaches

Intraoperative teamwork is vital for patient safety. Conventional tools for studying intraoperative teamwork typically rely on behaviorally anchored rating scales applied at the individual or team level, while others capture narrative information across several units of analysis. This prospective observational study characterizes teamwork using two conventional tools (Operating Theatre Team Non-Technical Skills Assessment Tool [NOTECHS]; Team Emergency Assessment Measure [TEAM]), and one alternative approach (modified-Systems Engineering Initiative for Patient Safety [SEIPS] model). We aimed to explore the advantages and disadvantages of each for providing feedback to improve teamwork practice. Fifty consecutive surgical cases at a Canadian academic hospital were recorded with the OR Black Box®, analyzed by trained raters, and summarized descriptively. Teamwork performance was consistently high within and across cases rated with NOTECHS and TEAMS. For cases analyzed with the modified-SEIPS tool, both optimal and suboptimal teamwork behaviors were identified, and team resilience was frequently observed. NOTECHS and TEAM provided summative assessments and overall pattern descriptions, while SEIPS facilitated a deeper understanding of teamwork processes. As healthcare organizations continue to prioritize teamwork improvement, SEIPS may provide valuable insights regarding teamwork behavior and the broader context influencing performance. This may ultimately enhance the development and effectiveness of multi-level teamwork interventions.

The timing of booster sessions may not improve resuscitation skill retention among healthcare providers: a randomized controlled trial

Introduction

Booster sessions can improve cardiopulmonary resuscitation (CPR) skill retention among healthcare providers; however, the optimal timing of these sessions is unknown. This study aimed to explore differences in skill retention based on booster session timing.

Methods

After ethics approval, healthcare providers who completed an initial CPR training course were randomly assigned to either an early booster, late booster, or no booster group. Participants' mean resuscitation scores, time to initiate compressions, and time to successfully provide defibrillation were assessed immediately post-course and four months later using linear mixed models.

Results

Seventy-three healthcare professionals were included in the analysis. There were no significant differences by randomization in the immediate post-test (9.7, 9.2, 8.9) or retention test (10.2, 9.8, and 9.5) resuscitation scores. No significant effects were observed for time to compression. Post-test time to defibrillation (mean ± SE: 112.8 ± 3.0 sec) was significantly faster compared to retention (mean ± SE: 120.4 ± 2.7 sec) (p = 0.04); however, the effect did not vary by randomization.

Conclusion

No difference was observed in resuscitation skill retention between the early, late, and no booster groups. More research is needed to determine the aspects of a booster session beyond timing that contribute to skill retention.

Professional Coaching as a Continuing Professional Development Intervention to Address the Physician Distress Epidemic

ABSTRACT

Physician distress and burnout are reaching epidemic proportions, threatening physicians' capacities to develop and maintain competencies in the face of the increasingly demanding and complex realities of medical practice in today's world. In this article, we suggest that coaching should be considered both a continuing professional development intervention as well as an integral part of a balanced and proactive solution to physician distress and burnout. Unlike other interventions, coaching is intended to help individuals gain clarity in their life, rather than to treat a mental health condition or to provide advice, support, guidance, or knowledge/skills. Certified coaches are trained to help individuals discover solutions to complex problems and facilitate decision-making about what is needed to build and maintain capacity and take action. Across many sectors, coaching has been shown to enhance performance and reduce vulnerability to distress and burnout, but it has yet to be systematically implemented in medicine. By empowering physicians to discover and implement solutions to challenges, regain control over their lives, and act according to their own values, coaching can position physicians to become leaders and advocates for system-level change, while simultaneously prioritizing their own well-being.

Identifying positive and negative use of non-technical skills by anesthesiologists in the clinical operating room: An exploratory descriptive study

Background

Teamwork is a critical competency in high-risk settings like the operating room (OR). While conventional approaches focus on describing and learning from negative performance, there may be value in learning from high-performing behaviour, particularly in specialties where serious safety events are relatively rare. This study aimed to explore both the positive and negative use of non-technical skills by anesthesia practitioners in the OR and situate them within the clinical OR context.

