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Purpose: The ABCDEF bundle may improve delirium outcomes among intensive care unit (ICU) patients, however population-based studies are lacking. In this study we evaluated effects of a quality improvement initiative based on the ABCDEF bundle in adult ICUs in Alberta, Canada., Material and Methods: We conducted a pre-post, registry-based clinical trial, analysed using interrupted time series methodology. Outcomes were examined via segmented linear regression using mixed effects models. The main data source was a population-based electronic health record., Results: 44,405 consecutive admissions (38,400 unique patients) admitted to 15 general medical/surgical and/or neurologic adult ICUs between 2014 and 2019 were included. The proportion of delirium days per ICU increased from 30.24% to 35.31% during the pre-intervention period. After intervention implementation it decreased significantly (bimonthly decrease of 0.34%, 95%CI 0.18-0.50%, p < 0.01) from 33.48% (95%CI 29.64-37.31%) in 2017 to 28.74% (95%CI 25.22-32.26%) in 2019. The proportion of sedation days using midazolam demonstrated an immediate decrease of 7.58% (95%CI 4.00-11.16%). There were no significant changes in duration of invasive ventilation, proportion of partial coma days, ICU mortality, or potential adverse events., Conclusions: An ABCDEF delirium initiative was implemented on a population-basis within adult ICUs and was successful at reducing the prevalence of delirium., Competing Interests: Declaration of competing interest The authors are unaware of any conflicts of interest., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Introduction: We aimed to analyze intensive care unit (ICU)-acquired pneumonia according to 7 definitions, estimating associated hospital mortality., Methods: This cohort study was nested within an international randomized trial, evaluating the effect of probiotics on ICU-acquired pneumonia in 2650 mechanically ventilated adults. Each clinically suspected pneumonia was adjudicated by two physicians blinded to allocation and center. The primary outcome was ventilator-associated pneumonia (VAP) informed by ventilation for ≥2 days, new, progressive or persistent infiltrate plus 2 of: temperature > 38 °C or < 36 °C; leukopenia (<3 × 10(Fernando et al., 2020 6) /L) or leukocytosis (>10 × 10(Fernando et al., 2020 6) /L); and purulent sputum. We also used 6 other definitions estimating the risk of hospital mortality., Results: The frequency of ICU-acquired pneumonia varied by definition: the trial primary outcome VAP (21.6%), Clinical Pulmonary Infection Score (CPIS) (24.9%), American College Chest Physicians (ACCP) (25.0%), International Sepsis Forum (ISF) (24.4%), Reducing Oxidative Stress Study (REDOXS) (17.6%), Centers for Disease Control (CDC) (7.8%), and invasively microbiologically confirmed (1.9%). The trial primary outcome VAP (HR 1.31 [1.08, 1.60]), ISF (HR 1.32 [1.09,1.60]), CPIS (HR 1.30 [1.08,1.58]) and ACCP definitions (HR 1.22 [1.00,1.47]) were associated with hospital mortality., Conclusions: Rates of ICU-acquired pneumonia vary by definition and are associated with differential increased risk of death., Competing Interests: Declaration of Competing Interest None of the authors disclose any competing interests except for peer review grants for this study, per below., (Copyright © 2023. Published by Elsevier Inc.)

Purpose: Pre-existing psychiatric disorders may lead to negative outcomes following intensive care unit (ICU) discharge. We evaluated the association of pre-existing psychiatric disorders with subsequent healthcare utilization and mortality in patients discharged from ICU., Materials and Methods: We retrospectively studied adult patients admitted to 14 medical-surgical ICUs (January 2014-June 2016) with ICU length stay ≥24 h who survived to hospital discharge. Pre-existing psychiatric disorders were identified using algorithms for diagnostic codes captured ≤5 years before ICU admission. Outcomes were healthcare utilization (emergency department visit, hospital or ICU readmission) and mortality. We used logistic regression models with propensity scores to estimate associations, converted to risk ratios (RR)., Results: We included 10,598 patients. 37.6% (n = 3982) had a psychiatric history. Patients with pre-existing psychiatric disorders were at higher risk of subsequent emergency department visits (RR 1.49, 95%CI 1.29-1.71), hospital readmission (RR 1.49, 95%CI 1.34-1.66), ICU readmission (RR 2.64, 95%CI 1.55-4.49) one-year post-ICU discharge, compared to patients without pre-existing psychiatric disorders. Patients with pre-existing psychiatric disorders had a higher risk of mortality (RR 1.31, 95%CI 1.00-1.71) six-months post-ICU discharge., Conclusion: Critically ill patients with pre-existing psychiatric disorders have an increased risk of healthcare utilization and mortality outcomes following an ICU stay., Competing Interests: Declaration of Competing Interest Dr. Stelfox's institution received funding from the Canadian Institutes of Health Research (CIHR). The remaining authors declare that they have no potential conflicts of interest., (Copyright © 2021 The Authors. Published by Elsevier Inc. All rights reserved.)

