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Purpose: The ordering of routine blood test panels in advance is common in intensive care units (ICUs), with limited consideration of the pretest probability of finding abnormalities. This practice contributes to anemia, false positive results, and health care costs. We sought to understand practices and attitudes of Canadian adult intensivists regarding ordering of blood tests in critically ill patients., Methods: We conducted a nationwide Canadian cross-sectional survey consisting of 15 questions assessing three domains (global perceptions, test ordering, daily practice), plus 11 demographic questions. The target sample was one intensivist per adult ICU in Canada. We summarized responses using descriptive statistics and present data as mean with standard deviation (SD) or count with percentage as appropriate., Results: Over seven months, 80/131 (61%) physicians responded from 77 ICUs, 50% of which were from Ontario. Respondents had a mean (SD) clinical experience of 12 (9) years, and 61% worked in academic centres. When asked about their perceptions of how frequently unnecessary blood tests are ordered, 61% responded "sometimes" and 23% responded "almost always." Fifty-seven percent favoured ordering complete blood counts one day in advance. Only 24% of respondents believed that advanced blood test ordering frequently led to changes in management. The most common factors perceived to influence blood test ordering in the ICU were physician preferences, institutional patterns, and order sets., Conclusion: Most respondents to this survey perceived that unnecessary blood testing occurs in the ICU. The survey identified possible strategies to decrease the number of blood tests., (© 2024. Canadian Anesthesiologists' Society.)

Introduction: Acute kidney injury (AKI) requiring treatment with renal replacement therapy (RRT) is a common complication after admission to an intensive care unit (ICU) and is associated with significant morbidity and mortality. However, the prevalence of RRT use and the associated outcomes in critically patients across the globe are not well described. Therefore, we describe the epidemiology and outcomes of patients receiving RRT for AKI in ICUs across several large health system jurisdictions., Methods: Retrospective cohort analysis using nationally representative and comparable databases from seven health jurisdictions in Australia, Brazil, Canada, Denmark, New Zealand, Scotland, and the USA between 2006 and 2023, depending on data availability of each dataset. Patients with a history of end-stage kidney disease receiving chronic RRT and patients with a history of renal transplant were excluded., Results: A total of 4,104,480 patients in the ICU cohort and 3,520,516 patients in the mechanical ventilation cohort were included. Overall, 156,403 (3.8%) patients in the ICU cohort and 240,824 (6.8%) patients in the mechanical ventilation cohort were treated with RRT for AKI. In the ICU cohort, the proportion of patients treated with RRT was lowest in Australia and Brazil (3.3%) and highest in Scotland (9.2%). The in-hospital mortality for critically ill patients treated with RRT was almost fourfold higher (57.1%) than those not receiving RRT (16.8%). The mortality of patients treated with RRT varied across the health jurisdictions from 37 to 65%., Conclusion: The outcomes of patients who receive RRT in ICUs throughout the world vary widely. Our research suggests that differences in access to and provision of this therapy are contributing factors., (© 2024 The Author(s). Published by S. Karger AG, Basel.)

Objective: Effective communication between clinicians is essential for seamless discharge of patients between care settings. Yet, discharge summaries are commonly not available and incomplete. We implemented and evaluated a structured electronic health record-embedded electronic discharge (eDischarge) summary tool for patients discharged from the ICU to a hospital ward., Design: Multiple baseline trial with randomized and staggered implementation., Setting: Adult medical-surgical ICUs at four acute care hospitals serving a single Canadian city., Patients: Health records of patients 18 years old or older, in the ICU 24 hours or longer, and discharged from the ICU to an in-hospital patient ward between February 12, 2018, and June 30, 2019., Intervention: A structured electronic note (ICU eDischarge tool) with predefined fields (e.g., diagnosis) embedded in the hospital-wide electronic health information system., Measurements and Main Results: We compared the percent of timely (available at discharge) and complete (included goals of care designation, diagnosis, list of active issues, active medications) discharge summaries pre and post implementation using mixed effects logistic regression models. After implementing the ICU eDischarge tool, there was an immediate and sustained increase in the proportion of patients discharged from ICU with timely and complete discharge summaries from 10.8% (preimplementation period) to 71.1% (postimplementation period) (adjusted odds ratio, 32.43; 95% CI, 18.22-57.73). No significant changes were observed in rapid response activation, cardiopulmonary arrest, death in hospital, ICU readmission, and hospital length of stay following ICU discharge. Preventable (60.1 vs 5.7 per 1,000 d; p = 0.023), but not nonpreventable (27.3 vs 40.2 per 1,000d; p = 0.54), adverse events decreased post implementation. Clinicians perceived the eDischarge tool to produce a higher quality discharge process., Conclusions: Implementation of an electronic tool was associated with more timely and complete discharge summaries for patients discharged from the ICU to a hospital ward., Competing Interests: Dr. Stelfox’s institution received funding from the Canadian Institutes of Health Research; he received funding from Workers’ Compensation Board, Alberta; he disclosed that this work was conducted in partnership with Alberta Health Services. Ms. Brundin-Mather received Research Associate salary support from grants supporting this work. Dr. Bagshaw received funding from Baxter and BioPorto; he reports grants, consulting fees, and honoraria from Baxter, outside the submitted work; he participates on the data safety monitoring board of An Adaptive Platform Trial for Critically Ill Patients (I-SPY COVID) trial and the advisory board of BioPorto. The remaining authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2022 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.)