Methods

This study employed a prospective observational design. Following research ethics approval, a sample of surgical cases in a tertiary hospital were recorded using the OR Black Box®. Data related to surgical phase timing, non-technical skills, team factors, and environmental factors were identified by analysts according to a modified Systems Engineering Initiative for Patient Safety model. We performed descriptive statistics and qualitative description of these observations.

Results

We observed 25 surgical cases capturing 242 instances of positive non-technical skills among anesthesiologists in the operating room and 9 instances of negative demonstrations. Situational awareness was most frequently (n = 160) observed, followed by communication and teamwork skills (n = 82), and were most often demonstrated in the context of potential environmental distractions (e.g., doors opening, unnecessary interruptions). The least common category of positive non-technical skills observed was leadership (n = 3).

Conclusions

Our findings show anesthesiologists are doing a lot "right" and there may be many opportunities for learning from positive practice in the clinical setting. These findings can inform future work to better understand and standardize best practices for non-technical performance in anesthesia.

Impact of coaching on physician wellness: A systematic review

Physician wellness is critical for patient safety and quality of care. Coaching has been successfully and widely applied across many industries to enhance well-being but has only recently been considered for physicians. This review aimed to summarize the existing evidence on the effect of coaching by trained coaches on physician well-being, distress and burnout. MEDLINE, Embase, ERIC, PsycINFO and Web of Science were searched without language restrictions to December 21, 2022. Studies of any design were included if they involved physicians of any specialty undergoing coaching by trained coaches and assessed at least one measure along the wellness continuum. Pairs of independent reviewers determined reference eligibility. Risk of bias was assessed using the Cochrane Risk of Bias Tools for Randomized Controlled Trials (RCTs) and for Non-randomized Studies of Interventions (ROBINS-I). Meta-analysis was not possible due to heterogeneity in study design and outcome measures as well as inconsistent reporting. The search retrieved 2531 references, of which 14 were included (5 RCTs, 2 non-randomized controlled studies, 4 before-and-after studies, 2 mixed-methods studies, 1 qualitative study). There were 1099 participants across all included studies. Risk of bias was moderate or serious for non-RCTs, while the 5 RCTs were of lower risk. All quantitative studies reported effectiveness of coaching for at least one outcome assessed. The included qualitative study reported a perceived positive impact of coaching by participants. Evidence from available RCTs suggests coaching for physicians can improve well-being and reduce distress/burnout. Non-randomized interventional studies have similar findings but face many limitations. Consistent reporting and standardized outcome measures are needed.

Interprofessional Collaboration in the OR: A Qualitative Study of Nurses' Perspectives

Interprofessional collaboration (IPC) in the OR enhances safe and effective patient care. The aim of this qualitative study was to explore perioperative nurses' perspectives on their contributions to IPC. We conducted a secondary analysis of 19 semistructured interviews with perioperative RNs and completed inductive thematic analysis with subsequent categorization of the themes into the Interprofessional Education for Collaborative Patient-Centred Practice Framework. Nurses expressed the importance of being heard through effective communication, feeling confident in their role, being aware of interdependent roles, and sharing a common understanding. From nurses' perspectives, use of structured processes enabled organization of interdisciplinary patient care. Nurses showed leadership skills when they anticipated the needs of the team and recognized they needed support to develop these skills. They contributed to IPC through their shared understanding of common goals, leadership skills in the OR, and active involvement in delivering structured processes.

Selecting implementation models, theories, and frameworks in which to integrate intersectional approaches

Background

Models, theories, and frameworks (MTFs) provide the foundation for a cumulative science of implementation, reflecting a shared, evolving understanding of various facets of implementation. One under-represented aspect in implementation MTFs is how intersecting social factors and systems of power and oppression can shape implementation. There is value in enhancing how MTFs in implementation research and practice account for these intersecting factors. Given the large number of MTFs, we sought to identify exemplar MTFs that represent key implementation phases within which to embed an intersectional perspective.