Purpose: This study aimed to create a trigger tool for our intensive care units (ICUs) to support our departmental quality improvement efforts., Methods: We compiled an initial list of triggers used in an ICU setting through literature review. We used a modified Delphi method to develop a unique set of triggers. An expert panel was selected for multidisciplinary and multi-site representation from four adult medical-surgical ICUs of a Canadian city. Respondents ranked triggers on a Likert scale based on its likelihood of being associated with adverse event (sensitivity to harm), and likelihood of being associated with suboptimal ICU processes (specificity for internal recommendations)., Outcomes: Our literature search yielded 10 articles and 59 triggers. Completion of the rating process resulted in 12 items that achieved consensus. Triggers included specific clinical, hospital-acquired infection, medication related, and procedural occurrences. One additional trigger (cardiopulmonary arrest) which consistently held high scores but did not achieve multidisciplinary consensus, was also included., Conclusions: We used the modified Delphi process to derive consensus-selected triggers to identify ICU specific adverse events with opportunity for improvement in local care. This methodology can be adopted by other centers looking to introduce trigger tools in a manner selective to their practice needs., Competing Interests: Declaration of Competing Interest On behalf of all authors, the corresponding author states that there is no conflict of interest., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Purpose: We aimed to describe the association of two frailty screening tools, the validated Clinical Frailty Scale (CFS) score and the recently described modified Frailty Index (mFI) in critically ill patients., Materials and Methods: We performed a post-hoc analysis of a multicenter cohort of patients admitted to six Canadian Intensive Care Units (ICU) between 2010 and 2011. Frailty was screened using the CFS and the mFI. Concordance between these tools was evaluated, as well as discrimination and predictive ability for clinical outcomes after adjustments., Results: The cohort included 421 patients. Prevalence of frailty was 32.8% with the CFS and 39.2% with the mFI. However, concordance between the two tools was low [(intraclass correlation of 0.37; 95% confidence interval [CI] 0.29-0.45) and partial Spearman rank correlation of 0.38 (95% CI 0.29-0.47)]. Hospital and 1-year mortality, as well as dependency after discharge and hospital readmission, were greater for frail compared to non-frail patients screened with the use of both tools., Conclusion: While the CFS and mFI showed low concordance, both showed good discrimination and predictive validity for hospital mortality. Both tools identify a subgroup of frail patients more likely to have worse clinical outcomes., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Purpose: Use systematic review methodology to summarize risk factors and outcomes for each delirium subtype (hypoactive, hyperactive and mixed) in an adult ICU population., Materials and Methods: We searched the MEDLINE, Embase, CINAHL, SCOPUS, Web of Science and PsycINFO databases from database inception until August 13, 2018, with no restrictions., Results: Of 9635 abstracts, 20 studies were included. Older age was not associated with any delirium subtype in 4/7 (57%) studies. Sex was not associated with any delirium subtype in 4/4 (100%) studies. Mortality was consistently associated with hypoactive delirium in 4/7 (57%) studies. The evidence supporting the association of APACHE-II score, mechanical ventilation, length of stay, duration of delirium and removal of tubes were inconsistent across studies., Conclusions: Although included studies reported on many subtype-specific risk factors and outcomes, heterogeneity in reporting and methodological quality limited the generalizability of the results and the evidence for many subtype-specific risk factors or outcomes is inconsistent across studies. Standardized methodology and the creation of a universal template for collecting data in ICU delirium studies are essential moving forward; helping to identify subtype-specific risk factors or outcomes and strengthen the association of potential risk factors or outcomes., Competing Interests: Declaration of Competing Interest The authors (KDK, HTS, EWE and KMF) do not have any conflicts of interest relevant to this manuscript., (Copyright © 2020 The Authors. Published by Elsevier Inc. All rights reserved.)