Background: Critical care research in Canada is conducted primarily in academically-affiliated intensive care units with established research infrastructure, including research coordinators (RCs). Recently, efforts have been made to engage community hospital ICUs in research albeit with barriers. Automation or artificial intelligence (AI) could aid the performance of routine research tasks. It is unclear which research study processes might be improved through AI automation., Methods: We conducted a cross-sectional survey of Canadian ICU research personnel. The survey contained items characterizing opinions regarding research processes that may be amenable to AI automation. We distributed the questionnaire via email distribution lists of 3 Canadian research societies. Open-ended questions were analyzed using a thematic content analysis approach., Results: A total of 49 survey responses were received (response rate: 8%). Tasks that respondents felt were time-consuming/tedious/tiresome included: screening for potentially eligible patients (74%), inputting data into case report forms (65%), and preparing internal tracking logs (53%). Tasks that respondents felt could be performed by AI automation included: screening for eligible patients (59%), inputting data into case report forms (55%), preparing internal tracking logs (51%), and randomizing patients into studies (45%). Open-ended questions identified enthusiasm for AI automation to improve information accuracy and efficiency while freeing up RCs to perform tasks that require human interaction. This enthusiasm was tempered by the need for proper AI education and oversight., Conclusions: There were balanced supportive (increased efficiency and re-allocation of tasks) and challenges (informational accuracy and oversight) with regards to AI automation in ICU research.

Objectives: Overnight physician staffing in the ICU has been recommended by the Society of Critical Care Medicine and the Leapfrog Consortium. We conducted a survey to review practice in the current era and to compare this with results from a 2006 survey., Design: Cross-sectional survey., Setting: Canadian adult ICUs., Participants: ICU directors., Interventions: None., Measurement and Main Results: A 29-question survey was sent to ICU directors describing overnight staffing by residents, fellows, nurse practitioners, and staff physicians, as well as duty duration, clinical responsibilities, and unit characteristics. We established contact with 122 ICU directors, of whom 107 (88%) responded. Of the 107 units, 60 (56%) had overnight in-house physicians. Compared with ICUs without overnight in-house physician coverage, ICUs with in-house physicians were in larger hospitals (p < 0.0001), had more beds (p < 0.0001), had more ventilated patients (p < 0.0001), and had more admissions (p < 0.0001). Overnight in-house physicians were first year residents (R1) in 20 of 60 (33%), second to fifth year residents (R2-R5) in 46 of 60 (77%), and Critical Care Medicine trainees in 19 of 60 (32%). Advanced practice nurses provided overnight coverage in four of 107 ICUs (4%). The most senior in-house physician was a staff physician in 12 of 60 ICUs (20%), a Critical Care Medicine trainee in 14 of 60 (23%), and a resident (R2-R5) in 20 of 60 (33%). The duration of overnight duty was on average 20-24 hours in 22 of 46 units (48%) with R2-R5 residents and 14 of 19 units (74%) covered by Critical Care Medicine trainees., Conclusions: Variability of in-house overnight physician presence in Canadian adult ICUs is linked to therapeutic complexity and unit characteristics and has not changed significantly over the decade since our 2006 survey. Additional evidence about patient and resident outcomes would better inform decisions to revise physician scheduling in Canadian ICUs.