Methods

We used a five-step process to prioritize MTFs for enhancement with an intersectional lens. We mapped 160 MTFs to three previously prioritized phases of the Knowledge-to-Action (KTA) framework. Next, 17 implementation researchers/practitioners, MTF experts, and intersectionality experts agreed on criteria for prioritizing MTFs within each KTA phase. The experts used a modified Delphi process to agree on an exemplar MTF for each of the three prioritized KTA framework phases. Finally, we reached consensus on the final MTFs and contacted the original MTF developers to confirm MTF versions and explore additional insights.

Results

We agreed on three criteria when prioritizing MTFs: acceptability (mean = 3.20, SD = 0.75), applicability (mean = 3.82, SD = 0.72), and usability (median = 4.00, mean = 3.89, SD = 0.31) of the MTF. The top-rated MTFs were the Iowa Model of Evidence-Based Practice to Promote Quality Care for the ‘Identify the problem’ phase (mean = 4.57, SD = 2.31), the Consolidated Framework for Implementation Research for the ‘Assess barriers/facilitators to knowledge use’ phase (mean = 5.79, SD = 1.12), and the Behaviour Change Wheel for the ‘Select, tailor, implement interventions’ phase (mean = 6.36, SD = 1.08).

Conclusions

Our interdisciplinary team engaged in a rigorous process to reach consensus on MTFs reflecting specific phases of the implementation process and prioritized each to serve as an exemplar in which to embed intersectional approaches. The resulting MTFs correspond with specific phases of the KTA framework, which itself may be useful for those seeking particular MTFs for particular KTA phases. This approach also provides a template for how other implementation MTFs could be similarly considered in the future.

Trial registration

Open Science Framework Registration: osf.io/qgh64.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12874-022-01682-x.

Bringing the patient voice into the operating room: engaging patients in surgical safety research with the Operating Room Black Box®

BACKGROUND

Surgery is one of the most common patient experiences in the health care system. Yet, efforts to engage patients in surgical safety research have not matched those of other health care fields. This is a critical issue given the nature of surgery inhibits patients' abilities to advocate for themselves as they are typically under anesthetic when the procedure is performed. We partnered with patients throughout our research program, which uses the Operating Room Black Box^® to enhance surgical patient safety through transparent and proactive analysis of human factors to detect and prevent avoidable errors.

MAIN BODY

In this article, we outline the need for, and our approach to, patient engagement in surgical safety research. Our approach included a series of planned activities and skill development opportunities designed to build capacity and bring together patients, clinicians, and researchers to inform research and practice. We also conducted evaluation surveys during the first year of our program, which have indicated a positive experience by both patient partners and the research team.

CONCLUSION

We believe our approach can serve as an important first step toward building a model for patient engagement in the surgical safety field and could significantly contribute to improved quality of care and outcomes for surgical patients.

Efficacy and safety of hyperbaric oxygen treatment to treat COVID-19 pneumonia: a living systematic review update

Introduction: As the COVID-19 pandemic evolves, new effective treatment options are essential for reducing morbidity and mortality as well as the strain placed on the healthcare system. Since publication of our initial review on hyperbaric oxygen treatment (HBOT) for hypoxaemic COVID-19 patients, interest in HBOT for COVID-19 has grown and additional studies have been published. Methods: For this living systematic review update the previously published search strategy (excluding Google Scholar) was adopted with an extension from 01 February 2021 to 01 April 2022. Study inclusion criteria, data extraction, risk of bias estimation and dispute resolution methods were repeated. Results: Two new studies enrolling 127 patients were included in this update, taking the total to eight studies with 224 patients. Both new studies were randomised controlled trials, one at moderate and one at high risk of bias. Across these eight studies, 114 patients were treated with HBOT. All reported improved clinical outcomes without observation of any serious adverse events. Meta-analysis remained unjustified given the high heterogeneity between studies and incomplete reporting. Conclusions: This updated living systematic review provides further evidence on the safety and effectiveness of HBOT to treat acute hypoxaemic COVID-19 patients.