Competing Interests: Declaration of Competing Interest The authors declare that they have no competing interests.

Purpose: We aimed to describe point of care communication encounters with patients' families in centers with open visitation practices., Materials and Methods: Cross-sectional one-day point prevalence study in 14 Canadian adult intensive care units (ICUs) located in 7 academic and 7 community hospitals with open family visitation policies., Results: ICU bedside nurses working on a randomly selected weekday completed a survey reporting all observed communication between providers and patients' families. Family point of care communication encounters were measured for 146 of 159 patients (92%) admitted to the study ICUs. Most patients had family (98%) with the majority observed visiting on the study date (73%). Of patients with family (n = 143), direct in-person communication occurred 71% of the time, either via participation in rounds (23%), family meetings (24%), and/or informal updates (71%). 43% (n = 62) of families had direct communication with a physician or nurse practitioner. Nurses provided the largest portion of informal bedside updates (83%, n = 85) and supplemented family communication with phone calls (22%, n = 31). There was no communication contact for 13% (n = 19) of families., Conclusions: ICUs adopt multiple ways of communicating with family members of critically ill patients. Significant interactions occur outside of traditional family meetings, in a less formal and more frequent fashion. Our study supports development of tools to support best practices within contemporary communication paradigms to support provider, patients and family needs., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Intensive care is resource intensive, with costs representing a substantial quantity of total hospitalization costs. Strained ICU capacity compromises care quality and adversely impacts outcomes; however, the association between strain and healthcare costs has not been explored., Materials and Methods: Population-based cohort study performed in 17 adult ICUs in Alberta, Canada. Data were captured on hospitalizations, ambulatory care, physician services and drug dispenses occurring 1-year before and 1-year after index ICU admission. Strain was defined as occupancy ≥90%; with 21 additional definitions evaluated. Patients were categorized as strain and non-strain admissions. Costs attributable to strain, were calculated as difference-in-difference costs using propensity-score matching., Results: 30,557 patients were included (strain: 11,830 [38.7%]; non-strain: 18,727 [61.3%]). At 1-year, strain admissions had adjusted-incremental per-patient cost of CA$9406 (95%CI, $5654-13,157) compared to non-strain admissions, due to hospitalization costs (CA$7930; 95%CI, $4553-11,307) and physician claims (CA$844; 95%CI, $430-1259). This equated to CA$111.3 million (95%CI, $66.9-155.6 million) in excess attributable costs. Strain portended longer hospitalization (3.3 days; 95%CI, 1.1-5.5); and more ambulatory visits (1.0; 95%CI, 0.1-2.0) and physician claims (9.5; 95%CI, 6.2-12.7). Incremental costs were robust across strain definitions., Conclusions: Admissions to ICUs experiencing strain incur incremental costs, attributed to longer hospitalization and physician services., (Copyright © 2019. Published by Elsevier Inc.)