Objective: To compare and contrast illustrative examples of the adoption of high value practices and the de-adoption of low value practices., Design: (1) Retrospective, population-based audit of low molecular weight heparin (LMWH) for venous thromboembolism (VTE) prophylaxis (high value practice) and albumin for fluid resuscitation (low value practice) and (2) cross-sectional survey of healthcare providers., Setting: Data were collected from nine adult medical-surgical intensive care units (ICUs) in two large Canadian cities. Patients are managed in these ICUs by a group of multiprofessional and multidisciplinary healthcare providers., Participants: Participants included 6946 ICU admissions and 309 healthcare providers from the same ICUs., Main Outcome Measures: (1) The use of LMWH for VTE prophylaxis (per cent ICU days) and albumin for fluid resuscitation (per cent of patients); and (2) provider knowledge of evidence underpinning these practices, and barriers and facilitators to adopt and de-adopt these practices., Results: LMWH was administered on 38.7% of ICU days, and 20.0% of patients received albumin.Most participants had knowledge of evidence underpinning VTE prophylaxis and fluid resuscitation (59.1% and 84.2%, respectively). Providers perceived these practices to be followed. The most commonly reported barrier to adoption was insufficient knowledge/understanding (32.8%), and to de-adoption was clinical leader preferences (33.2%). On-site education was the most commonly identified facilitator for adoption and de-adoption (67.8% and 68.6%, respectively)., Conclusions: Despite knowledge of and self-reported adherence to best practices, the audit demonstrated opportunity to improve. Provider-reported barriers and facilitators to adoption and de-adoption are broadly similar., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: Guidelines recommend offering family members of critically ill patients the option to attend interdisciplinary team rounds as a way to improve communication and satisfaction. Uncertainty remains around the benefits and risks., Design: We conducted an observational study to describe family participation in ICU rounds and its association with rounding processes., Setting: Rounds conducted under the leadership of 33 attending physicians in seven hospitals across three Canadian cities., Patients: Three hundred two individual rounds on 210 unique patients were observed., Interventions: Quantitative and qualitative data were collected using standardized observational tools., Measurements and Main Results: Among the 302 rounds observed, family attended in 68 rounds (23%), were present in ICU but did not attend in 59 rounds (20%), and were absent from the ICU in 175 rounds (58%). The median duration of rounds respectively for these three groups of patients was 20 minutes (interquartile range, 14-26 min), 16 minutes (interquartile range, 13-22 min), and 16 minutes (interquartile range, 10-23 min) (p = 0.01). There were no significant differences in prognostic discussions (35% vs 36% vs 36%; p = 0.99) or bedside teaching (35% vs 37% vs 34%; p = 0.88). The quality of rounds was not significantly associated with family attendance in rounds or presence in the ICU (quality score [1 (low) to 10 (high)] median 8 [interquartile range, 7-8] vs 7 [interquartile range, 6-9] vs 7 [interquartile range, 6-9]; p = 0.11). Qualitative analyses suggested that family attendance may influence relationship building, information gathering, patient and family education, team dynamics, future family meetings, workflow, and shared clinical decision-making., Conclusions: Our results suggest family attendance in ICU rounds is associated with longer duration of rounds, but not the frequency of trainee teaching, discussions of prognosis, or quality of rounds. Family attendance in rounds may enhance communication and complement family conferences.

Background: Transfer of patient care from an intensive care unit (ICU) to a hospital ward is often challenging, high risk and inefficient. We assessed patient and provider perspectives on barriers and facilitators to high-quality transfers and recommendations to improve the transfer process., Methods: We conducted semistructured interviews of participants from a multicentre prospective cohort study of ICU transfers conducted at 10 hospitals across Canada. We purposively sampled 1 patient, 1 family member of a patient, 1 ICU provider, and 1 ward provider at each of the 8 English-speaking sites. Qualitative content analysis was used to derive themes, subthemes and recommendations., Results: The 35 participants described 3 interrelated, overarching themes perceived as barriers or facilitators to high-quality patient transfers: resource availability, communication and institutional culture. Common recommendations suggested to improve ICU transfers included implementing standardized communication tools that streamline provider-provider and provider-patient communication, using multimodal communication to facilitate timely, accurate, durable and mutually reinforcing information transfer; and developing procedures to manage delays in transfer to ensure continuity of care for patients in the ICU waiting for a hospital ward bed., Interpretation: Patient and provider perspectives attribute breakdown of ICU-to-ward transfers of care to resource availability, communication and institutional culture. Patients and providers recommend standardized, multimodal communication and transfer procedures to improve quality of care., Competing Interests: Competing interests: Sean Bagshaw reports personal fees from Baxter Healthcare, outside the submitted work. No other competing interests were declared., (© 2018 Joule Inc. or its licensors.)