Tranexamic acid for prevention of bleeding in cesarean delivery: An overview of systematic reviews

BACKGROUND

Bleeding is the leading cause of maternal mortality in the world. Tranexamic acid reduces bleeding in trauma and surgery. Several systematic reviews of randomized trials have investigated tranexamic acid in the prevention of bleeding in cesarean delivery. However, the conclusions from systematic reviews are conflicting. This overview aims to summarize the evidence and explore the reasons for conflicting conclusions across the systematic reviews.

METHODS

A comprehensive literature search of Medline, Embase, and Cochrane Database of Systematic Reviews was conducted from inception to April 2021. Screening, data extraction, and quality assessments were performed by two independent reviewers. A Measurement Tool to Assess Reviews 2 and the Risk of Bias Assessment Tool for Systematic Reviews were used for study appraisal. A qualitative synthesis of evidence is presented.

RESULTS

In all, 14 systematic reviews were included in our analysis. Across these reviews, there were 32 relevant randomized trials. A modest reduction in blood transfusions and bleeding outcomes was found by most systematic reviews. Overall confidence in results varied from low to critically low. All of the included systematic reviews were at high risk of bias. Quality of evidence from randomized trials was uncertain.

CONCLUSIONS

Systematic reviews investigating prophylactic tranexamic acid in cesarean delivery are heterogeneous in terms of methodological and reporting quality. Tranexamic acid may reduce blood transfusion and bleeding outcomes, but rigorous well-designed research is needed due to the limitations of the included studies. Data on safety and adverse effects are insufficient to draw conclusions.

How gender shapes interprofessional teamwork in the operating room: a qualitative secondary analysis

BACKGROUND

Despite substantial implications for healthcare provider practice and patient outcomes, gender has yet to be systematically explored with regard to interprofessional operating room (OR) teamwork. We aimed to explore and describe how gender and additional social identity factors shape experiences and perceptions of teamwork in the OR.

METHODS

This study was a qualitative secondary analysis of semi-structured interviews with OR team members conducted between November 2018 and July 2019. Participants were recruited across hospitals in Ontario, Canada. We conducted both purposive and snowball sampling until data saturation was reached. Transcripts were analyzed thematically by two independent research team members, moving from open to axial coding.

RESULTS

Sixty-six interviews of OR healthcare professionals were completed: anesthesia (n=17), nursing (n=19), perfusion (n=2), and surgery (n=26). Traditional gender roles, norms, and stereotypes were perceived and experienced by both women and men, but with different consequences. Both women and men participants described challenges that women face in the OR, such as being perceived negatively for displaying leadership behaviours. Participants also reported that interactions and behaviours vary depending on the team gender composition, and that other social identities, such as age and race, often interact with gender. Nevertheless, participants indicated a belief that the influence of gender in the OR may be modified.

CONCLUSIONS

The highly gendered reality of the OR creates an environment conducive to breakdowns in communuication and patient safety risks in addition to diminishing team morale, psychological safety, and provider well-being. Consequently, until teamwork interventions adequately account for gender, they are unlikely to be optimally effective or sustainable.

Mapping multicenter randomized controlled trials in anesthesiology: a scoping review

BACKGROUND

Evidence suggests that there are substantial inconsistencies in the practice of anesthesia. There has not yet been a comprehensive summary of the anesthesia literature that can guide future knowledge translation interventions to move evidence into practice. As the first step toward identifying the most promising interventions for systematic implementation in anesthesia practice, this scoping review of multicentre RCTs aimed to explore and map the existing literature investigating perioperative anesthesia-related interventions and clinical patient outcomes.

METHODS

Multicenter randomized controlled trials were eligible for inclusion if they involved a tested anesthesia-related intervention administered to adult surgical patients (≥ 16 years old), with a control group receiving either another anesthesia intervention or no intervention at all. The electronic databases Embase (via OVID), MEDLINE, and MEDLINE in Process (via OVID), and Cochrane Central Register of Control Trials (CENTRAL) were searched from inception to February 26, 2021. Studies were screened and data were extracted by pairs of independent reviewers in duplicate with disagreements resolved through consensus or a third reviewer. Data were summarized narratively.