Purpose: This study evaluated a complex initiative to increase evidence-based use of low molecular weight heparin for venous thromboembolism prophylaxis among adult medical-surgical ICU patients., Materials and Methods: This study included: quantitative survey and interviews. Participants were healthcare providers within four ICUs. Surveys collected knowledge of evidence underpinning best practice, exposure to the implementation strategies and their perceived utility, and recommendations. The interview expanded on survey topics. Descriptive statistics summarized the data and chi-squared tests were used to compare groups. Qualitative data were analyzed using a blended deductive and inductive coding approach., Results: Providers had good knowledge of the evidence (range = 58% to 94%). Pharmacist-to-physician reminders (80%), other reminders (50%), and local guidelines (50%) were the most commonly observed strategies. Local champions (76%), on-site education (74%), and computerized decision support system (69%) were perceived to be most helpful. Interviews elicited five themes: provider roles, perceptions of the implementation strategies, facilitators and barriers to uptake of best practice, and recommendations. Assessment of the implementation strategies varied by professional group., Conclusions: The findings of this process evaluation identified implementation strategies that can improve the use of evidence-informed practices, help interpret outcomes in the context of interventions and guide future quality improvement initiatives., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Purpose: Transitions of care from the intensive care unit (ICU) to a hospital ward are high risk and contingent on effective communication. We sought to identify essential information elements to be included in an ICU to hospital ward transfer summary tool, and describe tool functionality and composition perceived to be important., Materials and Methods: A panel of 13 clinicians representing ICU and hospital ward providers used a modified Delphi process to iteratively review and rate unique information elements identified from existing ICU transfer tools through three rounds of review (two remote and one in person). Qualitative content analysis was conducted on transcribed audio recordings of the workshop to characterize tool functionality and composition., Results: A total of 141 unique information elements were reviewed of which 63 were identified by panelists as essential. Qualitative content analyses of panelist discussions identified three themes related to how information elements should be considered when developing an ICU transfer summary tool: 1) Flexibility, 2) Usability, and 3) Accountability., Conclusion: We identified 63 distinct information elements identified as essential for inclusion in an ICU transfer summary tool to facilitate communication between providers during the transition of patient care from the ICU to a hospital ward., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Purpose: This study measured the quality of data extracted from a clinical information system widely used for critical care quality improvement and research., Materials and Methods: We abstracted data from 30 fields in a random sample of 207 patients admitted to nine adult, medical-surgical intensive care units. We assessed concordance between data collected: (1) manually from the bedside system (eCritical MetaVision) by trained auditors, and (2) electronically from the system data warehouse (eCritical TRACER). Agreement was assessed using Cohen's Kappa for categorical variables and intraclass correlation coefficient (ICC) for continuous variables., Results: Concordance between data sets was excellent. There was perfect agreement for 11/30 variables (35%). The median Kappa score for the 16 categorical variables was 0.99 (IQR 0.92-1.00). APACHE II had an ICC of 0.936 (0.898-0.960). The lowest concordance was observed for SOFA renal and respiratory components (ICC 0.804 and 0.846, respectively). Score translation errors by the manual auditor were the most common source of data discrepancies., Conclusions: Manual validation processes of electronic data are complex in comparison to validation of traditional clinical documentation. This study represents a straightforward approach to validate the use of data repositories to support reliable and efficient use of high quality secondary use data., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Purpose: To describe pre-ICU frailty in critically ill patients using the Clinical Frailty Scale (CFS)., Methods: We included patients ≥18years admitted to 2 ICUs in Hamilton, Canada. The ICU Research Coordinator (RC) generated 3 CFS scores using: 1) chart review, 2) family interview, 3) patient interview. Subsequently, an overall impression was captured in a final score. Mean differences were calculated to assess the RC intra-rater reliability and inter-rater reliability of chart reviews by the RC, Occupational Therapist (OT), and Geriatrics Resident (GR). Scores were also compared between younger and older patients. We also analyzed the relationship between CFS scores and mortality., Results: We prospectively enrolled 150 patients (mean age 63.8 [SD 15.3] years, APACHE II score 21 [SD 7.3]). CFS were similar between RC, OT, and GR chart reviews (p>0.05 for all comparisons). There was no difference between RC chart review and RC final score, or between RC patient interview and RC final score. Scores following the RC family interview and the RC final score were significantly different (-0.24, 95% CI -0.38, -0.09, p<0.01). Each 1-point increase in the final CFS scored by the RC was weakly associated with ICU mortality (odds ratio 1.18, 95% CI 0.84-1.66, p=0.33), and hospital mortality (OR 1.19, 95% CI 0.89, -1.59, p=0.24)., Conclusions: CFS scores can be generated using medical chart review and can be reliably completed by ICU clinicians and research staff., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Purpose: To evaluate the associations between strained ICU capacity and patient outcomes., Methods: Multi-center population-based cohort study of nine integrated ICUs in Alberta, Canada. Path-analysis modeling was adopted to investigate direct and indirect associations between strain (available beds ≤1; occupancy ≥95%) and outcomes. Mixed-effects multivariate regression was used to measure the association between strain and acuity (APACHE II score), and both acuity and strain measures on ICU mortality and length of stay., Results: 12,265 admissions comprise the study cohort. Available beds ≤1 and occupancy ≥95% occurred for 22.3% and 17.0% of admissions. Lower bed availability was associated with higher APACHE II score (p<0.0001). The direct effect of ≤1 available beds at ICU admission on ICU mortality was 11.6% (OR 1.116; 95% CI, 0.995-1.252). Integrating direct and indirect effects resulted in a 16.5% increased risk of ICU mortality (OR 1.165; 95% CI, 1.036-1.310), which exceeded the direct effect by 4.9%. Findings were similar with strain defined as occupancy ≥95%. Strain was associated with shorter ICU stay, primarily mediated by greater acuity., Conclusions: Strained capacity was associated with increased ICU mortality, partly mediated through greater illness acuity. Future work should consider both the direct and indirect relationships of strain on outcomes., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Purpose: To identify elements which enable patient and family centred care (PFCC) in the intensive care unit (ICU) and priorities for PFCC research., Materials and Methods: We engaged a panel of multidisciplinary stakeholders in a modified Delphi process. Items generated from a literature review and panelist suggestions were rated in 3 successive rounds on a scale from 1 to 7. Median score was used to rate each item's priority, with 5 or more indicating "essential priority," 4 or 5 "moderate priority" and 3 or less "low priority." Interquartile range (IQR) was used to measure consensus, with IQR of 1 indicating "high" consensus, 2 "moderate" consensus, and 3 or greater "low" consensus., Results: Six items were rated essential elements for facilitating PFCC with high consensus (flexible visiting hours, family participation in bedside care, trained family support person, interventions to facilitate continuity of care, staff education to support families, continuity of staff assignments). Three items were rated essential research topics: interventions to facilitate continuity of care following ICU discharge (moderate consensus), family participation in bedside care (low consensus), and decision aids for end of life decision-making (low consensus)., Conclusions: Stakeholders identified clear and distinct priorities for PFCC in clinical care and research, though there was greater consensus for clinical care., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Purpose: Observational research focused upon emerging infectious diseases such as Ebola virus, Middle East respiratory syndrome, and Zika virus has been challenging to quickly initiate. We aimed to determine the duration of start-up procedures and barriers encountered for an observational study focused upon such infectious outbreaks., Materials and Methods: At 1 pediatric and 5 adult intensive care units, we measured durations from protocol receipt to a variety of outbreak research milestones, including research ethics board (REB) approval, data sharing agreement (DSA) execution, and patient study screening initiation., Results: The median (interquartile range) time from site receipt of the protocol to REB submission was 73 (30-126) days; to REB approval, 158 (42-188) days; to DSA completion, 276 (186-312) days; and to study screening initiation, 293 (269-391) days. The median time from REB submission to REB approval was 43 (13-85) days. The median time for all start-up procedures was 335 (188-335) days., Conclusions: There is a lengthy start-up period required for outbreak-focused research. Completing DSAs was the most time-consuming step. A reactive approach to newly emerging threats such as Ebola virus, Middle East respiratory syndrome, and Zika virus will likely not allow sufficient time to initiate research before most outbreaks are advanced., (Copyright © 2017 The Authors. Published by Elsevier Inc. All rights reserved.)