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: The transfer of patient care between the intensive care unit (ICU) and the hospital ward is associated with increased risk of medical error and adverse events. This study will describe patient transfer from ICU to hospital ward by documenting (1) patient, family and provider experiences related to ICU transfer, (2) communication between stakeholders involved in ICU transfer, (3) adverse events that follow ICU transfer and (4) opportunities to improve ICU to hospital ward transfer., Methods: This is a mixed methods prospective observational study of ICU to hospital ward transfer practices in 10 ICUs across Canada. We will recruit 50 patients at each site (n=500) who are transferred from ICU to hospital ward, and distribute surveys to enrolled patients, family members, and healthcare providers (ICU and ward physicians and nurses) after patient transfer. A random sample of 6 consenting study participants (patients, family members, healthcare providers) from each study site (n=60) will be offered an opportunity to participate in interviews to further describe stakeholders' experience with ICU to hospital ward transfer. We will abstract information from patient health records to identify clinical data and use of transfer tools, and identify adverse events that are related to the transfer., Ethics and Dissemination: Research ethics board approval has been obtained at the coordinating study centre (UofC REB13-0021) and 5 study sites (UofA Pro00050646; UBC-PHC H14-01667; Sunnybrook 336-2014; QCH 14-07; Sherbrooke 14-172). Dissemination of the findings will provide a comprehensive description of transfer from ICU to hospital ward in Canada including the uptake of validated or local transfer tools, a conceptual framework of the experiences and needs of stakeholders in the ICU transfer process, a summary of adverse events experienced by patients after transfer from ICU to hospital ward, and opportunities to guide quality improvement efforts., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Objective: Many healthcare workers are concerned about the provision of nonbeneficial treatment in the acute care setting. We sought to explore the perceptions of acute care practitioners to determine whether they perceived nonbeneficial treatment to be a problem, to generate an acceptable definition of nonbeneficial treatment, to learn about their perceptions of the impact and causes of nonbeneficial treatment, and the ways that they feel could reduce or resolve nonbeneficial treatment., Design: National, bilingual, cross-sectional survey of a convenience sample of nursing and medical staff who provide direct patient care in acute medical wards or ICUs in Canada., Main Results: We received 688 responses (response rate 61%) from 11 sites. Seventy-four percent of respondents were nurses. Eighty-two percent of respondents believe that our current means of resolving nonbeneficial treatment are inadequate. The most acceptable definitions of nonbeneficial treatment were "advanced curative/life-prolonging treatments that would almost certainly result in a quality of life that the patient has previously stated that he/she would not want" (88% agreement) and "advanced curative/life-prolonging treatments that are not consistent with the goals of care (as indicated by the patient)" (83% agreement). Respondents most commonly believed that nonbeneficial treatment was caused by substitute decision makers who do not understand the limitations of treatment, or who cannot accept a poor prognosis (90% agreement for each cause), and 52% believed that nonbeneficial treatment was "often" or "always" continued until the patient died or was discharged from hospital. Respondents believed that nonbeneficial treatment was a common problem with a negative impact on all stakeholders (> 80%) and perceived that improved advance care planning and communication training would be the most effective (92% and 88%, respectively) and morally acceptable (95% and 92%, respectively) means to resolve the problem of nonbeneficial treatment., Conclusions: Canadian nurses and physicians perceive that our current means of resolving nonbeneficial treatment are inadequate, and that we need to adopt new techniques of resolving nonbeneficial treatment. The most promising strategies to reduce nonbeneficial treatment are felt to be improved advance care planning and communication training for healthcare professionals.