RESULTS

We included 638 multicentre randomized controlled trials (n patients = 615,907) that met the eligibility criteria. The most commonly identified anesthesia-related intervention theme across all studies was pharmacotherapy (n studies = 361 [56.6%]; n patients = 244,610 [39.7%]), followed by anesthetic technique (n studies = 80 [12.5%], n patients = 48,455 [7.9%]). Interventions were most often implemented intraoperatively (n studies = 233 [36.5%]; n patients = 175,974 [28.6%]). Studies typically involved multiple types of surgeries (n studies = 187 [29.2%]; n patients = 206 667 [33.5%]), followed by general surgery only (n studies = 115 [18.1%]; n patients = 201,028 [32.6%]) and orthopedic surgery only (n studies = 94 [14.7%]; n patients = 34,575 [5.6%]). Functional status was the most commonly investigated outcome (n studies = 272), followed by patient experience (n studies = 168), and mortality (n studies = 153).

CONCLUSIONS

This scoping review provides a map of multicenter RCTs in anesthesia which can be used to optimize future research endeavors in the field. Specifically, we have identified key knowledge gaps in anesthesia that require further systematic assessment, as well as areas where additional research would likely not add value. These findings provide the foundation for streamlining knowledge translation in anesthesia in order to reduce practice variation and enhance patient outcomes.

Efficacy and safety of hyperbaric oxygen treatment in SARS-COV-2 (COVID-19) pneumonia: a systematic review

INTRODUCTION

The need for intubation and mechanical ventilation among COVID-19 patients is associated with high mortality rates and places a substantial burden on the healthcare system. There is a strong pathophysiological rationale suggesting that hyperbaric oxygen treatment (HBOT), a low-risk and non-invasive treatment, may be beneficial for COVID-19 patients. This systematic review aimed to explore the potential effectiveness and safety of HBOT for treating patients with COVID-19.

METHODS

Medline, Embase, Scopus, and Google Scholar were searched from December 2019 to February 2021, without language restrictions. The grey literature was searched via an internet search engine and targeted website and database searches. Reference lists of included studies were searched. Independent reviewers assessed studies for eligibility and extracted data, with disagreements resolved by consensus or a third reviewer. Risk of bias was assessed using the Newcastle Ottawa Scale. Data were summarised descriptively.

RESULTS

Six publications (one cohort study, five case reports/series) met the inclusion criteria with a total of 37 hypoxaemic COVID-19 patients treated with HBOT. Of these 37 patients, the need for intubation and mechanical ventilation and in-hospital survival were assessed for 26 patients across three studies. Of these 26 patients, intubation and mechanical ventilation were not required for 24, and 23 patients survived. No serious adverse events of HBOT in COVID-19 patients were reported. No randomised trials have been published.

CONCLUSIONS

Limited and weak evidence from non-randomised studies including one propensity-matched cohort study suggests HBOT is safe and may be a promising intervention to optimise treatment and outcomes in hypoxaemic COVID-19 patients. Randomised controlled studies are urgently needed.

Impact of surgeon and anaesthesiologist sex on patient outcomes after cardiac surgery: a population-based study

BACKGROUND

Effective teamwork between anaesthesiologists and surgeons is essential for optimising patient safety in the cardiac operating room. While many factors may influence the relationship between these two physicians, the role of sex and gender have yet to be investigated.

OBJECTIVES

We sought to determine the association between cardiac physician team sex discordance and patient outcomes.

DESIGN

We performed a population-based, retrospective cohort study.

PARTICIPANTS AND SETTING

Adult patients who underwent coronary artery bypass grafting (CABG) and/or aortic, mitral or tricuspid valve surgery between 2008 and 2018 in Ontario, Canada.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was all-cause 30-day mortality. Secondary outcomes included major adverse cardiovascular events at 30 days and hospital and intensive care unit lengths of stay (LOS). Mixed effects logistic regression was used for categorical outcomes and Poisson regression for continuous outcomes.