Purpose: To describe and compare intensive care unit (ICU) patient family member and provider experiences, preferences, and perceptions of family participation in ICU rounds., Methods: Cross-sectional survey of ICU family members and providers of patients admitted to 4 medical-surgical ICUs from September 2014 to March 2015., Measurements and Main Results: Surveys were completed by 63 (62%) family members and 258 (43%) providers. Provider respondents included physicians (9%), nurses (56%), respiratory therapists (24%), and other ICU team members (11%). Although 38% of providers estimated only moderate family member interest in participating in rounds, 97% of family members expressed high interest. Family members and providers reported listening (95% vs 96%; P=.594) and sharing information about the patient (82% vs 82%; P=.995) as appropriate roles for family members during rounds, but differed in their perceptions on asking questions (75% vs 86%; P=.043) and participating in decision making (36% vs 59%; P=.003). Compared with family members, providers were more likely to perceive family participation in rounds to cause family stress (7% vs 22%; P=.020) and confusion (0% vs 28%; P<.001)., Conclusion: Family members and providers share some perspectives on family participation in ICU rounds although other perspectives are discordant, with implications for communication strategies and collaborative decision making., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Performance measurement is essential for quality improvement and is inevitable in the shift to value-based payment. The National Quality Forum is an important clearinghouse for national performance measures in health care in the United States., Aim: We reviewed the National Quality Forum library of performance measures to highlight measures that are relevant to critical care medicine, and we describe gaps and opportunities for the future of performance measurement in critical care medicine., Conclusion: Crafting performance measures that address core aspects of critical care will be challenging, as current outcome and performance measures have problems with validity. Future quality measures will likely focus on interdisciplinary measures across the continuum of patient care., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Very elderly (80 years of age and above) critically ill patients admitted to medical intensive care units (ICUs) have a high incidence of mortality, prolonged hospital length of stay, and living in a dependent state should they survive., Objective: The objective was to develop a clinical prediction tool for hospital mortality to improve future end-of-life decision making for very elderly patients who are admitted to Canadian ICUs., Design: This was a prospective, multicenter cohort study., Setting: Data from 1033 very elderly medical patients admitted to 22 Canadian academic and nonacademic ICUs were analyzed., Interventions: A univariate analysis of selected predictors to ascertain prognostic power was performed, followed by multivariable logistic regression to derive the final prediction tool., Main Results: We included 1033 elderly patients in the analyses. Mean age was 84.6±3.5 years, 55% were male, mean Acute Physiology and Chronic Health Evaluation II score was 23.1±7.9, Sequential Organ Failure Assessment score was 5.3±3.4, median ICU length of stay was 4.1 (interquartile range, 6.2) days, median hospital length of stay was 16.2 (interquartile range, 25.0) days, and ICU mortality and all-cause hospital mortality were 27% and 41%, respectively. Important predictors of hospital mortality at the time of ICU admission include age (85-90 years of age had an odds ratio of hospital mortality of 1.63 [1.04-2.56]; >90 years of age had an odds ratio of hospital mortality of 2.64 [1.27-5.48]), serum creatinine (120-300 had an odds ratio of hospital mortality of 1.57 [1.01-2.44]; >300 had an odds ratio of hospital mortality of 5.29 [2.43-11.51]), Glasgow Coma Scale (13-14 had an odds ratio of hospital mortality of 2.09 [1.09-3.98]; 8-12 had an odds ratio of hospital mortality of 2.31 [1.34-3.97]; 4-7 had an odds ratio of hospital mortality of 5.75 [3.02-10.95]; 3 had an odds ratio of hospital mortality of 8.97 [3.70-21.74]), and serum pH (<7.15 had an odds ratio of hospital mortality of 2.44 [1.07-5.60])., Conclusion: We identified high-risk characteristics for hospital mortality in the elderly population and developed a Risk Scale that may be used to inform discussions regarding goals of care in the future. Further study is warranted to validate the Risk Scale in other settings and evaluate its impact on clinical decision making., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Purpose: The proportion of elderly patients is increasing, but it is unknown if there are age-based differences in care of hospitalized patients with sudden clinical deterioration. We sought to examine the relation between patient age and care for hospitalized patients experiencing sudden clinical deterioration., Methods: We identified hospitalized adults (n = 5103) in 4 hospitals with sudden clinical deteriorations triggering medical emergency team (MET) activation between January 1, 2007, and December 31, 2009. We compared intensive care unit (ICU) admission