Objective: To describe the occurrence of recurrent clinical deterioration and repeat medical emergency team activation and assess its effect on processes and outcomes of care., Design: Retrospective cohort study., Setting: Two community hospitals and two tertiary care hospitals, Alberta, Canada., Patients: Consecutive hospitalized adult patients with sudden clinical deterioration and medical emergency team activation without admission to ICU., Intervention: None., Measurement and Main Results: We compared ICU admission rates (admissions > 2 hr following index medical emergency team), hospital length of stay, and hospital mortality for a cohort of 3,200 patients with and without recurrent clinical deterioration following medical emergency team activation adjusting for patient, provider, and hospital characteristics.The cohort consisted of 3,200 patients. Ten percent of patients (n = 337) experienced recurrent clinical deterioration and repeat medical emergency team activation during their hospital stay. Patients more likely to experience recurrent clinical deterioration and repeat medical emergency team activation included those with chronic liver disease (odds ratio, 1.75; 95% CI, 1.14-2.69) or who received airway suctioning (odds ratio, 1.66; 95% CI, 1.23-2.25), noninvasive mechanical ventilation (odds ratio, 1.67; 95% CI, 0.94-2.94), or central IV catheter insertion (odds ratio, 1.81; 95% CI, 1.02-3.21) during the index medical emergency team activation. Patients with recurrent clinical deterioration were more likely than patients without recurrent clinical deterioration to be subsequently admitted to ICU (43% vs 13%; odds ratio, 6.11; 95% CI, 4.67-8.00; p < 0.01), to have longer lengths of hospital stay (median, 31 d vs 13 d; p < 0.01), and to die during their hospital stay (34% vs 23%; odds ratio, 1.98; 95% CI, 1.47-2.67; p < 0.01)., Conclusions: Recurrent clinical deterioration and repeat medical emergency team activation are common and associated with increased risk of subsequent ICU admission, increased length of hospital stay, and increased hospital mortality. It may be possible to identify patients at risk of recurrent clinical deterioration following medical emergency team activation and target interventions to improve patient care.

Purpose: The optimal timing for starting renal replacement therapy (RRT) in patients with acute kidney injury (AKI) is unknown. Defining current practice is necessary to design interventional trials. We describe the current Canadian practice regarding the timing of RRT initiation for AKI., Methods: An observational study of patients undergoing RRT for AKI was undertaken at 11 intensive care units (ICUs) across Canada. Data were captured on demographics, clinical and laboratory findings, indications for RRT, and timing of RRT initiation., Results: Among 119 consecutive patients, the most common ICU admission diagnosis was sepsis/septic shock, occurring in 54%. At the time of RRT initiation, the median and interquartile range (IQR) serum creatinine level was 322 (221-432) μmol·L(-1). The mean (SD) values for other parameters were as follows: Sequential Organ Failure Assessment (SOFA) score 13.4 (4.1), pH 7.25 (0.15), potassium 4.6 (1.0) mmol·L(-1). Also, 64% fulfilled the serum creatinine-based criterion for Acute Kidney Injury Network (AKIN) stage 3. Severity of illness, measured using Acute Physiology and Chronic Health Evaluation (APACHE II) and SOFA scores, did not correlate with AKI severity as defined by the serum creatinine-based AKIN criteria. Median (IQR) time from hospital and ICU admission to the start of RRT was 2.0 (1.0-7.0) days and 1.0 (0-2.0) day, respectively., Conclusion: Patients admitted to an ICU who were started on RRT generally had advanced AKI, high-grade illness severity, and multiorgan dysfunction. Also, they were started on RRT shortly after hospital presentation. We describe the current state of practice in Canada regarding the initiation of RRT for AKI in critically ill patients, which can inform the designs of future interventional trials.