RESULTS

79 862 patients underwent cardiac surgery by 98 surgeons (11.2% female) and 279 anaesthesiologists (23.3% female); 19 893 (24.9%) were treated by sex-discordant physician teams. Physician sex discordance was not associated with overall patient mortality or LOS; however, patients who underwent isolated CABG experienced longer hospital LOS when treated by an all-male physician team as compared with an all-female team (adjusted OR=1.07; p=0.049). When examining the impact of individual physician sex, the length of hospital stay was longer when isolated CABG procedures were attended by a male surgeon (OR=1.10; p=0.004) or anaesthesiologist (OR=1.02; p=0.01).

CONCLUSIONS

Patient mortality and length of stay after cardiac surgery may vary by sex concordance of the attending surgeon-anaesthesiologist team. Further research is needed to examine the underlying mechanisms of these observed relationships.

'Doing' or 'using' intersectionality? Opportunities and challenges in incorporating intersectionality into knowledge translation theory and practice

Intersectionality is a widely adopted theoretical orientation in the field of women and gender studies. Intersectionality comes from the work of black feminist scholars and activists. Intersectionality argues identities such as gender, race, sexuality, and other markers of difference intersect and reflect large social structures of oppression and privilege, such as sexism, racism, and heteronormativity. The reach of intersectionality now extends to the fields of public health and knowledge translation. Knowledge translation (KT) is a field of study and practice that aims to synthesize and evaluate research into an evidence base and move that evidence into health care practice. There have been increasing calls to bring gender and other social issues into the field of KT. Yet, as scholars outline, there are few guidelines for incorporating the principles of intersectionality into empirical research. An interdisciplinary, team-based, national health research project in Canada aimed to bring an intersectional lens to the field of knowledge translation. This paper reports on key moments and resulting tensions we experienced through the project, which reflect debates in intersectionality: discomfort with social justice, disciplinary divides, and tokenism. We consider how our project advances intersectionality practice and suggests recommendations for using intersectionality in health research contexts. We argue that while we encountered many challenges, our process and the resulting co-created tools can serve as a valuable starting point and example of how intersectionality can transform fields and practices.

Barriers and enablers to effective interprofessional teamwork in the operating room: A qualitative study using the Theoretical Domains Framework

Background

Effective teamwork is critical for safe, high-quality care in the operating room (OR); however, teamwork interventions have not consistently resulted in the expected gains for patient safety or surgical culture. In order to optimize OR teamwork in a targeted and evidence-based manner, it is first necessary to conduct a comprehensive, theory-informed assessment of barriers and enablers from an interprofessional perspective.

Methods

This qualitative study was informed by the Theoretical Domains Framework (TDF). Volunteer, purposive and snowball sampling were conducted primarily across four sites in Ontario, Canada and continued until saturation was reached. Interviews were recorded, transcribed, and de-identified. Directed content analysis was conducted in duplicate using the TDF as the initial coding framework. Codes were then refined whereby similar codes were grouped into larger categories of meaning within each TDF domain, resulting in a list of domain-specific barriers and enablers.

Results

A total of 66 OR healthcare professionals participated in the study (19 Registered Nurses, two Registered Practical Nurses, 17 anaesthesiologists, 26 surgeons, two perfusionists). The most frequently identified teamwork enablers included people management, shared definition of teamwork, communication strategies, positive emotions, familiarity with team members, and alignment of teamwork with professional role. The most frequently identified teamwork barriers included others’ personalities, gender, hierarchies, resource issues, lack of knowledge of best practices for teamwork, negative emotions, conflicting norms and perceptions across professions, being unfamiliar with team members, and on-call/night shifts.

Conclusions

We identified key factors influencing OR teamwork from an interprofessional perspective using a theoretically informed and systematic approach. Our findings reveal important targets for future interventions and may ultimately increase their effectiveness. Specifically, achieving optimal teamwork in the OR may require a multi-level intervention that addresses individual, team and systems-level factors with particular attention to complex social and professional hierarchies.