rates (within 2 hours of MET activation), goals of care (resuscitative vs nonresuscitative), and hospital mortality according to age (<50, 50-64, 65-79, and 80+ years), adjusting for patient, physician, and hospital characteristics., Results: Age was associated with decreased likelihood of admission to ICU (P < .0001) and increased likelihood of change in goals of care (P < .0001). Compared to patients younger than 50 years, patients 80 years or older had 67% lower odds of ICU admission (odds ratio, 0.33; 95% confidence interval, 0.26-0.41) and 587% higher odds (odds ratio, 6.87; 95% confidence interval, 4.20-11.26) of having their goals of care changed to exclude resuscitation. Hospital mortality was associated with patient age, ranging from 15% to 46% (P < .0001)., Conclusions: Patient age is associated with care for hospitalized patients with sudden clinical deterioration, suggesting that strategies to guide care of elderly patients during MET activation may be beneficial., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Introduction: Systematic reviews are an important knowledge synthesis tool for critical care medicine clinicians and researchers. With new literature available each day, reviewers must balance identifying all relevant literature against timely synthesis. We therefore sought to apply capture-mark-recapture, a novel methodology, to estimate the population of articles available for a systematic review of effective patient rounding practices in critical care medicine., Methods: Capture-mark-recapture was applied retrospectively to estimate the population of articles available for a systematic review of 4 bibliographic databases. All research studies (no methodology restrictions) of patient rounding practices in critical care medicine were included. Estimates of article population size were calculated for search of the bibliographic databases, selection of articles for full-text review, and selection of articles for inclusion in the systematic review., Results: Capture-mark-recapture estimated a population of 28839 articles (95% confidence interval [CI], 12393-70990) for search of the bibliographic databases, 169 articles (95% CI, 152-202) for full-text review, and 48 articles (95% CI, 39-131) for inclusion in the systematic review. These estimates suggest that our search identified 15% (4462/28839) of the population of potentially available articles for the search of the bibliographic databases, 79% (133/169) of articles for full-text review, and 79% (38/48) of articles for inclusion in the systematic review., Conclusions: The capture-mark-recapture technique can be applied to systematic reviews in critical care medicine with heterogeneous study methodologies to estimate the population of articles available. Capture-mark-recapture may help clinicians who use systematic reviews to estimate search completeness and researchers who perform systematic reviews to develop more efficient literature search strategies., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Purpose: To assess the safety and feasibility of treating critically ill adults with different fever control strategies., Methods: This was a pilot, open-label clinical trial (ClinicalTrials.gov, number NCT01173367) that randomized febrile patients to an aggressive or permissive fever control strategy. For the aggressive and permissive groups, antipyretic therapy (acetaminophen, physical cooling) was administered when the temperature was ≥ 38.3°C and ≥ 40.0°C respectively. The primary outcome was 28-day mortality., Results: Two hundred patients experienced a fever (31% of the originally projected estimate), among which 26 were randomized to the aggressive (n = 14) or permissive (n = 12) arm. The aggressive group received a greater dose of acetaminophen (2275 mg vs 0 mg, P = .0001), and more frequently received physical cooling than patients in the permissive group (57% vs 8%, P = .01). The mean daily temperature was lower in the aggressive group (37.8°C vs 38.0°C, P = .02). There was no difference in the primary outcome (21% vs 17%, P = 1.0) or in any safety outcome between the treatment groups., Conclusions: This study demonstrated the safety and feasibility of administering antipyretic therapy in critically ill adults. The key finding was a lower than expected incidence of fever., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Purpose: To determine whether fever control with antipyretic therapy effects the mortality of febrile critically ill adults., Methods: Systematic review using MEDLINE, EMBASE, Cochrane Central Register for Controlled Trials, CINAHL, Google Scholar, and 2 clinical trial registries from inception to April 2012. Randomized clinical trials comparing treatment of fever with no treatment or comparing different thresholds for fever control in adults without acute neurological injury admitted to intensive care units (ICUs) were selected for review. The effect of fever control on all-cause ICU-mortality was determined using a random effects meta-analysis., Results: Five randomized clinical trials in 399 patients were included. The temperature threshold for treatment in the intervention group was commonly 38.3°C to 38.5°C, whereas it was typically 40.0°C for controls. Four studies used physical measures and 3 used pharmacologic