Open in new tab Download slide OBJECTIVES The comparative effectiveness and safety of proton pump inhibitors (PPIs) versus histamine-2 receptor blockers for stress ulcer prophylaxis in the cardiac surgical intensive care unit population is uncertain. Although the Proton Pump Inhibitors versus Histamine-2 Receptor Blockers for Ulcer Prophylaxis Therapy in the Intensive Care Unit (PEPTIC) trial reported a higher risk of mortality in the PPI arm with no difference in gastrointestinal bleeding, detailed information on surgical variables and clinically relevant surgical subgroups was not available. METHODS The analysis included all Canadian cardiac surgery patients enrolled in the PEPTIC trial. Data were electronically linked using unique patient identifiers to a clinical information system. Outcomes of interest included in-hospital mortality, gastrointestinal bleeding, Clostridium difficile infections, ventilator-associated conditions and length of stay. RESULTS We studied 823 (50.6%) randomized to PPIs and 805 (49.4%) to histamine-2-receptor blockers. In the intention-to-treat analysis, there were no differences in hospital mortality [PPI: 4.3% vs histamine-2 receptor blockers: 4.8%, adjusted odds ratio (aOR) 0.97, 95% confidence interval (CI) 0.55–1.70], gastrointestinal bleeding (3.9% vs 4.8%, aOR 1.09, 95% CI 0.66–1.81), C. difficile infections (0.9% vs 0.1%, aOR 0.18, 95% CI 0.02–1.59), ventilator-associated conditions (1.6% vs 1.7%, aOR 0.92, 95% CI 0.85–1.00) or median length of stay (9.2 vs 9.8 days, adjusted risk ratio 1.06, 85% CI 0.99–1.13). No significant treatment differences were observed among subgroups of interest or per-protocol populations. CONCLUSIONS In a secondary analysis of cardiac surgery patients enrolled in the PEPTIC trial in Canada, no differences in effectiveness or safety were observed between use of PPIs and histamine-2 receptor blockers for stress ulcer prophylaxis. Clinical trial registration number anzctr.org.au identifier: ACTRN12616000481471. [ABSTRACT FROM AUTHOR]

Purpose: To provide a 360-degree description of ICU-to-ward transfers.Methods: Prospective cohort study of 451 adults transferred from a medical-surgical ICU to a hospital ward in 10 Canadian hospitals July 2014-January 2016. Transfer processes documented in the medical record. Patient (or delegate) and provider (ICU/ward physician/nurse) perspectives solicited by survey 24-72 h after transfer.Results: Medical records (100%) and survey responses (ICU physicians-80%, ICU nurses-80%, ward physicians-46%, ward nurses-64%, patients-74%) were available for most transfers. The median time from initiation to completion of transfer was 25 h (IQR 6-52). ICU physicians and nurses reported communicating with counterparts via telephone (78 and 75%) when transfer was requested (82 and 24%) or accepted (31 and 59%) and providing more elements of clinical information than ward physicians (mean 4.7 vs. 3.9, p < 0.001) and nurses (5.0 vs. 4.4, p < 0.001) reported receiving. Patients were more likely to report satisfaction with the transfer when they received more information (OR 1.32, 95% CI 1.18-1.48), had their questions addressed (OR 3.96, 95% CI 1.33-11.84), met the ward physician prior to transfer (OR 4.61, 95% CI 2.90-7.33), and were assessed by a nurse within 1 h of ward arrival (OR 4.70, 95% CI 2.29-9.66). Recommendations for improvement included having a documented care plan travel with the patient (all stakeholders), standardized face-to-face handover (physicians), avoiding transfers at shift change (nurses) and informing patients about pending transfers in advance (patients).Conclusions: ICU-to-ward transfers are characterized by failures of patient flow and communication; experienced differently by patients, ICU/ward physicians and nurses, with distinct suggestions for improvement. [ABSTRACT FROM AUTHOR]