Evaluating the Effectiveness of Online Training for a Comprehensive Violence Against Women Program: A Pilot Study

Evaluating violence against women (VAW) training is essential to moving the field forward with proven approaches that can improve service provision for survivors of violence. Given existing resource constraints involved in VAW work, online training represents an economical and flexible option; however, existing evaluations of online programs in the VAW field are scant and face a variety of limitations. This study aimed to fill this gap by using a pre-/posttest design, comparison group, and mixed-method analysis to assess the effectiveness and value of an online training program. The program was intended to provide foundational knowledge in feminist antiviolence principles and values to a range of individuals working with survivors of intimate partner violence (IPV). Program participants (N = 108) included volunteers, students, and professionals from various sectors, allowing for the application of the results to a broader field of VAW support services. This is important as individuals who work with IPV survivors may do so in a range of settings outside of the shelter context. Results demonstrate the potential for online VAW training to improve participants' knowledge of and attitudes about VAW, which can positively inform their work with survivors. Qualitative responses provide further insight into course impact and highlight positive and negative aspects of the course. Although preliminary, these results provide justification for continued development and evaluation of online VAW training programs.

Sex and gender analysis in knowledge translation interventions: challenges and solutions

Sex and gender considerations are understood as essential components of knowledge translation in the design, implementation and reporting of interventions. Integrating sex and gender ensures more relevant evidence for translating into the real world. Canada offers specific funding opportunities for knowledge translation projects that integrate sex and gender. This Commentary reflects on the challenges and solutions for integrating sex and gender encountered in six funded knowledge translation projects. In 2018, six research teams funded by the Canadian Institutes of Health Research’s Institute of Gender and Health met in Ottawa to discuss these challenges and solutions. Eighteen participants, including researchers, healthcare professionals, trainees and members of the Institute of Gender and Health, were divided into two groups. Two authors conducted qualitative coding and thematic analysis of the material discussed. Six themes emerged, namely Consensus building, Guidance, Design and outcomes effectiveness, Searches and recruitment, Data access and collection, and Intersection with other determinants of health. Solutions included educating stakeholders on the use of sex and gender concepts, triangulating perspectives of researchers and end-users, and participating in organisations and committees to influence policies and practices. Unresolved challenges included difficulty integrating sex and gender considerations with principles of patient-oriented research, a lack of validated measurement tools for gender, and a paucity of experts in intersectionality. We discuss our findings in the light of observations of similar initiatives elsewhere to inform the further progress of integrating sex and gender into the knowledge translation of health services research findings.

Interventions for improving teamwork in intrapartum care: a systematic review of randomised controlled trials

Background

The labour and delivery environment relies heavily on interdisciplinary collaboration from anaesthesiologists, obstetricians and nurses or midwives to deliver optimal patient care. A large number of adverse events in obstetrics are associated with failure in communication and teamwork among team members, with substantive consequences. The objective of this study is to perform a systematic review of interventions aimed at improving teamwork in obstetrics.

Methods

This systematic review identified and assessed randomised controlled trials (RCTs) of interventions aimed at improving teamwork among interdisciplinary teams in obstetrical care. Medline, CENTRAL, CINAHL and Embase were searched for studies evaluating one of: patient outcomes, team performance or processes of clinical efficiency. Identified citations were reviewed in duplicate for eligibility.

Results

Nine RCTs met the inclusion criteria; five of these RCTs were conducted under simulated clinical environments. Simulation-based teamwork training interventions were the most represented (n=7 studies, 3047 healthcare providers (HCPs), 107 782 births), followed by checklists (n=1 study, 136 HCPs) and an electronic-based decision support tool (n=1 study, 296 HCPs). Simulation-based teamwork training was found to improve team performance in 100% of relevant studies (3 of 3 studies assessing team performance) and patient morbidity in 75% of relevant studies (3 of 4 studies assessing patient morbidity). However, no direct mortality benefit was identified among all the studies reviewed. Studies were assessed to be of low-moderate quality and had significant limitations in their study designs.

Conclusion

While the evidence is still limited and from low to moderate quality RCTs, simulation-based teamwork interventions appear to improve team performance and patient morbidity in labour and delivery care.