measures for temperature control. There was no significant heterogeneity among the included studies (I(2) = 12.5%, P = .3). Fever control did not significantly effect ICU mortality with a pooled risk ratio of 0.98 (95% confidence interval 0.58-1.63, P = .9)., Conclusions: This meta-analysis found no evidence that fever treatment influences mortality in critically ill adults without acute neurological injury. However, studies were underpowered to detect clinically important differences., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Background: Quality improvement (QI) is a central tenant of trauma center accreditation in most countries, but its effectiveness is largely unknown. We sought to explore opportunities for improving trauma QI., Methods: We performed a qualitative research study using grounded theory analyses of interviews with medical directors and program managers from 75 verified trauma centers sampled from the United States (n = 51), Canada (n = 14), and Australasia (Australia and New Zealand [n = 10]) to explore experiences with trauma QI activities and identify opportunities for improvement., Results: Most trauma centers indicated that they perceived trauma QI to be important and devoted personnel for QI (data entry, data analyst, educator, nurse practitioner). Programs identified 5 principal opportunities to improve trauma QI: (1) ensure resource adequacy (human resources, registry maintenance, financial support, institutional support), (2) encourage stakeholder participation (engagement, communication, coordination), (3) ensure clinical relevance, (4) incorporate evidence-based tools, and (5) require provider and QI program accountability., Conclusions: Quality improvement programs exist as accreditation requirements in most centers. However, trauma QI practices depend on a range of local and regional factors, and concrete opportunities for improvement that address impact and sustainability exist., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Purpose: Critically ill patients are frequently managed with invasive technologies as part of their medical care. Little is known about use patterns. We examined use trends for invasive technologies used in critically ill patients., Materials and Methods: Using time series analysis and data on 26 989 patients from 3 medical-surgical intensive care units (ICUs) (n = 18 224) and 1 surgical ICU (n = 8765) between January 1, 1999, and January 1, 2007, we measured changes in the proportion of patients receiving the 4 most frequently used invasive technologies used in critically ill patients., Results: The 4 most common invasive technologies used in critically ill patients during the study period were arterial lines (71%), endotracheal intubations (61%), central venous catheters (51%), and pulmonary artery catheters (18%). The proportion of ICU patients who received pulmonary artery catheters decreased from 25% in 1999 to 8% in 2006 (P < .001). Use of central venous catheters increased from 39% to 46% (P < .001). After adjusting for baseline characteristics, patients admitted in 2006 were 4 times less likely to receive a pulmonary artery catheter (odds ratio, 0.28; 95% confidence interval, 0.24-0.33), but 42% (odds ratio, 1.42; 95% confidence interval, 1.27-1.58) more likely to receive a central venous catheter than patients admitted in 1999. No significant changes were observed for intubations and arterial lines., Conclusions: The use of invasive technologies in critically ill patients is changing and may have important implications for resource use, clinician education, and patient care. Initiatives should be considered for ensuring clinician competency during technology transitions.

Purpose: Patient care may be inconsistent during off hours. We sought to determine whether adults admitted to or discharged from intensive care units (ICUs) on evenings and weekends have increased mortality rates., Materials and Methods: All adults admitted to ICUs in the Calgary Health Region, Alberta, Canada, during 2000 to 2006 were included. The in-hospital mortality risk was assessed with admissions or discharges on weekdays (Monday to Friday) and daytime (8:00 am to 5:59 pm) as compared with weekends (Saturday and Sunday) and nights (6:00 pm to 7:59 am)., Results: Intensive care unit admissions (n = 20466) occurred during weekends in 18%, nights in 41%, and nights and/or weekends in 49%. Among the 17864 survivors to ICU discharge, 26% were discharged on weekends, 21% at night, and 41% on nights and/or weekends. Increased crude mortality rates were associated with both admission (24% vs 14%, P < .0001) and discharge (12% vs 5%, P < .0001) during nights as compared with days. Admission to (26% vs 16%, P < .0001) but not discharge from (6% vs 7%, P = .42) ICU during weekends as compared with weekdays was associated with increased mortality. After controlling for confounding variables using logistic regression analyses, neither weekend admission nor discharge was associated with death. However, both night admission and discharge were independently associated with mortality., Conclusions: Our observations of excess risk associated with admission to or discharge from ICU at night merits further exploration as to whether it may reflect inconsistencies in care after hours.