Purpose: Persistent critical illness has been described as a subtype of chronic critical illness, characterized as a transition after ICU admission where primary diagnosis and illness acuity are no better at predicting outcome than pre-hospital characteristics. Herein we describe the occurrence and outcomes associated with persistent critical illness in a large Canadian health region.Methods: In this multi-center observational cohort study, all patients aged older than 14 years admitted to 12 ICUs in Alberta, Canada, between June 2012 and December 2014 were included. Primary outcome was in-hospital mortality. Predictors at ICU admission were separated into: (1) antecedent characteristics component (e.g., demographics, chronic health component of the APACHE II score, comorbid conditions); and (2) acute illness component (e.g., APACHE II score at admission, SOFA score, primary diagnostic category, surgical status, acute organ support). Using multiple statistical methods and randomly splitting the cohort into development and validation samples for risk scoring using logistic regression, we examined mortality prediction of each of these components to characterize the timing of transition to persistent critical illness.Results: We included 17,783 patients with a median (IQR) age 61 years (49-71), 62% were male, and mean APACHE II score was 19.0 (7.9). In-hospital mortality was 16.8%. Among patients alive and in ICU, the acute illness component, which accurately predicted outcome at the time of admission [area under the receiver operating characteristics curve (AUC) 0.861; 95% CI 0.860-0.862], progressively lost predictive ability and was no longer more predictive than antecedent characteristics after 9 days. This transition defined the onset of persistent critical illness and comprised 16.1% (n = 2856) of the cohort. Transition ranged between 5 and 21 days across subgroups. In-hospital mortality was greater for those with persistent critical illness [23.9% vs. 15.5%, odds ratio (OR) 1.54; 95% CI 1.43-1.67, p < 0.001]. Persistently critically ill patients accounted for 54.5% of 97844 ICU bed-days and 36.3% of 420119 hospital bed-days, respectively.Conclusions: Persistent critical illness occurred in one in six patients admitted to Alberta ICUs and portended greater risk of death, prolonged ICU and hospital stay, and disproportionate use of health resources compared to patients without persistent critical illness. [ABSTRACT FROM AUTHOR]

Background: Transfer of patient care from an intensive care unit (ICU) to a hospital ward is often challenging, high risk and inefficient. We assessed patient and provider perspectives on barriers and facilitators to high-quality transfers and recommendations to improve the transfer process.Methods: We conducted semistructured interviews of participants from a multicentre prospective cohort study of ICU transfers conducted at 10 hospitals across Canada. We purposively sampled 1 patient, 1 family member of a patient, 1 ICU provider, and 1 ward provider at each of the 8 English-speaking sites. Qualitative content analysis was used to derive themes, subthemes and recommendations.Results: The 35 participants described 3 interrelated, overarching themes perceived as barriers or facilitators to high-quality patient transfers: resource availability, communication and institutional culture. Common recommendations suggested to improve ICU transfers included implementing standardized communication tools that streamline provider-provider and provider-patient communication, using multimodal communication to facilitate timely, accurate, durable and mutually reinforcing information transfer; and developing procedures to manage delays in transfer to ensure continuity of care for patients in the ICU waiting for a hospital ward bed.Interpretation: Patient and provider perspectives attribute breakdown of ICU-to-ward transfers of care to resource availability, communication and institutional culture. Patients and providers recommend standardized, multimodal communication and transfer procedures to improve quality of care. [ABSTRACT FROM AUTHOR]

Rationale: The optimal nutritional strategy for critically ill adults at high nutritional risk is unclear.Objectives: To examine the effect of permissive underfeeding with full protein intake compared with standard feeding on 90-day mortality in patients with different baseline nutritional risk.Methods: This is a post hoc analysis of the PermiT (Permissive Underfeeding versus Target Enteral Feeding in Adult Critically Ill Patients) trial.Measurements and Main Results: Nutritional risk was categorized by the modified Nutrition Risk in Critically Ill score, with high nutritional risk defined as a score of 5-9 and low nutritional risk as a score of 0-4. Additional analyses were performed by categorizing patients by body mass index, prealbumin, transferrin, phosphate, urinary urea nitrogen, and nitrogen balance. Based on the Nutrition Risk in Critically Ill score, 378 of 894 (42.3%) patients were categorized as high nutritional risk and 516 of 894 (57.7%) as low nutritional risk. There was no association between feeding strategy and mortality in the two categories; adjusted odds ratio (aOR) of 0.84 (95% confidence interval [CI], 0.56-1.27) for high nutritional risk and 1.01 (95% CI, 0.64-1.61) for low nutritional risk (interaction P = 0.53). Findings were similar in analyses using other definitions, with the exception of prealbumin. The association of permissive underfeeding versus standard feeding and 90-day mortality differed when patients were categorized by baseline prealbumin level (≤0.10 g/L: aOR, 0.57 [95% CI, 0.31-1.05]; >0.10 and ≤0.15 g/L: aOR, 0.79 [95% CI, 0.42-1.48]; >0.15 g/L: aOR, 1.55 [95% CI, 0.80, 3.01]; interaction P = 0.009).Conclusions: Among patients with high and low nutritional risk, permissive underfeeding with full protein intake was associated with similar outcomes as standard feeding. [ABSTRACT FROM AUTHOR]