PROSPERO Trial registration number

CRD42018090452

Anesthesia interventions that alter perioperative mortality: a scoping review

BACKGROUND

With over 230 million surgical procedures performed annually worldwide, better application of evidence in anesthesia and perioperative medicine may reduce widespread variation in clinical practice and improve patient care. However, a comprehensive summary of the complete available evidence has yet to be conducted. This scoping review aims to map the existing literature investigating perioperative anesthesia interventions and their potential impact on patient mortality, to inform future knowledge translation and ultimately improve perioperative clinical practice.

METHODS

Searches were conducted in MEDLINE, EMBASE, CINAHL, and the Cochrane Library databases from inception to March 2015. Study inclusion criteria were adult patients, surgical procedures requiring anesthesia, perioperative intervention conducted/organized by a professional with training in anesthesia, randomized controlled trials (RCTs), and patient mortality as an outcome. Studies were screened for inclusion, and data was extracted in duplicate by pairs of independent reviewers. Data were extracted, tabulated, and reported thematically.

RESULTS

Among the 10,505 publications identified, 369 RCTs (n = 147,326 patients) met the eligibility criteria. While 15 intervention themes were identified, only 7 themes (39 studies) had a significant impact on mortality: pharmacotherapy (n = 23), nutritional (n = 3), transfusion (n = 4), ventilation (n = 5), glucose control (n = 1), medical device (n = 2), and dialysis (n = 1).

CONCLUSIONS

By mapping intervention themes, this scoping review has identified areas requiring further systematic investigation given their potential value for reducing patient mortality as well as areas where continued investment may not be cost-effective given limited evidence for improving survival. This is a key starting point for future knowledge translation to optimize anesthesia practice.

Intravenous fosfomycin for pulmonary exacerbation of cystic fibrosis: Real life experience of a large adult CF centre

BACKGROUND

The increased prevalence of multi-drug resistant strains of P.aeruginosa and allergic reactions among adult patients with cystic fibrosis (CF) limits the number of antibiotics available to treat pulmonary exacerbations. Fosfomycin, a unique broad spectrum bactericidal antibiotic, might offer an alternative therapeutic option in such cases.

AIM

To describe the clinical efficacy, safety and tolerability of intravenous fosfomycin in combination with a second anti-pseudomonal antibiotic to treat pulmonary exacerbations in adult patients with CF.

METHOD

A retrospective analysis of data captured prospectively, over a 2-years period, on the Unit electronic medical records for patients who received IV fosfomycin was performed. Baseline characteristics in the 12 months prior treatment, lung function, CRP, renal and liver function and electrolytes at start and end of treatment were retrieved.

RESULTS

54 patients received 128 courses of IV fosfomycin in combination with a second antibiotic, resulting in improved FEV1 (0.94 L vs 1.24 L, p < 0.01) and reduced CRP (65 mg/L vs 19.3 mg/L, p < 0.01). Renal function pre- and post-treatment remained stable. 4% (n = 5) of courses were complicated with AKI at mid treatment, which resolved at the end of the course. Electrolyte supplementation was required in 18% of cases for potassium and magnesium and 7% for phosphate. Nausea was the most common side effect (48%), but was well controlled with anti-emetics.

CONCLUSION

Antibiotic regimens including fosfomycin appear to be clinically effective and safe. Fosfomycin should, therefore, be considered as an add-on therapy in patients who failed to respond to initial treatment and with multiple drug allergies.

From "Buzzword" to Best Practice: Applying Intersectionality to Children Exposed to Intimate Partner Violence

Empirical studies on the impact of intimate partner violence (IPV) on children have burgeoned over the last three decades. Notably absent from existing approaches to studying children exposed to IPV, however, is attention to how various positionalities intersect to impact the experiences of children and their families. In fact, while the importance of an intersectional framework for understanding IPV has been discussed for over two decades, little or no attention has been given to issues of children's exposure to IPV. In this article, we examine the current state of the literature on children exposed to IPV through an exploratory meta-analysis, finding limited application of intersectionality and a focus on discrete categories of difference. We then demonstrate why and how an intersectional framework should be applied to children exposed to IPV, with specific strategies for research and policy. We suggest a child-centered approach that recognizes diversity among children exposed to IPV, extending the challenge to traditional "one-size-fits-all" models to include an intersectionality-informed stance.