Background: We aimed to determine the impact of nighttime discharge from the intensive care unit (ICU) to the ward on hospital mortality and readmission rates in consecutive critically ill patients admitted to five Canadian ICUs. We hypothesized that hospital mortality and readmission rates would be higher for patients discharged after hours compared with discharge during the day.Methods: A multi-center retrospective cohort study was carried out at five hospitals in Edmonton, Canada, between July 2002 and December 2009. Nighttime discharge was defined as discharge from the ICU occurring between 07:00 pm and 07:59 am. Logistic regression analysis was used to explore the associations between nighttime discharge and outcomes.Results: Of 19,622 patients discharged alive from the ICU, 3,505 (17.9%) discharges occurred during nighttime. Nighttime discharge occurred more commonly among medical than surgical patients (19.9% vs. 13.8%, P < 0.001) and among those with more comorbid conditions, compared with daytime discharged patients. Crude hospital mortality (11.8% versus 8.8%, P < 0.001) was greater for nighttime discharged as compared to daytime discharged patients. In a multivariable analysis, after adjustment for comorbidities, diagnosis and source of admission, nighttime discharge remains associated with higher mortality (odds ratio [OR] 1.29; 95% CI, 1.14 to 1.46, P < 0.001). This finding was robust in two sensitivity analyses examining discharges occurring between 00:00 am and 04:59 am (OR 1.28; 1.12-1.47; P < 0.001) and for those who died within 48 h of ICU discharge without readmission (OR 1.24; 1.07-1.42, P = 0.002). There was no difference in ICU readmission for nighttime compared with daytime discharges (7.4% vs. 6.9 %, p = 0.26). However, rates were higher for nighttime discharges in community compared with tertiary hospitals (7.7% vs. 5.7%, P = 0.023).Conclusions: In a large integrated health region, 1 in 5 ICU patients are discharged at nighttime, a factor with increasing occurrence during our study and shown to be independently associated with higher hospital mortality. [ABSTRACT FROM AUTHOR]

The article discusses a study which described the characteristics, treatment and outcomes of critically ill patients in Canada with 2009 influenza A(H1N1) infection. The study used 168 critically ill patients with 2009 influenza A(H1N1) infection in various Canadian adult and pediatric intensive care units (ICUs) during the period April 16-August 12, 2009. Primary outcome measures for the study were 28-day and 90-day mortality, while secondary measures included frequency and duration of mechanical ventilation and duration of stay in the ICU. Occurrence of critical illness in 215 patients with community-acquired 2009 influenza A(H1N1) infection was observed in the study. It also concluded that critical illness due to the virus has occurred rapidly after hospital admission.

Objectives: The optimum duration of antimicrobial treatment for patients with bacteremia is unknown. Our objectives were to determine duration of antimicrobial treatment provided to patients who have bacteremia in ICUs, to assess pathogen/patient factors related to treatment duration, and to assess the relationship between treatment duration and survival.Design: Retrospective cohort study.Settings: Fourteen ICUs across Canada.Patients: Patients with bacteremia and were present in the ICU at the time culture reported positive.Interventions: Duration of antimicrobial treatment for patients who had bacteremia in ICU.Measurements and Main Results: Among 1,202 ICU patients with bacteremia, the median duration of treatment was 14 days, but with wide variability (interquartile range, 9-17.5). Most patient characteristics were not associated with treatment duration. Coagulase-negative staphylococci were the only pathogens associated with shorter treatment (odds ratio, 2.82; 95% CI, 1.51-5.26). The urinary tract was the only source of infection associated with a trend toward lower likelihood of shorter treatment (odds ratio, 0.67; 95% CI, 0.42-1.08); an unknown source of infection was associated with a greater likelihood of shorter treatment (odds ratio, 2.14; 95% CI, 1.17-3.91). The association of treatment duration and survival was unstable when analyzed based on timing of death.Conclusions: Critically ill patients who have bacteremia typically receive long courses of antimicrobials. Most patient/pathogen characteristics are not associated with treatment duration; survivor bias precludes a valid assessment of the association between treatment duration and survival. A definitive randomized controlled trial is needed to compare shorter versus longer antimicrobial treatment in patients who have bacteremia. [ABSTRACT FROM AUTHOR]